Search

OBJECTIVES: We examined the relationship between obstetrical intervention and preterm birth in the United States between 1991 and 2006. METHODS: We assessed changes in preterm birth, cesarean delivery, labor induction, and associated risks. Logistic regression modeled the odds of preterm obstetrical intervention after risk adjustment. RESULTS: From 1991 to 2006, the percentage of singleton preterm births increased 13%. The cesarean delivery rate for singleton preterm births increased 47%, and the rate of induced labor doubled. In 2006, 51% of singleton preterm births were spontaneous vaginal deliveries, compared with 69% in 1991. After adjustment for demographic and medical risks, the mother of a preterm infant was 88% (95% confidence interval [CI] = 1.87, 1.90) more likely to have an obstetrical intervention in 2006 than in 1991. Using new birth certificate data from 19 states, we estimated that 42% of singleton preterm infants were delivered via induction or cesarean birth without spontaneous onset of labor. CONCLUSIONS: Obstetrical interventions were related to the increase in the US preterm birth rate between 1991 and 2006. The public health community can play a central role in reducing medically unnecessary interventions. [ABSTRACT FROM AUTHOR]

BACKGROUND: As cesarean rates increase worldwide, a debate has arisen over the relationship of method of delivery to maternal postpartum physical health. This study examines mothers' reports of their postpartum experiences with pain stratified by method of delivery. METHODS: Listening to Mothers II was a survey of a total of 1,573 (200 telephone and 1,373 online) mothers aged 18 to 45 years, who had a singleton, hospital birth in 2005. They were interviewed by the survey research firm, Harris Interactive, in early 2006. Online respondents were drawn from an existing Harris panel. Telephone respondents were identified through a national telephone listing of new mothers. Results were weighted to reflect a United States national birthing population. Mothers were asked if they experienced any of eight postpartum conditions and the extent and the duration of the problem. Responses were compared by method of delivery. RESULTS: The most frequently cited postpartum difficulty was among mothers with a cesarean section, 79 percent of whom reported experiencing pain at the incision in the first 2 months after birth, with 33 percent describing it as a major problem and 18 percent reporting persistence of the pain into the sixth month postpartum. Mothers with planned cesareans without labor were as likely as those with cesareans with labor to report problems with postpartum pain. Almost half (48%) of mothers with vaginal births (68% among those with instrumental delivery, 63% with episiotomy, 43% spontaneous vaginal birth with no episiotomy) reported experiencing a painful perineum, with 2 percent reporting the pain persisting for at least 6 months. CONCLUSIONS: Substantial proportions of mothers reported problems with postpartum pain. Women experiencing a cesarean section or an assisted vaginal delivery were most likely to report that the pain persisted for an extended period. [ABSTRACT FROM AUTHOR]

BACKGROUND: The percentage of United States births delivered by cesarean section continues to increase, even for women considered to be at low risk for the procedure. The purpose of this study was to use an 'intention-to-treat' methodology, as recommended by a National Institutes of Health conference, to examine neonatal mortality risk by method of delivery for low-risk women. METHODS: Low-risk births were singleton, term (37-41 weeks' gestation), vertex births, with no reported medical risk factors or placenta previa and with no prior cesarean section. All U.S. live births and infant deaths for the 1999 to 2002 birth cohorts (8,026,415 births and 17,412 infant deaths) were examined. Using the intention-to-treat methodology, a 'planned vaginal delivery' category was formed by combining vaginal births and cesareans with labor complications or procedures since the original intention in both cases was presumably a vaginal delivery. This group was compared with cesareans with no labor complications or procedures, which is the closest approximation to a 'planned cesarean delivery' category possible, given data limitations. Multivariable logistic regression was used to model neonatal mortality as a function of delivery method, adjusting for sociodemographic and medical risk factors. RESULTS: The unadjusted neonatal mortality rate for cesarean deliveries with no labor complications or procedures was 2.4 times that for planned vaginal deliveries. In the most conservative model, the adjusted odds ratio for neonatal mortality was 1.69 (95% CI 1.35-2.11) for cesareans with no labor complications or procedures, compared with planned vaginal deliveries. CONCLUSIONS: The finding that cesarean deliveries with no labor complications or procedures remained at a 69 percent higher risk of neonatal mortality than planned vaginal deliveries is important, given the rapid increase in the number of primary cesarean deliveries without a reported medical indication. [ABSTRACT FROM AUTHOR]

Objectives: To examine the national policymaking process in maternal and child health through a case study of the passage of a national law aimed at extending postpartum hospital stays. Methods: The study is based on a review of official and unofficial documents associated with the bill's legislative progress as well as an examination of scholarly research on early discharge and media coverage of the issue. Interviews were also conducted with legislative and interest group staff. Results: The passage of early discharge legislation occurred in an unusually short time frame and was aided by its minimal public costs, the willingness of its supporters to compromise on key elements, and its perceived appeal to female voters in an election year. Clinical and public health research had little influence on the process. Conclusions: Maternal and child health advocates, while facing a problem with a politically weak constituency base, can benefit from their important symbolic role in policymakers' minds. They must respect the importance of compromise to legislative institutions and be alert to opportunities to frame their issues in a politically popular way. [ABSTRACT FROM AUTHOR]

Media accounts of the Ockenden report give the impression that midwives are ultimately responsible for the deaths that occurred at SaTH and that perinatal deaths would be reduced by increased use of caesarean sections. Such a pause is not only a disservice to mothers and midwives - CoC with appropriate staffing levels reduces preterm births, medical interventions, and staff burnout - but it ignores what we know about medical organisations. We thank the Ockenden team for their response[1] to our critical look at their review of the maternity services at the Shrewsbury and Telford Hospital NHS Trust (SaTH). [Extracted from the article]

Objective: This study evaluated the short- and long-term cardiovascular- and cancer-related morbidities during cross-sex hormone therapy in a large sample of trans persons. Subjects and methods: A specialist center cross-sectional study compared 214 trans women (male-to-female transsexual persons) and 138 trans men (female-to-male trans persons) with an age- and gender-matched control population (1-3 matching). The participants were on cross-sex hormone therapy for an average of 7.4 years. We assessed physical health and possible treatmentrelated adverse events using questionnaires. Results: Five percent of trans women experienced venous thrombosis and/or pulmonary embolism during hormone therapy. Five of these adverse events occurred during the first year of treatment, while another three occurred during sex reassignment surgery. Trans women experienced more myocardial infarctions than the control women (P=0.001), but a similar proportion compared with control men. The prevalence of cerebrovascular disease (CVD) was higher in trans women than in the control men (P=0.03). The rates of myocardial infarction and CVD in trans men were similar to the control male and female subjects. The prevalence of type 2 diabetes was higher in both trans men and women than in their respective controls, whereas the rates of cancer were similar compared with the control men and women. Conclusion: Morbidity rate during cross-sex hormone therapy was relatively low, especially in trans men. We observed a higher prevalence of venous thrombosis, myocardial infarction, CVD, and type 2 diabetes in trans women than in the control population. Morbidity rates in trans men and controls were similar, with the exception of the increased prevalence of type 2 diabetes. [ABSTRACT FROM AUTHOR]

To examine trends in repeat cesarean delivery, the characteristics of women who have repeat cesareans, and the risk of neonatal mortality for repeat cesarean birth compared to vaginal birth after cesarean (VBAC). Trends and characteristics of repeat cesareans were examined for: the period 1998-2002 for [] all births, [] low-risk births (singleton, term, vertex births) and [] 'no indicated risk' (NIR) births (singleton, term, vertex presentation births with no reported medical risks or complications). For low-risk and NIR births, neonatal mortality rates for repeat cesareans and VBACs were compared. Multivariate logistic regression was used to examine the risk of neonatal mortality for repeat cesareans and VBACs, after controlling for demographic and health factors. In 2002 the repeat cesarean rate was 87.4%, and varied little by maternal risk status or by demographic and health characteristics. From 1998-2002 rates increased by 20% for low risk and by 21% for NIR births, respectively. For low-risk women for the 1998-2002 birth cohorts, the adjusted odds ratio for neonatal mortality associated with repeat cesarean delivery (compared with VBAC) was 1.36 (95% C.I. 1.20-1.55). For NIR women, the adjusted odds ratio was 1.24 (0.99-1.55). The experience of a prior cesarean has apparently become a major indication for a repeat cesarean. Regardless of maternal risk status, almost 90% of women with a prior cesarean have a subsequent (i.e., repeat) cesarean delivery. This is the case even if there was no other reported medical indication. Our findings do not support the widely-held belief that neonatal mortality risk is significantly lower for repeat cesarean compared to VBAC delivery. [ABSTRACT FROM AUTHOR]

The current US addiction treatment system does not effectively meet the needs of pregnant and parenting women with substance use disorder (SUD). The aim of this research was to identify barriers and facilitators to engagement and retention in SUD residential treatment for pregnant and parenting women. This research was part of a co-design process to collaboratively create a more patient-centered long-term residential program. The study conducted semi-structured individual interviews with both parenting women with lived experience (WWLE) in residential SUD treatment and SUD treatment providers. Interviews aimed to elicit participants' experiences either receiving or providing care. The study team analyzed data in NVivo-12 using a deductive codebook based on the six principles of trauma informed care (TIC). We conducted a total of 32 interviews (WWLE =13, SUD providers =19). The study identified four major themes: 1) peer relationships provide inspiration and diminish shame; 2) providing individuals safe space to stumble in recovery creates opportunities for growth and builds self-efficacy; 3) reasonable, clear boundaries create a structured, protective environment for early recovery; 4) nonjudgmental connections facilitate engagement and build trust. We identified small pivotal moments along the continuum of care that showed how the elements in the four themes enhanced engagement and retention in treatment. These interactions, along the care continuum, are either structural (workflow process) or relational (interpersonal). This research increases understanding of the interplay of the structural and relational barriers and facilitators to engagement and retention in treatment. These seemingly minor positive or negative interactions along the care continuum are pivotal to fully operationalizing TIC and optimizing women's engagement in treatment. Improvement strategies that integrate the voices of WWLE and collaboratively co-design a more patient-centered system are critical steps to improving engagement in SUD treatment and more equitable SUD treatment services. • Identifies barriers and facilitators for pregnant and parenting women's engagement in residential treatment • Qualitative insights into creating opportunities for building self-efficacy and non-judgmental interpersonal connection • Identifies pivotal interactions andactionable approaches for operationalizing trauma informed care along the care continuum [ABSTRACT FROM AUTHOR]

Objective:To describe maternal and perinatal morbidity and mortality associated with uterine rupture (UR) among women with prior cesarean/s, singleton term pregnancies and a trial of labor after cesarean (TOLAC).Study Design:Linked hospital discharge files and birth/fetal death certificates identified potential cases of UR in Massachusetts from 1990 to 1998 with definitive identification by medical record abstraction.Result:Among the 347 identified URs, severe outcomes occurred in 86 cases (25%), in 49 (14%) of mothers and 49 (14%) of infants. Of the infants, 25 were discharged with a good prognosis. Maternal age and interdelivery interval <18 months (relative risk (RR)=1.55; 95% confidence interval (CI): 1.05, 2.31) were associated with a severe outcome. The type of hospital and labor were not associated with the increased risk of a severe outcome.Conclusion:Assuming a 0.7% UR rate among women at term with a TOLAC, the increased rate of severe outcomes related to UR above the baseline risk of elective cesarean is estimated to be 1.3 per 1000 TOLACs. [ABSTRACT FROM AUTHOR]

In 1998, the Damien Foundation Bangladesh invited semi-qualified, private 'gram dakter' (Bangla for 'village doctors') to participate in tuberculosis (TB) programmes in a population of 26 million people in rural Bangladesh. The organization trained 12 525 village doctors to not only refer suspected TB cases for free diagnosis but also to provide directly observed treatment (DOT) free of charge. Source of referral and place of DOT was recorded as part of the standardized TB recording and reporting system, which enabled us to quantify the contribution of village doctors to case detection rates and also allowed disaggregated cohort analysis of treatment outcome. During 2002 and 2003, 11% of all TB cases with positive sputum smears in the study area had been referred by village doctors; the rate of positive tests in patients referred by village doctors was 14.4%. 18 792 patients received DOT from village doctors, accounting for between 20% and 45% of patients on treatment during the 1998-2003 period. The treatment success rate was about 90% throughout the period. Urine samples taken during random checks of treatment compliance were positive for isoniazid in 98% of patients treated by village doctors. Within the framework of Public-Private Mix DOTS, services provided by semi-qualified private health care providers are a feasible and effective way to improve access to affordable high quality TB treatment in poor rural populations. The large informal health workforce that exists in resource poor countries can be used to achieve public health goals. Involvement of village doctors in TB control has now become national policy in Bangladesh. Copyright © 2006 World Health Organization [ABSTRACT FROM AUTHOR]

In 1998, the Damien Foundation Bangladesh invited semi-qualified, private "gram dakter" (Bangla for "village doctors") to participate in tuberculosis (TB) programmes in a population of 26 million people in rural Bangladesh. The organization trained 12 525 village doctors to not only refer suspected TB cases for free diagnosis but also to provide directly observed treatment (DOT) free of charge. Source of referral and place of DOT was recorded as part of the standardized TB recording and reporting system, which enabled us to quantify the contribution of village doctors to case detection rates and also allowed disaggregated cohort analysis of treatment outcome. During 2002 and 2003, 11% of all TB cases with positive sputum smears in the study area had been referred by village doctors; the rate of positive tests in patients referred by village doctors was 14.4%. 18 792 patients received DOT from village doctors, accounting for between 20% and 45% of patients on treatment during the 1998-2003 period. The treatment success rate was about 90% throughout the period. Urine samples taken during random checks of treatment compliance were positive for isoniazid in 98% of patients treated by village doctors. Within the framework of Public-Private Mix DOTS, services provided by semiqualified private health care providers are a feasible and effective way to improve access to affordable high quality TB treatment in poor rural populations. The large informal health workforce that exists in resource poor countries can be used to achieve public health goals. Involvement of village doctors in TB control has now become national policy in Bangladesh. [ABSTRACT FROM AUTHOR]