Victoria L. Holt

Risk of uterine rupture during labor among women with a prior cesarean delivery

Background Each year in the United States, approximately 60 percent of women with a prior cesarean delivery who become pregnant again attempt labor. Concern persists that a trial of labor may increase the risk of uterine rupture, an uncommon but serious obstetrical complication. Methods We conducted a population-based, retrospective cohort analysis using data from all primiparous women who gave birth to live singleton infants by cesarean section in civilian hospitals in Washington State from 1987 through 1996 and who delivered a second singleton child during the same period (a total of 20,095 women). We assessed the risk of uterine rupture for deliveries with spontaneous onset of labor, those with labor induced by prostaglandins, and those in which labor was induced by other means; these three groups of deliveries were compared with repeated cesarean delivery without labor. Results Uterine rupture occurred at a rate of 1.6 per 1000 among women with repeated cesarean delivery without labor (11 women), 5.2 ...

Young maternal age and depressive symptoms : Results from the 1988 National Maternal and Infant Health Survey

OBJECTIVES The goal of this study was to provide population-based estimates of the prevalence of depressive symptoms among primiparous US adolescent mothers. METHODS Data from the live-birth component of the 1988 National Maternal and Infant Health Survey were analyzed. RESULTS The prevalence of depressive symptoms varied by age and race, from 14% among White adult mothers to 48% among Black mothers 15 to 17 years old. After control for income and marital status, the increased prevalence of depressive symptoms associated with adolescent motherhood was greatly diminished (for 15- to 17-year-old Black women and 18- to 19-year-old White women) or eliminated (for 18- to 19-year-old Black women and 15- to 17-year-old White women). CONCLUSIONS Adolescent mothers experience high rates of depressive symptoms relative to adult mothers, and mental health and other interventions that alleviate the exacerbating influence of poverty and unmarried status are warranted.

Rates and relative risk of hospital admission among women in violent intimate partner relationships.

OBJECTIVES This study assessed the history of hospitalization among women involved in violent intimate relationships. METHODS In this 1-year retrospective cohort study, female residents of King County, Washington, who were aged 18 to 44 years and who had filed for a protection order were compared with nonabused women in the same age group. Outcome measures included overall and diagnosis-specific hospital admission rates and relative risk of hospitalization associated with abuse. RESULTS Women known to be exposed to a violent intimate relationship were significantly more likely to be hospitalized with any diagnosis (age-specific relative risks [RRs] ranging from 1.2 to 2.1), psychiatric diagnoses (RR = 3.6, 95% confidence interval [CI] = 2.8, 4.6), injury and poisoning diagnoses (RR = 1.8, 95% CI = 1.2, 2.8), digestive system diseases (RR = 1.9, 95% CI = 1.3, 2.9), and diagnoses of assault (RR = 4.9, 95% CI = 1.1, 22.1) or attempted suicide (RR = 3.7, 95% CI = 1.6, 9.2) in the year before filing a protection order. CONCLUSIONS This study showed an increased relative risk of both overall and diagnosis-specific hospitalizations among abused women. Intimate partner violence has a significant impact on womens health and use of health care.

First-birth cesarean and placental abruption or previa at second birth

Objective To assess the association between first-birth cesarean delivery and second-birth placental abruption and previa. Methods We conducted a population-based, retrospective cohort analysis using data from the Washington State Birth Events Record Database. The study cohort included all primiparas who gave birth to live singleton infants in nonfederal short-stay hospitals from January 1, 1987, through December 31, 1996, and who had second singleton births during the same period (n = 96,975). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for placental abruption or previa at second births associated with first-birth cesareans. Results Among our study cohort, abruptio placentae complicated 11.5 per 1000 and placenta previa 5.2 per 1000 singleton deliveries at second births. In logistic regression analyses adjusted for maternal age, women with first-birth cesareans had significantly increased risk of abruptio placentae (OR 1.3, 95% CI 1.1, 1.5), and placenta previa (OR 1.4, 95% CI 1.1, 1.6) at second births, compared with women with prior vaginal deliveries. Conclusion We found moderately increased risk of placental abruption and previa as a long-term effect of prior cesarean delivery on second births.

Body weight and risk of oral contraceptive failure.

OBJECTIVE To examine the hypothesis that higher body weight increases the risk of oral contraceptive (OC) failure. METHODS We conducted a retrospective cohort analysis of data from 755 randomly selected female enrollees of Group Health Cooperative of Puget Sound who completed an in‐person interview and dietary questionnaire between 1990 and 1994 as control subjects for a case‐control study of ovarian cysts. Among the 618 women who were OC ever‐users, we used Cox proportional hazards regression models to estimate the relative risk (RR) of pregnancy while using OCs associated with body weight quartile. RESULTS During 2822 person‐years of OC use, 106 confirmed pregnancies occurred (3.8 per 100 person‐years of exposure). After controlling for parity, women in the highest body weight quartile (70.5 kg or more) had a significantly increased risk of OC failure (RR 1.6, 95% confidence interval [CI] 1.1, 2.4) compared with women of lower weight. Higher elevations of risk associated with the highest weight quartile were seen among very low‐dose OC users (RR 4.5, 95% CI 1.4, 14.4) and low‐dose OC users (RR 2.6, 95% CI 1.2, 5.9), controlling for parity, race, religion, and menstrual cycle regularity. CONCLUSION Our findings suggest that body habitus may affect metabolism sufficiently to compromise contraceptive effectiveness. Consideration of a womans weight may be an important element of OC prescription.

Body mass index, weight, and oral contraceptive failure risk.

OBJECTIVE: This project was supported by grant 1 R01 HD-34712 from the U.S. National Institute of Child Health and Human Development. To estimate the effect of body mass index (BMI) and weight on risk of pregnancy while using oral contraceptives (OCs). METHODS: We conducted a case-control study of 248 health maintenance organization enrollees who became pregnant while using OCs between 1998 and 2001 and 533 age-matched enrollees who were nonpregnant OC users during the same period. Using logistic regression we calculated adjusted odds ratios (ORs) to estimate the risk of pregnancy according to BMI and weight quartile. RESULTS: Among all OC users, when compared with women having a BMI of 27.3 or less, the risk of pregnancy was nearly 60% higher in women with BMI greater than 27.3 (OR 1.58, 95% confidence interval [CI] 1.11–2.24) and over 70% higher in women with BMI greater than 32.2 (OR 1.72, 95% CI 1.04–2.82). Among consistent users (women who missed no pills in reference month), the risk of pregnancy was more than doubled in women with BMI greater than 27.3 (OR 2.17, 95% CI 1.38–3.41) or BMI greater than 32.2 (OR 2.22, 95% CI 1.18–4.20). When compared with women weighing 74.8 kg or less, among consistent OC users the risk of pregnancy was over 70% higher in women weighing more than 74.8 kg (OR 1.71, 95% CI 1.08–2.71) and nearly doubled in women weighing more than 86.2 kg (OR 1.95, 95% CI 1.06–3.67). CONCLUSION: Our results suggest that being overweight may increase the risk of becoming pregnant while using OCs. If causal, this association translates to an additional 2–4 pregnancies per 100 woman-years of use among overweight women, for whom consideration of additional or effective alternative contraceptive methods may be warranted. LEVEL OF EVIDENCE: II-2

Maternal depressive symptoms and child behavior problems in a nationally representative normal birthweight sample.

Objective: To evaluate the association between maternal depressive symptoms and child behavior problems in a nationally representative sample of U.S. mothers of normal birthweight babies. Methods: We analyzed data from the 1988 National Maternal and Infant Health Survey (NMIHS) and a 1991 follow-up survey. Depressive symptoms were measured at both surveys using the CES-D, and child behavior problems were assessed by maternal self-report at follow-up. Results: Approximately 28% of the 5303 mothers reported depressive symptoms at a mean of 17 months after delivery, as did 20% at 36 months. In multivariate analyses, women with depressive symptoms at either or both surveys were significantly more likely than women without depressive symptoms to report that their children had frequent temper tantrums or difficulty getting along with other children, and were difficult to manage, unhappy, or fearful. Compared to women without depressive symptoms, the risks of reporting three out of the five child behavior problems for women with depressive symptoms were OR = 1.6 (CI = 1.1–2.1), 1988 only; OR = 2.3 (CI = 1.6;3.3), 1991 only; and OR = 3.6 (2.6–5.0), both 1988 and 1991. Conclusions: Study findings indicate that a substantial proportion of mothers of young children in the United States experience depressive symptoms and that their children are at significantly increased risk of maternally reported behavior problems. Our results suggest that efforts to identify and treat depression in new mothers should be increased and that mothers whose children are found to have behavior problems should be assessed for depression.

Psychiatric and substance use disorders as risk factors for low birth weight and preterm delivery.

OBJECTIVE We examined the associations between psychiatric and substance use diagnoses and low birth weight (LBW), very low birth weight (VLBW), and preterm delivery among all women delivering in California hospitals during 1995. METHODS This population‐based retrospective cohort analysis used linked hospital discharge and birth certificate data for 521,490 deliveries. Logistic regression analyses were conducted to assess the associations between maternal psychiatric and substance use hospital discharge diagnoses and LBW, VLBW, and preterm delivery while controlling for maternal demographic and medical characteristics. RESULTS Women with psychiatric diagnoses had a significantly higher risk of LBW (adjusted odds ratio [OR] 2.0; 95% confidence interval [CI] 1.7, 2.3), VLBW (OR 2.9; 95% CI 2.1, 3.9), and preterm delivery (OR 1.6; 95% CI 1.4, 1.9) compared with women without those diagnoses. Substance use diagnoses were also associated with higher risk of LBW (OR 3.7; 95% CI 3.4, 4.0), VLBW (OR 2.8; 95% CI 2.3, 3.3), and preterm delivery (OR 2.4; 95% CI 2.3, 2.6). CONCLUSION Maternal psychiatric and substance use diagnoses were independently associated with low birth weight and preterm delivery in the population of women delivering in California in 1995. Identifying pregnant women with current psychiatric disorders and increased monitoring for preterm and low birth weight delivery among this population may be indicated.

RECOMMENDATIONS FOR THE DESIGN OF EPIDEMIOLOGIC STUDIES OF ENDOMETRIOSIS

This paper proposes a standard definition of endometriotic disease for epidemiologic studies and suggests subject-selection strategies to increase the validity of clinic- or population-based studies of the disease. Although endometriosis can be defined simply as the presence of ectopic endometrial tissue, emerging evidence indicates that to be pathologic, such tissue must persist and progress. The proposed disease definition incorporates the concepts of persistence and progression, and its use may increase the likelihood of observing true associations in etiologic studies. Potential threats to validity of substantial magnitude exist in both clinic- and population-based epidemiologic studies of endometriosis. In clinic-based studies, control subjects (infertility clinic patients, women delivering infants, or women undergoing tubal ligation) often are not representative of the population from which the cases arose, and bias can be considerable for behavioral and hormone-related exposures. In population-based studies, substantial case underascertainment may exist, and diagnosed cases may be a biased sample of all potential cases in the population. Although neither the ideal design nor the ideal case and control groups are likely to be achievable in epidemiologic studies of endometriosis, the subject-selection strategies suggested may improve the validity of studies that are obliged to depart from the ideal.

Do protection orders affect the likelihood of future partner violence and injury

BACKGROUND Approximately 20% of U.S. women who experience intimate partner violence (IPV) annually obtain a civil protection order (CPO). The effect of these orders on future abuse has been estimated in only a few studies, with mixed results. The objective of this study was to assess the effect of a CPO on the risk of future self-reported IPV and injury. METHODS In this prospective cohort study of 448 adult female Seattle WA residents with IPV between October 1997 and December 1998, interviews were conducted at baseline, 5 months, and 9 months after the index incident. Odds ratios (ORs) estimated risks of contact; unwelcome calls or visits; threats; weapon threats; psychological, sexual, or physical abuse or injury; and abuse-related medical care among women who obtained a CPO after the index incident, compared with those who did not. RESULTS Women who obtained a CPO following the index IPV incident had significantly decreased risk of contact by the abuser (OR=0.4); weapon threats (OR=0.03); injury (OR=0.3); and abuse-related medical care (OR=0.2) between the first and second follow-up interviews. Stronger decreases in risk were seen among women who had maintained the CPO throughout follow-up, which were significant for contact by the abuser (OR=0.2); weapon threats (OR=0.02); psychological abuse (OR=0.4); sexual abuse (OR=0.2); physical abuse (OR=0.3); injury (OR=0.1); and abuse-related medical care (OR=0.1) between first and second follow-up interviews. CONCLUSIONS CPOs are associated with decreased likelihood of subsequent physical and nonphysical IPV.