Roger W. Rochat

The measurement and meaning of unintended pregnancy.

Unintended pregnancy combines two aspects of fertility: unwanted and mistimed pregnancies. The personal partnership social and political realities of these two aspects are different and the use of separate categories may better reflect the way women think about a pregnancy. A better understanding of the multiple dimensions of unintended pregnancy also may lead to a better understanding of the consequences of these pregnancies. Likewise better knowledge of the extent of mistiming and perhaps the strength of intentions may be important in understanding health impact. Effective programs to prevent unintended pregnancy must use terms that are familiar to women and must build upon cultural understanding of the problem to be prevented. Research should focus on the meaning of pregnancy intentions to women and the processes women and their partners use in making fertility decisions. It should prospectively address the impact of pregnancy intentions on contraceptive use. Both qualitative and quantitative research have contributed to our understanding of fertility decisionmaking; both will be essential to the creation of more effective prevention programs. (excerpt)

Differences Between Mistimed and Unwanted Pregnancies Among Women Who Have Live Births

CONTEXT Mistimed and unwanted pregnancies that result in live births are commonly considered together as unintended pregnancies, but they may have different precursors and outcomes. METHODS Data from 15 states participating in the 1998 Pregnancy Risk Assessment Monitoring System were used to calculate the prevalence of intended, mistimed and unwanted conceptions, by selected variables. Associations between unintendedness and womens behaviors and experiences before, during and after the pregnancy were assessed through unadjusted relative risks. RESULTS The distribution of intended, mistimed and unwanted pregnancies differed on nearly every variable examined; risky behaviors and adverse experiences were more common among women with mistimed than intended pregnancies and were most common among those whose pregnancies were unwanted. The likelihood of having an unwanted rather than mistimed pregnancy was elevated for women 35 or older (relative risk, 2.3) and was reduced for those younger than 25 (0.8); the pattern was reversed for the likelihood of mistimed rather than intended pregnancy (0.5 vs. 1.7-2.7). Parous women had an increased risk of an unwanted pregnancy (2.1-4.0) but a decreased risk of a mistimed one (0.9). Women who smoked in the third trimester, received delayed or no prenatal care, did not breast-feed, were physically abused during pregnancy, said their partner had not wanted a pregnancy or had a low-birth-weight infant had an increased risk of unintended pregnancy; the size of the increase depended on whether the pregnancy was unwanted or mistimed. CONCLUSION Clarifying the difference in risk between mistimed and unwanted pregnancies may help guide decisions regarding services to women and infants.

Maternal Mortality in Addis Ababa, Ethiopia

Between July and September 1983, a two-stage probability survey was conducted in Addis Ababa, Ethiopia to obtain data on pregnancy outcomes for all women aged 13-49 in 32,215 houses. The survey covered a two-year period, from 11 September 1981 to 10 September 1983. Of the 9,315 women who were pregnant during those two years, 45 died from complications of pregnancy, delivery, and the puerperium. The maternal mortality rate for 1982-83 was estimated to be 566 per 100,000 live births. Mortality was highest for nullipara, the unmarried, women employed as maids/janitresses, and students. The most common cause of death was abortion. It appears that reliable data on maternal mortality can be obtained retrospectively through a probability survey.

The epidemiology of neonatal death in twins

The epidemiology of twin pregnancies was studied with the use of data on 7,001 live-born twins from the Georgia neonatal surveillance network for the period 1974-1978. A cesarean section did not appreciably reduce the risk of neonatal death for a twin with a vertex presentation. The relative risk of such a neonatal death was 1.4 after adjustment was made for birth weight. A cesarean section did improve the outcome for breech and other presentations. Twins had a sixfold higher neonatal mortality rate than had singleton infants (p less than 0.001), which can be explained on the basis of distribution of birth weights. Twins had a weight-specific mortality rate equivalent to or significantly less than that for singletons after adjustment was made for birth weight. The relative risk of neonatal death for Twin 2 compared with Twin 1 was not significant. Breech presentation was more common in twins than in singletons, and for Twin 2 more than for Twin 1. As birth weight increased, the number of breech presentations decreased for Twin 2 but not for Twin 1. To reduce the high neonatal mortality rate for twins, the objective should be to reduce the incidence of low-birth-weight twins, rather than to increase the cesarean section rate for them.

Perinatal and maternal mortality in a religious group avoiding obstetric care

We investigated perinatal and maternal deaths occurring among women who were members of a religious group in Indiana; these women received no prenatal care and gave birth at home without trained attendants. Members of the religious group had a perinatal mortality rate three times higher and a maternal mortality rate about 100 times higher than the statewide rates. These findings suggest that, even in the United States, women who avoid obstetric care have a greatly increased risk of perinatal and maternal death.

Maternal death after cesarean section in Georgia

Few reliable data exist on the risk of maternal death from cesarean section. To identify more deaths after cesarean section than reported by vital records alone, we linked data from Georgia resident live-birth certificates to those from death certificates of Georgia women aged 10 to 44 years. We found 16 maternal deaths after cesarean section in Georgia during 1975 and 1976, five more (45%) than the 11 reported through vital records alone. We attributed nine of these 16 deaths to the cesarean section per se. We than calculated a total death-to-case rate of 105.3 deaths per 100,000 cesarean sections and a rate attributable to cesarean section of 59.3 deaths per 100,000 procedures. Pulmonary embolism and cardiopulmonary arrest during general anesthesia were the leading causes of death in this series. Preventive measures aimed at reducing these complications may reduce deaths after cesarean section.

The intrauterine device and deaths from spontaneous abortion.

To evaluate the intrauterine device as a risk factor for mortality associated with spontaneous abortion, we analyzed all deaths from spontaneous abortions reported in the period 1972-1974. Women dying from spontaneous abortions with a device in place were more likely to be young, white and married than those not wearing a device. Risk of death from spontaneous abortion was over 50 times greater for women who continued their pregnancy with a device in place than for those who did not. The Dalkon shield carried an increased risk of death, as compared to other devices, even after rates were adjusted for duration of use. However, pregnant women with either a loop or a coil in place also had a higher risk of dying from spontaneous abortion than those without any device. The results support the clinical recommendation that any device should be removed when pregnancy is first diagnosed.

Maternal and abortion related deaths in Bangladesh, 1978–1979

The incidence and causes of pregnancy‐related deaths are unknown for most of Asia; only local area studies have been done for Bangladesh. Between December 1978 and May 1979, we interviewed 1118 health workers in 63 hospitals and 732 non‐hospital facilities to identify case reports of maternal and abortion‐related deaths in Bangladesh. Of 1933 pregnancy‐related deaths identified, 498 (25.8%) were due to induced abortion. Abortion mortality rates varied significantly in the 18 administrative districts; the highest were in Dinajpur and Chittagong, the most northern and southern districts, and the lowest in Comilla and Noakhali.

Injury-related deaths among women aged 10-50 years in Bangladesh, 1996-97

BACKGROUND Few studies have examined injury-related deaths among women in Bangladesh. We did a case-finding study to identify causes and the impact of intentional and unintentional injury-related deaths among women aged 10-50 years in Bangladesh. METHODS Between 1996 and 1997, health care and other service providers at 4751 health facilities throughout Bangladesh were interviewed about their knowledge of deaths among women aged 10-50 years. In addition, at all public facilities providing inpatient service, medical records of women who died during the study period were reviewed. The reported circumstances surrounding each death were carefully reviewed to attribute the most likely cause of death. FINDINGS 28,998 deaths among women aged 10-50 years were identified in our study, and, of these, 6610 (23%) were thought to be caused by intentional or unintentional injuries. About half (3317) of the injury deaths were attributable to suicide, 352 (5%) to homicide, 1100 (17%) to accidental injuries, and the intent was unknown for 1841 (28%) deaths. The unadjusted rate of suicides were higher in the Khulna administrative division (27.0 per 100,000) than the other four administrative divisions of Bangladesh (range 3.5-11.3 per 100,000). Poisoning (n=3971) was the commonest cause of injury-related death--60% of all injury deaths (6610) and 14% of all deaths (28,998). Other common causes of injury deaths in order of frequency were hanging or suffocation, road traffic accidents, burns, drowning, physical assault, firearm or sharp instrument injury, and snake or animal bite. INTERPRETATION Intentional and unintentional injuries are a major cause of death among women aged 10-50 years in Bangladesh. Strategies to reduce injury-related deaths among women need to be devised.

Missed opportunities for congenital syphilis prevention in an urban southeastern hospital.

Background Despite recent declines in syphilis rates nationally, recent outbreaks suggest that prevention of congenital syphilis remains an ongoing public health problem. Goals To identify missed opportunities for congenital syphilis prevention during prenatal care. Study Design Retrospective medical record review of 157 live birth or stillbirth deliveries that involved cases of congenital syphilis from Grady Memorial Hospital (Atlanta, GA). Results The hospital congenital syphilis prevalence was 8.2 cases per 1000 live births. Six percent of case patients were HIV positive. Opportunities for earlier maternal screening, treatment, or diagnosis were missed in 60% of case patients who received timely prenatal care. Congenital syphilis cases attributable to preventable missed opportunities were significantly more common among case patients with fewer prenatal visits (66% versus 28%, P = 0.01). Conclusion Provider efforts to reduce congenital syphilis in high-risk populations receiving prenatal care should focus on (1) screening patients at the first opportunity, at both the first prenatal visit and during the third trimester (i.e., 28 weeks); (2) performing on-site testing and same-day treatment; (3) providing appropriate treatment to infected women with penicillin allergy; (4) referring sex partners for treatment to prevent reinfection; and (5) screening all pregnant women attending emergency clinics.