Archive for the ‘reproductive health’ Category

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database

October 23, 2014 Comments off

Maternal Clinical Diagnoses and Hospital Variation in the Risk of Cesarean Delivery: Analyses of a National US Hospital Discharge Database
Source: PLoS Medicine

Cesarean delivery is the most common inpatient surgery in the United States, where 1.3 million cesarean sections occur annually, and rates vary widely by hospital. Identifying sources of variation in cesarean use is crucial to improving the consistency and quality of obstetric care. We used hospital discharge records to examine the extent to which variability in the likelihood of cesarean section across US hospitals was attributable to individual women’s clinical diagnoses.

Methods and Findings
Using data from the 2009 and 2010 Nationwide Inpatient Sample from the Healthcare Cost and Utilization Project—a 20% sample of US hospitals—we analyzed data for 1,475,457 births in 1,373 hospitals. We fitted multilevel logistic regression models (patients nested in hospitals). The outcome was cesarean (versus vaginal) delivery. Covariates included diagnosis of diabetes in pregnancy, hypertension in pregnancy, hemorrhage during pregnancy or placental complications, fetal distress, and fetal disproportion or obstructed labor; maternal age, race/ethnicity, and insurance status; and hospital size and location/teaching status.

The cesarean section prevalence was 22.0% (95% confidence interval 22.0% to 22.1%) among women with no prior cesareans. In unadjusted models, the between-hospital variation in the individual risk of primary cesarean section was 0.14 (95% credible interval 0.12 to 0.15). The difference in the probability of having a cesarean delivery between hospitals was 25 percentage points. Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics (0.16 [95% credible interval 0.14 to 0.18]). A limitation is that these data, while nationally representative, did not contain information on parity or gestational age.

Variability across hospitals in the individual risk of cesarean section is not decreased by accounting for differences in maternal diagnoses. These findings highlight the need for more comprehensive or linked data including parity and gestational age as well as examination of other factors—such as hospital policies, practices, and culture—in determining cesarean section use.

See also: Variation in Caesarean Section Rates in the US: Outliers, Damned Outliers, and Statistics

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The Effects of Poor Neonatal Health on Children’s Cognitive Development

October 17, 2014 Comments off

The Effects of Poor Neonatal Health on Children’s Cognitive Development (PDF)
Source: Institute for Policy Research, Northwestern University

This working paper makes use of a new data resource—merged birth and school records for all children born in Florida from 1992 to 2002—to study the effects of birth weight on cognitive development from kindergarten through schooling. Using twin fixed effects models, the researchers find that the effects of birth weight on cognitive development are essentially constant through the school career, that these effects are very similar across a wide range of family backgrounds, and that they are invariant to measures of school quality. They conclude that the effects of poor neonatal health on adult outcomes are therefore set very early.

Attitudinal Survey of Women Living with Low Sexual Desire

October 17, 2014 Comments off

Attitudinal Survey of Women Living with Low Sexual Desire
Source: Journal of Women’s Health

Survey data provide evidence that low sexual desire is commonly reported among pre- and postmenopausal women. About 10% of women with low sexual desire experience related personal distress. This survey assessed women’s attitudes toward the condition and how it affects personal relationships, along with level of awareness of low sexual desire as a medical condition and treatment-seeking history.

The online survey was conducted in a convenience sample of 450 pre- and postmenopausal women aged 20 to 60 years with self-described low sexual desire and related distress. The percentage reported is the ratio of responses over number of respondents for each point on visual analogy scales or option(s) on multiple-choice questions.

Twenty-seven percent of premenopausal and 34% of postmenopausal women were very dissatisfied with their current sexual desire level. Over 70% attributed personal and interpersonal difficulties to low sexual desire, most often negative impacts on body image and self-confidence. Feeling “less connectedness” was the most frequently selected impact on partner relationships. Approximately 90% of respondents would like to have or desire sex more often; 95% believed that one or two more satisfying sexual experiences per month would be meaningful. Most respondents did not realize that distressing low sexual desire was a treatable medical condition and had never mentioned their low sexual desire to health care providers.

Despite reporting negative impacts of low sexual desire and a desire for more frequent sex, most women had not sought medical help. These results add to the evolving recognition of the importance of sexual functioning in women’s lives.

Impact of the Federal Contraceptive Coverage Guarantee on Out-of-Pocket Payments for Contraceptives: 2014 Update

October 16, 2014 Comments off

Impact of the Federal Contraceptive Coverage Guarantee on Out-of-Pocket Payments for Contraceptives: 2014 Update (PDF)
Source: Contraception Journal (forthcoming)

The Affordable Care Act requires most private health plans to cover contraceptive methods, services and counseling, without any out-of-pocket costs to patients; that requirement took effect for millions of Americans in January 2013.

Design Data for this study come from a subset of the 1,842 women aged 18–39 who responded to all four waves of a national longitudinal survey. This analysis focuses on the 892 women who had private health insurance and who used a prescription contraceptive method during any of the four study periods. Women were asked about the amount they paid out of pocket in an average month for their method of choice.

Between fall 2012 and spring 2014, the proportion of privately insured women paying zero dollars out of pocket for oral contraceptives increased substantially, from 15% to 67%. Similar changes occurred among privately insured women using injectable contraception, the vaginal ring and the IUD.

The implementation of the federal contraceptive coverage requirement appears to have had a notable impact on the out-of-pocket costs paid by privately insured women, and that impact has increased over time.

This study measures the out-of-pocket costs for women with private insurance prior to the federal contraceptive coverage requirement and after it took effect; in doing so, it highlights areas of progress in eliminating these costs.

Human Papillomavirus Vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP)

October 9, 2014 Comments off

Human Papillomavirus Vaccination: Recommendations of the Advisory Committee on Immunization Practices (ACIP)
Source: Morbidity and Mortality Weekly Report (CDC)

This report summarizes the epidemiology of human papillomavirus (HPV) and associated diseases, describes the licensed HPV vaccines, provides updated data from clinical trials and postlicensure safety studies, and compiles recommendations from CDC’s Advisory Committee on Immunization Practices (ACIP) for use of HPV vaccines.

Persistent infection with oncogenic HPV types can cause cervical cancer in women as well as other anogenital and oropharyngeal cancers in women and men. HPV also causes genital warts. Two HPV vaccines are licensed in the United States. Both are composed of type-specific HPV L1 protein, the major capsid protein of HPV. Expression of the L1 protein using recombinant DNA technology produces noninfectious virus-like particles (VLPs). Quadrivalent HPV vaccine (HPV4) contains four HPV type-specific VLPs prepared from the L1 proteins of HPV 6, 11, 16, and 18. Bivalent HPV vaccine (HPV2) contains two HPV type-specific VLPs prepared from the L1 proteins of HPV 16 and 18. Both vaccines are administered in a 3-dose series.

ACIP recommends routine vaccination with HPV4 or HPV2 for females aged 11 or 12 years and with HPV4 for males aged 11 or 12 years. Vaccination also is recommended for females aged 13 through 26 years and for males aged 13 through 21 years who were not vaccinated previously. Males aged 22 through 26 years may be vaccinated. ACIP recommends vaccination of men who have sex with men and immunocompromised persons (including those with HIV infection) through age 26 years if not previously vaccinated.

As a compendium of all current recommendations for use of HPV vaccines, information in this report is intended for use by clinicians, vaccination providers, public health officials, and immunization program personnel as a resource. ACIP recommendations are reviewed periodically and are revised as indicated when new information and data become available.

Who Pays for Sexual Assault Medical Forensic Exams? It Is Not the Victim’s Responsibility

October 7, 2014 Comments off

Who Pays for Sexual Assault Medical Forensic Exams? It Is Not the Victim’s Responsibility (PDF)
Source: Urban Institute

The Violence Against Women Act of 2005 requires that sexual assault victims must not be required to file law enforcement reports in order to receive free exams. This study aimed to examine how states are meeting these goals. We found victim compensation funds are by far the largest funder of exams across the country. In the 19 jurisdictions included in case studies, victims generally received free exams without having to report if they did not want to. However, barriers to even accessing the exam prevent some victims from seeking help.

Effect of Enhanced Information, Values Clarification, and Removal of Financial Barriers on Use of Prenatal Genetic Testing: A Randomized Clinical Trial

October 1, 2014 Comments off

Effect of Enhanced Information, Values Clarification, and Removal of Financial Barriers on Use of Prenatal Genetic Testing: A Randomized Clinical Trial
Source: Journal of the American Medical Association

Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood.

To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels.

Setting, and Participants Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks’ gestation (n = 710).

A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353).

Main Outcomes and Measures
The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks’ gestation.

Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret.

Conclusions and Relevance
Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing.


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