Rebecca A. Jackson

Perinatal outcomes in singletons following in vitro fertilization: A meta-analysis

OBJECTIVE: To estimate whether singleton pregnancies following in vitro fertilization (IVF) are at higher risk of perinatal mortality, preterm delivery, small for gestational age, and low or very low birth weight compared with spontaneous conceptions in studies that adjusted for age and parity. DATA SOURCES: We searched MEDLINE, BIOSIS, Doctoral Dissertations On-Line, bibliographies, and conference proceedings for studies from 1978–2002 using the terms “in vitro fertilization,” “female infertility therapy,” and “reproductive techniques” combined with “fetal death,” “mortality,” “fetal growth restriction,” “small for gestational age,” “birth weight,” “premature labor,” “preterm delivery,” “infant,” “obstetric,” “perinatal,” and “neonatal.” METHODS OF STUDY SELECTION: Inclusion criteria were singleton pregnancies following IVF compared with spontaneous conceptions, control for maternal age and parity; 1 of the above outcomes; and risk ratios or data to determine them. Study selection and data abstraction were performed in duplicate after removing identifying information. TABULATION, INTEGRATION, AND RESULTS: Fifteen studies comprising 12,283 IVF and 1.9 million spontaneously conceived singletons were identified. Random-effects meta-analysis was performed. Compared with spontaneous conceptions, IVF singleton pregnancies were associated with significantly higher odds of each of the perinatal outcomes examined: perinatal mortality (odds ratio [OR] 2.2; 95% confidence interval [CI] 1.6, 3.0), preterm delivery (OR 2.0; 95% CI 1.7, 2.2), low birth weight (OR 1.8; 95% CI 1.4, 2.2), very low birth weight (OR 2.7; 95% CI 2.3, 3.1), and small for gestational age (OR 1.6; 95% CI 1.3, 2.0). Statistical heterogeneity was noted only for preterm delivery and low birth weight. Sensitivity analyses revealed no significant changes in results. Early preterm delivery, spontaneous preterm delivery, placenta previa, gestational diabetes, preeclampsia, and neonatal intensive care admission were also significantly more prevalent in the IVF group. CONCLUSION: In vitro fertilization patients should be advised of the increased risk for adverse perinatal outcomes. Obstetricians should not only manage these pregnancies as high risk but also avoid iatrogenic harm caused by elective preterm labor induction or cesarean.

Body Mass Index, Provider Advice, and Target Gestational Weight Gain

OBJECTIVE: To study the relationships among prepregnancy body mass index (BMI), womens target gestational weight gain, and provider weight gain advice. METHODS: Project WISH, the acronym for Women and Infants Starting Healthy, is a longitudinal cohort study of pregnant women in the San Francisco Bay area. We excluded subjects with preterm birth, multiple gestation, or maternal diabetes. RESULTS: Among overweight women (prepregnancy BMI 26.1–29.0), 24.1% reported a target weight gain above the Institute of Medicine (IOM) guidelines, compared with 4.3% of normal weight women (P < .001). Among women with a low prepregnancy BMI (< 19.8), 51.2% reported a target weight gain below the guidelines, compared with 10.4% of normal weight women (P < .001). These patterns persisted in a multivariate analysis. Latina ethnicity, lower maternal education, low prepregnancy BMI (< 19.8), lack of provider advice about weight gain, and provider advice to gain below guidelines were all independently associated with a target weight gain below IOM guidelines. Prepregnancy BMI more than 26, multiparity, lower age, and provider advice to gain above guidelines were all associated with a target gain above IOM guidelines. CONCLUSION: Womens beliefs about the proper amount of weight gain and provider recommendations for weight gain vary significantly by maternal prepregnancy BMI. Many women report incorrect advice about gestational weight gain, and women with high or low prepregnancy BMI are more likely to have an incorrect target weight gain. New approaches to provider education are needed to implement the IOM guidelines for gestational weight gain. LEVEL OF EVIDENCE: II-2

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.

Urinary Incontinence in Elderly Women: Findings From the Health, Aging, and Body Composition Study

OBJECTIVE: To estimate the prevalence of and risk factors for stress and urge incontinence in a biracial sample of well-functioning older women. METHODS: We performed a cross-sectional analysis of 1,584 white and black women, aged 70–79 years, enrolled in a longitudinal cohort study. Participants were asked about incontinence, medical problems, and demographic and reproductive characteristics and underwent physical measurements. Using multivariable logistic regression, we compared women reporting at least weekly incontinence with those without incontinence. RESULTS: Overall, 21% reported incontinence at least weekly. Of these, 42% reported predominantly urge incontinence, and 40% reported stress. Nearly twice as many white women as black women reported weekly incontinence (27% versus 14%, P < .001). Factors associated with urge incontinence included white race (odds ratio [OR] 3.1, 95% confidence interval [CI] 2.0–4.8), diabetes treated with insulin (OR 3.5, 95% CI 1.6–7.9), depressive symptoms (OR 2.7, 95% CI 1.4–5.3), current oral estrogen use (OR 1.7, 95% CI 1.1–2.6), arthritis (OR 1.7, 95% CI 1.1–2.6), and decreased physical performance (OR 1.6 per point on 0–4 scale, 95% CI 1.1–2.3). Factors associated with stress incontinence were chronic obstructive pulmonary disease (OR 5.6, 95% CI 1.3–23.2), white race (OR 4.1, 95% CI 2.5–6.7), current oral estrogen use (OR 2.0, 95% CI 1.3–3.1), arthritis (OR 1.6, 95% CI 1.0–2.4), and high body mass index (OR 1.3 per 5 kg/m2, 95% CI 1.1–1.6). CONCLUSION: Urinary incontinence is highly prevalent, even in well-functioning older women, whites in particular. Many risk factors differ for stress and urge incontinence, suggesting differing etiologies and prevention strategies. LEVEL OF EVIDENCE: II-2

Pre-pregnancy and pregnancy-related factors and the risk of excessive or inadequate gestational weight gain

Objective: Gestational weight gain consistent with the Institute of Medicines recommendations is associated with better maternal and infant outcomes. The objective was to quantify the effect of pre‐pregnancy factors, pregnancy‐related health conditions, and modifiable pregnancy factors on the risks of inadequate and excessive gestational weight gain. Method: A longitudinal cohort of pregnant women (N = 1100) who completed questions about diet and weight gain during pregnancy and delivered a singleton, full‐term infant. Results: Gestational weight gain was inadequate for 14% and excessive for 53%. Pre‐pregnancy factors contributed 74% to excessive gain, substantially more than pregnancy‐related health conditions (15%) and modifiable pregnancy factors (11%). Pre‐pregnancy factors, pregnancy‐related health conditions, and modifiable pregnancy factors contributed fairly equally to the risk of inadequate gain. Conclusion: Interventions to prevent excessive gestational gain may need to start before pregnancy. Women at risk for inadequate gain would also benefit from interventions directed toward modifiable factors during pregnancy.

Changes in the Health Status of Women During and After Pregnancy

OBJECTIVE: To characterize the changes in health status experienced by a multi-ethnic cohort of women during and after pregnancy.DESIGN: Observational cohort.SETTING/PARTICIPANTS: Pregnant women from 1 of 6 sites in the San Francisco area (N=1,809).MEASUREMENTS AND MAIN RESULTS: Women who agreed to participate were asked to complete a series of telephone surveys that ascertained health status as well as demographic and medical factors. Substantial changes in health status occurred over the course of pregnancy. For example, physical function declined, from a mean score of 95.2 prior to pregnancy to 58.1 during the third trimester (0–100 scale, where 100 represents better health), and improved during the postpartum period (mean score, 90.7). The prevalence of depressive symptoms rose from 11.7% prior to pregnancy to 25.2% during the third trimester, and then declined to 14.2% during the postpartum period. Insufficient money for food or housing and lack of exercise were associated with poor health status before, during, and after pregnancy.CONCLUSIONS: Women experience substantial changes in health status during and after pregnancy. These data should guide the expectations of women, their health care providers, and public policy.

Risk factors associated with presenting for abortion in the second trimester.

OBJECTIVE: To determine factors associated with delay of induced abortion into the second trimester of pregnancy. METHODS: Using audio computer-assisted self-interviewing, 398 women from 5 to 23 weeks of gestation at an urban hospital described steps and reasons that could have led to a delayed abortion. Multivariable logistic regression identified independent contributors to delay. RESULTS: Half of the 70-day difference between the average gestational durations in first- and second-trimester abortions is due to later suspicion of pregnancy and administration of a pregnancy test. Delays in suspecting and testing for pregnancy cumulatively caused 58% of second-trimester patients to miss the opportunity to have a first-trimester abortion. Women presenting in the second trimester experienced more delaying factors (3.2 versus 2.0, P < .001), with logistical delays occurring more frequently for these women (63.3% versus 30.4%, P < .001). Factors associated with second-trimester abortion in logistic regression were prior second-trimester abortion, delay in obtaining state insurance, difficulty locating a provider, initial referral elsewhere, and uncertainty about last menstrual period. Factors associated with decreased likelihood of second-trimester abortion were presence of nausea or vomiting, prior abortion, and contraception use. CONCLUSION: Abortion delay results from myriad factors, many of them logistical, such as inappropriate or delayed referrals and delays in obtaining public insurance. Public health interventions could promote earlier recognition of pregnancy, more timely referrals, more easily obtainable public funding, and improved abortion access for indigent women. However, accessible second-trimester abortion services will remain necessary for the women who present late due to delayed recognition of and testing for pregnancy. LEVEL OF EVIDENCE: II-2

Improving diet and exercise in pregnancy with Video Doctor counseling: a randomized trial.

OBJECTIVE To determine if an interactive, computerized Video Doctor counseling tool improves self-reported diet and exercise in pregnant women. METHODS A randomized trial comparing a Video Doctor intervention to usual care in ethnically diverse, low-income, English-speaking pregnant women was conducted. Brief messages about diet, exercise, and weight gain were delivered by an actor-portrayed Video Doctor twice during pregnancy. RESULTS In the Video Doctor group (n=158), there were statistically significant increases from baseline in exercise (+28 min), intake of fruits and vegetables, whole grains, fish, avocado and nuts, and significant decreases in intake of sugary foods, refined grains, high fat meats, fried foods, solid fats, and fast food. In contrast, there were no changes from baseline for any of these outcomes in the usual care group (n=163). Nutrition knowledge improved significantly over time in both groups but more so in the Video Doctor group. Clinician-patient discussions about these topics occurred significantly more frequently in the Video Doctor group. There was no difference in weight gain between groups. CONCLUSION A brief Video Doctor intervention can improve exercise and dietary behaviors in pregnant women. PRACTICE IMPLICATIONS The Video Doctor can be integrated into prenatal care to assist clinicians with effective diet and exercise counseling.

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

We performed a multivariate analysis to determine factors associated with knowledge and willingness to use emergency contraception in a consecutive sample of 371 post-partum women from an inner-city public hospital. Women were queried about previous contraceptive use, pregnancy history including abortions and unplanned pregnancies, and demographic characteristics. Outcomes included knowledge of emergency contraception and willingness to use it. Questionnaires were conducted in person, in English or Spanish.Of 371 women, 3% had used emergency contraception, 36% had heard of it, and 7% knew the correct timing for use. Two-thirds of the population indicated a willingness to use emergency contraception in the future. Factors positively associated with knowledge included being a teenager or more than 30 years old, prior use of condoms, and history of an elective abortion. Being multiparous, monolingual Spanish-speaking, or Asian were negatively associated with knowledge. Willingness to use emergency contraception was positively associated with being multiparous and negatively associated with a higher income, moral or religious objections to the use of emergency contraception, a belief that it is unsafe or a perception that it is an abortificient. Knowledge about emergency contraception, especially correct timing, remains low. Multiparous women should receive increased education given their lack of knowledge but willingness to use emergency contraception. In order to increase the acceptability of emergency contraception, educational efforts must include accurate information about its mechanism of use and safety.

Predictors of delay in each step leading to an abortion.

BACKGROUND Approximately 1 out of 10 abortions in the United States occurs in the second trimester of pregnancy. This study uses survival analysis to identify the factors which delay each step of the process of obtaining an abortion. STUDY DESIGN This is a secondary data analysis of a cross-sectional study investigating a sample of 398 women who presented for elective abortion at an urban hospital. Respondents completed a survey using an audio-assisted self-interviewing program and provided a timeline for their process of obtaining an abortion. RESULTS In our analysis, we divided the abortion process into three steps ending in three distinct events (first pregnancy test, calling a clinic, getting an abortion). Factors associated with delay during the first step include obesity [hazard ratio (HR) 0.8, 95% CI 0.6-1.0], abuse of drugs or alcohol (HR 0.7, 95% CI 0.6-1.0), prior second-trimester abortion (HR 0.6, 95% CI 0.4-0.8) and being unsure of last menstrual period (HR 0.6, 95% CI 0.4-0.7) and emotional factors such as being in denial (HR 0.8, 95% CI 0.6-1.0) and fear of abortion (HR 0.7, 95% CI 0.5-1.0). CONCLUSION This study identified key factors associated with delay in obtaining abortion care. Interventions which seek to address these factors, especially those factors associated with later pregnancy suspicion and testing, may reduce abortion delay and facilitate women obtaining their abortions when medical risk and overall cost are lower.