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BackgroundAnemia is a term that describes low hemoglobin concentrations and can result from micronutrient deficiencies, infection, or low birth weight. Early-life anemia, particularly iron-deficiency anemia (IDA) is associated with several negative metabolic, developmental, and cognitive outcomes, some of which persist into adulthood.ObjectiveThe aim of this study was to investigate alterations in systemic metabolism and fecal microbial diversity and functionality associated with anemia and IDA in male and female infants from Iquitos, Peru.DesignCross-sectional stool and serum samples were collected from 95 infants (53 boys and 42 girls) at 12 mo of age. The fecal microbiome was assessed by using 16S ribosomal RNA gene sequencing, and the fecal and serum metabolomes were quantified using 1H-nuclear magnetic resonance.ResultsThe prevalence of anemia was 64%, with a greater proportion of anemia in male infants attributed to iron deficiency. Metabolically, anemia was associated with decreased concentrations of tricarboxylic acid cycle metabolites in both sexes (males: succinate, P=0.031; females: fumarate, P=0.028). In addition, anemic male infants exhibited significantly lower serum concentrations of several amino acids compared with nonanemic male infants. Although no specific structural or functional differences in the microbiota were observed with anemia in general, likely due the heterogeneity of its etiology, IDA affected the microbiome both structurally and functionally. Specifically, the abundance of butyrate-producing bacteria was lower in IDA subjects of both sexes than in nonanemic, non-iron-deficient subjects of the same sex (females: Butyricicoccus, P=0.041; males: Coprococcus, P=0.010; Roseburia, P=0.027). IDA male infants had higher concentrations of 4-hydroxyphenyllactate (P&nbsp

A double-blind, randomized clinical trial was conducted to determine the effects of prevention of zinc deficiency on cognitive and sensorimotor development during infancy. At 6 mo of age, infants were randomly assigned to be administered a daily liquid supplement containing 10 mg/d of zinc (zinc sulfate), 10 mg/d of iron (ferrous sulfate), and 0.5 mg/d of copper (copper oxide), or an identical daily liquid supplement containing only 10 mg/d of iron and 0.5 mg/d of copper. Various controls were implemented to ensure adherence to the supplement protocol. A battery of developmental assessments was administered from 6 to 18 mo of age that included a visual habituation/recognition memory task augmented with heart rate at 6, 9, and 12 mo of age; the Bayley Scales of Infant Development, 2nd edition (BSID2) at 6, 12, and 18 mo; the A-not-B error task at 9 and 12 mo; and free-play attention tasks at 12 and 18 mo. Only infants supplemented with zinc had the normative decline in look duration from 6 to 12 mo during habituation and a normative decline in shifting between objects on free-play multiple-object attention tasks from 12 to 18 mo of age. The 2 groups did not differ on any of the psychophysiologic indices, the BSID2, or the A-not-B error task. The findings are consistent with zinc supplementation supporting a profile of normative information processing and active attentional profiles during the first 2 y of life. This trial was registered at clinicaltrials.gov as NCT00589264.

It is well known that vitamin C is an important enhancer of nonheme iron bioavailability due to its high reducing capacity. Camu-camu, a fruit that grows in the jungle of Peru, contains high amount of vitamin C (2,780 mg per 100 g). In this study, we investigated the effect of camu-camu on nonheme iron bioavailability from two different meals (rice with lentils and wheat flour porridge) using an in vitro Caco-2 cell model. These two meals were treated with three different camu-camu juice concentrations (C 0 = 0 g, C 1 = typical consumption, and C 2 = 3X typical consumption). The results showed that camu-camu reduced rather than enhanced nonheme iron bioavailability. The inhibiting trend was significant (p

We evaluated changes in the status of iron, zinc, and copper in non-anemic Peruvian infants who were receiving daily supplements of 10 mg of iron and 0.5 mg of copper with or without 10 mg of zinc from 6 to 18 mo of age.Overall, 251 infants were randomized to receive one of two daily supplements. Venous blood draws at 6, 12, and 18 mo of age were taken to characterize hemoglobin, plasma ferritin, zinc, and copper concentrations. The urinary excretion of zinc was also measured at each time point. Repeated measures analysis of variance was used to evaluate changes over time and by supplement type.Both hemoglobin and copper concentrations increased significantly and plasma ferritin decreased from 6 to 12 mo of age (P0.05). Mean plasma zinc concentrations in the zinc treatment group were maintained over time, whereas zinc concentrations in the control group declined; differences by treatment were found at 12 and 18 mo of age (P0.05). Urinary zinc concentration was increased in the zinc group at 12 mo only. There was evidence that zinc treatment improved the hemoglobin level at 18 mo of age (P = 0.09). Compliance with supplementation was high, with 81% of the intended dose consumed over the 12-mo period.Daily mineral supplementation over the course of 1 y appears to be feasible and acceptable in this population. A combined supplement can improve the status of iron, zinc, and copper in infants at the same time.

Maternal prenatal zinc supplementation improved fetal autonomic regulation in a nutrient-deficient population in Peru. To evaluate whether differences in autonomic regulation existed in early childhood, we studied 165 children from a zinc supplementation trial (80% of original sample) as part of a comprehensive evaluation at age 54 mo. Electrocardiogram (ECG) data were collected from the children at rest and while they underwent a cognitive testing battery following a standardized protocol. Of these, 79 were born to mothers receiving 25 mg/d zinc in addition to 60 mg/d iron and 250 μg/d folic acid during pregnancy, and 86 were born to mothers receiving iron and folic acid only. Derived cardiac measures included heart period (HP), range, HP variability (HPV), mean square of successive differences (MSSD), and a measure of vagal tone (V). Children in the zinc supplementation group had greater HP (i.e. slower heart rate), greater range, higher time-independent (HPV) and time-dependent (MSSD) variability in HP, and higher V (P < 0.05) during baseline. Analyses conducted across the cognitive testing period revealed similar effects of prenatal zinc supplementation on cardiac patterns. Concurrent child zinc plasma concentration was also associated with longer HP, greater variability, and marginally higher range and V (P < 0.10). Differences in cardiac patterns due to prenatal zinc supplementation were detectable in children at 54 mo of age during conditions of both rest and challenge, indicating that supplementing zinc-deficient pregnant women has beneficial long-term consequences for neural development associated with autonomic regulation.

Background Previous growth studies of Peruvian children have featured high stunting rates and limited information about body composition. Objective We aimed to characterize anthropometric measures of Peruvian infants 0 to 12 months of age in relation to the international growth references and biological, environmental, and socioeconomic factors. Methods Infants ( n = 232) were followed longitudinally from birth through 12 months of age from a prenatal zinc supplementation trial conducted in Lima, Peru, between 1995 and 1997. Anthropometric measures of growth and body composition were obtained at enrollment from mothers and monthly through 1 year of age from infants. Weekly morbidity and dietary intake surveillance was carried out during the second half of infancy. Results The prevalence rates of stunting, underweight, and wasting did not exceed 4% based on the World Health Organization growth references. Infants of mothers from high-altitude regions had larger chest circumference ( p = .006) and greater length ( p = .06) by 12 months. Significant predictors of growth and body composition throughout infancy were age, sex, anthropometric measurements at birth, breastfeeding, maternal anthropometric measurements, primiparity, prevalence of diarrhea among children, and the altitude of the region of maternal origin. No associations were found for maternal education, asset ownership, or sanitation and hygiene factors. Conclusions Peruvian infants in this urban setting had lower rates of stunting than expected. Proximal and familial conditions influenced growth throughout infancy.

Objective To determine if vitamin C and E supplementation in high-risk pregnant women with low nutritional status reduces pre-eclampsia. Design Multicentred, randomised, controlled, double-blinded trial. Setting Antenatal care clinics and Hospitals in four countries. Population Pregnant women between 14 and 22 weeks’ gestation. Method Randomised women received 1000 mg vitamin C and 400 iu of vitamin E or placebo daily until delivery. Main outcome measures Pre-eclampsia, low birthweight, small for gestational age and perinatal death. Results Six hundred and eighty-seven women were randomised to the vitamin group and 678 to the placebo group. Groups had similar gestational ages (18.1; SD 2.4 weeks), socio-economic, clinical and demographical characteristics and blood pressure at trial entry. Risk factors for eligibility were similar, except for multiple pregnancies: placebo group (14.7%), vitamins group (11.8%). Previous pre-eclampsia, or its complications, was the most common risk factor at entry (vitamins 41.6%, placebo 41.3%). Treatment compliance was 87% in the two groups and loss to follow-up was low (vitamins 2.0%, placebo 1.3%). Supplementation was not associated with a reduction of pre-eclampsia (RR: 1.0; 95% CI: 0.9–1.3), eclampsia (RR: 1.5; 95% CI: 0.3–8.9), gestational hypertension (RR: 1.2; 95% CI: 0.9–1.7), nor any other maternal outcome. Low birthweight (RR: 0.9; 95% CI: 0.8–1.1), small for gestational age (RR: 0.9; 95% CI: 0.8–1.1) and perinatal deaths (RR: 0.8; 95% CI: 0.6–1.2) were also unaffected. Conclusion Vitamins C and E at the doses used did not prevent pre-eclampsia in these high-risk women.

Objective We describe the levels and patterns of change in red blood cell (RBC) metallothionein (MT) during pregnancy and the neonate and relate RBCMT to other indicators of zinc and iron status. Methods As part of a double-masked controlled trial of prenatal zinc supplementation among 242 Peruvian pregnant women, we determined RBCMT at enrollment (10–16 wk), at 28 and 36 wk of gestation, and in the cord blood at delivery in 158 women (86 who received daily supplements containing 60 mg of iron and 250 μg of folic acid and 72 whose supplements also contained 25 mg of zinc). In addition, we measured plasma and urinary zinc concentrations, hemoglobin and serum ferritin, and, on a limited sample, RBC zinc and placental MT. Results RBCMT increased during pregnancy, and levels in the cord blood approximated maternal values at 36 wk. Only RBC zinc at 36 wk differed by supplement type ( P Conclusion Changes in RBCMT throughout pregnancy were consistent with the hypothesized role of MT in regulating zinc homeostasis. RBCMT appears to not be responsive during pregnancy to changes in zinc status achieved with supplements.

Cluster-based studies involving aggregate units such as hospitals or medical practices are increasingly being used in healthcare evaluation. An important characteristic of such studies is the presence of intracluster correlation, typically quantified by the intracluster correlation coefficient (ICC). Sample size calculations for cluster-based studies need to account for the ICC, or risk underestimating the sample size required to yield the desired levels of power and significance. In this article, we present values for ICCs that were obtained from data on 97,095 pregnancies and 98,072 births taking place in a representative sample of 120 hospitals in eight Latin American countries. We present ICCs for 86 variables measured on mothers and newborns from pregnancy to the time of hospital discharge, including 'process variables' representing actual medical care received for each mother and newborn. Process variables are of primary interest in the field of implementation research. We found that overall, ICCs ranged from a minimum of 0.0003 to a maximum of 0.563 (median 0.067). For maternal and newborn outcome variables, the median ICCs were 0.011 (interquartile range 0.007-0.037) and 0.054 (interquartile range 0.013-0.075) respectively; however, for process variables, the median was 0.161 (interquartile range 0.072-0.328). Thus, we confirm previous findings that process variables tend to have higher ICCs than outcome variables. We demonstrate that ICCs generally tend to increase with higher prevalences (close to 0.5). These results can help researchers calculate the required sample size for future research studies in maternal and perinatal health.

OBJECTIVE: To set up a global system for monitoring maternal and perinatal health in 54 countries worldwide. METHODS: The WHO Global Survey for Monitoring Maternal and Perinatal Health was implemented through a network of health institutions, selected using a stratified multistage cluster sampling design. Focused information on maternal and perinatal health was abstracted from hospital records and entered in a specially developed online data management system. Data were collected over a two- to three-month period in each institution. The project was coordinated by WHO and supported by WHO regional offices and country coordinators in Africa and the Americas. FINDINGS: The initial survey was implemented between September 2004 and March 2005 in the African and American regions. A total of 131 institutions in seven African countries and 119 institutions in eight Latin American countries participated. CONCLUSION: This project has created a technologically simple and scientifically sound system for large-scale data management, which can facilitate programme monitoring in countries.

OBJECTIVE: To report stillbirth and early neonatal mortality and to quantify the relative importance of different primary obstetric causes of perinatal mortality in 171 perinatal deaths from 7993 pregnancies that ended after 28 weeks in nulliparous women. METHODS: A review of all stillbirths and early newborn deaths reported in the WHO calcium supplementation trial for the prevention of pre-eclampsia conducted at seven WHO collaborating centres in Argentina, Egypt, India, Peru, South Africa and Viet Nam. We used the Baird-Pattinson system to assign primary obstetric causes of death and classified causes of early neonatal death using the International classification of diseases and related health problems, Tenth revision (ICD-10). FINDINGS: Stillbirth rate was 12.5 per 1000 births and early neonatal mortality rate was 9.0 per 1000 live births. Spontaneous preterm delivery and hypertensive disorders were the most common obstetric events leading to perinatal deaths (28.7% and 23.6%, respectively). Prematurity was the main cause of early neonatal deaths (62%). CONCLUSIONS: Advancements in the care of premature infants and prevention of spontaneous preterm labour and hypertensive disorders of pregnancy could lead to a substantial decrease in perinatal mortality in hospital settings in developing countries.

Background: Maternal zinc deficiency is relatively common in developing countries, but its consequences for fetal growth are not established. Objective: The goal was to examine whether improvement in maternal gestational zinc status is positively associated with fetal growth as assessed by ultrasonography. Design: We conducted a double-masked, randomized trial among 242 pregnant Peruvian women in an impoverished shantytown in Lima, Peru. At 10 –16 wk of gestation, the women were randomly assigned to receive daily supplements containing 60 mg Fe and 250 g folic acid, with or without 25 mg Zn. We measured fetal head circumference, biparietal diameter, abdominal circumference, and femur diaphysis length at 20, 24, 28, 32, 36, and 38 wk of gestation. Fetal measures were analyzed longitudinally to evaluate differences in trends of fetal growth by supplement type, and within-subject correlations were taken into account. Results: Femur diaphysis length was greater in fetuses whose mothers received zinc supplements (P 0.05), and the difference tended to increase with gestational age. No significant differences by supplement type were observed for the other anatomical sites measured. Conclusions: The observed positive effect of prenatal zinc on fetal femur diaphysis length is consistent with the results of experimental studies in animals and in vitro. The supplementation effect represents an upward shift in mean femur diaphysis length at term of about one-quarter of the reference SD. These findings suggest the potential importance of maternal zinc status for fetal bone growth in humans and illustrate the value of ultrasonography for evaluating the effect of prenatal nutritional interventions on components of fetal growth. Am J Clin Nutr 2004;79:826 –30.

Women with symptoms of iron deficiency while pregnant can anticipate adverse effects on both their own and their infant's health. Premature births and low birth weight are more frequent, and the risk of death at delivery and perinatally is increased. Previous studies done to determine how maternal iron deficiency affects the ability of the fetus to accumulate iron have given mixed results. The present study used a stable-isotope technique to quantify iron transfer in 41 pregnant Peruvian women, 26 of whom received daily supplements of iron and folate, with or without zinc, from week 10 to 24 of pregnancy up to I month postoperatively. At an average of 33 weeks gestation, the women were given 10 mg of 5 7 Fe orally and 0.6 mg of 5 8 Fe intravenously. Isotope enrichment and markers of iron status were estimated in cord blood samples at the time of delivery. Isotope ratios were measured by a mass spectrometric method. The net amount of 5 7 Fe in the neonatal circulation, a result of maternal supplementation, correlated directly with maternal iron absorption and inversely with maternal iron status in the third trimester as reflected by serum levels of ferritin, folate, and transferrin receptor. As expected, the women given supplements had significantly better iron status than did those in the control group. When women did not receive supplements, significantly more 5 7 Fe was transferred to their infants. This was the case whether or not iron supplementation was accompanied by zinc. In contrast, the amount of the 5 8 Fe tracer in the neonatal circulation was not significantly related to the mother's iron status. There were no significant differences in birth weight or length between the 2 groups. These findings demonstrate that the transfer of maternal iron to the fetus is regulated by the prevailing maternal iron status. The fact that transfer of intravenously administered iron was not a function of maternal iron status suggests that iron transfer takes place chiefly in the gastrointestinal tract. The fetal need for iron appears to take priority over maternal needs.

Background: To ensure multiple micronutrient powders (MNP) for children have their intended effect, it is important to understand caregivers’ experiences. Objective: We aimed to assess perceptions, practices, and preferences relating to the use of MNP among caregivers of children enrolled in a study to compare different MNP dosing schemes in Cajamarca, Peru. Methods: Infants age 6-11 mo (n=400) were randomly assigned to 6 mo daily, 6 mo intermittent (every other day), 12 mo daily, or 12 mo intermittent MNP supplementation. MNP were provided monthly and field staff conducted home visits twice monthly. Unused MNP sachets were collected throughout and at endline (12 mo) all caregivers were asked about their experiences using MNP. Results: Most (94%) reported being very satisfied with MNP. One quarter (27%) reported difficulties remembering to give the MNP scheme as recommended. The most frequently reported strategies for remembering were keeping the MNP in the kitchen or bedroom. Most (98%) reported that giv...

Fractional iron absorption from a breakfast meal was determined in Peruvian children employing stable iron isotopes as labels. Iron isotopic analysis was performed by the recently developed negative thermal ionization technique for high-precision iron isotope ratio measurements using FeF4– ions. By increasing the ascorbic acid content of the standard breakfast meal as served within the Peruvian school-breakfast program from 27 mg to 70 mg, it was possible to increase the geometric mean fractional iron absorption significantly from 5.1% (range 1.6–13.5%) to 8.2% (range 3.1–25.8%). Fractional iron absorption was calculated according to isotope dilution principles and by considering the non-monoisotopic character of the used spikes.

Zinc deficiency in pregnancy probably is common all over the world but especially in developing countries and where women eat a diet based on cereals, vegetables, and legumes. It has been estimated that approximately 80% of pregnant women worldwide may consume an inadequate amount of zinc. Whether maternal zinc deficiency impedes fetal growth is not clear. This double-blind, randomized trial related maternal zinc status during pregnancy to fetal growth as measured sonographically. The subjects were 242 Peruvian women living in an impoverished area of Lima. At 10 to 16 weeks gestation, they were assigned to receive daily supplements of 60 mg iron and 250 μg folic acid with or without 25 mg of zinc. Fetal head circumference, biparietal diameter, abdominal circumference, and length of the femoral diaphysis were measured every 4 weeks from 20 to 38 weeks gestation. Compliance with taking supplements was estimated at 87%. Women took their assigned supplements a median of 6 days a week. There were no significant differences between the 2 groups in duration of pregnancy, neonatal size, head circumference, biparietal diameter, or abdominal circumference. Femoral diaphysial length, however, was greater in zinc-supplemented women than in those taking only iron and folic acid. The effect of zinc on femoral length appeared to increase with advancing gestational age. It approximated one fourth of the reference standard deviation. The positive effect of supplemental zinc on fetal femoral length observed in this study is consistent with experimental animal and in vitro studies that have demonstrated a stimulatory effect of zinc on bone growth. Previous studies also have shown an adverse effect of maternal zinc deficiency on bone growth and fetal bone metabolism. The present findings endorse the use of zinc supplements when dietary zinc intake is inadequate.

Summary Background We report the main findings of the WHO Multicountry Survey on Maternal and Newborn Health (WHOMCS), which aimed to assess the burden of complications related to pregnancy, the coverage of key maternal health interventions, and use of the maternal severity index (MSI) in a global network of health facilities. Methods In our cross-sectional study, we included women attending health facilities in Africa, Asia, Latin America, and the Middle East that dealt with at least 1000 childbirths per year and had the capacity to provide caesarean section. We obtained data from analysis of hospital records for all women giving birth and all women who had a severe maternal outcome (SMO; ie, maternal death or maternal near miss). We regarded coverage of key maternal health interventions as the proportion of the target population who received an indicated intervention (eg, the proportion of women with eclampsia who received magnesium sulphate). We used areas under the receiver operator characteristic curves (AUROC) with 95% CI to externally validate a previously reported MSI as an indicator of severity. We assessed the overall performance of care (ie, the ability to produce a positive effect on health outcomes) through standardised mortality ratios. Results From May 1, 2010, to Dec 31, 2011, we included 314 623 women attending 357 health facilities in 29 countries (2538 had a maternal near miss and 486 maternal deaths occurred). The mean period of data collection in each health facility was 89 days (SD 21). 23 015 (7·3%) women had potentially life-threatening disorders and 3024 (1·0%) developed an SMO. 808 (26·7%) women with an SMO had post-partum haemorrhage and 784 (25·9%) had pre-eclampsia or eclampsia. Cardiovascular, respiratory, and coagulation dysfunctions were the most frequent organ dysfunctions in women who had an SMO. Reported mortality in countries with a high or very high maternal mortality ratio was two-to-three-times higher than that expected for the assessed severity despite a high coverage of essential interventions. The MSI had good accuracy for maternal death prediction in women with markers of organ dysfunction (AUROC 0·826 [95% CI 0·802–0·851]). Interpretation High coverage of essential interventions did not imply reduced maternal mortality in the health-care facilities we studied. If substantial reductions in maternal mortality are to be achieved, universal coverage of life-saving interventions need to be matched with comprehensive emergency care and overall improvements in the quality of maternal health care. The MSI could be used to assess the performance of health facilities providing care to women with complications related to pregnancy. Funding UNDP–UNFPA–UNICEF–WHO–World Bank Special Programme of Research, Development and Research Training in Human Reproduction (HRP); WHO; USAID; Ministry of Health, Labour and Welfare of Japan; Gynuity Health Projects.

Background: Zinc is necessary for central nervous system development, and maternal zinc status has been associated with developmental differences in offspring. Objective: The objective was to evaluate differences in cognitive, social, and behavioral function in Peruvian children at 54 mo of age whose mothers participated during pregnancy in a zinc supplementation trial. Design: We attempted to follow up 205 children from a prenatal zinc supplementation trial and present data on 184 (90%) children—86 whose mothers took 25 mg zinc/d in addition to 60 mg iron and 250 lg folic acid and 98 whose mothers took iron and folic acid only. Following a standardized protocol, we assessed children’s intelligence, language and number skills, representational ability, interpersonal understanding, as well as adaptive behavior and behavioral adjustment. We also assessed aspects of the mother (eg, age, education, verbal intelligence, stresses, and social support in parenting) and the home environment [HOME (Home Observation for the Measurement of the Environment) inventory]. Results: No differences were observed between any of the tests used to characterize cognitive, social, or behavioral development (P . 0.05). Child sex, parity, or treatment compliance did not modify the effects of supplementation on any outcomes. Conclusion: The addition of zinc to prenatal supplements did not influence developmental outcomes in Peruvian children when assessed at 4.5 y of age. Am J Clin Nutr doi: 10.3945/ajcn.2010. 29407.

Little is known about how maternal zinc intake influences growth in utero and in postnatal life in humans.We aimed to assess the effect of maternal zinc supplementation during pregnancy on infant growth through age 1 y.A double-blind, randomized controlled trial of prenatal zinc supplementation was conducted from 1995 to 1997 in Lima, Peru. Women (n = 1295) were enrolled at 15.6 +/- 4.6 wk gestation and assigned to receive daily supplements with zinc (15 mg Zn + 60 mg Fe + 250 microg folic acid) or without zinc (60 Fe + 250 microg folic acid) through pregnancy to 1 mo after delivery. At birth, 546 infants were followed for 12 mo to assess growth. Anthropometric measures of body size and composition were collected monthly, and morbidity and dietary intake surveillance was carried out weekly.No differences in maternal socioeconomic characteristics by treatment group or follow-up period were found. Infants born to mothers prenatally supplemented with zinc had significantly (P0.05) larger average growth measures beginning in month 4 and continuing through month 12. In longitudinal regression modeling, prenatal zinc was associated with greater weight (by 0.58 +/- 0.12 kg; P0.001), calf circumference (by 1.01 +/- 0.21 cm; P0.001), chest circumference (by 0.60 +/- 0.20 cm; P = 0.002), and calf muscle area (by 35.78 +/- 14.75 mm(2); P = 0.01) after adjustment for a range of covariates. No effect was observed for linear growth.Maternal zinc supplementation in this population was associated with offspring growth, which is suggestive of lean tissue mass accretion.

Objective The objective of the study was to examine whether blood pressure in early pregnancy and its rise in the second half of gestation are associated with spontaneous preterm birth in healthy, normotensive, nulliparous women. Study Design We included 5167 women with singleton gestation who participated in the World Health Organization Calcium Supplementation for the Prevention of Preeclampsia Trial. Systolic, diastolic, and mean arterial blood pressure and pulse pressure at baseline (12-19 weeks of gestation) and at the midthird trimester (30-34 weeks) were calculated. Rise in blood pressure was the difference between the midthird trimester and baseline. Preterm birth was defined as early preterm (less than 34 completed weeks) and late preterm birth (34-36 weeks). Results Women experiencing early or late preterm birth had over 10 mm Hg and 3 mm Hg higher rise, respectively, in systolic, diastolic, and mean arterial blood pressure than women delivering at term. A rise in systolic pressure over 30 mm Hg or diastolic pressure over 15 mm Hg was associated with a statistically significant 2- to 3-fold increase in risk of spontaneous preterm birth. Conclusion An excessive rise in either systolic or diastolic blood pressures from early pregnancy to the midthird trimester is associated with spontaneous preterm birth in a dose-response pattern.

Background Caesarean section rates continue to increase worldwide with uncertain medical consequences. Auditing and analysing caesarean section rates and other perinatal outcomes in a reliable and continuous manner is critical for understanding reasons caesarean section changes over time. Methods We analyzed data on 97,095 women delivering in 120 facilities in 8 countries, collected as part of the 2004-2005 Global Survey on Maternal and Perinatal Health in Latin America. The objective of this analysis was to test if the "10-group" or "Robson" classification could help identify which groups of women are contributing most to the high caesarean section rates in Latin America, and if it could provide information useful for health care providers in monitoring and planning effective actions to reduce these rates. Results The overall rate of caesarean section was 35.4%. Women with single cephalic pregnancy at term without previous caesarean section who entered into labour spontaneously (groups 1 and 3) represented 60% of the total obstetric population. Although women with a term singleton cephalic pregnancy with a previous caesarean section (group 5) represented only 11.4% of the obstetric population, this group was the largest contributor to the overall caesarean section rate (26.7% of all the caesarean sections). The second and third largest contributors to the overall caesarean section rate were nulliparous women with single cephalic pregnancy at term either in spontaneous labour (group 1) or induced or delivered by caesarean section before labour (group 2), which were responsible for 18.3% and 15.3% of all caesarean deliveries, respectively. Conclusion The 10-group classification could be easily applied to a multicountry dataset without problems of inconsistencies or misclassification. Specific groups of women were clearly identified as the main contributors to the overall caesarean section rate. This classification could help health care providers to plan practical and effective actions targeting specific groups of women to improve maternal and perinatal care.