Assessing Capacity to Change in High‐Risk Pregnant Women: A Pilot Study

Pre‐birth risk assessment is a process by which circumstances affecting an unborn child can be identified and support for mother and infant embedded. This mixed methods study describes a community‐based pre‐birth assessment and care pathway that utilised the Parents Under Pressure (PuP) programme to assess parenting capacity and provide support pre‐ and post‐birth for ‘at risk’ women. Sixty‐eight pregnant women referred to children's social care services were allocated to the pre‐birth assessment and care pathway (n = 35) or to routine care (n = 33). Standardised measures of psychological distress, social support and alcohol measured change for the women in the assessment and care pathway. Twenty women who provided pre‐ and post‐data reported significant improvements on all measures except alcohol use. Safeguarding outcomes at 12 months were obtained for both groups using administrative data. Forty‐two per cent of the infants whose mothers received the pre‐birth assessment and care pathway showed an improvement in child protection status compared to 14 per cent of the routine care infants. Safeguarding status deteriorated or stayed the same in 52 per cent of the routine cases compared to 26 per cent of those receiving the pathway. Qualitative data revealed that the pathway was acceptable and helpful to service users and service providers. Copyright © 2017 John Wiley & Sons, Ltd.

‘Describes a community‐based pre‐birth assessment and care pathway that utilised the Parents Under Pressure (PuP) programme’

Key Practitioner Messages

• The current project found that a community‐based pre‐birth assessment and care pathway with high‐risk pregnant women was feasible and acceptable for practitioners and service users.
• The pathway began mid‐pregnancy and support was provided following the birth of the infant for up to 12 months.
• Over 40 per cent of infants whose mothers were allocated to the pre‐birth risk assessment pathway showed improvements in child safeguarding status at 12 months.

     

Maternal Tactile Stimulation and the Neurodevelopment of Low Birth Weight Infants

The purpose of this study was to determine the relationship of early maternal touch to the neurodevelopmental status of low birth weight (LBW) infants. One hundred and eight LBW infants and their mothers were videotaped during a typical feeding when the infant was 3 months old. This tape was used to analyze both the mother's touch and other facets of caregiving behavior using standardized coding systems. Data on perinatal medical risk were also acquired through chart review, and neurodevelopmental tests were administered to the infants at age 1 year. Results indicate that infants whose mothers used more stimulating touch during caregiving had better visual‐motor skills at 1 year of age. In addition, infants of mothers who touched them frequently had more advanced gross motor development. Findings suggest that stimulating and frequent touch may help to compensate for early neurosensory deficits and promote neurodevelopment for LBW infants. Infant birth weight made the strongest contribution to all measures of infant neurodevelopmental status at age 1 year.     

Neurobehavioral Consequences of Prenatal Exposure to Smoking at 6 to 8 Months of Age

Between 400,000 and 800,000 infants are born in the United States each year to women who smoked cigarettes during their pregnancy. Whereas the physical health consequences to infants of prenatal exposure to smoking are well established, the early neurobehavioral consequences are less well understood. This study investigated the neurobehavioral consequences of prenatal exposure to smoking using an epidemiologically derived sample of 454 infants who were drawn from a larger sample of 1,292 infants whose families were recruited at birth. Results indicated that, on average, infants who were exposed to higher levels of prenatal smoking exhibited less positive affect and greater irritability. Moreover, among male infants, elevated levels of prenatal exposure to smoking were associated with lower levels of approach, gross motor movement, reactivity, and attention. There was no evidence that the effects of prenatal exposure to smoking on infant neurobehavioral functioning were mediated by physical growth parameters (infant weight and head circumference) that are also known to be affected by prenatal exposure to smoking.     

Birth weight and income: interactions across generations

This paper attempts to answer a series of questions regarding the interaction of income and birth weight across generations. First, does the effect of the income of a mother during her pregnancy on her infant's birth weight depend on the family's birth weight history (genetic predisposition)? Second, does the effect of low birth weight status on adult life chances depend on income during early childhood? These questions have implications for the way we envision the biological and social worlds as interacting across generations. To address these issues, this study uses intergenerational data from the Panel Study of Income Dynamics, survey years 1968 through 1992. Results of sibling comparisons (family-fixed-effects models) demonstrate that maternal income has a significant impact on birth weight for those infants who are already at high risk hereditarily (i.e., who have a low birth weight parent). However, it is not clear whether income acts as a developmental buffer for low birth weight infants as their lives progress. These findings suggest the existence of biosocial interactions between hereditary predisposition and socio-economic environment.     

Temperamental Susceptibility to Parenting among Preterm and Full‐Term Infants in Early Cognitive Development

The current study examined the interaction between premature birth, temperamental reactivity, and parenting in early cognitive development. Participants were 142 infants (80 preterm; 62 full term) and their parents. Parent–child interactions (maternal, paternal, and co‐parental) were observed at age 6 months to assess parental structuring behaviors. Additionally, both parents reported on infants' temperamental reactivity. At 12 months of age, infants' cognitive abilities were assessed. Consistent with the diathesis–stress model, preterm infants had lower cognitive outcomes than full‐term infants when exposed to low levels of co‐parental structuring, but functioned similarly when exposed to high levels of co‐parental structuring. However, temperamental reactivity moderated this effect: Infants who carried one susceptibility factor (i.e., premature birth or reactive temperament) were similarly affected by co‐parental structuring, whereas infants who carried two or no susceptibility factors were not. Furthermore, consistent with the differential susceptibility hypothesis, infants with highly reactive temperaments had lower cognitive functioning when exposed to low maternal structuring, but higher cognitive functioning when exposed to high maternal structuring compared to infants with lower reactivity. Results from this study highlight the importance of considering both temperamental reactivity and quality of parenting in understanding preterm infants' early cognitive vulnerability.     

The Other Side of the Paradox: The Risk of Low Birth Weight among Infants of Migrant and Nonmigrant Households within Mexico

The main aim of this study is to understand how the international migration process affects the risk of low birth weight among Mexican‐born infants using the ENADID 1997 (Encuesta Nacional de la Dinámica Demográfica), a nationally representative survey of the Mexican population. The total sample includes 23,607 infants. We employ logistic regression to estimate models in which migration status is included as a risk factor for low birth weight. The analysis demonstrates that membership in a migrant household provides protection from the risk of low birth weight largely through the receipt of remittances. In light of this evidence, it is particularly important that international migration be recognized as one of the processes that has a positive and significant effect on perinatal outcomes in both countries of origin and in countries of destination.     

Distribution, Inequality and Concentration of Incomeamong Older Immigrants in Canada

While there are many studies on differences in earnings between immigrants and the native‐born or among immigrant groups, they do not consider distribution and concentration of income among immigrants explicitly. These aspects are important for understanding the distribution of economic welfare and consumer behaviour among members and hence are policy relevant. Using the 1991 Census data, the distribution and concentration of incomehave been examined among 15 broad birthplace groups for population aged55 years and over. About 19 per cent of males and 15 per cent of femalesreceive less than half the median income and obtain 5 per cent and 3 per centof the aggregate income respectively. About 30 per cent of males and29 per cent of females receive more than one and half times the medianincome and obtain 61 per cent and 59 per cent of aggregate incomerespectively. About 51 per cent of males and 56 per cent of females whoreceive incomes between half and one and half times the median income aretermed middle‐class and their shares of aggregate income amount to 34 and38 per cent respectively. Although older immigrants aged 55 years and over, as a group, have roughlythe same quartile distribution and concentration of income as theirCanadian‐born counterparts, the birthplace groups differ considerably.Those from the developing regions, that is, the groups that have loweraverage annual incomes, also have more inequitable distribution of incomethan the Canadian‐born or their counterparts from the developed regions. Thus, income distribution is more polarized in populations from developingregions than in populations from developed regions or in the Canadian‐bornpopulation. On average, females receive 45 per cent less income than males, and thereis less polarization of income among them than among males regardless ofthe place of birth. A part of the explanation lies in the receipt of government transfers, whichtend to equalize rather than polarize incomes, and older women derive ahigher proportion of their income from government transfers than older men.     

Comparison at 32–37 Weeks Postconception of Infants Born 1983–1989 and 1995–2004 on the Neurobehavioral Assessment of the Preterm Infant

In spite of numerous recent outcome studies of extremely low birth weight (ELBW) infants, no data exist on their development prior to term. In this study we traced and compared the neurobehavioral development of 251 ELBW (< 1,000 g) and 240 low birth weight (LBW; 1,000 g–2,500 g) preterms born between 1995 and 2004 from 32 to 37 weeks postconceptional age (PCA), using the Neurobehavioral Assessment of the Preterm Infant (NAPI Korner & Thom, 1990). Compared to the original NAPI cohort of 521 infants (born 1983–1989), the ELBW and LBW infants were at higher medical risk, displayed weaker motor development, a tighter scarf sign and popliteal angle at all or most PCAs, and a weaker cry at older PCAs; they did not differ in irritability and percent asleep ratings. Few differences were noted between the ELBW and LBW groups. Research is now needed to determine whether the 1995 to 2004 NAPI values of ELBW and LBW infants at 32 to 37 weeks PCA are predictive of later outcome of high‐risk preterms.     

The Association Between Infants’ Attention Control and Social Inhibition is Moderated by Genetic and Environmental Risk for Anxiety

Infant social inhibition is associated with increased risk for anxiety later in life. Although both genetic and environmental factors are associated with anxiety, little empirical work has addressed how developing regulatory abilities work with genetic and environmental risk to exacerbate or mitigate problem behaviors. The current study was aimed at addressing this gap in research by investigating an early emerging regulatory behavior, attention control, in association with genetic and environmental risk for anxiety. Participants included 9‐month‐old adopted infants, their birth mothers, and adoptive parents (N = 361). Lifetime diagnosis of birth mother social phobia was obtained using structured interviews. Adoptive parents completed self‐report measures of anxiety symptoms. Infant social inhibition and attention control were coded during a stranger interaction and a barrier task, respectively. Neither adoptive nor birth parent anxiety was directly associated with social inhibition. The association of attention control with social inhibition in infants was moderated by birth and adoptive parent anxiety symptoms. When infants of birth mothers with social phobia were raised by adoptive parents with high self‐reported anxiety symptoms, greater attention control was associated with greater social inhibition. However, when raised by adoptive parents with low self‐reported anxiety, greater attention control was associated with less social inhibition.     

Reaching the child in need

"Reaching the Deprived Child" is India's theme for the Year of the Child. This paper describes the recording system employed in the Community Health Programme of Christian Medical College, Ludhiana and how it enables us to reach not only deprived children, but those in danger of deprivation, the majority being the children of the socioeconomically underprivileged. Many are nutritionally normal at 12 months but 57 per cent of the males and 75 per cent of the females suffer from malnutrition in the 2nd year, 50 per cent of females having severe malnutrition. The etiology, discerned from a study of the deprived, allowed a preventive approach to be designed for those at risk. Intensive nutrition education is given in the homes, commencing as each baby reaches 5 months, and mothers are taught to feed them on suitable modifications of the food available in Punjab homes. The results in respect of 123 babies who had a minimum of 6 months of this care, are described. Complete compliance was achieved in 82 per cent and in the rest partial compliance was achieved. The nutritional status of these infants, compared with a control group, improved greatly, especially in females in whom the prevalence of normal nutrition rose from 26 to 61 per cent and that of severe malnutrition fell from 50 to 17 per cent. The success of this approach depends on an accurate knowledge of the community since this allows priorities to be selected with clarity and maximum effort to be expanded upon those in greatest need.     

THE SOCIAL GEOGRAPHY OF GENDER-SWITCHING IN VIRTUAL ENVIRONMENTS ON THE INTERNET

The virtual social worlds of the internet give people unparalleled control over the construction and presentation of their identities. Gender-switching is perhaps the most dramatic example of how people exercise this control. It occurs when people present a gender that is different from their biological sex. While gender-switching figures prominently in academic commentaries and popular writings about on-line social life, there is little systematic research on the phenomenon. On-line surveys of two stratified random samples (N's=233 and 202) of MOO users were conducted. The majority of participants (60 per cent) in social MOOs (popular text-based internet social venues) had never engaged in gender-switching, while the majority in role-playing MOOs were either gender-switching currently (40 per cent) or had done so in the past (16.7 per cent). More than half of those who currently gender-switched did so for less than 10 per cent of their time on-line. In spite of the freedom to use indeterminate or even plural gender identities, most participants who switched genders (78.7 per cent) did so within traditional binary conventions (male to female, female to male). The primary reason for gender-switching was the desire to play roles of people different from one's self. The primary barrier to gender-switching was the belief that it is dishonest and manipulative. Attitudes toward gender-switching and on-line participation were better predictors of gender-switching than personal background demographics or personality measures. The images of gender-switching that emerge from this first systematic study of the phenomenon are considerably more benign than that usually portrayed in the literature. Gender-switching appears to be practised by a minority of MOO users for a small percentage of their time on-line. Gender-switching within MOOs of all kinds might best be understood as an experimental behaviour rather than as an enduring expression of sexuality, personality, or gender politics.     

Overnight Custody Arrangements,Attachment, and Adjustment Among Very Young Children

Large numbers of infants and toddlers have parents who live apart due to separation, divorce, or nonmarital/noncohabiting childbearing, yet this important topic, especially the controversial issue of frequent overnights with nonresidential parents, is understudied. The authors analyzed data from the Fragile Families and Child Wellbeing Study, a longitudinal investigation of children born to primarily low‐income, racial/ethnic minority parents that is representative of 20 U.S. cities with populations over 200,000. Among young children whose parents lived apart, 6.9% of infants (birth to age 1) and 5.3% of toddlers (ages 1 to 3) spent an average of at least 1 overnight per week with their nonresident parent. An additional 6.8% of toddlers spent 35%–70% of overnights with nonresident parents. Frequent overnights were significantly associated with attachment insecurity among infants, but the relationship was less clear for toddlers. Attachment insecurity predicted adjustment problems at ages 3 and 5, but frequent overnights were not directly linked with adjustment problems at older ages.     

The Impact of Anti‐Immigration Policies and Perceived Discrimination in the United States on Migration Intentions among Mexican Adolescents

This exploratory study examined whether higher levels of perceived discrimination against Mexican immigrants in the United States (USA) were related to the migration intentions of Mexican adolescents. I drew the data for this study from a sample of 755 from a total of 980 adolescent students surveyed in Tijuana, Mexico in February 2009, who indicated they had some interest to migrate to the USA to either live or work in the USA. There were 392 male participants (51.9%) and 363 female participants (48.1%), with a mean age of the participants of 16 years. Over 65 per cent of the participants were born in Tijuana, Mexico and over 62 per cent of the participants indicated that their families had very low to average socio‐economic status, as measured by an SES scale. The majority of participants' mothers (74.2%) and fathers (68.6%) had less than a high school education. Multivariate OLS regressions were run controlling for gender, age and socio‐economic status. Results indicated that higher levels of perceived discrimination in the USA were a moderately significant predictor of lower migration intentions among Mexican adolescents who identified that they wanted to live or work in the USA, but higher levels of perceived discrimination did not significantly predict lower migration intentions among participants, who indicated that they felt they had to move to the USA to work and support their families.     

Grandparents' Education and Infant Health: Pathways Across Generations

Using data from the Fragile Families and Child Wellbeing survey linked to respondents' medical records (N = 2,870), this study examines the association between grandparents' education and birth outcomes and explores potential pathways underlying this relationship. Results show that having a grandfather with less than a high school education was associated with a 93 gram reduction in birth weight, a 59% increase in the odds of low birth weight, and a 136% increase in the odds of a neonatal health condition when compared with having a grandfather with a high school education or more. These associations were partially accounted for by mother's educational attainment and marital status as well as by prenatal history of depression, hypertension, and prenatal health behaviors, depending on the specific outcome. The findings from this study call for heightened attention to the multigenerational influences of educational attainment for infant health.     

Longitudinal assessment of social attention in preterm and term infants: Its relation to social communication and language outcome

Preterm birth has been reported to be associated with an increased risk of social communication and language problems. Recently, we found that preterm infants showed atypical patterns of social attention compared with term infants. However, it is still unknown how social attention develops and whether the individual differences are associated with developmental outcomes for social communication and language in preterm infants. The social attention of preterm and term infants at 6, 12, and 18 months was investigated using two types of social attention tasks (human-geometric preference task and gaze-following task). The Modified Checklist for Autism in Toddlers (M-CHAT) and the MacArthur Communicative Development Inventory adapted for Japanese were measured at 18 months. We found that compared with term infants, preterm infants spent less time looking toward dynamic human images and followed another's gaze directions less frequently through 6, 12, and 18 months. Moreover, hierarchical multiple regression analysis revealed that less preference for dynamic human images and gaze-following abilities was associated with high M-CHAT and low language scores in preterm and term infants, respectively. These findings suggest that birth status affects development of social attention through 18 months and individual differences in social attention reflect differences in social communication and language outcomes.     

Sharing Health Services: Two Universities,a Seminary,and a Community

Abstract

“The Inverse Relation Between Fish Consumption and 20-Year Mortality From Coronary Heart Disease,” DAAN KROMHOUT, et al. The low death rate from coronary heart disease among the Greenland Eskimos has been ascribed to their high fish consumption. We therefore decided to investigate the relation between fish consumption and coronary heart disease in a group of men in the town of Zutphen, the Netherlands. Information about the fish consumption of 852 middle-aged men without coronary heart disease was collected in 1960 by a careful dietary history obtained from the participants and their wives. During 20 years of follow-up 78 men died from coronary heart disease. An inverse dose-response relation was observed between fish consumption in 1960 and death from coronary heart disease during 20 years of follow-up. This relation persisted after multiple logistic-regression analyses. Mortality from coronary heart disease was more than 50 per cent lower among those who consumed at least 30g of fish per day than among those who did not eat fish.

We conclude that the consumption of as little as one or two fish dishes per week may be of preventive value in relation to coronary heart disease. (New England Journal of Medicine 1985;312:1205–9.)

“Teaching Touch at Medical School,” JULES OLDER. The association between touch and healing is ancient and worldwide. Skilled hands are among the physician's most important diagnostic and therapeutic tools. Yet a survey of medical schools in the English-speaking world revealed that most offer no touch training in their curricula. Of 169 medical schools, only 12 give any formal instruction in the uses and meaning of therapeutic touch in medicine. The teaching modes of these 12 schools are discussed, and the program of the most touch-conscious school, the University of Otago, is described. (Journal of the American Medical Association 1984;252:931–3.)

“Tubal Infertility and the Intrauterine Device,” DANIEL W. CRAMER, et al. To study the association between intrauterine devices (IUDs) and pelvic inflammatory disease, we compared contraceptive histories in 4185 white women—283 nulliparous women with primary tubal infertility, 69 women with secondary tubal infertility, and 3833 women admitted for delivery at seven collaborating hospitals from 1981 to 1983. The relative risk of tubal infertility associated with IUD use was calculated by means of multivariate logistic regression to control for confounding factors, including region, year of menarche, religion, education, smoking, and reported number of sexual partners. The adjusted risk of primary tubal infertility associated with any IUD use before a first live birth was 2.0 (95 per cent confidence limits, 1.5 to 2.6) relative to nonuse. Users of the Dalkon Shield had an adjusted risk of 3.3 (1.7 to 6.1), users of the Lippes Loop or Saf-T-Coil had a risk of 2.9 (1.7 to 5.2), and users of copper IUDs had a risk of 1.6 (1.1 to 2.4). Women who reported having only one sexual partner had no increased risk of primary tubal infertility associated with IUD use. The adjusted risk of secondary tubal infertility associated with use of a copper IUD after a first live birth was not statistically significant (1.5; 95 per cent confidence limits, 0.8 to 3.0), whereas the risk from similar use of noncopper devices was significant (2.8; 1.3 to 5.9). We conclude that tubal infertility is associated with IUD use, but less so with copper IUDs. (New England Journal of Medicine 1985;312:941–7.)     

Mortality rates as indicators of cross-cultural development: regional variations in the Third World

"While infant mortality and the under 5 mortality rates are widely used as measures of development, the death rate among 1-4 year olds may be a more effective measure of socioenvironmental conditions affecting mortality, since this age group is less influenced by genetic and biological factors than infants. This article looks at the relationship between infant, under 5, and 1-4 mortality rates and level of development, immunization, information, access to drinking water and health services, and literacy rates among mothers for 78 less developed countries. The evidence suggests that socioenvironmental variables have greater degrees of correlation with age group 1-4 mortality than infant or under 5 mortality, pointing to the importance of this measure in cross-cultural research."     

MONEY TRANSFER AND BIRTH WEIGHT: EVIDENCE FROM THE ALASKA PERMANENT FUND DIVIDEND

The positive relationship between income and health is well established. However, the direction of causality remains unclear: do economic resources influence health, or vice versa? Exploiting a new source of exogenous income variation, this study examines the impact of the Alaska Permanent Fund Dividend (APFD) on newborns' health outcomes. The results show that income has a significantly positive, but modest effect on birth weight. We find that an additional $1,000 ($2,331 in 2011 dollars) increases birth weight by 17.7 g and substantially decreases the likelihood of a low birth weight (a decrease of around 14% of the sample mean). Furthermore, the income effect is higher for less‐educated mothers. Based on a gestation‐weight profile in the sample, increased gestation owing to the APFD could explain a maximum of 34%–57% of the measured weight increase, although we are unable to examine all the potential mechanisms. (JEL I10, I18, I12)     

Child‐Care Usage and Mother‐Infant “Quality Time”

Mothers' time‐use patterns were compared in families in which infants spent more than 30 hours per week in child care (In‐Care group; n= 143) versus 0 hours per week (At‐Home group; n= 183) from birth to 6 months of age. In‐Care group mothers spent about 12 fewer hours per week interacting with their infants, for about 32% less time; fathers of these infants were more involved in caregiving. The groups did not differ in the quality of mother‐infant interaction. In the In‐Care group, quantity of interaction was related to greater separation anxiety and concerns about effects of maternal employment. Time‐use data were not related to child outcomes at 15 months of age. Results suggest that the effect of extensive time spent apart on the quantity and quality of mother‐infant interaction may be smaller than anticipated.     

Postcoital Contraception: Awareness of the Existence of Postcoital Contraception among Students who have had a Therapeutic Abortion

Abstract

A two-semester survey was conducted to obtain information about the underutilization of postcoital contraception (PCC) in terms of fear about using it or ignorance of its existence. Among 437 students attending the women's health clinic at California State University/Fresno, 41% had had a therapeutic abortion. One hundred fifty-two, or 84.9%, of those who had had terminations were not aware of PCC. Some were not aware that they had taken a chance of becoming pregnant. It is concluded that students who have had a therapeutic abortion either were unaware of the existence of PCC or were unaware they were risking pregnancy and therefore unable to utilize PCC to avoid the need for a surgical procedure. It would appear that ignorance about the existence of PCC is a major reason for its underutilization.

“Treatment of First Episodes of Genital Herpes Simples Virus Infection with Oral Acyclovir,” YVONNE J. BRYSON, MARYANNE DILLON, MICHAEL LOVETT, GUILLERMO ACUNA, STEPHEN TAYLOR, JAMES D. CHERRY, B. LAMAR JOHNSON, EDWARD WIESMEIER, WILLIAM GROWDON, TERRI CREAGH-KIRK, RONALD KENNEY. We performed a double-blind placebo-controlled trial of oral acyclovir in the treatment of first episodes of genital herpes simplex virus infections in 48 young adults (31 women and 17 men). Subjects were randomized to receive either placebo or acyclovir (200 mg per dose) five times daily for 10 days; they were examined on at least eight visits until healed and at monthly visits thereafter. Acyclovir treatment, as compared with placebo, significantly reduced virus shedding, new lesion formation after 48 hours, and the duration of genital lesions in both men and women. The total duration and severity of clinical symptoms (such as pain, adenopathy, dysuria, and malaise) were significantly reduced by acyclovir in both men and women by the third and fourth day, respectively (P ≤ 0.025), as compared with placebo. No toxicity was observed. Recurrence rates have so far been similar in placebo and acyclovir recipients. Oral acyclovir treatment of first-episode genital herpes simplex virus infections is clincially effective, but it does not seem to prevent virus latency or associated recurrent disease. (New England Journal of Medicine 1983;308:916–21)

“Cesarean Section: Risk and Benefits for Mother and Fetus,” BEN P. SACHS, BRIAN J. McCARTHY, GEORGE RUBIN, ANTHONY BURTON, JULES TERRY, CARL W. TYLER. We studied the effects of cesarean section on neonatal mortality for breech infants and low-birth weight vertex infants using data from the Georgia neonatal surveillance network on 392,241 singleton deliveries between 1974 and 1978. The risk of neonatal death for breech infants weighing 4,000 g or less delivered vaginally was significantly higher than the risk for those delivered by cesarean section. The lower the birthweight, the higher the risk for a vaginal breech delivery. For breech infants weighing 1,000 to 2,500 g, the risk was almost 2½ times greater for a vaginal delivery v a cesarean delivery. The best outcome for high-risk vertex infants weighing 1,000 to 1,500 g was for those delivered by cesarean section in a tertiary perinatal center. An increase in the cesarean section rate may be associated with increased neonatal survival; however, the benefits must be weighed against the costs of an increased maternal mortality and morbidity. (Journal of the American Medical Association 1983;250:2157–2159)