Women's Health Highlights: Recent Findings (continued) [2]

Women's Health Highlights: Recent Findings (continued)

Women's Health Highlights: Recent Findings

Cervical Cancer Some Latinas have higher rates of cervical cancer than white women. According to this study, women of Mexican descent born in the United States are at higher risk for contracting the human papilloma virus (HPV) that causes cervical cancer than white women and foreign-born Latinas. Indeed, those who have acculturated—i.e., they think, speak, and read English at home or with friends—are more likely than less acculturated Latinas to contract HPV and cervical cancer. The researchers note that rates of HPV in U.S.-born Mexican women may be a result of increased sexual behavior, since more acculturated U.S.-born Mexican women also had higher rates of chlamydia, gonorrhea, and herpes II. Kepka, Coronado, Rodriguez, and Thompson, Prev Med 51(2):182-184, 2010 (AHRQ HS13853). Study identifies barriers to followup of an abnormal Pap test in Latinas. This study found four primary barriers to women having colposcopy as a followup to an abnormal Pap smear result: (1) anxiety or fear of the test, (2) difficulty scheduling the test around work or child care commitments, (3) poor doctor-patient communication, and (4) concern about pain. The study involved 40 Latinas, of whom 75 percent spoke only Spanish. Percac-Lima, Aldrich, Gamba, et al., J Gen Intern Med 25(11):1198-1204, 2011 (AHRQ grant HS19161). Physicians and patients may not be adhering to recommendations for less frequent Pap testing. Increased understanding of cervical cancer has led professional organizations to revise clinical guidelines to allow for Pap test intervals of 2 to 3 years after the age of 30 for women who have had three consecutive normal Pap tests. However, recent reports suggest that many physicians are continuing to screen annually. This study found that only 32 percent of physicians had adopted a 3-year Pap test interval. Women older than age 65 were more willing than younger women to follow a 3-year interval. Meissner, Tiro, Yabroff, et al., Med Care 48(3):249-259, 2010. See also Saraiya, Berkowitz, Yabroff, et al., Arch Intern Med 170(11):977-986 (Intramural). Many homeless women decline the offer of free cervical cancer screening. Homeless women have higher rates of cervical cancer than other women, yet even when barriers to cervical screening are removed, many homeless women do not take advantage of free Pap smears. The researchers collected medical and demographic information on 205 homeless women who had been admitted to a medical facility; 129 of the women met the criteria for Pap testing. Only 80 of the women (62 percent) agreed to the testing, and just 56 of the women (70 percent) actually had the test performed. Bharel, Casey, and Wittenberg, J Women's Health 18(12):2011-2016, 2010 (AHRQ HS14010). Many young women have not received the HPV vaccine. This survey found that more than 60 percent of 1,011 young women aged 13 to 26 years knew about Gardasil®, the vaccine against human papilloma virus (HPV) that causes cervical cancer. However, only 30 percent of those aged 13 to 17 and 9 percent of those aged 18-26 had received the vaccine. Because the vaccine is most beneficial when given before young women become sexually active, the authors urge practitioners and parents to better educate young women about the vaccine. Caskey, Lindau, and Alexander, J Adolesc Health 45(5):453-462, 2009 (AHRQ grant HS15699). Less than 25 percent of physicians report guideline-consistent recommendations for cervical cancer screening. Researchers used a large, nationally representative sample of primary care physicians to identify current Pap test screening practices in 2006-2007. They used clinical vignettes to describe women by age and sexual and screening history to elicit physicians' recommendations. Guideline-consistent recommendations varied by physician specialty: obstetrics/gynecology 16.4 percent, internal medicine 27.5 percent, and family/general practice 21.1 percent. Yabroff, Saraiya, Mesisner, et al., Ann Intern Med 151(9):602-611, 2009 (AHRQ grant HS10565). A majority of older women think lifelong cervical cancer screening is important. Researchers conducted face-to-face interviews with 199 women aged 65 and older to determine their views about continuing to receive Pap tests to screen for cervical cancer. Most of the women were minorities, and about 45 percent were Asian. Despite recent changes in clinical recommendations to stop Pap screening in women older than 65, more than two thirds of the women in this study felt that lifelong screening was either important or very important. Most of the women (77 percent) planned on being screened for the rest of their lives. Sawaya, Iwaoka-Scott, Kim, et al., Am J Obstet Gynecol 200(1):40.e1-40.e7, 2009. See also Huang, Perez-Stable, Kim, et al., J Gen Intern Med 23(9):1324-1329, 2008 (AHRQ grant HS10856). Instituting new processes can reduce diagnostic errors in Pap smear interpretation. Lean methods are used to weigh the expenditure of resources against value received. For this study, researchers compared the diagnostic accuracy of Pap tests procured by five clinicians before (5,384 controls) and after (5,442 cases) implementing a process redesign using Lean methods. Following process redesign, there was a significant improvement in Pap smear quality, and the case group showed a 114 percent increase in newly detected cervical intraepithelial cancer following a previous benign Pap test. Raab, Andrew-Jaja, Grzybicki, et al, J Low Genit Tract Dis 12(2):103-110, 2008 (AHRQ grant HS13321). Ovarian Cancer Study finds racial disparities in receipt of chemotherapy after ovarian cancer surgery. Researchers examined 11 years of data for 4,264 women aged 65 or older who were diagnosed with stage IC-IV ovarian cancer (cancer in one or both ovaries with early signs of spreading) to examine receipt of chemotherapy, which is recommended following surgery to remove the cancer. Just over 50 percent of black women received chemotherapy following surgery, compared with nearly 65 percent of white women. Survival rates did not differ between the two groups of women, but women in the lowest socioeconomic group were more likely to die than those in the highest group. Du, Sun, Milam, et al., Int J Gynecol Cancer 18(4):660-669, 2008 (AHRQ grant HS16743). One type of chemotherapy for ovarian cancer carries an elevated risk for hospitalization. Researchers studied 9,361 women aged 65 and older who were diagnosed with stage IC to IV ovarian cancer between 1991 and 2002. Of the 1,694 patients who received nonplatinum chemotherapy, 8 percent were hospitalized because of a gastrointestinal ailment, compared with 6.6 percent of the 1,363 women who received platinum-based chemotherapy and 6.4 percent of the 3,094 women who received platinum-taxane therapy. Receipt of nonplatinum chemotherapy was also associated with a higher risk of hospitalization for infections, hematologic problems (e.g., anemia), and thrombocytopenia (low blood platelet count). Nurgalieva, Liu, and Du, Int J Gynecol Cancer 19(8):1314-1321, 2009 (AHRQ grant HS16743). Less access to effective treatment may explain poorer survival of elderly black women with ovarian cancer. Researchers studied 5,131 elderly women diagnosed with ovarian cancer between 1992 and 1999 with up to 11 years of followup. Overall, 72 percent of white women and 70 percent of black women were diagnosed with stage III or IV (advanced) disease, however, fewer blacks received chemotherapy than whites (50 vs. 65 percent, respectively). Among those with stage IV disease, those who underwent ovarian surgery and received adjuvant chemotherapy were 50 percent less likely to die during the followup period compared with those who did not, regardless of race. Du, Sun, Milam, et al., Int J Gynecol Cancer 18:660-669, 2008 (AHRQ grant HS16743). Other Cancers Certain chemotherapy drugs used to treat ovarian cancer increase the risk of hospitalization for older women. Researchers studied 9,361 women aged 65 or older who were diagnosed with stage I to IV ovarian cancer between 1991 and 2002. Eight percent of the 1,694 women who received nonplatinum chemotherapy were hospitalized for a gastrointestinal ailment while on the chemotherapy, compared with 6.6 percent of the 1,363 women who received platinum-based chemotherapy and 6.4 percent of the 3,094 women who received platinumtaxane therapy. Nurgalieva, Liu, Du, Int J Gynecol Cancer 19(8):1314-1321, 2009 (AHRQ grant HS16743). A survey instrument used initially with breast cancer patients is also appropriate for patients with other types of cancer. This study found that the 47-item Impact of Cancer, version 2, survey instrument, which was first tested with breast cancer survivors, may also be useful in measuring the effects of other cancers on survivors' quality of life. Researchers gave the survey to 1,188 breast cancer survivors and 652 non-Hodgkins lymphoma survivors and found that the survey measured important and common concerns shared by both groups. Because the survey also pinpointed differences between the two groups, it is also useful for differentiating the impacts specific cancers have on survivors. Crespi, Smith, Petersen, et al., J Cancer Survivor 4(1):45-58, 2010 (AHRQ T32 HS00032). A family history of colon cancer does not negatively affect survival for women diagnosed with the same cancer. Researchers tracked nearly 1,400 women who were diagnosed with invasive colon cancer and found that women who had two or more relatives with colorectal cancer appeared to have a lower risk of dying from the disease compared with women who had no family history of the cancer. Of the 262 women who had a family history of colorectal cancer, 44 died of the disease; of the 1,129 women who had no family history of the disease, 224 died. Kirchhoff, Newcomb, Trentham-Dietz, et al., Fam Cancer 7(4):287-292,2008 (AHRQ grant HS13853). Women's perception of risk affects screening for colon cancer but not cervical or breast cancer. Researchers interviewed 1,160 white, black, Hispanic, and Asian women (aged 50 to 80) about their perceived risk for breast, cervical, and colon cancer and compared their perceived risk with screening behavior. The women's perceived lifetime risk of cancer varied by ethnicity, with Asian women generally perceiving the lowest risk and Hispanic women the highest risk for all three types of cancer. Nearly 90 percent of women reported having a mammogram, and about 70 percent of the women reported having a Pap test in the previous 2 years; 70 percent of the women were current with colon cancer screening. There was no relationship between screening and perception of risk for cervical or breast cancer; however, a moderate to very high perception for colon cancer risk was associated with nearly three times higher odds of having undergone colonoscopy within the last 10 years. Kim, Perez-Stable, Wong, et al., Arch Int Med 168(7):728-734, 2008 (AHRQ grant HS10856). Return to Contents Reproductive Health Pregnancy and Childbirth Prenatal appointments provide an opportunity to screen for depression and other problems. This study found that clinicians often fail to screen pregnant women during their first prenatal visit for depression, stress, support, and whether the pregnancy was planned. Such screening allows clinicians to identify women who may be at risk for post-partum depression or need social support once the baby arrives. During 48 prenatal visits with 16 providers in an academic medical center, 35 women indicated their pregnancies were unplanned. Of these, only eight of the women were told about pregnancy options, four received information about birth control options, and just six were referred to counselors or social services. Meiksin, Chang, Bhargava, et al., Patient Educ Couns 81(3):462-467, 2010 (AHRQ grant HS13913). See also Manber, Schnyer, Lyell, et al., Obstet Gynecol 115(3):511-520, 2010 (AHRQ grant HS09988) and Roman, Gardiner, Lindsay, et al., Arch Women's Mental Health 12:379-391, 2009 (AHRQ grant HS14206). Certain women are at increased risk for mental health problems during pregnancy. An analysis of data on more than 3,000 pregnant women revealed that levels of social support, general health status, and a woman's mental health history affected her risk for developing mental health problems during pregnancy. Overall, nearly 8 percent of the women reported poor mental health while pregnant. A history of mental health issues prior to pregnancy was strongly predictive of poor mental health during pregnancy. Only 5 percent of women without any mental health problems before pregnancy developed such problems while pregnant. Witt, DeLeire, Hagen, et al., Arch Women's Mental Health 13(5):425-437, 2010 (AHRQ grant T32 HS00083). Pelvic ultrasound in the ER is highly effective in ruling out ectopic pregnancy. The chances of a woman having an ectopic pregnancy at the same time as a normal pregnancy is very low—about 1 in 4,000. Thus pelvic ultrasound can be used to confirm a normal pregnancy and at the same time rule out an ectopic pregnancy. Using pooled data from 10 clinical studies of ED pelvic imaging, these researchers concluded that pelvic ultrasound at the bedside in the ER had 99.3 percent sensitivity and a negative predictive value of 99.96 percent. They note that ED physicians can learn to quickly rule out ectopic pregnancy without waiting for radiology consultation with a specialist. Stein, Wang, Adler, et al., Ann Emerg Med 56(6):674-683, 2010 (AHRQ grant HS15569). Most American women experience complications during childbirth. An analysis of 2008 data from AHRQ's Healthcare Cost and Utilization Project (HCUP) revealed that 94 percent of women hospitalized for pregnancy and delivery had one or more complications, (e.g. premature labor, urinary infection, anemia, diabetes, bleeding, and other problems). Hospital stays for pregnancies with complications were longer (average of 2.9 days) compared with uncomplicated deliveries (average of 1.9 days), cost more ($4,100 vs. $2,600), and accounted for $17.4 billion, or nearly 5 percent of total U.S. hospital costs in 2008. Complicating Conditions of Pregnancy and Childbirth, 2008; available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.jsp (Intramural). See also Toledo, McCarthy, Burke, et al., Am J Obstet Gynecol 202(4):400.e1-400.e5, 2010 (AHRQ grant T32 HS00078). Perceived lower social standing is linked to unplanned pregnancies. More than 1,000 pregnant women in the San Francisco area responded to a survey, and more than one-third of the women reported that their pregnancies were unplanned. Black women reported the highest rate of unintended pregnancy (62 percent), and white women reported the lowest rate (23 percent). Although just 18 percent of those surveyed were black, they accounted for 33 percent of the unintended pregnancies. The researchers also found that a woman's subjective social standing was associated with unintended pregnancy; the lower the woman's level of self-perceived social standing, the more likely her pregnancy was unplanned. Bryant, Nakagawa, Gregorich, and Kuppermann, J Women's Health 19(6):1195-1200, 2010 (AHRQ grant HS10856). Use of episiotomy and forceps during delivery is down, but c-section rates are up. An analysis of 1997 and 2008 data from AHRQ's Healthcare Cost and Utilization Project (HCUP) found that the use of episiotomy fell by 60 percent, and the use of forceps declined by 32 percent over that 11-year period. Conversely, the proportion of hospital stays following a c-section increased by 72 percent during the same period. Hospitalizations Related to Childbirth, 2008; available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb110.jsp (Intramural). An accurate screening tool is needed to identify women most likely to need a repeat c-section. These researchers sought to evaluate existing screening tools for vaginal birth after cesarean (VBAC) and to identify additional factors that might predict VBAC or failed trial of labor. They found that none of the models provided consistent ability to identify women at risk for a failed trial of labor. They note the need for a scoring model that incorporates known antepartum factors and labor patterns to allow women and their clinicians to better identify those individuals most likely to require repeat c-section. Eden, McDonagh, Denman, et al., Obstet Gynecol 116(4):967-981, 2010. See also Guise, Denman, Emeis, et al., Obstet Gynecol 115(6):1267-1278, 2010 (AHRQ contract 290-07-10057). Cesarean delivery rates may not be a useful measure of obstetric quality. This study found that 60 percent of 107 hospitals in California and Pennsylvania with risk-adjusted rates of cesarean delivery that were lower than expected also had a higher than expected rate of at least one of six adverse outcomes. This compared with 36.1 percent of the "as expected" group and 19.6 percent of hospitals that had higher than expected risk-adjusted cesarean delivery rates. Currently, there are no uniformly accepted measures of obstetrical quality, and historically, the risk-adjusted cesarean delivery rate has been a proposed measure. The researchers correlated risk-adjusted cesarean delivery rates with important maternal and neonatal outcomes in a study of 845,000 women from 401 hospitals in the two States. Srinivas, Fager, and Lorch, Obstet Gynecol 115(5):1007-1013, 2010. See also Edmonds, Fager, Srinivas, and Lorch, Obstet Gynecol 118(1):49-56, 2011 (AHRQ grant HS15696). Bariatric surgery before pregnancy reduces the risk of gestational diabetes in obese women. According to this study, obese women who have surgery to lose weight before becoming pregnant are 77 percent less likely than those who don't to develop gestational diabetes during pregnancy. Also, obese women who have bariatric surgery before conceiving are much less likely than those who don't to require a c-section. These findings are based on a study involving 700 women who had bariatric surgery, either before (354 women) or after (346 women) childbirth. Burke, Bennett, Jamshidi, et al., J Am Coll Surg 211(2):169-175, 2010 (AHRQ contract 290-05-0034). Novel program offers innovative tools for caring for women with gestational diabetes. AHRQ's Health Care Innovations Exchange offers health care professionals practical tools to educate themselves and pregnant women about gestational diabetes and to help them care for women with the condition during and after pregnancy. A number of approaches are described, including telephone case management coupled with periodic home visits from registered nurses and cell phone text messaging to provide monthly educational messages and appointment reminders for glucose testing. For more information, visit www.innovations.ahrq.gov, a searchable database of more than 500 innovations and 1,550 quality tools (Intramural). Also go to Hospitalizations Related to Diabetes in Pregnancy, 2008, available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb102.jsp (Intramural). Researchers find a link between race/ethnicity and risk for gestational diabetes. According to this analysis of data on nearly 140,000 women who developed gestational diabetes, women who are Asian, Hispanic, or American Indian are more likely than white or black women to develop the condition. Asian women had the highest rate (6.8 percent) of gestational diabetes, followed by American Indian (5.6 percent) and Hispanic (4.9 percent) women; 3.4 percent of white women and 3.2 percent of black women developed gestational diabetes. The rate was even higher when the father was Asian (6.5 percent), Hispanic (4.6 percent), or American Indian (4.5 percent), compared with white (3.9 percent), and black (3.3 percent) fathers. Caughey, Cheng, Stotland, et al., Am J Obstet Gynecol 202(6):616.e1-616.e5, 2010, (AHRQ grant HS10856). Uncertainty surrounds use of terbutaline to prevent preterm birth. According to this AHRQ research report, there is not enough evidence to determine whether terbutaline administered by a subcutaneous infusion pump can effectively and safely prevent repeat episodes of preterm labor. In addition, the report notes that the adverse effects of terbutaline pump therapy for mothers and their babies have not been fully explored. Terbutaline is FDA-approved for treatment of asthma bronchospasm, but it is sometimes used off-label to prevent uterine contractions and delay preterm labor. Go to Terbutaline Pump for the Prevention of Preterm Birth, available at http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=920 (AHRQ contract HHSA 290-07-10059-I). Study identifies ways to enhance prenatal care in underresourced settings. Based on a literature review and key informant interviews, these researchers identified 17 innovative strategies involving health information technology that have been or can be used to improve prenatal care in traditionally underresourced settings that serve black, Hispanic, and Asian American patients, as well as low income children. The strategies could be used to improve the content of prenatal care, increase access to timely prenatal care, and enhance the organization and delivery of prenatal care. Lu, Kotelchuck, Hogan, et al., Med Care Res Rev 67(5 Suppl):198-230, 2010 (AHRQ contract P233200900421P). Prenatal GBS screening may fall short of CDC-recommended guidelines. According to guidelines issued by the Centers for Disease Control and Prevention, pregnant women should be screened for Group B streptococci (GBS) between weeks 35 and 37 of their pregnancies, and those who test positive should be given IV antibiotics 4 or more hours before delivery. This study of 877 live births in 11 Tennessee counties during 2003 and 2004 found that the test was often performed too early (before week 35) and that not every woman who tested positive for GBS was given antibiotics before delivery. Goins, Talbot, Schaffner, et al., Obstet Gynecol 115(6):1217-1224, 2010 (AHRQ grant HS13833). Clinicians vary in the options they offer to women who are experiencing a miscarriage. Treatments for miscarriage can include letting it progress naturally, treating it medically with misoprostol, or surgical evacuation; studies have shown that all three options are safe and acceptable to women. According to this study of 976 practitioners (obstetricians [Obs], midwives, and family practitioners [FPs]), a majority of midwives (55 percent) and FPs (65 percent), but just 24 percent of Obs, prefer to let the miscarriage progress naturally. Forty-six percent of Obs prefer surgical evacuation in an operating room; all three groups ranked treatment with misoprostol as the second preferred option. Dalton, Harris, Gold, et al., Am J Obstet Gynecol 202(6):531.e1-531.e8, 2010 (AHRQ grant HS15491). 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 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 this 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. 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 290-07-10057-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). 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. 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 improved in women following weight-loss surgery. 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). 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). 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. 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). 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. Gelberg, Lu, Leake, et al., Matern Child Health 12:52-60, 2008 (AHRQ grant HS08323). Birth Outcomes One-fifth of mothers do not receive recommended corticosteroids before delivery of premature infants. Strong evidence shows that administration of antenatal corticosteroids during preterm labor reduces the incidence of respiratory distress syndrome and other complications associated with prematurity. This study of premature births at three New York City hospitals found that 20 percent of eligible mothers did not receive indicated antenatal corticosteroid therapy. The failure to administer recommended steroids was related strongly to how long after admission the delivery took place, as well as lack of prenatal care, longer gestation, advanced cervical exam, and intact membranes at admission. The study included 515 women eligible for corticosteroid therapy; 70 percent of the women were black or Hispanic, and most were insured through Medicaid or a Medicaid HMO. Howell, Stone, Kleinman, et al., Matern Child Health J 14:430-436, 2010 (AHRQ grant HS10859). Birth defects may be linked to high blood pressure itself and not the drugs used to treat it in early pregnancy. According to this analysis of data on 465,000 babies born over 13 years in Northern California, a woman's use of medications to lower blood pressure early in pregnancy does not increase the risk of having a baby with a birth defect. The study suggests that the underlying high blood pressure itself—and not the use of angiotensin-converting enzyme inhibitors or other blood pressure medications—may increase the risk of birth defects. Although the FDA warns against the use of ACE inhibitors during the second and third trimesters of pregnancy, this study found no correlation between the occurrence of birth defects and the use of the drugs during the first trimester. Li, Yang, Andrade, et al., BMJ 18:343, online, 2011 (AHRQ contract 290-050033-1) See also Davis, Eastman, McPhillips, et al., Pharmacoepidemiol Drug Saf 20:138-145, 2011 (AHRQ grant HS10391). Chronic stress during pregnancy may be associated with less than ideal birth outcomes. Pregnant women who are stressed are at risk for early delivery and/or low birthweight babies. To test whether self-reports of stress coincide with the presence of stress biomarkers, researchers used blood samples and questionnaires from 205 reproductive-age women who were receiving welfare in the Chicago area. After determining the women's levels of two common stress biomarkers—Epstein-Barr virus (EBV) and C-reactive protein (CRP)— they compared the results with the women's responses about their levels of actual or perceived stress. Women who reported elevated levels of stress or discrimination had higher levels of EBV than other women, while CRP levels were not strongly associated with self-reported stress. Borders, Grobman, Holl, et al., Am J Obstet Gynecol 203(6):577e1-577e8, 2010 (AHRQ grant T32 HS00078). Extreme distress in pregnant women appears to disproportionately affect male fetuses. For pregnant women, the stress associated with a natural or social disaster can lead to production of corticosteroids that adversely affect male more than female fetuses. This study found that the events of September 11, 2001 led to a rise in miscarriages of male fetuses at 20 weeks or more gestation. Using 1996 to 2002 data on fetal deaths and birth certificate data, the researchers found that the odds of male fetal death increased unexpectedly in the United States in September 2001. In addition, the ratio of males expected to be born in December 2001 fell below expected values. Bruckner, Catalano, and Ahern, BMC Public Health 10:273, 2010 (AHRQ grant T32 HS00086). Mothers' anxiety and history of abuse contribute to risk for low birthweight babies. According to this study of 554 pregnant women, abuse and anxiety are linked to low birthweight, possibly due to their effects on a woman's hormone levels. The women were seen at obstetric clinics in Memphis, TN, from 1990 to 1991, and most were black, poor, and unmarried. Those who experienced either verbal or physical abuse during pregnancy delivered babies that averaged 3.5 ounces lighter than women who did not suffer abuse, anxious mothers delivered babies that were 2.50 ounces lighter than average. The researchers also found a link between high-crime neighborhoods and low birthweight infants; mothers who experienced neighborhood stress delivered babies 2.28 ounces lighter than average. Witt, Keller, Gottlieb, et al., J Behav Health Serv Res, 2009 (AHRQ grants T32 HS00063, T32 HS00083). See also Fried, Cabral, Amaro, and Aschengrau, J Midwifery Womens Health 53(6):522-528, 2008 (AHRQ grant HS08008). No clear association found between inherited thrombophilia and small-for-gestational-age fetuses. Pregnant women who suffer from blood disorders that cause excessive clotting (thrombophilia) are sometimes given blood thinning drugs to prevent intrauterine growth restriction (IUGR) or small-for-gestational-age fetuses (below the 10th percentile for a given gestational age). A meta-analysis of 19 studies found no clear association between inherited thrombophilia and IUGR. Facco, You, and Grobman, Obstet Gynecol 113(6):1206-1216, 2009 (AHRQ grant T32 HS00078). Primary care doctors blame lack of time for failing to counsel women about drugs that cause birth defects. Eight focus groups were held with 48 primary care physicians in Pittsburgh, PA, to discuss counseling women about drugs that cause birth defects (teratogens). The doctors reported several barriers to providing such counseling, including short appointment times, lack of reimbursement for counseling, limited resources for finding up-do-date drug information, problems in determining a woman's reproductive plans, and concerns that such counseling may cause the woman to refuse a needed drug. Schwarz, Santucci, Borrero, et al., Birth Defects Res A Clin Mol Teratol 85(10):858-863, 2009 (AHRQ grant HS17093). Maternal weight gain is associated with some outcomes for mothers and babies. According to this review of the scientific evidence, there is a strong association between a pregnant woman's weight gain and the following outcomes: preterm birth, total birthweight, low birthweight, large- and small-for-gestational-age infants, and very large infants. The researchers found a moderate association between maternal weight gain and two additional outcomes: cesarean delivery and postpartum weight retention for up to 3 years following childbirth. Outcomes of Maternal Weight Gain, Evidence Report/Technology Assessment No. 168 (AHRQ Publication No. 08-E009)* (AHRQ Contract 290-02-0016). Race and ethnicity appear not to have an effect on c-section delivery outcomes. The researchers tested two risk-adjustment models for primary c-section rates to determine whether adding race and ethnicity to an otherwise identical model would improve the predictive impact of the model. They found that the two models did not differ substantially in predictive discrimination or in model calibration. They conclude that race and ethnicity can safely be left out of cesarean rate risk-adjustment models. Bailit and Love, Am J Obstet Gynecol 69:e1-e5, 2008 (AHRQ grant HS14352). Other Satisfaction after hysterectomy is linked to quality-of-life improvements. Women with persistent pelvic problems—such as fibroids and heavy bleeding—often choose to have a hysterectomy when other treatments don't work. These researchers analyzed data on 208 women who participated in an 8-year study and found that nearly 64 percent of the women were satisfied and 21 percent were somewhat satisfied in the year after their hysterectomy. Not surprisingly, women were more likely to be satisfied if their symptoms had improved. Kuppermann, Learman, Schembri, et al., Obstet Gynecol 115(3):543-551, 2010 (AHRQ grant HS11657). Mothers' medical visits may provide an opportunity to administer HPV vaccine to their adolescent daughters. Two vaccines are available to prevent human papilloma virus (HPV) infection, which causes cervical cancer, yet most young women in the United States are not vaccinated. Approaching young women's mothers during routine medical visits may be a possible route for increasing awareness about HPV and vaccination. Researchers mailed surveys to 3,000 urban and suburban women who had received Pap tests or mammograms; 937 women responded. Of these, 232 women had daughters aged 9 to 17 years, the age range recommended for vaccination. Carlos, Dempsey, Resnicow, et al., J Women's Health 19(12):2271-2275, 2010 (AHRQ grant HS15491). Two widely used data sources differ in estimates of rates of exclusive breastfeeding. Researchers compared estimates of "any" breastfeeding and "exclusive" breastfeeding through 3 and 6 months using data from two different sources: the Centers for Disease Control and Prevention and the California Department of Public Health. They found that the rates for "any" breastfeeding for the State as a whole were similar for most racial/ethnic groups and geographic areas, but the two sources differed significantly on rates of "exclusive" breastfeeding, suggesting that either or both sources may be flawed measures of "exclusive" breastfeeding. Flaherman, Chien, McCulloch, Dudley, Breastfeed Med 6(1):31-35, 2011 (AHRQ grant HS17146). See also Ip, Chung, Raman, et al., Breastfeed Med 4(suppl):S17-S30, 2009 (AHRQ contract 290-02-0022). Some women with vaginal symptoms can be safely treated without exams and lab tests. Treating women suffering from uncomfortable vaginal conditions—such as bacterial vaginosis, trichomoniasis, and candidiasis—based on their symptoms and without speculum examination and lab tests appears to be appropriate for some women, according to this study. The 23 women who received treatment for their vaginal symptoms without an exam had outcomes and satisfaction ratings similar to the 21 women who underwent traditional examination and lab testing. Symptoms for 93 percent of all 44 women improved in the 2-week followup period, and both physicians and patients were comfortable with the approach. Anderson, Cohrssen, Klink, and Brahver, J Am Board Fam Med 22(6):617-624, 2009 (AHRQ grant HS16050). Rural and community hospitals can use mobile simulators to gain hands-on experience with childbirth emergencies. A simulator training initiative was developed to address a crisis in obstetric care in Oregon, where a 2002 survey indicated that one-third of obstetric providers (66 percent rural) planned to stop delivering babies within 1-5 years. Although there were a number of permanent simulation centers, smaller community and rural hospitals lacked the resources to travel for training. This study showed that mobile simulators could do the job, while allowing team members to work in a familiar setting and improve teamwork skills. Guise, Lowe, Deering, et al., Joint Comm J Qual Patient Saf 36(10):443-453, 2010 (AHRQ grant HS15800). IVF may be an option for prospective parents when both carry the cystic fibrosis gene. In vitro fertilization (IVF) combined with preimplantation genetic diagnosis (PGD) holds an advantage over natural conception and genetic testing for couples when both carry the cystic fibrosis gene, according to this study. Children with two copies of the CF allele have an average life expectancy of 37 years, so genetic screening for CF is now offered to all couples actively planning to have children. When twocarrier couples use IVF and PGD, affected embryos can be discarded before implantation, while a couple using natural conception and prenatal testing would face a decision about terminating a pregnancy. Davis, Champion, Fair, et al., Fertil Steril 93(6):1793-1804, 2010 (AHRQ grant T32 HS00028). Settlement of an obstetrical malpractice claim has minimal impact on access to care. This study focused on whether the timing of malpractice claims and/or the size of awards had any impact on obstetrical practice patterns in Florida during the study period (1992-2000). The researcher found a small decrease (six fewer per year) in the number of inpatient deliveries performed by physicians 3 years after the closing of a malpractice claim. When the malpractice award was $250,000 or higher, the physician performed 14 fewer deliveries on average. There was no effect on C-section rates or access to obstetrical services. Grimm, Health Serv Res 45(1):195-211, 2010 (AHRQ grant HS14515). Breastfeeding benefits both mothers and infants. According to a 2007 AHRQ evidence report, breastfeeding is beneficial for both mother and infant. In this question-and-answer article, the authors discuss the report and the role of clinicians in promoting breastfeeding, the particular advantages of breastfeeding for premature infants, lifestyle factors that affect nursing mothers, and ways to overcome societal barriers to breastfeeding. Godfrey and Meyers, J Women's Health 18(9):1307-1310, 2009 (AHRQ Publication No. 10-R034).* See also Meyers, Breastfeed Med 4(Suppl 1):S-13-S-15, 2009 (AHRQ Publication No. 10-R024)* (Intramural). Treatment without exams and lab texts appears effective for some women with vaginal symptoms. Offering women treatment for uncomfortable symptoms of bacterial vaginosis, trichomoniasis, or vaginal candidiasis based on their symptoms—while skipping speculum examination and lab tests—may be appropriate in some cases, according to this study of 44 women. The 23 women who received treatment for their vaginal symptoms without examination had outcomes and satisfaction ratings similar to those of the 21 women who underwent a traditional exam and lab tests. Anderson, Cohrssen, Klink, and Brahver, J Am Board Fam Med 22(6):617-624, 2009 (AHRQ grant HS16050). Researchers examine associations among various pathogens and bacterial vaginosis. Bacterial vaginosis (BV) is a common lower genital tract infection that may lead to pelvic inflammatory disease (PID) and other conditions. Researchers analyzed stored specimens from 50 randomly selected women with confirmed endometritis to determine the associations among various pathogens and BV. They found several types of bacteria known to be associated with BV among women with confirmed PID. Haggerty, Totten, Ferris, et al., Sex Transm Infect 85:242-248, 2009 (AHRQ grant HS08358) Despite CDC-recommended treatment, the pathogen that causes PID may persist. Pelvic inflammatory disease (PID) is associated with the pathogen Mycoplasma genitalium, and it appears to be very resistant to commonly used treatments. The PID Evaluation and Clinical Health Study (PEACH) examined stored cervical and endometrial specimens from 682 women treated with ceftoxin and doxycycline and found that the pathogen persisted among nearly half of the women after 30 days of treatment. Haggerty, Totten, Astete, et al., Sex Transmit Dis 84(5):338-342, 2008. See also Short, Totten, Ness, et al., Clin Infect Dis 48(1):41-47, 2009 (AHRQ grant HS08358). Symptoms of menopause may persist for as long as 4 years. Researchers reviewed 410 studies to determine the duration of vasomotor symptoms (hot flashes and night sweats) in menopausal women. They found that these symptoms tend to peak 1 year after a woman's last menstrual period, but 50 percent of women continue to experience vasomotor symptoms for up to 4 years. The researchers note that clinical guidelines may need to be modified so that women's quality of life is balanced against the risks of hormone therapy. Politi, Schleinitz, and Col, J Gen Intern Med 23(9):1507-1513, 2008 (AHRQ grant HS13329). Abnormally heavy uterine bleeding has both quality of life and financial effects. This study of 237 women who had surgery for dysfunctional uterine bleeding (DUB) between 1997 and 2001 found that women with the condition experience both decreased quality of life (cramps, pain, fatigue, and limited physical activity) and financial burdens, including out-ofpocket costs for drugs and sanitary products (average of $333/year) and lost productivity due to missed work and/or the inability to function at home (average of $2,625/year). Frick, Clark, Steinwachs, et al., Womens Health Issues 19(1):70-78, 2009 (AHRQ grant HS09506). Both behavioral and drug therapies can help women with urinary incontinence. Researchers analyzed existing evidence on nonsurgical treatment for urinary incontinence (UI) in women and found that pelvic floor muscle training (Kegel exercises) and bladder training resolved women's UI compared with usual care. Certain medications also resolved UI compared with placebo, while the effects of electrostimulation, medical devices, injectable bulking agents, and vaginal estrogen therapy were inconsistent. Shamliyan, Kane, Wyman, and Wilt, Ann Intern Med 148(6):459-473, 2008 (AHRQ contract 290-02-0009). Task Force recommends screening atrisk women for certain sexually transmitted infections. The U.S. Preventive Services Task Force recommends that women at increased risk of infection be screened for Chlamydia, gonorrhea, HIV, and syphilis. The Task Force also recommends that pregnant women be screened for hepatitis B, HIV, and syphilis. Those pregnant women at high risk for STIs should be additionally screened for Chlamydia and gonorrhea, and sexually active women younger than age 25 should be considered at increased risk for Chlamydia and gonorrhea. Meyers, Wolff, Gregory, et al., Am Fam Physician 77(6):819-824, 2008 (AHRQ Publication No. 08-R056)* (Intramural).