- Some Latinas have higher rates of
cervical cancer than white women.
According to this study, women of
Mexican descent born in the United
States are at higher risk for contracting
the human papilloma virus (HPV) that
causes cervical cancer than white
women and foreign-born Latinas.
Indeed, those who have acculturated—i.e., they think, speak, and read English
at home or with friends—are more
likely than less acculturated Latinas to
contract HPV and cervical cancer. The
researchers note that rates of HPV in
U.S.-born Mexican women may be a
result of increased sexual behavior, since
more acculturated U.S.-born Mexican
women also had higher rates of
chlamydia, gonorrhea, and herpes II.
Kepka, Coronado, Rodriguez, and
Thompson, Prev Med 51(2):182-184,
2010 (AHRQ HS13853).
- Study identifies barriers to followup of
an abnormal Pap test in Latinas.
This study found four primary barriers
to women having colposcopy as a
followup to an abnormal Pap smear
result: (1) anxiety or fear of the test, (2)
difficulty scheduling the test around
work or child care commitments, (3)
poor doctor-patient communication,
and (4) concern about pain. The study
involved 40 Latinas, of whom 75
percent spoke only Spanish. Percac-Lima, Aldrich, Gamba, et al., J Gen
Intern Med 25(11):1198-1204, 2011
(AHRQ grant HS19161).
- Physicians and patients may not be
adhering to recommendations for less
frequent Pap testing.
Increased understanding of cervical
cancer has led professional organizations
to revise clinical guidelines to allow for
Pap test intervals of 2 to 3 years after
the age of 30 for women who have had
three consecutive normal Pap tests.
However, recent reports suggest that
many physicians are continuing to
screen annually. This study found that
only 32 percent of physicians had
adopted a 3-year Pap test interval.
Women older than age 65 were more
willing than younger women to follow a
3-year interval. Meissner, Tiro, Yabroff,
et al., Med Care 48(3):249-259, 2010.
See also Saraiya, Berkowitz, Yabroff, et
al., Arch Intern Med 170(11):977-986
- Many homeless women decline the
offer of free cervical cancer screening.
Homeless women have higher rates of
cervical cancer than other women, yet
even when barriers to cervical screening
are removed, many homeless women do
not take advantage of free Pap smears.
The researchers collected medical and
demographic information on 205
homeless women who had been
admitted to a medical facility; 129 of
the women met the criteria for Pap
testing. Only 80 of the women (62
percent) agreed to the testing, and just
56 of the women (70 percent) actually
had the test performed. Bharel, Casey,
and Wittenberg, J Women's Health
18(12):2011-2016, 2010 (AHRQ
- 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 better educate young women about the vaccine. 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).
- 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. 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).
- Certain chemotherapy drugs used to
treat ovarian cancer increase the risk of
hospitalization for older women.
Researchers studied 9,361 women aged
65 or older who were diagnosed with
stage I to IV ovarian cancer between
1991 and 2002. Eight percent of the
1,694 women who received
nonplatinum chemotherapy were
hospitalized for a gastrointestinal
ailment while on the chemotherapy,
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 platinumtaxane
therapy. Nurgalieva, Liu, Du, Int
J Gynecol Cancer 19(8):1314-1321,
2009 (AHRQ grant HS16743).
- A survey instrument used initially with
breast cancer patients is also
appropriate for patients with other
types of cancer.
This study found that the 47-item
Impact of Cancer, version 2, survey
instrument, which was first tested with
breast cancer survivors, may also be
useful in measuring the effects of other
cancers on survivors' quality of life.
Researchers gave the survey to 1,188
breast cancer survivors and 652 non-Hodgkins lymphoma survivors and
found that the survey measured
important and common concerns
shared by both groups. Because the
survey also pinpointed differences
between the two groups, it is also useful
for differentiating the impacts specific
cancers have on survivors. Crespi,
Smith, Petersen, et al., J Cancer Survivor
4(1):45-58, 2010 (AHRQ T32
- A family history of colon cancer does not negatively affect survival for women diagnosed with the same
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. 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 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).
Return to Contents
Pregnancy and Childbirth
- Prenatal appointments provide an
opportunity to screen for depression
and other problems.
This study found that clinicians often
fail to screen pregnant women during
their first prenatal visit for depression,
stress, support, and whether the
pregnancy was planned. Such screening
allows clinicians to identify women who
may be at risk for post-partum
depression or need social support once
the baby arrives. During 48 prenatal
visits with 16 providers in an academic
medical center, 35 women indicated
their pregnancies were unplanned. Of
these, only eight of the women were
told about pregnancy options, four
received information about birth control
options, and just six were referred to
counselors or social services. Meiksin,
Chang, Bhargava, et al., Patient Educ
Couns 81(3):462-467, 2010 (AHRQ
grant HS13913). See also Manber,
Schnyer, Lyell, et al., Obstet Gynecol
115(3):511-520, 2010 (AHRQ grant
HS09988) and Roman, Gardiner,
Lindsay, et al., Arch Women's Mental
Health 12:379-391, 2009 (AHRQ grant
- Certain women are at increased risk
for mental health problems during
An analysis of data on more than 3,000
pregnant women revealed that levels of
social support, general health status, and
a woman's mental health history affected
her risk for developing mental health
problems during pregnancy. Overall,
nearly 8 percent of the women reported
poor mental health while pregnant. A
history of mental health issues prior to
pregnancy was strongly predictive of
poor mental health during pregnancy.
Only 5 percent of women without any
mental health problems before pregnancy developed such problems
while pregnant. Witt, DeLeire, Hagen,
et al., Arch Women's Mental Health
13(5):425-437, 2010 (AHRQ grant
- Pelvic ultrasound in the ER is highly
effective in ruling out ectopic
The chances of a woman having an
ectopic pregnancy at the same time as a
normal pregnancy is very low—about 1
in 4,000. Thus pelvic ultrasound can be
used to confirm a normal pregnancy
and at the same time rule out an ectopic
pregnancy. Using pooled data from 10
clinical studies of ED pelvic imaging,
these researchers concluded that pelvic
ultrasound at the bedside in the ER had
99.3 percent sensitivity and a negative
predictive value of 99.96 percent. They
note that ED physicians can learn to
quickly rule out ectopic pregnancy
without waiting for radiology
consultation with a specialist. Stein,
Wang, Adler, et al., Ann Emerg Med
56(6):674-683, 2010 (AHRQ grant
- Most American women experience
complications during childbirth.
An analysis of 2008 data from AHRQ's
Healthcare Cost and Utilization Project
(HCUP) revealed that 94 percent of
women hospitalized for pregnancy and
delivery had one or more complications,
(e.g. premature labor, urinary infection,
anemia, diabetes, bleeding, and other
problems). Hospital stays for
pregnancies with complications were
longer (average of 2.9 days) compared
with uncomplicated deliveries (average
of 1.9 days), cost more ($4,100 vs.
$2,600), and accounted for $17.4
billion, or nearly 5 percent of total U.S.
hospital costs in 2008. Complicating
Conditions of Pregnancy and Childbirth,
2008; available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb113.jsp
(Intramural). See also Toledo,
McCarthy, Burke, et al., Am J Obstet
Gynecol 202(4):400.e1-400.e5, 2010
(AHRQ grant T32 HS00078).
- Perceived lower social standing is
linked to unplanned pregnancies.
More than 1,000 pregnant women in
the San Francisco area responded to a
survey, and more than one-third of the
women reported that their pregnancies
were unplanned. Black women reported
the highest rate of unintended
pregnancy (62 percent), and white
women reported the lowest rate (23
percent). Although just 18 percent of
those surveyed were black, they
accounted for 33 percent of the
unintended pregnancies. The researchers
also found that a woman's subjective
social standing was associated with
unintended pregnancy; the lower the
woman's level of self-perceived social
standing, the more likely her pregnancy
was unplanned. Bryant, Nakagawa,
Gregorich, and Kuppermann, J Women's
Health 19(6):1195-1200, 2010 (AHRQ
- Use of episiotomy and forceps during
delivery is down, but c-section rates are
An analysis of 1997 and 2008 data from
AHRQ's Healthcare Cost and
Utilization Project (HCUP) found that
the use of episiotomy fell by 60 percent,
and the use of forceps declined by 32
percent over that 11-year period.
Conversely, the proportion of hospital
stays following a c-section increased by
72 percent during the same period.
Hospitalizations Related to Childbirth,
2008; available at http://www.hcup-us.ahrq.gov/reports/statbriefs/sb110.jsp
- An accurate screening tool is needed to
identify women most likely to need a
These researchers sought to evaluate
existing screening tools for vaginal birth
after cesarean (VBAC) and to identify
additional factors that might predict
VBAC or failed trial of labor. They
found that none of the models provided
consistent ability to identify women at
risk for a failed trial of labor. They note
the need for a scoring model that
incorporates known antepartum factors
and labor patterns to allow women and
their clinicians to better identify those
individuals most likely to require repeat
c-section. Eden, McDonagh, Denman,
et al., Obstet Gynecol 116(4):967-981,
2010. See also Guise, Denman, Emeis,
et al., Obstet Gynecol 115(6):1267-1278,
2010 (AHRQ contract 290-07-10057).
- Cesarean delivery rates may not be a
useful measure of obstetric quality.
This study found that 60 percent of
107 hospitals in California and
Pennsylvania with risk-adjusted rates of
cesarean delivery that were lower than
expected also had a higher than
expected rate of at least one of six
adverse outcomes. This compared with
36.1 percent of the "as expected" group
and 19.6 percent of hospitals that had
higher than expected risk-adjusted
cesarean delivery rates. Currently, there
are no uniformly accepted measures of
obstetrical quality, and historically, the
risk-adjusted cesarean delivery rate has
been a proposed measure. The
researchers correlated risk-adjusted
cesarean delivery rates with important
maternal and neonatal outcomes in a
study of 845,000 women from 401
hospitals in the two States. Srinivas,
Fager, and Lorch, Obstet Gynecol
115(5):1007-1013, 2010. See also
Edmonds, Fager, Srinivas, and Lorch,
Obstet Gynecol 118(1):49-56, 2011
(AHRQ grant HS15696).
- Bariatric surgery before pregnancy
reduces the risk of gestational diabetes
in obese women.
According to this study, obese women
who have surgery to lose weight before
becoming pregnant are 77 percent less
likely than those who don't to develop
gestational diabetes during pregnancy.
Also, obese women who have bariatric
surgery before conceiving are much less
likely than those who don't to require a
c-section. These findings are based on a
study involving 700 women who had
bariatric surgery, either before (354
women) or after (346 women) childbirth. Burke, Bennett, Jamshidi, et
al., J Am Coll Surg 211(2):169-175,
2010 (AHRQ contract 290-05-0034).
- Novel program offers innovative tools
for caring for women with gestational
AHRQ's Health Care Innovations
Exchange offers health care professionals
practical tools to educate themselves and
pregnant women about gestational
diabetes and to help them care for
women with the condition during and
after pregnancy. A number of
approaches are described, including
telephone case management coupled
with periodic home visits from
registered nurses and cell phone text
messaging to provide monthly
educational messages and appointment
reminders for glucose testing. For more
www.innovations.ahrq.gov, a searchable
database of more than 500 innovations
and 1,550 quality tools (Intramural).
Also go to Hospitalizations Related to
Diabetes in Pregnancy, 2008, available at
- Researchers find a link between
race/ethnicity and risk for gestational
According to this analysis of data on
nearly 140,000 women who developed
gestational diabetes, women who are
Asian, Hispanic, or American Indian are
more likely than white or black women
to develop the condition. Asian women
had the highest rate (6.8 percent) of
gestational diabetes, followed by
American Indian (5.6 percent) and
Hispanic (4.9 percent) women; 3.4
percent of white women and 3.2
percent of black women developed
gestational diabetes. The rate was even
higher when the father was Asian (6.5
percent), Hispanic (4.6 percent), or
American Indian (4.5 percent),
compared with white (3.9 percent), and
black (3.3 percent) fathers. Caughey,
Cheng, Stotland, et al., Am J Obstet
Gynecol 202(6):616.e1-616.e5, 2010,
(AHRQ grant HS10856).
- Uncertainty surrounds use of
terbutaline to prevent preterm birth.
According to this AHRQ research
report, there is not enough evidence to
determine whether terbutaline
administered by a subcutaneous infusion
pump can effectively and safely prevent
repeat episodes of preterm labor. In
addition, the report notes that the
adverse effects of terbutaline pump
therapy for mothers and their babies
have not been fully explored.
Terbutaline is FDA-approved for
treatment of asthma bronchospasm, but
it is sometimes used off-label to prevent
uterine contractions and delay preterm
labor. Go to Terbutaline Pump for the
Prevention of Preterm Birth, available at
http://www.effectivehealthcare.ahrq.gov/index.cfm/search-for-guides-reviews-and-reports/?pageaction=displayproduct&productid=920 (AHRQ contract
- Study identifies ways to enhance
prenatal care in underresourced
Based on a literature review and key
informant interviews, these researchers
identified 17 innovative strategies
involving health information technology
that have been or can be used to
improve prenatal care in traditionally
underresourced settings that serve black,
Hispanic, and Asian American patients,
as well as low income children. The
strategies could be used to improve the
content of prenatal care, increase access
to timely prenatal care, and enhance the
organization and delivery of prenatal
care. Lu, Kotelchuck, Hogan, et al., Med
Care Res Rev 67(5 Suppl):198-230,
2010 (AHRQ contract
- Prenatal GBS screening may fall short
of CDC-recommended guidelines.
According to guidelines issued by the
Centers for Disease Control and
Prevention, pregnant women should be
screened for Group B streptococci
(GBS) between weeks 35 and 37 of
their pregnancies, and those who test
positive should be given IV antibiotics 4
or more hours before delivery. This study of 877 live births in 11 Tennessee
counties during 2003 and 2004 found
that the test was often performed too
early (before week 35) and that not
every woman who tested positive for
GBS was given antibiotics before
delivery. Goins, Talbot, Schaffner, et al.,
Obstet Gynecol 115(6):1217-1224, 2010
(AHRQ grant HS13833).
- Clinicians vary in the options they
offer to women who are experiencing a
Treatments for miscarriage can include
letting it progress naturally, treating it
medically with misoprostol, or surgical
evacuation; studies have shown that all
three options are safe and acceptable to
women. According to this study of 976
practitioners (obstetricians [Obs],
midwives, and family practitioners
[FPs]), a majority of midwives (55
percent) and FPs (65 percent), but just
24 percent of Obs, prefer to let the
miscarriage progress naturally. Forty-six
percent of Obs prefer surgical
evacuation in an operating room; all
three groups ranked treatment with
misoprostol as the second preferred
option. Dalton, Harris, Gold, et al., Am
J Obstet Gynecol 202(6):531.e1-531.e8,
2010 (AHRQ grant HS15491).
- 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 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 this 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. 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 290-07-10057-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).
- 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. 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 improved in women following weight-loss
surgery. 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).
- 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).
- 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.
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
- 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. Gelberg, Lu, Leake, et al., Matern Child Health 12:52-60, 2008 (AHRQ grant HS08323).
- One-fifth of mothers do not receive
recommended corticosteroids before
delivery of premature infants.
Strong evidence shows that
administration of antenatal
corticosteroids during preterm labor
reduces the incidence of respiratory
distress syndrome and other
complications associated with
prematurity. This study of premature
births at three New York City hospitals
found that 20 percent of eligible
mothers did not receive indicated
antenatal corticosteroid therapy. The
failure to administer recommended
steroids was related strongly to how
long after admission the delivery took
place, as well as lack of prenatal care,
longer gestation, advanced cervical
exam, and intact membranes at
admission. The study included 515
women eligible for corticosteroid
therapy; 70 percent of the women were
black or Hispanic, and most were
insured through Medicaid or a
Medicaid HMO. Howell, Stone,
Kleinman, et al., Matern Child Health J
14:430-436, 2010 (AHRQ grant
- Birth defects may be linked to high
blood pressure itself and not the drugs
used to treat it in early pregnancy.
According to this analysis of data on
465,000 babies born over 13 years in
Northern California, a woman's use of
medications to lower blood pressure
early in pregnancy does not increase the
risk of having a baby with a birth defect.
The study suggests that the underlying
high blood pressure itself—and not the
use of angiotensin-converting enzyme
inhibitors or other blood pressure
medications—may increase the risk of
birth defects. Although the FDA warns
against the use of ACE inhibitors during
the second and third trimesters of
pregnancy, this study found no
correlation between the occurrence of
birth defects and the use of the drugs
during the first trimester. Li, Yang,
Andrade, et al., BMJ 18:343, online,
2011 (AHRQ contract 290-050033-1)
See also Davis, Eastman, McPhillips, et
al., Pharmacoepidemiol Drug Saf 20:138-145, 2011 (AHRQ grant HS10391).
- Chronic stress during pregnancy may
be associated with less than ideal birth
Pregnant women who are stressed are at
risk for early delivery and/or low
birthweight babies. To test whether self-reports
of stress coincide with the
presence of stress biomarkers,
researchers used blood samples and
questionnaires from 205 reproductive-age
women who were receiving welfare
in the Chicago area. After determining
the women's levels of two common
stress biomarkers—Epstein-Barr virus
(EBV) and C-reactive protein (CRP)— they compared the results with the
women's responses about their levels of
actual or perceived stress. Women who
reported elevated levels of stress or
discrimination had higher levels of EBV
than other women, while CRP levels
were not strongly associated with self-reported
stress. Borders, Grobman,
Holl, et al., Am J Obstet Gynecol
203(6):577e1-577e8, 2010 (AHRQ
grant T32 HS00078).
- Extreme distress in pregnant women
appears to disproportionately affect
For pregnant women, the stress
associated with a natural or social
disaster can lead to production of
corticosteroids that adversely affect male
more than female fetuses. This study
found that the events of September 11,
2001 led to a rise in miscarriages of
male fetuses at 20 weeks or more
gestation. Using 1996 to 2002 data on
fetal deaths and birth certificate data,
the researchers found that the odds of
male fetal death increased unexpectedly
in the United States in September 2001.
In addition, the ratio of males expected
to be born in December 2001 fell below
expected values. Bruckner, Catalano,
and Ahern, BMC Public Health 10:273,
2010 (AHRQ grant T32 HS00086).
- 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. Schwarz, Santucci, Borrero, et al., Birth Defects Res A Clin Mol Teratol 85(10):858-863, 2009 (AHRQ grant HS17093).
- Maternal weight gain is associated
with some outcomes for mothers and
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).
- 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).
- Satisfaction after hysterectomy is linked
to quality-of-life improvements.
Women with persistent pelvic
problems—such as fibroids and heavy
bleeding—often choose to have a
hysterectomy when other treatments
don't work. These researchers analyzed
data on 208 women who participated in
an 8-year study and found that nearly
64 percent of the women were satisfied
and 21 percent were somewhat satisfied
in the year after their hysterectomy. Not
surprisingly, women were more likely to
be satisfied if their symptoms had
improved. Kuppermann, Learman,
Schembri, et al., Obstet Gynecol
115(3):543-551, 2010 (AHRQ grant
- Mothers' medical visits may provide an
opportunity to administer HPV
vaccine to their adolescent daughters.
Two vaccines are available to prevent
human papilloma virus (HPV)
infection, which causes cervical cancer,
yet most young women in the United
States are not vaccinated. Approaching
young women's mothers during routine
medical visits may be a possible route
for increasing awareness about HPV and
vaccination. Researchers mailed surveys
to 3,000 urban and suburban women
who had received Pap tests or mammograms; 937 women responded.
Of these, 232 women had daughters
aged 9 to 17 years, the age range
recommended for vaccination. Carlos,
Dempsey, Resnicow, et al., J Women's
Health 19(12):2271-2275, 2010
(AHRQ grant HS15491).
- Two widely used data sources differ in
estimates of rates of exclusive
Researchers compared estimates of "any"
breastfeeding and "exclusive"
breastfeeding through 3 and 6 months
using data from two different sources:
the Centers for Disease Control and
Prevention and the California
Department of Public Health. They
found that the rates for "any"
breastfeeding for the State as a whole
were similar for most racial/ethnic
groups and geographic areas, but the
two sources differed significantly on
rates of "exclusive" breastfeeding,
suggesting that either or both sources
may be flawed measures of "exclusive"
breastfeeding. Flaherman, Chien,
McCulloch, Dudley, Breastfeed Med
6(1):31-35, 2011 (AHRQ grant
HS17146). See also Ip, Chung, Raman,
et al., Breastfeed Med 4(suppl):S17-S30,
2009 (AHRQ contract 290-02-0022).
- Some women with vaginal symptoms
can be safely treated without exams
and lab tests.
Treating women suffering from
uncomfortable vaginal conditions—such as bacterial vaginosis,
trichomoniasis, and candidiasis—based
on their symptoms and without
speculum examination and lab tests
appears to be appropriate for some
women, according to this study. The 23
women who received treatment for their
vaginal symptoms without an exam had
outcomes and satisfaction ratings similar
to the 21 women who underwent
traditional examination and lab testing.
Symptoms for 93 percent of all 44
women improved in the 2-week
followup period, and both physicians
and patients were comfortable with the
approach. Anderson, Cohrssen, Klink,
and Brahver, J Am Board Fam Med
22(6):617-624, 2009 (AHRQ grant
- Rural and community hospitals can
use mobile simulators to gain hands-on
experience with childbirth emergencies.
A simulator training initiative was
developed to address a crisis in obstetric
care in Oregon, where a 2002 survey
indicated that one-third of obstetric
providers (66 percent rural) planned to
stop delivering babies within 1-5 years.
Although there were a number of
permanent simulation centers, smaller
community and rural hospitals lacked
the resources to travel for training. This
study showed that mobile simulators
could do the job, while allowing team
members to work in a familiar setting
and improve teamwork skills. Guise,
Lowe, Deering, et al., Joint Comm J
Qual Patient Saf 36(10):443-453, 2010
(AHRQ grant HS15800).
- IVF may be an option for prospective
parents when both carry the cystic
In vitro fertilization (IVF) combined
with preimplantation genetic diagnosis
(PGD) holds an advantage over natural
conception and genetic testing for
couples when both carry the cystic
fibrosis gene, according to this study.
Children with two copies of the CF
allele have an average life expectancy of
37 years, so genetic screening for CF is
now offered to all couples actively
planning to have children. When twocarrier
couples use IVF and PGD,
affected embryos can be discarded
before implantation, while a couple
using natural conception and prenatal
testing would face a decision about
terminating a pregnancy. Davis,
Champion, Fair, et al., Fertil Steril 93(6):1793-1804, 2010 (AHRQ grant
- Settlement of an obstetrical malpractice
claim has minimal impact on access to
This study focused on whether the
timing of malpractice claims and/or the
size of awards had any impact on
obstetrical practice patterns in Florida
during the study period (1992-2000).
The researcher found a small decrease
(six fewer per year) in the number of
inpatient deliveries performed by
physicians 3 years after the closing of a
malpractice claim. When the
malpractice award was $250,000 or
higher, the physician performed 14
fewer deliveries on average. There was
no effect on C-section rates or access to
obstetrical services. Grimm, Health Serv
Res 45(1):195-211, 2010 (AHRQ grant
- Breastfeeding benefits both mothers
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. Godfrey and
Meyers, J Women's Health 18(9):1307-1310, 2009 (AHRQ Publication No.
10-R034).* See also Meyers, Breastfeed
Med 4(Suppl 1):S-13-S-15, 2009
(AHRQ Publication No. 10-R024)*
- Treatment without exams and lab texts
appears effective for some women with
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
- Researchers examine associations
among various pathogens and bacterial
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.
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
- 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
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-ofpocket
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
- Both behavioral and drug therapies
can help women with urinary
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. Shamliyan, Kane, Wyman,
and Wilt, Ann Intern Med 148(6):459-473, 2008 (AHRQ contract 290-02-0009).
- Task Force recommends screening atrisk
women for certain sexually
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.
Meyers, Wolff, Gregory, et al., Am Fam
Physician 77(6):819-824, 2008 (AHRQ
Publication No. 08-R056)*
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