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Cited by 123Advanced Causal Inference TechniquesMaternal and fetal healthcarePregnancy and preeclampsia studies

Placental abruption and perinatal mortality with preterm delivery as a mediator: disentangling direct and indirect effects

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Ananth, Cande V., VanderWeele, Tyler J.·2011·American Journal of Epidemiology
DOI 10.1093/aje/kwr045PMC PMC3159429
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Abstract

The authors use recent methodology in causal inference to disentangle the direct and indirect effects that operate through a mediator in an exposure-response association paradigm. They demonstrate how total effects can be partitioned into direct and indirect effects even when the exposure and mediator interact. The impact of bias due to unmeasured confounding on the exposure-response association is assessed through a series of sensitivity analyses. These methods are applied to a problem in perinatal epidemiology to examine the extent to which the effect of abruption on perinatal mortality is mediated through preterm delivery. Data on over 26 million US singleton births (1995-2002) were utilized. Risks of mortality among abruption and nonabruption births were 102.7 and 6.2 per 1,000 births, respectively. Risk ratios of the natural direct and indirect (preterm delivery-mediated) effects of abruption on mortality were 10.18 (95% confidence interval: 9.80, 10.58) and 1.35 (95% confidence interval: 1.33, 1.38), respectively. The proportion of increased mortality risk mediated through preterm delivery was 28.1%, with even higher proportions associated with deliveries at earlier gestational ages. Sensitivity analyses underscore that the qualitative conclusions of some mediated effects and substantial direct effects are reasonably robust to unmeasured confounding of a fairly considerable magnitude.

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  • Perinatal morbidity and mortality associated with preterm abruption is impacted by gestational age at delivery, which is a mediating variable on the causal pathway between abruption and adverse perinatal outcomes.

    “This is because much of the perinatal morbidity and mortality associated with preterm abruption is impacted by gestational age at delivery, which is a mediating variable that features on the causal pathway between abruption and adverse perinatal outcomes (3).”

    From Placental abruption at near-term and term gestations: Pathophysiology, epidemiology, diagnosis, and management (2023) · cites this paper as [3]

    The Case Study in Perinatal Epidemiology section places preterm delivery on the causal pathway between abruption and mortality, and the Mediation Analysis section estimates that it mediates some perinatal deaths. The paper does not establish the claim about perinatal morbidity. Its Discussion also says early delivery is not the primary mediator of the overall abruption–mortality association, qualifying the suggestion that it accounts for much of that association. (LLM, conf=0.87)

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Authors
Ananth, C. V., & VanderWeele, T. J.
Affiliations
  • Rutgers, The State University of New Jersey (US)
  • University of Medicine and Dentistry of New Jersey (US)
Corresponding author
Ananth, Cande V.
ORCID
Venue
American Journal of Epidemiology
Publisher
Oxford University Press (OUP)
Published
2011-03-23
Volume
174
Issue
1
Pages
99-108
ISSN
  • 0002-9262 (ISSN-L)
  • 1476-6256
DOI
10.1093/aje/kwr045
PMC
PMC3159429
OpenAlex
W2137942010
Cited by
123
References
47
Citations by year
2026: 7 · 2025: 6 · 2024: 14 · 2023: 3 · 2022: 13 · 2021: 9 · 2020: 7 · 2019: 5 · 2018: 9 · 2017: 12 · 2016: 7 · 2015: 9 · 2014: 10 · 2013: 5 · 2012: 5
FWCI
6.15
Type
journal article
Language
en
Open access
Locations
  • American Journal of Epidemiology (publishedVersion)
  • PubMed Central (publishedVersion)
  • PubMed (publishedVersion)
Funders
  • National Institutes of Health
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (R03HD060696, HD060696)
Topics
  • Physical Sciences › Mathematics › Statistics and Probability › Advanced Causal Inference Techniques
  • Health Sciences › Medicine › Pediatrics, Perinatology and Child Health › Maternal and fetal healthcare
  • Health Sciences › Medicine › Obstetrics and Gynecology › Pregnancy and preeclampsia studies
Keywords
placental abruption, perinatal mortality, preterm birth, mediation analysis, natural direct and indirect effects, unmeasured confounding, sensitivity analysis, gestational age, singleton births
MeSH terms
Abruptio Placentae, Adult, Female, Gestational Age, Humans, Infant, Newborn, Mathematical Computing, Pregnancy, Retrospective Studies, Risk Factors, United States, Survival Rate, Confidence Intervals, Odds Ratio, Risk Assessment, Premature Birth, Perinatal Mortality

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