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PubMed2003

Integrated perinatal health framework. A multiple determinants model with a life span approach.

BACKGROUND: Despite great strides in improving prenatal care utilization among American women, key perinatal indicators have remained stagnant or worsened in the past decade, and the United States continues to rank near the bottom compared to other developed countries. A new approach is needed if we are to achieve improvements in perinatal health. METHODS: To propose a new framework that integrates a "life span" approach with a multiple determinants model. RESULTS: We recognize that (1) powerful influences on outcome occur long before pregnancy begins; (2) pregnancy outcome is shaped by social, psychological, behavioral, environmental, and biological forces; and (3) the demography of pregnancy has changed dramatically in the last few decades with more women delaying their first birth. Approaches that simultaneously consider the entire life span as well as multiple determinants may need to be adopted. We propose a framework that integrates these approaches and is supported by the research literature. The life span perspective focuses attention toward the preconceptional and interconceptional periods as targets for intervention in improving perinatal health. The multiple determinants model distinguishes among concepts of disease, health and functioning, and well-being for both women and their offspring. CONCLUSIONS: Our intent is to influence how policymakers, public health professionals, clinicians, and researchers approach perinatal health.

Family Planning Services↗
PubMed2006

Prevailing discourses among AIDS care professionals about childbearing by couples with HIV in Taiwan.

The aim of this study was to analyze the dynamics of ideology, power and language in the dominant discourses about childbearing by couples with HIV that were expressed by AIDS care professionals in Taiwan. Critical discourse analysis of the interview texts with 11 AIDS care professionals identified three prevailing discourses on childbearing by couples with HIV/AIDS: pro-children, conditional pro-choice and pro-rights. The pro-children and conditional pro-choice were the predominant discourses. The two discourses both medicalized childbearing among couples with HIV/AIDS by identifying medical authorities as the proper persons to decide which reproductive choices people with HIV/AIDS should make under what conditions. Even though the pro-rights discourse embodied an ideology of individualism, empowerment and autonomy, it was weak and relatively rare in the other two discourses.

Adult↗
PubMed1993

Pregnancy planning and pre-conception counseling. The PRAMS Working Group.

OBJECTIVE: To estimate the percentage of women with one or more of four potentially modifiable risks who could have availed themselves of pre-conception counseling. METHODS: We defined pre-conception counseling to be consultation that occurs shortly before a couple attempts conception. Thus, we assumed that to obtain pre-conception counseling, a woman must plan her pregnancy. We used data from a population-based survey of 12,452 new mothers in four states who delivered babies during 1988-1990. Mothers were contacted 3-6 months after delivery and asked about pre-conception behaviors and the planning status of their pregnancies. We estimated the percentage of women who planned their pregnancies and had an indication for pre-conception counseling related to smoking, drinking, being underweight, or delaying initiation of prenatal care. RESULTS: State-specific response rates ranged from 68-84%. Sixty percent of mothers reported that their pregnancies were planned. In general, mothers with unintended pregnancies were more likely to have an indication for pre-conception counseling than mothers with planned pregnancies. Thirty-eight percent of all mothers planned their pregnancies and had one or more indications for pre-conception counseling. An additional 30% had one or more indications for counseling but did not have a planned pregnancy. CONCLUSIONS: Despite the limited range of indications for counseling that we considered, a substantial percentage of women potentially could have used counseling. A similar percentage of women could have benefited from family planning services.

Adult↗
PubMedDate not supplied

Management of epilepsy and pregnancy.

Epilepsy is recognized as the commonest serious neurological disorder in the world. Women with epilepsy (WWE) experience several gender-related physical and social problems. They constitute high obstetric risk because of reduced fertility, risk of seizures during pregnancy and complications of pregnancy. Hormonal and other factors can alter the pharmacokinetics of antiepileptic drugs (AED) during pregnancy and puerperium. Antenatal exposure to AEDs, particularly at higher dosage and in polytherapy, increases the risk of fetal malformation. Recent reports raise the possibility of selective developmental language deficits and neurocognitive deficits with antenatal exposure to AEDs. There are concerns regarding the effect of traces of AEDs that pass to the infant during breast-feeding. The pre conception management is the cornerstone for epilepsy care in WWE. A careful reappraisal of each case should ascertain the diagnosis, the need for continued AED therapy, selection of appropriate AEDs, optimization of the dosage and prescription of folic acid. During pregnancy, the fetal status needs to be monitored with estimation of serum a-feto-protein and ultrasound screening for malformations. The dosage of AEDs can be adjusted according to clinical requirement and blood levels of AEDs. Several institutions recommend oral vitamin K toward the end of pregnancy when enzyme-inducing AEDs are prescribed because the latter may potentially predispose the new born to hemorrhagic disease, but recent reports indicate that such a risk is practically negligible. WWE who are using enzyme-inducing AEDs (phenobarbitone, primidone, phenytoin, carbamazepine and oxcarbazepine) need to know that these AEDs may lead to failure of oral contraception.

Anticonvulsants↗
PubMed2005

Knowledge and use of folic acid in Croatian pregnant women--a need for health care education initiative.

Adequate periconceptional folic acid (FA) intake reduces the risk of neural tube defects. There are still no official FA supplementation guidelines, FA fortification policies or larger studies of awareness regarding FA or number of planned pregnancies in Croatia. This study assesses the knowledge and practice regarding FA supplementation and reports the trends in pregnancy planning in Croatia. A total of 569 pregnant women completed an anonymous questionnaire and about 72% of them were aware of the benefits of FA. Despite 75.53% of planned pregnancies, only 14.41% of all women took FA appropriately. Croatian women get information about FA from the media, health professionals and friends, but 63.77% got this information too late. The present study showed low percentage of appropriate FA intake despite high number of planned pregnancies in Croatia. It emphasizes the need for immediate and continuous public health education initiative about FA intake targeted to the women of childbearing age before their pregnancies have occurred.

Croatia↗
PubMed1996

Guidelines for the management of insulin-dependent diabetes mellitus in pregnancy.

The infant of an insulin-dependent diabetic mother is at increased risk of perinatal death, neonatal problems and major congenital malformations: Many of these problems are preventable. All young women with diabetes should receive contraceptive advice and information about pregnancy. The objects of pre-pregnancy care are to assess suit-ability for pregnancy, to optimise control in early pregnancy and to improve pregnancy outcome through the provision of individualised education and information. Pre-pregnancy care can reduce the congenital malformation rate to approximately that of the nondiabetic. In each area there should be one designated diabetologist and one designated obstetrician who, together with their team, should see all pregnant women in a combined clinic in a hospital with an intensive care baby unit. All pregnant women with diabetes should have 24-hour access to the specialist team. Tight glycaemic control during pregnancy can reduce complications of pregnancy greatly, improving infant mortality and morbidity. Insulin requirements usually change during pregnancy. Education about hypoglycaemia and avoidance of ketoacidosis is essential. Women should have regular examination of the fundi and renal function. They should have ultrasound scanning to assess gestation, to look for abnormalities and to assess fetal growth. Fetal monitoring should be used, particularly for those at high risk. Women with good diabetic control and no complications of diabetes or pregnancy may be delivered at 39 to 40 weeks but those at high risk earlier. During labour or caesarean section blood glucose should be normalised using intravenous glucose and insulin supervised by a specialist team. An experienced paediatrician should be available. Breast feeding should be encouraged.

Blood Glucose↗
PubMed2003

The effect of caffeine consumption and nausea on the risk of miscarriage.

Evidence for a harmful effect of caffeine intake on risk of miscarriage (spontaneous abortion) is inconsistent and nausea during pregnancy has been claimed to explain any association seen. The objective of this analysis was to determine whether caffeine consumption both before and during pregnancy influenced the risk of miscarriage in a group of pregnant women in the UK. We examined the association with maternal caffeine intake in a case-control study of 474 nulliparous women. Participants were recruited during the years 1987-89 from the Royal Berkshire Hospital in Reading and from a large group practice situated within the hospital's catchment area. Cases were 160 women with a clinically diagnosed miscarriage and controls were 314 pregnant women attending for antenatal care. Information on coffee/tea/cola consumption and potential confounders was collected by interview and caffeine content was assigned to individual drinks according to published data on caffeine content of beverages. Compared with a maternal caffeine intake of < 151 mg/day, we found evidence that caffeine consumption > 300 mg/day doubled the risk of miscarriage. Adjusted odds ratios were 1.94 [95% CI 1.04, 3.63] for 301-500 mg/day and 2.18 [95% CI 1.08, 4.40] for > 500 mg/day. This effect could not be explained by nausea in pregnancy. Nausea appeared to be strongly independently associated with a reduced risk of miscarriage (test for trend P < 0.0001). There was no evidence that prepregnancy caffeine consumption affected the risk. Our results indicate that high caffeine consumption during pregnancy (>300 mg/day), in particular coffee consumption, is an independent risk factor for increased risk and nausea is an independent protective factor for a lower risk of miscarriage.

Abortion, Spontaneous↗
PubMed2000

Stages in reproduction particularly vulnerable to xenobiotic hazards and nutritional deficits.

Biochemical research has identified many failures in reproductive processes with specific nutrient deficits, xenobiotics and some infectious illnesses. This has led to some effective safeguards. During meiosis and fertilization, as genetic material divides and rearranges, it is exposed and open to mutation. A nutritionally unfavourable environment is a major risk factor. At stages of rapid cell division, differentiation and organisation, as in the embryo and later in the fetal brain, the child's survival, completeness and future health and ability are at stake. From months before conception, reproduction needs preparing for, especially with today's environmental pollution, even entering the foodchain. Care from before conception can contribute not only to the child's healthy basis for life, full development of brain, eyesight and other complex attributes, but also to the health of at least the subsequent generation. Since the female baby's oocytes are being formed while she is still in the womb, the grandmother's nutritional status, around the time of conceiving a daughter, can permanently affect a grandchild. Recent insights into evolution, particularly of the brain, give us fresh indications of dietary needs to fulfil human potential for health and acuity. Despite the hazards, nature is remarkably successful. This paper is not designed to alarm but to help attainment of full genetic potential. With healthy parents serious malformations are a low percentage. The numbers of babies with avoidable disorders, however, calls urgently for action, especially in our own inner cities and in developing countries where there is inadequate nutrition. Action will more than justify itself, including financially. It will reward handsomely.

Brain↗
PubMed2005

Maternal knowledge, attitude and practice on folic acid intake among Arabian Qatari women.

BACKGROUND: Periconceptional folic acid supplementation is effective in preventing primary and secondary neural tube defects (NTDs) and other congenital defects. It is important to estimate folate intake and knowledge in women of child-bearing age, in relation to risk of congenital anomalies. AIM: The aim of this study was to determine the level of knowledge about the usefulness of periconceptional folic acid supplementation in a sample of women in the child-bearing age. DESIGN: This is a cross-sectional survey. SETTING: Eleven primary health care centers and women's hospital in Qatar. SUBJECTS: A multistage sampling design was used and a representative sample of 1,800 Qatari women aged between 18 and 45 years were surveyed during the period June to November 2004. One thousand four hundred and eighty women (82.2%) expressed their consent to participate in this study. METHODS: A confidential, anonymous questionnaire was completed by the selected subjects assessing folic acid awareness. Questionnaires were administered to women who were seeking routine antenatal care at health centers and Women's Hospital. Questions covered knowledge and use of folic acid supplements, pregnancy intention, and demographic and socioeconomic characteristics. Factors affecting study outcomes were examined individually by computing crude odd ratios and adjusted for other covariates using unconditional logistic regression. RESULTS: Out of 1480 women surveyed, 53.7% of them reported that they heard of folate. Of these, only half of the subjects knew that folate was something important. Overall, 20.3% of the respondents took folic acid. The most common information sources on folate were physicians (63.4%), and newspapers/magazine/books (21.7%). From those who heard of folate, only 14% knew that it can prevent birth defects. 40.6% of the subjects who heard folate were aware that green leafy vegetables were fortified with folic acid. In univariate analysis, awareness of folic acid was significantly associated with education of mother. Again, higher educated women (41.3%) knew more about folic acid and used it more often in the periconceptional and first trimester period. CONCLUSION: Awareness and use of folic acid was less prevalent among Qatari women. Educated women were aware of the importance of the intake of folic acid. The study findings suggested possible avenue for intervention to increase awareness and intake of folic acid.

Adult↗
PubMed2001

Pre-pregnancy drinking: how drink size affects risk assessment.

AIMS: We considered the role of drink size in determining average daily consumption among groups at risk for Fetal Alcohol Syndrome. DESIGN: In-person hour-long interviews gathered cross-sectional retrospective data about drinking before an index pregnancy. SETTING: Subjects were recruited at public clinics in Los Angeles and the San Francisco Bay area. To reach those not necessarily seeking prenatal care, community outreach in the same urban areas was undertaken. PARTICIPANTS: Three hundred and twenty-one pregnant women were interviewed: 102 Native Americans, 185 African Americans, and 34 Caucasians. MEASUREMENTS: Volume of drinking prior to pregnancy was assessed using the graduated frequency series, which asks respondents to specify their drinking in terms of standard drinks. Using vessel models and photographs, respondent-defined drink sizes were then determined, and volume was recalculated accordingly. FINDINGS: For most beverages, the difference in milliliters between self-selected drink size and a standard size drink was significant, with the mean self-selected drink sizes ranging from 49% above the standard size (for beer) to 307% above the standard size (for spirits). For women whose pre-pregnancy average daily volume (ADV) was at the risk level of > or = 1 standard drink per day, ADV increased from four to almost 10 standard drinks per day when self-defined drink sizes were instead considered. Similarly, for women having three or more standard drinks a day, their daily dose of ethanol increased from 57 g to 153 g of ethanol per day. CONCLUSIONS: If risk levels have been based on underestimates that assume women with alcohol-affected infants had standard drink sizes, then true risk levels may be higher than previously thought. Related, risk drinkers presenting at prenatal clinics may be missed if screening protocols do not ask about drink size.

Black or African American↗
PubMed2006

Folic acid knowledge and use in a multi-ethnic pregnancy cohort: the role of language proficiency.

OBJECTIVE: To investigate the role of language proficiency as determinant of folic acid knowledge and use in a multi-ethnic pregnancy cohort. DESIGN: Prospective cohort study. SETTING AND POPULATION: Pregnant women from Amsterdam attending obstetric care for their first antenatal visit. Number approached: 12,373 women, response rate: 67% (8266 women aged 14-49 years). Ethnicity was based on the country of birth: the Netherlands, Surinam, Antilles, Turkey, Morocco, Ghana, other non-Western and other Western countries. MAIN OUTCOME MEASURES: Knowledge about and use of folic acid supplements in pregnancy as elicited in a multilingual questionnaire, as well as determinants of these in ethnic groups separately. RESULTS: Both periconceptional folic acid use and knowledge were significantly lower among Ghanaian, Moroccan, Turkish, and other non-Western women than among women born in the Netherlands or other Western countries. Language proficiency in Dutch was a major determinant of knowledge in all the ethnic groups with a mother tongue other than Dutch [adjusted odds ratios (OR): Western 3.2, non-Western (all countries combined) 7.5], while educational attainment was of secondary importance. Knowledge in turn was the strongest determinant of use (adjusted OR: Western 17.4, non-Western 27.0). CONCLUSIONS: Periconceptional folic acid supplement use among women born in non-Dutch-speaking non-Western countries is low, reflecting a lack of knowledge that is determined by the inability to speak and understand the language of the country of residence. Measures to tackle this problem include the provision of linguistically appropriate information via ethnic health advisors, and language courses integrating health education for immigrants.

Adolescent↗
PubMed2003

Women's interest in GP-initiated pre-conception counselling in The Netherlands.

BACKGROUND: Pre-conception counselling has the potential to reduce pregnancy complications and congenital disorders. The timing of counselling, before conception, is crucial to maximize the benefit. As many couples are unaware of their risk status and the fact that the first period of pregnancy is crucial, they do not seek information before pregnancy occurs. To reach couples with timely information, it seems that a health care worker needs to take the initiative. In The Netherlands, the GP is in an ideal position to offer pre-conception counselling. OBJECTIVE: The aim of this study was to determine the interest of women aged 18-40 in pre-conception counselling if this is offered to them by their own GP. METHOD: A cohort of women (n = 1206) received a personal letter from their own GP with an offer of pre-conception counselling. The women were requested to fill in a reply form, indicating if they were interested, might be interested (if they decided to become pregnant) or were not interested in an invitation for pre-conception counselling. When interested, they were asked to give an indication as to when they were planning a pregnancy. Women who were not interested were requested to give a reason. RESULTS: Almost 70% of the women returned the reply form. Up to the age of 29 years, at least 80% of the respondents were interested or might be interested should they decide to have children. Most women, especially the younger women, do not know exactly when they wish to become pregnant. Regardless of age, >70% of the respondents were interested. Only 11% of the respondents indicated specifically that they were not interested in advice. CONCLUSION: Women are interested in GP-initiated pre-conception counselling. Further research is needed to assess the effect of programmed and systematic pre-conception counselling, offered by GPs, on pregnancy outcome and the health of the children. A randomized controlled trial to assess these effects currently is being conducted at the Department of General Practice in Leiden.

Adolescent↗
PubMed2002

Folic acid awareness and use among women with a history of a neural tube defect pregnancy--Texas, 2000-2001.

The use of folic acid is a critical component in preventing birth defects. Health-care providers should take advantage of all health-care visits to counsel not only women at high risk (i.e., those with a history of having an infant with a neural tube defect [NTD]) but all women regarding the importance of folic acid use. A study conducted in Texas confirmed that white and Hispanic mothers were equally likely to recall receiving postpartum advice to use folic acid; however, Hispanic women were much less likely to use folic acid, compared with white women. This report covers data from May 2000 through November 2001. A study was conducted in Texas to determine whether women at high risk recall and follow recommendations to use folic acid. The study included 195 women at high risk and 223 control mothers who gave birth to infants without birth defects. These women participated in a telephone interview for a population-based case-control study of NTDs. Approximately 56.4% (110 of 195) of mothers who had infants affected by an NTD recalled receiving postpartum advice to use folic acid, compared with 25.6% (57 of 223) of control mothers (p < 0.01). Among nonpregnant case mothers, 54 (32.7%) of 165 reported regular use of supplements containing folic acid, and 53 (25.2%) of 210 nonpregnant control mothers reported this behavior (p = 0.11). Among case mothers, use of folic acid was significantly higher for whites (64.7%) versus Hispanics (16.5%) (p < 0.001); for women with some college education (57.1%) versus no college education (20.2%; p < 0.001); for women who were trying to get pregnant (66.7%) versus those using birth control (38.3%) or reporting using no contraceptive method (18.8%) (p = 0.001); and for women who reported receiving advice to use folic acid (40.9%) versus those who did not (22.2%; p = 0.01). Findings from this study support the need to implement NTD recurrence prevention activities in Texas. Data also identify a need for educational strategies in Texas that target Hispanic women at high risk, especially those who primarily speak Spanish. Further efforts should be made to determine why Hispanic women have low rates of folic acid use (e.g., the cost of vitamins and language and cultural barriers). On the basis of a review of research and current practice, recommendations developed by the Public Health Service include 1) women at risk for a recurrent NTD-affected pregnancy should take 0.4 mg of folic acidper day; and 2) if a woman at high risk is planning a pregnancy, she should consult her physician regarding taking the higher dose of 4.0 mg per day.

Adult↗
PubMed2005

Prepregnancy health status and the risk of preterm delivery.

BACKGROUND: Despite extensive evaluation, our understanding of risk factors for premature delivery is incomplete. OBJECTIVE: To examine whether a woman's health status and risk factors before pregnancy are associated with a woman's risk of preterm delivery, independent of risk factors that occur during pregnancy. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort of pregnant women in the San Francisco Bay area who delivered a singleton infant (n = 1619). MAIN OUTCOME MEASURE: Preterm delivery (<37 weeks' gestational age). RESULTS: Sociodemographic characteristics alone explained 13.0% of the risk of preterm delivery, whereas risk factors that occurred before pregnancy explained 39.8% and risk factors that occurred during pregnancy explained 47.1%. After we adjusted for sociodemographic characteristics, prepregnancy risk factors, and pregnancy risk factors, women who reported poor physical function during the month before conception were nearly twice as likely to experience a preterm delivery (odds ratio, 1.97; 95% confidence interval, 1.18-3.30) as women with better physical function. CONCLUSION: A broader focus on the health of women prior to pregnancy may improve rates of preterm delivery.

Adolescent↗