Diana Cheng

Unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors.

BACKGROUND This study was conducted to determine the relationship between unintended pregnancy and maternal behaviors before, during and after pregnancy. STUDY DESIGN Data were analyzed from a stratified random sample of 9048 mothers who delivered live born infants between 2001 and 2006 and completed the Pregnancy Risk Assessment Monitoring System (PRAMS) survey 2 to 9 months after delivery. Binary and ordinal logistic regression methods with appropriate survey weights were used to control for socio-demographic factors. RESULTS Compared to women with intended pregnancies, mothers with unwanted pregnancies were more likely to consume less than the recommended amount of preconception folic acid [adjusted odds ratio (OR) 2.39, 95% confidence interval (CI) 1.7-3.2], smoke prenatally (OR 2.03, 95% CI 1.5-2.9), smoke postpartum (OR 1.86, 95% CI 1.35-2.55) and report postpartum depression (OR 1.98, 95% CI 1.48-2.64); they were less likely to initiate prenatal care during the first trimester (OR 0.34, 95% CI 0.3-0.5) and breastfeed for 8 or more weeks (OR 0.74, 95% CI 0.57-0.97). Compared to women with intended pregnancies, women with mistimed pregnancies were also more likely to consume inadequate folic acid, delay prenatal care and report postpartum depression. CONCLUSION Even after controlling for multiple socio-demographic factors, unwanted and mistimed pregnancies were associated with unhealthy perinatal behaviors.

Intimate-Partner Homicide Among Pregnant and Postpartum Women

OBJECTIVE: To identify pregnancy-associated homicide cases and to estimate the proportion that were perpetrated by a current or former intimate partner. METHODS: This was an analysis of pregnancy-associated homicides occurring from 1993 to 2008 among Maryland residents using linked birth and death certificates, medical examiner charts, police records, and news publications. RESULTS: Homicides (n=110) were the leading cause of death during pregnancy and the first postpartum year. Women who were African American, younger than 25 years, and unmarried were at the highest risk for homicide. Firearms were the most common (61.8%) method of death. A current or former intimate partner was the perpetrator in 54.5% (n=60) of homicide deaths and a nonpartner in 31.8% (n=35). If the cases (n=15) in which the victim–offender relationship could not be identified are excluded, 63.2% of homicides were committed by an intimate partner. Compared with homicides in which the perpetrator was not an intimate partner, a significantly higher percentage (P<.05) of intimate-partner homicides occurred at home (66.7% compared with 28.6%), among women who had completed more than 12 years of education (23.3% compared with 5.7%), and who were married (28.3% compared with 8.6%). Intimate-partner homicides were most prevalent (25.0%) during the first 3 months of pregnancy and least prevalent during the first 3 months postpartum (5.0%). CONCLUSION: The majority of pregnancy-associated homicides were committed by current or former intimate partners, most commonly during the first 3 months of pregnancy. Efforts to protect women from partners optimally should begin before conception or very early in pregnancy. LEVEL OF EVIDENCE: III

Effectiveness of pregnancy check boxes on death certificates in identifying pregnancy-associated mortality

Objectives. Information that would allow the identification of women who were pregnant at the time of death or within the year preceding death has historically been underreported on death certificates. As a result, the magnitude of the problem of pregnancy-associated mortality is underestimated. To improve the identification of these deaths, check boxes for reporting pregnancy status have been added to death certificates in a number of states. We used multiple external data sources to determine whether check boxes have been effective in identifying pregnancy-associated deaths. Methods. We collected data on deaths occurring among pregnant or recently pregnant women residing in Maryland during the years 2001–2008 using multiple data sources. We determined the percentage of these deaths that could be identified through check boxes placed on death certificates. Results. Overall, 64.5% of pregnancy-associated deaths were identified through pregnancy check boxes on death certificates, including 98.1% of maternal deaths—defined as deaths occurring during pregnancy or within 42 days of delivery from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes—and 46.7% of deaths from nonmaternal causes, such as homicide, suicide, accidents, and substance abuse. Conclusions. Check boxes on death certificates are effective in identifying pregnancy-associated deaths resulting from maternal causes. However, they are far less effective in identifying deaths resulting from nonmaternal causes, such as homicide, accidental death, and substance abuse, which represent three of the four leading causes of pregnancy-associated death in Maryland.

Alcohol Consumption During Pregnancy Prevalence and Provider Assessment

OBJECTIVE: To estimate the prevalence of prenatal alcohol consumption and the extent of provider screening and discussion about alcohol use during pregnancy. METHODS: Data were obtained from a stratified random sample of 12,611 mothers from Maryland who delivered live infants during the years 2001–2008 and completed the Maryland Pregnancy Risk Assessment Monitoring System survey. Analyses were conducted using Proc Surveyfreq in SAS 9.2. RESULTS: Nearly 8% (95% confidence interval 7.1–8.4) of mothers from Maryland reported alcohol consumption during the last 3 months of pregnancy. The highest prevalence of late-pregnancy alcohol consumption was reported by mothers who were non-Hispanic white, (10.9%, confidence interval 9.8–11.9), aged 35 years or older (13.4%, confidence interval 12.4–14.4), and college graduates (11.4%, confidence interval 10.2–12.6) (P<.001). Nineteen percent (confidence interval 17.6–21.0) of mothers reported that their prenatal care provider did not ask whether they were drinking alcoholic beverages, and 30% (confidence interval 28.3–30.8) reported that a healthcare provider did not counsel them about the consequences of alcohol use on the child. Reported screening and counseling were least prevalent among mothers who were non-Hispanic white, aged 35 years or older, and college graduates (P<.01). CONCLUSION: Despite the substantial number of women who continue to drink alcohol during pregnancy, healthcare providers do not routinely assess alcohol consumption or counsel all women about its harmful effects. Counseling was least prevalent among the same groups of women with the highest rates for drinking. Provider alcohol assessment, as recommended by the U.S. Surgeon General to prevent alcohol misuse, needs further promotion as a routine part of prenatal care. LEVEL OF EVIDENCE: III

Neonatal circumcision in Maryland: A comparison of hospital discharge and maternal postpartum survey data

OBJECTIVE To study circumcision rates in Maryland using hospital discharge and maternal survey data in order to provide healthcare providers, parents and policy makers with more accurate and comprehensive information about this common yet controversial procedure. METHODS Secondary data analyses were performed using Maryland hospital discharge data files containing records of 96,457 male newborns, and postpartum survey data collected from 4273 mothers through the Maryland Pregnancy Risk Assessment Monitoring System. RESULTS Hospital discharge data showed that 75.3% of male infants were circumcised, and survey data showed that 82.3% of male infants were circumcised. The circumcision rate among infants weighing <1500 g at birth was 38.9% using hospital discharge data and 74.5% using maternal survey data. Both sources revealed lower circumcision rates among Asian and Hispanic infants than among non-Hispanic white and non-Hispanic black infants. CONCLUSIONS Despite reports of decreasing circumcision rates nationally, rates remain high in Maryland. In addition to providing for the inclusion of circumcision procedures that may not have been coded properly in hospital discharge records and procedures that were performed after hospital discharge, maternal survey data provide more comprehensive information than hospital discharge data about parental characteristics and factors relevant to the circumcision decision-making process.

UNDERREPORTING OF PREGNANCY-ASSOCIATED DEATHS

In the March issue of the Journal, Chang et al. call attention to the finding that homicide is a leading cause of death among pregnant and postpartum women.1 However, their findings substantially underestimate the magnitude of the problem, because data on pregnancy-associated deaths collected by the Centers for Disease Control and Prevention’s Division of Reproductive Health (DRH) through the Pregnancy Mortality Surveillance System are incomplete. To collect data for the Pregnancy Mortality Surveillance System, the DRH asks states to voluntarily send death certificates for all maternal deaths, that is, deaths resulting from medical causes related to the pregnancy that occur during pregnancy or within 42 days of delivery or termination of pregnancy. The DRH also asks states to send information on pregnancy-associated deaths, that is, deaths from any cause that occur during pregnancy or within a year of delivery or termination of pregnancy. This would include homicides. Because it is impossible to identify all pregnancy-associated deaths with only the information contained on death certificates, and few states use additional sources of data to identify pregnancy-associated deaths,2 the information reported to the DRH is incomplete. Our Maryland study showed that only a small proportion of pregnancy-associated deaths can be identified from death certificates alone and that comprehensive identification of pregnancy-associated deaths requires collection of data from additional sources, including medical examiners’ records and linkage of death records with birth and fetal death records.3 Medical examiners’ records are a critical source of information on homicides that occur among women who are pregnant at the time of death, but Maryland may be the only state that routinely reviews medical examiners’ records for this purpose. Linkage of death records with birth and fetal death records is important in identifying homicides among postpartum women, but few states routinely link these records at all and even fewer do so for a full year following pregnancy. Further evidence of underreporting in Chang’s study is that their reported pregnancy-associated homicide rate of 1.7 per 100000 live births is substantially lower than rates cited in other reports. The pregnancy-associated homicide rate in Maryland was found to be 10.5 per 100000 live births when death records, linkage of records, and medical examiner records were used to identify deaths.3 Using only death certificates and linked records to identify deaths, Parsons and Harper4 in North Carolina and Nannini et al.5 in Massachusetts found rates of 7.2 and 3.5, respectively. Both states and the Centers for Disease Control and Prevention must improve their efforts to collect complete and accurate data on pregnancy-associated deaths. This is a critical step in the prevention of pregnancy-associated mortality from all causes.

Enhanced Surveillance for Pregnancy-Associated Mortality—Maryland, 1993–1998

COMPLETE AND ACCURATE IDENtification of all deaths associated with pregnancy is a critical first step in the prevention of such deaths. Only by having a clear understanding of the magnitude of pregnancy-associated mortality can comprehensive prevention strategies be formulated to prevent these unanticipated deaths among primarily young, healthy women. Death statistics compiled through the National Vital Statistics System by the National Center for Health Statistics, Centers for Disease Control and Prevention, are a major source of data on deaths occurring during pregnancy and in the postpartum period. Original death certificates from which state and national vital statistics are derived are filed in and maintained by individual states. Causes of death on death certificates are reported by attending physicians or, under certain circumstances such as death from external trauma or unexplained death, by medical examiners or coroners. The National Center for Health Statistics is required to use the World Health Organization (WHO) definition of a maternal death for preparation and presentation of mortality data. According to the WHO definition, a maternal death is “the death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and the site of the pregnancy, from any cause related to or aggravated by the pregnancy or its management but not from accidental or incidental causes.” This definition includes deaths assigned to the cause “complication of pregnancy, childbirth, and the puerperium” (International Classification of Diseases, Ninth Revision [ICD-9] codes 630-676). Death records are an important source of data on pregnancy mortality because they are routinely collected by the states and are comparable over time and across the nation. However, there are several limitations to using these data to identify all deaths associated with pregnancy. First, the cause-of-death information provided on these records is sometimes not accurate. Previous studies have shown that physicians completing death records following a maternal death fail to report that the woman was pregnant or had a recent pregnancy in 50% or more of these cases, resulting in the misclassification of the underlying cause of death. Since these deaths cannot be identified as maternal deaths through routine surveillance