Cervical Cancer

• Many young women have not received the HPV vaccine.

  This survey found that more than 60 percent of 1,011 young women aged 13 to 26 years knew about Gardasil®, the vaccine against human papilloma virus (HPV) that causes cervical cancer. However, only 30 percent of those aged 13 to 17 and 9 percent of those aged 18-26 had received the vaccine. Because the vaccine is most beneficial when given before young women become sexually active, the authors urge practitioners and parents to step up efforts to educate young women about the importance of receiving the vaccine early. Caskey, Lindau, and Alexander, J Adolesc Health 45(5):453-462, 2009 (AHRQ grant HS15699).

• Less than 25 percent of physicians report guideline-consistent recommendations for cervical cancer screening.

  Researchers used a large, nationally representative sample of primary care physicians to identify current Pap test screening practices in 2006-2007. They used clinical vignettes to describe women by age and sexual and screening history to elicit physicians' recommendations. Guideline-consistent recommendations varied by physician specialty: obstetrics/gynecology 16.4 percent, internal medicine 27.5 percent, and family/general practice 21.1 percent. Yabroff, Saraiya, Mesisner, et al., Ann Intern Med 151(9):602-611, 2009 (AHRQ grant HS10565).

• A majority of older women think lifelong cervical cancer screening is important.

  Researchers conducted face-to-face interviews with 199 women aged 65 and older to determine their views about continuing to receive Pap tests to screen for cervical cancer. Most of the women were minorities, and about 45 percent were Asian. Despite recent changes in clinical recommendations to stop Pap screening in women older than 65, more than two thirds of the women in this study felt that lifelong screening was either important or very important. Most of the women (77 percent) planned on being screened for the rest of their lives. Sawaya, Iwaoka-Scott, Kim, et al., Am J Obstet Gynecol 200(1):40.e1-40.e7, 2009. See also Huang, Perez-Stable, Kim, et al., J Gen Intern Med 23(9):1324-1329, 2008 (AHRQ grant HS10856).

• Instituting new processes can reduce diagnostic errors in Pap smear interpretation.

  Lean methods are used to weigh the expenditure of resources against value received. For this study, researchers compared the diagnostic accuracy of Pap tests procured by five clinicians before (5,384 controls) and after (5,442 cases) implementing a process redesign using Lean methods. Following process redesign, there was a significant improvement in Pap smear quality, and the case group showed a 114 percent increase in newly detected cervical intraepithelial cancer following a previous benign Pap test. Raab, Andrew-Jaja, Grzybicki, et al, J Low Genit Tract Dis 12(2):103-110, 2008 (AHRQ grant HS13321).

Ovarian Cancer

• Study finds racial disparities in receipt of chemotherapy after ovarian cancer surgery.

  Researchers examined 11 years of data for 4,264 women aged 65 or older who were diagnosed with stage IC-IV ovarian cancer (cancer in one or both ovaries with early signs of spreading) to examine receipt of chemotherapy, which is recommended following surgery to remove the cancer. They found that just over 50 percent of black women received chemotherapy following surgery, compared with nearly 65 percent of white women; survival rates did not differ between the two groups of women, but women in the lowest socioeconomic group were more likely to die than those in the highest group. Du, Sun, Milam, et al., Int J Gynecol Cancer 18(4):660-669, 2008 (AHRQ grant HS16743).

• One type of chemotherapy for ovarian cancer carries an elevated risk for hospitalization.

  Researchers studied 9,361 women aged 65 and older who were diagnosed with stage IC to IV ovarian cancer between 1991 and 2002. Of the 1,694 patients who received nonplatinum chemotherapy, 8 percent were hospitalized because of a gastrointestinal ailment, compared with 6.6 percent of the 1,363 women who received platinum-based chemotherapy and 6.4 percent of the 3,094 women who received platinum-taxane therapy. Receipt of nonplatinum chemotherapy was also associated with a higher risk of hospitalization for infections, hematologic problems (e.g., anemia), and thrombocytopenia (low blood platelet count). Nurgalieva, Liu, and Du, Int J Gynecol Cancer 19(8):1314-1321, 2009 (AHRQ grant HS16743).

• Less access to effective treatment may explain poorer survival of elderly black women with ovarian cancer.

  Researchers studied 5,131 elderly women diagnosed with ovarian cancer between 1992 and 1999 with up to 11 years of followup. Overall, 72 percent of white women and 70 percent of black women were diagnosed with stage III or IV (advanced) disease, however, fewer blacks received chemotherapy than whites (50 vs. 65 percent, respectively). Among those with stage IV disease, those who underwent ovarian surgery and received adjuvant chemotherapy were 50 percent less likely to die during the followup period compared with those who did not, regardless of race. Du, Sun, Milam, et al., Int J Gynecol Cancer 18:660-669, 2008 (AHRQ grant HS16743).

• Evidence does not support use of genomic tests to detect ovarian cancer.

  According to this scientific review, there is no evidence relevant to the impact of genomic tests for ovarian cancer on health outcomes in asymptomatic women. The researchers used model simulations to predict the usefulness and efficacy of genomic tests for ovarian cancer. The model simulations suggest that annual screening, even with a highly sensitive test, will not reduce ovarian cancer mortality, and that frequent screening has a very low positive predictive value. Genomic Tests for Ovarian Cancer Detection and Management, Evidence Report/ Technology Assessment No. 145 (AHRQ Publication No. 07-E001)* (AHRQ Contract 290-02-0025).

Other Cancers

• A family history of colon cancer does not negatively affect survival for women diagnosed with the same cancer.

  Researchers tracked nearly 1,400 women who were diagnosed with invasive colon cancer and found that women who had two or more relatives with colorectal cancer appeared to have a lower risk of dying from the disease compared with women who had no family history of the cancer. Of the 262 women who had a family history of colorectal cancer, 44 died of the disease; of the 1,129 women who had no family history of the disease, 224 died. Thus, determining a family history of colorectal cancer appears to be a cost-effective way to identify individuals who may be at risk for the condition. Kirchhoff, Newcomb, Trentham-Dietz, et al., Fam Cancer 7(4):287-292,2008 (AHRQ grant HS13853).

• Women's perception of risk affects screening for colon cancer but not cervical or breast cancer.

  Researchers interviewed 1,160 white, black, Hispanic, and Asian women (aged 50 to 80) about their perceived risk for breast, cervical, and colon cancer and compared their perceived risk with their screening behavior. The women's perceived lifetime risk of cancer varied by ethnicity, with Asian women generally perceiving the lowest risk and Hispanic women the highest risk for all three types of cancer. Nearly 90 percent of women reported having a mammogram, and about 70 percent of the women reported having a Pap test in the previous 2 years; 70 percent of the women were current with colon cancer screening. There was no relationship between screening and perception of risk for cervical or breast cancer; however, a moderate to very high perception for colon cancer risk was associated with nearly three times higher odds of having undergone colonoscopy within the last 10 years. Kim, Perez-Stable, Wong, et al., Arch Int Med 168(7):728-734, 2008 (AHRQ grant HS10856).

• Among older patients with early-stage lung cancer, women live longer than men, regardless of treatment choice.

  Researchers examined differences between women and men in the natural history of lung cancer, after controlling for unrelated causes of death and type of treatment among 18,967 Medicare patients with stages I and II non-small cell lung cancer who were diagnosed between 1991 and 1999. They found that the women lived longer than the men, regardless of the type of treatment they received, and that the women's longer survival was independent of differences in life expectancy between men and women due to unrelated causes of death. They found improved survival advantages even among untreated women, suggesting that lung cancer in women has a different natural history and potentially a different tumor biology. Wisnivesky and Halm, J Clin Oncol 25(13):1705-1712, 2007 (AHRQ grant HS13312).

Return to Contents

Reproductive Health

AHRQ's research on reproductive health focuses on pregnancy and childbirth, fertility problems, use of contraceptives, chronic pelvic pain, sexually transmitted diseases, and other conditions that can affect fertility and childbearing.

Pregnancy and Childbirth

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

• Booklet discusses the pros and cons of choosing to have labor induced.

  Labor induction rates more than doubled between 1990 and 2005 to an all-time high of 22 percent. This increase reflects not only an increase in induction for medical indications but also broader use of elective induction for reasons such as a woman's physical discomfort, scheduling issues, and distance from the hospital. This booklet explains methods used to induce labor and possible complications, as well as what is still not known about elective induction. Thinking About Having Your Labor Induced? A Guide for Pregnant Women (AHRQ Publication No. 10-EHC004-A).* See also Elective Induction of Labor: Safety and Harms; Clinician Guide (AHRQ Publication No. 10-EHC004-3)* (AHRQ contract 290-02-0019)

• Home visits by a nurse help low-income pregnant women cope with depressive symptoms.

  Having a nurse-community health worker team make home visits substantially reduces stress and depressive symptoms among low-income pregnant women, according to this study of 613 women in Michigan. Half of the women were assigned to a home visit intervention group and half received usual care. Women who received the home visits had significantly fewer depressive symptoms and lower levels of stress than women in the control group. Roman, Gardiner, Lindsay, et al., Arch Womens Ment Health 12:379-391, 2009 (AHRQ grant HS14206).

• Vaginal birth after a prior cesarean found to be safe for most women.

  According to a recent AHRQ evidence report, choosing to have a vaginal birth following an earlier c-section—often referred to as VBAC—is a safe and reasonable choice for most women. More than 1 million c-sections are performed each year in the United States, and nearly one in every three births in 2007 was by cesarean. Evidence shows that compared with a trial of labor, an elective c-section carries a significantly higher risk for maternal death. Also, women who undergo multiple cesarean deliveries are at significant risk of life-threatening conditions. Vaginal Birth After Cesarean: New Insights, Evidence Report/Technology Assessment No. 191 (AHRQ Publication No. 10-E001)* (AHRQ contract 290-2007-10057-I).

• Study examines treatment patterns for early pregnancy failure in Michigan.

  Researchers identified 21,311 women enrolled in Michigan's Medicaid program and 1,493 women from a university-affiliated health plan who experienced miscarriages between January 2001 and December 2005 to determine the type of care they received: expectant management, drug therapy, or surgery. They found that Medicaid-enrolled women were more likely to be treated surgically (35 percent) than women in the private plan (18 percent). Among those who had surgery, just 0.5 percent of Medicaid enrollees had surgery in medical offices, compared with nearly 31 percent of the privately insured women. Drug use (misoprostol) was low for both groups. Dalton, Harris, Clark, et al., J Womens Health 18(6):787-793, 2009 (AHRQ grant HS15491).

• Childbirth and deliveries are becoming more complicated.

  A recent analysis of data from the Nationwide Inpatient Sample, a part of AHRQ's Healthcare Cost and Utilization Project, revealed that the number of hospital stays related to childbirth increased 16 percent from 4.3 million to 5 million between 1997 and 2007. However, the number of hospital stays for women who had a normal or uncomplicated birth declined by 43 percent (from 544,000 to 312,000) during the same time period. The analysis showed an increase in stays for women who had: a previous cesarean section, up 107 percent (from 271,000 to 562,000); high blood pressure, up 28 percent (185,000 to 235,000); or perineal trauma during childbirth, up 22 percent (713,000 to 868,000). HCUP Facts and Figures 2007; online at http://www.hcup-us.ahrq.gov/reports/factsandfigures/2007/TOC_2007.jsp (Intramural).

• Obese women are at risk for pregnancies exceeding 40 weeks.

  In this study of nearly 120,000 women who gave birth between 1995 and 1999 in California, those who were obese before becoming pregnant ran a high risk of having a pregnancy that went 40 weeks or longer. Prolonged pregnancy increases the risk to the baby of excessive birth weight, restricted growth, diminished oxygen supply, and death. White women, older women (aged 30-39), and women who had never given birth were also more likely to have pregnancies that went 40, 41, or even 42 weeks. Caughey, Stotland, Washington, and Escobar, Am J Obstet Gynecol 200(6):683.e1-683.e5, 2009 (AHRQ grant HS10856).

• Some pregnancy-related complications are minimized for women who have had weight-loss surgery.

  A review of 75 studies revealed that women who undergo weight-loss surgery and later become pregnant after losing weight may be at lower risk than pregnant women who are obese for pregnancy-related diabetes and high blood pressure—complications that can seriously affect the mother and/or her baby. Neonatal outcomes—such as preterm delivery, low birthweight, and high birthweight—also were found to be better in women following weight-loss surgery compared with obese women. Maggard, Yermilov, Li, et al., JAMA 300(19):2286-2296, 2008. See also Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy, Evidence Report/Technology Assessment No. 169 (AHRQ Publication No. 08-E013)* (AHRQ contract 290-02-0003).

• Repeat c-sections rose dramatically in the past decade.

  The percentage of women undergoing a repeat cesarean delivery jumped from 65 percent to 90 percent between 1997 and 2006, according to data from AHRQ's Healthcare Cost and Utilization Project (HCUP). The data also showed that nearly one-third of the 4.3 million births in 2006 were delivered by cesarean, compared with one-fifth in 1997; c-sections are more costly than vaginal deliveries—$4,500 vs. $2,600 in uncomplicated deliveries; and c-sections account for 34 percent of all deliveries by women with private insurance, compared with 25 percent in women who are uninsured. See Hospitalizations Related to Childbirth, 2006, HCUP Statistical Brief No. 71, online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb71.jsp (Intramural).

• Numeric tool helps women determine their birthing preferences following a previous cesarean.

  Using a computer-based graphic-numeric decision tool, 96 women who had undergone a previous cesarean delivery made a series of paired comparisons to help them understand their priorities for their next childbirth experience. They used four decision criteria to examine their preferences: avoiding harm to the baby, avoiding side effects for the mother; avoiding risk to future pregnancies, and having a good delivery experience. The women placed the highest priority on avoiding harm to their babies and ranked having a good delivery experience as last. Eden, Dolan, Guise, et al., J Clin Epidemiol 62:415-424, 2009 (AHRQ grants HS11338, HS13959, HS15321).

• Childbirth injuries have fallen sharply, but more could be prevented.

  Between 2000 and 2006, injuries to mothers during childbirth decreased by 30 percent for those giving birth vaginally without instruments and by 20 percent for cesarean births and vaginal births with instruments. Despite these declines, nearly 158,000 potentially preventable injuries occurred to mothers and infants during childbirth in U.S. hospitals in 2006. See Potentially Avoidable Injuries to Mothers and Newborns During Childbirth, 2006, HCUP Statistical Brief No. 74; online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb74.jsp (Intramural).

• Researchers describe use of teamwork in obstetric critical care.

  Crew Resource Management (CRM) is a teamwork approach developed in industry that is being applied today in medical settings to reduce risk to patient safety. At the heart of CRM are communication techniques, situational awareness, and leadership. These authors provide an overview of 11 currently available medical team training programs that use many CRM principles. Guise and Segel, Obstet Gynecol 22(5):937-951, 2008 (AHRQ grants HS15800, HS16673).

• Computerized tool helps women decide about prenatal genetic testing.

  A computerized tool—the Prenatal Testing Decision-Assisting Tool, PT tool—provides personalized estimates of the chances that a woman is carrying a fetus with chromosomal abnormalities, describes prenatal screening and diagnostic tests, and develops a tailored testing strategy. Researchers evaluated the PT tool in a group of pregnant women and found that nearly 80 percent of women who used the tool were able to correctly answer questions on prenatal testing, compared with 65 percent of women in the control group who only read an educational booklet on the topic, and they were more satisfied with the education intervention and more confident about their decision to undergo or forego genetic testing. Kuppermann, Norton, Gates, et al., Obstet Gynecol 113(1):53-63 2009 (AHRQ grant HS10856).

• Bariatric surgery results in improved fertility in formerly obese women.

  There has been a six-fold increase in bariatric (weight loss) surgery over the past 7 years, and nearly half of all bariatric surgery patients are women of reproductive age. This review of the evidence indicates that fertility improves after bariatric surgical procedures, nutritional deficiencies for mother and child are minimal, and maternal and neonatal outcomes are acceptable with laparoscopic band and gastric bypass, as long as adequate nutrition and supplemental vitamins are maintained. There was no evidence that delivery complications are higher in post-surgery pregnancies. Bariatric Surgery in Women of Reproductive Age: Special Concerns for Pregnancy, Evidence Report/Technology Assessment No. 169 (AHRQ Publication No. 08-E013)* (AHRQ contract 290-02-0003).

• Researchers find little high-quality evidence to support the choice of assisted reproductive technology.

  Researchers reviewed the available evidence on the outcomes of interventions used in ovulation induction, superovulation, and in vitro fertilization (IVF) for the treatment of infertility. They found that the majority of studies (80 percent) were conducted outside the United States, and there was little high-quality evidence on which to base a choice among the various interventions for infertility. They were able to substantiate improved pregnancy or live birth rates for several of the therapies. Effectiveness of Assisted Reproductive Technology, Evidence Report/Technology Assessment No. 167 (AHRQ Publication No. 08-E012)* (AHRQ contract 290-02-0025).

• Study examines factors related to infertility in women who have had pelvic inflammatory disease.

  Women who have been exposed to Chlamydia trachomatis, as evidenced by the presence of C. trachomatis elementary bodies (EBs), have lower rates of pregnancy and higher rates of recurrence of pelvic inflammatory disease (PID) after an initial episode of mild to moderate PID, according to this study. The researchers examined Chlamydia antibodies and adverse sequelae after PID among 443 women with mild to moderate PID; they followed the women for a mean of 84 months. Ness, Soper, Richter, et al., Sex Transm Dis 35(2):129-135, 2008 (AHRQ grant HS08383).

• Several factors affect women's perceived risk of prenatal diagnostic screening procedures.

  Invasive prenatal diagnostic tests—such as chorionic villus sampling and amniocentesis—are used to detect Down syndrome and other fetal chromosomal abnormalities, and they entail some risk, principally to the fetus. According to this study, women's perceived risk of adverse procedure-related outcomes varies based on factors that have little to do with risk. For example, among women younger than age 35, the perceived risk of carrying a fetus with Down syndrome was higher in women who had not attended college or had poor health status. Hispanic women, women with incomes less than $35,000, and those who had difficulty conceiving perceived a higher procedure-related risk of miscarriage. Caughey, Washington, and Kuppermann, Am J Obstet Gynecol 198:333.e1-333.e8, 2008 (AHRQ grant HS07373).

• Pregnant women with a prior c-section often receive insufficient information about delivery options.

  According to this study, many women with a prior cesarean delivery who choose to have a subsequent vaginal birth (VBAC) or another cesarean receive little or no information about the risk of both procedures, including forceps or vacuum delivery, future incontinence problems, and risk of fetal death or injury. Researchers surveyed 92 women who had a prior cesarean after either a VBAC or repeat cesarean at a large teaching hospital. Overall 44 percent of the women had scheduled cesarean deliveries, 29 percent had VBAC, and 27 percent had a cesarean following an attempted VBAC. Renner, Eden, Osterweil, et al., Am J Obstet Gynecol 196(5):e14-e16, 2007 (AHRQ grant HS11338).

• Race, education, income, and social status all interact to affect the health of pregnant women.

  Researchers studied 1,802 ethnically diverse women receiving prenatal care at one of six San Francisco area delivery sites; the women were generally healthy and had low depression scores. Differences by race/ethnicity were pronounced, with whites and Asians doing better on all measures. More black and Hispanic women were in the lower social and economic strata than white and Asian women, and they reported worse physical functioning. Subjective social standing was more highly correlated with education and income in whites and Asians than in Hispanic and black women. Stewart, Dean, Gregorich, et al., J Health Psychol 12(2):285-300, 2007 (AHRQ grant HS10856).

• One-third of homeless women are at risk for unintended pregnancy.

  This survey of 974 homeless women in Los Angeles County in 1997 showed that one-third of the women rarely or never used contraception. Women who had a partner, were monogamous, and did not engage in the sex trade were 2.4 times as likely as other women to not use or rarely use contraception. Having a regular source of care and having been encouraged to use contraception increased the likelihood of contraception use. Gelberg, Lu, Leake, et al., Matern Child Health 12:52-60, 2008 (AHRQ grant HS08323).

• Several factors contribute to high rates of maternal birth trauma in one State.

  Compared with national rates, the State of Iowa has lower rates of cesarean delivery and higher rates of maternal trauma, according to this study. Researchers analyzed Iowa data for the years 2002-2004 and national data from 2003 and found significant risk factors for one type of maternal trauma—third/fourth degree lacerations—including episiotomy, artificial rupture of the amniotic membranes, obstructed labor, and late pregnancies, as well as disproportionately large babies. They note that the higher rates of maternal birth trauma at predominantly rural hospitals may be due in part to lack of infrastructure to perform cesareans for difficult deliveries. Roberts, Ely, and Ward, Am J Med Qual 22(5):334-343, 2007 (AHRQ grant HS15009).

• Postpartum discharge against medical advice usually signals serious financial or mental health issues.

  Researchers used hospital discharge data for women who gave birth in California, Florida, and New York during the period 1998-2000 to examine factors associated with discharge against medical advice, which averaged 0.10 percent. Women who were more likely to leave the hospital against medical advice were black; had low income, no insurance or public health insurance, and greater medical problems (e.g., drug abuse, mental illness); lived in medium or large metropolitan areas; and were discharged from hospitals in California or New York (compared with Florida). Fiscella, Meldrum, and Franks, Matern Child Health J 11:431-436, 2007 (AHRQ grant HS10910).

• Pregnancies that progress beyond the estimated due date are risky for both mother and baby.

  This study found that women who delivered babies beyond 37 weeks' gestational age had higher rates of operative vaginal delivery (use of forceps or vacuum extraction), perineal laceration, primary cesarean delivery, postpartum hemorrhage, and infection of the amniotic fluid and/or placental membranes. Other risks of prolonged pregnancy (38-42 weeks) included nonreassuring fetal heart rate and cephalopelvic disproportion (i.e., the baby's head is too large for the woman's pelvis). The researchers studied more than 119,000 fully insured, low-risk women who delivered babies beyond 37 weeks gestational age from 1995 to 1999. Caughey, Stotland, Washington, and Escobar, Am J Obstet Gynecol 196:155.e1-155.e6, 2007 (HS07373).

• Midwife practices vary widely in compensation and employment structure.

  Researchers surveyed 102 certified nurse-midwives in Connecticut in 2005 and found variations in practice freedom and style, income, benefits, job descriptions, and requirements for full-time work. Full-time midwives in Connecticut worked an average of 77 hours per week and had a mean salary of nearly $80,000 per year; 87 percent had on-call responsibilities. Among the midwives surveyed, 75 percent provided gynecologic care, antepartum care, and interpartum care; 16 percent did not offer gynecologic care; and 6 percent offered gynecologic care without antepartum or interpartum care. Some midwives performed endometrial biopsies, repaired third-degree perineal lacerations, and/or acted as a surgical assistant at cesarean births. Holland and Holland, J Midwifery Women's Health 52(2):106-115, 2007 (AHRQ grant T32 HS00044).

• Fewer girls under age 18 are having babies.

  The rate of teens and younger girls giving birth in U.S. hospitals dropped by one-fourth between 1997 and 2004, from 55 to 41 admissions per 100,000 girls under age 18, according to a recent AHRQ report. Despite this drop, the United States continues to lead all industrialized nations in teen pregnancy and childbirth. There were 4 million childbirth-related hospitalizations in 2004; 148,000 of these were for girls younger than age 18, resulting in nearly $465 million in hospital costs. Medicaid was billed for nearly three of every four teen childbirths, with total costs of about $348 million. See Childbirth-Related Hospitalizations Among Adolescent Girls, 2004, HCUP Statistical Brief No. 31; online at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb31.jsp (Intramural).

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

  Episiotomy is a common procedure used in an estimated one-third of vaginal deliveries to hasten birth or prevent tearing of the skin during delivery. According to this evidence report, routine use of episiotomy for uncomplicated vaginal births does not provide immediate or longer term benefits for the mother. The evidence shows that women who experience spontaneous tears without episiotomy have less pain than women with episiotomies. Furthermore, complications related to the healing of the perineum are the same with and without episiotomy. Use of Episiotomy in Obstetrical Care: A Systematic Review. Evidence Report No. 112 (AHRQ Publication Nos. 05-E009-1, summary and 05-E009-2, report); What You Need to Know About Episiotomy (AHRQ Publication No. 06-0005, consumer card) (AHRQ contract 290-02-0016).*

Birth Outcomes

• Mothers' anxiety and history of abuse contribute to risk for low birthweight babies.

  According to this study of 554 pregnant women, abuse and anxiety are linked to low birthweight, possibly due to their effects on a woman's hormone levels. The women were seen at obstetric clinics in Memphis, TN, from 1990 to 1991, and most were black, poor, and unmarried. Those who experienced either verbal or physical abuse during pregnancy delivered babies that averaged 3.5 ounces lighter than women who did not suffer abuse, anxious mothers delivered babies that were 2.50 ounces lighter than average. The researchers also found a link between high-crime neighborhoods and low birthweight infants; mothers who experienced neighborhood stress delivered babies 2.28 ounces lighter than average. Witt, Keller, Gottlieb, et al., J Behav Health Serv Res, 2009 (AHRQ grants T32 HS00063, T32 HS00083). See also Fried, Cabral, Amaro, and Aschengrau, J Midwifery Womens Health 53(6):522-528, 2008 (AHRQ grant HS08008).

• No clear association found between inherited thrombophilia and small-for-gestational- age fetuses.

  Pregnant women who suffer from blood disorders that cause excessive clotting (thrombophilia) are sometimes given blood thinning drugs to prevent intrauterine growth restriction (IUGR) or small-for-gestational-age fetuses (below the 10th percentile for a given gestational age). A meta-analysis of 19 studies found no clear association between inherited thrombophilia and IUGR. Facco, You, and Grobman, Obstet Gynecol 113(6):1206-1216, 2009 (AHRQ grant T32 HS00078).

• Primary care doctors blame lack of time for failing to counsel women about drugs that cause birth defects.

  Eight focus groups were held with 48 primary care physicians in Pittsburgh, PA, to discuss counseling women about drugs that cause birth defects (teratogens). The doctors reported several barriers to providing such counseling, including short appointment times, lack of reimbursement for counseling, limited resources for finding up-do-date drug information, problems in determining a woman's reproductive plans, and concerns that such counseling may cause the woman to refuse a needed drug. The physicians proposed several solutions, including online plain language information on the risks of taking teratogenic drugs and reminders in electronic medical records to ask patients about their childbearing plans. Schwarz, Santucci, Borrero, et al., Birth Defects Res A Clin Mol Teratol 85(10):858-863, 2009 (AHRQ grant HS17093).

• Race and ethnicity appear not to have an effect on c-section delivery outcomes.

  The researchers tested two risk-adjustment models for primary c-section rates to determine whether adding race and ethnicity to an otherwise identical model would improve the predictive impact of the model. They found that the two models did not differ substantially in predictive discrimination or in model calibration. They conclude that race and ethnicity can safely be left out of cesarean rate risk-adjustment models. Bailit and Love, Am J Obstet Gynecol 69:e1-e5, 2008 (AHRQ grant HS14352).

• Few data are available on the incidence and outcomes of cesarean delivery on maternal request.

  The researchers reviewed published reports from 1990 through 2005 and found only 82 articles marginally related to cesarean delivery on maternal request (CDMR). They report that the incidence of CDMR appears to be increasing, but accurately assessing either its true incidence or trends over time is difficult because of the dearth of research focused on the topic. They cite the need to create a minimum data set, reach a consensus on terminology to be used, improve study design and statistical analyses, deal better with confounders, and consider the value and/or utility of different outcomes. Cesarean Delivery on Maternal Request, Evidence Report/Technology Assessment No. 133 (AHRQ Publication No. 06-E009)* (AHRQ contract 290-02-0016).

• Maternal weight gain is associated with some outcomes for mothers and babies.

  According to this review of the scientific evidence, there is a strong association between a pregnant woman's weight gain and the following outcomes: preterm birth, total birthweight, low birthweight, large- and small-for-gestational- age infants, and very large infants. The researchers found a moderate association between maternal weight gain and two additional outcomes: cesarean delivery and postpartum weight retention for up to 3 years following childbirth. Outcomes of Maternal Weight Gain, Evidence Report/Technology Assessment No. 168 (AHRQ Publication No. 08-E009)* (AHRQ Contract 290-02-0016).

• Among disadvantaged minority women, Hispanics have better birth outcomes than blacks.

  Researchers analyzed the pregnancy outcomes of 10,755 Medicaid-insured women who gave birth at one North Carolina medical center between 1994 and 2004. They found that black women were younger than the other women and were more likely to have another medical condition while pregnant, to remain in the hospital for more than 4 days, to have a preterm birth or small-for-gestational-age infant, to have preeclampsia, and to have a stillbirth. Birth outcomes for Hispanic women were similar to or better than those for white women. For example, Hispanic women were 34 percent less likely than other women to have a preterm birth. Brown, Chireau, Jallah, and Howard, Am J Obstet Gynecol 197:e1-e9, 2007 (AHRQ grant HS13353).

• Study details association between maternal asthma and smoking and bronchiolitis in infants.

  Researchers studied hospitalizations for bronchiolitis among infants of 100,000 women enrolled in the Tennessee Medicaid program during 1995-2003. They found that infants of mothers who smoked and had asthma were twice as likely to end up in the emergency department (ED) with bronchiolitis as infants whose mothers had neither problem. Infants whose mothers had only one of the problems had a lower but still significantly elevated risk for ED visits and hospitalizations compared with infants whose mothers had neither problem. Although maternal asthma was the most important of these two risk factors, infants were 50 percent more likely to be hospitalized for bronchiolitis if their mothers had asthma and also smoked. Carroll, Gebretsadik, and Griffin, Pediatrics 119(6):1104-1112, 2007 (AHRQ grant HS10384).

• Pregnant minority women with asthma are at increased risk for poor outcomes.

  Among pregnant women with asthma, this study found that minority women have significantly higher rates of preterm labor, gestational diabetes, and infection of the amniotic cavity than white women. Black women were the youngest (age 24) and had the highest incidence of preterm labor (5.5 percent) and pregnancy-induced hypertension (5 percent). Asian women had the highest occurrence of gestational diabetes (7.2 percent) and were more than three times as likely as white women to have infection of the amniotic cavity (5.7 vs. 1.8 percent, respectively). Black and Hispanic women also had more infections of the amniotic cavity (3.1 and 2.7 percent, respectively) than white women. Findings are based on examination of 11 adverse outcomes across four ethnic groups of 13,900 pregnant women with asthma who gave birth in 1998 and 1999. MacMullen, Tymkow, and Shen, Am J Matern Child Nurs 31(4):263-268, 2006 (AHRQ grant HS13506).

• Majority of low-income black women are unhappy with their body size 6 months after giving birth.

  Body image dissatisfaction is associated with negative self-esteem and depression, and all three can be intensified during the postpartum period. Black mothers are twice as likely to suffer from postpartum depression as white mothers, according to this study. The researchers examined body perceptions among black women at four inner city clinics at 2 and 6 months postpartum. At 6 months postpartum, 79 percent of the women felt they did not meet what they considered to be a healthy size for women their age; 20 percent of the women thought they were too small and wanted to gain weight. Boyington, Johnson, and Carter-Edwards, J Obstet Gynecol Neonatal Nurs 36(2):144-151, 2007 (AHRQ grant HS13353).

Hysterectomy

Hysterectomy is second only to cesarean delivery as the most frequently performed major surgical procedures for women of reproductive age in the United States. Approximately 600,000 hysterectomies are performed each year, and an estimated 20 million U.S. women have had a hysterectomy. Hysterectomy is performed most often in women aged 40-44 years, and the three conditions most often associated with hysterectomy are fibroid tumors, endometriosis, and uterine prolapse.

• Three clinical characteristics increase the likelihood of hysterectomy for women with certain noncancerous conditions.

  In this study of 734 women at several California clinics and offices, three clinical characteristics—abnormal uterine bleeding, chronic pelvic pain, and symptomatic uterine fibroids—predicted the likelihood of subsequent hysterectomy. Nearly half of the women had suffered from symptoms for more than 5 years, and some of the women had already had surgery to remove fibroids, undergone removal of uterine lining, or had hormone treatment. A total of 99 of the women (13.5 percent) underwent hysterectomies during the 4-year study period. Women with multiple pelvic symptoms or symptomatic fibroids were nearly twice as likely to have a hysterectomy as other women. Learman, Kuppermann, Gates, et al., J Am Coll Surg 204:633-641, 2007 (AHRQ grants HS07373, HS09478, HS11657).

• Many young women who underwent hysterectomy during their childbearing years had lingering depression.

  Researchers interviewed 1,140 women before they underwent hysterectomies in 1992 and 1993 and followed up with them for 2 years after surgery. Although 86 percent of the women said they were fine with their childbearing days being over, 14 percent were either ambiguous or said they would have liked to have children. The women who wanted children tended to put off their surgeries for 4.5 years, despite severe pelvic pain. Women who wanted children were twice as likely as those who did not to have sought mental health counseling prior to surgery and to still be depressed 2 years after surgery. Leppert, Legro, and Kjerulff, J Psychosom Res 63(3):269-274, 2007 (AHRQ grant HS06865).

• Removal of the ovaries in premenopausal women does not negatively affect quality of life.

  This study found that women who underwent bilateral salpingo-oophorectomy had an initial decline in quality of life in the first 6 months after surgery, but they had no apparent differences in quality of life 2 years later, compared with women who had hysterectomies but kept their ovaries. At 6 months after surgery, there were no differences between the two groups in sexual functioning, hot flushes, urinary incontinence, or pelvic pain. And at the 2-year followup, scores were similar for both groups on all measures of health-related quality of life and sexual functioning, irrespective of estrogen use. Teplin, Vittinghoff, Lin, et al., Obstet Gynecol 109(2):347-354, 2007 (AHRQ grant HS09478).

Other

• Breastfeeding benefits both mothers and infants.

  According to a 2007 AHRQ evidence report, breastfeeding is beneficial for both mother and infant. In this question-and-answer article, the authors discuss the report and the role of clinicians in promoting breastfeeding, the particular advantages of breastfeeding for premature infants, lifestyle factors that affect nursing mothers, and ways to overcome societal barriers to breastfeeding. J. Godfrey, D. Meyers, J Womens Health, September 2009; 18(9):1307-1310 (AHRQ Publication No. 10-R034).* See also D. Meyers, Breastfeed Med, 2009; 4(Suppl 1):S-13-S-15 (AHRQ Publication No. 10-R024)* (Intramural) and Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries, Evidence Report/Technology Assessment No. 153 (AHRQ Publication No. 07-E007)* (AHRQ contract 290-02-0022).

• Treatment without exams and lab texts appears effective for some women with vaginal symptoms.

  Offering women treatment for uncomfortable symptoms of bacterial vaginosis, trichomoniasis, or vaginal candidiasis based on their symptoms—while skipping speculum examination and lab tests—may be appropriate in some cases, according to this study of 44 women. The 23 women who received treatment for their vaginal symptoms without examination had outcomes and satisfaction ratings similar to those of the 21 women who underwent a traditional exam and lab tests. Anderson, Cohrssen, Klink, and Brahver, J Am Board Fam Med 22(6):617-624, 2009 (AHRQ grant HS16050).

• Researchers examine associations among various pathogens and bacterial vaginosis.

  Bacterial vaginosis (BV) is a common lower genital tract infection that may lead to pelvic inflammatory disease (PID) and other conditions. Researchers analyzed stored specimens from 50 randomly selected women with confirmed endometritis to determine the associations among various pathogens and BV. They found several types of bacteria known to be associated with BV among women with confirmed PID. Haggerty, Totten, Ferris, et al., Sex Transm Infect 85:242-248, 2009 (AHRQ grant HS08358)

• Despite CDC-recommended treatment, the pathogen that causes PID may persist.

  Pelvic inflammatory disease (PID) is associated with the pathogen Mycoplasma genitalium, and it appears to be very resistant to commonly used treatments. The PID Evaluation and Clinical Health Study (PEACH) examined stored cervical and endometrial specimens from 682 women treated with ceftoxin and doxycycline and found that the pathogen persisted among nearly half of the women after 30 days of treatment. The researchers conclude that M. genitalium is associated with endometritis and short-term PID treatment failure as evidenced by persistent endometritis and continued pelvic pain. Haggerty, Totten, Astete, et al., Sex Transmit Dis 84(5):338-342, 2008. See also Short, Totten, Ness, et al., Clin Infect Dis 48(1):41-47, 2009 (AHRQ grant HS08358).

• Symptoms of menopause may persist for as long as 4 years.

  Researchers reviewed 410 studies to determine the duration of vasomotor symptoms (hot flashes and night sweats) in menopausal women. They found that these symptoms tend to peak 1 year after a woman's last menstrual period, but 50 percent of women continue to experience vasomotor symptoms for up to 4 years. The researchers note that clinical guidelines may need to be modified so that women's quality of life is balanced against the risks of hormone therapy. Politi, Schleinitz, and Col, J Gen Intern Med 23(9):1507-1513, 2008 (AHRQ grant HS13329).

• Abnormally heavy uterine bleeding has both quality of life and financial effects.

  This study of 237 women who had surgery for dysfunctional uterine bleeding (DUB) between 1997 and 2001 found that women with the condition experience both decreased quality of life (cramps, pain, fatigue, and limited physical activity) and financial burdens, including out-of-pocket costs for drugs and sanitary products (average of $333/year) and lost productivity due to missed work and/or the inability to function at home (average of $2,625/year). Frick, Clark, Steinwachs, et al., Womens Health Issues 19(1):70-78, 2009 (AHRQ grant HS09506).

• Noncancerous pelvic problems are linked to poor quality of life for premenopausal women.

  Researchers examined the treatment and outcomes of 1,493 women who sought care for noncancerous pelvic problems and had not undergone a hysterectomy. Such problems typically include heavy bleeding and pelvic pain and pressure. The women were asked about their symptoms, attitudes, quality of life, sexual functioning, and treatment satisfaction. The majority of women reported no or only partial symptom resolution from treatment, and nearly half said their pelvic problems interfered with their ability to have and enjoy sex. The women's physical and mental health scores were substantially lower than population norms for women aged 40 to 49 years, and overall, less than half of the women were satisfied with their treatment. Kuppermann, Learman, Schembri, et al., Obstet Gynecol 110(3):633-642, 2007 (AHRQ grants HS09478, HS11657, HS07373).

• Researchers find that evidence is lacking on the effectiveness of most interventions for symptomatic fibroids.

  This review was intended to update a previous AHRQ report published in 2001 on the management of symptomatic fibroids. The first evidence review found that the overall quality of the literature on the management of fibroids was poor, and that there was almost no evidence to support the effectiveness of commonly recommended treatments. The authors of this review found essentially the same thing. They found the lack of well-conducted trials in U.S. populations that directly compared treatment options to be particularly notable. Management of Uterine Fibroids: An Update of the Evidence, Evidence Report/Technology Assessment No. 154 (AHRQ Publication No. 07-E011)* (AHRQ contract 290-02-0016).

• Both behavioral and drug therapies can help women with urinary incontinence.

  Researchers analyzed existing evidence on nonsurgical treatment for urinary incontinence (UI) in women and found that pelvic floor muscle training (Kegel exercises) and bladder training resolved women's UI compared with usual care. Certain medications also resolved UI compared with placebo, while the effects of electrostimulation, medical devices, injectable bulking agents, and vaginal estrogen therapy were inconsistent. UI affects nearly one in five women age 44 or younger and as many as one in three elderly women. Shamliyan, Kane, Wyman, and Wilt, Ann Intern Med 148(6):459-473, 2008 (AHRQ contract 290-02-0009).

• Uterine artery embolization found to be a low-risk procedure.

  Researchers examined the outcomes of more than 3,000 women who underwent uterine artery embolization for fibroids. The women were treated at 72 sites across the United States. Overall, less than 1 percent of women suffered from major inpatient complications; 4.8 percent suffered from major events (mostly inadequate pain relief ) within the first 30 days following hospital discharge. There were no deaths related to the procedure, but 31 women required additional surgical intervention with 30 days of the procedure. Worthington-Kirsch, Spies, Myers, et al., Obstet Gynecol 106(1):52-59, 2005; see also pp. 44-51 by the same authors in the same journal (AHRQ grant HS09760).

• Task Force recommends screening at-risk women for certain sexually transmitted infections.

  The U.S. Preventive Services Task Force recommends that women at increased risk of infection be screened for Chlamydia, gonorrhea, HIV, and syphilis. The Task Force also recommends that pregnant women be screened for hepatitis B, HIV, and syphilis. Those pregnant women at high risk for STIs should be additionally screened for Chlamydia and gonorrhea, and sexually active women younger than age 25 should be considered at increased risk for Chlamydia and gonorrhea. The Task Force identifies women as being at high risk for STIs if they have multiple current partners, have unprotected sex, or have sex in exchange for money or drugs. Meyers, Wolff, Gregory, et al., Am Fam Physician 77(6):819-824, 2008 (AHRQ Publication No. 08-R056)* (Intramural).

• Two simple steps can improve rates of screening for Chlamydia in young women.

  Use of exam room screening reminders and clinic-level intervention strategies (physician opinion leaders and physician feedback) can improve Chlamydia testing rates in young women making preventive care visits, according to this study. Researchers randomized 23 primary care clinics in one managed care plan to either standard care or intervention care. They found that a combination of clinic-level change and patient activation may improve testing, particularly among asymptomatic women. Scholes, Grothaus, McClure, et al., Prev Med 43:343-350, 2006 (AHRQ grant HS10514).

• Certain factors predict chronic pelvic pain after PID.

  One-third of women with pelvic inflammatory disease (PID) subsequently suffer from chronic pelvic pain. A study of 780 urban women with PID found that women who smoked, those who had previous episodes of PID, women who were married, and those who had low mental health scores were more likely than other women to experience chronic pelvic pain. The researchers also note that recurrent PID can cause adhesions to form and may represent persistent, chronic infection or inflammation, all of which can result in chronic pelvic pain. Haggerty, Peipert, Weitzen, et al., Sex Trans Dis 32(5):293-299, 2005 (AHRQ grant HS08358).

Return to Contents
Proceed to Next Section