text:
Are socioeconomic inequalities in the incidence of small-for-gestational-age birth narrowing? Findings from a population-based cohort in the South of England
Sam Wilding1,
http://orcid.org/0000-0002-8964-5029Nida Ziauddeen1,
Paul Roderick1,
Dianna Smith2,
Debbie Chase3,
Nick Macklon4,5,
Nuala McGrath1,6,
Mark Hanson7,8,
http://orcid.org/0000-0002-4134-8463Nisreen A Alwan1,8
1 School of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
2 Geography & Environment, University of Southampton, Southampton, UK
3 Public Health, Southampton City Council, Southampton, UK
4 Department of Obstetrics and Gynaecology, University of Copenhagen, Roskilde, Denmark
5 London Women's Clinic, London, UK
6 School of Economic, Social and Political Science, Faculty of Social Sciences, University of Southampton, Southampton, UK
7 Institute of Developmental Sciences, Academic Unit of Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
8 NIHR Southampton Biomedical Research Centre, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
Correspondence to Dr Nisreen A Alwan; N.A.Alwan{at}soton.ac.uk
Objectives To investigate socioeconomic inequalities, using maternal educational attainment, maternal and partner employment status, and lone motherhood indicators, in the risk of small-for-gestational-age (SGA) births, their time trend, potential mediation by maternal smoking and body mass index, and effect modification by parity.
Design Population-based birth cohort using routine antenatal healthcare data.
Setting Babies born at University Hospital Southampton, UK, between 2004 and 2016.
Participants 65 909 singleton live births born to mothers aged ≥18 years between 24-week and 42-week gestation.
Main outcome measures SGA (birth weight <10th percentile for others born at the same number of completed weeks compared with 2013/2014 within England and Wales).
Results Babies born to mothers educated up to secondary school level (adjusted OR (aOR) 1.32, 99% CI 1.19 to 1.47), who were unemployed (aOR 1.27, 99% CI 1.16 to 1.38) or with unemployed partners (aOR 1.27, 99% CI 1.13 to 1.43), were at greater risk of being SGA. There was no statistically significant change in the magnitude of this risk difference by these indicators over time between 2004 and 2016, as estimated by linear interactions with year of birth. Babies born to lone mothers were not at higher risk compared with partnered mothers after adjusting for maternal smoking (aOR 1.05, 99% CI 0.93 to 1.20). The inverse association between maternal educational attainment and SGA risk appeared greater in multiparous (aOR 1.40, 99% CI 1.10 to 1.77) compared with primiparous women (aOR 1.28, 99% CI 1.12 to 1.47), and the reverse was true for maternal and partner's unemployment where the association was stronger in primiparous women.
Conclusions Socioeconomic inequalities in SGA risk by educational attainment and employment status are not narrowing over time, with differences in association strength by parity. The greater SGA risk in lone mothers was potentially explained by maternal smoking. Preventive interventions should target socially disadvantaged women, including preconception and postpartum smoking cessation to reduce SGA risk.
social medicine
small for gestational age
socioeconomic inequalities
This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
http://dx.doi.org/10.1136/bmjopen-2018-026998
Strengths and limitations of this study
This study uses a relatively large sample of population-level antenatal care data to examine the risk of small-for-gestational-age births by socioeconomic factors.
Standard routinely collected measures recorded at the first antenatal appointment are utilised which can be used for risk prediction in practice without the need to collect extra data during antenatal appointments.
Limitations include the transferability of results from this population to others with differing characteristics, that socioeconomic factors were only assessed at one time point in pregnancy, and self-reporting of educational qualifications and employment.
Babies born small for gestational age (SGA) are at higher risk of neonatal morbidity, mortality1 and childhood obesity potentially through compensatory early growth.2 3 Numerous clinical and lifestyle risk factors are associated with the risk of being SGA, including maternal height, weight, diet, ethnicity, parity, smoking, pre-eclampsia and hypertension.4 5 Closely linked to these risk factors there is extensive evidence of socioeconomic status (SES) inequalities, with more SGA babies born to mothers living in the most deprived communities compared with those in the most affluent.6
Several proxies of SES are present in the literature, with area measures of wealth, maternal education, employment and income being the most common indicators, while paternal factors being notably absent.7 Disadvantaged SES groups (in terms of education and income) typically experience greater rates of SGA births.8 9 The majority of studies rely on one proxy of SES, but studies controlling for several SES measures find that different aspects of SES are independently associated with the risk of SGA.10–14
Despite the wealth of research on the association between parental SES and SGA, the underlying mechanisms are poorly understood.15 Current explanations focus on the availability of (physiological and material) resources and mediating factors that differ between women of high and low SES. For resources, the 'weathering' hypothesis states that women in low SES at the time of conception have experienced relatively high levels of cumulative disadvantage in terms of income, stress and diet, which have led to a deterioration in physiological health.16 This association may also be mediated by lifestyle factors, wherein mothers in low SES are more likely to be exposed to or partake in risk factors for SGA such as smoking. Mediation analyses have found that higher rates of underweight and smoking at conception among mothers with low educational attainment mediate the association between SES and birth outcomes in the UK.15 17
The extent of these SES inequalities in the risk of SGA may differ between first and higher order births. The birth of the first child brings significant physiological, wellbeing and social changes,18 and women in low SES may have weaker social support mechanisms to adjust to these changes, as they appear to be at higher risk of SGA in subsequent births after adjusting for clinical risk factors.19 Risk factors for SGA specific to second and higher order births are more prevalent in women of low SES, with postnatal depression being more common in mothers without a university degree and those in poverty.20 21
In England, public health policy aims to narrow SES inequalities in birth outcomes over time,22 23 and changes in the extent of inequalities in SGA have been noted in other European countries since the early 2000s.24 Major welfare reforms enacted in the UK between 1999 and 2002 increased in-work tax incentives, which particularly increased the net income of part-time working women, relative to those out of work.25 In 2008, the global 'great recession' occurred, after which single mothers in England became increasingly less likely to be employed, while facing disproportionate losses of welfare income, facing a double income penalty relative to working mothers.26 The recession appears to have had differential impacts on women by level of educational attainment, with those without a university degree experiencing a postrecession rise in the prevalence of obesity, relative to those with degrees.27
Utilising an antenatal healthcare database in Hampshire, England, we aimed to examine differences in SGA risk by SES indicators, investigate if these differences are mediated by maternal body mass index (BMI) and smoking, and whether the inequalities gap has narrowed over the 13 year study period (2004–2016). In addition, we aimed to stratify by parity in order to examine whether the SES gap in SGA risk is the same at first births, relative to second and higher order births.
This analysis is based on a population-based cohort including anonymised antenatal and birth records of women aged ≥18 years who had a live singleton birth between 1 January 2004 and 31 December 2016 at the University Hospital Southampton (UHS) National Health Service (NHS) Trust in the South of England. UHS is the primary centre for maternity care for the city of Southampton and the surrounding areas, and is the regional centre for high-risk pregnancies. The process of deriving a sample for analysis is outlined in online supplementary figure 1. To ensure that the findings are applicable to the majority of (non-high-risk) pregnancies, records with late first antenatal (booking) appointments (after 24-week gestation, as assessed by ultrasound) and of mothers under the age of 18 were excluded. First, we analysed the risk of SGA by SES in all births (including more than one birth per mother if in the database and study timeframe), adjusting for confounding and clustering. We then tested whether differences between SES groups (by maternal education, employment, paternal employment and partnership status) have changed over the study period (2004–2016). We then limited the analysis to the first recorded birth per mother in the dataset, and stratified by parity (primiparous and multiparous), to avoid biassing subanalyses via double counting.
[bmjopen-2018-026998supp001.docx]
Assessment of SES exposures
Socioeconomic measures were self-reported at the first antenatal (booking) appointment, which is recommended by the National Institute for Health and Care Excellence Antenatal Care Guidelines to occur by the 10th week of gestation.28 Mothers were asked to report their highest educational qualification, classified as university degree (highest level), college (A levels) or secondary school (General Certificate of Secondary Education), whether they were currently employed, and if their partners were currently employed (possible answers included employed, unemployed and seeking work or student, with the latter two being combined). Partnership status was self-reported at the same appointment. All four SES proxies were categorised to be compared with mothers with advantaged SES (mother has a university degree; mother is employed; mother's partner is employed; mother has a partner). Time trends in SES factors were examined, and presented in online supplementary figure 2.
Assessment of outcome
Birth weight was measured by healthcare professionals for all births in the dataset. Gestational age was based on a dating ultrasound scan performed by healthcare professionals, and was present for all records in the dataset. Birth weight centile for gestational age is calculated using reference values provided in the most recently released data (2013–2014) for England and Wales, which were validated using 2015 records.29 Given that the association between SES and preterm births is well established in the literature,30 and that gestational age is strongly associated with birth weight, we used a SGA measure to assess low birth weight rather than the standard birth weight cut-off.
The birth centile references are available for 24–42 completed weeks of gestation, so live births at ≤23 (71) or >42 (568) completed weeks or with indeterminate sex (16) are excluded from the analysis (SGA sample=65 909/66 564). In line with WHO guidelines, UK guidelines and common practice, SGA is defined as a birth weight lower than the 10th percentile compared with others born at the same number of weeks gestation in the sex-specific reference centiles,31–33 and all others are defined as not small for gestational age (non-SGA).
Assessment of confounder and mediator variables
Maternal age, height, parity, ethnicity and smoking history were self-reported at the booking antenatal appointment. Baby's sex was recorded at birth by a healthcare professional. Maternal weight and blood pressure were measured by a healthcare professional at the booking appointment, and screening for gestational diabetes was carried out for women identified as at high risk in the second trimester of pregnancy.28 Maternal age, ethnicity, gestational diabetes, gestational hypertension and systolic blood pressure at booking were adjusted for in the multivariable models, as these factors have been associated with size at birth in previous analyses.4 34 35 Parity (no versus one or more previous births) was treated as a confounder in the models analysing the whole sample, and then as an effect modifier for SES through interaction terms and later stratification. Maternal BMI and smoking history are included as potential mediators of the relationship between SES and risk of SGA, based on previous evidence.15 17 Maternal BMI was categorised as underweight (<18.5), normal (18.5–24.9), overweight/preobese (25.0–29.9) and obese (30+),36 and treated as a categorical variable in all analyses. Maternal smoking was reported as follows (never smoked, ex-smoker, <10 per day, 10–20 per day and 20+ per day), and also treated as a categorical variable in all analyses.
This analysis uses routinely collected antenatal data where patient identifiers were anonymised. No patients or members of the public were recruited or consulted by the research team.
All analyses were conducted using Stata V.15. Descriptive statistics and the unadjusted ORs between all variables and risk of SGA are presented in table 1. T-tests were used to test whether the mean of each continuous variable (maternal BMI, age and systolic blood pressure at booking) differed between those born SGA and non-SGA. Multivariable logistic regression models were used to estimate ORs, p values and respective 99% CI for SES differences in the risk of SGA independently after adjustment for control variables, after adjustment for other SES indicators, and then after controlling for mediators. A p value cut-off of 0.01 is used to test for statistical significance when reporting risk rather than the more conventional 0.05 cut-off in order to minimise the risk of type I error due to multiple testing, as adjusted models control for multiple SES indicators.37 Evidence of mediation is examined through assessing the attenuation of SES with SGA associations once known risk factors are controlled for, and the significance once each a priori mediator (first BMI, then smoking) is controlled for.38 In all logistic regressions, cases with missing data for variables within the model were dropped (complete case analysis).
Maternal/pregnancy characteristics by small-for-gestational-age (SGA) status (birth weight <10th percentile for gestational age) in the University Hospital Southampton (UHS) maternity population-based cohort (singleton live births 2004–2016, n=65 909)
In the first analysis, adjusted ORs (aORs) for the risk of a baby being born SGA are presented in model 1 (control variables include maternal age, parity, ethnicity, gestational diabetes, gestational hypertension and systolic blood pressure at booking) independently for maternal education, employment and partnership status, adjusting for clustering of births within the same mother. In model 2, all three of these SES proxies are controlled for, in addition to the control variables in model 1, before including the two mediators (maternal BMI and smoking) sequentially in models 3 and 4. Due to collinearity between maternal partnership status and partner's employment, the association for the latter is tested separately with the same structure.
In the second analysis, year and the interactions between year and SES indicator (slope) effects are included to model 4 for maternal education, employment, partner's employment and partnership status, to test whether SES inequalities in the risk of being born SGA are widening or narrowing over time during the study period. These slopes represent the change in relative odds of SGA for the socioeconomic group relative to the control group for each year in the dataset (2004–2016). ORs>1 indicate that this group became at higher risk of SGA births over time, relative to the control group.39 Further models were estimated including SES interactions between a dummy indicator for records pre-2008 (2004–2008) and post-2008 (2009–2016), to test whether SES inequalities in the risk of SGA changed in magnitude between the two periods.
In the third analysis, the sample is limited to the first birth for each mother (one birth per mother), and then stratified by parity (primiparous or multiparous). Limiting the sample to the first birth for each mother acts as a sensitivity analysis for the first analysis, ensuring that the results are not influenced by multiple births per mother. Interactions between SES and parity are estimated to test whether the association between SES and risk of SGA is modified by parity, and then parity-stratified modelling was conducted. A p value cut-off of 0.05 is used to test for interactions. As in the first analysis, adjusted SES ORs are presented for each subsample, then these ORs are adjusted for other SES indicators, before including mediators (maternal BMI and smoking).
There are 65 909 singleton live births within the dataset which can be categorised as SGA or non-SGA to 44 428 mothers. Of births, 71% were to women with no university degree, in employment (67.9%), have partners the time of booking (92.3%), who are in employment (90.4%), of white ethnicity (82.4%) and with normal (<140 mm Hg) systolic blood pressure (98.7%). Of these 65 909 births, 6360 (9.7%, 99% CI 9.4% to 9.9%) were born SGA (table 1).
Time trends in SES factors are displayed in online supplementary figure 1. Briefly, less than college (A levels) educational qualification, maternal unemployment and lone motherhood became less prevalent over time (39%, 34% and 9% in 2004 to 22%, 29% and 6% in 2016, respectively), while partner unemployment remained relatively stable.
The proportion of SGA births was higher than the average for births to mothers in all disadvantaged SES groups. This includes births to mothers with no university degree (college qualification: 9.0% born SGA, 99% CI 8.5 to 9.5, secondary school qualification: 11.9% born SGA, 99% CI 11.3 to 12.5), births to unemployed mothers (11.6% born SGA, 99% CI 11.1 to 12.2), births to mothers with unemployed partners (14.2% born SGA, 99% CI 13.0 to 15.4) and births to single mothers (12.4% born SGA, 99% CI 11.3 to 13.7). Other maternal factors associated with a higher than average rate of SGA include maternal BMI <18.5 kg/m2 (19.9% born SGA, 99% CI 17.6 to 22.3), maternal smoking at booking (16.8% born SGA, 99% CI 15.9 to 17.8) and Asian ethnicity (18.3% born SGA, 99% CI 16.8 to 19.8).
SES differences in SGA risk in the whole cohort
Estimates of the association between maternal SES indicators and risk of SGA are presented in table 2. The univariable associations between each SES indicator and the risk of SGA are presented in the unadjusted risk row, with all SES indicators being associated with SGA. The size of these effects increases in the first adjusted model (controlling for maternal age, ethnicity, parity, gestational diabetes, gestational hypertension and systolic blood pressure at booking), and attenuate once other SES indicators are controlled for (model 2). Accounting for maternal BMI class had limited impact on effect sizes (model 3). After including maternal smoking, all SES inequalities reduced in size (model 4), with the ORs for college qualification compared with university degree (OR 1.11, 99% CI 1.00 to 1.22) and lone motherhood compared with partnered status attenuating at the 99% level (OR 1.05, 99% CI 0.93 to 1.20). The full results for model 4 are presented in online supplementary table 1.
Risk of being born small for gestational age (birth weight <10th percentile for gestational age) by maternal socioeconomic indicator in the University Hospital Southampton maternity population-based cohort (singleton live births 2004–2016)
In unadjusted estimates presented in table 3, those born to mothers with unemployed partners at the antenatal booking appointment are 68% more likely to be born SGA (OR 1.68 99% CI 1.51 to 1.88) in comparison to those born to mothers with employed partners. This association slightly attenuates once maternal education and employment are controlled for (model 2). The association attenuates further once maternal BMI is controlled for (model 3) and remains similar once smoking is accounted for (model 4 OR 1.27, 99% CI 1.13 to 1.43). The full results for model 4 are presented in online supplementary table 2.
Risk of being born small for gestational age (birth weight <10th percentile for gestational age) by partner's employment status in the University Hospital Southampton maternity population-based cohort (singleton live births 2004–2016)
As a sensitivity analysis, we repeated the modelling for a subgroup of women who were resident in Southampton at the time of delivery to address the potential that the whole sample results may be biased by including potential high-risk referrals from other regions to this specialised maternity centre. The geographical residence data (lower super output areas) were retrieved from health visitor records, and linked to births in this cohort as part of a bigger research project using an anonymised linked mother–child dataset. Each child in England and Wales is followed up by health visitor teams for at least five key appointments which start at 28 weeks into pregnancy,40 so this subsample is unlikely to be affected by selection bias. From the sample of 64 535 births, 30 663 (47.5%) were resident in Southampton at this 28-week appointment. In a model that adjusts for all confounders, maternal BMI category and smoking, the CIs for the SES factors overlap in the Southampton-only sample, and those results presented in tables 2 and 3 (see online supplementary table 3 for full results), indicating largely similar risk estimates between the two samples.
Time trend in SES inequalities in the risk of SGA between 2004 and 2016
To test whether SES inequalities are narrowing or widening over time, interactions between year (continuous) and SES ('slope') were included to model 4 in tables 2 and 3, and expressed as ORs. A positive slope OR indicates that the disadvantaged SES group is becoming at greater risk of SGA relative to the advantaged group over calendar year, and vice versa for a negative effect.
Figure 1A–D displays the adjusted ORs for each SES indicator by year in the cohort (UHS), and the accompanying p value for the slope over calendar year. The slopes for maternal college and school qualifications (OR 1.00, 99% CI 0.97 to 1.02; OR 1.00, 99% CI 0.97 to 1.02), maternal employment (OR 1.01, 99% CI 0.98 to 1.03), lone motherhood (OR 1.00, 99% CI 0.97 to 1.03) and partner unemployment (OR 1.00, 99% CI 0.97 to 1.03) were not statistically significant. Models using a binary indicator for pre-2008 and post-2008 (2003–2008 and 2009–2016) showed no significant differences in the magnitude of SES inequalities (results not shown).
Risk of being born small for gestational age (SGA) (birth weight <10th percentile for gestational age) by parental socioeconomic status indicators in the University Hospital Southampton (UHS) maternity population-based cohort (singleton live births 2004–2016).
SES differences in SGA risk by maternal parity status
For this analysis, the sample was restricted to the first antenatal care record per mother included in our dataset with no missing information (20 748 records dropped, with a new total of 43 787). Interaction terms between each SES indicator and parity (accounting for control variables) were conducted using this sample showing a significant interaction between maternal employment status and SGA (p=0.010). We then stratified the sample by parity (n primiparous (0 previous live births)=28 171; n multiparous (1 or more previous live births)=15 616). The modelling strategy used in the first analysis is repeated on these subsamples to assess the risk estimates by parity.
The association between secondary school qualification versus university degree and the risk of SGA appeared less pronounced among primiparous (OR 1.28, 99% CI 1.12 to 1.47) than multiparous women (OR 1.40, 99% CI 1.10 to 1.77). Maternal unemployment (relative to mothers who were employed) was associated with higher risk of SGA in primiparous women (aOR 1.29, 99% CI 1.13 to 1.46) than among multiparous women (aOR 1.17, 99% CI 0.99 to 1.38). The associations between college qualification versus university degree, and lone motherhood versus partnered status, with SGA risk appeared to be mediated by smoking in all subsamples (table 4).
Risk of being born small for gestational age (birth weight <10th percentile for gestational age) by maternal socioeconomic indicator and stratified by parity in the University Hospital Southampton maternity population-based cohort (singleton live births 2004–2016, one live birth per mother)
Table 5 displays the results for partner's employment (total n mothers=41 841; 26 498 primiparous, 15 343 multiparous). The association between partner's employment and risk of SGA appeared to be mediated by maternal smoking among multiparous women (aOR 1.15, 99% CI 0.93 to 1.43), but not primiparous women (aOR 1.33, 99% CI 1.12 to 1.58). The estimates of SES differences in the risk of SGA were similar in the reduced sample (tables 4 and 5) and the whole sample (tables 2 and 3).
Risk of being born small for gestational age (birth weight <10th percentile for gestational age) by partner's employment and stratified by parity in the University Hospital Southampton maternity population-based cohort (singleton live births 2004–2016)
To summarise the above models, both maternal and partner's employment status appeared to be more strongly associated with SGA risk in primiparous than multiparous women, and the reverse is true for maternal educational attainment.
In this analysis of routine maternity healthcare data from a regional hospital in Southampton, UK, multivariable logistic regression was used to examine the relationship between SES indicators (education, employment and partnership) and SGA, and whether these relationships are stable over time and different by parity. Educational attainment and employment (of the mother and her partner) were independently associated with the risk of SGA, although differences between the association between single motherhood and SGA were attenuated by adjusting for smoking status. SES differences in the risk of SGA were stable over the study period (2004–2016). The strength of these SES differences varied between mothers at their first and higher order births. Maternal and partner unemployment were associated with a higher risk of SGA in mothers with no previous live births, with lower educational qualification being more strongly associated with SGA risk in mothers with previous live births.
Comparison with other studies
The evidence for SES inequalities by maternal educational attainment, employment and partner's employment in the risk of SGA is consistent with the literature, and the third analysis shows that these associations remain robust after limiting the sample to one record per mother. Within a systematic review of socioeconomic disparities in birth outcomes conducted in 2010,7 6 of the 9 (66%) studies of SGA and maternal education reported a significant association, in addition to single studies finding an association for maternal41 and paternal employment.42 Part of the complexity in the relationship between maternal SES and SGA results from many analyses using only one measure of SES, with maternal education15 43 and employment44 being the main indicators used. Factors related to the mother's partner are usually excluded, due to a lack of appropriate data or small sample sizes, despite the potential of these factors to influence pregnancy conditions and outcomes.45 Whether the mother has a partner or not is largely overlooked as a risk factor in this area, with the exception of Kleijer et al,46 who found that single mothers are at higher risk of SGA. The final estimates of SES inequalities in this study are adjusted for other SES indicators, suggesting that there are multiple pathways through which SES is linked to gestational growth.
Since the publication of Blumenshine et al's systematic review,7 there has been an increased focus on how SES differences in weight outcomes at birth and during early life may be mediated through maternal BMI and smoking. In a Dutch cohort, maternal smoking and height during pregnancy were reported to explain 75% of the difference in risk of SGA between mothers with low and high education.15 In an Australian cohort, maternal smoking and the BMI of both parents were reported to explain 83.5% of SES differences in their children's BMI Z-score at age 10–11 years.47 In the present analysis, accounting for maternal smoking reduced the magnitude of the SGA risk difference by SES from a 36% increase in risk to 20% among mothers without a university degree, and from a 42% to 27% increase in risk among unemployed mothers. Maternal smoking also explained the relatively high risk of SGA among single mothers. This attenuation corroborates previous research indicating that single mothers are more likely to smoke, and that this may be related to the level of stress that they report, relative to partnered mothers.48 Single mothers may be relying on smoking as a means of stress relief or management during pregnancy, and smoking cessation and support programmes may be effective in reducing inequalities in birth outcomes as a result.
To our knowledge, there has been no analysis of socioeconomic inequality time trends in SGA from the mid-2000s onwards in England. Inequalities in birth weight (adjusting for gestational age) were stable between 1961 and 2000 in a regional city-based study in North East England,30 and the same is found between 2004 and 2016 in this study. The stability of SES inequalities in SGA implies that further interventions and initiatives are required to narrow SES inequalities in SGA births.
Our hypothesis was that the extent of SES inequalities in the risk of SGA may differ by parity, as the birth of the first child is a period which brings about significant physiological, lifestyle and social changes, in addition to postpartum weight retention.18 An analysis of birth register data in Norway found that mothers who had several SGA births were characterised by low educational attainment and partners employed in low SES occupations.19 In the present analysis, the strength of the association between SES indicators and the risk of SGA varied between primiparous and multiparous women, with education inequalities being greater for multiparous women, and employment inequalities being greater for primiparous women. The explanation may be that more advantaged women are economically able to leave the workforce after their first birth when planning further pregnancies (thus attenuating the differences between those in and outside employment when having subsequent births), while educational differences in terms of health behaviours, health literacy and mental well-being are risk factors of having repeat or new SGA outcomes.49 This group may benefit from additional support following the birth of their first baby to promote mental and physical well-being, access appropriate services, enhance health literacy and facilitate healthy behaviours.
Strengths and limitations of the study
This study benefits from a large regionally representative sample over many years. The exposure measures are prospectively collected in the course of routine antenatal care. As data from the local hospital system are used, there is no selection bias which may arise from participation in a research cohort, and the sample is therefore representative of all those receiving care under this NHS site. The outcome (SGA) is derived from birth weight, which is objectively measured by a health professional at birth. The most recent birth centiles for England and Wales were used29 to reflect changes in birth weight since the 1990 birth centiles.50 The measures of SES used are also collected within the usual course of NHS care before birth, so the results may be used to inform risk stratification interventions at or following the booking appointment to curtail SGA births and other associated adverse health outcomes. The antenatal booking appointment is a critical point for intervention as health professionals see all mothers receiving care under the NHS. The results herein find that women who report low educational qualifications are unemployed, or their partner is unemployed at this stage are at higher risk of SGA delivery. These groups, as well as women with no partners and/or other social support at the time of the booking appointment, may then be referred for additional support to minimise the risk of an SGA birth and other adverse maternal and health outcomes. A limitation of our dataset is that such processes were not electronically recorded and hence not included in our analyses. In addition, as this research is based on a cohort, we cannot infer that SES has a causal effect on SGA risk.
Some potential risk factors were not adjusted for in this study due to inconsistency of data for those specific variables as captured routinely in antenatal care, including diet during pregnancy and alcohol intake. These factors may also mediate the effect of SES on SGA risk, wherein disadvantaged SES groups could be more likely to engage in risky health behaviours. Other important SES factors such as sector of employment and income have been related to SGA outcomes in previous research,9 but are also not routinely collected in antenatal practice. The same is true for other measures of deprivation level such as housing, transportation methods and access to healthcare and other facilities.
For the parity analysis, we did not account for the length of the interpregnancy interval which has been related to birth outcomes previously.51 52 It was not possible to control for this in our study due to a lack of data on this variable in the whole sample, because we have included the first pregnancy in the database per mother and some multiparous mothers would have given birth before the study period, or at other hospitals; hence, this information is lacking for them. In addition, this analysis did not account for characteristics of the residential environments mothers lived in during pregnancy. Systematic reviews indicate that social, built and air characteristics of the environment experienced during pregnancy are strongly associated with birth outcomes,6 53 and this will be addressed in a follow-up study on the associations between environmental characteristics and birth outcomes for the cohort.
As the data used in this study are limited to a hospital serving the city of Southampton and the surrounding region, the results may not apply to hospitals serving populations with differing characteristics. Southampton is a provincial urban city which is more deprived than the average Local Authority in England, although the surrounding area (Hampshire) is relatively affluent.54 Southampton has a similar ethnicity profile to the rest of England and Wales,55 but with a relatively large university student population, and women in Southampton are under-represented in managerial, administrative and professional occupations, relative to others in England.56 As a result, findings from this study may not be replicated using healthcare records in areas with predominantly rural populations, or areas with non-student and managerial populations.
The UHS is a regional maternity centre to which high-risk pregnancies may be referred leading to potential over-representation of them. We have addressed this through excluding pregnancies booking in the UHS system after 24-week gestation. Mothers attending later than this date may have been referred to UHS due to their pregnancy being identified as high risk. We have also conducted sensitivity analyses restricting the sample to those who were living in the city of Southampton at the time of birth, and there was no significant difference in effect sizes. The proportion of mothers in employment (64%) and with a university degree (28%) was similar in our cohort in comparison to Census figures for Southampton women aged 20–39 (69%) and 16–34 (29%), respectively, indicating that our sample is representative of the catchment area for the UHS.57 58
Implications for research and practice
The persistence of educational and employment inequalities in the risk of SGA found within this study justifies further interventions and initiatives in order to narrow SES inequalities in the risk of SGA, and subsequently their long-term adverse health impact. The antenatal booking appointment offers an opportune moment for risk stratification and signposting of additional support for women with low educational qualification, in unemployed households and low social support. Smoking appeared as a potential mediator for SES inequalities in this study, despite support in smoking cessation being offered in the course of NHS care.59 This suggests that further support is required for mothers of low SES, and preconception and interconception programmes may have the added benefit of reducing the extent of SES inequalities in SGA, in addition to overall SGA rates. For research, this study aligns with recent calls to incorporate paternal/partner influences in developmental health research,45 in that similar levels of SGA risk are found for maternal and partner unemployment. Research in this area should adopt a more family-centred approach in relation to offspring health outcomes, taking into account contributing exposures from others within the household structure (partners and siblings).
This study confirms that SES indicators, including educational attainment, employment status and single motherhood, are strongly and independently associated with the risk of SGA birth, and they are not narrowing over time. Maternal smoking appears to play a significant role in these inequalities, particularly for lone mothers. However, the associations between educational attainment and employment status with SGA risk remain strong even after accounting for maternal smoking and BMI. Inequalities in SGA risk by maternal educational attainment appear greater for multiparous compared with primiparous women, while the opposite is true by maternal and partner employment status. Further research is needed to identify critical windows of opportunity (preconception/pregnancy/interconception) and effective interventions in order to narrow these inequalities. Prevention programmes targeting socioeconomically disadvantaged women which incorporate smoking cessation and social support are vital to tackling health inequalities in SGA.
The authors thank Ravita Taheem (Senior Public Health Practitioner, Southampton City Council) for her input in the conception of this paper, David Cable (Electronic Patient Records Implementation and Service Manager) and Florina Borca (Senior Information Analyst for R&D, NIHR Southampton Biomedical Research Centre) at University Hospital Southampton NHS Foundation Trust for their support in extracting the data used in this study.
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Contributors NAA is the Principal Investigator of the project, and acts as the guarantor of this study. SW, NZ, PR, DS, DC, NM, MH and NAA contributed to study conception and design. NM provided input on the statistical analysis for this study. SW conducted the statistical analyses, and drafted the initial report. NZ checked the accuracy of the reported estimates from the statistical models. All authors contributed to the interpretation of data and revising the manuscript critically for important intellectual content. All authors read and approved the final manuscript.
Funding This research is supported by an Academy of Medical Sciences and Wellcome Trust grant to NAA [Grant no: HOP001\1060], and the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre. The research funders had no input on research design or manuscript drafting. MAH is supported by the British Heart Foundation and the National Institute for Health Research through the NIHR Southampton Biomedical Research Centre.
Competing interests NAA had financial support from the Academy of Medical Sciences/Wellcome Trust and the NIHR Southampton Biomedical Research Centre for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; NAA is a member of the National Institute for Health and Care Excellence Antenatal Care Guideline Committee; no other relationships or activities that could appear to have influenced the submitted work.
Ethics approval This study used anonymised antenatal record data supplied by University Hospital Southampton Trust. This analysis forms part of a research project reviewed and approved by the University of Southampton Faculty of Medicine Ethics Committee (ref 24433) and the National Health Service Health Research Authority (ref 242031).
Data sharing statement The authors' ethical approval from the Faculty of Medicine Ethics Committee, University of Southampton (Reference number 24433) restricts public sharing of the data used in this study. The data owner is University Hospital Southampton NHS Trust. Contact NAA to request data access beyond that included in the manuscript. Further ethical and research governance approval may be required.
© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ. This is an open access article distributed in accordance with the Creative Commons Attribution 4.0 Unported (CC BY 4.0) license, which permits others to copy, redistribute, remix, transform and build upon this work for any purpose, provided the original work is properly cited, a link to the licence is given, and indication of whether changes were made. See: https://creativecommons.org/licenses/by/4.0/.
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This exhibit brings together the work of Jewish and non-Jewish German artists whose work was eventually branded as "degenerate" by the Nazis and who were forced to flee Germany. On display will be works by Georg Stahl, Arthur Segal, Julius Schülein, Samson Schames, and others.
The exhibit focuses on Stahl, who responded to the political turmoil of the Weimar Republic, and later World War II and the Holocaust, with work that moved from a modernist style in the 1920's to pure abstraction in the 1950's.
In the years following the cataclysmic events of World War I, the tenets of modernism, developed in the early parts of the century, began to crumble. Amid hyperinflation, staggering unemployment, and political turmoil, many artists questioned the existing political order, joining forces with progressive political movements, although continuing to work in a modernist style. Georg Stahl, who lived in Kassel at the time, first joined the Socialist party and later the Communist party.
In other parts of the country, artists looked to Munich where the Independent Social Democratic Party staged an uprising against the Bavarian monarchy on November 7, 1918 that was subsequently referred to as the "November Revolution." In its wake, a group of visual artists, musicians, and writers established the Novembergruppe (November Group) among whose many members were Arthur Segal, Lou Albert-Lazard, and Gert Wollheim. Although they worked in different styles, they were united by their aspiration to integrate the arts into the social fabric and set new standards for public art.


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'Thor' actor Isaac Kappy commits suicide
by IANS Published on Thursday 16th May 2019, 02:18 PM
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Washington, May 16 (IANS) Actor Isaac Kappy, who got featured in the movie "Thor", has committed suicide, according to Arizona Department of Public Safety. He was 42.
Kappy died after jumping off a bridge onto the highway near Flagstaff, Arizona, reports usatoday.com.
He had played small roles in major movies. He played the pet store clerk in the 2011 blockbuster movie "Thor". He had the role of Barbarossa in the 2009 "Terminator Salvation" and Garfunkel in the 2009 "Fanboys."
Kappy was also a member of of the band Monster Paws.
Before his death, Kappy posted a message on Instagram via an account without a blue tick, about US President Donald Trump and paedophiles.
"Beware the man that has nothing to lose, for he has nothing to protect," he captioned the note.
"Over the course of the last week, through introspection that should have happened many years ago, I have come to some stark revelations about my character. It is a testament to my utter ignorance that these revelations had not come sooner. 'You see, I believed myself to be a good guy. I have not been a good guy. In fact, I have been a pretty bad guy throughout my life."
"I hope that the people of the world can utilize my folly in a positive light. That you all may use my mistakes as an example for personal growth. The lesson has come too late for me, but perhaps it can inspire you," he said.
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redpajama_set_name: RedPajamaCommonCrawl


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Casino Answers » Slots » 1x2 Gaming » Alice and the Red Queen
Alice and the Red Queen
About Alice and the Red Queen
Alice and the Red Queen, released in May 2014, is a fantasy and fairy tale-themed video slot made by 1X2 Gaming. Relatable games from 1X2 Gaming include Faerie Nights (January 2019), Gingerbread Joy (2015), and Red Dragon (July 2015). The rival games include Alice in Wonderland (June 2013) from Proprietary, Cinderella (September 2013) from Novomatic, and Enchanted (January 2010) from Betsoft Gaming.
Alice and the Red Queen is a video slot game adaptation of Lewis Caroll's 1871 book titled "Through the Looking-Glass and her 1865 book named Alice's Adventures in Wonderland. The game's name is borrowed from the two protagonists therein, called Alice and the Red Queen. Seven of the symbols (gray rabbit, photo of Twedledee alongside Twedeledum, army ant, white rabbit, Chesire cat, Mad Hatter, and teapot) require three, four, or five winning combinations. Five symbols (queen cake, medicine bottle, Red Queen, Alice, and heart cake) require two, three, four, or five winning combinations. Moreover, there are special payouts for any five-of-a-kind playing suit.
Alice and the Red Queen Game Characteristics
Alice and the Red Queen has 5X3 grid, 25 adjustable pay lines, 13 symbols, and 15 maximum free spins. The three special symbols are: a circular brown-and-red heart cake (of hearts) that shows up during the free games mode; a coiled "Wild" that is a substitute; the scatter is a sparkling blue teapot (of diamonds) that offers the free games.
The ten Alice and the Red Queen ordinary symbols: a staring red-eyed gray rabbit of clubs; human twin characters called Tweedledum and Tweedledee (of spades) wearing navy blue hats; a blue ant of spades; a bespectacled white rabbit (of clubs) holding a clock; a smiling yellow-eyed pink Chesire cat of spades; a red-haired Mad Hatter in a blue hat (of diamonds); an "eat me" queen cake of spades; a blue "drink me" medicine bottle of diamonds; a red-haired Red Queen of hearts; a yellow-haired Alice of hearts.
The Alice and the Red Queen coin values: $0.01, $0.02, $0.05, $0.10, $0.20, and $0.50. There are five coins (bet levels); the minimum bet is $0.01 and the maximum bet is $62.50.
Alice and the Red Queen has these payouts for three, four, and five matching symbols. The black rabbit pays X13, X14, and X20. Tweedledum/Tweedledum twins have X13, X20, and X45. The ant pays X14, X24, and X20. The white rabbit offers X14, X28, and X70. The Chesire cat has X18, X32, and X80. Mad Hatter pays X20, X40, and X80. The teapot offers X24, X80, and X400.
The Alice and the Red Queen payouts for two, three, four, and five matching symbols. The queen cake has X12, X24, X40, and X100. The medicine bottle gives X12, X32, X75, and X300. The Red Queen pays X12, X40, X150, and X500. Alice has X12, X45, X200, and X750. Heart cakes offer X12, X30, X100, and X200. The so-called "Flush" payout, which is for symbols that have five matching playing suits, is: five clubs has X15, five hearts pay X30, five diamonds offer X25, and five spades offer X20.
Three teapots offer five free games, four teapots give ten free games, and five teapots offer 15 free games. The non-progressive jackpot in Alice and the Red Queen is $10000.00.
The good Alice and the Red Queen software has advanced features such as autobet, reset bets, a volume slider, and high/medium/low display resolutions. The animated illustrations of the fairy characters and cautionary prompts (like "be wary of the red queen") are outstanding. There are rhythmic magical sounds and children chattering occassionally in the background.
Luck in Alice and the Red Queen
A game of chance, the RTP rate of Alice and the Red Queen is 96.21% and the house edge is 3.79%.


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Ann Coulter on the 'Liberal Mob' of the American Left
Ann Coulter explains America's "liberal mob" in her new book, "Demonic."
• 25 min read
Anthony Weiner Scandal: Ann Coulter Weighs In
Provocative bestselling author discusses state of politics and her new book.
June 7, 2011— -- New York Times bestselling author and conservative political commentator Ann Coulter's new book, "Demonic: How the Liberal Mob is Endangering America", tackles politics once again, this time taking on the liberal left and what she describes as their "mob behavior."
In "Demonic," Coulter traces the words and movements of groups from the Ku Klux Klan and the SDS to anti-war protesters and Democrats today to argue her point that liberals have "consistently used mob tactics to implement their idea of the 'general will.'"
"Just as fire seeks oxygen, Democrats seek power, which is why they will always be found championing the mob whether the mob consists of Democrats lynching blacks or Democrats slandering the critics of Obama Care as racists," Coulter writes.
"Demonic" is the eighth book from Coulter, also a frequent television political commentator.
Read an excerpt from "Demonic" below, then check out some other books in the "GMA" library
The Liberal Mob
2 When Jesus got out of the boat, a man with an impure spiritcame from the tombs to meet him.
3 This man lived in the tombs, and no one could bind himanymore, not even with a chain.
4 For he had often been chained hand and foot, but he tore thechains apart and broke the irons on his feet. No one was strongenough to subdue him.
5 Night and day among the tombs and in the hills he would cry outand cut himself with stones.
6 When he saw Jesus from a distance, he ran and fell on his kneesin front of him.
7 He shouted at the top of his voice, "What do you want with me,Jesus, Son of the Most High God? In God's name don't torture me!"
8 For Jesus had said to him, "Come out of this man, you impurespirit!"
9 Then Jesus asked him, "What is your name?""My name is Legion," he replied, "for we are many."
-- Mark 5:2--9
The demon is a mob, and the mob is demonic. It is the nihilistic mob of the French Revolution; it is the revolutionaries who seized control of Russia at the beginning of the twentieth century; it is the Maoist gangs looting villages and impaling babies in China; it is the Ku Klux Klan terrorizing Republicans and blacks in the South; it is the 1992 Los Angeles riot that left fifty dead and did $1 billion of damage after the first Rodney King verdict; it is the bloody riots at the 1968 Democratic National Convention; it is the masked hoodlums smashing up Seattle when bankers came to town; it is the 500,000 illegal aliens marching under a foreign flag in Los Angeles; it is throngs of Islamic fanatics attending the Ayatollah Ruhollah Khomeini's funeral, tearing his body out of its coffin; it is left-wing protesters destroying property and attacking delegates at the 2004 and 2008 Republican National Conventions.
Everything else changes, but mobs are always the same. A mob is anirrational, childlike, often violent organism that derives its energy fromthe group. Intoxicated by messianic goals, the promise of instant gratification, and adrenaline-pumping exhortations, mobs create mayhem,chaos, and destruction, leaving a smoldering heap of wreckage for theirleaders to climb to power.
The Democratic Party is the party of the mob, irrespective of whatthe mob represents. Democrats activate mobs, depend on mobs, coddlemobs, publicize and celebrate mobs -- they are the mob. Indeed, thevery idea of a "community organizer" is to stir up a mob for some politicalpurpose. "As so frequently happens when a crowd goes wild," historianEric Durschmied says, "there is always one who shouts louder andthereby appoints himself as their leader."1 Those are the people we call"elected Democrats."
The Democrats' playbook doesn't involve heads on pikes -- as yet -- but uses a more insidious means to incite the mob. The twisting of truth,stirring of passions, demonizing of opponents, and relying on propagandistic images in lieu of ideas -- these are the earmarks of a mob leader. Over and over again, one finds the Democrats manipulating themob to gain power. It is official Democratic policy to appeal to the least informed, most weak-minded and perpetually alarmed members of thepublic.
Their base consists of soccer moms, actresses, felons, MSNBC viewers (both of them), non-English speakers, welfare recipients, heads-up-their-butts billionaires, and government workers -- who can never be laid off. The entire party gave up on attracting the votes of white men decades ago. It's easier to round up votes by frightening women about "assault weapons" and promising excellent free health care to non-English speakers. Yes, a free health care system that is so superior that they exempt themselves and their friends from having to be in it. Liberals frighten people about their health care in order to stampede through ObamaCare. They claim the Earth is overheating in order to seize taxpayer money for solar panels and compact fluorescent lightbulbs.
They call out union thugs to force politicians to accede to insane benefits packages. They stage campaigns of calumny to get their way on gay marriage. Faddish ideas that would never have occurred to anyonefifty years ago -- or even twenty years ago -- are suddenly foisted on therest of us by the liberal mobs.
Although the left in America is widely recognized as hysterical, unreasonable, and clueless, the "root cause" of these traits has generallybeen neglected. More than a century ago, Gustave Le Bon perfectly captured the liberal psychological profile in his 1896 book, "The Crowd: AStudy of the Popular Mind." Le Bon -- a French physician, scientist, andsocial psychologist -- was the first to identify the phenomenon of masspsychology. His groundbreaking book "The Crowd" paints a disturbingpicture of the behavior of mobs. Adolf Hitler and Benito Mussolini usedhis book to learn how to incite a mob. Our liberals could have been LeBon's study subjects.
Even the left-wing Guardian has admitted that Le Bon's study ofcrowd behavior was "possibly the most influential work of psychologyever written." Presumably recognizing themselves in his psychologicalprofile, liberals have recently tried to undermine Le Bon. They have complained that he merely "articulated the propertied classes' fear of the mob." Who likes mobs? Renters? Window manufacturers? Rope salesmen? Liberals also objected that Le Bon did not hold the police accountable for a mob's behavior -- which is like demanding that we take into account the length of the rape victim's skirt.
It is revealing that liberals so fear Le Bon that they try to sully him as "controversial" and "reactionary." (Those particular complaints, incidentally, were lodged by liberal activist George Monbiot, who has called for "citizen's arrests" of former government offiials from George W. Bush's UN ambassador John Bolton to former British prime minister Tony Blair. No wonder he doesn't like psychological studies of mob behavior.)
It was all the usual claptrap, but the piercing truth of Le Bon's study speaks for itself. Liberals wouldn't go after him if, even a century later, his theories didn't still ring true. All the characteristics of mob behavior set forth by Le Bon in 1895 are evident in modern liberalism -- simplistic, extreme black-and-white thinking, fear of novelty, inability to follow logical arguments, acceptance of contradictory ideas, being transfixed by images, a religious worship of their leaders, and a blind hatred of their opponents.
Many of liberals' peculiarities are understandable only when one realizesthat they are a mob. For example, a crowd's ability to grasp onlythe simplest ideas is reflected in the interminable slogans.
Liberals have boatloads of them: Bush Lied, Kids Died! Our Bodies, Our Selves! No Blood for Oil! No Justice, No Peace! Save the Whales; Love Your Mother (Earth); Ban the Bomb; Make Love, Not War; Friends Don't Let Friends Vote Republican; Diversity Is Our Strength! Save the Planet! Pro-Choice, Pro-Child! Support Our Troops, Bring them Home! Co-Exist! Hey, Hey, LBJ, How Many Kids Did You Kill Today? Dissent Is Patriotic! War Is Not the Answer! Go Green! Healthcare Is a Right, Not a Privilege! Imagine Peace; Celebrate Diversity! Beat the Bushes for Peace! No Nukes! Give Peace a Chance; Think Globally/Act Locally; No Tax Cuts for the Rich; Save the Planet! Venceremos! One, Two, Three, Four, We Don't Want Your F--King War! Bush = Hitler; Hell No, We Won't Go! Off the Pig! Eat the Rich! Die Yuppie Scum! Peace Now! We Are the Ones We've Been Waiting For! Solidarity Forever! Bring America Home! You Can't Hug a Child with Nuclear Arms; Meat Is Murder! Books Not Bombs! Fight the Power! Yes We Can!
And those are just the ones on my neighbor's car.
What is the Tea Party's slogan? There is none. Republicans almost never have slogans, certainly none that even they can remember -- except when our presidential candidates are forced to come up with some utterlyforgettable catchphrase for their campaigns.
There are only three memorable Republican slogans in the past halfcentury -- unless you count what Dick Cheney said to Pat Leahy on theSenate floor in 2004, in which case there have been four. There was, "27Million Americans Can't Be Wrong," after Goldwater lost in a historiclandslide in 1964. There were the YAF buttons made in tribute to WilliamF. Buckley's mayoral campaign platform in 1965: "Don't Let ThemImmanentize the Eschaton!"
And when there were few other reasons to vote for the reelection of the first President Bush in 1992, there was,"Annoy the Media, Vote Bush!" Republicans display crosses and fish, college and sports decals, and a few parodies of liberal slogans ("Imagine an Unborn Child"), but no bossy demands on our bumper sticker.
Conservatives don't cotton to slogans. When they finally produce one, it's never the sort of rallying cry capable of sending people to the ramparts, such as "Yes We Can!" or "Bush Lied, Kids Died!" "27 Million Americans Can't Be Wrong" is a wry observation, not an urgent call to battle. "Annoy the Media, Vote Bush!" -- barely qualifies as a suggestion.
Conservatives write books and articles, make arguments, and seek debates, but are perplexed by slogans. (Of course, another reason Republicans may avoid bumper stickers is to prevent their cars from beingvandalized, which brings us right back to another mob characteristic ofliberals.)
By contrast, liberals thrive on jargon as a substitute for thought. Accordingto Le Bon, the more dramatic and devoid of logic a chant is, the better it works to rile up a mob: "Given to exaggeration in its feelings, a crowd is only impressed by excessive sentiments. An orator wishing to move a crowd must make an abusive use of violent affirmations. To exaggerate, to affirm, to resort to repetitions, and never to attempt to prove anything by reasoning are methods of argument well known to speakers at public meetings."
Liberals love slogans because the "laws of logic have no action oncrowds." Mobs, Le Bon says, "are not to be influenced by reasoning, andcan only comprehend rough-and-ready associations of ideas."5 He couldbe describing the New York Times and other journals of elite opinionwhen he describes periodicals that "manufacture opinions for their readersand supply them with ready- made phrases which dispense them ofthe trouble of reasoning."
You will see all the techniques for inspiring mobs in liberal behavior.
There are three main elements to putting an idea in a crowd: affirmation, repetition, and contagion. The effects takes time, Le Bon says, but "once produced are very lasting." It's the same reason annoying TV commercials are so effective. "Head On! Apply directly to the forehead. Head On! Apply directly to the forehead. Head On! Apply directly to the forehead."
Affirmation is the creation of a slogan, free of all reasoning and all proof." Indeed, the "conciser an affirmation is, the more destitute of every appearance of proof and demonstration," he says, "the more weight it carries." This is "one of the surest means of making an idea enter the mind of crowds."
Affirmation only works if it is "constantly repeated, and so far as possible in the same terms." The power of repetition "is due to the fact that the repeated statement is embedded in the long run in those profound regions of our unconscious selves in which the motives or our actions are forged. At the end of a certain time we have forgotten who is the author of the repeated assertion, and we finish by believing it."
Short slogans endlessly repeated create a "current of opinion" allowing "the powerful mechanism of contagion" to operate. Ideas spread through the crowd as easily as microbes, Le Bon says, which explains the mass panics common to rock concerts, financial markets, street protests, and Dennis Kucinich rallies. "A panic that has seized only a few sheep," he observes, "will soon extend to the whole flock."
Liberals have it down to an art: The cacophonous method of yelling until conservatives shut up just because they just want to go home, the purblind assertions -- No WMDs in Iraq! Civilian Deaths! Violence at Tea Parties! Head On! Apply directly to the forehead! -- and overnight the entire mass of liberals is robotically repeating the same slogans.
It isn't only in their incessant street demonstrations that liberals talk in slogans. This is how liberals discuss serious policy matters with the public. It's as if they're speaking to a vast O.J. Simpson jury, mesmerizedby a pair of gloves and a closing argument that rhymes ("If it doesn't fit,you must acquit").
Conservatives talk the same on TV as off TV -- unless they are inarticulate politicians using sound bites to avoid saying anything stupid. But regular conservatives talk on TV as if they're having a normal conversation with their friends or neighbors.
Liberals don't know how to do this because they don't have normal friends and neighbors -- only fellow demonstrators. Their self-image is as little Lenins, rousing the masses at the Finland Station, which is why they always sound as if they've gotten control of the PA system and are broadcasting from Big Brother, Inc. -- or if they're Al Gore, addressing a kindergarten class.
Here, for example, is Stephanie Bloomingdale, of the Wisconsin AFL-CIO, being interviewed on MSNBC about the union's beef withGovernor Scott Walker: "Well, America, we need all of you to help us with our fight. Because this is a fight to reclaim the values of the middle class. This is the movement of our time. And we need people all across America, working people, to stand up and say, this is the time we need to restore economic justice. And we know that the only -- that the union movement is the only thing that stands between unbridled corporategreed and a true economic democracy. And we -- what I would like tosay is, America, stand with us, stand with us who are fighting for justiceand economic justice in our society."
The next night, Katrina Vanden Huevel was engaging in the same sort of "Internationale" hectoring: "People are waking up. And they're in the streets. There are going to be fifty rallies around this country. Maybe a million people in the streets of this country. And what are they saying? Enough! You're giving our people's money away. Invest in our country, invest in jobs, invest in education. Keep cops on the street, keep teachers in the classrooms. Enough with these perks for corporations. There's a movement called U.S. uncut, which is inspired by an article in The Nation.
"If we can recoup from the very richest who brought us this financial crisis and from corporate tax dodgers, we can balance budgets in a fair way. Justice, fairness, concepts that may be coming back to America in this moment."
The advantage of slogans like these -- "working families," "economicjustice," "unbridled corporate greed," and "invest in our country, invest in jobs, invest in education" -- is that liberals never have to talk about the actual issues being discussed. You'd never know in the fog of jargon that the Republican governor of Wisconsin, Scott Walker, was only asking government employees to start paying 6 percent of their pensioncontributions (up from zero percent) and 12 percent of their health careinsurance (up from six percent).
Similarly, the pro-abortion movement depends on never ever using the word "abortion" -- only cant, such as "choice," "family planning," and "reproductive freedom."
The Left's robotic speaking style helps explain why liberals have never been able to make a dent in talk radio, despite many tries. Apparently, even the people who get bused in to their rallies can't be paid to listen to liberals hectoring them on talk radio. Being endlessly lectured by deadly earnest liberals is boring. Ask any Cuban.
Based on their public commentary, it appears that not one liberal has the vaguest idea how the economy imploded. The only thing liberals know is -- as President Obama explained -- "Republicans drove the car into the ditch, made it as diffiult as possible for us to pull it back, now they want the keys back. No! You can't drive. We don't want to have to go back into the ditch. We just got the car out."11 (It was always a "ditch" and not a "lake" because a lake would have been offensive to Teddy Kennedy.)
A liberal would stare at you slack-jawed if you explained that the federal government, via Fannie Mae, Freddie Mac, and the Department of Housing and Urban Development, forced politically correct lending policies on the banks -- policies that were attacked by Republicans but ferociously defended by Democrats -- and that the banks' suicidal loans were then bundled into mortgage- backed securities and dispersed throughout the entire financial system, which poisoned the economy, bringing down powerful institutions, such as Lehman Brothers, and destroying innumerable families' financial portfolios.
In light of the Democrats' direct role in creating the policies at the heart of the nation's financial collapse, it's not surprising that they prefer metaphors to facts. What's strange is that the image of a car in a ditch is sufficient for the bulk of Democratic voters and commentators to adjudge themselves experts on the economic crisis and refuse to listen to explanations that aren't images of Bush driving a car into a ditch. Image is all that matters to the mob. Obama can take in the biggest campaign haul from Wall Street in world history, as he did in 2008, but the mob will never believe he is in the pocket of Wall Street bankers.
The top- three corporate employers of donors to Barack Obama, Joe Biden, and Rahm Emanuel were Goldman Sachs, Citigroup, and JPMorgan. Six other financial giants were in the top thirty donors to the White House Dream Team: UBS AG, Lehman Brothers, Morgan Stanley, Bank of America, Merrill Lynch, and Credit Suisse Group.12 In 2008 alone, Goldman Sachs employees gave more to Obama -- nearly $1 million -- than any other employer, with the sole exception of the entireUniversity of California, which has 230,000 employees -- ten times more than Goldman.13
And still Republicans are called the Party of Wall Street. Bush let Lehman Brothers go under -- what else do Republicans have to do? Liberals latched on to the image of Bush, Cheney, and even Tom DeLay as "oilmen" to blame them for everything from Enron's collapse to blackouts and high oil prices.
In 2006, Speaker Nancy Pelosi blamed "oilmen" in public office forhigh oil prices -- and hearing Pelosi try to craft a syllogism is like watchingMichael Moore attempt ballet. She said, "We have two oilmen in the White House. The logical follow-up from that is $3-a-gallon gasoline. It is no accident. It is a cause and effect. A cause and effect." That's all liberals needed to know. Two "oilmen" in the White House -- cause and effect. Strangely though, a barrel of oil costs the same on the world market for all those other countries that were not being run by "oilmen."
A few years earlier, she had blamed Bush and Representative Tom DeLay for the blackout throughout the Northeast United States and parts of Canada -- presumably because they are both from Texas -- sayingthey had "put the interests of the energy companies before the interests ofthe American people."14 In fact, the blackout was due to a failure of humans operating electric power; it had nothing whatsoever to do with oil.
The New York Times's Paul Krugman has written more than a dozencolumns making hazy connections between Bush and the corrupt andcollapsed Enron -- "Some cynics attribute the continuing absence ofEnron indictments to the Bush family's loyalty code" 15 -- despite Bush'shaving absolutely nothing to do with the company, other than being from Texas.
By contrast, Krugman was on Enron's advisory board while he was writing encomiums to Enron in Fortune magazine.16 Once a year, when I don't feel like writing a column, I think I'll reprint Krugman's column singing Enron's praises -- although, again, in fairness, he was being paid by Enron at the time.
Democrats wouldn't make such absurd statements if absurdity didn'tseem perfectly logical to their base. This is how Democrats communicatewith their constituents: They use mob tactics to rile up the irrationalmasses. Crowds can't grasp logic, only images. "These image- like ideas," Le Bon says, "are not connected by any logical bond of analogy or succession, and may take each other's place like the slides of a magiclantern which the operator withdraws from the groove in with they were placed one above the other."
Republicans love Wall Street -- oh look, Wall Street just made historiccampaign contributions to Obama; he must be really cool. Republicans hate the poor because they're trying to block government policies promoting easy mortgages. . . . Oops, I wonder why the economy just tanked. It's because Bush drove it into a ditch! Enron collapsed and Paul Krugman says it's Bush's fault. Krugman was paid by Enron and Bush wasn't? Bush lied, kids died! Oil prices went up under Bush -- it's his fault -- he's an oilman! Oh but then oil prices went down under Bush. . . . Hey, look over there! A shiny object!
Despite their perennial enthusiasm for revolution and "change" in almost any form, Le Bon says, crowds are wildly conservative when it comes to scientific progress. Want to scare a liberal? Mention nuclear power plants, genetically modified fruits, new pharmaceuticals, food irradiation, or guns with plastic frames. We could probably get a crowd of liberal protesters to scatter just by coming at them with a modern vacuum cleaner.
It certainly works on dogs and cats. The Left's abject terror of technological development is yet another mob attribute. Le Bon says that the mob's "unconscious horror" of "all novelty capable of changing the essential conditions of their existence is very deeply rooted."
While mobs go about changing the names of institutions and demanding radical changes to society, he says, when it comes to scientific progress, crowds have a "fetish- like respect" for tradition.18
Thus, according to Le Bon, if "democracies possessed the power they wield today at the time of the invention of mechanical looms or of the introduction of steam- power and of railways, the realization of theseinventions would have been impossible." It is lucky "for the progress ofcivilization that the power of crowds only began to exist when the greatdiscoveries of science and industry had already been effected."
Our liberals are even worse than Le Bon imagined. Democrats don't merely want to block scientific progress, they want to roll it back. Al Gore's global warming fantasy book Earth in the Balance called for the worldwide elimination of the internal combustion engine within twenty-five years. (Which, if nothing else, would have ruined Obama's "car in the ditch" catch-phrase.)
In 2007, Democrats in Congress banned the incandescent lightbulb,currently scheduled for elimination in 2014. Indeed, banning ThomasEdison's invention was among the very fi rst acts of the new House majority elected in 2006, in a bill cosponsored by 195 Democrats and only 3 Republicans (two of whom are no longer in office). When Democrats came up with the idea of banning the lightbulb, what image appeared in their heads? A litcandle? Only four Democrats voted against the bill in both the House and then Senate, with the vast majority of Republicans voting against it in both chambers.
Consider that the two industries that provoke the most fear and loathing in liberals are two of the most innovative: the oil and pharmaceutical industries. When a majority of the country objected to national health care because, among other reasons, it would mean the end of innovation in medicine once the government took over, liberals stared inblank incomprehension. (It was almost as if they'd been drugged.) Theybelieve every drug, every diagnosis, every therapy, every cure that will ever be invented has already been invented. Their job is to spread all the existing cures, not to worry about who will discover new ones.
The only traditions liberals are eager to smash are moral and sexual ones, such as marriage and protecting the unborn. Crowds are too impulsive to be moral, according to Le Bon, which explains why liberals are mad for innovation when it comes to thousands-year-old institutions like marriage. Only when it comes to scientifi c innovation, are they hidebound traditionalists.
Indeed, the only way to get liberals interested in novel scientific research is to propose slaughtering human embryos. When adult stem cell researchers had already produced treatments for eighty different diseases, 21 while embryonic stem cell researchers were stuck in the dark ages, the failed researchers won liberal hearts by pointing out that their method destroyed human fetuses, while adult stem research did not.
As long as Democrats can win by demagoguing the mob, they are perfectly happy to turn America into a banana republic. With the countrydrowning in debt and Medicare and Social Security putting us on ahigh-speed bullet train to bankruptcy, the entire Democratic Party refusesto deal with entitlements. Instead, they will gin up the mobs to throw out any politician who cuts these increasingly theoretical "benefits." The country will have the economy of Uganda, but Democrats will be in total control.
Rich liberals want chaos for everyone except themselves, confident that they can afford a "green" lifestyle and their children will still attend Sidwell Friends. The rest of us are forced to live in a lawless universe of no energy, gay marriage, girl soldiers, and marauding criminals because liberals can't enjoy their wealth unless other people are living in completepandemonium. They promote anarchy, believing the middle class should live in squalor, while liberals will be protected by their wealth against the mob.
The seminal event of the New Testament -- Jesus' crucifixion -- is adramatic illustration of the power of the mob.
When the mob was howling for Pontius Pilate to sentence Jesus to death, even Pilate's wife couldn't convince him to spare Jesus. After having a dream about Jesus, Pilate's wife sent her husband a note saying Jesus was innocent -- a "just man." Pilate knew Jesus was innocent and that the mob hated Jesus out of "envy." But not his wife, not even his own common sense, was enough for him to resist the mob.
Three times Pilate told the "multitude" that Jesus was innocent and should be spared. He pleaded with the mob, proposing to "chastise him, and release him." But the mob was immovable, demanding Jesus' crucifixion. Pilate was required to release one of the prisoners, so he gave the mob the choice of Jesus or Barabbas, a notorious murderer and insurrectionist -- in other words, someone who incites mobs. Again, the mob "spoke with one voice," demanding "with loud shouts" that Jesus be crucified.
Capitulating to the mob, Pilate ordered Jesus' death.
Even one of the mob's victims, a thief being crucifi ed alongside Jesus,joined the mob's taunting, saying to Jesus, "If thou be Christ, save thyselfand us." The other thief rebuked him, noting that they were guilty, whereas Jesus was not. He said to Jesus, "Lord, remember me when thou comest into thy kingdom." And Jesus said "Today shalt thou be with me in paradise."22
Pilate gave in to the mob out of fear. The thief joined the mob to side with the majority. The mob itself was driven by envy.
Although it all worked out in the end -- Jesus died, darkness fell over the Earth, the ground trembled, and the temple veil was ripped in two, and three days later, Jesus rose from the dead, giving all people the promise of everlasting life -- here was the stark choice, to be repeated like Nietzsche's eternal recurrence: Jesus or Barabbas?
Liberals say Barabbas: Go with the crowd. C'mon, everybody's doing it -- it's cool. Now let's go mock Jesus. (As is so often the case, the mob said, "Kill the Jew.")
Conservatives -- sublimely uninterested in the opinion of the mob -- say Jesus.


The NYS HIMSS Chapter is once again holding the scholarship program for graduate and undergraduate level students. Last year, the Chapter awarded two scholarships to a graduate ($2,500) and an undergraduate ($1,500) level student. We are seeking volunteers to read and score essays submitted by scholarship entrants.
Winners will be provided with a one-year membership to HIMSS.
The scholarship will be announced prior to the New York State annual Mini-HIMSS conference in New York City on June 2017.
Please contact Susan Rueckwald, JD, MS, CPHIMS (Co-Secretary NYS HIMSS Chapter and Chair of Scholarship Committee) if you are interested in volunteering at: susan.rueckwald@outlook.com.
We thank you for considering volunteering your time to this important program to assist our future HIT leaders!


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text:
After Missing the Olympic Track and Field Team, Keni Harrison Broke a 28-Year-Old Record
You have to watch how she reacts to the news.
By Kathleen Mulpeter
U.S. hurdler Keni Harrison may not be headed to Rio this summer, but that didn't stop her from breaking a world record over the weekend.
Harrison, 23, finished first in the women's 100-meter hurdles at the Diamond League meet in London on Friday evening with a time of 12.20 seconds, beating the previous record—held by Bulgarian Yordanka Donkova since 1988—by one one-hundredth of a second.
Aside from setting a new mark, Harrison finished ahead of three fellow American athletes who will compete in the Olympics in August: Brianna Rollins (who finished with a time of 12.57 seconds), Kristi Castlin (12.59 seconds), and Nia Ali (12.63 seconds).
Earlier this month, Harrison missed her chance at a spot on the 2016 Track and Field roster after finishing in sixth place at the trials in Eugene, Oregon, with a time of 12.62 seconds. Harrison saw the race in London as an opportunity to deliver a powerful message: "I wanted to come out here and show the world that I still have it even though I won't be going to the Olympics," Harrison said. "I had to give it all I had."
RELATED: 5 Reasons We're Inspired by 16-Year-Old Olympian Sydney McLaughlin
The hurdler from Tennessee won Friday's race by a huge margin (more than a quarter-second). But her victory became even sweeter a few seconds after she crossed the finish line, when the official clock was corrected from 12.58 to 12.20.
This clip captures the incredible joy on Harrison's face as she learned she had broken the 28-year-old world record.
"Initially I saw 12.5, and I was just happy to come out here and win. I was so happy when [the real time] came up and I was feeling really blessed. It shows that even if you don't go out there and make the team, you have to keep going and be strong. I just ran my best and look what happened," she said.
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