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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 measure trends before, during, and after implementation of Georgia House Bill 954, a limit on abortion at 22 or more weeks of gestation passed in 2012, in total abortions and abortions by gestational age and state residence. Methods. We analyzed aggregate year-level induced termination of pregnancy data from the Georgia Department of Public Health from 2007 to 2017. We used linear regression to describe annual trends in the number of abortions and χ2 analyses to describe changes in proportions of abortions by gestational age ( 21 weeks) across policy implementation periods (before, partial, and full implementation) for Georgia residents and nonresidents. Results. Although the total number of abortions and abortions at 21 weeks or less remained stable from 2007 to 2017, the number of abortions at more than 21 weeks declined (P = .02). The decline in number of abortions at more than 21 weeks was steeper for nonresidents (31/year; Β = −31.3; P = .02) compared with Georgia residents (14/year; Β = −13.9; P = .06). Conclusions. Findings suggest that implementation of Georgia’s 22-week gestational age limit has effectively limited access to needed abortion services in Georgia and beyond.

Integration of routine infant immunization and family planning services (FP/EPI) seeks to create opportunities for increased uptake of postpartum contraception. This evaluation assessed the implementation of a combined service provision model and experiences of postpartum women seeking services at integrated FP/EPI facilities in Benin. We used a mixed qualitative methods design to conduct a process evaluation of services at eight facilities supported by CARE’s HIN NOU VIVO! project. We facilitated focus group discussions with 56 postpartum women who attended integrated sessions, divided into family planning users and non-users. Using grounded theory methodology, we explored women’s experiences with the integrated services. We conducted 159 patient flow analyses and evaluated fidelity to the integration model. Focus group participants responded positively to FP group education sessions during integrated FP/EPI days, but found the referral process confusing. Contraceptive use was motivated mainly by a desire for birth spacing, whereas fear of side effects and lack of spousal engagement were cited as reasons for contraceptive non-use. In four out of eight facilities, staffing shortages prevented FP group education sessions and referrals. Integrated FP/EPI services are feasible and accepted by postpartum women, but require consistent implementation across facilities. To achieve service integration goals, projects need to ensure availability of trained staff, supportive supervision, clear referral processes, and activities addressing the role of spouses and other stakeholders in reproductive health decisions.

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.

Women comprise two-thirds of the global-health (GH) workforce but are underrepresented in leadership. GH departments are platforms to advance gender equality in GH leadership. Using a survey of graduates from one GH department, we compared women's and men's post-training career agency and GH employment and assessed whether gender gaps in training accounted for gender gaps in career outcomes. Master-of-Public-Health (MPH) and mid-career-fellow alumni since 2010 received a 31-question online survey. Forty-four per cent of MPH alum and 24% of fellows responded. Using logistic regression, we tested gender gaps in training satisfaction, career agency, and GH employment, unadjusted and adjusted for training received. Women (

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 the context of a shifting health care landscape, better understanding of the factors that motivate women to seek services from specialized family planning clinics like Planned Parenthood (PP) can provide insights about potential changes in the role of specialized family planning clinics. Methods We surveyed 725 women seeking services at two PP health centers in Louisiana and Kentucky from March 2016 to May 2017. We examined differences in care-seeking between women who had varying levels of access including those who did and did not have insurance instability or a regular source of care (RSOC) besides the clinic. Results More than 60% of women attending the health centers did not have a regular source of care and nearly 40% experienced instability in insurance. Women who experienced insurance instability and a lack of a regular source of care more frequently sought primary preventive services such as pap tests and well-woman care at PP than women with better access. For women with better access, PP health centers also served important roles for those seeking contraceptive and sexually transmitted infection–related services. The most frequent reasons for choosing the PP were that it was faster to get an appointment, wanting to go to the PP clinic more than other clinics, and the confidentiality of services. Conclusions Our analysis suggests that PP health centers in Southern states still provide vital services for women with and without other sources of care and are critical for women needing access to timely services for preventative and sexually transmitted infection–related care.

Purpose The purpose of this study is to assess whether Maternal and Child Health (MCH) graduate programs address abortion content in their programs' foundational courses, elective courses, and general curricula. Description Between January and March 2017, we conducted a descriptive study with faculty from the 13 Centers of Excellence in Maternal and Child Health Education, Science and Practice (COEs). We reviewed syllabi and discussed foundational and elective course content via email and key informant interviews with COE faculty. We categorized abortion coverage in foundational courses as "transparent" or "tangential" depending on inclusion of the word "abortion" in course syllabi. We identified electives addressing abortion as "electives including abortion" and courses that focus on abortion as "abortion-specific electives." Assessment Evidence demonstrated that most programs do not transparently address abortion in required course curricula. Only one of 13 COEs transparently addresses abortion in the foundational course(s); seven COEs tangentially include abortion in foundational courses; and all programs address abortion in some capacity though no standard exists to ensure its inclusion. Despite barriers, including avoidance of controversy and fear of losing funding, COEs could address abortion by establishing shared curricular standards, facilitating values clarification and attitude transformation activities, utilizing information-sharing networks, strengthening relationships between MCH programs and abortion-related organizations, and using professional societies. The scope of our study does not allow us to conclude why abortion content is lacking nor the quality of current content. Conclusion MCH programs should transparently incorporate abortion content in foundational and electives courses to educate students on how to engage with complex and sometimes stigmatized public health issues.

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.

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.

Purpose Despite having an obstetrician/gynecologist (ob/gyn) workforce comparable to the national average, Georgia is ranked 50th in maternal mortality and 40th in infant mortality. The Georgia Maternal and Infant Health Research Group (GMIHRG) was founded in 2010 to evaluate and address this paradox. Description In the several years since GMIHRG's inception, its graduate allied health student researchers and advisors have collaborated with community partners to complete several requisite research initiatives. Their initial work demonstrated that over half the Georgia areas outside metropolitan Atlanta lack adequate access to obstetric services, and their subsequent research evaluated the reasons for and the consequences of this maldistribution of obstetric providers. Assessment In order to translate their workforce and outcomes data for use in policymaking and programming, GMIHRG created reader-friendly reports for distribution to a wide variety of stakeholders and prepared concise, compelling presentations with targeted recommendations for change. This commitment to advocacy ultimately enabled them to: (a) inspire the Georgia Study Committees on Medicaid Reform and Medical Education, (b) influence Georgia General Assembly abortion bills, medical scholarship/loan legislation, and appropriations, and (c) motivate programming initiatives to improve midwifery education and perinatal regionalization in Georgia. Conclusion GMIHRG members have employed inventive research methods and maximized collaborative partnerships to enable their data on Georgia's maternal and infant outcomes and obstetric workforce to effectively inform state organizations and policymakers. With this unique approach, GMIHRG serves as a cost-efficient and valuable model for student engagement in the translation of research into advocacy efforts, policy change, and innovative programming.

The need for conducting evaluations which reflect of the influence of context on complex programs is increasingly recognized in the field of evaluation. Better data visualization techniques for connecting context with program evaluation data are needed. We share our experience developing a mixed methods timeline to visualize complexity and context with evaluation data. Mixed methods timelines provide a meaningful way to show change over time in both a visually stimulating and accessible format for evaluation audiences. This paper provides an innovative example of using mixed methods timelines to integrate evaluation data with key program activities and milestones, while also showing internal and external contextual influences in one cohesive visual. We present methods and best practices for collecting contextual data and for incorporating a variety of data sources into such a visual. We discuss several strategies to collect and organize context related data including: qualitative interviews, program materials, narrative reports, and member checking with stakeholders and staff. Gathering multiple perspectives is essential to better capture the multi-layered elements of program activities and context.

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 During the last decade, conflict or natural disasters have displaced unprecedented numbers of persons. This leads to conditions prone to outbreaks that imperil the health of displaced persons and threaten global health security. Past literature has minimally examined the association of communicable disease outbreaks with complex emergencies (CEs) and natural disasters (NDs). Methods To examine this association, we identified CEs and NDs using publicly available datasets from the Center for Research on the Epidemiology of Disasters and United Nations Flash and Consolidated Appeals archive for 2005–2014. We identified outbreaks from World Health Organization archives. We compared findings to identify overlap of outbreaks, including their types (whether or not of a vaccine-preventable disease), and emergency event types (CE, ND, or Both) by country and year using descriptive statistics and measure of association. Results There were 167 CEs, 912 NDs, 118 events linked to ‘Both’ types of emergencies, and 384 outbreaks. Of CEs, 43% were associated with an outbreak; 24% NDs were associated with an outbreak; and 36% of ‘Both’ types of emergencies were associated with an outbreak. Africa was disproportionately affected, where 67% of total CEs, 67% of ‘Both’ events (CE and ND), and 46% of all outbreaks occurred for the study period. The odds ratio of a vaccine-preventable outbreak occurring in a CE versus an ND was 4.14 (95% confidence limits 1.9, 9.4). Conclusions CEs had greater odds of being associated with outbreaks compared with NDs. Moreover, CEs had high odds of a vaccine-preventable disease causing that outbreak. Focusing on better vaccine coverage could reduce CE-associated morbidity and mortality by preventing outbreaks from spreading.

Objectives The Iowa Department of Public Health I-Smile program provides dental screening and care coordination to over 23,000 low-income and Medicaid-enrolled children per year. The purposes of this study were to evaluate I-Smile program effectiveness to ensure that Medicaid-enrolled children obtained dental treatment after having been screened and to determine the factors associated with failure to receive dental care after screening through the I-Smile program. Methods Based on I-Smile program priorities, we limited our sample to children younger than 12 years of age who screened positive for decay and who linked to a paid Medicaid claim for dental treatment (n = 1,816). We conducted bivariate analyses to examine associations between children's characteristics who screened positive for decay and received treatment within 6 months of their initial screening. We also performed multivariate logistic regression to assess the association of sociodemographic characteristics with receipt of treatment among children who screened positive for decay. Results Eleven percent of children screened positive for decay. Nearly 24 percent of children with decay received treatment based on a Medicaid-paid claim. Being 5 years or older [adjusted odds ratio (aOR): 1.48, confidence interval (CI): 1.17, 1.88] and not having a dental home (aOR: 1.90, CI: 1.41, 2.58) were associated with higher odds of not receiving dental treatment. Conclusions Children 5 years and older and without a dental home were less likely to obtain dental treatment. Opportunities exist for the I-Smile program to increase the numbers of at-risk children with dental homes and who obtain dental care after screening.

Background: Integrating family planning into postabortion and postpartum services can increase contraceptive use and decrease maternal and child death; however, little information exists on the monitoring and evaluation of such programs. This article draws on research completed by the EngenderHealth’s AgirPF project in three urban areas of Togo on the extent to which monitoring and evaluation systems of health services, which operated within the AgirPF project area in Togo, captured integrated family planning services. Methods: This mixed methods case study used 25 health facility assessments with health service record review in hospitals, large community clinics, a dispensary, and private clinics and 41 key informant interviews with health faculty, individuals working at reproductive health organizations, individuals involved in reproductive health policy and politics, health care workers, and health facility directors. Results: The study found the reporting system for health care was labor intensive and involved multiple steps for health care workers. The system lacked a standardized method to record family planning services as part of other health care at the patient level, yet the Ministry of Health required integrated family planning services to be reported on district and partner organization reporting forms. Key informants suggested improving the system by using computer-based monitoring, streamlining the reporting process to include all necessary information at the patient level, and standardizing what information is needed for the Ministry of Health and partner organizations. Conclusion: Future research should focus on assessing the best methods for recording integrated health services and task shifting of reporting. Recommendations for future policy and programming include consolidating data for reproductive health indicators, ensuring type of information needed is captured at all levels, and reducing provider workload for reporting.

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.

SummaryContraceptive prevalence has risen markedly in rural Bangladesh due in part to a doorstep-delivery system initiated by the International Centre for Diarrhoeal Disease Research, Bangladesh (ICDDR,B). This study investigates effects of residence in the Matlab MCH-FP treatment area on men’s involvement in family planning. The analysis compares for treatment and comparison areas knowledge of and attitudes toward contraception, as well as levels of contraceptive use, among 413 married men interviewed at the baseline of an ICDDR,B men’s involvement project. Although residence in the MCH-FP area is associated with a higher overall contraceptive prevalence, it also is associated with a lower adjusted ratio of male-to-female method use, and lower odds of other indicators of men’s involvement in family planning. Historical decisions to exclude men from contraceptive decision-making may place the ‘burden’ of contraception on women and may preclude the productive involvement of men. These and other implications and strategies for increased men’s involvement are discussed.

1Summary objectives To investigate community health workers’ (CHW) adherence over time to guidelines for treating ill children and to assess the effect of refresher training on adherence. methods Analysis of 7151 ill-child consultations performed by 114 CHWs in their communities from March 1997–May 2002. Adherence was assessed with a score (percentage of recommended treatments that were prescribed), calculated for each consultation. Recommended treatments were those that were indicated based on CHW assessments. We used piecewise regression models to evaluate adherence before and after training. results The average adherence score was 79.4%. Multivariable analyses indicate that immediately after the first refresher training, the mean adherence level improved for patients with a severe illness, but worsened for patients without severe illness. Adherence scores declined rapidly during the 6 months after the second refresher training. conclusions The first refresher was partially effective, the second refresher had an effect contrary to that intended, and patient characteristics had a strong influence on adherence patterns. Longitudinal studies are useful for monitoring the dynamics of CHW performance and evaluating effects of quality improvement interventions.

Evaluation of a community health worker (CHW) programme in Siaya district, Kenya, showed CHWs commonly made errors in managing childhood illness. We assessed the effect of multiple interventions on CHW healthcare practices. A sample of 192 ill-child consultations performed by 114 CHWs in a hospital outpatient department between February and March 2001 were analysed. The mean percentage of assessment, classification and treatment procedures performed correctly for each child was 79.8% (range 13.3-100%). Of the 187 children who required at least one treatment or referral to a health facility, only 38.8% were prescribed all treatments (including referral) recommended by the guidelines. Multivariate analyses found no evidence that the intervention-related factors studied (refresher training, supervision, involvement of community women in the CHW selection process, adequacy of medicine supplies, and use of a guideline flipchart during consultations) were significantly associated with overall or treatment-specific guideline adherence. A multivariate linear regression analysis revealed that several non-intervention-related factors, such as patient characteristics, were significantly associated with overall guideline adherence. Given that our study was cross-sectional and our measurement of exposure to several interventions was based on CHW recall, the estimated effects of the interventions should be interpreted with caution. Despite these limitations, however, our results raise questions about the effectiveness, in the setting of Siaya district, of several interventions commonly used to improve the quality of care given by CHWs.

To determine whether results from an evaluation that involved observation of community health workers while they performed patient consultations in a hospital reflected normal everyday practices.Comparison of two samples of ill-child consultations: (i) consultations performed during an evaluation in which we observed community health workers in a hospital in-patient and outpatient department from February to March 2001 and (ii) consultations performed under no observation in villages and documented in clinical registers within the 90 days before the hospital evaluation.Siaya District Hospital and villages in Kenya.Community health workers.Treatment error indicator, defined as the percentage of consultations where at least one recommended treatment (where recommended treatments were those that were indicated based on community health worker assessments of the child's condition) was not prescribed.We analyzed data on 1132 consultations (372 from the hospital evaluation and 760 from the community) performed by 103 community health workers. For all types of consultations combined, the difference between treatment error indicators (hospital minus community) was -16.4 [95% confidence interval (CI): -25.6, -7.1].We found that community health workers made treatment errors less frequently when they were observed in a hospital in-patient or outpatient department than when they were not observed in the community. Evaluations that involve the observation of community health workers in a hospital setting might overestimate the quality of care that they normally give in their villages.

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)

Identifying and addressing malnutrition among US-bound refugee children is an important human rights issue. Failure to address childhood malnutrition can impair cognitive development and productivity. The target population was children aged 6–59 months, originating from eight countries representing 51 % of US-resettled refugees for 2005–2011, living in 22 camps prior to potential US-resettlement. The corresponding camp-level nutritional survey data were evaluated. State Refugee Health Coordinators were surveyed on nutritional assessment, reporting and referrals for their US-refugee medical screenings. From 2004 to 2010, half of the camps (63 total surveys) had global acute malnutrition prevalence over 15 % at least once (surveys not done annually) and anemia prevalence greater than 40 %. The majority of US-refugee medical screenings included height and weight measurements but few used national or WHO standards to evaluate presence or level of malnutrition. Improve overseas camp monitoring and link these nutritional data to US-resettling refugee children to inform potential nutritional interventions. Domestically, use WHO or US growth standards for anthropometrics to determine presence of malnutrition and need for corrective action.

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.

OBJECTIVES: Although more fetal deaths than neonatal deaths occur, routinely collected fetal death data are seldom used for perinatal epidemiologic research because of data quality concerns. We developed a strategy for identifying and correcting errors in birthweight and gestational age in fetal death records. METHODS: Using data from Georgia for 1989 and 1990, we detected singleton fetal death records having improbable or missing birthweight or gestational age by comparing these values with referent values. To verify the questionable values, we contacted 100 reporting hospitals in 1992. RESULTS: In 817 of 2226 records, values were either improbable (60.1%) or missing (39.9%). We were able to contact the hospitals to verify data for 716 (88%) of these records. Verification resulted in corrections to 405 (57%) records, and 48% of unreported birthweights were obtained. CONCLUSIONS: Many errors in recorded gestational age and birthweight were identified by this method. Rather than deleting or inputting problem data for analyses, researchers should consider efforts to verify them. Efforts to improve this information should include improved reporting, strict quality assurance, and procedures for routine verification and correction of records.

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.

In 2006, the Colombian Constitutional Court issued a decision largely decriminalizing abortion; however, illegal abortion persists. Understanding the barriers that cause women to resort to unsafe, illegal abortions could help improve access to legal services.In-depth interviews were conducted in 2014 with 17 women aged 18 or older who had had legal abortions in the past year in Bogotá, Colombia, to identify barriers to abortion access and elucidate the ways in which these barriers affect women's decision making regarding abortion. Interview transcripts were coded and analyzed using standard techniques to find patterns, parallels and differences; a phenomenological approach guided the thematic analysis.Barriers related to knowledge and information, along with logistic, emotional, financial, cultural and religious barriers culminated in delays in obtaining comprehensive abortion services. Religion influenced social stigma, which manifested most powerfully in the obstructive behavior of health care providers and health insurance companies. Lack of understanding of current laws on abortion and conscientious objection was evident on the part of patients, health care providers and insurers.Dissemination of accurate information regarding the availability of clinical and legal abortion is needed. Better training may help physicians, nurses and insurance company personnel understand their roles and legal responsibilities in abortion care and reduce delays in women's access to services.RESUMEN Contexto: En 2006, La Corte Constitucional de la República de Colombia emitió una decisión que en gran medida despenalizó el aborto; sin embargo, el aborto ilegal persiste. Comprender las barreras que conducen a las mujeres a acudir a abortos ilegales e inseguros podría ayudar a mejorar el acceso a los servicios legales. Métodos: En 2014 se condujeron entrevistas en profundidad con 17 mujeres de 18 años de edad o mayores que habían tenido abortos legales el año anterior en Bogotá, Colombia, con el fin de identificar barreras de acceso al aborto y esclarecer las formas por las cuales estas barreras afectan la toma de decisiones de las mujeres en relación con el aborto. Las transcripciones de las entrevistas se codificaron y analizaron mediante técnicas estándar para identificar patrones, paralelismos y diferencias; un enfoque fenomenológico guio el análisis temático. Resultados: Las barreras relacionadas con conocimientos e información, junto con las barreras logísticas, emocionales, financieras, culturales y religiosas culminaron en retrasos a la hora de obtener servicios integrales de aborto. La religión influyó en el estigma social, el cual se manifestó con mayor fuerza en conductas obstructivas por parte de proveedores de servicios de salud y compañías de seguros de salud. Fue evidente la falta de comprensión en torno a las leyes actuales de aborto y a la objeción de conciencia por parte de pacientes, proveedores de servicios de salud y aseguradoras. Conclusiones: Se necesita difundir información precisa relacionada con la disponibilidad del aborto legal y clínico. Una mejor capacitación puede ayudar a médicos, enfermeras y personal de las compañías de seguros a comprender sus roles y responsabilidades legales en la atención del aborto y reducir los retrasos en el acceso de las mujeres a los servicios.RÉSUMÉ Contexte: En 2006, la Cour constitutionnelle de Colombie a rendu une décision décriminalisant l'avortement dans une large mesure. L'avortement clandestin persiste cependant. Il pourrait être utile, pour améliorer l'accès aux services légaux, de comprendre les obstacles qui poussent les femmes à recourir à l'avortement clandestin non médicalisé. Méthodes: En 2014, des entretiens en profondeur ont été menés avec 17 femmes âgées de 18 ans ou plus ayant obtenu un avortement légal au cours des 12 derniers mois à Bogota (Colombie), dans le but d'identifier les obstacles à l'accès à l'avortement et d'en élucider les effets sur la décision des femmes concernant l'avortement. Les transcriptions de ces entretiens ont été codées et analysées selon les techniques standard d’établissement des tendances, parallèles et différences. Une approche phénoménologique a guidé l'analyse thématique. Résultats: Les obstacles ayant trait à la connaissance et à l'information, de même que ceux de nature logistique, affective, financière, culturelle et religieuse, aboutissent à des retards d'obtention de services d'avortement complets. La religion influence la stigmatisation sociale, manifestée le plus intensément dans le comportement obstructif des prestataires de soins de santé et des compagnies d'assurance-maladie. Le manque de compréhension des lois actuelles sur l'avortement et l'objection de conscience est évident chez les patientes, les prestataires de santé et les assureurs.La diffusion d'une information exacte concernant la disponibilité de l'avortement clinique légal est nécessaire. Une meilleure formation peut aider les médecins, le personnel infirmier et les compagnies d'assurance à comprendre leurs rôles et responsabilités légales dans les soins d'avortement et réduire les retards d'accès des femmes aux services.

Hawaii currently ranks first among states for chlamydia screening of young women based on recent Healthcare Effectiveness Data and Information Set (HEDIS) measures and has consistently ranked in the top ten states in the US for annual reported chlamydia rates since 2002. A statewide provider survey was conducted in October 2007 and March 2008 to assess chlamydia screening practices and beliefs and identify potential barriers to screening. The overall reported screening rate for 15–19 year old females was 66.9% with significant differences by practice specialty (obstetrician/gynecologists were more likely to screen than family practitioners or pediatricians) and practice setting (higher rates of screening in non-private practice settings). Providers who were unaware of health plan reimbursement for screening and those who targeted screening only for clients perceived to be at “high risk” were significantly less likely to routinely provide screening. The Hawaii State Department of Health is currently working in consort with health care providers and the state’s dominant health insurance carriers to address these issues through targeted provider educational interventions.

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.

Research to improve the health of American Indians and Alaska Natives (AI/AN) is subject to many special challenges. To that end, the merits and barriers of health disparities research was a central discussion topic by the editorial advisory board members for this special issue when they met in the fall of 2006. This discussion reflected that the comparison of AI/AN and non-Hispanic white health issues has limited value when limited ability exists to control contextual differences. These differences include the AI/AN history, level of poverty, culture, living environment, and the ability to access quality health services. Therefore, the board agreed to give priority to research papers that focused on measures for improving AI/AN health. AI/AN are dispersed in large cities such as New York City and Los Angeles and in small cities like Anchorage and Tulsa. In addition, they live in relatively isolated tribal reservations and villages disproportionately located in the 30% of U.S. counties that are sparsely populated and located at a great distance or travel time from the closest significant service center or market (Fig. 1). Most AI/AN live west of the Mississippi River. The National Center for Frontier Communities has described the challenges of economic development in these areas. We included papers that demonstrate the diversity of AI/AN with respect to their place of residence, as well as critical health issues. We cannot adequately represent the geographic and other diversity of the federally recognized 562 tribes who live on reservations or in urban areas. Assisting AI/AN in developing their own public health interventions will require knowledge and sensitivity to a multitude of variations. Maternal and child health practice research among AI/ AN is plagued by low response rates that limit generalization of specific findings. Response rates are often available for the overall survey, but not for AI/AN. In this issue, low reported response rates included 51% for inner city youth in two Oklahoma cities, 54% overall in the National Survey of Child Health [1] and 63% among AI in the Pregnancy Risk Assessment Systems (PRAMS) [2]. The median AI/AN response rates for Behavioral Risk Factor Surveys declined from 63% in 1997 to 50% in 2000 [3]. Kim noted that the 2000 US Census had an overall response rate from AI of 67%, with only 8.5% of tribes having a response rate of 70% or higher [4]. On the positive side, Kim documented that non-response in PRAMS was chiefly due to inability to contact the desired respondent. Once contacted, AI/AN responded as often as non-Hispanic whites. Conducting valid research to improve the health of AI/ AN may require more resources than research on the general population. Methods to increase research validity may include oversampling, face-to-face (rather than telephone) interviews; large record-linkage studies; identifying county code of residence of birth mothers for local area analysis; and the engagement of communities and their leaders in developing health assessment and practice methods. Moreover, educational resources should be devoted to developing more AI/AN researchers who can lead in achieving relevant research to improve the health of AI/AN mothers and children. R. Rochat (&) Hubert Department of Global Health, Rollins School of Public Health, STE 768, Emory University, 1518 Clifton Road NE, Atlanta, GA 30322, USA e-mail: rrochat@sph.emory.edu 1 http://www.frontierus.org/geography.htm

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.

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.

OBJECTIVES: This study compared injury deaths between postpartum women and other women aged 15 to 44. METHODS: Risk ratios and 95% confidence intervals (CIs) were computed for injury fatality rates. RESULTS: Fifty percent (29/58) of postpartum injury deaths were homicides, compared with 26% (427/1648) of injury deaths among nonpregnant, nonpostpartum women. For females aged 15 to 19, the homicide rate was 2.6 times higher (95% CI = 1.17, 5.95) for postpartum females than for other females. The motor-vehicle fatality rate was lower for postpartum females than for nonpregnant, nonpostpartum females (risk ratio = 0.30, CI = 0.18, 0.48). CONCLUSIONS: Postpartum females aged 15 to 19 years were at higher risk of homicide. Postpartum women were at reduced risk of motor-vehicle fatalities.

In 1988, we identified playground hazards at 58 child-care centers (CCCs) and intervened by showing the director the hazards and distributing safety information. In 1990, we evaluated the 58 intervention CCCs as well as 71 randomly selected control CCCs. Intervention centers had 9.4 hazards per playground; control centers had 8.0. We conclude that the intervention was ineffective.

Many studies have explored maternal and infant factors as risks for infant mortality, but little attention is given to paternal factors. In Georgia, listing a father's name on the birth certificate is optional for married couples and possible after paternal acknowledgment for unmarried couples. The authors evaluated father's name reporting as a paternity measure and risk for infant mortality. Using the linked 1989–1990 birth and death certificates of singleton Georgia infants to calculate relative risks (RRs), infant mortality rates for 38,943 infants with no father's names listed were compared to rates for 178,100 with father's names listed. Compared with the rate for married women listing names, the death rates were higher for unmarried mothers not listing fathers (relative risk, RR=2.5; 95% CI 2.3–2.7), unmarried mothers listing fathers (RR=1.4; 95% CI 1.3–1.6), and married women not listing fathers (RR=2.3; 95% CI 1.6–3.1). Increased risks remained after stratifying by maternal race, age, adequacy of prenatal care and medical risks; and congenital malformations, birthweight, gestational age, and small-for-gestational age. Using logistic regression to examine for effect modification and to adjust for these factors together, the adjusted relative risks for death varied across different groups without fathers' names, regardless of marital status. For example, it remained statistically higher for infants with no father listed and without effect-modifying conditions such as low birthweight (estimated RR=2.0; 95% CI 1.6–2.4). Although these findings suggest paternal involvement, as measured by listing fathers' names, is protective against low birthweight and infant mortality, further evaluation is needed.

Lung cancer mortality was reported to be higher among Mexican-American women as compared with Anglo women from 1950 until 1970; however, smoking habits of Mexican-American women have not been adequately described. This study updates lung cancer mortality data in Texas, describes smoking patterns of 1,255 Mexican-American women from a household survey in the four states bordering Mexico, and compares these findings to a reference group of Anglo women residing in the same area. In 1970, lung cancer mortality rates were similar for Mexican-American and Anglo women in Texas; however, by 1974-1976 Mexican-American women in Texas had a 40 per cent lower rate than Anglo women and by 1979, a 49 per cent lower rate. In our 1979 survey results, Mexican-American women reported lower levels of smoking, both in prevalence and amount smoked, as compared with Anglo women. The lower prevalence was reported for all social and demographic categories examined. The relatively low lung cancer mortality rate is most likely due to relatively low levels of cigarette smoking among Mexican-American women. Based on the trend in lung cancer deaths and our survey findings, we would anticipate a continuing low level of lung cancer mortality among Mexican-American women.

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.

To determine the completeness of reporting of maternal deaths after live born deliveries in Georgia for 1975 and 1976, we matched death certificates with corresponding birth certificates for women of reproductive age. For these two years, more intensive searching led to our finding a minimum of a 27 per cent higher number of maternal deaths than that found by routine death certificate surveillance. When the delivery-death interval was not restricted to 42 days, use of the record linkage method led to a 50 per cent increase in reporting of maternal deaths. We recommend that special efforts be made to obtain more complete reporting of all pregnancy-related deaths and that completeness of reporting be periodically evaluated for all states.

Recent studies in several states have found that the incidence of maternal mortality is higher than traditional vital statistics reports indicate. Since no comprehensive national study has been done to evaluate the completeness of maternal mortality ascertainment through the national vital statistics reporting system, the Centers for Disease Control (CDC) undertook such a study with the assistance of the National Center for Health Statistics and state health departments. The state health departments provided CDC with death certificates for all pregnancy-related deaths occurring during 1974-78. We reviewed and classified these certificates using both International Classification of Diseases, Adapted, Eighth Revision (ICDA-8) and International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) maternal death codes. We found that the actual incidence of maternal mortality for 1974-78 was approximately 20 per cent and 30 per cent greater than that published in national vital statistics reports using ICDA-8 and ICD-9-CM, respectively.

In 1979 the Centers for Disease Control conducted a household probability survey of reproductive aged women living in 51 selected US countries on the US-Mexico border. Information on the incidence of breastfeeding for the period 1971-1979 was analyzed on 345 Anglo women and 689 Hispanic women of Mexican origin. Results indicated that the Anglos are following the national trend of increased breastfeeding, but Hispanics show no indication of an increase in the practice of breastfeeding.