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PubMed1991

Maternity care and outcomes in a high-risk service: the North Central Bronx Hospital experience.

The maternity service of the North Central Bronx Hospital, a New York City municipal hospital for the medically indigent, has demonstrated that good maternal and infant outcomes can be obtained in an unselected population of disadvantaged women by using obstetric interventions only when medically indicated. Approximately 70 percent of the mothers cared for in the service are considered at risk or high risk. Of the 3287 deliveries in 1988, 86.1 percent were performed by the midwives on staff. Midwives were the primary providers of prenatal, intrapartum, and postpartum care for all low-risk mothers, and comanaged with the attending obstetricians the care of all high-risk mothers. The cesarean section rate was 11.8 percent, and the rate of instrumental delivery was 0.3 percent, with minimal use of oxytocin augmentation (6.4%). Among the 3323 infants delivered in 1988, the last full year before an obstetric residency program was established, the rate of those requiring special or intensive care was 11.1 percent, and neonatal mortality was 9.2 per 1000 live births for all birth weights and 3.7 per 1000 for infants over 1000 g. The experience gained from 10 years and over 25,000 births suggests that the maternity care of both high- and low-risk mothers could be improved by minimizing obstetric intervention whenever possible.

Delivery, Obstetric↗
PubMed2004

Perinatal HIV-1 transmission among low income women participants in the HIV/AIDS Control Program in Southern Brazil: a cohort study.

OBJECTIVE: To determine the rate and factors associated with perinatal transmission among women infected with HIV-1. DESIGN: Cohort study. SETTING: Centro Municipal de Atendimento em DST/AIDS is a major reference centre for HIV treatment in Porto Alegre city, southern Brazil. POPULATION: Pregnant and puerperal women infected with HIV-1. METHODS: Women were enrolled during pregnancy and seen monthly at the antenatal care centre. Those detected at delivery that presented at the centre within the first 10 days of postpartum were included. Maternal, obstetric and infant-related characteristics were ascertained and testing for CD4 cell count, HIV PCR/RNA assay, anti-HCV, HBSAg and syphilis were performed. Antiretrovirals and formula were provided free of charge following Brazilian guidelines. MAIN OUTCOME MEASURE: HIV-1 infection status in the infant. RESULTS: Perinatal transmission was assessed in 343 children (95% of the whole sample). Overall, the transmission rate was 3.2% (95% CI: 1.7-5.8%). Perinatal transmission rates increased with maternal viral load (>/=10,000 copies/mL; RR: 11.27; 95% CI: 1.38-92.23). In multivariate analyses, the only independent risk factor for perinatal transmission was the maternal viral load at baseline (OR = 2.72 per log increase in the number of copies; 95% CI: 1.17-6.50). CONCLUSION: Perinatal transmission rate was low among HIV-1 infected women in clinical care and on antiretroviral therapy despite poor socio-economic conditions. Viral load level was the only independent predictor of perinatal transmission. It is possible to prevent HIV-1 perinatal transmission in a developing country if we provide antiretrovirals and formula.

Adult↗
PubMed2005

Validation of pressure measurements and electromyographic results for the uterus of cattle during the early postpartum period.

OBJECTIVE: To evaluate methods for on-farm measurements of uterine contractility in postpartum dairy cows by comparing data simultaneously recorded by use of 2 intrauterine pressure (IUP) devices and quantified electromyographic (EMG) signals. ANIMALS: 5 cows during the first 48 hours after parturition. PROCEDURE: 2 EMG electrodes were implanted on the surface of the gravid uterine horn. Parturition was induced by injection of a prostaglandin F2alpha analogue at day 274 of gestation. An open-tip catheter and pressure microtransducer were transcervically inserted and affixed to a caruncle immediately after calving. Changes in IUP were recorded concurrent with EMG recordings during 2-hour periods at 2, 6, 12, 18, 24, 36, and 48 hours after parturition. Novel acquisition and analysis software programs were used with a digital data-filtering capability for evaluation of IUP and EMG signals. RESULTS: The method for intrauterine fixation of the 2 pressure measurement instruments was effective and allowed easy, externally guided removal of the devices 48 hours after parturition. There was a high correlation between the data obtained by the 2 pressure measuring systems. Good correlation was also found between pressure data obtained by the open-tip catheter system and EMG signals. Although the quantified IUP and EMG signals were highly comparable, synchronization was not always evident during visual inspection of these signals. CONCLUSIONS AND CLINICAL RELEVANCE: The open-tip IUP catheter system with a special fixation method is suitable for use in on-farm studies. It will enable investigators to record natural and pharmacologically influenced uterine contractility in early postpartum dairy cows.

Animals↗
PubMed2005

Impact of domestic violence and drug abuse in pregnancy on maternal attachment and infant temperament in teenage mothers in the setting of best clinical practice.

We examined whether the prenatal detection of family violence and initiation of a comprehensive prenatal individualised care program could ameliorate the impact of family violence on maternal attachment to her infant at 6-months of age. An assessment of domestic violence was established for each subject at the 1(st) antenatal visit and women were classified as being exposed to domestic violence in pregnancy (EDV) or as being not exposed to domestic violence. Outcomes were determined 6 months postpartum. Of 173 consecutive women who met the eligibility criteria, consent was obtained from 150 (87% response). Women who had been subjected to domestic violence showed reduced overall attachment scores to their infants. Following multivariate analysis, drug use in pregnancy and domestic violence showed a significant independent effect on maternal attachment. Drug abuse and domestic violence were also associated with an increase in the easy-difficult scale of infant temperament. Thus, despite excellence in prenatal care, drug abuse and domestic violence were associated with poorer maternal attachment and assessment of infant temperament, suggesting that additional interventions are still required.

Adolescent↗
PubMed1993

Changes in pituitary gonadotropin-releasing hormone receptor messenger ribonucleic acid content during lactation and after pup removal.

Lactation is associated with a reduction in pituitary GnRH receptor content (GnRH-R) when compared with diestrus of the estrous cycle. These studies examined whether the changes in GnRH-R during lactation involved alterations in GnRH-R gene expression. GnRH-R messenger RNA (mRNA) levels were assessed by in situ hybridization, using a 35S-labeled antisense riboprobe coding for the transmembrane region of the mouse GnRH-R gene. The area occupied by grains in 20-microns sections of the pituitary was assessed with an image analysis program. The specificity of the probe for GnRH-R mRNA was demonstrated by the presence of only background grains over the pituitary when a sense riboprobe to GnRH-R mRNA was used. Also, there was an absence of clusters of grains over the posterior pituitary, an area devoid of gonadotropes. In lactating rats suckling eight pups on day 10 postpartum, GnRH-R mRNA levels in the anterior pituitary were suppressed by 60% when compared with the levels observed during diestrus. Removal of the eight-pup suckling stimulus for 24 h reestablished the diestrous pattern of GnRH-R mRNA expression. These results demonstrate that the suckling stimulus results in a significant suppression of GnRH-R mRNA levels that is reversed by removal of the stimulus. These changes in GnRH-R mRNA most likely contribute to the changes in GnRH-R content observed in response to the suckling stimulus.

Animals↗
PubMed2004

Peripartal propylene glycol supplementation and metabolism, animal health, fertility, and production in dairy cows.

The effect of peripartal supplementation with concentrate enriched at 10% propylene glycol (PG) on metabolism, animal health, fertility, and milk production was studied using 234 cows from 8 dairy farms with production averages of 8019 to 10,656 kg/yr. The feeding schedule for the PG group (n=117) was as follows: 13 d antepartum: 1.5 kg/d (= 150 mL PG); 12 d antepartum until parturition: 3 kg/d (= 300 mL PG); 1 to 12 d postpartum: 1 kg/d (= 100 mL PG). Control cows (n=117) received the same concentrate without PG. From a subset of cows (PG: n = 43; control: n = 40), blood samples were collected at 6, 3, and 1 wk antepartum, 3 d antepartum, on the day of parturition, and 1, 3, 5, 7, 9, and 11 wk postpartum for the determination of nonesterified fatty acids (NEFA), beta-hydroxybutyrate (BHBA), insulin-like growth factor (IGF)-I, and activities of aspartate-aminotransferase (AST) and glutamate-dehydrogenase (GLDH). From another subset of cows (PG: n=11; control: n=10), blood samples were collected 1 wk antepartum, on the day of parturition, and 1 wk postpartum to determine immunophenotypical and functional parameters of blood neutrophils. From 1 wk antepartum to 1 d postpartum, concentrations of NEFA were significantly lower in cows receiving PG compared with controls. Also, concentrations of BHBA in cows receiving PG were significantly lower from 1 wk antepartum until 7 wk postpartum. Concentrations of IGF-I were significantly higher in the PG group, from 1 wk antepartum until 1 wk postpartum than in the control group. Activities of AST and GLDH did not differ between groups. Immunophenotypical and functional characteristics of blood neutrophils were not influenced by treatment nor were animal health, reproduction, or milk production. Although indicators of metabolic status were improved by peripartal use of PG-enriched concentrate, economic benefits are questionable for dairy farms with good nutritional programs, as economically important factors such as milk production, animal health, and fertility were not influenced.

3-Hydroxybutyric Acid↗
PubMed2006

Evaluation of a web-based course for community nurses on postpartum emotional distress.

The purpose of this multicentre and quasi-experimental study is to evaluate the effect of a web-based course for community nurses in Iceland with regard to outcome of postpartum emotional distress. A sample of six community health centres was selected and equally divided into an experimental and a control group. All nurses at the experimental centres attended a web-based course focusing on evidence-based interventions for postpartum emotional distress. All new mothers were screened 9 weeks postpartum using the Edinburgh Postpartum Depression Scale (EPDS). If they scored 12 points or more they were eligible for the study. Mothers answered the EPDS at three different points in time, (9, 15 and 24 weeks postpartum) and the Parent Stress Index: Short Form (PSI/SF) at two times (9 and 15 weeks). Results showed no significant difference in the rate of depressive symptoms between study centres at 9 weeks. At 15 and 24 weeks there was, however, a significant difference between mothers at the experimental and control centres. Nurses at the experimental centres documented significantly more evidence-based interventions than did nurses at the control centres, and they had more frequent contact with new mothers suffering from postpartum emotional distress. There was no significant variation in PSI scores between the groups at any time. More women at the experimental centres were on antidepressants compared to the control centres. Of the total of 32 women eligible for the study, 10 declined participation. The findings are limited by small sample size and a probable confounding effect of antidepressants with the nursing interventions. Findings indicate that the web-based transfer of knowledge to nurses on evidence-based interventions for postpartum emotional distress has a positive effect on distressed women in the postpartum period and warrants further study.

Adult↗
PubMed1997

Correlates of voluntary human immunodeficiency virus antibody testing reported by postpartum women.

OBJECTIVES: This study examined attitudes, knowledge, and behaviors reported by postpartum women in an AIDS epicenter toward voluntary human immunodeficiency virus (HIV) counseling and testing. METHODS: From February 1993 to March 1994, a convenience sample of 544 women underwent postpartum interviews at a municipal hospital in the Bronx, New York City. Demographic information and obstetric, sexual, drug use, and HIV testing histories were elicited, and selected variables were abstracted from the medical charts. Univariate and multivariate logistic regression analyses were performed. RESULTS: Seventy-nine percent of women were voluntarily tested for HIV. In the multivariate model, the strongest individual correlate of HIV testing was a history of drug use. Other independent correlates were being age 25 or younger, having only one child, knowing someone who died of AIDS, and having stigma-related concerns about testing. In univariate analysis, women with a drug risk were more than nine times as likely as others to have delivered without receiving any prenatal care during this pregnancy. CONCLUSIONS: Voluntary counseling and testing programs can succeed in testing a majority of hospitalized childbearing women. However, women at risk of drug use, who more often reported testing, were probably tested outside of prenatal care settings. Efforts to reduce vertical transmission of HIV infection must focus on bringing more women, especially women who use drugs, into prenatal care.

Adult↗
PubMedDate not supplied

Medicaid expenditures for maternity and newborn care in America.

An Alan Guttmacher Institute (AGI) survey of the Medicaid programs in each state and the District of Columbia found that some 542,000 low-income women have a Medicaid-subsidized delivery each year--about 15 percent of all women who give birth. The proportion ranges from three percent in Alaska to 25 percent in Michigan. The federal and state governments spend almost $1.2 billion annually for maternity care (including prenatal, postpartum and newborn care); the average expenditure per patient is $2,200. Tennessee reports the highest expenditure per patient ($3,500) and Louisiana the lowest ($1,300). Only the highest payments under Medicaid are close to charges for maternity care in the open market, a fact that results in a significant disincentive for physicians and hospitals to accept Medicaid patients. The $1.2 billion spent for Medicaid-subsidized maternity care compares with an estimated $11.5 billion spent for such care nationwide. Thus, Medicaid pays for about 10 percent of the nation's maternity care bill, although Medicaid subsidizes deliveries for 15 percent of all women who give birth. The figures for maternity care do not include Medicaid expenditures for neonatal intensive care, which, for the 17 states reporting data, average about $11,800 per infant. Although only about six percent of all newborns whose deliveries are subsidized by Medicaid require neonatal intensive care, such care is so expensive that it adds about 30 percent to all Medicaid expenditures for maternity care. Increased Medicaid payments for maternity care, including prenatal care, could have a positive impact on health outcomes for low-income mothers and their babies, and could reduce the necessity for massive and expensive medical treatment for newborns.

Child Health Services↗
PubMed1980

Post-partum tubal ligation by nurse-midwives and doctors in Thailand.

A shortage of doctors limits the provision of post-partum sterilisation services in rural areas of Thailand. To overcome this problem nurse-midwives with theatre experience were trained to perform post-partum tubal ligation by a mini-laparotomy incision under local anaesthesia. The performance of the nurse-midwives was compared with that of doctors in a controlled, randomised clinical trial. Some operative difficulty was encountered by the nurses in 4.9% of cases and by the doctors in 2.0% of cases. This difference is not statistically significant and arose largely because the nurse-midwife cases were more obese. Nurse-midwives required a significantly longer operating-time (18.5 min) than doctors (11.9 min). However, postoperative morbidity was similar in the two groups (7.0% and 6.0%, respectively). These results suggest that trained nurse-midwives with theatre experience can safely provide post-partum sterilisation services. A further field trial is underway.

Clinical Trials as Topic↗
PubMedDate not supplied

Is lactation nature's contraceptive? Data from Samoa.

Data from a Samoan menstruation study suggest that lactation, even intensive on-demand lactation, does not inhibit menstruation or conception. This paper explores the applied and theoretical implications of continuing to accept lactation as a universally effective fertility control mechanism. Such thinking can have disastrous implications for family planning programs, and it keeps us from challenging long-held assumptions about lactation's role in population growth in early populations.

Body Weight↗
PubMed2000

Triple marker screening for trisomy 21, trisomy 18 and open neural tube defects in singleton pregnancies of native Japanese pregnant women.

OBJECTIVE: To report the results of prenatal triple marker screening on a population of Japanese pregnant women. METHODS: From April 1994 through March 1999, a total of 32,925 native Japanese women with singleton pregnancies requested a triple marker-screening test. Multiples of the median values for 3 markers and individual risks for each patient were calculated following adjustment for the Japanese weight correction factor. The risk cut-off values used for Down syndrome (T21), open spina bifida (OSB) and trisomy 18 (T18) were 1: 295, 1: 290, and 1: 100, respectively. Follow-up information was collected postpartum and statistically analyzed. RESULTS: Detection rates (DR) of T21 for women less than 35 years, over 35 years and overall were 58, 94, and 83%, respectively. DR of T18 for women less than 35 years, over 35 years and overall were 75, 79, and 79%, respectively. DR of open neural tube defects (ONTD) was 100%. CONCLUSIONS: The first cumulative data of an intervention program and prospective follow-up studies in Japan have proven to be similar to other published reports. Individual risk values were calculated for each pregnancy for T21, T18 and ONTD. This screening program is more effective than age-dependent screening for detecting T21, T18 and ONTD pregnancies.

Adult↗
PubMed1996

[Puerperium with short-term hospitalization].

Seventy seven cases with discharge before 12 hours post-partum and 240 cases with discharge after 24 or more hours after delivery, were evaluated at Hospital General de México, in an observational, prospective, cohort, study in low risk deliveries. Both groups were reviewed ten days after delivery. There were no different ratios for abnormal uterine hemorrhage, urinary tract infection or endometritis. Thrombophlebitis was more frequent in early discharge patients, both statistically and clinically significant (RR3.58, CI95% 1.48-8.67, P = 0.003). This finding is discussed, as well as measures to prevent it. It is concluded that early discharge programs in low risk conditions, are convenient.

Adult↗
PubMed2004

The appropriateness of red blood cell transfusions in the peripartum patient.

OBJECTIVE: Despite published guidelines, numerous studies have consistently shown that a significant proportion of red blood cell (RBC) transfusions are unnecessary. The purpose of this study was to evaluate the reasons for and the appropriateness of RBC transfusions in the peripartum patient. METHODS: We reviewed all RBC transfusions given to peripartum inpatients at Sunnybrook and Women's College Health Sciences Centre in Toronto, Ontario, Canada between April 1994 and July 2002. Appropriateness of RBC transfusion was ascertained using current hospital transfusion guidelines. RESULTS: We identified 33,795 obstetrics-related admissions. In 218 admissions (0.65% of all admissions), an RBC transfusion was given to 216 women. There were 83 vaginal deliveries, 94 deliveries by cesarean, and 42 operations (for ectopic pregnancies or dilatation and curettage). A total of 779 RBC units were transfused (median, 2 units per woman; range, 1-32), most commonly for postpartum bleeding (34% of cases). There were 16 adverse events from transfusion recorded. According to guidelines, 248 of the transfused RBC units (32%) were not appropriate. In addition, in 24 patients (11%) the mean corpuscular volume on admission to the hospital for delivery was less than or equal to 80 fL. CONCLUSION: A significant proportion of RBC transfusions given to peripartum women are inappropriate. Educational programs that promote adherence to transfusion guidelines might help reduce exposure to RBC transfusion. Aggressive oral and intravenous iron therapy might have prevented transfusion in 11% of the women in the cohort who were possibly iron deficient.

Adult↗
PubMed2003

The effect of a parenting education program on the use of preventive pediatric health care services among low-income, minority mothers: a randomized, controlled study.

OBJECTIVE: To determine if a community-based intervention program focusing on parenting education will have an impact on preventive health care utilization behaviors among low-income, minority mothers in Washington, DC. DESIGN: The experimental design was a randomized, controlled study in which 286 mother-infant dyads were assigned to either the standard social services (control) group or to the intervention group. Women and their newborn infants were recruited during the immediate postpartum period in 4 Washington, DC, hospital sites from April 1995 to April 1997. The year-long multicomponent intervention included home visits and hospital-based group sessions in addition to the standard social services available at the hospital sites. A total of 286 postpartum women with inadequate prenatal care were assigned randomly to the control or the intervention group. Women and their infants were followed for 1 full year. Outcome measures included usage of preventive health care services including well care infant visits and adherence to immunization schedules during the first year of the infant's life. RESULTS: Infants in the intervention group initiated well care at an earlier age than controls (by 6 weeks, 62.5% vs 50% had received their first well infant visit). Infants in the intervention group had more frequent well visits (by 12 months of age, 3.5 vs 2.7 visits). Multivariate analyses showed infants in the intervention group to be more likely to complete their scheduled immunizations (by 9 months, odds ratio = 2.2, 95% confidence interval: 1.09-4.53). Those in the intervention group with more frequent contacts (30+ visits) with study personnel were most likely to have followed age-appropriate immunization schedules when compared with controls (at 9 months odds ratio = 3.63, 95% confidence interval: 1.58-8.33). CONCLUSIONS: It is possible to influence health care usage patterns of high-risk minority populations through public health interventions that are global in their perspective. Focusing on parental knowledge and beliefs regarding health-related issues and life skills in a self-efficacy model is associated with improved usage of infant health care resources.

Adult↗
PubMed1988

Warm bodies, cool milk: conflicts in post partum food choice for Indochinese women in California.

The Federal Special Supplemental Food Program for Women, Infants and Children provides nutritious foods and dietary counselling to low income women and children with a medically certified nutritional risk. The Public Health Foundation, a large WIC agency in Los Angeles, observed declining breastfeeding rates among Indochinese participants. We interviewed 110 Cambodian, ethnic Chinese and Vietnamese WIC participants about their infant feeding decisions and experience. These women believed that formula was superior to breastmilk for a number of reasons, some related to the Asian humoral medical system. The women described 'excessive cooling' during childbirth that they hoped to counter-balance by consuming humorally hot foods for 100 days post partum. A hot maternal diet was thought to produce unhealthy breastmilk after 1 month, so the women preferred using infant formula, perceived to be stable and more nourishing than breastmilk. The WIC Program is using these and other findings to make breastfeeding more attractive to Southeast Asians.

Adolescent↗
PubMed1998

Smoking relapse prevention during pregnancy. A trial of coordinated advice from physicians and individual counseling.

INTRODUCTION: Our objective was to examine the efficacy of physicians' advice and referral to individual counseling in preventing relapse to smoking among women who were smokers early in pregnancy, but quit prior to their first prenatal visit. DESIGN: A randomized controlled trial of prompted physician's advice and individual relapse prevention counseling during pregnancy compared to usual physician advice. Smoking status was assessed by self-report, exhaled carbon monoxide, and urinary cotinine during pregnancy and by self-report 1 year postpartum. RESULTS: There were no significant differences in relapse rates between the intervention and usual-care groups during pregnancy, nor at 1 year postpartum. Relapse rates were 23% in both groups at the 36-week visit, and 32% and 22%, respectively, 1 year postpartum. Younger age, higher motivation to resume smoking, and higher levels of exhaled carbon monoxide at the first prenatal visit were predictive of relapse to smoking during pregnancy. With the conservative assumption that all those lost to follow-up relapsed, the combined 1-year postpartum relapse rate, 51%, was 17 percentage points lower than we observed in an earlier relapse prevention trial, and 15 percentage points lower than that observed nationally a decade earlier. CONCLUSION: Prompting physicians to provide supportive advice combined with referral to individual relapse prevention counseling did not reduce smoking relapse rates during pregnancy, or postpartum. However, the level of attention paid to smoking by physicians in both intervention and usual-care groups during pregnancy may have contributed to the relatively low relapse rates seen 1-year postpartum.

Adult↗