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Two denominators for one numerator: the example of neonatal mortality

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Abstract

Preterm delivery is one of the strongest predictors of neonatal mortality. A given exposure may increase neonatal mortality directly, or indirectly by increasing the risk of preterm birth. Efforts to assess these direct and indirect effects are complicated by the fact that neonatal mortality arises from two distinct denominators (i.e. two risk sets). One risk set comprises fetuses, susceptible to intrauterine pathologies (such as malformations or infection), which can result in neonatal death. The other risk set comprises live births, who (unlike fetuses) are susceptible to problems of immaturity and complications of delivery. In practice, fetal and neonatal sources of neonatal mortality cannot be separated—not only because of incomplete information, but because risks from both sources can act on the same newborn. We use simulations to assess the repercussions of this structural problem. We first construct a scenario in which fetal and neonatal factors contribute separately to neonatal mortality. We introduce an exposure that increases risk of preterm birth (and thus neonatal mortality) without affecting the two baseline sets of neonatal mortality risk. We then calculate the apparent gestational-age-specific mortality for exposed and unexposed newborns, using as the denominator either fetuses or live births at a given gestational age. If conditioning on gestational age successfully blocked the mediating effect of preterm delivery, then exposure would have no effect on gestational-age-specific risk. Instead, we find apparent exposure effects with either denominator. Except for prediction, neither denominator provides a meaningful way to define gestational-age-specific neonatal mortality.

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Acknowledgements

The authors gratefully acknowledge the comments on earlier drafts by Dr. Donna Baird, Dr. David Umbach, and anonymous reviewers.

Funding

This research has been supported in part by the Intramural Research Program of the National Institute of Environmental Health Sciences, National Institutes of Health.

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Authors and Affiliations

  1. National Institute of Environmental Health Sciences, P.O. Box 12233, Durham, NC, 27709, USA

    Quaker E. Harmon & Allen J. Wilcox

  2. Department of Obstetrics and Gynecology, McGill University, Montreal, QC, Canada

    Olga Basso

  3. Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, QC, Canada

    Olga Basso

  4. Biostatistics and Computational Biology Branch, National Institute of Environmental Health Sciences, Durham, NC, USA

    Clarice R. Weinberg

Authors
  1. Quaker E. Harmon
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  2. Olga Basso
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  3. Clarice R. Weinberg
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  4. Allen J. Wilcox
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Correspondence to Quaker E. Harmon.

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Harmon, Q.E., Basso, O., Weinberg, C.R. et al. Two denominators for one numerator: the example of neonatal mortality. Eur J Epidemiol 33, 523–530 (2018). https://doi.org/10.1007/s10654-018-0373-0

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  • DOI: https://doi.org/10.1007/s10654-018-0373-0

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