Low birthweight prevalence among Spanish women during the economic crisis: differences by parity.

Previous studies have demonstrated a negative, significant impact on birthweight associated with the current economic crisis in Spain, which has also been reported for other European countries. Effects by parity are not known. Our aim is to compare the trends in low birthweight (LBW) by parity in Spain from 1996 to 2016. Using the National Vital Statistics data, joinpoint regression analysis was used to identify the time periods of significant changes in the prevalence of LBW by parity. Adjusted relative risk (RR) of LBW by year of birth was calculated in order to confirm that the time trend differences in LBW by parity were independent of possible confounders. The prevalence of LBW among live births to primiparous increased from 5.12% to 6.87% in 2008 and then stabilised at maximum values, while among live births to multiparous LBW increased from 3.96% to a maximum of 5.20% and then significantly reduced. Trends in adjusted RR of LBW by parity confirm that primiparous and multiparous were affected differently by the economic crisis. Older, nulliparous women may have felt more biosocial pressure to reproduce during the economic crisis, compared to women who were already mothers. This biosocial pressure may have increased the risks for LBW.

Social disparities in low birth weight among Spanish mothers during the economic crisis (2007-2015) / Disparidades sociales en bajo peso al nacer en madres españolas durante la crisis económica (2007-2015)

Objective: to evaluate the impact of the economic crisis on the disparities in the prevalence and risk of low birth weight (LBW) according to the maternal socioeconomic profile. Methods: the data analysed corresponds to 1,779,506 single births to Spanish mothers in the years 2007, 2009, 2011, 2013 and 2015. The temporal changes in available maternal-foetal variables are described. Secondly, the possible increase in disparities in prevalence and risk of LBW due to the occupation and education of the mother is evaluated, taking 2007 as the reference year. Results: a trend of the maternal profile is described among women who had children during this period, with an increasing contribution of highly qualified professional and educated women, a trend already existing before the economic crisis, but which was deepened by the recession. The prevalence of LBW increased in all socio-economic groups, with a marked increase in disparities during the worst years of the economic crisis. Conclusion: results confirm the persistence of social inequalities in perinatal health described prior to the economic crisis, as well as a possibly negative effect of the recession between 2007 and 2015. Results also confirm that disparities in LBW are more clearly associated with the educational level of mothers than with their occupation

Objetivo: evaluar el impacto de la crisis económica sobre las disparidades en la prevalencia y en el riesgo de bajo peso al nacer (BPN) en función del perfil socioeconómico materno. Métodos: los datos analizados corresponden a 1.779.506 partos simples de madres españolas ocurridos en los años 2007, 2009, 2011, 2013 y 2015. Se describe el cambio temporal en las variables materno-fetales disponibles. En segundo lugar, se evalúa el posible incremento de las disparidades por ocupación y educación maternas en prevalencias y riesgos relativos de BPN, considerando 2007 como el año de referencia. Resultados: se describe un cambio en el perfil de las mujeres que decidieron tener hijos durante este periodo, con una mayor presencia de madres de alta cualificación profesional y alto nivel educativo, una tendencia ya previa a la crisis económica, pero que la recesión ha radicalizado. La prevalencia de BPN aumentó en todos los grupos maternos, con un claro incremento de las disparidades durante los peores años de la crisis económica. Conclusión: se confirma la persistencia de desigualdades sociales en salud perinatal descritas antes de la crisis, así como el efecto negativo de la recesión en el periodo 2007-2015. Los resultados confirman, además, que las disparidades en BPN se asocian más claramente con el nivel educativo de las madres que con su ocupación

[Social disparities in low birth weight among Spanish mothers during the economic crisis (2007-2015)]. / Disparidades sociales en bajo peso al nacer en madres españolas durante la crisis económica (2007-2015).

OBJECTIVE: to evaluate the impact of the economic crisis on the disparities in the prevalence and risk of low birth weight (LBW) according to the maternal socioeconomic profile. METHODS: the data analysed corresponds to 1,779,506 single births to Spanish mothers in the years 2007, 2009, 2011, 2013 and 2015. The temporal changes in available maternal-foetal variables are described. Secondly, the possible increase in disparities in prevalence and risk of LBW due to the occupation and education of the mother is evaluated, taking 2007 as the reference year. RESULTS: a trend of the maternal profile is described among women who had children during this period, with an increasing contribution of highly qualified professional and educated women, a trend already existing before the economic crisis, but which was deepened by the recession. The prevalence of LBW increased in all socio-economic groups, with a marked increase in disparities during the worst years of the economic crisis. CONCLUSION: results confirm the persistence of social inequalities in perinatal health described prior to the economic crisis, as well as a possibly negative effect of the recession between 2007 and 2015. Results also confirm that disparities in LBW are more clearly associated with the educational level of mothers than with their occupation.

Objetivo: evaluar el impacto de la crisis económica sobre las disparidades en la prevalencia y en el riesgo de bajo peso al nacer (BPN) en función del perfil socioeconómico materno. Métodos: los datos analizados corresponden a 1.779.506 partos simples de madres españolas ocurridos en los años 2007, 2009, 2011, 2013 y 2015. Se describe el cambio temporal en las variables materno-fetales disponibles. En segundo lugar, se evalúa el posible incremento de las disparidades por ocupación y educación maternas en prevalencias y riesgos relativos de BPN, considerando 2007 como el año de referencia. Resultados: se describe un cambio en el perfil de las mujeres que decidieron tener hijos durante este periodo, con una mayor presencia de madres de alta cualificación profesional y alto nivel educativo, una tendencia ya previa a la crisis económica, pero que la recesión ha radicalizado. La prevalencia de BPN aumentó en todos los grupos maternos, con un claro incremento de las disparidades durante los peores años de la crisis económica. Conclusión: se confirma la persistencia de desigualdades sociales en salud perinatal descritas antes de la crisis, así como el efecto negativo de la recesión en el periodo 2007-2015. Los resultados confirman, además, que las disparidades en BPN se asocian más claramente con el nivel educativo de las madres que con su ocupación.

The impact of delayed maternity on foetal growth in Spain: An assessment by population attributable fraction.

BACKGROUND: Delayed childbearing is considered a risk factor for maternal-foetal health. As in other higher-income countries, in Spain age at maternity has steadily increased during the last two decades. AIM: To quantify the impact of the delay in the age at maternity on small for gestational age (SGA) categories of <3rd, 3rd-5th and 5th-10th percentiles. METHODS: 2,672,350 singleton live births born to Spanish mothers in 2007-2015 were analysed. Adjusted relative risk was calculated to estimate the adjusted partial population attributable fractions (PAFp) for mothers aged 35-39 and ≥40 years for each category of SGA considering the interaction between age at maternity and parity. FINDINGS: Primipara 35-39 years old mothers have the highest PAFp in the three categories of SGA, with the maximum value for SGA <3rd percentile (2.57%, 95% CI 2.25, 2.88). PAFp for both primipara and multipara ≥40 years old mothers were less than 1%. PAFp for primipara older mothers increased significantly in 2007-2015 for the three categories of SGA, more clearly among those aged 35-39 years. The contribution of multipara mothers of both age groups did not increase significantly during the period. CONCLUSION: Delayed maternity is a significant adjusted risk factor for SGA, contributing to the increase of its prevalence. However, results also suggest a limited clinical impact of delayed maternity on foetal growth. Positive changes in maternal profile associated with the shift in maternal age might contribute to explain the limited impact of mothers aged 35 years and older on negative birth outcome in Spain.

New birthweight charts according to parity and type of delivery for the Spanish population / Nuevas curvas de peso al nacer por paridad y tipo de parto para la población española

Objective: Birthweight by gestational age charts enable fetal growth to be evaluated in a specific population. Given that maternal profile and obstetric practice have undergone a remarkable change over the past few decades in Spain, this paper presents new Spanish reference percentile charts stratified by gender, parity and type of delivery. They have been prepared with data from the 2010-2014 period of the Spanish Birth Statistics Bulletin. Methods: Reference charts have been prepared using the LMS method, corresponding to 1,428,769 single, live births born to Spanish mothers. Percentile values and mean birth weight are compared among newborns according to gender, parity and type of delivery. Results: Newborns to primiparous mothers show significantly lower birthweight than those born to multiparous mothers (p<0.036). Caesarean section was associated with a substantially lower birthweight in preterm births (p<0.048), and with a substantially higher birthweight for full-term deliveries (p<0.030). Prevalence of small for gestational age is significantly higher in newborns born by Caesarean section, both in primiparous (p<0.08) and multiparous mothers (p<0.027) and, conversely, the prevalence of large for gestational age among full-term births is again greater both in primiparous (p<0.035) and in multiparous mothers (p<0.007). Conclusions: Results support the consideration of establishing parity and type of delivery-specific birthweight references. These new charts enable a better evaluation of the impact of the demographic, reproductive and obstetric trends currently in Spain on fetal growth (AU)

Objetivo: Las tablas de peso al nacer por edad gestacional permiten evaluar el crecimiento fetal en una población específica. Dado que el perfil materno y la práctica obstétrica han experimentado un sustancial cambio en las últimas décadas en España, este trabajo propone nuevas tablas de referencia de percentiles estratificadas por sexo, paridad y tipo de parto, elaboradas con los datos del periodo 2010-2014 del Boletín Estadístico de Partos. Métodos: Las curvas de referencia han sido elaboradas mediante el método LMS, correspondientes a 1.428.769 nacidos vivos de partos simples y madres españolas. Se comparan los valores por percentiles y la media del peso al nacer, por sexo, paridad y tipo de parto. Resultados: Los nacidos de madres primíparas muestran un peso menor que los nacidos de multíparas (p<0,036). Los nacidos pretérmino por cesárea tienen un peso menor que los nacidos pretérmino por parto vaginal (p<0,048), mientras que ocurre lo contrario en los nacidos a término (p<0,030). La prevalencia de nacidos pequeños para la edad gestacional es mayor entre los nacidos por cesárea de madres tanto primíparas (p<0,08) como multíparas (p<0,027), y la prevalencia de nacidos grandes para la edad gestacional es mayor entre los nacidos a término de madres tanto primíparas (p<0,035) como multíparas (p<0,007). Conclusiones: Los resultados apoyan establecer referencias de peso al nacer por paridad y tipo de parto. Estas nuevas curvas permiten una mejor evaluación del impacto de las actuales tendencias demográficas, reproductivas y obstétricas en España sobre el crecimiento fetal (AU)

New birthweight charts according to parity and type of delivery for the Spanish population.

OBJECTIVE: Birthweight by gestational age charts enable fetal growth to be evaluated in a specific population. Given that maternal profile and obstetric practice have undergone a remarkable change over the past few decades in Spain, this paper presents new Spanish reference percentile charts stratified by gender, parity and type of delivery. They have been prepared with data from the 2010-2014 period of the Spanish Birth Statistics Bulletin. METHODS: Reference charts have been prepared using the LMS method, corresponding to 1,428,769 single, live births born to Spanish mothers. Percentile values and mean birth weight are compared among newborns according to gender, parity and type of delivery. RESULTS: Newborns to primiparous mothers show significantly lower birthweight than those born to multiparous mothers (p<0.036). Caesarean section was associated with a substantially lower birthweight in preterm births (p<0.048), and with a substantially higher birthweight for full-term deliveries (p<0.030). Prevalence of small for gestational age is significantly higher in newborns born by Caesarean section, both in primiparous (p<0.08) and multiparous mothers (p<0.027) and, conversely, the prevalence of large for gestational age among full-term births is again greater both in primiparous (p<0.035) and in multiparous mothers (p<0.007). CONCLUSIONS: Results support the consideration of establishing parity and type of delivery-specific birthweight references. These new charts enable a better evaluation of the impact of the demographic, reproductive and obstetric trends currently in Spain on fetal growth.

Is the economic crisis affecting birth outcome in Spain? Evaluation of temporal trend in underweight at birth (2003-2012).

BACKGROUND: There is growing evidence of the impact of the current European economic crisis on health. In Spain, since 2008, there have been increasing levels of impoverishment and inequality, and important cuts in social services. AIM: The objective is to evaluate the impact of the economic crisis on underweight at birth in Spain. METHOD: Trends in underweight at birth were examined between 2003 and 2012. Underweight at birth is defined as a singleton, term neonatal weight lesser than -2 SD from the median weight at birth for each sex estimated by the WHO Standard Growth Reference. Using data from the Statistical Bulletin of Childbirth, 2 933 485 live births born to Spanish mothers have been analysed. Descriptive analysis, seasonal decomposition analysis and crude and adjusted logistic regression including individual maternal and foetal variables as well as exogenous economic indicators have been performed. RESULTS AND CONCLUSIONS: Results demonstrate a significant increase in the prevalence of underweight at birth from 2008. All maternal-foetal categories were affected, including those showing the lowest prevalence before the crisis. In the full adjusted logistic regression, year-on-year GDP per capita remains predictive on underweight at birth risk. Previous trends in maternal socio-demographic profiles and a direct impact of the crisis are discussed to explain the trends described.

Labor management and mode of delivery among migrant and Spanish women: does the variability reflect differences in obstetric decisions according to ethnic origin?

Based on previous findings showing both better birth outcomes in migrant than in Spanish women and different rates of medical intervention according to mother's origin, we hypothesize that mode of delivery decisions to solve similar problems differ according to ethnic origin. Ethnic differences for maternal characteristics, medical intervention, and mode of delivery were evaluated in 16,589 births from a Maternity Hospital in Madrid (Spain). Multinomial logistic regression analysis was used to evaluate the effect of mother's ethnic origin on the mode of delivery, adjusting for mother's age, parity, gestational age, birth weight, and epidural anesthesia. Compared with the Spanish mothers, the risk of having a Caesarean section is significantly higher in Latin Americans and significantly lower for the Chinese. Both low birth weight and macrosomic deliveries are at higher risk for Caesarean section. The interventionist system characterizing Spain is being extended to all ethnic groups and, at the same time, different medical interventions are applied to similar problems depending on women's ethnic origin. Obstetric interventions might be contributing to the increasing trend of low birth weight and late preterm/early full term deliveries (37-38 weeks) observed in Spain. Behavioral and cultural values of the women and of the health care providers may contribute to systematic differences in labor management and mode of delivery.

Hour of birth and birth assistance: from a primate to a medicalized pattern?

OBJECTIVES: Previous studies generally agree that in Homo sapiens births without medical intervention occur mostly at night, although with a less accentuated pattern than in other primate species. The present study has three main objectives: (a) to establish the hourly pattern of births in a modern medicalized population, (b) to explore the association between the hour of birth and maternal and fetal variables and mode of delivery, and (c) to evaluate the risk for medical intervention at different hours of the day. METHODS: The hourly distribution of 25,779 deliveries at the "La Paz" Madrid University Maternity Hospital (Spain) has been analyzed. Two different multivariate analyses have been used to evaluate, respectively, the relationships between maternal and fetal characteristics and the type of birth and hour of delivery. RESULTS: The increasing of unnecessary hospital interventions seems to have transformed the nocturnal pattern of birth into a diurnal one and may be contributing to the rise of preterm and low birth weight deliveries, reducing their probability of being breastfeed, and eliminating or transforming emotional and social support. Immigrant women present a higher frequency of the nocturnal pattern of delivery than their Spanish counterparts. CONCLUSIONS: The predominant nocturnal pattern of birth seems to have disappeared in a Spanish highly medicalized population. However, the hallmark of primate nocturnal deliveries is evident when multiple births, malpresentation, Caesarean sections, and vaginal interventions are excluded. Possible consequences of diurnal birth include reduced infant-mother bonding, breast feeding, and later life reductions to health.

The economic and nutrition transition in Equatorial Guinea coincided with a double burden of over- and under nutrition.

We assess trends in children's nutritional status in Equatorial Guinea, a country in socioeconomic transition. Nationally representative samples were conducted in 1997, at the start of the economic take off, and again in 2004. Children aged 0-60 months were included in the surveys (N=436, 552). Both surveys included a sociodemographic, dietary and health questionnaire, and anthropometric measurements from which height-for-age (HAZ); weight-for-age (WAZ) and weight-for-height (WHZ) Z-scores were calculated. Between 1997 and 2004, the prevalence of child overweight for all children increased from 21.8% to 31.7%, especially in urban areas (from 18.2% to 29.4%, p=0.01). Stunting prevalence among children >or=2 years old decreased (from 57.9% to 45.3%, p<0.02), but for all age groups remained very high (34.7% overall, 46.5% rural and 28.5% urban in 2004). The economic take off in Equatorial Guinea appeared to coincide with substantial increases in the prevalence of child overweight whereas the prevalence of stunting decreased even if it remained high. The results suggest that the country is undergoing a nutrition transition and acquiring the concomitant double burden of under and over nutrition.

Nutritional and socio-economic factors associated with Plasmodium falciparum infection in children from Equatorial Guinea: results from a nationally representative survey.

BACKGROUND: Malaria has traditionally been a major endemic disease in Equatorial Guinea. Although parasitaemia prevalence on the insular region has been substantially reduced by vector control in the past few years, the prevalence in the mainland remains over 50% in children younger than five years. The aim of this study is to investigate the risk factors for parasitaemia and treatment seeking behaviour for febrile illness at country level, in order to provide evidence that will reinforce the EG National Malaria Control Programme. METHODS: The study was a cross-sectional survey of children 0 to 5 years old, using a multistaged, stratified, cluster-selected sample at the national level. It included a socio-demographic, health and dietary questionnaires, anthropometric measurements, and thick and thin blood smears to determine the Plasmodium infection. A multivariate logistic regression model was used to determine risk factors for parasitaemia, taking into account the cluster design. RESULTS: The overall prevalence of parasitemia was 50.9%; it was higher in rural (58.8%) compared to urban areas (44.0%, p = 0.06). Age was positively associated with parasitemia (p < 0.0001). In rural areas, risk factors included longer distance to health facilities (p = 0.01) and a low proportion of households with access to protected water in the community (p = 0.02). Having had an episode of cough in the 15 days prior to the survey was inversely related to parasitemia (p = 0.04). In urban areas, the risk factors were stunting (p = 0.005), not having taken colostrum (p = 0.01), and that someone in the household slept under a bed net (p = 0.002); maternal antimalarial medication intake during pregnancy (p = 0.003) and the household socio-economic status (p = 0.0002) were negatively associated with parasitemia. Only 55% of children with fever were taken outside their homes for care, and treatment seeking behaviour differed substantially between rural and urban populations. CONCLUSION: Results suggest that a national programme to fight malaria in Equatorial Guinea should take into account the differences between rural and urban communities in relation to risk factors for parasitaemia and treatment seeking behaviour, integrate nutrition programmes, incorporate campaigns on the importance of early treatment, and target appropriately for bed nets to reach the under-fives.

Nutritional status and its correlates in Equatorial Guinean preschool children: results from a nationally representative survey.

BACKGROUND: In Equatorial Guinea, as a result of the recent growth of the oil industry, there is an opportunity to address important public health problems through public and private initiatives. To propose effective nutrition and public health strategies, it is important first to have reliable information on the nutritional status of the population and the underlying factors affecting it. OBJECTIVE: To assess the nutritional status and the prevalence of anemia among Equatoguinean children in a nationally representative sample and to identify the risk factors associated with the nutritional problems detected. METHODS: The study was a cross-sectional survey using a multistaged, stratified, cluster-selected sample. The survey included a sociodemographic, health, and dietary questionnaire and measurement of hematocrit and anthropometric features, from which nutritional indicators based on the National Center for Health Statistics (NCHS) reference and the World Health Organization (WHO) standards were calculated. Logistic regression models were used for the multivariate analysis. A total of 552 children aged 0 to 60 months were surveyed. RESULTS: The overall prevalence of stunting (< -2 height-for-age z-scores [HAZ]) was 29.7% based on the NCHS reference and 35.2% based on WHO standards; the risk factors associated with stunting were age (p < .0001), low socioeconomic status (p = .01), and fishing by a member of the household (p = .003) The prevalence of mild anemia (hemoglobin < 110 g/L) was 69.3%, and that of moderate or severe anemia (hemoglobin < 80 g/L) was 8.3%. The only significant risk factor associated with moderate to severe anemia was low household socioeducational level (p = .01). CONCLUSIONS: Stunting and anemia are public health problems in Equatorial Guinea. Integrated strategies, including fighting poverty and improving maternal education, should be undertaken.

Environmental contexts of menopause in Spain: comparative results from recent research.

OBJECTIVE: This study had two main objectives: (1) to detect the differences in basic aspects of the reproductive aging process (age at menopause, menopausal symptoms, the medicalization of aging) among women from the region of Madrid, who at the time of the study were living in three different environmental contexts (rural, semiurban, and urban), and (2) to identify the main factors responsible for these differences. DESIGN: Data from two different research projects have been pooled for the DAMES project (Decisions At MEnopause Study), and the Ecology of Reproductive Aging Project. The sample size was 1,142, women 45 to 55 years of age (103 rural, 744 semiurban, 295 urban). RESULTS: Probit analysis was used to estimate median age at natural menopause in the three contexts. Rural women have a later onset of menopause (rural, 52.07 y; semiurban, 51.9 y; urban, 51.23 y) and significantly higher levels of the symptoms related to declines in estrogen, eg, hot flashes (rural, 56%; semiurban, 43%; urban, 46%; chi2=6.717, P=0.035) or loss of sexual desire (rural, 51%; semiurban, 44%; urban, 41%; chi2=24.934, P=0.001). Conversely, urban women suffer more from symptoms related to stress, eg, impatience (rural, 34%; semiurban, 25%; urban, 45%; chi2=41.328, P<0.001). The medicalization of menopause, measured in terms of both surgical menopause and the use of hormone therapy, is significantly higher in the urban population (surgical menopause: rural, 5.8%; semiurban, 8.7; urban, 10%; chi2=16.009, P<0.001). Despite these differences, levels of postmenopausal hormone therapy use are still somewhat lower than in other West European and North American populations. Two different logistic regression analyses were carried out to identify (1) factors associated with differences in ovarian aging, measured through menopausal status, and (2) factors associated with prevalence of hot flashes with respect to ovarian aging. Parity, body mass index, age, environmental context, and, slightly less so, smoking, alcohol consumption, age, education, age at menarche, and marital status all contribute significantly or nearly significantly and independently to the explanation of differences found. For the likelihood of having hot flashes, environmental context, age, education, age at menarche, menopausal status, and postmenopausal hormone therapy use all hae a significant or borderline significant effect. CONCLUSIONS: Significant differences have been shown to exist in rural, semiurban and urban settings in the median age at menopause, in basic symptom frequency and type, and in the levels of medicalization of the process of reproductive aging. Within multivariate regression models, it has been shown that body mass index, age, and environmental context all contribute to differences in reproductive aging. The factors associated with ovarian aging and hot flashes are comparable to those in other industrialized populations, although standard interpretations should be expanded to include context-based realities, including (1) the higher levels of modernization of urban women that influence differential behavior with respekt to risk factors at menopausal age; (2) the different ecological realities surrounding nutrition, physical activity, and social support that characterize women's period of development; and (3) the differential construction of their identity as women in terms of assertiveness, aesthetic perceptions, and the use of health services. Context does, indeed, matter.