Stillbirth risk by fetal size among 126.5 million births in 15 countries from 2000 to 2020: A fetuses-at-risk approach.

OBJECTIVE: To compare stillbirth rates and risks for small for gestational age (SGA), large for gestational age (LGA) and appropriate for gestational age (AGA) pregnancies at 24-44 completed weeks of gestation using a birth-based and fetuses-at-risk approachs. DESIGN: Population-based, multi-country study. SETTING: National data systems in 15 high- and middle-income countries. POPULATION: Live births and stillbirths. METHODS: A total of 151 country-years of data, including 126 543 070 births across 15 countries from 2000 to 2020, were compiled. Births were categorised into SGA, AGA and LGA using INTERGROWTH-21st standards. Gestation-specific stillbirth rates, with total births as the denominator, and gestation-specific stillbirth risks, with fetuses still in utero as the denominator, were calculated from 24 to 44 weeks of gestation. MAIN OUTCOME MEASURES: Gestation-specific stillbirth rates and risks according to size at birth. RESULTS: The overall stillbirth rate was 4.22 per 1000 total births (95% CI 4.22-4.23) across all gestations. Applying the birth-based approach, the stillbirth rates were highest at 24 weeks of gestation, with 621.6 per 1000 total births (95% CI 620.9-622.2) for SGA pregnancies, 298.4 per 1000 total births (95% CI 298.1-298.7) for AGA pregnancies and 338.5 per 1000 total births (95% CI 337.9-339.0) for LGA pregnancies. Applying the fetuses-at-risk approach, the gestation-specific stillbirth risk was highest for SGA pregnancies (1.3-1.4 per 1000 fetuses at risk) prior to 29 weeks of gestation. The risk remained stable between 30 and 34 weeks of gestation, and then increased gradually from 35 weeks of gestation to the highest rate of 8.4 per 1000 fetuses at risk (95% CI 8.3-8.4) at ≥42 weeks of gestation. The stillbirth risk ratio (RR) was consistently high for SGA compared with AGA pregnancies, with the highest RR observed at ≥42 weeks of gestation (RR 9.2, 95% CI 15.2-13.2), and with the lowest RR observed at 24 weeks of gestation (RR 3.1, 95% CI 1.9-4.3). The stillbirth RR was also consistently high for SGA compared with AGA pregnancies across all countries, with national variability ranging from RR 0.70 (95% CI 0.43-0.97) in Mexico to RR 8.6 (95% CI 8.1-9.1) in Uruguay. No increased risk for LGA pregnancies was observed. CONCLUSIONS: Small for gestational age (SGA) was strongly associated with stillbirth risk in this study based on high-quality data from high- and middle-income countries. The highest RRs were seen in preterm gestations, with two-thirds of the stillbirths born as preterm births. To advance our understanding of stillbirth, further analyses should be conducted using high-quality data sets from low-income settings, particularly those with relatively high rates of SGA.

Stillbirths: Contribution of preterm birth and size-for-gestational age for 125.4 million total births from nationwide records in 13 countries, 2000-2020.

OBJECTIVE: To examine the contribution of preterm birth and size-for-gestational age in stillbirths using six 'newborn types'. DESIGN: Population-based multi-country analyses. SETTING: Births collected through routine data systems in 13 countries. SAMPLE: 125 419 255 total births from 22+0 to 44+6 weeks' gestation identified from 2000 to 2020. METHODS: We included 635 107 stillbirths from 22+0 weeks' gestation from 13 countries. We classified all births, including stillbirths, into six 'newborn types' based on gestational age information (preterm, PT, <37+0 weeks versus term, T, ≥37+0 weeks) and size-for-gestational age defined as small (SGA, <10th centile), appropriate (AGA, 10th-90th centiles) or large (LGA, >90th centile) for gestational age, according to the international newborn size for gestational age and sex INTERGROWTH-21st standards. MAIN OUTCOME MEASURES: Distribution of stillbirths, stillbirth rates and rate ratios according to six newborn types. RESULTS: 635 107 (0.5%) of the 125 419 255 total births resulted in stillbirth after 22+0 weeks. Most stillbirths (74.3%) were preterm. Around 21.2% were SGA types (PT + SGA [16.2%], PT + AGA [48.3%], T + SGA [5.0%]) and 14.1% were LGA types (PT + LGA [9.9%], T + LGA [4.2%]). The median rate ratio (RR) for stillbirth was highest in PT + SGA babies (RR 81.1, interquartile range [IQR], 68.8-118.8) followed by PT + AGA (RR 25.0, IQR, 20.0-34.3), PT + LGA (RR 25.9, IQR, 13.8-28.7) and T + SGA (RR 5.6, IQR, 5.1-6.0) compared with T + AGA. Stillbirth rate ratios were similar for T + LGA versus T + AGA (RR 0.7, IQR, 0.7-1.1). At the population level, 25% of stillbirths were attributable to small-for-gestational-age. CONCLUSIONS: In these high-quality data from high/middle income countries, almost three-quarters of stillbirths were born preterm and a fifth small-for-gestational age, with the highest stillbirth rates associated with the coexistence of preterm and SGA. Further analyses are needed to better understand patterns of gestation-specific risk in these populations, as well as patterns in lower-income contexts, especially those with higher rates of intrapartum stillbirth and SGA.

Neonatal mortality risk for vulnerable newborn types in 15 countries using 125.5 million nationwide birth outcome records, 2000-2020.

OBJECTIVE: To compare neonatal mortality associated with six novel vulnerable newborn types in 125.5 million live births across 15 countries, 2000-2020. DESIGN: Population-based, multi-country study. SETTING: National data systems in 15 middle- and high-income countries. METHODS: We used individual-level data sets identified for the Vulnerable Newborn Measurement Collaboration. We examined the contribution to neonatal mortality of six newborn types combining gestational age (preterm [PT] versus term [T]) and size-for-gestational age (small [SGA], <10th centile, appropriate [AGA], 10th-90th centile or large [LGA], >90th centile) according to INTERGROWTH-21st newborn standards. Newborn babies with PT or SGA were defined as small and T + LGA was considered as large. We calculated risk ratios (RRs) and population attributable risks (PAR%) for the six newborn types. MAIN OUTCOME MEASURES: Mortality of six newborn types. RESULTS: Of 125.5 million live births analysed, risk ratios were highest among PT + SGA (median 67.2, interquartile range [IQR] 45.6-73.9), PT + AGA (median 34.3, IQR 23.9-37.5) and PT + LGA (median 28.3, IQR 18.4-32.3). At the population level, PT + AGA was the greatest contributor to newborn mortality (median PAR% 53.7, IQR 44.5-54.9). Mortality risk was highest among newborns born before 28 weeks (median RR 279.5, IQR 234.2-388.5) compared with babies born between 37 and 42 completed weeks or with a birthweight less than 1000 g (median RR 282.8, IQR 194.7-342.8) compared with those between 2500 g and 4000 g as a reference group. CONCLUSION: Preterm newborn types were the most vulnerable, and associated with the highest mortality, particularly with co-existence of preterm and SGA. As PT + AGA is more prevalent, it is responsible for the greatest burden of neonatal deaths at population level.

Changes in Resources and Volunteering: A Longitudinal Study of Active Engagement Among Older Europeans.

BACKGROUND AND OBJECTIVES: Volunteering is an important dimension of successful aging. Although prior studies have found that personal resources such as health and financial situations are associated with volunteering, there is a lack of research exploring the relationship between resource changes and volunteering. Here, we investigated whether changes in individuals' resources were associated with volunteer engagement among older Europeans. RESEARCH DESIGN AND METHODS: Using data from the Survey of Health, Aging, and Retirement in Europe, collected in five waves between 2011 and 2020 across 19 countries (57,410 observations from 17,498 individuals aged 50 and above), we employed asymmetric fixed-effect ordinal regression models to investigate whether positive or negative resource changes were associated with the frequency of volunteering over time. We used three resource indicators: health, financial condition, and time availability (measured by engagement in paid work, grandparenting, and family care). RESULTS: Health deterioration and worsening financial condition were associated with a decreased frequency of volunteering. A transition out of weekly paid work and beginning to provide weekly grandchild care were both associated with an increased frequency of volunteering. We did not detect any further significant effects of resource changes on volunteering. DISCUSSION AND IMPLICATIONS: Our study revealed asymmetrical associations between changes in resources and volunteering, providing new insights into their interplay. The results deepen our understanding of successful aging by emphasizing the need to consider the dynamics of all resources that either facilitate or hinder active engagements among older adults.

Comparing the cognitive functioning of middle-aged and older foreign-origin population in Estonia to host and origin populations.

Background: In migration and health research, the healthy migrant effect has been a common finding, but it usually pertains to specific contexts only. Existing findings are inconsistent and inconclusive regarding the cognitive functioning of the (aging) foreign-origin population relative to the populations of their host and sending countries. Moreover, this comparison is an understudied design setting. Objective: We analyze the outcomes and associations of cognitive functioning outcomes of the non-institutionalized middle-aged and older population, comparing the Russian-origin population in Estonia with Estonians in Estonia and Russians in Russia in a cross-sectional design. We aim to estimate the (long-term) effects of migration on cognitive functioning in later life, contextualizing the findings in previous research on the healthy migrant effect. Data and methods: We use data from face-to-face interviews conducted within the SHARE Estonia (2010-2011) and SAGE Russia (2007-2010) surveys. Respondents aged 50+ living in urban areas were grouped by self-identified ethnicity, including 2,365 Estonians, 1,373 Russians in Estonia, and 2,339 Russians in Russia (total N = 6,077). Cognitive functioning was measured using a 25-percentile cut-off threshold for the results of two cognition outcomes - immediate recall and verbal fluency - and the odds of impairment were estimated using binary logistic regression. Results: Russian men and women living in Estonia have significantly higher odds of impairment in immediate recall than Estonian men and women, though they do not differ from Russians in Russia in the final adjusted models. The differences between all groups are non-significant if age at migration is considered. There are no significant differences between the groups in verbal fluency. Conclusion: Contrary to the commonly found healthy migrant effect, the middle-aged and older foreign-origin population in Estonia fares initially worse than the native population in the immediate recall outcome, but does not differ from their sending country population, possibly due to Russia's higher mortality rate and therefore the selective survival of healthier people. Different results depending on the cognitive functioning outcome suggest that migration may affect temporary memory more than crystallized knowledge. However, there are no differences between the groups if defined based on age at migration, which suggests that the age profile differences explain most of the groups' differences in cognitive functioning.

Factors associated with incidence of depressiveness among the middle-aged and older Estonian population.

OBJECTIVE: Relatively scant research among older Estonian population describes factors associated with the incidence of depressive symptoms. This study identifies factors associated with the incidence of depressiveness among middle-aged and older Estonians over 2- and 4-year periods. METHOD: In this cross-sectional analysis, logistic regression models are used to identify the factors associated with the incidence of depressiveness over 2- and 4-year periods. The data were drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE) 2011-2015 which included Estonian population aged 53 years and older in 2013. After excluding those younger than 53 years, not interviewed 2 years later, those with depressive symptoms at baseline in 2013, and missing values for depressiveness or other variables, our analytical sample comprised 2513 people. RESULTS: Among those who were not depressive in 2013, 21.9% became depressive within 2 years; 16.1% of non-depressive individuals since 2011 became depressive by 2015. No age differences in incidence remained in adjusted models. Women have almost 50% higher odds of becoming depressive. A previous history of depressiveness and the presence of everyday activity limitations were important factors increasing the incidence of depression. DISCUSSION: Changes related to the individual's unique ageing experience are important explanatory factors related to the likelihood of developing depressive symptoms, rather than age itself. To diminish the incidence of depressive symptoms among older Estonian population, public health interventions should attempt to address factors which complicate existing health problems and facilitate continued independence and community involvement, both of which contribute to overall satisfaction with life.

Associations between self-rated health and health behaviour among older adults in Estonia: a cross-sectional analysis.

OBJECTIVES: The population of Estonia has one of the lowest life expectancies and health statuses in Europe. This is reflected in a lower perception of health among older adults. This study focuses on the role of health behaviour (smoking, alcohol consumption, physical activity and nutrition) in self-rated health, accounting for sociodemographic characteristics, activity limitations and long-term illnesses as well as satisfaction with life of older Estonian men and women. DESIGN: We use representative cross-sectional data from Wave 4 of the Estonian Survey of Health, Ageing and Retirement in Europe, conducted mainly in 2011. PARTICIPANTS: Frequencies, χ2 tests and logistic regression models include respondents aged 50 years and older, with no upper age limit (n=6660). RESULTS: Men have 20% higher odds (CI 1.02 to 1.43) of poor self-rated health. Being of foreign origin (OR 1.48; CI 1.24 to 1.77), having a basic (2.50; CI 2.06 to 3.00) or secondary (1.71; CI 1.43 to 2.04) education, being retired (2.00; CI 1.65 to 2.44) or staying at home (1.49; CI 1.16 to 1.93) and having activity limitations (3.25; CI 2.77 to 3.80) or long-term illnesses (4.78; CI 4.08 to 5.60) are related to poor self-rated health. Never being involved in vigorous (2.30; CI 1.90 to 2.79) or moderate physical activity (1.41; CI 1.02 to 1.94), and consuming legumes and eggs less frequently (1.25; CI 1.08 to 1.45) is associated with poorer self-rated health. Lower satisfaction with life accounts for some of the variation (2.28; CI 1.92 to 2.71). CONCLUSIONS: There is a strong cumulative effect of one's previous life course on the self-rated health of older adults in Estonia, suggesting that public health policies have long-term consequences rather than immediate consequences. Health services supporting health behaviours and targeting vulnerable population groups with specific sociodemographic characteristics and health problems may influence self-rated health for some. Public health services emphasising social activities or psychological aspects may be most successful in improving self-rated health of older Estonians through satisfaction with life.