Risk status at discharge and cause of death for postneonatal infant deaths: a total population study

OBJECTIVES

To obtain population-based, clinical information regarding potentially modifiable factors contributing to death during the postneonatal period (28 to 364 days), we examined all postneonatal infant deaths in four areas of the United States to determine: (1) the cause of death from clinical and autopsy data rather than vital statistics, (2) whether death occurred during initial hospitalization or after discharge, and (3) the portion of postneonatal mortality attributable to infants who left the hospital with identified high-risk medical conditions.

DESIGN AND SETTING

Retrospective medical record review of all postneonatal infant deaths with birth weights greater than 500 g (total N = 386) born to mothers residing in: (1) the city of Boston (1984 and 1985, N = 55), (2) the city of St Louis and contiguous areas (1985 and 1986, N = 123), (3) San Diego County (1985, N = 112), and (4) the state of Maine (1984 and 1985, N = 96). Deaths were identified using linked birth and death vital statistics, and medical record audits of infants' and mothers' charts were performed. Causes of death were obtained from medical record review in conjunction with autopsy if performed (72%, N = 278), medical record alone (17%, N = 67), or vital statistics if no other source was available (11%, N = 41). The medical conditions at the time of discharge for each infant were reviewed and, if judged to confer an increased risk of morbidity or mortality, were classified as high risk.

RESULTS

The causes of death were sudden infant death syndrome (47%, N = 181), congenital conditions (20%, N = 77), prematurity-related conditions (11%, N = 43), infections (9%, N = 34), external causes (including injuries, drownings, ingestions, and burns) (7%, N = 25), and other (6%, N = 23). In 24% of congenital and 25% to 44% of prematurity-related deaths, infection was the acute or associated cause of death. Infants born to black mothers were more likely than those born to white mothers to die during the postneonatal period of all major causes of death (7.3 per 1000 vs 3.0 per 1000). Overall, 18% (N = 68) of deaths occurred to infants who never left the hospital; 79% (N = 305) of the infants were discharged before death; and discharge status was unknown in 3% (N = 13). Eighty-one percent of all infants with prematurity-related postneonatal deaths were never discharged, and of the total infants who were initially discharged, only 1% (N = 4) subsequently died of prematurity-related causes. Of all postneonatal deaths, only 16% (N = 62) left the hospital with identified high-risk medical conditions.

CONCLUSIONS

These findings suggest that the etiology of postneonatal mortality is heterogeneous, with significant complexity in attributing specific causes of death and making designations of "preventability." The vast majority of infants who died of prematurity-related postneonatal causes never left the hospital, and only a small percentage of all infants that left the hospital before death were identified as being at high medical risk. Therefore, strategies for further decreasing postneonatal mortality must link high-risk follow-up programs to more comprehensive strategies that address risk throughout pregnancy and early childhood.

High variability of glycated hemoglobin concentrations in patients with IDDM followed over 9 years. What is the best index of long-term glycemic control?

OBJECTIVE

To determine variability of long-term glycemic control in patients with IDDM.

RESEARCH DESIGN AND METHODS

A retrospective analysis of HbA1 among 122 IDDM patients followed over 9 years.

RESULTS

Annual group mean HbA1 ranged from 8.4 to 9.3% with large standard deviations (1.7-2.0%), indicating marked variability among individuals. Fluctuations of more than +/- 1% HbA1 occurred in 50% of the patients year to year, and over 9 years the minimum-maximum range was > 3 and > 5% HbA1 in 55 and 11% of patients, respectively. In any one year, 22-43% of patients had HbA1 < 8%, but over 9 years only 3.3% were consistently < 8%. Groups divided according to baseline HbA1 of < 8, 8-10, and > 10% were significantly separated over 9 years by frequency distribution analysis of individual mean HbA1 but were indistinguishable when analyzed by individual HbA1 interquartile range (measure of variability).

CONCLUSIONS

High variability of long-term glycemic control is a marked feature of IDDM, the extent of which may be relevant to microvascular risk.

Inadequate hepatitis B vaccination of adolescents and adults at an urban community health center

Hepatitis B remains a major public health problem in the United States, but public vaccination policy has targeted infants rather than the high-risk adults who constitute the vast majority of patients at imminent risk of infection. The effects of this policy were studied at a community health center in Boston. Adolescents and adults who attended a community health center between January 1, 1992 and May 31, 1993 and had human immunodeficiency virus (HIV) or another sexually transmitted disease (STD)--indications for vaccination according to the Centers for Disease Control and Prevention--were identified through chart review. The vaccination rate and missed opportunities were determined. In addition, directors of Boston health centers were surveyed on hepatitis B vaccine at their clinics. Of 178 individuals with HIV or another STD and without serologic evidence of prior exposure to hepatitis B, two (1.1%) received the vaccine. There were 342 missed opportunities. Only two of 14 medical directors said their clinics routinely offered vaccine to individuals with STDs. The medical directors rated financial barriers as more important obstacles to hepatitis B vaccination than nonfinancial barriers. These results indicate that many high-risk adolescents and adults do not receive a preventive intervention that is federally recommended, potentially life saving, and cost effective. Inadequate public funding for vaccine may be a key barrier for this population.

Home uterine activity monitoring in the prevention of very low birth weight

OBJECTIVES

Despite controversy regarding the efficacy of home uterine activity monitoring (HUAM), it is currently licensed for detection of preterm labor in women with previous preterm deliveries. In practice, however, it is being more widely utilized in an effort to prevent preterm delivery. This study seeks to determine which group of mothers delivering very low birth weight (VLBW) infants would have qualified for HUAM given three different sets of criteria and in which women it could have been used to help prolong gestation.

METHODS

The authors reviewed the medical records of mothers of VLBW infants born in five U.S. locations (N = 1440), retrospectively applying three sets of eligibility criteria for HUAM use: (a) the current FDA licensing criterion for use of HUAM, a previous preterm birth; (b) indication for HUAM commonly cited in published reports; (c) a broad set of criteria based on the presence of any reproductive or medical conditions that might predispose to premature delivery. The authors then analyzed the conditions precipitating delivery for each group to determine whether delivery might have been prevented with HUAM and tocolytic therapy.

RESULTS

Only 4.4% of the total group of women delivering VLBW infants would have been eligible for HUAM under the FDA criterion and might potentially have benefited from this technology. If extremely broad criteria had been applied to identify those eligible for monitoring, under which almost 80% of all women who delivered VLBW infants would have been monitored, only 20.3% of the total group would have been found eligible and would potentially have benefited. If such broad criteria were applied to all pregnant women, a sizable proportion of pregnancies would be monitored at great expense with small potential clinical benefit.

CONCLUSIONS

Because VLBW births are usually precipitated by conditions that are unlikely to benefit from HUAM, this technology will have little impact on reducing VLBW and neonatal mortality rates. More comprehensive preventive strategies should be sought.

The first injustice: socioeconomic disparities, health services technology, and infant mortality

"Infant mortality has long been viewed as a synoptic indicator of the health and social condition of a population. In this article we examine critically the structure of this reflective capacity with a particular emphasis on how new health care technologies may have altered traditional pathways of social influence.... Current patterns of infant mortality in the United States provide a useful illustration of the dynamic interaction of underlying social forces and technological innovation in determining trends in health outcomes. We review the implications of this perspective for [future] sociological research into disparate infant mortality...."

Racial disparities in outcomes of military and civilian births in California

OBJECTIVE

To examine racial disparities in prenatal care utilization, birth weight, and fetal and neonatal mortality in a population for whom financial barriers to health care services are minimal.

STUDY-DESIGN

Using linked birth, fetal death, and infant death certificate files, we examined prenatal care utilization, birth weight distribution, and fetal and neonatal mortality rates for all white and black births occurring in military hospitals in California from January 1, 1981, to December 31, 1985. These patterns were compared with the experience of their civilian counterparts during the same time period.

RESULTS

Black mothers had higher percentages of births occurring in teenaged and unmarried mothers than did white mothers in military and civilian populations. First-trimester prenatal care initiation was lower for blacks in the military (relative risk, 0.79; 95% confidence interval, 0.75-0.82) and civilian (relative risk, 0.51; 95% confidence interval, 0.50-0.52) populations. However, the scale of the disparity in prenatal care utilization was significantly smaller (P < .001) in the military group. Rates of low birth weight and fetal and neonatal mortality among blacks were elevated in the military and civilian groups. However, the racial disparity in low birth weight was significantly smaller in the military group (P < .01 and P < .001, respectively).

CONCLUSIONS

In populations with decreased financial barriers to health care, racial disparities in prenatal care use and low birth weight were reduced. However, the persistence of significant disparities suggests that more comprehensive strategies will be required to ensure equity in birth and neonatal outcome.

The influence of the wider use of surfactant therapy on neonatal mortality among blacks and whites

BACKGROUND

Surfactant therapy reduces morbidity and mortality among premature infants with the respiratory distress syndrome (RDS). Fetal pulmonary surfactant matures more slowly in white than in black fetuses, and therefore RDS is more prevalent among whites than among blacks. We reasoned that the increased use of surfactant after its approval by the Food and Drug Administration (FDA) in 1990 might have reduced neonatal mortality more among whites than among blacks.

METHODS

We merged vital-statistics information for all 1563 infants with very low birth weights (500 to 1500 g) born from 1987 through 1989 or in 1991 and 1992 to residents of St. Louis with clinical data from the four neonatal intensive care units in the St. Louis area; we then compared neonatal mortality during two periods, one before and one after the FDA's approval of surfactant for clinical use (1987 through 1989 and 1991 through 1992).

RESULTS

The use of surfactant increased by a factor of 10 between 1987 through 1989 and 1991 through 1992. The neonatal mortality rate among all very-low-birth-weight infants decreased 17 percent, from 220.3 deaths per 1000 very-low-birth-weight babies born alive (in 1987 through 1989) to 183.9 per 1000 (in 1991 through 1992; P = 0.07). This decrease was due to a 41 percent reduction in the mortality rate among white newborns with very low birth weights (from 261.5 per 1000 to 155.5 per 1000; P = 0.003). In contrast, among black infants, the mortality rate for very-low-birth-weight infants did not change significantly (195.6 per 1000 and 196.8 per 1000). The relative risk of death among black newborns with very low birth weights as compared with white newborns with similar weights was 0.7 from 1987 through 1989 and 1.3 from 1991 through 1992 (P = 0.02). The differences in mortality were not explained by differences in access to surfactant therapy, by differences in mortality between black and white infants who received surfactant, or by differences in the use of antenatal corticosteroid therapy.

CONCLUSIONS

After surfactant therapy for RDS became generally available, neonatal mortality improved more for white than for black infants with very low birth weights.

The importance of extreme prematurity and low birthweight to US neonatal mortality patterns: implications for prenatal care and women's health

OBJECTIVE

In order to frame the appropriateness of neonatal mortality reduction efforts that begin only after pregnancy is recognized, this study examined the relative contributions of different gestational age and birthweight groups to total neonatal mortality and to racial disparities in neonatal mortality in the United States.

METHODS

Using the national linked birth/infant death data set for the 1988 cohort, the relative contributions of different birthweight and gestational age groups to national neonatal mortality rates were calculated. The relative contributions of these groups to the racial disparity in neonatal mortality were also assessed.

RESULTS

Very low birthweight infants (< 1,500 g) accounted for 1.2% of all births, but 64.2% of all neonatal deaths. The very low birthweight rate for whites was 0.93%, while that for blacks was 2.79% with the contribution of this group to neonatal mortality higher for blacks than whites. Infants less than 1,000 g contributed more than 80% of the racial disparity in neonatal mortality.

CONCLUSION

Neonatal mortality patterns in the United States have become highly dependent on infants with gestational ages that approach the second trimester. Preventing neonatal mortality by enhancing care only after pregnancy has been recognized, therefore, may be limited. Strategies that link prenatal care to broader initiatives to improve the health of women regardless of pregnancy status may be more effective.

Mortality rates among 15- to 44-year-old women in Boston: looking beyond reproductive status

Mortality rates were examined for Boston women, aged 15 to 44, from 1980 to 1989. There were 1234 deaths, with a rate of 787.8/100,000 for the decade. Leading causes were cancer, accidents, heart disease, homicide, suicide, and chronic liver disease. After age adjustment, African-American women in this age group were 2.3 times more likely to die than White women. Deaths at least partly attributable to smoking and alcohol amounted to 29.8% and 31.9%, respectively. Mortality was found to be related more directly to the general well-being of young women than to their reproductive status, and many deaths were preventable. African-American/White disparities were most likely linked to social factors. These findings suggest that health needs of reproductive-age women transcend reproductive health and require comprehensive interventions.

The impact of extreme prematurity and congenital anomalies on the interpretation of international comparisons of infant mortality

OBJECTIVE

To identify the potential impact that different definitions of live births and practice patterns have on infant mortality rates in England and Wales, France, Japan, and the United States.

METHODS

United States data were obtained from the 1986 linked national birth-infant death cohort, and those for the other countries came from either published sources or directly from the Ministries of Health.

RESULTS

In 1986 in the United States, infants weighing less than 1 kg accounted for 36% of deaths (32% white and 46% black); 32% resulted from fatal congenital anomalies. These rates were much higher in both categories than in England and Wales in 1990 (24 and 22%, respectively), France in 1990 (15 and 25%, respectively), and Japan in 1991 (9% for infants weighing less than 1 kg, percentage of fatal congenital anomalies unknown). These cases are more likely to be excluded from infant mortality statistics in their countries than in the United States.

CONCLUSIONS

In 1990, the United States infant mortality rate was 9.2 per 1000 live births, ranking the United States 19th internationally. However, infant mortality provides a poor comparative measure of reproductive outcome because there are enormous regional and international differences in clinical practices and in the way live births are classified. Future international and state comparisons of reproductive health should standardize the definition of a live birth and fatal congenital anomaly, and use weight-specific fetal-infant mortality ratios and perinatal statistics.

The accessibility of drug treatment for pregnant women: a survey of programs in five cities

Through simulated calls to 294 drug treatment programs in five cities, this study investigated access for pregnant women and compared New York City's provision of services in 1989 to that in 1993. In all sites, the majority of programs accepted pregnant women. There was also a marked improvement in the availability of services in New York City. Yet options were more limited for Medicaid recipients and women needing child care, and an appointment or referral for prenatal care was usually not offered. Although the door for treatment may be opening for pregnant women, institutional barriers still remain.

Effect of advertising on awareness of symptoms of diabetes among the general public: the British Diabetic Association Study

OBJECTIVE

To determine the impact of posters advertising symptoms of diabetes on public knowledge of these symptoms.

DESIGN

Structured street interviews of members of the general public before, at the end of, and 10 weeks after a campaign advertising the main symptoms of diabetes.

SETTING

Basingstoke and Wolverhampton.

SUBJECTS

Three samples of 1000 members of the general public were interviewed. Samples were selected randomly but stratified to match the local population's age (20-75), sex, social class, and racial characteristics.

MAIN OUTCOME MEASURES

Knowledge of symptoms of diabetes; perceived seriousness of diabetes; and induction of anxiety about symptoms in the target population.

RESULTS

Advertising significantly raised knowledge (without prompting) of symptoms: thirst, 245 before v 411 at end of campaign (P < 0.0001) v 341 after (P = 0.0012 v before); polyuria, 72 v 101 (P = 0.0211) v 92 (P = 0.5169); lethargy, 180 v 373 (P < 0.0001) v 298 (P < 0.0001); knowledge of weight loss and visual disturbance was unaffected. The number of subjects lacking knowledge of any symptoms was reduced from 550 to 388 (P < 0.0001). The perceived seriousness of diabetes was unaffected (mean 7.6 in each phase on a scale of 1 (not) to 10 (very). Before advertising, 449 (45%) claimed to have one or more symptoms of diabetes, but this number fell at the end of the campaign (403; P = 0.0419) and 10 weeks afterwards (278; P < 0.0001).

CONCLUSIONS

An advertising campaign raised public knowledge of diabetes symptoms without inducing fear of diabetes or anxiety about symptoms. Its potential for achieving earlier detection of non-insulin dependent diabetes should be evaluated.

Finding common ground: the necessity of an integrated agenda for women's and children's health

During the past decade, a new term has entered the medical/legal lexicon : maternal-fetal conflict. Implicit in the terminology is the assumption that a pregnant woman and her fetus have separate and competing rights. This concept has stimulated extensive legal and ethical debate, primarily in the context of medical interventions (cesarean sections and blood transfusions) forced on unwilling pregnant women, and in corporate efforts to bar fertile women from hazardous jobs. On one side of the debate are the proponents of the future child's right to be born of sound mind and body, and society's interest in the delivery of healthy newborns. On the other side, are advocates of a woman's right to reproductive autonomy, bodily integrity, due process, confidential medical treatment, and freedom from gender discrimination. Neither side has challenged the formulation of the problem, or has examined its permeation into public health policy.

Comparison of paired short Synacthen and insulin tolerance tests soon after pituitary surgery

The cortisol responses to hypoglycaemia (insulin tolerance test, ITT) and tetracosactrin (short Synacthen test, SST) were compared after hypophysectomy to evaluate the SST for the assessment of hypothalamo-pituitary-adrenocortical (HPA) axis function in the immediate post-operative period. In 12 patients who were tested a mean of 21 months postoperatively (range 1-96) peak plasma cortisol in the SST correlated with that in the ITT (r = 0.90). Correlation was also seen in 12 patients tested a mean of 9 days (range 4-18) after hypophysectomy (r = 0.73). Basal-peak cortisol increments did not correlate. The peak plasma cortisol response in each test was classified by comparison with a reference value of 550 nmol/L. On this basis there was a notable discrepancy between the ITT and SST results in only one patient who was tested 4 days after hypophysectomy. The close correlation between ITT and SST responses after pituitary surgery extends into the immediate post operative period and indicates that the latter test can be used to screen HPA axis function at this time.

Confronting racial disparities in infant mortality: reconciling science and politics

The public debate surrounding disparities in infant mortality has resulted from a profound failure to seek a common wisdom. Because of its essential social roots, infant mortality will always remain the province of fundamental ideological and political conflict. However, without a more integrated analytic approach, progress in reducing disparate infant mortality will remain limited by internecine struggles for disciplinary purview and false claims of societal relevance. For in the end, the struggle to address disparate infant mortality will be advanced best by integrated technical and political strategies that recognize that the pursuits of efficacy and justice are inextricably linked.

Infant mortality

Infant mortality continues to be a major public health issue in the United States. Although some preventive strategies for neonatal mortality are emerging for congenital malformations, notably neural tube defects, the prevention of preterm deliveries among disadvantaged populations remains elusive, suggesting the need for different approaches to women's health needs. Despite the lack of success in preventing preterm birth, neonatal mortality rates continued to decline substantially, a decline attributed to improvements in neonatal intensive care associated with surfactant use. The increasing survival of very preterm infants continues to raise questions about their longer term outcomes especially with several recent studies on difficulties in school, and about the need for postdischarge developmental interventions. Attempts to decrease postneonatal mortality received marked attention with the recommendations for specific positioning to prevent sudden infant death syndrome and heightened attention to increased immunization completion rates. The dismal ranking of the United States in infant mortality rates among industrialized countries, however, continues to present a social policy challenge.

Restriction fragment length polymorphisms of the human aldose reductase gene: a preliminary report

Abnormal metabolism through the polyol pathway during episodes of hyperglycaemia is implicated in the development of the chronic complications of diabetes. Since aldose reductase is the first and ratelimiting enzyme of the polyol pathway, it is predicted that restriction fragment length polymorphisms at the aldose reductase gene locus may influence catalytic activity and determine individual susceptibility to the diabetic complications. This paper reports the existence of EcoRI and TaqI restriction fragment length polymorphisms at the human aldose reductase locus.

Prevalence of haemochromatosis amongst patients with diabetes mellitus

Four hundred and six white caucasian patients with diabetes mellitus (243 male, mean age 54 +/- 16 (SD) years) were screened for haemochromatosis. Four patients had a fasting transferrin saturation > 62% and all were HLA A3 positive. Two were probable homozygotes for haemochromatosis and two heterozygotes. Homozygote haemochromatosis prevalence in this diabetic population was therefore 2/406 (0.0049) which is identical to that reported in the general population. These findings do not support a genetic relationship between the two conditions.

Clinical determinants of the racial disparity in very low birth weight

BACKGROUND

Although the risk of very low birth weight (less than 1500 g) is more than twice as high among blacks as among whites in the United States, the clinical conditions associated with this disparity remain poorly explored.

METHODS AND RESULTS

We reviewed the medical records of over 98 percent of all infants weighing 500 to 1499 g who were born in Boston during the period 1980 through 1985 (687 infants), in St. Louis in 1985 and 1986 (397 infants), and in two health districts in Mississippi in 1984 and 1985 (215 infants). The medical records of the infants' mothers were also reviewed. These data were linked to birth-certificate files. During the study periods, there were 49,196 live births in Boston, 16,232 in St. Louis, and 16,332 in the Mississippi districts. The relative risk of very low birth weight among black infants as compared with white infants ranged from 2.3 to 3.2 in the three areas. The higher proportion of black infants with very low birth weights was related to an elevated risk in their mothers of major conditions associated with very low birth weight, primarily chorioamnionitis or premature rupture of the amniotic membrane (associated with 38.0 percent of the excess proportion of black infants with very low birth weights [95 percent confidence interval, 31.3 to 45.4 percent]); idiopathic preterm labor (20.9 percent of the excess [95 percent confidence interval, 16.0 to 26.4 percent]); hypertensive disorders (12.3 percent [95 percent confidence interval, 8.6 to 16.6]); and hemorrhage (9.8 percent [95 percent confidence interval, 5.5 to 13.5]).

CONCLUSIONS

The higher proportion of black infants with very low birth weights is associated with a greater frequency of all major maternal conditions precipitating delivery among black women. Reductions in the disparity in birth weight between blacks and whites are not likely to result from any single clinical intervention but, rather, from comprehensive preventive strategies.