Eleanor Bimla Schwarz

Duration of Lactation and Risk Factors for Maternal Cardiovascular Disease

OBJECTIVE: To examine dose–response relationships between the cumulative number of months women lactated and postmenopausal risk factors for cardiovascular disease. METHODS: We examined data from 139,681 postmenopausal women (median age 63 years) who reported at least one live birth on enrolling in the Women’s Health Initiative observational study or controlled trials. Multivariable models were used to control for sociodemographic (age, parity, race, education, income, age at menopause), lifestyle, and family history variables when examining the effect of duration of lactation on risk factors for cardiovascular disease, including obesity (body mass index [BMI] at or above 30), hypertension, self-reported diabetes, hyperlipidemia, and prevalent and incident cardiovascular disease. RESULTS: Dose-response relationships were seen; in fully adjusted models, women who reported a lifetime history of more than 12 months of lactation were less likely to have hypertension (odds ratio [OR] 0.88, P<.001), diabetes (OR 0.80, P<.001), hyperlipidemia (OR 0.81, P<.001), or cardiovascular disease (OR 0.91, P=.008) than women who never breast-fed, but they were not less likely to be obese. In models adjusted for all above variables and BMI, similar relationships were seen. Using multivariate adjusted prevalence ratios from generalized linear models, we estimate that among parous women who did not breast-feed compared with those who breast-fed for more than 12 months, 42.1% versus 38.6% would have hypertension, 5.3% versus 4.3% would have diabetes, 14.8% versus 12.3% would have hyperlipidemia, and 9.9% versus 9.1% would have developed cardiovascular disease when postmenopausal. Over an average of 7.9 years of postmenopausal participation in the Women’s Health Initiative, women with a single live birth who breast-fed for 7–12 months were significantly less likely to develop cardiovascular disease (hazard ratio 0.72, 95% confidence interval 0.53–0.97) than women who never breast-fed. CONCLUSION: Among postmenopausal women, increased duration of lactation was associated with a lower prevalence of hypertension, diabetes, hyperlipidemia, and cardiovascular disease. LEVEL OF EVIDENCE: II

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.

Advance supply of emergency contraception: effect on use and usual contraception—a randomized trial

OBJECTIVE To evaluate whether advance provision of emergency contraception increases its use and/or adversely affects usual contraceptive practices. METHODS We performed a randomized controlled trial comparing advance provision of emergency contraception with usual care in 370 postpartum women from an inner-city public hospital. Participants were followed for 1 year; 85% were available for at least one follow-up session. All participants received routine contraceptive education. The intervention group received a supply of emergency contraception (eight oral contraceptive pills containing 0.15 mg of levonorgestrel and 30 μg of ethinyl estradiol) and a 5-minute educational session. We compared use of emergency contraception and changes in contraceptive behaviors between groups. RESULTS Women provided with pills were four times as likely to have used emergency contraception as women in the control group over the course of the year (17% versus 4%; relative risk [RR] 4.0; 95% confidence interval [CI] 1.8, 9.0). Women were no more likely to have changed to a less effective method of birth control (30% versus 33%; RR 0.92; 95% CI 0.63, 1.3), or to be using contraception less consistently (18% versus 25%; RR 0.74; 95% CI 0.45, 1.2). About half of each group reported at least one episode of unprotected intercourse during follow-up, but women who received emergency contraception were six times as likely to have used it (25% versus 4%; RR 5.8; 95% CI 2.1, 16.4). CONCLUSION Advance provision of emergency contraception significantly increased use without adversely affecting use of routine contraception. It is safe and appropriate to provide emergency contraception to all postpartum women before discharge from the hospital.

Cost Analysis of Maternal Disease Associated With Suboptimal Breastfeeding

OBJECTIVE: To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs. METHODS: Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars. RESULTS: If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of

Lactation and Maternal Risk of Type 2 Diabetes: A Population-based Study

17.4 billion in cost to society resulting from premature death (95% confidence interval [CI]

“It just happens”: a qualitative study exploring low-income women’s perspectives on pregnancy intention and planning☆

4.38–24.68 billion),

Knowledge and willingness to use emergency contraception among low-income post-partum women

733.7 million in direct costs (95% CI

Obesity and Oral Contraceptive Pill Failure

612.9–859.7 million), and

Prospective assessment of pregnancy intentions using a single- versus a multi-item measure.

126.1 million indirect morbidity costs (95% CI

Lactation and Maternal Measures of Subclinical Cardiovascular Disease

99.00–153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI –810–7,918). CONCLUSIONS: Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.