Juliette S. Kendrick

The prevalence of bacterial vaginosis in the United States, 2001-2004; associations with symptoms, sexual behaviors, and reproductive health

Objectives: Bacterial vaginosis (BV), a disturbance of vaginal microflora, is a common cause of vaginal symptoms and is associated with an increased risk of acquisition of sexually transmitted infections, HIV, and with adverse pregnancy outcomes. We determined prevalence and associations with BV among a representative sample of women of reproductive age in the United States. Study Design: Women aged 14–49 years participating in the National Health and Nutrition Examination Survey 2001–2004 were asked to submit a self-collected vaginal swab for Gram staining. BV, determined using Nugent’s score, was defined as a score of 7–10. Results: The prevalence of BV was 29.2% (95% confidence interval 27.2%–31.3%) corresponding to 21 million women with BV; only 15.7% of the women with BV reported vaginal symptoms. Prevalence was 51.4% among non-Hispanic blacks, 31.9% among Mexican Americans, and 23.2% among non-Hispanic whites (P <0.01 for each comparison). Although BV was also associated with poverty (P <0.01), smoking (P <0.05), increasing body mass index (&khgr;2P <0.0001 for trend), and having had a female sex partner (P <0.005), in the multivariate model, BV only remained positively associated with race/ethnicity, increasing lifetime sex partners (&khgr;2P <0.001 for trend), increasing douching frequency (&khgr;2P for trend <0.001), low educational attainment (P <0.01), and inversely associated with current use of oral contraceptive pills (P <0.005). Conclusion: BV is a common condition; 84% of women with BV did not report symptoms. Because BV increases the risk of acquiring sexually transmitted infections, BV could contribute to racial disparities in these infections.

The Reduction in Risk of Ovarian Cancer Associated with Oral-Contraceptive Use

Although several studies have reported that the use of oral contraceptives decreases the risk of ovarian cancer, it is not clear whether the effect varies according to the oral-contraceptive formulation or the histologic type of cancer. To characterize this association more fully, we used data from a case-control study, the Cancer and Steroid Hormone Study. From 1980 to 1982, 546 women 20 to 54 years of age with ovarian cancer were enrolled from eight population-based cancer registries. The controls were 4228 women selected from the same areas. Women who had used oral contraceptives had a risk of epithelial ovarian cancer of 0.6 (95 percent confidence interval, 0.5 to 0.7) as compared with those who had never used them. This protective effect was seen in women who had used oral contraceptives for as little as three to six months, and it continued for 15 years after use ended; it was independent of the specific oral-contraceptive formulation and of the histologic type of epithelial ovarian cancer. (We could not adequately assess the association with nonepithelial ovarian cancers because of an insufficient number of cases.) We conclude that the use of oral contraceptives decreases the risk of epithelial ovarian cancer.

Cigarette smoking as a risk factor for ectopic pregnancy

OBJECTIVE Our purpose was to assess the risk of ectopic pregnancy among women who smoke cigarettes. STUDY DESIGN We used data from a case-control study of ectopic pregnancy conducted from October 1988 to August 1990 at an inner-city hospital in Georgia. Cases were 196 non-Hispanic black women with a surgically confirmed ectopic pregnancy. Controls were non-Hispanic black women who had delivered either a live or a stillborn infant weighing at least 500 gm (n = 882) or who were pregnant and seeking an induced abortion (n = 237). RESULTS After we adjusted for parity, douching history, history of infertility, and age, the odds ratio for ectopic pregnancy was 1.9 (95% confidence interval 1.4 to 2.7) for women who smoked during the periconception period compared with women who did not smoke at that time. After stratification by the amount of daily smoking during the periconception period, the odds ratio rose from 1.6 (95% confidence interval 0.9 to 2.9) for women who smoked 1 to 5 cigarettes to 1.7 (95% confidence interval 1.1 to 2.8) for women who smoked 6 to 10 cigarettes to 2.3 (95% confidence interval 1.3 to 4.0) for women who smoked 11 to 20 cigarettes, and to 3.5 (95% confidence interval 1.4 to 8.6) for women who smoked >20 cigarettes per day. CONCLUSION In this inner-city population, cigarette smoking was an independent, dose-related risk factor for ectopic pregnancy among black women. The public health and medical care communities should inform the public of this additional risk associated with cigarette smoking and intensify intervention strategies to reduce cigarette smoking among women of reproductive age.

Vaginal douching and the risk of ectopic pregnancy among black women

OBJECTIVE Our goal was to determine whether vaginal douching was associated with ectopic pregnancy among black women and whether specific douching behaviors were associated with differences in risk. STUDY DESIGN We analyzed data from a case-control study of ectopic pregnancy conducted between October 1988 and August 1990 at a major public hospital in Atlanta, Georgia. Case subjects were 197 black women with surgically confirmed ectopic pregnancies; the control group included 882 black women who were delivered of live or stillborn infants and 237 black women who were seeking to terminate a pregnancy. RESULTS The adjusted odds ratio for ectopic pregnancy associated with ever having douched was 3.8 (95% confidence interval 1.6 to 8.9). The risk increased with increasing number of years of douching at least once per month. No douching behavior was found to be without risk; even women who douched for routine cleanliness were at increased risk of ectopic pregnancy. CONCLUSIONS Vaginal douching is a modifiable behavior that may greatly increase a womans risk of ectopic pregnancy.

Trends in obstetric operative procedures, 1980 to 1987.

OBJECTIVES Increasing rates of cesarean deliveries have received widespread attention in recent years, as concern in the United States about unnecessary surgical procedures has increased. However, little information has been published on the national trends of other operative obstetric procedures occurring during deliveries. METHODS We analyzed data from the National Hospital Discharge Survey to examine trends in the use of forceps, vacuum extraction, and cesarean section from 1980 through 1987. RESULTS The rate of cesarean sections increased by 48%, while the rate of forceps procedures declined by 43%. Although the risk of cesarean section was significantly increased for older women, the risk of forceps and vacuum extraction procedures did not vary by age. Women with private insurance were significantly more likely to receive a cesarean section (rate ratio [RR] = 1.2), forceps procedure (RR = 1.7), and vacuum extraction procedure (RR = 1.8) than were women without private insurance. CONCLUSIONS As pressure mounts to decrease the national cesarean section rate from 24% to 15% by the year 2000, attention should also be given to surveillance of other operative delivery procedures.

Surveillance in a time of changing health care practices: estimating ectopic pregnancy incidence in the United States.

Objectives: Ectopic pregnancy is a common condition with significant health consequences; complications are a major cause of maternal mortality in the United States. Accurate ascertainment of the number of ectopic pregnancies occurring in the United States has been dramatically affected by changing medical practices, causing estimates based on hospital data to be falsely low. This study was performed to identify nationally representative data on ectopic pregnancies and determine overlap of these data, to calculate the annual weighted number of ectopic pregnancies and confidence intervals for these estimates, and to determine barriers to estimation of ectopic pregnancy incidence. Methods: To assess whether a national estimate of the incidence of ectopic pregnancy could be calculated, we analyzed 1992–99 data from the six nationally representative data sets that include information on ectopic pregnancy. We examined relevant data in each data set and assessed whether any combination of data sets could be used to estimate ectopic pregnancy incidence. We calculated weighted estimates and 95% confidence intervals for hospitalizations, outpatient surgeries, outpatient medical procedures, and physician visits for and self-reports of ectopic pregnancy. Results: Small sample sizes severely limited calculation of estimates of ectopic pregnancy. Data needed for assessing multiple counting was not available consistently. The likelihood of multiple counting of cases was substantial when data set counts were combined. Conclusions: A reliable incidence rate for ectopic pregnancy in the United States could not be estimated from existing nationally representative data sources. Major advances in diagnosis and treatment of ectopic pregnancy have affected surveillance in two ways: inpatient hospital treatment of ectopic pregnancy has decreased, and multiple health care visits for a single ectopic pregnancy have increased. Alternate means of surveillance are needed to improve understanding of risk factors and trends for ectopic pregnancy, and we recommend examination of the databases of public and private insurance systems and managed care systems. Similar alternate means of surveillance may be needed for other health conditions with comparable changes in management of care.

Hospitalization for pregnancy complications, United States, 1986 and 1987

OBJECTIVE The purpose of our analysis was to provide a national overview of the magnitude of the public health burden associated with inpatient care for pregnancy complications. STUDY DESIGN We analyzed data from the National Hospital Discharge Survey for 1986 and 1987. We calculated ratios of hospitalizations for pregnancy complications for every 100 hospitalizations involving a birth. Standard errors for these ratios were calculated with RATIOEST, and relative ratios with 95% confidence intervals were calculated for subgroups of interest. RESULTS We found that for every 100 hospitalizations involving a birth, there were 22.2 nondelivery hospitalizations for pregnancy complications (14.6 antenatal complications, 7.6 pregnancy loss complications). These ratios were higher for black than for white women (relative ratio 1.4, 95% confidence interval 1.2 to 1.6). The effects of marital status, age, and insurance coverage differed between black and white women, and mean length of stay was longer for black than for white women. CONCLUSION Hospitalization for pregnancy complications is far more common than is widely appreciated and is more frequent among black than white women.

Text4baby: Development and Implementation of a National Text Messaging Health Information Service

Text4baby is the first free national health text messaging service in the United States that aims to provide timely information to pregnant women and new mothers to help them improve their health and the health of their babies. Here we describe the development of the text messages and the large public-private partnership that led to the national launch of the service in 2010. Promotion at the local, state, and national levels produced rapid uptake across the United States. More than 320,000 people enrolled with text4baby between February 2010 and March 2012. Further evaluations of the effectiveness of the service are ongoing; however, important lessons can be learned from its development and uptake.

The risk of low birth weight associated with vaginal douching

Objective To examine the association between vaginal douching and low birth weight (LBW) after accounting for known risk factors. Methods We used cross-sectional interview data from the 1988 National Survey of Family Growth, a nationally representative sample of 4665 women of child-bearing age and 11,553 singleton live births. We compared the risk of LBW among women who reported they douched regularly with the risk among women who did not douche, after controlling for potential confounders including maternal age, race, household income, marital status, total number of pregnancies, smoking, alcohol use, drug use during the pregnancy, year of birth of each infant, geographic region, and self-reported history of pelvic inflammatory disease. Results In multivariate analysis, regular douching was associated with an increased risk of LBW (adjusted odds ratio [OR], 1.29; 95% confidence interval [CI] 1.06, 1.57). Frequency of douching and LBW exhibited a dose-response. The adjusted OR for the association between daily douching and LBW was 2.49 (95% CI 1.23, 5.01) compared with an adjusted OR of 1.13 (95% CI 0.83, 1.55) for the association between monthly douching and LBW. There was no racial difference in the risk of LBW associated with douching. Conclusion These preliminary data suggest an association between douching and LBW risk. If these findings are replicated in future studies, douching may represent a major preventable risk factor for LBW.

Why Do Women Douche? Results from a Qualitative Study

Objectives: To explore womens attitudes and practices related to douching. Methods: We conducted focus groups between July and December 1999 with 34 black and 27 white women enrolled in a managed care plan in Memphis, Tennessee. Participants were at least 18 years of age and had douched at some time in their lives. Five groups were held with black women and five with white women. Results: The focus groups identified 13 themes that fell in four broad categories: general perceptions about feminine hygiene, douching behavior, factors perpetuating douching, and health information. Each of these categories is briefly discussed with supporting evidence. Conclusions: First, women have deeply-rooted beliefs about the critical role of douching in making them feel clean. Second, douching generally starts at a young age and is reinforced by family, friends, and the media. Third, douching is a very difficult behavior to change; any efforts to influence this behavior must consider womens beliefs and the media marketing efforts that promote douching. Finally, simplistic interventions that only provide risk information about douching are not likely to result in behavior change.