Prospective Analysis of Health and Mortality Risk in Veteran and Non-Veteran Participants in the Women's Health Initiative

BackgroundThe health of postmenopausal women veterans is a neglected area of study. A stronger empirical evidence base is needed, and would inform the provision of health care for the nearly 1 million U.S. women veterans currently 50 years of age or older. To this end, the present work compares salient health outcomes and risk of all-cause mortality among veteran and non-veteran participants of the Women's Health Initiative (WHI).MethodsThis study features prospective analysis of long-term health outcomes and mortality risk (average follow-up, 8 years) among the 3,706 women veterans and 141,009 non-veterans who participated in the WHI Observational Study or Clinical Trials. Outcome measurements included confirmed incident cases of cardiovascular disease (CVD), cancer, diabetes, hip fractures, and all-cause mortality.ResultsWe identified 17,968 cases of CVD, 19,152 cases of cancer, 18,718 cases of diabetes, 2,817 cases of hip fracture, and 13,747 deaths. In Cox regression models adjusted for age, sociodemographic variables, and health risk factors, veteran status was associated with significantly increased risk of all-cause mortality (hazard ratio [HR], 1.13; 95% CI, 1.03–1.23), but not with risk of CVD (HR, 1.00; 95% CI, 0.90–1.11), cancer (HR, 1.04; 95% CI, 0.95–1.14), hip fracture (HR, 1.16; 95% CI, 0.94–1.43), or diabetes (HR, 1.00; 95% CI, 0.89–1.1).ConclusionsWomen veterans' postmenopausal health, particularly risk for all-cause mortality, warrants further consideration. In particular, efforts to identify and address modifiable risk factors associated with all-cause mortality are needed.     

Residual confounding explains the association between high parity and child mortality

Background

This study used data from recent Demographic and Health Surveys (DHS) to examine the impact of high parity on under-five and neonatal mortality. The analyses used various techniques to attempt eliminating selection issues, including stratification of analyses by mothers’ completed fertility.

Methods

We analyzed DHS datasets from 47 low- and middle-income countries. We only used data from women who were age 35 or older at the time of survey to have a measure of their completed fertility. We ran log-binominal regression by country to calculate relative risk between parity and both under-five and neonatal mortality, controlled for wealth quintile, maternal education, urban versus rural residence, maternal age at first birth, calendar year (to control for possible time trends), and birth interval. We then controlled for maternal background characteristics even further by using mothers’ completed fertility as a proxy measure.

Results

We found a statistically significant association between high parity and child mortality. However, this association is most likely not physiological, and can be largely attributed to the difference in background characteristics of mothers who complete reproduction with high fertility versus low fertility. Children of high completed fertility mothers have statistically significantly increased risk of death compared to children of low completed fertility mothers at every birth order, even after controlling for available confounders (i.e. among children of birth order 1, adjusted RR of under-five mortality 1.58, 95% CI: 1.42, 1.76). There appears to be residual confounders that put children of high completed fertility mothers at higher risk, regardless of birth order. When we examined the association between parity and under-five mortality among mothers with high completed fertility, it remained statistically significant, but negligible in magnitude (i.e. adjusted RR of under-five mortality 1.03, 95% CI: 1.02-1.05).

Conclusions

Our analyses strongly suggest that the observed increased risk of mortality associated with high parity births is not driven by a physiological link between parity and mortality. We found that at each birth order, children born to women who have high fertility at the end of their reproductive period are at significantly higher mortality risk than children of mothers who have low fertility, even after adjusting for available confounders. With each unit increase in birth order, a larger proportion of births at the population level belongs to mothers with these adverse characteristics correlated with high fertility. Hence it appears as if mortality rates go up with increasing parity, but not for physiological reasons.

     

Early mortality among aboriginal and non-aboriginal women who had a preterm birth in Western Australia: A population-based cohort study

Background

Having a preterm (<37 weeks' gestation) birth may increase a woman's risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women.

Objectives

We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status.

Methods

This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cause-specific mortality.

Results

There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95% CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95% CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95% CI 1.32, 1.66) and 1.35 (95% CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes.

Conclusions

Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening.     

Anthropometric measures and risk of all-cause and cardiovascular mortality: An 18 years follow-up

BackgroundThe contribution of anthropometric measures to predict mortality in normal-weight subjects is unclear. We aimed to study the association of central obesity measures, e.g., waist circumference (WC), waist-to-hip ratio (WHR), waist-to-height ratio (WHtR), with the risk of all-cause and CVD mortality.MethodsIn a prospective population-based Tehran Lipid and Glucose Study, 8287 participants aged ≥30 y, followed for a median of 18 years. The association of WC, WHR and WHtR with the risk for mortality was estimated using multivariate Cox proportional hazard models in different BMI groups.ResultsWe documented 821 deaths, of which 251 were related to CVD mortality. Normal weight individuals with central obesity were significantly at increased risk of all-cause (HR: 1.5; 95% CI: 1.10, 2.1) and CVD mortality (HR: 1.6; 95% CI: 0.92, 2.9) compared with normal-weight individuals without central obesity; the risk remained significant only in women. Also, normal-weight women (not men) with high WHR were at increased risk of all-cause (HR: 1.7; 95% CI: 1.0, 2.8) and CVD mortality (HR: 5.9; 95% CI: 1.5, 23.2). High WHtR increased the risk of all-cause (HR: 1.5; 95% CI: 1.2, 1.8) and CVD mortality (HR: 1.8; 95% CI: 1.2, 2.7) which remained significant in normal-weight men and women. All central obesity indicators were significantly associated with all-cause and CVD mortality in subjects aged under 65.ConclusionEven in normal-weight individuals, WC and WHR in women and WHtR in both sexes are predictors of all-cause and CVD mortality. WHtR shows a stronger association, especially in the population aged under 65.     

Predicting cause-specific mortality of older men living in the veterans home by handgrip strength and walking speed: a 3-year, prospective cohort study in Taiwan

ObjectiveTo determine prognostic value of handgrip strength (HGS) and walking speed (WS) in predicting the cause-specific mortality for older men.DesignProspective cohort study.SettingBanciao Veterans Care Home.Participants558 residents aged 75 years and older.MeasurementsAnthropometric data, lifestyle factors, comorbid conditions, biomarkers, HGS, and WS at recruitment; all-cause and cause-specific mortality at 3 years after recruitment.ResultsDuring the study period, 99 participants died and the baseline HGS and WS were significantly lower than survivors (P both <.001). Cox survival analysis showed that subjects with slowest quartile of WS were at significantly higher risk of all-cause mortality and cardiovascular mortality (hazard ratio [HR] 3.55, 95% confidence interval [CI] 1.69–7.43; HR 11.55, 95% CI 2.30–58.04, respectively), whereas the lowest quartile of HGS significantly predicted a higher risk of infection-related death (HR 5.53, 95% CI 1.09–28.09). Participants in the high-risk status with slowest quartile for WS but not those in the high-risk status with weakest quartile for HGS had similar high risk of all-cause mortality with the group with combined high-risk status (HR 2.96, 95% CI 1.68–5.23; HR 2.58, 95% CI 1.45–4.60, respectively) compared with the participants without high-risk status (reference group).ConclusionsSlow WS predicted all-cause and cardiovascular mortality, whereas weak HGS predicted a higher risk of infection-related death among elderly, institutionalized men in Taiwan. Combining HGS with WS simultaneously had no better prognostic value than using WS only in predicting all-cause mortality.     

Impact of Prenatal Care on Infant Survival in Bangladesh

Despite improvements in public health in recent decades, levels of infant and child mortality remain unacceptably high, particularly in developing countries where primary healthcare services including prenatal care services are not universally available. Using information on 7,001 childbirths in five years preceding the 2004 Bangladesh Demographic and Health Survey, this study examined the relationship between receiving prenatal care during pregnancy and infant mortality using multivariate survival analysis. The results are presented in hazard ratios (HR) with 95% confidence intervals (95% CI). Results indicate that children of mothers who did not receive prenatal care during pregnancy were more than twice as likely to die during infancy as children whose mothers received prenatal care during pregnancy (HR=2.40, 95% CI: 1.74, 3.31) independent of child's sex, delivery assistance, birth order; mother's age at child birth, nutritional status, education level; household living conditions, and other factors. Children born to older mothers living in households without safe drinking water were at an increased risk. The study concludes that prenatal care is strongly negatively associated with infant mortality in Bangladesh independent of other risk factors. The results suggest that improving prenatal care services at the community level is key to improving child survival in Bangladesh. Informed consent : This study is based on an analysis of existing survey data with all identifier information removed. The survey acquired informed consent from mothers of the children included in this study before asking any questions and before obtaining anthropometric measurements.     

Frailty Status Predicts All-Cause and Cause-Specific Mortality in Community Dwelling Older Adults

ObjectivesTo examine the relationship between frailty status and risk of all-cause and cause-specific mortality.DesignLongitudinal cohort study with an 11-year follow up.Setting and participantsData from the Survey on Health, Aging and Retirement in Europe (SHARE) were used. In the analysis, we included data from 11 European countries. We included men and women older than 50 years residing in Europe. Overall, 24,634 participants were analyzed with a mean age of 64.2 (9.8), 53.6% female, where 14.7% and 6.9% were found to be prefrail or frail, respectively, at the baseline.MethodsFrailty status was calculated using the SHARE–Frailty Instrument, categorizing the participants as robust, prefrail, and frail. Multivariate Cox regression models were used to estimate the risk of all-cause and cause-specific (stroke, heart attack, other cardiovascular disease, cancer, respiratory illness, infectious, and digestive and other) mortality.ResultsDuring the follow-up, and after adjusting for sex, age, education, body mass index, smoking, alcohol consumption, and number of comorbidities, frailty was associated with a higher risk of all-cause (HR 2.17, 95% CI 1.90-2.48) and mortality due to stroke (HR 2.06, 95% CI 1.37-3.10), heart attack (HR 1.67, 95% CI 1.19-2.34), other cardiovascular disease (HR 2.77, 95% CI 1.87-4.12), cancer (HR 2.11, 95% CI 1.63-2.73), respiratory disease (HR 2.76, 95% CI 1.66-4.60), infectious diseases (HR 1.79, 95% CI 1.03-3.11), and digestive and other causes (HR 2.02, 95% CI 1.51-2.71). Prefrailty was associated with a higher risk of all-cause (HR 1.47, 95% CI 1.31-1.63), heart attack (HR 1.31, 95% CI 1.01-1.72), other cardiovascular disease (HR 2.03, 95% CI 1.46-2.81), respiratory disease (HR 1.70, 95% CI 1.09-2.65), and digestive and other causes (HR 1.50, 95% CI 1.18-1.91) mortality.Conclusions and implicationsBaseline prefrailty and frailty are associated with increased all-cause and cause-specific mortality over an 11-year follow up. Public health policy should include preventive programs aimed at older adults to prevent frailty and reduce mortality.     

Maternal Age at Menarche and Pubertal Timing in Boys and Girls: A Cohort Study From Chongqing,China

PurposeThis study explored the association of maternal age at menarche (AAM) with pubertal timing among girls and boys in Chongqing, China.MethodsPubertal development of 1,237 children (542 girls and 695 boys) were examined half-yearly through inspection and palpation from April 2014 to June 2019. Characteristics of parents and maternal AAM were collected by a parental questionnaire at baseline. Maternal AAM was used both as a continuous and a categorical variable in Cox regression models.ResultsA total of 1,198 children (528 girls and 670 boys) were included in the study. In the simple Cox model, earlier maternal AAM was associated with girls' earlier menarche, breast and pubic hair development, and boys' first ejaculation, testicular development, and genital development. When adjusting for children's body mass index z-scores (BMIz) and socioeconomic covariates, we found that girls whose mothers had early AAM had a higher risk of earlier onset of menarche (hazard ratio [HR]: .922, 95% confidence interval [CI]: .852–.998 for continuous maternal AAM, HR: 1.297, 95% CI: 1.041–1.616 for maternal AAM ≤13 years), and boys whose mother achieved menarche earlier experienced a higher risk of earlier onset of first ejaculation (HR: .896, 95% CI: .830–.968). Children's BMIz were related to all nine pubertal milestones. Parental education and relationship, birth weight, parity, and family type were also associated with pubertal timing.ConclusionsEarlier maternal AAM was related to earlier pubertal timing in both girls and boys in Chongqing, especially girls' age at menarche and boys' first ejaculation. Children's BMIz was the most consistent factor for pubertal timing. Children's BMIz and socioeconomic conditions had greater influence on most pubertal milestones than maternal AAM.     

Parity and risk of death from lung cancer among a cohort of premenopausal parous women in Taiwan

Background

We examined the association between parity and risk of lung cancer.

Methods

The study cohort consisted of all women with a record of a first singleton birth in the Taiwanese Birth Register between 1978 and 1987. We tracked each woman from the time of their first childbirth to 31 December 2009. Follow-up was terminated when the mother died, when she reached age 50 years, or on 31 December 2009, whichever occurred first. The vital status of mothers was ascertained by linking records with the computerized mortality database. Cox proportional hazard regression models were used to estimate hazard ratios (HRs) for death from lung cancer associated with parity.

Results

There were 1375 lung cancer deaths during 32 243 637.08 person-years of follow-up. The mortality rate of lung cancer was 4.26 cases per 100 000 person-years. As compared with women who had given birth to only 1 child, the adjusted HR was 1.13 (95% CI, 0.94–1.35) for women who had 2 children, 1.10 (0.91–1.33) for those who had 3 children, and 1.22 (0.96–1.54) for those who had 4 or more children.

Conclusions

The findings suggest that premenopausal women of higher parity tended to have an increased risk of lung cancer, although the trend was not statistically significant.Key words: lung cancer, parity, mortality, cohort study     

Ethnic differences in all-cause and cardiovascular mortality by physical activity levels among older adults in the US

Aims: This study sought to determine whether the association between varying levels of physical activity (PA) and all-cause and cardiovascular mortality differ by race/ethnicity in older adults.

Methods: The sample comprised 2520 women and 2398 men drawn from National Health and Nutrition Examination Survey III (1988–1994) aged?≥?60 years. We used the metabolic equivalent (MET) of self-reported PA levels to define activity groups (inactive: those who did not report any PA; active: those who reported 3–6 METs for ≥5 times/week or >6 METs, ≥3 times/week; insufficiently active: those meeting neither criteria). Racial/Ethnic differences were modeled using proportional hazard regression (HR) adjusting for age, education, smoking, diabetes, and hypertension.

Results: Among those classified as inactive, Non-Hispanic Blacks (NHB) (HR: 0.72, 95% CI: 0.58–0.90) and Mexican Americans (HR: 0.59, 95%CI: 0.45–0.78) had a lower risk of all-cause mortality when compared to non-Hispanic Whites (NHW). Among those classified as insufficiently active, Mexican Americans (HR: 0.63, 95% CI: 0.51–0.77), but not NHB (HR: 0.81, (95% CI: 0.64–1.02) had a lower risk of all-cause mortality when compared to NHWs Similar results were observed for cardiovascular mortality.

Conclusion: Overall, PA in the elderly (either insufficient or active) is associated with a lower all-cause mortality across all race/ethnic groups as compared to NHW. Further investigation, including studies with larger sample, is needed to address the health consequences of varying degrees of PA in ethnically diverse populations.     

Causes of Mortality and Risk Factors for Injury Mortality Among Children in the Agricultural Health Study

Abstract

Farm children face unique health risks due to sharing their residential environment with hazardous machinery and materials. Causes of mortality among farm children have not been comprehensively described.

Objective: In the Agricultural Health Study (AHS) cohort, we examined causes of mortality among 21,360 children in Iowa and North Carolina between 1975 and 1998.

Methods: We matched identifying information for children provided by mothers on self-administered questionnaires to state death registries (1975–1998). Data on farm and family characteristics were provided by parents via enrollment questionnaires (1993–1997). Standardized mortality ratios (SMRs) were calculated, using state mortality data to generate expected deaths. We used logistic regression to examine parent, child and farm characteristics associated with injury mortality.

Results: There were 162 deaths in Iowa (SMR = 0.69; 95% confidence interval (CI) = 0.60, 0.81) and 26 deaths in North Carolina (SMR = 0.42; 95%CI = 0.28, 0.61) in children aged 0–19 years. This deficit was largely due to deaths in the first year of life. Although deaths from overall unintentional injury were not increased, excess agricultural machinery mortality was observed in Iowa (SMR = 9.25; 95% CI = 5.12, 16.70). In case-control comparisons, maternal age less than 25 years at child's birth (OR = 2.17; 95%CI = 1.05, 4.49) and having more than 2 children in the family (OR = 2.79; 95%CI = 1.47, 5.30) were associated with increased child injury mortality. For children under 14 years, participation in farm work was associated with increased risk of agricultural machine-related mortality (OR = 3.92; 95% CI = 1.04, 14.78).

Conclusions: Parent and child characteristics associated with child injury mortality could be used to target farm safety interventions.     

Maternal Smoking, Breastfeeding, and Risk of Childhood Overweight: Findings from a National Cohort

To examine the association between exposure to tobacco compounds in breast milk and risk of childhood overweight, we used historical data for a subset of 21,063 mother–child pairs in the US Collaborative Perinatal Project. Based on self-reports, mothers were classified as non-smokers, light (1–9 cigarettes/day), moderate (10–19), or heavy (20+) smokers. Feeding type (exclusive breastfeeding or bottle-feeding) was observed during nursery stay after birth. We stratified children by maternal smoking and feeding type, and then fit interaction terms to isolate exposure to tobacco compounds via breast milk from exposure in uterus and in ambient air after birth. Using measured weight and height, overweight at age 7 was defined as a body mass index ≥85th percentile by sex and age. Among exclusively bottle-fed children, adjusted odds ratios (ORs) of overweight at age 7 were 1.24 (95 % confidence interval [CI], 1.12–1.38; vs. non-smoking) for light maternal smoking, 1.43 (95 % CI, 1.25–1.63) for moderate maternal smoking, and 1.46 (95 % CI, 1.28–1.66) for heavy maternal smoking. Among exclusively breastfed children, the corresponding ORs were 1.33 (95 % CI, 0.96–1.84) for light, 1.86 (95 % CI, 1.27–2.73) for moderate, and 2.22 (95 % CI, 1.53–3.20) for heavy maternal smoking. There was a modest positive interaction between breastfeeding and heavy maternal smoking on overweight risk at age 7. Tobacco compounds via breast milk of smoking mothers (significantly for heavy smokers) appear to be associated with a modest elevation in childhood overweight risk at 7 years of age. More aggressive intervention is needed to help pregnant and breastfeeding women to quit smoking.     

Birth weight predicts the risk of gestational diabetes mellitus and pregravid obesity

ObjectivesIt has been suggested that birth weight may determine metabolic abnormalities later in life. The aim of the current study was to assess the association between birth weight and future risk of gestational diabetes mellitus (GDM) and pregravid obesity in a homogenous sample of Caucasian Polish women.MethodsIn this retrospective study, we collected the medical reports of 787 women with GDM and 801 healthy pregnant women. We analyzed the following data: birth weight, age, pregravid weight, prior GDM, prior macrosomia, parity, and family history of diabetes.ResultsBirth weight was inversely associated with the risk of GDM; for each decrease in birth weight of 500 g, the risk increased by 11% (odds ratio [OR], 1.11; 95% confidence interval [CI], 1.02–1.21). Birth weight was a strong predictor of GDM independent of other risk factors (OR, 1.19; 95% CI, 1.09–1.31), and it was positively correlated with pregravid weight (R = 0.21; P < 0.00001). An increase in birth weight of 500 g substantially increased the risk of overweight and obesity (OR, 1.17; 95% CI, 1.01–1.34 and OR, 1.35; 95% CI 1.11–1.64, respectively). Each of the traditional risk factors for GDM were also strong predictors of pregravid obesity: age (P < 0.0001), prior GDM (P < 0.01), prior macrosomia (P < 0.0001), multiparity (P < 0.0001), and maternal (but not paternal) history of diabetes (P < 0.0001).ConclusionsAmong Caucasian Polish women, the risk of GDM is associated with low birth weight, and pregravid obesity is associated with high birth weight. Traditional risk factors for GDM, including maternal (but not paternal) history of diabetes, are also risk factors for pregravid obesity.     

Risk Factors for Non-use of Skilled Birth Attendants: Analysis of South Sudan Household Survey, 2010

Objectives South Sudan has the lowest percentage of births attended by skilled health personnel in the world. This paper aims to identify potential risk factors associated with non-use of skilled birth attendants at delivery in South Sudan. Methods Secondary data analyses of the 2010 South Sudan Household Health Survey second round were conducted with data for 3504 women aged 15–49 years who gave birth in the 2 years prior to the survey. The risk of non-use of skilled birth attendants was examined using simple and multiple logistic regression analyses. Results The prevalence rates for skilled, unskilled and no birth attendants at delivery were 41 [95 % confidence interval (CI) 38.2, 43.0], 36 [95 % CI 33.9, 38.8], and 23 % [95 % CI 20.6, 24.9] respectively. Multivariable analyses indicated that educated mothers [adjusted odds ratio (AOR) 0.70; 95 % CI 0.57, 0.86], mothers who had three and more complications during pregnancy [AOR 0.77; 95 % CI 0.65, 0.90], mothers who had at least 1–3 ANC visits [AOR 0.38; 95 % CI 0.30, 0.49] and mothers from rich households [AOR 0.52; 95 % CI 0.42, 0.65] were significantly more likely to use skilled birth attendants (SBAs) at delivery. Mothers who lived in rural areas [AOR 1.44; 95 % CI 1.06, 1.96] were less likely to deliver with SBAs. Conclusion Intensive investments to recruit and train more skilled birth attendants’ on appropriate delivery care are needed, as well as building a community-based skilled birth attendants’ program to reduce avoidable maternal mortality in South Sudan.     

Association Between Muscular Strength and Mortality in Clinical Populations: A Systematic Review and Meta-Analysis

ObjectivesTo assess the relationship between muscular strength measures and mortality in outpatient populations with chronic diseases such as cancer, chronic obstructive pulmonary disease, renal disease, and metabolic and vascular diseases, and in critically ill hospitalized patients.DesignA systematic review and random-effects meta-analysis of prospective cohort studies was performed.Setting and participantsThe databases Medline, Embase, Clinical Trial Register, and Cochrane Trial Register were searched from inception until September 30, 2018. The systematic literature review yielded 39 studies with a total of 39,852 participants.ResultsLowest vs highest category of muscular strength revealed a statistically significant increased risk of all-cause mortality with a hazard ratio (HR) and 95% confidence intervals (CI) of 1.80 (95% CI 1.54–2.10). Lower muscular strength was associated with enhanced mortality in patients with cancer (HR 2.40; 95% CI 1.57–3.69), critical illness (HR 2.06; 95% CI 1.33–3.21), renal disease (HR 1.84; 95% CI 1.37–2.47), metabolic and vascular diseases (HR 1.64; 95% CI 1.26–2.14), and chronic obstructive pulmonary disease (HR 1.36; 95% CI 1.16–1.61). Conversely, a 5-kg higher level of muscular strength conferred a reduced risk of overall mortality (HR 0.72; 95% CI 0.59–0.89) and was accompanied by a reduction in mortality in patients with metabolic and vascular diseases (HR 0.52; 95% CI 0.29–0.91), critical illness (HR 0.78; 95% CI 0.61–0.99), and renal disease (HR 0.82; 95% CI 0.73–0.91).Conclusions and implicationsMuscular strength is inversely associated with mortality risk in various acute and chronic conditions. Future trials should focus on developing validated cut-points for diagnosing low muscular strength and their predictive value for hard end-points.     

Effect Of Maternal HIV Infection On Child Survival In Ghana

The purpose of this study was to measure the association between maternal HIV infection and infant mortality in Ghana. Using a censored synthetic cohort life table based on the birth history of 3,639 childbirths during 1999–2003 obtained from the interviews of a nationally representative sample of 5,691 women age 15–49 in 6,251 households in the 2003 Ghana Demographic and Health Survey. The survey collected demographic, socioeconomic, and health data of the respondents as well as obtained voluntary counseling test for HIV infection from all eligible women. The effects of maternal HIV status and other factors on infant mortality were estimated using multivariate survival regression analysis and the results are presented as Hazard Ratios (HR) with 95% confident interval (95% CI). Children born to HIV infected mothers were three times as likely to die during infancy as those born to uninfected mothers (HR=3.01; 95% CI: 1.64, 5.50). Controlling for other factors affecting infant mortality further sharpens this relationship (HR=3.51; 95% CI: 1.87, 6.61). Not receiving antenatal care, low birth weight, and living in households that use high pollution cooking fuels were associated with a higher risk of infant mortality. Maternal HIV status is a strong predictor of infant mortality in Ghana, independent of several other factors. The results of this study suggest that HIV/AIDS epidemic has had great impact on child well-being and child survival. This impact tends to increase as the HIV/AIDS epidemic matures and infection in adults increases.     

Exploring the association between short/long preceding birth intervals and child mortality: using reference birth interval children of the same mother as comparison

Background

This study used data from recent Demographic and Health Surveys (DHS) to examine the impact of short or long preceding birth intervals on neonatal and under-five mortality. In order to minimize the effect of selection issues, we examined child mortality outcomes of the same mother, comparing short or long interval births against births with what had previously been considered optimal intervals.

Methods

We analyzed 47 DHS datasets from low- and middle-income countries. For each dataset, we compared neonatal and under-five mortality of short preceding interval births (<18 months, <24 months) to reference interval births (24-<60 months) of a mother, using conditional logistic regression matching on the mother. We also conducted the same matched analysis for long (≥60 months, ≥72 months) preceding interval births. These associations were then meta-analyzed. We also stratified the analyses by mothers’ completed fertility (fertility at end of reproductive period) to assess whether maternal characteristics highly correlated with completed fertility modify the association between birth interval and child mortality.

Results

Children with shorter preceding intervals had increased odds of both neonatal (<24 months, OR: 1.61, 95% CI: 1.52-1.70) and under-five mortality (<24 months, OR: 1.48, 95% CI: 1.40-1.56). When the associations were stratified by the mothers’ completed fertility, the impact of short intervals was greatly reduced or eliminated for low fertility mothers. In contrast, mortality associations became stronger for children of high fertility mothers. However, when the births of high fertility mothers were limited to birth orders 2-4, the associations were comparable to those of low fertility mothers. Longer preceding birth intervals had lower odds of mortality than reference intervals (i.e. under-5 mortality for ≥60 months, OR 0.59, 95% CI: 0.52-0.67). This effect was also mediated by mothers’ completed fertility; there was a strong protective effect of longer birth intervals for the high fertility mothers but not for low fertility mothers.

Conclusions

These analyses reproduced findings reported in previous literature that shorter birth intervals are associated with higher child mortality. However the negative impact of short birth intervals may only occur in high parity births. Reproductive health interventions that seek to lengthen birth intervals may have larger impact by targeting women with high parity. This finding is consistent with the concept of maternal depletion as the underlying cause of increased adverse child outcomes associated with shorter birth intervals.

     

Medically induced preterm birth and the associations between prenatal care and infant mortality

PurposeDuring the last 30 years, the use of prenatal care, both the proportion of women receiving the recommended number of visits and the average number of visits, has increased substantially. Although infant mortality has decreased, the incidence of preterm birth has increased. We hypothesized that prenatal care may lead to lower infant mortality in part by increasing the detection of obstetrical problems for which the clinical response may be to medically induce preterm birth.MethodsWe examined whether medically induced preterm birth mediates the association between prenatal care and infant mortality by using newly developed methods for mediation analysis. Data are the cohort version of the national linked birth certificate and infant death data for 2003 births. Analyses were adjusted for maternal sociodemographic, geographic, and health characteristics.ResultsReceiving more prenatal care visits than recommended was associated with medically induced preterm birth (odds ratio [OR], 2.44; 95% confidence interval [95% CI], 2.40–2.49) compared with fewer visits than recommended). Medically induced preterm birth was itself associated with greater infant mortality (OR, 5.08; 95% CI, 4.61–5.60) but that association was weaker among women receiving extra prenatal care visits (OR 3.08; 95% CI, 2.88–3.30) compared with women receiving the recommended number of visits or fewer.ConclusionsThese analyses suggest that some of the benefit of prenatal care in terms of infant mortality may be in part due to medically induced preterm birth. If so, the use of preterm birth rates as a metric for tracking birth policy and outcomes could be misleading.     

Very low maternal lead level in pregnancy and birth outcomes in an eastern Massachusetts population

PurposeMaternal lead exposure is associated with poor birth outcomes in populations with moderate to high blood levels. However, no studies have looked at exposure levels commonly experienced by US women.MethodsWe evaluated the relationship between maternal red blood cell (RBC) lead levels in midpregnancy and birth outcomes in 949 mother–child pairs in a prebirth cohort. We used multiple linear regression and logistic regression, adjusted for potential confounders including maternal age, race, prepregnancy body mass index, and smoking to relate maternal lead to infant birth size and risk for preterm birth (<37 weeks).ResultsMean RBC lead level was 1.2 μg/dL (range, 0.0–5.0). Mean (standard deviation) birthweight was 3505 (520) g, birthweight for gestational age z-score 0.22 (0.93), and length of gestation 39.5 (1.7) weeks. Mothers in the highest versus lowest lead quartile did not have higher odds (OR, 1.85; 95% confidence interval [CI], 0.79–4.34) of preterm delivery; after stratifying by child sex, there was an association among males (OR, 5.51; 95% CI, 1.21–25.15) but not females (OR, 0.82; 95% CI, 0.24–2.85). Maternal RBC lead was not associated with any continuous outcomes in combined or sex-stratified analyses.ConclusionsMaternal lead exposure, even at very low levels, may adversely affect some childbirth outcomes, particularly preterm birth among males.     

Association between Functional Status of Chinese Nursing Home Older Adults and Long Term Mortality

ObjectiveTo investigate the strength of association between impaired functional status and long-term (3-year) mortality in Chinese nursing home older adults.DesignA 3-year prospective multicenter cohort study.SettingNine nursing homes in Hong Kong.ParticipantsA total of 672 nursing home older adults (224 men; 448 women), mean age 85.0 ± 7.4.MeasurementsFunctional statuses of participants were assessed by Barthel Index (BI) and participants were stratified into different groups according to their BI score: BI score 100, BI score 75–95, BI score 45–70, BI score 15–40, and BI score 0–10. Other covariates included age, sex, comorbidities, score of abbreviated mental test, serum albumin, serum creatinine, serum hemoglobin, and hospitalization in the preceding year. The outcome measures were the 1-year, 2-year, and 3-year all-cause mortality.ResultsOlder adults with lower BI score had significantly higher all-cause mortality and this trend persisted in 1-year, 2-year, and 3-year mortality (P < .001). After multivariate analysis, there was a dose-response relationship in hazard ratio (HR) between BI score and 3-year all-cause mortality (compared with BI score 100; BI score 75–95: HR 1.38 [CI: 1.00–2.56; P < .05]; BI score 45–70: HR 1.80 [CI: 1.04–3.11; P < .001]; BI score 15–40: HR 2.12 [1.21–3.70; P < .001]; BI score 0–10: HR 3.13 [1.82–5.41; P < .001]; and trend test P < .05). Similar relationships were found in 1-year and 2-year mortality.ConclusionImpaired functional status is associated with higher short-term and long-term mortality with a dose-response relationship in Chinese nursing home older adults.