Joseph E. Potter

Unwanted caesarean sections among public and private patients in Brazil: prospective study

Abstract Objective: To assess and compare the preferences of pregnant women in the public and private sector regarding delivery in Brazil. Design: Face to face structured interviews with women who were interviewed early in pregnancy, about one month before the due date, and about one month post partum. Setting: Four cities in Brazil. Participants: 1612 pregnant women: 1093 public patients and 519 private patients. Main outcome measures: Rates of delivery by caesarean section in public and private institutions; womens preferences for delivery; timing of decision to perform caesarean section. Results: 1136 women completed all three interviews; 476 women were lost to follow up (376 public patients and 100 private patients). Despite large differences in the rates of caesarean section in the two sectors (222/717 (31%) among public patients and 302/419 (72%) among private patients) there were no significant differences in preferences between the two groups. In both antenatal interviews, 70-80% in both sectors said they would prefer to deliver vaginally. In a large proportion of cases (237/502) caesarean delivery was decided on before admission: 48/207 (23%) in women in the public sector and 189/295 (64%) in women in the private sector. Conclusions: The large difference in the rates of caesarean sections in women in the public and private sectors is due to more unwanted caesarean sections among private patients rather than to a difference in preferences for delivery. High or rising rates of caesarean sections do not necessarily reflect demand for surgical delivery. What is already known on this topic In Brazil, one quarter of all women deliver in the private sector The rate of caesarean deliveries in the private sector is extremely high (70%) and more than twice that in the public sector, where rates have recently fallen due to a new policy Previous studies in which women were interviewed after birth showed that a substantial proportion of private patients who have caesarean sections would have preferred normal delivery What this study adds In two antenatal interviews, preferences regarding type of delivery were nearly identical among public and private patients and strongly favoured vaginal births Contrary to popular belief, middle and upper class women in Brazil do not want to deliver by caesarean section

Maternal health care utilization in Jordan: a study of patterns and determinants.

This article analyzes the patterns and determinants of maternal health care utilization in Jordan, using data from the Jordan Fertility and Family Health Survey of 1983. The study focuses on the 2,949 women who had a child in the five years preceding the survey. Through multivariate analyses of differentials in the utilization of prenatal care and health care at delivery, the study assesses the effect of sociodemographic factors, including residence, education, parity, and standard of living. The coverage of maternal health care in Jordan is discussed in relation to the overall organization of health services, the various providers of care, and the role of cultural factors.

Fertility and development: evidence from Brazil

Using microdata from the Brazilian demographic censuses of 1960, 1970, 1980, and 1991, aggregated into 518 consistently defined spatial units called microregions, we estimated fertility and mortality and constructed indicators of development and living conditions in the rural and urban areas of the microregions in each census. We then estimated cross-sectional and fixed-effects models to answer questions about the degree to which changes in these indicators are associated with changes in fertility and whether the relationship between fertility and development shifts through time. We found strong and consistent relationships between the decline in fertility and measurable changes in social and economic circumstances.

Problems in using birth-history analysis to estimate trends in fertility

Summary The problem investigated is the adequacy of birth-history analysis as a method for estimating fertility change. The analysis demonstrates that inaccurate reporting of the dates of birth of live-born children can, under reasonable assumptions, significantly distort cohort fertility schedules in such a way that estimates of change in fertility will be biased in the direction of exaggerating declines in fertility. This kind of bias is shown to exist in fertility estimates obtained from survey data in El Salvador and Bangladesh. An important implication is that birth history questionnaires should begin with the most recent, rather than the earliest, event in a respondents experience.

Unmet demand for highly effective postpartum contraception in Texas

OBJECTIVES We aimed to assess womens contraceptive preferences and use in the first 6 months after delivery. The postpartum period represents a key opportunity for women to learn about and obtain effective contraception, especially since 50% of unintended pregnancies to parous women occur within 2 years of a previous birth. METHODS We conducted a prospective cohort study of 800 postpartum women recruited from three hospitals in Austin and El Paso, TX. Women aged 18-44 who wanted to delay childbearing for at least 24 months were eligible for the study and completed interviews following delivery and at 3 and 6 months postpartum. Participants were asked about the contraceptive method they were currently using and the method they would prefer to use at 6 months after delivery. RESULTS At 6 months postpartum, 13% of women were using an intrauterine device or implant, and 17% were sterilized or had a partner who had had a vasectomy. Twenty-four percent were using hormonal methods, and 45% relied on less effective methods, mainly condoms and withdrawal. Yet 44% reported that they would prefer to be using sterilization, and 34% would prefer to be using long-acting reversible contraception (LARC). CONCLUSIONS This study shows a considerable preference for LARC and permanent methods at 6 months postpartum. However, there is a marked discordance between womens method preference and actual use, indicating substantial unmet demand for highly effective methods of contraception. IMPLICATIONS In two Texas cities, many more women preferred long-acting and permanent contraceptive methods (LAPM) than were able to access these methods at 6 months postpartum. Womens contraceptive needs could be better met by counseling about all methods, by reducing cost barriers and by making LAPM available at more sites.

Change in abortion services after implementation of a restrictive law in Texas

OBJECTIVES In 2013, Texas passed omnibus legislation restricting abortion services. Provisions restricting medical abortion, banning most procedures after 20 weeks and requiring physicians to have hospital-admitting privileges were enforced in November 2013; by September 2014, abortion facilities must meet the requirements of ambulatory surgical centers (ASCs). We aimed to rapidly assess the change in abortion services after the first three provisions went into effect. STUDY DESIGN We requested information from all licensed Texas abortion facilities on abortions performed between November 2012 and April 2014, including the abortion method and gestational age (< 12 weeks vs. ≥ 12 weeks). RESULTS In May 2013, there were 41 facilities providing abortion in Texas; this decreased to 22 in November 2013. Both clinics closed in the Rio Grande Valley, and all but one closed in West Texas. Comparing November 2012-April 2013 to November 2013-April 2014, there was a 13% decrease in the abortion rate (from 12.9 to 11.2 abortions/1000 women age 15-44). Medical abortion decreased by 70%, from 28.1% of all abortions in the earlier period to 9.7% after November 2013 (p<0.001). Second-trimester abortion increased from 13.5% to 13.9% of all abortions (p<0.001). Only 22% of abortions were performed in the states six ASCs. CONCLUSIONS The closure of clinics and restrictions on medical abortion in Texas appear to be associated with a decline in the in-state abortion rate and a marked decrease in the number of medical abortions. IMPLICATIONS Supply-side restrictions on abortion - especially restrictions on medical abortion - can have a profound impact on access to services. Access to abortion care will become even further restricted in Texas when the ASC requirement goes into effect in 2014.

Accuracy of Self-Screening for Contraindications to Combined Oral Contraceptive Use

OBJECTIVE: To estimate how well a convenience sample of women from the general population could self-screen for contraindications to combined oral contraceptives using a medical checklist. METHODS: Women 18–49 years old (N=1,271) were recruited at two shopping malls and a flea market in El Paso, Texas, and asked first whether they thought birth control pills were medically safe for them. They then used a checklist to determine the presence of level 3 or 4 contraindications to combined oral contraceptives according to the World Health Organization Medical Eligibility Criteria. The women then were interviewed by a blinded nurse practitioner, who also measured blood pressure. RESULTS: The sensitivity of the unaided self-screen to detect true contraindications was 56.2% (95% confidence interval [CI] 51.7–60.6%), and specificity was 57.6% (95% CI 54.0–61.1%). The sensitivity of the checklist to detect true contraindications was 83.2% (95% CI 79.5–86.3%), and specificity was 88.8% (95% CI 86.3–90.9%). Using the checklist, 6.6% (95% CI 5.2–8.0%) of women incorrectly thought they were eligible for use when, in fact, they were contraindicated, largely because of unrecognized hypertension. Seven percent (95% CI 5.4–8.2%) of women incorrectly thought they were contraindicated when they truly were not, primarily because of misclassification of migraine headaches. In regression analysis, younger women, more educated women, and Spanish speakers were significantly more likely to correctly self-screen (P<.05). CONCLUSION: Self-screening for contraindications to oral contraceptives using a medical checklist is relatively accurate. Unaided screening is inaccurate and reflects common misperceptions about the safety of oral contraceptives. Over-the-counter provision of this method likely would be safe, especially for younger women and if independent blood pressure screening were encouraged. LEVEL OF EVIDENCE: II

Population and Development in Mexico since 1940: An Interpretation

In this discussion of population and development in Mexico since 1940 attention is directed initially to the 30-year period of sustained economic growth that began in 1940. After identifying the mainstays of the governments efforts to promote development during the period focus shifts to the ways in which these policies were shaped by and in turn fostered rapid population growth. Turning to the recurrent frustration of Mexican development objectives from the late 1960s onwards the discussion turns to the exhaustion of the mechanisms of population accommodation that had been relied on and to the ways successive governments tried to cope with the problems they encountered. In the final section consideration turns to 1 of the responses i.e. the population policy announced in 1973. After analyzing the nature of the government efforts the discussion explores how they were related to the rapid change in reproductive behavior that has occurred in the interim. A marked acceleration in the rate of growth of Mexicos population took place in the 1930s and the 1940s. In the 30 years following 1940 the Mexican population increased by 157% in contrast to an increase in the previous years of only 30%. The net annual addition to the population which numbered about 300000 persons in the 1930s had increased to nearly 2 million persons by 1970. The acceleration was brought about by a rapid decline in mortality and to a lesser extent by a slight but appreciable increase in fertility. It was an amazing accomplishment of the Mexican economy and society that they were able without visible strain to accommodate this unexpected and sizable increase in numbers. Several policies pursued during this period appear to have been particularly pertinent to the pattern of accommodation that was achieved including the agrarian reform policy the agricultural policy government support of the industrial sector and a series of policies designed to promote private sector initiative. Much of the explanation for the persistence of high fertility in Mexico lies with the particular policy initiatives that defined the style of development during the 1940-70 period. They gave rise to important social and economic transformations but failed to produce environments in which high fertility posed a serious problem for most families at least until well toward the end of this period. If in 1940 there was no apparent reason for Mexico to have much interest in limiting fertility this was no longer the case by 1970. The submission in September 1973 of a legislative proposal for major reforms in the countrys laws concerning population was notable. A constitutional amendment and the revisions and extensions of the population code became effective before the end of the year. Yet the marked decline in fertility in Mexico realized by 1982 will have no more than a minimal influence on the growth in the labor force that will take place during the rest of this century. This continuing rapid population growth engenders much condern about the effects of the dramatic break with past macroeconomic performance that has occurred since the early 1980s.

Continuation of Prescribed Compared With Over-the-Counter Oral Contraceptives

OBJECTIVE: To estimate differences in continuation of oral contraceptive pills (OCPs) between U.S. resident women obtaining pills in U.S. family planning clinics compared with over-the-counter in Mexican pharmacies. METHODS: In El Paso, Texas, we recruited 514 OCP users who obtained pills over the counter from a Mexican pharmacy and 532 who obtained OCPs by prescription from a family planning clinic in El Paso. A baseline interview was followed by three consecutive surveys over 9 months. We asked about date of last supply, number of pill packs obtained, how long they planned to continue use, and experience of side effects. Retention was 90%, with only 105 women lost to follow-up. RESULTS: In a multivariable Cox proportional hazards model, discontinuation was higher for women who obtained pills in El Paso clinics compared with those who obtained their pills without a prescription in Mexico (hazard ratio 1.6, 95% confidence interval [CI] 1.1–2.3). Considering the number of pill packs dispensed to clinic users, discontinuation rates were higher (hazard ratio 1.8, 95% CI 1.2–2.7) for clinic users who received one to five pill packs. However, there was no difference in discontinuation between clinic users receiving six or more pill packs and users obtaining pills without a prescription. CONCLUSION: Results suggest providing OCP users with more pill packs and removing the prescription requirement would lead to increased continuation. LEVEL OF EVIDENCE: II

Perceptions of the safety of oral contraceptives among a predominantly Latina population in Texas

BACKGROUND Fear of side effects and previous negative experiences are common reasons for contraceptive nonuse. STUDY DESIGN We collected information about perceptions of oral contraceptive (OC) safety from 1271 women 18-49 years old in El Paso, TX, and compared their responses to a medical evaluation by a nurse practitioner. We also asked participants about their interest in obtaining OCs over the counter (OTC). RESULTS Among 794 women potentially at risk of unintended pregnancy, 56.0% said that OCs were medically safe for them. Reasons given for OCs being unsafe were related to fears of side effects and prior negative experiences rather than true contraindications. Older women and participants recruited at the less affluent recruitment site were significantly more likely to report that OCs were medically unsafe for them (p<.05). Nonusers who thought OCs were medically unsafe for them were as likely to be medically eligible for use as current hormonal users. Among nonusers or nonhormonal users and potential OC candidates (n=601), 60.2% said they would be more likely to use OCs if they were available OTC. CONCLUSIONS Womens perception of OC safety does not correlate well with medical eligibility for use. More education about the safety and health benefits of hormonal contraception is needed. OTC availability might contribute to more positive safety perceptions of OCs compared to a prescription environment.