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Despite nearly four million deliveries in the United States each year, minimal information exists on unintended health consequences following childbirth, particularly in relation to delivery method. The purpose of this study was to assess the association between method of delivery and the general health status, sexual, bowel and urinary functioning of primiparous women as measured at 7 weeks postpartum. Data from the Statewide Obstetrical Review of Quality System (StORQS) Survey of Maternity Care in Washington State were analysed. Participants included all primiparous women with a delivery of a singleton infant discharged alive between August and December 1991 from 10 non-federal short-stay hospitals who responded to the StORQS Survey of Maternity Care (n = 971). The main outcome measures included the modified Medical Outcomes Study 36-Item Short-Form Health Survey and self-reported sexual, bowel and urinary functioning. At 7 weeks postpartum, women who had caesarean or assisted vaginal deliveries reported significantly lower postpartum general health status scores than women with unassisted vaginal delivery. Additionally, women with assisted vaginal delivery reported significantly worse sexual, bowel and urinary functioning. Our results suggest that more careful attention to the postpartum general health and sexual functioning of women with caesarean and assisted vaginal delivery may be merited. [ABSTRACT FROM AUTHOR]

With dramatic changes in health, social services, and welfare systems and escalating pressure to increase clinical productivity, midwives need to enhance their capacity to work with federal, regional, and state partners to promote and protect comprehensive, culturally competent, and community-based quality health care for pregnant women and their families. Information about maternal and child health (MCH) regional and state resources is provided, and strategies for obtaining additional MCH resources are suggested, so that midwives and other women's health care providers can more effectively improve health care programs and systems that benefit women and their families. In addition, ways to work with MCH programs at the regional and state levels are described. [ABSTRACT FROM AUTHOR]

Abstract Background Obstetrical interventions during childbirth vary widely across European and North American countries. Regional differences in intrapartum care may reflect an inpatient-based, clinician-oriented, interventional practice style. Methods Using nationally representative hospital discharge data, a retrospective cohort study was conducted to explore regional variation in obstetric intervention across four major regions (Dublin Mid Leinster; Dublin Northeast; South; West) within the Republic of Ireland. Specific focus was given to rates of induction of labour, caesarean delivery, epidural anaesthesia, blood transfusion, hysterectomy and episiotomy. Logistic regression analyses were performed to assess the association between geographical region and interventions while adjusting for patient case-mix. Results 323,588 deliveries were examined. The incidence of interventions varied significantly across regions; the greatest disparities were observed for rates of induction of labour and caesarean delivery. Women in the South had nearly two-fold odds of having prostaglandins (adjusted OR: 1.75, 95% CI 1.68-1.82), whereas women in the West had 1.85 odds (95% CI 1.77-1.93) of artificial rupture of membrane. Women delivering in the Dublin Northeast, South and West regions had more than two-fold increased odds of elective caesarean delivery relative to women delivering in the Dublin Mid Leinster region. The Dublin Northeast region had the highest odds of emergency caesarean delivery (adjusted OR: 1.36; 95% CI: 1.31-1.40). Conclusions Substantial regional variation in intrapartum care was observed within this small, relatively homogeneous population. The association of intervention use with region illustrates the need to encourage uptake of scientific based practice guidelines to better inform clinical judgment.

The goal of this study was to assess whether interruption of care for chronic periodontitis during pregnancy increased the risk of low-birthweight infants. A population-based case-control study was designed with 793 cases (infants < 2,500 g) and a random sample of 3,172 controls (infants >or= 2,500 g). Generalized estimating equation models were used to relate periodontal treatment history to low birthweight risk and to common risk factors. The results indicate that periodontal care utilization was associated with a 2.35-fold increased odds of self-reported smoking during pregnancy (95% confidence interval: 1.48-3.71), a 2.19-fold increased odds for diabetes (95% confidence interval: 1.21-3.98), a 3.90-fold increased odds for black race (95% confidence interval: 2.31-6.61), and higher maternal age. After adjustment for these factors, interruption of periodontal care during pregnancy did not lead to an increased risk for a low-birthweight infant when compared to women with no history of periodontal care (odds ratio, 0.96; 95% confidence interval, 0.60-1.52). In conclusion, women receiving periodontal care had genetic and environmental characteristics, such as smoking, diabetes and race, that were associated with an increased risk for low-birthweight infants. Periodontal care patterns, in and of themselves, were unrelated to low-birthweight risk.

Numerous researchers have expressed concern over the impacts on medical records availability of the newly effective Medical Information Privacy rule, as authorized by the Health Insurance Portability and Accountability Act (HIPAA). The increased costs associated with compliance with the rule, and the increased potential for financial liability, raises the possibility that hospitals may be less likely to participate in such research, resulting in a decrease of the validity of multisite studies designed to represent an entire population. Our multisite medical record validation study, designed to assess the accuracy of maternally linked birth records, provides an overview of a number of HIPAA implementation challenges. We found that the new HIPAA rule presents new challenges for those who rely on the release of medical record information for epidemiologic research. At the very minimum, increased compliance costs associated with human subjects protection and increased administrative burden for researchers would seem to be inevitable as medical institutions address the requirements of the new HIPAA rule by instituting more complex and thus more cumbersome procedures. Researchers should anticipate increased costs and plan accordingly when budgeting for human subjects review processes.

Objective: To assess the association between first-birth cesarean delivery and second-birth placental abruption and previa., Methods: We conducted a population-based, retrospective cohort analysis using data from the Washington State Birth Events Record Database. The study cohort included all primiparas who gave birth to live singleton infants in nonfederal short-stay hospitals from January 1, 1987, through December 31, 1996, and who had second singleton births during the same period (n = 96,975). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for placental abruption or previa at second births associated with first-birth cesareans., Results: Among our study cohort, abruptio placentae complicated 11.5 per 1000 and placenta previa 5.2 per 1000 singleton deliveries at second births. In logistic regression analyses adjusted for maternal age, women with first-birth cesareans had significantly increased risk of abruptio placentae (OR 1.3, 95% CI 1.1, 1.5), and placenta previa (OR 1.4, 95% CI 1.1, 1.6) at second births, compared with women with prior vaginal deliveries., Conclusion: We found moderately increased risk of placental abruption and previa as a long-term effect of prior cesarean delivery on second births.

Objective: This study was undertaken to examine associations between induction of labor and maternal and neonatal outcomes among women without an identified indication for induction., Study Design: This was a population-based cohort study of 2886 women with induced labor and 9648 women with spontaneous labor who were delivered at 37 to 41 weeks' gestation, all without identified medical and obstetric indications for induction., Results: Among nulliparous women 19% of women with induced labor versus 10% of those with spontaneous labor underwent cesarean delivery (adjusted relative risk, 1.77; 95% confidence interval, 1.50-2.08). No association was seen in multiparous women (relative risk, 1.07; 95% confidence interval, 0. 81-1.39). Among all women induction was associated with modest increases in instrumental delivery (19% vs 15%; relative risk, 1.20; 95% confidence interval, 1.09-1.32) and shoulder dystocia (3.0% vs 1. 7%; relative risk, 1.32; 95% confidence interval, 1.02-1.69)., Conclusion: Among women who lacked an identified indication for induction of labor, induction was associated with increased likelihood of cesarean delivery for nulliparous but not multiparous women and with modest increases in the risk of instrumental delivery and shoulder dystocia for all women.

Context: Despite nearly 4 million deliveries in the United States each year, minimal information exists on unintended health consequences following childbirth, particularly in relation to delivery method., Objective: To assess the risk for maternal rehospitalization associated with cesarean or assisted vaginal delivery compared with spontaneous vaginal delivery., Design: Retrospective cohort study of data from the Washington State Birth Events Record Database for 1987 through November 1, 1996., Setting and Participants: All primiparous women without selected chronic medical conditions who delivered live singleton infants in nonfederal short-stay hospitals in Washington State (N =256,795)., Main Outcome Measures: Relative risks (RRs) of rehospitalization within 60 days of cesarean or assisted vaginal vs spontaneous vaginal deliveries., Results: A total of 3149 women (1.2%) were rehospitalized within 60 days of delivery. In logistic regression analyses adjusting for maternal age, rehospitalization was found to be more likely among women with cesarean delivery (RR, 1.8; 95% confidence interval [CI], 1.6-1.9) or assisted vaginal delivery (RR, 1.3; 95% CI, 1.2-1.4) than among women with spontaneous vaginal delivery. Cesarean delivery was associated with significantly increased risks of rehospitalization for uterine infection, obstetrical surgical wound complications, and cardiopulmonary and thromboembolic conditions. Among women with assisted vaginal delivery, significant increased risks were seen for rehospitalization with postpartum hemorrhage, obstetrical surgical wound complications, and pelvic injury., Conclusions: Women with cesarean and assisted vaginal deliveries were at increased risk for rehospitalization, particularly with infectious morbidities. Effective strategies for preventing and controlling peripartum infection should be an obstetrical priority.

Background: A Cochrane systematic review has shown that drug treatment of asymptomatic bacteriuria in pregnant women substantially decreases the risk of pyelonephritis and reduces the risk of preterm delivery. However, it is not clear whether single dose therapy is as effective as longer conventional antibiotic treatment., Objectives: The objective of this review was to assess the effects of different durations of treatment for asymptomatic bacteriuria in pregnancy., Search Strategy: We searched the Cochrane Pregnancy and Childbirth Group trials register, the Cochrane Controlled Trials Register and the reference lists of articles., Selection Criteria: Randomised and quasi-randomised trials comparing antimicrobial therapeutic regimens that differed in duration (particularly comparing single dose with longer duration regimens) in pregnant women diagnosed with asymptomatic bacteriuria., Data Collection and Analysis: Trial quality was assessed and data were extracted independently by the reviewers., Main Results: Eight studies involving over 400 women were included. All were comparisons of single dose treatment with four to seven day treatments. The trials were generally of poor quality. No difference in 'no-cure' rate was detected between single dose and short course (4-7 day) treatment for asymptomatic bacteriuria in pregnant women (relative risk 1.13, 95% confidence interval 0.82 to 1.54) as well as in the recurrent asymptomtic bacteriuria (relative risk 1.08, 95% confidence interval 0.70 to 1.66). However these results showed significant heterogeneity. No differences were detected for preterm births and pyelonephritis although sample size of trials was small. Longer duration treatment was associated with an increase in reports of adverse effects (relative risk 0.53, 95% confidence interval 0.31 to 0.91)., Reviewer's Conclusions: There is not enough evidence to evaluate whether single dose or longer duration doses are more effective in treating asymptomatic bacteriuria in pregnant women. Because single dose has lower cost and increases compliance, this comparison should be explored in a properly sized randomized controlled trial.

The objective of this study was to describe the association between maternal age and selected risk indicators (both recognized and potential) to determine whether any were predictive of labor complications in women having a first child. Low-risk primigravidas (n = 1,792) were selected from a large national probability sample of births for 1988 (the National Maternal and Infant Health Survey). Recognized and potential risk indicators were described according to categories of maternal age and the occurrence of labor problems. Stratified analysis and logistic regression were used to assess the association of various risk factors with labor complications adjusted for maternal age. Only cesarean delivery varied significantly across maternal age groups, the rate being 11.6% for those < 20, 15.9% for those age 20-29, and 28.3% for those > or = 30. Cesarean delivery was associated with several characteristics of social advantage. Independent risk factors for cesarean delivery were maternal age (particularly > or = 30), epidural anesthesia, and receipt of adequate prenatal care. We conclude that older primigravidas have significantly more cesarean deliveries, and this is partially explained by characteristics of social advantage. To address the high cesarean rate, care providers need a better understanding of the relationship between social circumstances and cesarean delivery.

This pilot study's objective was to determine the effectiveness of postpartum education received by midwifery clients at the University of New Mexico Hospital. The authors of the study randomized 100 women following delivery to two groups. Group one, n = 55, received written postpartum instructions only. Group two, n = 45, received oral instructions by the certified nurse-midwife in addition to the written instructions. Both groups answered a written questionnaire after the teaching. Analyses were carried out on 100 posttest scores. Mean test scores for group one was 17.9 out of a possible score of 20. Mean score for group two was 18.3. No significant difference was detected between these two mean scores. A 95% confidence interval for the difference between mean scores was -1.9 to 1.1 (P > .05). Reliability of instrument was established via the Kuder-Richardson formula 21. This conservative estimate of internal consistency yielded r = .50. The authors found that oral instructions by the certified nurse-midwife did not significantly increase the knowledge of primiparas as evidenced by posttest results. However, results must be interpreted cautiously for three reasons: low reliability of the instrument, the small difference between groups, and the sample size. The need to determine how best to approach postpartum education is imperative in this era of early hospital discharge. A certified nurse-midwife's time may be better spent focusing on individual concerns rather than on a set teaching agenda. Alternative opportunities such as postpartum home visits need to be explored as a means of providing support and guidance to new mothers.

This article describes the association among perineal outcomes, selected risk factors, and alternative intrapartum approaches used by nurse-midwives. This nonrandomized concurrent (cohort) study analyzed all spontaneous vaginal births (N = 1211) attended by nurse-midwives at a university hospital over a 2-year period. Univariate analysis was used to calculate relative risks for the associations between two perineal outcomes and selected variables. Study results indicated that parity, ethnicity, birth weight, and use of two techniques (hot compresses and lubrication) were associated with lacerations. The same factors that increase the risk of perineal lacerations also made the performance of an episiotomy more likely; however, for episiotomy, an inverse relationship with perineal hot compresses was noted, and perineal lubrication had no effect. Lack of perineal support was associated with a 66% rise in the risk of episiotomy. Use of birthing positions other than lithotomy significantly reduced the likelihood of episiotomy. The authors concluded that selected care measures to protect the perineum may reduce maternal morbidity and simplify intrapartum care. The risks and benefits of alternative strategies commonly used by nurse-midwives while caring for diverse populations during birth should be further evaluated in large multiethnic populations.