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To estimate the prevalence of cerebral palsy (CP) and the frequency of co-occurring developmental disabilities (DDs), gross motor function (GMF), and walking ability using the largest surveillance DD database in the US.We conducted population-based surveillance of 8-year-old children in 2006 (N=142,338), in areas of Alabama, Georgia, Wisconsin, and Missouri. This multi-site collaboration involved retrospective record review at multiple sources. We reported CP subtype, co-occurring DDs, Gross Motor Function Classification System (GMFCS) level, and walking ability as well as CP period prevalence by race/ethnicity and sex.CP prevalence was 3.3 (95% confidence interval [CI]: 3.1-3.7) per 1000 and varied by site, ranging from 2.9 (Wisconsin) to 3.8 (Georgia) per 1000, 8-year olds (p0.02). Approximately 81% had spastic CP. Among children with CP, 8% had an autism spectrum disorder and 35% had epilepsy. Using the GMFCS, 38.1% functioned at the highest level (I), with 17.1% at the lowest level (V). Fifty-six percent were able to walk independently and 33% had limited or no walking ability.Surveillance data are enhanced when factors such as functioning and co-occurring conditions known to affect clinical service needs, quality of life, and health care are also considered.

For conditions with wide-ranging consequences, such as cerebral palsy (CP), population-based surveillance provides an estimate of the prevalence of case status but only the broadest understanding of the impact of the condition on children, families or society. Beyond case status, information regarding health, functional skills and participation is necessary to fully appreciate the consequences of the condition. The purpose of this study was to assess the feasibility and reliability of enhancing population-based surveillance by classifying gross motor function (GMF) from information available in medical records of children with CP. We assessed inter-rater reliability of two GMF classification methods, one the Gross Motor Function Classification System (GMFCS) and the other a 3-category classification of walking ability: (1) independently, (2) with handheld mobility device, or (3) limited or none. Two qualified clinicians independently reviewed abstracted evaluations from medical records of 8-year-old children residing in southeast Wisconsin, USA who were identified as having CP (n = 154) through the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network. Ninety per cent (n = 138) of the children with CP had information in the record after age 4 years and 108 (70%) had adequate descriptions of gross motor skills to classify using the GMFCS. Agreement was achieved on 75.0% of the GMFCS ratings (simple kappa = 0.67, 95% confidence interval [95% CI 0.57, 0.78], weighted kappa = 0.83, [95% CI 0.77, 0.89]). Among case children for whom walking ability could be classified (n = 117), approximately half walked independently without devices and one-third had limited or no walking ability. Across walking ability categories, agreement was reached for 94% (simple kappa = 0.90, [95% CI 0.82, 0.96], weighted kappa = 0.94, [95% CI 0.89, 0.98]). Classifying GMF in the context of active records-based surveillance is feasible and reliable. Future surveillance efforts that include functional level among children with cerebral palsy may provide important information for monitoring the impact of the condition for programmatic and policy purposes.

Objective To examine the feasibility of using routine labour and delivery hospitalization data and international classification of diseases (ICD-10CA) codes for carrying out surveillance of severe maternal morbidity in Canada. Methods We identified ICD-10CA diagnosis codes and Canadian Classification of Interventions (CCI) procedure codes associated with severe maternal illness. Severe maternal morbidity rates in Canada (excluding Quebec) for the period 2003 to 2007 were estimated using the Discharge Abstract Database of the Canadian Institute for Health Information. Rates were compared across maternal age, parity, plurality, labour induction, delivery by Caesarean section, and other factors. Case fatality rates and length of hospitalization were also estimated. Results Among the 1 336 356 women who delivered between 2003 and 2007, the rate of severe maternal morbidity was 13.8 per 1000 deliveries. The mean length of hospital stay for women with and without a severe illness was 5.4 days vs. 2.5 days, while the frequency of prolonged hospital stay (≥7 days) was 19.8% vs. 1.8%, respectively (rate ratio 9.3; 95% CI 9.0 to 9.6). Case fatality rates differed significantly between women with and without a severe illness at 2.98 vs. 0.008 per 1000, respectively (rate ratio 392.8; 95% CI 200.3 to 700.4). Rates of severe maternal morbidity were higher among deliveries to older and nulliparous women and to those delivering twins or triplets. Conclusion Disease frequency, case fatality, and length of hospitalization patterns suggest that comprehensive and timely surveillance of severe maternal morbidity in Canada is feasible using the Canadian Institute for Health Information hospitalization data and ICD-10CA/CCI codes.

The value of any public health surveillance program is derived from the ways in which data are managed and used to improve the public's health. Although birth defects surveillance programs vary in their case volume, budgets, staff, and objectives, the capacity to operate efficiently and maximize resources remains critical to long-term survival. The development of a fully-integrated relational database management system (DBMS) can enrich a surveillance program's data and improve efficiency. To build upon the Florida Birth Defects Registry--a statewide registry relying solely on linkage of administrative datasets and unconfirmed diagnosis codes-the Florida Department of Health provided funding to the University of South Florida to develop and pilot an enhanced surveillance system in targeted areas with a more comprehensive approach to case identification and diagnosis confirmation. To manage operational and administrative complexities, a DBMS was developed, capable of managing transmission of project data from multiple sources, tracking abstractor time during record reviews, offering tools for defect coding and case classification, and providing reports to DBMS users. Since its inception, the DBMS has been used as part of our surveillance projects to guide the receipt of over 200 case lists and review of 12,924 fetuses and infants (with associated maternal records) suspected of having selected birth defects in over 90 birthing and transfer facilities in Florida. The DBMS has provided both anticipated and unexpected benefits. Automation of the processes for managing incoming case lists has reduced clerical workload considerably, while improving accuracy of working lists for field abstraction. Data quality has improved through more effective use of internal edits and comparisons with values for other data elements, while simultaneously increasing abstractor efficiency in completion of case abstraction. We anticipate continual enhancement to the DBMS in the future. While we have focused on enhancing the capacity of our DBMS for birth defects surveillance, many of the tools and approaches we have developed translate directly to other public health and clinical registries.

To analyze survival patterns among infants with hypoplastic left heart syndrome (HLHS) in the State of Michigan.Cases of HLHS prevalent at live birth were identified and confirmed within the Michigan Birth Defects Registry from 1992 to 2005 (n=406). Characteristics of infants with HLHS were compared with a 10:1 random control sample.Compared with 4060 control subjects, the 406 cases of HLHS were more frequently male (62.6% vs 51.4%), born prematurely (37 weeks gestation; 15.3% vs 8.7%), and born at low birth weight (LBW) (2.5 kg; 16.0% vs 6.6%). HLHS 1-year survival rate improved over the study period (P=.041). Chromosomal abnormalities, LBW, premature birth, and living in a high poverty neighborhood were significantly associated with death. Controlling for neighborhood poverty, term infants versus preterm with HLHS or LBW were 3.2 times (95% CI: 1.9-5.3; P.001) more likely to survive at least 1 year. Controlling for age and weight, infants from low-poverty versus high-poverty areas were 1.8 times (95% CI: 1.1-2.8; P=.015) more likely to survive at least 1 year.Among infants with HLHS in Michigan, those who were premature, LBW, had chromosomal abnormalities, or lived in a high-poverty area were at increased risk for early death.

Background Greater epidemiologic understanding of the relationships among fetal-infant mortality and its prognostic factors, including birthweight, could have vast public health implications. A key step toward that understanding is a realistic and tractable framework for analyzing birthweight distributions and fetal-infant mortality. The present paper is the second of a two-part series that introduces such a framework. Methods We propose estimating birthweight-specific mortality within each component of a normal mixture model representing a birthweight distribution, the number of components having been determined from the data rather than fixed a priori. Results We address a number of methodological issues related to our proposal, including the construction of confidence intervals for mortality risk at any given birthweight within a component, for odds ratios comparing mortality within two different components from the same population, and for odds ratios comparing mortality within analogous components from two different populations. As an illustration we find that, for a population of white singleton infants, the odds of mortality at 3000 g are an estimated 4.15 times as large in component 2 of a 4-component normal mixture model as in component 4 (95% confidence interval, 2.04 to 8.43). We also outline an extension of our framework through which covariates could be probabilistically related to mixture components. This extension might allow the assertion of approximate correspondences between mixture components and identifiable subpopulations. Conclusions The framework developed in this paper does not require infants from compromised pregnancies to share a common birthweight-specific mortality curve, much less assume the existence of an interval of birthweights over which all infants have the same curve. Hence, the present framework can reveal heterogeneity in mortality that is undetectable via a contaminated normal model or a 2-component normal mixture model.

Background: This study was designed to evaluate the hypothesis that the prevalence of autism spectrum disorder (ASD) among children in the United States is positively associated with socioeconomic status (SES). Methods: A cross-sectional study was implemented with data from the Autism and Developmental Disabilities Monitoring Network, a multiple source surveillance system that incorporates data from educational and health care sources to determine the number of 8-year-old children with ASD among defined populations. For the years 2002 and 2004, there were 3,680 children with ASD among a population of 557 689 8-year-old children. Area-level census SES indicators were used to compute ASD prevalence by SES tertiles of the population. Results: Prevalence increased with increasing SES in a dose-response manner, with prevalence ratios relative to medium SES of 0.70 (95% confidence interval [CI] 0.64, 0.76) for low SES, and of 1.25 (95% CI 1.16, 1.35) for high SES, (P,0.001). Significant SES gradients were observed for children with and without a pre-existing ASD diagnosis, and in analyses stratified by gender, race/ethnicity, and surveillance data source. The SES gradient was significantly stronger in children with a pre-existing diagnosis than in those meeting criteria for ASD but with no previous record of an ASD diagnosis (p,0.001), and was not present in children with co-occurring ASD and intellectual disability. Conclusions: The stronger SES gradient in ASD prevalence in children with versus without a pre-existing ASD diagnosis points to potential ascertainment or diagnostic bias and to the possibility of SES disparity in access to services for children with autism. Further research is needed to confirm and understand the sources of this disparity so that policy implications can be drawn. Consideration should also be given to the possibility that there may be causal mechanisms or confounding factors associated with both high SES and vulnerability to ASD.

Autism spectrum disorders (ASDs) often co-occur with other developmental, psychiatric, neurologic, or medical diagnoses.This study examined co-occurring non-ASD diagnoses and symptoms in a population-based cohort of 8 year olds identified with ASD.Data on 2,568 children meeting surveillance case definition for ASD were collected by a multi-site surveillance program. Information was systematically abstracted and reviewed from existing health and education source records and systematically entered into a summary record in a secure database.Eighty-one percent of study children were male; 63% white, 23% black, 14% Hispanic, Asian, or not stated. When age of ASD classification was available, 20% were classified before age 3 years, 36% between ages 3 and 5 years, and 44% after age 5 years. The co-occurrence ofor = 1 non-ASD developmental diagnoses was 83%,or = 1 psychiatric diagnoses was 10%,or = 1 neurologic diagnoses was 16%, and at least one possibly causative genetic or neurologic diagnosis was 4%. Children with a previous ASD classification and co-occurring psychiatric or neurologic conditions were more likely to be diagnosed or classified at a later age. Each category of co-occurring non-ASD diagnosis was significantly increased in children whose records did not include an ASD diagnosis or educational classification but who met surveillance criteria for ASD.These data highlight the need for clinicians to keep in mind the high prevalence of associated diagnoses with an ASD diagnosis, and the possibility that in younger children other symptoms or disorders may be masking or obscuring core symptoms of ASD, which would lead to a diagnosis.

The purpose of this study is to explore state-level fetal death rates and24 h infant mortality rates for deliveries less than 500 g in order to estimate outcomes classification differences at the edge of viability. We selected singleton deliveries to US resident mothers born500 g and20 weeks gestation from the NCHS live birth-infant death and fetal death files for 1999-2002 (n = 37,813). Infant deaths within 24 h of birth were selected to estimate odds of classification as a fetal death versus a live birth/infant death by state. Logistic regression was used to derive odds of classification as a fetal death and to adjust for maternal characteristics, calculating unadjusted and adjusted odds ratios. We identified 37,813 outcomes from 48 states reporting in this birthweight category. Unadjusted odds of classification of outcomes as a fetal death versus a live birth/death within 24 h by state ranged from OR = 0.38 (95% CI = 0.24-0.59) to OR = 2.93 (95% CI = 2.26-3.78); adjusted for maternal age and race, the range narrowed slightly to a OR = 0.31 (95% CI = 0.20-0.48) to aOR = 2.54 (95% CI = 1.96-3.30). Six states were more likely to classify outcomes as a live birth/infant death, while 14 states were more likely to classify as a fetal death, when compared to a large reference state. The remaining states did not differ significantly in their outcomes. The fraction of outcomes classified as fetal deaths varied by state during the years studied. This study suggests fetal death and early infant death outcomes reported for babies less than 500 g reflect differential classification thus influencing the validity of these vital statistics data at the state level. Further studies are needed to explore the factors that influence these differences.

Objective: White blood cells are mobilized under both hypoxic and infectious conditions. Intrauterine hypoxia is linked to increased risk of cerebral palsy and is potentiated by the presence of infection. We hypothesized that umbilical vein white blood cell elevation in term neonates is associated with intrauterine acidemia.Methods: We prospectively evaluated all liveborn neonates delivered at our institution for a 6-month period. Umbilical arterial blood was analyzed for pH and blood gas and venous blood for hematologic indices. Medical records of cases greater than or equal to 37 weeks' gestation were reviewed for correlative data. Student's t-test was used to determine difference of means and Chi-square test for goodness of fit. Pearson coefficients of correlation were applied where appropriate.Results: A total of 1,948 liveborn, term neonates were delivered during the study period; 1,561 cases had white blood cell analysis and arterial blood gas data available. Acidemic cases had higher white blood ce...

To examine and describe neonatal resuscitation preparedness, presence of connections to wider systems of care, continuing education activities, presence of trained staff, and other indicators of high performance in rural perinatal microsystems.A nonexperimental, retrospective, descriptive, cross-sectional design was utilized. Rural hospitals (n = 124) providing perinatal services in five southern states were invited to participate. Nurse managers completed the Hospital Neonatal Resuscitation Survey, describing policies, healthcare team members, educational activities, organizational culture, system connections, and process improvement. Descriptive data were also collected.A total of 44 (35.1%) hospitals participated. Annual birth volume ranged from 22 to 1,614 (M = 515.53; SD = 336.27). Low birth volume hospitals (125 births per year) had significantly lower levels of preparedness than high volume hospitals (125 births per year). Preparedness was not influenced by rurality. One-third (34.1%) did not identify relationships with Level III NICUs. Support of continuing education was universal. Efforts to increase interdisciplinary teamwork were common. Medical provider shortages were prevalent (n = 25: 56.8%), and the presence of midwifery services was infrequent (n = 12; 27.2%). Hospital nursing shortages (n = 35; 81.8%) were widespread.Challenges faced by rural hospitals and healthcare professionals in the delivery of perinatal care emphasize the importance of creating and maintaining high performance microsystems that are responsive to the changing needs of providers and the populations they serve. Lower levels of preparedness and the lack of established relationships with level III NICUs is concerning.

Early parenting practices are significant to public health because of their linkages to child health outcomes. This paper focuses on the current state of the science regarding conceptual frameworks that incorporate early parenting practices in epidemiologic research and evidence supporting reliability and validity of self-report measures of such practices. Guided by a provisional definition of early parenting practices, literature searches were conducted using PubMed and Sociological Abstracts. Twenty-five published studies that included parent-report measures of early parenting practices met inclusion criteria. Findings on conceptual frameworks were analyzed qualitatively, whereas evidence of reliability and validity were organized into four domains (safety, feeding and oral health, development promotion, and discipline) and summarized in tabular form. Quantitative estimates of measures of reliability and validity were extracted, where available. We found two frameworks incorporating early parenting: one a program theory and the other a predictive model. We found no reported evidence of the reliability or validity of parent-report measures of safety or feeding and oral health practices. Evidence for reliability and validity were reported with greater frequency for development promotion and discipline practices, but report of the most pertinent type of reliability estimation, test–retest reliability, was rare. Failure to examine associations of early parenting practices with any child outcomes within most studies resulted in missed opportunities to indirectly estimate validity of parenting practice measures. Stronger evidence concerning specific measurement properties of early parenting practices is important to advancing maternal-child research, surveillance, and practice.

Objectives. We examined individual, household, and neighborhood correlates of intimate partner violence (IPV) before and during pregnancy. Methods. We used multilevel modeling to investigate IPV among 2887 pregnant women in 112 census tracts who sought prenatal care in 8 public clinics in Jefferson County, Alabama, from 1997 through 2001. Data were collected from the Perinatal Emphasis Research Center project, the 2000 Census, and the local Sheriff and Police Departments Uniform Crime Reports for 1997 through 2001. Results. Participants were predominantly young, African American, on Medicaid, and residents of low-income neighborhoods. The prevalence of past-year male partner–perpetrated physical or sexual violence was 7.4%. Neighborhood residential stability, women performing most of the housework (lack of involvement among partners), being unmarried (being in an uncommitted relationship), and alcohol use were positively associated with elevated IPV risk. Significant protective factors for IPV included older age at first vaginal intercourse and a greater sense of mastery (e.g., the perception of oneself as an effective person). Conclusions. Both neighborhood contextual and individual and household compositional effects are associated with IPV among low-income pregnant women. The results imply that combined interventions to improve neighborhood conditions and strengthen families may effectively reduce IPV.

From 30% to 60% of children with an autism spectrum disorder (ASD) have an IQ measure that falls in the intellectual disability (ID) range. It is not well studied whether, for children within this ASD subgroup, there is variation in the risk for low IQ based on a child's perinatal risk factors.We assessed whether preterm delivery and term small-for-gestational-age (tSGA) were associated with various measures of cognitive deficit among children with ASDs.A sample of 1129 singleton children born in 1994 and identified through school and health record review as having an ASD by age 8 years were selected from a U.S. population-based surveillance network. Mean IQ and dichotomous IQ outcomes indicating various levels of ID were examined according to whether a child was preterm (37 weeks' gestation) or tSGA (term delivery and birth weight10th percentile for gestational age of a U.S. referent). Results for the total sample and within race-ethnicity/maternal education strata were adjusted for child sex and ASD subtype classification.Mean IQ was significantly (p.05) lower in children delivered preterm (69.5) than term (74.5) and tSGA (69.3) than term appropriate-for gestational age (75.3). In stratified analyses, the preterm-IQ association was significant only among non-Hispanic white (NHW) children with maternal education at birth of high school or less; adjusted mean IQ was 8 points lower among those delivered preterm (65.4) than term (73.8). Term-SGA was associated with a significant 8-point deficit in adjusted mean IQ (75.5 vs. 83.8) in NHW children with maternal education greater than high school and a 6-point deficit that approached significance (68.4 vs. 74.5, p=0.10) in NHW children with maternal education of high school or less. Non-Hispanic black children in both maternal education groups had significantly lower mean IQs than NHW children with little variation by preterm or tSGA.In children with ASDs, the risk for concurrent ID or IQ deficit is associated with both preterm delivery and tSGA; these associations may vary by race-ethnicity and SES. Further studies of ASD-ID co-occurrence and the effectiveness of intervention strategies should consider both perinatal and sociodemographic factors.

BACKGROUND: The prevalence of gastroschisis is increasing in many parts of the world, although the etiology is largely unexplained. Young maternal age has been the only consistently identified, strong risk factor. The objective of this study was to examine the role of maternal nativity in relation to other suspected risk factors for gastroschisis in Florida. METHODS: We conducted a retrospective cohort study of singleton infants born in Florida from 1998–2003. Gastroschisis cases were identified from the Florida Birth Defects Registry. Demographic and perinatal data were obtained from birth records. Multivariable Poisson regression was used to estimate adjusted prevalence ratios (PRs) and 95% confidence intervals (CIs) for each factor of interest. RESULTS: The 6-year birth prevalence of gastroschisis was 3.26 per 10,000 live births, and the annual rate increased 41% during the study period. In addition to maternal age and marital status, maternal race/ethnicity and nativity were significantly associated with the risk of delivering an infant with gastroschisis. Compared with non-Hispanic white women, non-Hispanic black women had the lowest risk of delivering an infant with gastroschisis (PR, 0.19; 95% CI, 0.13–0.26), followed by Hispanic women (PR, 0.60; 95% CI, 0.43–0.83). Women born outside the United States were significantly less likely than U.S.-born women to deliver an infant with gastroschisis (PR, 0.59; 95% CI, 0.41–0.86). CONCLUSIONS: Although young maternal age remains a strong significant risk factor for gastroschisis in Florida, other factors such as maternal race/ ethnicity and nativity could be important in explaining the increasing prevalence of gastroschisis. Birth Defects Research (Part A) 85:890–896, 2009. 2009 Wiley-Liss, Inc.

BACKGROUND: The recurrence risk for neural tube defects (NTDs) in subsequent pregnancies is approximately 3%, or 40 times the background risk. Prevention projects target these high-risk women to increase their folic acid consumption during the periconceptional period, a behavior which decreases their recurrence risk by at least 85%. This study surveyed birth defect surveillance programs to assess their NTD recurrence prevention activities and to identify components of intervention projects that might be implemented in states with limited resources. METHODS: In 2005, the National Birth Defects Prevention Network developed and distributed an online survey to primary state birth defects surveillance contacts for the purpose of gathering information on NTD recurrence prevention activities in the United States. RESULTS: Responses came from 37 contacts in 34 states and Puerto Rico. There were 13 active NTD recurrence prevention projects, four past projects, and three planned projects. Fifteen past and present projects recommended that women with a prior NTD-affected birth take 4.0 mg of folic acid daily, and four projects provided folic acid to the women. Reasons given for not having an NTD recurrence prevention project included staffing limitations (53%), lack of funds (47%), lack of priority (18%), and confidentiality/privacy concerns (6%). CONCLUSIONS: Only 15 states and Puerto Rico had or were planning NTD recurrence prevention projects. An NTD recurrence prevention project using minimal resources should consist of timely case ascertainment, educational materials, and mechanisms for disseminating these materials. Birth Defects Research (Part A), 2009. © 2009 Wiley-Liss, Inc.

Patterns of recurrence of restricted fetal growth provide important insights to understand the relative contributions of genetic versus environmental influences. Although there is evidence of increased tendency of small for gestational age (SGA) births to recur, whether similar patterns of recurrence in twins among women that delivered a prior singleton SGA birth remains poorly studied.We used Missouri's maternally-linked data (1978-1997), and restricted the analysis to women that delivered their first two consecutive live births. SGA (birthweight10th and5th centile for gestational age) recurrence was examined in two distinct analyses: women that delivered their first two singleton live births (n = 305,654) and those that delivered their first singleton live birth followed by twin live births (n = 8594). Sib-sib pairwise odds ratio (pOR) were estimated from bivariate logistic regression with robust variance estimation after adjustments for confounders.Risks of SGA were 24.3% and 6.1% in the second singleton birth among women with and without a previous singleton SGA, respectively (pOR 3.9, 95% CI 3.7-4.0). The corresponding risks among twins with and without a previous singleton SGA birth were 16.9% and 6.7%, respectively (pOR 2.3, 95% CI 1.8-2.8). In the singleton-singleton cohort, the highest recurrence risk for SGA occurred around the same gestational age window as the first singleton SGA birth. These associations were stronger for more severe forms of SGA (5th centile).The likelihood of SGA to recur within sibships is strong, with varying magnitude of risks between singleton-singleton and singleton-twin births.

Since the 1970s, the prevalence of multiple births (MBs) in the United States has increased significantly. This has been attributed, in large part, to iatrogenic MBs resulting from infertility treatments that include ovulation stimulation. A past study has indicated that children from MBs have an increased prevalence of cerebral palsy (CP). Other studies also have suggested an association between MBs and intellectual disabilities (ID) and autism spectrum disorders (ASDs); however, results have been inconsistent. From the Autism and Developmental Disabilities Monitoring (ADDM) Network, a surveillance project among several US populations, we obtained MB estimates among children born in 1994 and classified by 8 years of age as having: an ASD (n=1,626 total children from 11 sites; 50 born as part of an MB); CP (n=302 total children from 3 sites; 25 born as part of an MB); or ID (n=1,195 total children from 3 sites; 45 born as part of an MB). All three MB estimates were notably higher than age-adjusted expected estimates of naturally conceived MBs derived from 1971 US natality data. However, when MB estimates from the ADDM Network were compared with expected MB estimates derived from 1994 natality data for the states corresponding to the relevant ADDM Network sites, we observed no association with ASDs (observed/expected=1.08 [0.78-1.38]), a moderate, but not statistically significant association with ID (observed/expected=1.34 [0.95-1.73]), and a strong association with CP (observed/expected=2.96 [1.80-4.12]). Further investigation of specific types of MBs (natural vs. iatrogenic) is warranted.

Objective: At what age are children with an autism spectrum disorder (ASD) identified by community providers? What factors influence the timing of when children are identified with ASDs? This study examined the timing of when children with ASDs are identified. Method: Data came from 13 sites participating in the Centers for Disease Control and Prevention’s 2002 multisite ongoing autism surveillance program, the Autism and Developmental Disabilities Monitoring Network. Survival analysis was used to examine factors that influence the timing of community-based identification and diagnosis. Result: Data from health and education records reveal that the median age of identification was 5.7 years (SE 0.08 years). Parametric survival models revealed that several factors were associated with a younger age of identification: being male, having an IQ of 70 or lower, and having experienced developmental regression. Significant differences in the age of identification among the 13 sites were also discovered. Conclusions: The large gap between the age at which children can be identified and when they actually are identified suggests a critical need for further research, innovation, and improvement in this area of clinical practice. J. Am. Acad. Child Adolesc. Psychiatry, 2009;48(5):474Y483. Key Words: pervasive child development disorders, autism, diagnosis, epidemiology, survival analysis. Timely community-based identification of children with an autism spectrum disorder (ASD) has important implications for individual development, clinical practice, and policy decisions. Identification is a broad construct that includes both clinical diagnoses of ASD and eligibility-related designations of ASD for public services, including early intervention and special education. The American Academy of Pediatrics recently emphasized the importance of early identification of ASDs and recommended close developmental observation at

Objective: To determine risk of delivering a preterm infant (

Aim: While delayed initiation of childbearing is associated with adverse perinatal outcomes, whether or not risk persists and whether interpregnancy interval (IPI) affects the subsequent pregnancy remains unclear. Objectives: To examine second-pregnancy perinatal outcomes for women initiating childbearing age ≥30 compared to those initiating childbearing aged 20–29, specifically examining the distribution of adverse perinatal outcomes, and their associations with the interpregnancy interval. Methods: Retrospective cohort study using the Missouri maternally linked files 1978–1997. Perinatal outcomes included fetal death, low birthweight, preterm birth and small-for-gestational age. Predictor variables included maternal age at first pregnancy and IPI between the first and second pregnancy. Results: With an increasing maternal age at first pregnancy, rates of very low birthweight (P = 0.0095), preterm delivery (P = 0.0126), moderately preterm (P = 0.0458), and extremely preterm (P = 0.0008) in the second pregnancy increased, while the rate of small-for-gestational age (P

To estimate whether the preponderance of obesity among black women could explain the black-white disparity in neonatal mortality.This is a population-based study using longitudinally collected data among pregnant women from the state of Missouri spanning almost two decades (1978-1997). Obesity is defined in this study as body mass index (BMI) of at least 30 and further categorized into the typically reported three subclasses: class I (BMI 30.0-34.9), class II (BMI 35.0-39.9), and extreme/morbid obesity (BMI at least 40). The main outcome measures were neonatal mortality, early neonatal mortality, and late neonatal mortality.Overall, neonatal mortality and early neonatal mortality but not late neonatal mortality increased with higher obesity subclass, with the greatest risk registered among morbidly obese mothers (hazards ratio for neonatal mortality 1.3; 95% confidence interval [CI] 1.1-1.5; hazards ratio for early neonatal mortality 1.3; 95% CI 1.1-1.5). Among blacks, the risk for neonatal, early, and late neonatal mortality increased significantly with rising BMI (50-100% increments). However, offspring of obese white mothers had no elevated risks for any of the three indices of mortality regardless of maternal obesity subclass.Neonates of obese black mothers have an elevated risk of mortality throughout the neonatal period, whereas those of obese white mothers do not. Obesity among black mothers may contribute to the persistent black-white disparity in infant survival in the United States and could provide an avenue for narrowing the black-white gap in infant mortality.II.

BACKGROUND: The prevalence of NTDs in the US declined significantly after mandatory folic acid fortification; however, it is not known if the prevalence of NTDs has continued to decrease in recent years relative to the period immediately following the fortification mandate. METHODS: Population-based data from 21 birth defects surveillance systems were used to examine trends in the birth prevalence of spina bifida and anencephaly during 1999–2000, 2001–2002, and 2003–2004. Prevalence data were stratified by non-Hispanic White, non-Hispanic Black, and Hispanic race or ethnicity. Prevalence ratios were calculated by dividing the birth prevalences during the later time periods (2001–2002 and 2003–2004) by the birth prevalences during 1999–2000. RESULTS: During 1999–2004, 3,311 cases of spina bifida and 2,116 cases of anencephaly were reported. Hispanic infants had the highest prevalences of NTDs for all years. For all infants, the combined birth prevalences of spina bifida and anencephaly decreased 10% from the 1999–2000 period to the 2003–2004 period. The decline in spina bifida (3%) was not significant; however the decline in anencephaly (20%) was statistically significant. CONCLUSIONS: While the prevalences of spina bifida and anencephaly in the United States have declined since folic acid fortification in the food supply began, these data suggest that reductions in the prevalence of anencephaly continued during 2001–2004 and that racial and ethnic and other disparities remain. Birth Defects Research (Part A), 2008. © 2008 Wiley-Liss, Inc.

We examined recurrence of preterm birth in twin pregnancy in the presence of a previous singleton preterm pregnancy, and assessed if these recurrence risks differed for medically indicated and spontaneous preterm birth.A retrospective cohort study was designed using the maternally-linked data of women who delivered a first singleton live birth followed by a twin birth in the second pregnancy (n = 2329) in Missouri (1989--97). We examined preterm birth recurrence at37 in the second twin pregnancy among women with a prior singleton preterm birth. Recurrence risks were based on hazard ratios (HR) and 95% confidence intervals (CI) estimated from Cox proportional hazards models after adjusting for potential confounders.Preterm birth rates in the second twin pregnancy were 69.0% and 49.9% among women who had a previous preterm and term singleton birth, respectively (HR 1.8, 95% CI 1.6-2.1). The preterm birth rate in the second pregnancy was about 95% when the first singleton pregnancy ended at30 weeks. Women delivering preterm following a medical intervention in the first pregnancy had increased recurrence for both spontaneous (HR 1.4, 95% CI 1.1-2.0) and indicated (HR 2.4, 95% CI 1.8-3.2) preterm birth; similarly among women with a prior spontaneous preterm birth, hazard ratios were 1.8 (95% CI 1.5-2.1) and 1.6 (95% CI 1.3-1.9), for spontaneous and indicated preterm birth in the second twin pregnancy, respectively.Women with a singleton preterm birth carry increased risk of preterm birth in the subsequent twin pregnancy. A history of a singleton preterm birth has an independent and additive contribution to risk of preterm birth in the subsequent twin gestation.

To assess whether risk for early mortality is increased with recurrent small for gestational age (SGA) compared with nonrecurrent SGA.We used the Missouri maternally linked cohort data containing births from 1978-1997. We identified mothers according to four categories: 1) appropriate for gestational age (AGA)-AGA: both first and second pregnancies were AGA; 2) AGA-SGA: first pregnancy was AGA, second pregnancy outcome changed to SGA (a switch); 3) SGA-AGA: first pregnancy was SGA, second pregnancy outcome AGA (a switch); 4) SGA-SGA: both first and second pregnancies were SGA. We then compared the success of fetal programming in the second pregnancy with a switch compared with a pregnancy without a switch (AGA-SGA compared with SGA-SGA; and SGA-AGA compared with AGA-AGA). We used neonatal mortality as primary outcome with infant and postneonatal mortality as secondary outcomes.Appropriate for gestational age infants from a SGA-primed uterus (SGA-AGA switch) had a 19% (odds ratio 1.19; 95% confidence interval 1.11-1.28) and 29% (odds ratio 1.29; 95% confidence interval 1.17-1.42) greater likelihood of infant and neonatal mortality, respectively, when compared with AGA infants from AGA-primed uterus (AGA-AGA; nonswitch). Approximately the same magnitude of risk elevation for neonatal and infant mortality was noted among SGA infants resulting from AGA-primed uterus (a switch) as among SGA infants from SGA-primed uterus (a nonswitch). Overall, the greatest risk of neonatal, infant, and postneonatal mortality was associated with an AGA-SGA switch.Fetal programming switch in subsequent gestation adversely affects early survival of affected infants compared with those with no change in fetal growth pattern.

The purpose of this study was to examine the association between prenatal smoking and intrapartum stillbirth by the use of a cohort of singleton births in Missouri from 1978 through 1997. Overall, the authors identified a total of 7,325 counts of stillbirth, yielding a stillbirth rate of 4.4 per 1,000. The timing of the occurrence of the stillbirth to onset of labor was specified in 85.6% (n = 6,273). Of these, 1,070 (17.0%) occurred intrapartum. Smoking mothers were 50% more likely to experience intrapartum fetal death as compared with nonsmoking gravidas (adjusted hazard ratio = 1.5; 95% confidence interval = 1.3-1.7). Women who smoked 10 to 19 cigarettes per day were at the highest risk of experiencing intrapartum stillbirth (adjusted hazard ratio = 1.7 [95% confidence interval = 1.4-2.0]). Our findings underscore the need for increased smoking-cessation education efforts targeted toward pregnant women.

OBJECTIVE. The goal was to estimate the prevalence of cerebral palsy and cerebral palsy subtypes among children in 3 areas of the United States by using a population-based surveillance system.METHODS. Using methods developed by the Centers for Disease Control and Prevention Metropolitan Atlanta Developmental Disabilities Surveillance Program, investigators from the Autism and Developmental Disabilities Monitoring Network conducted surveillance of cerebral palsy among 8-year-old children living in northern Alabama, metropolitan Atlanta, and southeastern Wisconsin in 2002 (N = 114897). Cross-sectional data were collected through retrospective record review from multiple sources. Cases were linked to birth certificate and census files to obtain additional information. Period prevalence estimates were calculated per 1000 children 8 years of age.RESULTS. The average prevalence of cerebral palsy across the 3 sites was 3.6 cases per 1000, with notably similar site-specific prevalence estimates (3.3 cases per 1000 in Wisconsin, 3.7 cases per 1000 in Alabama, and 3.8 cases per 1000 in Georgia). At all sites, prevalence was higher in boys than girls (overall boy/girl ratio: 1.4:1). Also, at all sites, the prevalence of cerebral palsy was highest in black non-Hispanic children and lowest in Hispanic children. At all sites, the prevalence among children living in low- and middle-income neighborhoods was higher than that among children living in high-income neighborhoods. Spastic cerebral palsy was the most common subtype (77% of all cases), with bilateral spastic cerebral palsy dominating the spastic group (70%).CONCLUSION. These findings contribute new knowledge to the epidemiology of cerebral palsy in the United States. The similarities in prevalence rates and patterns of cerebral palsy reported for 8-year-old children at 3 geographically distinct sites provide evidence of the reliability of the surveillance methods used by the Autism and Developmental Disabilities Monitoring Network.

Previous studies suggest that autism may be more common in the offspring of older parents. There is also a positive association between birth order, parental age, and autism, and a number of reports have shown firstborn children to be at increased risk. The aim of this prospective population-based cohort study was to determine whether advancing maternal and paternal ages were each independent risk factors for the development of autism spectrum disorder (ASD) in a large, population-based cohort of US children. Data were obtained from the Centers for Disease Control and Prevention's Autism and Developmental Disabilities Monitoring Network, a group of 10 participating centers, which monitored 253,347 live births and had complete information from birth certificates on parental age, birth order, and other variables. The study group was comprised of 1251 children aged 8 years from this birth cohort who met the criteria for an ASD set forth in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision. Following multivariable analysis to control for the other parent's age, birth order, and other covariables, maternal and paternal ages were each independently associated with autism: the adjusted odds ratio (aOR) for maternal age ≥35 versus 25 to 29 years was 1.3, with a 95% confidence interval (CI) of 1.1 to 1.6; the aOR for paternal age ≥40 years versus 25 to 29 years was 1.4, with a 95% CI of 1.1 to 1.8. There was a 3-fold greater likelihood of autism among firstborn offspring of 2 older parents compared to third- or later-born offspring of mothers aged 20 to 34 years and fathers aged

The effects of advanced maternal age and smoking in pregnancy on fetal survival have previously been reported. However, whether advanced maternal age modifies the relationship between smoking in pregnancy and intrapartum stillbirth remains unknown. We therefore set out to determine the impact of advanced maternal age (or =35 years) on the association between smoking during pregnancy and intrapartum stillbirth by employing retrospective analysis of birth registry data.We used a cohort of singleton births in Missouri from 1978 through 1997 (N = 1,436,628) to compute the risk of total, antepartum, and intrapartum stillbirth in smoking mothers. We categorized mothers into two age groups: "younger" (35 years), and "older" (or =35 years). Non-smoking mothers age35 years were the referent category. Cox regression models were used to generate independent measures of association between intrauterine tobacco exposure and the risk of total, antepartum, and intrapartum stillbirth in each age group.A total of 5,772 counts of stillbirth were identified, yielding a stillbirth rate of 4.0 per 1,000. Approximately 33% (N = 1,900) occurred among older smokers resulting in a stillbirth rate of 9.1 per 1,000. The probability of intrapartum stillbirth was greatest among older smokers, followed by younger smokers and lowest among younger non-smokers (P0.01). As compared to non-smoking younger gravidas, younger smoking mothers had a 30% greater likelihood for both antepartum and intrapartum stillbirth (adjusted hazard ratio [95% confidence interval]: 1.3 [1.2-1.4] and 1.3 [1.2-1.5], respectively). Among older smokers the risk for intrapartum stillbirth was three times that of the referent group (adjusted hazard ratio: 3.2, 95% confidence interval: 2.2-4.5).The risk of intrapartum stillbirth associated with smoking in pregnancy is potentiated by the age of the mother. This information will help policy makers develop targeted smoking cessation campaigns and positively impact quit rates in older mothers.

Introduction Reducing racial/ethnic disparities is a key objective of the Healthy People 2010 initiative. Unfortunately, racial disparities among women delaying initiation of childbearing have received limited attention. As more women in the US are delaying initiation of childbearing, it is important to examine racial disparities in reproductive health outcomes for this subgroup of women. Objective To examine racial disparities in perinatal outcomes, interpregnancy interval, and to assess the risk for adverse outcomes in subsequent pregnancy for women delaying initiation of childbearing until age 30 or older compared to those initiating childbearing at age 20–29. Methods We conducted a retrospective cohort study using the Missouri maternally linked cohort files 1978–1997. Final study sample included 239,930 singleton sibling pairs (Whites and African Americans). Outcome variables included first and second pregnancy outcomes (fetal death, low birth weight, preterm delivery and small-for-gestational age) and interpregnancy interval between first and second pregnancy. Independent variables included maternal age at first pregnancy and race. Analysis strategies used involved stratified analyses and multivariable unconditional logistic regression; interactions between maternal race, age and interpregnancy interval were examined in the regression models. Results Compared to Whites, African American mothers initiating childbearing at age 30 or older had significantly higher rates of adverse outcomes in the first and second pregnancy (P

Objective To evaluate the association between preterm birth and major birth defects by maternal and infant characteristics and specific types of birth defects. Study Design We pooled data for 1995–2000 from 13 states with population-based birth defects surveillance systems, representing about 30% of all U.S. births. Analyses were limited to singleton, live births from 24–44 weeks gestational age. Results Overall, birth defects were more than twice as common among preterm births (24–36 weeks) compared with term births (37–41 weeks gestation) (prevalence ratio [PR] = 2.65, 95% confidence interval [CI] 2.62–2.68), and approximately 8% of preterm births had a birth defect. Birth defects were over five times more likely among very preterm births (24–31 weeks gestation) compared with term births (PR = 5.25, 95% CI 5.15–5.35), with about 16% of very preterm births having a birth defect. Defects most strongly associated with very preterm birth included central nervous system defects (PR = 16.23, 95% CI 15.49–17.00) and cardiovascular defects (PR = 9.29, 95% CI 9.03–9.56). Conclusions Birth defects contribute to the occurrence of preterm birth. Research to identify shared causal pathways and risk factors could suggest appropriate interventions to reduce both preterm birth and birth defects.

No standards exist for reporting the accuracy and completeness of pregnancy histories created by linking the birth and fetal death certificates for all the deliveries occurring to one woman. To link certificates, analysts use deterministic and/or probabilistic approaches. Errors in linkage occur randomly and non-randomly. Any type of error can cause incorrect estimation of the magnitude of relationships. Methods for assessing linkage correctness are proposed. Analysts can detect errors in linkage by comparing the linkage results with the pregnancy history reported by the mother. The analyst interviews a random sample of women, ascertaining the dates and outcomes (stillbirth or live birth) for their births and, if the linkage used certificates from one state, the state where they occurred. For each woman, he/she then assesses the accuracy and completeness of this linkage by comparing it with her reported pregnancy history. An alternative approach is to chronologically sequence each woman's births. The parity for the most recent birth shows the number of babies born to the same woman and should equal the number of births that the analyst linked. In the absence of maternally reported pregnancy histories, an analyst can use data on the certificates to assess linkage correctness. Although this will show whether the correct number of births have been linked, it provides no information concerning the accuracy of linkages. It may be, however, the most universally applicable way of reporting the completeness of the linkage of deliveries.

To test the hypothesis that the presence of preeclampsia, small for gestational age (SGA)-birth, and placental abruption in the first pregnancy confers increased risk in the second pregnancy.A retrospective cohort study entailing a case-crossover analysis was performed based on women who had two consecutive singleton live births (n=154,810) between 1989 and 1997 in Missouri. Small for gestational age was defined as infants with birth weight below the 10th centile for gestational age. Risk and recurrence of ischemic placental disease was assessed from fitting logistic regression models after adjusting for several confounders.Preeclampsia in the first pregnancy was associated with significantly increased risk of preeclampsia (odds ratio 7.03, 95% confidence interval 6.51, 7.59), SGA (odds ratio 1.16, 95% confidence interval 1.06, 1.27), and placental abruption (odds ratio 1.90, 95% confidence interval 1.51, 2.38) in the second pregnancy. Similarly, women with SGA and abruption in the first pregnancy were associated with increased risks of all other conditions in the second pregnancy.Women with preeclampsia, SGA, and placental abruption in their first pregnancy--conditions that constitute ischemic placental disease--are at substantially increased risk of recurrence of any or all these conditions in their second pregnancy. Although causes of these conditions remain largely speculative, these entities may manifest through a common pathway of ischemic placental disease with significant risk of recurrence.

Autism spectrum disorders (ASDs) encompass a spectrum of conditions, including autistic disorder; pervasive developmental disorders, not otherwise specified (PDD-NOS); and Asperger disorder. Impairments associated with ASDs can range from mild to severe. In 2000, in response to increasing public heath concern regarding ASDs, CDC established the Autism and Developmental Disabilities Monitoring (ADDM) Network. The primary objective of this ongoing surveillance system is to track the prevalence and characteristics of ASDs in the United States. ADDM data are useful to understand the prevalence of ASDs and have implications for improved identification, health and education service planning, and intervention for children with ASDs. Because complete, valid, timely, and representative prevalence estimates are essential to inform public health responses to ASDs, evaluating the effectiveness and efficiency of the ADDM methodology is needed to determine how well these methods meet the network's objective.2002.The ADDM Network is a multiple-source, population-based, active system for monitoring ASDs and other developmental disabilities. In 2002, data were collected from 14 collaborative sites. This report describes an evaluation conducted using guidelines established by CDC for evaluating public health surveillance systems and is based on examination of the following characteristics of the ADDM Network surveillance system: simplicity, flexibility, data quality, acceptability, representativeness, sensitivity, predictive value positive (PVP), timeliness, stability, data confidentiality and security, and sources of variability.Using multiple sources for case ascertainment strengthens the system's representativeness, sensitivity, and flexibility, and the clinician review process aims to bolster PVP. Sensitivity and PVP are difficult to measure, but the ADDM methodology provides the best possible estimate currently available of prevalence of ASDs without conducting complete population screening and diagnostic clinical case confirmation. Although the system is dependent on the quality and availability of information in evaluation records, extensive quality control and data cleaning protocols and missing records assessments ensure the most accurate reflection of the records reviewed. Maintaining timeliness remains a challenge with this complex methodology, and continuous effort is needed to improve timeliness and simplicity without sacrificing data quality. The most difficult influences to assess are the effects of changes in diagnostic and treatment practices, service provision, and community awareness. Information sharing through education and outreach with site-specific stakeholders is the best mechanism for understanding the current climate in the community with respect to changes in service provision and public policy related to ASDs, which can affect prevalence estimates.These evaluation results and descriptions can be used to help interpret the ADDM Network 2002 surveillance year data and can serve as a model for other public health surveillance systems, especially those designed to monitor the prevalence of complex disorders.

OBJECTIVE. Our goal was to examine relationships among access to a medical home, special-health-care-needs status, and child and family characteristics in one Southern state. We hypothesized that access to a medical home is influenced by several family and child sociodemographic characteristics, including special-health-care status.METHODS. We used data from the 2003 National Survey of Children's Health. The study sample comprised all Alabama resident children. The main dependent variable was a medical home; the primary independent variable classified children according to children-with-special-health-care-needs status. We controlled for child age, gender, race, family structure, health status, insurance coverage, household education, and poverty. We first explored means or proportions for the study variables and then estimated multivariate logistic regression models.RESULTS. Children with special health care needs were significantly more likely than children without special health care needs to have a personal doctor or nurse, to have a preventive health care visit in the previous 12 months, and to have good communication with their provider. Children with special health care needs were also more likely to experience problems accessing specialty care, equipment, or services. Being uninsured, living at or near the federal poverty level, in a household where no one completed high school, being black, having less than excellent or good health, and living in a nontraditional family structure were characteristics associated with being less likely to have a medical home. In general, children-with-special-health-care-needs status was not related to having a medical home, but dependency on prescription medicine was.CONCLUSIONS. Assuring that all children, irrespective of family income, have access to and are enrolled in health insurance plans will move us closer to the national goal of having a medical home for all children, especially those with a special health care need, by 2010.

Objective The objective of the study was to examine whether the risk and indications for primary cesarean in the second pregnancy are influenced by changes in prepregnancy body mass index (BMI) between pregnancies. Study Design We performed a cohort analysis using the Missouri maternally linked birth and infant death surveillance datasets (1989-1997), comprised of women with their first 2 consecutive live births (n = 113,789). BMI (kilograms per square meter) was categorized as underweight (less than 18.5 kg/m 2 ), normal (18.5 to 24.9 kg/m 2 ), overweight (25 to 29.9 kg/m 2 ), and obese (30 kg/m 2 or greater). Indications for primary cesarean were categorized as breech, dystocia, fetal distress, and others. Timing of primary cesarean was categorized as elective (prior to labor) and emergent (after initiation of labor). Adjusted odds ratio (OR) was used to quantify the associations between changes in prepregnancy BMI and indications for primary cesarean. Results The rate of primary cesarean in the second pregnancy was 9.2%. Compared with women with normal BMI in their first 2 pregnancies, women who increased their BMI between pregnancies had increased risk of primary cesarean for all indications. Women who remained obese or overweight in both pregnancies were at increased risk of primary cesarean following breech (OR 1.28 and 1.13, respectively); dystocia (OR 1.94 and 1.41, respectively); fetal distress (OR 1.43 and 1.26, respectively); others (OR 3.17 and 1.63, respectively); and elective (OR 2.31 and 1.43, respectively) and emergent (OR 1.66 and 1.30, respectively) cesarean section. Women who lowered their BMI from obese to overweight or overweight to normal between pregnancies had risks of primary cesarean comparable with those with normal BMI in both pregnancies. Any increase in BMI from underweight to overweight or obese between the first 2 pregnancies was associated with increased risk of primary cesarean (OR 1.20 to 3.04) in the second pregnancy. Conclusion Increases in prepregnancy BMI between first 2 pregnancies from normal to obese is associated with increased risk of indications for primary cesarean. The association between being overweight or obese or increases in prepregnancy BMI between pregnancies and primary cesarean in the second pregnancy suggests that counseling women with regard to their high BMI may be beneficial.

BACKGROUND: With the significant advancement of geographic information systems (GIS), mapping and evaluating the spatial distribution of health events has become easier. We examine the role of GIS in birth defects surveillance and research. METHODS: We briefly describe the geocoding process and potential problems in accuracy of the obtained geocodes, and some of the capabilities and limitations of GIS. We illustrate how GIS has been applied using the Metropolitan Atlanta Congenital Defects Program geocoded dataset. We provide some comments on potential data quality and confidentiality issues with birth defects in relation to GIS. RESULTS: It is desirable to geocode addresses using a multistrategy approach to achieve a high-quality and accurate GIS dataset. Beyond the basic but important function of mapping, sophisticated statistical approaches and software are available to analyze the spatial or spatial-temporal occurrence of birth defects, alone or in association with environmental hazards, and to present this information without compromising the confidentiality of the subjects. CONCLUSIONS: We recommend a broad and systematic use of GIS in birth defects spatial surveillance and research. © Birth Defects Research (Part A) 76:825–833, 2006. © 2006 Wiley–Liss, Inc.

BACKGROUND A history of stillbirth may result in an increased risk for recurrence, although information regarding this remains scanty. It is also uncertain whether race is a determinant of stillbirth recurrence given that the risk of stillbirth varies across racial and ethnic populations. METHODS The Missouri maternally linked cohort data set containing births from 1978 through 1997 was used. We identified the study group (women who experienced a stillbirth in the first pregnancy) and a comparison group (women who delivered a live birth in their first pregnancy) and compared the outcome (stillbirth) in the second pregnancy between the 2 groups. RESULTS We analyzed 404,180 women with information on first and second pregnancies (1,979 [0.5%] in the study arm, and 402,201 [99.5%] in the comparison arm). Of the 1,929 cases of stillbirths in the second pregnancy, 45 cases occurred in mothers with a history of stillbirth (stillbirth rate = 22.7/1000) and 1,884 in the comparison group (stillbirth rate 4.7/1,000, P < .001). The adjusted risk of stillbirth was almost 5-fold as high in women with a prior stillbirth (odds ratio 4.7, 95% confidence interval 3.3-6.6). Analysis across racial groups revealed that whites had lower absolute risk for stillbirth recurrence than African Americans (19.1/1,000 compared with 35.9/1,000, P < .05). The elevated stillbirth recurrence risk was confirmed after adjusting for potential confounders (odds ratio 2.6, 95% confidence interval 1.2-5.7). CONCLUSION History of stillbirth is associated with a 5-fold increase for subsequent stillbirth. The recurrence of stillbirth is almost tripled in African Americans as compared with whites. LEVEL OF EVIDENCE II-2.

We examine the association between prior cesarean delivery and risk of stillbirth in a subsequent pregnancy.The Missouri maternally linked cohort data set containing births from 1978 through 1997 was used. We identified a cohort of women who delivered live births by cesarean delivery and a comparison cohort of women who delivered live births vaginally in their first pregnancies. We then compared the risks of stillbirth in the second pregnancy between the 2 groups.We analyzed 396,441 women with information on first and second pregnancies, comprising 71,950 (18.1%) in the cesarean arm, and 324,491 (81.9%) in the vaginal birth arm. Rates of stillbirth among women with and those without history of cesarean delivery were 4.4 and 4.1 per 1,000 births, respectively (P = .2). The adjusted estimates also showed no difference in risk for stillbirth between the 2 groups (odds ratio [OR] 1.1, 95% confidence interval [CI] 1.0-1.3). Among whites, the stillbirth rates in women with and those without history of cesarean delivery were 3.7 and 3.6 per 1,000 births, respectively (OR 1.0, 95% CI 0.9-1.2). Among blacks, both the absolute and the adjusted relative risks for stillbirth were elevated in mothers with history of cesarean delivery (stillbirth rate 9.3 versus 6.8 per 1,000 births; OR 1.4, 95% CI 1.1-1.7).Overall, our analysis did not detect an association between cesarean history and subsequent stillbirth. However, cesarean delivery may increase the risk for subsequent stillbirth among black mothers, a group with the highest cesarean delivery rate in the country.III.