Utilisation of prenatal services and birth outcomes: a community-based study in Israel

Periodontitis as a risk factor for preeclampsia

BACKGROUND

Periodontitis is an inflammatory process caused by a specific group of microorganisms, resulting in the destruction of the tooth-supporting tissue and the resorption of the alveolar bone. Therefore, periodontitis has been considered a risk factor for preeclampsia because infection is one of the factors involved in the etiology and pathogenesis of preeclampsia. The aim of the present study is to determine whether periodontitis is a risk factor for preeclampsia and to identify other possible risk factors.

METHODS

A case-control study was performed with 574 puerperae under care at the university hospital at the Universidade Federal de Pernambuco in the city of Recife, Brazil. Data collection was preceded by a training exercise and a pilot study. Biologic and socioeconomic data were collected along with medical and dental records. A periodontal examination was performed on all dental elements to determine probing depth and gingival recession. The association between periodontitis and preeclampsia was first adjusted for the variables within each block, and adjusted for the variables of all blocks in the final multivariate model.

RESULTS

The multivariate logistic regression analysis showed that, after adjustment for other risk factors, periodontitis remained an independent risk factor for preeclampsia (adjusted odds ratio [OR] = 8.60, confidence interval [CI] = 3.92 to 18.88, P < 0.001 and adjusted OR = 2.03, 95% CI = 1.43 to 2.90, P < 0.001, when using the Centers for Disease Control and Prevention/American Academy of Periodontology definition).

CONCLUSION

The results suggest that within the population studied, periodontitis was a risk factor for preeclampsia.

Ethnic differences in the monthly variation of preeclampsia among Bedouin and Jewish parturients in the Negev

OBJECTIVE

To assess seasonal patterns and monthly variations in the incidence of preeclampsia in the Jewish and Bedouin population in Israel, assuming that ethnicity and environmental factors may have a role in the causal mechanism.

METHODS

A retrospective population-based study comparing all singleton pregnancies of patients with and without preeclampsia was performed. The study included all deliveries between and including 1988 and 2007. For each month, the percentage of births complicated by preeclampsia was calculated. The relative risks of preeclampsia by month of delivery were estimated as odds ratios, using the month of August as the reference category.

RESULTS

During the study period, 203,461 deliveries took place, of which 8,421 (4.1%) were complicated with preeclampsia (either mild or severe). Significantly higher incidence of preeclampsia was demonstrated in the Jewish population: 4.7% (n = 4,783 deliveries) versus 3.6% in the Bedouin population (n = 3,683), (p < 0.001). A similar U shaped trend in the incidence of preeclampsia was noted in both populations: the incidence was highest in the winter months and reached its nadir in August, with subsequent increase through the fall months (p < 0.001). Using August as the reference month, odds ratios were 1.32 (95% CI 1.19-1.48) for January, 1.38 (95% CI 1.24-1.54) for February and 1.33 (95% CI 1.19-1.48) for March. Time series analysis demonstrated a difference in the behavior of the 2 populations. Whereas the Jewish population had demonstrated a Gregorian-month cycle, the Bedouin population had demonstrated a lunar-month cycle.

CONCLUSION

Preeclampsia is significantly more common in the Jewish population. However, both populations demonstrate the same seasonal pattern, with higher incidence of preeclampsia in the winter months. Our findings suggest that climate and environmental exposure may have an important role in the pathophysiology of preeclampsia.

Within prisons, is there an association between the quantity of prenatal care and infant birthweight?

There is still controversy surrounding the effectiveness of prenatal care in reducing low birthweight. In addition, very few studies have assessed the relationship between prenatal care and infant birthweight among pregnant women within the prison system. We sought to ascertain whether there is an association between the quantity of prenatal care and infant birthweight among pregnant women within such a setting. We examined the prison medical records of 147 infants born to women delivering at term (37-41 weeks of gestation) between 1 January 2002 and 31 December 2004 who were incarcerated during pregnancy in Texas state prisons. Linear regression was used to evaluate the association between the number of prison prenatal care visits and infant birthweight while adjusting for potential confounders (age, gravidity, maternal education, maternal race, history of substance use, history of alcohol use, history of tobacco use and the presence of any chronic disease). We also adjusted for the interaction between the gestational age at admission to prison and the number of prison prenatal care visits. There was a statistically significant 120.5 g increase in adjusted mean birthweight with each additional prison prenatal care visit (P = 0.001) among study infants whose mothers entered prison during the first trimester. This trend was not observed among women who came in after the first trimester. There appears to be a positive association between the amount of prison prenatal care and infant birthweight among incarcerated pregnant women delivering at term, but this association appears to be limited to women entering prison during the first trimester of pregnancy.

Inadequate prenatal care and its association with adverse pregnancy outcomes: a comparison of indices

Background

The objectives of this study were to determine rates of prenatal care utilization in Winnipeg, Manitoba, Canada from 1991 to 2000; to compare two indices of prenatal care utilization in identifying the proportion of the population receiving inadequate prenatal care; to determine the association between inadequate prenatal care and adverse pregnancy outcomes (preterm birth, low birth weight [LBW], and small-for-gestational age [SGA]), using each of the indices; and, to assess whether or not, and to what extent, gestational age modifies this association.

Methods

We conducted a population-based study of women having a hospital-based singleton live birth from 1991 to 2000 (N = 80,989). Data sources consisted of a linked mother-baby database and a physician claims file maintained by Manitoba Health. Rates of inadequate prenatal care were calculated using two indices, the R-GINDEX and the APNCU. Logistic regression analysis was used to determine the association between inadequate prenatal care and adverse pregnancy outcomes. Stratified analysis was then used to determine whether the association between inadequate prenatal care and LBW or SGA differed by gestational age.

Results

Rates of inadequate/no prenatal care ranged from 8.3% using APNCU to 8.9% using R-GINDEX. The association between inadequate prenatal care and preterm birth and LBW varied depending on the index used, with adjusted odds ratios (AOR) ranging from 1.0 to 1.3. In contrast, both indices revealed the same strength of association of inadequate prenatal care with SGA (AOR 1.4). Both indices demonstrated heterogeneity (non-uniformity) across gestational age strata, indicating the presence of effect modification by gestational age.

Conclusion

Selection of a prenatal care utilization index requires careful consideration of its methodological underpinnings and limitations. The two indices compared in this study revealed different patterns of utilization of prenatal care, and should not be used interchangeably. Use of these indices to study the association between utilization of prenatal care and pregnancy outcomes affected by the duration of pregnancy should be approached cautiously.

Risk factors for spontaneous preterm birth among Aboriginal and non-Aboriginal women in Manitoba

In the province of Manitoba, the incidence of preterm birth has been increasing and the rate is higher among Aboriginal than non-Aboriginal women. The purpose of this study was to identify risk factors for spontaneous preterm birth in Manitoba women, and to compare risk factors among Aboriginal and non-Aboriginal women. A case-control study was performed at two tertiary care hospitals in Winnipeg, Manitoba, Canada from October 1999 to December 2000. Cases delivered a live singleton infant at < 37 weeks gestation (n = 226; 36% Aboriginal), while controls delivered between 37 and 42 weeks gestation (n = 458; 38% Aboriginal). An interview was conducted with each subject on the postpartum unit, and information was collected from the health record. Using stratified analyses to control for race/ethnicity, several risk factors for preterm birth had a uniform effect measure across strata, while others demonstrated heterogeneity. After adjusting for other maternal characteristics in a multivariable logistic regression model, significant risk factors for all women included previous preterm birth, two or more previous spontaneous abortions, vaginal bleeding after 12 weeks gestation, gestational hypertension, antenatal hospitalisation, and prelabour rupture of membranes. In addition, potentially modifiable risk factors included low weight gain during pregnancy and inadequate prenatal care for all women, and high levels of perceived stress for Aboriginal women. These modifiable risk factors lend themselves to public health interventions, and should be targeted in future prevention efforts.

Adequação do pré-natal e peso ao nascer: uma revisão sistemática

Esta foi uma revisão sistemática da literatura de publicações em que o pré-natal foi investigado com uma das variáveis preditoras do peso ao nascer. Os bancos de dados MEDLINE, Cochrane Library e SciELO foram rastreados usando-se a combinação dos seguintes descritores: "prenatal care", "antenatal care", "quality", "adequacy", "birthweight", e "low birthweight". Foram localizados 25 estudos: 17 transversais, quatro coortes, três caso-controle e um ensaio randomizado. Os indicadores de adequação empregados foram os de utilização (quantitativos) e os de conteúdo do cuidado (de processo ou qualitativos). A maioria dos autores aplicou indicadores de utilização, principalmente o Índice de Kessner e o Adequacy of Prenatal Care Utilization Index. Somente dois estudos usaram critérios qualitativos. De modo geral, os estudos transversais detectaram efeito protetor do pré-natal sobre o baixo peso ao nascer, enquanto que os resultados de investigações com outros desenhos foram conflitantes. Os achados desta revisão evidenciam que o impacto do pré-natal sobre o peso ao nascer não é inequívoco, principalmente devido ao efeito do viés de auto-seleção. Há a necessidade de realização de ensaios randomizados para esclarecer essa relação.

Trends in prenatal care use and low birthweight in southeast Brazil

OBJECTIVES

We investigated trends in prenatal care use and its association with low birthweight in a developing country.

METHODS

We examined data from 2 southeast Brazilian cohort surveys, 1 conducted in 1978-1979 and the other in 1994.

RESULTS

Socioeconomic inequalities in prenatal care use increased during the 15-year period of 1979-1994. Although prenatal care use increases paralleled increases in low birthweight rate during this period, having no prenatal care was associated with higher risk of low birthweight in both surveys. Inadequate prenatal care use was also associated with higher risk of low birthweight in 1978-1979 only.

CONCLUSIONS

Increasing low birthweight rates among women who adequately used prenatal care may be causing a bias by reducing the estimates of the effect of inadequate prenatal care use on low birthweight rates.

Fatores associados à cesariana entre mulheres de baixa renda em Pelotas, Rio Grande do Sul, Brasil

O objetivo do estudo foi investigar a associação entre as características das mulheres e do cuidado pré-natal na rede de Atenção Primária à Saúde de Pelotas com o tipo de parto. Realizou-se um estudo transversal, incluindo a estrutura dos serviços e o processo de atendimento. Foram estudados todos os centros de saúde da cidade e entrevistadas 712 mães. A taxa de cesarianas foi de 30,0%. Na análise ajustada, o risco de cesariana associou-se com características maternas (menor altura, menor número de gestações, gestação planejada, internações hospitalares e hipertensão arterial na gravidez). Entre as características dos serviços encontrou-se influência protetora do maior tempo de formado do médico pré-natalista e o cumprimento às normas do Programa de Pré-natal. As maiores taxas foram verificadas entre os hospitais universitários. Além da educação da mulher no pré-natal, o reconhecimento precoce e o manejo adequado da hipertensão arterial e das causas de hospitalização sugerem a possibilidade de abordagem pelo setor primário a fim de reduzir a taxa de cesarianas.

Factors associated with preterm births in southeast Brazil: a comparison of two birth cohorts born 15 years apart

An increase in preterm deliveries in Ribeirão Preto stimulated an analysis of possible explanatory factors. Two cohorts of singleton livebirths were studied, the first based on 6746 births in 1978-9 and the second based on 2846 births in 1994. A logistic regression was carried out to assess the association of preterm birth with several sociodemographic, behavioural and clinical variables, including year of survey. Delivery in private settings compared with a public setting, maternal age of < or = 17 compared with any other age group, and mothers who had had previous abortions and previous stillbirths were associated with greater rates of preterm birth. Although there was an increase in preterm birth rates regardless of mode of delivery, the increase was greater in the caesarean section group than in the vaginal delivery group. Over the study period, deliveries in private hospitals and caesarean section operations increased markedly (from 4% to 36% and from 30% to 51% respectively). Caesarean section may be the main contributor to the increase of preterm birth rate in this study. It is essential to ensure that health-care staff, especially those in private facilities, are properly educated and audited.

Decisions regarding pregnancy termination among Bedouin couples referred to third level ultrasound clinic

OBJECTIVE

To identify predictors of parental decision whether to terminate a pregnancy after a diagnosis of a major congenital malformation in a traditional society.

STUDY DESIGN

The Bedouin Arabs in southern Israel are a traditional society, with a high incidence of congenital disorders. Data were abstracted from medical records of 295 families who sought counseling in the third level ultrasound clinic between 1990 and 1996. Statistical analysis included univariate and multiple logistic regression.

RESULTS

The diagnosis of a major malformation was confirmed in 64% of the cases. Pregnancy termination was a realistic option for 125 women (66.5%) as the rest were too advanced in their pregnancy. Such a delay was less common in cases of multiple malformations than in a single malformation (19.2% versus 39.0% respectively, P < 0.01). Forty-nine of the 125 women (39.2%) chose to terminate their pregnancy. The only significant predictors of termination decision were earlier gestational week at diagnosis and previous uncompleted pregnancies.

CONCLUSIONS

These findings indicate the importance of promoting early genetic counseling and early prenatal diagnosis, for any population where abortions are not readily acceptable.