Epidemiology of unintended pregnancy and contraceptive use

Decomposing the Gap in Contraceptive Use Among Female Adolescents and Young Women Aged 15-24 in India: An Analysis of Appended Datasets of NFHS-4 and 5

PURPOSE

Owing to the reproductive health needs of the budding adolescent and young population, the present study aims to determine the factors associated with and decomposing the gap in contraceptive use among adolescents and young women in India.

DESIGN

Cross sectional design.SettingThe present study is based in India using the appended datasets (IV and V rounds) of the Indian Demographic Health Survey (DHS), also known as National Family Health Survey (NFHS) conducted in 2015-16 and 2019-21.

SAMPLE

The adequate sample size was 475,294 adolescents and young women in NFHS-4 and 229,705 in NFHS-5, totaling 704,999 adolescents (appended for NFHS-4 and 5) for the present study.

MEASURES

Sociodemographic, sexual and reproductive history and contraceptive measures.

ANALYSIS

Descriptive statistics, chi-square tests, and a binary logistic regression model were executed. Additionally, a decomposition technique called Fairlie decomposition was employed to identify the primary causes of the difference in the prevalence of contraceptive use between the two survey periods.

RESULTS

Almost 96% of young women aged 15-24 knew about contraception, but only 12% used it. Regression analysis revealed that contraceptive use was associated with higher age (AOR 1.09), higher education (AOR 1.28), married adolescents (AOR 4.08), richest wealth quantile (AOR 2.95), joint decision making (AOR 4.40), knowledge of ovulatory cycle (AOR 1.47), interaction with a health worker about any methods of family planning (AOR 3.29) and three and above children ever born (AOR 18.54). Decomposition analysis showed that factors like decision-making of contraception, age, interaction with family planning worker, the intention of last pregnancy, place of residence and age at first sex contributed to increasing the probability of contraceptive use from NFHS-4 to 5.

CONCLUSION

A target-based approach dedicated to understanding the mindset of adolescents and keeping up with their unique needs is the need of the hour.

Effect of Picture-based health education and counselling on knowledge and adherence to preconception Iron-folic acid supplementation among women planning to be pregnant in Eastern Ethiopia: a randomized controlled trial

The present study examined the effect of picture-based nutrition education on knowledge and adherence to pre-conception iron-folic acid supplement (IFAS) in Ethiopia, a country where there is a high burden of neural tube defects (NTDs) and anaemia. In eastern Ethiopia, a parallel randomised controlled trial design was employed among women planning to get pregnant. The interventional arm (n 122) received a preconception picture-based nutrition education and counselling along with an IFAS and the control arm (n 122) received only a preconception IFAS. The effects of the intervention between-group differences were assessed using a χ 2 and independent sample t-test. Bivariate and multivariable linear regression model was fitted to detect independent variables affecting the outcome. The outcome measures regarding the knowledge and adherence to the IFAS intake during the three months of the intervention period were deteremined. It was observed that large proportion of women in the intervention group (42⋅6 %) had an adherence to IFAS compared to the control group (3⋅3 %); (P < 0⋅0001). Based on bivariate and multivariable linear regression analyses, among NTDs affecting pregnancy, the history of spontaneous abortion and knowledge were independently associated with adherence to the IFAS (P < 0⋅05). Preconception nutrition education with regular follow-ups could be effective in improving knowledge and adherence to the IFAS intake. This intervention is very short, simple, cost-effective and has the potential for adaptation development to a large-scale implementation in the existing healthcare system in Ethiopia to prevent NTDs and adverse birth outcomes among women who plan to get pregnant. This clinical trial was registered on 6 April 2021 under the ClinicalTrials.gov with an identifier number PACTR202104543567379.

Prevalence of and factors associated with unplanned pregnancy among women in Koshu, Japan: cross-sectional evidence from Project Koshu, 2011-2016

Background

Unplanned pregnancy is a public health issue with adverse consequences for maternal and neonatal health. In Japan, the prevalence of unplanned pregnancy was 46.2% in 2002. However, few studies have investigated this topic, and there is little recent data from Japan. We described and examined the prevalence and determinants of unplanned pregnancy among rural women in Japan from 2011 to 2016.

Methods

We used cross-sectional data from a community-based cohort study (Project Koshu). Data were collected from 2011 to 2016 via a self-report questionnaire included in the Maternal and Child Health Handbook of Japan. Pregnancy intention was measured as a binary variable (planned or unplanned). Univariate and multivariate logistic regression analyses were performed to examine factors associated with unplanned pregnancy, with results reported as odds ratios (ORs) and 95% confidence intervals (CIs). We conducted sensitivity analyses with different definitions of pregnancy intention to assess the robustness of the results. The significance level was set at 5%.

Results

Of the 932 participants (mean ± standard deviation age at baseline: 31.3 ± 5.2 years), 382 (41%) pregnancies were reported as unplanned. The multivariate analyses showed that maternal age (+ 1 year: OR = 0.94, 95% CI: 0.92–0.97, p <  0.001), ‘other’ family structure (OR = 2.76, 95% CI: 1.12–6.76, p = 0.03), three or more pregnancies (OR = 2.26, 95% CI: 1.66–3.08, p <  0.001), current smoking (OR = 2.60, 95% CI: 1.26–5.35, p = 0.01), balanced diet (OR = 0.62, 95% CI: 0.47–0.83, p <  0.001) and current depression (OR = 1.63, 95% CI: 1.24–2.16, p <  0.001) were strongly associated with unplanned pregnancy. These associations were consistent across definitions of pregnancy intention, supporting the robustness of our results.

Conclusions

The prevalence of unplanned pregnancy in the study population was high (41%). Risk factors for unplanned pregnancy were age, number of pregnancies, smoking, having a balanced diet and current depression. These results suggest greater efforts are needed to enhance sex education for young people, improve access to family planning services and provide comprehensive health care for high-risk women to help reduce unplanned pregnancies.

Competing Priorities: Partner-Specific Relationship Characteristics and Motives for Condom Use Among At-Risk Young Adults

Condoms protect against human immunodeficiency virus (HIV)/sexually transmitted infections (STIs) and unintended pregnancy and are essential to sexual health efforts targeting young adults, who are disproportionately affected by both outcomes. Understanding condom use motives is critical to increasing condom use. Research in this area is limited, particularly regarding the roles of partners and relationship factors. Using a longitudinal sample of 441 young adults and 684 reported partnerships we examined associations between relationship factors and condom use motives (pregnancy prevention, disease prevention, or dual protection). Simultaneous multilevel models identified variables associated with motives; level-specific models identified the levels (individual, partnership, time) variables impacted motives. Participants reported choosing condoms for pregnancy prevention, disease prevention, and dual protection in 51%, 17%, and 33% of partnerships, respectively. Partner-specific factors varied, to a differing degree, across the three levels. Seven variables (duration, condom self-efficacy, commitment, sexual decision-making, power, and vulnerability to harm [HIV/STIs] and pregnancy) distinguished condom use motives. The level of this association varied but was most pronounced at the partner and individual levels. Researchers and practitioners should consider the impact of both individual- and partner-level factors on condom use motives, in both research and sexual health programs.

The Influence of Parental Educational Attainment on the Partnership Context at First Birth in 16 Western Societies

In the US, growing up with parents with a low socio-economic status (SES) has been shown to increase the chance of having a birth outside marriage. However, less is known about the influence of parental SES in other Western countries. The current paper examines the association between parental educational attainment with the partnership context at first birth in 16 European and North American countries, by differentiating births within marriage, within cohabitation, or while being single. Moreover, we test whether the association between parental education and partnership context at childbirth changes over cohorts and whether its influence changes when controlling for own educational attainment. Data from the Generations and Gender Programme were used, as well as data from the American National Survey of Family Growth, the Canadian General Social Survey, and the Dutch Survey on Family Formation. The results show that in North American and East European countries, but not in West European countries, lower parental education increases the risk of having a birth within cohabitation. Moreover, in North American countries and half of the West and East European countries, lower parental education increases the risk of having a birth while being single. The association of parental education with the partnership context at birth tends to change furthermore over cohorts, although no clear pattern could be observed between countries. The study suggests that the intergenerational transmission of education is an important mechanism in explaining the influence of parental education, although other mechanisms also appear to be at work.

Unintended pregnancy and the changing demography of American women, 1987-2008

BACKGROUND

In 1987, the U.S. unintended pregnancy rate was 59 per 1,000 women aged 15–44; the rate fell to 54 in 2008. Over this period, American women experienced dramatic demographic shifts, including an aging population that was better educated and more racially and ethnically diverse.

OBJECTIVE

This study aims to explain trends in unintended pregnancy and understand what factors contributed most strongly to changes in rates over time, focusing on population composition and group-specific changes.

METHODS

We used the 1988 and 2006–10 waves of the National Survey of Family Growth and employed a decomposition approach, looking jointly at age, relationship status, and educational attainment.

RESULTS

When we decomposed by the demographic factors together, we found that changes in population composition contributed to an increase in the overall rate, but this was more than offset by group-specific rate declines, which had an impact nearly twice as great in the downward direction. Increases in the share of the population that was cohabiting and the share that was Hispanic were offset by declines in rates among married women.

CONCLUSIONS

Our findings suggest that a combination of compositional shifts and changes in group-specific rates drove unintended pregnancy, sometimes acting as counterbalancing forces and at other times operating in tandem.

Level, Trend and Correlates of Mistimed and Unwanted Pregnancies among Currently Pregnant Ever Married Women in India

Unintended pregnancy accounts for more than 40% of the total pregnancies worldwide. An Unintended pregnancy can have serious implications on women and their families. With more than one-fourth of the children in India born out of unintended pregnancies such pregnancies are considered to be one of the major public health concerns today. The present study is aimed at determining major predictors of unintended pregnancy among currently pregnant ever-married women in India. The present study has used National Family Health Survey (NFHS) data, conducted by the International Institute for Population Sciences (IIPS), Mumbai, to show the trend, pattern and determinants of mistimed and unwanted pregnancies. Bivariate and multinomial logistic regression model have been used with the help of Stata 13 software. The results show that the likelihood of a mistimed pregnancy is more prevalent among young women whereas the prevalence of unwanted pregnancy is observed more among the women aged 35 years or more. The results also show that the risk of experiencing mistimed pregnancy decreases if the woman belongs to 'other' castes and has higher education. The likelihood of unwanted pregnancy decreases among married women aged 18 years and above, those women having higher education, some autonomy and access to any mode of mass communication. Knowledge of these predictors of mistimed and unwanted pregnancy will be helpful in identifying the most vulnerable group and prioritize the intervention strategies of the reproductive health programmes for the population in need.

Birth prevalence of selected external structural birth defects at four hospitals in Dar es Salaam, Tanzania, 2011-2012

BACKGROUND

94% of all birth defects (BD) and 95% of deaths due to the BD occur in low and middle income countries, many of which are preventable. In Tanzania, there is currently a paucity of BD data necessary to develop data informed prevention activities.

METHODS

A cross-sectional analysis was conducted of deliveries identified with BD in the labor ward registers at four Dar es Salaam hospitals between October, 2011 and February, 2012. The birth prevalence of structural BD, case fatality proportion, and the distribution of structural defects associated deaths within total deaths were calculated.

RESULTS

A total of 28 217 resident births were encountered during the study period. Overall birth prevalence of selected defects was 28.3/10 000 live births. Neural tube defects and indeterminate sex were the most and least common defects at birth (9.9 and 1.1/10 000 live births, respectively). Among stillbirths (66.7%) and deaths that occurred within less than 5 days of an affected live birth (18.5%), neural tube defects were the most frequently associated structural defect.

CONCLUSION

Structural BD is common and contributes to perinatal mortality in Dar es Salaam. More than half of perinatal deaths encountered among the studied selected external structural BD are associated with neural tube defects, a birth defect with well-established evidence based prevention interventions. By establishing a population-based BD surveillance program, Tanzania would have the information about neural tube defects and other major structural BD needed to develop and monitor prevention activities.

Selection bias in the link between child wantedness and child survival: theory and data from Matlab, Bangladesh

We examine the potential effects of selection bias on the association between unwanted births and child mortality from 7,942 women from Matlab, Bangladesh who declared birth intentions in 1990 prior to conceiving pregnancies. We explore and test two opposing reasons for bias in the distribution of observed births. First, some women who report not wanting more children could face starvation or frailty; and if these women are infecund, the remaining unwanted births would appear more healthy. Second, some women who report not wanting more children could have social privileges in acquiring medical services, abortion, and contraceptives; and if these women avoid births, the remaining unwanted births would appear less healthy. We find (1) no overall effect of unwantedness on child survival in rural Bangladesh in the 1990s, (2) no evidence that biological processes are spuriously making the birth cohort look more healthy, and (3) some evidence that higher schooling for women who avoid unwanted births is biasing the observed sample to make unwanted births look less healthy. Efforts to understand the effect of unwantedness in data sets that do not control for complex patterns of selective birth may be misleading and require more cautious interpretation.

Contraception after cancer treatment: describing methods, counseling, and unintended pregnancy risk

OBJECTIVE

The objective was to describe contraceptive methods utilized by young female cancer survivors and determine whether pretreatment fertility counseling decreases unintended pregnancy risk.

METHODS

One thousand and forty-one nongynecologic cancer survivors between 18 and 40 years of age responded to a survey of reproductive health, contraceptive methods utilized and history of fertility counseling before cancer treatment. Subjects who had resumed menstrual bleeding following treatment and had not undergone surgical sterilization were defined at risk of unintended pregnancy if they reported unprotected vaginal intercourse in the prior month but did not desire conception. Statistical methods utilized were Student's t test and χ(2).

RESULTS

Overall, 918 women (88%) received treatment with potential to affect fertility (chemotherapy, radiation or sterilizing surgery). Of 476 women younger than 40 years old who still had menses, 58% did not want to conceive; of these 275 women, 21% reported unprotected intercourse in the prior month and were defined at risk of unintended pregnancy. This compares to the 7.3% risk of unintended pregnancy reported by the National Center for Health Statistics. Increasing age was associated with greater risk of unintended pregnancy (odds ratio 1.07, p=.006). The following contraceptive methods were reported: barrier (25.5%), hormonal (24.5%), tubal ligation (21.3%) vasectomy (17.5%), intrauterine device (7.2%) and other (4.0%). Sixty-seven percent of women received pretreatment fertility counseling. Counseling prior to treatment did not decrease risk of unintended pregnancy (p=.93).

CONCLUSIONS

Sexually active cancer survivors are at threefold increased risk of unintended pregnancy compared to the US population. Contraceptive counseling in this high-risk population is recommended posttreatment.

IMPLICATIONS

Sexually active cancer survivors are at considerable risk of unintended pregnancy. Patient report of pretreatment counseling regarding fertility was not associated with a decline in risk of unintended pregnancy, highlighting the importance of clear recommendations regarding content and timing of counseling.

Prevalence and correlates of drinking in early pregnancy among women who stopped drinking on pregnancy recognition

Women of child bearing age that regularly drink alcohol are at risk for drinking in early pregnancy. Evidence indicates a majority of women stop alcohol consumption on pregnancy recognition. However, there is a dearth of studies reporting on patterns and correlates of drinking in early pregnancy prior to stopping on pregnancy recognition, which the current study aims to address. In 2005, a New Zealand nationwide cross-sectional survey was conducted on a random sample of 1,256 women aged 16-40 years. Data were collected via an interviewer-administered questionnaire using a web-assisted telephone interviewing system. Of the 1,256 women who participated, 127 (10 %) were currently pregnant and 425 women (34 %) were previously pregnant. Half of currently pregnant women and 37 % of previously pregnant women reported that they ceased drinking on recognising pregnancy. Women categorised as "risky drinkers" and those aged 16-24 years had higher odds to drink and binge drink in early pregnancy, compared with non-risky drinkers and women of other age categories respectively. A majority of women stop alcohol consumption on pregnancy recognition but prior to this, drink at levels posing a risk for the developing foetus. Women most at risk for drinking and binge drinking in early pregnancy were younger in age and exhibited risky drinking behaviour prior to pregnancy. A targeted intervention to reduce the risk for an alcohol exposed pregnancy is warranted for sexually active younger women in New Zealand and elsewhere.

Prevalence and determinants of unintended pregnancy among women in Nairobi, Kenya

Background

The prevalence of unintended pregnancy in Kenya continues to be high. The 2003 Kenya Demographic and Health Survey (KDHS) showed that nearly 50% of unmarried women aged 15–19 and 45% of the married women reported their current pregnancies as mistimed or unwanted. The 2008–09 KDHS showed that 43% of married women in Kenya reported their current pregnancies were unintended. Unintended pregnancy is one of the most critical factors contributing to schoolgirl drop out in Kenya. Up to 13,000 Kenyan girls drop out of school every year as a result of unintended pregnancy. Unsafe pregnancy termination contributes immensely to maternal mortality which currently estimated at 488 deaths per 100 000 live births. In Kenya, the determinants of prevalence and determinants of unintended pregnancy among women in diverse social and economic situations, particularly in urban areas, are poorly understood due to lack of data. This paper addresses the prevalence and the determinants of unintended pregnancy among women in slum and non-slum settlements of Nairobi.

Methods

This study used the data that was collected among a random sample of 1262 slum and non-slum women aged 15–49 years in Nairobi. The data was analyzed using simple percentages and logistic regression.

Results

The study found that 24 percent of all the women had unintended pregnancy. The prevalence of unintended pregnancy was 21 per cent among women in slum settlements compared to 27 per cent among those in non-slum settlements. Marital status, employment status, ethnicity and type of settlement were significantly associated with unintended pregnancy. Logistic analysis results indicate that age, marital status and type of settlement had statistically significantly effects on unintended pregnancy. Young women aged 15–19 were significantly more likely than older women to experience unintended pregnancy. Similarly, unmarried women showed elevated risk for unintended pregnancy than ever-married women. Women in non-slum settlements were significantly more likely to experience unintended pregnancy than their counterparts in slum settlements.

The determinants of unintended pregnancy differed between women in each type of settlement. Among slum women, age, parity and marital status each had significant net effect on unintended pregnancy. But for non-slum women, it was marital status and ethnicity that had significant net effects.

Conclusion

The study found a high prevalence of unintended pregnancy among the study population and indicated that young and unmarried women, irrespective of their educational attainment and household wealth status, have a higher likelihood of experiencing unintended pregnancy. Except for the results on educational attainments and household wealth, these results compared well with the results reported in the literature.

The results indicate the need for effective programs and strategies to increase access to contraceptive services and related education, information and communication among the study population, particularly among the young and unmarried women. Increased access to family planning services is key to reducing unintended pregnancy among the study population. This calls for concerted efforts by all the stakeholders to improve access to family planning services among the study population. Increased access should be accompanied with improvement in the quality of care and availability of information about effective utilization of family planning methods.

The relationship between perinatal psychiatric disorders and contraception use among postpartum women

BACKGROUND

The relationship between perinatal psychiatric disorders and the use of effective contraceptive methods among postpartum women served by primary care clinics has not been established.

STUDY DESIGN

This was a prospective cohort study with 831 pregnant women recruited from 10 primary care clinics of the public sector in São Paulo followed up to 18 months after delivery.

RESULTS

Among 701 postpartum women, 644 women (91.8%) had resumed sexual activity. Two hundred fifty-three women (39.2%) were classified as using a less effective contraception method (LECM). The presence of perinatal psychiatric disorder (in pregnancy and/or postpartum) was not associated with LECM. Resumption of sexual life 3 months or beyond after delivery was associated with LECM (odds ratio=1.28, 95% confidence interval: 1.02-1.56).

DISCUSSION

Although the use of an LECM after delivery is common, contraception choice is not associated with perinatal depressive/anxiety symptoms. However, women who delay the resumption of sexual activity after delivery should be counseled on the use of available contraceptive methods.

Unintended pregnancies in England in 2010: costs to the National Health Service (NHS)

INTRODUCTION

Here we estimate the direct medical costs to the National Health Service (NHS) of unintended pregnancies in 2010 and identify populations at risk for unintended pregnancies.

METHODS

The number of unintended pregnancies in England in 2010 was estimated based on the number of induced and spontaneous abortions, live births and ectopic pregnancies reported by the NHS and Office for National Statistics. Direct medical costs associated with these were obtained from the NHS Reference Costs.

RESULTS

In 2010, there were an estimated 225,600 unintended pregnancies in England, of which 218,100 were paid for by the NHS. Of these, 155,500 led to induced abortions, 53,900 to births, 7,500 to spontaneous abortions and 1,200 to ectopic pregnancies. These unintended pregnancies cost the NHS £193,200,000 ($299,200,000) in direct medical costs.

DISCUSSION

London, the North West and the West Midlands should be targeted in efforts to reduce unintended pregnancies. More specifically, women between the ages of 20 and 34 years produce the greatest costs.

Motivational interviewing with computer assistance as an intervention to empower women to make contraceptive choices while incarcerated: study protocol for randomized controlled trial

BACKGROUND

Unplanned pregnancies and sexually transmitted infections (STIs) are important and costly public health problems in the United States resulting from unprotected sexual intercourse. Risk factors for unplanned pregnancies and STIs (poverty, low educational attainment, homelessness, substance abuse, lack of health insurance, history of an abusive environment, and practice of commercial sex work) are especially high among women with a history of incarceration. Project CARE (Contraceptive Awareness and Reproductive Education) is designed to evaluate an innovative intervention, motivational interviewing with computer assistance (MICA), aimed at enhancing contraceptive initiation and maintenance among incarcerated women who do not want a pregnancy within the next year and who are anticipated to be released back to the community. This study aims to: (1) increase the initiation of highly effective contraceptives while incarcerated; (2) increase the continuation of highly effective contraceptive use at 3, 6, 9, and 12  months after release; and (3) decrease unsafe sexual activity.

METHODS/DESIGN

This randomized controlled trial will recruit 400 women from the Rhode Island Department of Corrections (RI DOC) women's jail at risk for an unplanned pregnancy (that is, sexually active with men and not planning/wanting to become pregnant in the next year). They will be randomized to two interventions: a control group who receive two educational videos (on contraception, STIs, and pre-conception counseling) or a treatment group who receive two sessions of personalized MICA. MICA is based on the principles of the Transtheoretical Model (TTM) and on Motivational Interviewing (MI), an empirically supported counseling technique designed to enhance readiness to change targeted behaviors. Women will be followed at 3, 6, 9, and 12  months post release and assessed for STIs, pregnancy, and reported condom use.

DISCUSSION

Results from this study are expected to enhance our understanding of the efficacy of MICA to enhance contraceptive initiation and maintenance and reduce sexual risk-taking behaviors among incarcerated women who have re-entered the community.

TRIAL REGISTRATION

NCT01132950.

Tailored health messaging improves contraceptive continuation and adherence: results from a randomized controlled trial

BACKGROUND

Discontinuation and incorrect use of contraceptive methods may contribute to as many as 1 million unintended pregnancies annually in the United States. Interventions to improve contraceptive method continuation and adherence are needed.

STUDY DESIGN

A three-arm randomized controlled trial was conducted at two family planning sites testing the efficacy of a computer-based contraceptive assessment module in increasing the proportion of patients who continued use of their chosen contraceptive method 4 months after the family planning visit (n=224).

RESULTS

In analyses adjusting for clinical site of recruitment, family planning patients who used the module and received individually tailored health materials (n=78), compared to those in the control group (n=70), were significantly more likely to continue use of their chosen contraceptive method [95% compared to 77%; odds ratio (OR)=5.48; 95% confidence interval (CI): 1.72-17.42] and to adhere to their method (86% compared to 69%; OR=2.74; 95% CI: 1.21-6.21). No significant differences in these outcomes were found for participants who used the module but did not receive tailored materials (n=76), compared to the control group.

CONCLUSIONS

Tailored health materials significantly improved contraceptive method continuation and adherence. Additional research on the impact of the intervention on continuation and adherence in a larger sample and over a longer follow-up period is merited.

Healthcare-related characteristics of low vs normal folate levels among women of child-bearing age

OBJECTIVE

Despite the institution of mandatory folic acid fortification in the US, folate deficiencies still occur and are associated with an increased risk of several conditions. Since little is known regarding the relationship between folate status and other clinical, demographic, and healthcare-related characteristics, the objective of the study was to compare healthcare-related characteristics among US child-bearing age women with low vs normal red blood cell (RBC) folate levels.

RESEARCH DESIGN AND METHODS

Data from the 2003-2006 National Health and Nutrition Examination Survey (NHANES) were used to conduct a retrospective cohort study. Women (aged 18-45 when surveyed) were categorized in two cohorts for comparison: normal RBC folate level (≥ 140 ng/ml, NFL) and low RBC folate level (<140 ng/ml, LFL).

RESULTS

Of the 2816 subjects, 5.9% were assigned to the LFL cohort and were significantly younger (28 vs 30 years, p=0.01); a greater proportion were 18-25 years old (55.7% vs 39.9%, p<0.001) or African-American (55.1% vs 22.3%, p<0.01). A lower proportion of LFL women were insured (67.3% vs 75.5%, p=0.01) with low rates of private insurance (39.5% vs 53.1%, p<0.01), while Medicaid/SCHIP coverage was similar (16.8% vs 15.1%, p=0.56). Predictors of low folate levels included aged 36-45 years (OR: 2.14 [95% CI: 1.04, 4.39]) and never being married (2.65 [1.34, 5.24]), while a household income ≥ $75,000 reduced the likelihood of having low folate levels (0.20 [0.06, 0.73]).

LIMITATIONS

The proportion of women with low folate levels was small, with the sample size limiting the ability to adjust for other factors during analysis. Medical histories were based on patient interviews and are subject to recall bias.

CONCLUSION

LFL women are younger and have low rates of private insurance coverage compared to women with normal folate levels. Differences in age, marital status, and household income are associated with folate status.

The effect of folic acid, protein energy and multiple micronutrient supplements in pregnancy on stillbirths

Background

Pregnancy is a state of increased requirement of macro- and micronutrients, and malnourishment or inadequate dietary intake before and during pregnancy, can lead to adverse perinatal outcomes including stillbirths. Many nutritional interventions have been proposed during pregnancy according to the nutritional status of the mother and baseline risk factors for different gestational disorders. In this paper, we have reviewed three nutritional interventions including peri-conceptional folic acid supplementation, balanced protein energy supplementation and multiple micronutrients supplementation during pregnancy. This paper is a part of a series to estimate the effect of interventions on stillbirths for input to Live Saved Tool (LiST) model.

Methods

We systematically reviewed all published literature to identify studies evaluating effectiveness of peri-conceptional folic acid supplementation in reducing neural tube defects (NTD), related stillbirths and balanced protein energy and multiple micronutrients supplementation during pregnancy in reducing all-cause stillbirths. The primary outcome was stillbirths. Meta-analyses were generated where data were available from more than one study. Recommendations were made for the Lives Saved Tool (LiST) model based on rules developed by the Child Health Epidemiology Reference Group (CHERG).

Results

There were 18 studies that addressed peri-conceptional folic acid supplementation for prevention of neural tube defects (NTDs). Out of these, 7 studies addressed folic acid supplementation while 11 studies evaluated effect of folic acid fortification. Pooled results from 11 fortification studies showed that it reduces primary incidence of NTDs by 41 % [Relative risk (RR) 0.59; 95 % confidence interval (CI) 0.52-0.68]. This estimate has been recommended for inclusion in the LiST as proxy for reduction in stillbirths. Pooled results from three studies considered to be of low quality and suggest that balanced protein energy supplementation during pregnancy could lead to a reduction of 45% in stillbirths [RR 0.55, 95 % CI 0.31-0.97]. While promising, the intervention needs more effectiveness studies before inclusion in any programs. Pooled results from 13 studies evaluating role of multiple micronutrients supplementation during pregnancy showed no significant effect in reducing stillbirths [RR = 0.98; 95% CI: 0.88 – 1.10] or perinatal mortality [RR = 1.07; 95% CI: 0.92 – 1.25; random model]. No recommendations have been made for this intervention for inclusion in the LiST model.

Conclusions

Peri-conceptional folic acid supplementation reduces stillbirths due to NTDs by approximately 41%, a point estimate recommended for inclusion in LiST.

Risky health behaviors among mothers-to-be: the impact of adverse childhood experiences

OBJECTIVES

Adverse childhood experiences (ACEs) are risk factors for health problems later in life. This study aims to assess the influence of ACEs on risky health behaviors among mothers-to-be and determine whether a dose response occurs between ACEs and risky behaviors.

METHODS

A prospective survey of women attending health centers was conducted at the first prenatal care visit, and at 3 and 11 months postpartum. Surveys obtained information on maternal sociodemographic and health characteristics, and 7 ACEs prior to age 16. Risky behaviors included smoking, alcohol use, marijuana use, and other illicit drug use during pregnancy.

RESULTS

Our sample (N = 1476) consisted of low-income (mean annual personal income, $8272), young (mean age, 24 years), African American (71%), single (75%) women. Twenty-three percent of women reported smoking even after finding out they were pregnant, 7% reported alcohol use, and 7% reported illicit drug use during pregnancy. Nearly three fourths (72%) had one or more ACEs. There was a higher prevalence of each risky behavior among those exposed to each ACE than among those unexposed. The exception was alcohol use during pregnancy, where there was not an increased risk among those exposed when compared with those unexposed to witnessing a shooting or having a guardian in trouble with the law or in jail. The adjusted odds ratio for each risky behavior was >2.5 for those with >3 ACEs when compared with those without.

CONCLUSIONS

ACEs were associated with risky health behaviors reported by mothers-to-be. Greater efforts should target the prevention of ACEs to lower the risk for adverse health behaviors that have serious consequences for adults and their children.

Correlates of unintended pregnancy among currently pregnant married women in Nepal

BACKGROUND

Women living in every country, irrespective of its development status, have been facing the problem of unintended pregnancy. Unintended pregnancy is an important public health issue in both developing and developed countries because of its negative association with the social and health outcomes for both mothers and children. This study aims to determine the prevalence and the factors influencing unintended pregnancy among currently pregnant married women in Nepal.

METHODS

This paper reports on data drawn from Nepal Demographic and Health Survey (NDHS) which is a nationally representative survey. The analysis is restricted to currently pregnant married women at the time of survey. Association between unintended pregnancy and the explanatory variables was assessed in bivariate analysis using Chi-square tests. Logistic regression was used to assess the net effect of several independent variables on unintended pregnancy.

RESULTS

More than two-fifth of the currently pregnant women (41%) reported that their current pregnancy was unintended. The results indicate that age of women, age at first marriage, ideal number of children, religion, exposure to radio and knowledge of family planning methods were key predictors of unintended pregnancy. Experience of unintended pregnancy augments with women's age (odds ratio, 1.11). Similarly, increase in the women's age at first marriage reduces the likelihood of unintended pregnancy (odds ratio, 0.93). Those who were exposed to the radio were less likely (odds ratio, 0.63) to have unintended pregnancy compared to those who were not. Furthermore, those women who had higher level of knowledge about family planning methods were less likely to experience unintended pregnancy (odds ratio, 0.60) compared to those having lower level of knowledge.

CONCLUSION

One of the important factors contributing to high level of maternal and infant mortality is unintended pregnancy. Programs should aim to reduce unintended pregnancy by focusing on all these identified factors so that infant and maternal mortality and morbidity as well as the need for abortion are decreased and the overall well-being of the family is maintained and enhanced.

The resistance to contraceptive use in young Italian women

OBJECTIVE

To investigate the personal relationship and social factors that influence young women not to use contraceptives.

METHODS

A total of 104 young women aged 14-23 years were studied using a 26-item questionnaire which was to be filled out individually. The questionnaire addressed use of contraceptives at the first intercourse and current use, together with various items related to age, educational level, self-image, fantasy about parenthood, and characteristics of the relationships with the partner and the family. A descriptive analysis and a multivariate logistic regression model investigated the relationship between contraceptive non-use and selected variables.

RESULTS

Twenty-four percent of the girls did not use any effective contraceptive method at the first sexual intercourse and 21% were current non-users. The study of characteristics associated with inconsistent contraceptive use shows a complex picture where young age, poor knowledge of the partner, an older partner and living in a incomplete family nucleus or outside the family represent significant risk factors. Considering our results as a whole, contraceptive non-use is not only a marker of risk-taking behavior, but sometimes expresses irrational feelings which emerge when facing new sexual experience.

Coitus interruptus as a contraceptive method: Turkish women's perceptions and experiences

AIM

This paper is a report of a study conducted to determine the perceptions and experiences of coitus interruptus as a contraceptive method used by married women in Turkey.

BACKGROUND

Various factors affect women's choice of contraceptive methods. One of these factors is socioeconomic status, which may have an effect on the practice of coitus interruptus by women. Socioeconomic status refers to the relative position of a family or individual in a hierarchical social structure based on their access to or control over wealth, prestige and power.

METHODS

The study population consisted of married Turkish women from two different socioeconomic status groups in Turkey who were currently using coitus interruptus. Structured interviews on their demographic characteristics and perceptions and experiences of coitus interruptus were carried out between August 2004 and August 2005 with a convenience sample of 422 women (response rate 97.2%).

FINDINGS

Most participants were satisfied with the practice of coitus interruptus. Conception was the most common reason for discontinuing practice of the method. Age and educational level of participants did not affect failure in coitus interruptus practice in women of either socioeconomic status. The majority of the women of both socioeconomic statuses began practising coitus interruptus again after having stopped.

CONCLUSIONS

Women generally favoured coitus interruptus, believing in its efficacy and safety, and stated that both women and their husbands preferred to use it. Nurses and midwives should promote knowledge of all effective methods for fertility regulation while women are in the fertile ages.

Chapter 30: historical aspects of the major neurological vitamin deficiency disorders: the water-soluble B vitamins

This historical review addresses major neurological disorders associated with deficiencies of water-soluble B vitamins: beriberi, Wernicke-Korsakoff syndrome, pellagra, neural tube defects, and subacute combined degeneration of the spinal cord. Beriberi: Beriberi was known for millennia in Asia, but was not described by a European until the 17th century when Brontius in the Dutch East Indies reported the progressive sensorimotor polyneuropathy. The prevalence of beriberi increased greatly in Asia with a change in the milling process for rice in the late 19th century. In the 1880s, Takaki demonstrated the benefits of dietary modification in sailors, and later instituted dietary reforms in the Japanese Navy, which largely eradicated beriberi from the Japanese Navy by 1887. In 1889 Eijkman in Java serendipitously identified dietary factors as a major contributor to "chicken polyneuritis," which he took to be an animal model for beriberi; the polyneuritis could be cured or prevented by feeding the chickens either unpolished rice or rice polishings. By 1901, Grijns, while continuing studies of beriberi in Java, suggested a dietary deficiency explanation for beriberi after systematically eliminating deficiencies of known dietary components and excluding a toxic effect. Wernicke-Korsakoff syndrome: In the late 1870s, Wernicke identified a clinicopathological condition with ophthalmoparesis, nystagmus, ataxia, and encephalopathy, associated with punctate hemorrhages symmetrically arranged in the grey matter around the third and fourth ventricles and the aqueduct of Sylvius. In the late 1880s, Korsakoff described a spectrum of cognitive disorders, including a confabulatory amnestic state following an agitated delirium, occurring in conjunction with peripheral polyneuropathy. Beginning around 1900, investigators recognized the close relationship between Korsakoff's psychosis, delirium tremens, and Wernicke's encephalopathy, but not until several decades later were Wernicke's encephalopathy, Korsakoff's psychosis, and beriberi all linked to the deficiency of a specific dietary factor, i.e. thiamin. Thiamin: Thiamin was crystallized from rice polishings by Jansen and Donath in 1926, and synthesized by Williams and Cline in 1936. In the late 1930s and early 1940s, characteristic pathological changes of Wernicke-Korsakoff syndrome were produced in animal models, the biochemical roles of thiamin in intermediary carbohydrate metabolism were elaborated by Peters and others, and the therapeutic benefits of thiamin for Wernicke-Korsakoff syndrome and beriberi were demonstrated. By the 1950s synthetic forms of the vitamin were produced cheaply, allowing both therapeutic administration and prevention with food enrichment. Pellagra and niacin: Pellagra was unknown prior to the introduction of maize into Europe from the New World. In the 18th century, Casàl and Frapolli described the clinical features of pellagra in Europe, and linked it with poverty and subsistence on nutritionally marginal corn-based diets. In the United States, pellagra became epidemic among poor Southerners in the early 20th century, in part because of economically-driven reliance on monotonous, nutritionally inadequate diets, combined with new manufacturing methods that removed vitamins from processed grain. From 1914-1929, Goldberger completed well-designed epidemiologic investigations, tested theories with human experiments, and utilized an animal model ("black tongue" in dogs) - all strongly supporting a dietary deficiency explanation for pellagra over prevailing toxic and infectious theories. Initial prevention and treatment approaches proved inadequate because of complex social issues linked to poverty, even after Goldberger and colleagues established that dried brewer's yeast could cure or prevent pellagra less expensively than dietary modification. During the depression, the collapse of cotton as an economically viable crop facilitated crop diversification, which contributed to an abrupt decline in pellagra mortality in the early 1930s. In 1937 Elvehjem isolated the P-P (pellagra preventive) factor, identified it as nicotinic acid (niacin), and demonstrated that nicotinic acid and nicotinic acid amide cure black tongue in dogs. Although clinical trials soon confirmed dramatic therapeutic effects in individual people, therapeutic administration of niacin had relatively little impact on population-level morbidity and mortality. Vitamin fortification of foodstuffs during World War II ultimately eradicated endemic pellagra in the United States. In the 1940s and 1950s, with expanded biochemical knowledge, pellagra was reformulated as a deficiency disease due to inadequate niacin and its amino acid precursor tryptophan. Neural tube defects and folate: Folate deficiency was initially recognized clinically as a macrocytic anemia in the 1920s, and only clearly separated from pernicious anemia by the mid-20th century. When folic acid was isolated and synthesized in the 1940s, it was shown to correct the macrocytic anemia associated with pernicious anemia, while the neurological manifestations progressed. In the 1950s and 1960s, the biochemical role of folates in transferring single carbon units was elucidated. Beginning in the 1960s, folate deficiency was increasingly recognized as the major cause of preventable neural tube defects. In the early 1990s well-designed randomized trials established that folate supplementation could prevent neural tube defects. Trial data, collectively indicating that periconceptual folate administration reduces both the occurrence and recurrence risks of neural tube defects by at least 70%, helped establish governmental recommendations concerning folic acid intake and health policy concerning vitamin fortification of foodstuffs. When dietary modification and supplementation strategies proved inadequate, folic acid food fortification was legally mandated in the US in the late 1990s, which significantly improved population folate status and produced an abrupt decline (20%-27%) in the prevalence of neural tube defects at birth. Recent studies have established genetic predispositions for neural tube defects, including both infant and maternal gene polymorphisms for enzymes involved in folate-dependent homocysteine metabolism, which help explain how the genotype of the mother, the genotype of the unborn child, and environmental factors (e.g. folate intake) can all impact on the risk of neural tube defects. Subacute combined degeneration and B(12) deficiency: Pernicious anemia was recognized clinically in the mid-19th century by Addison, but the most important neurological manifestation - subacute combined degeneration of the spinal cord - was not recognized clinically and linked with pernicious anemia until the end of the 19th century, particularly by Lichtheim, Putnam, and Dana. At the beginning of the 20th century, pernicious anemia and the associated subacute combined degeneration of the spinal cord were considered, by many investigators, to result from infectious or toxic causes. During the first quarter of the 20th century, various therapies were employed, but, with the possible exception of transfusion, were largely ineffective. In the 1920s, Minot and Murphy showed that large quantities of ingested liver could be used to effectively treat pernicious anemia, and specifically could improve or prevent progression of neurological manifestations, and could extend life expectancy beyond 2 years. Beginning in the late 1920s, Castle demonstrated that a substance elaborated by the gastric mucosa ("intrinsic factor") was essential for the absorption of a dietary factor ("extrinsic factor," later shown to be vitamin B(12)) needed to prevent pernicious anemia. Over two decades, from the late 1920s until the late 1940s, increasingly potent liver extracts were manufactured that could be given either intramuscularly or intravenously. In 1947, vitamin B(12) was isolated by Folkers and colleagues, and nearly simultaneously by Smith. Shortly thereafter the therapeutic efficacy of vitamin B(12) on subacute combined degeneration was demonstrated by West and Reisner and others. By 1955, Hodgkin determined the molecular structure of cyanocobalamin using computer-assisted x-ray crystallography, allowing complete chemical synthesis of vitamin B(12) in 1960 by an international consortium. Beginning in the late 1950s, the absorption and biochemistry of vitamin B(12) were elaborated, and several lines of evidence converged to support an autoimmune basis for pernicious anemia.

Association between symptoms of depression and contraceptive method choices among low-income women at urban reproductive health centers

Among adult women of reproductive age, research has focused on depression symptoms after unintended pregnancy, or associated with hormonal contraceptive method use, with little focus on depression as a predictor of unintended pregnancy. This study was conducted to identify mental and behavioral health characteristics associated with use of less effective contraceptive methods. Choosing a less effective method of contraception places sexually active women who are not seeking pregnancy at increased risk of unintended pregnancy. Analysis was conducted using administrative data from family planning visits of 2,476 predominantly Latina and black women who received standardized behavioral and mental health screening as part of clinical care at eight reproductive health centers in New York City serving low-income women. Sociodemographic characteristics, method choice, and behavioral and mental health characteristics were compared between patients who screened positive for depression (using the PHQ-9) and those who did not. The primary outcome measure, contraceptive method choice, was dichotomized into two groups: more effective method or less effective method. In a multivariate logistic regression model adjusting for all behavioral health characteristics (binge drinking, illicit drug use, smoking, anxiety, and childhood or adult physical or sexual abuse) and birthplace, women screening positive for depression had significantly lower odds of choosing a more effective method of contraception (adjusted OR = 0.56, 95% CI: 0.36-0.87). These findings suggest that screening positive for depression may have an effect on contraceptive choice. Contraceptive counseling strategies should be individually tailored to promote decision-making and appropriate contraceptive choice, particularly among women with depression.

Moderate level fetal alcohol exposure and serotonin transporter gene promoter polymorphism affect neonatal temperament and limbic-hypothalamic-pituitary-adrenal axis regulation in monkeys

BACKGROUND

A length polymorphism in the serotonin (5-HT) transporter gene promoter region in humans and rhesus monkeys affects functional characteristics of the brain 5-HT system. Prenatal alcohol exposure (FA-exposure) can have an impact on brain and psychosocial development that could interact with genetic endowment. This study determined whether moderate FA-exposure interacts with polymorphism in the 5-HT transporter gene to increase the incidence or severity of fetal alcohol effects in rhesus monkeys.

METHODS

The offspring of monkeys who did or did not consume moderate amounts of alcohol during pregnancy were assessed for temperament as neonates and adrenocorticotropic hormone (ACTH) and cortisol (CORT) in response to mother-infant separation at 6 months of age. Serotonin promoter region genotypes (homozygous s/s or heterozygous s/l versus homozygous l/l) were determined.

RESULTS

Prenatal alcohol exposed carriers of the s allele exhibited increased neonatal irritability and increased ACTH and CORT compared with FA-exposed monkeys homozygous for the l allele and monkeys that were not FA-exposed regardless of genotype.

CONCLUSIONS

The s allele of the 5-HT transporter increases the probability of neonatal irritability and increased stress responsiveness in FA-exposed monkeys, and this gene-environment interaction may affect psychosocial development. It is probable that FA-exposure contributes to 5-HT transporter gene-environment interactions in humans.

Differences in contraceptive choice among female adolescents at a state-funded family planning clinic

Our objective was to examine differences in contraceptive choice among female adolescents from low socioeconomic backgrounds both before and after an appointment for reproductive health care at a community-based, state-funded, family planning clinic. This study utilized data collected from 4237 charts from young women attending a family planning clinic. Logistic regression was utilized to examine variables associated with the following main questions: (1) the selection of use or nonuse of contraception; (2) the selection of barrier versus hormonal contraception; and (3) within those who selected hormonal contraception, the preference for injectable versus oral hormonal methods. We found that race, age, school status, and type of health insurance were all associated with contraceptive decision-making among female adolescents. Some but not all of these associations remained after the clinic visit, which included no-cost contraception.

Predictors of abortion provision among practicing obstetrician-gynecologists: a national survey

OBJECTIVE

The objective of the study was to identify the factors that predict whether physicians include pregnancy termination in their practices.

STUDY DESIGN

We surveyed all 5055 obstetrician-gynecologists who became board certified between 1998 and 2001 about personal characteristics, career plans, intention to provide abortions before residency, residency training, and current abortion practice.

RESULTS

Of 2149 respondents (43%), 22% had provided elective abortion in the past year. In multivariate analysis controlling for preresidency intentions, personal beliefs, and other variables, the following were independently associated with current abortion provision: completing a residency program with abortion training (odds ratio [OR], 1.6; confidence interval [CI], 1.1-2.3; P = .007) and performing a greater number of abortions during residency (>25 abortions: OR, 2.8; CI, 1.9-4.1; P < .001). Factors negatively associated with working in a practice (OR, 0.4; CI, 0.2-0.6; P < .001) or hospital (OR, 0.4; CI, 0.3-0.6; P < .001) that prohibits abortion.

CONCLUSION

Regardless of intention to provide abortion before residency, abortion training availability was positively correlated with providing abortion in future practice.

Socioeconomic inequalities in unintended pregnancy and abortion decision

Pregnancy planning allows women to better control their life trajectory and contributes to the future child's health and development. Many studies that have analyzed socioeconomic inequalities in unintended pregnancy only took into account those pregnancies ending in births. Few of them that analyzed unintended pregnancy, including both induced abortion and births, and its socioeconomic determinants, concluded that unintended pregnancy is more frequent in young, poor, or unmarried women. These inequalities have been poorly studied in Europe, especially in the southern European context. The aim of the present study is to describe socioeconomic inequalities in unintended pregnancy and in abortion decision in Barcelona, Spain. The major findings are that unintended pregnancies accounted for 41% of total pregnancy and of these, 60% ended in abortion. From all pregnancies, the proportion of induced abortion reached 25.6%. Compared to women with university studies, those with primary education incomplete had more unintended pregnancies (OR=7.22). When facing an unintended pregnancy, women of lower socioeconomic position are more likely to choose induced abortion, although this is not the case among young or single women. This study reveals deep socioeconomic inequalities in unintended pregnancies and abortion decision in Barcelona, Spain, where the birth rate is very low and the abortion rate is rising. Women in low socioeconomic positions have many more unintended pregnancies than better educated women. Except for young or single women, the lower the socioeconomic position, the higher the proportion of women who choose an induced abortion when facing an unintended pregnancy.

Unintended childbearing and knowledge of emergency contraception in a population-based survey of postpartum women

OBJECTIVES

We examined the relationship between unintended childbearing and knowledge of emergency contraception.

METHODS

The Oregon Pregnancy Risk Assessment Monitoring System (PRAMS) is a population-based survey of postpartum women. We analyzed data from the 2001 PRAMS survey using logistic regression to assess the relationship between unintended childbearing and emergency contraception while controlling for maternal characteristics such as age, race/ethnicity, education, marital status, family income, and insurance coverage before pregnancy.

RESULTS

In 2001, 1,795 women completed the PRAMS survey (78.1% weighted response proportion). Of the women who completed the survey, 38.2% reported that their birth was unintended and 25.3% reported that they did not know about emergency contraception before pregnancy. Unintended childbearing was associated with a lack of knowledge of emergency contraception (OR 1.43, 95% CI 1.00, 2.05) after controlling for marital status and age.

CONCLUSIONS

Women in Oregon who were not aware of emergency contraception before pregnancy were more likely to have had an unintended birth when their marital status and age were taken into account. Unintended birth was more likely among women who were young, unmarried, lower income, and uninsured. Given that emergency contraception is now available over-the-counter in the US to women who are 18 years of age or older, age- and culturally-appropriate public health messages should be developed to expand women's awareness of, dispel myths around, and encourage appropriate use of emergency contraception as a tool to help prevent unintended pregnancy and birth.

Alcohol and tobacco consumption among 6-24-months post-partum New Zealand women

Maternal alcohol or tobacco consumption may negatively impact the fetus and breastfeeding infants. Maternal tobacco consumption is also known to negatively affect exposed young children. The current study therefore aimed to assess the prevalence of these lifestyle behaviours in a sample of 6-24-months post-partum women and to elucidate socio-demographic and maternal factors associated with these behaviours. A community-based cross-sectional survey was conducted on 6-24-months post-partum women (n = 318) in three cities in the South Island of New Zealand. Self-reported data on current alcohol and tobacco consumption were collected from these women using a self-administered questionnaire. The results showed that nearly 72% and 23% of these women consumed alcohol and tobacco, respectively. Being Caucasian, having a higher level of education and higher household income were significant factors for alcohol consumption, while being of younger age and of lower educational status were significant factors for tobacco consumption. Pregnancy was associated with lower odds for alcohol consumption (0.07; P < 0.001), but not with lower odds for tobacco consumption. In contrast, breastfeeding was not associated with lower odds of alcohol consumption (0.08; P = 0.075). In conclusion, younger women with lower levels of education and household income must be targeted for public health education on the negative effects of tobacco consumption on their own health and on the health of their children.

The Relationship Context: Its Effects on Low-Income Women's Desire for a Baby

Little is known about the influence of relationship characteristics on a woman's desire for a baby with her partner. This study addresses that gap, using data from a study of 1,114 low-income women in the southeast who were in a relationship. Controlling for sociodemographic factors, women who were in more established relationships, who had not had a previous child with their partner, or who had higher expectations of their partner were generally more likely to want a baby with him. In investigating women's childbearing desires, it is important to consider not only individual characteristics but also women's relationship characteristics.

The history of preconception care: evolving guidelines and standards

This article explores the history of the preconception movement in the United States and the current status of professional practice guidelines and standards. Professionals with varying backgrounds (nurses, nurse practitioners, family practice physicians, pediatricians, nurse midwives, obstetricians/gynecologists) are in a position to provide preconception health services; standards and guidelines for numerous professional organizations, therefore, are explored. The professional nursing organization with the most highly developed preconception health standards is the American Academy of Nurse Midwives (ACNM); for physicians, it is the American College of Obstetricians and Gynecologists (ACOG). These guidelines and standards are discussed in detail.

Improving birth control service utilization by offering services prerelease vs postincarceration

OBJECTIVES

We examined whether incarcerated women would substantially increase birth control initiation if contraceptive services were available within the prison compared with after their release back into the community.

METHODS

During phase 1 of the study, a nurse educator met with women at the Rhode Island Adult Correctional Institute and offered them referrals for contraceptive services at a community health clinic after their release. During phase 2, contraceptive services were offered to women during their incarceration.

RESULTS

The majority of the participants (77.5%) reported a desire to initiate use of birth control methods. Within 4 weeks of their release, 4.4% of phase 1 participants initiated use of a contraceptive method, compared with 39.1% of phase 2 participants (odds ratio [OR]=14.6; 95% confidence interval [CI]=5.5, 38.8).

CONCLUSIONS

Provision of contraceptive services to women during their incarceration is feasible and greatly increases birth control initiation compared to providing services only in the community.

Prevalence of periconceptional folic acid use and perceived barriers to the postgestation continuance of supplemental folic acid: Survey results from a Teratogen Information Service

BACKGROUND

Fewer than 40% of U.S. women are taking folic acid supplements periconceptionally at a time when the risk of neural tube defects (NTDs) can be reduced by supplementation. A better understanding of the vitamin-taking habits of childbearing-age women and effective methods for improving periconceptional supplement use are needed.

METHODS

A telephone survey conducted through the California Teratogen Information Service (TIS) between August 2003 and January 2004 assessed the prevalence and characteristics of pregnant callers who did not use folic acid supplements in the periconceptional period, and explored attitudes toward advice to continue vitamin use following pregnancy in order to be protected in a future pregnancy.

RESULTS

A total of 327 pregnant women who called the TIS for information agreed to participate in the survey. More than half (53.2%) were not taking folic acid-containing supplements in the periconceptional period. Predictors of lack of use included a higher prepregnancy body mass index, younger maternal age, non-white race/ethnicity, lower education level, and unplanned pregnancy. One-quarter of the women said they would be willing to continue taking vitamins after the pregnancy if advised to do so by a physician. The remainder identified obstacles to following that advice--notably, not planning to become pregnant again and the belief that enough folate is derived from diet alone.

CONCLUSIONS

More than half of the callers to the TIS were not compliant with recommendations regarding periconceptional folic acid supplementation. This represents an opportunity for TIS specialists and physicians to intervene in a current pregnancy to encourage maintenance of supplement use in the subsequent interpregnancy interval.

The Association Between Body Weight, Unintended Pregnancy Resulting in a Livebirth, and Contraception at the Time of Conception

OBJECTIVES

Annually, 3 million pregnancies in the United States are classified as unintended, with many of these unintended pregnancies occurring to women who use some type of contraceptive. Obesity may be affecting the biological effectiveness of contraceptives. We investigated whether there is an association between body weight and unintended pregnancy and whether this association differs by a woman's contraceptive status at the time of conception.

METHODS

We conducted a case-control study using multistate data from the 1999 Pregnancy Risk Assessment Monitoring System. A total of 18,445 women provided complete information on pregnancy intention, contraceptive use at the time of conception, weight, height, and other covariates. Multivariable logistic regression was used to obtain odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Among contraceptors, overweight and obese women had nearly twice the odds of having an unintended pregnancy as compared to women with normal body mass indices (OR=1.73 [95% CI: 1.20, 2.36] and OR=1.75 [95% CI: 1.21, 2.52], respectively) after adjustment for age, marital status, education, socioeconomic status, Medicaid, race/ethnicity, and parity. No association was found between heavier weight and unintended pregnancy among noncontraceptors.

CONCLUSIONS

Though the observed associations could be the result of selection bias or unmeasured confounding, the findings suggest that the effect of obesity on unintended pregnancy is limited to contraceptive failure. Prospective studies designed specifically to examine a body weight-contraceptive failure association are needed to determine if heavier women should be advised to use contraceptive methods other than hormonal contraceptives to prevent unintended pregnancy.

Contraception during perimenopause

Perimenopause marks the transition from normal ovulation to anovulation and ultimately to permanent loss of ovarian function. Fecundity, the average monthly probability of conception, declines by half as early as the mid-forties, however women during the perimenopause still need effective contraception. Issues arising at this period such as menstrual cycle abnormalities, vasomotor instability, the need for osteoporosis and cardiovascular disease prevention, as well as the increased risk of gynecological cancer, should be taken into consideration before the initiation of a specific method of contraception. Various contraceptive options may be offered to perimenopausal women, including oral contraceptives, tubal ligation, intrauterine devices, barrier methods, hormonal injectables and implants. Recently, new methods of contraception have been introduced presenting high efficacy rates and minor side-effects, such as the monthly injectable system, the contraceptive vaginal ring and the transdermal contraceptive system. However, these new methods have to be further tested in perimenopausal women, and more definite data are required to confirm their advantages as effective contraceptive alternatives in this specific age group. The use of the various contraceptive methods during perimenopause holds special benefits and risks that should be carefully balanced, after a thorough consultation and according to each woman's contraceptive needs.