Melissa M. Adams

The relationship between pregnancy intendedness and physical violence in mothers of newborns

Objective To determine if pregnancy intendedness is associated with physical violence, and to identify factors that modify this association. Methods Three to 6 months after delivery, we mailed a questionnaire to a population-based sample of 12,612 mothers of infants born during 1990 and 1991 in four states. We used multiple logistic regression to compute odds ratios. Results The state-specific prevalences (± standard error) of physical violence ranged from 3.8 ± 0.5 to 6.9 ± 0.8%; the prevalences of unwanted or mistimed pregnancies ranged from 36.9–46.3%. In each state, higher rates of physical violence were reported by women who had fewer than 12 years of education, lived in crowded conditions, participated in the Special Supplemental Food Program for Women, Infants, and Children, received no or delayed prenatal care, or were of races other than white, under 20 years old, or not married. Regardless of other attributes, women with unwanted or mistimed pregnancies reported higher rates of physical violence than women with intended pregnancies and accounted for 70% of women who reported physical violence. Overall, women with unwanted pregnancies had 4.1 (95% confidence interval 2.7–6.2) times the odds of experiencing physical violence than did women with intended pregnancies. This association was weaker for women with few social advantages than for those with more advantages. Conclusion Physical violence toward women during the periconceptional and antenatal periods occurs in all sociodemographic groups. Women with unwanted or mistimed pregnancies are at an increased risk for violence by their partners compared with women with intended pregnancies.

Hospitalizations during pregnancy among managed care enrollees.

OBJECTIVE To describe the prevalence of hospitalizations during pregnancy, the reason for hospitalization, the length of stay, and the associated costs. METHODS We analyzed data from a national managed care organization and determined the occurrence of hospitalizations for 46,179 women who had a live birth or a pregnancy loss in 1997. RESULTS Overall, 8.7% of women were hospitalized during their pregnancy. Of these, 5.7% were hospitalized and discharged while pregnant, 0.8% experienced extended stays before a live birth or pregnancy loss, and 2.1% experienced pregnancy loss. Hospitalizations were more common among younger women, women with multiple gestations, and women in the northeastern United States. Women who had a live birth were primarily hospitalized for preterm labor (24%), hyperemesis (9%), hypertension (9%), kidney disorders (6%), and prolonged premature rupture of membranes (6%). Charges totaled over

Prevalence of Duchenne and Becker Muscular Dystrophies in the United States

36 million. CONCLUSION Antenatal hospitalizations are common.

Utilization of prenatal genetic diagnosis in women 35 years of age and older in the United States, 1977 to 1978

OBJECTIVE: To estimate prevalence of childhood-onset Duchenne and Becker muscular dystrophies (DBMD) in 6 sites in the United States by race/ethnicity and phenotype (Duchenne muscular dystrophy [DMD] or Becker muscular dystrophy [BMD]). METHODS: In 2002, the Centers for Disease Control and Prevention established the Muscular Dystrophy Surveillance, Tracking, and Research Network (MD STARnet) to conduct longitudinal, population-based surveillance and research of DBMD in the United States. Six sites conducted active, multiple-source case finding and record abstraction to identify MD STARnet cases born January 1982 to December 2011. We used cross-sectional analyses to estimate prevalence of DBMD per 10 000 boys, ages 5 to 9 years, for 4 quinquennia (1991–1995, 1996–2000, 2001–2005, and 2006–2010) and prevalence per 10 000 male individuals, ages 5 to 24 years, in 2010. Prevalence was also estimated by race/ethnicity and phenotype. RESULTS: Overall, 649 cases resided in an MD STARnet site during ≥1 quinquennia. Prevalence estimates per 10 000 boys, ages 5 to 9 years, were 1.93, 2.05, 2.04, and 1.51, respectively, for 1991–1995, 1996–2000, 2001–2005, and 2006–2010. Prevalence tended to be higher for Hispanic individuals than non-Hispanic white or black individuals, and higher for DMD than BMD. In 2010, prevalence of DBMD was 1.38 per 10 000 male individuals, ages 5 to 24 years. CONCLUSIONS: We present population-based prevalence estimates for DBMD in 6 US sites. Prevalence differed by race/ethnicity, suggesting potential cultural and socioeconomic influences in the diagnosis of DBMD. Prevalence also was higher for DMD than BMD. Continued longitudinal surveillance will permit us to examine racial/ethnic and socioeconomic differences in treatment and outcomes for MD STARnet cases.

Trends in the percentage of women who received no prenatal care in the United States, 1980–1992: Contributions of the demographic and risk effects

As a measure of access to and acceptability of prenatal chromosomal diagnosis among older gravidas, we determined the ratio of use of prenatal diagnosis among women 35 years of age and older in Alabama, California, Manhattan, and Nebraska for the period 1977-1978. Utilization ratios were higher in 1978. Overall, utilization ratios were between 6% and 28%, well below the adjusted rates of 40% to 50% found in certain United States and British localities. Urban women tended to have higher utilization ratios than had rural women, and white women had higher ratios than had black women. Ratios were extremely low for black and rural residents. The oldest women (those greater than or equal to 40 years), who were at fivefold greater risk than women 35 to 36 years of age, had less than a onefold increase in utilization over the latter groups. The vast majority of older gravidas initiated prenatal care sufficiently early in their pregnancies to receive prenatal diagnosis. Current program strategies need to ensure access to prenatal diagnosis, especially for women greater than or equal to 40 years of age, women who are black, and women who live in rural areas.

Fragmentation of immunization history among providers and parents of children in selected underserved areas

Objective To determine if the increase in the percentage of women who received no prenatal care in the United States relative to 1980 (from 1.3% in 1980 to 2.2% in 1989 and 1.7% in 1992) was due to increasing risks of no care subgroups of women or increasing percentages of births to women at high demographic risk of no care. Methods We analyzed U.S. birth certificates for the period 1980–1992. The annual adjusted odds of no prenatal care relative to 1980 were computed by logistic regression models that included year, maternal characteristics, and interactions of these characteristic with year. We also examined changes in the annual distributions of births by maternal characteristics. Results The risk of no prenatal care in most subgroups increased during the early 1980s, peaked in the late 1980s, and declined thereafter. For example, among black women, the adjusted risk of no care more than doubled from 1980 to 1989. Throughout the 1980s and into the 1990s, the percentage of births to women at high demographic risk of no care increased. This increase in the percentage of births to women at high demographic risk shows no sign of abating. Conclusions During the 1980s, increasing risks in subgroups of women drove the increase in the crude rate of no prenatal care. Despite decreases in the risks of no care in the early 1990s, increasing percentages of births to women with high demographic risk for no care prevanted a decrease in the crude rate to the 1980 level.

Prenatal smoking in two consecutive pregnancies: Georgia, 1989-1992.

OBJECTIVE We assessed fragmentation of childrens immunization history among providers and parents of children aged 12 to 35 months in four selected underserved areas. STUDY DESIGN Area probability cluster sample surveys were conducted in 1997-1998 in northern Manhattan, San Diego, Detroit, and rural Colorado. Surveys consisted of face-to-face interviews with parents followed by record checks with all named immunization providers. We used Advisory Committee on Immunization Practices recommendations to determine up-to-date (UTD) status with vaccinations. The UTD status for each child was determined in four ways: (1) according to the parent-held immunization records, (2) according to the records of the childs most recent provider, (3) according to the records of the childs second most recent provider, and (4) according to provider and parent-reconciled information. RESULTS In all four areas, the majority of records of the most recent provider agreed with the reconciled information. However, in all areas, the percentage of children UTD according to provider- and parent-reconciled information was higher than the percentage of children UTD according to information from only the childs most recent provider or from only parent-held immunization records. Across all sites, the percentage of children UTD with the DTP/DTaP vaccine was 2% to 9% lower, according to the most recent providers information than according to reconciled information. Similar results were seen for other vaccines. The most recent provider not having complete immunization history was significantly associated with not being UTD in New York and having received unnecessary immunizations in San Diego and Detroit. CONCLUSION For most children, although the records of the most recent provider give accurate data for clinical decision making, the immunization histories of some children in these underserved areas are fragmented between providers and parents. This can limit the providers ability to vaccinate children appropriately.

Patterns of prenatal care initiation in Georgia, 1980-1992.

Objective: To explore the patterns of prenatal smoking among women whose first and second pregnancies ended in live births. Methods: We used population-based data to explore prenatal smoking among 14,732 white and 8968 black Georgia residents whose first and second pregnancies ended in live births during 1989–1992. Smoking status was obtained from birth certificates linked for individual mothers. Because of demographic differences, we analyzed white and black women separately. Results: Approximately 15% (2253) of white women and 4% (318) of black women smoked during their first pregnancy. Of those smokers, 69% (1551) of white women and 58% (184) of black women also smoked during their second pregnancy. For both white and black nonsmokers during the first pregnancy, low education was the most significant predictor of smoking during the second pregnancy, after adjusting for consistency of the fathers name on the birth certificate, prenatal care, birth interval, mothers county of residence, and birth outcome. Conclusions: The prevalence of smoking in this study may be low because of underreporting of prenatal smoking on birth certificates. The majority of women who smoked during their first pregnancy also smoked during their second, suggesting that these women exposed their first infant to tobacco smoke both in utero and after delivery. Practitioners should offer smoking cessation programs to women during, as well as after, pregnancy. Pediatricians should educate parents on the health risks to young children of exposure to environmental tobacco smoke and refer smoking parents to smoking cessation programs.

The Future of Very Preterm Infants: Learning From the Past

Objective To determine whether characteristics in a womans first pregnancy were associated with the trimester in which she initiated prenatal care in her second pregnancy. Methods Data for white and black women whose first and second pregnancies resulted in singleton live births between 1980 and 1992 were obtained from Georgia birth certificates (n = 177,041). Adjusted relative risks (RRs) for early prenatal care in the second pregnancy were computed by logistic regression models that included trimester of prenatal care initiation, infant outcomes, or maternal conditions in the womans first pregnancy as the exposure and controlled for maternal age, education, childs year of birth, interval between first and second pregnancy, presence of fathers name on the birth certificate, and the interaction between prenatal care and education. Models were stratified by race. Results Women of both races who initiated prenatal care in the first trimester of their first pregnancies were more likely than those with delayed care to initiate prenatal care in the first trimester of their second pregnancies (RR = 1.25 and 1.63 for white and black women educated beyond high school, respectively). Both white and black women who delivered a baby with very low birth weight (RR = 1.06 and 1.15, respectively) or who suffered an infant death (RR = 1.09 and 1.31, respectively) in their first pregnancies were more likely than those who did not experience these events to begin prenatal care in the first trimester of their second pregnancies. Conclusion Women with some potentially preventable adverse infant outcomes tend to obtain earlier care in their next pregnancy. Unfortunately, women who delayed prenatal care in their first pregnancy frequently delay prenatal care in their next.

Live births resulting from unintended pregnancies: is there variation among states? The PRAMS Working Group

WHAT IS THE LONG-TERM FUTURE OF INFANTS WHO arebornaftervery short gestations ( 33weeks) compared with infants born at term? As the article by Swamy and colleagues in this issue of JAMA suggests, the experience of a population of very preterm infants in Norway offers some insights. This retrospective cohort included 1.1 million singleton births in Norway from 1967 through 1988 occurring at 22 or more weeks of gestation and weighing 500 g or more. The investigators assessed the perinatal, childhood, and adolescent mortality of this cohort through 2002 and followed a subset of survivors for educational and reproductive outcomes through 2004. They found that male and female very preterm offspring (born at 22-32 weeks of gestation) had a higher risk of mortality from the perinatal period through age 5 years compared with their term counterparts (born at 37-42 weeks of gestation). The highest mortality rate occurred at delivery and at the shortest gestations. The rate of stillbirths at 22 to 27 weeks of gestation was 53.1%, whereas at term the rate was 0.38%. Survival rates increased from infancy to late childhood. The investigators also analyzed adult educational attainment and reproduction in this cohort. Compared with term infants, preterm infants had lower educational attainment: the lower the gestational age, the lower the average educational attainment. Men and women in the study who were born very preterm (22-32 weeks) were less likely to reproduce. Among adults who were preterm at birth, only women had an increased risk of having a preterm infant compared with women who were term at birth. Unlike other studies among preterm infants, Swamy et al used gestational age rather than birth weight to assess longterm and intergenerational outcomes. Using a detailed and complete vital records registry, the authors demonstrate the utility of longitudinal data in understanding life-course influences on the health of Norwegian men and women born in the late 1960s to 1980s. Despite these strengths, the findings should be interpreted withcaution.TheNorwegianenvironmentdiffers fromthatof the United States. In many respects, Norway is a best-case scenario.TheNorwegiancohort and their reproductionoccurred in a relatively homogeneous population with universal access to medical care and a well-developed social safety net. Another consideration is that maternal and neonatal treatment given during the 1970s and 1980s differed from that of the past 2 decades. Any long-term follow-up study, however, will have this limitation. To compensate for it, the potential influence of differences in clinical course and treatment must be considered. One difference between the births occurring during this study and births within the past 2 decades in the United States relates to the proportion of preterm deliveries that were induced and the proportion that were spontaneous. The rate of medically induced preterm deliveries has increased in the United States during the past decade and in Norway during the 1990s. Spontaneous deliveries probably accounted for most of the very preterm births in Norway throughout the 1960s and 1970s. But the cause of these preterm births is unclear. Preterm rupture of membranes can be an important causal mechanism. A portion of preterm deliveries following rupture of membranes is associated with intrauterine infection, which involves a potential risk of sepsis and adverse neurological outcomes. Compared with infants whose deliveries were induced after 28 to 31 weeks of gestation, infants of comparable gestational age who were delivered spontaneously were more likely to have cerebral palsy. Swamy et al do not report rates of induction or cesarean delivery among the index participants by gestational length. A prior Norwegian study using births for 1970 through 1988 from the same registry reported a cesarean delivery rate of 6%. In the 1970s in the United States, the rate of cesarean delivery was 5% to 6%. By 2005, it was 30.3%. In the United States, Norway, and other developed countries, preterm deliveries due to induction or cesarean delivery are increasing. Reasons for these increases are not completely known but include fetal monitoring, delayed childbearing, assisted reproductive technologies, multiple births, litigation concerns, and, possibly, maternal requests. These changes and improving neonatal survival during and after the 1990s likely explain clinicians’ increased willingness to induce delivery despite very short gestations. Another difference in clinical practice and outcomes relates to substantial improvements during the past 2 decades in the clinical care of very preterm infants. During the 1970s and 1980s, perinatal regionalization improved the referral and transport of women with imminent high-risk deliveries to ap-