Home School or School House Essay

What do George Washington and the Hanson brothers have in common? Do you give up? Well, the answer is that both of them were educated in their homes. Queen Elizabeth, Thomas Edison, and Theodore Roosevelt were also educated at home. According to the Home Education Research Institute, 1. 5 million students are staying home for class today. This number is five times more than ten years ago (Kantrow and Wingert 66). This trend leads to many questions. Does home school education work? Do students receive a proper education? How does a home school student’s education compare to that of public school student? Does home schooling isolate a child socially? These questions are concerns of parents, educators, and politicians alike. The future of America rests on the academic and social education of our youth, and home school education should be considered as an effective alternative to public school education. In the past, parents mainly chose to educate their children at home because of religious preference. These parents viewed the public school system as a source of negative influence on children. Violence, sex, drugs, and peer pressure were influences these parents sought to avoid. However, today parents have other reasons for home school education, which primarily all point to a lackluster public school system. Other reasons include a desire to build a strong family closeness, safety, and a handful of parents chose home school for their children because of special needs such as disabilities or special talents. However, no matter how good the reasons, the home school education system must prove to be an acceptable alternative to public schools. There are many advantages to giving a student a home school education. First, parents can make direct decisions concerning what their children are taught. According to the Home School Statistics and Reports in 1997, written by founder and President Dr. Brian D. Ray, seventy-one percent of the parents who educate their children hand pick the curriculum from a variety of books, videos, and educational manuals. Another twenty-three percent order entire cirriculum packages (Ray 14). With the technology of today, parents have an unlimited source for information via the Internet, which can be easily integrated in home school education. The study also shows the education level of the parent supervising and administering the curriculum has little or no effect on the  quality of education received by a student. Home-educated students whose parents did not have college degrees scored equally high on tests compared to students whose parents had college degrees(Ray 56). In addition to students’ own parents teaching them, groups are formed among home school families. These groups allow students to be taught a variety of subjects by different parents that have a better understanding of subjects such as algebra, chemistry, and biology. These groups also take field trips, participate in sports, and do volunteer projects together. Another advantage of home schooling is the quality of education received by the student. How do home school students compare with public school students? This is a very important question to answer, but the answer can never be a concrete one. However all of the research I did shows that students educated in their homes have an equal or higher level of academic skills compared to the public school students. In the 1997 and 1998 ACT test scores, home school students averaged a score of 23; meanwhile the public school students averaged a score of 21(Farris 8). Also, on nationally standardized achievement exams home students again outscored public school students by at least thirty percentile points(Ray 7). While these numbers can’t truly reflect the comparison, an equal percentage of students from both groups seek college education(Ray 9). The government on all levels faces problems concerning the public school system. Funding for schools tops the problem list; local school boards and city governments are continuously fighting for tax proposals, meanwhile students in the schools suffer because of poor facilities and low salaries for teachers. The cost for taxpayers to send one student to a public school for one year is approximately $5325, while a home school student costs a parent $546 per year (Ray 11). Could an increase in home schools cut taxes? Could the money allotted for education now be used more effectively if there were fewer students? Maybe or maybe not, but if fewer students were in public schools, the chances of giving the public school student a better educational environment would increase. Many people who oppose home school programs claim interactions with other children at school are vital to their education. However, this argument usually does not work because parents who home school do not want to release their children into the negative influences that infect the public school system. After an interview with Beverly Decateau, a mother who taught her children at home for over seven years; I found that home school students participate in equally as many or more activities than public school students do. Her children and many others she knew of were active in church groups, Four-H groups, sports teams, and dance squads. All of these activities can be considered social interactions. I don’t believe the public school system has a responsibility to socialize students; that job belongs to parents. In a public school system, some students can be pinpointed and teased, and these images can damage children for life. Despite the several advantages of the home school system, many people still oppose home schooling. Home school students may not miss interactions with other students, but they will miss the experience. Certain experiences at school are considered an important part of the American way of life. Public school students will never forget experiencing homeroom parties, pep rallies, and finding classes on the first day of high school. Can a home school student’s experience compare? Probably not, but to what importance these experiences play in the education and socialization skills of a student depends on each individual student. Home school education can cause problems among children and parents. Children who have parents constantly looking over their shoulders may have difficulty breaking away from home to attend college or enter the workplace. Children might also have trouble respecting their own parent as an educator, and this lack of respect may have a negative effect on the student’s education. In order for home school education to work, the parents must be willing to sacrifice time and patience above and beyond the average parents. The parents must also be willing to give up their own careers for the future of their children. Furthermore, not all children can be successful home school students. The children must be able to make friends in informal settings, and see home school education as a way of exploring different avenues of learning. Not everyone can educate their children at home, but the more students who can receive a solid education at home would improve the education given to students at public schools. Fewer students would lead to smaller classrooms where higher paid teachers could give more attention to public school students. Funds and taxes could be used more effectively because there would be fewer students to accommodate. In the future we should support home school programs and public school education to interact with each other for the benefit of all students. Regardless of where the education of America’s youth takes place, it is vital that parents have a major role in the education of their children in order to build strong families and a strong America. WORKS CITED Decateau, Beverly. Personal interview. 2 NOV 1998. Farris, Micheal. â€Å"Home Schooling Today. † The Washington Times 27 OCT 1998: E8. Kantrowitz, Barbara, and Pat Wingert. â€Å"Learning At Home: Does It Pass The Test? † Newsweek 5 OCT. 1998: 64-70. Ray, Brian D. â€Å"Home School Statistics and Reports† Home School Legal Defense HomePage. Dec 1997 http://www. hsdla. org//.

President Wilson Urges Support for Ideal of League of Nations Essay

After the end of World War One, President Woodrow Wilson sought national support for his idea of a League of Nations. He took his appeal directly to the American people in the summer of nineteen nineteen. The plan for the League of Nations was part of the peace treaty that ended World War One. By law, the United States Senate would have to vote on the treaty. President Wilson believed the Senate would have to approve it if the American people demanded it. So Wilson traveled across America. He stopped in many places to speak about the need for the League of Nations. He said the league was the only hope for world peace. It was the only way to prevent another world war. Wilson’s health grew worse during the long journey across the country. He was forced to return to Washington. The Senate was completing debate on the Treaty of Versailles. That was the World War One peace agreement that contained Wilson’s plan for the league. It seemed clear the Senate would reject the treaty. Too many Senators feared the United States would lose some of its independence and freedom if it joined the league. Wilson wrote a letter from his sick bed, to the other members of the Democratic Party. He urged them to continue debate on the League of Nations. He said a majority of Americans wanted the treaty approved. The Senate Foreign Relations Committee agreed to re-open discussion on the treaty. It searched yet again for a compromise. Wilson refused. He said the treaty must be approved as written. Wilson’s unwillingness to compromise helped kill the treaty once and for all. The Senate finally voted again, and the treaty was defeated by seven votes. The treaty was dead. Yet history would prove him correct, and the Second World War would be far more destructive than the first. The debate over the Treaty of Versailles was the central issue in American politics during the end of Woodrow Wilson’s administration. It also played a major part in the presidential election of nineteen twenty.

Science vs. Romanticism

Science/technology and Romanticism I believe that there is a balance that exists between science and romanticism because everybody will eventually have to view something in a scientific way, whether it is a particular profession or simply an activity which they are in contact with every day. That being said, one particular occupation is not all inclusive, so not everybody will see scientifically or technologically about the same items or activities.For example, Mark Twain said, â€Å"No, the romance and beauty were all gone from the river,† to show that what he once felt about the glorious river had now vanished due to his job as a riverboat pilot, where he trades the knowledge of the river for its beauty. In the same way he talked about a doctor; â€Å"what does a lovely flush in a beauty cheeks mean to a doctor but a â€Å"break† that ripples above some deadly disease? The doctor reads the beauty of the girl for the knowledge that he uses in his medical practice. The re is a balance between Mark Twain and the doctor because Twain still sees the beauty in the girl, and the doctor continues to see and understand the â€Å"romance and beauty' of the river. Though each perceives their respective activities in a scientific way, they can offset each other because neither sees the technological side of everything.In a way, a person in our society takes a certain career pathway or a pacific Job for the exact purpose of allowing others to observe the beauty of these areas of life through their ignorance, while the person taking the Job sacrifices their ignorance for knowledge which, in effect, sucks the beauty out of the profession. The balance that exists between science and romanticism remains because we all see beauty in some things that others see the science in, while others see the beauty that inhabits the things that we can only distinguish the technology and science in.

Operations Management (Flow Charts) Case Study Example | Topics and Well Written Essays - 1250 words

Operations Management (Flow Charts) - Case Study Example The surgeon uses staples to dissect the stomach into upper and bottom section. The upper section is usually smaller while the bottom section is larger (Klein 86). The smaller upper section is where the food flows after eating. The smaller upper section, also called the pouch, is compared to the size of a walnut. This section holds about a single ounce of food. The second procedure for this surgery is called the bypass. During this step, the surgeon connects jejuna to a small hole in a patient’s pouch. The eaten food will flow from the pouch to the small intestines. This will enable the patient to absorb fewer calories. Bypass surgery can be carried out in two ways. In open surgery the surgeon makes a surgical cut to open the belly. Bypass will be done by working on the patients small intestines, stomach, and other parts. Consequently, the surgeon might use the tiny camera referred as laparoscope (Apple, Lock, and Peebles 76). This process is termed as the laparoscopy; camera i s put in the patient's body. In laparoscopy, the surgeon makes small cuts in the patient's belly. Then he passes the camera through one of the cuts. The process is linked to the monitor of the video in the operating room. The surgeon will keep track of the belly at the screen. The surgeon then uses surgical instruments to carry out the bypass. The process can be represented in the form of a flow chart as shown below. 2. The minimum time the patient takes in the hospital before being discharged after paying cash is four days. The average time for those using insurance is about two weeks. Subsequently, the patient undergoing a laparoscopic surgery takes only two days. When the patient pays cash for the bariatric surgery, it will save the patient that stress of going through counseling, and various tests. Paying cash will also save the patient the agony of proving to the surgeon that he has tried other means of weight loss. Consequently, it reduces the patient stress of waiting for hal f a year before the procedure. Therefore, paying cash is something that the patient needs to consider (Apple, Lock, and Peebles 76). When surgery is paid in cash, they give the patient an option of choosing the surgeon to carry out the surgery. It does not involve longer procedures like the insurance. When the patient pays by cash, he normally spends one to three days in the hospital. When a patient undergoes laparoscopy, he stays in the hospital for two to three days. When he patients undergo this procedure, they recover faster and return to normal in two weeks time (McGowan and Chopra 89). The hernias rate in open surgery is reduced significantly. Therefore, the patients who pay cash are better off based on the procedural types to select from. Paying cash enables the patient to choose his location for the surgery and the kind of surgeon to be attended to. Dealing with insurance is always frustrating, but most insurance companies have realized that to cover procedures of bariatric makes financial sense (Apple, Lock, and Peebles 54). Paying cash enables the patient to have surgery almost immediately and also discharging is soon. The patient does not undergo the risk of being turned down due to coverage issues. There are reported cases of turn down from insurance companies at the last minutes of the surgery. 6. Assuming the patients get treatment by an insurance cover and go for open surgery. The Bariatric center will make 945,000 Dollars: Number of

The world I live in Research Paper Example | Topics and Well Written Essays - 500 words

The world I live in - Research Paper Example The punishment by death, awarded in this case, corresponds to Aristotle’s ethical philosophy, which suggests that justice takes place when â€Å"all agents deserve equal concern of justice, in the quest to ensure that all agents get what they deserve and agents do not get what they do not deserve† (Aikin, para.34). It only appears ethically reasonable that a person who inflicts severe pain on another human being and takes away her life, deserves to die for that crime because such individuals may repeat the crime and become a threat to the society, if not dealt with severely. Danette Elg, a 31 year old lady was cruelly murdered in her residence during July 1984 by Richard A Leavitt. The offender had stabbed her multiple times and cut off her sexual organs. The victim’s body was discovered days after her murder and was identified for police by her murderer. He was not arrested until December 1984, for the crime. Leavitts trial started on September 12, 1985 and Seventh District Judge, H Reynold George sentenced him to death, considering the extreme cruelty inflicted to the victim. The judge noted that the crime was monstrous, dreadful and cruel. Leavitt’s death warrant was issued and executed on June 6, 2012 by lethal injection, 28 years after committing the murder. There can be both ethical and unethical issue involved in punishing an offender by the award of death penalty. In most cases, sometimes the judge may tend to ignore some of the ethical aspects and punish the offender without properly taking into consideration all the circumstances that led to the culmination of the crime. However, in the instant case, the Judge’s decision to execute Richard Leavitt appears ethical as the crime he had committed is gruesome, barbaric and extremely threatening to women as a whole. He wounded Danette Jean Elg â€Å"repeatedly with exceptional force, and had cut out her sexual organs† (Boone, para. 16). The

Folktale assignment Example | Topics and Well Written Essays - 500 words

Folktale - Assignment Example The morale of the story is not to take advice from the devil/fox/sharpest person as they always give open ended advice which can end in either way victory or loss. They never assure sincerity on the cost of their personal security. Secondly, brain power is necessary for any fight to become a success or loss, the more the merry one is. Once a Bear and Fox met while jogging, the Bear asked Fox , â€Å"who do you think is the cleverest of all creatures?†. Fox replied, â€Å"Of course, who else; the creator of artificial intelligence gadgets, facebook, google and cloning; the eminent Man.† Bear with his gigantic head and sturdy physique took it as an insult. He suggested to Fox that he can fight with man’s intelligence in just one blow. The fox and Bear sat on the bench and waited for the other joggers to pass by. A lady passed by and Bear asked her, who she was? She said, â€Å"I am Kim Kardashian, the reality television star.† The Bear grunted in disgust, â€Å"No, good for nothing!† requested her to continue her Jog. Fox and Bear waited and a young girl came across, the Bear stood in the path stopped her and asked her who she was. The girl replied, â€Å"I am not a girl, I am Justin Beiber a famous singer and iconic pop-star.† The Bear looked closely and said, â€Å"You definitely sound like a girl.† But his perfume and pink pants made him nauseated and he let him go quickly. Next came a police officer, the Bear jumped in between the path and asked, â€Å"Who are you?† The officer took out the gun and yelled, â€Å"Put your hands behind your head or I’ll shoot you!† Fox shouted, â€Å"He’s a man!† In no time Bear landed a KungFu Panda Kick to the officer and he fell far away. Bear gave a devilish smile to the Fox but just after a moment he was electrocuted by another officer. Bear severely injured stood up with difficulty and hid behind bushes. When he looked around for Fox to help him,

FIVE short seminar Essay Example | Topics and Well Written Essays - 1000 words

FIVE short seminar - Essay Example The texts were available before in the local orthodox language and beliefs of the Church which were given new expression in the print media and led to more openness of the expression. The target segment for receiving the benefits of print revolution already existed. The paper and block printing was first invented in China in the first century which spread to Europe in the twelfth century (Eisenstein, 2012, p.53). The spread of Martin Luther’s ideas and the lessons of the Church found channels of expression. In the nineteenth century, the print presses were power driven and faster dissemination of information happened among the masses. Development in investment scenario of the countries like Australia, etc is also a contribution of the print media. Radio days The emergence of radio as a mass medium happened long back from the days of Marconi. Marconi invented ways of decoding the communication codes used in a telegraph and transmitting useful information through a radio. In the early days, the use of radio was an amateurish activity by the audiences who used crystal radio sets. People also pursued hobbies of using radio as a communication medium. In 1920, the corporate radio broadcasting centres stared to operate for reaching out to the masses. With time the desire and the need for radios developed. This gave rise to subsequent developments of the radio communication through the introduction of vacuum tube radio and loudspeakers for better communication. During the time of depression in 19298, radio became the mass medium of communication. Thus for the stages of hobby, radio developed into a wired mass medium for distant communications. Messages and information starting from emergency to entertainment were spread through the radio. The sinking of Titanic and messaging for SOS happened through telegraphic system. However, the news of the world wars was more wide spread with the help of radio. In the field of entertainment, radio started to broadcast new on films, broadcasted musical events and commentaries on live sporting events like Olympics, Football world cup, etc. Image Technologies and Mass Society The image technologies came into vogue during the end of the nineteenth century. The image technologies marked the emergence of the mass society in the twentieth century. In the twentieth century, the communication in the world circulated through wired media like telegraph and telephone. The advent of the image technology brought about the spread of news and entertainment to a wider section of the society. Almost all the spheres of life that include urbanisation of the regions, transportation and public works, information on the time zones were all the more accessible with the help of image technologies. Consumerism developed rapidly with the formation of departmental stores, exhibitions and fairs, e.g. Paris Exposition of 1901. Numerous small theatres developed along with the stardom of the celebrities also grew. The spread of pictu res led to change in lifestyles of the population with more interest to the world of eminent personalities. The Paris Exposition of 1901 received overwhelming responses on sensual pleasures as compared to the knowledge part. The heritage properties like the Crystal Palace of 1950 were designed for the awareness of the masses. The manufacturers started to apply

Set operations and Venn diagrams. week 5 MAT Essay

Set operations and Venn diagrams. week 5 MAT - Essay Example So using the example above, cars, buses and vans should be written inside the circle for land vehicles, while rafts and yachts belong to the circle for water vehicles. It is also possible that an object possesses both characteristics. For example, if you want to use a Venn diagram to organize a variety of tools based on whether it is for kitchen (circle 1) or for plumbing (circle 2), you know that scissors belong to both circles. To represent this, we write ‘scissors’ in the overlap of two circles. What if you have an object that does not have any of the characteristics represented by your circles? Then you simply put its name outside the overlapping circles, to signify that it does not belong to any of the groups. Taking the Venn diagram of tools, you know that a watering can does not belong to either kitchen or plumbing tools because it is a gardening tool. Thus, you put ‘watering can’ outside the overlapping

Health care law Article Example | Topics and Well Written Essays - 250 words

Health care law - Article Example s capability to compensate injured patients equitably and quickly, in the process offering answerable mechanisms that focus on ensuring safe care instead of assigning individual blame. Disadvantages of the system include the perception that the systems method of compensation and treating patients excludes other illnesses (Paterson and Bismark, 2004). This is likely to generate tensions because the assistance given by ACC is higher compared to the treatments received from welfare systems and health. The same benefits and disadvantages are applicable in the Canadian context because the Canadian system addresses similar issues as the New Zealand system. In formulating policies on assisted suicide, it is essential to incorporate limits in these policies. These limits are crucial in ensuring effective decision making as people seek to obtain medical assistance in ending life. In this case, the decision for assisted suicide should involve the family and medical specialist. These individuals are crucial in ensuring that the patient makes the right decision. In addition, it is essential to outline conditions for euthanasia. This is crucial in guiding the healthcare provider in assisting in the suicide. In this case, only individuals with fatal illnesses are eligible for assisted suicide. This will eliminate other people who want to kill themselves without any medical motivations (Behuniak & Svenson, 2003). Paterson, R. and Bismark, M. (2004). No-Fault Compensation in New Zealand: Harmonizing Injury Compensation, Provider Accountability, and Patient Safety. Commonwealth Fund’s International Symposium on Health Care Policy.

College degree Essay Example for Free

College degree Essay Like almost everyone already asked this question when they have finished high school. Where will I be in about 10, 20 or even more 40 years? . I do not think anyone would like to be a waiter or taxi driver the rest of life; hence, going to college is a good way to know what you will be. It will help you to develop your abilities, your skills, accomplish your goals. People with a higher education can make a difference in the world. My reason for going to college is because I want a better life for myself and it will open many doors in my future life. I graduated from high school in 2007, when I was 17 years old in Peru. My family always encouraged me to get higher education so I started thinking about what would I want to be? . I went to see many universities around my town in order to get more information about majors. I was confused between Hospitality Management and International Business but I decided to study Hospitality Management. It caught my attention because it deals with tourism and I love traveling. Besides hotels, I can get a job in many other places such restaurants, casinos, resorts and hospitals. I enrolled at San Ignacio de Loyola University because they have the best program in my major. It is  located an hour and a half from my house. When I was studying there, I learned a lot; especially, when I can deal for myself without my moms help because she did everything for me when I was at school. In Peru, there are many cases of delinquency and a few times robbers attacked me. The first occasion was a week of starting classes. I could remember that I spent a whole day at the college doing my assignment. It was a lot and I was very tired that day. When I was on my way home and got off the bus, someone stole my handbag. My first reaction was to go running after him because he had all my work with my effort in it, my new purchased  books. That was horrible. The other times, robbers just stole my phone. It was because of these facts that gradually I did not want to go anymore. I was very scared on the streets, looking around; I could not take out my phone from my pockets. Because of that, I decided to leave the university. One the day, I talked with my grandmother who lives in the USA. We were discussing about my life and I told her that I wanted to continue studying, so she asked me to move in with her. It was a very difficult decision for me because I would go to another country, starting a new life away from my  parents and friends, and also I was afraid because I did not speak English fluently. However, I had to think about my future so I decided to move to the USA, but the problem was that my parents disagreed about coming here illegal. I went to the University to see if they have any program to study outside the country. They have it but one of the requirements is to have 60 credits. Unfortunately, I did not have that amount. I checked on internet any other possibilities and I found out about the student visa. I did everything I needed to process the visa, such as translating my documents from high  school, filling some papers, looking for my sponsor, and medical examination. A few days later, I went to the USA embassy with my parents, I was so nervous because my dream of keep studying was depending of their answer. The counselor looked my documents and approved my student visa. I was so happy that day. In the first days of arriving in USA, I enrolled at Union County College. At the beginning, I took ESL classes since level 4th. Now, I am almost done with it. Moreover, I am taking other courses in the fields of hotel management. Therefore, Im pretty sure that I will graduate in two  more years and get my associate degree in Applied Science Program in Hotel, Restaurant, and Tourism Management. However, getting a degree in USA and go back to my country will help me to get a more job opportunities since Im bilingual. According to the article The Benefits of Earning a College Degree states, â€Å"One of the most important and obvious reasons to earn a college degree is to increase your earning potential†. Therefore, a good salary since people that have achieved a college degree are hired in at a higher pay and are considered to be much more employable. For the reason that I want  my own family, I would like to give them a good quality of life, and also provide inspiration to my children. In conclusion, I strongly believe that people should go to college. I feel good going to college because every time I learn something new. I am satisfied with every step Im taking to get more knowledge and grow as a person. Also, see my parents feel proud of me is priceless. In fact, I recommend going to college is worth and it is not a waste of time because college will give a person the tools to succeed in the field of their choice. By graduating from college, everyone can get a dream job and start to make those dreams come true.

Pros and cons of Marijuana legalization

Pros and cons of Marijuana legalization Who would have thought that one green plant, Cannabis sativa, could create so much controversy throughout the centuries? The debate on medical marijuana has been around since the 17th and 18th century. The debate if marijuana is a dangerous and addictive drug, or a helpful medication for pain reliever, preventing vomiting, and treatment of glaucoma (Schwartz, 1994).Science has proven the medical benefits marijuana brings to the field of medicine. Although the American justice system is still undecided about the facts and safety of marijuana, and if marijuana should be legalized, some states have accepted the legalization of marijuana such as California. Many other states are still debating the pros and cons of marijuanas legalization. If marijuana was legalized and regulated it could save lives, help our economy grow in this economic downturn, and let our national security system attend to more alarming issues. Allegar, I. (2000). A factual guide to medical uses of marijuana. Townsend Letter for Doctors Patients Dec2000, (209), 121. This is the only book that presents many of the scientific facts about medical marijuana. Facts such as the origin of where marijuana plants came from, to facts about President Regans term, where the war on drugs began which gave marijuana a bad reputation. My favorite line from this article sums up why marijuana should be legalized. A primary fact is the proven safety of this plant- no one has ever died, overdosed, or even become ill from using marijuana. So how did this green leaf plant get such a bad reputation?(Allegar, 2000, p.209) This quote presents a great argument for the legalization of marijuana. Other drugs cause people to overdose and die, yet those drugs are legalized. So what is the problem with legalization of marijuana? Arias, d. (2007). Health findings. Nations Health, 37(3), 16. This article talks about many public health findings of medical marijuana. The discovery that marijuana relieves pain for patients that suffer from peripheral neuropathy, a nerve condition that is present in those affected with HIV (Arias, 2007). The marijuana relieved pain by 34%.Another amazing statistic is that the patients suffering from peripheral neuropathy reduced their chronic pain by 72% when smoking their first marijuana cigarette (Arias, 2007, 16). The placebo cigarette was not even comparable. This article presents good documentation of public health findings on marijuana. The procedure is organized well and easy to understand the benefits that marijuana presents in the experiment. In the research collected, this article makes the strongest point of how effective marijuana is as a pain reliever. With such high statics how can our government not legalize marijuana? Boire, R, Feeney, K. (2006). Medical marijuana law. Oakland, CA: Ronin Publishing Inc The book covers every question to what marijuana is, to why it is legal in some states. Also the book explains how the state law and federal law are two different things, and the federal law always wins. This book also brings a more in-depth explanation on marijuana history and the medical benefits. The book talked about two different alternatives to smoking marijuana such as Marinol and sativex. The pros and cons are listed for each drug. The book also explained the procedure of seeing a doctor and getting registration for the marijuana, where a safe place is to get the marijuana, and what the regulations are for growing your own marijuana plants. The book explains how to deal with the federal system and possession of marijuana. The book lists the amount of marijuana that is legal for each state. Boire and Fenney gave more information on the marijuana tax act of 1937. This book also makes the clear distinction on the federal law vs. state law. The most useful information I found in the book was the description on the qualifying conditions for medical marijuana, which are: AIDS, cancer, cachexia, epilepsy, glaucoma, HIV, multiple sclerosis, seizures, and severe nausea (Boire, Fenny, 2006, p.5).Another great part of the book is about the doctors role in prescribing the marijuana. Some states require a copy of the doctors license and signed physician statement (Boire, Feeney, 2006).The different forms of medical marijuana makes a great argument on why it should be legalize. Marinol, which contains synthetic THC, is a better option than smoking marijuana because, smoking is harmful. The down fall with the synthetic THC, is it does not produce the same pain relieving effect (Boire, Feeney, 2006). The book also talks about the patients rights and restrictions about medical mariju ana. This information helped me better understand both sides of the debate. Durand, M. (2007). Considering cannabis. Inside MS Jun/Jul2007, 25(3), 56-57. The article deals with the medical affects that Cannabis (marijuana) has on patients with multiple sclerosis. The marijuana helps prevent vomiting and muscle spasm. Experiments were done on rats to prove the medical benefit of marijuana. Some of the reverse side effects of marijuana are also listed. This article helps back up my thesis with the proof of medical facts to legalize marijuana. The drug is helpful with patients who suffer from multiple sclerosis. With dosage controlled and overseen by a physician I feel there is no reason to have these patients suffer and not be able to have marijuana. Garner-Wizard, M. (2006). FDA denies medicinal value of smoked marijuana. . HerbalGram Sep-Dec2006, 25(72), 22. This article is very interesting; because attention is brought to what party the U.S. government or medical system is lying. The FDA (Food and Drug Administration) says that there is no medical proof of medical marijuana. The FDA also argues that no science experiment on animals has been conducted and documented. The medical system talks about the lack of faith they have with the FDA. Medical experts do not believe that it is a communication error between the science departments and government officials, rather than the government does not want to accept the medical facts and legalize marijuana. The government wants to keep a strong stand on drugs. This article is perfect for playing devils advocate on the debate of medical marijuana. Medical experts have the facts and experiments in books and other science journal researched in this paper. So if the public can receive these written documents why is the government unable to? This article also presents the question of what is the true motivatation of not legalizing marijuana. What else is the government keeping from us? Krisberg, k. (2009). Fight for reform of U.S. drug policies slowly Making headway. [cover story]. Nations Health, 39(8), 1-10. Krisberg has presented facts and many view points from different medical experts. The reading is hard to understand what party believes what. The main concept retained from this reading is the president Barack Obama says he has the willingness to put science before policies (Krisberg, 2009, p.7) Meaning he would put opinions and policies aside and make a decision based on facts. While this article was difficlulent to understand and follow, the article is somewhat humorous. The president suggests he will move the legalization of medical marijuana if facts are presented. This entire annotated bibliography is filled of sources with many facts on the benefits of marijuana. So what is the hold up? Why has marijuana only been legalized in some states, and even then the federal law has many regulation and restrictions. What kind of facts are the government looking for. How can the American society observe the medical benefits of medical marijuana, but our public officials cannot? This creates a great viewpoint to think about while researching. Marandino, c. (1998). Fired up. Vegetarian Times, (247), 18. This article is a little old but still presents a great point. The National Institutes of Health (NIH) recommend that marijuana does present some medical benefits for serious illnesses. The American Medical Association also agreed that marijuana had some medical benefits. The public views are also document about the legalization of marijuana. This article prevents proof that medical research has been conducted and presented to the public. This article was written in 1998, and even though medical facts have been presented for medical marijuana many still opposed the idea of legalization. Marijuana has been viewed as a dangerous drug for centuries. No matter how many statics and facts are presented on why marijuana should be legalized for medical purposes, can change the mind of the American justice system. Marijuana. (2007). Marijuana fast facts, 1-2. This article presented some common background information. Because this was the first article researched, on the quest to understand the legalization of medical marijuana it was very helpful. To understanding the scientific name of the drug, to understanding the positive and negative aspects of marijuana, this article was very helpful. After reading this article and gaining some background knowledge, the more in-depth and complicated articles were easier to follow. Some of the information about the problem facing federal and state laws conflicting the legalization of medical marijuana. Also the information about marijuana being a risk and side effects that come with the drug will be helpful in presenting both sides of the debate. Marijuana and future psychosis. (2007). Nutrition Health Review: The Consumers Medical Journal , (98), 17. This article argues against the legalization of medical marijuana. All of the information in the article is about the life long lasting side effects of marijuana. How the use of marijuana can lead to psychosis and severe mood changes. There are two view points to very argument. While there is not sufficient medical evidence shown in this document to oppose the legalization of marijuana, this side still must be presented. The main reason for this view point is because of the side effects of marijuana. Like any other drug, marijuana has side effects. Some side effects are more harmful than those of marijuana, yet they are still legal. Minamide, E. (2007). Medical marijuana. Framington Hills, MI: Greenhaven Press. Minamide organized his text to show both sides of the legalization of marijuana debate. Some of the key topics are if medical marijuana is effective medical treatment or not. If the legalization of medical marijuana would negatively impact society or not, and finally if the federal government should ban medical marijuana or not. Debra J. Saunders argues that marijuana should be legalized because it can help many serious illnesses. Saunders believes that congress should move marijuana out of the classification of Schedule I drug, a caterogory that includes more serious drugs like heroine, to a Schedule II drug , like cocaine and morphine, which are available for medical use(Minamide,2007,p.12). Medical experts have facts that prove marijuana as a helpful medicine. Experts in medicane also believe the drug should be moved into the Schedule II drug. On the opposing viewpoints the book highlights a key point that harm of medical marijuana may outweigh the medical benefits (Minamide, 2007, p.34). Smoking in itself is harmful to the respiratory system regardless if it relieves pain and prevents nausea. Another great point highlighted in the book is if the legalization would negatively impact society. Mark R.Trouville says that the legalization of marijuana would interfere with the undermine law enforcement efforts to combat drug trafficking and would send a dangerous message that marijuana is a harmless substance (Minamide, 2007, p.38). The book also plays devil advocate and presents arguments for the legalization of marijuana that help my thesis out. Schwartz, H. (1994). Psychiatric practice under fire the influence of government, the media, and special interest on somatic therapies. Washington, DC: American Psychiatric press, Inc. The book gave facts on medical marijuana and the battle it has been facing for years. The book was written in the 1994 so the legal status was not up to date. Although, the history of marijuana and the medical benefits it had was very informational. The book also broke down the main ingredient in marijuana, and describes how they had medical benefits. A lot of case experiments proved medical marijuana helped the patient. The book also talked about the historic time line of marijuana. From the beginning of time when marijuana came from India in the 17th and 18th century, to Marijuana Tax Act of 1937 all the way to 1942 when American framers started to grow hemp for rope in World War II. The helpful information presented in this book had some general background information of marijuana. The author talked about THC (delta-9-tetrahydrocannabinol) is the main ingredient of marijuana. In 1895 THC was approved by the Food and Drug administration (FDA). The FDA noted that THC was combating nausea and vomiting associated with cancer chemotherapy.(Schwartz, 1994, p.106) The book also noted three main reasons why medical marijuana should be legalized. The first of the three reasons is to treat glaucoma. The next main reason was to relieve nausea, and last but not least is to stimulate appetite. I think that congress should look at all of the medical facts about medical marijuana and how it relieves pain for cancer patients and also prevents vomiting. In todays medical world there are a lot of addictive drugs used as pain relievers. Yet these drugs are legalized. The legalization of medical marijuana could help our economy grow. The last piece of information presented in this book was a great example of why marijuana should be legalized. In August 1992, for example, Valarie Corral, a 40-year-old woman from Santa Cruz, California, who smoked marijuana for 18 years to control epileptic seizures, was arrested for growing five plants in a vegetable garden near her porch (Rogers 1993).Under California Law, she faced up to 3 years for her offense. Valarie did not get sentenced 3 years for her plants; the judge understood her medical purpose for them. Valaries doctor reported her prescription for medical marijuana to help with her spastic muscles when she had seizures. Before her muscles were out of control and she complained of pain. Once she started smoking marijuana when she felt a seizure coming along, her seizures were not as intense or long. This is just one example of how medical marijuana has positively impacted a life. Now Valarie can drive a car and perform day to day tasks thanks to help of marijuana she can live her life.

Causes of Stillbirth

Causes of Stillbirth Abstract: Feto-infant mortality is increasing worldwide. Stillbirth is defined as uterofetal death at 20 weeks of gestation or greater. Stillbirths contribute as a primary factor to the growing magnitude of feto-infant mortality. The reasons for stillbirth are usually not reported. In many cases, the specific cause of fetal death remains unknown. The key risk factors include smoking, increased maternal age, being overweight, fetal-maternal hemorrhage. Even though there has been remarkable development in prenatal and intranatal care, stillbirths have been consistently increasing and remain an important problem in obstetrics and gynecology. Current research studies focus mainly on the epidemiology of stillbirths. I review the known and suspected causes of stillbirth. It also describes the recommended diagnostic tests to evaluate definite cause of stillbirth. In this paper, I also review analysis of stillbirths in the United States (US). The National Center of Health Statistics recorded 26,359 stillbirths in 2001. The number of stillbirths can be greatly reduced if the specific reasons for stillbirth are understood. Introduction: A pregnancy ending in stillbirth can be mentally devastating to a patient and her family. The most widely accepted definition of stillbirth is death of the fetus inside the uterus at 20 weeks of gestation or greater (Cartlidge et al., 1995). Much information is available on protocols for evaluating other types of postmortem examination but little work has been done on the evaluation of the causes of stillbirths (Mirlene et al., 2004). No universally followed protocol is available to guide the evaluation of stillbirths. In part because a wide variety of causes can be involved in stillbirths and it can be difficult to designate a specific cause of death. A stillbirth might result from various diseases, infections, trauma or genetic defects in the mother or fetus (Gardosi et al., 2005). In many cases, a specific reason is not known. Even though stillbirths are a serious problem, few resources have been focused on them and most obstetricians lack a sound method of evaluating of stillbirths (Petersson, 2002). In this document, I will review the accepted causes of still birth and the suggested diagnostic tests for evaluating the reason behind stillborn infants. In the year 2001 in the US, the National Center of Health Statistics recorded 26,359 stillbirths (Ananth et al., 2005). When compared to 27,568 infant deaths were reported in the same year. More than half of the stillbirths are before 28 weeks of gestation and almost 20% are close to the term. If a history of stillbirth exists then there is a 5-fold increase for subsequent stillbirth to occur. Prominent racial discrimination occurs in the rates of stillbirths. Stillbirths are almost three times more prevalent in African Americans when compared to whites (Puza et al., 2006). In 2001, the rate of stillbirths among white mothers was 5.5 per 1000 live births and 12.1 per 1000 among the black mothers. According to an analysis of U.S. vital statistics between 1995 and 1998, the increased risk of black, compared with white, stillbirths is greatest among singleton stillbirths (Puza et al., 2006). Reduction of proportion of fetal deaths at gestation of 20weeks or longer to 4.1 per 1000 live births and also reduction of fetal deaths for all racial and ethnic groups are the objectives of U.S. National Health for 2010. Categorization of Stillbirths: Different attempts were made in order to classify causes of stillbirth. Baird and his colleagues were among the first to classify the causes of perinatal death from the available clinical information. Depending on the British perinatal mortality survey, in 1958 Butler and Bonham designed a classification scheme that included the results of postmortem examinations. The most widely used is the 9 category classification system formulated by Wigglesworth and his coworkers (Wigglesworth, 1980). A new classification scheme which does not include neonatal deaths was proposed by Gardosi and his colleagues known as the ReCoDe Classification which focuses on the relevant conditions at the time of death in the uterus. It includes factors which affect the fetus followed by the factors which affect the mother (Gardosi et al., 2005). When compared with the Wigglesworth classification, a remarkable decrease in the number of unclassified stillbirth was achieved using this classification. One of the most vital aspects is to develop a proper definition of the factors that lead to death of the fetus. The basic definition for the â€Å"cause of death† is injury or disease responsible for a death. Froendefined cause of death in stillbirth as â€Å"an event or condition of sufficient severity, magnitude, and duration for death to be expected in a majority of such cases in a continued pregnancy in the clinical setting where it was observed† (Froen, 2002). When the definition of â€Å"cause of death† is reviewed, it is observed that only a few disorders are directly responsible for fetal death while many others are not. Causes of Stillbirth: Infection: Infections such as viral, protozoal and bacterial are linked with stillbirth. Almost 10-25% of stillbirths result from feto-maternal infections in the developed countries where as bacterial infections are common in developing countries (Goldenberg et al., 2003). Stillbirths that result from infection might be due to various factors which include direct infection, placental damage, and severe maternal illness. Usually the stillbirths in the initial weeks of gestation are linked with infection. Bacterial infections caused by Escherichia coli, group B streptococci, and Ureaplasma urealyticum are a cause of stillbirth in developed countries (Goldenberg et al., 2003). If syphilis epidemic occurs in an area then it might be the cause of a considerable proportion of stillbirths. If women come in contact with a parasite like malaria for the first time then stillbirth might be attributed to it. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, Q fever, and Lyme disease are associated with the occurrence of stillbirth (Goldenberg et al., 2003). The magnitude of stillbirths due to viral infections is not known mainly due to the absence of a well defined systematic evaluation of infections in stillborn infants. The problem lies behind the fact that these viruses are difficult to culture and moreover, a positive viral serological diagnostic test identifying the DNA or RNA of the virus in the fetal tissue or placental tissue does not definitely determine that infection was the reason behind death. In most of the cases, infection is linked with stillbirth in early gestational weeks around twenty weeks. If molecular diagnostic technology (DNA and RNA polymerase chain reaction [PCR]) is utilized, it will help in diagnosis of viral infections without any error. Parvovirus B-19 appears to have the strongest association with stillbirth. According to a Swedish survey, in 8%of stillbirths B-19 PCR positive tissues were observed (Enders et al., 2004). In the United States, less than 1% of all stillbirths are reported to be due to parvovirus infection Parvovirus B19 moves across the placenta spreading the infection to fetal erythropoetic tissue resulting in fetal anemia leading to fetal death (Wapner et al., 2002). Myocardial damage may also occur due to Parvovirus B19. Here the virus directly attacks the fetal cardiac tissue. Parvovirus infection that leads to stillbirth usually occurs before 20 weeks of gestation (Wapner et al., 2002). Enteroviruses which include Coxsackie A and B, echoviruses and other enteroviruses are associated with stillbirth. Coxsackie viruses can cross the placenta and lead to villous necrosis, inflammatory cell infiltration, calcific pancarditis, and hydrops. Echovirus infection begins with severe maternal illness and finally ends with stillbirth. Cytomegalovirus (CMV) belongs to herpesvirus family and it is a congenital viral infection. Initially, the mother is infected and then it is transmitted to the fetus. CMV causes placental damage leading to intrauterine fetal growth restriction, but an association with stillbirth remains controversial (Goldenberg et al., 2003). Viral infections in the mother like rubella, mumps and measles are linked with stillbirth. If the vaccinations are administered on time then the proportion of stillbirths occurring due to infections can be reduced greatly. Genetics: Genetic causes are responsible for a considerable magnitude of stillbirths. 6- 12% of stillbirths attributed to genetic etiologies are due to karyotyping abnormalities. Due to the fact that in some of the cases cells cannot be cultured, karyotyping is not possible. Such factors alter the exact estimate of stillbirths resulting from chromosomal abnormalities. In stillborn fetuses which show apparent structural defects the probability of chromosomal abnormality is much higher when compared to normal stillborn fetuses. The usually focused abnormalities include monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%). There are many instances where the karyotype of the stillborn is normal yet the cause of death is a genetic abnormality. Indeed, 25-35% of stillborn infants undergoing autopsy have intrinsic abnormalities (Wapner et al., 2002) .These include single malformations (40%), multiple malformations (40%), and deformations or dysplasia (20%) (Wapner et al., 2002). Almost 25% ofstillborns due to intrinsic defects show an abnormal karyotype whereas the rest of the 75% may have genetic defects which are not identifiable by the regular cytogenetic tests. This holds good for fetuses with multiple abnormalities. Single gene mutations may be responsible for death of the fetus in early weeks of development. Stillbirths in the midgestational weeks might be due to abnormal placental growth, development, or angiogenesis. Some autosomal recessive disorders including glycogen storage diseases and hemoglobinopathies have been reported as the cause of stillbirth (Wapner et al., 2002). In male fetuses, X-linked disorders may prove to be fatal. Many other genetic defects that are not recognized by the conventional cytogenetic diagnostics may lead to stillbirth. For example, conventional karyotype cannot identify chromosomal microdeletions that are linked with unexplained mental retardation. Confined placental mosaicism has also been associated with fetal growth impairment and stillbirth (Kalousek et al., 1994). Heritable Thrombophilia is another probable etiology of stillbirth.It is thought that placental infarction occurs due to thrombosis in the uteroplacental circulation leading to death. This poses concern over other thrombophilic defects and their effects on stillbirth. It is noteworthy that many heritable thrombophilias are common in normal individuals without a history of thrombosis or pregnancy loss (Rey et al., 2003). Even though many studies relate thrombophilias to fetal loss, most of the women with thrombophilias have healthy pregnancies with no lethal complications. It can be said that in the absence of any previous obstetric problems, thrombophilia will not result in stillbirth. Feto-maternal Hemorrhage: Feto-maternal hemorrhage has been linked to almost 3- 14% of all stillbirths which implies that it is responsible for a considerable number of stillbirths. Obstetric procedures such as external cephalic version and cesarean section lead to fetal maternal hemorrhage. Hemorrhage can also result due to placental abruption and/or abdominal trauma during pregnancy. Fetal maternal hemorrhage must be identified and quantitated using a proper dependable diagnostic test to attribute this reason behind the death of fetus. Hypoxia and anemia are indicators of death due to fetal hemorrhage. So, they should be confirmed by autopsy as in some normal cases too, few fetal cells can be seen in maternal blood. Maternal Features: Delayed child bearing or increased maternal age, prepregnancy obesity and stress are found to have their effects on the occurrence of stillbirth. The underlying mechanisms of action are unknown; however, with both obesity and delayed child-bearing on the rise, their importance as potential causes of stillbirth deserves greater attention (Cnattingius et al., 2002). Women whose only risk factor is being overweight have about a 2-fold increased risk of stillbirth (Nohr et al., 2005). Likewise, compared with women younger than 35 years of age, the stillbirth rate is increased 2- fold for women 35-39 years of age, and 3- to 4-fold for women aged 40 years old or olderwhereas some age-associated risk is due to higher rates of maternal complications, in uncomplicated pregnancies there may be a 50% increased risk associated only with maternal age 35 years or older (Nohr et al., 2005). Stress is a suspected cause of stillbirth which might occur as a result of a major life event (such as loss or poverty) (Huang et al., 2000) or through unexplained health changes related to adverse childhood experiences (Hillis et al., 2004). Different exposures are attributed to stillbirth. One of the most prevalent and preventable cause of stillbirth is cigarette smoking (Hillis et al., 2004). Smoking negatively affects fetal growth and oxygen supply to the tissues as it produces high levels of carboxyhemoglobin and decreases blood supply to the placenta. Smoking is also associated with increased risks of placenta previa and placental abruption and women who stop smoking in the first trimester have stillbirth rates equivalent to women who never smoked which indicates that quitting smoking in early pregnancy may significantly reduce the chances of occurrence of stillbirth (Hillis et al., 2004). A variety of complications result due to continuous exposure of different recreational drugs. Consumption of cocaine during pregnancy is also linked with stillbirth because it causes fetal growth restriction and/or abruption. The use of meth amphetamines leads to premature deliveries and stunted growth but its association with stillbirth remains unknown. In some cases, alcohol consumption during pregnancy has been associated with an increased risk of stillbirth (Mary et al., 2006). According to a study in Scandinavia, for women who consume less than 1 drink per week, the rate of stillbirth is 1.37 per 1000 births while the rate increases to 8.83 per 1000 births in women who consume 5 drinks or more per week. If smoking habits, caffeine intake, prepregnancy body mass index, marital status, occupational status, education, parity, and fetal gender are considered, the risk of stillbirth for women consuming 5 drinks or more per week was 2.96 (95% confidence interval 1.37 to 6.41) (Mary et al., 2006). Some studies show a protective effect on both stillbirth and fetal growth restriction rates if small amounts of alcohol are consumed during pregnancy (Mary et al., 2006). A link between pesticide exposure and stillbirth was observed by Pastore and his colleagues in 1997. Occupational exposures prove to be deleterious compared to residential exposure because the occupational exposures cause congenital abnormalities in addition to risk of stillbirth. A noteworthy fact is that the use of fertility drugs is also associated with stillbirths. This finding is problematic due to the fact that many women make use of fertility treatments to conceive. However, data on stillbirths due to exposures is obtained from retrospective studies which are prone to bias. The link between exposures and stillbirth should therefore be dealt with great attention and care. Maternal Diseases: Diabetes: There is always an increased danger of stillbirths in second and third trimester for mothers who are affected with type I or type II diabetes mellitus (DM) pregestationally. Even with modern obstetric care and diabetes management, stillbirth rates in women with type 2 DM have been reported to be 2.5-fold higher than nondiabetic women (Mary et al., 2006). The rate of stillbirth is the same between women with gestational diabetes (GDM) as well as normal women when the whole population is taken into account. The magnitude of danger involved with fetal death in women with type II DM is identical to women with GDM who in fact entered the pregnancy with undiagnosed type II DM. Therefore, women with GDM who have an undiagnosed type II DM are usually at a greater danger of encountering stillbirth. Examples of women with undiagnosed type II DM include history of GDM in previous pregnancies, high fasting glucose values;random glucose values greater than 200mg/dL or diagnosis of GDM early in pregnancy. The reason behind fetal death in late gestation in diabetic women is not known precisely. In addition to an increased risk of fetal death in diabetic women, there also exists a higher magnitude of danger associated with fetal abnormalities in these women compared to healthy women. Stress, hypertension and obesity complement each other in DM patients. In women with DM, there is a higher risk of stillbirth as it may lead to fetal abnormalities which may be either abnormally increased growth rate or retarded growth. To maintain the physiological range of the plasma glucose level, tremendous amounts of insulin is produced by the fetus resulting in fetal hyperglycemia. This fetal hyperglycemia is acquired from maternal hyperglycemia which finally results in fetal death due to excessive growth. The precise limit of plasma glucose level which poses a threat to the fetal life is not well defined. The most that could be done is to detect and deal with it using needed medications to lower the incidents of stillbirths.Many other maternal diseases have been linked to stillbirth, including thyroid disease, cardiovascular disease, asthma, kidney disease, and systemic lupus erythematosus (Simpson, 2002). These are subclinical diseases which in many cases has not been proven to be direct causes of stillbirth and women had normal pregnancies giving birth to healthy babies. Multiple Gestation and Stillbirth: Nearly 3% of all births and 10% of all stillbirths result from multiple pregnancies. According to national vital statistics, 1.8% of twin, 2.4% of triplet, 3.7% of quadruplet, and 5.6% of quintuplet fetuses suffered intrauterine fetal deaths (Salihu et al., 2003). The stillbirth rate among singleton pregnancies is approximately 0.5%. The reason behind fetal death in multiple pregnancies is difficult to be resolved when compared to singleton pregnancies. The broad causes of fetal death in multiple pregnancies include fetal growth retardation, preclamsia, abruption and cord accidents. It is vital to determine the chorionicity of multiple gestations as the rate of stillbirth is higher in monochorionic multiple gestations (Salihu et al., 2003) (Lynch et al., 2007). Assisted Reproductive Technology (ART) is an essential aspect in the occurrence of multiple pregnancies and stillbirth (Helmerhorst et al., 2004). Complications in Fetus: Fetal Growth Restriction: Some stillbirths result from fetuses which are smaller for a particular gestational age (SGA) compared to normal fetuses. Birth weight and risk of stillbirth are inversely proportional. If one increases, the other decreases. The main fact behind stillbirths in this condition is retardation of fetal growth and not the small size of fetus. An obstacle that occurs in determining the precise time of death of fetus due to SGA is the fact that the death might have occurred a long time before but the gestational age at the time of delivery is considered to be the time of death. This gives a false implication of the magnitude of stillbirths resulting from SGA. This problem can be solved by analysis of early and mid pregnancy placental hormones which are very specific for gestational periods (Smith et al., 2004). An evaluation of the amounts of these hormones relates directly to the time of death. Umbilical Cord Accidents: An increased number of stillbirths are due to â€Å"accidents† of umbilical cord like cord occlusion or blockage due to true knots, nuchal cords and compression of the cord. In almost 30% of normal healthy infant deliveries, nuchal cord and true knots in umbilical cords are observed. According to a study in Sweden, 9% of stillbirths were due to cord accidents (Petersson, 2002). Determination of cord accidents leading to fetal death by autopsy is smaller in proportion (up to 2.5%) (Horn et al., 2004). This difference indicates that in the absence of a proper cause, many times fetal death is attributed to cord entanglement. Due to the increased load of complications with live infants, little concern is expressed towards dead fetuses. In order to precisely relate a fetal death to cord accident, a clear indication of either hypoxic tissue injury or cord occlusion must be observed in autopsy. As nuchal cords are observed in normal deliveries also, the exact proportion of stillbirths due to cord accidents is biased. Obstetric Complications: Some of the obstetric complications are preclampsia, preterm premature rupture of membranes, preterm labor, cervical insufficiency, abruption, placenta previa, and vasa previa. These may either be direct or primary causes or may be indirect or secondary causes of stillbirth. Almost 10-19% of stillbirths occur due to abruption. Since cervical insufficiency or preterm labor lead to neonatal death, their role in causing stillbirth is not well defined. Evaluation of Stillbirth Stillbirth in itself may be emotionally devastating to many patients and their families. There the likelihood of carrying out genetic testing or autopsy on the fetus may not be readily agreeable from the family and culture. Lastly the procedures for evaluation must be cost effective and within reach. The two important facts that should be kept in mind while deciding which tests would prove as the most useful ones are primarily the consideration of cost of that test. It should not be beyond limits. Secondarily, if this test would be helpful in prevention of recurrent or sporadic stillbirths. In recurrent stillbirths, medical interference may prove helpful by preventing them in future. Analyzing the etiology of sporadic stillbirths might lead to reassurance and avoid irrelevant diagnostic tests in future pregnancies. The single most useful diagnostic test is a fetal autopsy (Peterson et al., 1999). Not only does the visible genetic and structural abnormalities but also an autopsy would be of great help in relating specific etiologies to stillbirth. The frequency of fetal autopsy is very less due to the fact that it is costly, not many trained pathologists are available and also it may be of great discomfort to the family and clinicians to deal with such a case. If autopsy is refused, partial autopsy or postmortem magnetic resonance imaging (MRI) scans may provide the necessary data. Embryonic membranes, placenta and umbilical cord must be physically and histologically examined while evaluating stillbirth etiology. This would give a precise cause of fetal death and might also provide clues for death due to secondary causes like infections, thrombophilia, and anemia. In most cases, families do not object on placental evaluation. In the cases where autopsy is not performed karyotyping the fetus would prove helpful. Cells and tissues from placenta (especially chorionic plate), fascia lata, skin from the nape of the neck, and tendons can be isolated and cultured and used for diagnostic tests like karyotyping. Comparative genomic hybridization shows tremendous promise for the identification of chromosomal abnormalities in stillbirths wherein fetal cells cannot be successfully cultured (Silver et al., 2006). An autopsy followed by a careful histological examination might help in relating stillbirths that result due to infections from the bacteria or virus. Parvovirus serology may be useful because this virus has been implicated in a meaningful proportion of cases (Erik et al., 2002). Diagnostic tests are performed for the detection of syphilis also since it contributes to the list of accepted causes of stillbirth. For various viral and protozoal agents like toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV) {TORCH}, serological screening is carried out. For bacterial and viral infections in the fetus, nucleic acid based tests are more helpful when compared to tissue cultures. Feto-maternal hemorrhage can be detected using Kleihauer – Betke test (KBT). Most laboratories use manual KBT which is prone to error. It has been found that flow cytometry is a better tool in detecting fetal erythrocytes in maternal blood. In order to eliminate red cell alloimmunization as an etiology of stillbirth, an indirect Coomb’s test is performed. Autopsy and examination of placenta are helpful in this situation. During the initial prenatal visits, if the antibody screen comes out to be negative then there is a need for recurrent testing. Diagnostic tests for conditions like diabetes and heritable thrombophilias must be carried out on a regular basis to prevent any complications which may lead to stillbirth. The treatment of such conditions at the appropriate time may prevent similar complications in subsequent pregnancies. Heritable thrombophilia might be of concern in the cases where there is recurrent fetal loss or there is a history of thrombosis or with complications involving placental insufficiency like placental infarction and intrauterine growth restriction. Administration of illicit drugs through various modes may be a cause of stillbirth in many cases. Toxicological examination may reveal the results for women who are subjected to such exposures. A simple urinary examination may prove helpful. The advanced and cost effective technology like ELISA (Enzyme Linked Immuno Sorbent Assay) can be used to detect a variety of metabolites like steroids in various tissues like blood, hair, and homogenized umbilical cord. Conclusion: Many medical and nonmedical agents govern the best approach to evaluate a stillbirth. The obstacles faced by obstetricians in solving these issues include the fact that in most of the cases the reason behind fetal death is unknown. Also the magnitude of stillbirths resulting from a single cause is not known precisely. Here there arises a need for population based studies to attribute stillbirths to their specific etiologies. There is a clear cut need of experts in the field of perinatal pathology and the required funding should be provided at the national level to promote it. Moreover, the clinician should be aware of the history of pregnant women in better evaluation. In cases where the local clinicians cannot reach a conclusion, the tissue samples must be sent to senior pathologists who have a thorough command on the subject and can help in reaching decisive conclusions. A universally accepted protocol is required for a systematic evaluation of stillbirths. Due to its absence a difference of opinion occurs among the obstetricians and gynecologists. The institutions like Stillbirth Collaborative Research Network should formulate guidelines for the proper judgement of stillbirth etiologies. The responsibility lies in the hands of the clinicians to do the best they can to reach a definite conclusion from the available data. It is noteworthy that the proportion of stillbirths that are â€Å"explained† is much higher in centers using systematic evaluations for recognized causes and potential causes of stillbirth (Petersson, 2002) (Horn et al., 2004). In conclusion, autopsy, placental evaluation, karyotype, Kleihauer-Betke, antibody screen, and serologic test for syphilis are useful in evaluating the etiologies of stillbirth. Depending on the case, other relative tests should be performed. The approach towards the testing of potential causes of stillbirth is not clear if it should be very specific and sequential or should it be comprehensive which means that it is targeted towards a broad spectrum of causes. Each of these has its own advantage. Sequential testing avoids false positive results and is directed to a specific cause and more over, it is cost effective. Comprehensive testing may prove helpful in cases where more than one factor is responsible for stillbirth. The problem with autopsy, placental evaluation, karyotype, screen for fetal-maternal hemorrhage, and toxicology screen is that they are dependant on time, that is, these tests should be performed immediately after the delivery. Autopsy cannot be delayed because death of the fetus already occurred and this would lead to physiological changes in the whole body and decay begins. The necessary evidence for stillbirth is easily available from fresh samples of placenta and also for toxicology screen. As the time since death increases, the physiology of fetus also changes leading to false positive or false negative results. If the time of fetal examination is delayed, fetal hemorrhage may be mistaken for postmortem lividity. Therefore a serious call for action is expected from institutions like Stillbirth Collaborative Research Network (SCRN) which would help in creating the most applicable diagnostic setting for evaluation of stillbirth (Silver et al., 2006). SCRN was developed by the National Institute of Child Health and Human Development to target the range of etiologies of stillbirth in the U.S. The aim of SCRN is to focus on the following objectives. The use of standardized surveillance in a geographic catchment area will show that the stillbirth rates are greater than those reported in the vital statistics catchment. The use of a prospectively implemented, standardized, postmortem, and placental examination protocols will improve diagnosis of fetal or placental conditions that cause or contribute to stillbirth. Maternal biologic and environmental risk factors in combination with genetic predisposition increase the risk for stillbirth. This is a population based study which is carried out in different counties of different states in the U.S. This study would take into account all the stillbirths and live births occurring in rural as well as urban areas in different racial groups. Even though occurrence of stillbirths cannot be stopped completely, yet attempts of such sort can be made atleast to prevent them to a maximum extent. Glossary Abruptio placenta totalis A placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before the baby is born. Achondrogenesis Dwarfism characterized by various bone aplasias and hypoplasias of the extremities and a short trunk with delayed ossification of the lower spine. Alloimmunization Development of antibodies in response to alloantigens; antigens derived from a genetically dissimilar animal of the same species. Angiogenesis The formation of new blood vessels. Anomaly abnormality Autosome a chromosome other than the X and Y sex-determining chromosomes. Camptomelia bending of the limbs that produce a permanent curving or bowing. Cholestasis a condition caused by rapidly developing or long-term interruption in the excretion of bile (a digestive fluid that helps the body process fat). Chondrodysplasia Congenital dwarfism similar to but milder than achondroplasia, not familial and not evident until mid-childhood, in which the skull and facial features remain normal. Chorioamnionitis Inflammation of the fetal membranes. Dystocia Difficult delivery or parturition. Erythema infectiosum mild infectious disease occurring mainly in early childhood, marked by a rosy-red maculopapular rash on the cheeks, often spreading to the tr Causes of Stillbirth Causes of Stillbirth Abstract: Feto-infant mortality is increasing worldwide. Stillbirth is defined as uterofetal death at 20 weeks of gestation or greater. Stillbirths contribute as a primary factor to the growing magnitude of feto-infant mortality. The reasons for stillbirth are usually not reported. In many cases, the specific cause of fetal death remains unknown. The key risk factors include smoking, increased maternal age, being overweight, fetal-maternal hemorrhage. Even though there has been remarkable development in prenatal and intranatal care, stillbirths have been consistently increasing and remain an important problem in obstetrics and gynecology. Current research studies focus mainly on the epidemiology of stillbirths. I review the known and suspected causes of stillbirth. It also describes the recommended diagnostic tests to evaluate definite cause of stillbirth. In this paper, I also review analysis of stillbirths in the United States (US). The National Center of Health Statistics recorded 26,359 stillbirths in 2001. The number of stillbirths can be greatly reduced if the specific reasons for stillbirth are understood. Introduction: A pregnancy ending in stillbirth can be mentally devastating to a patient and her family. The most widely accepted definition of stillbirth is death of the fetus inside the uterus at 20 weeks of gestation or greater (Cartlidge et al., 1995). Much information is available on protocols for evaluating other types of postmortem examination but little work has been done on the evaluation of the causes of stillbirths (Mirlene et al., 2004). No universally followed protocol is available to guide the evaluation of stillbirths. In part because a wide variety of causes can be involved in stillbirths and it can be difficult to designate a specific cause of death. A stillbirth might result from various diseases, infections, trauma or genetic defects in the mother or fetus (Gardosi et al., 2005). In many cases, a specific reason is not known. Even though stillbirths are a serious problem, few resources have been focused on them and most obstetricians lack a sound method of evaluating of stillbirths (Petersson, 2002). In this document, I will review the accepted causes of still birth and the suggested diagnostic tests for evaluating the reason behind stillborn infants. In the year 2001 in the US, the National Center of Health Statistics recorded 26,359 stillbirths (Ananth et al., 2005). When compared to 27,568 infant deaths were reported in the same year. More than half of the stillbirths are before 28 weeks of gestation and almost 20% are close to the term. If a history of stillbirth exists then there is a 5-fold increase for subsequent stillbirth to occur. Prominent racial discrimination occurs in the rates of stillbirths. Stillbirths are almost three times more prevalent in African Americans when compared to whites (Puza et al., 2006). In 2001, the rate of stillbirths among white mothers was 5.5 per 1000 live births and 12.1 per 1000 among the black mothers. According to an analysis of U.S. vital statistics between 1995 and 1998, the increased risk of black, compared with white, stillbirths is greatest among singleton stillbirths (Puza et al., 2006). Reduction of proportion of fetal deaths at gestation of 20weeks or longer to 4.1 per 1000 live births and also reduction of fetal deaths for all racial and ethnic groups are the objectives of U.S. National Health for 2010. Categorization of Stillbirths: Different attempts were made in order to classify causes of stillbirth. Baird and his colleagues were among the first to classify the causes of perinatal death from the available clinical information. Depending on the British perinatal mortality survey, in 1958 Butler and Bonham designed a classification scheme that included the results of postmortem examinations. The most widely used is the 9 category classification system formulated by Wigglesworth and his coworkers (Wigglesworth, 1980). A new classification scheme which does not include neonatal deaths was proposed by Gardosi and his colleagues known as the ReCoDe Classification which focuses on the relevant conditions at the time of death in the uterus. It includes factors which affect the fetus followed by the factors which affect the mother (Gardosi et al., 2005). When compared with the Wigglesworth classification, a remarkable decrease in the number of unclassified stillbirth was achieved using this classification. One of the most vital aspects is to develop a proper definition of the factors that lead to death of the fetus. The basic definition for the â€Å"cause of death† is injury or disease responsible for a death. Froendefined cause of death in stillbirth as â€Å"an event or condition of sufficient severity, magnitude, and duration for death to be expected in a majority of such cases in a continued pregnancy in the clinical setting where it was observed† (Froen, 2002). When the definition of â€Å"cause of death† is reviewed, it is observed that only a few disorders are directly responsible for fetal death while many others are not. Causes of Stillbirth: Infection: Infections such as viral, protozoal and bacterial are linked with stillbirth. Almost 10-25% of stillbirths result from feto-maternal infections in the developed countries where as bacterial infections are common in developing countries (Goldenberg et al., 2003). Stillbirths that result from infection might be due to various factors which include direct infection, placental damage, and severe maternal illness. Usually the stillbirths in the initial weeks of gestation are linked with infection. Bacterial infections caused by Escherichia coli, group B streptococci, and Ureaplasma urealyticum are a cause of stillbirth in developed countries (Goldenberg et al., 2003). If syphilis epidemic occurs in an area then it might be the cause of a considerable proportion of stillbirths. If women come in contact with a parasite like malaria for the first time then stillbirth might be attributed to it. Toxoplasma gondii, leptospirosis, Listeria monocytogenes, Q fever, and Lyme disease are associated with the occurrence of stillbirth (Goldenberg et al., 2003). The magnitude of stillbirths due to viral infections is not known mainly due to the absence of a well defined systematic evaluation of infections in stillborn infants. The problem lies behind the fact that these viruses are difficult to culture and moreover, a positive viral serological diagnostic test identifying the DNA or RNA of the virus in the fetal tissue or placental tissue does not definitely determine that infection was the reason behind death. In most of the cases, infection is linked with stillbirth in early gestational weeks around twenty weeks. If molecular diagnostic technology (DNA and RNA polymerase chain reaction [PCR]) is utilized, it will help in diagnosis of viral infections without any error. Parvovirus B-19 appears to have the strongest association with stillbirth. According to a Swedish survey, in 8%of stillbirths B-19 PCR positive tissues were observed (Enders et al., 2004). In the United States, less than 1% of all stillbirths are reported to be due to parvovirus infection Parvovirus B19 moves across the placenta spreading the infection to fetal erythropoetic tissue resulting in fetal anemia leading to fetal death (Wapner et al., 2002). Myocardial damage may also occur due to Parvovirus B19. Here the virus directly attacks the fetal cardiac tissue. Parvovirus infection that leads to stillbirth usually occurs before 20 weeks of gestation (Wapner et al., 2002). Enteroviruses which include Coxsackie A and B, echoviruses and other enteroviruses are associated with stillbirth. Coxsackie viruses can cross the placenta and lead to villous necrosis, inflammatory cell infiltration, calcific pancarditis, and hydrops. Echovirus infection begins with severe maternal illness and finally ends with stillbirth. Cytomegalovirus (CMV) belongs to herpesvirus family and it is a congenital viral infection. Initially, the mother is infected and then it is transmitted to the fetus. CMV causes placental damage leading to intrauterine fetal growth restriction, but an association with stillbirth remains controversial (Goldenberg et al., 2003). Viral infections in the mother like rubella, mumps and measles are linked with stillbirth. If the vaccinations are administered on time then the proportion of stillbirths occurring due to infections can be reduced greatly. Genetics: Genetic causes are responsible for a considerable magnitude of stillbirths. 6- 12% of stillbirths attributed to genetic etiologies are due to karyotyping abnormalities. Due to the fact that in some of the cases cells cannot be cultured, karyotyping is not possible. Such factors alter the exact estimate of stillbirths resulting from chromosomal abnormalities. In stillborn fetuses which show apparent structural defects the probability of chromosomal abnormality is much higher when compared to normal stillborn fetuses. The usually focused abnormalities include monosomy X (23%), trisomy 21 (23%), trisomy 18 (21%), and trisomy 13 (8%). There are many instances where the karyotype of the stillborn is normal yet the cause of death is a genetic abnormality. Indeed, 25-35% of stillborn infants undergoing autopsy have intrinsic abnormalities (Wapner et al., 2002) .These include single malformations (40%), multiple malformations (40%), and deformations or dysplasia (20%) (Wapner et al., 2002). Almost 25% ofstillborns due to intrinsic defects show an abnormal karyotype whereas the rest of the 75% may have genetic defects which are not identifiable by the regular cytogenetic tests. This holds good for fetuses with multiple abnormalities. Single gene mutations may be responsible for death of the fetus in early weeks of development. Stillbirths in the midgestational weeks might be due to abnormal placental growth, development, or angiogenesis. Some autosomal recessive disorders including glycogen storage diseases and hemoglobinopathies have been reported as the cause of stillbirth (Wapner et al., 2002). In male fetuses, X-linked disorders may prove to be fatal. Many other genetic defects that are not recognized by the conventional cytogenetic diagnostics may lead to stillbirth. For example, conventional karyotype cannot identify chromosomal microdeletions that are linked with unexplained mental retardation. Confined placental mosaicism has also been associated with fetal growth impairment and stillbirth (Kalousek et al., 1994). Heritable Thrombophilia is another probable etiology of stillbirth.It is thought that placental infarction occurs due to thrombosis in the uteroplacental circulation leading to death. This poses concern over other thrombophilic defects and their effects on stillbirth. It is noteworthy that many heritable thrombophilias are common in normal individuals without a history of thrombosis or pregnancy loss (Rey et al., 2003). Even though many studies relate thrombophilias to fetal loss, most of the women with thrombophilias have healthy pregnancies with no lethal complications. It can be said that in the absence of any previous obstetric problems, thrombophilia will not result in stillbirth. Feto-maternal Hemorrhage: Feto-maternal hemorrhage has been linked to almost 3- 14% of all stillbirths which implies that it is responsible for a considerable number of stillbirths. Obstetric procedures such as external cephalic version and cesarean section lead to fetal maternal hemorrhage. Hemorrhage can also result due to placental abruption and/or abdominal trauma during pregnancy. Fetal maternal hemorrhage must be identified and quantitated using a proper dependable diagnostic test to attribute this reason behind the death of fetus. Hypoxia and anemia are indicators of death due to fetal hemorrhage. So, they should be confirmed by autopsy as in some normal cases too, few fetal cells can be seen in maternal blood. Maternal Features: Delayed child bearing or increased maternal age, prepregnancy obesity and stress are found to have their effects on the occurrence of stillbirth. The underlying mechanisms of action are unknown; however, with both obesity and delayed child-bearing on the rise, their importance as potential causes of stillbirth deserves greater attention (Cnattingius et al., 2002). Women whose only risk factor is being overweight have about a 2-fold increased risk of stillbirth (Nohr et al., 2005). Likewise, compared with women younger than 35 years of age, the stillbirth rate is increased 2- fold for women 35-39 years of age, and 3- to 4-fold for women aged 40 years old or olderwhereas some age-associated risk is due to higher rates of maternal complications, in uncomplicated pregnancies there may be a 50% increased risk associated only with maternal age 35 years or older (Nohr et al., 2005). Stress is a suspected cause of stillbirth which might occur as a result of a major life event (such as loss or poverty) (Huang et al., 2000) or through unexplained health changes related to adverse childhood experiences (Hillis et al., 2004). Different exposures are attributed to stillbirth. One of the most prevalent and preventable cause of stillbirth is cigarette smoking (Hillis et al., 2004). Smoking negatively affects fetal growth and oxygen supply to the tissues as it produces high levels of carboxyhemoglobin and decreases blood supply to the placenta. Smoking is also associated with increased risks of placenta previa and placental abruption and women who stop smoking in the first trimester have stillbirth rates equivalent to women who never smoked which indicates that quitting smoking in early pregnancy may significantly reduce the chances of occurrence of stillbirth (Hillis et al., 2004). A variety of complications result due to continuous exposure of different recreational drugs. Consumption of cocaine during pregnancy is also linked with stillbirth because it causes fetal growth restriction and/or abruption. The use of meth amphetamines leads to premature deliveries and stunted growth but its association with stillbirth remains unknown. In some cases, alcohol consumption during pregnancy has been associated with an increased risk of stillbirth (Mary et al., 2006). According to a study in Scandinavia, for women who consume less than 1 drink per week, the rate of stillbirth is 1.37 per 1000 births while the rate increases to 8.83 per 1000 births in women who consume 5 drinks or more per week. If smoking habits, caffeine intake, prepregnancy body mass index, marital status, occupational status, education, parity, and fetal gender are considered, the risk of stillbirth for women consuming 5 drinks or more per week was 2.96 (95% confidence interval 1.37 to 6.41) (Mary et al., 2006). Some studies show a protective effect on both stillbirth and fetal growth restriction rates if small amounts of alcohol are consumed during pregnancy (Mary et al., 2006). A link between pesticide exposure and stillbirth was observed by Pastore and his colleagues in 1997. Occupational exposures prove to be deleterious compared to residential exposure because the occupational exposures cause congenital abnormalities in addition to risk of stillbirth. A noteworthy fact is that the use of fertility drugs is also associated with stillbirths. This finding is problematic due to the fact that many women make use of fertility treatments to conceive. However, data on stillbirths due to exposures is obtained from retrospective studies which are prone to bias. The link between exposures and stillbirth should therefore be dealt with great attention and care. Maternal Diseases: Diabetes: There is always an increased danger of stillbirths in second and third trimester for mothers who are affected with type I or type II diabetes mellitus (DM) pregestationally. Even with modern obstetric care and diabetes management, stillbirth rates in women with type 2 DM have been reported to be 2.5-fold higher than nondiabetic women (Mary et al., 2006). The rate of stillbirth is the same between women with gestational diabetes (GDM) as well as normal women when the whole population is taken into account. The magnitude of danger involved with fetal death in women with type II DM is identical to women with GDM who in fact entered the pregnancy with undiagnosed type II DM. Therefore, women with GDM who have an undiagnosed type II DM are usually at a greater danger of encountering stillbirth. Examples of women with undiagnosed type II DM include history of GDM in previous pregnancies, high fasting glucose values;random glucose values greater than 200mg/dL or diagnosis of GDM early in pregnancy. The reason behind fetal death in late gestation in diabetic women is not known precisely. In addition to an increased risk of fetal death in diabetic women, there also exists a higher magnitude of danger associated with fetal abnormalities in these women compared to healthy women. Stress, hypertension and obesity complement each other in DM patients. In women with DM, there is a higher risk of stillbirth as it may lead to fetal abnormalities which may be either abnormally increased growth rate or retarded growth. To maintain the physiological range of the plasma glucose level, tremendous amounts of insulin is produced by the fetus resulting in fetal hyperglycemia. This fetal hyperglycemia is acquired from maternal hyperglycemia which finally results in fetal death due to excessive growth. The precise limit of plasma glucose level which poses a threat to the fetal life is not well defined. The most that could be done is to detect and deal with it using needed medications to lower the incidents of stillbirths.Many other maternal diseases have been linked to stillbirth, including thyroid disease, cardiovascular disease, asthma, kidney disease, and systemic lupus erythematosus (Simpson, 2002). These are subclinical diseases which in many cases has not been proven to be direct causes of stillbirth and women had normal pregnancies giving birth to healthy babies. Multiple Gestation and Stillbirth: Nearly 3% of all births and 10% of all stillbirths result from multiple pregnancies. According to national vital statistics, 1.8% of twin, 2.4% of triplet, 3.7% of quadruplet, and 5.6% of quintuplet fetuses suffered intrauterine fetal deaths (Salihu et al., 2003). The stillbirth rate among singleton pregnancies is approximately 0.5%. The reason behind fetal death in multiple pregnancies is difficult to be resolved when compared to singleton pregnancies. The broad causes of fetal death in multiple pregnancies include fetal growth retardation, preclamsia, abruption and cord accidents. It is vital to determine the chorionicity of multiple gestations as the rate of stillbirth is higher in monochorionic multiple gestations (Salihu et al., 2003) (Lynch et al., 2007). Assisted Reproductive Technology (ART) is an essential aspect in the occurrence of multiple pregnancies and stillbirth (Helmerhorst et al., 2004). Complications in Fetus: Fetal Growth Restriction: Some stillbirths result from fetuses which are smaller for a particular gestational age (SGA) compared to normal fetuses. Birth weight and risk of stillbirth are inversely proportional. If one increases, the other decreases. The main fact behind stillbirths in this condition is retardation of fetal growth and not the small size of fetus. An obstacle that occurs in determining the precise time of death of fetus due to SGA is the fact that the death might have occurred a long time before but the gestational age at the time of delivery is considered to be the time of death. This gives a false implication of the magnitude of stillbirths resulting from SGA. This problem can be solved by analysis of early and mid pregnancy placental hormones which are very specific for gestational periods (Smith et al., 2004). An evaluation of the amounts of these hormones relates directly to the time of death. Umbilical Cord Accidents: An increased number of stillbirths are due to â€Å"accidents† of umbilical cord like cord occlusion or blockage due to true knots, nuchal cords and compression of the cord. In almost 30% of normal healthy infant deliveries, nuchal cord and true knots in umbilical cords are observed. According to a study in Sweden, 9% of stillbirths were due to cord accidents (Petersson, 2002). Determination of cord accidents leading to fetal death by autopsy is smaller in proportion (up to 2.5%) (Horn et al., 2004). This difference indicates that in the absence of a proper cause, many times fetal death is attributed to cord entanglement. Due to the increased load of complications with live infants, little concern is expressed towards dead fetuses. In order to precisely relate a fetal death to cord accident, a clear indication of either hypoxic tissue injury or cord occlusion must be observed in autopsy. As nuchal cords are observed in normal deliveries also, the exact proportion of stillbirths due to cord accidents is biased. Obstetric Complications: Some of the obstetric complications are preclampsia, preterm premature rupture of membranes, preterm labor, cervical insufficiency, abruption, placenta previa, and vasa previa. These may either be direct or primary causes or may be indirect or secondary causes of stillbirth. Almost 10-19% of stillbirths occur due to abruption. Since cervical insufficiency or preterm labor lead to neonatal death, their role in causing stillbirth is not well defined. Evaluation of Stillbirth Stillbirth in itself may be emotionally devastating to many patients and their families. There the likelihood of carrying out genetic testing or autopsy on the fetus may not be readily agreeable from the family and culture. Lastly the procedures for evaluation must be cost effective and within reach. The two important facts that should be kept in mind while deciding which tests would prove as the most useful ones are primarily the consideration of cost of that test. It should not be beyond limits. Secondarily, if this test would be helpful in prevention of recurrent or sporadic stillbirths. In recurrent stillbirths, medical interference may prove helpful by preventing them in future. Analyzing the etiology of sporadic stillbirths might lead to reassurance and avoid irrelevant diagnostic tests in future pregnancies. The single most useful diagnostic test is a fetal autopsy (Peterson et al., 1999). Not only does the visible genetic and structural abnormalities but also an autopsy would be of great help in relating specific etiologies to stillbirth. The frequency of fetal autopsy is very less due to the fact that it is costly, not many trained pathologists are available and also it may be of great discomfort to the family and clinicians to deal with such a case. If autopsy is refused, partial autopsy or postmortem magnetic resonance imaging (MRI) scans may provide the necessary data. Embryonic membranes, placenta and umbilical cord must be physically and histologically examined while evaluating stillbirth etiology. This would give a precise cause of fetal death and might also provide clues for death due to secondary causes like infections, thrombophilia, and anemia. In most cases, families do not object on placental evaluation. In the cases where autopsy is not performed karyotyping the fetus would prove helpful. Cells and tissues from placenta (especially chorionic plate), fascia lata, skin from the nape of the neck, and tendons can be isolated and cultured and used for diagnostic tests like karyotyping. Comparative genomic hybridization shows tremendous promise for the identification of chromosomal abnormalities in stillbirths wherein fetal cells cannot be successfully cultured (Silver et al., 2006). An autopsy followed by a careful histological examination might help in relating stillbirths that result due to infections from the bacteria or virus. Parvovirus serology may be useful because this virus has been implicated in a meaningful proportion of cases (Erik et al., 2002). Diagnostic tests are performed for the detection of syphilis also since it contributes to the list of accepted causes of stillbirth. For various viral and protozoal agents like toxoplasmosis, rubella, cytomegalovirus (CMV) and herpes simplex virus (HSV) {TORCH}, serological screening is carried out. For bacterial and viral infections in the fetus, nucleic acid based tests are more helpful when compared to tissue cultures. Feto-maternal hemorrhage can be detected using Kleihauer – Betke test (KBT). Most laboratories use manual KBT which is prone to error. It has been found that flow cytometry is a better tool in detecting fetal erythrocytes in maternal blood. In order to eliminate red cell alloimmunization as an etiology of stillbirth, an indirect Coomb’s test is performed. Autopsy and examination of placenta are helpful in this situation. During the initial prenatal visits, if the antibody screen comes out to be negative then there is a need for recurrent testing. Diagnostic tests for conditions like diabetes and heritable thrombophilias must be carried out on a regular basis to prevent any complications which may lead to stillbirth. The treatment of such conditions at the appropriate time may prevent similar complications in subsequent pregnancies. Heritable thrombophilia might be of concern in the cases where there is recurrent fetal loss or there is a history of thrombosis or with complications involving placental insufficiency like placental infarction and intrauterine growth restriction. Administration of illicit drugs through various modes may be a cause of stillbirth in many cases. Toxicological examination may reveal the results for women who are subjected to such exposures. A simple urinary examination may prove helpful. The advanced and cost effective technology like ELISA (Enzyme Linked Immuno Sorbent Assay) can be used to detect a variety of metabolites like steroids in various tissues like blood, hair, and homogenized umbilical cord. Conclusion: Many medical and nonmedical agents govern the best approach to evaluate a stillbirth. The obstacles faced by obstetricians in solving these issues include the fact that in most of the cases the reason behind fetal death is unknown. Also the magnitude of stillbirths resulting from a single cause is not known precisely. Here there arises a need for population based studies to attribute stillbirths to their specific etiologies. There is a clear cut need of experts in the field of perinatal pathology and the required funding should be provided at the national level to promote it. Moreover, the clinician should be aware of the history of pregnant women in better evaluation. In cases where the local clinicians cannot reach a conclusion, the tissue samples must be sent to senior pathologists who have a thorough command on the subject and can help in reaching decisive conclusions. A universally accepted protocol is required for a systematic evaluation of stillbirths. Due to its absence a difference of opinion occurs among the obstetricians and gynecologists. The institutions like Stillbirth Collaborative Research Network should formulate guidelines for the proper judgement of stillbirth etiologies. The responsibility lies in the hands of the clinicians to do the best they can to reach a definite conclusion from the available data. It is noteworthy that the proportion of stillbirths that are â€Å"explained† is much higher in centers using systematic evaluations for recognized causes and potential causes of stillbirth (Petersson, 2002) (Horn et al., 2004). In conclusion, autopsy, placental evaluation, karyotype, Kleihauer-Betke, antibody screen, and serologic test for syphilis are useful in evaluating the etiologies of stillbirth. Depending on the case, other relative tests should be performed. The approach towards the testing of potential causes of stillbirth is not clear if it should be very specific and sequential or should it be comprehensive which means that it is targeted towards a broad spectrum of causes. Each of these has its own advantage. Sequential testing avoids false positive results and is directed to a specific cause and more over, it is cost effective. Comprehensive testing may prove helpful in cases where more than one factor is responsible for stillbirth. The problem with autopsy, placental evaluation, karyotype, screen for fetal-maternal hemorrhage, and toxicology screen is that they are dependant on time, that is, these tests should be performed immediately after the delivery. Autopsy cannot be delayed because death of the fetus already occurred and this would lead to physiological changes in the whole body and decay begins. The necessary evidence for stillbirth is easily available from fresh samples of placenta and also for toxicology screen. As the time since death increases, the physiology of fetus also changes leading to false positive or false negative results. If the time of fetal examination is delayed, fetal hemorrhage may be mistaken for postmortem lividity. Therefore a serious call for action is expected from institutions like Stillbirth Collaborative Research Network (SCRN) which would help in creating the most applicable diagnostic setting for evaluation of stillbirth (Silver et al., 2006). SCRN was developed by the National Institute of Child Health and Human Development to target the range of etiologies of stillbirth in the U.S. The aim of SCRN is to focus on the following objectives. The use of standardized surveillance in a geographic catchment area will show that the stillbirth rates are greater than those reported in the vital statistics catchment. The use of a prospectively implemented, standardized, postmortem, and placental examination protocols will improve diagnosis of fetal or placental conditions that cause or contribute to stillbirth. Maternal biologic and environmental risk factors in combination with genetic predisposition increase the risk for stillbirth. This is a population based study which is carried out in different counties of different states in the U.S. This study would take into account all the stillbirths and live births occurring in rural as well as urban areas in different racial groups. Even though occurrence of stillbirths cannot be stopped completely, yet attempts of such sort can be made atleast to prevent them to a maximum extent. Glossary Abruptio placenta totalis A placental abruption is a serious condition in which the placenta partially or completely separates from the uterus before the baby is born. Achondrogenesis Dwarfism characterized by various bone aplasias and hypoplasias of the extremities and a short trunk with delayed ossification of the lower spine. Alloimmunization Development of antibodies in response to alloantigens; antigens derived from a genetically dissimilar animal of the same species. Angiogenesis The formation of new blood vessels. Anomaly abnormality Autosome a chromosome other than the X and Y sex-determining chromosomes. Camptomelia bending of the limbs that produce a permanent curving or bowing. Cholestasis a condition caused by rapidly developing or long-term interruption in the excretion of bile (a digestive fluid that helps the body process fat). Chondrodysplasia Congenital dwarfism similar to but milder than achondroplasia, not familial and not evident until mid-childhood, in which the skull and facial features remain normal. Chorioamnionitis Inflammation of the fetal membranes. Dystocia Difficult delivery or parturition. Erythema infectiosum mild infectious disease occurring mainly in early childhood, marked by a rosy-red maculopapular rash on the cheeks, often spreading to the tr