Women's Health Highlights: Recent Findings

Violence Against Women

An estimated 1.3 million women are physically abused by their intimate partners each year, and about one of every four women seeking care in emergency rooms has injuries resulting from domestic violence. There are many consequences of domestic violence, as reflected in the high use of health care services by abused women. In addition to physical injuries, women who are victims of domestic violence experience higher rates of depression, substance abuse, suicidal thoughts, and suicide attempts.

• Three brief questions can help to identify women who are victims of intimate partner violence.

  A total of 448 urban women who reported intimate partner violence to police or the court system completed surveys at 8 weeks (baseline) and 5 and 10 months after the incident. The researchers compared answers to three questions about physical and psychological abuse and found that the physical abuse question at baseline identified 93 percent of abused women. Two questions about psychological abuse identified 94 percent of victims. The researchers call for testing of these three questions in real-world settings to assess their usefulness as a tool for initiating conversations with women about abuse.

  Bonomi, Holt, Thompson, and Martin, Am J Prev Med 28(1):55-8, 2005 (AHRQ grant HS10909).

• Programs and tools are available to enhance care for victims of domestic violence.

  This publication describes training programs and tools, such as the Domestic Violence Assessment Tool, that are available for use by health care providers, social workers, and staff at shelters and other facilities that care for victims of domestic violence.

  Kass-Bartelmes and Rutherford, Women and Domestic Violence: Programs and Tools that Improve Care for Victims. Research in Action No. 15 (AHRQ Publication No. 04-0055).*

• Task Force issues recommendation on screening for domestic violence.

  The U.S. Preventive Service Task Force suggests that clinicians always be alert to physical and behavioral signs and symptoms associated with abuse or neglect, treat any injuries, and arrange for professional counseling for the patient. Clinicians should provide patients with contact information for local crisis centers, shelters, and protective services agencies.

  U.S.Preventive Services Task Force, Ann Intern Med 140(5):382-86, 2004; and Nelson, Nygren, McInerney, and Klein, Ann Intern Med 140(5):387-96, 2004 (contract 290-02-0024).

• Physicians are the key to identifying and referring women who are victims of domestic violence.

  Only 8 percent of women who are abused by their partners ever tell a doctor, and less than 50 percent ever tell anyone. Physicians should make an effort to identify and refer these women to appropriate community services, according to these researchers. They note that simply identifying abuse can influence the evaluation of patient complaints as well as the outcomes of care.

  Rhodes and Levinson, JAMA 289(5):601-5, 2003 (AHRQ grant HS11096).

• Online tool helps hospitals evaluate their domestic violence programs.

  AHRQ provided support for development of a 37-item, Web-based instrument for use by hospitals to conduct a formal evaluation of their domestic violence screening and intervention programs.

  The instrument is available online at http://www.ahrq.gov/research/domesticviol/ or in print (AHRQ Publication No. 03-0004)* (Intramural).

• Study links stressful life events to abuse during pregnancy.

  Using survey responses from 2,600 postpartum women, researchers examined sociodemographic characteristics, experience of 13 stressful life events during the year before childbirth, and experience of physical abuse. Physical abuse was associated with 5 of the 13 stressors. Additionally, 12 percent of the participants were poor (most were married, white, high school graduates, and aged 20 or older); 14 percent had suffered through five or more stressful events; and almost 9 percent were physically abused before and/or during pregnancy (usually by their husbands/partners).

  Martin, Griffin, Kupper, et al., Matern Child Health J 5(3):145-52, 2001 (NRSA training grant T32 HS00032).

• A new tool helps clients define abusive situations.

  Researchers developed the Domestic Violence Survivor Assessment for use with women who disclose intimate partner violence through screening or by seeking counseling or shelter. Family violence counselors can use this tool to help clients define their domestic situations and take the steps to live lives free from abuse.

  Dienemann, Campbell, Landenburger, et al., Patient Educ Couns 46:221-8, 2002 (AHRQ HS10731).

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HIV/AIDS

The number of AIDS cases is growing more rapidly among U.S. women than among men. In 1985, women made up only 7 percent of all reported AIDS cases, compared with 18 percent in 1994 and 23 percent in 1999. AIDS occurs most often among women in their reproductive years (15 to 44 years of age). HIV/AIDS is the sixth leading cause of death among U.S. women 25 to 34 years of age and the leading cause of death for black women in that age group.

• Study finds disparities among privately insured men and women in use and costs of HIV care.

  In this study of men and women enrolled in the health insurance plans of 24 large employers across the country, women with HIV disease were much less likely than men with HIV to receive potentially life-prolonging drugs, even though they had private insurance and should have had equal access to drug therapies. On average, women had total health care expenditures of $10,397 in 2000, compared with $16,405 for men.

  Hellinger and Encinosa, Health Serv Res 39(4):949-67, 2004 (Intramural).

• HIV-infected women who have abnormal Pap smears should be referred for colposcopy to rule out cervical cancer.

  Women with HIV whose Pap smears show atypical squamous cells of uncertain significance have a 15 percent risk for high-grade cervical cancer precursors. Although colposcopy is costly and uncomfortable, it should continue to be the next diagnostic step for these women, according to this study. It found that the alternative test, a DNA assay obtained by cervicovaginal lavage, was not sensitive enough for use in women with HIV

  Massad, Schneider, Watts, et al., J Women's Health 13(2):147-53, 2004 (sponsored by AHRQ, NIH, and CDC).

• Incidence of hepatitis C virus is low among HIV-infected women.

  The researchers examined blood samples obtained from HIV-infected and uninfected women during 1994-1999 to detect the presence of hepatitis C virus (HCV) antibody and viremia in the blood. The incidence rate of HCV in HIV-infected women was 2.7 cases per 1,000 person-years, compared with 3.3 cases for HIV-negative women. In most cases, HCV infection in women with HIV was linked to drug use, supporting the contention that drug use is the single most important risk factor for HCV infection.

  Augenbraun, Goedert, Thomas, et al., Clin Infect Dis 37:1357-64, 2003 (cosponsored by AHRQ, NIH, and CDC).

• Women with HIV infection are at increased risk for psychiatric conditions.

  This study of 847 women participating in AHRQ's HIV Cost and Services Utilization Study (HCSUS) found that 55 percent of them showed signs of mood disorders, drug dependence, or heavy drinking. Increased risk for psychiatric conditions was associated with younger age, having an AIDS diagnosis, prior physical abuse, needing income assistance, needing to care for someone else, and other factors.

  Sherbourne, Forge, Kung, et al., Women's Health Issues 13:104-10, 2003 (AHRQ grant HS08578).

• Women with HIV are especially vulnerable after childbirth.

  This study involved women with HIV who were enrolled in Medicaid. It found that the women were particularly vulnerable to substance abuse and noncompliance with antiretroviral therapy during the postpartum period.

  Warner, Wei, McSpiritt, et al., J Amer Med Women's Assoc 58(3):143-53, 2003 (AHRQ grant HS11625).

• Substance abuse treatment may contribute to menstrual problems in HIV-infected women.

  This study involving 1,075 seropositive or seronegative women enrolled in the Women's Interagency HIV Study found that women on methadone maintenance who used injection drugs or psychotherapeutic medications were likely to have very short menstrual cycles (less than 18 days) or very long cycles (90 days or more).

  Harlow, Cohen, Ohmit, et al., Amer J Obstet Gynecol 188:881-6, 2003 (cosponsored by AHRQ, NIH, and CDC).

• One-fifth of deaths among women with HIV are not AIDS related.

  Based on data from death certificates and CD4 cell count, researchers classified the causes of death for 414 women with HIV infection as AIDS- or non-AIDS-related. Data show that 20 percent of deaths among HIV-infected women are due to causes other than AIDS.

  Cohen, French, Benning, et al., Am J Med 113:91-8, 2002 (sponsored by AHRQ, NIH, and CDC).

• Nonadherence to HIV treatment is linked to risky behaviors.

  Data were collected on 766 HIV-positive U.S. women to examine adherence to therapy, risk behavior, and disease markers. Two-thirds of the women took all medications as prescribed 95 percent or more of the time; however, the remaining one-third were more than twice as likely to engage in unprotected sexual activity. Women who were less adherent were more likely than those who adhered to treatment to have a detectable virus load, more impaired immune systems, and bothersome symptoms; use condoms inconsistently; and report drug use.

  Wilson, Barron, Cohen, et al., Clin Infect Dis 34:529-34, 2002 (sponsored by AHRQ, NIH, and CDC).

• Special outreach needed for HIV-positive black women and drug abusers.

  Researchers analyzed antiretroviral medication use among 1,690 HIV-positive women, the majority of whom were black or Hispanic. Results show that women who are college-educated, are not black, are privately insured, and have not used illicit drugs are more likely to receive highly active antiretroviral therapy (HAART) to treat their HIV infection.

  Cook, Cohen, Grey, et al., Am J Public Health 92(1):82-7, 2002 (sponsored by NIH, CDC, and AHRQ).

• Research uncovers important services for HIV-infected women.

  This study focused on the evaluation and management of HIV infection in women, particularly treatment issues specific to women with HIV. According to the author, women usually are not diagnosed until they seek medical attention for a gynecologic infection.

  Levine, Ann Intern Med 136(3):228-42, 2002 (sponsored by AHRQ, NIH, and CDC).

• Increased use of health care is related to increased screening.

  This study examined mammography use among 2,059 HIV-positive and 569 HIV-negative socioeconomically disadvantaged women involved in the Women's Interagency HIV Study. Mammography use was also compared with U.S. women in the general population using data from the National Health Interview Survey. The HIV-positive women were 60 percent more likely than HIV-negative women to be screened for the first time while in the study. And, more HIV-positive than HIV-negative women reported having health insurance (82 vs. 59 percent); having a primary care provider (93 vs. 67 percent); and visiting a doctor in the past 2 months (84 vs. 54 percent).

  Preston-Martin, Kirstein, Pogoda, et al., Prev Med 34:386-92, 2002 (sponsored by AHRQ, NIH, CDC).

• Highly active antiretroviral therapy alters progression of cervical disease.

  A multicenter longitudinal study involving 2,059 HIV-infected and at-risk women enrolled at six clinical sites sought to determine the effect of HAART on human papillomavirus (HPV) disease. Investigators obtained Pap smears and cervicovaginal lavage for HPV DNA testing from HIV-infected women at 6-month intervals. Women on HAART were 1.4 times more likely to experience regression, while those not on HAART were more likely to show HPV disease progression.

  Minkoff, Ahdieh, Massad, et al., AIDS 15(16):2157-64, 2001 (AHRQ grant HS10399).

• Black women are recruited/retained in HIV clinical trials.

  Researchers describe the recruitment and retention of a diverse group of women infected with HIV and at-risk HIV uninfected women participating in the Women's Interagency HIV Study. Factors found to be associated with retention were older age, black race, stable housing, HIV-infected serostatus, past experience in studies of HIV/AIDS, and site of enrollment.

  Hessol, Schneider, Greenblatt, et al., Am J Epidemiol 154:563-73, 2001 (sponsored by AHRQ, NIH, and CDC).

• Survey shows people with HIV consider parenthood.

  The HIV Cost and Services Utilization Study (HCSUS) surveyed 2,864 adults infected with HIV who were receiving medical care in the United States in early 1996. The study revealed that more than one in four HIV-positive men and women desired children in the future. Of those who wanted children, 6 in 10 men and 7 in 10 women expected to have children.

  Chen, Phillips, Kanouse, et al., Fam Plann Perspect 33(4):144-52,165, 2001 (AHRQ grant HS08578).

• Modifications suggested for cervical cancer screening guidelines for women with HIV.

  By incorporating data from studies, databases, and the literature, researchers calculated quality-adjusted life expectancy, lifetime costs, and the cost-effectiveness of targeted and universal cervical cytologic screening in HIV-infected women. Results show that adding an HPV test to the first two Pap smears (within the year after HIV diagnosis) and modifying subsequent screening intervals based on HPV test result will make screening more efficient.

  Goldie, Freedberg, Weinstein, et al., Am J Med 111:140-9, 2001 (AHRQ grant HS07317).

• Women's HIV study identifies prevalence and predictors of skin disease.

  The Women's Interagency HIV Study analyzed baseline data on 2,018 HIV-infected women and 557 uninfected women and found that HIV-infected women were more likely than uninfected women to report skin abnormalities (63 vs. 44 percent) and diagnoses with more than two skin problems (6 vs. 2 percent).

  Paradi, Mirmirani, Hessol, et al., J Am Acad Dermatol 44:785-8, 2001 (sponsored by AHRQ, NIH, and CDC).

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Homelessness

Homelessness is a major problem in the United States today, and the fastest growing segment of this population is made up of women and young families. Research on the health needs of homeless women has suggested that they are unlikely to use birth control, and they are likely to have limited gynecological care, unplanned pregnancies, inadequate prenatal care, and poor birth outcomes.

• Studies demonstrate high rates of sexual assault and unmet health care needs among homeless women.

  In one study, 9 percent of women reported a history of sexual assault, and 31 percent reported physical assault. Both mental illness and sex work were common among the women. There was a strong association among sexual and physical assault, mental illness, poor health, sex work, and alcohol and drug use. In the second study, more than one-third of 974 homeless women (ages 15 to 44) reported an inability to access needed health care in the preceding 2 months.

  Kushel, Evans, Perry, et al., Arch Intern Med 163:2492-9, 2003 (AHRQ grant HS11415); and Lewis, Anderson, and Gelberg, J Gen Intern Med 18:921-8, 2003 (AHRQ grant HS08323).

• Many homeless women use faith-based providers.

  This survey of nearly 1,000 homeless women in Los Angeles, CA, found that 52 percent of the women were using the services of faith-based providers. Those with no religious affiliation were less likely than Christian women to use faith-based providers, and blacks and Hispanics were less likely than white women to use them.

  Heslin, Andersen, and Gelberg, J Urban Health 80(3):371-82, 2003 (AHRQ grant HS08323).

• Homeless women express dissatisfaction with care delivered in traditional government clinics.

  Homeless women in Los Angeles, CA, are more satisfied with health care that is provided at homeless-focused health care sites (shelter/outreach clinics and mobile vans) and doctors' offices versus county/government clinics. Researchers assessed the women's satisfaction with scheduling, quality of care, and access to care, and the appointment itself.

  Swanson, Andersen, and Gelberg, J Women's Health 12(7):675-86, 2003 (AHRQ grant HS08323).

• Homeless women report deterrents to use of contraceptives.

  Homeless women reported deterrents to consistent use of contraceptives to prevent unintended pregnancy, including side effects, fear of potential health risks, partner's dislike of contraception, and cost. Hispanic women were much more likely than white women to cite not knowing how to use contraceptives or which method to use. Black women were more likely than white women to cite not knowing which method to use, lack of storage, health risks, and discomfort as barriers to use.

  Gelberg, Leake, Lu, et al., Perspect Sex Reprod Health 34(6):278-85, 2002 (AHRQ grant HS08323).

• Homeless women should be encouraged to have an HIV test.

  This 1997 survey of homeless women in Los Angeles County revealed that 68 percent of them had an HIV test in the preceding year, and 1.6 percent of the women had been diagnosed with HIV at some point. About one-fourth of homeless women with indications for HIV testing had not been tested in the previous year.

  Herndon, Asch, Kilbourne, et al., Public Health Reports 118:261-9, 2003 (AHRQ grant HS08323).

• More assertive outreach programs are needed to link homeless women to case managers and more services.

  Over half (56 percent) of nearly 1,000 homeless women interviewed in Los Angeles County in 1997 had case managers to help them find and obtain care. Women with case managers were nearly twice as likely as those without case managers to use food stamps and more than twice as likely to have found shelter in the month before the interview. Heslin, Andersen, and Gelberg.

  Heslin, Andersen, and Gelberg. J Health Care Poor Underserved 14(1):34-51, 2003 (AHRQ grant HS08323).

• Study identifies deterrents to contraceptive use among homeless women.

  This survey of 974 homeless women in Los Angeles County in 1997 found that they had substantial deterrents that reduced their use of contraceptives, including side effects, fear of potential health risks, partner's dislike of contraception, and cost. Black and Hispanic women were much more likely than white women to report barriers to contraceptive use.

  Gelberg, Leake, Lu, et al., Perspect Sex Reprod Health 34(6):278-85, 2002 (AHRQ grant HS08323).

• Community clinics serve as a safety net for homeless women.

  Researchers surveyed administrators and clinicians at 112 clinic sites that provide or could provide primary health care to 95 percent of the homeless women in Los Angeles County. Results from 73 completed surveys revealed that the clinics treat 30 or more homeless, primarily Hispanic women monthly; struggle to provide comprehensive care; and suffer from staff burnout and scarce resources. Despite being unable to offer substance abuse, mental health, and support services, the sites enhance access to care with evening and weekend hours, walk-in visits, and proximity to pubic transportation.

  Luck, Andersen, Wenzel et al., J Ambulatory Care Manage 25(2):53-67, 2002 (AHRQ grant HS08323).

• Homeless women lack sufficient access to medical care.

  Investigators interviewed 974 homeless women about their number of hospitalizations, outpatient visits, and preventive health screens. Homeless women living on the streets were less likely than women who stayed in shelters and traditional housing to have been hospitalized (21, 28, and 38 percent); had outpatient visits (3.7, 7.2, and 7.4 visits); or had health screens in the past year (2.9, 3.6, and 3.6 out of 4 screens).

  Lim, Andersen, and Leake, et al., Med Care 40(6):510-20, 2002 (AHRQ grant HS08323).

• Accessible ob-gyn services are needed for homeless women.

  When nearly 1,000 Los Angeles County homeless women of reproductive age were interviewed, two-thirds reported symptoms during the previous year ranging from abnormal vaginal discharge, severe pelvic pain, and skipped periods to breast lumps and burning during urination. One-fourth of the women were either pregnant at the time of the study or had been pregnant during the preceding year.

  Wenzel, Andersen, Gifford, et al., J Health Care Poor Underserved 12(3):323-43, 2001 (AHRQ grant HS08323).

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Prevention

In addition to supporting research on preventive services, AHRQ supports a panel of independent, private-sector experts in prevention and primary care—the U.S. Preventive Services Task Force (USPSTF)—and conducts a program to increase the appropriate use of preventive services—Put Prevention Into Practice. The USPSTF reviews the scientific evidence and develops recommendations for interventions such as screening tests, counseling, immunizations, and chemoprophylactic regimens. Many of these preventive interventions are of particular importance to women.

• Sociodemographic factors affect receipt of preventive care among older women.

  This study found that despite Medicare coverage of preventive care services, wealth, age, education, and race continue to be important factors in the receipt of preventive services by women aged 65 and older. Women enrolled in one of two Medicare HMOs who lived in wealthier households were 11 to 17 percent more likely than women in the lowest wealth category to receive a mammogram and colorectal cancer screening. Women who had a college education were more likely to receive colorectal cancer screening, and they received a greater average number of preventive services than women without a high school education.

  Morales, Rogowski, Freedman, et al., Prev Med 39(4):738-45, 2004 (AHRQ grant HS09630).

• Drugs to prevent breast cancer should not be used routinely.

  The USPSTF reviewed three randomized controlled trials on the use of tamoxifen and raloxifene to reduce the risk of breast cancer. They recommend that clinicians discuss with their female patients who are at high risk for the disease the benefits and risks of taking prescription medicines to reduce their risk of breast cancer. The Task Force recommends against the use of these drugs by women at low or average risk for breast cancer.

  USPSTF, Ann Intern Med 137(1):56-8, 2002 (AHRQ contract 290-97-0011).

• The USPSTF recommends routine screening for chlamydia.

  The USPSTF recommends the routine screening of all sexually active women, including pregnant women, 25 years of age and younger for chlamydial infection. Other asymptomatic women at increased risk of infection should be screened as well.

  USPSTF, Am Fam Physician 65(4):673-6 (AHRQ contract 290-97-0011). See also What's New from the Third USPSTF: Screening for Chlamydial Infection (AHRQ Publication No. APPIP01-0010).*

• Routine screening for bacterial vaginosis in pregnancy lacks support.

  The USPSTF concludes there is insufficient evidence to recommend for or against routine screening of high-risk pregnant women for bacterial vaginosis. The Task Force recommends against routine screening of average-risk asymptomatic pregnant women for bacterial vaginosis.

  USPSTF, Am Fam Physician 65(6):1147-50 (AHRQ contract 290-97-0011). See also What's New from the Third USPSTF: Screening for Bacterial Vaginosis in Pregnancy (AHRQ Publication No. APPIP 01-0012).*

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Pregnancy, Birth Outcomes, and Family Planning

The last half of the 20th century saw a decline in maternal deaths among U.S. women—from about 74 deaths in 1950 to about 7 deaths in 1993 for every 100,000 live births. Mortality related to pregnancy and childbirth is low for U.S. women compared with other causes of death, primarily because of health care advances that have occurred over the past 50 years. However, black women and older women continue to be at higher risk of death from complications of pregnancy.

• Screening new mothers for postpartum depression is particularly important in women of color.

  According to this survey of 655 women who were 2 to 6 weeks postpartum, nearly one-half of Hispanic (47 percent) and black (45 percent) mothers reported depressive symptoms, compared with less than one-third (31 percent) of white mothers. Factors associated with postpartum depression—the burden of physical symptoms, lack of social support, and lack of self-confidence in infant care—were the same for all women regardless of race.

  Howell, Mora, Horowitz, and Leventhal, Obstet Gynecol 105(6):1442-50, 2005 (AHRQ grant HS09698).

• Prenatal screening is needed to identify pregnant women with asymptomatic chlamydial infection.

  Nine percent of pregnant women who have chlamydia have no symptoms associated with the infection, according to this study of nearly 2,000 pregnant women with chlamydia. In 44 percent of the women, the infection resolved spontaneously, but most women with asymptomatic infection who were not treated had persistent infection. This finding reinforces the current recommendation for screening pregnant women for chlamydia at the first prenatal visit and, for at-risk women, screening a second time in the third trimester.

  Sheffield, Andrews, Klebanoff, et al., Obstet Gynecol 105:557-62, 2005 (AHRQ contract 290-92-0055).

• Evidence is insufficient to determine safety of inducing labor in women with a prior cesarean.

  According to this systematic review, there is little high-quality evidence to guide clinical and health policy decisions about the safety of inducing labor in women who have had a prior cesarean delivery. Evidence is particularly lacking on the appropriate dose of oxytocin and other agents used to induce labor and the reasons for inducing labor instead of waiting for spontaneous labor. Better quality studies that include appropriate comparison groups are also needed.

  McDonagh, Osterweil, and Guise, BJOG 112:1007-15, 2005 (AHRQ grant HS11338).

• Screening asymptomatic, low-risk pregnant women for hepatitis C is not cost effective.

  An estimated 1 to 4 percent of pregnant women are infected with hepatitis C virus (HCV), yet screening all pregnant women for HCV would not be cost effective, according to this study. Compared with no screening, the additional cost of screening, treatment, and cesarean delivery was $117, with a cost-effectiveness ratio of $1.17 million per quality-adjusted life year-way above the $50,000 per QALY typically considered to be cost effective.

  Plunkett and Grobman, Am J Obstet Gynecol 192:1153-61, 2005 (AHRQ grant T32 HS00078).

• Task Force recommends HIV screening for all pregnant women.

  The U.S. Preventive Services Task Force issued a new recommendation calling for all pregnant women—not just at-risk women—to be screened for HIV infection. This recommendation is based on evidence that currently available tests accurately identify pregnant women who are HIV infected. This will permit the use of recommended treatments to dramatically reduce the chances that an infected mother will transmit HIV to her infant. In addition, elective cesarean section and avoidance of breastfeeding have been shown to further reduce mother-to-infant transmission of HIV infection.

  Chou, Smits, Huffman, et al., Ann Intern Med 143(1):38-54, 2005; also in the same journal, see pages 32-7, and pages 55-73 (AHRQ contract 290-97-0011).

• Half of pregnant women who support abortion availability would only consider a first-trimester procedure.

  Researchers interviewed more than 1,000 socioeconomically diverse pregnant women receiving prenatal care in the San Francisco Bay area; nearly half were aged 35 or older. Most of the women (92 percent) were in favor of abortion availability, but half (50 percent) said they would only consider having the procedure in the first trimester of pregnancy. Among women willing to consider abortion, 84 percent would do so after rape or incest or if their life was endangered by continuing the pregnancy. Three-quarters of the women (76 percent) would consider an abortion if their fetus had Down syndrome.

  Learman, Drey, Gates, et al., Am J Obstet Gynecol 192:1939-47, 2005 (AHRQ grants HS10214, HS10856).

• Attitudes toward pregnancy outcomes determine women's preferences for prenatal testing.

  A pregnant woman's attitude toward miscarriage, pregnancy termination, and the possibility of giving birth to a baby with Down syndrome are more important than her age in determining her preferences for prenatal testing to detect fetal chromosomal abnormalities, according to this study. The researchers assessed the preferences for 12 potential prenatal testing outcomes of 584 racially and economically diverse pregnant women recruited from 23 San Francisco Bay area practices. Women gave the highest preference scores to outcomes resulting in the birth of a chromosomally normal infant; their least preferred outcome was the birth of a Down syndrome infant.

  Kupperman, Nease, Gates, et al., Prenatal Diagnosis 24:424-9, 2004 (AHRQ grants HS07373 and HS10214).

• Pregnant women who give birth in jail are more likely to have low-birthweight and premature babies.

  Women in their 30s who are in an urban jail during pregnancy are more likely than women not in jail to have low-birthweight and preterm babies, according to this study. The researchers compared outcomes for 496 births to women who were in jail for part of their pregnancy with nearly 5,000 Medicaid-funded births in the community. Younger women (aged 18-29) were less likely than older women (aged 30-39) to deliver a low birthweight infant.

  Bell, Zimmrman, Cawthon, et al., J Urban Health 81(4), online at www.biomedcentral.com (AHRQ grant T32 HS13853).
• Acupuncture may be a safe alternative for treating depression in pregnant women.

  Antidepressant medications are not recommended during pregnancy for fear they may harm the fetus. In this study, pregnant women with depression who received acupuncture specifically tailored for depressive symptoms got more relief than women who received nonspecific acupuncture or massage. Also, women who responded to any treatment reported significantly less depression at 10 weeks postpartum.

  Manber, Schnyer, Allen, et al., J Affect Disorder 83:89-95, 2004 (AHRQ grant HS09988).

• Difficulty sleeping and other problems common during pregnancy may mask symptoms of perinatal depression.

  According to this evidence report, depression is as common in women while they are pregnant as it is after childbirth. However, health care providers and patients may not recognize depression during pregnancy because signs of depression like tiredness, inability to sleep, emotional changes, and weight gain may also occur with pregnancy. Factors contributing to depression during or after pregnancy include personal or family history of depression or substance abuse, anxiety about the unborn child, problems with a previous pregnancy or birth, and marital or financial problems. The report also discusses screening for depression, the effectiveness of psychotherapy and antidepressants, and the value of providing psychosocial support to pregnant and postpartum women with depression.

  Perinatal Depression: Prevalence, Screening, Accuracy, and Screening Outcomes. Evidence Report No. 119 (AHRQ Publication Nos. 05-E006-1, summary; 05-E006-2, report) (AHRQ contract 290-02-0016).*

• Potential benefits of episiotomy do not offset the fact that many women would have less injury without it.

  Episiotomy is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery. According to this evidence report, routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother. The evidence shows that women who experience spontaneous tears without episiotomy have less pain than women with episiotomies.. Furthermore, complications related to the healing of the perineum are the same with and without episiotomy.

  Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report No. 112 (AHRQ Publication Nos. 05-E009-1, summary and 05-E009-2, report) (AHRQ contract 290-02-0016).*

• Study focused on trends in repeat c-section.

  Using 1996-1998 hospital discharge data for New York State, the researchers compared changes in obstetric methods over time. They found that there was a dramatic fall in the rate of repeat c-sections and a large increase in the proportion of births paid for by HMOs.

  Determinants of Cesarean Section: Explaining Recent Changes. Grant final report; available from NTIS at http://www.ntis.gov (HS10065).

• Most obstetricians are against first-time c-section without medical indications.

  A growing number of women are asking their obstetricians for a cesarean delivery, even though there is no medical reason for the procedure. Some women want the convenience of scheduling their delivery, while others are tired of being pregnant and want to get it over with. This study found that most obstetricians are reluctant to agree to these requests, although male physicians are more likely than female physicians to respond favorably, especially for patients in higher socioeconomic brackets. However, when cesarean delivery was medically indicated, there was no difference between female and male physicians.

  Ghetti, Chan, and Guise, Birth 31(4):280-4, 2004 (AHRQ grant HS11338).

• Stress incontinence occurs more often among women who have given birth vaginally than those with cesarean-only deliveries.

  Women who have given birth via c-section only are 40 percent less likely to suffer from stress incontinence later in life than women who have had vaginal deliveries. A survey of 1,299 women scheduled for elective hysterectomy revealed that both stress incontinence and urinary urgency increased nearly two-fold after a single vaginal delivery.

  Handa, Harvey, Fox, and Kjerulff, Am J Obstet Gynecol 191:463-9, 2004 (AHRQ grant HS06865).

• Study focused on the cost-effectiveness of cesarean delivery to prevent perinatal HCV transmission.

  The goal of this study was to determine the cost-effectiveness of elective cesarean delivery to avert perinatal hepatitis C virus (HCV) transmission. The researchers considered two approaches: one, offering elective c-section to pregnant women infected with HCV, and two, performing a cesarean only for obstetric indications. They calculated that when elective cesarean delivery prevented all HCV transmissions, 18 elective cesareans were necessary to avert one neonatal HCV infection, resulting in a cost-effectiveness ratio that was similar or less than other accepted therapies. However, if rates of HCV transmission were relatively low, elective cesarean was not cost effective even if it prevented all perinatal HCV transmissions.

  Plunkett and Grobman, Am J Obstet Gynecol 191:998-1003 (AHRQ grant T32 HS00078).

• Risk of rupture from tubal pregnancy is highest within 48 hours after onset of symptoms.

  According to this study, the risk of rupture from tubal pregnancy is highest—at 5 to 7 percent—within 48 hours after onset of symptoms such as abdominal or pelvic pain, vaginal bleeding, and tenderness or mass of the fallopian tubes or ovaries. The researchers note that factors important in diagnosing tubal pregnancy are not helpful in predicting the risk of rupture. They reviewed inpatient, clinic, and physician office charts of 221 women with tubal pregnancy to assess the risk of rupture and correlate the risk with time passed since symptom onset and other factors.

  Bickell, Bodian, Anderson, and Kase, Obstet Gynecol 104(4):789-94, 2004 (AHRQ grant HS09698).

• Service coordination for pregnant women in prison can improve their use of health services after release.

  This study involved 453 women who were in custody in one jail and had an estimated delivery date during the period 1994-1998. It demonstrated that jail settings can become a place of coordination between public health and criminal justice professionals to ensure that pregnant women receive essential services—including family planning and substance abuse treatment—following their release from jail.

  Bell, Zimmerman, Huebner, et al., J Health Care Poor Underserved 15:426-42, 2004 (AHRQ grant T32 HS13853).

• Researchers examine perinatal outcomes among pregnant women hospitalized for respiratory infection.

  This study involved 294 pregnant women enrolled in Medicaid during eight influenza seasons from 1985 to 1993 who had an acute hospitalization for respiratory infection. They were matched (age, race, trimester of pregnancy, and coexisting conditions) with 590 similar women without such hospitalizations. Although there was no significant association between respiratory hospitalization during flu season and adverse perinatal outcomes, the researchers conclude that pregnant women should be encouraged to receive flu vaccination.

  Hartert, Neuzil, Shintani, et al., Am J Obstet Gynecol 189:1705-12, 2003 (AHRQ grant HS10384).

• Women who have low-risk deliveries in birth centers fare as well as those delivered in hospitals.

  Whether low-risk women give birth in collaborative care birth centers that use certified nurse-midwife/obstetrician management or in a hospital where care is managed by an obstetrician, maternal and infant outcomes are similar. However, the birth centers have fewer surgical deliveries and use fewer medical resources. Surgical deliveries and hospital stays—major determinants of cost—were substantially reduced with collaborative care.

  Jackson, Lang, Swartz, et al., Am J Public Health 93(6):999-1006, 2003 (AHRQ grant HS07161).

• Home visits by a nurse-health advocate team benefits low-income minority mothers and infants.

  Researchers examined maternal/infant outcomes for 406 black and 186 Mexican-American low-income pregnant women from two university-associated prenatal clinics in Chicago who received regular home visits by a nurse-health advocate team over the 12-month period after childbirth. Many of the mothers were depressed and had several difficult life circumstances, such as an abusive partner or inability to pay bills. For black women the program resulted in better tracking of infant immunizations, better parenting skills, and higher 12-month infant mental development scores. For Mexican American women, the program improved daily living skills and knowledge of appropriate play materials for their infants.

  Kuzujanakis, Kleinman, Rifas-Shiman, and Finkelstein, Ambul Pediatr 3(4):203-10, 2003 (AHRQ grant HS10247).

• Higher rate of cesarean delivery does not necessarily correlate with better infant outcomes.

  The researchers linked vital birth certificate data to corresponding hospital discharge records on 171,295 singleton births in New Jersey in 1996 and 1997. They compared rates of perinatal mortality, birth injury, and uterine rupture among obstetricians performing low, medium, and high rates of cesarean delivery and found comparable perinatal mortality rates among the three groups. High cesarean rates did not improve the survival of low and very low birthweight infants.

  Li, Rhoads, Smulian, et al., Obstet Gynecol 101(6):1204-12, 2003 (AHRQ grant HS10795).

• Use of tocolytic therapy to stop uterine contractions may prolong pregnancy and prevent preterm birth.

  Treatment of preterm labor with bed rest, hydration, medication, and combinations of these interventions may be used to prevent preterm birth, the leading cause of infant death and serious neonatal problems. According to this review of the evidence, management of uterine contractions with first-line tocolytic therapy can prolong gestation, but maintenance tocolytic therapy has little or no value.

  Berkman, Thorp, Lohr, et al., Am J Obstet Gynecol 188(6):1648-59, 2003 (contract 290-97-0011).

• Delaying the urge to push during second-stage labor does not benefit women who receive low-dose epidural analgesia.

  According to this study, women giving birth for the first time who receive low concentration epidural analgesia do not benefit from delaying pushing efforts until there is a strong urge to push. Such a delay did not reduce the duration of pushing in the second stage of labor or increase maternal satisfaction among women in this study.

  Plunkett, Lin, Wong, et al., Obstet Gynecol 102(1):109-14, 2003 (AHRQ grant T32 HS00078).

• Later admission in labor and collaborative care increase spontaneous vaginal delivery in low-risk women.

  In this study, pregnant women who delayed hospital admission until active labor was established (at least 4 cm cervical dilation) and had collaborative care by a certified nurse midwife and obstetrician were more likely to have a spontaneous vaginal delivery—that is, unassisted by forceps, cesarean, or other intervention—than women who were admitted to the hospital early in labor (dilation of 3 cm or less).

  Jackson, Lang, Ecker, et al., J Obstet Gynecol Neonatal Nurs 32(2):147-57, 2003 (AHRQ grant HS07161).

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