3. In many European countries, mothers continue to smoke during pregnancy. Briefly discuss how smoking habits were measured in this study and the validity of these estimates

MPH MCH Course: Assessment Task Two.

Post-Course written assignment

Read the attached paper from the British Medical Journal titled Maternal Overweight and Obesity in Early Pregnancy and Risk of Infant Mortality: A Population Based Cohort Study in Sweden“.

Answer the following questions. There are 10 questions and a total of 25 marks are available for this assignment. Marks allocated to each question are clearly shown in parentheses. Recommended time to complete the assignment is 3 hours. Answer each question in not more than 100-150 words. Unnecessarily long answers will be penalized. Use Font size 11. Do not type outside the boxes provided. Do not cut and paste. Adjusted the provided space after each question to fit your answer.

When you have completed all the questions, save the file using a name that includes your first name and student ID number and then upload it through BlackBoard©

Please upload your completed assignment by 0900 on Sunday 25 Feb 2018.

The study aimed to investigate the associations between maternal overweight and obesity and infant mortality outcomes. Study researchers adjusted odds ratios for seven confounders. Briefly explain and discuss the justification for controlling each confounder in the analysis (3 marks). Note: You may need to search on PubMed to find the associations between these variables.   Answer: The confounder factors in the document are smoking, education, country of birth, maternal age, year of delivery, height and parity. Therefore, to control smoking, pregnant mothers should be advised effectively and made known on the effect of smoking. This can be done through public awareness. Moreover, pregnant mothers should be taught on the necessary information to ensure safe pregnancy periods and after delivery in order to take care of the born child. There has been an increase in child mortality rates due to lack of information. These would include information on diet, healthy surrounding and the materials to use. The cohort height is related to the nutrition value and thus the health care should make sure that the mothers should take nutrients related to growth. The country of birth should have necessary equipment and professional health personnel for effect delivery process and after delivery advice and services to the mothers. The government and the society should ensure that there are no underage pregnancies due to immaturity issues. The health practitioners should create awareness of the period before having on another business.  
Although the researchers adjusted the odds ratios for parity, birth spacing was not included in the adjusted model. Briefly discuss whether you think the researchers should have adjusted the odds ratios for inter-pregnancy interval(s) (2 marks). Note: You may need to search on PubMed to find the associations between birth spacing and both the exposure variable and the outcome variable.   Answer: I think the researchers should have adjusted the odds for inter-pregnancy interval since it is a causative factor affecting infant mortality rate. The intervals between births are important for life or death of the infants. This is important since most of the people don’t have the right information about the factor. Therefore, because of the risks and lack of information, the researchers should have adjusted the odds for clarity and to avoid the level of bias.  
In many European countries, mothers continue to smoke during pregnancy. Briefly discuss how smoking habits were measured in this study and the validity of these estimates (2 marks)   Answer: The study was conducted based on estimation techniques. The estimation of smoking habits was done by comparing these habits with people who don’t smoke. These estimates were proven to be valid when the results came to show that mortality rates of infants are higher in maternal smoking. There was a correlation between the mortality rates and the maternal smoking. Moreover, out of 100 mothers who were smoking about 90 of the mothers lost their children.  
Discuss whether you think the strength of the association between maternal overweight/obesity and infant mortality may have been affected by information bias related to the exposure variable (3 marks)   Answer: Yes, I think there might be some information that is biased, since being overweight/obese can be also accompanied by other diseases that might affect the infant health leading to death. An example of such diseases is maternal diabetes which can cause congenital heart defects, polycythemia and neural tube defects, which can be fatal and not very related to being overweight/obese.  
Review Table 1 and briefly discuss why you think the rates of infant, neonatal and post neonatal mortality declined from 1992-1996, 1997-2000, 2001-2005, 2006-2010 (3 marks)   Answer: There existed a decline due to the health focus based on research and proper screening methods. Moreover, the decline might be attributable to increased awareness about many unhealthy lifestyle practices (e.g. Smoking, being overweight/obese, etc.), especially in the development of social media, television and other news sources. This decline might also be highly attributable to the development of health care centers and facilities.  
Study authors report that the population attributable fraction (PAF) related to maternal overweight/obesity was 11% and 7% for smoking. Interpret and discuss the public health significance of the reported PAF (3 marks).   Answer: Approximately 458 of infant deaths are attributed to overweight/obesity whereas 333 deaths are attributed to smoking within the population sample; this should direct our attention towards controlling this risk factor and taking strict actions – like quitting smoking while pregnant. This should be able to create awareness for the females especially the pregnant want to eat healthy to avoid being obese. Therefore, taking care of the two factors that is smoking and obesity will control the rate of death.
The authors report that the study findings may have been influenced by residual confounding. Define the term residual confounding and discuss the potential role of residual confounding in the context of this study (2 marks)   Answer: Residual confounding: Measuring a confounding variable with some errors and the adjustment using that imperfect measure does not remove the effect of the variable.it is used to determine whether the cofounders are related, in order to investigate the level of biasness. The unrelated cofounder is an indication of an exposure error.
One method to minimize potential residual confounding is to use a within-siblings study (or sibship) design or sibling control analysis. Briefly discuss how sibling control analysis can be used to decrease potential residual confounding in observational epidemiological studies (2 marks). Note: your answer does not need to be related to the context of this study; rather, observational epidemiological studies in general.   Answer: The sibling control analysis is able to provide a more valid relative risk estimates and being carried at low cost. It is able to provide information on parental characteristics which is part of the residual social confounding. The analysis is able to determine the relationship between the cofounding in check to the availability of bias and any other risk related to the experiment. Therefore, through sibling control analysis acts as a control factor.    
Briefly discuss the public health implications of the study findings for female UAE Nationals (or other female GCC nationals) (2 marks). Consider the public health interventions during preconception planning and the periconception period, the first antenatal appointment, and throughout pregnancy.   Answer:   During the preconception planning, the female UAE nationals should ensure that they have the information about the height factor and inter pregnancy periods. The females should have information about the diet and other health issues such as obesity and the BMI before and during the pregnancy periods. A smoking mother should stop smoking since it is one of the factors the study has shown to cause an increase in child mortality rate. The female parents should have a general knowledge on taking care of the child.        
Briefly discuss the challenges and opportunities for conducting this study in the UAE (or another GCC country of your choice; 3 marks). Consider the sources of data and linkage b etween registries/databases required for the exposure variable, outcome variable, and confounding variables.   Answer:   Collecting data in UAE will be a challenge since the people are always very secretive. Therefore, the researcher would likely find some information while others would be irrelevant due to lack of connectivity between the factors under the study. For example sibling study analysis would not take place. However, the availability of large population with information on maternal BMI and other factors like age, height.  

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