Modeling maternal weight and height in studies of pregnancy outcome among Hispanic women.

The objective of this study was to evaluate methods of using maternal weight and height in studies of pregnancy outcome for Hispanic women. Reference anthropometric data came from 1166 Mexican-American women in the Hispanic Health and Nutrition Examination Survey (HHANES). Prospective data on maternal anthropometry and infant birth weight came from 1362 Hispanic women in the Kaiser-Permanente Contraceptive Drug Study and 12,786 women in the Guatemalan Cooperative Perinatal Study. Five methods of standardizing weight for height were evaluated, including power-type indexes and weights relative to HHANES reference data. In linear- and logistic-regression analyses, these methods were practically interchangeable, with no evident advantage of Hispanic reference data. However, if weight was not height-standardized the effect of height was underestimated; if height was omitted and weight was not height-standardized the effects of weight were exaggerated. Therefore, analyses of pregnancy outcome should include both height and height-standardized weight.

The effect on fetal growth of protozoan and helminthic infection during pregnancy.

This is a prospective study of 14,914 pregnant women conducted in Guatemala City, Guatemala. Stool samples were obtained from the studied patients before the first prenatal visit (mean gestational age 21.6 +/- 8.4 weeks) for the diagnosis of parasitic infections during pregnancy. Forty-four percent had at least one parasite detected, and 24% were infected with helminths. Ascaris lumbricoides was the most prevalent (14.5%). Infected mothers were less educated, had less adequate water and sanitary conditions, and had lower nutritional status. The incidence of intrauterine growth retardation (IUGR) increased with the number of parasitic species detected (up to two or more species, P less than .01). High levels of infection (greater than or equal to + +) were associated with an increased risk of IUGR for protozoa and helminths, except for Strongyloides stercoralis and Hymenolepis nana. Chronically malnourished women of short stature had significantly higher IUGR rates when infected with one or two or more species (P less than .01). Up to 10% of the IUGR rates may be attributed to parasitic infections among the malnourished women.

Improved lactose digestion during pregnancy: a case of physiologic adaptation?

Loss of intestinal lactase activity among adults could theoretically limit milk consumption and hence dietary availability of calcium during pregnancy. The present study sought to define, using breath hydrogen (H2) production as an index of incomplete carbohydrate absorption, the prevalence during pregnancy of lactose maldigestion of 360 mL of milk (18 g of lactose), and to determine whether lactose digestion improved as pregnancy advanced. The prevalence of lactose maldigestion among 114 pregnant women tested before the 15th week of gestation was 54%. By term, 44% of those originally classified as maldigesters had become digesters. There was a significant reduction in the four-hour sum of the changes in breath H2 concentration from the period before 15 weeks (116.6 +/- 9.6 ppm) to the time after 36 weeks (54.4 +/- 7.3 ppm; P less than .01). This apparent adaptive improvement in intestinal handling of milk lactose during gestation has implications for calcium intake and absorption.

FIGO Save the Mothers Initiative: the Central America and USA collaboration.

The American College of Obstetricians and Gynecologists (ACOG) and the Central American Federation of Associations and Societies of Obstetrics and Gynecology (FECASOG), as a part of the FIGO Save the Mothers Initiative, undertook a pilot project to improve provision of basic emergency obstetric care in selected departments in four Central American countries. This article describes the process of the development and implementation of the project. Preliminary results suggest that the capacity to provide this care has been improved by the training of healthcare personnel.

Reservas de ácido fólico intraeritrocitario en madres y recién nacidos con defectos del tubo neural comparado con un grupo control sano / Folic acid stores in mothers and infants with neural tube defects compared with a healthy control group

Introducción: la prevalencia de los defectos del tubo neural, especialmente la anencefalia, espina bifida y encefalocele, se presentan mayormente en poblaciones que presentan deficiencias nutricionales. Pocos estudios de países en desarrollo han estudiado la relación de los niveles de ácido fólico sérico e intraeritrocitario en la madre y el recién nacido que presenta DTN. El ácido fólico intraeritrocitario es un marcador del depósito celular de este folato...

[Maternal mortality in Central America. The basis for national programs on epidemiologic surveillance]. / Mortalidad materna en Centro America: bases para programas nacionales de vigilancia epidemiologica.

PIP: Although maternal mortality rates worldwide have declined dramatically over the past several decades, maternal mortality rates in developing countries are considered a public health problem. The true rates of maternal mortality are unknown and frequently underestimated. Data from the UN annual demographic report show that only 4 Central American countries met the requirements for publication of their maternal mortality rates. 1984 rates ranged from the high of 75.6/100,000 live births in Guatemala to the low of 22.4/100,000 in Costa Rica. The principal or only source of maternal mortality data in Central American countries is vital statistics reported by official organizations. Difficulties in reporting and collecting this information and the fact that vital statistics were not developed for study of maternal mortality make them a poor source of data. Death certificates do not include the final cause of death. Review of death certificates of fertile-aged women and combining other sources of data such as clinical histories or autopsy reports with the vital statistics are techniques for improving the registration of maternal deaths. A national system of epidemiologic surveillance of maternal mortality has the advantage of obtaining information from multiple sources, including the press, private physicians, midwives, hospital obstetrics and gynecology departments, health centers and posts, family planning clinics, private hospitals, maternal mortality committees, families, and the local and national vital statistics. A national level surveillance program should be recognized as the coordinator of activities in this area, and the systems of data collection, analysis, and use of the results should be easily adaptable, inexpensive, simple, and able to motivate. An outline of steps to be followed in organizing and developing a system of surveillance is included in this work, beginning with establishing the objectives and determining what data are needed and ending with identifying requisites for future development. The data should include the pregnancy outcome, type of delivery, gestational age, type of anesthesia used, medications given before death, and other factors that could have contributed to the death. Since there are no universally accepted scientific definitions or usages for causes or rates of maternal death, each national surveillance program must review and attempt to standardize its definitions. Definitions proposed by the maternal division of the US Centers for Disease Control are discussed in this article, including deaths associated with or related to pregnancy, maternal mortality rates and ratios, and specific mortality rates during pregnancy. Such a national surveillance program can help detect misclassified maternal deaths and clarify risk factors so that national level priorities and strategies can be developed to combat maternal deaths.^ieng

Wanted: better care for pregnant women.

In three prenatal clinics in Latin America the average attendance time by pregnant women was 129 minutes but the average time spent with a doctor was only 8-10 minutes. In order to improve prenatal care, providers should analyse what happens during visits. Assessments should be made of the usefulness of the services offered and some thought should be given as to who might best provide them.

PIP: An evaluation of 3 prenatal care clinics in Mexico City, Panama City, and Caracas was conducted to examine the effect of long waiting times before appointments on a woman's decision to continue attending clinics. The clinic in Mexico City had more patients per day than did those in Panama City and Caracas (136 vs. 64 and 102). The average daily hours of operation were more or less equal (5 hours, 35 minutes to 6 hours, 31 minutes). There was a wide range in the average waiting time in the clinics (71-190 minutes), but the average time with clinic personnel was about the same (17-21 minutes). The average time patients had with physicians was short (8-10 minutes). Women with high-risk pregnancies were in the clinics for 81-147 minutes, with clinic personnel for 23-25 minutes, and with physicians for 11-15 minutes. The only slightly improved times for high-risk pregnancies suggested inadequate prenatal care. 34% and 47% of the time physicians spent at the clinics in Panama City and Caracas, respectively, consisted of 2-7 minute long interviews. Physical examinations generally lasted on average about 1 minute. They included measurement of uterine height, blood pressure, fetal heart rate, and vaginal and ankle edema examinations. These findings can help clinic staff identify major administrative and management problems and find ways to resolve them. The length of time with clinic personnel and physicians is not conducive to a sympathetic and considerate attitude. Health providers should encourage women to ask questions and express their views. All clinic staff should work to make the clinic atmosphere welcoming. These program managers should use evaluations to analyze what happens during prenatal care visits and to assess the value of the services provided. They can also use evaluations to determine who can best provide prenatal care services.

Guatemala: maternal mortality in Guatemala: assessing the gap, beginning to bridge it.

Developing countries which have somewhat reliable vital statistics but poor or incomplete information about maternal mortality must make the most of the data available. Such data may require modification for maternal mortality analyses. What is important, however, is the decision to use available information and to analyse it properly. The analysis of maternal mortality in Guatemala, using data from 1986 birth and death certificates, identified particular areas, health regions, and particular ethnic groups that had significantly higher maternal mortality ratios than others. Small but disproportionately affected populations that had no available maternal health assistance were identified-a problem found in many developing countries. These groups urgently need the services of traditional birth attendants or other forms of assistance before, during and after delivery. The analysis of vital statistics led to the beginning of operative research and the collection of background information for establishing an epidemiologic surveillance programme for maternal mortality.

PIP: Guatemala vital statistics data on maternal mortality from official sources is variable. Generally about 5% of all deaths among women 10-49 years old are attributed to maternal mortality. This analysis of birth and death certificates for 1986 reveals a J-shaped curve for the maternal mortality ratio by age. The indigenous population had higher rates in all departments. The highest maternal mortality ratio (MMR) in 22 departments was in the department of Alta Verapaz (214.2/100,000 live births). The lowest MMR was found in Progreso department. The MMR in 1986 was calculated as 132.5/100,000 live births for Guatemala, or 1 pregnant woman's death every day. Among 8 health regions, the northern health region had the highest MMR (213.3/100,000). The metropolitan region had the lowest MMR (84.9/100,000). Hospital deliveries ranged from 4.7% for the northwest region to 70.7% for the metropolitan region. MMR was found to decrease by about 1/100,000 for every increase in the percentage of hospital-based deliveries, with the exception of the indigenous population, where MMR increased for every 1% increase in hospital-based deliveries. MMR was higher in hospitals for most regions. Births without medical assistance in 6 out of 8 regions had higher MMRs. For example in the northern region MMR for births without assistance was 3539.8/100,000. 5.5% of Guatemalan women had no assistance with deliveries (98 deaths out of 17,532 live births). Physician-attended deliveries had a MMR of 91.5/100,000, and traditional birth attendant-deliveries had a MMR of 96.6/100,000. In 1986 a UN assessment team found registrations reasonably completed, and estimates of registration were determined to be about 90%. Problems in recording may be due to the absence of any reference to a pregnancy on the death certificate, or the absence of the final cause or autopsy findings on the death certificate.

Pregnancy-related mortality in Guatemala, 1993-1996.

To select the proper interventions that could prevent maternal mortality, adequate and appropriate maternal mortality data are needed. Nevertheless, the quality and quantity of information and the scope of maternal health- and death-related data are inadequate in many countries, particularly in the developing world. From January 1993 to December 1996 a surveillance program in maternal mortality was developed to conduct surveillance studies in the department of Guatemala, Guatemala. With an active surveillance system, our approach gave a more complete picture of maternal death and produced information on the specific causes of maternal mortality. Using multiple sources of information, we reviewed and analyzed all deaths of women of childbearing age (10 to 49 years). Each death was investigated to determine whether it was pregnancy-related or not. The maternal mortality ratio for the four-year study period was 156.2 deaths per 100,000 live births. Women 35 and older had a higher risk of maternal death than women under that age. Women who were 35-39 years old had a maternal death risk almost three times as high as women aged 20-24. For women who were 40 or older the risk was more than double that of women 20-24 years old. Overall, the two leading causes of maternal mortality were infection and hemorrhage. Vaginal deliveries where there was medical assistance had the highest rate of delivery-related maternal death from general infection. In deliveries attended by nonmedical personnel, delivery-related maternal deaths from hemorrhage were most frequently associated with retained placenta. Developing countries are called on to implement systems that can provide continuous and systematic data collection so that policymakers and health managers have adequate information to design proper interventions to save women's lives.

Measurement error in clinical perinatal data.

The error measurement of clinical perinatal variables obtained during the standardization and data-collection periods of a large prospective epidemiologic study is presented. The error is considerably larger during the data-collection period, particularly with regard to uterine height, birth weight, and blood pressure values. This information strongly supports the need to continuously supervise and monitor perinatal data collection systems, even after standardization.

Epidemiologic identification of infants with low birth weight in urban areas of Latin America: II. A simplified risk score for early prenatal identification in Guatemala City.

A simple, empirically derived instrument is needed in developing countries to identify mothers at risk of delivering low birth weight (LBW) infants, in order to help reduce the incidence of LBW deliveries and provide mothers at high risk with appropriate health care. The study reported here was devoted to developing an instrument of this kind using data obtained before the twenty-sixth week of gestation from an urban study population of 17,135 Guatemalan women. It appears that this instrument could be appropriately applied to urban populations in other developing countries.

A health priority for developing countries: the prevention of chronic fetal malnutrition.

PIP: A prospective study of 3557 consecutively born neonates from a lower middle class district in Guatemala City documented a 23.8% incidence of intrauterine growth retardation due to fetal malnutrition. Those infants whose weights are below the 10th percentile of a sex- and race-specific birthweight and gestational age distribution, based on a developed country population, were considered to manifest intrauterine growth retardation. Ponderal index values were then used to further classify this population as having chronic fetal malnutrition (above the 10th percentile of the standard distribution) or subacute fetal malnutrition (below the 10th percentile); the incidences of these conditions were 79.1% and 20.8%, respectively. The results of numerous studies carried out in various populations suggest that developing countries have a higher incidence of chronically malnourished infants within the intrauterine growth retardation population, while subacute fetal malnutrition is more prevalent in developed countries. Moreover, it has been shown that chronically malnourished infants do not recover from their intrauterine damage and score the lowest in mental development tests even up to school age. They remain lighter, shorter, and with a smaller head circumference until at least 3 years of age. Based on the incidence rates ascertained in this study, it can be estimated that at least 2 million infants born each year in Latin America are at risk of chronic intrauterine growth retardation. Screening programs are needed to identify at-risk mothers early in pregnancy so that medical and nutritional interventions can be implemented.^ieng

Maternal height and newborn size relative to risk of intrapartum caesarean delivery and perinatal distress.

OBJECTIVE: To estimate the changes, in risk of intrapartum caesalrean delivery and perinatal distress that may be introduced through increased birth size, resulting from interventions such as improving nutrition of the mother; and to characterise delivery risk relative to maternal stature by birth size. DESIGN: Model these risks using data from the Guatemalan Perinatal Study. SETTING: The antenatal clinic of the Gynaecology and Obstetrics Hospital of the Guatemalan Social Security Institute in Guatemala City serving predominantly working class women. POPULATION: Women who had their first prenatal visit between April 1984 and January 1986. METHODS: Multivariate logistic regression models were developed to estimate incidence of intrapartum caesarean delivery and perinatal distress and used to calculate changes in risk associated with changes in size. MAIN OUTCOME MEASURES: Incidences of intrapartum caesarean delivery and perinatal distress. RESULTS: A woman of 146cm height (-1 SD) relative to another of 160 cm (+1 SD) has a 2.5 times higher risk of intrapartum caesarean delivery. An increase in newborn head circumference and weight (from -1 SD to +1 SD) are each independently associated with an increase in risk of intrapartum caesarean delivery (2.0 times and 1.5 times. respectively). An increase in birthweight from 2,450 g to 2,550 g is associated with a decrease in risk of perinatal distress of 34/1,000 cases and an increase in risk of intrapartum caesarean delivery of 8/1,000 cases. CONCLUSIONS: Increases in fetal growth comparable to those attributable to improved nutrition during pregnancy are associated with a larger decrease in risk of perinatal distress relative to the increase in risk of intrapartum caesarean delivery for the mother. Greater maternal stature is associated with lower risk of intrapartum caesarean delivery.

Perinatal data reliability in a large teaching obstetric unit.

In this inter-rater agreement study of antenatal and neonatal variables collected in a large teaching obstetric unit, information routinely collected by hospital staff was compared with that collected by a specially trained physician and a social worker. Agreement between the two sources of data was evaluated using kappa statistics and intraclass correlation coefficients. Excellent agreement was observed for some variables such as maternal and newborn anthropometric measures, and previous birthweight, but there was poor agreement for others such as indicators of physical activity, work during pregnancy and blood pressure measures. Some of the limitations are due to problems in phrasing questions, patients' recall, interviewer bias and abstracting data. We recommend that epidemiological studies should always include a reliability component, proper standardization of personnel and instruments and include, when published, validity data and examples of questions used.

[Identification of pregnant patients at risk of delivering low birthweight infants in urban areas of Guatemala]. / Identificacion de embarazos con riesgo de producir ninos de bajo peso al nacer en areas urbanas de Guatemala.

PIP: A prospective epidemiologic study of pregnant women obtaining prenatal care at a social security hospital in Guatemala City was the basis for an attempt to develop a method of identifying early in pregnancy women at risk of having low birth weight infants. Existing classifications of risk are not completely satisfactory for low income women in urban areas of developing countries. The sample included 17,135 women seen between April 1984 and January 1986. Women who had no prenatal care or who obtained it elsewhere were excluded. Social workers interviewed each woman at the 1st prenatal visit to obtain sociodemographic data. The nurses or physicians attending the women completed forms based on perinatal records developed by the Latin American Center for Perinatology and Human Development and adapted to local needs. A final visit was made just after delivery to complete the information in each file. Great care was taken to assure that the 24 examiners used the same standards for all measurement variables. The standardized data collection techniques were evaluated in a study of agreement between observers. The study was conducted in 4 sections covering sociodemographic variables, obstetric history, prenatal variables, and labor and delivery. Taking into account the size of the sample and the number of observers, it was concluded that the data were of acceptable quality. It is strongly recommended that periodic evaluation of the quality of data collected be included in all perinatal epidemiologic studies. It was also concluded that longitudinal studies of perinatal risk factors might not be needed in all regions or health areas; the association between the best known risk factors and the evolution of pregnancy has been established, and with few exceptions it appears to be relatively constant in all populations. It is recommended that perinatal services reduce the amount of data routinely collected to a minimum and apply the quality control and standardization procedures to a sample of patients and to all personnel completing records. This would assure an acceptable quality of data as a basis for medical or public health decision making. Relevant additional variables could be added as needed^ieng

Effect of fat and fat-free mass deposition during pregnancy on birth weight.

OBJECTIVES: The purposes of our study were to describe the patterns and location of fat and fat-free mass deposition during pregnancy and to evaluate their effects on fetal growth. STUDY DESIGN: Our study is a prospective follow-up of 105 healthy pregnant women who were delivered of term infants. Body composition was evaluated eight times during gestation with anthropometric measures and bioimpedance techniques. Body fat and fat-free mass were calculated with equations specifically developed for this population. RESULTS: Total weight gain was 10.0 +/- 3.5 kg; net weight gain was 3.7 +/- 0.31 kg; birth weight was 3211 +/- 467 gm (values are mean +/- SEM). In these women fat was deposited mostly in the thigh and subscapular region for a total of 6.23 +/- 0.19 kg at term. The period of pregnancy of the largest maternal fat deposition per week is between the twentieth and thirtieth weeks. After adjusting by prepregnancy weight, birth weight is associated with maternal changes in thigh skin folds and fat gain before the thirtieth week of gestation. Infants born to mothers with low fat gain before the thirtieth week were 204 gm lighter than infants born to mothers with fat gain > or = 25th percentile of this population. CONCLUSION: Maternal nutritional status at the beginning of gestation and the rate of fat gain early in pregnancy are the two nutritional indicators most strongly associated with fetal growth in this population.

The effect of maternal work on fetal growth and duration of pregnancy: a prospective study.

The effect on birth outcome of work requiring different degrees of physical exertion was examined among 15,786 pregnant women who were followed through the Guatemalan Social Security Institute's hospital. Work inside and outside the home was ascertained through a questionnaire administered to each women before delivery. Odds ratios were adjusted for household income, maternal height and age, and birthweight of previous infant. Women with three or more children and no household help were at increased risk for small-for-gestational-age (SGA) births compared with women with family (odds ratio (OR) 1.79; 95% confidence interval (CI) 1.31, 2.47) or hired help (OR 2.0; 95% CI 1.16 to 3.33). Compared with office work, manual work increased the risk for an SGA (OR 1.32; 95% CI 1.12 to 1.56) and SGA/preterm birth (OR 2.56; 95% CI 1.10 to 5.96). Work in a standing compared with sitting position significantly increased the risk for a preterm birth (OR 1.56; 95% CI 1.04 to 2.60). There was a significant positive trend in frequency of SGA and SGA/preterm birth with an increase in the physical demands at work, as measured by an activity score. These data suggest that interventions to reduce physical exertion among pregnant women could improve birth outcome.

The differential neonatal morbidity of the intrauterine growth retardation syndrome.

This is a prospective study of differential morbidity among subgroups of intrauterine growth retardation. Cases of intrauterine growth retardation (N = 3450) (greater than or equal to 37 weeks, less than 10th percentile birth weight for gestational age) were classified by their ponderal index (weight/length3) in four subgroups using the 10th, 25th, and 90th percentiles of the Lubchenco's ponderal index-gestational age distribution. There were 432 cases (12.5%) with low ponderal index or disproportionate intrauterine growth retardation, 936 (27.1%) with intermediate ponderal index, 2030 (58.8%) with adequate ponderal index or proportionate intrauterine growth retardation, and 52 (1.5%) with high ponderal index. The low ponderal index group or disproportionate intrauterine growth retardation group had a statistically significant higher risk (between 1.6 and 12.5 times) for low 1- and 5-minute Apgar scores, aspiration syndrome, hypoglycemia, and perinatal asphyxia than the adequate ponderal index group. The low ponderal index group also had an increased risk (relative risk = 2.0 [95% confidence interval, 1.0 to 3.8]) for hospital stay of more than 1 week. These differences persist after a stratified analysis by birth weight and in a multiple logistic regression analysis. Similarly, higher neonatal morbidity is observed among infants with normal birth weights but with low ponderal index. These data provide further evidence of the heterogeneity of the intrauterine growth retardation syndrome and of the independent effect of body disproportion on neonatal morbidity, even among infants with normal birth weights. Because there are significant clinical implications attributed to the low ponderal index group, this subgroup should be identified as early as possible.

Epidemiologic identification of infants with low birth weight in urban areas of Latin America:: II A simplified risk score for early prenatal

A simple, empirically derived instrument is needed in developing countries to identify mothers at risk of delivering low birth weight (LBW) infants, in order to help reduce the incidence of LBW deliveries and provide mothers at high risk with appropriate health care. The study reported here was devoted to developing an instrument of this kind using data obtained before the twenty-sixth week of gestation from an urban study population of 17,135 Guatemalan women. It appears that this instrument could be appropriately applied to urban populations in other developing countries

Identificación de embarazos de alto riesgo de bajo peso al nacer en zonas urbanas de América Latina: II. Indice simplificado de detección precoz en la Ciudad de Guatemala / Epidemiologic identification of infants with low birth weight in urban areas of Latin America: II. A simplified risk score for early prenatal identification in an urban area of Guatemala City

En los países en desarrollo hace falta un instrumento empírico sencillo para identificar a embarazadas en alto riesgo de dar a luz un hijo de bajo peso. Tal instrumento ayudaría a reducir la incidencia de bajo peso al nacer, ya que permitiría brindar a estas madres cuidados prenatales apropiados. El propósito del presente estudio fue crear un instrumento de este tipo a partir de datos obtenidos antes de la 26a. semana de gestación en una población compuesta de 17 135 embarazadas de la Ciudad de Guatemala. El instrumento al parecer, podría servir para detectar el riesgo de bajo peso al nacer en las poblaciones urbanas de otros países en desarrollo