IUD IFS, ANDS AND BUTS
Virtually all obstetrician-gynecologists polled in 2000 agreed that the copper IUD is safe and effective, but few provide the method with great frequency.1 While 80% of the 357 respondents had inserted IUDs in the last year, only 17% had done more than 10 insertions. By contrast, 49% had inserted at least 21 IUDs during their residency. Half of respondents said that no more than 15% of their patients were appropriate candidates for IUD use. Eight in 10 agreed that a woman should not use an IUD if she is in a nonmonogamous relationship or has a history of pelvic inflammatory disease (PID), two-thirds if a woman has never given birth or has had a sexually transmitted disease, and three in 10 if she is unmarried. Sixteen percent feared that providing IUDs would leave them open to lawsuits, and 29% believed that a copper IUD increases the long-term risk of PID. In analyses of variance, the fear of litigation, the belief that the IUD causes PID and restrictive criteria for providing the method were associated with low levels of insertion. The investigators contend that "the evidence does not support" physicians' concerns about the IUD and that many physicians' policies are "unduly restrictive." Better physician education, they conclude, could help expand use of the method.
1. Stanwood NL, Garrett JM and Konrad TR, Obstetrician-gynecologists and the intrauterine device: a survey of attitudes and practices, Obstetrics & Gynecology, 2002, 99(2):275-280.
YOU GOTTA HAVE HAART
Before highly active antiretroviral therapy (HAART) became available for the treatment of HIV in 1996, women's likelihood of using antiretroviral therapy was influenced mainly by clinical and behavioral factors; use of HAART, however, is affected by additional factors, some of which reflect possible differentials in access to therapy.1 Among 1,690 women participating in a multisite longitudinal study, those with low CD4 counts, those with clinical symptoms of HIV or AIDS, and those who had participated in clinical trials had elevated odds of using antiretroviral therapy before HAART was available (odds ratios, 1.4-5.2); recent substance users had reduced odds (0.6). Once HAART became available, its use was predicted by the same factors. In addition, the odds of HAART use were elevated among women with a high CD4 count and a high viral load, some college education or private insurance (1.2-2.4). The odds were reduced among black women and women who had ever injected drugs (0.8 for each). "Given the complexity of these regimens, their expense, and their reliance on near-perfect adherence for efficacy," the researchers comment, these differentials may not be surprising. "The challenge," they conclude, is to ensure that HAART is not restricted to particular subgroups of women.
1. Cook JA et al., Use of highly active antiretroviral therapy in a cohort of HIV-seropositive women, American Journal of Public Health, 2002, 92(1):82-87.
CATHOLIC SCHOOLS THINKING OUTSIDE THE BOX
Although the Church hierarchy and many Catholic employers oppose legislation requiring that employee health benefits include coverage of contraceptives, a sizable proportion of Catholic universities have devised ways to offer such coverage to faculty members "in a manner that they feel does not compromise their identity as Catholic institutions."1 Of the 121 four-year Catholic universities that participated in a survey conducted in 2001, all but one provide coverage for pregnancy-related services as part of their health benefits. Sixty--about one-third of all Catholic universities in the United States--offer a choice of plans, including at least one that covers contraceptives. Fourteen of these schools are in states that require contraceptive coverage in employer-based plans. Nine of the schools surveyed are in states that allow Catholic institutions to opt out of contraceptive coverage; four of these exercise that option, but five provide coverage. The findings are consistent with results of an earlier study showing that many Catholic health maintenance organizations offer contraceptive coverage.
1. Miller P, Employee benefits: contraceptive coverage at America's Catholic universities, Conscience, 2001/2002, 22(4):30-31.
THOUSANDS WITH HIV DELAY GETTING CARE
An estimated 850,000-950,000 Americans are infected with HIV, including 180,000-280,000 who do not know it, according to the Centers for Disease Control and Prevention (CDC).1 Of those who know that they have HIV infection, about one-third are not receiving care. Four in 10 of all infected persons begin treatment later than recommended and therefore have a sharply increased risk of dying of AIDS. CDC researchers point to several possible reasons underlying these statistics: People who are too young to remember the peak of the epidemic mistakenly believe that current treatments can cure HIV, young people at risk are tired of being warned about AIDS, and drug advertisements create false impressions of the reality of living with HIV. The CDC has launched a public campaign to increase HIV testing rates and is urging hospitals to provide HIV testing more routinely than they currently do. In addition, the agency is urging manufacturers of rapid HIV tests that are not yet licensed in the United States to seek government approval to market them here. (Several such tests, which yield results within one day rather than one week, are used in other countries, but only one is available in the United States.)
1. Altman LK, Many Americans with H.I.V. don't know it or don't seek care, New York Times, Feb. 26, 2002, <http://www.nytimes.com/2002/02/ 26/health/261MMU.html>.
SHE WHO HESITATES...
When women delay childbearing until age 35 or older, their risk of having adverse outcomes increases, and those outcomes have an important impact at the population level, according to an analysis of birth data from Alberta, Canada.1 Between 1990 and 1996, while the number of births in the province declined, the number of births to women aged 35 and older rose by 32%; the proportion of births that were to women of this age increased by half. Older mothers had a significantly higher risk than younger mothers of having a baby who was low-birth-weight (less than 2,500 g) and of delivering preterm (before 37 weeks' gestation), as indicated by a relative risk of 1.2 for each of these outcomes. Furthermore, the prevalence of these events--which the analysts describe as "the most important determinants of neonatal mortality, as well as infant and childhood morbidity"--increased by about 10% among women 35 and older. Older mothers accounted for 78% of the change in the prevalence of low birth weight and 36% of the increase in the occurrence of preterm deliveries during the study period. These findings, the analysts note, "suggest that the number of infants who require neonatal transport, intensive care, and ongoing medical care will continue to rise if the trend toward delayed childbearing continues."
1. Touch SC et al., Delayed childbearing and its impact on population rate changes in lower birth weight, multiple birth, and preterm delivery, Pediatrics, 2002, 109(3):399-403.
THE IRISH HAVE SPOKEN ON ABORTION
By a margin of less than one percentage point--50.4% vs. 49.6%--Irish voters in March defeated a referendum proposal that would have tightened the country's already highly restrictive abortion law.1 Under Irish law, a doctor may provide an abortion only if a pregnancy endangers the woman's life. A 1992 court decision established that the threat of suicide resulting from an unwanted pregnancy constitutes a risk to the woman's life and thus is legal grounds for abortion; the proposal in the March referendum would have rejected that principle, making abortions even more difficult to get. Their country's near ban on abortion does not prevent Irish women from terminating unwanted pregnancies: Each year, an estimated 7,000 Irish women travel to England for abortions; these procedures represent about 10% of pregnancies among Irish women.
1. Lavery B, Irish voters reject broader ban on abortions, New York Times, Mar. 8, 2002, p. A6.
STAY UNTIL IT'S TIME FOR YOU TO GO
Since 1998, when a state law went into effect prohibiting insurance companies from limiting benefits for hospital postpartum care to the first 48 hours after delivery, Utah women have become more likely to remain hospitalized for at least that long and to express satisfaction with the length of their stay.1 Using data on more than 18,000 women who had normal vaginal deliveries at three urban hospitals between July 1996 and June 1999, analysts studied the effect of the law by examining maternal and newborn outcomes while controlling for a variety of factors that could affect mothers' and infants' health. Results showed that compared with women who gave birth before the law went into effect, those who delivered subsequently had significantly elevated odds of staying in the hospital for at least 48 hours postpartum (odds ratio, 4.0) and of saying that the length of their stay was about right (5.5). Their infants were more likely than those born earlier to be in the hospital for two days or more (4.0) and were less likely than others to be readmitted within seven days after discharge (0.6); infants born to first-time mothers benefited more than those whose mothers had given birth previously. These improvements come at a cost, however: Average hospitalization costs increased by $116 per delivery after the law went into effect.
1. Mosen DM et al., The medical and economic impact of the Newborns' and Mothers' Health Protection Act, Obstetrics & Gynecology, 2002, 99(1):116-124.
• A new database offers a catalogue of professional and consumer materials about emergency contraception. Created by the American Society for Emergency Contraception and the Consortium for Emergency Contraception, the database includes educational, media, medical and training materials from around the world, with complete information on how to obtain them. The database may be found at <http://ec.princeton.edu/ecmaterials/default.asp>.
• In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men, a new publication from The Alan Guttmacher Institute (AGI), provides an overview of some fundamental patterns in men's sexual and reproductive lives, and their implications for policy and programs. With a focus on men aged 15-49, the report underscores gaps in what is known and obstacles to serving men effectively. The report is available through AGI's Web site, In Their Own Right: Addressing the Sexual and Reproductive Health Needs of American Men, New York: AGI, 2002.]
• Evidence is accumulating that nonoxynol-9 is ineffective as a vaginal microbicide. Investigators in Cameroon randomly assigned 1,251 women at high risk for sexually transmitted disease to use either condoms alone or condoms plus a nonoxynol-9 gel. By the end of six months of follow-up, they found no differences between the groups in rates of new urogenital infections, gonorrhea infections or chlamydia infections. The findings are consistent with results of an earlier study in Cameroon. [Roddy RE et al., Effect of nonoxynol-9 on urogenital gonorrhea and chlamydial infection: a randomized controlled trial, JAMA, 2002, 287(9):1117-1122.]