Factors That Mediate Racial/Ethnic Disparities in US Fetal Death Rates

Objectives. We sought to determine the importance of socioeconomic factors, maternal comorbid conditions, antepartum and intrapartum complications of pregnancy, and fetal factors in mediating racial disparities in fetal deaths.Methods. We undertook a mediation analysis on a retrospective cohort study of hospital-based deliveries with a gestational age between 23 and 44 weeks in California, Missouri, and Pennsylvania from 1993 to 2005 (n = 7 104 674).Results. Among non-Hispanic Black women and Hispanic women, the fetal death rate was higher than among non-Hispanic White women (5.9 and 3.6 per 1000 deliveries, respectively, vs 2.6 per 1000 deliveries; P < .01). For Black women, fetal factors mediated the largest percentage (49.6%; 95% confidence interval [CI] = 42.7, 54.7) of the disparity in fetal deaths, whereas antepartum and intrapartum factors mediated some of the difference in fetal deaths for both Black and Asian women. Among Hispanic women, socioeconomic factors mediated 35.8% of the disparity in fetal deaths (95% CI = 25.8%, 46.2%).Conclusions. The factors that mediate racial/ethnic disparities in fetal death differ depending on the racial/ethnic group. Interventions targeting mediating factors specific to racial/ethnic groups, such as improved access to care, may help reduce US fetal death disparities.In the United States, there continue to be racial/ethnic disparities in perinatal outcomes such as fetal death.1–4 Studies have identified factors that are associated with increased rates of fetal death overall, including advanced maternal age,5–7 previous cesarean delivery,8 inadequate prenatal care,9 and some chronic medical conditions.10–12 However, none of these studies examined whether higher fetal death rates seen in minority racial/ethnic groups are potentially mediated by factors that occur later in pregnancy.13–15 Understanding these factors and whether these mediating factors differ between racial/ethnic groups will better focus potential interventions to reduce these disparities.We have identified factors that mediate racial/ethnic differences in fetal death rates between 23 and 44 weeks gestation. We grouped factors into 4 areas using the conceptual framework shown in Figure 1. These sets of factors included socioeconomic factors; maternal preexisting comorbid conditions; antepartum and intrapartum factors, primarily complications of pregnancy; and fetal factors, specifically gestational age at delivery.Open in a separate windowFIGURE 1—Hierarchical conceptual framework: racial/ethnic differences in fetal death, California, Missouri, Pennsylvania, 1993–2005.Note. SES = socioeconomic status. The residual disparity in fetal deaths, or fetal deaths unexplained by any of the included factors, is shown as the bottom pathway.     

胎死宫内40例母体因素及治疗分析

目的 探讨胎死宫内(intrauterine fetal death,IUFD)的母体因素及治疗方法.方法 选择2004年3月至2010年3月本院收治的40例胎死宫内患者为研究对象,年龄为20～38岁,平均为30岁;初产妇为32例(80.0%),经产妇为8例(20.0%);孕龄为22～39孕周,平均为34孕周(本研究遵循的程序符合本院人体试验委员会所制定的伦理学标准,得到该委员会批准和受试对象本人的知情同意,并与之签署临床研究知情同意书).采用回顾性分析法分析胎死宫内的母体相关因素及诊治方法.结果 合并产科并发症患者占胎死宫内比例最大,包括妊娠期高血压疾病12例(30.0%),前置胎盘9例(22.5%)和胎盘早剥7例(17.5%).脐带因素所占比例次之.治疗措施应根据患者病情、产道条件和胎儿死亡时间综合制定,同时积极防治胎死宫内并发弥散性血管内凝血(disseminated intravascular coagulation,DIC).结论 胎儿缺氧缺血死亡是胎死宫内的主要病因.早期诊断、适时终止妊娠、正确治疗胎死宫内所致并发症至关重要.     

Racial and Ethnic Variations in Temporal Changes in Fetal Deaths and First Day Infant Deaths

The purpose was to examine changes in overall and gestational age-specific proportions and rates of fetal death, first day death (<24 h), and combined fetal-first day death from 1990–1991 to 2001–2002. Changes were considered by race/ethnicity. Deliveries to U.S. white, black, and Hispanic mothers were selected from the NCHS linked live birth-infant death cohort and fetal deaths files (1990–1991 and 2001–2002). There was an overall improvement in mortality, but improvements were not uniform across all racial/ethnic groups or by gestational age. The fetal mortality rate among whites and Hispanics declined 4.32 and 12.82 percent, respectively. For blacks, the fetal mortality rate increased 4.06 percent between 1990–1991 and 2001–2002. Despite overall reductions in perinatal and <24 h mortality, black rates in all outcomes maintained a twofold disparity. The overall black: white fetal mortality rate ratio increased from 2.17 to 2.36 over time. The gestational age-specific black: white combined fetal-first day mortality rate ratios were greater than 1 at later gestational ages. In some cases, the ratio increased over time, indicating that despite reductions, fetal mortality did not decline uniformly among whites and blacks at term and post-term. Despite overall improvements in fetal, first day, and combined fetal-first day mortality, racial disparities persisted and in some cases widened. This study identifies lack of improvements in fetal death in the black population compared to the white or Hispanic population at later gestational ages.     

妊娠晚期死胎相关危险因素分析

目的探讨妊娠晚期死胎发生的相关危险因素,以期减少死胎发生,降低围生儿死亡率,提高围生医疗质量。方法回顾性分析2005年1月至2007年6月在本院住院分娩的9733例孕妇中,发生妊娠晚期死胎的孕妇。结果9733例住院分娩孕妇中,发生妊娠晚期(≥28孕周)死胎170例,死胎发生率为17.47‰(170/9733)。剔除因胎儿畸形所致死胎后,校正后死胎发生率为12.24‰(118/9733)。发生妊娠晚期死胎孕妇中16.47%(28/170)年龄≥35岁,64.12%(109/170)孕妇职业为农民及待业者,42.94%(73/170)孕妇孕期未进行产前检查或仅行不定期产前检查,35.88%(61/170)孕妇在死胎发生前自觉胎动异常。妊娠晚期死胎发生原因中,母体因素占第1位,发生率为70.59%(120/170),依次为合并妊娠期高血压疾病(30/170,17.65%)、妊娠期肝内胆汁淤积症(18/170,10.59%)、胎膜早破(17/170,10.00%)、妊娠期糖尿病(16/170,9.41%)、梅毒(2.94%);其余因素依次为胎儿因素(88/170,51.76%)、脐带因素(35/170,20.59%)、胎盘因素(23/17,13.53%)。结论加强围生期宣教及孕期保健,提高孕妇保健意识,积极治疗母体合并症及并发症,可有效降低妊娠晚期死胎发生率,提高围生医疗质量。     

Studying Sudden and Unexpected Infant Deaths in a Time of Changing Death Certification and Investigation Practices: Evaluating Sleep-Related Risk Factors for Infant Death in New York City

We describe an approach for quantifying and characterizing the extent to which sudden and unexpected infant deaths (SUIDs) result from unsafe sleep environments (e.g., prone position, bedsharing, soft bedding); and present data on sleep-related infant deaths in NYC. Using a combination of vital statistics and medical examiner data, including autopsy and death scene investigation findings, we analyzed any death due to accidental threat to breathing (ATB) (ICD-10 W75 & W84), and deaths of undetermined intent (UND) (Y10-Y34) between 2000 and 2003 in NYC for the presence of sleep-related factors (SRF). Homicide deaths were excluded as were SIDS, since in NYC SIDS is not a certification option if environmental factors were possibly contributors to the death. All 19 ATB and 69 (75%) UND had SRFs as per the OCME investigation. Black infants and infants born to teen mothers had higher SRF death rates for both ATB and UND deaths. Bedsharing was the most common SRF (53%-ATB; 72%-UND deaths); the majority of non-bedsharing infants were found in the prone position (60%-ATB; 78%-UND deaths). We found a high prevalence of SRFs among ATB and UND deaths. This is the first local study to illustrate the importance of knowing how SUIDs are certified in order to ascertain the prevalence of infant deaths with SRFs. Advancing the research requires clarity on the criteria used by local medical examiners to categorize SUIDs. This will help jurisdictions interpret their infant mortality statistics, which in turn will improve education and prevention efforts.     

大学生时间管理倾向及影响因素

目的探讨大学生时间管理倾向情况及影响因素。方法采用黄希庭等编制的青少年时间管理倾向量表（ATMD）和症状自评量表（SCL-90）,对江西省南昌市5所高校1 603名学生进行调查,并进行统计分析。结果大学生时间管理倾向的总分均值为144.76±21.28,处于中等稍偏上水平;人口统计学特征中的性别、年级与时间管理倾向显著相关（P〈0.01）,心理健康水平与时间管理倾向显著相关（P〈0.01）。结论人口统计学特征中的性别、年级和心理健康水平是大学生时间管理倾向的影响因素,提示高校在开展时间管理教育时要因性别、年级而异,同时要关注大学生心理健康水平。     

Disparities in Adverse Preconception Risk Factors Between Women with and Without Disabilities

Objective The objective of this study was to compare the prevalence of select preconception health indicators among women with and without disabilities. Methods 2010 Behavioral Risk Factor Surveillance System data were used to estimate the prevalence of health behaviors, health status indicators, and preventive health care among non-pregnant women ages 18–44 years with (N = 8370) and without (N = 48,036) disabilities. Crude percentages were compared with Chi square statistics. Multivariable logistic regressions adjusted for socio-demographic factors. Results Women with disabilities were more likely than women without disabilities to currently smoke (30.5 vs. 14.5 %, p < 0.0001) and less likely to exercise in the past month (67.1 vs. 79.8 %, p < 0.0001). Heavy drinking was similar in the two groups (4.4 vs. 4.5 %, p = 0.9). Health status indicators were worse among women with disabilities, with 35.0 % reporting fair/poor health and 12.4 % reporting diabetes, compared with 6.7 and 5.6 %, respectively, among women with no disabilities (p < 0.0001 for both). Frequent mental distress, obesity, asthma, and lack of emotional support were also higher among women with disabilities compared with their non-disabled counterparts. Women with disabilities were more likely to receive some types of preventive care, (HIV), but less likely to receive others (recent dental cleaning, routine checkup). Disparities in health behaviors and health status indicators between the two groups remained after adjusting for socio-demographic factors. Conclusion Women with disabilities at reproductive age are more vulnerable to risk factors associated with adverse pregnancy outcomes compared to their counterparts without disabilities. Our findings highlight the need for preconception health care for women with disabilities.     

心脑血管病主要危险因素对其发病和死亡的归因危险

(中国医学科学院中国协和医科大学阜外心血管病医院流行病研究室，北京loo037)     

儿童肺炎死亡危险因素的病例对照研究

1986年在6个示范县进行肺炎监测的同时,进行了0~14岁儿童肺炎死亡危险因素的病例对照研究。对189对研究资料进行了单因素和多因素分析,结果表明,引起儿童肺炎死亡的主要个体因素是佝偻病,新生儿硬肿,先天畸形,营养不良和低出生体重。此外,家长对肺炎严重性不认识,不能及时就医,基层卫生人员对肺炎的诊断、处理不当也是重要的死亡危险因素。     

MAPK Genes Interact with Diet and Lifestyle Factors to Alter Risk of Breast Cancer: The Breast Cancer Health Disparities Study

Mitogen-activated protein kinases (MAPK) are integration points for multiple biochemical signals. We evaluated 13 MAPK genes with breast cancer risk and determined if diet and lifestyle factors mediated risk. Data from 3 population-based case-control studies conducted in Southwestern United States, California, and Mexico included 4183 controls and 3592 cases. Percent Indigenous American (IA) ancestry was determined from 104 ancestry informative markers. The adaptive rank truncated product (ARTP) was used to determine the significance of each gene and the pathway with breast cancer risk, by menopausal status, genetic ancestry level, and estrogen receptor (ER)/progesterone receptor (PR) strata. MAP3K9 was associated with breast cancer overall (P_ARTP = 0.02) with strongest association among women with the highest IA ancestry (P_ARTP = 0.04). Several SNPs in MAP3K9 were associated with ER+/PR+ tumors and interacted with dietary oxidative balance score (DOBS), dietary folate, body mass index (BMI), alcohol consumption, cigarette smoking, and a history of diabetes. DUSP4 and MAPK8 interacted with calories to alter breast cancer risk; MAPK1 interacted with DOBS, dietary fiber, folate, and BMI; MAP3K2 interacted with dietary fat; and MAPK14 interacted with dietary folate and BMI. The patterns of association across diet and lifestyle factors with similar biological properties for the same SNPs within genes provide support for associations.     

孕早期妊娠呕吐相关危险因素回顾性队列研究

目的 调查分析武汉市孕早期妊娠剧烈呕吐的相关危险因素,指导孕期妇女的预防保健工作。方法 采用回顾性队列研究的方法,选择孕早期来院产检的孕妇,了解其早孕反应的情况,采用logistic回归分析对资料进行分析。结果 武汉市孕早期妊娠剧烈呕吐的相关危险因素有：孕周、噪音、睡眠不好、新近装修、咖啡和孕后食量减少,而孕后口味嗜酸辣、少吃蔬菜、TORCH至少有一项IGM阳性是HG的保护因素,并且孕前体重越大则HG的发生越少。结论 应重视孕早期剧烈呕吐问题,减少噪音等不良因素的暴露,创造良好妊娠条件,注意均衡饮食,保证睡眠,不提倡瘦身怀孕．以尽量减少HG的发生。     

2006年临清市胎儿畸形种类及其发生的影响因素分析

[目的]分析胎儿畸形发生类型及其危险因素,为该病防治提供依据.[方法]对2006年孕期检查发现胎儿畸形到临清市妇幼保健院引产的95例孕妇进行分析,并与216名正常待产妇,采用非条件Logistic回归方法分析影响畸形发生的危险因素.[结果]95例畸形胎儿中.无脑儿脊柱裂38例,脑积水18例,唇裂并腭裂15例,内脏畸形12例.先天性心脏病9例,其他3例.多因素非条件Logistic回归分析结果.引起胎儿畸形的危险因素有孕前后患有内科疾病、感冒发热、工作中接触有毒物质、妊娠前半年家庭装修或购置家具、妊娠合并症、孕期服用药物、感染病毒、工作有压力、与同事或家庭成员关系紧张,孕妇丈夫患有慢性病、工作中接触有毒物质、吸烟、饮酒;孕妇孕前检查、孕期增补叶酸是保护性因素.[结论]临清市胎儿畸形主要是无脑儿脊柱裂、脑积水、唇裂并腭裂和内脏畸形;引起畸形的危险因素包括孕妇及其丈夫的疾病、中毒及精神因素,孕前检查、孕期增补叶酸可降低胎儿畸形发生.     

急性心肌梗死患者住院期间死亡的危险因素分析

目的探讨影响急性心肌梗死患者住院期间死亡的危险因素。方法338例急性心肌梗死患者根据住院期间死亡与否分成死亡组和存活纽．回顾性分析两纽患者的临床资料,对可能影响死亡的危险因素通过Logistic回归进行分析。结果338例患者中．病死率为9．2％（31／338）。死亡组在年龄＞65岁、入院时收缩压＜100mmHg、心率＞100次／min、Killip分级＞儿级、肾功能不全、前壁心肌梗死、新发心房颤动、恶性心律失常、心源性休克等指标与存活组相比,有显著性差异（P＜0．05）。多因素Logistic回归分析表明,Killip分级＞Ⅱ级、新发心房颤动、恶性心律失常、肾功能不全是AMI患者住院期间死亡的独立危险因素。结论mmp分级＞Ⅱ级、新发心房颤动、恶性心律失常、肾功能不全是AMI患者住院期间死亡的独立危险因素。     

儿童社区获得性肺炎临床特点及其死亡危险因素分析

目的探讨儿童社区获得性肺炎临床特点及其死亡危险因素。方法选择2015年1月至2018年1月在我院接受治疗的350例社区获得性肺炎患儿的临床资料进行回顾性分析。所有患儿均接受同一组医护人员在《儿童社区获得性肺炎管理指南(2013修订)》指导下所采取的综合治疗措施。在查阅相关参考文献和咨询专家的基础上对影响因素进行选择,主要包括一般资料及临床资料两个部分。结果两组患儿性别及基础病差异无统计学意义(P>0.05),存活组年龄明显大于死亡组,院前病程明显较死亡组短(P<0.05)。两组患儿体温、心率、白细胞、CRP、PCT、白蛋白、ALT差异均无统计学意义(P>0.05),死亡组在呼吸率、低血压率、胸腔积液率、多页病变率、中性粒细胞比值、BUN、FPG、SCr均明显高于生存组,而在Alb及PaO_2/FiO_2则明显低于生存组(P<0.05)。多因素分析结果显示:年龄、低血压、呼吸率、SCr、BUN、FPG及多页病变为儿童社区获得性肺炎死亡独立性危险因素(P<0.05)。结论儿童社区获得性肺炎患者死亡与年龄、低血压、呼吸率、SCr、BUN、FPG及多页病变有关,临床上应加强对上述因素的干预。     

外科重症监护病房医院感染和相关死亡危险因素

目的分析我院外科重症监护病房(SICU)医院感染情况和相关死亡危险因素。方法对SICU在2002年1月~2005年1月,收治的患者中医院感染发生、感染部位、感染病原微生物等进行回顾性分析,并用Logistic回归分析筛选出医院感染患者死亡的相关危险因素。结果SICU医院感染的发生率为4.2%,死亡率为48.9%;最常见的感染部位依次为下呼吸道(88.9%)、血液系统(48.9%)和泌尿系统(26.7%);病原微生物中革兰阴性杆菌占64.1%,最常见的依次为铜绿假单胞菌、嗜麦芽寡养单胞菌、乙酸钙/鲍氏不动杆菌和产酸克雷伯菌;革兰阳性球菌占24.8%,最常见的依次为耐甲氧西林金黄色葡萄球菌、耐甲氧西林表皮葡萄球菌和屎肠球菌;真菌占11.1%,以白色念珠菌为最常见。结论应加强对SICU患者下呼吸道、血液系统和泌尿系统的感染监测;SICU医院感染病原菌菌种多样性和多重耐药的特点使得早期经验性抗菌药物治疗十分困难,应根据SICU医院感染病原菌的分布和药敏情况选择适当的抗菌药物。     

The Influence of Socioeconomic Factors on Cardiovascular Disease Risk Factor Development

In the industrialized, urban United States, there is an increasingly strong inverse association of socioeconomic status (SES) and cardiovascular disease (CVD) risk and mortality. The large difference in levels and trends in CVD risk associated with SES indicates a major potential for primordial prevention if carried out at both individual and community levels and with broader socioeconomic improvements.