Risk factors for stunting and wasting at age six, twelve and twenty-four months for squatter children of Karachi, Pakistan.

OBJECTIVE: A high proportion of stunting and wasting in children under-five has been reported from developing countries. This paper presents the nutritional status of a two year cohort of urban squatter children in Karachi, Pakistan and assesses risk factors for wasting and stunting at the reference ages of six, twelve and twenty-four months. METHODS: A birth cohort of 738 children were visited at specific intervals by trained nurses to collect information on anthropometric measurements, feeding practices and intercurrent illnesses. Socioeconomic and demographic information included water and sanitation facilities, availability of electricity, type of house construction material and average monthly income. Information about the mother's reproductive history was also obtained. RESULTS: At two years the proportion of stunting and wasting was 41.8% and 10.6% respectively. Intrauterine growth retarded children had a higher risk of stunting and wasting at all reference ages as compared to children who were appropriate for gestational age. In the logistic regression models, intrauterine growth retardation was the only significant risk factor that remained in all models at each reference age. CONCLUSION: The consistent association of IUGR for stunting and wasting adds to the growing body of evidence that by improving maternal health we will ultimately break the vicious cycle of malnourishment and improve the health and well-being of future generations. We suggest interventions to improve the nutritional status of Pakistani urban children living in squatter settlements focused on mothers and children.

The role of son preference in reproductive behaviour in Pakistan.

The sex of surviving children is an important determinant of reproductive behaviour in South Asia in general and Pakistan in particular. This cohort study evaluates the role of the sex of children on reproductive intentions and subsequent behaviour of women in urban slums of Karachi, Pakistan. The analysis is based on two rounds of surveys conducted in 1990-91 and 1995 of a cohort of married women aged 15-49 years. The results show that pregnancies became increasingly unwanted as the number of surviving sons increased. The sex of surviving children was strongly correlated with subsequent fertility and contraceptive behaviour. However, rather than an exclusive son preference, couples strove for one or more sons and at least one surviving daughter. The policy implications of the link between overt son preference and low status of women are discussed.

Serial levels of serum organochlorines during pregnancy and postpartum.

In utero exposure to dichlorodiphenyldichloroethene and polychlorinated biphenyls, within the range found in the general U.S. population, may produce detectable effects in offspring. To design studies of the effects of in utero organochlorine exposure, we obtained data on the relationship between gestational and perinatal maternal levels in females on several occasions. We studied 67 pregnant women in the United States who agreed to have their blood drawn once during each trimester and once postpartum. We examined the Pearson correlation coefficient between the natural logarithm of levels (microg/g serum lipid). The correlation, r, among levels in the first and third trimester was .86 and .77 for dichlorodiphenyldichloroethene and for polychlorinated biphenyls. Correlations among levels determined at other times (i.e., second trimester and postpartum) were similar. On the basis of these results, we suggest that in studies of the effects of in utero or perinatal exposure to the aforementioned compounds, the time when specimens are collected is not critical.

Role of intrauterine growth retardation on physical growth of Pakistani squatter children from birth to 2 years of age.

A birth cohort of 727 squatter children from Karachi was followed to study growth patterns by measuring anthropometric parameters at specific ages during the first 2 years of life. The mean weight and length of the intrauterine growth retarded and appropriate for gestational age children fell below the 10th percentile of the NCHS standards after 9 months and further deteriorated in the subsequent study period. However, the intrauterine growth retarded children showed slightly higher growth velocities compared to appropriate for gestational age children in the first few months for all four measurements, but subsequently these differences in growth velocities diminished. Our results suggest that nutrition intervention strategies should begin in early pregnancy.

Infant injury deaths with unknown intent: what else do we know?

OBJECTIVES: Strong evidence based on case record reviews indicates that the incidence of child homicide reported from death certificates is under ascertained. The characteristics of infant injury fatalities with undetermined, but suspicious, intent were compared for the probability that they should be considered homicides. METHODS: Using linked birth and death certificates for all birth cohorts in the US from 1983-91, 2345 injury fatalities reported as intentional, 7594 as unintentional, and 431 as undetermined intent were identified. Maternal and infant variables potentially predictive of injury fatalities were selected based on increased bivariate associations. Relative risks of injury death by intentional, unintentional, and undetermined intent were assessed for maternal and infant characteristics. RESULTS: Relative risks were consistently higher across all intent categories for infants of mothers with the least education, no prenatal care, young maternal age, and single marital status, as well as for infants who are second or later born, preterm, black, or American Indian. Fatalities with undetermined intent have larger relative risks in the highest risk categories than either intentional or unintentional injuries. Deaths with undetermined intent have risk profiles that more closely resemble profiles for intentional deaths than unintentional. CONCLUSIONS: Injury homicide rates would be almost 20% greater than official classifications indicate if deaths with undetermined intent were included. In analyses of infant homicide, excluding deaths of undetermined intent may lead to an underestimation of the magnitude of the public health problem of intentional injuries among infants. Other studies based on record reviews from multiple sources indicate that misclassification and under ascertainment of homicides may be even greater.

Risk factors for infant homicide in the United States.

BACKGROUND: Homicide is the leading cause of infant deaths due to injury. More than 80 percent of infant homicides are considered to be fatal child abuse. This study assessed the timing of deaths and risk factors for infant homicide. METHODS: Using linked birth and death certificates for all births in the U.S. between 1983 and 1991, we identified 2776 homicides occurring during the first year of life. Birth-certificate variables were reviewed in both bivariate and multivariate stratified analyses. Variables potentially predictive of homicide were selected on the basis of increased relative risks among subcategories with adequate numbers for stable estimates. RESULTS: Half the homicides occurred by the fourth month of life. The most important risk factors were a second or subsequent infant born to a mother less than 17 years old (relative risk, 10.9) or 17 to 19 years old (relative risk, 9.3), as compared with a first infant born to a mother 25 years old or older; a maternal age of less than 15 years, as compared with an age of at least 25 years (relative risk, 6.8); no prenatal care as compared with early prenatal care (relative risk, 10.4); and less than 12 years of education among mothers who were at least 17 years old (relative risk, 8.0), as compared with 16 or more years of education. CONCLUSIONS: Childbearing at an early age was strongly associated with infant homicide, particularly if the mother had given birth previously. Our findings may have implications for prevention.

Prevalence and predictors of the prone sleep position among inner-city infants.

CONTEXT: The prone sleep position is associated with an increased risk of sudden infant death syndrome (SIDS), but few studies have assessed factors associated with the choice of infant sleep position. OBJECTIVES: To describe infant sleep position in a cohort of infants born to predominantly low-income, inner-city mothers and to identify predictors of the prone sleep position in this population. DESIGN: Prospective birth cohort study. PATIENTS AND SETTING: Three hundred ninety-four mother-infant dyads, systematically selected from 3 District of Columbia hospitals between August 1995 and September 1996. Mothers were interviewed shortly after delivery and again at 3 to 7 months postpartum. MAIN OUTCOME MEASURES: Position in which infants were placed for sleep on the night prior to the 3- to 7-month interview. RESULTS: At 3 to 7 months of age, 157 infants (40%) were placed for sleep in the prone position. Independent predictors of prone sleep position included poverty (odds ratio [OR], 1.81; 95% confidence interval [CI], 1.10-2.99), black race (OR, 2.06; 95% CI, 1.05-4.04), presence of infant's grandmother in the home (OR, 1.83; 95% CI, 1.11-3.00), and intent, as measured shortly after delivery, to place the infant in the prone position (OR, 2.28; 95% CI, 1.44-3.60). Importantly, of the 43 mothers who observed their infants in the prone sleep position while in the hospital, 40 (93%) intended to place their infants prone at home. CONCLUSIONS: A substantial proportion of infants in this predominantly low-income population were placed in the prone sleep position. Educational efforts should address both initial intentions and reinforcement of the correct sleep position, once initiated. Hospitals should ensure that healthy newborn infants are placed in the supine sleep position during the postpartum hospital stay.

Contextual determinants of maternal mortality in rural Pakistan.

Maternal mortality is high in Pakistan, particularly in the rural areas which have poor access to health services. We investigated the risk factors associated with maternal mortality in sixteen rural districts of Balochistan and the North-West Frontier (NWFP) provinces of Pakistan. We designed a nested case-control study comprising 261 cases (maternal deaths reported during last five years) and 9135 controls (women who survived a pregnancy during last five years). Using contextual analysis, we estimated the interactions between the biological risk factors of maternal mortality and the district-level indicators of health services. Women under 19 or over 39 yr of age, those having their first birth, and those having a previous history of fetal loss were at greater risk of maternal death. Staffing patterns of peripheral health facilities in the district and accessibility of essential obstetric care (EOC) were significantly associated with maternal mortality. These indicators also modified the effects of the biological risk factors of maternal mortality. For example, nulliparous women living in the under-served districts were at greater risk than those living in the better-served districts. Our results are consistent with several studies which have pointed out the role of health services in the causation of maternal mortality. Many such studies have implicated distance to hospital (an indicator of access to EOC) and lack of prenatal care as major determinants of maternal mortality. We conclude that better staffing of peripheral health facilities and improved access to EOC could reduce the risk of maternal mortality among women in rural Balochistan and the NWFP.

Maternal mortality in different Pakistani sites: ratios, clinical causes and determinants.

BACKGROUND: Population-based estimates of maternal mortality from Pakistan are inadequate to define the magnitude of the problem or provide information on clinical causes and determinants. METHODS: Surveys were conducted in selected clusters in Karachi, Balochistan and North West Frontier Province from 1989-1992. Pre-coded questionnaires were administered to 38,563 households to ascertain household characteristics, complete pregnancy histories and deaths of household members in the five years preceding the survey. Verbal autopsy questionnaires were then conducted to establish cause of death to women in the reproductive age group. Descriptive, bivariate and multivariable analyses were carried out to determine the association between the background variables, biological and women's status indicators and maternal mortality using a nested case-control design. RESULTS: Overall, the estimated maternal mortality ratio combining the data from the different sites was 433 per 100,000 livebirths. The estimated maternal mortality ratios per 100,000 livebirths ranged from a low of 281 in Karachi to a high of 673 in Khuzdar [Balochistan]. Hemorrhage (52.9%), puerperal sepsis (16.3%) and eclampsia (14.4%) were the leading causes for direct maternal deaths. Logistic regression identified the important risk factors as poor housing construction material (OR = 2.1; 95% CI = 1.3,3.2), distance of 40 or more miles from nearest hospital (OR = 1.3; 95% CI = 0.9,1.8), grandmultigravidity (OR = 1.6; 95% CI = 1.1,2.4) and prior fetal losses (OR = 5.3; 95% CI = 3.8,7.4). CONCLUSION: Focusing on special groups of pregnant women with targeted programs such as training, monitoring and supervision of birth attendants for the provision of oxytocics, will go a long way in decreasing the proportion of maternal deaths attributed to direct, avoidable causes.

PIP: To determine the magnitude of and factors associated with maternal mortality in Pakistan, population-based surveys were conducted in selected clusters in Karachi, Balochistan, and North West Frontier Provinces during 1989-92. Questionnaires were administered to 38,563 households and verbal autopsy questionnaires were conducted when a maternal death was reported. The overall maternal mortality ratio was 433 per 100,000 live births, with a range from 281 in Karachi to 673 in Balochistan. The leading causes of death were hemorrhage (52.9%), puerperal sepsis (16.3%), and eclampsia (14.4%). Overall, the majority of maternal deaths occurred among women 20-35 years of age with 2-7 children. According to logistic regression analysis, the primary risk factors for maternal mortality were poor housing construction material (odds ratio (OR), 2.1; 95% confidence interval (CI), 1.3-3.2), distance of 40 miles or more from the nearest hospital (OR, 1.3; 95% CI, 0.9-1.8), grandmultigravidae (OR, 1.6; 95% CI, 1.1-2.4), and prior fetal losses (OR, 5.3; 95% CI, 3.8-7.4). These findings indicate a need to focus on special groups of pregnant women, especially those with a poor obstetric history and disadvantaged socioeconomic status, to decrease the high rate of maternal mortality in Pakistan.

Maternal anthropometry and infant feeding practices in Israel in relation to growth in infancy: the North African Infant Feeding Study.

Relations between maternal anthropometric status during pregnancy and infant feeding practices and growth from birth through the first 6 mo of life were examined in a cohort of 351 Israeli mother-infant pairs of North African descent. Maternal weight, height, and triceps skinfold thicknesses were determined at 6 and 9 mo of pregnancy, while infants' weights and lengths were measured at birth and at 1, 2, 3, and 6 mo of age with concurrent collection of age-specific maternal-reported infant feeding data. On the basis of multiple-linear-regression analysis that adjusted for potential covariates, mean maternal weight at the first prenatal visit and at 6 and 9 mo of pregnancy were positively associated with birth length (P for trend in all cases < 0.0001) and with linear growth between birth and 1, 3, and 6 mo of age. Maternal skinfold thickness at 9 mo of pregnancy and maternal height were also significantly associated with birth length. Moreover, maternal height, weight, and skinfold thickness at 6 and 9 mo of pregnancy were positively associated with mean birth weight. After adjustment for morbidity in the past month and other covariates, infants breast-fed exclusively had greater attained weight and weight gain in the first 3 mo compared with infants who were bottle-fed exclusively, breast-fed and bottle-fed, or solid-fed exclusively. These findings underscore the need for programs that improve the nutritional status of women before, during, and after pregnancy, and encourage exclusive breast-feeding of infants for at least the first 3 mo of life.

PIP: The associations between maternal anthropometric measures during pregnancy and infant feeding practices and growth in the first 6 months of life were investigated in a cohort of 351 mother-infant pairs of North African (Morocco, Tunisia, Algeria, or Libya) descent but currently residing in Israel's Negev region. Mean maternal weight at the first prenatal visit and at 6 and 9 months of pregnancy was significantly and positively associated with birth length and with linear growth between birth and 1, 3, and 6 months of age. Maternal skinfold thickness at 9 months of pregnancy and maternal height also were significantly associated with birth length, while maternal height, weight, and skinfold thickness at 6 and 9 months of pregnancy were positively associated with mean birth weight. The rate of exclusive breast feeding declined from 34% at 1 month to 18% at 2 months to 6% at 3 months. After adjustment for covariates such as morbidity in the preceding month, maternal anthropometric status, and socioeconomic factors, infants who were exclusively breast-fed had greater attained weight and weight gain in the first 3 months of life than their counterparts who were exclusively bottle-fed, breast- and bottle-fed, or solid-fed. These findings underscore the importance of programs that improve the nutritional status of women before, during, and after pregnancy and promote exclusive breast feeding for at least the first 3 months.

Evaluation of the effectiveness of a community-based enriched model prenatal intervention project in the District of Columbia.

OBJECTIVE: To evaluate an enriched prenatal intervention program designed to reduce the risk of low birth weight. STUDY SETTING: Freestanding community-based prenatal intervention project located in a poor inner-city community, serving mostly African American women. STUDY DESIGN: All women less than 29 weeks pregnant were eligible to participate. They were compared to women who lived in neighborhoods with similar rates of poverty. DATA COLLECTION: The birth certificate was the source of data on maternal age, education, marital status, timing and frequency of prenatal care attendance, parity, gravidity, prior pregnancy terminations, fetal and child deaths, and birth weight. PRINCIPAL FINDINGS: Thirty-eight percent of the women who delivered live-born infants in the study area participated in the program. There were no differences in low- and very low birthweight rates in the study and comparison groups. In a secondary analysis comparing participants and nonparticipants in the study census tracts, participants were at higher risk for low and very low birth weight, and they adhered more closely to the schedule of prenatal visits than nonparticipants. Low- and very low birthweight rates were lower among participants than among nonparticipants and comparison women. CONCLUSION: The Better Babies Project did not have an effect on the overall low- and very low birthweight rates in the study census tracts. This was probably due to the low participation rates and the high population mobility.

A rapid community based health evaluation of pregnant women in low socioeconomic settlements of Karachi.

A rapid nutritional and health evaluation of a random sample of 163 pregnant women was conducted in low socioeconomic settlements of Karachi, with the objective of determining the morbidity and nutritional status of pregnant women. These data are expected to be used in an ongoing community-based antenatal care programme. Twenty-nine percent of women reported fever, 14 percent diarrhoea and 33 percent respiratory infections in the previous week. Mean weight was 54.8 (+/- 10.6) kg, mean height was 151.6 (+/- 6.0) cm and mean midarm circumference was 25.6 (+/- 3.2) cm. The mean uterine height at gestational ages 8 months and over was 32.1 (+/- 10.2) cm which is below the 10th percentile. These results suggest a chronic, mildly malnourished population with a high rate of infections. Specifically, we suggest that maternal height and uterine height be used to assess women at high risk for low birthweight.

Undernutrition among Bedouin Arab children: a follow-up of the Bedouin Infant Feeding Study.

After 10 y of urban settlement, 680 Bedouin Arab children, who had had anthropometric assessment from birth (1981-1982) through early childhood, were reassessed in 1991-1992 to compare the rates of stunting in early and later childhood as well as to describe the factors influencing current height-for-age. Stunting had dropped from 32.7% at 18 mo to 7.2% at 10 y in the 1981 birth cohort and dropped from 17.5% at 9 mo to 8.2% at 9 y in the 1982 birth cohort. Based on a multiple-linear-regression analysis, height in early childhood and maternal height were statistically significantly and positively associated with current mean height-for-age in both cohorts. In the 1982 cohort socioeconomic status in early childhood was positively and current family size was negatively and significantly associated with current mean height-for-age. Thus, conditions that were present in early childhood had the largest influence on current height. In 1992, 10% and 6% of the infant siblings of the 1981 and 1982 cohorts, respectively, were stunted compared with 17% and 1% of the siblings aged 1-2 y of the respective cohorts. Therefore, the high rates of early childhood stunting in 1981-1982 appeared to be a birth cohort-specific phenomenon.

PIP: During 1991-1992 in Israel, researchers re-examined the anthropometric assessment of Bedouin children 9-10 years old, living in the Negev, whose anthropometric assessment was initially examined when they were 6-18 months old, to compare the rates of stunting in early and later childhood and to determine the factors affecting current height-for-age. For the 1981 birth cohort, stunting fell from 32.7% at 18 months to 7.2% at 10 years. The corresponding figures for the 1982 birth cohort were 17.5% at 9 months and 8.2% at 9 years. Thus, despite the social change and urban settlement the children experienced in the 10 year span, they still had some catch-up growth. Stunting among the siblings less than 2 years old of the 1991-1992 cohorts was much less common than stunting of the index children in early childhood in 1981 (17% vs. 44%), but not so in 1982 (14% vs. 11%). In 1992, the prevalence of stunting stood at 10% and 6% of siblings less than one year old of the 1981 and 1982 cohorts, respectively, while it was 17% and 1% for siblings 1-2 years old of the 1981 and 1982 cohorts, respectively. Maternal height and index child's height-for-age in early childhood were positively associated with current height-for-age in the 1981 cohort (p = 0.0001). They explained 33% of the variation in height-for-age. In the 1981 cohort, neither socioeconomic status (SES) in early childhood nor family size were associated with current height-for-age. Yet, in the 1982 cohort, both SES in early childhood and family size were associated with current height-for-age, SES positively (p = 0.04) and family size negatively (p = 0.03). Maternal height and height-for-age in early childhood were positively associated with current height-for-age (p = 0.002 and 0.0001, respectively). These 4 variables accounted for 34% of the variation in height-for-age in the 1982 cohort. These findings indicate that factors or conditions present in early childhood had the greatest impact on current height-for-age.

A community-based nested case-control study of maternal mortality.

OBJECTIVES: Population-based information from Pakistan on maternal mortality is inadequate to define the magnitude of the problem or to contribute information on the distribution of clinical causes and risk factors. A population-based survey was conducted in eight urban squatter settlements of Karachi, Pakistan, to address these key issues. METHODS: Pre-coded questionnaires were administered to the 10,135 households to ascertain deaths of household members in the 5 years preceding the survey (1984-1989). A verbal autopsy questionnaire was administered to the 121 households where a female death between 15 and 49 years of age was reported. RESULTS: The maternal mortality ratio was estimated as 281 per 100,000 livebirths with hemorrhage, eclampsia and puerperal sepsis as the major causes of maternal deaths. Important risk factors identified were maternal employment, paternal unemployment, and poor prior pregnancy history. Women did seek health care but the assistance sought was often inappropriate. CONCLUSION: Intervention programs for improving timely referral and upgrading of hospitals are suggested.

Risk factors for intrauterine growth retardation: results of a community-based study from Karachi.

There is a serious lack of community-based information on low birthweight or intrauterine growth retardation from Pakistan. A community based prospective study was conducted in four squatter settlements of Karachi, to examine the prevalence and risk factors for adverse pregnancy outcome. This paper reports on the prevalence and risk factors for intrauterine growth retardation (<10th percentile birthweight gestational age) among 755 singleton births. The incidence of intrauterine growth retardation was 25.4% (192 intrauterine growth retarded and 563 appropriate for gestational age). Major socioeconomic risk factors identified were low maternal education (RR = 1.4, 95% CI = 1.0,2.1) and poor housing material (RR = 1.7, 95% CI = 1.0,3.0). Among the significant biologic factors, primiparity (RR = 1.9, 95% CI = 1.4,2.7), consanguinity (RR = 1.4, 95% CI = 1.4,2.7), consanguinity (RR = 1.4, 95% CI = 1.1,1.8), short birth to CI = 1.1,2.1), short stature (RR = 2.2, 95% CI = 1.6,3.0), low maternal weight (RR = 2.0, 95% CI = 1.6,2.5) and non-vegetarian diet (RR = 2.3, 95% CI = 1.3,4.2) were especially important. Investigations to assess the adverse mortality and morbidity effects of intrauterine growth retardation are ongoing.

Risk factors for term intrauterine growth retardation: a community-based study in Karachi.

Reported are the results of a community-based prospective study in four urban squatter settlements in Karachi that was carried out to assess the incidence of and risk factors for intrauterine growth retardation. The incidence of term intrauterine growth retardation was 24.4% among 738 singleton births. The socioeconomic and biological risk factors that were found to be statistically significant in a bivariate analysis were included in a logistic regression model to assess their independent effects. The major risk factors were low level of maternal education, paternal unemployment, consanguinity, short birth-to-conception intervals, short maternal stature, and low maternal weight. The population risk estimates suggest the desirability of public health interventions to improve maternal weight and birth spacing and of improvements in socioeconomic conditions, especially maternal education. Public education programmes to discourage consanguineous marriages should also be considered.

Causes of reproductive age mortality in low socioeconomic settlements of Karachi.

The Maternal and Infant Mortality Survey (MIMS) was conducted in eight squatter settlements of Karachi. The female mortality rate was 151.0 per 100,000 women aged 10-49 years and the maternal mortality ratio was 281 per 100,000 livebirths. The leading causes of deaths among women were complications of pregnancy (28.1%), infectious diseases (24.8%), cardiovascular diseases (20.7%), neoplasia (10.7%) and trauma (10.7%). Hemorrhage (47.1% of all maternal deaths), tuberculosis (40.0% of all infectious disease deaths), oropharyngeal cancer (23.1% of all neoplastic deaths), and burns (61.5% of all trauma deaths) were among the major causes identified. Maternal deaths were associated with young age and nulliparity (p-value < 0.01), and a higher proportion occurred in the hospital or on the way to the hospital as compared to non-maternal deaths.