Samantha Garbers

Maternal Obesity and Diabetes as Risk Factors for Adverse Pregnancy Outcomes: Differences Among 4 Racial/Ethnic Groups

OBJECTIVES We examined associations between obesity, diabetes, and 3 adverse pregnancy outcomes--primary cesarean delivery, preterm birth, and low birth-weight (LBW)--by racial/ethnic group. Our goal was to better understand how these associations differentially impact birth outcomes by group in order to develop more focused interventions. METHODS Data were collected from the 1999, 2000, and 2001 New York City birth files for 329,988 singleton births containing information on prepregnancy weight and prenatal weight gain. Separate logistic regressions for 4 racial/ethnic groups predicted the adverse pregnancy outcomes associated with diabetes. Other variables in the regressions included obesity, excess weight gain, hypertension, preeclampsia, and substance use during pregnancy (e.g., smoking). RESULTS Chronic and gestational diabetes were significant risks for a primary cesarean and for preterm birth in all women. Diabetes as a risk for LBW varied by group. For example, whereas chronic diabetes increased the risk for LBW among Asians, Hispanics, and Whites (adjusted odds ratios=2.28, 1.69, and 1.59), respectively, it was not a significant predictor of LBW among Blacks. CONCLUSIONS In this large, population-based study, obesity and diabetes were independently associated with adverse pregnancy outcomes, highlighting the need for women to undergo lifestyle changes to help them control their weight during the childbearing years and beyond.

Barriers to breast cancer screening for low-income Mexican and Dominican women in New York City

The proportion of Mexican and Dominican women has increased rapidly in New York City and in other urban areas, and breast cancer screening rates continue to be lower for Latina women as a whole, but particularly for some nationality sub-groups. The current analysis explored the reasons why Mexican and Dominican women from medically underserved communities in New York City do not seek breast cancer screening. Data were collected through interviews with 298 Mexican and Dominican women aged 40–88 years; the interviews included an open-ended question on the barriers women face in seeking screening. The three most commonly cited barriers were not taking care of oneself (descuido) (52.3%), lack of information (49.3%), and fear (44.6%). Women who had been screened cited fear, pain, or other personal barriers more often, but women who had never had a mammogram cited cost or other logistical barriers. Responses from Dominican and Mexican women were significantly different, with Mexican women more often citing shame or embrarrassment and Dominican women more often citing fear. The dependent variable, barriers to screening, was grouped into major categories. When sociodemographic factors were controlled for, the effect of ethnicity disappeared. Multivariate logistic regression revealed that women with a source of health care were less likely to cite any logistical barriers, but significantly more likely to report only personal barriers (such as fear ordescuido). The analysis indicated that personal barriers were very prevalent in the communities studied. It may not be sufficient merely to increase access to breast cancer screening services for low-income Latinas: even when women have a source of health care, personal barriers may prevent many women from seeking screening. Outreach programs need to be tailored to the target communities as there are significant differences among groups of Latinas. Targeted outreach programs must work in tandem with programs to increase access to ensure that both personal and logistical barriers to screening are addressed.

Randomized controlled trial of a computer-based module to improve contraceptive method choice.

BACKGROUND Unintended pregnancy is common in the United States, and interventions are needed to improve contraceptive use among women at higher risk of unintended pregnancy, including Latinas and women with low educational attainment. STUDY DESIGN A three-arm randomized controlled trial was conducted at two family planning sites serving low-income, predominantly Latina populations. The trial tested the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients choosing an effective method of contraception (<10 pregnancies/100 women per year, typical use). Participants were randomized to complete the module and receive tailored health materials, to complete the module and receive generic health materials, or to a control condition. RESULTS In intent-to-treat analyses adjusted for recruitment site (n=2231), family planning patients who used the module were significantly more likely to choose an effective contraceptive method: 75% among those who received tailored materials [odds ratio (OR)=1.56; 95% confidence interval (CI): 1.23-1.98] and 78% among those who received generic materials (OR=1.74; 95% CI: 1.35-2.25), compared to 65% among control arm participants. CONCLUSIONS The findings support prior research suggesting that patient-centered interventions can positively influence contraceptive method choice.

Continuation of copper-containing intrauterine devices at 6 months.

BACKGROUND Intrauterine devices (IUDs) are highly effective at preventing pregnancy and cost-effective. Suboptimal continuation of IUDs places women at risk of unintended pregnancy. Little is known about prevalence or predictors of discontinuation of IUDs within the first 6 months. STUDY DESIGN A retrospective cohort analysis was conducted among 306 family planning patients who had a CuT380A IUD inserted from November 2008-August 2011. Rates of continuation among 283 users were calculated using survival analyses, and predictors of removal within 6 months of insertion were assessed using logistic regression. RESULTS Among 306 IUD insertions, 13 (4.2%) full or partial expulsions occurred within the first 6 months: 9 (10.7%) among nulliparous and 4 (2.0%) among parous women (chi-square, p<.001). In the first 6 months, four (1.3%) pregnancies occurred among women without prior removal or expulsion of the device (unadjusted Pearl Index: 2.61 per 100 woman-years at 6 months), all among parous women. Of 283 women in continuation analyses, 26% were under 20 years old and 29% nulliparous. Most (84%) received health education specific to IUDs before insertion. Overall, 11% had their IUD removed within 6 months of insertion. In an adjusted logistic regression model, women who did not receive health education were significantly more likely (Adjusted Odds Ratio=3.37, 95% confidence interval: 1.35-8.39) to have a removal within 6 months, but no significant association was found for age, race/ethnicity or parity. CONCLUSION Early discontinuation of IUDs was prevalent but lower among women who received method-specific health education.

Tailored health messaging improves contraceptive continuation and adherence: results from a randomized controlled trial

BACKGROUND Discontinuation and incorrect use of contraceptive methods may contribute to as many as 1 million unintended pregnancies annually in the United States. Interventions to improve contraceptive method continuation and adherence are needed. STUDY DESIGN A three-arm randomized controlled trial was conducted at two family planning sites testing the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients who continued use of their chosen contraceptive method 4 months after the family planning visit (n=224). RESULTS In analyses adjusting for clinical site of recruitment, family planning patients who used the module and received individually tailored health materials (n=78), compared to those in the control group (n=70), were significantly more likely to continue use of their chosen contraceptive method [95% compared to 77%; odds ratio (OR)=5.48; 95% confidence interval (CI): 1.72-17.42] and to adhere to their method (86% compared to 69%; OR=2.74; 95% CI: 1.21-6.21). No significant differences in these outcomes were found for participants who used the module but did not receive tailored materials (n=76), compared to the control group. CONCLUSIONS Tailored health materials significantly improved contraceptive method continuation and adherence. Additional research on the impact of the intervention on continuation and adherence in a larger sample and over a longer follow-up period is merited.

Functional health literacy in Spanish-speaking Latinas seeking breast cancer screening through the National Breast and Cervical Cancer Screening Program

Background: This analysis examines the association between functional health literacy and follow-up after mammography among women receiving breast cancer screening at a National Breast and Cervical Cancer Early Detection Program site in New York City that provides universal bilingual case management. Methods: A total of 707 Latinas who spoke Spanish as their primary language completed a survey of health and demographic characteristics and the Test of Functional Health Literacy in Spanish (TOFHLA-S). Survey results were matched with clinical outcome data. Results: Among the survey participants, 98% were foreign-born and 99% had no health insurance. While the study found significant differences in access to health information and past screening behavior, women without adequate health literacy in Spanish were no less likely to receive clinical resolution of abnormal mammograms within 60 days (81.8% overall; n = 110) or to return for a repeat mammogram within 18 months (57.2% overall; n = 697). In fact, among those referred for a Pap test (n = 310), women without adequate health literacy were more likely to receive a Pap test within 60 days of their mammogram than those with adequate health literacy (82% compared to 71%, OR: 1.83, 95% CI: 1.04–3.22). Discussion: The lack of significantly lower follow-up outcomes among women with inadequate and marginal functional health literacy in this population of primary Spanish-speaking Latinas suggests that, once women have accessed screening services, programmatic approaches may exist to mitigate barriers to follow-up and to ensure optimal cancer screening outcomes for women of all literacy levels.

Contraceptive history unintended pregnancy and contraceptive method choice among urban low-income women.

BACKGROUND Nearly half of pregnancies in the United States are unintended, a proportion that has remained constant in the last decade. Half of unintended pregnancies occur among women not using any contraception, but little is known about how contraceptive history and contraceptive priorities predict contraceptive method choice. METHODS Among 1454 women not currently seeking pregnancy who completed a computer-based contraceptive assessment module at an urban reproductive health center, factors associated with not obtaining a contraceptive method were assessed. RESULTS The 1454 participants were low-income (98% had incomes <200% federal poverty level), predominantly Hispanic (71%), and foreign-born (76%). None were seeking to become pregnant, but 15% did not obtain a method of contraception. In adjusted analyses, women who had ever had an unintended pregnancy-41% of the sample-were significantly more likely to leave their visit without receiving a method (adjusted odds ratio [AOR]=1.67, 95% confidence interval [CI]: 1.21-2.30), as were women who were not using contraception at the start of their visit (AOR=3.82, 95% CI: 2.73-5.35). In an adjusted model, prioritizing no hormones or the preference of not wanting to interrupt sex to use a method was not a significant predictor of obtaining a method. CONCLUSIONS Analyses revealed that women at higher risk of unintended pregnancy identified by their contraceptive histories were significantly more likely to leave their healthcare visit without a method of contraception. Additional research is needed on ways to help women obtain effective, medically indicated contraceptive methods that fit their reproductive life goals, priorities, and preferences.

Measuring Success: Evaluation Designs and Approaches to Assessing the Impact of School-Based Health Centers

Since the founding of the first school-based health centers (SBHCs) >45 years ago, researchers have attempted to measure their impact on child and adolescent physical and mental health and academic outcomes. A review of the literature finds that SBHC evaluation studies have been diverse, encompassing different outcomes and varying target populations, study periods, methodological designs, and scales. A complex picture emerges of the impact of SBHCs on health outcomes, which may be a function of the specific health outcomes examined, the health needs of specific communities and schools, the characteristics of the individuals assessed, and/or the specific constellation of SBHC services. SBHC evaluations face numerous challenges that affect the interpretation of evaluation findings, including maturation, self-selection, low statistical power, and displacement effects. Using novel approaches such as implementing a multipronged approach to maximize participation, entering-class proxy-baseline design, propensity score methods, data set linkage, and multisite collaboration may mitigate documented challenges in SBHC evaluation.

IUD services among primary care practices in New York City

OBJECTIVE Intrauterine devices (IUDs) are one of the most effective forms of reversible contraception and can reduce unintended pregnancy rates. We explored practice characteristics associated with IUD services across a network of primary care practices in New York City during 2010-2013. STUDY DESIGN Data were extracted from electronic health records (EHRs) for 253 primary care practices participating in an EHR quality improvement program in New York City. We used diagnostic and procedure codes to count IUD insertions and removals among females aged 10-49 years during 2010-2013. Logistic regression models predicted the likelihood of IUD insertion, removal or no activity for 2013, based on practice characteristics. We stratified trends in IUD services over time by practice type and specialty. RESULTS From 2010 to 2013, the proportion of practices that inserted IUDs increased slightly from 4.7% to 6.3% (p=0.17), and the proportion removing IUDs increased from 8.3% to 12.3% (p<0.01). More than 60% of obstetricians/gynecologists and midwives performed insertions or removals each year; fewer than 10% of internal medicine and pediatric providers did so. Community health centers had higher odds of performing removals than independent practices (adjusted odds ratio=10.24, 95% confidence interval: 3.37-31.17). Practices seeing >66% female patients had higher odds of performing both insertions and removals. CONCLUSIONS From 2010 to 2013, IUD services increased but remained low among primary care practices in this network. Provider training and system readiness programs should include independent primary care practices, which rarely provide IUDs, to ensure that women can receive IUDs or IUD service referrals in the primary care setting. IMPLICATIONS Much of primary care in the United States takes place in independent practices with one or two providers. Our study of a major urban area found that these types of practices are much less likely to offer IUD services than community health centers. Ensuring that small practices know where to refer women for IUD insertion and removal services is warranted to ensure womens access to IUDs.

Get It and Forget It: online evaluation of a theory-based IUD educational video in English and Spanish.

OBJECTIVES Get It & Forget It, an educational video about intrauterine devices (IUDs), was developed and evaluated. STUDY DESIGN A feasibility study and a pre/post evaluation nested within a randomized trial were conducted to test change in knowledge about IUDs and intention to get an IUD after viewing a theory-driven dramatic video. Participants (n=315) completed surveys before and after watching the video. RESULTS Knowledge about IUD effectiveness increased significantly (33% to 64%, p<.001), as did intention to use an IUD (18% to 36%, p<.001) postvideo. CONCLUSION An online theory-driven video intervention can reach young women seeking information about long-acting contraception.