Educational Attainment of Grandmothers and Preterm Birth in Grandchildren.

BACKGROUND: Maternal education has been shown repeatedly to be inversely associated with preterm birth. Both preterm birth and educational level of families are correlated across generations, but it is not clear if educational level of grandparents affects the risk of preterm delivery of their grandchildren, and, if so, if the association with grandmother's education is independent of mother's education. METHODS: We used New Jersey birth certificates to create a transgenerational dataset to examine the effect of grandmother's education on risk of PTB in White, Black and Hispanic grandchildren. We matched birth certificates of girls born in 1979-1983 to mothers listed on NJ birth certificates for the years 1999-2011. Thus, grandmothers were the women delivering in 1979-1983, and mothers were those born to the grandmothers who in turn delivered grandchildren in 1999-2011. We performed descriptive tabulations and multivariate logistic regression to develop risk estimates. RESULTS: Overall, maternal education was associated inversely with PTB in each of the demographic groups. There was a substantial inter-generational increase in education between grandmothers and mothers in each group, which was most striking in Hispanics After adjusting for maternal age and education, grandmother's education continued to be associated with preterm birth of her grandchildren. CONCLUSIONS: Grandmother's education was an additional, independent predictor of PTB in her grandchildren. This result supports the idea that mother's childhood and preconception socioeconomic environment, including the educational level of her childhood household affect her reproductive health.

Risk of peripartum hysterectomy by mode of delivery and prior obstetric history: data from a population-based study.

PURPOSE: To provide an estimate of the incidence of peripartum hysterectomy in the state of New Jersey and calculate the effect of mode of delivery and prior obstetric history. METHODS: A perinatal-linked dataset provided by the Maternal Child Health Epidemiology Program in the New Jersey Department of Health was used to obtain information from birth certificates and hospital discharge records. Using multivariate logistic regression, various demographic and clinical factors were assessed for association with peripartum hysterectomy. RESULTS: A total of 1,004,116 births were identified between 1997 and 2005 and 853 peripartum hysterectomies were performed (0.85/1,000 deliveries). Parity increased the risk of hysterectomy with nulliparous women having approximately half the risk compared to multiparous women. Cesarean delivery with no previous c-section almost doubled the risk (OR 2.20, CI 1.80-26.69) while in the presence of a previous c-section the risk was almost four times higher (OR 4.51, CI 3.76-5.40). Operative vaginal delivery did not result in any increase in the risk. CONCLUSIONS: Mode of delivery and prior obstetric history are major risk factors for peripartum hysterectomy. Patients desiring cesarean delivery need to be counseled on the risk of this serious complication.

Obstetric outcomes in normal weight and obese women in relation to gestational weight gain: comparison between Institute of Medicine guidelines and Cedergren criteria.

We compared obstetric outcomes based on gestational weight gain in normal-weight and obese women using traditional Institute of Medicine (IOM) guidelines and newly recommended Cedergren criteria. Using the New Jersey Pregnancy Risk Assessment Monitoring System (PRAMS) database and electronic birth records, perinatal outcomes were analyzed to estimate the independent effects of prepregnancy body mass index (BMI) and gestational weight gain by IOM versus Cedergren criteria. Of 9125 subjects in PRAMS database from 2002 to 2006, 53.7% had normal BMI, 12.3% were overweight, 18.2% were obese, and the rest were underweight. Among normal-weight mothers, when compared with the IOM guidelines, macrosomia (6.45% versus 4.27%) and cesarean delivery rates (30.42% versus 29.83%) were lower using Cedergren criteria but the rates of preterm delivery (5.06% versus 9.44%), low birth weight (0.38% versus 2.42%), and neonatal intensive care unit (NICU) admissions (7.02% versus 10.86%) were higher with the Cedergren criteria. Similarly, among obese patients, when compared with IOM guidelines, macrosomia (10.79% versus 5.47%) and cesarean delivery rates (43.95% versus 40.71%) were lower using Cedergren criteria but the rates of preterm delivery (6.83% versus 8.32%), low birth weight (0.87% versus 1.88%), and NICU admissions (8.92% versus 13.78%) were higher with the Cedergren criteria. Based on our results, ideal gestational weight gain is presumably somewhere between the IOM and Cedergren's guidelines.

Birth weight discordance and adverse fetal and neonatal outcomes among triplets in the United States.

OBJECTIVE: To examine the association between intratriplet birth weight discordance, fetal and neonatal mortality, and smallness for gestational age. METHODS: The 1995-1997 Centers for Disease Control and Prevention's Matched Multiple Birth file was used for this analysis. Birth weight discordance was calculated as the difference in birth weight between the largest and the smallest triplet's weight and expressed as percentage of the largest triplet's weight. For the middle-weight triplet, we also used the largest triplet's weight as a reference in calculating percentage birth weight discordance, which was then grouped into quintiles. RESULTS: Among 15,511 triplet live births and fetal deaths (at least 20 weeks' gestation), 35% had less than 10% birth weight discordance, 19.3% had 10-15%, 16.4% had 15-21%, 15.2% had 21-29%, and 14.1% had 29% or more. After controlling for confounders, the risk of fetal death associated with quintile V was significantly higher than that associated with quintile I for smallest (odds ratio [OR] 10.88; 95% confidence interval [CI] 4.87, 26.56), middle (OR 22.6; 95% CI 11.05, 46.3), and largest (OR 2.41; 95% CI 1.01, 5.89) triplets. Smallest and middle triplets in quintile V were more likely than quintile I triplets to be born small for gestational age (OR 26.0; 95% CI 17.1, 39.9 for smallest, and OR 13.4; 95% CI 8.01, 22.3 for middle). Birth weight discordance quintile was not associated with smallness for geatational age among largest triplets nor consistently with neonatal mortality among smallest, middle, or largest triplets. CONCLUSION: Increasing birth weight discordance was associated with increased risk of fetal death and smallness for gestational age. A birth weight discordance threshold of at least 29% should alert obstetricians for appropriate decision making.

Obstetric outcomes in pregnant women with diabetes versus hypertensive disorders versus both.

OBJECTIVE: To compare obstetrical outcomes in pregnant women with diabetes versus hypertensive disorders versus both. METHODS: One million patients in the New Jersey Database were analyzed. Of which 6.91% had hypertension, 4.79% had diabetes, and 0.91% had both. Information was derived from a perinatal linked data-set provided by the Maternal Child Health Epidemiology (MCH Epi) Program in the New Jersey Department of Health and Senior Services. Linking of electronic birth certificates, hospital discharge records for mother and newborn, and infant death certificates for all infants born in New Jersey between the years 1997 and 2005 created the data-set. RESULTS: Coexistence of hypertension and diabetes increased with advancing maternal age (OR 3.41; CI 3.12-3.72). Among ethnic groups, diabetes was more common in Asians (OR 2.92; CI 2.84-3.00), while hypertension was more common in Blacks (OR 1.49; CI 1.46-1.53). Blacks followed by Asians had a higher risk of being in the combined category. Induction of labor (OR 4.16; CI 3.96-4.38), shoulder dystocia (OR 2.56; CI 2.05-3.19), operative vaginal delivery (OR 3.92; CI 3.29-4.66), cesarean deliveries with no trial of labor (OR 2.54; CI 2.40-2.69) as well as with failed trial of labor (OR 4.09; CI 3.88-4.31) were more common in the combined group. Neonatal outcomes were poor in the combined category, with high rate of preterm deliveries, neonatal intensive care unit (NICU) admissions (OR 2.14; CI 2.01-2.28), neonatal seizures (OR 2.30; CI 1.31-4.04), low 5-min APGAR scores (OR 1.78; CI 1.57-2.01), and longer NICU stay (OR 2.30; CI 2.15-2.47). CONCLUSIONS: Coexistence of hypertension and diabetes was associated with worse obstetric and neonatal outcomes than either alone. This should be emphasized to mothers during prenatal counseling. Further research should focus on interventions to improve morbidity in the combined category.

Impact of mode of delivery on neonatal complications: trends between 1997 and 2005.

OBJECTIVE: This study examined whether rates of selected neonatal complications vary by mode of delivery and whether these rates are changing as a result of the increasing cesarean delivery rate. METHOD: Birth certificates in New Jersey from 1997 to 2005 were matched to hospital discharge records for mothers and newborns. RESULTS: In New Jersey, the total cesarean section rate for 2005 was 35.3%, a relative increase of 46% since 1997 (from 24.2%). Rates of transient tachypnea of the newborn (TTN) and respiratory distress syndrome (RDS), regardless of mode of delivery, increased between 1997 and 2005 from 3.3 to 3.9% and 2.1 to 2.4%, respectively. Newborn injuries declined sharply (from 4.1 to 2.6%), whereas intra-ventricular hemorrhage (IVH) rates remained stable. The rates of RDS, TTN and IVH were highest for cesarean delivery without trial of labor, while the rate of injuries was highest for instrumental vaginal delivery. CONCLUSION: Neonatal complication rates varied by mode of delivery and decreased with gestational age.

Amniotic fluid embolism-risk factors, maternal and neonatal outcomes.

OBJECTIVE: To investigate demographic characteristics, risk factors, maternal and neonatal outcomes of all cases of amniotic fluid embolism that occurred in New Jersey during 1997-2005. METHODS: Information was derived from a perinatal linked dataset provided by the MCH-Epidemiology Program in the New Jersey Department of Health. Bivariate analysis for dichotomous variables used the Chi-square test. Stepwise logistic regression models were created to assess the influence of potential risk factors and p value < 0.05 considered statistically significant. RESULTS: Forty-five cases of amniotic fluid embolism were identified among 1,004,116 deliveries, for a prevalence rate of 1 in 22,313 pregnancies. Statistically, significant association was found with multifetal pregnancy, caesarean section, placenta previa, placental abruption, eclampsia and cervical laceration. The rate of maternal complications such as coagulopathy, seizures, neurological damage, shock and cardiac arrest were significantly greater in the cases as compared with the overall study population. Neonatal morbidity was significant as demonstrated by higher NICU admissions and neonatal intubation rates and lower 5-min Apgar scores. CONCLUSIONS: Significant correlation was identified between historically reported risk factors and amniotic fluid embolism. The fetal and maternal mortality rates were lower compared with previous studies, attributed both to improvements in perinatal healthcare and reporting of 'milder' cases.

Characteristics of obstetric intensive care unit admissions in New Jersey.

OBJECTIVE: To assess the demographic characteristics, risk factors and perinatal outcomes among maternal intensive care unit (ICU) admissions in New Jersey from 1997 to 2005. METHODS: Data were obtained from a perinatal linked database from MCH epidemiology programme in New Jersey. Chi-square test was used for bivariate analysis and stepwise logistic regression was used to assess the influence of the potential risk factors and pregnancy complications. RESULTS: There were 15,447 (1.54%) ICU admissions and 23 maternal deaths (0.15%) among the 1,004,116 pregnancies. Analysis of demographic factors revealed that maternal age, race and smoking were significantly associated with ICU admission. Regression analysis adjusting for maternal age, parity, gravida, race, smoking status, maternal education and place of delivery found the following predictors for ICU admission, preeclampsia (odds ratio (OR): 2.8, 95% confidence interval (CI): 2.6-3.0), eclampsia (OR: 6.8, 95% CI: 5.4-8.6), placenta previa (OR: 3.0, 95% CI: 2.7-3.4), abruption (OR: 8.9, 95% CI: 8.3-9.6), multifetal pregnancy (OR: 4.2, 95% CI: 4.1-4.4), diabetes (OR: 3.1, 95% CI: 2.7-3.5), acute renal failure (OR: 22.1, 95% CI: 13.3-36.6) and cesarean delivery (OR: 1.9, 95% CI: 1.5-2.4). Infants born to ICU admitted mothers had higher rates of NICU admission, neonatal intubations and lower Apgar scores compared with infants born to non-ICU admitted mothers. CONCLUSION: Pregnancy complications are predictive of ICU admission amongst pregnant patients after adjusting for demographic factors.

Maternal obesity: can pregnancy weight gain modify risk of selected adverse pregnancy outcomes?

Reports by the Institute of Medicine (IOM) recommend that gestational weight gain goals should be modified according to prepregnancy body mass index (BMI), which could result in better maternal and infant outcomes. The authors assessed whether the risk of the pregnancy outcomes such as rate of cesarean section to primiparous and multiparous women, macrosomia, and breastfeeding at 10 weeks postpartum can be modified by following the IOM guidelines for gestational weight gain irrespective of prepregnancy BMI. Staff from the New Jersey Pregnancy Risk Assessment Monitoring System interviewed a sample of women who delivered live births in New Jersey during 2002 through 2005 (n = 7661). In New Jersey, 18% of mothers were obese, 13% were overweight, and 16% were underweight. In logistic regression analyses, after controlling for maternal characteristics, the effect of prepregnancy obesity and weight gain more than 34 lb independently and significantly increased the risk of all four adverse outcomes. For no outcomes was the 25- to 34-pound weight gain category significantly distinguishable from the 16- to 24-pound reference category. These results strongly support the idea that the IOM weight gain recommendation (education during preconception regarding the importance of optimal BMI at the start of pregnancy) will help to achieve better pregnancy outcomes in obese and overweight women.

Surveillance of cesarean section deliveries, New Jersey, 1999-2004.

BACKGROUND: Nationally and in New Jersey, the cesarean delivery rate has been increasing steadily for nearly a decade, and especially since 1999. The purpose of this study was to describe recent trends in cesarean section delivery in New Jersey. METHODS: Data on delivery method, medical indications and patient characteristics were extracted from electronic birth certificate files. RESULTS: Cesarean section deliveries increased as a proportion of live births by 6 percent annually. Growth was roughly uniform across Robson's clinical classification. Repeat cesareans contributed only proportionately to the overall trend. The greatest acceleration was observed for procedures without trial of labor, and in medical situations where cesarean delivery had been relatively rare. CONCLUSIONS: Medical indications recorded on the birth certificate explained little of the rapid growth in utilization of cesarean delivery, since trends were comparable in most categories we examined. A sustained autonomous shift in practice patterns, patient preferences, or both seems the most likely driver of the overall trend.

Shoulder dystocia at noninstrumental vaginal delivery.

This study examines the relationship between episiotomy and the occurrence of shoulder dystocia among noninstrumental vaginal deliveries. Analysis of data from a retrospective database was used to study noninstrumental vaginal deliveries in New Jersey during the years 1996 to 2001. The episiotomy group and nonepisiotomy group were analyzed separately using univariate and multivariate analysis. Among 358,664 deliveries, rate of shoulder dystocia was 1.0% (n = 3596). Thirty-five percent of deliveries were assisted by episiotomy. Rate of dystocia was 1.42% with the use of episiotomy, and 0.81% when episiotomy was not used. This increased rate with episiotomy was noted across all of the racial groups, all birthweight categories, and all of the risk factor subgroups analyzed. There was a gradual decrease in the use of episiotomy from 37.30 to 26.03% without a corresponding increase in the rate of dystocia. Among noninstrumental deliveries, the rate of shoulder dystocia is higher in the episiotomy group. Decrease in the use of episiotomy has not resulted in an increase in the occurrence of dystocia.

Efficacy of tobacco dependence treatment in the context of a "smoke-free grounds" worksite policy: a case study.

BACKGROUND: Smoking restrictions provide opportunities to modify smoking behavior. A large insurance company implemented a smoke-free grounds policy at two of their office complexes in January, 2000. METHODS: This cohort study evaluated the impact of the smoke-free grounds policy on abstinence among 128 employees who participated in a tobacco dependence treatment program. RESULTS: The overall quit rate at 6 months was 44.5%. The larger complex showed a trend for higher quit rates compared to the smaller complex (46.5 vs. 28.6%). Post-ban participants had higher quit rates than pre-ban participants (52.4 vs. 43.0%). The probability of abstinence at 6 months follow-up was higher for post-ban compared to pre-ban participants (P = 0.03). Post-ban participants were 80% less likely to relapse than pre-ban participants. Non-quitters decreased their consumption by 6.6 cigarettes/day (39.1% decrease). CONCLUSIONS: A "smoke-free grounds" policy encourages abstinence and may play a significant role in harm reduction among continuing tobacco users.