Maternal and Child Health Library
MCH Alert: Focus on Infant Mortality is developed by the Maternal
and Child Health Library in collaboration with the National Sudden
Infant Death Resource Center. This and past issues are available online
at http://www.mchlibrary.info/alert/archives.html and http://www.sidscenter.org/alert/archives.html.
June 27, 2008
1. Brief Outlines Opportunities to Improve Preconception
Health and Health Care
2. Analysis Examines Surveillance Data on Assisted
Reproductive Technology Procedures and Outcomes
3. Study Explores Relationship Between Obesity and
Neonatal Mortality in Black Women and White Women
4. Randomized Controlled Trial Investigates the Safety of
Dental Treatment in Pregnant Women
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Special Notices:
Prevention of Tobacco Use and Secondhand Smoke Exposure Before, During,
and After Pregnancy highlighted research, information, and programs at
the national, state, and local levels on smoking cessation among
pregnant and parenting women. The Webcast, presented on June 19, 2008,
by the National Association of City and County Health Officials,
included a discussion of systems-level approaches to smoking cessation
among pregnant and parenting women, as well as the connection between
environmental tobacco smoke and infant health. The Webcast archive is
available at http://webcasts.naccho.org/session-archived.php?id=1446.
The Surgeon General's Conference on the Prevention of Preterm Birth
convened experts and community leaders from the research, public
health, and medical communities in preliminary discussions to inform a
national agenda to prevent preterm birth. The Webcast, presented on
June 16-17, 2008, by the Office of the Surgeon General in partnership
with public and private organizations, was based on existing
recommendations from the Institute of Medicine’s (IOM's) 2006 report on
preterm birth and emerging literature concerning activities needed to
help prevent preterm birth. The agenda and background materials,
including the IOM reports, workgroup reports, and information on the
Prematurity Research Expansion and Education for Mothers Who Deliver
Infants Early (PREEMIE) Act, are available at http://www.nichd.nih.gov/about/meetings/2008/SG_pretermbirth.cfm.
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1.BRIEF OUTLINES OPPORTUNITIES TO IMPROVE PRECONCEPTION HEALTH AND
HEALTH CARE
Healthy Women, Healthy Babies identifies issues and obstacles facing
the United States in promoting preconception care and recommends
further actions to enhance women's health, and, consequently, to ensure
healthier infants. The issue brief, produced by Trust for America's
Health with support from the Annie E. Casey Foundation, is presented in
the following five parts: (1) overview; (2) moving into a new era of
well-woman care; (3) challenges; (4) federal, state, and local
initiatives; and (5) recommendations for preconception care. Topics
include the need for preconception care to become an integral part of
primary and preventive care for all women and for all couples and the
role of local health departments in promoting preconception health,
linking women to needed services, and providing care in underserved
areas. Additional topics include health disparities, insurance
coverage, clinical practice, health conditions and high-risk behaviors
that affect pregnancy outcomes, and strategies to reduce risk and
improve outcomes. The report is available at http://healthyamericans.org/reports/files/BirthOutcomesLong0608.pdf.
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2. ANALYSIS EXAMINES SURVEILLANCE DATA ON ASSISTED REPRODUCTIVE
TECHNOLOGY PROCEDURES AND OUTCOMES
"Balancing the chance of success of ART [assisted reproductive
technology] against the risk for multiple births is challenging," state
the authors of a report published in the June 20, 2008, issue of
Morbidity and Mortality Weekly Report Surveillance Summaries. ART
includes fertility treatments in which both eggs and sperm are handled
in the laboratory (i.e., in vitro fertilization and related
procedures). The use of ART has increased steadily in the United States
since 1996, when ART surveillance began. The primary focus in
collecting ART data has been on live-birth deliveries as an indicator
of success. However, success-rate data should be balanced with
consideration of effects on maternal and infant health. Data collected
on pregnancy outcomes of public health significance enables monitoring
of risks associated with ART. The emphasis of this report is on
presenting state-specific data and more detailed data about risks
(e.g., multiple births, preterm delivery, and low birthweight)
associated with ART.
The report is based on ART surveillance data provided to the Centers
for Disease Control and Prevention (CDC) relevant to procedures
performed in 2005. Data collected include patient demographics, medical
history and infertility diagnoses, clinical information pertaining to
the ART procedure, and information on resultant pregnancies and births.
The data file is organized with one record per ART procedure performed.
Multiple procedures from a single patient are not linked.
The authors found that
- A total of 134,260 ART procedures performed in 2005 were reported
to CDC.
- The 38,910 live-birth deliveries from ART procedures performed in
2005 resulted in 52,041 infants.
- The largest number of ART procedures occurred among patients who
used their own freshly fertilized embryos (97,442 [73%]).
- Overall, 42% of ART procedures that progressed to the transfer
stage resulted in a pregnancy; 35% resulted in a live-birth delivery.
- ART procedures that used donor eggs and freshly fertilized
embryos had the highest success rates (61% pregnancy rate, 52%
live-birth rate, and 31% singleton live-birth rate), and procedures
using the patient's eggs and thawed embryos had the lowest (36%
pregnancy rate, 28% live-birth rate, and 22% singleton live-birth rate).
- The two states that had the most ART medical centers (California
and New York) also had the highest numbers of ART procedures performed.
- Of 52,041 infants born through ART, 49% (25,469) were born in
multiple-birth deliveries.
- Of 4,138,349 infants born in the United States in 2005, a total
of 49,308 (1%) were conceived with ART.
- The percentage of low-birthweight infants varied from 9% among
singletons to 95% among triplets or higher-order multiples. The
percentages of very-low-birthweight, preterm, and preterm
low-birthweight infants followed similar patterns.
"Implementation of approaches to limit the number of embryos
transferred for patients undergoing ART should reduce the occurrence of
multiple births resulting from ART," state the authors. They conclude
that "continued research is needed to understand the adverse effects of
ART on maternal and child health."
Wright VC, Chang J, Jeng J, et al. 2008. Assisted reproductive
technology surveillance -- United States, 2005. MMWR Surveillance
Summaries 57(SS05):1-23. Available at http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5705a1.htm?s_cid=ss5705a1_e.
Readers: More information is available from the following MCH Library
resource:
- Assisted Reproductive Technologies: Selected Resources at
http://www.mchlibrary.info/guides/ART.html
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3. STUDY EXPLORES RELATIONSHIP BETWEEN OBESITY AND NEONATAL MORTALITY
IN BLACK WOMEN AND WHITE WOMEN
"Our study found maternal obesity to be an independent risk factor for
neonatal mortality among blacks but not whites," state the authors of
an article published in the June 2008 issue of Obstetrics and
Gynecology. During the previous two decades, the prevalence of obesity
(particularly morbid or extreme obesity) has been rising continuously
in the United States, especially among women. Currently, information on
the association between obesity and neonatal survival is sparse. The
study described in this article sought to estimate the effect of
maternal obesity on neonatal survival using a data source that has
consistently obtained pre-pregnancy body mass index (BMI) indices as
well as infant survival data for almost two decades. Although the
article focuses primarily on maternal obesity in general, the authors
also examine gradation of obesity as well as obesity-related
black-white disparity in neonatal survival.
Data for the study comes from Missouri maternally linked cohort data
files covering the period 1978-1997. The authors selected singleton
live births within the gestational age range of 20-44 weeks. BMI was
used to define maternal pre-pregnancy weight groups. Women were
assigned to the following BMI-based categories: normal (18.5-24.9),
class I obesity (30.0-34.9), class II obesity (35.0-39.9), and morbid
or extreme obesity (40 or higher). The authors considered information
on the following maternal characteristics to evaluate any differences
in sociodemographic features between obese and non-obese mothers: race
(black or white), maternal age, marital status, educational status,
cigarette smoking during pregnancy, and adequacy of prenatal care. The
outcome of interest was neonatal mortality, which was defined as death
occurring between the day of birth (day 0) and 27 days after birth (day
27). Neonatal mortality was further subdivided into early neonatal
mortality (days 0-6) and late neonatal mortality (days 7-27).
The authors found that
- The number of mother-infant pairs analyzed was 1,405,698.
- Approximately 9.5% of mothers (12.8% of black mothers and 8.9% of
white mothers) were categorized as obese based on a BMI greater than 30.
- Among obese mothers, class I obesity was most common (5.9%),
followed by class II obesity (2.3%), and extreme or morbid obesity
(1.3%).
- A comparison of the distribution of the three classes of obesity
indicated a preponderance of black mothers in all obesity subclasses:
(class I: 7.5% vs. 5.6%), class II (3.2% vs. 2.2%), and extreme or
morbid obesity (2.1% vs. 1.1%).
- Neonates born to obese white women had risk levels for neonatal
mortality similar to those born to non-obese women, regardless of the
severity of obesity.
- Neonates born to obese black women had significantly elevated
risks for neonatal death that increased in a monotonic fashion with the
mother's increasing BMI.
- These contrasting results for white and black neonates were
confirmed in the early and late neonatal periods.
The authors conclude that "the results suggest a possible avenue for
targeting interventions that aim to reduce the black-white disparity in
infant survival, a problem that has been persistent for decades in the
United States."
Salihu HM, Alio AP, Wilson RE, et al. 2008. Obesity and extreme
obesity: New insights into the black-white disparity in neonatal
mortality. Obstetrics and Gynecology 111(6):1410-1416. Abstract
available at http://www.greenjournal.org/cgi/content/abstract/111/6/1410.
Readers: More information is available from the following MCH Library
resources:
- Infant Mortality: Knowledge Path at
http://www.mchlibrary.info/KnowledgePaths/kp_infmort.html
- Pregnancy and Preconception: Knowledge Path at
http://www.mchlibrary.info/KnowledgePaths/kp_pregnancy.html
- Racial and Ethnic Disparities in Health: Knowledge Path at
http://www.mchlibrary.info/KnowledgePaths/kp_race.html
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4. RANDOMIZED CONTROLLED TRIAL INVESTIGATES THE SAFETY OF DENTAL
TREATMENT IN PREGNANT WOMEN
"In this population, periodontal treatment and EDT [essential dental
treatment], administered at 13 to 21 weeks' gestation, did not
significantly increase the risk of any adverse outcome evaluated,"
state the authors of an article published in the June 2008 issue of the
Journal of the American Dental Association. Collectively, recent
findings suggest that use of oral health services during pregnancy may
be driven more by attitudes than by economics or convenience. Attitudes
and behaviors may be influenced by fear of harm to the pregnant woman
or fetus, fear of litigation, or patient safety concerns. The article
describes safety outcomes related to the provision of oral health care
in pregnant women.
Data for the study were drawn from a multi-center randomized controlled
clinical trial (the Obstetrics and Periodontal Therapy [OPT] Trial)
conducted to determine whether periodontal therapy in pregnant women
reduces the risk of preterm delivery. The study sample included women
recruited from obstetrics clinics serving minority and other
underserved groups who are at an elevated risk of experiencing preterm
birth. All women had periodontitis. A total of 413 women were randomly
assigned to receive scaling and root planing at a time before 21 weeks'
gestation. The 410 women in the control group were monitored during
their pregnancy and treated with scaling and root planing after
delivery. Women in both groups were also evaluated for EDT needs
(defined as the presence of moderate-to-severe caries or fractured or
abscessed teeth). The analysis examined associations between adverse
pregnancy outcomes (spontaneous abortion or fetal death, pregnancy
ending before 37 weeks' gestation, fetal or congenital anomaly) and
EDT, anesthetic use during nonsurgical periodontal treatment, and
combinations of EDT and periodontal treatment.
The authors found that
- EDT administered at 13 to 21 weeks' gestation was not associated
with an increased risk of experiencing serious medical adverse events,
preterm (less than 37 weeks' gestation) deliveries, spontaneous
abortions or fetal deaths, or fetal anomalies.
- Use of topical and local anesthetics for scaling and root planing
was not associated with an increased risk of experiencing these adverse
events and outcomes.
"Several ongoing randomized controlled intervention trials should help
to define more precisely the risk of adverse pregnancy outcomes
associated with nonsurgical periodontal procedures, including the risk
of spontaneous abortion and stillbirth," state the authors.
"Nevertheless," the authors conclude, "our study provides evidence that
dental care providers can safely meet the preventive and routine
treatment needs of their pregnant patients."
Michalowicz BS, DiAngelis AJ, Novak MJ, et al. 2008. Examining the
safety of dental treatment in pregnant women. The Journal of the
American Dental Association 139(6):685-695. Abstract available at http://jada.ada.org/cgi/content/short/139/6/685.
Readers: More information is available from the following MCH Library
resource:
- Oral Health and Pregnant Women, Infants, Children, and Adolescents at
http://www.mchlibrary.info/KnowledgePaths/kp_oralhealth.html
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MCH Alert © 1998-2008 by National Center for Education in Maternal
and
Child Health and Georgetown University. MCH Alert: Focus on Infant
Mortality is produced by
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Health
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