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Few reliable data exist on the risk of maternal death from cesarean section. To identify more deaths after cesarean section than reported by vital records alone, we linked data from Georgia resident live-birth certificates to those from death certificates of Georgia women aged 10 to 44 years. We found 16 maternal deaths after cesarean section in Georgia during 1975 and 1976, five more (45%) than the 11 reported through vital records alone. We attributed nine of these 16 deaths to the cesarean section per se. We then calculated a total death-to-case rate of 105.3 deaths per 100,000 cesarean sections and a rate attributable to cesarean section of 59.3 deaths per 100,000 procedures. Pulmonary embolism and cardiopulmonary arrest during general anesthesia were the leading causes of death in this series. Preventive measures aimed at reducing these complications may reduce deaths after cesarean section.

Studies suggest that hysterectomy and tubal sterilization may alter the function of the remaining ovaries. Conceivably, this effect could alter breast cancer risk. To investigate whether these surgeries affect breast cancer risk, the authors analyzed data collected between December 1, 1980, and April 30, 1983, in a population-based, case-control study of women aged 20-54 years, the Cancer and Steroid Hormone Study. Compared with never-sterilized women, women with hysterectomy and no remaining ovaries had a decreased risk of breast cancer (relative risk (RR) = 0.7, 95% confidence interval (CI) = 0.6-0.8). Risk was lowest in women who had their surgery before age 40 years or 15 or more years in the past; surgery at an early age provided greater protection than surgery in the distant past. Hysterectomy with one or two remaining ovaries was also inversely associated with breast cancer risk (RR = 0.8, 95% CI = 0.7-0.9), but no relation was found with age at surgery or time since surgery. Women with tubal sterilization had a slightly increased risk of breast cancer, which was of borderline statistical significance (RR = 1.2, 95% CI = 1.0-1.3). However, no relation was found with age at surgery or time since surgery. The data suggest that hysterectomy with bilateral oophorectomy decreases the breast cancer risk in women aged less than 55 years, possibly by curtailing ovarian function at a critical period. However, neither hysterectomy without bilateral oophorectomy nor tubal sterilization appears to substantially alter breast cancer risk in women of this age.

To the Editor.— The article by Glebatis and Janerich, 1 "Ectopic Pregnancies in Upstate New York," and the accompanying editorial by Eschenbach and Daling 2 suggest that tubal sterilization may increase a woman's risk of ectopic pregnancy and that the increase in tubal sterilization procedures has contributed to the increasing incidence of ectopic pregnancy. Since more than 8% of reproductiveage women in the United States have had a tubal sterilization procedure, such an association would be of important public health concern. Although it is true that a large proportion (5% to 50% ) of pregnancies after tubal sterilization are ectopic gestations, pregnancy after sterilization surgery occurs so infrequently (approximately five per 1,000 women) that it is unlikely that the increase in popularity of tubal sterilization has contributed to the increasing incidence of ectopic pregnancy. Using data from several large studies of contraceptive practices and ectopic pregnancy risk, including a multi-center prospective

During the 1970s, tubal sterilization became an important method of fertility control in the United States. Over the same period laparoscopy emerged as an important innovation, one that has been associated with both a shift from postpartum to interval sterilization and a dramatic decrease in length of hospital stay required for sterilization. The use of laparoscopy has also been associated with an increase in hospital-based outpatient sterilization, particularly in the West. The number of sterilizations performed in hospitals and the use of laparoscopy for interval sterilization in hospitals both appear to have peaked. The laparoscope is an example of a technologic advance that has reduced medical care costs.The number and characteristics of women having laparoscopic sterilizations in hospitals in the United States over the 1975 through 1978 period are reported along with some of the important influences that the introduction of laparoscopy had on tubal sterilization trends in the 1970s. The data are derived from data collected by the National Center for Health Statistics in their National Hospital Discharge Survey for the years 1970 and 1975 to 1978. 4.2 million women in the age range of 15 to 44 had tubal sterilizations performed in the United States in the 1970 to 1978 period. In 1970, fewer than 1% of sterilizations were done with a laparoscope. In the 1975-1978 period, approximately 815,000, or 1/3 of all tubal sterilizations during that period, were performed via laparoscopy. Only 29% of women underwent interval sterilization in 1970, but by 1976 the proportion of interval sterilization had increased annually to a high of 58%. Over the same period that interval sterilization increased in popularity, the use of laparoscopy for interval sterilization also increased. With respect to geographic region, the South had the lowest and the Northeast had the highest percentage of interval sterilizations performed via laparoscopy. Older women were more likely to have interval sterilization performed via laparoscopy. The average length of hospital stay for tubal sterilization declined from 6.5 nights in 1970 to 4.0 nights in the period 1975 to 1978. Much of this change is attributable to the shortened length of stay for laparoscopic sterilization.

In the period 1983 to 1985, hysterosalpingography was performed in 76 women after laparotomy to manage ectopic gestations. Clinical characteristics of these women, including their operative findings, were then correlated with the follow-up hysterosalpingography. Study participants were classified into five groups according to surgical management of the ectopic gestation. In each of the five groups, a substantial percentage of those women with a nonpatent fallopian tube (contralateral to the tube bearing the ectopic gestation) on hysterosalpingography had a normal-appearing fallopian tube at laparotomy. Approximately 50% of women with a history of previous pelvic inflammatory disease were found to have nonpatent contralateral fallopian tubes on follow-up hysterosalpingography.

In the period 1970-1977, an estimated 4,236,000 women 15-44 years of age had tubal sterilization operations in United States hospitals. Both the number and the rate of tubal sterilizations increased each year from 1970-1977, but in 1978 both declined. Tubal sterilization rates for Black women were higher than for White women. Black women also tended to be younger at the time of tubal sterilization. For the nation as a whole, the mean age at the time of tubal sterilization remained constant at about 30 with the youngest age group having the highest proportion of never-married women.

To study the risks of mortality associated with hysterectomy that are specific to age, race, surgical approach, and associated conditions, we used data collected by the Commission on Professional and Hospital Activities during 1979 and 1980. Four hundred seventy-seven deaths were recorded among 317,389 women having abdominal hysterectomies and 46 deaths among 119,972 women having vaginal hysterectomies. The mortality rates for hysterectomy, standardized for age and race, were higher for procedures associated with pregnancy or cancer than for procedures not associated with these conditions (29.2, 37.8, and 6.0 per 10,000 procedures, respectively). Hysterectomies associated with pregnancy or cancer constituted 8% of all hysterectomies performed. However, 61% of all deaths occurred in women with pregnancy- or cancer-related conditions. The mortality rate associated with hysterectomy increased with age and was twice as high among black women.

From January 1, 1979, to March 31, 1980, 20 sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. The leading cause of death from tubectomy was anesthesia overdose and from vasectomy, scrotal infection. Overall. The sterilization-attributable death-to-case rate was 21.3 deaths/100,000 procedures. The health impact of contraceptive sterilization is highly favorable: for each 100,000 tubectomies performed, the cost in lives (19) is offset by approximately 1015 maternal deaths averted.Over the January 1, 1979 to March 31, 1980 period sterilization-attributable deaths were identified in Dacca and Rajshahi Divisions, Bangladesh. These deaths were identified primarily through government records of compensation to families of deceased sterilization patients. This list was augmented by deaths reported from clinics of the Bangladesh Association for Voluntary Sterilization, detected through a prospective study of sterilization in Bangladesh, and identified by interviews with government family planning officials. A sterilization-associated death was defined as the death of a patient from any cause occurring within 42 days of tubal ligation or vasectomy. Death-to-case rates for vasectomy and tubal ligation were calculated for each month with 95% confidence intervals based on the Poisson distribution. 31 sterilization-associated deaths were identified over the study period. 28 of these were sterilization attributable and 3 were not. The mean age of the 21 women was 30.6 years, and their mean parity was 4.8. The mean age of the 7 vasectomy patients was 37.0 years. Abdominal Pomeroy method of tubal ligation was the only female sterilization technique used. 2 temporal clusters of sterilization attributable deaths occurred during the study. The 1st was a cluster of 5 deaths from tubal ligation performed in June 1979. 3 of these operations took place on June 5, 1979 but in different facilities. 1 factor common to each of these operations was the unseasonably hot weather. The 2nd temporal cluster consisted of 3 deaths after vasectomy in July 1979. 2 men from the same village died from scrotal infections after vasectomy on July 19, 1979 by the same surgeon at a single clinic. A similar death occurred earlier the same month. Another patient of the same surgeon and clinic associated with the deaths after operation on July 19 died from scrotal infection in January 1980. 3 vasectomy deaths related to 1 surgeon in a single remote facility suggests a breach of sterile technique. This could not be confirmed as this clinic physician could not be interviewed. The death-to-case rate for all procedures combined was 21.3 deaths/100,000 procedures, with the rate for vasectomy 1.6 times higher than that for tubal ligation. Anesthesia overdosage was the leading cause of death attributed to tubal ligation with tetanus (24%), intraperitoneal hemorrhage (14%), and infection other than tetanus (5%) as other leading causes. 2 patients (10%) died from pulmonary embolism after tubal ligation; 1 (5%) died from each of the following: anaphylaxis from anti-tetanus serum, heat stroke, small bowel obstruction, and aspiration of vomitus. All 7 men died from scrotal infections after vasectomy. Improvement in anesthesia management and sterile technique can lower the death-to-case rate for contraceptive sterilization in 2 Divisions of Bangladesh.

Background: The Collaborative Group on Hormonal Factors in Breast Cancer has brought together and reanalysed the worldwide epidemiological evidence on the relation between breast cancer risk and use of hormonal contraceptives. Methods: Individual data on 53 297 women with breast cancer and 100 239 women without breast cancer from 54 studies conducted in 25 countries were collected, checked, and analysed centrally. Estimates of the relative risk for breast cancer were obtained by a modification of the Mantel-Haenszel method. All analyses were stratified by study, age at diagnosis, parity, and, where appropriate, the age a woman was when her first child was born, and the age she was when her risk of conception ceased. Findings: The results provide strong evidence for two main conclusions. First, while women are taking combined oral contraceptives and in the 10 years after stopping there is a small increase in the relative risk of having breast cancer diagnosed (relative risk [95% Cl] in current users 1·24 [1·15-1·33], 2p

Unnecessary deaths of women under age 65 should be a high priority among physicians and the medical community as a whole. In the discussion of the promotion of health for women and the reduction of smoking, the idea of health promotion is 1st embellished upon with smoking and the preventable diseases incurred by it being used as an example for consideration. A good base of health promotion is the development of a health education strategy. Health promotion is defined by the following activities: the advocation of healthy behaviors, the continuation of the promotion of such choices or the promotion of changes in unhealthy behavior, the parleying of preventive and curative health services and the acceptance of such facilities and the condoning of activities at a societal level that are supportive of preventative and health choices. As the number of young women who smoke now exceeds the number of young men, smoking among women is a growing concern. Although white women capture the greatest percentage in the ethnic division of smokers, black women are only a few percentage points behind. In addition, smoking increases inversely according to level of education with the greatest percentage occuring among women with little education. The consequences of smoking, lung cancer, cardiovascular disease and additional risks relative to oral contraceptive use, are both apparent and serious. Measures such a mutually agreeable "quit plan," the creation of a smoke-free office and firm reinforcement in the discussion of smoking control are only a few of the steps a physician can undertake to support the process.

Trends of the incidence and mortality associated with ectopic pregnancy (EP) in the United States were examined for 1970 through 1978. The estimated number of EPs rose from 17,800 in 1970 to 42,400 in 1978, and the EP incidence rate rose from 4.5 per 1,000 reported pregnancies to 9.4 during the same time period. The risk of EP was higher for older women and nonwhite women. Over 2.5% of all reported pregnancies among nonwhite women aged 35 to 44 years were ectopic. The death-to-case rate for EP declined almost 75% during the study period but remained consistently higher for nonwhite women as compared with white women. ( JAMA 1983;249:1725-1729)

Data on the risk of death associated with various contraceptive methods are incomplete. Therefore, we analyzed the mortality rates for young, black inner-city women who used one of four methods of contraception—oral contraceptives, depomedroxyprogesterone acetate, intrauterine (contraceptive) devices, and barrier methods. The subjects were 30,580 15-to 44-year-old women who enrolled at a family planning clinic between 1967 and 1972 and who were observed by monitoring death certificates through the end of 1977. Forty percent of the 218 deaths observed were from accidents and violence. Use of this family planning clinic greatly reduced the risk of death from childbearing; only two deaths were associated with pregnancy and childbirth, compared with the 24 deaths expected. Overall, users of the four methods died at similar, low rates. Given that this study involves considerable loss to follow-up, possible acute effects of contraceptives (eg, infections or thrombosis) are more accurately estimated than possible long-term effects (eg, cancer). ( JAMA 1984;251:1044-1048)

We analyzed data from the Walnut Creek Contraceptive Drug Study to compare the menstrual characteristics of 719 women who had tubal sterilizations and 1083 women whose partners had undergone a vasectomy. Study participants were enrolled from 1968 to 1972 and followed up through 1976. The tubal sterilization group had slightly increased, though in most instances not statistically significant, risks of moderate to severe menstrual cramps and adverse menstrual bleeding. At follow-up intervals longer than 2 years, the tubal sterilization group had significantly increased risks of abnormal menstrual cycles and combinations of two or more adverse menstrual outcomes. Tubal sterilization was not associated with an increased risk of premenstrual symptoms. These findings suggest that the types of tubal sterilization procedures which were performed during the early 1970s possibly carry some increased risk of menstrual disturbances, particularly abnormal cycles, and that it may take more than 2 years for the increased risk to become apparent.

In their zeal for simplicity the media frequently misinterpret comples scientific findings and thereby misinform the public. This occurred when the general press reporting on a medical journal article focused on a link between the oral contraceptive pill and infertility. The journal article in fact had concluded that the pill is associated with increased risks of lower genital tract infection by Chlamydia trachomatis and also speculated that the pill might not protect against all forms of pelvic inflammatory disease (PID) especially the more indolent syndrome associated with chlamydia. The authors had raised the possibility--in the articles final paragraph--of infertility as a possible sequela of chlamydial PID. No evidence was presented in the article--or has been published elsewhere--linking oral contraceptives and infertility. Qualification of the pills protective effect against all causes of salpingitis should not be misconstrued as evidence of a harmful effect. Because of the importance of this issue however further research should be conducted expeditiously. And in the case of women who run a higher risk of sexually transmitted diseases the use of barrier methods might be encouraged or if oral contraceptives are chosen these women and their doctors should be on the alert for symptoms of lower genital tract chlamydial infection; and the physicians should prescribe antibiotics effective against chlamydia if symptoms of cervicitis or salpingitis occur.

In Reply.— We appreciate learning of Drs Brown and Schanzer's experience but believe that present data do not permit a definitive assessment of the safety and efficacy of alternative methods of tubal sterilization. A preliminary analysis of recent data 1 does, however, support their belief that the length of hospitalization for tubal sterilization has declined further since the 1970 to 1975 period we studied. The recent data from the National Hospital Discharge Survey indicate that the length of hospitalization for tubal sterilization declined an additional 14% from 1976 to 1978. 1 A limitation of the analysis of recent hospital-based data on tubal sterilization is that an increasing proportion of tubal sterilizations are being performed in free-standing clinics that are not included in the National Hospital Discharge Survey. To clarify that impact of this trend, the Family Planning Evaluation Division of the Centers for Disease Control, in collaboration with the American Association

Despite the millions of women who have undergone tubal sterilization in United States hospitals, little has been published about the risk of death from these procedures. To estimate a case-fatality rate of tubal sterilization, we combined data from the Commission on Professional and Hospital Activities and the National Center for Health Statistics with a review of the clinical circumstances for each woman whose death was identified as being potentially sterilization attributable. Considering all deaths temporally associated with tubal sterilization, we estimate that the case-fatality rate is nearly 8/100,000 procedures. When only deaths determined to be attributable to the sterilization operation per se are considered, the case-fatality rate is approximately 4/100,000 procedures, making death attributable to tubal sterilization a rear event.To obtain an accurate estimate of the risk of dying from tubal sterlization, the Centers for Disease Control (CDC) combined an analysis of national data on numbers and characteristics of sterilization procedures with a review of individual medical records for women whose deaths were identified as being associated with sterilization. This estimate was refined to include just those deaths actually attributable to the sterilization operation. Data for calculating case factality rates in this study are based on information for the years 1977 and 1978, obtained from the Commission on Professional and Hospital Activities (CPHA) and the National Center for Health Statistics in their National Hospital Discharge Survey. To identify deaths that were potentially sterilization attributable, the CPHA performed a computer-file search to identify patients who died during hospitalization and who also underwent a procedure coded 66.2 (bilateral salpingectomy), 66.3 (endoscopic bilateral salpingectomy), or 66.4 (other bilateral destruction, ligation, and division of fallopian tubes). To make estimates of the denominator, the total number of tubal sterilizations performed in Professional Activity Study (PAS) hospitals in 1977 and 1978 were determined. The CPHA computer-file search identified 63 deaths as potentially sterilization attributable. Of these 63, 38 deaths were reviewed after permission was given by hospital administrators. For the other 25 deaths, hospital administrators refused to cooperate. Of the 38 deaths reviewed, 25 were sterilization associated. The remaining 13 involved miscoding, i.e., either the woman did not die, did not have a sterilization procedure, or had PAS numbers which hospitals could not identify. The 25 sterilization-associated deaths occurred in connection with 521,400 tubal sterilization procedures peformed in PAS hospitals in 1977 and 1978. Of the 25 sterilization-associated deaths, only 9 were determined to be sterilization attributable. Since 9 of 38 of the deaths reviewed were sterilization attributable, it can be assumed that 23.7% or 6 of the 25 deaths that were not reviewed were also sterilization attributable. If this assumption is correct, a total of 15 sterilization-attributable deaths occurred, resulting in a case-fatality rate of 3.6/100,000 tubal sterilization. If none of the 25 deaths was sterilization attributable, the case-fatality rate would be 2.2/100,000 tubal sterilizations. Death attributable to tubal sterilization is rare, occurring at the rate of approximately 4/100,000 procedures.