Last data update: Jan 27, 2025. (Total: 48650 publications since 2009)
Records 1-27 (of 27 Records) |
Query Trace: Alverson CJ[original query] |
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National and regional population attributable fractions for anemia risk factors (iron, folate, and vitamin B12) in Belize: potential impact of fortification
Rosenthal J , Alverson CJ , Largaespada-Beer N , Kauwell GP , Bailey LB , Sabido JJ , Diaz M , Williams JL , Bernard K . Rev Panam Salud Publica 2024 48 e61 OBJECTIVE: To estimate the national and regional population attributable fraction (PAF) and potential number of preventable anemia cases for three nutritional risk factors (iron, red blood cell folate [RBCF], and vitamin B12 deficiencies) among women of childbearing age in Belize. METHODS: A national probability-based household and micronutrient survey capturing sociodemographic and health information was conducted among 937 nonpregnant Belizean women aged 15-49 years. Blood samples were collected to determine hemoglobin, ferritin, alpha-1-glycoprotein (AGP), RBCF, and vitamin B12 status. All analyses used sample weights and design variables to reflect a complex sample survey. Logistic regression was used to determine adjusted prevalence risk (aPR) ratios, which were then used to estimate national and regional PAF for anemia. RESULTS: The overall prevalence of anemia (hemoglobin <12 g/dL) was 21.2% (95% CI [18.7, 25.3]). The prevalence of anemia was significantly greater among women with iron deficiency (59.5%, 95% CI [48.7, 69.5]) compared to women without iron deficiency (15.2%, 95% CI [12.2, 18.3]; aPR 3.9, 95% CI [2.9, 5.1]). The three nutritional deficiencies examined contributed to 34.6% (95% CI [22.1, 47.1]) of the anemia cases. If all these nutritional deficiencies could be eliminated, then an estimated 5 953 (95% CI [3 807, 8 114]) anemia cases could be prevented. CONCLUSIONS: This study suggests that among women of child-bearing age in Belize, anemia cases might be reduced by a third if three modifiable nutritional risk factors (iron, RBCF, and vitamin B12 deficiencies) could be eliminated. Fortification is one potential strategy to improve nutritional status and reduce the burden of anemia in this population. |
Narrowing the survival gap: Trends in survival of individuals with Down syndrome with and without congenital heart defects born 1979 - 2018
Wright LK , Stallings EB , Cragan JD , Pabst LJ , Alverson CJ , Oster ME . J Pediatr 2023 260 113523 OBJECTIVE: To evaluate the hypothesis that childhood survival for individuals with Down syndrome (DS) and congenital heart defects (CHDs) has improved in recent years, approaching survival of those with DS without CHDs. STUDY DESIGN: Individuals with DS born 1979-2018 were identified through the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects surveillance system administered by the Centers for Disease Control and Prevention. Survival analysis was performed to evaluate predictors of mortality for those with DS. RESULTS: The cohort included 1,671 individuals with DS; 764 had associated CHDs. Five-year survival in those with DS with CHD improved steadily among individuals born in the 1980s through the 2010s (85% to 93%, p=0.01) but remained stable (96% to 95%, p=0.97) in those with DS without CHDs. The presence of a CHD was not associated with mortality through 5 years of age for those born 2010 or later (hazard ratio 2.63 [95% confidence interval 0.95 - 8.37]). In multivariable analyses, atrioventricular septal defects were associated with early (<1 year) and late (>5 year) mortality, while ventricular septal defects were associated with intermediate (1-5 years) mortality and atrial septal defects with late mortality, when adjusting for other risk factors. CONCLUSIONS: The gap in five-year survival between children with DS with and without CHDs has improved over the last four decades. Survival after 5 years remains lower for those with CHDs, although longer follow-up will be needed to determine if this difference lessens for those born in the more recent years. |
Changes in spina bifida lesion level after folic acid fortification in the US
Mai CT , Evans J , Alverson CJ , Yue X , Flood T , Arnold K , Nestoridi E , Denson L , Adisa O , Moore CA , Nance A , Zielke K , Rice S , Shan X , Dean JH , Ethen M , Hansen B , Isenburg J , Kirby RS . Obstet Gynecol Surv 2023 78 (4) 189-191 following which a substantial decline in neural tube defects at birth occurred. Studies also have suggested that lesion levels in cases of spina bifida are directly affected by folic acid fortification. Locations of such lesions contribute to outcome and prognosis of the condition. When compared with sacral and lower lumbar lesions, the greatest risks of disability and mortality are associated with cervical, thoracic, and high lumbar lesions. Individuals with thoracic or high lumbar lesions require a wheelchair and orthosis in adulthood for ambulation 70% to 99% of the time. As lesion levels therefore determine function and overall quality of life, assessment of whether folic acid fortification significantly impacts lesion levels is important. This study aimed to examine patterns of lesion levels in spina bifida following mandatory folic acid fortification in the United States. | | A call was issued by the National Birth Defects Prevention Network for State Birth Defects Programs' spina bifida lesion data before and after fortification mandate. To be eligible, programs needed to provide verbatim medical record text descriptions of spina bifida diagnoses. The 6 participating programs were from the states of Arizona, California (covering 8 counties), Oklahoma, South Carolina, Utah, and metropolitan Atlanta (Georgia). Birth years examined included the prefortification years of 1992–1996 and the postfortification period of 1999–2016. Central processing and analysis occurred as each program provided case-level data (deidentified) based on the exclusion/inclusion criteria to the Centers for Disease Control and Prevention. Medical and record text description of the spina bifida diagnosis and codes were the basis of case information, using the International Classification of Diseases, Ninth Edition, Clinical Modification or the Centers for Disease Control and Prevention and Prevention/British Pediatric Association coding system. Types of spina bifida included in the study were spinal rachischisis, myelomeningocele/meningomyelocele, meningocele, and spina bifida not otherwise specified. Cases excluded were cranial lesions, lipomyelomeningocele/lipomeningomyelocele, dysraphism related to split cord malformations, and spina bifida occulta. | | Lesion-level information was provided based on the highest lesion using nonradiographic clinical assessment. Classification of severe upper-level lesions included cervical or thoracic lesion-level cases, whereas lower-level lesions included cases with lumbar or sacral. The study defined open lesion as leaking spinal fluid or membrane covered only, whereas closed lesions were defined as having intact-skin covering and lacking fluid leakage. Spina bifida cases were considered isolated when no other anomalies related to the primary cause of abnormal neural tube closure were present (nor were secondary to the neurologic complications caused by it). Examining associations between fortification period and the outcomes (lesion level and spina bifida) occurred using the generalized estimating approach to logistic (case severity analyses) and log-linear (PR analyses) regression, which accounted for clustering of cases by state. | | From a total of 7,816,062 live births, 2593 cases of spina bifida met the case inclusion criteria. Overall, 573 cases were included in the prefortification period (birth prevalence of 4.07 per 10,000 live births), and 2020 cases were included in the postfortification period (birth prevalence of 3.15 per 10,000 live births). Overall, 80.2% of cases resulted in live births, and most cases of spina bifida involved lower-level lesions (81.3%). Most lesions were lumbar, and the proportions prefortification and postfortification were 61.4% and 72.0%, respectively, with a higher proportion of lumbar lesions seen in the postfortification period. The odds of upper-level to lower-level lesions decreased by 70% after fortification. The spina bifida live birth prevalence decreased significantly and remained consistently low throughout the early, mid, and recent postfortification periods. The study found a 72% decrease overall in prevalence of severe, upper-level lesions following mandatory folic acid fortification in the United States. | | The limitations of the study include the shortcomings of relying on diagnostic codes, the difficulty of coding lesion level using the International Classification of Diseases, Ninth Edition, Clinical Modification coding scheme, the lack of recorded functional outcome for children in medical records (indirect indicators of severity), the lack of preconception and prenatal folic acid data, and the possible variation of case ascertainment within programs contributing studies. A major study strength is its potential to address additional important questions regarding epidemiology and spina bifida. The classification of spinal defects is complex, and this study adds to the limited distribution data that exist for prefortification and postfortification subtypes. | | The study concluded that the overall prevalence of severe upper-level lesions in spina bifida cases experienced a steep reduction following mandatory folic acid fortification institution within the United States, whereas no change in the prevalence of less severe lower-level lesions took place. Additional examinations are warranted to better understand the magnitude and mechanism of spina bifida severity in relation to folic acid intake. |
Using a Birth Defects Surveillance Program to Enhance Existing Surveillance of Stillbirth
Duke W , Alverson CJ , Evans SP , Atkinson M , Ailes EC . J Registry Manag 2022 49 (1) 17-22 OBJECTIVE: Fetal death certificates (FDCs) are the main source of stillbirth surveillance data in the United States, yet previous studies suggest FDCs have incomplete ascertainment. The objectives of this analysis were (1) to evaluate whether the use of an existing birth defects surveillance program (the Metropolitan Atlanta Congenital Defects Program [MACDP]) to conduct surveillance on stillbirths enhances case ascertainment, and (2) to compare stillbirth prevalence estimates in metropolitan Atlanta using data from MACDP and FDCs, independently and combined, from 2009-2015. METHODS: Stillbirths were ascertained by MACDP and FDCs from 2009-2015. Capture-recapture methods were used to estimate the relative contributions of each data source. Prevalence estimates generated from each data source independently and combined were compared. RESULTS: There were 3,031 stillbirths ascertained by FDCs and MACDP in metropolitan Atlanta from 2009-2015. It was assumed that 35% of FDCs unlinked to MACDP were misclassified as stillbirth. Under this assumption, an estimated 2,610 total stillbirths occurred. Accounting for potential misclassification in the FDC, the prevalence rate for stillbirth was 6.9 per 1,000 live births plus stillbirths for stillbirths captured only in FDC, and 6.2 per 1,000 live births plus stillbirths for stillbirths caught only in MACDP. Using both sources combined for casefinding, the prevalence rate was 10.0 per 1,000 live births plus stillbirths for all years combined. CONCLUSIONS: Expanding certain birth defects surveillance programs to conduct surveillance on stillbirths could potentially enhance existing surveillance data on stillbirths when linked to FDCs. |
Changes in spina bifida lesion level after folic acid fortification in the United States
Mai CT , Evans J , Alverson CJ , Yue X , Flood T , Arnold K , Nestoridi E , Denson L , Adisa O , Moore CA , Nance A , Zielke K , Rice S , Shan X , Dean JH , Ethen M , Hansen B , Isenburg J , Kirby RS . J Pediatr 2022 249 59-66 e1 OBJECTIVE: To assess whether the severity of cases of spina bifida changed after mandatory folic acid fortification in the United States. STUDY DESIGN: Six active population-based birth defects programs provided data on cases of spina bifida for 1992-1996 (pre-fortification) and 1999-2016 (post-fortification); programs contributed varying years of data. Case information included both medical record verbatim text description of the spina bifida diagnosis and spina bifida codes (International Classification of Diseases, Clinical Modification, or a modified birth defects surveillance coding system). Comparing pre- with post-fortification periods, adjusted odds ratios (aOR) for case severity [upper-level (cervical, thoracic) to lower-level (lumbar, sacral) lesion cases] and prevalence ratios (PR) were estimated. RESULTS: A total of 2,593 cases of spina bifida (7,816,062 live births) met inclusion criteria, with 573 and 2,020 cases from the pre- and post-fortification periods respectively. Case severity decreased 70% (aOR: 0.30; 95% confidence interval [CI] 0.26, 0.35) between the fortification periods. The decrease was most pronounced for non-Hispanic white mothers. Overall spina bifida prevalence declined 23% (PR=0.77, 95% CI=0.71, 0.85), with similar reduction seen across early, mid, and recent post-fortification periods. A statistically significant decrease in upper-level lesions occurred in the post-fortification compared with pre-fortification periods (PR=0.28, 95% CI=0.22, 0.34), while prevalence of lower-level lesions remained relatively similar (PR: 0.94, 95% CI: 0.84, 1.05). CONCLUSIONS: Severity of cases of spina bifida decreased after mandatory folic acid fortification in the United States. Further examination is warranted to understand better the potential effect of folic acid on spina bifida severity. |
National population-based estimates for major birth defects, 2010-2014
Mai CT , Isenburg JL , Canfield MA , Meyer RE , Correa A , Alverson CJ , Lupo PJ , Riehle-Colarusso T , Cho SJ , Aggarwal D , Kirby RS . Birth Defects Res 2019 111 (18) 1420-1435 BACKGROUND: Using the National Birth Defects Prevention Network (NBDPN) annual data report, U.S. national prevalence estimates for major birth defects are developed based on birth cohort 2010-2014. METHODS: Data from 39 U.S. population-based birth defects surveillance programs (16 active case-finding, 10 passive case-finding with case confirmation, and 13 passive without case confirmation) were used to calculate pooled prevalence estimates for major defects by case-finding approach. Fourteen active case-finding programs including at least live birth and stillbirth pregnancy outcomes monitoring approximately one million births annually were used to develop national prevalence estimates, adjusted for maternal race/ethnicity (for all conditions examined) and maternal age (trisomies and gastroschisis). These calculations used a similar methodology to the previous estimates to examine changes over time. RESULTS: The adjusted national birth prevalence estimates per 10,000 live births ranged from 0.62 for interrupted aortic arch to 16.87 for clubfoot, and 19.93 for the 12 critical congenital heart defects combined. While the birth prevalence of most birth defects studied remained relatively stable over 15 years, an increasing prevalence was observed for gastroschisis and Down syndrome. Additionally, the prevalence for atrioventricular septal defect, tetralogy of Fallot, omphalocele, and trisomy 18 increased in this period compared to the previous periods. Active case-finding programs generally had higher prevalence rates for most defects examined, most notably for anencephaly, anophthalmia/microphthalmia, trisomy 13, and trisomy 18. CONCLUSION: National estimates of birth defects prevalence provide data for monitoring trends and understanding the impact of these conditions. Increasing prevalence rates observed for selected conditions warrant further examination. |
Receipt of American Heart Association-recommended preconception health care among privately insured women with congenital heart defects, 2007-2013
Farr SL , Downing KF , Ailes EC , Gurvitz M , Koontz G , Tran EL , Alverson CJ , Oster ME . J Am Heart Assoc 2019 8 (18) e013608 Background Our objective was to estimate receipt of preconception health care among women with congenital heart defects (CHD), according to 2017 American Heart Association recommendations, as a baseline for evaluating recommendation implementation. Methods and Results Using 2007 to 2013 IBM MarketScan Commercial Databases, we identified women with CHD diagnosis codes ages 15 to 44 years who became pregnant and were enrolled in health insurance for >/=11 months in the year before estimated conception. We assessed documentation of complete blood count, electrolytes, thyroid-stimulating hormone, liver function, ECG, comprehensive echocardiogram, and exercise stress test, using procedural codes, and outpatient prescription claims for US Food and Drug Administration category D and X cardiac-related medications. Differences were examined according to CHD severity, age, region of residence, year of conception, and documented encounters at obstetric and cardiology practices. We found 2524 pregnancies among 2003 women with CHD (14.4% severe CHD). In the 98.3% of women with a healthcare encounter in the year before conception, <1% received all and 22.6% received no American Heart Association-recommended tests or assessments (range: 54.4% for complete blood count to 3.1% for exercise stress test). Women with the highest prevalence of receipt of recommended care were 35 to 44 years old, pregnant in 2012 to 2013, or had a documented obstetric or cardiology encounter in the year before conception (P<0.05 for all). In 9.0% of pregnancies, >/=1 prescriptions for US Food and Drug Administration category D or X cardiac-related medications were filled in the year before conception. Conclusions A low percentage of women with CHD received American Heart Association-recommended preconception health care in the year before conception. |
Outcomes of infants born to women with influenza A(H1N1)pdm09
Newsome K , Alverson CJ , Williams J , McIntyre AF , Fine AD , Wasserman C , Lofy KH , Acosta M , Louie JK , Jones-Vessey K , Stanfield V , Yeung A , Rasmussen SA . Birth Defects Res 2019 111 (2) 88-95 BACKGROUND: Pregnant women with influenza are more likely to have complications, but information on infant outcomes is limited. METHODS: Five state/local health departments collected data on outcomes of infants born to pregnant women with 2009 H1N1 influenza reported to the Centers for Disease Control and Prevention from April to December 2009. Collaborating sites linked information on pregnant women with confirmed 2009 H1N1 influenza, many who were severely ill, to their infants' birth certificates. Collaborators also collected birth certificate data from two comparison groups that were matched with H1N1-affected pregnancies on month of conception, sex, and county of residence. RESULTS: 490 pregnant women with influenza, 1,451 women without reported influenza with pregnancies in the same year, and 1,446 pregnant women without reported influenza with prior year pregnancies were included. Women with 2009 H1N1 influenza admitted to an intensive care unit (ICU; n = 64) were more likely to deliver preterm infants (<37 weeks), low birth weight infants, and infants with Apgar scores <=6 at 5 min than women in comparison groups (adjusted relative risk, aRR = 3.9 [2.7, 5.6], aRR = 4.6 [2.9, 7.5], and aRR = 8.7 [3.6, 21.2], for same year comparisons, respectively). Women with influenza who were not hospitalized and hospitalized women not admitted to the ICU did not have significantly elevated risks for adverse infant outcomes. CONCLUSIONS: Severely ill women with 2009 H1N1 influenza during pregnancy were more likely to have adverse birth outcomes than women without influenza, providing more support for influenza vaccination during pregnancy. |
Population-based birth defects data in the United States, 2011-2015: A focus on eye and ear defects
Stallings EB , Isenburg JL , Mai CT , Liberman RF , Moore CA , Canfield MA , Salemi JL , Kirby RS , Short TD , Nembhard WN , Forestieri NE , Heinke D , Alverson CJ , Romitti PA , Huynh MP , Denson LE , Judson EM , Lupo PJ . Birth Defects Res 2018 110 (19) 1478-1486 BACKGROUND/OBJECTIVES: In this data brief, we examine major eye and ear anomalies (anophthalmia/microphthalmia, anotia/microtia, and congenital cataract) for a recent 5-year birth cohort using data from 30 population-based birth defects surveillance programs in the United States. METHODS: As a special call for data for the 2018 NBDPN Annual Report, state programs reported expanded data on eye/ear anomalies for birth years 2011-2015. We calculated the combined overall prevalence (per 10,000 live births) and 95% confidence intervals (CI), for the three anomalies as well as by maternal age, maternal race/ethnicity, infant sex, laterality, presence/absence of other major birth defects, and case ascertainment methodology utilized by the program (active vs. passive). RESULTS: The overall prevalence estimate (per 10,000 live births) was 1.5 (95% CI: 1.4-1.5) for anophthalmia/microphthalmia, 1.5 (95% CI: 1.4-1.6) for congenital cataract, and 1.8 (95% CI: 1.7-1.8) for anotia/microtia. Congenital cataract prevalence varied little by maternal race/ethnicity, infant sex, or case ascertainment methodology; prevalence differences were more apparent across strata for anophthalmia/microphthalmia and anotia/microtia. Prevalence among active vs. passive ascertainment programs was 50% higher for anophthalmia/microphthalmia (1.9 vs. 1.2) and two-fold higher for anotia/microtia (2.6 vs. 1.2). Anophthalmia/microphthalmia was more likely than other conditions to co-occur with other birth defects. All conditions were more frequent among older mothers (40+ years). CONCLUSIONS: This data brief provides recent prevalence estimates for anophthalmia/microphthalmia, congenital cataract, and anotia/microtia that address a data gap by examining pooled data from 30 population-based surveillance systems, covering a five-year birth cohort of about 12.4 million births. |
Population-based birth defects data in the United States, 2010-2014: A focus on gastrointestinal defects
Lupo PJ , Isenburg JL , Salemi JL , Mai CT , Liberman RF , Canfield MA , Copeland G , Haight S , Harpavat S , Hoyt AT , Moore CA , Nembhard WN , Nguyen HN , Rutkowski RE , Steele A , Alverson CJ , Stallings EB , Kirby RS . Birth Defects Res 2017 109 (18) 1504-1514 BACKGROUND: Gastrointestinal defects are a phenotypically and etiologically diverse group of malformations. Despite their combined prevalence and clinical impact, little is known about the epidemiology of these birth defects. Therefore, the objective of the 2017 National Birth Defects Prevention Network (NBDPN) data brief was to better describe the occurrence of gastrointestinal defects. METHODS: As part of the 2017 NBDPN annual report, 28 state programs provided additional data on gastrointestinal defects for the period 2010-2014. Counts and prevalence estimates (per 10,000 live births) were calculated overall and by demographic characteristics for (1) biliary atresia; (2) esophageal atresia/tracheoesophageal fistula; (3) rectal and large intestinal atresia/stenosis; and (4) small intestinal atresia/stenosis. Additionally, we explored the frequency of these malformations co-occurring with other structural birth defects. RESULTS: Pooling data from all participating registries, the prevalence estimates were: 0.7 per 10,000 live births for biliary atresia (713 cases); 2.3 per 10,000 live births for esophageal atresia/tracheoesophageal fistula (2,472 cases); 4.2 per 10,000 live births for rectal and large intestinal atresia/stenosis (4,334 cases); and 3.4 per 10,000 live births for small intestinal atresia/stenosis (3,388 cases). Findings related to co-occurring birth defects were especially notable for esophageal atresia/tracheoesophageal fistula, rectal and large intestinal atresia/stenosis, and small intestinal atresia/stenosis, where the median percentage of non-isolated cases was 53.9%, 45.5%, and 50.6%, respectively. CONCLUSIONS: These population-based prevalence estimates confirm some previous studies, and provide a foundation for future epidemiologic studies of gastrointestinal defects. Exploring the genetic and environmental determinants of these malformations may yield new clues into their etiologies. |
Folate deficiency is prevalent in women of childbearing age in Belize and is negatively affected by coexisting vitamin B-12 deficiency: Belize National Micronutrient Survey 2011
Rosenthal J , Largaespada N , Bailey LB , Cannon M , Alverson CJ , Ortiz D , Kauwell GP , Sniezek J , Figueroa R , Daly R , Allen P . J Nutr 2017 147 (6) 1183-1193 Background: Folate deficiency, vitamin B-12 deficiency, and anemia can have adverse effects on birth outcomes. Also, low vitamin B-12 reduces the formation of metabolically active folate.Objectives: We sought to establish the baseline prevalence of and factors associated with folate deficiency and insufficiency, vitamin B-12 deficiency, and anemia among women of childbearing age (WCBA) in Belize.Methods: In 2011, a national probability-based survey was completed among Belizean nonpregnant WCBA aged 15-49 y. Blood samples for determination of hemoglobin, folate (RBC and serum), and vitamin B-12 (plasma) and sociodemographic and health information were collected from 937 women. RBC and serum folate concentrations were measured by microbiologic assay (MBA). Folate status was defined based on both the WHO-recommended radioproteinbinding assay and the assay adjusted for the MBA.Results: The national prevalence estimates for folate deficiency in WCBA, based on serum and RBC folate concentrations by using the assay-matched cutoffs, were 11.0% (95% CI: 8.6%, 14.0%) and 35.1% (95% CI: 31.3%, 39.2%), respectively. By using the assay-matched compared with the WHO-recommended cutoffs, a substantially higher prevalence of folate deficiency was observed based on serum (6.9% absolute difference) and RBC folate (28.9% absolute difference) concentrations. The prevalence for RBC folate insufficiency was 48.9% (95% CI: 44.8%, 53.1%). Prevalence estimates for vitamin B-12 deficiency and marginal deficiency and anemia were 17.2% (95% CI: 14.2%, 20.6%), 33.2% (95% CI: 29.6%, 37.1%), and 22.7% (95% CI: 19.5%, 26.2%), respectively. The adjusted geometric means of the RBC folate concentration increased significantly (P-trend < 0.001) in WCBA who had normal vitamin B-12 status relative to WCBA who were vitamin B-12 deficient.Conclusions: In Belize, the prevalence of folate and vitamin B-12 deficiencies continues to be a public health concern among WCBA. Furthermore, low folate status co-occurred with low vitamin B-12 status, underlining the importance of providing adequate vitamin B-12 and folic acid intake through approaches such as mandatory food fortification. |
Population-based microcephaly surveillance in the United States, 2009 to 2013: An analysis of potential sources of variation
Cragan JD , Isenburg JL , Parker SE , Alverson CJ , Meyer RE , Stallings EB , Kirby RS , Lupo PJ , Liu JS , Seagroves A , Ethen MK , Cho SJ , Evans M , Liberman RF , Fornoff J , Browne ML , Rutkowski RE , Nance AE , Anderka M , Fox DJ , Steele A , Copeland G , Romitti PA , Mai CT . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 972-982 BACKGROUND: Congenital microcephaly has been linked to maternal Zika virus infection. However, ascertaining infants diagnosed with microcephaly can be challenging. METHODS: Thirty birth defects surveillance programs provided data on infants diagnosed with microcephaly born 2009 to 2013. The pooled prevalence of microcephaly per 10,000 live births was estimated overall and by maternal/infant characteristics. Variation in prevalence was examined across case finding methods. Nine programs provided data on head circumference and conditions potentially contributing to microcephaly. RESULTS: The pooled prevalence of microcephaly was 8.7 per 10,000 live births. Median prevalence (per 10,000 live births) was similar among programs using active (6.7) and passive (6.6) methods; the interdecile range of prevalence estimates was wider among programs using passive methods for all race/ethnicity categories except Hispanic. Prevalence (per 10,000 live births) was lowest among non-Hispanic Whites (6.5) and highest among non-Hispanic Blacks and Hispanics (11.2 and 11.9, respectively); estimates followed a U-shaped distribution by maternal age with the highest prevalence among mothers <20 years (11.5) and ≥40 years (13.2). For gestational age and birth weight, the highest prevalence was among infants <32 weeks gestation and infants <1500 gm. Case definitions varied; 41.8% of cases had an HC ≥ the 10th percentile for sex and gestational age. CONCLUSION: Differences in methods, population distribution of maternal/infant characteristics, and case definitions for microcephaly can contribute to the wide range of observed prevalence estimates across individual birth defects surveillance programs. Addressing these factors in the setting of Zika virus infection can improve the quality of prevalence estimates. |
A quality assessment of reporting sources for microcephaly in Utah, 2003 to 2013
Steele A , Johnson J , Nance A , Satterfield R , Alverson CJ , Mai C . Birth Defects Res A Clin Mol Teratol 2016 106 (11) 983-988 BACKGROUND: Obtaining accurate microcephaly prevalence is important given the recent association between microcephaly and Zika virus. Assessing the quality of data sources can guide surveillance programs as they focus their data collection efforts. The Utah Birth Defect Network (UBDN) has monitored microcephaly by data sources since 2003. The objective of this study was to examine the impact of reporting sources for microcephaly surveillance. METHODS: All reported cases of microcephaly among Utah mothers from 2003 to 2013 were clinically reviewed and confirmed. The UBDN database was linked to state vital records and hospital discharge data for analysis. Reporting sources were analyzed for positive predictive value and sensitivity. RESULTS: Of the 477 reported cases of microcephaly, 251 (52.6%) were confirmed as true cases. The UBDN identified 94 additional cases that were reported to the surveillance system as another birth defect, but were ultimately determined to be true microcephaly cases. The prevalence for microcephaly based on the UBDN medical record abstraction and clinical review was 8.2 per 10,000 live births. Data sources varied in the number and accuracy of reporting, but a case was more likely to be a true case if identified from multiple sources than from a single source. CONCLUSION: While some reporting sources are more likely to identify possible and true microcephaly cases, maintaining a multiple source methodology allows for more complete case ascertainment. Surveillance programs should conduct periodic assessments of data sources to ensure their systems are capturing all possible birth defects cases. |
Dental caries and periodontal disease among U.S. pregnant women and nonpregnant women of reproductive age, National Health and Nutrition Examination Survey, 1999-2004
Azofeifa A , Yeung LF , Alverson CJ , Beltran-Aguilar E . J Public Health Dent 2016 76 (4) 320-329 OBJECTIVES: This study assessed and compared the prevalence and severity of dental caries and the prevalence of periodontal disease among pregnant and nonpregnant women of reproductive age (15-44 years) using data from the National Health and Nutrition Examination Survey, NHANES (1999-2004). METHODS: Estimates were derived from a sample of 897 pregnant women and 3,971 nonpregnant women. Chi-square and two-sample t-tests were used to assess differences between groups stratified by age, race/ethnicity, education, and poverty. Bonferroni method was applied to adjust for multiple comparisons. RESULTS: In general, there were no statistically significant differences in the prevalence estimates of dental caries and periodontal disease between pregnant women and nonpregnant women. However, results showed significant differences when stratified by sociodemographic characteristics. For example, the prevalence of untreated dental caries among women aged 15-24 years was significantly higher in pregnant women than in nonpregnant women (41 percent versus 24 percent, P = 0.001). Regardless of their pregnancy status, racial/ethnic minorities or women with less education or lower family income had higher prevalence of untreated dental caries, severity of dental caries, and periodontal disease compared to the respective reference groups of non-Hispanic whites or women with more education or higher family income. CONCLUSION: Results of this study show few clinical differences in dental caries and periodontal disease between pregnant and nonpregnant women but persistent disparities by sociodemographic characteristics. In order to reduce oral health disparities in the United States, it is important to improve access to oral health care particularly among vulnerable groups. Integrating oral health into the overall health care could benefit and improve women's oral health outcomes. |
Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence
Mai CT , Isenburg J , Langlois PH , Alverson CJ , Gilboa SM , Rickard R , Canfield MA , Anjohrin SB , Lupo PJ , Jackson DR , Stallings EB , Scheuerle AE , Kirby RS . Birth Defects Res A Clin Mol Teratol 2015 103 (11) 972-93 Major structural birth defects collectively affect 3 to 5% of births in the United States and contribute substantially to mortality and morbidity (CDC, 2008; TDSHS, 2015). Since 2000, the National Birth Defects Prevention Network (NBDPN) has annually published state-specific data for selected major birth defects affecting a range of organ systems, including central nervous, eye, ear, cardiovascular, orofacial, gastrointestinal, genitourinary, and musculoskeletal, as well as chromosomal and other conditions, such as amniotic bands. While the NBPDN list of birth defects had remained relatively unchanged for two decades, it was recently revised and released with the 2014 NBDPN Annual Report (Mai et al., 2014). Several factors necessitated an in-depth examination of the list of conditions: (1) development of national data quality standards for birth defects surveillance in the United States; (2) transition of the diagnostic coding system from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) to ICD-10-CM; and (3) inclusion of newborn screening for critical congenital heart defects (CCHD), with 12 primary and secondary CCHD targets, on the national Recommended Uniform Screening Panel. The revision process included a review of each condition in relation to its public health importance, state of current knowledge, and clinical factors, such as accuracy of diagnosis within a child’s first year of life. Table 1 presents the revised list of birth defects and their diagnostic codes [ICD-9-CM and Centers for Disease Control and Prevention/British Pediatric Association Classification of Diseases (CDC/BPA)]. |
Oral health conditions and dental visits among pregnant and nonpregnant women of childbearing age in the United States, National Health and Nutrition Examination Survey, 1999-2004
Azofeifa A , Yeung LF , Alverson CJ , Beltran-Aguilar E . Prev Chronic Dis 2014 11 E163 INTRODUCTION: Oral diseases can be prevented or improved with regular dental visits. Our objective was to assess and compare national estimates on self-reported oral health conditions and dental visits among pregnant women and nonpregnant women of childbearing age by using data from the National Health and Nutrition Examination Survey (NHANES). METHODS: We analyzed self-reported oral health information on 897 pregnant women and 3,971 nonpregnant women of childbearing age (15-44 years) from NHANES 1999-2004. We used chi2 and 2-sample t tests to assess statistical differences between groups stratified by age, race/ethnicity, poverty, and education. We applied the Bonferroni adjustment for multiple comparisons. RESULTS: Our data show significant differences in self-reported oral health conditions and dental visits among women, regardless of pregnancy status, when stratified by selected sociodemographic characteristics. Significant differences were also found in self-reported oral health conditions and dental visits between pregnant and nonpregnant women, especially among young women, women from minority race/ethnicity groups, and women with less than high school education. CONCLUSION: We found disparities in self-reported oral health conditions and use of dental services among women regardless of pregnancy status. Results highlight the need to improve dental service use among US women of childbearing age, especially young pregnant women, those who are non-Hispanic black or Mexican American, and those with low family income or low education level. Prenatal visits could be used as an opportunity to encourage pregnant women to seek preventive dental care during pregnancy. |
The association between race/ethnicity and major birth defects in the United States, 1999-2007
Canfield MA , Mai CT , Wang Y , O'Halloran A , Marengo LK , Olney RS , Borger CL , Rutkowski R , Fornoff J , Irwin N , Copeland G , Flood TJ , Meyer RE , Rickard R , Alverson CJ , Sweatlock J , Kirby RS . Am J Public Health 2014 104 (9) e1-e10 OBJECTIVES: We investigated the relationship between race/ethnicity and 27 major birth defects. METHODS: We pooled data from 12 population-based birth defects surveillance systems in the United States that included 13.5 million live births (1 of 3 of US births) from 1999 to 2007. Using Poisson regression, we calculated prevalence estimates for each birth defect and 13 racial/ethnic groupings, along with crude and adjusted prevalence ratios (aPRs). Non-Hispanic Whites served as the referent group. RESULTS: American Indians/Alaska Natives had a significantly higher and 50% or greater prevalence for 7 conditions (aPR = 3.97; 95% confidence interval [CI] = 2.89, 5.44 for anotia or microtia); aPRs of 1.5 to 2.1 for cleft lip, trisomy 18, and encephalocele, and lower, upper, and any limb deficiency). Cubans and Asians, especially Chinese and Asian Indians, had either significantly lower or similar prevalences of these defects compared with non-Hispanic Whites, with the exception of anotia or microtia among Chinese (aPR = 2.08; 95% CI = 1.30, 3.33) and Filipinos (aPR = 1.90; 95% CI = 1.10, 3.30) and tetralogy of Fallot among Vietnamese (aPR = 1.60; 95% CI = 1.11, 2.32). CONCLUSIONS: This is the largest population-based study to our knowledge to systematically examine the prevalence of a range of major birth defects across many racial/ethnic groups, including Asian and Hispanic subgroups. The relatively high prevalence of birth defects in American Indians/Alaska Natives warrants further attention. |
Role of health insurance on the survival of infants with congenital heart defects
Kucik JE , Cassell CH , Alverson CJ , Donohue P , Tanner JP , Minkovitz CS , Correia J , Burke T , Kirby RS . Am J Public Health 2014 104 (9) e1-e9 OBJECTIVES: We examined the association between health insurance and survival of infants with congenital heart defects (CHDs), and whether medical insurance type contributed to racial/ethnic disparities in survival. METHODS: We conducted a population-based, retrospective study on a cohort of Florida resident infants born with CHDs between 1998 and 2007. We estimated neonatal, post-neonatal, and infant survival probabilities and adjusted hazard ratios (AHRs) for individual characteristics. RESULTS: Uninsured infants with critical CHDs had 3 times the mortality risk (AHR = 3.0; 95% confidence interval = 1.3, 6.9) than that in privately insured infants. Publicly insured infants had a 30% reduced mortality risk than that of privately insured infants during the neonatal period, but had a 30% increased risk in the post-neonatal period. Adjusting for insurance type reduced the Black-White disparity in mortality risk by 50%. CONCLUSIONS: Racial/ethnic disparities in survival were attenuated significantly, but not eliminated, by adjusting for payer status. |
Case-control analysis of maternal prenatal analgesic use and cardiovascular malformations: Baltimore-Washington Infant Study
Marsh CA , Cragan JD , Alverson CJ , Correa A . Am J Obstet Gynecol 2014 211 (4) 404 e1-9 OBJECTIVE: To assess maternal prenatal use of analgesics and risk of cardiovascular malformations (CVM) in the offspring. STUDY DESIGN: Data from the Baltimore-Washington Infant Study, a population based case-control investigation of CVM, were used to examine selected isolated CVM diagnoses and maternal analgesic use during the periconceptional period (3 months before and after conception). We compared case and control infants on frequency of maternal use of analgesics and estimated adjusted odds ratios (adjORs) and 95% confidence intervals (CI) with logistic regression models for specific CVM phenotypes. RESULTS: Frequency of periconceptional use of any analgesic was 52% among control mothers and 53% among case mothers. Analyses by CVM diagnoses identified an association of tetralogy of Fallot with maternal acetaminophen use (adjOR=1.6, 95%CI=1.1, 2.3) and dextro-transposition of the great arteries with intact ventricular septum with maternal non-steroidal anti-inflammatory drug use (adjOR=3.2, 95%CI=1.2, 8.7). CONCLUSION: Analgesic use during the periconceptional period was not associated with CVM in the aggregate or with most phenotypes of CVM examined. Associations with two phenotypes of CVM may have occurred by chance. These findings warrant corroboration and further study, including further evaluation of the observed associations, the dose of analgesic taken, more specific timing of analgesic use, and indications for use. |
Selected birth defects data from population-based birth defects surveillance programs in the United States, 2006 to 2010: featuring trisomy conditions
Mai CT , Kucik JE , Isenburg J , Feldkamp ML , Marengo LK , Bugenske EM , Thorpe PG , Jackson JM , Correa A , Rickard R , Alverson CJ , Kirby RS . Birth Defects Res A Clin Mol Teratol 2013 97 (11) 709-25 The annual National Birth Defects Prevention Network (NBDPN) Congenital Malformations Surveillance Report includes state-level data on major birth defects (i.e., conditions present at birth that cause adverse structural changes in one or more parts of the body) and a directory of population-based birth defects surveillance systems in the United States. Beginning in 2012, these annually updated data and directory information are available in an electronic format accompanied by a data brief. This year’s report includes data from 41 population-based birth defects surveillance programs and a data brief highlighting the more common trisomy conditions (i.e., disorders characterized by an additional chromosome): trisomy 21 (commonly referred to as Down syndrome), trisomy 18, and trisomy 13. |
Race/ethnicity disparities in dysglycemia among U.S. women of childbearing age found mainly in the nonoverweight/nonobese
Marcinkevage JA , Alverson CJ , Narayan KM , Kahn HS , Ruben J , Correa A . Diabetes Care 2013 36 (10) 3033-9 OBJECTIVE: To describe the burden of dysglycemia-abnormal glucose metabolism indicative of diabetes or high risk for diabetes-among U.S. women of childbearing age, focusing on differences by race/ethnicity. RESEARCH DESIGN AND METHODS: Using U.S. National Health and Nutrition Examination Survey data (1999-2008), we calculated the burden of dysglycemia (i.e., prediabetes or diabetes from measures of fasting glucose, A1C, and self-report) in nonpregnant women of childbearing age (15-49 years) by race/ethnicity status. We estimated prevalence risk ratios (PRRs) for dysglycemia in subpopulations stratified by BMI (measured as kilograms divided by the square of height in meters), using predicted marginal estimates and adjusting for age, waist circumference, C-reactive protein, and socioeconomic factors. RESULTS: Based on data from 7,162 nonpregnant women, representing >59,000,000 women nationwide, 19% (95% CI 17.2-20.9) had some level of dysglycemia, with higher crude prevalence among non-Hispanic blacks and Mexican Americans vs. non-Hispanic whites (26.3% [95% CI 22.3-30.8] and 23.8% [19.5-28.7] vs. 16.8% [14.4-19.6], respectively). In women with BMI <25 kg/m2, dysglycemia prevalence was roughly twice as high in both non-Hispanic blacks and Mexican Americans vs. non-Hispanic whites. This relative increase persisted in adjusted models (PRRadj 1.86 [1.16-2.98] and 2.23 [1.38-3.60] for non-Hispanic blacks and Mexican Americans, respectively). For women with BMI 25-29.99 kg/m2, only non-Hispanic blacks showed increased prevalence vs. non-Hispanic whites (PRRadj 1.55 [1.03-2.34] and 1.28 [0.73-2.26] for non-Hispanic blacks and Mexican Americans, respectively). In women with BMI >30 kg/m2, there was no significant increase in prevalence of dysglycemia by race/ethnicity category. CONCLUSIONS: Our findings show that dysglycemia affects a significant portion of U.S. women of childbearing age and that disparities by race/ethnicity are most prominent in the nonoverweight/nonobese. |
Neural tube defects in Latin America and the impact of fortification: a literature review
Rosenthal J , Casas J , Taren D , Alverson CJ , Flores A , Frias J . Public Health Nutr 2013 17 (3) 1-14 OBJECTIVE: Data on the prevalence of birth defects and neural tube defects (NTD) in Latin America are limited. The present review summarizes NTD prevalence and time trends in Latin American countries and compares pre- and post-fortification periods to assess the impact of folic acid fortification in these countries. DESIGN: We carried out a literature review of studies and institutional reports published between 1990 and 2010 that contained information on NTD prevalence in Latin America. RESULTS: NTD prevalence in Latin American countries varied from 0.2 to 9.6 per 1000 live births and was influenced by methods of ascertainment. Time trends from Bogota, Costa Rica, Dominican Republic, Guatemala City, Mexico and Puerto Rico showed average annual declines of 2.5 % to 21.8 %. Pre- and post-fortification comparisons were available for Argentina, Brazil, Chile, Costa Rica, Puerto Rico and Mexico. The aggregate percentage decline in NTD prevalence ranged from 33 % to 59 %. CONCLUSIONS: The present publication is the first to review data on time trends and the impact of folic acid fortification on NTD prevalence in Latin America. Reported NTD prevalence varied markedly by geographic region and in some areas of Latin America was among the lowest in the world, while in other areas it was among the highest. For countries with available information, time trends showed significant declines in NTD prevalence and these declines were greater in countries where folic acid fortification of staples reached the majority of the population at risk, such as Chile and Costa Rica. |
Racial/ethnic variations in the prevalence of selected major birth defects, metropolitan Atlanta, 1994-2005
Kucik JE , Alverson CJ , Gilboa SM , Correa A . Public Health Rep 2012 127 (1) 52-61 ![]() OBJECTIVES: Birth defects are the leading cause of infant mortality and are responsible for substantial child and adult morbidity. Documenting the variation in prevalence of birth defects among racial/ethnic subpopulations is critical for assessing possible variations in diagnosis, case ascertainment, or risk factors among such groups. METHODS: We used data from the Metropolitan Atlanta Congenital Defects Program, a population-based birth defects registry with active case ascertainment. We estimated the racial/ethnic variation in prevalence of 46 selected major birth defects among live births, stillbirths, and pregnancy terminations at >20 weeks gestation among mothers residing in the five central counties of metropolitan Atlanta between 1994 and 2005, adjusting for infant sex, maternal age, gravidity, and socioeconomic status (SES). We also explored SES as a potential effect measure modifier. RESULTS: Compared with births to non-Hispanic white women, births to non-Hispanic black women had a significantly higher prevalence of five birth defects and a significantly lower prevalence of 10 birth defects, while births to Hispanic women had a significantly higher prevalence of four birth defects and a significantly lower prevalence of six birth defects. The racial/ethnic disparities in the prevalence of some defects varied by SES, but no clear pattern emerged. CONCLUSIONS: Racial/ethnic disparities were suggested in 57% of included birth defects. Disparities in the prevalence of birth defects may result from different underlying genetic susceptibilities; exposure to risk factors; or variability in case diagnosis, ascertainment, or reporting among the subpopulations examined. Policies that improve early diagnosis of birth defects could reduce associated morbidity and mortality. |
Maternal smoking and congenital heart defects in the Baltimore-Washington Infant Study
Alverson CJ , Strickland MJ , Gilboa SM , Correa A . Pediatrics 2011 127 (3) e647-53 OBJECTIVE: We investigated associations between maternal cigarette smoking during the first trimester and the risk of congenital heart defects (CHDs) among the infants. METHODS: The Baltimore-Washington Infant Study was the first population-based case-control study of CHDs conducted in the United States. Case and control infants were enrolled during the period 1981-1989. We excluded mothers with overt pregestational diabetes and case mothers whose infants had noncardiac anomalies (with the exception of atrioventricular septal defects with Down syndrome) from the analysis, which resulted in 2525 case and 3435 control infants. Self-reported first-trimester maternal cigarette consumption was ascertained via an in-person interview after delivery. Associations for 26 different groups of CHDs with maternal cigarette consumption were estimated by using logistic regression models. Odds ratios (ORs) corresponded to a 20-cigarette-per-day increase in consumption. RESULTS: We observed statistically significant positive associations between self-reported first-trimester maternal cigarette consumption and the risk of secundum-type atrial septal defects (OR: 1.36 [95% confidence interval (CI): 1.04-1.78]), right ventricular outflow tract defects (OR: 1.32 [95% CI: 1.06-1.65]), pulmonary valve stenosis (OR: 1.35 [95% CI: 1.05-1.74]), truncus arteriosus (OR: 1.90 [95% CI: 1.04-3.45]), and levo-transposition of the great arteries (OR: 1.79 [95% CI: 1.04-3.10]). A suggestive association was observed for atrioventricular septal defects among infants without Down syndrome (OR: 1.50 [95% CI: 0.99-2.29]). CONCLUSIONS: These findings add to the existing body of evidence that implicates first-trimester maternal cigarette smoking as a modest risk factor for select CHD phenotypes. |
Congenital heart defects and major structural noncardiac anomalies, Atlanta, Georgia, 1968 to 2005
Miller A , Riehle-Colarusso T , Alverson CJ , Frias JL , Correa A . J Pediatr 2011 159 (1) 70-78 e2 OBJECTIVE: To identify the proportion of major structural noncardiac anomalies identified with congenital heart defects (CHDs). STUDY DESIGN: Records of infants with CHDs in the Metropolitan Atlanta Congenital Defects Program who were born during the period 1968 through 2005 were classified as having isolated, syndromic, multiple CHD (ie, having an unrecognized pattern of multiple congenital anomalies or a recognized pattern of multiple congenital anomalies of unknown etiology), or laterality defects. Frequencies of associated noncardiac anomalies were obtained. RESULTS: We identified 7984 live-born and stillborn infants and fetuses with CHDs. Among them, 5695 (71.3%) had isolated, 1080 (13.5%) had multiple, 1048 (13.1%) had syndromic, and 161 (2.0%) had laterality defects. The percentage of multiple congenital anomalies was highest for case with atrial septal defects (18.5%), cardiac looping defects (17.2%), and conotruncal defects (16.0%), and cases with atrioventricular septal defects represented the highest percentages of those with syndromic CHDs (66.7%). CONCLUSIONS: Including those with syndromes and laterality defects, 28.7% of case infants with CHDs had associated major noncardiac malformations. Thus, infants with CHDs warrant careful examination for the presence of noncardiac anomalies. |
Associations between maternal fever and influenza and congenital heart defects
Oster ME , Riehle-Colarusso T , Alverson CJ , Correa A . J Pediatr 2011 158 (6) 990-5 OBJECTIVE: To examine associations between maternal reports of prenatal fever or influenza and congenital heart defects (CHDs), and to evaluate whether those associations varied with antipyretic use. STUDY DESIGN: We analyzed case infants with CHD (n = 2361) and control infants without CHD (n = 3435) from the Baltimore-Washington Infant Study (1981-1989). Participating mothers were asked whether they experienced a "fever of 101 degrees F or higher," had "influenza (flu)," or used an antipyretic agent (ie, acetaminophen, salicylate, or nonsteroidal anti-inflammatory drug) during the period extending from 3 months before pregnancy through the end of the third month of pregnancy. We used logistic regression to compute ORs and 95% CIs while controlling for potential confounders. RESULTS: There were significant associations between fever and influenza and specific CHDs, namely right-sided obstructive defects (fever: OR, 2.04; 95% CI, 1.27-3.27; influenza: OR, 1.75; 95% CI, 1.16-2.62) and atrioventricular septal defects in infants with Down syndrome (fever: OR, 1.92; 95% CI, 1.10-3.38; influenza: OR, 1.66; 95% CI, 1.04-2.63). Maternal antipyretic use in the setting of fever or influenza tended to decrease these associations. CONCLUSIONS: Prenatal maternal fever or influenza may be associated with right-sided obstructive lesions in all infants and with atrioventricular septal defects in infants with Down syndrome. The use of antipyretics might attenuate such associations. |
Survey of knowledge, attitudes, and practice management patterns of Atlanta-area obstetricians regarding stillbirth
Duke W , Shin M , Correa A , Alverson CJ . Womens Health Issues 2010 20 (5) 366-70 OBJECTIVE: Existing surveillance data on fetal death certificates are suboptimal for conducting reliable epidemiologic studies on stillbirth. The objective of this survey was to better understand the factors potentially affecting the quality of data collected on stillbirths among a defined population. METHODS: A survey was mailed to all physicians (n = 661) listed in the July 2007 version of the American Medical Association master file with a primary specialty of obstetrics/gynecology and a mailing address within five counties in metropolitan Atlanta. RESULTS: A total of 487 physicians met eligibility criteria: 279 returned the survey, 179 did not return the survey, and 29 were returned as unable to locate. Two respondents returned incomplete surveys, leaving 277 participants for the final analysis. Respondents reported seeing an average of six stillbirths per year. A cause of death was not identified in two thirds of cases. Almost half (46.8%) of participants responded that 20 weeks was the minimum gestational age defining stillbirth, whereas 33.1% responded that it was 24 weeks. A majority (92.6%) responded that a standardized definition for stillbirth should be adopted. More than 80% agreed that a comprehensive evaluation was important to identify a cause of death, and 91.9% agreed that the use of a standardized protocol for post-mortem stillbirth evaluation would be helpful. A majority also agreed that ongoing surveillance of stillbirths and a national research agenda on causes of stillbirth are important. CONCLUSION: Comprehensive educational and awareness efforts for obstetricians and other related health care personnel are needed to further improve on the data collected for surveillance purposes on stillbirth. |
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