BIRTH DEARTH FALLOUT
In Japan, where the population is aging and the birthrate is falling, the number of obstetricians declined by more than 5% between 2000 and 2004. About half of obstetricians are at least 50 years old, and the majority of younger obstetricians—those in their 20s and 30s—are women, many of whom who will retire when they have children of their own. With many established obstetricians shifting their practices exclusively to gynecology, decreasing numbers of medical students choosing to specialize in obstetrics and maternity wards closing or being consolidated, pregnant women often need to go to great lengths to get delivery care. Somemake an appointment as soon as they learn their due date; others have to travel substantial distances, even if they are experiencing complications. In remote areas, an unlikely technological device provides a bridge between patients and faraway doctors: Machines used to monitor pregnant women transmit data in real time to obstetricians’ cell phones; when a doctor judges a woman is about to go into labor, she is sent to the nearest maternity ward.
1. Onishi N, In Japan’s rural areas, remote obstetrics fills the gap, New York Times, Apr. 8, 2007, < http://www.nytimes.com/2007/04/08/world/asia/08japan.html? pagewanted=1&_r=1>, accessed Apr. 11, 2007.
IS THE SYSTEM THE PROBLEM?
Reports by disadvantaged people with HIV suggest that discrimination from within the health care system may deter some portion of this population from obtaining necessary care. Among a sample of HIV-infected homeless individuals living in single room occupancy hotels in New York City, 40% said that someone in the health care system had discriminated against them in at least one of three ways: by exhibiting hostility or lack of respect, by paying less attention to them than to other clients or by refusing them service. Asked what they thought was the cause of the discrimination, the largest proportion (60%) said that it was their HIV status. Individuals who had experienced discrimination more often attributed it to medical or nonmedical support staff than to medical providers. Those who reported discrimination rated their access to care and their trust in their providers lower, and their mistrust in the health care system higher, than those who did not. The researchers emphasize "the urgent need to identify the components of the health care system that patients have found to be alienating."
1. Sohler N, Li X and Cunningham C, Perceived discrimination among severely disadvantaged people with HIV infection, Public Health Reports, 2007, 122(3):347–355.
ANOTHER RACIAL DISPARITY
Not only do black women with breast cancer learn of their illness later than whites, but a hospital based study of more than 1,000 women who underwent mammography in 1996–1998 suggests that they more often receive inadequate communication of the test results. Within six months after their mammogram, 15% of women had received inadequate communication about the result—that is, they had never been notified of it (13%) or they had been notified but could not accurately report it (2%). The proportion was significantly higher among blacks (21%) than among whites (11%), and this disparity was confirmed in analyses that controlled for socioeconomic, service-related, medical and psychosocial characteristics. Moreover, the odds of inadequate communication were elevated for black women with an abnormal test result (odds ratio,1.9), but not for white women. According to the researchers, the "‘real world’ efficacy of mammography screening" appears to be "somewhat compromised" for black women.
1. Jones BA et al., Adequacy of communicating results from screening mammograms to African American and white women, American Journal of Public Health, 2007, 97(3):531–538.
WILL YOUR DOCTOR TELL YOU WHAT YOU NEED TO KNOW?
An individual whose physician has a moral or religious objection to a particular procedure may not be able to count on the physician to provide information about it or a referral to a doctor who will perform it. In a survey conducted among a random sample of practicing physicians in 2003, nearly two-thirds of participants said that if a doctor has a moral or religious objection to a procedure, it is ethically permissible for the doctor to describe that objection to a patient requesting the procedure. However, substantial proportions did not consider themselves obligated to provide information about or referrals for procedures that they find objectionable (14% and 29%, respectively); those with objections to controversial procedures were more likely than others to feel this way. Given that half of physicians surveyed objected to providing abortions to women who experienced a contraceptive failure and four in 10 objected to providing contraception to adolescents without parental consent, the ramifications for sexual and reproductive health may be nonnegligible. As the investigators comment, people who are concerned about certain "legal yet controversial" procedures may want to find out in advance whether their doctor will discuss them.
1. Curlin FA et al., Religion, conscience, and controversial clinical practices, New England Journal of Medicine, 2007, 356(6):593–600.
GONORRHEA IS NOW A SUPERBUG
Gonorrhea’s resistance to the class of antibiotics most commonly used to treat infected individuals has exceeded acceptable levels, causing the Centers for Disease Control and Prevention (CDC) to modify its recommendations for the treatment of the disease itself and related conditions.  Data from a CDC surveillance system show steady and widespread increases in fluoroquinolone resistance since the late 1990s; between 2001 and the first half of 2006, the proportion of gonorrhea infections that were resistant to these drugs rose from less than 1% to 7% among heterosexual men. (Depending on the prevalence of infection and other factors, the CDC modifies treatment recommendations when resistance exceeds 5% in particular groups or locations.) The elimination of fluoroquinolones from gonorrhea treatment regimens leaves only one class of antibiotics to fight the disease; resistance to those drugs will be monitored closely.
1. del Rio C et al., Update to CDC’s Sexually Transmitted Diseases Treatment Guidelines, 2006: fluoroquinolones no longer recommended for treatment of gonococcal infections, Morbidity and Mortality Weekly Report, 2007, 56(14):332–336.
BIRTH OUTCOMES IMPROVE FOR HIV-EXPOSED INFANTS
Between 1989 and 2004, a span including the introduction of antiretroviral therapy for pregnant HIV-positive women and their infants, birth outcomes in a large longitudinal perinatal and HIV study improved dramatically.  The proportion of infants born to infected mothers who were low-birth-weight declined from 35% to 21%; the proportion delivered preterm fell from 35% to 22%.Declines occurred among blacks, whites and Hispanics. No association was found between use of antiretroviral therapy and the risk of having a low-birth weight baby, but nonuse of antiretroviral drugs and use of highly active antiretroviral therapy including a protease inhibitor were associated with increased risks of preterm delivery among women who received prenatal care. Noting that the study cannot establish whether access to antiretroviral therapy is responsible for the observed trends in this cohort, the researchers stress the need for "ongoing surveillance... to monitor pregnancy outcomes as more HIV-infected women choose to bear children."
1. Schulte J et al., Declines in low birth weight and preterm birth among infants who were born to HIV-infected women during an era of increased use of maternal antiretroviral drugs: Pediatric Spectrum of HIV Disease, 1989–2004, Pediatrics, 2007, 119(4):e900–e906.
IS SMOKING RELATED TO AIDS?
Smoking tobacco may be related to HIV acquisition but apparently not to the development of AIDS.1 In a systematic review of the literature, researchers found six studies, all conducted during the 1990s, that examined the relationship between cigarette smoking and HIV seroconversion among adults in populations exposed to the infection. Five of these showed significant associations between smoking and the likelihood of serologically confirmed HIV infection; odds ratios in analyses that adjusted for important confounders ranged from 1.6 to 3.5. Ten studies, also conducted during the 1990s, explored the relationship between smoking and an AIDS diagnosis; the only one that found any significant associations was limited by important design weaknesses. The researchers acknowledge that the studies varied in quality and that they assessed risk factors that are difficult to measure. Nevertheless, they contend that because "smoking prevalence is high among groups who are also vulnerable to HIV infection, including sex workers and men who have sex with men," it is important to understand the best approaches to ensuring the health of these groups.
1. Furber AS et al., Is smoking tobacco an independent risk factor for HIV infection and progression to AIDS? a systematic review, Sexually Transmitted Infections, 2007, 83(1):41–46.
IT’S ALL IN THE TIMING
Three-fifths of sexually experienced students participating in a British survey said that they had used condoms the last time they had vaginal intercourse, but the way some had used the method could have sharply reduced its effectiveness. Six percent of the 375 young people reporting recent use had put the condom on after penetration, and 6% had continued intercourse after removing the condom. In diaries kept by a subsample of respondents for six months, 31% recorded at least one instance of putting a condom on after penetration, and 9% recorded at least one instance of removing a condom before finishing intercourse. The researchers observe that the prevalence of imperfect use calls into question the validity of dichotomous self-reported measures to assess risk behaviors and condom effectiveness. Moreover, they conclude that policies and interventions aimed at promoting condom use "may not maximise their impact if the possibility of imperfect use is not...addressed."
1. Hatherall B et al., How, not just if, condoms are used: the timing of condom application and removal during vaginal sex among young people in England, Sexually Transmitted Infections, 2007, 83(1):68–70.
CONSIDER THE SOURCE
Advance provision of emergency contraception may have greater impact than both clinic and pharmacy access, according to results of a randomized trial conducted among family planning clinic clients in the San Francisco Bay area in 2001–2003. During the six-month study period, 29% of the 1,950 participants used emergency contraception; those who had been given the method in advance were significantly more likely to use it than were women who had direct pharmacy access and women who had to see a clinician to obtain it, but the level of use did not differ between the last two groups. Eighty-three percent of women who used the method took the first dose within 24 hours after having unprotected sex. Compared with women who had to visit a clinician, those who had received the method in advance were more likely to begin use within 24 hours (odds ratio, 2.4); again, however, the pharmacy access group did not differ from the controls. Similarly, 92% of users considered the method convenient to use, but only women who had received it in advance were more likely than those who had to make a clinic visit to find it convenient (4.3). Although the nature of the sample limits the generalizability of the findings, the researchers contend that "promotion of advance provision will be imperative to improving access and use."
1. Rocca CH et al., Beyond access: acceptability, use and nonuse of emergency contraception among young women, American Journal of Obstetrics & Gynecology, 2007, 196(1):29.e1–29.e6. Volume 39, Number 2, June 2007 73