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Book Review: Fragile Beginnings

April 16th, 2012 by avatar

By regular contributor, Darline Turner-Lee, BS, MHS, PA-C

Book Review: Fragile Beginnings

Fragile Beginnings by Adam Wolfberg, M.D., is a deeply personal account of the events surrounding the birth of his daughter Larissa at 26 weeks and the emerging technologies that are being developed to save such fragile infants. Dr. Wolfberg examines the question, should such fragile infants be saved and what are the ethical issues associated with the research and development of treatments and the care of these tiny infants.

Interestingly, the book reads more like a novel. It reminded me of the books by Robin Cook, you know, Coma, Brain, Fever, etc…Had this book been called “Baby” I would have had to wonder if Dr. Wolfberg really was the author! I say this because while this book is factually accurate, it is quite easy to read and I personally found it engaging. I found myself wondering what happened to Larissa, so I kept reading.

The strength of the book comes from the great wealth of information presented. Dr. Wolfberg provides in-depth information on neuroplasticity, intraventricular hemorrhage in premature neonates, the research and development of treatments for premature infants with these disorders, discusses the ethics surrounding treating these conditions such as whether or not it is prudent to develop treatments for children who may have what many consider “sub-standard” lives.

What provided interest were the background stories about Kelly, Dr. Wolfberg’s wife, as well as back stories about the various health care providers. All of the doctors and health care professionals mentioned were three dimensional. They were introduced and their integral role in Larissa’s care was described via their personal histories, trials and tribulations. We learned Jason Martin became a doctor in an effort to try to find a cure for his brother who had a spinal cord injury. We got to know Dr. Steven Ringer, the head of the Brigham and Women’s Hospital NICU and about his passion for saving babies.

Although I enjoyed reading the book, I kept asking, what is the point the author is trying to make and who is his intended audience? Is the intended audience other doctors or health care professionals? Is it a tribute to Brigham and Women’s Hospital NICU? Is it a piece outlining how far medicine has come in the care of fragile infants?

The book is called Fragile Beginnings and initially I thought that the book would focus more on Larissa and the Wolfberg family as they struggled to cope with Larissa’s prematurity. Yet, Larissa wasn’t really the star. The main focus was on the medical advances that have been made in neonatology, the doctors making those advances and the ethics behind the advances.

As such, this is not a book that I would recommend to new parents who recently gave birth to a premature infant. In my opinion, those parents need information on how to cope with this unexpected situation and resources to help raise and develop their child. This book does not at all address such issues. Towards the end of the book, we see Larissa developing and progressing, but we really have no idea how her parents found the physical therapists, occupational therapists and other ancillary health care personnel that helped care for Larissa.

We get a glimpse into the fact that the family lives in a town that provides a lot of social services. If I were a parent of a preemie, I would want to know how I go about finding out what services are available in my town and getting my child connected. This isn’t addressed.

I think parent readers would also prefer more details about what Dr. Wolfberg and his wife were going through on an emotional level. How about a chapter describing how they explained what happened to Larissa to her sister and their responses? How about a chapter describing how his wife Kelly coped with delaying her own career to care for such a fragile child? This is truly a difficult situation for many moms and while Dr. Wolfberg once mentioned Kelly’s irritation that he was able to continue this career while hers was stalled, a mom reading this chapter may be wondering how Kelly may have dealt with any resentment or feelings of guilt for having resentment at all.

As a parent of a fragile infant, I would want to know how Larissa’s medical issues specifically affected her development. Was she significantly delayed? When did she walk, talk and learn how to feed herself? If I was a mother of a severely premature infant, I would want to know how and when Kelly potty trained Larissa. If I were a new parent of a premature child, born around the same time as Larissa, I would want the “uncut” version of everything that I am about to encounter; how to find specialists, best ways to soothe the child, how and when to recognize when you can teach your child a new skill, etc.

We see Larissa as an infant in the NICU, then she goes home, and then we see her at about a year and then again at ages 5 and 9.

What happened in the interim? At what age did she start school? Did she begin in any sort of special education classes? Is she behind cognitively? Did she learn to speak on time? There are too many gaps to get a real impression of what it’s like raising a fragile infant. We as readers are left with too many inferences to make.

One other point of concern is that Larissa seemed to get the “creme de la creme” treatment. Describing Larissa being rushed to the NICU, Dr. Wolfberg talks about how the staff overrode the elevator asking other hospital guests to vacate while they whisked her away “for they were taking care of one of their own”. It made me wonder, is this the standard treatment that all premature infants receive? Larissa was the daughter of one of the OB/GYN residents. It doesn’t get much closer than that! (Except if she was the child of a neonatology resident!)

Would my child have received the same treatment if she had been born at Brigham and Women’s Hospital? Would a child whose parents were on Medicaid? Would a Medicaid child have the same access to care and services that Larissa had? Larissa’s family lives in Newton, MA, an affluent suburb of Boston known for its excellent schools and social services. I know this because I grew up there. But could a family that didn’t come from a town with the abundant social resources hope for the same outcome for their child? Would they have been informed about the program at the University of Birmingham? Would the family have been eligible or have had the means to attend? I would have preferred to have learned more about the particular services that Larissa had access to, what they contributed to her development and as a parent I would have liked more information on how to access those services in my hometown.

Overall, the book is well written and informative. However, I’ll recommend it like this; if you want to read a well written book about prematurity and advances in neonatology and brain injury, this is a really good book. If you want a book that reads like an episode of Grey’s Anatomy, you will probably like this book. If you are a parent of a premature infant, you may want to read this book to gain some understanding of why your child’s neonatologist is making the recommendations and decisions s/he is making.

But if you are a parent of a premature infant trying to cope with they myriad of emotions, while at the same time wondering what types of care your child will need, where to find services and providers, how to find out what is available in your area and how to access those services, this is not the book for you as it doesn’t answer any of those questions.

Authoritative Knowledge, Babies, Book Reviews, Childbirth Education, NICU , , ,

Bed Rest, When Used for Anything Other Than Sleep Has no Proven Benefit and May, In Fact, Be Harmful

January 27th, 2012 by avatar

“Bed rest is ineffective in treating anything”

So reads the title of the clinical POEM presented in Essential Evidence (www.essentialevidence.com) in January 2000. The poem is a summary of a study published in the Lancet by Allen et al entitled, “Bed rest: a potentially harmful treatment needing more careful evaluation”. In this study, Allen and associates perform a meta-analysis of bed rest studies up to that time and found that bed rest was ineffective in improving outcomes for a variety of medical conditions, including pregnancy complications, and in many instances caused patients to have worse outcomes.

Judith Maloni, PhD, RN, FAAN, nursing professor at the Frances Payne Bolton School of Nursing at Case Western Reserve University has studied high risk pregnancy and ante partum bed rest since 1989 and has found that despite its prevalence, there is no scientific basis for the bed rest prescription. In “Antepartum Bed Rest for Pregnancy
Complications: Efficacy and Safety for Preventing Preterm Birth” (2010)
Maloni also shows that in addition to being ineffective at preventing preterm birth, bed rest actually has many negative health effects on both mother and baby. In mothers prescribed bed rest, many experience muscle atrophy, cardiovascular problems, bone loss, insufficient weight gain and depressive symptoms. For babies born to mothers on bed rest, many are born at low birth weight and many end up in the NICU with complications. Maloni also shows that hospital bed rest is no better than bed rest at home and that bed rest at home often has better outcomes as mothers feel more secure and comfortable in familiar surroundings.

Where did the “bed rest” prescription come from?

Bed rest has been described in medical literature since the beginning of time. However, in the 19th century, Silas Weir Mitchell, a prominent neurologist at the time, introduced “the bed rest cure” which consisted of isolation, confinement to bed, a high fat diet and massage. The bed rest cure was initially indicated for those suffering “nervous injuries and maladies” as a result of fighting in the Civil War. Later, the bed rest cure was specifically prescribed to people (primarily women) with mental disorders, particularly hysteria. Most physicians abandoned the bed rest cure when it became apparent that it did not help their patients and in many cases made them more mentally unstable.

Charlotte Perkins Gillman, a 19th century feminist, sociologist and writer was treated by Mitchell with the bed rest cure. Best known for her semi-autobiographical short story The Yellow Wallpaper, Gillman wrote the story after her own ordeal with post partum psychosis. Interestingly, the narrator in the story is driven insane by her rest cure.

So why is bed rest prescribed and given the lack of evidence, why does it persist as a treatment for preterm labor? Most other medical disciplines have abandoned bed rest as a treatment. Most heart patients are sat up and ambulated almost as soon as they are extubated, because it has become common knowledge that prolonged bed rest can lead to complication, notably pneumonia.

In orthopedics, post operative back and joint patients are quickly started on physical therapy so that they can achieve the optimum function and range of motion in the area treated. Yet, we persist in putting pregnant women on prescribed bed rest. Why?

Bedrest persists as a “treatment” for high risk pregnancy primarily because of litigation and lack of research (or more aptly, lack of implementation of current research). The potential for litigation in the United States makes it almost impossible for obstetricians not to utilize bed rest. Who wants to be responsible for the death of a baby or mother? If a pregnant woman has a complication and an obstetrician doesn’t put her on bed rest and she has an adverse outcome (or worse yet, she, her baby or both die), it can be career ending. Yet, our statistics show that bed rest is not improving outcomes nor making any dent whatsoever in maternal or infant mortality. Everyday I read articles and studies showing “promising” new treatments and yet these potentially lifesaving treatments and procedures are years away because of the need to provide evidence of efficacy and then for them to go through the approval process of the US FDA and then final adoption by ACOG. Yes we want safety and efficacy of treatments, but with all this bureaucracy, are we providing protection for mothers and babies or for those who treat them? It’s heartening to see so many new treatments available such as Fetal Fibronectin tests and the broadening use of Progesterone therapies. But we still need more.

Should bed rest be completely eliminated as a treatment for high risk pregnancy? It can’t be because when a pregnant woman presents with acute vaginal bleeding or with uncontrolled hypertension, or preterm labor, she needs to be stabilized and immediate bed rest needs to be part of that stabilization.  But once she is stabilized, it becomes unclear whether further confinement is necessary or beneficial. This is where more research, new treatments and new information are essential.

Bed rest has been around for a long time. Organizations like Sidelines and Better Bedrest have been in operation supporting high risk pregnant women since 1991 and 1995 respectively. I first came to know bed rest when it was suggested for me in 2002 when I was pregnant with my daughter. It is amazing to me that here we are in 2012 and we are still prescribing bed rest for high risk pregnancy. Bypasses have been changed and are more streamlined and less invasive. Prostate surgeries and hysterectomies are facilitated by robotics. Most disciplines have moved away from bed rest, but in obstetrics, still the same old prescription. Why am I so “anti” bed rest? I have a daughter who is 9. I imagine that in roughly 20 years, she’ll be considering starting a family of her own. I don’t know if my reproductive problems will be passed on to her or not, but it is my sincerest hope that if my daughter becomes pregnant with a high risk pregnancy (circa 2032), we’ll have something more effective and beneficial to offer her than the same bed rest prescription offered to her mother almost 30 years prior.

References
Allen C, Glasziou P, Del Mar C. “Bed rest: a potentially harmful treatment needing more careful evaluation”. Lancet 1999: 354:1229-33.
Judith Maloni, PhD, RN, FAAN. “Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth”. Biological Research for Nursing: 12(2) 106-124
ª The Author(s) 2010
Reprints and permission:
DOI: 10.1177/1099800410375978

Bed Rest ,

A Follow Up: Maternal Obesity from All Sides

November 7th, 2011 by avatar

Science & Sensibility readers may recall the Maternal Obesity from all Sides series* we did a few months ago.  Last week, while walking my dog and catching up on a few news podcasts, I heard this story on NPR’s Morning Edition—a segment that was a part of the news outlet’s series on Obesity in America.  The story discusses new research that looks at why it can be so difficult to lose and keep weight off from a hormonal and biological perspective.  The gist of the research referenced in this news piece is that when we concertedly work to lose weight, our body produces less of the hormone leptin (a natural appetite suppressant) which prompts a starvation signal in our brain, telling the body to conserve energy by decreasing metabolism and, at the same time, feel more hungry—prompting increased caloric intake.

Additionally, the Morning Edition segment made the point that once a person has gained more weight than that which is healthy for his/her stature, it becomes harder and harder to lose and keep the weight off.  As the reporter summarizes, “lower metabolism lasts a lifetime.”  (Despite this, some excellent points are later made in the segment which suggest that moderate exercise six days a week—such as brisk walking, swimming or cycling, can have positive effects on weight loss and maintenance.)

What does all this have to do with maternity care issues?

Well, in the Maternal Obesity from all Sides series, we discussed the growing correlations between maternal overweight and pregnancy and L&D outcomes:  how women of size are more likely to experience gestational hypertension and diabetes; how they are more likely to be offered labor inductions and undergo cesarean deliveries as a result of those comorbidities—whether or not those procedures are actually evidence-based for the given situation(s).  And we also discussed how addressing size and/or weight once a woman is pregnant is both unfruitful and unfair—because most of us recognize that pregnancy is not a time when a woman should be attempting to lose weight.  Likewise, it is not a time when a woman should be shamed for a preexisting condition (as if shaming is ever acceptable).

But, in the spirit of preventative care, I felt the NPR piece was enlightening: while there are MANY opportunities to improve maternal outcomes through preconception/interconception care, as pointed out in the recent blog post by Christine Morton, and the more distant series by Walker Karraa, perhaps working to prevent obesity in the first place—rather than focusing on after-the-fact individual or public health weight loss programming—is a better approach.  Because, according to the news segment linked to above, once extra weight has been acquired, losing and maintaining that weight loss is exceptionally more difficult.

A similar NPR story on All Things Considered aired just a few days earlier which covered this same topic and reviewed the findings of a study recently published in the New England Journal of Medicine.  The study by Priya Sumithran et al. assessed the hormone and metabolism changes that accompanied significant weight loss in severely calorie-restricted study subjects.  As described in the Morning Edition segment, Sumithran’s study described significant weight loss maintenance difficulties that were hormonally based.  In essence: maintaining weight loss is about hormones, not will power.

Women of childbearing age have enough maternity care-related challenges to face: escalating labor induction and cesarean delivery rates, racial disparities in access to care.  We talk a lot on this blog site about the cascade of interventions, a concept that is also frequently referred to in Lamaze teachings.  Perhaps it is time we should also be talking about a healthy cascade of prevention, with maternal obesity being a prime target.  Ideally this cascade of prevention begins well before women of childbearing age find themselves contemplating pregnancy, or preparing for birth.  But even as childbirth educators, we can play a part in this healthy cascade.  When covering postpartum topics, we can talk with our expectant parents about the importance of interconception health:  nutritious dietary choices and adequate exercise.  We can couch these discussions as approaches to optimizing health in various ways with various downstream benefits:  having adequate energy to play with one’s child(ren), reducing a family’s healthcare cost burden, and yes, laying the ground work for healthfully supporting a future pregnancy if and when that occurs.

As Dr. Miranda Waggoner stated in her interview with Dr. Morton, “…we do have to worry about viewing women as pregnancy vessels,” but I also think we need to begin looking at expectant women beyond just the here and now.

 

*The Maternal Obesity from All Sides series is also reviewed in the current Journal of Perinatal Education.  If you don’t already receive the JPE and would like to check it out, you can request a free copy of the journal here.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Maternal Obesity , , , , , , , , , , ,

Perinatal Disparities: Not Just Black and White ~ Part Two

November 2nd, 2011 by avatar

[Editor’s note:  Yesterday, Darline Turner-Lee introduced us to a new study by Ashley Schempf, et al that looks at racial disparities in maternal mortality rates, and the socioeconomic factors that influence those disparities.  Today, Darline expounds upon this issue further, including her own experiences practicing medicine in the areas described in the study.]

 

Discussion

This was an interesting and difficult study to read and analyze. While I appreciate the authors’ desire to pinpoint causation in an effort to propose disparity-reducing interventions, the situations are far more complex than the study leads one to believe. The authors themselves admitted that,

 

 A comprehensive neighborhood socioeconomic index explained only half of the total neighborhood contribution to racial disparities in MPTB, suggesting an impact of racial inequalities in neighborhood environments that is not just a function of measured socioeconomic disadvantage.”

 

I strongly agree with this assessment. I earned my Master’s Degree at Duke University and trained as a physician assistant in the very counties described. While race and neighborhood deprivation (poverty) are significant factors, there are many more that come into play. To begin with, there is little choice of providers.If you are uninsured or on Medicare in Durham County, unless you have a tertiary care medical issue, you get your care from the county regional hospital on the far north end of the county, not at the high tech, well equipped Duke University Medical Center”. With the various Medicare and Planned Parenthood cuts, there is now likely little to no availability of prenatal care in local neighborhoods. If you live in one of the lower income neighborhoods, it’s difficult to get to the regional hospital for services via public transit. I can only imagine trying to get to the hospital, via public transportation and you are 13 years old (the age of one of the young ladies that I delivered).  Does a13- or even 16-year-old pregnant girl know the importance of prenatal care for herself and her baby?  Their concerns are the repercussions for even being pregnant! Many girls deny and/or try to hide the pregnancy, not protect and nurture it. Fear trumps care.

 

Fear and mistrust towards the medical community is huge amongst African Americans. The Tuskegee Experiment is well known lore in the African American community and if that isn’t enough, almost everyone has a tale of healthcare gone wrong, mistreatment, humiliation and an adverse outcome for which there was no restitution. While in training, I was on rounds in a group of about 6 students. We were all instructed by the attending physician to feel a woman’s adnexal mass. At no time during this interaction was she asked if she could be examined by 6 students (I just hope that the attending asked her before the fact!). At no time were we introduced to her. At no time did any of us say one word to her. We simply walked up to her perineum in the lithotomy position and one after the other performed a pelvic examination while the attending talked about “her case” as if she were a test dummy and not a live human being. How many of us reading this would have submitted to such treatment? And with the best-selling book The Immortal Life of Henrietta Lacks, once again the flames of mistrust towards the (white) medical community are fanned.

 

And then there is simply life stress itself. One of my Mamas on Bedrest lost her job after 12 weeks when she was prescribed bed rest and admitted to the hospital. A single mama, her 9 year old son was left with her mother who insisted that she couldn’t care for her grandson indefinitely. So there she was in the hospital, newly unemployed and now without medical benefits. (She scrambled and was able to get emergency Medicaid.) She was worried about losing her apartment because she could no longer pay her rent (we were able to get her an emergency grant.) She was worried about her son at home. She was worried about the baby she was carrying and how she would care for him. Is it any wonder she delivered him at 28 weeks? He stayed in the NICU for weeks before being discharged home, yet was denied Early Childhood Intervention by the state. Here was a newly unemployed mama of 2, whose infant likely will have lifelong special needs.

 

The complexities of racial and socioecomomic disparities are myriad and make huge contributions to adverse pregnancy outcomes. While I believe that Schempf and her colleagues mean well in trying to pinpoint factors that could be modified to improve birth outcomes, “The Gap” in maternal and infant morbidity and mortality between African American and white women in the United States has so many inter-related factors, I really don’t believe that you can control for them all or regard them independently-at least at this point in time as our societal and health care systems are structured. Covert and overt racism still exist in this country and its effects create “unobserved” factors that are difficult to measure. When I had my son nearly 6 years ago, I was approached by a “well meaning” social worker who came into my private room to present me with a binder of Medicare, WIC and Social Services information. “Here is some information you may need,” she explained. Quickly perusing the binder of papers, my immediate response was indignation and anger.

 

“Why would you think I needed this information?” I asked her. “Oh well, I just thought…” she trailed off. I politely informed her that we had private PPO insurance, that my husband would be in shortly on his way to work (at a local semiconductor corporation) and that her information was neither needed nor wanted. She turned all kinds of red, and quickly left. I quickly recovered (so I thought) from the incident, yet can vividly recall it today. How did that incident impact my health in that moment? What impact did it have on my memory of my son’s birth, of my experience as a patient in that hospital and as a birthing black woman in Texas? Was my experience unique or par for the course as a black woman?  Can it be measured? Should it be ignored?

 

The logistical analyses applied to the data from North Carolina, I believe, portray an artificial, misleading picture that race and SES, when “leveled out” or “controlled” really don’t have a statistically significant impact on birth outcome in black women. There are just too many other factors involved, many for which there are no controls that are contributing to the disparities. While I believe that this is a plausible start, there needs to be much more research in racial disparities in maternity care, including SES and birth outcomes and examining the interactions between patients of color and white providers before we’ll be able to develop effective interventions to bridge and eventually eliminate “The Gap.”

*To read yesterday’s post, go here.

 

Posted by:  Darline Turner-Lee, BS, MHS, PA-C

Maternal Mortality, New Research, Pregnancy Complications, Research , , , , , ,

Perinatal Disparities: Not Just Black and White ~ Part One

November 1st, 2011 by avatar

 [Editor's note: Today is part one of a two-part series by Darline Turner-Lee, looking at racial disparities in maternal outcomes.  Come back tomorrow to read Darline's discussion on this recent study.]

 

 

INTRO: The Financial Burden and Racial Disparities of the US Health Care System

Despite the enormous amount of money the United States spends annually on health care, nearly 17% of the Gross Domestic Product according to www.HealthCare.gov,  Americans overall are less healthy and have higher morbidity and higher mortality than many other citizens around the world. Nowhere is this more apparent than in US maternal mortality rates. Amnesty International’s Deadly Delivery: The Maternal Health Care Crisis in the USA states,

 

Maternal mortality ratios have increased from 6.6 deaths per 100,000 live births in 1987 to 13.3 deaths per 100,000 live births in 2006. While some of the recorded increase is due to improved data collection, the fact remains that maternal mortality ratios have risen significantly. African-American women are nearly four times more likely to die of pregnancy-related complications than white women. These rates and disparities have not improved in more than 20 years.

 

Researchers have tried to determine what is causing this huge health care disparity between African American women and white women. To try to identify the causative factors, most researchers have compared pregnancy outcomes of African American women and white women living in the same or similar neighborhoods and have attributed much of the disparity to socioeconomic status (SES); i.e. poverty, lack of education, poor access to care. Yet SES alone has not been able to account for the large gap in outcomes. In The Neighborhood Contribution to Black-White Perinatal Disparities: An Example From Two North Carolina Counties, 1999-2001 Ashley Schempf and her colleagues at the US Department of Health and Human Services sought,

 

to determine the total contribution of neighborhood inequalities, both observed and unobserved, to the black-white gap in the birth outcomes, low birth weight (LBW), preterm birth (PTB) and small for gestational age (SGA) using hybrid fixed-effects approach to compare only black and white women who lived in the same neighborhoods”

 

Schempf et al added in the fixed-effects models to better characterize the impact of neighborhood features such as social cohesion and access to goods and services that may vary depending on the racial make up of the neighborhood. Their aim was to compare the results they found with results from conventionally run studies to get a more complete picture of the effect of neighborhood factors on maternal mortality.

 

Study Population

The study consisted of 31,489 women: 21,221 white women and 10,268 black women. A validated neighborhood deprivation index was used as an indicator of neighborhood SES. The index was constructed from a principle analysis of 8 variables from the 2000 Census of Population and Housing. Individual maternal control factors included age, years of education, marital status, and gravity. Please refer to the tables at the end of this post from the study for demographic data.

 

Analytic Methods

The researchers employed a complex series of statistical analyses to the birth certificate data obtained. For each outcome analyzed, they used 4 logistic models to determine 1) The total contribution of neighborhood to the racial disparity and 2) To compare the performance of a neighborhood fixed-effects estimator with the simple control for neighborhood SES (the standard analysis method). Model 1 was an unadjusted logistic that measured the difference of race on maternal outcomes. Model 2 was an adjusted logistic that controlled for individual maternal characteristics. Model 3 was a hybrid fixed-effect model that accounts for all between neighborhood variation in risk that is associated with race and provides a within-neighborhood race contrast. This model controlled for the excess odds of an adverse outcome associated with living in a neighborhood with a higher proportion of black births. Finally, Model 4 controlled for neighborhood SES. (Please refer to the actual study for statistical equations).

 

Results

The authors noted clear differences in sociodemographic characteristics and neighborhood deprivation. Black women were at least twice as likely to deliver LBW, preterm and SGA infants as white women. When data was adjusted for race and neighborhood deprivation, the disparities were reduced. With all confounding variables controlled for by the fixed effect analyses PTB was the only adverse outcome that continued to have higher adverse outcomes. The disparities in PTB persisted even when parceled out for Moderate preterm birth (MPTB) 32-36 weeks gestation and Very preterm birth (VPTB) <32 weeks gestation. The absolute risk of MPTB was nearly twice that of VPTB while the relative risk of VPTB was much greater than that of MPTB. Based on this data, the authors believe that there are other significant yet unobserved neighborhood contributions to disparities for preterm birth. The results are presented in the tables below.

 


*Click here to jump to part two of this series.

 

 

 

 

 

 

Posted by:  Darline, Turner-Lee, BS, MHS, PA-C

Maternal Mortality, Maternal Mortality Rate, New Research, Research, Uncategorized , , , , , , ,