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Background: Environmental lead exposure poses a risk to educational performance, especially among poor, urban children. Previous studies found low-level lead exposure was a risk factor for diminished academic abilities, however, this study is distinct because of the very large sample size and because it controlled for very low birth weight and early preterm birth-two factors closely associated with lower academic performance. In this study we examined the association between lead concentration in whole blood (B-Pb) of Chicago Public School (CPS) children and their performance on the 3(rd) grade Illinois Standard Achievement Tests (ISAT) reading and math scores., Methods: We examined 58,650 children born in Chicago between 1994 and 1998 who were tested for blood lead concentration between birth and 2006 and enrolled in the 3(rd) grade at a CPS school between 2003 and 2006. We linked the Chicago birth registry, the Chicago Blood Lead Registry, and 3(rd) grade ISAT scores to examine associations between B-Pb and school performance., Results: After adjusting for other predictors of school performance including poverty, race/ethnicity, gender, maternal education and very low birth weight or preterm-birth, we found that B-Pbs below 10 μg/dL were inversely associated with reading and math scores in 3(rd) grade children. For a 5 μg/dL increase in B-Pb, the risk of failing increased by 32% for reading (RR = 1.32, 95%CI = 1.26, 1.39) and math (RR = 1.32, 95%CI = 1.26, 1.39). The effect of lead on reading was non-linear with steeper failure rates at lower B-Pbs. We estimated that 13% of reading failure and 14.8% of math failure can be attributed to exposure to blood lead concentrations of 5 to 9 vs. 0 to 4 μg/dL in Chicago school children., Conclusions: Early childhood lead exposure is associated with poorer achievement on standardized reading and math tests in the third grade, even at very low B-Pbs. Preventing lead exposure in early childhood is critical to improving school performance.

The aim of this study is to examine the relationship between prenatal care (PNC) provider site and the extent of documented adherence to recommended PNC content, and the relationship between adherence to recommended PNC content and adverse pregnancy outcomes among women in Illinois' Medical Assistance Program (MA). Utilizing the medical record, MA claims, and birth certificate data of 374 women who gave birth in 2003 and 2004 in four high-risk communities in Chicago, crude and adjusted analyses of the relationship between provider site and the extent of documented adherence to PNC content, and between adherence to PNC content and the incidence of low birthweight (LBW) and preterm birth (PTB) were conducted. The extent of documented adherence to recommended PNC content was measured from medical records as the percentage of 19 components of standard obstetrical practice that were delivered during pregnancy, converted to a three level categorical variable (low 50%, medium 50-79% and high 80% or greater). The majority of women had less than 80% of the recommended PNC content documented in their medical records. Among high-risk women, a greater proportion of women served by hospitals received care in which the extent of documented adherence was high (≥80%) compared to women served by physicians'offices (P < 0.05). Among low-risk women, a greater proportion of women served by FQHCs received care in which the extent of documented adherence was high compared to women served by hospitals (P < 0.10). Lower adherence to PNC content was significantly associated with LBW and PTB among women receiving prenatal care from physicians. Examination of the extent of adherence to recommended PNC content and its relationship to adverse pregnancy outcomes provides valuable data to inform potential interventions. In particular, a relationship between adherence to recommended PNC content and LBW and PTB among women receiving PNC at physicians' offices suggests the importance of increased quality assurance and provider education efforts.

Objective: To examine the relationship between prior cesarean delivery and placenta previa., Methods: A hospital-based, case-control study was conducted in which 316 multiparous women with placenta previa were identified. Controls consisted of 2051 multiparous women with spontaneous vaginal deliveries. Information on prior cesarean delivery was examined in three forms: as a dichotomous variable, as an ordinal variable, and as a set of three indicator variables for one, two, and three or more cesarean deliveries. Multivariable logistic regression modeling was used to obtain an adjusted estimate of this association., Results: Women with a prior cesarean delivery were more likely to have a placenta previa than those without (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.21, 2.08). The likelihood of placenta previa increased as both parity and number of cesarean deliveries increased. Thus, the adjusted OR for a primiparous woman with one cesarean delivery was 1.28 (95% CI 0.82, 1.99). For a woman who has four or more deliveries with only a single cesarean delivery, the OR increases to 1.72 (95% CI 1.12, 2.64). This trend continues with greater parity and a greater number of cesarean deliveries such that the likelihood of placenta previa for a woman with parity greater than four and greater than four cesarean deliveries was OR 8.76 (95% CI 1.58, 48.53)., Conclusion: This study supports the association between prior cesarean delivery and placenta previa and demonstrates that the joint effect of parity and prior cesarean delivery is greater than that of either variable alone.

Maternal mortality is the major indicator used to monitor maternal health in the United States. For every woman who dies, however, many suffer serious life-threatening complications of pregnancy. Yet relatively little attention has been given to identifying a general category of morbidities that could be called near misses. Characterizing near-miss morbidity is valuable for monitoring the quality of hospital-based obstetric care and for assessing the incidence of life-threatening complications. Cases of near-miss morbidity also provide an appropriate comparison group both for dinical case review and for epidemiologic analysis. This paper presents an initial framework and a process for the definition and identification of near-miss morbidity that minimizes loss of information yet has practical utility. A clinical review team classified 22 of 186 women as near misses and 164 as other severe morbidity. A quantitative score classified 28 women as near misses and 156 as other severe morbidity. Precise classification of near-miss morbidity is the first step in analyzing factors that may differentiate survival from death on the continuum from morbidity to mortality. Ultimately, a methodology for the identification and analysis of near-miss morbidity will allow for integrated morbidity and mortality reviews that can then be institutionalized. The results will serve as important models for other researchers, state health agencies, and regionalized perinatal systems that are engaged in morbidity and mortality surveillance.

Objectives: The objective of this study was to explore the relation between prenatal care characteristics and satisfaction among Medicaid recipients., Methods: African-American (n = 75) and Mexican-American (n = 26) nonadolescent primiparous pregnant women who had at least three prenatal care visits participated in a 25-minute telephone survey that asked them about satisfaction with prenatal care (art of care, technical quality, physical environment, access, availability and efficacy); prenatal care characteristics (practitioner attributes, service availability, and features of the delivery of care); and, personal characteristics (sociodemographics, health status and behaviors, and pregnancy-related variables). Univariate and multivariable analyses were conducted to explore the relations between personal characteristics and satisfaction and between care characteristics and satisfaction., Results: For the overall sample, the following prenatal care characteristics were associated with increased satisfaction: having procedures explained by the provider, short waiting times at the prenatal care site, the availability of ancillary services, and reporting that the prenatal care practitioner was male. When examining the data by ethnicity, whether the provider explained procedures was the most important determinant of satisfaction for both African-American and Mexican-American women., Conclusions: Knowledge of the care characteristics that impact low-income pregnant women's satisfaction can be utilized to alter service delivery to increase use of prenatal care and ultimately to improve perinatal outcomes.

Objective: To evaluate the reliability and construct validity of a prenatal care satisfaction scale., Method: A prenatal care satisfaction scale that included six dimensions of care based on the literature was tested during a telephone interview with 101 first-time African-American and Mexican-American mothers 18 and over who receive Medicaid., Results: The scale exhibited high reliability (Cronbach's alpha = 0.95), as well as good construct validity. The correlation between the scale and rating of the quality of care overall was 0.74 (p < 0.001); the correlation between the scale and whether the women would recommend this provider to a friend was 0.67 (p < 0.001). Results from correlation and factor analysis suggested a different set of dimensions than those described in the literature., Conclusion: The 22-question satisfaction with prenatal care scale has excellent reliability and construct validity and taps six established dimensions of satisfaction, including the art of care, technical quality, access, physical environment, availability, and efficacy. The multidimensional scale allows for alternative groupings of the domains of satisfaction as our understanding of prenatal care satisfaction increases.

This study describes the characteristics of women who received maternity care from the Chicago Department of Health or from private practitioners in 1988 and the first half of 1989, and who delivered at the University of Illinois Hospital or Cook County Hospital. The risk of preterm low birthweight for the infants of these women was compared according to source of prenatal care. The likelihood of giving birth to a preterm, low-birthweight infant was significantly greater (odds ratio 3.1, 95% confidence interval 2.3-4.0) for women who received care only from private physicians (n = 530) compared with those who received care entirely from the Chicago Department of Health (n = 2465). This relationship remained after adjustment for race, age, parity, history of adverse pregnancy outcomes, smoking, and use of drugs during pregnancy. We examined alternative explanations for these findings, and concluded that although the role of urban public health departments in the direct delivery of maternity care services continues to be a source of controversy, these institutions remain an important provider of such care for low-income women.

Regionalized perinatal care is intended to guarantee pregnant women and neonates access to appropriate care regardless of ability to pay. Its effectiveness depends on the willingness of hospitals to transfer high-risk patients according to established protocols and affiliations. This study examines maternal transfers (n = 896) to Cook County Hospital (CCH), a public facility and a designated perinatal center in Chicago. In 1987 and 1988, the majority (68%) of maternal transfers to CCH came from out-of-network hospitals, and 52% of these came directly from another perinatal center. The data indicate that 62% of the out-of-network transfers who delivered were medically high-risk. The study also documents the transfer of women in active labor, a violation of federal law. The term "perinatal dumping" is introduced to mean the transfer of high-risk pregnant women between hospitals for economic rather than medical reasons. Strategies for safeguarding the integrity of regionalized perinatal care are discussed.