Blair G. Darney

Comparison of family-planning service quality reported by adolescents and young adult women in Mexico

Associations between age and patient‐reported quality of family planning services were examined among young women in Mexico.

Systems factors in obstetric care: the role of daily obstetric volume.

OBJECTIVE: To evaluate whether relatively high-volume days are associated with measures of obstetric care in California hospitals. METHODS: This is a population-based retrospective cohort study of linked data from birth certificates and antepartum and postpartum hospital discharge records for California births in 2006. Birth asphyxia and nulliparous, term, singleton, vertex cesarean delivery rates were analyzed as markers of quality of obstetric care. Rates were compared between hospital-specific relatively high-volume days (days when the number of births exceeded the 75th percentile of daily volume for that hospital) and low-volume or average-volume days. Analyses were stratified by weekend and weekday and overall hospital obstetric volume. Multivariable logistic regression was used to control for confounders. RESULTS: On weekends, relatively high-volume days were significantly associated with an elevated risk of asphyxia (27 out of 10,000 compared with 17 out of 10,000; P=.013), whereas no association was present on weekdays (13 out of 10,000 on high-volume days and 15 out of 10,000 on low-volume or average-volume days; P=.182). The cesarean delivery rate among the nulliparous, term, singleton, vertex population was significantly lower on high-volume weekend days (22.0% compared with 23.6% on low-volume or average-volume weekend days; P=.009), whereas no association was present on weekdays (27.1% on high-volume days and 27.6% on low-volume or average-volume days; P=.092). CONCLUSION: Delivery on relatively high-volume weekend days is a risk factor for birth asphyxia in California. High-volume weekend days also are associated with a lower rate of cesarean delivery in nulliparous women with singleton, vertex presentation pregnancies at term. LEVEL OF EVIDENCE: II

Oregon's Hard-Stop Policy Limiting Elective Early-Term Deliveries: Association With Obstetric Procedure Use and Health Outcomes.

OBJECTIVE: To evaluate the association of Oregons hard-stop policy limiting early elective deliveries (before 39 weeks of gestation) and the rate of elective early-term inductions and cesarean deliveries and associated maternal–neonatal outcomes. METHODS: This was a population-based retrospective cohort study of Oregon births between 2008 and 2013 using vital statistics data and multivariable logistic regression models. Our exposure was the Oregon hard-stop policy, defined as the time periods prepolicy (2008–2010) and postpolicy (2012–2013). We included all term or postterm, cephalic, nonanomalous, singleton deliveries (N=181,034 births). Our primary outcomes were induction of labor and cesarean delivery at 37 or 38 weeks of gestation without a documented indication on the birth certificate (ie, elective early term delivery). Secondary outcomes included neonatal intensive care unit admission, stillbirth, macrosomia, chorioamnionitis, and neonatal death. RESULTS: The rate of elective inductions before 39 weeks of gestation declined from 4.0% in the prepolicy period to 2.5% during the postpolicy period (P<.001); a similar decline was observed for elective early-term cesarean deliveries (from 3.4% to 2.1%; P<.001). There was no change in neonatal intensive care unit admission, stillbirth, or assisted ventilation prepolicy and postpolicy, but chorioamnionitis did increase (from 1.2% to 2.2%, P<.001; adjusted odds ratio 1.94, 95% confidence interval 1.80–2.09). CONCLUSIONS: Oregons statewide policy to limit elective early-term delivery was associated with a reduction in elective early-term deliveries, but no improvement in maternal or neonatal outcomes.

Evidence-Based Selection of Candidates for the Levonorgestrel Intrauterine Device (IUD)

Background: Recent evidence-based guidelines expanded the definition of appropriate candidates for the levonorgestrel-releasing intrauterine system (LNG-IUS). We investigated correlates of evidence-based selection of candidates for the LNG-IUS by physicians who offer insertion. Methods: We conducted a mixed-mode (online and mail) survey of practicing family physicians and obstetrician-gynecologists in Seattle. Results: A total of 269 physicians responded to the survey (44% response rate). Of the 217 respondents who inserted intrauterine devices, half or fewer routinely recommended the LNG-IUS to women who are nulliparous, younger than 20 years old, or have a history of sexually transmitted infections (STIs). In multivariable analyses, training/resident status was positively associated with recommending the LNG-IUS to women <20 years old (adjusted odds ratio [aOR], 3.6; 95% confidence interval [CI], 1.6–8.0) and women with history of STI (aOR, 3.7; 95% CI, 1.6–8.4). Perceived risk of infection or infertility was negatively associated with recommending the LNG-IUS to nulliparous women (aOR, 0.2; 95% CI, 0.1–0.5) and women with a history of STI (aOR, 0.3; 95% CI, 0.1–0.8). Conclusions: Many family physicians and obstetrician-gynecologists who insert the LNG-IUS are overly restrictive in selecting candidates, although those who train residents are more likely to follow evidence-based guidelines. Interventions that address negative bias and perceptions of risks, in addition to improving knowledge, are needed to promote wider use of the LNG-IUS.

Measuring the adequacy of antenatal health care: a national cross sectional study in Mexico

Abstract Objective To propose an antenatal care classification for measuring the continuum of health care based on the concept of adequacy: timeliness of entry into antenatal care, number of antenatal care visits and key processes of care. Methods In a cross-sectional, retrospective study we used data from the Mexican National Health and Nutrition Survey (ENSANUT) in 2012. This contained self-reported information about antenatal care use by 6494 women during their last pregnancy ending in live birth. Antenatal care was considered to be adequate if a woman attended her first visit during the first trimester of pregnancy, made a minimum of four antenatal care visits and underwent at least seven of the eight recommended procedures during visits. We used multivariate ordinal logistic regression to identify correlates of adequate antenatal care and predicted coverage. Findings Based on a population-weighted sample of 9 052 044, 98.4% of women received antenatal care during their last pregnancy, but only 71.5% (95% confidence interval, CI: 69.7 to 73.2) received maternal health care classified as adequate. Significant geographic differences in coverage of care were identified among states. The probability of receiving adequate antenatal care was higher among women of higher socioeconomic status, with more years of schooling and with health insurance. Conclusion While basic antenatal care coverage is high in Mexico, adequate care remains low. Efforts by health systems, governments and researchers to measure and improve antenatal care should adopt a more rigorous definition of care to include important elements of quality such as continuity and processes of care.

Pregnancy among US women: differences by presence, type, and complexity of disability

BACKGROUND Approximately 12% of women of reproductive age have some type of disability. Very little is known about sexual and reproductive health issues among women with disabilities, including what proportion of women with disabilities experience pregnancy. Data on pregnancy are important to inform needs for preconception and pregnancy care for women with disabilities. OBJECTIVE The purpose of this study was to describe the occurrence of pregnancy among women with various types of disability and with differing levels of disability complexity, compared with women without disabilities, in a nationally representative sample. STUDY DESIGN We conducted cross-sectional analyses of 2008-2012 Medical Expenditure Panel Survey annualized data to estimate the proportion of women aged 18-44 years with and without disabilities who reported a pregnancy during 1 year of participation on the survey panel. We used a multivariable logistic regression to test the association of pregnancy with presence, type, and complexity of disability, controlling for other factors associated with pregnancy. RESULTS Similar proportions of women with and without disabilities reported a pregnancy (10.8% vs 12.3%, with 95% confidence intervals overlapping). Women with the most complex disabilities (those that impact activities such as self-care and work) were less likely to have been pregnant (adjusted odds ratio, 0.69, 95% confidence interval, 0.52-0.93), but women whose disabilities affected only basic actions (seeing, hearing, movement, cognition) did not differ significantly from women with no disabilities. CONCLUSION Women with a variety of types of disabilities experience pregnancy. Greater attention is needed to the reproductive health care needs of this population to ensure appropriate contraceptive, preconception, and perinatal care.

Term elective induction of labour and perinatal outcomes in obese women: retrospective cohort study

To compare perinatal outcomes between elective induction of labour (eIOL) and expectant management in obese women.

The relationship of age and place of delivery with postpartum contraception prior to discharge in Mexico: A retrospective cohort study.

Objectives To test the association of age (adolescents vs. older women) and place of delivery with receipt of immediate postpartum contraception in Mexico. Study design Retrospective cohort study, Mexico, nationally representative sample of women 12–39 years old at last delivery. We used multivariable logistic regression to test the association of self-reported receipt of postpartum contraception prior to discharge with age and place of delivery (public, employment based, private, or out of facility). We included individual and household-level confounders and calculated relative and absolute multivariable estimates of association. Results Our analytic sample included 7022 women (population, N = 9,881,470). Twenty percent of the population was 12–19 years old at last birth, 55% aged 20–29 and 25% 30–39 years old. Overall, 43% of women reported no postpartum contraceptive method. Age was not significantly associated with receipt of a method, controlling for covariates. Women delivering in public facilities had lower odds of receipt of a method (Odds Ratio = 0.52; 95% Confidence Interval (CI) = 0.40–0.68) compared with employment-based insurance facilities. We estimated 76% (95% CI = 74–78%) of adolescents (12–19 years) who deliver in employment-based insurance facilities leave with a method compared with 59% (95% CI = 56–62%) who deliver in public facilities. Conclusion Both adolescents and women ages 20–39 receive postpartum contraception, but nearly half of all women receive no method. Place of delivery is correlated with receipt of postpartum contraception, with lower rates in the public sector. Lessons learned from Mexico are relevant to other countries seeking to improve adolescent health through reducing unintended pregnancy. Implications Adolescents receive postpartum contraception as often as older women in Mexico, but half of all women receive no method.

Reclassifying causes of obstetric death in Mexico: a repeated cross-sectional study.

Abstract Objective To describe causes of maternal mortality in Mexico over eight years, with particular attention to indirect obstetric deaths and socioeconomic disparities. Methods We conducted a repeated cross-sectional study using the 2006–2013 Búsqueda intencionada y reclasificación de muertes maternas (BIRMM) data set. We used frequencies to describe new cases, cause distributions and the reclassification of maternal mortality cases by the BIRMM process. We used statistical tests to analyse differences in sociodemographic characteristics between direct and indirect deaths and differences in the proportion of overall direct and indirect deaths, by year and by municipality poverty level. Findings A total of 9043 maternal deaths were subjected to the review process. There was a 13% increase (from 7829 to 9043) in overall identified maternal deaths and a threefold increase in the proportion of maternal deaths classified as late maternal deaths (from 2.1% to 6.9%). Over the study period direct obstetric deaths declined, while there was no change in deaths from indirect obstetric causes. Direct deaths were concentrated in women who lived in the poorest municipalities. When compared to those dying of direct causes, women dying of indirect causes had fewer pregnancies and were slightly younger, better educated and more likely to live in wealthier municipalities. Conclusion The BIRMM is one approach to correct maternal death statistics in settings with poor resources. The approach could help the health system to rethink its strategy to reduce maternal deaths from indirect obstetric causes, including prevention of unwanted pregnancies and improvement of antenatal and post-obstetric care.

Elective induction of labor symposium: Nomenclature, research methodological issues, and outcomes

Elective induction of labor is a controversial topic. An observed relationship between elective induction and primary cesarean delivery has been of particular concern, and has guided much of the research to date on both indicated and elective induction of labor. However, it is unclear whether elective induction of labor actually increases the risk of cesarean delivery. This chapter focuses on key method issues to consider in studies of elective induction of labor. We first identify methodological concerns with the existing literature and discuss each in turn. We then review existing evidence about the relationship between elective induction and cesarean delivery.