Deborah Rosenberg

The likelihood of placenta previa with greater number of cesarean deliveries and higher parity.

OBJECTIVE To examine the relationship between prior cesarean delivery and placenta previa. METHODS A hospital‐based, case‐control study was conducted in which 316 multiparous women with placenta previa were identified. Controls consisted of 2051 multiparous women with spontaneous vaginal deliveries. Information on prior cesarean delivery was examined in three forms: as a dichotomous variable, as an ordinal variable, and as a set of three indicator variables for one, two, and three or more cesarean deliveries. Multivariable logistic regression modeling was used to obtain an adjusted estimate of this association. RESULTS Women with a prior cesarean delivery were more likely to have a placenta previa than those without (odds ratio [OR] 1.59, 95% confidence interval [CI] 1.21, 2.08). The likelihood of placenta previa increased as both parity and number of cesarean deliveries increased. Thus, the adjusted OR for a primiparous woman with one cesarean delivery was 1.28 (95% CI 0.82, 1.99). For a woman who has four or more deliveries with only a single cesarean delivery, the OR increases to 1.72 (95% CI 1.12, 2.64). This trend continues with greater parity and a greater number of cesarean deliveries such that the likelihood of placenta previa for a woman with parity greater than four and greater than four cesarean deliveries was OR 8.76 (95% CI 1.58, 48.53). CONCLUSION This study supports the association between prior cesarean delivery and placenta previa and demonstrates that the joint effect of parity and prior cesarean delivery is greater than that of either variable alone.

Incidence of fecal incontinence after childbirth

OBJECTIVE: Fecal incontinence is an embarrassing and disabling condition of which the epidemiology is poorly understood. Our goal is to estimate the incidence of fecal incontinence after childbirth. METHODS: A population-based survey was mailed to all women who delivered a liveborn infant in the state of Oregon between April 2002 and September 2002. The survey estimated the incidence of fecal incontinence. Surveys were to be completed within 3–6 months postpartum. Women were considered to have fecal incontinence based upon the National Institute of Child Health and Human Development definition of fecal incontinence: recurring episodes of involuntary loss of stool or flatus. RESULTS: Surveys were mailed to 21,824 eligible postpartum women. A total of 8,774 women responded (40%) to the survey, 2,569 (29%) of whom reported experiencing fecal incontinence since delivery. Almost half (46%) of all women with postpartum fecal incontinence reported incontinence of stool, and 38% reported exclusively incontinence of flatus. Approximately 46% reported onset of incontinence after delivery of their first child. Higher body mass index, longer pushing, forceps-assisted delivery, third- or fourth-degree laceration, and smoking were associated with severe fecal incontinence. CONCLUSION: In this population-based study, more than one in four women reported fecal incontinence within 6 months of childbirth, with almost half reporting onset of symptoms after delivery of their first child. Four in 10 women reported loss of flatus or stool during intercourse. Given the burden of this condition, both in number and social impact coupled with the hesitancy of women to want to initiate this conversation, providers should ask women about symptoms of fecal incontinence during postpartum examinations. Additionally, these data suggest that there may be a benefit to extending postpartum follow-up visits beyond the typical 6–8 weeks to provide surveillance for potential incontinence. LEVEL OF EVIDENCE: II

HEALTH CARE CHARACTERISTICS ASSOCIATED WITH WOMEN'S SATISFACTION WITH PRENATAL CARE

OBJECTIVES The objective of this study was to explore the relation between prenatal care characteristics and satisfaction among Medicaid recipients. METHODS African-American (n = 75) and Mexican-American (n = 26) nonadolescent primiparous pregnant women who had at least three prenatal care visits participated in a 25-minute telephone survey that asked them about satisfaction with prenatal care (art of care, technical quality, physical environment, access, availability and efficacy); prenatal care characteristics (practitioner attributes, service availability, and features of the delivery of care); and, personal characteristics (sociodemographics, health status and behaviors, and pregnancy-related variables). Univariate and multivariable analyses were conducted to explore the relations between personal characteristics and satisfaction and between care characteristics and satisfaction. RESULTS For the overall sample, the following prenatal care characteristics were associated with increased satisfaction: having procedures explained by the provider, short waiting times at the prenatal care site, the availability of ancillary services, and reporting that the prenatal care practitioner was male. When examining the data by ethnicity, whether the provider explained procedures was the most important determinant of satisfaction for both African-American and Mexican-American women. CONCLUSIONS Knowledge of the care characteristics that impact low-income pregnant womens satisfaction can be utilized to alter service delivery to increase use of prenatal care and ultimately to improve perinatal outcomes.

The relationship between exposure during pregnancy to cigarette smoking and cocaine use and placenta previa

OBJECTIVE This study examined the relationship between two maternal exposures, cigarette smoking and cocaine use, and placenta previa. STUDY DESIGN A hospital-based case-control study was conducted. Three hundred four cases of placenta previa were compared with 2732 controls with respect to demographic characteristics, substance use, and perinatal characteristics. Logistic regression was used to examine the individual effects of cigarette smoking and cocaine use on placenta previa, independent of other known risk factors. RESULTS A dose-response relationship between smoking cigarettes and placenta previa was observed independent of other known risk factors (ptrend < 0.01). Pregnant women who smoked > or = 20 cigarettes per day were over two times more likely to experience a placenta previa relative to nonsmokers (odds ratio 2.3, 95% confidence interval 1.5 to 3.5). Pregnant women who used cocaine were 1.4 times (95% confidence interval 0.8 to 2.4) as likely to experience a placenta previa as nonusers. CONCLUSIONS The previously observed association between smoking and placenta previa is supported by the dose-response relationship observed in this study. The potential association of cocaine with placenta previa needs more exploration.

Prenatal care initiation among very low-income women in the aftermath of welfare reform: does pre-pregnancy Medicaid coverage make a difference?

Objectives: To examine pre-pregnancy Medicaid coverage and initiation of prenatal care among women likely eligible for Medicaid coverage regardless of pregnancy. Methods: The Pregnancy Risk Assessment Monitoring System (PRAMS) was used to identify very low-income women with Medicaid payment for delivery. We then compared prenatal care initiation among women with (Non-GAP) and without (Medicaid GAP) pre-pregnancy Medicaid coverage. Results: Rates of first trimester prenatal care were 47.3% for women in the Medicaid GAP, 70.0% for women who were not. The adjusted odds ratio for being in the Medicaid GAP and delayed prenatal care was 2.7 (95% CI 1.2, 6.2), although this varied by race/ethnicity and education. The relationship was strongest among White and Hispanic women with less than a high school education: OR=13.8, (95% CI 3.0, 62.7) and OR=19.0 (95% CI 2.4, 149.2), respectively. Conclusions: Pre-pregnancy Medicaid coverage appears to be associated with early initiation of prenatal care. Almost a decade after welfare reform, it is essential to preserve the Medicaid expansions for pregnant women, foster Medicaid family planning waivers, and promote access to primary care and early prenatal care, particularly for very low-income women.

Factors associated with health care access for Mississippi children with special health care needs

Objectives: This purpose of the study was to examine the factors associated with access to routine care and to specialty care for Mississippi children with special health care needs (CSHCN). Methods: We analyzed data for Mississippi CSHCN from the 2001 National Survey of Children with Special Health Care Needs. Using a modified version of Andersen and Aday’s Behavioral Model of Health Services Use, we explored the relationship of independent variables (e.g., demographics, insurance, severity of illness) to dependent variables (did not obtain routine care, did not obtain specialty care). We conducted bivariate and logistic regression analyses using SAS and SUDAAN. Results: Based on self-reported data, with a 61% response rate, 66% of Mississippi CSHCN needed routine health care, and 52.8% needed specialty care. Of these children, 6.5% did not receive routine care and 9.3% did not receive specialty care. In a fully adjusted model, discontinuous insurance coverage was an important factor associated with not having obtained routine care (OR = 7.8; CI = 1.7–35.9) and specialty care (OR = 8.6; CI = 2.0–36.8). Children with a high illness severity rank were more likely to have not obtained routine care than children with a low rank (OR 1.4; CI = 1.1–1.9). Conclusions: It may be important to establish a health insurance safety net for families who lack insurance continuity since it appears that a lapse in insurance coverage impedes health care access. Further research is needed to understand the relationship between illness severity and lack of health care access, especially for children with special health care needs.

Prenatal care characteristics and African-American women’s satisfaction with care in a managed care organization

This study examined the characteristics of prenatal care affecting womens satisfaction for two groups of African-American women, those with Medicaid insurance and those with commercial insurance, who sought care through a large managed care organization in the Midwest. African-American pregnant managed care patients (n = 400), regardless of payer status, were more satisfied when their providers spent more time with them and when their providers engaged them by explaining procedures, asking them questions, and answering their questions. Satisfaction was also higher for both Medicaid (n = 125) and commercially insured women (n = 275) when the waiting room was clean and comfortable. The care characteristics most important to an African-American womans satisfaction with prenatal care do not appear to be dependent on her payer status, nor do they seem to be particularly dependent on the financial arrangements of her care provider. While improvements in health care delivery tend to focus on increasing technical proficiency to improve pregnant womens satisfaction with care, prenatal care providers should focus on improvements in patient-provider communication, as well as features of the prenatal care setting (e.g., cleanliness, waiting times, availability of ancillary services).

Validity of self-reported use of assisted reproductive technology treatment among women participating in the Pregnancy Risk Assessment Monitoring System in five states, 2000.

Objectives: To assess the validity of a question on assisted reproductive technology (ART) incorporated into the Pregnancy Risk Assessment Monitoring System (PRAMS) in 2000. While the intent of the question is to ascertain whether the index infant was conceived using ART, the phrasing was ambiguous for women who had used ART while trying to conceive the index infant but became pregnant after discontinuing treatment. Methods: We compared weighted PRAMS estimates from five states that incorporated the ART question in 2000 with data from the U.S. ART Surveillance System (ART-SS) maintained by the Centers for Disease Control and Prevention (CDC). U.S. medical practices are mandated to report data for every ART procedure to CDC annually; thus, the ART-SS is highly specific and complete. Results: ART use was reported for 156 of the PRAMS births in our study population, representing 4,571 (95% Confidence Limit, 3,452–5,690) births from the total birth cohort in the five states of interest in 2000. For the same maternal residency states and year, 1,768 births were reported to the ART-SS. Thus, we calculate that PRAMS overestimated ART use by 2,803 births. PRAMS estimated 2.59 times as many ART births as reported to the ART-SS. While for singletons, a large excess in estimated births from PRAMS was observed (ratio=3.50), there was little difference between the PRAMS estimates and ART-SS for twin and triplet births. Conclusion: These findings suggest women responding to PRAMS may be reporting past ART use in addition to current. The findings by plurality support this hypothesis.

Relationship between gestational weight gain and birthweight among clients enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Hawaii, 2003-2005.

AbstractTo investigate the relationship between gestational weight gain (GWG) and birthweight outcomes among a low-income population in Hawaii using GWG recommendations from the 2009 Institute of Medicine (IOM) guidelines. Data were analyzed for 19,130 mother-infant pairs who participated in Hawaii’s Special Supplemental Nutrition Program for Women, Infants, and Children from 2003 through 2005. GWG was categorized as inadequate, adequate, or excessive on the basis of GWG charts in the guidelines. Generalized logit models assessed the relationship between mothers’ GWG and their child’s birthweight category (low birthweight [LBW: <2,500 g], normal birthweight [2,500 g ≤ BW < 4,000 g], or high birthweight [HBW: ≥4,000 g]). Final models were stratified by prepregnancy body mass index (underweight, normal weight, overweight, or obese) and adjusted for maternal age, education, race/ethnicity, smoking status, parity, and marital status. Overall, 62 % of the sample had excessive weight gain and 15 % had inadequate weight gain. Women with excessive weight gain were more likely to deliver a HBW infant; this relationship was observed for women in all prepregnancy weight categories. Among women with underweight or normal weight prior to pregnancy, those with inadequate weight gain during pregnancy were more likely to deliver a LBW infant. Among the low-income population of Hawaii, women with GWG within the range recommended in the 2009 IOM guidelines had better birthweight outcomes than those with GWG outside the recommended range. Further study is needed to identify optimal GWG goals for women with an obese BMI prior to pregnancy.

The need for care coordination among children with special health care needs in Illinois

Objectives: The objectives of this study were: 1) to estimate the need for care coordination among children with special health care needs (CSHCN) in Illinois, 2) to assess the need for care coordination among CSHCN in Illinois by sociodemographic, condition-related, and access to care factors, and 3) to discuss approaches for meeting the need for care coordination. Methods: The study included 745 Illinois families interviewed as part of the State and Local Area Integrated Telephone Survey (SLAITS) of CSHCN. Classifying families of CSHCN as needing care coordination was based on three survey questions. The prevalence of the need for care coordination among CSHCN in Illinois was examined overall and by sociodemographic characteristics, descriptors of the child’s health condition, and measures of access to services. Multivariable modeling was carried out to jointly assess these factors and the need for care coordination. Results: In Illinois, 25.2% of CSHCN families reported a need for care coordination. Condition severity, need for supplementary/ancillary services, lack of insurance coverage and inadequate communication among providers were significantly associated with the need for care coordination (OR = 1.14, OR = 1.72, OR = 2.45, and OR = 3.08, respectively). Having a primary care provider/medical home was not associated with the need for care coordination in multivariable analysis. Conclusion: Coordination of health services is important for all children and all adults, but it is particularly important for children with special health care needs. The variation in the need for care coordination both within and across states underscores the need for flexibility in program and policy development for CSHCN.