Reproductive Health - Women's Health Highlights: Recent Findings (continued)

Reproductive Health
AHRQ's research on reproductive health focuses on pregnancy and childbirth, fertility problems, use of contraceptives, chronic pelvic pain, sexually transmitted diseases, and other conditions that can affect fertility and childbearing.

Pregnancy and Childbirth
The last half of the 20th century saw a decline in maternal deaths among U.S. women—from about 74 deaths in 1950 to about 7 deaths in 1993 for every 100,000 live births. Mortality related to pregnancy and childbirth is low for U.S. women compared with other causes of death, primarily because of health care advances that have occurred over the past 50 years. However, black women and older women continue to be at higher risk of death from complications of pregnancy.

•Booklet discusses the pros and cons of choosing to have labor induced.
Labor induction rates more than doubled between 1990 and 2005 to an all-time high of 22 percent. This increase reflects not only an increase in induction for medical indications but also broader use of elective induction for reasons such as a woman's physical discomfort, scheduling issues, and distance from the hospital. This booklet explains methods used to induce labor and possible complications, as well as what is still not known about elective induction. Thinking About Having Your Labor Induced? A Guide for Pregnant Women (AHRQ Publication No. 10-EHC004-A).* See also Elective Induction of Labor: Safety and Harms; Clinician Guide (AHRQ Publication No. 10-EHC004-3)* (AHRQ contract 290-02-0019)

•Home visits by a nurse help low-income pregnant women cope with depressive symptoms.
Having a nurse-community health worker team make home visits substantially reduces stress and depressive symptoms among low-income pregnant women, according to this study of 613 women in Michigan. Half of the women were assigned to a home visit intervention group and half received usual care. Women who received the home visits had significantly fewer depressive symptoms and lower levels of stress than women in the control group. Roman, Gardiner, Lindsay, et al., Arch Womens Ment Health 12:379-391, 2009 (AHRQ grant HS14206).

•Vaginal birth after a prior cesarean found to be safe for most women.
According to a recent AHRQ evidence report, choosing to have a vaginal birth following an earlier c-section—often referred to as VBAC—is a safe and reasonable choice for most women. More than 1 million c-sections are performed each year in the United States, and nearly one in every three births in 2007 was by cesarean. Evidence shows that compared with a trial of labor, an elective c-section carries a significantly higher risk for maternal death. Also, women who undergo multiple cesarean deliveries are at significant risk of life-threatening conditions. Vaginal Birth After Cesarean: New Insights, Evidence Report/Technology Assessment No. 191 (AHRQ Publication No. 10-E001)* (AHRQ contract 290-2007-10057-I).

•Study examines treatment patterns for early pregnancy failure in Michigan.
Researchers identified 21,311 women enrolled in Michigan's Medicaid program and 1,493 women from a university-affiliated health plan who experienced miscarriages between January 2001 and December 2005 to determine the type of care they received: expectant management, drug therapy, or surgery. They found that Medicaid-enrolled women were more likely to be treated surgically (35 percent) than women in the private plan (18 percent). Among those who had surgery, just 0.5 percent of Medicaid enrollees had surgery in medical offices, compared with nearly 31 percent of the privately insured women. Drug use (misoprostol) was low for both groups. Dalton, Harris, Clark, et al., J Womens Health 18(6):787-793, 2009 (AHRQ grant HS15491).

•Childbirth and deliveries are becoming more complicated.
A recent analysis of data from the Nationwide Inpatient Sample, a part of AHRQ's Healthcare Cost and Utilization Project, revealed that the number of hospital stays related to childbirth increased 16 percent from 4.3 million to 5 million between 1997 and 2007. However, the number of hospital stays for women who had a normal or uncomplicated birth declined by 43 percent (from 544,000 to 312,000) during the same time period. The analysis showed an increase in stays for women who had: a previous cesarean section, up 107 percent (from 271,000 to 562,000); high blood pressure, up 28 percent (185,000 to 235,000); or perineal trauma during childbirth, up 22 percent (713,000 to 868,000). HCUP Facts and Figures 2007; online at http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/TOC_2007.jsp (Intramural).

•Obese women are at risk for pregnancies exceeding 40 weeks.
In this study of nearly 120,000 women who gave birth between 1995 and 1999 in California, those who were obese before becoming pregnant ran a high risk of having a pregnancy that went 40 weeks or longer. Prolonged pregnancy increases the risk to the baby of excessive birth weight, restricted growth, diminished oxygen supply, and death. White women, older women (aged 30-39), and women who had never given birth were also more likely to have pregnancies that went 40, 41, or even 42 weeks. Caughey, Stotland, Washington, and Escobar, Am J Obstet Gynecol 200(6):683.e1-683.e5, 2009 (AHRQ grant HS10856).

•Some pregnancy-related complications are minimized for women who have had weight-loss surgery.
A review of 75 studies revealed that women who undergo weight-loss surgery and later become pregnant after losing weight may be at lower risk than pregnant women who are obese for pregnancy-related diabetes and high blood pressure—complications that can seriously affect the mother and/or her baby. Neonatal outcomes—such as preterm delivery, low birthweight, and high birthweight—also were found to be better in women following weight-loss surgery compared with obese women. Maggard, Yermilov, Li, et al., JAMA 300(19):2286-2296, 2008. See also Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy, Evidence Report/Technology Assessment No. 169 (AHRQ Publication No. 08-E013)* (AHRQ contract 290-02-0003).

•Repeat c-sections rose dramatically in the past decade.
The percentage of women undergoing a repeat cesarean delivery jumped from 65 percent to 90 percent between 1997 and 2006, according to data from AHRQ's Healthcare Cost and Utilization Project (HCUP). The data also showed that nearly one-third of the 4.3 million births in 2006 were delivered by cesarean, compared with one-fifth in 1997; c-sections are more costly than vaginal deliveries—$4,500 vs. $2,600 in uncomplicated deliveries; and c-sections account for 34 percent of all deliveries by women with private insurance, compared with 25 percent in women who are uninsured. See Hospitalizations Related to Childbirth, 2006, HCUP Statistical Brief No. 71, online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb71.jsp (Intramural).

•Numeric tool helps women determine their birthing preferences following a previous cesarean.
Using a computer-based graphic-numeric decision tool, 96 women who had undergone a previous cesarean delivery made a series of paired comparisons to help them understand their priorities for their next childbirth experience. They used four decision criteria to examine their preferences: avoiding harm to the baby, avoiding side effects for the mother; avoiding risk to future pregnancies, and having a good delivery experience. The women placed the highest priority on avoiding harm to their babies and ranked having a good delivery experience as last. Eden, Dolan, Guise, et al., J Clin Epidemiol 62:415-424, 2009 (AHRQ grants HS11338, HS13959, HS15321).

•Childbirth injuries have fallen sharply, but more could be prevented.
Between 2000 and 2006, injuries to mothers during childbirth decreased by 30 percent for those giving birth vaginally without instruments and by 20 percent for cesarean births and vaginal births with instruments. Despite these declines, nearly 158,000 potentially preventable injuries occurred to mothers and infants during childbirth in U.S. hospitals in 2006. See Potentially Avoidable Injuries to Mothers and Newborns During Childbirth, 2006, HCUP Statistical Brief No. 74; online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb74.jsp (Intramural).

•Researchers describe use of teamwork in obstetric critical care.
Crew Resource Management (CRM) is a teamwork approach developed in industry that is being applied today in medical settings to reduce risk to patient safety. At the heart of CRM are communication techniques, situational awareness, and leadership. These authors provide an overview of 11 currently available medical team training programs that use many CRM principles. Guise and Segel, Obstet Gynecol 22(5):937-951, 2008 (AHRQ grants HS15800, HS16673).

•Computerized tool helps women decide about prenatal genetic testing.
A computerized tool—the Prenatal Testing Decision-Assisting Tool, PT tool—provides personalized estimates of the chances that a woman is carrying a fetus with chromosomal abnormalities, describes prenatal screening and diagnostic tests, and develops a tailored testing strategy. Researchers evaluated the PT tool in a group of pregnant women and found that nearly 80 percent of women who used the tool were able to correctly answer questions on prenatal testing, compared with 65 percent of women in the control group who only read an educational booklet on the topic, and they were more satisfied with the education intervention and more confident about their decision to undergo or forego genetic testing. Kuppermann, Norton, Gates, et al., Obstet Gynecol 113(1):53-63 2009 (AHRQ grant HS10856).

•Bariatric surgery results in improved fertility in formerly obese women.
There has been a six-fold increase in bariatric (weight loss) surgery over the past 7 years, and nearly half of all bariatric surgery patients are women of reproductive age. This review of the evidence indicates that fertility improves after bariatric surgical procedures, nutritional deficiencies for mother and child are minimal, and maternal and neonatal outcomes are acceptable with laparoscopic band and gastric bypass, as long as adequate nutrition and supplemental vitamins are maintained. There was no evidence that delivery complications are higher in post-surgery pregnancies. Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy, Evidence Report/Technology Assessment No. 169 (AHRQ Publication No. 08-E013)* (AHRQ contract 290-02-0003).

•Researchers find little high-quality evidence to support the choice of assisted reproductive technology.
Researchers reviewed the available evidence on the outcomes of interventions used in ovulation induction, superovulation, and in vitro fertilization (IVF) for the treatment of infertility. They found that the majority of studies (80 percent) were conducted outside the United States, and there was little high-quality evidence on which to base a choice among the various interventions for infertility. They were able to substantiate improved pregnancy or live birth rates for several of the therapies. Effectiveness of Assisted Reproductive Technology, Evidence Report/Technology Assessment No. 167 (AHRQ Publication No. 08-E012)* (AHRQ contract 290-02-0025).

•Study examines factors related to infertility in women who have had pelvic inflammatory disease.
Women who have been exposed to Chlamydia trachomatis, as evidenced by the presence of C. trachomatis elementary bodies (EBs), have lower rates of pregnancy and higher rates of recurrence of pelvic inflammatory disease (PID) after an initial episode of mild to moderate PID, according to this study. The researchers examined Chlamydia antibodies and adverse sequelae after PID among 443 women with mild to moderate PID; they followed the women for a mean of 84 months. Ness, Soper, Richter, et al., Sex Transm Dis 35(2):129-135, 2008 (AHRQ grant HS08383).

•Several factors affect women's perceived risk of prenatal diagnostic screening procedures.
Invasive prenatal diagnostic tests—such as chorionic villus sampling and amniocentesis—are used to detect Down syndrome and other fetal chromosomal abnormalities, and they entail some risk, principally to the fetus. According to this study, women's perceived risk of adverse procedure-related outcomes varies based on factors that have little to do with risk. For example, among women younger than age 35, the perceived risk of carrying a fetus with Down syndrome was higher in women who had not attended college or had poor health status. Hispanic women, women with incomes less than $35,000, and those who had difficulty conceiving perceived a higher procedure-related risk of miscarriage. Caughey, Washington, and Kuppermann, Am J Obstet Gynecol 198:333.e1-333.e8, 2008 (AHRQ grant HS07373).

•Pregnant women with a prior c-section often receive insufficient information about delivery options.
According to this study, many women with a prior cesarean delivery who choose to have a subsequent vaginal birth (VBAC) or another cesarean receive little or no information about the risk of both procedures, including forceps or vacuum delivery, future incontinence problems, and risk of fetal death or injury. Researchers surveyed 92 women who had a prior cesarean after either a VBAC or repeat cesarean at a large teaching hospital. Overall 44 percent of the women had scheduled cesarean deliveries, 29 percent had VBAC, and 27 percent had a cesarean following an attempted VBAC. Renner, Eden, Osterweil, et al., Am J Obstet Gynecol 196(5):e14-e16, 2007 (AHRQ grant HS11338).

•Race, education, income, and social status all interact to affect the health of pregnant women.
Researchers studied 1,802 ethnically diverse women receiving prenatal care at one of six San Francisco area delivery sites; the women were generally healthy and had low depression scores. Differences by race/ethnicity were pronounced, with whites and Asians doing better on all measures. More black and Hispanic women were in the lower social and economic strata than white and Asian women, and they reported worse physical functioning. Subjective social standing was more highly correlated with education and income in whites and Asians than in Hispanic and black women. Stewart, Dean, Gregorich, et al., J Health Psychol 12(2):285-300, 2007 (AHRQ grant HS10856).

•One-third of homeless women are at risk for unintended pregnancy.
This survey of 974 homeless women in Los Angeles County in 1997 showed that one-third of the women rarely or never used contraception. Women who had a partner, were monogamous, and did not engage in the sex trade were 2.4 times as likely as other women to not use or rarely use contraception. Having a regular source of care and having been encouraged to use contraception increased the likelihood of contraception use. Gelberg, Lu, Leake, et al., Matern Child Health 12:52-60, 2008 (AHRQ grant HS08323).

•Several factors contribute to high rates of maternal birth trauma in one State.
Compared with national rates, the State of Iowa has lower rates of cesarean delivery and higher rates of maternal trauma, according to this study. Researchers analyzed Iowa data for the years 2002-2004 and national data from 2003 and found significant risk factors for one type of maternal trauma—third/fourth degree lacerations—including episiotomy, artificial rupture of the amniotic membranes, obstructed labor, and late pregnancies, as well as disproportionately large babies. They note that the higher rates of maternal birth trauma at predominantly rural hospitals may be due in part to lack of infrastructure to perform cesareans for difficult deliveries. Roberts, Ely, and Ward, Am J Med Qual 22(5):334-343, 2007 (AHRQ grant HS15009).

•Postpartum discharge against medical advice usually signals serious financial or mental health issues.
Researchers used hospital discharge data for women who gave birth in California, Florida, and New York during the period 1998-2000 to examine factors associated with discharge against medical advice, which averaged 0.10 percent. Women who were more likely to leave the hospital against medical advice were black; had low income, no insurance or public health insurance, and greater medical problems (e.g., drug abuse, mental illness); lived in medium or large metropolitan areas; and were discharged from hospitals in California or New York (compared with Florida). Fiscella, Meldrum, and Franks, Matern Child Health J 11:431-436, 2007 (AHRQ grant HS10910).

•Pregnancies that progress beyond the estimated due date are risky for both mother and baby.
This study found that women who delivered babies beyond 37 weeks' gestational age had higher rates of operative vaginal delivery (use of forceps or vacuum extraction), perineal laceration, primary cesarean delivery, postpartum hemorrhage, and infection of the amniotic fluid and/or placental membranes. Other risks of prolonged pregnancy (38-42 weeks) included nonreassuring fetal heart rate and cephalopelvic disproportion (i.e., the baby's head is too large for the woman's pelvis). The researchers studied more than 119,000 fully insured, low-risk women who delivered babies beyond 37 weeks gestational age from 1995 to 1999. Caughey, Stotland, Washington, and Escobar, Am J Obstet Gynecol 196:155.e1-155.e6, 2007 (HS07373).

•Midwife practices vary widely in compensation and employment structure.
Researchers surveyed 102 certified nurse-midwives in Connecticut in 2005 and found variations in practice freedom and style, income, benefits, job descriptions, and requirements for full-time work. Full-time midwives in Connecticut worked an average of 77 hours per week and had a mean salary of nearly $80,000 per year; 87 percent had on-call responsibilities. Among the midwives surveyed, 75 percent provided gynecologic care, antepartum care, and interpartum care; 16 percent did not offer gynecologic care; and 6 percent offered gynecologic care without antepartum or interpartum care. Some midwives performed endometrial biopsies, repaired third-degree perineal lacerations, and/or acted as a surgical assistant at cesarean births. Holland and Holland, J Midwifery Women's Health 52(2):106-115, 2007 (AHRQ grant T32 HS00044).

•Fewer girls under age 18 are having babies.
The rate of teens and younger girls giving birth in U.S. hospitals dropped by one-fourth between 1997 and 2004, from 55 to 41 admissions per 100,000 girls under age 18, according to a recent AHRQ report. Despite this drop, the United States continues to lead all industrialized nations in teen pregnancy and childbirth. There were 4 million childbirth-related hospitalizations in 2004; 148,000 of these were for girls younger than age 18, resulting in nearly $465 million in hospital costs. Medicaid was billed for nearly three of every four teen childbirths, with total costs of about $348 million. See Childbirth-Related Hospitalizations Among Adolescent Girls, 2004, HCUP Statistical Brief No. 31; online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb31.jsp (Intramural).

•Potential benefits of episiotomy do not offset the fact that many women would have less injury without it.
Episiotomy is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery. According to this evidence report, routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother. The evidence shows that women who experience spontaneous tears without episiotomy have less pain than women with episiotomies. Furthermore, complications related to the healing of the perineum are the same with and without episiotomy. Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report No. 112 (AHRQ Publication Nos. 05-E009-1, summary and 05-E009-2, report); What You Need to Know About Episiotomy (AHRQ Publication No. 06-0005, consumer card) (AHRQ contract 290-02-0016).*

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Women's Health Highlights: Recent Findings (continued)