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Introduction Georgia's 2012 House Bill 954 (HB954) prohibiting abortions after 22 weeks from last menstrual period (LMP) has been associated with a significant decrease in abortions after 22 weeks. However, the policy's effects by race or ethnicity remain unexplored. We investigated whether changes in abortion numbers and ratios (per 1,000 live births) in Georgia after HB954 varied by race or ethnicity. Methods Using Georgia Department of Public Health induced terminations of pregnancy data from 2007 to 2017, we examined changes in number of abortions and abortion ratios (per 1,000 live births) by race and ethnicity following HB954 implementation. Results After full implementation of HB954 in 2015, the number of abortions and abortion ratios at or after 22 weeks (from last menstrual period) decreased among White (bNumber = -261.83, p Conclusion The full implementation of HB954 had differential effects by race/ethnicity and gestational age. Although abortion at 22 weeks or more decreased for all groups, abortion at less than 22 weeks increased among Black people. Additional research should elucidate the possible causes, consequences, and reactions to differential effects of abortion restrictions by race and ethnicity.

Objectives To determine trends for Georgia and contiguous state residents seeking abortions in Georgia between 1994 and 2016. Methods We analyzed aggregate vital statistics data, collected in Georgia, on Georgia residents (n = 675,995) and contiguous state residents (Alabama, Florida, North Carolina, South Carolina, Tennessee) (n = 76,232) obtaining abortion and delivery services in Georgia between 1994 and 2016. We examined demographic, pregnancy, and abortion characteristics using counts, ratios, and χ2 tests of proportion. Results Of the data analyzed, 10.1% of all abortions were for contiguous state residents. The number of abortions in Georgia for contiguous state residents increased 35.3% from 1994 to 2016 (from n = 3115 to n = 4216) while it decreased for Georgia residents by 11.1% (from n = 32,934 to n = 29,264). Contiguous state residents exhibited a higher abortion ratio (1115) compared to Georgia women (224). These populations exhibited statistically significant differences across all variables and time points. Both populations demonstrated similar trends in ethnicity, race, education, marital status, and age. However, contiguous state residents were more likely to obtain an abortion at ≥ 20 weeks gestational age (13.8%) and obtained a lower proportion of suction curettage abortions (60.0%) and a higher proportion of dilation and evacuation procedures (31.9%). They were also less likely to be primigravid. Conclusions for Practice Women from neighboring states seek abortions in Georgia later in gestation and may therefore lack affordable, safe, early abortion care in their home states. Understanding trends in travel for abortion can allow providers and policymakers to better respond to the needs of patients.

Background In population level studies, the conventional practice of categorizing women into low and high maternal risk samples relies upon ascertaining the presence of various comorbid conditions in administrative data. Two problems with the conventional method include variability in the recommended comorbidities to consider and inability to distinguish between maternal and fetal risks. High maternal risk sample selection may be improved by using the Obstetric Comorbidity Index (OCI), a system of risk scoring based on weighting comorbidities associated with maternal end organ damage. The purpose of this study was to compare the net benefit of using OCI risk scoring vs the conventional risk identification method to identify a sample of women at high maternal risk in administrative data. Methods This was a net benefit analysis using linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. We compared the value identifying a sample of women at high maternal risk using the OCI score to the conventional method of dichotomous identification of any comorbidities. Value was measured by the ability to select a sample of women designated as high maternal risk who experienced severe maternal morbidity or mortality. Results The high maternal risk sample created with the OCI had a small but positive net benefit (+ 0.6), while the conventionally derived sample had a negative net benefit indicating the sample selection performed worse than identifying no woman as high maternal risk. Conclusions The OCI can be used to select women at high maternal risk in administrative data. The OCI provides a consistent method of identification for women at risk of maternal morbidity and mortality and avoids confounding all obstetric risk factors with specific maternal risk factors. Using the OCI may help reduce misclassification as high maternal risk and improve the consistency in identifying women at high maternal risk in administrative data.

Objective This study explored the associations between delivery hospital self-reported level of maternal service, as defined by the American Hospital Association, and both maternal and neonatal outcomes among women at high maternal risk, as defined by the Obstetric Comorbidity Index. Methods This was a secondary analysis of linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. The need for maternal transfer was defined using a sample-specific cut-off of the risk score calculated using the Obstetric Comorbidity Index. Outcomes included poor maternal outcome (severe maternal morbidity or death), maternal length of stay, preterm delivery, low birth weight, and perinatal death. The analysis was completed using hierarchical logistic regression with a two-level model considering hospital level of maternal service and controlling for maternal race and transfer status. Results In these data, there was no difference in the odds of a poor maternal or neonatal outcome according to delivery hospital level of maternal care; however, delivery at a hospital with maternal service level III was associated with a higher odds of an extended length of stay. Conclusions For this group of pregnant women in need of maternal transfer, delivery hospital self-reported level of maternal care was not associated with the odds of poor maternal or neonatal outcomes. This study supports the need for improved definitions of hospital level of maternal services.

Introduction In Kenya, abortion is illegal under most circumstances, yet about 48 abortions per 1,000 women occurred in 2012. Given the stigma around abortion, little is known about the availability of safe abortion. Thus, we explored the feasibility and acceptability of using SMS mobile surveys to collect information about women's pregnancy and abortion histories in Kenya. Methods We sent a one-time mobile survey to 500 18–24 year old women who had opted-in to a 16,000-person mobile survey panel. Women elected to answer questions about pregnancy only (number of pregnancies, number of births, age at first pregnancy) or pregnancy and abortion (ever tried to obtain an abortion and whether medical treatment was sought for any complications). The final question for all survey versions was an open-ended question asking respondents how they felt answering these questions. Results 356 (71%) responded to the initial survey question and 333 (94%) consented to answer questions about pregnancy. Of these, 233 (70%) agreed to answer questions about just pregnancy and 76 (23%) agreed to answer questions about pregnancy and abortion. Three-quarters of respondents indicated that they had positive or neutral feelings about answering these questions over SMS. Lastly, all data was retrieved within 24 h of survey distribution allowing for immediate analysis and dissemination. Conclusion Women's willingness to share their pregnancy history suggests mobile surveys are a cost-effective and accessible method for gathering information on abortion in Kenya.

In 2015, the Democratic Republic of the Congo (DRC) recorded an estimated maternal mortality ratio of 693/100,000 live births. Strict abortion laws, high fertility rates, low contraceptive prevalence, and lack of emergency obstetric care all contribute to the high maternal mortality ratio. This study explored influences on contraceptive use and abortion in the DRC. Qualitative in-depth interviews were conducted with 32 women and 10 healthcare providers in four provinces. Participants were recruited at health centers and households in the study communities. Thematic analysis was used and identified that Congolese women's contraceptive decision-making was shaped by a range of external influences rather than their own independent decisions. Non- autonomous decisions and strict abortion laws influenced the methods used to abort a pregnancy, exposing risks of infection, complication, and fatality. These findings highlight that Congolese women's decisions about their fertility and family planning are constrained by policy and socio-cultural influences.

Since the decriminalisation of abortion in 2006, women in Colombia have continued to seek clandestine abortions, endangering their health and contributing to maternal mortality and morbidity. The goal of this study was to explore physicians' opinions towards and knowledge about legal abortion in Bogotá, Colombia, and key barriers to the legal abortion access. We conducted 13 key informant interviews followed by a survey with a probability sample of 49 doctors working in public hospitals in Bogotá. Interview and survey data showed lack of technical experience in the provision of abortion and nuanced opinions towards its practice. Key informants described ignorance and lack of abortion training in medical schools as key barriers to provision. In the survey, 16/49 respondents had performed an abortion, 24/49 had referred a woman for an abortion and only 33/49 showed correct knowledge of the law.

Summary Background In 2007, WHO launched a global initiative for the elimination of mother-to-child transmission of syphilis (congenital syphilis). An important aspect of the initiative is strengthening surveillance to monitor progress towards elimination. In 2008, using a health systems model with country data inputs, WHO estimated that 1·4 million maternal syphilis infections caused 520 000 adverse pregnancy outcomes. To assess progress, we updated the 2008 estimates and estimated the 2012 global prevalence and cases of maternal and congenital syphilis. Methods We used a health systems model approved by the Child Health Epidemiology Reference Group. WHO and UN databases provided inputs on livebirths, antenatal care coverage, and syphilis testing, seropositivity, and treatment in antenatal care. For 2012 estimates, we used data collected between 2009 and 2012. We updated the 2008 estimates using data collected between 2000 and 2008, compared these with 2012 estimates using data collected between 2009 and 2012, and performed subanalyses to validate results. Findings In 2012, an estimated 930 000 maternal syphilis infections caused 350 000 adverse pregnancy outcomes including 143 000 early fetal deaths and stillbirths, 62 000 neonatal deaths, 44 000 preterm or low weight births, and 102 000 infected infants worldwide. Nearly 80% of adverse outcomes (274 000) occurred in women who received antenatal care at least once. Comparing the updated 2008 estimates with the 2012 estimates, maternal syphilis decreased by 38% (from 1 488 394 cases in 2008 to 927 936 cases in 2012) and congenital syphilis decreased by 39% (from 576 784 to 350 915). India represented 65% of the decrease. Analysis excluding India still showed an 18% decrease in maternal and congenital cases of syphilis worldwide. Interpretation Maternal and congenital syphilis decreased worldwide from 2008 to 2012, which suggests progress towards the elimination of mother-to-child transmission of syphilis. Nonetheless, maternal syphilis caused substantial adverse pregnancy outcomes, even in women receiving antenatal care. Improved access to quality antenatal care, including syphilis testing and treatment, and robust data are all important for achieving the elimination of mother-to-child transmission of syphilis. Funding The UNDP-UNFPA-UNICEF-WHO-World Bank Special Programme of Research, Development and Research Training in Human Reproduction in WHO, and the US Centers for Disease Control and Prevention.

Objectives In 2010, Georgia had the nation's highest maternal mortality rate, sixteenth highest infant mortality rate, and a waning obstetrician/gynecologist (ob/gyn) workforce. Statewide ob/gyn workforce data, however, masked obstetric-specific care shortages and regional variation in obstetric services. The Georgia Maternal and Infant Health Research Group thereby assessed each Georgia region's obstetric provider workforce to identify service-deficient areas. Methods We identified 63 birthing facilities in the 82 Primary Care Service Areas (PCSAs) outside metropolitan Atlanta and interviewed nurse managers and others to assess the age, sex, and expected departure year of each delivering professional. Using accepted annual delivery rates of 155 per obstetrician (OB), 100 per certified nurse midwife (CNM), and 70 per family medicine physician (FP) we converted obstetric providers into "OB equivalents" to standardize obstetric services available in any given area. Using facility births and computed OB equivalents (contemporary and 2020 estimates), we calculated current and projected average annual births per provider (AABP) for each PCSA, categorizing its obstetric provider workforce as "adequate" (AABP 144), "at risk" (144 ≤ AABP ≤ 166), or "deficient" (AABP 166). We mapped results using ArcGIS. Results Of 82 surveyed PCSAs, 52 % (43) were deficient in obstetric care; 16 % (13) had a shortage and 37 % (30) lacked obstetric providers entirely. There were no delivering FPs in 89 % (73) of PCSAs and no CNMs in 70 % (56). If Georgia fails to recruit delivering providers, 72 % (58/77) of PCSAs will have deficient or no obstetric care by 2020. Conclusions Obstetric provider shortages in Georgia hinder access to prenatal and delivery services. Care-deficient areas will expand if recruitment and retention of delivering professionals does not improve.

OBJECTIVES: To systematically examine prevalence of first trimester prenatal care (FTPNC) in the 44 US counties and 80 Mexican municipios of the binational border region; and to describe disparities between border and nonborder areas within states border states and countries. METHODS: We combined 2009 records of singleton live births from the 10 US-Mexico border states (N=1370206) into a single file. We included FTPNC; county/municipio state and country of maternal residence; and demographic variables common to all records. We computed prevalence of FTPNC for border and nonborder residents by state and country. Using multivariable regression we computed adjusted prevalence ratios (aPR) for FTPNC in border relative to nonborder residents states relative to one another and the US relative to Mexico. RESULTS: In 2009 68.8% of US-Mexico border mothers and 72.9% of nonborder mothers received FTPNC. After adjustment nonborder residents had higher prevalence of FTPNC than border residents in Sonora New Mexico Arizona Coahuila and Chihuahua (aPR=1.09-124). In US states prevalence was 13%-36% higher in New Mexico Arizona and California than Texas. In Mexico when compared with Coahuila adjusted prevalence was 12%-20% higher in neighboring states. Between countries FTPNC prevalence in border counties/municipios was higher in Mexico among women with low parity/low education and in the United States among women with high parity/high education. CONCLUSIONS: In the US and Mexico women in border counties/municipios receive less timely prenatal care than their nonborder counterparts but the magnitude of the disparity varies by state. Lack of a consistent binational approach to birth data collection requires cautious interpretation of findings.

Background Rape, unintended pregnancy, and abortion are among the most controversial and stigmatized topics facing sexual and reproductive health researchers, advocates, and the public today. Over the past three decades, public health practicioners and human rights advocates have made great strides to advance our understanding of sexual and reproductive rights and how they should be protected. The overall aim of the study was to understand young women’s personal experiences of unintended pregnancy in the context of Nicaragua’s repressive legal and sociocultural landscape. Ten in-depth interviews (IDIs) were conducted with women ages 16–23 in a city in North Central Nicaragua, from June to July 2014. Case presentation This case study focuses on the story of a 19-year-old Nicaraguan woman who was raped, became pregnant, and almost died from complications resulting from an unsafe abortion. Her case, detailed under the pseudonym Ana Maria, presents unique challenges related to the fulfillment of sexual and reproductive rights due to the restrictive social norms related to sexual health, ubiquitous violence against women (VAW) and the total ban on abortion in Nicaragua. The case also provides a useful lens through which to examine individual sexual and reproductive health (SRH) experiences, particularly those of rape, unintended pregnancy, and unsafe abortion; this in-depth analysis identifies the contextual risk factors that contributed to Ana Maria’s experience. Conclusions Far too many women experience their sexuality in the context of individual and structural violence. Ana Maria’s case provides several important lessons for the realization of sexual and reproductive health and rights in countries with restrictive legal policies and conservative cultural norms around sexuality. Ana Maria’s experience demonstrates that an individual’s health decisions are not made in isolation, free from the influence of social norms and national laws. We present an overview of the key risk and contextual factors that contributed to Ana Maria’s experience of violence, unintended pregnancy, and unsafe abortion. Electronic supplementary material The online version of this article (10.1186/s12905-019-0771-9) contains supplementary material, which is available to authorized users.

Background The prevalence of unplanned pregnancy in Saudi Arabia has not been thoroughly investigated. Objective To conduct a psychometric evaluation study of the Arabic version of the London Measure of Unplanned Pregnancy (LMUP). Methods To evaluate the psychometric properties of the LMUP, we conducted a self-administered online survey among 796 ever-married Saudi women aged 20–49 years, and a re-test survey among 24 women. The psychometric properties evaluated included content validity measured by content validity index (CVI), structural validity assessed by exploratory factor analysis (EFA), substantive validity assessed by hypothesis testing, contextual stability for the test-retest assessed by weighted Kappa, and internal consistency assessed by Cronbach’s alpha. Results The psychometric analysis of the Arabic version of LMUP exhibited valid and reliable properties. The CVIs for individual items and at the scale level were >0.7. EFA confirmed a unidimensional extraction of the scale item. Hypothesis testing confirmed expected associations. The tool was stable with weighted kappa = 0.78 and Cronbach’s alpha = 0.88. Conclusion and recommendations In this study, the validity and reliability of the Arabic version of the LMUP were confirmed according to well-known psychometric criteria. This LMUP version can be used in research studies among Arabic-speaking women to measure unplanned pregnancy and investigate correlates and outcomes related to unplanned pregnancy.

Abortion is one of the most important public health issues in the United States. Yet, public health education has given it minimal attention despite the American Public Health Association's policy that “urges medical, nursing and public health schools, residency training programs and midwifery and physician assistant programs to develop and incorporate materials on the medical need, procedures, technology as well as the history and public health aspects of abortion into current curricula [1]. At least six public health texts provide public health perspectives on abortion, such as morbidity, mortality, case studies, legality, sex selection and postabortion care [2–8], while a few have brief or no mention of abortion [9,10]. To our knowledge, no US-based school of public health offers a course focused solely on preventing unsafe abortion's contribution to maternal morbidity and mortality. We have developed, pilot tested and expanded a course specifically on abortion and its contribution to maternal mortality worldwide and will describe the course and its reception. Some 215 million women worldwide desire protection from pregnancy but have limited or no access to contraception [11]. Annually, close to 50% of worldwide pregnancies are unintended, and of those, at least half end in abortion. In 2008, 21.6 million of the 55 million abortions performed were unsafe and led to 47,000 maternal deaths and hundreds of thousands of complications resulting in severe maternal morbidity [12]. Most unsafe abortions take place in

Objectives In 2011, a workforce assessment conducted by the Georgia Maternal and Infant Health Research Group found that 52 % of Primary Care Service Areas outside metropolitan Atlanta, Georgia, had an overburdened or complete lack of obstetric care services. In response to that finding, this study’s aim was twofold: to describe challenges faced by providers who currently deliver or formerly delivered obstetric care in these areas, and to identify essential core components that can be integrated into alternative models of care in order to alleviate the burden placed on the remaining obstetric providers. Methods We conducted 46 qualitative in-depth interviews with obstetricians, maternal-fetal medicine specialists, certified nurse midwives, and maternal and infant health leaders in Georgia. Interviews were digitally recorded, transcribed verbatim, uploaded into MAXQDA software, and analyzed using a Grounded Theory Approach. Results Providers faced significant financial barriers in service delivery, including low Medicaid reimbursement, high proportions of self-pay patients, and high cost of medical malpractice insurance. Further challenges in provision of obstetric care in this region were related to patient’s late initiation of prenatal care and lacking collaboration between obstetric providers. Essential components of effective models of care included continuity, efficient use of resources, and risk-appropriate services. Conclusion Our analysis revealed core components of improved models of care that are more cost effective and would expand coverage. These components include closer collaboration among stakeholder populations, decentralization of services with effective use of each type of clinical provider, improved continuity of care, and system-wide changes to increase Medicaid benefits.

Objectives In Georgia, 52 % of the primary care service areas outside metropolitan Atlanta have a deficit of obstetric providers. This study was designed to identify factors associated with the likelihood of Georgia's obstetric trainees (obstetrics and gynecology (OB/GYN) residents and certified nurse midwifery (CNM) students) to practice in areas of Georgia that lack obstetric providers and services, i.e. rural Georgia. Methods Pilot-tested electronic and paper surveys were distributed to all of Georgia's OB/GYN residents (N = 95) and CNM students (N = 28). Mixed-methods survey questions assessed characteristics, attitudes, and incentives that might be associated with trainee desire to practice in areas of Georgia that lack obstetric providers and services. Surveys also gathered information about concerns that may prevent trainees from practicing in shortage areas. Univariate and bivariate analyses were performed, and qualitative themes were abstracted from open-ended questions. Results The survey response rate was 87.8 % (108/123). Overall, 24.4 % (19/78) of residents and 53.6 % (15/28) of CNM students expressed interest in practicing in rural Georgia, and both residents and CNM students were more likely to desire to practice in rural Georgia with the offer of any of six financial incentives (P

Objectives Georgia has the highest rate of maternal mortality in the United States, and ranks 40th for infant mortality. The Georgia Maternal and Infant Health Research Group was formed to investigate and address the shortage of obstetric care providers outside the Atlanta area. Because access to prenatal care (PNC) can improve maternal and infant health outcomes, we used qualitative methods to identify the access barriers experienced by women who live in rural and peri-urban areas of the state. Methods We conducted semi-structured, in-depth interviews with 24 mothers who gave birth between July and August 2013, and who live in either shortage or non-shortage obstetric care service areas. We also conducted key informant interviews with four perinatal case managers, and analyzed all data using applied thematic analysis. We then utilized Thaddeus and Maine's "Three Delays to Care" theoretical framework structure to describe the recognized barriers to care. Results We identified delays in a woman's decision to seek PNC (such as awareness of pregnancy and stigma); delays in accessing an appropriate healthcare facility (such as choosing a doctor and receiving insurance coverage); and delays in receiving adequate and appropriate care (such as continuity of care and communication). Moreover, many participants perceived low self-worth and believed this influenced their PNC exchanges. Conclusion As a means of supporting Georgia's pregnant women who face barriers and delays to PNC, these data provide a rationale for developing contextually relevant solutions to both mothers and their providers.

In this article, the authors focus on epidemic-assistance investigations that dealt with maternal and child health problems, including unintended and adolescent pregnancy and family planning; international reproductive health surveys among refugees; pregnancy outcomes, including abortion, maternal mortality, infant mortality, and birth defects; leukemia; and Reye syndrome. During 1946-2005, a total of 1,969 investigations had sufficient data to classify them as possibly related to maternal and child health and were characterized by distinctive periods. Those related to family planning, pregnancy intention, and reproductive health among refugees began in the early 1970s and continued through 2005. Abortion-related investigations occurred during 1971-1982. Investigations of non-abortion-related maternal morbidity and mortality began in 1979 and included 2 international epidemic-assistance investigations. Investigations of clusters of disease among infants began in the 1960s, with a special focus on Reye syndrome during 1964-1984. Investigations of childhood cancer and birth defects began in the late 1950s. The Centers for Disease Control and Prevention has used the epidemic-assistance investigations mechanism to respond to a wide range of health concerns of women and children. The investigations of abortion-related health problems might have had the best-documented impact on public policy and public health.

Context: Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies but they may have different precursors and outcomes. Methods: Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended mistimed and unwanted conceptions by selected variable. Associations between unintendedness and womens behaviors and experiences before during and after the pregnancy were assessed through unadjusted relative risks. Results: The distribution of intended mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester received delayed or no prenatal care did not breastfeed were physically abused during pregnancy said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed. Conclusion: Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants. (authors)

Unintended pregnancy combines two aspects of fertility: unwanted and mistimed pregnancies. The personal partnership social and political realities of these two aspects are different and the use of separate categories may better reflect the way women think about a pregnancy. A better understanding of the multiple dimensions of unintended pregnancy also may lead to a better understanding of the consequences of these pregnancies. Likewise better knowledge of the extent of mistiming and perhaps the strength of intentions may be important in understanding health impact. Effective programs to prevent unintended pregnancy must use terms that are familiar to women and must build upon cultural understanding of the problem to be prevented. Research should focus on the meaning of pregnancy intentions to women and the processes women and their partners use in making fertility decisions. It should prospectively address the impact of pregnancy intentions on contraceptive use. Both qualitative and quantitative research have contributed to our understanding of fertility decisionmaking; both will be essential to the creation of more effective prevention programs. (excerpt)

Objectives: The purpose of this study was to measure and to describe obstetric deaths in Bangladesh. Methods: We reviewed hospital records and interviewed health workers in clinic sites and field workers who cared for pregnant women. Results: We obtained case reports of 28 998 deaths of women aged 10–50, of which 8562 (29.5%) were maternal deaths. Most (7086, 82.8%) of these deaths were due to obstetric causes. The most common causes of direct obstetric death were eclampsia (34.3%), hemorrhage (27.9%), and obstructed and/or prolonged labor (11.3%). National direct obstetric death rate was estimated to be 16.9 per 100 000 women. Conclusions: Efforts to reduce fertility in Bangladesh have led to an estimated 49% reduction in the maternal mortality rate per 1000 women during the past 18 years. Variations in maternal mortality suggest the need to develop local strategies to improve obstetric care.

We explored how low-risk, nulliparous pregnant women and their doctors in two contiguous U.S.–Mexico border communities communicate about methods of delivery and how they perceive that the delivery method decision is made. We recruited 18 women through obstetricians in El Paso, Texas (n = 10), and prenatal care providers in Ciudad Juarez, Mexico (n = 8). We observed prenatal care visits, interviewed women prenatally and postpartum, and interviewed the El Paso obstetricians. Qualitative analysis demonstrated that birthing decisions are complex and involve multiple influences, including women's level of knowledge about birth, doctor–patient communication, and women's participation in decision making.

To identify perceived barriers to accessing reproductive health care according to the women of Ocotal, Nicaragua; describe their understanding of their reproductive rights; and document their opinions about Nicaragua's total ban on abortion.From May to June 2014, three focus group discussions were held in Spanish with 17 women from two different neighborhoods (barrios) in the city of Ocotal, Nicaragua. A semi-structured discussion guide with open-ended questions was employed to elucidate local perspectives regarding the focus group discussions themes.Serious obstacles including 1) violence against women, 2) machismo, 3) criticism from others, and 4) lack of communication and education limit women's ability to make their own reproductive health decisions. Women had a pervasive lack of knowledge about reproductive rights and the international human rights documents that define them. In addition, due to religious and cultural ideologies, most women supported the country's total ban on abortion in most circumstances, with the possible exception of rape.Both men and women in Ocotal should be encouraged to participate in community-level programs designed to reduce the impact of the following obstacles to receiving reproductive health care: 1) violence against women and machismo; 2) insufficient, non-standardized sexual education and information about reproductive rights; and 3) poor communication within families and the community at large. Any future public health campaigns to address women's reproductive health needs in Ocotal should implement these types of programs, at the neighborhood level, to reduce stigma surrounding sexual health and activity.

Background Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem. Goals To identify missed opportunities for congenital syphilis prevention during prenatal care. Study design Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA). Results The hospital congenital syphilis prevalence was 8.2 cases per 1,000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01). Conclusion Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.

Objective: More than half of pregnancy-related deaths are not identified through routine surveillance methods. The purpose of this study was to evaluate the effectiveness of the pregnancy check box on death certificates in ascertaining pregnancy-related deaths. Methods: Data derived from the Centers for Disease Control and Prevention’s ongoing Pregnancy Mortality Surveillance System were used to identify states that included a check box on the death certificate in 1991 and 1992. Death certificates from those states were evaluated to determine the number and proportion of pregnancy-related deaths identified by a marked check box. Characteristics of death were also examined. Results: Sixteen states and New York City included a check box or question specifically asking about pregnancy of the decedent. Of the 425 pregnancy-related deaths identified in the 17 reporting areas, 124 (29%) were determined to be pregnancy-related deaths only because of the pregnancy status information provided in the check box. The proportion of deaths identified only by a marked check box ranged from less than 5% for four states to 40% or more for seven states. Conclusions: The availability of pregnancy status information on death certificates is a simple and effective aid in ascertaining a pregnancy-related death, when no other indicators of pregnancy appear on the death certificate. Routine use of the pregnancy check box for all states would lead to substantially increased classification of maternal deaths and more accurate classification of the causes of and risk factors for maternal deaths.

We compared the initiation of prenatal care during the first trimester of pregnancy (adequacy of initiation) between mother’s recall and the prenatal health information system (SISPRENATAL). We asked 238 women that received prenatal care at Family Health Units in Vespasiano, Minas Gerais their gestational age at first prenatal visit. Both recall and SISPRENATAL indicated that 30% of women had inadequate initiation. There was fair agreement in the adequacy of initiation (Kappa=0.35, 95% CI: 0.22-0.48) between recall and SISPRENATAL. Through regression models, we found that agreement was more likely with mother’s shorter recall period and non-use of the private sector. Use of the private sector (16.4%) was also correlated with a later date of initiation by SISPRENATAL than by mother’s recall. In sum, differences in the adequacy of initiation between recall and SISPRENATAL were associated with longer recall periods and with use of the private sector. Despite the limitation of recall bias, mother’s recall is preferable to SISPRENATAL for capturing the public use by the pregnant women.

A collaborative March of Dimes study was designed to examine the utility of dried blood spot (DBS) materials routinely collected from newborns as a source for monitoring cocaine exposure and to assess the prevalence of cocaine use among childbearing women in Georgia. We used a modified urinary radioimmunoassay (RIA) to anonymously detect the cocaine metabolite benzoylecgonine (BE) in DBSs. Extensive efforts were undertaken to assure absolute nonlinkage of BE data to any individual. The positive results found by RIA were confirmed by a mass spectrometry (MS) method specifically developed to detect BE in DBSs. BE was measured in 23,141 DBSs collected during 2 months of routine newborn screening in Georgia. A good correlation was observed for RIA results versus MS results (r2= 0.97). The estimated minimal statewide BE prevalence was 4.8 per 1000 childbearing women. We demonstrated that immunoassay testing for cocaine without confirmatory testing can yield falsely elevated prevalence rates. When proper confirmatory testing is done, DBSs are a valuable source for population-based monitoring of substance abuse among childbearing women.

Objective: To explore the patterns of prenatal smoking among women whose first and second pregnancies ended in live births. Methods: We used population-based data to explore prenatal smoking among 14,732 white and 8968 black Georgia residents whose first and second pregnancies ended in live births during 1989–1992. Smoking status was obtained from birth certificates linked for individual mothers. Because of demographic differences, we analyzed white and black women separately. Results: Approximately 15% (2253) of white women and 4% (318) of black women smoked during their first pregnancy. Of those smokers, 69% (1551) of white women and 58% (184) of black women also smoked during their second pregnancy. For both white and black nonsmokers during the first pregnancy, low education was the most significant predictor of smoking during the second pregnancy, after adjusting for consistency of the father's name on the birth certificate, prenatal care, birth interval, mother's county of residence, and birth outcome. Conclusions: The prevalence of smoking in this study may be low because of underreporting of prenatal smoking on birth certificates. The majority of women who smoked during their first pregnancy also smoked during their second, suggesting that these women exposed their first infant to tobacco smoke both in utero and after delivery. Practitioners should offer smoking cessation programs to women during, as well as after, pregnancy. Pediatricians should educate parents on the health risks to young children of exposure to environmental tobacco smoke and refer smoking parents to smoking cessation programs.

To estimate trends in prepregnancy obesity prevalence among women who delivered live births in the US during 2003-2009, by state, age, and race-ethnicity.We used Pregnancy Risk Assessment Monitoring System (PRAMS) data from 2003, 2006, and 2009 to measure prepregnancy obesity (body mass index [BMI]≥30kg/m(2)) trends in 20 states. Trend analysis included 90,774 records from 20 US states with data for all 3 study years. We used a chi-square test for trend to determine the significance of actual and standardized trends, standardized to the age and race-ethnicity distribution of the 2003 sample.Prepregnancy obesity prevalence increased by an average of 0.5 percentage points per year, from 17.6% in 2003 to 20.5% in 2009 (P0.001). Obesity increased among women aged 20-24 (P0.001), 30-34 (P=0.001) and 35 years or older (P=0.003), and among non-Hispanic white (P.001), non-Hispanic black (P=0.02), Hispanic (P=0.01), and other women (P=0.03).Overall, prepregnancy obesity prevalence continues to increase and varies by race-ethnicity and maternal age. These findings highlight the need to address obesity as a key component of preconception care, particularly among high-risk groups.

Objective To understand the experiences of women undergoing legal first-trimester abortion through Mexico City's Ministry of Health (MOH) services. Aims included comparing satisfaction with medical and surgical abortion services; drawing evidence-based recommendations for program improvement; and measuring contraceptive uptake following abortion. Methods A total of 350 women completed a 65-item survey questionnaire at 2 main MOH abortion facilities. Moreover, a subset of 20 participated in an in-depth interview. Multivariate analysis was performed to investigate satisfaction with abortion care and in-depth interview (IDI) data were analyzed. Results The participants overwhelmingly reported satisfaction with the care they received, with no significant differences between the medical and surgical abortion groups. However, qualitative data revealed a need for a more sympathetic staff, reduced waiting times, more comprehensive information on surgical abortion, and counseling that includes psychosocial issues. Postabortion contraception uptake was high, with most women opting for the intrauterine device. Conclusion The quantitative analysis suggests that although most women were satisfied with the services, some areas were identified as requiring improvement. The IDI data suggest that women wanted counseling to better address psychosocial needs and allow for discussion on a wider range of contraceptive methods.

In an analysis of surveillance data from the state of Georgia (US), Saad Omer and colleagues show an association between receipt of influenza vaccination among pregnant women and reduced risk of premature births., Background Infections during pregnancy have the potential to adversely impact birth outcomes. We evaluated the association between receipt of inactivated influenza vaccine during pregnancy and prematurity and small for gestational age (SGA) births. Methods and Findings We conducted a cohort analysis of surveillance data from the Georgia (United States) Pregnancy Risk Assessment Monitoring System. Among 4,326 live births between 1 June 2004 and 30 September 2006, maternal influenza vaccine information was available for 4,168 (96.3%). The primary intervention evaluated in this study was receipt of influenza vaccine during any trimester of pregnancy. The main outcome measures were prematurity (gestational age at birth, Editors' Summary Background Maternal infections during pregnancy can have harmful effects on both mother and baby. For example, influenza is associated with increased morbidity and mortality among pregnant women compared to women who are not pregnant or who acquire influenza infection after delivery. And some respiratory infections, especially those that can cause maternal pneumonia such as influenza virus, are known to be associated with the baby being small—below the 10th percentile—for gestational age and with an increased risk of preterm birth—birth before 37 weeks of gestation. Previous studies have shown that inactivated influenza vaccination during pregnancy provides protection against influenza virus for both mother and baby. As there has been an increase in the rate of preterm birth the United States from 9.5% in 1981 to 12.8% in 2006, the impact of maternal influenza immunization on birth outcomes has important public health implications and is of particular interest during influenza pandemics. Why Was This Study Done? Given that maternal vaccination can protect babies from influenza virus, it is plausible that influenza vaccination in pregnancy could mitigate adverse birth outcomes such as prematurity and the baby being small for gestational age. The researchers of this study set out to evaluate this hypothesis by investigating whether there was an association between women receiving inactivated influenza vaccine during pregnancy and positive birth outcomes for their babies in the population of the state of Georgia, in the United States. What Did the Researchers Do and Find? The researchers conducted a retrospective cohort analysis of a large surveillance dataset (the Georgia Pregnancy Risk Assessment Monitoring System) to analyze the relationship between receipt of inactivated influenza vaccine during any trimester of pregnancy by mothers of infants born between June 1, 2004, and September 30, 2006, and their baby being premature or small for gestational age. The study period encompassed the 2004–2005 and 2005–2006 influenza seasons—the two most recent seasons for which the data were available. The researchers did a stratified analysis for the overall study period, and various periods during it, and also weighted their analysis to adjust for possible oversampling. They used logistic regression to evaluate the association of maternal influenza vaccine and (a) prematurity and (b) small for gestational age, and also used linear regression to evaluate the statistical significance of differences between vaccinated and unvaccinated women for mean gestational age at first antenatal visit and mean birth weight. During the study period, 4,168 mother–baby pairs were included in the analysis. Local influenza activity was detected during 27 weeks (22.1%), and 578 women (14.9% [weighted]) had received the influenza vaccine during pregnancy, giving a vaccination coverage of 19.2% (weighted) among mothers of infants born during the assumed influenza season. In the study sample, 1,547 babies (10.6% [weighted]) were born premature, and 1,186 babies (11.2% [weighted]) were small for gestational age. Infants who were born during the assumed influenza season (October–May) and whose mothers were vaccinated against influenza during pregnancy were less likely to be premature than infants of unvaccinated mothers born in the same period, with an adjusted odds ratio of 0.60. The effect of maternal influenza vaccine on reducing prematurity was the highest for infants born during the period of widespread influenza activity, with 72% lower odds of prematurity in infants of vaccinated mothers than infants of unvaccinated mothers. Compared with newborns of unvaccinated women, babies of vaccinated mothers also had 69% lower odds of being small for gestational age during the period of widespread influenza activity, but the adjusted and unadjusted odd ratios were not significant for the pre-influenza activity period. What Do These Findings Mean? These results show that there was an association between maternal immunization with the inactivated influenza vaccine during pregnancy and reduced likelihood of prematurity during local, regional, and widespread influenza activity periods. In addition, during the period of widespread influenza activity there was an negative association between maternal receipt of influenza vaccine and small for gestational age birth. Additional Information Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000441. More information about influenza vaccination during pregnancy is available from the World Health Organization and the UK National Health Service More information about the Georgia Pregnancy Risk Assessment Monitoring System is also available

SummaryHealth systems in developing countries infrequently implement and evaluate maternal death surveillance. This study identified under-reported and misclassified maternal deaths among women of reproductive age between 1999 and 2004 in a rural service unit in Vellore, India. In-depth interviews, semi-structured interviews and structured questionnaires were used to identify maternal deaths known to health care providers and community leaders who regularly come in contact with pregnant women. Eighteen under-reported and misclassified cases – or 50% of maternal deaths – were reported. These included 29% of abortion-related and 7% of domestic violence-related deaths. Based on this study’s fieldwork, the existing death surveillance system detected 100% of the maternal deaths reported by hospital staff; however, it missed most maternal deaths reported by community workers. The latter are more likely than deaths reported by hospital workers to result from abortion and family violence. The existing surveillance system should be augmented with a community-based death surveillance system. This comprehensive approach identified twice as many maternal deaths than previously recorded and could be applied in other settings. Appropriate public health interventions should be initiated to prevent maternal deaths in this community.

Limited information is available at the national and district levels on causes of death among women of reproductive age in Bangladesh. During 1996-1997, health-service functionaries in facilities providing obstetric and maternal and child-heath services were interviewed on their knowledge of deaths of women aged 10-50 years in the past 12 months. In addition, case reports were abstracted from medical records in facilities with in-patient services. The study covered 4,751 health facilities in Bangladesh. Of 28,998 deaths reported, 13,502 (46.6%) occurred due to medical causes, 8,562 (29.5%) due to pregnancy-related causes, 6,168 (21.3%) due to injuries, and 425 (1.5%) and 259 (0.9%) due to injuries and medical causes during pregnancy respectively. Cardiac problems (11.7%), infectious diseases (11.3%), and system disorders (9.1%) were the major medical causes of deaths. Pregnancy-associated causes included direct maternal deaths (20.1%), abortion (5.1%), and indirect maternal deaths (4.3%). The highest proportion of deaths among women aged 10-19 years was due to injuries (39.3%) with suicides accounting for 21.7%. The largest proportion of direct obstetric deaths occurred among women aged 20-29 years (30.5%). At least one quarter (24.3%) of women (n = 28,998) did not receive any treatment prior to death, and 47.8% received treatment either from a registered physician or in a facility. More focus is needed on all causes of deaths among women of reproductive age in Bangladesh.

In 2006, the Colombian Constitutional Court partially decriminalized abortion. However, barriers to access, including improper use of conscientious objection, remain.To explore conscientious objection from the objectors' perspectives, in-depth interviews were conducted in 2014 with 13 key informants and with 15 Colombian physicians who self-identified as conscientious objectors. Recruitment included snowball and purposive sampling techniques. Analysis was conducted in tandem with data collection and focused on objectors' attitudes, beliefs and behaviors related to abortion and referral.Objectors had varied perspectives. Three types of objectors were evident: extreme, moderate and partial. Extreme objectors refused to perform abortions or make referrals, and often lectured their patients; they also provided misleading or false medical and legal information, preventing women from accessing abortions to which they were legally entitled. Moderate objectors would not perform abortions, but respected their patients and viewed referral as a way to save "one out of two" lives. Partial objectors performed some abortions but refused to do others on the basis of gestational age or case-by-case circumstances. Across the typology, objectors linked conscientious objection with medical ethics, and many described a duty to protect the fetus, which they conceptualized as a patient.Conscientious objectors exhibit diverse opinions and behaviors. Potential areas for future investigation include identifying factors that lead objectors to refer and estimating the prevalence of each type of objector. Results suggest potential interventions that could reduce the role of conscientious objection as a barrier to care.RESUMEN Contexto: En 2006, la Corte Constitucional de Colombia descriminalizó parcialmente el aborto. Sin embargo, aún existen barreras al acceso, incluido el uso inapropiado de la objeción de conciencia. Métodos: Con el fin de explorar la objeción de conciencia desde las perspectivas de los objetores, en 2014 se llevaron a cabo entrevistas en profundidad con 13 informantes clave y 15 médicos colombianos que se autoidentificaron como objetores de conciencia. El reclutamiento incluyó técnicas de muestreo por bola de nieve e intencional. El análisis se llevó a cabo conjuntamente con la recolección de datos y se focalizó en las actitudes, creencias y conductas de los objetores en relación con el aborto y las referencias a otros proveedores. Resultados: Los objetores tienen perspectivas diversas. Fueron evidentes tres tipos de objetores: extremos, moderados y parciales. Los objetores extremos rechazaron realizar abortos o hacer referencias y, con frecuencia, sermonearon a sus pacientes; también proporcionaron información médica y legal engañosa o falsa, para evitar que las mujeres tuvieran acceso a abortos a los cuales legalmente tenían derecho. Los objetores moderados no realizaron abortos, pero respetaron a sus pacientes y consideraron las referencias como una forma de salvar “una de dos” vidas. Los objetores parciales realizaron algunos abortos pero rechazaron practicar otros en base a la edad gestacional o circunstancias relacionadas con cada caso. A lo largo de esta tipología, los objetores vincularon la objeción de conciencia con la ética médica y muchos describieron un deber de proteger el feto, el cual conceptualizaron como paciente. Conclusión: Los objetores de conciencia exhiben diversas opiniones y conductas. Algunas áreas con potencial para futuras investigaciones incluyen la identificación de factores que conducen a los objetores a referir a otros proveedores y la estimación de la prevalencia de cada tipo de objetor. Los resultados sugieren intervenciones potenciales que podrían reducir el rol de la objeción de conciencia en tanto una barrera a la hora de recibir atención.RÉSUMÉ Contexte: En 2006, le Tribunal constitutionnel de Colombie a décriminalisé partiellement l'avortement. Des obstacles d'accès, notamment l'invocation abusive de l'objection de conscience, persistent cependant. Méthodes: Afin d'explorer l'objection de conscience dans la perspective des intéressés, des entretiens en profondeur ont été menés en 2014 avec 13 informateurs clés et 15 médecins colombiens qui s’étaient dits objecteurs de conscience. Le recrutement a été effectué selon les techniques d’échantillonnage en boule de neige et par choix raisonné. Parallèlement à la collecte de données, l'analyse s'est concentrée sur les attitudes, croyances et comportements des objecteurs concernant l'avortement et l'orientation vers un prestataire. Résultats: Différentes perspectives expliquent la position des objecteurs. Trois grands types d'objection se sont révélés: absolue, modérée et partielle. Les objecteurs absolus refusent toute pratique de l'avortement ou orientation afférente, faisant souvent la leçon à leurs patientes; ils fournissent aussi une information médicale et légale trompeuse ou fausse, empêchant les femmes d'accéder aux procédures d'avortement auxquelles elles ont légalement droit. Les objecteurs modérés refusent de pratiquer l'avortement mais ils respectent leurs patientes et voient dans leur orientation vers un prestataire un moyen de «sauver une vie sur deux». Les objecteurs partiels pratiquent certains avortements mais en refusent d'autres en fonction de l’âge gestationnel ou de circonstances considérées au cas par cas. Dans les trois types, les objecteurs lient l'objection de conscience à l’éthique médicale. Beaucoup parlent d'une obligation de protection du fœtus, qu'ils conceptualisent tel un patient.Les objecteurs de conscience présentent des opinions et des comportements divers. Les points potentiels de recherche future comprennent l'identification des facteurs qui amènent les objecteurs à l'orientation vers un prestataire et l'estimation de la prévalence de chaque type d'objecteur. Les résultats laissent entendre de potentielles interventions aptes à réduire le rôle de l'objection de conscience parmi les obstacles aux soins.

In most countries, female condoms are not widely available and uptake has been slow. More information is needed on how women and men successfully negotiate female condom use.In-depth interviews were conducted at two sites in Cape Town, South Africa, with 14 women and 13 men who had used female condoms. A structured interview guide was used to elicit information on how women negotiate female condom use, and how male partners negotiate or respond to negotiations of female condom use. Thematic analysis was used to identify key patterns in the data.Participants reported that female condoms are easier for women to negotiate than male condoms, largely because the method is understood to be under a woman's control. The main barrier to use was lack of familiarity with the method; strong negative reactions from partners were not a major barrier. Personal comfort and tensions with partners usually improved after first use. Some male respondents preferred the method because it shifts responsibility for condom use from men to women.Findings suggest that female condoms empower women to initiate barrier method use, and that programs designed to educate potential users about female condoms and familiarize them with the method may be useful. That some men preferred female condoms because they wanted women to take responsibility for condom use is cause for concern, and suggests that counseling efforts should be directed toward men as well as women, and should include a discussion of gender dynamics and responsibility that emphasizes condom use as a choice that couples make together.RESUMEN Contexto: En la mayoría de los países, la disponibilidad de condones femeninos no es amplia y su aceptación ha sido lenta. Se necesita más información acerca de cómo las mujeres y los hombres negocian exitosamente el uso del condón femenino. Métodos: Se condujeron entrevistas en profundidad en dos zonas de Ciudad del Cabo, Sudáfrica, con 14 mujeres y 13 hombres que habían usado condones femeninos. Se utilizó una guía de entrevista estructurada para obtener información acerca de cómo las mujeres negocian el uso del condón femenino y cómo las parejas masculinas negocian o responden a las negociaciones relativas al uso del condón femenino. Se usó análisis temático para identificar patrones claves en los datos. Resultados: Los participantes informaron que para las mujeres es más fácil negociar el uso de condones femeninos en lugar de los masculinos, en gran medida debido a que se entiende que dicho método está bajo el control de la mujer. La principal barrera para su uso fue la falta de familiaridad con el método, mientras que las reacciones negativas fuertes de las parejas no fueron una barrera importante. La comodidad personal y las situaciones de tensión con la pareja usualmente mejoraron después del primer uso. Algunos hombres entrevistados prefirieron el método porque transfiere la responsabilidad de los hombres a las mujeres. Conclusiones: Los hallazgos sugieren que los condones femeninos empoderan a las mujeres para iniciar el uso de métodos de barrera, y que son importantes los programas diseñados para educar a usuarios potenciales sobre los condones femeninos y familiarizarles con el método. El hecho de que algunos hombres prefirieran los condones femeninos porque querían que las mujeres se responsabilizaran del uso del condón es causa de preocupación y sugiere que se deben realizar esfuerzos de consejería dirigidos tanto a hombres como a mujeres, y que estos deben incluir una discusión sobre dinámica de género y responsabilidad, que ponga énfasis en el uso del condón en tanto una decisión que las parejas toman de forma conjunta.RÉSUMÉ Contexte: Dans la plupart des pays, le préservatif féminin n'est pas largement disponible et son adoption est lente. Il serait utile de documenter davantage la manière dont les femmes et les hommes négocient avec succès l'usage du préservatif féminin. Méthodes: Des entretiens en profondeur ont été menés sur deux sites de Cape Town, en Afrique du Sud, avec 14 femmes et 13 hommes qui avaient utilisé le préservatif féminin. Un guide d'entretien structuré a permis d'obtenir une information sur la façon dont les femmes négocient l'usage du préservatif féminin et sur celle dont les partenaires masculins négocient cet usage ou répondent aux négociations le concernant. Les tendances clés des données ont été identifiées par analyse thématique. Résultats: Les déclarations des participants révèlent qu'il est plus facile pour les femmes de négocier le préservatif féminin, plutôt que le masculin, largement parce que la méthode est comprise comme relevant du contrôle de la femme. L'obstacle principal à son usage est le manque de familiarité avec la méthode. Les fortes réactions négatives des partenaires ne représentent pas un obstacle majeur. Le confort personnel et les tensions avec les partenaires s'améliorent généralement après le premier usage. Certains répondants masculins préfèrent la méthode car elle fait passer la responsabilité de l'homme à la femme.Les observations laissent entendre que le préservatif féminin permet aux femmes de prendre l'initiative d'une méthode barrière et que les programmes conçus pour informer les utilisateurs potentiels et les familiariser avec la méthode peuvent être utiles. La préférence exprimée par certains hommes à l'égard du préservatif féminin parce qu'ils attendent des femmes qu'elles assument la responsabilité de l'usage du préservatif est préoccupante. Elle donne à penser que les efforts de counseling doivent viser les hommes aussi bien que les femmes et inclure une discussion sur la dynamique de genre et la responsabilité, qui souligne l'importance de l'utilisation du préservatif en tant que choix mutuel des partenaires.

Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes.Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and women's behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks.The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed.Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.

OBJECTIVES: This study assessed the association between maternal cigarette smoking during pregnancy and the risk of invasive meningococcal disease during early childhood. METHODS: Using a retrospective cohort study design, cases from an active surveillance project monitoring all invasive meningococcal disease in the metropolitan Atlanta area from 1989 to 1995 were merged with linked birth and death certificate data files. Children who had not died or acquired meningococcal disease were assumed to be alive and free of the illness. The Cox proportional hazards analysis was used to assess the independent association between maternal smoking and meningococcal disease. RESULTS: The crude rate of meningococcal disease was 5 times higher for children whose mothers smoked during pregnancy than for children whose mothers did not smoke (0.05% vs 0.01%). Multivariate analysis revealed that maternal smoking (risk ratio [RR] = 2.9; 95% confidence interval [CI] = 1.5, 5.7) and a mother's having fewer than 12 years of education (RR = 2.1; 95% CI = 1.0, 4.2) were independently associated with invasive meningococcal disease. CONCLUSIONS: Maternal smoking, a likely surrogate for tobacco smoke exposure following delivery, appears to be a modifiable risk factor for sporadic meningococcal disease in young children.

Objective: To assess whether women who experienced physical violence by their partner during the 12 months before delivery were more likely to delay entry into prenatal care than were women who had not experienced physical violence. Methods: We analyzed data from the Pregnancy Risk Assessment Monitoring System. The sample included 27,836 women who delivered live infants during 1993–1994 in nine states and were surveyed 2–6 months after delivery. We calculated risk ratios and 95% confidence intervals (CIs) to measure the association between physical violence within the 12 months before delivery and entry into prenatal care. Results: The prevalence of delayed entry into prenatal care (entering after the first trimester) was 18.1% and that of reported physical violence was 4.7%. Overall, women who experienced physical violence were 1.8 times more likely (95% CI 1.5, 2.1) to have delayed entry into prenatal care than women who had not experienced such violence. When stratifying by selected maternal characteristics, this association was found only for groups of women who were 25 years of age or older or were of higher socioeconomic status. Conclusion: Older women and women of higher socioeconomic status who reported physical violence were more likely to delay entry into prenatal care than younger or less affluent women.

Objective To determine whether characteristics in a woman's first pregnancy were associated with the trimester in which she initiated prenatal care in her second pregnancy. Methods Data for white and black women whose first and second pregnancies resulted in singleton live births between 1980 and 1992 were obtained from Georgia birth certificates ( n = 177,041). Adjusted relative risks (RRs) for early prenatal care in the second pregnancy were computed by logistic regression models that included trimester of prenatal care initiation, infant outcomes, or maternal conditions in the woman's first pregnancy as the exposure and controlled for maternal age, education, child's year of birth, interval between first and second pregnancy, presence of father's name on the birth certificate, and the interaction between prenatal care and education. Models were stratified by race. Results Women of both races who initiated prenatal care in the first trimester of their first pregnancies were more likely than those with delayed care to initiate prenatal care in the first trimester of their second pregnancies (RR = 1.25 and 1.63 for white and black women educated beyond high school, respectively). Both white and black women who delivered a baby with very low birth weight (RR = 1.06 and 1.15, respectively) or who suffered an infant death (RR = 1.09 and 1.31, respectively) in their first pregnancies were more likely than those who did not experience these events to begin prenatal care in the first trimester of their second pregnancies. Conclusion Women with some potentially preventable adverse infant outcomes tend to obtain earlier care in their next pregnancy. Unfortunately, women who delayed prenatal care in their first pregnancy frequently delay prenatal care in their next.

To Identify causes and risk factors for pregnancy-related mortality in New York City, we analyzed 224 pregnancy-related deaths that occurred from 1980 to 1984. The leading causes of death were ectopic pregnancy complications, embolism, intrapartum cardiac arrest, and hypertension. Mortality ratios were determined by comparing the characteristics of the women whose death was pregnancy-related with those of women who had survived delivery of a live infant in New York City during the same period. Black and Hispanic women had mortality ratios that were respectively 4.2 and 2.0 times higher than those for white, non-Hispanic women. In comparison with women aged 20 to 24, those older than 30 were more than twice as likely to die from pregnancy-related causes, and those older than 40 were five times as likely to do so. Other factors that were associated with an increased risk of pregnancy-related mortality included 9 to 11 years of education, lack of private medical insurance, more than five previous pregnancies, and fewer than five prenatal visits. This study suggests that changes in current maternal-health and family-planning services will be required to achieve further reductions in preventable pregnancy-related mortality.

A national survey of health-care providers in Bangladesh identified 298 women who died from pregnancy-related tetanus. Immunising all girls with tetanus toxoid and providing safe menstrual regulation services would prevent such deaths.This letter discusses pregnancy-related tetanus mortality in Bangladesh. A national survey of health care providers identified 298 women from 5 urban infectious disease hospitals who had died from pregnancy-related tetanus after an induced abortion or during the postpartum period. In response to the problem, the Bangladesh government has provided a tetanus toxoid vaccination program for pregnant women to prevent neonatal and postpartum tetanus and has begun training health workers to perform menstrual regulation procedures. Considering the contribution of traditional abortion practices to tetanus death in Bangladesh, a proposal on maternal tetanus prevention policies would be most effective if it included safe menstrual regulation services and provision of tetanus toxoid immunization to all girls before they reach reproductive age (i.e., at age 12).

To assess the usefulness of vital statistics and surveillance for monitoring abortion mortality, the authors compared data from two systems of classification: 1) deaths classified according to the underlying cause by the National Center for Health Statistics (NCHS) under the International Classification of Disease, Adapted (ICDA) code numbers 640-645 (abortion) for 1972-1975; and 2) abortion-related deaths reported to the Center for Disease Control (CDC) through its epidemiologic surveillance of abortion mortality for the same years. Vital statistics classifications dealing with the underlying cause of death are based on criteria defined by ICDA guidelines applied to all available information listed on death certificates, and exclude some deaths classified as abortion-related by CDC. Surveillance classifications are based on broader criteria developed by CDC for expanded data gathered by individual case investigation. Results showed that the surveillance techniques had identified more deaths as abortion-related and had resolved more cases into the specific abortion categories of legal, illegal, and spontaneous than vital statistics tabulations based on death certificates. The authors estimate that the surveillance system alone reported 88% of all abortion-related deaths, the vital statistics system 52%, and the two systems combined a total of 94%. Inadequate physician documentation on the death certificate was the primary reason vital statistics data contained a smaller number of reported abortion deaths than surveillance data.The National Vital Statistics System coordinated by the National Center for Health Statistics (NCHS) classifies the underlying cause of death according to criteria defined by International Classification of Diseases Adapted (ICDA). The Center for Disease Control's (CDC) epidemiologic surveillance of abortion uses broader criteria developed from expanded data gathered from individual case investigation. By employing these broader criteria, CDC was able to identify more deaths as abortion-related and resolved more cases into the specific abortion categories of legal, illegal, and spontaneous than vital statistics tabulations based on death certificates. In the estimation of the authors, the CDC's surveillance system alone reported 88% of all abortion-related deaths, the vital statistics system 52%, and the 2 systems combined a total of 94%. The authors believe that incomplete death certificate documentation by physicians was the reason for: 2) the discrepancy between NCHS vital statistics and the CDC's, and 2) why deaths correctly attributed to abortion by NCHS were not more specifically classified by type of abortion.

The use of combined estrogen-progestogen oral contraceptives (EP-OC) by lactating women has been associated with suppression of lactation. To determine the extent to which physicians prescribe combined EP-OC for lactating women, the International Planned Parenthood Federation (IPPF) and the United States Centers for Disease Control (CDC) collaborated in a global mail survey of 3697 physicians affiliated with Family Planning Associations (FPA) in 72 countries. Usable responses were received from 831 physicians (22%) in 65 countries. The percent of clinicians who provide EP-OC to lactating women was higher in developing regions (63% or more) than in developed regions (40% or less). Patient preference was rated important more often than any other factor in the decision to prescribe EP-OC for lactating women. The percentage of clinicians who reported complaints of decreased milk production from women using EP-OC was higher (32% or more) in developing regions where breast milk is often essential to infant nutrition.

Health-workers in 795 health centres in Bangladesh were interviewed about complications arising from induced abortion in rural Bangladesh. 1590 cases of complications from abortion were reported. Dais (traditional birth attendants) and traditional practitioners were the larger groups of operators (42.1% and 18.1%, respectively). Menstrual regulation or dilatation and curettage (the medically approved procedures) were used 9.1% of the time. Nearly half the complicated abortions were induced by inserting a foreign object, such as a stick or root (sometimes treated with an herb), into the uterus and leaving it until either abortion or complications ensued. 498 abortion-related deaths were reported. The proportion of complicated abortions resulting in death was lowest for medically approved procedures (4.9%) and highest for vigorous physical activity (100%) and abdominal pressure (66.7%), although the last two together accounted for only 2.3% of abortion procedures. Women who died after abortion were more likely than were women who survived to be further along in their pregnancies. An extrapolation from these results gives a figure of 780000 abortions in Bangladesh in 1978 and 7800 deaths that year from abortion complications. Many of these deaths might have been prevented if a means of safe, affordable termination of unwanted pregnancy had been available.Induced abortion, although illegal, is common in Bangladesh. A number of health workers were interviewed in 1978-79 in 795 health centers to investigate the magnitude of the problem in rural areas. There were 1590 reported cases of complicated abortions, of which 498, i.e. 31.3% were fatal. 42.1% of abortions were performed by traditional birth attendants, and 18.1% by traditional practitioners; a very small number was performed by husbands, or by the women themselves. Medically approved procedures for abortion, such as dilatation and curettage and menstrual regulation, were used only in 9.1% of cases. Most abortions were caused by inserting a foreign object, such as a stick, into the uterus. Abortion complications after medically approved procedures were only 4.9%. Fatal cases were more likely to occur in advanced pregnancies. It is estimated that in 1978 there were 780,000 abortions in Bangladesh, resulting in 7800 deaths.

Both non-abortion-related maternal and abortion-related mortality declined prior to the Supreme Court decisions of 1973. In order to determine the effect of legalized abortion on maternal mortality, we have analyzed the secular trends in national abortion mortality ratios for 1940 through 1976, compared the trends to those maternal mortality ratios, and hypothesized reasons for differences between these trends. Between 1940 and 1950 and after 1965, deaths from abortion declined more rapidly than deaths from other causes associated with childbirth. However, between 1951 and 1965, maternal mortality related to pregnancy of childbirth declined more rapidly than abortion-related mortality. Five possible explanations exist for the more rapid decline in abortion deaths since 1965--selected underreporting, changes in coding practices, improved safety of illegal abortion, introduction of more effective contraception, and increased availability of legal abortion. We consider the last two explanations as the most likely reasons for the accelerated decline in abortion-related deaths.Both non-abortion-related maternal and abortion-related mortality have declined in the U.S. Between 1940-1950 and after 1965, deaths from abortion declined more rapidly than deaths from other pregnancy and birth-related causes. 1970-1976 average annual rate, 25%). Between 1951-1965, maternal mortality related to pregnancy or childbirth declined more rapidly than abortion-related mortality (average annual rate, 13% until 1965, and 5% thereafter). It is suggested that 5 reasons exist which explain the decline in abortion deaths since 1965: 1) increased use of effective contraceptives, 2) availability of legal abortions, 3) possibility of increased safety of illegal abortion, 4) selected underreporting, and 5) changes in coding practices.

The epidemiology of twin pregnancies was studied with the use of data on 7,001 live-born twins from the Georgia neonatal surveillance network for the period 1974-1978. A cesarean section did not appreciably reduce the risk of neonatal death for a twin with a vertex presentation. The relative risk of such a neonatal death was 1.4 after adjustment was made for birth weight. A cesarean section did improve the outcome for breech and other presentations. Twins had a sixfold higher neonatal mortality rate than had singleton infants (p less than 0.001), which can be explained on the basis of distribution of birth weights. Twins had a weight-specific mortality rate equivalent to or significantly less than that for singletons after adjustment was made for birth weight. The relative risk of neonatal death for Twin 2 compared with Twin 1 was not significant. Breech presentation was more common in twins than in singletons, and for Twin 2 more than for Twin 1. As birth weight increased, the number of breech presentations decreased for Twin 2 but not for Twin 1. To reduce the high neonatal mortality rate for twins, the objective should be to reduce the incidence of low-birth-weight twins, rather than to increase the cesarean section rate for them.

We analyzed population-based data from the Georgia Neonatal Surveillance Network from 1974 to 1978 to determine the effect of the hospital of delivery on the neonatal mortality rate (NMR) of infants later admitted to neonatal intensive case units (NICUs). The NMR of 3,524 infants transported from primary centers to NICUs was significantly higher [relative risk (RR) = 2.1; 95% CL = 1.9 to 2.3] than that of 10,764 infants born in tertiary centers and admitted directly to an NICU. This effect persisted even after adjustment for birth-weight differences (RR = 1.6; 95% CL = 1.5 to 1.8). The relative risk in favor of delivery in a tertiary center increased with increasing birth weight. However, the proportion of infants of less than 1,000 gm surviving was higher for transported infants and increased with distance transported. This finding suggests that, at these very low birth weights, the hardiest infants were selectively transported. A surprising finding was the very low proportion of low-birth-weight infants delivered in primary centers and transported to NICUs (eg, 32% of infants weighing between 1,001 and 1,200 gm). Our findings support previous reports that delivery in a hospital with an NICU is preferable to later neonatal transport and suggest that efforts to increase the rate of maternal transport in high-risk pregnancies can lead to a substantial reduction in infant deaths.

To determine the safety of tubal sterilization performed at the time of induced abortion, we compared data on 616 women who underwent induced abortion and concurrent tubal ligation (Group 1) with 1,805 women who had induced abortion only (Group 2). These two groups of women were healthy, seven to 12 weeks pregnant, and between the ages of 16 and 44 years. The parity-standardized moroidity rates for Group 1 and Group 2 were 5.4 and 3.6 per cent, respectively. Thus, the sterilization procedure added 1.8 per cent to the complication rate of induced abortion only. The complication rate for women who had interval culdoscopic ligation under the same conditions in the same department was 2.4 per cent. This is not significantly different from the complication rate of 1.8 per cent attributable to sterilization procedures in women who had abortion and concurrent ligation. We conclude that these data support our present practice of performing tubal ligation at the time of induced abortion, rather than changing to the practice of abortion followed by interval sterilization six weeks later, with its many disadvantages to the patient as well as to those providing family-planning services.

The Center for Disease Control (CDC), Atlanta, Georgia implemented an eight-month prospective surveillance system in 24 hospitals distributed among states with and without public funding for abortion. Out of 3,157 visits for abortion-related complications, only 10 women gave a history of non-physician or self-induced abortion and none were Medicaid recipients. The small number of hospitals located in non-funded states and the smaller numbers of women served in these hospitals than in the funded states limited the power of out study. Women living along the Texas-Mexico border appeared more likely to have complications after illegal abortions than women from other areas of the country.The Center for Disease Control, Atlanta, Georgia, conducted a survey to determine the effect of Medicaid funds being restricted for abortion. 3,157 abortion-related complications were reported from 24 institutions in 14 states between October, 1977-June, 1978. Out of these visits only 10 women gave a history of nonphysician or selfinduced abortion. None were Medicaid recipients. The scope of the study was limited by the small number of hospitals located in nonfunded states and the smaller numbers of women served in these hospitals than in the funded states. In nonfunded states Medicaid-eligible women received legally induced abortions at a later gestational age (11.7 weeks vs. 11 weeks). More complications after illegal abortion were reported for women living along the Texas-Mexico border than any other area. 27% of all women received Medicaid. Women from nonfunded states were slightly younger, more likely to be white, and had a greater percentage of complications.

We reviewed the neonatal outcome of 3,369 infants who weighed less than or equal to 1500 grams and who were born in Georgia during the years 1974--76. We matched 1,465 of these infants with a death certificate registered in the State's Vital Records. Upon review of the hospital records of the remaining infants, we identified 453 infants that died during the neonatal period without a death certificate being registered. Subsequently, we compared the hospital death registries for 1977 in Georgia and death certificates registered in Vital Records during 1977. We identified an additional 236 infants who died without a death certificate being registered. Forty per cent of these infants weighed greater than 1500 grams. Two major procedural errors regarding the filing of death certificates in Georgia at the local level contributed to this 21 per cent underregistratioon of neonatal deaths in 1974--77. The underregistration occurred disproportionately for rural areas, for unmarried mothers, and for Black infants. The reason for underregistration included failure of hospitals and morticians to file death certificates with the county registrars.The authors investigate neonatal mortality rates in Georgia between 1974 and 1977. The suspected under-registration of neonatal deaths is analyzed with respect to errors in the processing of birth and/or death certificates and the failure to register some infant deaths. The relationship of under-registration to factors such as birth weight, urban or rural residence, age and marital status of mother, and race is examined. The problem of under-registration in other states is discussed

In Tennessee between 1975 and 1978, birth rates among teenagers decreased while they increased among older age groups. This trend was unlike previous years and coincided temporally with the increased availability of legal abortion services in Tennessee and the special efforts to prevent unwanted pregnancies among teenagers. Increased use of family planning services was significantly associated with the drop in the fertility rate for Black teenagers; legal abortion use was significantly associated with the change in the fertility rate for Black females aged 20 years or older.