Association between race/skin color and premature birth: a systematic review with meta-analysis

Racial Disparities in Medication Use During Pregnancy: Results from the NISAMI Cohort

Purpose

This study aimed to evaluate racial disparities in medication use and associated factors among pregnant women receiving prenatal care at Brazilian Unified Health System primary care health units in the northeast region.

Patients and Methods

A total of 1058 pregnant women in the NISAMI Cohort were interviewed between June 2012 and February 2014. Medicines used during pregnancy were classified according to the Anatomical Therapeutic Chemical (ATC) classification system and ANVISA pregnancy risk categories. Prevalence ratios (crude and adjusted) and 95% confidence intervals (CIs) were estimated using Poisson regression with robust error variance. All analyses were stratified by race (Asian, black, brown/mixed, Brazilian indigenous, and white).

Results

Approximately 84% of the pregnant women used at least one medication, with a lower proportion among white women. The most reported medications were antianemic preparations (71.08%; 95% CI 68.27-73.72%), analgesics (21.74%; 95% CI 19.36-24.32%), and drugs for functional gastrointestinal disorders (18.81%; 95% CI 16.57-21.28%). Approximately 29% of women took potentially risky medications during pregnancy, with a higher prevalence among Asian and white women. Factors associated with medication use during pregnancy include a greater number of prenatal consultations, higher education levels, health problems, and smoking. In addition, maternal age above 25 years, smoking status, and two or more previous pregnancies were associated with potentially risky medication use during pregnancy.

Conclusion

A high prevalence of medication use during pregnancy was found; however, this prevalence was lower among white women. Nonetheless, black and brown women used antianemic preparations less frequently. This finding suggests that race is a factor of inequity in prenatal care, demanding public policies to mitigate it.

The Effects of Health Disparities on Neonatal Outcomes

The history of racism in the United States was established with slavery, and the carry-over effect continues to impact health care through structural and institutional racism. Racial segregation and redlining have impacted access to quality health care, thereby impacting prematurity and infant mortality rates. Health disparities also impact neonatal morbidities such as intraventricular hemorrhage and necrotizing enterocolitis and the family care experience including the establishment of breastfeeding and health care provider interactions.

Environmental factors affecting pregnancy outcomes

INTRODUCTION

Pregnancy represents a fragile period in the life of a woman, vulnerable to hazardous environmental substances which might affect maternal and fetal metabolism. The possible influence of environmental factors, including endocrine disrupting chemicals (EDCs), upon the mother and the fetus before and/or during pregnancy might be associated directly and/or indirectly to deleterious pregnancy outcomes. Because the existence of such associations would be, to our view, of major importance to the scientific community, their investigation is the scope of this critical review.

METHODS

This critical review includes in vivo animal and human studies regarding the role of environmental factors, including EDCs, on pregnancy outcomes complying with the SANRA (a scale for the quality assessment of narrative review articles) questions for narrative reviews. Studies were identified by searching the MEDLINE (PubMed and PubMed Central), the Cochrane library and the Google Scholar databases till October 2022 with the combinations of the appropriate key words (detailed environmental factors including EDCs AND detailed negative pregnancy outcomes) as well as by scanning references from already included articles and relevant reviews manually. Because environmental factors and EDCs have been associated to epigenetic alterations, special care has been given to EDC-induced transgenerational effects on pregnancy outcomes.

RESULTS

The existing evidence suggests positive associations between specific environmental factors and negative pregnancy outcomes such as ectopic pregnancies, pregnancy losses, gestational diabetes, hypertensive disorders of pregnancy, preterm births, birth defects, intrauterine growth restriction, and small or large for gestational age babies.

CONCLUSION

Environmental factors and EDCs may have a catalytic effect on the course and the outcomes of pregnancy.

Bolsa Familia Program and Perinatal Outcomes: NISAMI Cohort

This study aimed to assess the impact of the Bolsa Familia Program on perinatal outcomes of pregnant women. A cohort study was conducted with pregnant women supported by prenatal services at 17 Family Health Units in Bahia, Brazil. A previously tested structured questionnaire, which has sociodemographic, economic, prenatal care, lifestyle, and nutritional variables, has been used to collect data. The outcomes included premature birth and low birth weight. A hierarchical conceptual model was constructed, and logistic regression analysis was performed. From a total of 1173 pregnant women, the identified average age was 25.44 years and 34.10% had pre-gestational overweight. The non-beneficiary pregnant women presented a 1.54 (95% CI = 0.46-5.09) times higher chance of giving birth to children with low weight and a 1.03 (95% CI = 95% CI = 0.53-2.00) times chance of premature birth when compared to the beneficiary group. In the multilevel model, some variables were statistically significant, such as age between 18 and 24 years (p = 0.003), age greater than or equal to 35 years (p = 0.025), family income (p = 0.008), employment status (p = 0.010), and maternal height (p = 0.009). The Bolsa Familia Program, as an integrated strategy of social inclusion and economic development, is suggested to exert a protective effect on the health of mother-concept binomial.

Socio-demographic, maternal, and infant characteristics associated with early childhood development delays among children of young mothers in Brasília, Brazil

Background

Holistic attention to adolescent health is needed to sustain the benefits of investment in early childhood development. Any such interventions must make sure to address the needs of adolescent and young adult parents. This study explored the social and demographic maternal variables associated with risk of early childhood development (ECD) delay for children of young mothers in Brazil.

Methods

Cross-sectional secondary data analysis was done using data from young mothers (aged 13–24) and their children (aged 0–2), collected from community health centers in Brasília, Brazil, between 2017–2018. The Denver Developmental Screening Test II was used to assess risk of ECD delay outcomes. Descriptive analyses were conducted across the full sample and sub-groups of adolescent (13–19) and young adult (20–24) mothers. Multivariable logistic regressions based on theory modelling approach were conducted for the full sample to examine the associations between maternal age and risk of ECD delay, adjusted for a battery of household, maternal, pregnancy, and infant variables.

Results

Risk of ECD delay was found in 17.39% (N = 76) of the children who participated (N = 437). No significant differences in risk of ECD delay were found for children of adolescent mothers compared to children of young adult mothers. Across the full sample, 60.36% (N = 236) of mothers were living in poverty, 73.17% (N = 319) had 9 or more years of education, and 86.14% (N = 373) were not working outside the home at time of data collection. Furthermore, 90.11% (N = 392) did not identify as head of their household and 73.68% (N = 322) were primiparous. Socially-mediated factors such as lower maternal educational attainment, unemployment, and lack of household support were associated with increased risk of ECD delays for children under age 2. Adjusted logistic regression identified multiparity as an independent maternal factor associated with increased risk of ECD delay (AOR = 2.51; 95% CI, 1.23–5.13).

Conclusions

Multiparity was the only independent maternal factor associated with ECD delay among children under 2 years old. Other socio-demographic factors relevant to young mothers may influence ECD delays. Ensuring sustained, concurrent attention to children’s and young parent’s developmental needs may improve multi-generational health outcomes.

Association between maternal cadmium exposure and preterm birth: a meta-analysis

The association between Cadmium and the risk of preterm birth (PTB) has remained controversial. A number of studies found a positive correlation between maternal Cd exposure and PTB; however, there are conflicting reports about this correlation. Therefore, herein we performed this meta-analysis to examine the association between maternal Cd exposure and the risk of PTB.A systematic search was conducted through PubMed, Scopus, Embase and OpenGrey from inception to May 2020 to find all eligible studies. Odds ratios (ORs) and corresponding 95% confidence intervals (CIs) were used to examine this correlation. A random-effects model was applied in this meta-analysis due to significant statistical heterogeneity among included studies.Overall, 10 eligible studies met the inclusion criteria and were included in our analysis, and results of the present meta-analysis indicated that maternal cadmium exposure is associated with the risk of PTB (OR = 1.32; 95% CI = 1.08-1.61).This meta-analysis suggests that maternal Cd exposure might be associated with the risk of PTB. Yet, large prospective studies from different ethnic populations which consider other influencing parameters are still required to confirm this finding.

Effect of acetaminophen use during pregnancy on adverse pregnancy outcomes: a systematic review and meta-analysis

INTRODUCTION

A high number of women are exposed to acetaminophen during pregnancy worldwide. This drug safety during pregnancy regarding preterm birth, birth weight, and fetal development has not been well described. This study investigated the effect of acetaminophen use during pregnancy on selected adverse pregnancy outcomes.

AREAS COVERED

Databases were searched to identify studies reporting the effects of acetaminophen use during pregnancy on preterm birth, low birth weight, and small for gestational age. The studies' quality was assessed by the Newcastle-Ottawa Scale and the Methodological Index for Non-Randomized Studies. Relative risk with 95% confidence intervals of each outcome was estimated using a fixed or random-effects model. Six studies were included for final review, four cohort and two case-control studies. We found no increased risk of preterm birth (RR 0.97; 95% CI 0.59-1.58), and decreased risks of low birth weight (RR 0.65; 95% CI 0.59-0.72) and small for gestational age (RR 0.69; 95% CI 0.50-0.97). Acetaminophen exposure during the third trimester revealed non-significantly in the outcomes.

EXPERT OPINION

Exposure to acetaminophen during pregnancy appears to not increase the risk of the outcomes analyzed. However, there is a lack of information regarding the exposure dose and frequency of acetaminophen use.

Perinatal Outcomes and Factors Associated with Ethnic Group in cases of Preterm Birth: the Multicenter Study on Preterm Birth in Brazil

OBJECTIVE

 To investigate the characteristics of women who had preterm birth (PTB) and related outcomes according to ethnicity.

METHODS

 A secondary analysis of a multicenter cross-sectional study conducted in Brazil. Women who had PTB were classified by self-report as white and non-white. Clinical, pregnancy, and maternal data were collected through postpartum interviews and reviews of medical charts. The sociodemographic, obstetric and clinical characteristics of the women, as well as the mode of delivery and the neonatal outcomes among different ethnic groups were compared through a bivariate analysis.

RESULTS

 Of the 4,150 women who had PTB, 2,317 (55.8%) were non-white, who were more likely: to be younger than 19 years of age (prevalence ratio [PR]: 1.05; 95% confidence interval [95%CI]: 1.01-1.09); to be without a partner; to live on low income; to have lower levels of schooling; to have ≥ 2 children; to perform strenuous work; to be from the Northeastern region of Brazil rather than the from Southern region; to have a history of ≥ 3 deliveries; to have an interpregnancy interval < 12 months; to have pregnancy complications such as abortion, PTB, preterm premature rupture of membranes (pPROM), and low birth weight; to initiate antenatal care (ANC) visits in the second or third trimesters; to have have an inadequate number of ANC visits; to be under continuous overexertion; to smoke in the first and second or third trimesters; and to have anemia and gestational hypertension. The maternal and neonatal outcomes did not differ between the groups, except for the higher rate of low birth weight (73.7% versus 69.0%) in infants born to non-white women, and the higher rate of seizures (4.05% versus 6.29%) in infants born to white women.

CONCLUSION

 Unfavorable conditions were more common in non-whites than in whites. Proper policies are required to decrease inequalities, especially in the context of prematurity, when women and their neonates have specific needs.

The influence of gestational age at term on breastfeeding: a cohort study

OBJECTIVE

To identify the effect of the category gestational age at term on breastfeeding in he first hour of life, the duration of exclusive breastfeeding, and practice of breastfeeding twelve months from birth.

METHOD

Single cohort, with a one-year prospective follow-up of 541 children. A hierarchical analysis was performed, with models adjusted per Cox regression, considering critical p < 0.05.

RESULTS

During raw analysis there was a statistical difference on breastfeeding in the first hour of life (RR = 1.54; CI 95% = 1.12-2.12; p = 0.008). However, in the final analysis, there was no association between gestational age at term and breastfeeding in the first hour of life, duration of exclusive breastfeeding, and the practice of breastfeeding twelve months from birth. Secondarily, higher age and education, cesarean section, birth at private services, and the need for resuscitation were observed to have a negative influence. Duration of previous pregnancy favored breastfeeding in the first hour of life. Using baby bottle and pacifier was negative for breastfeeding in the first year of life.

CONCLUSION

There was no association between the category gestational age at term and breastfeeding. The association of outcomes pointed out by the scientific literature have been confirmed.

The iatrogenesis of obstetric racism in Brazil: beyond the body, beyond the clinic

In Brazil, Black women are disproportionately denied access to timely care and are made vulnerable to death by avoidable obstetric causes. However, they have not been at the center of recent initiatives to improve maternal health. This paper contends that the effectiveness of Brazilian maternal and infant health policy is limited by failures to robustly address racial health inequities. Multi-sited ethnographic research on the implementation of the Rede Cegonha program in Bahia, Brazil between 2012 and 2017 reveals how anti-Blackness structures iatrogenic harms for Black women as well as their kin in maternal healthcare. Building on the work of Black Brazilian feminists, the paper shows how Afro-Brazilian women experience anti-Black racism in obstetric care, which the paper argues can be better understood through Dána-Ain Davis' concept of obstetric racism. The paper suggests that such forms of violence reveal the necropolitical facets of reproductive governance and that the framing of obstetric violence broadens the scales and temporalities of iatrogenesis.

Climate-related migration and population health: social science-oriented dynamic simulation model

BACKGROUND

Social science models find the ecological impacts of climate change (EICC) contribute to internal migration in developing countries and, less so, international migration. Projections expect massive climate-related migration in this century. Nascent research calls to study health, migration, population, and armed conflict potential together, accounting for EICC and other factors. System science offers a way: develop a dynamic simulation model (DSM). We aim to validate the feasibility and usefulness of a pilot DSM intended to serve as a proof-of-concept and a basis for identifying model extensions to make it less simplified and more realistic.

METHODS

Studies have separately examined essential parts. Our DSM integrates their results and computes composites of health problems (HP), health care (HC), non-EICC environmental health problems (EP), and environmental health services (ES) by origin site and by immigrants and natives in a destination site, and conflict risk and intensity per area. The exogenous variables include composites of EICC, sociopolitical, economic, and other factors. We simulate the model for synthetic input values and conduct sensitivity analyses.

RESULTS

The simulation results refer to generic origin and destination sites anywhere on Earth. The effects' sizes are likely inaccurate from a real-world view, as our input values are synthetic. Their signs and dynamics are plausible, internally consistent, and, like the sizes, respond logically in sensitivity analyses. Climate migration may harm public health in a host area even with perfect HC/ES qualities and full access; and no HP spillovers across groups, conflict, EICC, and EP. Deviations from these conditions may worsen everyone's health. We consider adaptation options.

CONCLUSIONS

This work shows we can start developing DSMs to understand climate migration and public health by examining each case with its own inputs. Validation of our pilot model suggests we can use it as intended. We lay a path to making it more realistic for policy analysis.

Cervical length varies considering different populations and gestational outcomes: Results from a systematic review and meta-analysis

BACKGROUND

The uterine cervical length is an important risk factor for preterm birth. The aim of this study was to assess cervical length distribution in women with singleton pregnancies, measured by transvaginal ultrasound between 16 and 24 weeks, and its association with population characteristics.

MATERIALS AND METHODS

We searched electronic databases and other sources for studies published from April 1, 1990 to July 21, 2020. Of the 2019 retrieved publications, full-text versions of 137 articles were considered. We included 77 original articles that reported cervical length measurements of 363,431 women. The main aim of this study was to identify the pattern of cervical length in different populations. We collected demographic and clinical data concerning the population, in addition to information regarding the ultrasound examination and cervical length measurement. Regarding study bias, 56 were at low risk of bias and 21 were at medium risk of bias.

RESULTS

The meta-analysis included 57 articles with data from 158,346 women. The mean cervical length was 37.96. mm (95% CI [36.68, 39.24]). Cervical length was shorter in women from Africa and Asia, in those from low-income countries, with a lower body weight, and in those who delivered before 37 gestational weeks. We found that the cervical length from pooled studies is longer than that usually discussed in the literature. Regarding limitations, we had difficulty assessing our main variable because there was no consistent pattern in the way authors reported cervical length measurement. Another limitation was the great heterogeneity between studies.

CONCLUSIONS

The use of a single cutoff value to define a short cervix diagnosis, an important risk factor for preterm birth, may not be correct and cervical length must be considered according to maternal population characteristics. Future studies should identify different specific curves and cutoff values for cervical length in different populations. This meta-analysis was registered in the PROSPERO database under CRD42017070246 at https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=70246.

Racial inequality in perinatal outcomes in two Brazilian birth cohorts

This study aimed to estimate and compare racial inequality in low birth weight (LBW), preterm birth (PTB), and intrauterine growth restriction (IUGR) in two Brazilian birth cohorts. This was a cross-sectional study nested within two birth cohorts in Ribeirão Preto (RP) and São Luís (SL), whose mothers were interviewed from January to December 2010. In all, 7430 (RP) and 4995 (SL) mothers were interviewed. The maternal skin color was the exposure variable. Associations were adjusted for socioeconomic and biological covariates: maternal education, per capita family income, family economic classification, household head occupation, maternal age, parity, marital status, prenatal care, type of delivery, maternal pre-pregnancy BMI, hypertension, hypertension during pregnancy, and smoking during pregnancy collected from questionnaires applied at birth. Statistical analysis was done with the chi-squared test and logistic regression. In RP, newborns from mothers with black skin color had a higher risk of LBW and IUGR, even after adjusting for socioeconomic and biological variables (P<0.001). In SL, skin color was not a risk factor for LBW (P=0.859), PTB (P=0.220), and IUGR (P=0.062), before or after adjustment for socioeconomic and biological variables. The detection of racial inequality in these perinatal outcomes only in the RP cohort after adjustment for socioeconomic and biological factors may be reflecting the existence of racial discrimination in the RP society. In contrast, the greater miscegenation present in São Luís may be reflecting less racial discrimination of black and brown women in this city.

Anosmia and COVID-19: perspectives on its association and the pathophysiological mechanisms involved

With the spread of SARS-CoV-2, contingency measures and plans to facilitate the screening of infected patients are needed. Changes in olfaction have been cited as symptoms of the disease, and it is important to prove or exclude its association with this condition to refine the symptomatic criteria for early isolation. This article aims to analyze the association between olfactory disorders and SARS-CoV-2 infection as well as investigate the possible underlying pathophysiological mechanisms. The research was carried out using the PubMed, Science Direct, and LILACS databases on May 9, 2020, and updated on May 21. Combinations of MeSH descriptors and the Boolean operator, “AND,” were used: coronavirus infections AND olfactory disorders, coronavirus infections, and neurological manifestations. A total of 1187 articles were found in the databases, of which 17 were included in the study. The data suggest that changes in smell are strongly associated with Covid-19, especially in women and patients with fever; these changes increase the degree of suspicion of Covid-19, and they warrant early implementation of isolation and surveillance measures. There are still gaps in the elucidation of the pathways involved in the loss of smell caused by SARS-CoV-2; however, the great affinity of the virus for ACE-2 receptors, which are present in large quantities in the nasal cavity and olfactory bulb, has been considered.

Evaluation of the birthplace of newborns with gestational age less than 34 weeks according to the complexity of the Neonatal Unit in maternity hospitals linked to the "Rede Cegonha": Brazil, 2016-2017

This study aims to evaluate the birthplace of preterm infants with less than 34 gestational weeks at birth by type of neonatal care service in maternity hospitals of the "Rede Cegonha" and estimate the maternal factors associated with the inadequate place of birth for gestational age. This national cross-sectional study was performed in 2016/2017 to evaluate health establishments with the Rede Cegonha's action plan. Information was analyzed from 303 puerperae and the respective health establishments of their births. Newborns were classified by gestational age at birth (<30 and 30-33 weeks) and health establishments as hospitals with neonatal intensive care service, hospitals with intermediate neonatal care service, and hospitals without neonatal care service. Ministerial Ordinance N° 930/2012 was used to classify the birthplace as appropriate for the newborn's gestational age. Preterm birth prevalence was 37.3 at less than 30 weeks' gestation and 66.8 at 30-33 weeks. Birth in inappropriate services for the newborn's gestational age occurred in 6.3%, with significant regional and social differences. Inequalities in access to neonatal care for preterm infants persist in the "Rede Cegonha" despite advances.