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ABSTRACT: OBJECTIVE:: We previously reported an increased risk of stillbirth associated with increases in trimester-specific ambient air pollutant concentrations. Here, we consider whether sudden increase in the mean ambient air pollutant concentration immediately before delivery triggers stillbirth. METHODS:: We used New Jersey linked fetal death and hospital discharge data and hourly ambient air pollution measurements from particulate matter ≤2.5 mm (PM2.5), carbon monoxide (CO), nitrogen dioxide (NO2), and sulfur dioxide (SO2) monitors across New Jersey for the years 1998-2004. For each stillbirth, we assigned the concentration of air pollutants from the closest monitoring site within 10 km of the maternal residence. Using a time-stratified case-crossover design and conditional logistic regression, we estimated the relative odds of stillbirth associated with interquartile range (IQR) increases in the mean pollutant concentrations on lag day 2 and lag days 2 through 6 before delivery, and whether these associations were modified by maternal risk factors. RESULTS:: The relative odds of stillbirth increased with IQR increases in the mean concentrations of CO (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.05-1.37), SO2 (OR = 1.11, 95% CI = 1.02-1.22), NO2 (OR = 1.11, 95% CI = 0.97-1.26), and PM2.5 (OR = 1.07, 95% CI = 0.93-1.22) 2 days before delivery. We found similar associations with increases in pollutants 2 through 6 days before delivery. These associations were not modified by maternal risk factors. CONCLUSION:: Short-term increases in ambient air pollutant concentrations immediately before delivery may trigger stillbirth.
Epidemiology (Cambridge, Mass.) 05/2013; · 5.51 Impact Factor
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ABSTRACT: The purpose of the present study was to examine the risk of stillbirth associated with ambient air pollution during pregnancy. Using live birth and fetal death data from New Jersey from 1998 to 2004, the authors assigned daily concentrations of air pollution to each birth or fetal death. Generalized estimating equation models were used to estimate the relative odds of stillbirth associated with interquartile range increases in mean air pollutant concentrations in the first, second, and third trimesters and throughout the entire pregnancy. The relative odds of stillbirth were significantly increased with each 10-ppb increase in mean nitrogen dioxide concentration in the first trimester (odds ratio (OR) = 1.16, 95% confidence interval (CI): 1.03, 1.31), each 3-ppb increase in mean sulfur dioxide concentration in the first (OR = 1.13, 95% CI: 1.01, 1.28) and third (OR = 1.26, 95% CI: 1.03, 1.37) trimesters, and each 0.4-ppm increase in mean carbon monoxide concentration in the second (OR = 1.14, 95% CI: 1.01, 1.28) and third (OR = 1.14, 95% CI: 1.06, 1.24) trimesters. Although ambient air pollution during pregnancy appeared to increase the relative odds of stillbirth, further studies are needed to confirm these findings and examine mechanistic explanations.
American journal of epidemiology 07/2012; 176(4):308-16. · 5.59 Impact Factor
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ABSTRACT: The purpose of this study was to examine the trends in the rates of stillbirth by race and ethnicity and to determine the risk factors of stillbirth.
We used New Jersey data (1997-2005) for live births and fetal deaths. Cox proportional hazards model was used to estimate the risk of stillbirth associated with maternal risk factors and pregnancy complications.
The rate of stillbirth was 4.4/1000 total births (3.4 for white and 7.9 for black non-Hispanics and 4.4 for Hispanics/1000 total births). The rates of stillbirth decreased from 3.8 in 1997 to 2.7/1000 total births in 2005 for white non-Hispanics but remained unchanged for other race/ethnicity groups. Adjusted relative risks for the risk factors associated with stillbirth were 1.3 (95% CI, 1.2-1.4) for maternal age ≥ 35 years, 1.9 (95% CI, 1.7-2.1) for black non-Hispanics, 2.8 (95% CI, 2.4-3.3) for no prenatal care, 40.2 (95% CI, 36.9-43.9) for placental abruption, 5.3 (95% CI, 3.4-8.2) for eclampsia, 3.5 (95% CI, 2.8-4.3) for diabetes mellitus and 1.7 (95% CI, 1.3-2.2) for preeclampsia.
There was a decline in the rate of stillbirth but there were persistent racial disparities with the highest rates of stillbirth for black non-Hispanics.
The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 02/2012; 25(6):699-705. · 1.36 Impact Factor
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ABSTRACT: To investigate demographic characteristics, risk factors, maternal and neonatal outcomes of all cases of amniotic fluid embolism that occurred in New Jersey during 1997-2005.
Information was derived from a perinatal linked dataset provided by the MCH-Epidemiology Program in the New Jersey Department of Health. Bivariate analysis for dichotomous variables used the Chi-square test. Stepwise logistic regression models were created to assess the influence of potential risk factors and p value < 0.05 considered statistically significant.
Forty-five cases of amniotic fluid embolism were identified among 1,004,116 deliveries, for a prevalence rate of 1 in 22,313 pregnancies. Statistically, significant association was found with multifetal pregnancy, caesarean section, placenta previa, placental abruption, eclampsia and cervical laceration. The rate of maternal complications such as coagulopathy, seizures, neurological damage, shock and cardiac arrest were significantly greater in the cases as compared with the overall study population. Neonatal morbidity was significant as demonstrated by higher NICU admissions and neonatal intubation rates and lower 5-min Apgar scores.
Significant correlation was identified between historically reported risk factors and amniotic fluid embolism. The fetal and maternal mortality rates were lower compared with previous studies, attributed both to improvements in perinatal healthcare and reporting of 'milder' cases.
The journal of maternal-fetal & neonatal medicine: the official journal of the European Association of Perinatal Medicine, the Federation of Asia and Oceania Perinatal Societies, the International Society of Perinatal Obstetricians 06/2009; 22(5):439-44. · 1.36 Impact Factor
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ABSTRACT: Congenital cardiovascular malformations (CCVMs) are relatively common with a prevalence of 5-10 per 1000 live births. Pulse oximetry screening is proposed to identify newborns with critical CCVMs which are missed by routine prenatal ultrasound and by pre-discharge physical examinations. The purpose of this study was to identify the number of infants with a delayed diagnosis of critical CCVMs potentially detectable by pre-discharge pulse oximetry screening.
Hospital Discharge records in New Jersey from 199-2004 for infants with critical CCVMs were identified using ICD-9 codes. These records were matched to the Electronic Birth Certificate records to identify newborns who were discharged as normal newborns and were later admitted with a diagnosis of critical CCVMs. Chart review was completed on these cases to confirm a delay in diagnosis.
Chart reviews confirmed delayed diagnosis of critical CCVM in 47 infants out of 670,245 births. Coarctation of the Aorta was the most common delayed diagnosis. The age at final diagnosis varied from 3 days to 6.5 months.
Further examination of pulse oximetry as a routine newborn screening service is warranted. Implementation of pre-discharge pulse oximetry screening for newborns may improve the timely detection of asymptomatic critical CCVMs.
Acta Paediatrica 09/2007; 96(8):1146-9. · 2.07 Impact Factor
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ABSTRACT: This study examines the relationship between episiotomy and the occurrence of shoulder dystocia among noninstrumental vaginal deliveries. Analysis of data from a retrospective database was used to study noninstrumental vaginal deliveries in New Jersey during the years 1996 to 2001. The episiotomy group and nonepisiotomy group were analyzed separately using univariate and multivariate analysis. Among 358,664 deliveries, rate of shoulder dystocia was 1.0% (n = 3596). Thirty-five percent of deliveries were assisted by episiotomy. Rate of dystocia was 1.42% with the use of episiotomy, and 0.81% when episiotomy was not used. This increased rate with episiotomy was noted across all of the racial groups, all birthweight categories, and all of the risk factor subgroups analyzed. There was a gradual decrease in the use of episiotomy from 37.30 to 26.03% without a corresponding increase in the rate of dystocia. Among noninstrumental deliveries, the rate of shoulder dystocia is higher in the episiotomy group. Decrease in the use of episiotomy has not resulted in an increase in the occurrence of dystocia.
American Journal of Perinatology 11/2006; 23(7):439-44. · 1.32 Impact Factor
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ABSTRACT: Breastfeeding, in spite of proven benefits and energetic promotion, lags behind national goals, is less prevalent in disadvantaged populations, and declines across successive children in a family. Using longitudinally linked data from the New Jersey Electronic Birth Certificate (EBC) from 1996 to 2001, we found considerable fluidity in breastfeeding status at hospital discharge for births to the same mother. Among mothers who breastfed exclusively after the first birth, only 69% did so after the second (we refer to this as recurrence). Among mothers who exclusively formula fed after the first birth, 16% initiated exclusive breastfeeding after the second birth (referred to as recruitment). Combination feeding the first born, i.e., breastfeeding supplemented by formula, was followed by exclusive breastfeeding for 38% of second births. Rates of recurrence and recruitment differed in distinct ways by race/ethnicity and immigrant status. We conclude that breastfeeding initiation is not necessarily or exclusively a matter of fixed preferences, and that opportunities exist to expand breastfeeding to realize national goals by enhancing both recurrence and recruitment.
Maternal and Child Health Journal 02/2006; 10(1):13-8. · 2.24 Impact Factor
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ABSTRACT: Healthy breastfeeding practice in the United States depends decisively on high rates of initiation at the delivery hospital. We sought to estimate the component of hospital variation in rates of exclusive breastfeeding at discharge that was dependent on demographic composition. Isolating that component can help to illuminate the potential independent contribution of hospital policies, practices, and staff behaviors.
Electronic birth certificate data in New Jersey from 1996 to 2001 (n = 545,837) were used to measure variations in hospital-level rates of breastfeeding initiation. The method of infant feeding within 24 hours before hospital discharge was reported as exclusive breastfeeding, formula feeding, combination feedings, other methods, and unknown. Rates of exclusive breastfeeding by hospital were standardized to remove sociodemographic differences in hospitals' service populations that influence initiation rates.
Sociodemographic variables predicted about 60 percent of the variation in hospital-specific rates of exclusive breastfeeding at discharge. Hospitals that were designated intensive or regional perinatal centers, delivered higher volumes of infants, and served more breastfeeding-prone populations were only slightly more likely to have higher adjusted rates compared with other hospitals; considerable unexplained variation remained.
Standardized exclusive breastfeeding rates pointed to the contribution of population demographics to breastfeeding initiation, and other contributions, including hospital practices, are also important. To protect, promote, and support breastfeeding, a more detailed evidence base on hospital policies and practices should be developed, and hospitals should review their policies and practices in light of documented best breastfeeding practice.
Birth 07/2005; 32(2):81-5. · 2.18 Impact Factor
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ABSTRACT: Background: Healthy breastfeeding practice in the United States depends decisively on high rates of initiation at the delivery hospital. We sought to estimate the component of hospital variation in rates of exclusive breastfeeding at discharge that was dependent on demographic composition. Isolating that component can help to illuminate the potential independent contribution of hospital policies, practices, and staff behaviors. Methods: Electronic birth certificate data in New Jersey from 1996 to 2001 (n = 545,837) were used to measure variations in hospital-level rates of breastfeeding initiation. The method of infant feeding within 24 hours before hospital discharge was reported as exclusive breastfeeding, formula feeding, combination feedings, other methods, and unknown. Rates of exclusive breastfeeding by hospital were standardized to remove sociodemographic differences in hospitals’ service populations that influence initiation rates. Results: Sociodemographic variables predicted about 60 percent of the variation in hospital-specific rates of exclusive breastfeeding at discharge. Hospitals that were designated intensive or regional perinatal centers, delivered higher volumes of infants, and served more breastfeeding-prone populations were only slightly more likely to have higher adjusted rates compared with other hospitals; considerable unexplained variation remained. Conclusions: Standardized exclusive breastfeeding rates pointed to the contribution of population demographics to breastfeeding initiation, and other contributions, including hospital practices, are also important. To protect, promote, and support breastfeeding, a more detailed evidence base on hospital policies and practices should be developed, and hospitals should review their policies and practices in light of documented best breastfeeding practice. (BIRTH 32:2 June 2005)
Birth 05/2005; 32(2):81 - 85. · 2.18 Impact Factor
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ABSTRACT: To compare perinatal outcomes in obstetric practices with high and low cesarean delivery rates.
We conducted a population-based study based on 171295 singleton births in New Jersey in 1996 and 1997. Vital certificate data for each birth were linked to the corresponding hospital discharge records. Nonsubspecialist obstetricians were divided into three groups based on their cesarean delivery rates during the study period: low (less than 18%), medium (18-27%), and high (greater than 27%). Perinatal mortality, rates of birth injury, and uterine rupture were compared among the physician groups after adjustment for differences in patient risks.
Physicians in the frequent cesarean delivery group performed more cesarean deliveries for all major indications. Perinatal mortality rates were comparable among the three physician groups. Low and very low birth weight infants delivered by the high-rate physicians did not have a lower risk of mortality. The risk of intracranial hemorrhage was significantly higher for infants delivered by low-rate physicians than for those delivered by medium-rate physicians (adjusted relative risk [RR] 1.53; 95% confidence interval [CI] 1.07, 2.19). Relative to deliveries by medium-rate physicians, deliveries by low-rate physicians were associated with a lower overall risk of uterine rupture (adjusted RR 0.56; 95% CI 0.34, 0.92). Medium- and high-rate groups had similar occurrences of birth injury and uterine rupture.
Low cesarean delivery rates reduced the rate of uterine rupture and were not associated with increased perinatal mortality. The data suggest a small increase in intracranial hemorrhages in infants delivered by physicians who perform relatively few cesarean deliveries.
Obstetrics and Gynecology 07/2003; 101(6):1204-12. · 4.73 Impact Factor
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ABSTRACT: Increasing breastfeeding initiation has been a national goal since Healthy People targets were first set in 1979. Sensitive methods used to measure incidence of breastfeeding initiation are important in the evaluation of breastfeeding trends. The authors used the statewide electronic birth certificate (EBC) as a surveillance system to measure breastfeeding initiation rates in New Jersey from 1997 to 2000. Overall breastfeeding initiation rates rose over the 4 years surveyed, yet exclusive breastfeeding rates remained stable. Trends demonstrated persistent racial and ethnic disparities in breastfeeding practices. The EBC was a valuable tool for monitoring breastfeeding initiation rates and evaluating the statewide goal of increasing exclusive breastfeeding.
Journal of Human Lactation 12/2002; 18(4):373-8. · 1.15 Impact Factor
