title: Natality decline and miscarriages associated with the 1918 influenza pandemic: the Scandinavian and United States experiences.
abstract: BACKGROUND
  Although pregnancy is a recognized risk factor for severe influenza infection, the effect of influenza on miscarriages and births remains unclear. We examined the relationship between influenza and birth rates during the 1918 pandemic in the United States, Denmark, Sweden, and Norway.
  
  
  METHODS
  We compiled monthly birth rates from 1911 through 1930 in 3 Scandinavian countries and the United States, identified periods of unusually low or high birth rates, and quantified births as "missing" or "in excess" of the normal expectation. Using monthly influenza data, we correlated the timing of peak pandemic exposure and depressions in birth rates, and identified pregnancy stages at risk of influenza-related miscarriage.
  
  
  RESULTS
  Birth rates declined in all study populations in spring 1919 by a mean of 2.2 births per 1000 persons, representing a 5%-15% drop below baseline levels (P < .05). The 1919 natality depression reached its trough 6.1-6.8 months after the autumn pandemic peak, suggesting that missing births were attributable to excess first trimester miscarriages in ∼1 in 10 women who were pregnant during the peak of the pandemic. Pandemic-related mortality was insufficient to explain observed patterns.
  
  
  CONCLUSIONS
  The observed birth depressions were consistent with pandemic influenza causing first trimester miscarriages in ∼1 in 10 pregnant women. Causality is suggested by temporal synchrony across geographical areas.
authors.affiliation: Division of International Epidemiology and Population Studies, Fogarty International Center, National Institutes of Health, Bethesda, Maryland 20892, USA. kimberlybf@gmail.com
authors.forename: Kimberly
authors.initials: K
authors.lastname: Bloom-Feshbach
authors.forename: Lone
authors.initials: L
authors.lastname: Simonsen
authors.forename: Cécile
authors.initials: C
authors.lastname: Viboud
authors.forename: Kåre
authors.initials: K
authors.lastname: Mølbak
authors.forename: Mark A
authors.initials: MA
authors.lastname: Miller
authors.forename: Magnus
authors.initials: M
authors.lastname: Gottfredsson
authors.forename: Viggo
authors.initials: V
authors.lastname: Andreasen
mesh_terms: D000022:Abortion, Spontaneous / Q000453:epidemiology / Q000821:virology*; D001723:Birth Rate; D016001:Confidence Intervals; D005260:Female; D006801:Humans; D009980:Influenza A virus / Q000302:isolation & purification*; D007251:Influenza, Human / Q000453:epidemiology* / Q000401:mortality / Q000821:virology; D015233:Models, Statistical; D058873:Pandemics; D011247:Pregnancy; D011251:Pregnancy Complications, Infectious / Q000453:epidemiology* / Q000401:mortality / Q000821:virology*; D012189:Retrospective Studies; D012537:Scandinavian and Nordic Countries / Q000453:epidemiology; D014481:United States / Q000453:epidemiology