Sara M. Parisi

Validity of Birth Certificate-Derived Maternal Weight Data

BACKGROUND Studies using vital records-based maternal weight data have become more common, but the validity of these data is uncertain. METHODS We evaluated the accuracy of prepregnancy body mass index (BMI) and gestational weight gain (GWG) reported on birth certificates using medical record data in 1204 births at a teaching hospital in Pennsylvania from 2003 to 2010. Deliveries at this hospital were representative of births statewide with respect to BMI, GWG, race/ethnicity, and preterm birth. Forty-eight strata were created by simultaneous stratification on prepregnancy BMI (underweight, normal weight/overweight, obese class 1, obese classes 2 and 3), GWG (<20th, 20-80th, >80th percentile), race/ethnicity (non-Hispanic white, non-Hispanic black), and gestational age (term, preterm). RESULTS The agreement of birth certificate-derived prepregnancy BMI category with medical record BMI category was highest in the normal weight/overweight and obese class 2 and 3 groups. Agreement varied from 52% to 100% across racial/ethnic and gestational age strata. GWG category from the birth registry agreed with medical records for 41-83% of deliveries, and agreement tended to be the poorest for very low and very high GWG. The misclassification of GWG was driven by errors in reported prepregnancy weight rather than maternal weight at delivery, and its magnitude depended on prepregnancy BMI category and gestational age at delivery. CONCLUSIONS Maternal weight data, particularly at the extremes, are poorly reported on birth certificates. Investigators should devote resources to well-designed validation studies, the results of which can be used to adjust for measurement errors by bias analysis.

Maternal obesity and gestational weight gain are risk factors for infant death

Assessment of the joint and independent relationships of gestational weight gain and prepregnancy body mass index (BMI) on risk of infant mortality was performed.

Counseling About Medication-Induced Birth Defects with Clinical Decision Support in Primary Care

BACKGROUND We evaluated how computerized clinical decision support (CDS) affects the counseling women receive when primary care physicians (PCPs) prescribe potential teratogens and how this counseling affects womens behavior. METHODS Between October 2008 and April 2010, all women aged 18-50 years visiting one of three community-based family practice clinics or an academic general internal medicine clinic were invited to complete a survey 5-30 days after their clinic visit. Women who received prescriptions were asked if they were counseled about teratogenic risks or contraception and if they used contraception at last intercourse. RESULTS Eight hundred one women completed surveys; 27% received a prescription for a potential teratogen. With or without CDS, women prescribed potential teratogens were more likely than women prescribed safer medications to report counseling about teratogenic risks. However, even with CDS 43% of women prescribed potential teratogens reported no counseling. In multivariable models, women were more likely to report counseling if they saw a female PCP (odds ratio: 1.97; 95% confidence interval: 1.26-3.09). Women were least likely to report counseling if they received angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Women who were pregnant or trying to conceive were not more likely to report counseling. Nonetheless, women who received counseling about contraception or teratogenic risks were more likely to use contraception after being prescribed potential teratogens than women who received no counseling. CONCLUSIONS Physician counseling can reduce risk of medication-induced birth defects. However, efforts are needed to ensure that PCPs consistently inform women of teratogenic risks and provide access to highly effective contraception.

Perceptions of intrauterine contraception among women seeking primary care.

BACKGROUND Intrauterine contraception (IUC) is safe, highly effective and has few medical contraindications. Primary care providers see many women with chronic conditions who might benefit from IUC. STUDY DESIGN We surveyed women aged 18-50 who visited one of four primary care clinics in Pennsylvania between October 2008 and April 2010 to investigate perceptions of IUC and to identify factors associated with accurate perceptions. Key independent variables included patient characteristics, including knowing other women who had used IUC, and having discussed IUC with a provider. Logistic regression was used to examine the association between independent variables and accurate perceptions. RESULTS The study population included 1626 eligible respondents. Only 19.5% of women knew that IUC is more effective than oral contraceptive pills, 57.4% knew that IUC does not increase the risk of sexually transmitted infections and 28.7% knew that IUC is more cost-effective than oral contraceptive pills. Among women who had never used IUC, accurate perceptions were associated with higher levels of education, knowing one or more women who had used IUC and having discussed IUC with a health care provider. CONCLUSIONS Many women seeking primary care have inaccurate perceptions of IUC and may benefit from counseling about the advantages of this approach to preventing unintended pregnancy.

Routine counseling about intrauterine contraception for women seeking emergency contraception

OBJECTIVE To compare contraceptive knowledge and use among women seeking emergency contraception (EC) before and after an inner-city clinic began providing structured counseling and offering same-day intrauterine device (IUD) or implant placement to all women seeking EC. STUDY DESIGN For 8 months before and 21 months after this change in clinic policy, women aged 15-45 who wanted to avoid pregnancy for at least 6 months were asked to complete surveys immediately, 3 and 12 months after their clinic visit. In addition, we abstracted electronic medical record (EMR) data on all women who sought EC (n=328) during this period. We used chi-squared tests to assess pre/post differences in survey and EMR data. RESULTS Surveys were completed by 186 women. After the clinic began offering structured counseling, more women had accurate knowledge of the effectiveness of IUDs, immediately and 3 months after their clinic visit. In addition, more women initiated IUD or implant use (survey: 40% vs. 17% preintervention, p=0.04; EMR: 22% vs. 10% preintervention, p=0.01), and fewer had no contraceptive use (survey: 3% vs. 17% preintervention, p<0.01; EMR: 32% vs. 68%, p<0.01) in the 3 months after seeking EC. EMR data indicate that when same-day placement was offered, 11.0% of women received a same-day IUD. Of those who received a same-day IUD, 88% (23/26) reported IUD use at 3-months and 80% (12/15) at 12 months. CONCLUSIONS Routine provision of structured counseling with the offer of same-day IUD placement increases knowledge and use of IUDs 3 months after women seek EC. IMPLICATIONS Women seeking EC from family planning clinics should be offered counseling about highly effective reversible contraceptives with the option of same-day contraceptive placement.

Clinical Decision Support to Promote Safe Prescribing to Women of Reproductive Age: A Cluster-Randomized Trial

ABSTRACTBACKGROUNDPotentially teratogenic medications are frequently prescribed without provision of contraceptive counseling.OBJECTIVETo evaluate whether computerized clinical decision support (CDS) can increase primary care providers’ (PCPs’) provision of family planning services when prescribing potentially teratogenic medications.DESIGNCluster-randomized trial conducted in one academic and one community-based practice between October of 2008 and April of 2010.PARTICIPANTS/INTERVENTIONSForty-one PCPs were randomized to receive one of two types of CDS which alerted them to risks of medication-induced birth defects when ordering potentially teratogenic medications for women who may become pregnant. The ‘simple’ CDS provided a cautionary alert; the ‘multifaceted’ CDS provided tailored information and links to a structured order set designed to facilitate safe prescribing. Both CDS systems alerted PCPs about medication risk only once per encounter.MAIN MEASURESWe assessed change in documented provision of family planning services using data from 35,110 encounters and mixed-effects models. PCPs completed surveys before and after the CDS systems were implemented, allowing assessment of change in PCP-reported counseling about the risks of medication-induced birth defects and contraception.KEY RESULTSBoth CDS systems were associated with slight increases in provision of family planning services when potential teratogens were prescribed, without a significant difference in improvement by CDS complexity (p = 0.87). Because CDS was not repeated, 13% of the times that PCPs received CDS they substituted another potential teratogen. PCPs reported significant improvements in several counseling and prescribing practices. The multifaceted group reported a greater increase in the number of times per month they discussed the risks of medication use during pregnancy (multifaceted: +4.9 ± 7.0 vs. simple: +0.8 ± 3.2, p = 0.03). The simple CDS system was associated with greater clinician satisfaction.CONCLUSIONSCDS systems hold promise for increasing provision of family planning services when fertile women are prescribed potentially teratogenic medications, but further refinement of these systems is needed.

Computer-assisted provision of hormonal contraception in acute care settings

BACKGROUND We evaluated whether computerized counseling about contraceptive options and screening for contraindications increased womens subsequent knowledge and use of hormonal contraception. METHODS For the study 814 women aged 18-45 years were recruited from the waiting rooms of three emergency departments and an urgent care clinic staffed by non-gynecologists and asked to use a randomly selected computer module before seeing a clinician. RESULTS Women in the intervention group were more likely to report receiving a contraceptive prescription when seeking acute care than women in the control group (16% vs. 1%, p=.001). Women who requested contraceptive refills were not less likely than women requesting new prescriptions to have potential contraindications to estrogen (75% of refills vs. 52% new, p=.23). Three months after visiting the clinic, women in the intervention group tended to be more likely to have used contraception at last intercourse (71% vs. 65%, p=.91) and to correctly answer questions about contraceptive effectiveness, but these differences were not statistically significant. CONCLUSION Patient-facing computers appear to increase access to prescription contraception for women seeking acute care.

Low Gestational Weight Gain and Risk of Adverse Perinatal Outcomes in Obese and Severely Obese Women

Background: Our objective was to estimate associations between gestational weight gain z scores and preterm birth, neonatal intensive care unit admission, large- and small-for-gestational age birth, and cesarean delivery among grades 1, 2, and 3 obese women. Methods: We included singleton infants born in Pennsylvania (2003–2011) to grade 1 (body mass index 30–34.9 kg/m2, n = 148,335), grade 2 (35–39.9 kg/m2, n = 72,032), or grade 3 (≥40 kg/m2, n = 47,494) obese mothers. Total pregnancy weight gain (kg) was converted to gestational age-standardized z scores. Multivariable Poisson regression models stratified by obesity grade were used to estimate associations between z scores and outcomes. A probabilistic bias analysis, informed by an internal validation study, evaluated the impact of body mass index and weight gain misclassification. Results: Risks of adverse outcomes did not substantially vary within the range of z scores equivalent to 40-week weight gains of −4.3 to 9 kg for grade 1 obese, −8.2 to 5.6 kg for grade 2 obese, and −12 to −2.3 kg for grade 3 obese women. As gestational weight gain increased beyond these z score ranges, there were slight declines in risk of small-for-gestational age birth but rapid rises in cesarean delivery and large-for-gestational age birth. Risks of preterm birth and neonatal intensive care unit admission were weakly associated with weight gain. The bias analysis supported the validity of the conventional analysis. Conclusions: Gestational weight gain below national recommendations for obese mothers (5–9 kg) may not be adversely associated with fetal growth, gestational age at delivery, or mode of delivery.

Comparison of gestational weight gain z-scores and traditional weight gain measures in relation to perinatal outcomes.

BACKGROUND Conventional measures of gestational weight gain (GWG) are correlated with pregnancy duration, and may induce bias to studies of GWG and perinatal outcomes. A maternal weight-gain-for-gestational-age z-score chart is a new tool that allows total GWG to be classified as a standardised z-score that is independent of gestational duration. Our objective was to compare associations with perinatal outcomes when GWG was assessed using gestational age-standardised z-scores and conventional GWG measures. METHODS We studied normal-weight (n=522 120) and overweight (n=237 923) women who delivered liveborn, singleton infants in Pennsylvania, 2003-11. GWG was expressed using gestational age-standardised z-scores and three traditional measures: total GWG (kg), rate of GWG (kg per week of gestation), and the GWG adequacy ratio (observed GWG/GWG recommended by the Institute of Medicine). Log-binomial regression models were used to assess associations between GWG and preterm birth, and small- and large-for-gestational-age births, while adjusting for race/ethnicity, education, smoking, and other confounders. RESULTS The association between GWG z-score and preterm birth was approximately U-shaped. The risk of preterm birth associated with weight gain <10th percentile of each measure was substantially overestimated when GWG was classified using total kilogram and was moderately overestimated using rate of GWG or GWG adequacy ratio. All GWG measures had similar associations with small- or large-for-gestational-age birth. CONCLUSIONS Our findings suggest that studies of gestational age-dependent outcomes misspecify associations if total GWG, rate of GWG, or GWG adequacy ratio are used. The potential for gestational age-related bias can be eliminated by using z-score charts to classify total GWG.

Primary care physicians' perceptions of rates of unintended pregnancy

BACKGROUND Primary care physicians (PCPs) treat many women of reproductive age who need contraceptive and preconception counseling. STUDY DESIGN To evaluate perceptions of rates of unintended pregnancy, we distributed an online survey in 2009 to 550 PCPs trained in General Internal Medicine or Family Medicine practicing in Western Pennsylvania, Central Pennsylvania, Rhode Island or Oregon. RESULTS Surveys were completed by 172 PCPs (31%). The majority (54%) of respondents underestimated the prevalence of unintended pregnancy in the United States [on average, by 23±8 (mean±SD) percentage points], and 81% underestimated the risk of pregnancy among women using no contraception [on average, by 35±20 (mean±SD) percentage points]. PCPs also frequently underestimated contraceptive failure rates with typical use: 85% underestimated the failure rate for oral contraceptive pills, 62% for condoms and 16% for contraceptive injections. PCPs more often overestimated the failure rate of intrauterine devices (17%) than other prescription methods. In adjusted models, male PCPs were significantly more likely to underestimate the rate of unintended pregnancy in the United States than female PCPs [adjusted odds ratio (95% confidence interval): 2.17 (1.01-4.66)]. CONCLUSIONS Many PCPs have inaccurate perceptions of rates of unintended pregnancy, both with and without use of contraception, which may influence the frequency and the content of the contraceptive counseling they provide.