DO YOUR NEIGHBORS AFFECT YOUR BIRTH OUTCOMES?

Black women’s risks of having a low-birth-weight baby and a preterm birth, but not of experiencing an infant death, are positively related to the proportion of their county’s residents who are black; among Hispanics, by contrast, “ethnic density” has some negative associations with infant mortality and low-birth-weight risk.1 In analyses linking 2000 data on births and infant deaths with census data, researchers found that blacks living in counties in which 1–4.99% of the population was black had higher risks of having low-birth-weight babies and preterm births than did those living in counties with relatively smaller black populations (odds ratios, 1.25–1.26). The differentials were somewhat larger if 5–14.99% of county residents were black (1.31–1.34) and then leveled off. Among Hispanics, the low-birth-weight risk was reduced in counties where Hispanics made up 5–14.99% of the population (0.9); no other associations were found for low birth weight or prematurity, but the infant mortality risk was reduced in areas where 15% or more of residents were Hispanic (0.6–0.7). For both groups, the odds of smoking fell as ethnic density increased. The analysts suggest that the different patterns of associations may reflect that “high-density Hispanic communities … are likely to represent areas built on hope and aspiration,” while “black communities are the product of a long history of racism and the embodiment of disadvantage.”

1. Shaw RJ, Pickett KE and Wilkinson G, Ethnic density effects on birth outcomes and maternal smoking during pregnancy in the US Linked Birth and Infant Data Set, American Journal of Public Health, 2010, 100(4):707–713.

CONGENITAL SYPHILIS RISING

After a 14-year decline, the rate of congenital syphilis rose by 23%—from 8.2 to 10.1 cases per 100,000 live births—between 2005 and 2008.1 According to a report based on national surveillance data, the largest increases in rates were among infants born to women living in the South (from 9.6 to 15.7 per 100,000 live births) and to black women (from 26.6 to 34.6). Congenital syphilis can be prevented if infected women are identified early in pregnancy and receive treatment at least 30 days before delivery. However, in 29% of cases, the mother had not received prenatal care. Among mothers who had, 27% were screened for syphilis only within the last 30 days before delivery, and 24% tested positive for the infection earlier in their pregnancy but were not treated for it. The uptick in the congenital syphilis rate reflects a 38% increase in the rate of primary and secondary syphilis (i.e., the first two of three stages of the disease) among females aged 10 and older between 2004 and 2007. The authors comment that “reversing the upward trend in [congenital syphilis] rates will require collaboration among health-care providers, health departments, health insurers, policymakers, and the public to reduce syphilis among women and to increase early prenatal care access and syphilis screening during pregnancy.”

1. Su JR et al., Congenital syphilis—United States, 2003–2008, Morbidity and Mortality Weekly Report, 2010, 59(14):413–417.

“PROLIFE” VS. “PROCHOICE”: LABELS RUN NECK AND NECK

Statistically indistinguishable proportions of respondents to a May 2010 Gallup poll classified themselves as prochoice (45%) and prolife (47%), but three Gallup polls over 12 months have reflected what may be “a real change in public opinion.”1 Between 1995 and 2008, polls showed Americans more likely to consider themselves prochoice than prolife, but hints of change began to emerge in May 2009. The clearest shifts can be seen among Republicans, Republican-leaning independents and 50–64-year-olds. Both genders appear to be becoming more prolife, although the increase started earlier among men than among women. No clear trend is discernible in Americans’ view of the morality of abortion—perhaps, according to Gallup, an indication that “increased political polarization” is driving a shift among Republicans. Democrats, on the other hand, seem to be moving in the opposite direction: The proportion labeling themselves prolife appears to have fallen over a six-year period.

1. Saad L, The new normal on abortion: Americans more prolife, Princeton, NJ: Gallup, May 14, 2010, <http://www.gallup.com/poll/128036/new-normal-abortion-americans-pro-life..., accessed May 25, 2010.

PARENTAL SEX ED WANING

Parent-child communication about contraception and STDs appears to be on the decline, according to teenagers’ reports in multiple rounds of two national surveys.1 The proportion of 15–17-year-old women who reported never having discussed contraception or STDs with their parents declined from 34% to 24% between the 1988 and 1995 rounds of the National Survey of Family Growth (NSFG), but was back up to 35% in 2002. Similarly, the proportion who had discussed either topic or both with their parents increased between the two earlier surveys and then dropped in the last. Meanwhile, among 15–17-year-old male NSFG participants, 33% in 2002 said that they had ever discussed contraception with their parents; by comparison, in the 1995 and 1988 National Surveys of Adolescent Males, 41% and 43%, respectively, gave this response. (Data limitations precluded analysis of males’ discussion of STDs with their parents.) Given declines in school-based sex education during the period covered by the surveys, the analysts write, “public health officials should be concerned that adolescents are not getting the information they need.” They urge these offi-cials, along with clinicians and educators, to help and encourage parents to provide accurate sexuality-related information to their teenage children.

1. Robert AC and Sonenstein FL, Adolescents’ reports of communication with their parents about sexually transmitted diseases and birth control: 1988, 1995 and 2002, Journal of Adolescent Health, 2010(46):532–537.

MEDICATION ABORTION WORKS EVEN AFTER 63 DAYS

Medication abortion, which is generally used only within the first 63 days of pregnancy, proved effective up to 90 days in a study of 254 patients at a Norwegian hospital in 2005–2007.1 The women were all 63–90 days pregnant and were given 200 mg of oral mifepristone, followed in 48 hours by 800 mcg of vaginal misoprostol; up to five additional doses of misoprostol (400 mcg each) were administered at three-hour intervals if necessary. Ninety-two percent of the women had complete abortions with no complications, and 8% required surgical evacuation. The median number of misoprostol doses required was two (range, 1–5), and the median interval from induction to abortion was 4.5 hours (range 0–15.5). Of women who answered -questions about their satisfaction with the method, 91% said they were content with it, 76% said that they would choose it again if they needed another abortion and 82% said that they would recommend it to others. The researchers write that given its high levels of effectiveness and acceptability, medication abortion “should be offered routinely” in the late first trimester.

1. Lokeland M et al., Medication abortion at 63 to 90 days of gestation, Obstetrics & Gynecology, 2010, 115(5):962–968.

NOW FOR SOME GOOD NEWS

Pill use was not associated with an increased risk of death in a cohort of more than 46,000 British women followed for up to 39 years.1 In fact, compared with women who had never used the pill, ever-users had a 12% lower risk of dying from any cause between 1968, when they entered the study, and 2007. They also had lower risks of death due to any cancer, several specific cancers (including uterine and ovarian), circulatory disease (and, specifically, ischemic heart disease) and a broad range of other diseases; they were at increased risk of dying a violent death. Overall mortality risk did not differ by duration of pill use, but among women younger than 45, it varied by time since last use: It was elevated in the 5–9 years after discontinuation (relative risk, 1.8), reflecting increased risks of dying of cancer or circulatory disease (1.9 and 3.1, respectively); at 10 or more years, however, these differences were no longer significant. The investigators point out that while the results will be reassuring to many women, the pill’s risks and benefits may vary in different countries, depending on patterns of use and disease prevalence.

1. Hannaford PC et al., Mortality among contraceptive pill users: cohort evidence from Royal College of General Practitioners’ Oral Contraception Study, BMJ, 2010, 340:c927, doi:10.1136/bmj.c927.

WHO PICKS THE HABIT?

Confirming previous work based largely on samples of white women, a British study finds that for ethnic minorities, characteristics reflecting disadvantage are linked to the probability of smoking before and after pregnancy.1 Among a cohort of 2,140 ethnic minority mothers of children born in 2000–2002, 15% had smoked before becoming pregnant, 13% at nine months postpartum and 14% three years after giving birth. In a multivariate analysis, the odds of smoking before pregnancy were elevated among women whose fathers had worked in routine and manual occupations (1.7) and among those who had left school at age 18 or younger (2.1–3.1), had first given birth as teenagers (1.9), were single mothers nine months after giving birth (3.4) or had not had a previous live birth (1.5); the odds were reduced, however, among those who had never worked (0.3). Results were similar in analyses assessing predictors of smoking at nine months and at three years postpartum. According to the investigators, the findings bolster suggestions “that policies are … needed to address disadvantage in childhood, across the transition to adulthood and in adulthood, in order to reduce smoking.”

1. Hawkins SS, Law C and Graham H, Lifecourse influences on maternal smoking before pregnancy and postpartum among women from ethnic minority groups, European Journal of Public Health, 2010, 20(3):339–345.

THE COST OF PREVENTION

A computer-assisted motivational intervention to prevent repeat childbearing among teenagers “was not low cost,” according to researchers, but it was effective and was comparable in cost to other teenage pregnancy prevention initiatives.1 A cohort of 235 pregnant women aged 18 or younger in 2003–2005 enrolled in the study, were randomly assigned to receive usual care or one of two interventions, and were followed until two years after they gave birth. One intervention group received a quarterly visit from a counselor, who gathered information on their reproductive health–related behaviors, risks and intentions, and conducted a brief motivational interview; the other group received monthly visits from their counselor, who provided a broader array of services, including case management and assistance with life skills. Overall, the teenagers in the intervention were substantially less likely than controls to become pregnant again during follow-up (odds ratio, 0.5); the association was limited to those who received the enhanced intervention. The average cost of the intervention was $2,064 per teenager ($1,449 in the basic group and $2,735 in the enhanced group); the cost per prevented repeat birth was $17,388 ($15,078 and $19,247, respectively). The intervention was most cost-effective for teenagers who had been eligible for public insurance but had not enrolled until becoming pregnant, a group that the researchers say may be at particularly high risk.

1. Barnet B et al., Cost-effectiveness of a motivational intervention to reduce rapid repeated childbearing in high-risk adolescent mothers: a rebirth of economic and policy considerations, Archives of Pediatrics & Adolescent Medicine, 2010, 164(4):370–376.