www.thelancet.com Vol 367 June 17, 2006
It is startling to see how a seemingly insubstantial change
in practice might aff ect long-term results for infants.
When a medical text recommended immediate cord clam-
p ing in 1913, science was in its infancy and expert opinion
guided practice. Today, we have the benefi t of scientifi c
evidence to advise our actions. The article in today’s Lancet
by Camila Chaparro and colleagues1 provides additional
weight to the growing evidence that our haste to clamp
the umbilical cord and pass the baby off is ill-advised. The
mounting evidence that delayed cord clamping benefi ts
both term and preterm infants continues to build.2,3
Chaparro and colleagues’ international interdisciplinary
study with 358 randomised infants shows that waiting
2 min before clamping the umbilical cord provided
the infants with more body iron at 6 months of age
without causing any harm at birth. The rationale for the
study—the link between iron defi ciency in infancy and
neurodevelopmental delays—is well founded. The number
of infants in the study was ambitious and the protocol
for the 6-month follow-up was meticulously planned.
The exclusion criteria were carefully selected to rule out
women with conditions that negatively aff ect neonates.
higher CD4 thresholds remains unclear but enthusiasm
for that approach is likely to wane.5,6 One recent large
randomised clinical study of starting and stopping at CD4
cell counts above 350/µL revealed only slightly increased
risk of minor HIV-related complications in the interruption
arm (Staccato; table).7
The implications for the individual management of
anti retroviral therapy level are less clear. Because of
the Trivacan and SMART studies, the most recent US
Department of Health and Human Services guidelines
state that treatment interruptions should be avoided
in clinical practice and should only be done in a closely
monitored clinical trial.8 However, this is not practical
because many patients in clinical practice have signifi cant
side-eff ects, pill fatigue, or treatment fail ure. Presumably
any study that specifi cally focuses on those with strong
reasons to stop therapy might show a benefi t (or at least
a lack of harm) in going on and off therapy.
The fundamental challenge raised by Trivacan and
SMART is how to translate data from broad heterogeneous
study populations to an individual. For patients who are
doing well on a stable regimen, the Trivacan and SMART
data clearly indicate that uncontrolled HIV replication is
more harmful than modern treatment regimens, and that
well-tolerated drugs should be continued indefi nitely.
This fi nding is not surprising and was widely accepted
even before these studies were done (at least it pertains
to regions where treatment is widely available). At what
point the harm associated with treatment in an individual
outweighs the harm associated with uncontrolled
HIV replication requires a careful understanding of
treatment-related side-eff ects, HIV pathogenesis, and the
consequences of interrupting therapy. The Trivacan and
SMART studies provide a quantitative risk assessment of
the consequences of stopping therapy and are therefore
important studies for all treating clinicians. The task at
hand now is to ensure that all patients—including those in
resource-constrained regions, such as West Africa—have
access to well-trained health-care providers who can
readily adopt emerging data into any decision regarding
when (if ever) to stop antiretroviral therapy.
Steven G Deeks
San Francisco General Hospital, San Francisco, California 94110, USA
I have received research support or honoraria from Boehringer Ingelheim, Bristol-
Myers Squibb, GlaxoSmithKline, Pfi zer, Roche, Tibotec, and Trimeris.
1 Gulick RM, Mellors JW, Havlir D, et al. Treatment with indinavir, zidovudine,
and lamivudine in adults with human immunodefi ciency virus infection and
prior antiretroviral therapy. N Engl J Med 1997; 337: 734–39.
Levy AR, James D, Johnston KM, et al. The direct costs of HIV/AIDS care.
Lancet Infect Dis 2006; 6: 171–77.
Danel C, Moh R, Minga A, for the Trivacan ANRS 1269 trial group. CD4-guided
structured antiretroviral treatment interruption strategy in HIV-infected
adults in west Africa (Trivacan ANRS 1269 trial): a randomised trial. Lancet
2006; 367: 1981–86.
El-Sadr W, Neaton J, for the SMART Study Investigators. Episodic CD4 guided
use of antiretroviral therapy is inferior to continuous therapy: results of the
SMART study. 13th Conference on Retroviruses and Opportunistic Infections.
Denver, Colarado, USA; Feb 5–8, 2006: 106LB (abst).
Maggiolo F, Ripamonti D, Gregis G, Quinzan G, Callegaro A, Suter F. Eff ect of
prolonged discontinuation of successful antiretroviral therapy on CD4 T cells:
a controlled, prospective trial. AIDS 2004; 18: 439–46.
Cardiello PG, Hassink E, Ananworanich J, et al. A prospective, randomized trial
of structured treatment interruption for patients with chronic HIV type 1
infection. Clin Infect Dis 2005; 40: 594–600.
Ananworanich J, Gayet-Ageron A, Le Braz M, et al. Program and abstracts of
the 13th Conference on Retroviruses and Opportunistic Infections. Denver,
Colarado, USA; Feb 5–8, 2006: 102 (abst).
Panel on Clinical Practices for Treatment of HIV Infection convened by the
Department of Health and Human Services (DHHS). Guidelines for the use of
antiretroviral agents in HIV-infected adults and adolescents. May 4, 2006:
June 7, 2006).
Delayed cord clamping increases infants’ iron stores
See Articles page 1997
www.thelancet.com Vol 367 June 17, 2006 1957
Most importantly, the team used multiple methods for
identifying the main outcome variable of iron status at
6 months of age. There were no diff erences between the
groups of infants on the concerns about harm: neonatal
jaundice or polycythaemia. The protocol required that
obstetricians and midwives wait up to 2 min to clamp and
cut the umbilical cord. Studies in which cord clamping was
delayed for 3 min or longer also failed to show harm with
the assigned delay in cord clamping.2
Infants with delayed cord clamping in Dewey and
colleagues’ study were held level with the mother’s body
during the 2-min wait. Lowering the infant can speed
the transfusion.4 In our randomised trial of a brief delay
(30–45 s) in cord clamping at preterm births, we lowered
the infant below the introitus or incision to hasten
transfusion.5 However, if one places the infant on the
mother’s abdomen briefl y before cutting the cord, the
infant might receive less placental transfusion.6
The results of Chaparro and colleagues’ study suggest
that a modifi cation might be indicated in the active
management of the third-stage programme for
developing countries, in which anaemia in infancy is
often endemic. Active management of the third stage
prevents maternal haemorrhage after birth. As defi ned
initially and researched, the process involved three
steps: (1) a drug is used to contract the uterus; (2) the
cord is clamped immediately; and (3) traction is applied
to the cord to speed delivery of the placenta. The most
important part of active management is getting the
uterus to contract to avoid uterine atony. There is a fear
that giving the drug to contract the uterus (uterotonic)
with the infant still attached to the umbilical cord would
cause “overtransfusion.” Yao and co-workers showed
that giving such a drug and delaying cord clamping did
not result in overtransfusion because the blood volumes
of the infants in this study never went above 90 mL/kg,
even with a 5–6-min wait to clamp.7 Two of the large
studies on active management of the third stage reported
that infants who had immediate cord clamping weighed
substantially less than the infants who had delayed
cord clamping.8,9 We believe that more research on the
use of uterotonic drugs while leaving the cord intact is
Chaparro and colleagues’ study increases concern
about the ethics of routine cord-blood collection without
adequate informed consent and the advertisement
of cord blood as “medical waste.” It is very plausible
that those magical stem cells found in cord blood have
multiple protective and preventive roles to play in an
infant’s developing body.10 We support the American
Academy of Pediatrics’ statement which does not
recommend cord-blood collection and storage unless
there is a known family need.11 However, that valuable
cord blood should not be medical waste—let the infants
have what they need fi rst.
This excellent study by Chaparro and colleagues, the
largest ever done on delayed cord clamping with long-
term follow-up, adds important evidence in favour of
delayed cord clamping at the births of term infants.
*Judith Mercer, Debra Erickson-Owens
University of Rhode Island College, College of Nursing, Kingston,
RI 02881, USA
We declare that we have no confl ict of interest.
1 Chaparro CM, Neufeld LM, Tena Alavez G, Eguia-Liz Cedillo R,
Dewey KG. Eff ect of timing of umbilical cord clamping on iron status in
Mexican infants: a randomised controlled trial. Lancet 2006; 367:
van Rheenen P, Brabin B. Late umbilical cord-clamping as an intervention for
reducing iron defi ciency anaemia in term infants in developing and
industrialised countries: a systematic review. Ann Trop Paediatr 2004; 24:
Rabe H, Reynolds G, Diaz-Rossello J. Early versus delayed umbilical cord
clamping in preterm infants. Cochrane Database Syst Rev 2004; 4:
Yao AC, Lind J. Eff ect of gravity on placental transfusion. Lancet 1969; 2:
Mercer JS, Vohr BR, McGrath MM, Padbury JF, Wallach M, Oh W. Delayed cord
clamping in very preterm infants reduces the incidence of intraventricular
hemorrhage and late-onset sepsis: a randomized, controlled trial. Pediatrics
2006; 117: 1235–42.
Grisaru D, Deutsch V, Pick M, et al. Placing the newborn on the maternal
abdomen after delivery increases the volume and CD34 cell content in the
umbilical cord blood collected: an old maneuver with new applications.
Am J Obstet Gynecol 1999; 180: 1240–43.
Yao AC, Hirvensalo M, Lind J. Placental transfusion-rate and uterine
contraction. Lancet 1968; 1: 380–83.
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8 Rogers J, Wood J, McCandlish R, Ayers S, Truesdale A, Elbourne D. Active
versus expectant management of third stage of labour: the Hinchingbrooke
randomised controlled trial. Lancet 1998; 351: 693–99.
Prendiville WJ, Harding JE, Elbourne DR, Stirrat GM. The Bristol third stage
trial: active versus physiological management of third stage of labour. BMJ
1988; 297: 1295–300.
10 Ende N, Reddi AS. Administration of human umbilical cord blood to low birth
weight infants may prevent the subsequent development of type 2 diabetes.
Med Hypotheses 2006; 66: 1157–60.
11 American Academy of Pediatrics. Cord blood banking for potential future
transplantation: subject review. Pediatrics 1999; 104: 116–18.i.
Racism, socioeconomic deprivation, and health in New Zealand
Inequalities in health are deplored in modern democratic
nations and equal opportunities are extolled in principle,
if not in practice. Through the caste system, slavery,
colonisation, aristocracy, apartheid, and Nazism, inequal-
ities were institutionalised. The historical legacy of racism
and economic inequality of opportunity casts its shadow
even now, and the study by Ricci Harris and colleagues1 in
today’s Lancet explores the idea.
Inequalities in health status, disease occurrence, and
mortality are shaped by accumulated wealth, material
circumstances, environmental quality, nutrition, a wide
range of personal behaviours, genetic inheritance, and
health services. Within multiethnic societies, European-
origin White populations (henceforth, “White” as per
Bhopal’s glossary2) are characterised by being richer, more
powerful, and enjoying better material circumstances,
environmental quality, and health services than non-White
ethnic-minority populations. Ethnic-health inequalities in
such societies are inevitable.
Racism is the belief that some racial, ethnic, religious,
and cultural groups are better than others. This belief,
combined with power, leads to actions favouring
the supposedly superior groups. The power to enact
such beliefs is, currently, mostly in the hands of White
populations. Some like to believe racism is unimportant
in modern, industrialised, multiethnic societies, others
believe that racism is at the heart of ethnic and racial
disparities in health and health care.3 We need data to
progress our understanding.
Equity is the core ethical principle underpinning equality
of health care. It is based on fairness and justice. Most
research studies present data from the White population
as the standard against which to compare minority
groups. Not every inequality shown is an inequity. Ethnic
variations in smoking, for example, are not necessarily
inequitable but such variations in access to smoking
cessation services would be. Diff erences in life expectancy
in diff erent ethnic groups are usually inequitable,
because they mainly result from other social injustices.
Epidemiological data are essential to the identifi cation of
inequities, and monitoring eff ectiveness of interventions
to redress them.
Harris and colleagues’ study is of special interest, not
only because empirical research on racism and health
is rare outside the USA, but because it concerns the
Māori population, an Indigenous ethnic minority. The
term indigenous is usually used to mean a population
belonging naturally to a place in the sense of long-term
ancestral origins—eg, Aborigine (it might also mean the
majority population—eg, in the UK—as an alternative to
the word White).2
Indigenous populations across the world have poor
health, and many were decimated and demoralised
in the colonial era. Compared with other Indigenous
populations, including Native Americans and Australian
Aborigines, the Māori population largely escaped such
a fate. By contrast with other colonised Indigenous and
migrant ethnic minorities, Māoris are perceived to be
highly politically and socially organised, empowered, and
in control. This perception, at least in part, is related to
the negotiated Treaty of Waitangi of 1840 that enshrined
Māori rights, and that still plays a major role in governing
relations between Māoris and other New Zealanders.4
Nonetheless, Māori health is comparatively poor.
Bramley and colleagues5 compared the health
inequalities in New Zealand and the USA, with the
European (eff ectively White) and White population,
respectively, in each of these countries as the point of
comparison. They used a wide range of health and health-
care indicators. The inequalities were massive—eg, life
expectancy in Māori men was 8·9 years less than in
European men in New Zealand, larger than the 7·4 year
diff erence between American Indian or Alaskan native
and White men in the USA. In virtually every indicator,
inequalities were considerable, and greater in New Zealand
than in US comparisons. The life-expectancy defi cit in
Australian Aboriginal and Torres Strait Islanders is closer
to 20 years.6 By contrast, mortality diff erences between
See Articles page 2005