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Complications of Anesthesia for Cesarean

Delivery
Steven L. Bloom, MD, Catherine Y. Spong, MD, Steven J. Weiner, MS, Mark B. Landon, MD,
Dwight J. Rouse, MD, Michael W. Varner, MD, Atef H. Moawad, MD, Steve N. Caritis, MD,
Margaret Harper, MD, Ronald J. Wapner, MD, Yoram Sorokin, MD, Menachem Miodovnik, MD,
Mary J. OSullivan, MD, Baha Sibai, MD, Oded Langer, MD, and Steven G. Gabbe, MD,
for the National Institute of Child Health and Human Development MaternalFetal
Medicine Units Network*
Objective: To quantify anesthesia-related complications
associated with cesarean delivery in a well-described,
prospectively ascertained cohort from multiple universitybased hospitals in the United States and to evaluate
whether certain factors would identify women at increased
risk for a failed regional anesthetic.
Methods: A prospective observational study was conducted of women (n 37,142) with singleton gestations
undergoing cesarean delivery in the centers forming the
National Institute of Child Health and Human Development MaternalFetal Medicine Units Network. Detailed
information was collected regarding choice of anesthesia
and procedure-related complications, including failed regional anesthetic and maternal death. Potential risk factors
for a failed regional anesthetic were analyzed.
Results: Of the women studied, 34,615 (93%) received a
regional anesthetic. Few (3.0%) regional procedures failed,
and related maternal morbidity was rare. Increased maternal size, higher preoperative risk, rapid decision-to-incision
* For a list of other members of the National Institute of Child Health and Human
Development MaternalFetal Medicine Units Network, see the Appendix.
From the Department of Obstetrics and Gynecology, University of Texas
Southwestern Medical Center, Dallas, Texas.
Supported by grants (HD34116, HD27915, HD27869, HD34208,
HD34136, HD27917, HD21410, HD27860, HD34122, HD27905,
HD21414, HD27861, HD34210, HD36801) from the National Institute of
Child Health and Human Development.
Presented at the 24th Annual Meeting of the Society for MaternalFetal
Medicine, February 6, 2004, New Orleans, Louisiana.
Corresponding author: Steven L. Bloom, MD, Department of Obstetrics and
Gynecology, University of Texas Southwestern Medical Center, 5323 Harry Hines
Boulevard, Dallas, TX 75390-9032; e-mail: steven.bloom@utsouthwestern.edu.
2005 by The American College of Obstetricians and Gynecologists. Published by
Lippincott Williams & Wilkins.
ISSN: 0029-7844/05

VOL. 106, NO. 2, AUGUST 2005

interval, and placement later in labor were all significantly


related to an increased risk of a failed regional procedure.
Of the general anesthetics, 38% were administered when
the decision-to-incision interval was less than 15 minutes.
Women deemed at the greatest preoperative risk (American
Society of Anesthesiologists score 4) were approximately
7-fold more likely to receive a general anesthetic (odds ratio
6.9, 95% confidence interval 5.83 8.07). There was one
maternal death, due to a failed intubation, in which the
anesthetic procedure was directly implicated.
Conclusion: Regional techniques have become the preferred method of anesthesia for cesarean delivery. Procedure-related complications are rare and attest to the safety
of modern obstetric anesthesia for cesarean delivery in the
United States.
(Obstet Gynecol 2005;106:2817)

Level of Evidence: II-2

n 2002, the rate of cesarean delivery in the United


states was 26.1%, the highest ever recorded.1 According to the most recent National Hospital Discharge Survey, this rate corresponded to more than 1
million women being delivered by cesarean, making
it the most prevalent major nondiagnostic operation
performed in the United States in 2002.2 With contemporaneous concerns about the safety of vaginal
birth after cesarean, the relationship between child
birth and pelvic floor injury, and a burgeoning desire
of women to be able to choose to deliver by elective
cesarean, it is quite likely that the rate of cesarean
birth will increase even further.35 As obstetricians
weigh the risks and benefits of vaginal compared with
cesarean delivery in such increasing numbers, one of
the factors most often requiring consideration is the
OBSTETRICS & GYNECOLOGY

281

safety of anesthesia for cesarean delivery. Given the


ascendancy of cesarean surgery, what is actually
known about related anesthetic maternal mortality
and morbidity?
In 1987, the Centers for Disease Control and
Prevention established an ongoing National Pregnancy Mortality Surveillance System to monitor maternal deaths at the national level and to conduct
epidemiological studies of the deaths of pregnant
women. When these vital statistics data were recently
reviewed, the information regarding anesthesia-related morbidity and mortality was judged to be very
limited.6 Reasons for this limitation included incomplete ascertainment of the number of deaths as well as
incomplete information on anesthetic procedures and
no information on anesthesia-related morbidity. Our
purpose was to rigorously profile anesthesia-related
maternal mortality and morbidity associated with
cesarean delivery using a well-described cohort prospectively ascertained from multiple collaborating
centers in the United States. In addition, we sought to
evaluate whether certain risk factors would identify
women at increased risk for a failed regional anesthetic.

MATERIALS AND METHODS


The Maternal-Fetal Medicine Units Network was
established in 1986 by the National Institute of Child
Health and Human Development (NICHD) to study
clinical questions in obstetrics. Every 5 years university-based clinical centers compete to join the MaternalFetal Medicine Units Network, which at the time
of this study comprised 13 institutions and a datacoordinating center. These centers conduct research
under a cooperative agreement with one another and
the NICHD. Each center and the data-coordinating
center received institutional review board approval
for this study.
The cesarean registry was a prospective observational study conducted between 1999 and 2002 and
designed to assess several specific contemporary issues related to cesarean delivery. For the first 2 years,
data were collected on all women undergoing cesarean delivery or attempted vaginal birth after a prior
cesarean at a participating center. During 2001 and
2002, data were collected only on repeat cesarean
deliveries and attempted vaginal births after prior
cesarean. That is, data on primary cesarean deliveries
were not collected during the last 2 years. For the
purposes of this analysis, only data collected during
the first 2 years were included, thereby permitting
complete ascertainment of all cesarean births performed within the MaternalFetal Medicine Units
Network during a 2-year time span.
Detailed information regarding medical and obstetric history, intrapartum course, postpartum com282

Bloom et al

plications diagnosed before hospital discharge, and


infant outcome were abstracted directly from maternal and infant charts by specially trained and certified
research nurses. For the purpose of this specific
analysis, information was collected regarding choice
of anesthetic as well as procedure-related complications. Other variables collected included body mass
index (BMI), calculated using the formula weight (kg)
divided by height (m2), and emergency cesarean
delivery, defined as those operations with skin incision timed within 15 minutes of the first decision
recorded to operate.
American Society of Anesthesiologists (ASA)
scores assigned by obstetric anesthesia providers during preoperative assessments of each patient were also
recorded.7 Healthy parturients usually incur a minimum score of 1 or 2, using a 15 scale. As the score
increases, the preoperative condition of the patient is
considered more guarded. Specifically, a score of 1
denotes no increased risk, 2 implies mild-to-moderate
preoperative risk, 3 equates to severe preoperative
risk, and 4 represents the presence of a life-threatening illness with or without surgery. A score of 5 is
reserved for the moribund patient who has little
chance of survival but who is submitted to surgery as
a last resort.
Data from the 13 centers were transmitted weekly
by telecommunications link to the data coordinating
center, where they were edited for missing, out of range,
and inconsistent values. Edit reports were then transmitted to each center for correction or clarification.
Anesthetic procedures used for cesarean delivery
were grouped into spinal (subarachnoid block), epidural, combined spinal-epidural, or general, based
upon the first anesthetic administered. Women given
a general anesthetic because the initial regional procedure was inadequate were categorized as failed
regional anesthetics. Shown in Table 1 are the anesthetic complications ascertained in this study and
their corresponding definitions.
The charts of all maternal deaths were reviewed
in detail to determine whether the death was related
to the anesthetic procedure. The initial review was
conducted by the principal investigator at each site,
followed by a central review conducted by 3 members of the protocol subcommittee.
The study sample size was calculated based on
the primary goal of the cesarean registry, which was
to study uterine rupture following trial of labor.3 For
the purpose of that analysis, an estimated 12,000
women with prior cesareans undergoing a trial of
labor were required. The study was terminated after 4
years when the sample size for the uterine rupture
analysis was sufficient.
Chi-square and Fisher exact tests were used to

Anesthesia Complications for Cesarean Birth

OBSTETRICS & GYNECOLOGY

Table 1. Definitions of Anesthesia-Related Complications


Complication
High spinal
Failed intubation
Failed regional anesthesia
Spinal headache or blood patch
Chemical meningitis
Epidural hematoma
Extradural abscess

Definition
Respiratory suppression requiring intubation
Inability to place an endotracheal tube
Epidural or spinal attempted but general anesthesia required
Severe positional headache following delivery and/or instillation of blood into the
epidural space for relief of headache
Meningitis, not viral or bacterial, following regional anesthesia
Collection of blood beneath epidural site causing back pain and neurological dysfunction
An abscess outside the dura mater

compare the rates among women receiving different


types of anesthesia. Means were compared with Student t tests. Odds ratios and 95% confidence intervals
for newborn infant outcomes were calculated by using
logistic regression models, with adjustment for cesarean indication, gestational age at delivery, and a
binary indicator for emergency cesarean delivery.
Confidence limits for rates of anesthetic complications are exact limits for the binomial proportions.
Confidence limits for maternal mortality are based on
a Poisson distribution. All P values reflect 2-tailed
statistical analyses. Unless otherwise noted, all statistics are unadjusted for other factors.

RESULTS
Of the 70,442 women entered into the cesarean
registry, 47,112 delivered within the first 2 years. Of
these, a total of 9,970 were excluded from this analysis, including 7,829 with prior cesareans who delivered vaginally, 2,073 with multiple fetuses, and 68
with incomplete anesthesia records. The remaining
37,142 women included 21,809 (59%) who underwent
a primary cesarean delivery, 12,576 (34%) who underwent a repeat cesarean delivery, and 2,757 (7%)
who had an unsuccessful attempt at a vaginal birth
after a prior cesarean.
Over 93% of the women studied received a
regional anesthetic. Specifically, 14,797 (40%) women
received a spinal as the first anesthetic attempted;
15,443 (42%) women received an epidural as the first
anesthetic attempted; and 4,375 (12%) women received a combined spinal-epidural as the first anesthetic attempted. The remaining 2,527 (7%) women
received a primary general anesthetic. Shown in
Table 2 are the demographic characteristics for the
37,142 women analyzed in this study.
The distribution of cesarean deliveries according
to indication and type of anesthesia initially attempted
is shown in Table 3. Subarachnoid block (spinal) was
the most commonly used method in women undergoing a repeat cesarean, whereas epidural was the
most commonly used method in women undergoing
a primary cesarean delivery. General anesthesia was
VOL. 106, NO. 2, AUGUST 2005

Table 2. Demographic Characteristics


Characteristic
Maternal age (y)
Mean ( SD)
Range
Race
White
Black
Hispanic
Other or unknown
Nulliparous
Education, years completed*
Mean ( SD)
Range
Prenatal medical care

Overall Cohort
(n 37,142)
27.8 (6.4)
1151
14,670 (39.5)
11,316 (30.5)
9,222 (24.8)
1,934 (5.2)
15,120 (40.9)
12.1 (2.8)
016
36,169 (97.4)

SD, standard deviation.


Data are expressed as n (%) unless otherwise indicated.
* Years of education are truncated at 16.

commonly used when the need for delivery was most


urgent. Indeed, 900 (38%) of the general anesthetics
administered were in emergency cesareans in which
the decision-to-incision interval was less than 15
minutes. Maternal preoperative status, as reflected by
ASA score, was also related to choice of anesthesia.
For example, women deemed at the greatest preoperative risk (ASA score 4 or more) were approximately 7-fold more likely to receive a general anesthetic (odds ratio 6.9, 95% confidence interval [CI]
5.83 8.07). Women with preeclampsia, however,
were more likely to receive regional analgesia than a
general anesthetic (90% versus 10%), as were women
with eclampsia (70% versus 30%, overall P .001).
Infant outcomes according to type of anesthesia
for cesarean delivery are shown in Table 4. In this
analysis, each anesthetic subgroup was compared
with the remainder of the entire cohort. For example,
the odds ratio of various outcomes for infants in the
general anesthesia group were in relation to the
infants in all other subgroups combined. Odds ratios
were adjusted for indication for cesarean, gestational
age at delivery, and emergency cesarean. Newborn
infant condition at birth, as reflected in low Apgar

Bloom et al

Anesthesia Complications for Cesarean Birth

283

Table 3. Type of Initial Anesthetic Procedure According to Indication for Cesarean


Delivery, Preoperative ASA Score, and Decision-to-Incision Time Less Than 15
Minutes

Characteristic
Primary cesarean
Total
Dystocia
Fetal distress
Malpresentation
Other
Repeat cesarean
Total
No labor
Labor
Failed VBAC
Emergency cesarean*
Decision-to-incision
time 15 min
ASA Score
1 or 2
3
4
5
Pregnancy hypertension
None
Preeclampsia
Eclampsia

Spinal
(n 14,797)

Epidural
(n 15,443)

Combined
Spinal-Epidural
(n 4,375)

6,537
848 (13)
1,148 (18)
2,708 (41)
1,833 (28)

11,401
6,591 (58)
2,764 (24)
968 (8.5)
1,078 (9.5)

1,964
777 (40)
384 (20)
374 (19)
429 (22)

1,907
51 (2.7)
908 (48)
276 (14)
672 (35)

8,260
6,157 (75)
1,497 (18)
606 (7.3)

4,042
1,787 (44)
478 (12)
1,777 (44)

2,411
1,733 (72)
461 (19)
217 (9.0)

620
295 (48)
168 (27)
157 (25)

241 (1.9)

922 (6.2)

100 (2.4)

900 (38)

12,754 (88)
1,646 (11)
33 (0.2)
0

12,802 (86)
2,093 (14)
64 (0.4)
0

3,696 (86)
599 (14)
7 (0.2)
0

1,648 (67)
710 (29)
85 (3.5)
0

13,028 (88)
1,748 (12)
21 (0.1)

12,775 (83)
2,634 (17)
33 (0.2)

3,734 (85)
631 (14)
10 (0.2)

1,947 (77)
552 (22)
27 (1.1)

General
(n 2,527)

ASA, American Society of Anesthesiologists; VBAC, vaginal birth after cesarean.


Data are expressed as n (%).
* Data are missing for 7% of patients.

Includes women diagnosed either with preeclampsia, gestational hypertension, or hemolysis, elevated liver
enzymes, low platelets (HELLP) syndrome.

Table 4. Odds Ratio of Selected Newborn Infant Outcomes According to Type of Anesthesia Compared
With the Remainder of the Cohort
Type of Anesthesia

Characteristic
Apgar score
3 at 1 min
3 at 5 min
Umbilical artery
blood pH 7.0*
Neonatal death

Spinal
(n 14,471)

Epidural
(n 14,753)

Combined
Spinal-Epidural
(n 4,293)

General
(n 2,485)

General for
Failed Regional
(n 1,043)

0.52 (0.460.58)
0.52 (0.390.69)

0.89 (0.800.99)
0.57 (0.420.77)

0.70 (0.590.84)
1.01 (0.651.55)

2.86 (2.523.25)
2.68 (2.033.53)

2.46 (2.032.97)
2.69 (1.764.10)

0.49 (0.370.65)
1.13 (0.901.41)

0.84 (0.651.08)
0.71 (0.530.93)

1.08 (0.691.68)
0.96 (0.641.44)

2.71 (2.063.56)
1.17 (0.901.52)

1.15 (0.721.82)
1.19 (0.672.09)

Excluded are 3 cases without birth data and 94 stillbirths. Data are expressed as odds ratio (95% confidence interval). Odds ratios are
adjusted for cesarean delivery indication, birth gestational age, and emergency cesarean.
* Data are missing for 57% of patients.

scores and umbilical artery blood pH, was related to


the type of anesthesia for cesarean delivery. Although
these measures were about twice as common with
general anesthesia compared with regional techniques, there was no difference in the rate of neonatal
death associated with general anesthesia. Of note,
infant outcomes for those women who required general anesthesia for a failed regional procedure were
284

Bloom et al

not worse than for those women who received a


primary general anesthetic.
As shown in Table 5, maternal morbidity attributable to regional anesthesia was rare. The most
common complication was a failed regional procedure requiring general anesthesia, which occurred in
1,053 (3.0%) of the 34,615 women who received a
regional anesthetic. Epidural anesthetics failed signif-

Anesthesia Complications for Cesarean Birth

OBSTETRICS & GYNECOLOGY

Table 5. Anesthetic Complications According to the Method of Regional


Anesthesia First Attempted

Complication
Failed regional
Spinal headache
Blood patch
High spinal
Extradural abscess
Chemical meningitis
Epidural hematoma

Spinal
(n 14,797)
313 (2.1, 1.92.4)
73 (0.5, 0.40.6)
27 (0.2, 0.10.3)
9 (0.06, 0.030.12)
0
0
0

Epidural
(n 15,443)
666 (4.3, 4.04.6)
41 (0.3, 0.20.4)
32 (0.2, 0.10.3)
11 (0.07, 0.040.13)
0
0
0

Combined
Spinal-Epidural
(n 4,375)
74 (1.7, 1.32.1)
21 (0.5, 0.30.7)
18 (0.4, 0.20.7)
3 (0.07, 0.010.20)
0
0
0

Data are expressed as n (%, exact 95% confidence interval).

icantly more than spinal or combined spinal-epidural


procedures (4.3% versus 2.1% or 1.7%, P .001,
respectively). The overall incidence of postdural
puncture (spinal) headache was 0.4%, and 57% of
these women were treated with a blood patch. Of the
62 women who developed a postdural puncture headache following an epidural or a combined spinalepidural procedure, 50 (81%) received a blood patch.
Other more serious morbidities were exceedingly
rare and did not differ based upon the type of regional
anesthetic administered. Selected characteristics of
women who suffered a failed regional anesthetic are
shown in Table 6. Increased maternal BMI, higher
preoperative ASA score, rapid decision-to-incision
interval, and placement later in labor were all significantly related to an increased risk of a failed regional
anesthetic.
Of the 29 maternal deaths in the cohort, one was
attributed directly to the anesthetic procedure. This
death occurred in a woman with a skeletal dysplasia,
which precluded regional anesthesia, and class F diabe-

tes. The patient suffered a cardiac arrest due to hypoxia


following a failed attempt at awake intubation.

DISCUSSION
We performed a large study of anesthetic use and
complications in more than 37,000 women undergoing cesarean delivery from 13 university-based hospitals in the United States. Our results indicate that
regional techniques are clearly the most common
method of anesthesia, accounting for 93% of the
procedures performed. Few (3.0%) of the regional
procedures failed, and these were more likely to be
associated with increased maternal size, higher preoperative risk, rapid decision-to-incision interval, and
placement later in labor. Maternal mortality and
serious morbiditysuch as high spinal, meningitis,
and central nervous system hematomawere rare,
and this attests to the safety of modern obstetrical
anesthesia for cesarean delivery.
During the last 2 decades, there has been an
increasing impetus to avoid general anesthesia in

Table 6. Characteristics of Women Who had a Failed Regional Anesthetic

Characteristic
Body mass index at delivery (kg/m2)
Mean ( SD)
29
ASA Category
1 or 2
3
4
Decision-to-incision time 15 min
Cervical dilatation when regional placed (cm)*
03
49
10

Successful Regional
(n 33,562)

Failed Regional
Requiring General
Anesthesia
(n 1,053)

33.0 7.2
21,715 (68)

33.7 7.8
697 (71)

28,412 (87)
4,172 (13)
97 (0.3)
1,090 (3.5)

840 (83)
166 (16)
7 (0.7)
173 (17)

10,143 (51)
9,392 (47)
510 (2.5)

306 (40)
432 (57)
21 (2.8)

P
.004
.06
.001

.001
.001

SD, standard deviation; ASA, American Society of Anesthesiologists.


Data are expressed as n (%) unless otherwise indicated.
* Data are missing for 40% of patients.

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285

women undergoing cesarean delivery because of the


increased incidence of failed endotracheal intubation
in pregnant women compared with nongravid patients.8 This led to a shift toward regional anesthesia,
such that by 1992, 89% of all cesareans performed in
hospitals with at least 1,500 birthsas was the case for
all of the centers that participated in the cesarean
registrywere estimated to have been performed with
regional techniques, compared with 62% in 1981.9
Our results suggest that this shift to regional anesthetics has continued. With such a significant change in
practice, it was reassuring to find that the rate of
anesthesia-related complications was low.
Given the heightened concerns about endotracheal intubation in pregnant women, it is noteworthy
that the one maternal mortality attributable to anesthesia in our study was a result of a failed intubation.
The first national study of anesthesia-related maternal
mortality in the United States was for the period
1979 1990.8 The 19851990 maternal case fatality
rate for regional anesthesia in women undergoing
cesarean delivery reported in this national study was
0.19 per 100,000, compared with 3.2 per 100,000 in
women undergoing cesarean with a general anesthetic. These maternal death rates were based upon
estimates using linked maternal-infant death certificates and extrapolations based upon the prevailing
rates of cesarean delivery. It must be emphasized,
however, that pregnancy-related deaths are underreported, and the true number of deaths related to
pregnancy might increase 30 150% with improved
ascertainment.10 The maternal mortality rates in our
study attributable to regional and general anesthetics
for cesarean delivery were 0 (95% CI 0 11) and 28
(95% CI 0.7156) per 100,000, respectively. It should
be emphasized that these rates were calculated from a
completely ascertained cohort and strengthened by a
prospective review of patient records, both features
not possible in the first national study.11 Of note, the
rates measured in the earlier national study do fall
within the 95% confidence intervals that we found. To
put these mortality rates into some perspective, the
rates of death in the United States due to accidental
drowning and motor vehicle accidents in 1998 were
1.5 and 15.2 per 100,000, respectively.12
It is important to note that there are several
potential limitations to extrapolating the complication
rates observed in our study to the general population.
First, we did not collect data on the qualifications of
the individuals who actually administered the anesthetic. That is, the provider could have been a faculty
anesthesiologist, a resident or fellow in training, or a
certified nurse anesthetist. Second, the precise cause
of failed regionals was not recorded. Third, because of
the referral nature of the participating centers, it is
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Bloom et al

possible that the women included in this study were at


an increased risk of complication. Alternatively, it is
possible that receiving care at well-equipped tertiary
facilities favored a lower chance of an anestheticrelated complication. In spite of these limitations, we
are of the view that the findings of our study provide
the most accurate and comprehensive information
currently available on the outcomes of anesthesia for
cesarean delivery. This is buttressed by the fact that
we were able to achieve complete ascertainment of all
women delivering by cesarean during the study time
period. Moreover, all charts were reviewed by a
dedicated team of research nurses who received specialized training for this study, and all data collected
were subjected to a highly regimented process designed to reduce error.
Our purpose was not to determine the ideal
anesthetic for cesarean delivery, but instead, to describe contemporary anesthetic practices and their
attendant complications. We avoided making judgments about the effects of various anesthetic methods
on maternal or infant outcomes. We thought this
prudent because of the multiple interacting and confounding variables that enter into the decision to
administer a specific anesthetic in a specific situation.
Indeed, we noted remarkable integration of obstetric
and anesthetic care practices in our review of the data.
For example, general anesthetics were chosen for
those cesareans in which the fetus was judged to need
very rapid delivery. Similarly, preoperative maternal
characteristics, as reflected in the ASA score, suggest
that obstetric, pediatric, and anesthetic concerns are
all considered and inevitably intertwined in the
choice of anesthesia.
Commenting in the 12th edition of Williams
Obstetrics13 on a report from the Chicago Lying-In
Hospital14 that described 48 anesthetic fatalities
among 242 cesarean-related maternal deaths in 1952,
Nicholson Eastman and Louis Hellman wrote that
anesthesia indeed is becoming a greater hazard than
the operation itself. Now, a half-century later, the
story has dramatically changed.
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APPENDIX
Other members of the MaternalFetal Medicine Units
Network include:
1. University of Texas Southwestern Medical Center:

VOL. 106, NO. 2, AUGUST 2005

2.

15.

K. J. Leveno, S. Sharma (Department of Anesthesiology), J. McCampbell, D. Bradford.


The Ohio State University: J. Iams, F. Johnson, S.
Meadows, H. Walker.
University of Alabama at Birmingham: J. Hauth, A.
Northen, S. Tate.
University of Utah: M. Belfort, F. Porter, B. Oshiro, K.
Anderson, A. Guzman.
Thomas Jefferson University: A. Sciscione, M. DiVito,
M. Talucci, M. Pollock.
Wayne State University: M. Dombrowski, G. Norman,
A. Millinder, C. Sudz, B. Steffy.
University of Pittsburgh and Magee Womens Hospital: K. Lain, M. Cotroneo, D. Fischer, M. Luce.
Wake Forest University: P. Meis, M. Swain, C. Moorefield, K. Lanier, L. Steele.
University of Miami: G. Burkett, J. Gilles, J. Potter, F.
Doyle, S. Chandler.
University of Cincinnati: T. Siddiqi, H. How, N. Elder.
University of Tennessee: W. Mabie, R. Ramsey.
University of Chicago: J. Hibbard, P. Jones, M. RamosBrinson, M. Moran, D. Scott.
University of Texas Health Science Center at San
Antonio: D. Conway, S. Barker, M. Rodriguez.
George Washington University Biostatistics Center: E.
Thom, S. Leindecker, H. Juliussen-Stevenson, M. Fischer.
National Institute of Child Health and Human Development: D. McNellis, K. Howell, S. Pagliaro.

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