SCI核心期刊發表dissertation-汶川地震影響產生的結果分析-英文期刊dissertation發表范文

The Impact of the Wenchuan Earthquake on Birth Outcomes

1 Institute of Basic Medicine, Chengdu University of Traditional Chinese Medicine, Chengdu, China, 2 Shaanxi University of Chinese Medicine, Xi’An, China
Abstract
Background: Earthquakes and other catastrophic events frequently occurring worldwide can be considered as outliers and cause a growing and urgent need to improve our understanding of the negative effects imposed by such disasters.
Earthquakes can intensively impact the birth outcomes upon psychological and morphological development of the unbornchildren, albeit detailed characteristics remain obscure.
Methods and Findings: We utilized the birth records at Du Jiang Yan and Peng Zhou counties to investigate the birthoutcomes as a consequence of a major earthquake occurred in Wenchuan, China on May 12, 2008. Totally 13,003 ofneonates were recorded, with 6638 and 6365 for pre- and post- earthquake, respectively. Significant low birthweight, high
ratio of low birthweight, and low Apgar scores of post-earthquake group were observed. In contrast, the sex ratio at birth,birth length and length of gestation did not show statistical differences. The overall ratio of birth-defect in the postearthquake
(1.18%) is statistically high than that of pre-earthquake (0.99%), especially for those in the first trimester onearthquake day (1.47%). The birth-defect spectrum was dramatically altered after earthquake, with the markedly increasedoccurrences of ear malformations. The ratio of preterm birth post-earthquake (7.41%) is significant increased than that of
pre-earthquake (5.63%). For the birth outcomes of twins, significant differences of the ratio of twins, birth weight, ratio oflow birthweight and birth-defect rate were observed after earthquake.
Conclusion: A hospital-based study of birth outcomes impacted by the Wenchuan earthquake shows that the earthquake
was associated with significant effects on birth outcomes, indicating it is a major monitor for long-term pregnant outcomes.
Citation: Tan CE, Li HJ, Zhang XG, Zhang H, Han PY, et al. (2009) The Impact of the Wenchuan Earthquake on Birth Outcomes. PLoS ONE 4(12): e8200.
doi:10.1371/journal.pone.0008200
Editor: Qamaruddin Nizami, Aga Khan University, Pakistan
Received August 30, 2009; Accepted November 11, 2009; Published December 7, 2009
Copyright:
2009 Tan et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted
use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This work is supported by National Science Funds of China (NO.30873316, and NO.90709053)(http://www.nsfc.gov.cn/). The funders had no role in
study design, data collection and analysis, decision to publish, or preparation of the manuscript.#p#分頁標題#e#
Competing Interests: The authors have declared that no competing interests exist.
* E-mail: [email protected] (WJD); [email protected] (MQW)
SCI核心期刊發表dissertation-汶川地震影響產生的結果分析-英文期刊dissertation發表范文Introduction
On May 12, 2008, a catastrophic earthquake measuring 8.0 on
the Richter scale hit Wenchuan, in southwestern China, leading to
69,227 deaths and 374,643 injuries, with 17,923 listed as missing
[1]. This devastating earthquake struck the eastern edge of the
Tibetan plateau, collapsing buildings and killing thousands in
major cities aligned along the western Sichuan basin in China [2].
It destroyed around 70% of houses and at least 85% of local
public buildings, and shook the whole nation [1–3]. Consequently,
Du Jiang Yan, Peng Zhou and other counties surrounding the
earthquake center, Wenchuan, were simultaneously trapped.
More than 40 million citizens were impacted, including about
270,000 pregnant women and 12 million women of child-bearing
age [4].
Major earthquakes and other catastrophic events can be
considered as outliers and result from mechanisms involving
amplifying critical cascades [5]. Unfortunately, societies are
subjected to various disasters, ranging from natural catastrophes,
such as volcanic eruptions, hurricanes and tornadoes, landslides,
avalanches, to the failure of engineering structures, social
unrest, national and global economic downturns, regional power
blackouts, diseases and epidemics, etc [2–5]. Hence, there is a
growing and urgent need to grasp the intermittent dynamics of
disasters in order to improve our understanding of the negative
effects imposed by such occurrences.
Birth outcomes could be intensively impacted by all kinds of
environmental calamities. The effects of a major earthquake can
significantly impact the psychological and intellectual development
of fetus [6]. Saadat [7] reported that a severe earthquake in Iran
decreased the sex ratio at birth 6–12 months later as a result of
psychological tensions and stress associated with the earthquake.
Catalano et al.[8] pointed out that the Sept. 11, 2001 terrorist
attack in New York City reduced conception of males and
increased fetal deaths among males. Chang and colleagues [9]
observed much high proportions of minor psychiatric morbidity
(29.2%) and low birth weight neonates (7.8%) in a group of
women who were pregnant during or immediately after a major
earthquake. Based on the established rule that reproductive health
is primary to societal growth and evolution, analysis of the effects
of natural or man-made disasters upon pregnancies is a subject
worthy of investigation.
PLoS ONE | www.plosone.org 1 December 2009 | Volume 4 | Issue 12 | e8200
In this study, we evaluated the birth outcomes before and after the
Wenchuan earthquake. Here we report profound effects of the#p#分頁標題#e#
earthquake upon birth-defect, birth weight and sex ratio at birth and
other primary characteristics. Our data suggest that rare catastrophic
events are often a major monitor for long-term reproductive
health and pregnant outcome in the affected population.
Methods
Objectives
This work was conducted according to the principles expressed
in the Declaration of Helsinki, and approved by the Ethics
Board, Chengdu University of Traditional Chinese Medicine. We
employed exactly two year’s data of birth redords. Those collected
from May 12, 2007 through May 11, 2008 were put into a preearthquake
group, while samples collected from May 12, 2008
through May 11, 2009 were included as a post-earthquake group.
All participants signed informed consent before investigation. All
parents or guardians of the neonates gave informed consent to
publication of their case details in a style of anonymity. We began
the observation on July 25, 2008. Of those delieved after July 25,
2008, their parents consented at the time of their usual hospital
care during the birth. While for those born on July 25, 2008 or
before, the informed consents were signed within the homes of
their parents or guardians prior to the utilization of their medical
records. Although some birth records were retrospectively
collected, there has no substantive discrepancy on the collected
data, because they are all objective and quantitive data recoded in
the medical records of all neonates [7–9].
Two representative areas, Du Jiang Yan and Peng Zhou
counties, were chosen for the research. Both of them are located
less than 20 kilometers from the earthquake center, Yin Xiu Town
in Wenchuan County, and were severely damaged. Samples were
collected from every local hospital.
Data Process
Every case of parturition occurring in the observed counties
during survey period was included in the analysis. Major data for
pregnant outcome, including age of pregnant women, birth length,
birth weight and length of pregnancy, were evaluated by two
independent researcher groups. Data criteria were as follows:
(1.). Low-birth weight neonates: defined as birth weight ,
or = 2500 gram.
(2.). Preterm infants: defined as length of gestation ,or =
36 weeks.
(3.). Birth defects: referred to concepts defined in gynecological
textbooks. As the first trimester is a key period for organ
formation, we further classified these into three groups, e.g.
first trimester pregnancy on earthquake day, second and third
trimester pregnancy on earthquake day, and post-earthquake
pregnancy.
(4.). Apgar score: a standard evaluation for neonates, performed
within one minute or five minutes after birth [6,9]. We
employed 1-Min and 5-Min Apgar scores in the study. This#p#分頁標題#e#
appraisal system includes five physical signs: skin color, heart
beat, breath, muscle tension/movement, and reflexes. The
healthy neonates are scored as 8–10 points; for slight distress,
4–7 points; while for severe distress, ,4 points.
Statistical Methods
All data were analyzed using SPSS version 15.0 (SPSS Inc.,
Chicago, IL). We generated descriptive statistics and bivariate
associations for all variables and examined them for distributional
normality. Numbers fit to normal distribution were analyzed by
two-tailed t test and/or chi 2 test. For data that did not meet the
distributional normality, a Mann-Whitney U test was applied. The
significant differences were defined as P value less than 0.05.
Results
A total of 13,003 of neonates were recorded in the local
hospitals of Du Jiang Yan and Peng Zhou, two counties severely
devastated by the Wenchuan earthquake. For general maternal
index, no significant differences were observed between preearquake
group and post-earthquake group (Table 1). The preand
post- earthquake neonates were 6,638 and 6,365, respectively
(Table 2). Which indicate that there was a 4.29% birthrate
decrease after the earthquake. The ratio of preterm birth postearthquake
(7.41%) is significant increased than that of preearthquake
(5.63%). We also observed statistical lower birthweight
and Apgar scores, higher ratio of low birth weight and the rate of
premature births, of the post-earthquake group compared to those
of the pre-earthquake group. In contrast, no significant differences
were observed in the sex ratio at birth, birth length, length of
gestation, or general characteristics of pregnant women (Table 2).
During our survey periods, 141 infants with birth-defect were
observed. Compared with healthy neonates (as listed in Table 2),
the average birth weight of infants with birth-defects decreased but
did not reach statistical significance; yet the ratio of low
birthweight neonates with defects was statistically significant
(Table 3). For birth-defect infants, the male ratio at birth was
quite higher than that of healthy ones, especially those in the postearthquake
group. Results of Apgar scoring of birth-defect infants
in both pre- and post- earthquake groups were markedly lower
than that of healthy controls, with an even lower score observed in
the post-earthquake group.
The overall ratio of birth-defect in the post-earthquake group
was 1.18%, statistically higher than that of the pre-earthquake
group (0.99%). Importantly, neonates delivered from Dec. 12,
2008 through Feb. 11, 2009, who were in the first trimester on the
day of the earthquake, demonstrated a much higher ratio of birth-
Table 1. General characteristics of maternity participating in
the study.
Category#p#分頁標題#e#
Pre-earthquake
group
Post-earthquake
group p-Value
Age (years), Mean6SD 24.2964.15 24.9664.99 .0.05
Weight (kg), Mean6SD 50.8765.50 51.0563.99 .0.05
Spontaneous birth (%) 70.86 73.67 .0.05
Education level (%)
Primary school or less 32.62 31.19 .0.05
Junior middle school 35.36 37.55 .0.05
High school 24.70 24.25 .0.05
College or higher 7.32 6.71 .0.05
Multipara (%) 25.72 26.73 .0.05
Primipara (%) 74.28 73.21 .0.05
No statistic differences were observed between pre- and post- earthquake
group. The p-Values were obtained by t test or X2 test. All data were collected
at the delivery day. The significant differences were defined as P value less than
0.05.
doi:10.1371/journal.pone.0008200.t001
1).
(2).
3).
4).
Earthquake and Birth Outcomes
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defects than either pre-earthquake group or other post-earthquake
groups (Table 4).
We further subdivided the categories of birth defects (Table 5).
The results showed that cleft lip/palate, polydactylia, microtia/
anotia were the most frequent occurring birth defects in our survey
region. However, birth defects related to ears in the postearthquake
group were dramatically increased when compared
with the pre-earthquake group. Of particular interest was the
observation that in the patients who were in their first trimester on
the day of the earthquake, more than half of their birth defects
involved the ears.
Table 6 shows that significant differences of four indices, i.e. the
ratio of twins, birth weight, ratio of low birthweight and ratio of
birth-defects, were observed in twins delivered before and after the
earthquake. Which indicate in a unique aspect the significant
impact of the earthquake upon the basic index of birth outcome.
Although no statistical differences were observed in two indices
(gestational time and birth length), there was a trend to differences
when compared with single births.
Discussion
The Wenchuan earthquake was one of the most serious natural
disasters in Chinese history. More than 250,000 square kilometers
of Chinese land was ruined, 89,150 persons were killed or reported
as missing [1–3]. A sustained occurrence of more than 20,000
aftershocks have been ceaselessly stressing local earthquake
refugees, about 125,000 families are still live in temporary houses
due to remaining earthquake debris. Although the earthquake was
occurred in an under-populated area, about 27,000 neonates have
been born in the affected regions [4].
It is established that antenatal stress is associated with various
adverse birth outcomes in humans and other animals [10].
Therefore, the effect of natural disasters such as the Wenchuan#p#分頁標題#e#
earthquake on pregnant women is important and worthy of
analysis. Although several publications have documented maternal
vulnerability in earthquakes, few studies have completely examined
the effects of earthquake on pregnant women and their
neonatal outcomes [11]. Several prior studies suggest that prenatal
stress caused by disasters may result in low birth weight [9],
preterm delivery [12], skewed sex ratios [8,13], and retardation of
Table 2. Birth outcomes of neonates delived pre- and post-
Wenchuan earthquake.
Category
Pre-earthquake
group
Post-earthquake
group p-Value
NO. of overall births 6638 6365 .0.05
Gestation length (wks),
Mean6SD
39.7162.28 39.0662.41 .0.05
Birthweight (g), Mean6SD 3417.826473.90 3251.376491.88 0.05
Ratio of low birthweight (%) 3.72 5.01 ,0.01
Ratio of preterm delivery (%) 5.63 7.41 ,0.01
Birth length (cm), Mean6SD 49.9261.14 48.9761.15 .0.05
Ratio of male infants (%) 51.85 51.02 .0.05
1-Min Apgar score, Mean6SD 9.0861.75 8.3061.29 ,0.01
5-Min Apgar score, Mean6SD 9.4261.06 8.9561.42 ,0.05
doi:10.1371/journal.pone.0008200.t002
Table 3. Records of birth-defect neonates delived pre- and
post- Wenchuan earthquake.
Category
Pre-earthquake
group
Post-earthquake
group p-Value
Birth-defect neonates, N (%) 66 (0.99) 75 (1.18) ,0.05
Materal age (years);
Mean6SD
26.0263.21 25.7963.35 .0.05
Length of gestation (wks);
mean6SD
39.1462.55 38.9264.58 .0.05
Birth weight (g); Mean6SD 3214.516500.57 3299.216395.43 .0.05
Ratio of low birthweight
neonates (%)
8.52 10.78 ,0.01
Birth length (cm); Mean6SD 49.2162.97 49.4263.59 .0.05
Ratio of male infants (%) 59.67 68.83 ,0.01
1-Min Apgar score; Mean6SD 8.2561.69 7.4661.04 ,0.05
5-Min Apgar score; Mean6SD 8.9262.06 8.4261.33 ,0.05
doi:10.1371/journal.pone.0008200.t003
Table 4. Birth defects recorded around the Wenchuan
earthquake.
Gestation period on
earthquake day survey period
Total
infants, N
Birth-defect
infants, N (%)
Pre-earthquake 2007.05.12–2008.05.11 6638 66 (0.98)
1st trimester 2008.12.12–2009.02.11 1155 17 (1.47) **$$
2nd,3rd trimester 2008.05.12–2008.12.11 3886 44 (1.13) *
Post-earthquake 2009.02.12–2009.05.11 1324 14 (1.06)
Compared with pre-earthquake group: *P,0.05, **P,0.01;
Compared with other post-earthquake groups: $$P,0.01.
doi:10.1371/journal.pone.0008200.t004
Table 5. Top five birth defects occurred pre- and post-
Wenchuan earthquake.
Group
Name of
birth-defect
Frequency;
N(%)
Occurrence per
10,000 births
Pre-earthquake Cleft lip/ palate 17 (26.69) 26.7
polydactylia 10(14.97) 15.0
Microtia/notia 9(13.57) 13.6#p#分頁標題#e#
ankylodactylia 5(7.84) 7.8
Equinovarus 4(6.02) 6.0
Post-earthquake Microtia/notia 10(15.71) 15.7
Cleft lip/ palate 7(10.99) 11.0
polydactylia 6(9.43) 9.4
Equinovarus 6(9.43) 9.4
undescended testis 4(6.35) 6.4
1st trimester on
earthquake day
Microtia/ anotia 7(41.18) 60.6
other auris deformity 3(17.65) 25.9
polydactylia 2(11.76) 17.3
Limb shortening 2(11.76) 17.3
/ / /
doi:10.1371/journal.pone.0008200.t005
Earthquake and Birth Outcomes
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fetal brain development [10,14]. Therefore, in this study we
investigate the relationship between a major earthquake and birth
outcomes, in order to further understand the pathobiological
processes of such disasters, and define the types of support for
pregnant women that should be provided in order to increase the
likelihood of a normal pregnancy.
The most notable result of the present study was the significantly
high ratio of birth-defects connected with the Wenchuan
earthquake. There is little data regarding our observation that has
been previously reported in the medical literature. Montenegro et
al. [15] found that earthquake-induced stress significantly
increased the rate of facial clefts. Castilla and Orioli [16] suggested
that both psychological stress and the air pollution from the dust
and gases emitted during the earthquake induced adverse birth
outcomes. Our data indicates that the Wenchuan earthquake
markedly increased the birth-defect rate, with 11.78 per 1,000
births in contrast to 9.94 per 1,000 births in previous years.
Interestingly, neonates who were in the first trimester on the day
of the earthquake displayed a statistically significantly higher birthdefect
ratio when compared with other post-earthquake groups.
Consistent with this observation is that several reports have shown
that pregnancy is more susceptible to stress effects in the first
trimester than during the second and third trimesters [5,6,17]. The
first trimester is the period for the beginning of morphogenesis and
the most biologically vulnerable stage for the effects of diverse
environmental factors. Accordingly, it is one of the key periods for
birth-defect as well. Constant air pollution and water pollution
resulting from the earthquake itself, and thousands of aftershocks
with the associated stress caused by these events, might be
important determining factors that contribute to the abnormal
high ratio of birth-defect about the first trimester fetus and their
development in post-earthquake niches. It has been hypothesized
that as pregnancy advances, women become increasingly resistant
to the adverse effects of stress, and so early stress would have more
profound effects than later stress [14,18]. Our results strongly#p#分頁標題#e#
suggest that first trimester is the most sensitive period that would
be affected by the prolonged negative environmental factors
resulting from the earthquake.
Another unexpected finding is the apparently changed spectrum
of birth defects seen associated with the Wenchuan earthquake
(Table 5). The average incidence of microtia and anotia in China
was 1.40 per 10,000 during 1989–1992 [19]. However, the
incidences of microtia/anotia were 15.7 and 60.6, for overall postearthquake
and first trimester group, respectively (Table 5). Ear
malformations were significantly increased after Wenchuan
earthquake, especially for those of first trimester on the day of
the earthquake. In comparison, the ratio of cleft lip and/or palate
didn’t statistically increased in post-earthquake neonates, in
contrast to other studies [14,20]. These patterns of birth defects
following the Wenchuan earthquake are not easily explained, and
points to the need for more data on the role of environmental
stress and fetal development.
A main finding in this study is that the average post-earthquake
birthweight was statistically decreased. Lower birth weight is
usually associated with increased fetal mortality, neonatal
mortality, infant mortality and increased susceptibility to stress
in adulthood [14]. Our results indicate that both the average birth
weight and the low birthweight rate were significantly altered in
the post earthquake group as compared to the pre-earthquake
group (Table 2). Additionally, the statistically significant increased
preterm delivery rate after the earthquake is interrelated with the
abnormally high ratio of low birthweight neonates (Table 2). The
etiology of both low birth weight and preterm delivery is complex
and no single factor explains most of the variance in the rates of
these birth outcomes. Instead, many biological, behavioral and
social factors may impact these outcomes. Notwithstanding, this
data can offer some medical practitioners important information
regarding the type of care necessary for pregnant women
immediately after a natural or man-made disaster.
It is worth noting that the ratio of low birthweight (5.01%)
observed after the Wenchuan earthquake is lower than that of
previously reported, such as that recorded after the Taiwan major
earthquake (7.8%) [9]. Even if the factors influencing low
birthweight are not well understood, this decrease in vulnerability
may imply increasing protection of the mother and fetus from
additional adverse influences after the Wenchuan earthquake [14].
Furthermore, additional birth outcomes, such as birth length and
length of gestation, were not statistical different before and after
the Wenchuan earthquake further suggesting that favorable care
of pregnant women did ameliorate at least some aspects of the#p#分頁標題#e#
birth outcomes.
We do not observe the skewed sex ratio at birth within the
survey period. Several publications reported that the human
secondary sex ratio falls in populations subjected to exogenous
stressors such as earthquakes or political and social upheavals
[7,8,13]. Explanations of the association include reduced conception
of males and increased fetal deaths among males [7,8].
Simultaneously, a reduction in fertility was also observed in these
reports. We investigated the shrinkage of fertility after the
Wenchuan earthquake, taking into consideration a possible
change of the female population of reproductive age. However,
we did not observe any marked declination of sex ratio at birth
after the Wenchuan earthquake. Fukuda et al. [13] found a sex
ratio decline appeared in about 280 days following the earthquake,
thus indicating the need for a long term analysis of the
consequences of the Wenchaun earthquake.
The birth outcomes of twins suffering from prenatal disaster,
Wenchuan earthquake, is of interest. Our results indicate that
earthquake could increase the ratio of twins, and extensively
impair the birth outcomes (Table 6). Furthermore, the overall
results indicate that twins were more vulnerable to adverse
environmental factors during fetus development than that of single
births. Quite few reports have considered the impacts of natural
disasters upon the outcomes of twins. Some prior studies employed
twins as useful subjects to probe the effects of disasters on fetal
development, but had not considered the birth outcomes [17,18].
Bornstein et al. [12] reviewed that twin gestation is associated with
a high risk for different subtypes of preterm birth; yet they ignored
the impact of earthquake upon the birth outcomes of twins.
Wadhawan et al. [11] found that twin gestation in extremely low
Table 6. Twins born pre- and post- Wenchuan earthquake.
Category
Pre-earthquake
group
Post-earthquake
group p-Value
NO. of twins 35 46 ,0.05
Ratio of twins (%) 5.27 7.23 ,0.01
Gestation weeks, Mean6SD 38.4561.02 36.7462.72 .0.05
Birth length (cm), Mean6SD 47.1262.01 46.3863.33 .0.05
Birth weight (g), Mean6SD 2591.456225.72 2412.766295.43 ,0.05
Ratio of low-birth
weight neonates (%)
42.65 55.65 ,0.01
Ratio of birth-defect
twins (%)
3.01 9.43 ,0.01
doi:10.1371/journal.pone.0008200.t006
Earthquake and Birth Outcomes
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birthweight infants is associated with an independent increased
risk of death or neurodevelopment impairment compared with
single-gestation infants. However, they overlooked the adverse
influences from disasters such as earthquakes. Thus our study
provides evidence that further research focused upon twins who#p#分頁標題#e#
have experienced prenatal disasters may be warranted.
There are a number of limitations to the present study. First, the
sampling area is only the minor portion of the devastated region of
the Wenchuan earthquake, so it might not fully represent the
overall conditions. Second, the relatively small sample size of twins
and birth defects may have led to inadequate statistical power and
warrants caution in interpretation of the data. Last, we did not
include a few pregnancies inside the survey area who subsequently
moved outside the earthquake area, as data on these cases were
generally unavailable. Regardless our data provide new and
relevant information on the consequences of a natural disaster on
birth outcomes.
Acknowledgments
We are indebted to all the respondents for their participation in the survey.We would also like to thank the many nurses and physicians who made this
study possible. We also thank Dr. Howard Young in NIH/NCI, US, forthe language revision.
Author Contributions
Conceived and designed the experiments: WJD MQW. Performed theexperiments: CET HJL XGZ HZ PYh. Analyzed the data: CET HJL QA
WJD MQW.
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Earthquake and Birth Outcomes
PLoS ONE | www.plosone.org 5 December 2009 | Volume 4 | Issue 12 | e8200