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PubMed1998

Reasons for first teen pregnancies predict the rate of subsequent teen conceptions.

OBJECTIVE: To identify reasons for inconsistent contraceptive use that antedate conception and continue to predispose participants in adolescent-oriented maternity programs to unsafe sexual practices after delivery. We hypothesized that teens who attributed their failure to use contraceptives before their first conception exclusively to concerns about their side effects and/or their own lack of motivation to prevent conception would report less consistent contraceptive use and more repeat conceptions than would teens who attributed their previous failure to use contraceptives to their lack of capacity to do so. METHOD: We conducted a 2-year, prospective, longitudinal study of contraceptive use and repeat conceptions in a racially/ethnically diverse population of poor 13- to 18-year-olds. The 198 study participants were enrolled consecutively during their first pregnancies from an adolescent-oriented maternity program. RESULTS: The majority (84%) of the teens attributed their failure to use contraceptives before their first pregnancy partially to a lack of capacity to do so. As hypothesized, these teen mothers were significantly more likely to use hormonal contraceptives (85% vs 62%), (particularly Norplant, 47% vs 19%) and less likely to conceive again (13% vs 41%). Most teens attributed their inconsistent contraceptive use during the postpartum study period to three factors: side effects, plans to abstain from sexual intercourse, and their lack of motivation to postpone additional childbearing. CONCLUSIONS: The reasons teen mothers give for not using contraceptives consistently before their first pregnancies predict the occurrence of subsequent conceptions during adolescence. Those who attribute their previous failure to use contraceptives consistently to side-effect concerns and their own lack of motivation to postpone childbearing are least likely to use hormonal contraceptives after delivery and most likely to conceive again. Our findings suggest that future research should focus on the development of more effective interventions for preventing repeat conceptions among adolescent mothers who had the capacity to prevent their first pregnancies.

Adolescent↗
PubMed2006

[Association between maternal and newborn vitamin A status and economic stratum in Rio de Janeiro, Brazil].

BACKGROUND: Retinol was determined spectrophotometrically in the blood of 291 mothers at delivery and in the umbilical cord of the newborn. The mothers came from different socioeconomic strata in Rio de Janeiro. METHODS: Levels of retinol were determined using spectrophotometry (Bessey et al). RESULTS: The circulation levels of retinol were low (below 1.05 micromol/L) in 22.0% of the mothers and in 54.2% of the newborn. A close association was found between low levels in the mothers' serum and those in the children's umbilical cord (p <0.0001). There was no association between maternal vitamin A deficiency (DVA) and socioeconomic stratum, family income or level of education. CONCLUSIONS: DVA is a distressing health problem among mothers and newborns and its diagnosis must be included in antenatal care. This reinforces the concept that intervention programs must emphasize changes in feeding practices and focus on the most vulnerable groups, of which pregnant women warrant special attention, regardless of socioeconomic stratum.

Adult↗
PubMed2003

Integrating strategies for combating vitamin A deficiency: successes in Asia.

Indonesia and Bangladesh were among the first countries to distribute vitamin A capsules (VAC) to underfives in the early 1970s. Since then, VAC coverage has increased very much. In Indonesia, VAC are now distributed to underfives in two special months. In Cambodia, VAC distribution started less than a decade ago and coverage is yet <50%. After being linked to National Immunization Days, it is now linked to Immunization Outreach, which seems a good strategy. Because VAC are only distributed to underfives and postpartum women, and because coverage is usually around 50-80%, other strategies are implemented simultaneously. Recent HKI-evaluations found that promotion of dark-green leafy vegetables and eggs in Indonesia increased their consumption and improved vitamin A status. In Bangladesh, underfives and women of households with a homestead garden and/or poultry had a lower risk of vitamin A deficiency. The HKI Homestead Food Production Program aims at improving homestead food production activities in order to increase production and consumption of vitamin A-rich foods. Food fortification in Indonesia reaches large parts of the population, while coverage is related to socio-economic status and urban/rural location. The successes in Asia emphasize the need for multiple strategies and integration with other health and agricultural programs.

Adult↗
PubMed2006

Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women.

OBJECTIVE: With a prevalence of around 20%, childhood sexual abuse (CSA) is a relevant problem in obstetric care. The aim of our systematic review was to present the current knowledge on the influence of CSA on pregnancy, delivery, and early parenthood. DATA SOURCES: All English, French, or German primary and secondary literature from the reference lists found after screening the data banks Pubmed, PsycInfo, and Psyndex for publications that include the terms CSA or childhood traumatization and pregnancy, birth, delivery, labor, childbearing, breast feeding, or postpartum, and published after 1970 were reviewed for relevant data. METHODS OF STUDY SELECTION: Investigations of psychological/medical data banks and cross references revealed 43 relevant studies. Given the paucity of data on this important subject, we opted to review all of these studies. TABULATION, INTEGRATION, AND RESULTS: Although research projects on this topic are rare and the methodological quality of studies published to date is generally poor, women with a history of CSA seem to present a variety of long-term sequelae referring to pregnancy, delivery, and early parenthood. These sequelae include risk behaviors during pregnancy and disturbance of delivery by sudden memories of sexual abuse situations. Prenatal care is often complicated by the tendency to avoid situations that can trigger memories. CONCLUSIONS: As effective treatment programs to improve sequelae of CSA are available today, the question of such abuse experiences should be raised as early as possible and adequate interdisciplinary models to care for victimized patients should be established. However, to improve knowledge on the long-term effect of sexual abuse experiences in obstetrical care, methodologically well-designed research projects focusing on the kind and incidence of sequelae, mediating factors as well as prophylactic and therapeutic options are needed.

Adolescent↗
PubMed2004

Effectiveness of breastfeeding peer counseling in a low-income, predominantly Latina population: a randomized controlled trial.

BACKGROUND: Breastfeeding peer counseling has improved breastfeeding rates in developing countries; however, its impact in this country has not been adequately evaluated. OBJECTIVE: To evaluate the effectiveness of an existing, breastfeeding peer counseling program within the United States. DESIGN: Randomized, prospective, controlled trial in which participants were recruited prenatally and randomly assigned to receive either routine breastfeeding education or routine breastfeeding education plus peer counseling. SETTING: An urban hospital serving a large population of low-income Latinas. PARTICIPANTS: Pregnant women (< or =26 weeks' gestation) were recruited from the hospital's prenatal clinic. Inclusion criteria specified that participants be low income, be considering breastfeeding, have delivered a healthy, full-term singleton, and have access to a telephone. Intervention Breastfeeding peer counseling services included 1 prenatal home visit, daily perinatal visits, 3 postpartum home visits, and telephone contact as needed. MAIN OUTCOME MEASURES: Breastfeeding rates at birth and 1, 3, and 6 months postpartum. RESULTS: The proportion not initiating breastfeeding was significantly lower in the intervention group than among controls (8/90 [9%] vs 17/75 [23%]; relative risk, 0.39; 95% confidence interval, 0.18-0.86). The probability of stopping breastfeeding also tended to be lower in the intervention group at both 1 month (36% vs 49%; relative risk, 0.72; 95% confidence interval, 0.50-1.05) and 3 months (56% vs 71%; relative risk, 0.78; 95% confidence interval, 0.61-1.00). CONCLUSION: These findings demonstrate that, in the United States, peer counselors can significantly improve breastfeeding initiation rates and have an impact on breastfeeding rates at 1 and 3 months post partum.

Adolescent↗
PubMed1998

Trends of HIV-1 and sexually transmitted diseases among pregnant and postpartum women in urban Malawi.

OBJECTIVES: To examine rates of HIV-1 and sexually transmitted disease (STD) among pregnant and postpartum women in urban Malawi, Africa. DESIGN: Serial cross-sectional surveys and a prospective study. METHODS: Three major surveys were conducted in 1990, 1993 and 1994/1995. Consecutive first-visit antenatal women and women giving birth at the Queen Elizabeth Central Hospital were tested for HIV and STD after counseling and obtaining informed consent. Unlinked, anonymous HIV testing was also conducted on smaller samples of antenatal women in the same hospital to provide annual prevalence data. HIV-seronegative postpartum women from the 1990 and 1993 surveys were enrolled in a prospective study to determine HIV incidence. RESULTS: HIV seroprevalence rose from 2.0% in 1985 to 32.8% in 1996, a 16-fold increase. The highest age-specific HIV prevalence was in the following age-groups: 20-24 years during 1990, 25-29 years during 1993, and 30-34 years during 1996. Among 1173 women followed for a median of 30.9 months, HIV incidence was 5.98 per 100 person-years in women aged < 20 years and declined steadily in older women. The prevalence of STD significantly declined among both HIV-positive and negative women. This decline in STD prevalence, however, was not accompanied by increased condom use over time. CONCLUSIONS: Among urban childbearing women in Malawi, incidence of HIV is highest among young women while, currently, prevalence is highest among older women. Recent declines in STD prevalence suggest that HIV prevention programs are having an impact either through improved STD diagnosis and treatment or reduced risk behaviors. Sequential cross-sectional STD prevalence measures may be useful in monitoring effectiveness of STD and HIV prevention activities.

Adult↗
PubMed2000

A survey of managed care strategies for pregnant smokers.

OBJECTIVE: The purpose of this study was to measure the content and comprehensiveness of pregnancy specific smoking cessation strategies within managed care organisations (MCOs) responding affirmatively to the national 1997-98 Addressing Tobacco in Managed Care (ATMC) survey. DESIGN: This cross sectional follow up study consisted of a fax survey sent to medical directors and a 37 question telephone survey of program overseers about the smoking cessation strategy. SUBJECTS: 147 MCOs identifying a pregnancy specific smoking cessation strategy on the 1997-98 ATMC survey served as the initial sample; 88 MCOs of 128 eligible plans completed both components, with a response rate of 69%. RESULTS: Pregnancy specific smoking cessation strategies varied. 40% of respondents used the Agency for Health Care Policy and Research guidelines for clinical smoking cessation to design their strategy. Strategies included self help materials, quit classes, telephone support and brief counselling by providers, linkages to quality improvement efforts, and use of patient databases for outreach. Only 42% offered a postpartum relapse prevention element. Lack of patient interest, competing clinic priorities, and the lack of a smoker identification system were the most problematic barriers to implementing strategies, common to at least a quarter of respondents. A majority ranked best practice manuals and web site linkages as the most useful form of technical assistance, followed by peer-to-peer counselling, regional workshops, newsletters, on-site assistance, and national conferences. CONCLUSIONS: The survey provides the first profile of prenatal tobacco treatment strategies in managed care. While design limitations prevent generalisation of these results to all MCOs, such information can help guide technical assistance to plans interested in reducing smoking among pregnant women.

Cross-Sectional Studies↗
PubMedDate not supplied

Acupuncture: new perspectives in chemical dependency treatment.

The use of auricular acupuncture in treating acute drug withdrawal began in Hong Kong in 1972. Its practical application in the traditional drug treatment setting evolved at New York City's Lincoln Hospital during the 1970s, and over 250 acupuncture programs in diverse treatment settings have since been established world wide, based on the Lincoln protocol. Acupuncture treatment offers the client support during acute and postacute withdrawal through relief of classic symptoms. It has also been found useful as an entry point to treatment and/or recovery in such nontreatment settings as jails and shelters, and has particular efficacy in the treatment of resistant clients, and of prepartum and postpartum women. Though acceptance of the legitimacy of acupuncture by the chemical dependency community has been guarded, both research and outcome studies indicate that it holds promise as a complement to traditional substance abuse modalities.

Acupuncture Therapy↗
PubMed2005

Pertussis in adolescents and adults: should we vaccinate?

BACKGROUND: The incidence of reported pertussis among adolescents, adults, and young infants has increased sharply over the past decade. Combined acellular pertussis vaccines for adolescents and adults are available in Canada, Australia, and Germany and may soon be considered for use in the United States. OBJECTIVE: To evaluate the potential health benefits, risks, and costs of a national pertussis vaccination program for adolescents and/or adults. DESIGN, SETTING, AND POPULATION: The projected health states and immunity levels associated with pertussis disease and vaccination were simulated with a Markov model. The following strategies were examined from the health care payer and societal perspectives: (1) no vaccination; (2) 1-time adolescent vaccination; (3) 1-time adult vaccination; (4) adult vaccination with boosters; (5) adolescent and adult vaccination with boosters; and (6) postpartum vaccination. Data on disease incidence, costs, outcomes, vaccine efficacy, and adverse events were based on published studies, recent unpublished clinical trials, and expert panel input. MAIN OUTCOME MEASURES: Cases prevented, adverse events, costs (in 2004 US dollars), cost per case prevented, and cost per quality-adjusted life-year (QALY) saved. RESULTS: One-time adolescent vaccination would prevent 30800 cases of pertussis (36% of projected cases) and would result in 91000 vaccine adverse events (67% local reactions). If pertussis vaccination cost $15 and vaccine coverage was 76%, then 1-time adolescent vaccination would cost $1100 per case prevented (or $1200 per case prevented) or $20000 per QALY (or $23000 per QALY) saved, from the societal (or health care payer) perspective. With a threshold of $50000 per QALY saved, the adolescent and adult vaccination with boosters strategy became potentially cost-effective from the societal perspective only if 2 conditions were met simultaneously, ie, (1) the disease incidence for adolescents and adults was > or =6 times higher than base-case assumptions and (2) the cost of vaccination was less than $10. Adult vaccination strategies were more costly and less effective than adolescent vaccination strategies. The results were sensitive to assumptions about disease incidence, vaccine efficacy, frequency of vaccine adverse events, and vaccine costs. CONCLUSIONS: Routine pertussis vaccination of adolescents results in net health benefits and may be relatively cost-effective.

Adolescent↗
PubMed1997

Interpersonal psychotherapy: current status.

Interpersonal psychotherapy (IPT), a time-limited treatment for major depression, was developed, defined in a manual, and tested in randomized clinical trials by the late Gerald L Klerman, MD, and collaborators. It has subsequently been modified for different age groups (adolescents-elderly), types of mood disorders (dysthymia, bipolar disorder, antepartum and postpartum patients), and non-mood disorders (bulimia, drug abuse, borderline personality disorder, social phobia, somatization, medically ill patients). It has been used as a long-term treatment, in a group format, over the telephone, and as a patient guide. It has been translated into Italian, German and recently Japanese. Having begun as a research intervention, IPT is only recently being disseminated among clinicians or in residency training programs. The publication of efficacy data, the appearance of two practice guidelines in the United States that include IPT among treatments for depression, the interest in defined treatments for managed care and the endorsement of Consumers Guide have led to increasing requests for information and training. This paper briefly describes the concepts and techniques of IPT and the current status of adaptation. In summary, evidence from controlled clinical trials suggests that IPT is a reasonable alternative or adjunct to medication as an acute, continuation, and/or maintenance treatment for patients with major or mild depression, patients who are human immunodeficiency virus (HIV) positive, or who have bulimia. It is a promising treatment for depressed adolescents and for geriatric patients, for patients with dysthymia and as treatment for depressed couples marital disputes. A final conclusion awaits the completion of clinical trials underway before substantial claims can be made. IPT is not effective, as compared to a standard drug program, for opiate and cocaine addicted patients.

Adolescent↗
PubMed2000

Increased concentrations of plasma neuropeptide Y in patients with eclampsia and preeclampsia.

OBJECTIVE: Epinephrine and norepinephrine are associated with the hyperstimulation of the sympathetic nervous system. Neuropeptide Y is a potent vasoconstrictive substance that is released in response to sympathetic nerve stimulation. STUDY DESIGN: The concentrations of plasma neuropeptide Y in pregnant patients with eclampsia (n = 8), preeclampsia (n = 8), and normotension (n = 8) were measured by radioimmunoassay on admission and 6 days after delivery. Correlations between plasma concentration of neuropeptide Y and mean arterial blood pressure were also evaluated in these patients on admission and 6 days after delivery. RESULTS: The plasma level of neuropeptide Y in women with eclampsia (P <.001) and preeclampsia (P <.003) was found to be significantly elevated with respect to that in normotensive pregnant women. At 6 days after delivery the concentration of plasma neuropeptide Y was significantly decreased in women with eclampsia, women with preeclampsia, and women with normotensive pregnancies compared with the value measured on admission (P <.0001, P <.0001, and P <.002, respectively). At admission the plasma neuropeptide Y level was positively correlated with mean arterial blood pressure in women with eclampsia and preeclampsia. However, no significant correlations were observed between plasma neuropeptide Y concentration and mean arterial blood pressure both at admission and 6 days after delivery in normotensive pregnant women and 6 days after delivery in women with eclampsia and preeclampsia. CONCLUSION: We have concluded that the level of neuropeptide Y in plasma is increased in women with eclampsia and preeclampsia. Elevated plasma neuropeptide Y levels may play a key role in the development of eclampsia and preeclampsia.

Adult↗
PubMed2005

Increased rate of major malformations in offspring exposed to valproate during pregnancy.

OBJECTIVE: To determine the rate of occurrence of major malformations in infants whose mothers had taken the drug valproic acid (VPA) as monotherapy during the first trimester of pregnancy and had enrolled in the North American Antiepileptic Drug Pregnancy Registry. METHODS: Data were collected from pregnant women throughout the United States and Canada through telephone-based interviews. Each woman was interviewed at enrollment, at 7 months' gestation, and postpartum. With her written permission, the medical records of each mother and her infant were obtained. The major malformations tabulated were those identified at or before 5 days of age. The prevalence of congenital malformations among offspring of monotherapy VPA-exposed women was compared with that among infants of women exposed to all other antiepileptic drugs (internal comparison group) and with that among newborns in the Active Malformations Surveillance Program at Brigham and Women's Hospital (external comparison group). RESULTS: Sixteen affected cases were identified among 149 VPA-exposed women (proportion: 10.7%; 95% CI: 6.3 to 16.9%). The prevalence in the internal comparison group was 2.9% (95% CI: 2.0 to 4.1%; odds ratio: 4.0, 95% CI: 2.1 to 7.4; p < 0.001). Assuming a 1.62% prevalence in the external comparison group, the relative risk of having an affected offspring for VPA-exposed women was 7.3 (95% CI: 4.4 to 12.2; p < 0.001). CONCLUSION: Maternal exposure to valproic acid during the first trimester of pregnancy significantly increased the risk of major malformations.

Abnormalities, Drug-Induced↗
PubMed2001

The timing and predictors of the early termination of breastfeeding.

OBJECTIVE: To determine the prevalence and correlates of the early discontinuation of breastfeeding by mothers eligible for the Women, Infants, and Children Program (WIC). METHODOLOGY: A longitudinal observational study in which we enrolled English-speaking mothers who initiated breastfeeding after delivering healthy-term infants at Yale-New Haven Hospital and planned to bring their infants to the hospital's primary care center. Data on mother's baseline knowledge, attitudes, beliefs, and problems regarding breastfeeding were collected by semistructured interviews within 48 hours after delivery, at 1 and 2 weeks' postpartum, and by chart reviews at 2 and 4 months. A nonparticipating control group was used to test the Hawthorne effect. RESULTS: Of the 64 participating mothers, the majority were minority (56% black, 34% of Puerto Rican origin), single (75%), and already enrolled in WIC (91%). The rates of discontinuation of breastfeeding were 27%, 37%, 70%, and 89% by 1 week, 2 weeks, 2 months, and 4 months, respectively. The mother's knowledge and problems of lactation were not associated with the early discontinuation of breastfeeding. After using logistic regression to control for potential confounders, mothers who lacked confidence at baseline that they would still be breastfeeding at 2 months (risk ratio: 2.38, 95% confidence interval: 1.82-6.18), and those who believed that the baby prefers formula (risk ratio: 1.68, 95% confidence interval: 1.04-2.71) were more likely to stop breastfeeding within the first 2 weeks postpartum. CONCLUSIONS: The results of this study demonstrate that interventions aimed at prolonging the duration of breastfeeding in this population will need to shift focus from increasing knowledge and managing problems of lactation to enhancing the mother's confidence regarding breastfeeding, while also addressing beliefs regarding an infant's preferences.

Breast Feeding↗
PubMed2003

Triplet pregnancy after oocyte donation in women 46 years of age and older: three case reports.

PURPOSE: Presentation of three triplet pregnancies achieved in women 46 years of age and older with the use of donated oocytes. MATERIAL & METHODS: Two healthy perimenopausal women 46 and 48 years old and one healthy menopausal woman 48 years old, requesting fertility options. All of them followed oocyte donation programs resulting in triplet pregnancy. Maternal as well as perinatal complications, mode of delivery and birth weight are reported. RESULTS: Three triplet pregnancies were achieved using donated oocytes. Prenatal diagnosis was reassuring. Preterm rupture of membranes, preterm labor and gestational diabetes complicated the pregnancies. Cesarean section was the mode of delivery for all the cases giving birth to nine healthy neonates weighing between 1,130 and 2,450 g. No postpartum complications were encountered. CONCLUSIONS: Triplet pregnancies achieved with the use of donated oocytes at a very advanced maternal age represent high-risk obstetrical cases. Cautious prenatal evaluation of maternal health and intensive antenatal surveillance are imperative principles allowing the most favorable outcome of these pregnancies.

Cesarean Section↗
PubMed1998

WIC-based interventions to promote breastfeeding among African-American Women in Baltimore: effects on breastfeeding initiation and continuation.

We evaluated the single and combined effects of introducing a motivational video and peer counseling into four matched WIC clinics on breastfeeding initiation and continuation at 7-10 days among African-American WIC participants. Of the 242 women with complete data, 48% initiated breastfeeding, but only 31% were still breastfeeding at 7-10 days. Initiation was associated with cesarean delivery, infant feeding instruction, no artificial milk discharge pack, attending the peer counselor only-intervention site, and intention to breastfeed. Continuation was influenced by infant feeding instruction, no artificial milk discharge pack, and intention to breastfeed. Overall, trends toward a positive impact of the breastfeeding promotion activities were evident but weak, and largely gone by 7-10 days postpartum.

Adolescent↗
PubMed1985

The medical management of diabetes in pregnancy.

This article is divided into three sections. "Metabolic Adaptations to Normal Pregnancy" describes the changes in intermediary metabolism that normally attend pregnancy and relates these changes to states of insulin deficiency--i.e., diabetes. "Implications for the Conceptus" reviews our current understanding of how the metabolic derrangements that characterize maternal diabetes may affect embryo and fetal development. "Management" details practical aspects of a management program aimed at normalizing pregnancy outcome for women with both pregestational and gestational diabetes mellitus.

Blood Glucose↗