Patricia Aikins Murphy

Quick Start: a novel oral contraceptive initiation method.

Conventional oral contraceptive (OC) starting instructions require waiting until menses to begin the OC. The conventional approach requires detailed patient education about when to begin and also may require the use of less effective or less acceptable interim contraceptive protection until menses. At our urban family planning clinic, we routinely offer patients starting the OC the option of taking the first tablet sooner. We prospectively evaluated predictors of short-term OC continuation among 250 OC requestors who were offered several approaches to OC initiation. Telephone follow-up of 91% of participants showed that women who swallowed the first OC in the clinic were more likely to continue the OC until the second package than women who planned to start the OC later (adjusted OR 2.8, 95% C.I. 1.1-7.3). Other factors associated with short-term continuation were: partners knowledge of planned OC use, older age, and participants agreement that she would be very unhappy about becoming pregnant in the next 6 months.

Alternative therapies for nausea and vomiting of pregnancy.

Objective To assess the natural evolution of nuchal thickness in trisomy-21 fetuses. Methods Serial measurements of nuchal thickness were performed over a 1- to 6-week period in 45 consecutive fetuses with trisomy 21, between the 10th and the 23rd weeks of pregnancy. To avoid a gestational age confounding effect, nuchal thickness also was expressed in standard deviations (SDs) for the corresponding gestational week. In addition, the changes were assessed in terms of the presence of clinical positive thickening, considered as such when the measurement was above 2.5 SD. Result A mean increase of 1.8 mm (95% confidence interval [CI] 1.3, 2.3) for nuchal thickness was observed for a mean period of 21 days. When corrected by gestational age, the mean increase of 0.3 SD (95% CI −0.2, 0.9) was found to be not significant. No clinically relevant nuchal thickening changes were recorded (51% versus 69%) at re-examination. Conclusion Nuchal thickening at re-examination is observed in a similar proportion of trisomy-21 fetuses as when first observed.

Outcomes of Intended Home Births in Nurse-Midwifery Practice: A Prospective Descriptive Study

Objective To describe the outcomes of intended home birth in the practices of certified nurse-midwives. Methods Twenty-nine US nurse-midwifery practices were recruited for the study in 1994. Women presenting for intended home birth in these practices were enrolled in the study from late 1994 to late 1995. Outcomes for all enrolled women were ascertained. Validity and reliability of submitted data were established. Results Of 1404 enrolled women intending home births, 6% miscarried, terminated the pregnancy or changed plans. Another 7.4% became ineligible for home birth prior to the onset of labor at term due to the development of perinatal problems and were referred for planned hospital birth. Of those women beginning labor with the intention of delivering at home, 102 (8.3%) were transferred to the hospital during labor. Ten mothers (0.8%) were transferred to the hospital after delivery, and 14 infants (1.1%) were transferred after birth. Overall intrapartal fetal and neonatal mortality for women beginning labor with the intention of delivering at home was 2.5 per 1000. For women actually delivering at home, intrapartal fetal and neonatal mortality was 1.8 per 1000. Conclusion Home birth can be accomplished with good outcomes under the care of qualified practitioners and within a system that facilitates transfer to hospital care when necessary. Intrapartal mortality during intended home birth is concentrated in postdates pregnancies with evidence of meconium passage.

Outcomes of 11,788 planned home births attended by certified nurse-midwives A retrospective descriptive study

This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991. A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery home birth practices). It is estimated that 60-70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartum transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.This study describes the outcomes of 11,788 planned home births attended by certified nurse-midwives (CNMs) from 1987 to 1991. A retrospective survey was used to obtain information about the outcomes of intended home birth, including hospital transfers, as well as practice protocols, risk screening, and emergency preparedness. Ninety nurse-midwifery home birth practices provided data for this report (66.2% of identified nurse-midwifery home birth practices). It is estimated that 60–70% of all CNM-attended home births reported in national statistics data during this period were represented in this survey. The overall perinatal mortality was 4.2 per 1,000, including known third-trimester fetal demises. There were no maternal deaths. The intrapartum and neonatal mortality for those intending home birth at the onset of labor was 2 per 1,000; the overall neonatal mortality rate for this group was 1.3 per 1,000. When deaths associated with congenital anomalies were excluded, the intrapartum and neonatal mortality rate was 0.9 per 1,000; the neonatal mortality was 0.2 per 1,000. The overall transfer rate, including antepartum referrals, was 15.9%. The intrapartum transfer rate for those intending home birth at the onset of labor was 8%. Most responding nurse-midwives used standard risk-assessment criteria, only delivered low-risk women at home, and were prepared with emergency equipment necessary for immediate neonatal resuscitation or maternal emergencies. This study supports previous research indicating that planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.

Lactogenesis after early postpartum use of the contraceptive implant: a randomized controlled trial.

OBJECTIVE: To evaluate lactogenesis after early postpartum insertion of the etonogestrel contraceptive implant. METHODS: Healthy peripartum women with healthy, term newborns who desired the etonogestrel implant for contraception were randomly assigned to early (1–3 days) or standard (4–8 weeks) postpartum insertion. The primary outcomes, time to lactogenesis stage II and lactation failure, were documented by a validated measure. The noninferiority margin for the mean difference in time to lactogenesis stage II was defined as 8 additional hours. Secondary data (device continuation and contraceptive use, breast milk analysis, supplementation rates, side effects, and bleeding patterns) were collected at periodic intervals for 6 months. RESULTS: Sixty-nine women were enrolled. Thirty-five were randomly assigned to early insertion and 34 to standard insertion. There were no statistically significant differences between the groups in age, race, parity, mode of delivery, use of anesthesia, or prior breastfeeding experience. Early insertion was demonstrated to be noninferior to standard insertion in time to lactogenesis stage II (early: [mean±standard deviation] 64.3±19.6 hours; standard: 65.2±18.5 hours, mean difference, −1.4 hours, 95% confidence interval [CI] −10.6 to 7.7 hours). Early insertion was also demonstrated to be noninferior to standard insertion in incidence of lactation failure (1/34 [3%] in the early insertion group, 0/35 [0%] in the standard insertion group [risk difference, 0.03, 95% CI −0.02 to 0.08]). Use of formula supplementation was not significantly different between the groups. Milk composition at 6 weeks was not significantly different between the groups. CONCLUSION: Breastfeeding outcomes were similar in women who underwent early compared with standard postpartum insertion of the etonogestrel implant. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, www.clinicaltrials.gov, NCT00847587. LEVEL OF EVIDENCE: I

Predictors of ovarian follicle number

OBJECTIVE To identify factors associated with ovarian follicle density in women of reproductive age. DESIGN Women undergoing incidental oophorectomy responded to structured interviews. Grossly normal ovaries were sectioned and assessed for follicle density. SETTING University hospital. PATIENT(S) 102 women undergoing hysterectomy with incidental oophorectomy who had morphologically normal ovaries. MAIN OUTCOME MEASURE(S) Follicle density, age, parity, oral contraceptive use, body size, smoking, and alcohol consumption. RESULT(S) Follicle density decreased with age and with current or past cigarette smoking. Other factors were not associated with follicle density, although the study had adequate power to detect only strong associations. CONCLUSION(S) Some of the adverse effects of smoking on reproductive health may be due to irreversible follicular depletion.

Measuring Outcomes of Midwifery Care: Development of An Instrument To Assess Optimality

Research on the outcomes of midwifery care is hampered by the lack of appropriate instruments that measure both process and outcomes of care in lower risk women. This article describes an effort to adapt an existing measurement instrument focused on the optimal outcomes of care (The Optimality Index-US) to reflect the contemporary style of U.S.-based nurse-midwifery practice. Evidence for content validity of the instrument was derived from literature reports of randomized clinical trials, synthetic reviews, and the clinical consensus of professional reviewers. Eleven perinatal health professionals and consumers, representing disciplines of obstetrics and gynecology, midwifery, epidemiology, and neonatology reviewed the instrument. The instrument was then applied to an existing data set of women who intended to give birth at home (N = 1,286 women) to determine its utility in measuring events in the process and outcome of perinatal health care as managed by nurse-midwives. Results suggest that the tool holds promise for use in outcomes studies of U.S. perinatal care. Further testing of the instrument among diverse multicultural population groups, with various providers, and in diverse birth settings is warranted.

A survey of women obtaining emergency contraception: are they interested in using the copper IUD?

BACKGROUND This study aims to determine if women presenting for emergency contraception (EC) at family planning clinics may be interested in using the copper intrauterine device (IUD) for EC. STUDY DESIGN This convenience sample survey was offered to women who presented for EC at four participating clinics in urban Utah. Anonymous written questionnaires were distributed. The outcome variable of interest was interest in using the copper IUD for EC. RESULTS Of survey respondents, 320 (34.0%) of 941 said they would be interested in an EC method that was long term, highly effective and reversible. Interested women were not significantly different from noninterested women in relation to age, marital status, education, household income, gravidity, previous abortions, previous sexually transmitted infections (STIs) or relationship status. One hundred twenty women (37.5% of those interested or 12.8% of all those surveyed) would wait an hour, undergo a pelvic exam to get the method and would still want the method knowing it was an IUD. However, only 12.3% of these women could also pay

Bleeding patterns after immediate vs. conventional oral contraceptive initiation: a randomized, controlled trial ☆

350 or more for the device. Multivariable regression found the following predictors of interest in the IUD among EC users: non-Hispanic minorities (OR=2.12, 95% CI=1.14-3.93), desire to never be pregnant in the future (OR=2.87, 95% CI=1.38-5.66) and interest in adoption (OR=1.96, 95% CI=1.00-5.73) or abortion (OR=2.68, 95% CI=1.24-4.14) if pregnant when presenting for EC. CONCLUSION While one third of EC users surveyed at family planning clinics were interested in a long-term, highly effective method of contraception, only a small portion of all EC users may be interested in the copper IUD for EC. Cost is a potential barrier.

Evidence‐Based Approaches to Managing Nausea and Vomiting in Early Pregnancy

OBJECTIVE To compare bleeding patterns after immediate vs. conventional oral contraceptive (OC) initiation. DESIGN Randomized controlled trial. SETTING University-based clinic. PATIENT(S) One hundred thirteen women initiating combination OCs. INTERVENTION(S) Participants received a 4-month supply of a monophasic 35-microg ethinyl E(2) (EE) OC and a bleeding diary, were randomized to immediate or conventional OC start, underwent monthly telephone follow-up, and after 90 days returned the diary and completed an exit interview. MAIN OUTCOME MEASURE(S) Total number of bleeding-spotting days, using the World Health Organization 90-day reference period method. Comparisons were made by trial assignment (immediate vs. conventional) and cycle day of OC initiation (day 8+ vs. days 1-7). RESULT(S) There was no significant difference in the number of bleeding-spotting days (mean difference: -0.5 days; 95% CI: -3.4 to 2.3) or any other bleeding parameter between the immediate and conventional starters, or days 1-7 and day 8+ starters. CONCLUSION(S) Immediate start of OCs does not induce bleeding patterns different from conventional starting regimens. Concern about adverse bleeding patterns should not be considered a justification for instructing women to wait until menses before starting OCs.