High nutrition risk related to dietary intake is associated with an increased risk of hospitalisation and mortality for older Māori: LiLACS NZ

Objectives : To investigate the association between domains of nutrition risk with hospitalisations and mortality for New Zealand Māori and non‐Māori in advanced age. Methods : Within LiLACS NZ, 256 Māori and 399 non‐Māori octogenarians were assessed for nutrition risk using the Seniors in the Community: Risk Evaluation for Eating and Nutrition (SCREEN II) questionnaire according to three domains of risk. Sociodemographic and health characteristics were established. Five years from inception, survival analyses examined associations between nutrition risk from the three domains of SCREEN II with all‐cause hospital admissions and mortality. Results : For Māori but not non‐Māori, lower nutrition risk in the Dietary Intake domain was associated with reduced hospitalisations and mortality (Hazard Ratios [HR] [95%CI] 0.97 [0.95–0.99], p=0.009 and 0.91 [0.86–0.98], p=0.005, respectively). The ‘Factors Affecting Intake’ domain was associated with mortality (HR, [95%CI] 0.94 [0.89–1.00], p=0.048), adjusted for age, gender, socioeconomic deprivation, education, previous hospital admissions, comorbidities and activities of daily living. Conclusion : Improved dietary adequacy may reduce poor outcomes for older Māori. Implications for public health : Nutrition risk among older Māori is identifiable and treatable. Effort is needed to engage relevant community and whānau (family) support to ensure older Māori have food security and cultural food practices are met.     

Dietary protein intake may reduce hospitalisation due to infection in Māori of advanced age: LiLACS NZ

Objective: To investigate factors related to hospital admission for infection, specifically examining nutrient intakes of Māori in advanced age (80+ years). Method: Face‐to‐face interviews with 200 Māori (85 men) to obtain demographic, social and health information. Diagnoses were validated against medical records. Detailed nutritional assessment using the 24‐hour multiple‐pass recall method was collected on two separate days. FOODfiles was used to analyse nutrient intake. National Health Index (NHI) numbers were matched to hospitalisations over a two‐year period (12 months prior and 12 months following dietary assessment). Selected International Classification of Disease (ICD) codes were used to identify admissions related to infection. Results: A total of 18% of participants were hospitalised due to infection, most commonly lower respiratory tract infection. Controlling for age, gender, NZ deprivation index, diabetes, CVD and chronic lung disease, a lower energy‐adjusted protein intake was independently associated with hospitalisation due to infection: OR (95%CI) 1.14 (1.00–1.29), p=0.046. Conclusions: Protein intake may have a protective effect on the nutrition‐related morbidity of older Māori. Improving dietary protein intake is a simple strategy for dietary modification aiming to decrease the risk of infections that lead to hospitalisation and other morbidities.     

The association of infant feeding with parent-reported infections and hospitalisations in the West Australian Aboriginal Child Health Survey

OBJECTIVE: To examine infant feeding associations with parent-reported infections and hospitalisations in Western Australian Aboriginal infants and children. METHOD: Families in Western Australia with children under 18 years of Aboriginal or Torres Strait Islander descent were included. A stratified multi-stage sample using an area-based sampling frame was compiled. Survey weights produced unbiased estimates for the population of families with Aboriginal children. Data were collected on demographic variables, maternal and infant characteristics and parent-reported recurring chest, ear and gastrointestinal infections. The data were linked to the Hospital Morbidity System to identify hospitalisations for infections for the same children. RESULTS: Twenty-seven per cent of Aboriginal children were breastfed for less than three months. Parent-reported recurring chest, ear and gastrointestinal infections were reported in 47% of the 0-3 age group. Hospitalisations due to upper respiratory and gastrointestinal infections were most common in the older children, but wheezing lower respiratory infections were most common in younger children. Breastfeeding for less than three months and birth weight less than 2,500 g were risk factors for parent-reported chest infections and hospitalisations for upper and wheezing lower respiratory infections (p<0.05). CONCLUSION: Rates of parent-reported chest infections and hospitalisations due to these infections continue to be high in Aboriginal infants and children. Because breastfeeding for less than three months and low birth weight are risk factors for these infections, interventions to reduce the prevalence of low birth weight and to increase breastfeeding rates should be primary health goals in Aboriginal communities for the benefits of Aboriginal infants and children.     

Household crowding associated with childhood otitis media hospitalisations in New Zealand

Objective : To examine the association between hospitalisations for otitis media and area‐level measures of household crowding among children in New Zealand. Methods : Counts of hospital admissions for otitis media by census area unit were offset against population data from the 2006 national census. Area‐level household crowding, exposure to tobacco smoke in the home, equivalised income and individual‐level characteristics age and sex were adjusted for. To examine effect modification by ethnicity, three separate poisson models were examined for the total, Māori and non‐Māori populations. Results : Household crowding was significantly associated with hospital admissions for otitis media after adjustment in all three models. Neighbourhoods with the highest compared to the lowest proportion of crowded homes exhibited incidence rate ratios of 1.25 (95%CI 1.12–1.37) in the total population, 1.59 (95%CI 1.21–2.04) in the Māori restricted model and 1.17 (95%CI 1.06–1.32) in the non‐Māori restricted model. Conclusions : Otitis media hospitalisations are associated with area‐level measures of household crowding and other risk factors in this ecological study. The largest increase in otitis media incidence relative to neighbourhood rates of household crowding was exhibited among Māori cases of otitis media. Implications : This study adds weight to the growing body of literature linking infectious disease risk to overcrowding in the home.     

Population‐Based Study of Risk Factors for Severe Maternal Morbidity

Background: Severe maternal morbidity (SMM) is a serious health condition potentially resulting in death without immediate medical attention, including organ failure, obstetric shock and eclampsia. SMM affects 20 000 US women every year; however, few population‐based studies have examined SMM risk factors. Methods: We conducted a population‐based case–control study linking birth certificate and hospital discharge data from Washington State (1987–2008), identifying 9485 women with an antepartum, intrapartum or postpartum SMM with ≥3‐day hospitalisation or transfer from another facility and 41 112 random controls. Maternal age, race, smoking during pregnancy, parity, pre‐existing medical condition, multiple birth, prior caesarean delivery, and body mass index were assessed as risk factors with logistic regression to estimate odds ratios (OR) and 95% confidence intervals [CI], adjusted for education and delivery payer source. Results: Older women (35–39: OR 1.65 [CI 1.52, 1.79]; 40+: OR 2.48 [CI 2.16, 2.81]), non‐White women (Black: OR 1.82 [CI 1.64, 2.01]; American Indian: OR 1.52 [CI 1.32, 1.73]; Asian/Pacific Islander: OR 1.30 [CI 1.19, 1.41]; Hispanic: OR 1.17 [CI 1.07, 1.27]) and women at parity extremes (nulliparous: OR 1.83 [CI 1.72, 1.95]; parity 3+: OR 1.34 [CI 1.23, 1.45]) were at greater risk of SMM. Women with a pre‐existing medical condition (OR 2.10 [CI 1.88, 2.33]), a multiple birth (OR 2.54 [CI 2.26, 2.82]) and a prior caesarean delivery (OR 2.08 [CI 1.93, 2.23]) were also at increased risk. Conclusion: The risk factors identified are not modifiable at the individual level; therefore, provider and system‐level factors may be the most appropriate target for preventing SMM.     

Improving survival disparities in cervical cancer between Māori and non‐Māori women in New Zealand: a national retrospective cohort study

Objective: Māori women in New Zealand have higher incidence of and mortality from cervical cancer than non‐Māori women, however limited research has examined differences in treatment and survival between these groups. This study aims to determine if ethnic disparities in treatment and survival exist among a cohort of Māori and non‐Māori women with cervical cancer. Methods: A retrospective cohort study of 1911 women (344 Māori and 1567 non‐Māori) identified from the New Zealand Cancer Register with cervical cancer (adenocarcinoma, adenosquamous or squamous cell carcinoma) between 1 January 1996 and 31 December 2006. Results: Māori women with cervical cancer had a higher receipt of total hysterectomies, and similar receipt of radical hysterectomies and brachytherapy as primary treatment, compared to non‐Māori women (age and stage adjusted). Over the cohort period, Māori women had poorer cancer specific survival than non‐Māori women (mortality hazard ratio (HR) 2.07, 95% confidence interval (CI): 1.63–2.62). From 1996 to 2005, the survival for Māori improved significantly relative to non‐Māori. Conclusion: Māori continue to have higher incidence and mortality than non‐Māori from cervical cancer although disparities are improving. Survival disparities are also improving. Treatment (as measured) by ethnicity is similar. Implications: Primary prevention and early detection remain key interventions for addressing Māori needs and reducing inequalities in cervical cancer in New Zealand.     

Risk factors for respiratory syncytial virus bronchiolitis hospital admission in New Zealand

This study assessed risk factors for respiratory syncytial virus (RSV) hospitalization and disease severity in Wellington, New Zealand. During the southern hemisphere winter months of 2003--2005, 230 infants aged < 24 months hospitalized with bronchiolitis were recruited. RSV was indentified in 141 (61%) infants. Comparison with data from all live hospital births from the same region (2003--2005) revealed three independent risk factors for RSV hospitalization: birth between February and July [adjusted risk ratio (aRR) 1.62, 95% confidence interval (CI) 1.5-2.29], gestation <37 weeks (aRR 2.29, 95% CI 1.48-3.56) and Māori ethnicity (aRR 3.64, 95% CI 2.27-5.85), or Pacific ethnicity (aRR 3.60, 95% CI 2.14-6.06). The high risk for Māori and Pacific infants was only partially accounted for by other known risk factors. This work highlights the importance of RSV disease in indigenous and minority populations, and identifies the need for further research to develop public health measures that can reduce health disparities.     

Determinants of infant feeding method in relation to risk factors for breast cancer

BACKGROUND: Breastfeeding is considered to be an important factor for maternal and children's health. However, the epidemiological findings related to the effect of breastfeeding on women's health, especially with respect to breast cancer development, are inconsistent. Determinants of infant feeding method may contribute to the inconsistency. METHODS: A total of 24,769 women aged 40-64 in Miyagi Prefecture, Japan, responded to a self-administered questionnaire survey in 1990. Using the data obtained from 22,085 parous women, we calculated odds ratios (ORs) for the choice of "breastfeeding only" during reproductive period. RESULTS: Late age at menarche (> or = 16 years, OR = 1.57) and high body mass index (BMI) at 20 years of age (> or = 24, OR = 1.31) were associated with the choice of breastfeeding only. Late age at birth of first child (> or = 28 years, OR = 0.29), history of breast cancer in mother (OR = 0.68), and high educational level (more than a high school education, OR = 0.53) reduced the possibility of choosing breastfeeding only. CONCLUSION: The results indicate that the choice of infant feeding method is associated with several breast cancer risk factors. Based on this finding, we should construct appropriate breast cancer risk models for parous women and investigate the changes in the effects of breastfeeding and other breast cancer risk factors among these risk models. Especially in a risk model controlling for breastfeeding, the effects of other breast cancer risk factors should be reevaluated. Through comparisons among different risk models, we may find the best-fitted risk model and identify the true effect of breastfeeding.     

Epidemiologic comparisons of the sudden infant death syndrome with other major components of infant mortality

All 1998 resident infant deaths in the 1969--1977 King County, Washington birth cohort of 139,132 resident live births comprise the data base for epidemiologic comparisons of the sudden infant death syndrome (SIDS) with eight other major infant mortality components: hyaline membrane disease; respiratory distress syndrome; asphyxia of the newborn; immaturity; birth injury; congenital malformation; infection; and "all other." These components were compared with respect to age at death; sex; race; prior fetal loss; prior live-born, now dead; birth plurality; birth weight; maternal age; birth order; marital status; prenatal care; and season of death in an attempt to determine the uniqueness of these purported SIDS risk factors. Only the age at death distribution unequivocally distinguished SIDS from the other components. The combination of low maternal age and multiparity was demonstrated to be putatively synergistic for risk of SIDS, hyaline membrane disease, and respiratory disease syndrome. Only deaths from infection exhibited seasonal variation similar to SIDS. These observations probably reflect secondary associations with as yet unidentified primary risk factors relatable to maternal experience.     

Potential impact of a maternal vaccine for RSV: A mathematical modelling study

Respiratory syncytial virus (RSV) is a major cause of respiratory morbidity and one of the main causes of hospitalisation in young children. While there is currently no licensed vaccine for RSV, a vaccine candidate for pregnant women is undergoing phase 3 trials. We developed a compartmental age-structured model for RSV transmission, validated using linked laboratory-confirmed RSV hospitalisation records for metropolitan Western Australia. We adapted the model to incorporate a maternal RSV vaccine, and estimated the expected reduction in RSV hospitalisations arising from such a program. The introduction of a vaccine was estimated to reduce RSV hospitalisations in Western Australia by 6–37% for 0–2 month old children, and 30–46% for 3–5 month old children, for a range of vaccine effectiveness levels. Our model shows that, provided a vaccine is demonstrated to extend protection against RSV disease beyond the first three months of life, a policy using a maternal RSV vaccine could be effective in reducing RSV hospitalisations in children up to six months of age, meeting the objective of a maternal vaccine in delaying an infant’s first RSV infection to an age at which severe disease is less likely.     

Predictors of Breastfeeding Duration among Women in Kuwait: Results of a Prospective Cohort Study

The purposes of this paper are to report the prevalence of breastfeeding to six months among women in Kuwait and to determine the factors that are associated with the duration of breastfeeding. A cohort of 373 women recruited from maternity wards in four hospitals in Kuwait city were followed from birth to 26 weeks postpartum. The association of any and full breastfeeding duration and predictor variables were explored using multivariate Cox’s proportional hazards models. At six months, 39% of all infants were receiving some breast milk and only 2% of infants had been fully breastfed to 26 weeks. Women born in other Arab countries were less likely to discontinue breastfeeding than women born in Kuwait. Other factors positively associated with breastfeeding duration were level of maternal education, higher parity, infant being demand fed in hospital and a preference for breastfeeding on the part of the infant’s father and maternal grandmother. The introduction of a pacifier before four weeks of age and the mother intending to return to work by six months were negatively associated with duration. These findings present a number of opportunities for prolonging breastfeeding duration in Kuwait.     

Geographic analysis of infant mortality in New Zealand, 1995–2008: an ethnicity perspective

Objective : To detect spatial clusters of high infant mortality rates in New Zealand for Māori and non‐Māori populations and verify if these clusters are stable over a certain time period (1995–2008) and similar between the two populations. Method : We applied the Kulldorff's spatial scan statistics on data collected by New Zealand Ministry of Health (1995 to 2008) at the territorial local authorities (TLA) level. Kappa coefficient was used to assess the concordance between clusters obtained for Māori and non‐Māori populations. T‐test analyses were conducted to identify associations between spatial clusters and two predictors (population density and deprivation score). Results : There are some significant spatial clusters of infant mortality in New Zealand for both Māori and Non‐Māori. The concordance of the cluster locations between the two populations is strong (kappa=0.77). Unsurprisingly, infant mortality clusters for both Māori and Non‐Māori are associated with the deprivation score. The population density predictor is only significantly and positively associated with clusters obtained for the non‐Māori population. After controlling for deprivation the presence of spatial clusters is all but eliminated. Conclusions : Infant mortality patterns are geographically similar for both Māori and Non‐Māori. However, there are differences geographically between the two populations after accounting for deprivation. Implications : Health services that can affect infant mortality should be aware of the geographical differences across NZ. Deprivation is an important factor in explaining infant mortality rates and policies that ameliorate its effects should be pursued, as it is the major determinant of the geographical pattern of infant mortality in NZ.     

Coronary artery bypass graft surgery: socioeconomic inequalities in access and in 30 day mortality. A population-based study in Rome, Italy

OBJECTIVES: To evaluate whether coronary artery bypass graft (CABG) surgery is equally provided among different socioeconomic status (SES) groups in accordance with need. To estimate the association between SES and mortality occurring 30 days after CABG surgery. DESIGN: Individual socioeconomic index assigned with respect to the characteristics of the census tract of residence (level I = highest SES; level IV = lowest SES). Comparison of age adjusted hospital admission rates of ischaemic heart disease (IHD) and CABG surgery among four SES groups. Retrospective cohort study of all patients who underwent CABG surgery during 1996-97. SETTING: Rome (2 685 890 inhabitants) and the seven cardiac surgery units in the city. PARTICIPANTS: All residents in Rome aged 35 years or more. A cohort of 1875 CABG patients aged 35 years or more. MAIN OUTCOME MEASURES: Age adjusted hospitalisation rates for CABG and IHD and rate of CABG per 100 IHD hospitalisations by SES group, taking level I as the reference group. Odds ratios of 30 day mortality after CABG surgery, adjusted for age, gender, illness severity at admission, and type of hospital where CABG was performed. RESULTS: People in the lowest SES level experienced an excess in the age adjusted IHD hospitalisation rates compared with the highest SES level (an excess of 57% among men, and of 94% among women), but the rate of CABG per 100 IHD hospitalisations was lower, among men, in the most socially disadvantaged level (8.9 CABG procedures per 100 IHD hospital admissions in level IV versus 14.1 in level I rate ratio= 0.63; 95% CI 0.44, 0.89). The most socially disadvantaged SES group experienced a higher risk of 30 day mortality after CABG surgery (8. 1%) than those in the highest SES group (4.8%); this excess in mortality was confirmed even when initial illness severity was taken into account (odds ratio= 2.89; 95% CI 1.44, 5.80). CONCLUSIONS: The universal coverage of the National Health Service in Italy does not guarantee equitable access to CABG surgery for IHD patients. Factors related to SES are likely to influence poor prognosis after CABG surgery.     

NICU出院患儿母乳喂养现状及影响因素的前瞻性研究

目的通过前瞻性研究方法,调查滨州医学院附属医院NICU出院患儿4月龄母乳喂养现状及影响因素,指导加强母乳喂养措施,促进母婴健康。方法 1)分别选取629例NICU出院患儿为实验组和638例正常产科出院婴儿为对照组;2)收集可能影响婴儿母乳喂养的13个变量,采用单因素方差分析、χ2检验及多因素Logistic回归分析婴儿4月龄母乳喂养影响因素。结果经Logistic回归分析,有统计学意义的影响因素为出生胎龄(OR=0.848,P=0.000),出生体重(OR=0.394,P=0.000),住院费用(OR=3.100,P=0.000),住院天数(OR=1.245,P=0.000),是否维持泌乳指导(OR=0.054,P=0.000)。结论低出生胎龄,低出生体重,住院费用,住院天数,未进行维持泌乳指导是影响母乳喂养的高危因素,应引起医护人员及婴儿家长的重视。     

The influence of maternal age on very preterm birth of twins: differential effects by parity

For singleton births, parity can modify the effect of maternal age on birth outcomes such as low birthweight and preterm birth; however, it is unknown whether this relationship exists for twin births. As the rate of twin births increases among older women, it is important to understand how parity may influence the relationship between maternal age and adverse birth outcomes. The NCHS Matched Multiple Birth Data Set, which contains all twin births in the USA from 1995 to 1998, was analysed. Parity was grouped into two levels (primiparous--no prior live births, and multiparous--at least one prior live birth), and maternal age was divided into the following groups: 20-24, 25-29, 30-34, 35-39, and 40 years or more. Very preterm birth was defined as births occurring before 33 weeks. Logistic regression was used to obtain odds ratios (OR) to estimate the risk of very preterm birth, and to determine the relationships between parity, maternal age, and very preterm birth. Among primiparae, women 40 years and older had a reduced risk of very preterm birth compared with women of 25-29 years (OR 0.74 [95% CI=0.66, 0.84]). Among multiparae, women 40 years and older had the same risk of very preterm birth compared with women of 25-29 years (OR 1.00 [95% CI=0.90, 1.12]). However, stratification by education revealed that the age gradient was limited to women with >12 years education among primiparae. The effect of maternal age on very preterm birth of twins differs according to parity. To some extent, that effect is further modified by education. Therefore, future analyses of maternal age and twin birth outcomes should account for measures of obstetric history and other factors, which may influence these results.     

Racial differences in birthweight for gestational age and infant mortality in extremely-low-risk US populations

Using national data, we develop and contrast the birth-weight percentiles for gestational age by infants of extremely-low-risk (ELR) White and African-American women and examine racial differences in the proportion of small-for-gestational-age (SGA) births. We then scrutinise racial variations in infant mortality rates of the infants of ELR women. We further compare the infant mortality rates of infants at or below the 10th percentile of birthweight for gestational age of each race group to determine whether infants with similar restricted fetal growth have comparable risks of subsequent mortality. Single live births, 34-42 weeks' gestation, to White and African-American US-resident mothers were selected from the 1990-91 US Linked Live Birth--Infant Death File (n = 4,360,829). Extremely-low-risk mothers were defined as: married, aged 20-34 years, 13+ years of education, multiparae, with average parity for age, adequate prenatal care, vaginal delivery, and no reports of medical risk factors, tobacco use or alcohol use during pregnancy. Marked racial variation in birthweight percentiles by gestational age was evident. Compared with ELR White mothers, the risk of an SGA infant was 2.64 times greater for ELR African-American mothers and the risk of infant mortality was 1.61 times greater. For the ELR group, the infant mortality rates of African-American and White infants at or below the 10th percentile of birthweight for gestational age of their respective maternal race group were essentially identical after controlling for gestational age. In conclusion, race differences in fetal growth patterns remained after controlling for risk status. Efforts to remove racial disparities in infant mortality will need to develop aetiological pathways that can explain why African-Americans have relatively higher rates of preterm birth and higher infant mortality rates among term and non-SGA infants.     

Labor Epidural Anesthesia, Obstetric Factors and Breastfeeding Cessation

Breastfeeding benefits both infant and maternal health. Use of epidural anesthesia during labor is increasingly common and may interfere with breastfeeding. Studies analyzing epidural anesthesia’s association with breastfeeding outcomes show mixed results; many have methodological flaws. We analyzed potential associations between epidural anesthesia and overall breast-feeding cessation within 30 days postpartum while adjusting for standard and novel covariates and uniquely accounting for labor induction. A pooled analysis using Kaplan–Meier curves and modified Cox Proportional Hazard models included 772 breastfeeding mothers from upstate New York who had vaginal term births of healthy singleton infants. Subjects were drawn from two cohort studies (recruited postpartum between 2005 and 2008) and included maternal self-report and maternal and infant medical record data. Analyses of potential associations between epidural anesthesia and overall breastfeeding cessation within 1 month included additional covariates and uniquely accounted for labor induction. After adjusting for standard demographics and intrapartum factors, epidural anesthesia significantly predicted breastfeeding cessation (hazard ratio 1.26 [95 % confidence interval 1.10, 1.44], p < 0.01) as did hospital type, maternal age, income, education, planned breastfeeding goal, and breastfeeding confidence. In post hoc analyses stratified by Baby Friendly Hospital (BFH) status, epidural anesthesia significantly predicted breastfeeding cessation (BFH: 1.19 [1.01, 1.41], p < 0.04; non-BFH: 1.65 [1.31, 2.08], p < 0.01). A relationship between epidural anesthesia and breastfeeding was found but is complex and involves institutional, clinical, maternal and infant factors. These findings have implications for clinical care and hospital policies and point to the need for prospective studies.     

Incidence and management of hepatocellular carcinoma among Māori and non‐Māori New Zealanders

Objective: To investigate time trends in hepatocellular carcinoma (HCC) incidence disparities, and ethnic differences in risk factors, comorbidity and treatment pathways among HCC patients. Methods: Cohorts of the NZ population (1981–2004) were created and probabilistically linked to cancer registry records to investigate trends in incidence by ethnicity over time. Hospital notes of 97 Māori and 92 non‐Māori HCC patients diagnosed between 01/01/2006 and 31/12/2008 in NZ's North Island were reviewed. Results: Liver cancer incidence was higher among Māori for all time periods. Compared with non‐Māori, Māori males had nearly five times the rate of liver cancer (pooled RR=4.79, 95% CI 4.14–5.54), and Māori females three times the rate (pooled RR= 3.02, 95% CI 2.33–3.92). There were no significant differences in tumour characteristics or treatment of Māori and non‐Māori patients with HCC. Māori more commonly had hypertension (51% versus 25%) while more non‐Māori had cirrhosis recorded (62% versus 41%). The prevalence of hepatitis B among Māori patients (56%; 95% CI 45%‐67%) was more than double that of non‐Māori (27%; 95% CI 19%‐36%). The hazard ratio for cancer‐specific death for Māori compared with non‐Māori was 1.36 (95% CI 0.96–1.92). Conclusions and implications: HCC remains an important health problem particularly for Māori men. Efforts to improve coverage of screening for hepatitis B and surveillance of those with chronic hepatitis should be a priority to address the large inequalities found in liver cancer epidemiology.     

The effects of maternal smoking on fetal and infant mortality

Although maternal cigarette smoking has been shown to reduce the birth weight of an infant, previous findings on the relation between smoking and fetal and infant mortality have been inconsistent. This study used the largest data base ever available (360,000 birth, 2,500 fetal death, and 3,800 infant death certificates for Missouri residents during 1979-1983) to assess the impact of smoking on fetal and infant mortality. Multiple logistic regression was used to estimate the joint effects of maternal smoking, age, parity, education, marital status, and race on total mortality (infant plus fetal deaths). Compared with nonsmoking women having their first birth, women who smoked less than one pack of cigarettes per day had a 25% greater risk of mortality, and those who smoked one or more packs per day had a 56% greater risk. Among women having their second or higher birth, smokers experienced 30% greater mortality than nonsmokers, but there was no difference by amount smoked. The prevalence of smoking in this population was 30%. It was estimated that if all pregnant women stopped smoking, the number of fetal and infant deaths would be reduced by approximately 10%. The higher rate of mortality among blacks compared with whites could not be attributed to differences in smoking or the other four maternal characteristics studied. In fact, the black-white difference was greater among low-risk women (e.g., married multiparas aged 20 and over with high education) than among high-risk women (e.g., unmarried teenagers with low education).     

Effects of maternal education, age, and parity on fatal infant accidents

Accidents are a major cause of death among children. Using computerized linked birth and death record information, this study examined the relationship of selected parental factors to the risk of infant accidental death. The analyses suggest that maternal age and education are inversely related to infant accident mortality while mother's parity is directly related. Accident mortality rate differentials by educational level were more evident for certain categories of accidents.