Tubal sterilization in the United States, 1994-1996

CONTEXT

Although the number and rate of tubal sterilizations, the settings in which they are performed and the characteristics of women obtaining sterilization procedures provide important information on contraceptive practice and trends in the United States, such data have not been collected and tabulated for manyyears.

METHODS

Information on tubal sterilizations from the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery was analyzed to estimate the number and characteristics of women having a tubal sterilization procedure in the United States during the period 1994-1996 and the resulting rates of tubal sterilization. These results were compared with those of previous studies to examine trends in clinical setting, in the timing of the procedure and in patient characteristics.

RESULTS

In 1994-1996, more than two million tubal sterilizations were performed, for an average annual rate of 1 1.5 per 1,000 women; half were performed postpartum and half were interval procedures (i. e., were unrelated by timing to a pregnancy). All postpartum procedures were performed during inpatient hospital stays, while 96% of interval procedures were outpatient procedures. Postpartum sterilization rates were higher than interval sterilization rates among women 20-29 years of age; interval sterilization procedures were more common than postpartum procedures at ages 35-49. Sterilization rates were highest in the South. For postpartum procedures, private insurance was the expectedprimary source of payment for 48% and Medicaid was expected to pay for 41 %; for interval sterilization procedures, private insurance was the expected primary source of payment for 68% and Medicaid for 24%.

CONCLUSIONS

Outpatient tubal sterilizations andprocedures using laparoscopy have increased substantially since the last comprehensive analysis of tubal sterilization in 1987, an indication of the effect of technical advances on the provision of this service. Continued surveillance of both inpatient and outpatient procedures is necessary to monitor the role of tubal sterilization in contraceptive practice.

Abortion surveillance--United States, 1997

PROBLEM/CONDITION

In 1969, CDC began abortion surveillance to document the number and characteristics of women obtaining legal induced abortions, to monitor unintended pregnancy, and to assist efforts to identify and reduce preventable causes of morbidity and mortality associated with abortions.

REPORTING PERIOD COVERED

This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States in 1997.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data by state where the abortion occurred. The data are received from 52 reporting areas in the United States: 50 states, the District of Columbia, and New York City.

RESULTS

In 1997, a total of 1,186,039 legal abortions were reported to CDC, representing a 3% decrease from the number reported for 1996. The abortion ratio was 306 legal induced abortions per 1,000 live births, and since 1995, the abortion rate has remained at 20 per 1,000 women aged 15-44 years. The availability of information about characteristics of women who obtained an abortion in 1997 varied by state and by the number of states reporting each characteristic. The total number of legal induced abortions by state is reported by state of residence and state of occurrence; characteristics of women obtaining abortions in 1997 are reported by state of occurrence. Women who were undergoing an abortion were more likely to be young (i.e., aged < 25 years), white, and unmarried; approximately one half were obtaining an abortion for the first time. More than one half of all abortions for which gestational age was reported (55%) were performed at < or = 8 weeks of gestation, and 88% were performed before 13 weeks. Overall, 18% of abortions were performed at the earliest weeks of gestation (< or = 6 weeks), 18% at 7 weeks of gestation, and 20% at 8 weeks of gestation. From 1992 through 1997, increases have occurred in the percentage of abortions performed at the very early weeks of gestation. Few abortions were provided after 15 weeks of gestation--4% of abortions were obtained at 16-20 weeks, and 1.4% were obtained at > or = 21 weeks. A total of 19 reporting areas submitted information regarding abortions performed by medical (nonsurgical) procedures, comprising < 1% of procedures reported by all states. Younger women (i.e., aged < or = 24 years) were more likely to obtain abortions later in pregnancy than were older women.

INTERPRETATION

From 1990 through 1995, the number of abortions declined each year; in 1996, the number increased slightly, and in 1997, the number of abortions in the United States declined to it lowest level since 1978.

PUBLIC HEALTH ACTIONS

The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that trends in induced abortion can be assessed and efforts to prevent unintended pregnancy can be evaluated.

Racial disparity in pregnancy-related mortality associated with livebirth: can established risk factors explain it?

The authors conducted a nested case-control study to determine whether the fourfold increased risk of pregnancy-related mortality for US Black women compared with White women can be explained by racial differences in sociodemographic and reproductive factors. Cases were derived from a national surveillance database of pregnancy-related deaths and were restricted to White women (n = 840) and Black women (n = 448) whose pregnancies resulted in a livebirth and who died of a pregnancy-related cause between 1979 and 1986. Controls were derived from national natality data and were randomly selected White women and Black women who delivered live infants and did not die from a pregnancy-related cause (n = 5,437). Simultaneous adjustment for risk factors by using logistic regression did not explain the racial gap in pregnancy-related mortality. The largest racial disparity occurred among women with the lowest risk of pregnancy-related death: those of low to moderate parity who delivered normal-birth-weight babies (adjusted odds ratio = 3.53, 95% confidence interval: 2.9, 4.4). In contrast, no racial disparity was found among women with the highest risk of pregnancy-related death: high-parity women who delivered low-birth-weight babies. These findings indicate that reproductive health care professionals need to develop strategies to reduce pregnancy-related deaths among both high- and low-risk Black women.

Abortion reporting in the era of medical procedures: why is it important?

Food and Drug Administration approval of mifepristone and the subsequent widespread use of medical abortion will change the patterns and practice of abortion services in this country. Accurate monitoring of new, nonsurgical abortion techniques will be critical as this change takes place. Providers will want to know which women will be the predominant users of medical versus surgical methods. If medical procedures are used widely, the national trend in gestational age at the time of abortion is likely to change because medical procedures are usually performed early (at less than eight weeks' gestation). New and existing abortion providers must be informed about the reporting statutes and requirements in their areas. Information and instructions for reporting abortions are available from the vital statistics offices in each state health department and the health departments of New York City and the District of Columbia. Ongoing comprehensive monitoring of legal induced abortion is needed in all states to determine the number of procedures performed, the characteristics of women who obtain them, and the evolving trends in procedures.

Pregnancy-related mortality in Hispanic women in the United States

OBJECTIVE

To examine pregnancy-related mortality among Hispanic women in the United States.

METHODS

We used data from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System to examine all reported pregnancy-related deaths (deaths during or within 1 year of pregnancy that were caused by pregnancy, its complications, or treatment) in states that reported Hispanic origin for 1979-1992. The pregnancy-related mortality ratio was defined as the number of pregnancy-related deaths per 100,000 live births.

RESULTS

For the 14-year period, the overall pregnancy-related mortality ratio was 10.3 deaths per 100,000 live births for Hispanic women, 6.0 for non-Hispanic white women, and 25.1 for black women. In Hispanic subgroups, the pregnancy-related mortality ratio was 9.7 for Mexican women and ranged from 7.8 for Cuban women to 13.4 for Puerto Rican women. Pregnancy-induced hypertension was the leading cause of pregnancy-related death for Hispanic women overall.

CONCLUSION

Pregnancy-related mortality ratios for Hispanic women were higher than those for non-Hispanic white women, but markedly lower than those for black women. The similarity in socioeconomic status between Hispanic and black women was not an indicator of similar health outcomes. Prevention of pregnancy-related deaths in Hispanic women should include investigation of medical and nonmedical factors and consider the heterogeneity of the Hispanic population.

Spontaneous abortion-related deaths among women in the United States--1981-1991

OBJECTIVE

To examine trends in spontaneous abortion-related mortality and risk factors for these deaths from 1981 through 1991.

METHODS

We used national data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to identify deaths due to spontaneous abortion (less than 20 weeks' gestation). Case-fatality rates were defined as the number of spontaneous abortion-related deaths per 100,000 spontaneous abortions. We calculated annual case-fatality rates as well as risk ratios by maternal age, race, and gestational age.

RESULTS

During 1981-1991, a total of 62 spontaneous abortion-related deaths were reported to the Pregnancy Mortality Surveillance System. The overall case fatality rate was 0.7 per 100,000 spontaneous abortions. Maternal age 35 years and older (risk ratio [RR] 1.7, 95% confidence interval [CI] 0.9-3.0), maternal race other than white (RR 3.8, 95% CI 2.2-5.9), and gestational age over 12 weeks (RR 8.0, 95% CI 4.2-11.9) were risk factors for death due to spontaneous abortion. Of the 62 deaths, 59% were caused by infection, 18% by hemorrhage, 13% by embolism, 5% from complications of anesthesia, and 5% by other causes. Disseminated intravascular coagulation (DIC) was an associated condition among half of those deaths for which it was not the primary cause of death.

CONCLUSION

Women 35 years of age and older, of races other than white, and in the second trimester of pregnancy age are at increased risk of death from spontaneous abortion. In addition, DIC complicates many spontaneous abortion cases that end in death. Because spontaneous abortion is a common outcome of pregnancy, continued monitoring of spontaneous abortion-related deaths is recommended.

Vasectomy in the United States, 1991 and 1995

OBJECTIVES

This study sought to assess whether the controversy surrounding publications linking vasectomy and prostate cancer has had an effect on vasectomy acceptance and practice in the United States.

METHODS

National probability surveys of urology, general surgery, and family practices were undertaken in 1992 and 1996.

RESULTS

Estimates of the total number of vasectomies performed, population rate, and proportion of practices performing vasectomy were not significantly different in 1991 and 1995.

CONCLUSIONS

This study provides no solid evidence that the recent controversy over prostate cancer has influenced vasectomy acceptance or practice in the United States. However, the use of vasectomy appears to have leveled off in the 1990s.

The decline in US teen pregnancy rates, 1990-1995

OBJECTIVES

Estimate pregnancy, abortion, and birth rates for 1990 to 1995 for all teens, sexually experienced teens, and sexually active teens. DESISN: Retrospective analysis of national data on pregnancies, abortions, and births. Participants. US women aged 15 to 19 years.

OUTCOME MEASURES

Annual pregnancy, abortion, and birth rates for 1990 to 1995 for women aged 15 to 19 years, with and without adjustments for sexual experience (ever had intercourse), and sexual activity (had intercourse within last 3 months).

RESULTS

Approximately 40% of women aged 15 to 19 years were sexually active in 1995. Teen pregnancy rates were constant from 1990 to 1991. From 1991 to 1995, the annual pregnancy rate for women aged 15 to 19 years decreased by 13% to 83.6 per 1000. The percentage of teen pregnancies that ended in induced abortions decreased yearly; thus, the abortion rate decreased more than the birth rate (21% vs 9%). From 1988 to 1995, the proportion of sexually experienced teens decreased nonsignificantly.

CONCLUSIONS

After a 9% rise from 1985 to 1990, teen pregnancy rates reached a turning point in 1991 and are now declining. Physicians should counsel their adolescent patients about responsible sexual behavior, including abstinence and proper use of regular and emergency contraception.

Clinical aspects of vasectomies performed in the United States in 1995

OBJECTIVES

Currently, no surveillance system collects data on the numbers and characteristics of vasectomies performed annually in the United States. This study provides nationwide data on the numbers of vasectomies and the use of no-scalpel vasectomy, various occlusion methods, fascial interposition, and protocols for analyzing semen after vasectomy.

METHODS

A retrospective mail survey (with telephone follow-up) was conducted of 1800 urology, family practice, and general surgery practices drawn from the American Medical Association's Physician Master File and stratified by specialty and census region. Mail survey and telephone follow-up yielded an 88% response rate.

RESULTS

In 1995, approximately 494,000 vasectomies are estimated to have been performed by 15,800 physicians in the United States. Urologists performed 76% of all vasectomies, and nearly all (93%) urology practices performed vasectomies in 1995. Nearly one third (29%) of vasectomies in 1995 were no-scalpel vasectomies, and 37% of physicians performing no-scalpel vasectomies taught themselves the procedure. The most common occlusion method in 1995 (used for 38% of all vasectomies) was concurrent use of ligation and cautery. In 1995, slightly less than half (48%) of all physicians surveyed interposed the fascial sheath over one end of the vas when performing a vasectomy. Protocols for ensuring azoospermia varied: 56% of physicians required one postvasectomy semen specimen; 39% required two, and 5%, three or more.

CONCLUSIONS

No-scalpel vasectomy, used by nearly one third of U.S. physicians, has become an accepted part of urologic care. Physicians' variations in occlusion methods, use of fascial interposition, and postvasectomy protocols underscore the need for large scale, controlled, and statistically valid studies to determine the efficacy of occlusion methods and fascial interposition, as well as whether azoospermia is the only determination of a successful vasectomy.

Abortion surveillance--United States, 1995

CONDITION

Since 1990 (i.e., the year in which the number of abortions was highest), the annual number of abortions in the United States has decreased by 15%.

REPORTING PERIOD COVERED

This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States during 1995.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data received from 52 reporting areas: 50 states, the District of Columbia, and New York City.

RESULTS

In 1995, a total of 1,210,883 legal abortions were reported to CDC, representing a 4.5% decrease from the number reported for 1994. The abortion ratio was 311 legal induced abortions per 1,000 live births, and the abortion rate was 20 per 1,000 women aged 15-44 years, the lowest ratio and rate recorded since 1975. Women who were undergoing an abortion were more likely to be young, white, and unmarried; most were obtaining an abortion for the first time. Approximately half of all abortions (54%) were performed at < or =8 weeks of gestation, and approximately 88% were performed before 13 weeks. Approximately 16% of abortions were performed at the earliest weeks of gestation (< or =6 weeks), approximately 17% at 7 weeks of gestation, and approximately 21% at 8 weeks of gestation. Few abortions were provided after 15 weeks of gestation -- approximately 4% of abortions were obtained at 16-20 weeks, and 1.4% were obtained at > or =21 weeks. Younger women (i.e., women aged < or =24 years) were more likely to obtain abortions later in pregnancy than were older women.

INTERPRETATION

Since 1990, the number of abortions has declined each year. Since 1987, the abortion-to-live-birth ratio has declined; in 1995, it was the lowest recorded since 1975. This decrease in the abortion ratio reflects a trend that a lower proportion of pregnant women obtain induced abortion.

ACTIONS TAKEN

The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that trends in induced abortion can be assessed, efforts to prevent unintended pregnancy can be evaluated, and the preventable causes of morbidity and mortality associated with abortions can be identified and reduced.

Pregnancy-related mortality surveillance--United States, 1987-1990

PROBLEM/CONDITION

The Healthy People 2000: National Health Promotion and Disease Prevention Objectives specifies goals of no more than 3.3 maternal deaths per 100,000 live births overall and no more than 5.0 maternal deaths per 100,000 live births among black women; as of 1990, these goals had not been met. In addition, race-specific differences between black women and white women persist in the risk for pregnancy-related death.

REPORTING PERIOD COVERED

This report summarizes surveillance data for pregnancy-related deaths in the United States for 1987-1990.

DESCRIPTION OF SYSTEM

The National Pregnancy Mortality Surveillance System was initiated in 1988 by CDC in collaboration with the CDC/American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provided CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death records) of all identified pregnancy-related deaths.

RESULTS

During 1987-1990, 1,459 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 9.2 deaths per 100,000 live births. The pregnancy-related mortality ratio for black women was consistently higher than for white women for every risk factor examined by race. The disparity between pregnancy-related mortality ratios for black women and white women increased from 3.4 times greater in 1987 to 4.1 times greater in 1990. Older women, particularly women aged > or =35 years, were at increased risk for pregnancy-related death. The gestational age-adjusted risk for pregnancy-related death was 7.7 times higher for women who received no prenatal care than for women who received "adequate" prenatal care. The distribution of the causes of death differed depending on the pregnancy outcome; for women who died following a live birth (i.e., 55% of the deaths), the leading causes of death were pregnancy-induced hypertension complications, pulmonary embolism, and hemorrhage.

INTERPRETATION

Pregnancy-related mortality ratios for black women continued, as noted in previously published surveillance reports, to be three to four times higher than those for white women. The risk factors evaluated in this analysis confirmed the disparity in pregnancy-related mortality between white women and black women, but the reason(s) for this difference could not be determined from the available information.

ACTIONS TAKEN

Continued surveillance and additional studies should be conducted to assess the magnitude of pregnancy-related mortality, to identify those differences that contribute to the continuing race-specific disparity in pregnancy-related mortality, and to provide information that policy makers can use to develop effective strategies to prevent pregnancy-related mortality for all women.

Hysterectomy surveillance--United States, 1980-1993

PROBLEM/CONDITION

In the United States, approximately 600,000 hysterectomies are performed each year, and the procedure is the second most frequently performed major surgical procedure among reproductive-aged women.

REPORTING PERIOD COVERED

1980-1993.

DESCRIPTION OF SYSTEM

This surveillance system uses data obtained from CDC's National Hospital Discharge Survey (NHDS) to describe the epidemiology of hysterectomy. The NHDS is an annual probability sample of discharges from non-Federal, short-stay hospitals in the United States.

RESULTS

In the United States during 1980-1993, an estimated 8.6 million women aged > or =15 years had a hysterectomy. The overall rate of hysterectomy declined slightly from 1980 (7.1 hysterectomies per 1,000 women) to 1987 (6.6 per 1,000 women). The redesign of the NHDS in 1988 resulted in a decrease in estimated rates (i.e., the average annual rate for 1988-1993 was 5.5 per 1,000 women). Rates differed by age, with women aged 40-44 years most likely to have this procedure. Overall annual rates of hysterectomy did not differ significantly by race. The diagnosis most often associated with hysterectomy was uterine leiomyoma; during 1988-1993, this diagnosis accounted for 62% of hysterectomies among black women, 29% among white women, and 45% among women of other races. During 1988-1993, the percentage of hysterectomies performed by the vaginal route increased significantly; furthermore, an increasingly higher percentage of vaginal hysterectomies were accompanied by bilateral oophorectomy. From 1991 through 1993, laparoscopy was associated more frequently with vaginal hysterectomy than in previous years.

INTERPRETATION

The rate of hysterectomy decreased slightly during the first half of the 14-year surveillance period, then leveled off during the second half. The increase in simultaneous coding of laparoscopy and vaginal hysterectomy on hospital discharge forms probably reflected the growing use of laparoscopically assisted vaginal hysterectomy.

ACTIONS TAKEN

Continued surveillance for hysterectomy will enable changes in clinical practice (e.g., the use of LAVH) to be identified, and information derived from the surveillance system may assist in directing biomedical assessment priorities (e.g., to determine the reasons for race-specific differences in the prevalence of uterine leiomyoma).

Abortion surveillance--United States, 1993 and 1994

CONDITION

From 1991 through 1994, the number of legal induced abortions reported to CDC declined each year by < or =5% from the number reported for the preceding year.

REPORTING PERIOD COVERED

This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States during 1993 and 1994. This analysis also includes recently reported abortion-related deaths that occurred during 1991.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data received from 52 reporting areas: 50 states, the District of Columbia, and New York City.

RESULTS

In 1993, 1,330,414 legal abortions were reported to CDC, representing a 2.1% decrease from the number reported for 1992; in 1994, 1,267,415 abortions were reported, representing a 4.7% decrease from the number for 1993. In 1993 and 1994, the abortion ratio was 334 and 321 legal induced abortions per 1,000 live births, respectively. In 1993, the abortion rate was 22 per 1,000 women aged 15-44 years; in 1994, this rate declined to 21 per 1,000 women. Women who were undergoing an abortion were more likely to be young, white, and unmarried; most were obtaining an abortion for the first time. More than half of all abortions (52%-54%) were performed at < or =8 weeks of gestation, and approximately 88% were before 13 weeks. Approximately 15%-16% of abortions were performed at < or =6 weeks of gestation, 16% were performed at 7 weeks, and 22% at 8 weeks. Younger women (i.e., women aged < or =19 years) were more likely to obtain abortions later in pregnancy than were older women. In 1991, 12 women died as a result of induced abortion: 11 of these deaths were related to legal abortion and one to illegal abortion. During 1991, the case-fatality rate of legal induced abortion was 0.8 abortion-related deaths per 100,000 legal induced abortions.

INTERPRETATION

Since 1990, the number of abortions has declined each year. Since 1987, the abortion-to-live-birth ratio also has declined; in 1994, it was the lowest recorded since 1977. This decrease in the abortion ratio reflected the lower proportion of pregnant women who obtained an induced abortion. As in previous years, deaths related to legal induced abortions occurred rarely (i.e., approximately one death per 100,000 legal induced abortions).

ACTIONS TAKEN

The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that trends in induced abortion can be assessed, efforts to prevent unintended pregnancy can be evaluated, and the preventable causes of morbidity and mortality associated with abortions can be identified and reduced.

Anesthesia-related deaths during obstetric delivery in the United States, 1979-1990

BACKGROUND

Anesthesia-related complications are the sixth leading cause of pregnancy-related death in the United States. This study reports characteristics of anesthesia-related deaths during obstetric delivery in the United States from 1979-1990.

METHODS

Each state reports deaths that occur within 1 yr of delivery to the Centers for Disease Control and Prevention as part of the ongoing Pregnancy Mortality Surveillance. Maternal death certificates (with identifiers removed) matched with live birth or fetal death certificates when available from 1979-1990 were reviewed to identify deaths due to anesthesia, the cause of death, the procedure for delivery, and the type of anesthesia provided. Maternal mortality rates per million live births were calculated. Case fatality rates and risk ratios were computed to compare general to regional anesthesia for cesarean section deliveries.

RESULTS

The anesthesia-related maternal mortality rate decreased from 4.3 per million live births in the first triennium (1979-1981) to 1.7 per million in the last (1988-1990). The number of deaths involving general anesthesia have remained stable, but the number of regional anesthesia-related deaths have decreased since 1984. The case-fatality risk ratio for general anesthesia was 2.3 (95% confidence interval [CI], 1.9-2.9) times that for regional anesthesia before 1985, increasing to 16.7 (95% CI, 12.9-21.8) times that after 1985.

CONCLUSIONS

Most maternal deaths due to complications of anesthesia occurred during general anesthesia for cesarean section. Regional anesthesia is not without risk, primarily because of the toxicity of local anesthetics and excessively high regional blocks. The incidence of these deaths is decreasing, however, and deaths due to general anesthesia remain stable in number and hence account for an increased proportion of total deaths. Heightened awareness of the toxicity of local anesthetics and related improvements in technique may have contributed to a reduction in complications of regional anesthesia.

Pregnancy-related mortality in the United States, 1987-1990

OBJECTIVE

To use data from the Centers for Disease Control and Prevention's (CDC) Pregnancy-Related Mortality Surveillance System to examine trends in pregnancy-related mortality and risk factors for pregnancy-related death.

METHODS

In collaboration with ACOG and state health departments, the Pregnancy-Related Mortality Surveillance System has collected information on all deaths caused by pregnancy since 1979. Multiple data sources were used, including national death files, state health departments, maternal mortality review committees, individuals, and the media. As part of the initiation of the Pregnancy-Related Mortality Surveillance System in 1987, CDC staff contacted state health department personnel and encouraged them to identify and report pregnancy-related deaths. Data were reviewed and coded by experienced clinicians. Pregnancy-related mortality ratios (pregnancy-related deaths per 100,000 live births) were calculated.

RESULTS

After decreasing annually after 1979, the reported pregnancy-related mortality ratio increased from 7.2 in 1987 to 10.0 in 1990. This increase occurred among women of all races. A higher risk of pregnancy-related death was found with increasing maternal age, increasing live-birth order, no prenatal care, and among unmarried women. The leading causes of pregnancy-related death were hemorrhage, embolism, and hypertensive disorders of pregnancy. During the periods 1979-1986 and 1987-1990, the cause-specific pregnancy-related mortality ratios decreased for deaths due to hemorrhage and anesthesia, whereas pregnancy-related mortality ratios due to cardiomyopathy and infection increased. The leading causes of death varied according to the outcome of the pregnancy.

CONCLUSION

Increased efforts to identify pregnancy-related deaths have contributed to an increase in the reported pregnancy-related mortality ratio. More than half of such deaths, however, are probably still unreported. Adequate surveillance of pregnancy-related mortality and morbidity is necessary for interpreting trends, identifying high-risk groups, and developing effective interventions.

Abortion surveillance--United States, 1992

PROBLEM/CONDITION

From 1980 through 1992, the number of legal induced abortions reported to the CDC remained stable, varying each year by < or = 5%.

REPORTING PERIOD COVERED

This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States during 1992. This report also includes recently reported abortion-related deaths for 1988-1991 and an update on abortion-related deaths for 1985-1987.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data received from 52 reporting areas (i.e., the 50 states, the District of Columbia, and New York City).

RESULTS

In 1992, 1,359,145 abortions were reported--a 2.1% decrease from 1991. The abortion ratio was 335 legal induced abortions per 1,000 live births, and the abortion rate was 23 per 1,000 women 15-44 years of age. Women who were undergoing an abortion were more likely to be young, white, and unmarried; most had had no previous live births and were obtaining an abortion for the first time. More than half (51%) of all abortions were performed at or before the 8th week of gestation, and 87% were before the 13th week. Approximately 14% of abortions were performed at < or = 6 weeks of gestation, 15% were performed at 7 weeks of gestation, and 22% at 8 weeks of gestation. Younger women (i.e., women < or = 19 years of age) were more likely to obtain abortions later in pregnancy than were older women. Sixteen deaths in 1988, 12 deaths in 1989, and five deaths in 1990 were associated with legal induced abortion. The case-fatality rates for 1988, 1989, and 1990, respectively, were 1.2, 0.9, and 0.3 abortion-related deaths per 100,000 legal induced abortions.

INTERPRETATION

Since 1980, the number and rate of abortions have remained relatively stable, with only small year-to-year fluctuations of < or = 5%. However, since 1987, the abortion-to-live-birth ratio has declined; in 1992, the abortion ratio was the lowest recorded since 1977. More pregnant women have been opting to carry their pregnancies to term rather than choosing to have an abortion. As in previous years, deaths associated with legal induced abortions occurred rarely (i.e., one or fewer deaths per 100,000 legal induced abortions).

ACTIONS TAKEN

The number and characteristics of women who obtain abortions in the United States should continue to be monitored so that efforts to prevent unintended pregnancy can be assessed and the preventable causes of morbidity and mortality associated with abortions can be identified and reduced.

Pregnancy, abortion, and birth rates among US adolescents--1980, 1985, and 1990

OBJECTIVE

To analyze pregnancy, abortion, and birth rates among US adolescent girls in 1980, 1985, and 1990.

DESIGN

Retrospective analysis of trends in data on pregnancies, abortions, and births.

POPULATION

US adolescent girls aged 13 to 19 years.

MAIN OUTCOME MEASURES

Pregnancy, abortion, and birth rates (with and without adjustment for sexual experience) among teenaged girls aged 15 to 19 years and girls under 15 years.

RESULTS

Although pregnancy rates among all teenaged girls 15 to 19 years old remained fairly stable from 1980 to 1985, they increased by 9% during the last half of the decade, totaling 95.9 pregnancies per 1000 teenaged girls 15 to 19 years old by 1990. Because rates of sexual experience increased even faster, pregnancy rates among sexually experienced teens aged 15 to 19 actually declined between 1980 and 1990 by approximately 8%. Abortion rates among these teens remained stable during the 1980s, with 35.8 and 36.0 abortions per 1000 in 1980 and 1990, respectively. As with overall pregnancy rates, abortion rates among these sexually experienced teenaged girls declined during the 1980s. Between 1980 and 1985, birth rates among teenaged girls aged 15 to 19 years declined by 4%, but they increased by 18% during the latter half of the decade, totaling 59.9 births per 1000 in 1990. Among these sexually experienced teenagers, birth rates also declined between 1980 and 1985 and then increased over the next 5 years. In 1990, pregnancies and abortions among girls younger than 15 years accounted for only 3% of all adolescent pregnancies and abortions. However, the number of births among these younger adolescents increased by 15% over the decade. In that age group, trends in pregnancy, abortion and birth rates over the decade were similar to those for older teens. However, during the late 1980s, the abortion rate declined and the pregnancy rate remained stable, resulting in a 26% increase in the birth rate.

CONCLUSIONS

Despite efforts to reduce adolescent pregnancy in the United States, pregnancy and birth rates for that group continue to be the highest among developed countries. Considering that 95% of adolescent pregnancies are unintended, increased efforts to prevent these pregnancies are warranted.

Abortion surveillance--United States, 1991

PROBLEM/CONDITION

From 1980 through 1991, the number of legal induced abortions reported to CDC remained stable, varying each year by < or = 5%.

REPORTING PERIOD COVERED

This report summarizes and reviews information reported to CDC regarding legal induced abortions obtained in the United States during 1991.

DESCRIPTION OF SYSTEM

For each year since 1969, CDC has compiled abortion data received from 52 reporting areas: 50 states, the District of Columbia, and New York City.

RESULTS

In 1991, 1,388,937 abortions were reported--a 2.8% decrease from 1990. The abortion ratio was 339 legal induced abortions per 1,000 live births, and the abortion rate was 24 per 1,000 women 15-44 years of age. Women who were undergoing an abortion were more likely to be young, white, and unmarried; most had had no previous live births and had been obtaining an abortion for the first time. More than half (52%) of all abortions were performed at or before the 8th week of gestation, and 88% were before the 13th week. Younger women (i.e., women < 19 years of age) were more likely to obtain abortions later in pregnancy than were older women.

INTERPRETATION

Since 1980, the number and rate of abortions have remained relatively stable, with only small year-to-year fluctuations of < or = 5%. However, since 1987, the abortion-to-live-birth ratio has declined; in 1991, the abortion ratio was the lowest recorded since 1977. An increasing rate of childbearing may partially account for this decline.

ACTIONS TAKEN

An accurate assessment of the number and characteristics of women who obtain abortions in the United States is necessary both to monitor efforts to prevent unintended pregnancy and to identify and reduce preventable causes of morbidity and mortality associated with abortions.

Vasectomy in the United States, 1991

OBJECTIVES

Recent conflicting findings on possible health risks related to vasectomy have underscored the need for reliable and representative estimates of numbers and rates of vasectomies in the United States. The purpose of this study was to estimate the annual US number, rate, and characteristics of vasectomies in 1991.

METHODS

A national survey of urology, general surgery, and family practice physician practices was conducted with probability sampling methods (n = 1685 physicians).

RESULTS

An estimated 493,487 (95% confidence interval = 450,480, 536,494) vasectomies were performed in 1991, for a rate of 10.3 procedures per 1000 men aged 25 through 49 years. Most vasectomies were performed by urologists, and most were done in physicians' offices with local anesthesia and ligation as the method of occlusion. The rate of vasectomies was highest in the Midwest.

CONCLUSIONS

This survey provides the first national estimates of the number and rate of vasectomies in the United States, as well as the first estimates of occlusion method used. Results confirm previous findings that urologists perform most vasectomies and that most vasectomies are performed with local anesthesia. Recommendations include the monitoring of vasectomy numbers and rates as well as demographic studies of men obtaining vasectomies.

Hysterectomy in the United States, 1988-1990

OBJECTIVE

To describe patient characteristics and diagnoses associated with hysterectomy in the United States from 1988-1990 using data from the National Hospital Discharge Survey.

METHODS

We analyzed data from the National Hospital Discharge Survey, an annual probability sample of discharges from nonfederal, short-stay hospitals in the United States. A population-based sample of all women aged 15 years or older in the United States civilian population who had a hysterectomy during 1988-1990 was examined to characterize factors associated with hysterectomy: patients' age and race, diagnoses, surgical approach, and oophorectomy.

RESULTS

Approximately 1.7 million women had a hysterectomy during 1988-1990. The highest rates--100.5 hysterectomies per 10,000 women--were for women aged 30-54 years. Total rates of hysterectomy for black women were similar to those for white women (61.7 and 56.5 per 10,000 women, respectively); uterine leiomyoma ("fibroid tumor") was reported as the primary diagnosis for 61% of black women and 29% of white women. Abdominal surgery was used for 75% of all hysterectomies. Concomitant bilateral oophorectomy was done for 37% of the women under 45 years old and 68% of the women 45 years or older.

CONCLUSIONS

Two-thirds of all hysterectomies for noncancerous conditions were performed for uterine leiomyoma or endometriosis--conditions that are most common before the age of menopause. Future assessments of the appropriateness of hysterectomy will require better understanding of these disorders. Continued monitoring of hysterectomy rates is critical to understanding the appropriate use of hysterectomy, alternative therapies for uterine disorders, and future trends in women's health care.

Abortion surveillance--United States, 1990

CONDITION

Since 1980, the number of legal induced abortions reported to CDC has remained fairly stable, varying each year by < or = 5%.

REPORTING PERIOD COVERED

This report summarizes and reviews data received by CDC for legal induced abortions obtained in 1990.

DESCRIPTION OF SYSTEM

For each year, CDC compiles abortion data received from 52 reporting areas: 50 states, New York City, and the District of Columbia.

RESULTS

In 1990, 1,429,577 abortions were reported--a 2.4% increase from 1989. The abortion ratio for 1990 was 345 legal induced abortions per 1,000 live births, and the abortion rate was 24 per 1,000 women ages 15-44 years. Most women undergoing abortions were young, white, and unmarried; most had had no previous live births and were having the procedure for the first time. Approximately half of all abortions were performed before the 8th week of gestation, and 87% were before the 13th week of gestation. Younger women were more likely to obtain abortions later in pregnancy than were older women.

INTERPRETATION

Since 1980, the national number (and rate) of abortions has remained relatively stable, with only small (< or = 5%) year-to-year fluctuations. However, since 1984, the national abortion ratio has declined; in 1990, the abortion ratio was the lowest recorded since 1977. Increasing rates of childbearing may account for some of this decline.

ACTIONS TAKEN

The number and characteristics of women having abortions are needed from all states to furnish an accurate characterization of legal induced abortion in the United States and to assist efforts to identify and reduce preventable causes of morbidity and mortality associated with abortions.

Surveillance for pregnancy and birth rates among teenagers, by state--United States, 1980 and 1990

PROBLEM/CONDITION

In the United States in 1990, there were an estimated 1 million pregnancies and 521,826 births among women ages 15-19 years. Rates of teenage pregnancy and birth rates by state in 1990 exceeded those in most developed countries. An estimated 95% of teenage pregnancies are unintended (i.e., they occur sooner than desired or are not wanted at any time).

REPORTING PERIOD COVERED

This report summarizes and reviews surveillance data for pregnancies, abortions, and births among women ages 15-19, 15-17, and 18-19 years reported by CDC for 1980 and 1990.

DESCRIPTION OF SYSTEM

Data for births and abortions were reported to state health departments and other health agencies and sent to CDC. The data from each state included the total number of births and abortions by age and race/ethnicity.

RESULTS

Data in this report indicate that pregnancy rates by state among U.S. teenagers ages 15-19 years have changed little since 1980. Moreover, many states have reported increases in birth rates that are probably related to concurrent decreases in abortion rates. Pregnancy rates range from 25 to 75 per 1,000 for 15- to 17-year-olds and from 92 to 165 per 1,000 for 18- to 19-year-olds.

INTERPRETATION

States with low rates of teenage pregnancy or birth may have developed and used prevention strategies directed at the needs of both younger and older teenagers; these programs may serve as models for other states where birth rates have remained high or have increased since 1980.

ACTIONS TAKEN

CDC will continue to conduct surveillance of and analyze data for pregnancies, abortions, and births among teenagers to monitor progress toward national goals and to assist in targeting program efforts for reducing teenage pregnancy.

The epidemiology of placenta previa in the United States, 1979 through 1987

OBJECTIVE

Placenta previa can cause serious, occasionally fatal complications for fetuses and mothers; however, data on its national incidence and sociodemographic risk factors have not been available.

STUDY DESIGN

We analyzed data from the National Hospital Discharge Survey for the years 1979 through 1987 and from the Retrospective Maternal Mortality Study (1979 through 1986).

RESULTS

We found that placenta previa complicated 4.8 per 1000 deliveries annually and was fatal in 0.03% of cases. Incidence rates remained stable among white women but increased among black and other minority women (p < 0.1). In addition, the risk of placenta previa was higher for black and other minority women than for white women (rate ratio 1.3, 95% confidence interval 1.0 to 1.7), and it was higher for women > or = 35 years old than for women <20 years old (rate ratio 4.7, 95% confidence interval 3.3 to 7.0). Women with placenta previa were at an increased risk of abruptio placentae (rate ratio 13.8), cesarean delivery (rate ratio 3.9), fetal malpresentation (rate ratio 2.8), and postpartum hemorrhage (rate ratio 1.7).

CONCLUSION

Our findings support the need for improved prenatal and intrapartum care to reduce the serious complications and deaths associated with placenta previa.

Abortion surveillance--United States, 1989

Since 1980, the number of legal induced abortions reported to CDC has remained stable, varying each year by < 5%. In 1989, 1,396,658 abortions were reported--a 1.9% increase from 1988. The abortion ratio for 1989 was 346 legal induced abortions/1,000 live births, and the abortion rate was 24/1,000 women ages 15-44 years. The abortion ratio was highest for black women and women of other minority racial groups and for women < 15 years of age. Overall, women undergoing abortions tended to be young, white, and unmarried; to have had no previous live births; and to be having the procedure for the first time. Approximately half of all abortions were performed before the eighth week of gestation, and 87% were before the thirteenth week of gestation. Younger women tended to obtain abortions later in pregnancy than older women. This report also includes newly reported abortion-related deaths for 1986 and 1987, as well as an update on abortion-related deaths for the period 1978-1985. Ten deaths in 1986 and six deaths in 1987 were associated with legal induced abortion. The case-fatality rate in 1986 was 0.8 abortion-related deaths/100,000 legal induced abortions and 0.4/100,000 in 1987.

Abortion surveillance, United States, 1988

Since 1980, the number of legal abortions reported to CDC has remained fairly stable, varying each year by less than 3%. In 1988, 1,371,285 abortions were reported--a 1.3% increase from 1987. The abortion ratio for 1988 was 352 legally induced abortions/1,000 live births, and the abortion rate was 24/1,000 women ages 15-44 years. The abortion ratio was higher for black women and women of other minority races and for women less than 15 years of age. However, the abortion ratio for women less than 15 years was lower in 1988 than in any previous year since 1972. Women undergoing legally induced abortions tended 1) to be young, white, and unmarried, 2) to live in a metropolitan area, 3) to have had no previous live births, and 4) to be having the procedure for the first time. Approximately half of all abortions were performed before the eighth week of gestation, and greater than 85% were performed during the first trimester of pregnancy (less than 13 weeks of gestation). Black women and women of other minority races tended to obtain abortions later in pregnancy than did white women; however, age was a more dominant influence than race. Younger women tended to obtain abortions later than older women. Educational level strongly influenced when an abortion was performed; better educated women had an abortion earlier in gestation.

Maternal mortality surveillance, United States, 1979-1986

To understand further the epidemiology and causes of maternal death, the Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, CDC, reviewed all identified maternal deaths in the United States, including Puerto Rico, for the period from 1979 through 1986. The maternal mortality ratio for the period was 9.1 deaths/100,000 live births. The ratios increased with age and were higher among women of black and other minority races than among white women for all age groups, particularly for women ages greater than or equal to 40 years. Unmarried women had a higher risk of death than married women. Women who had received any prenatal care had a lower risk of dying than women who had received no care (RR = 0.19, 95% confidence limits (CL) 0.15, 0.23). Women who received no prenatal care had a gestational age-adjusted risk of maternal death 5.7 times that of women receiving care defined as "adequate." The risk of maternal death increased with decreasing levels of education for all age groups, particularly among women ages greater than or equal to 35 years. The causes of death varied for different outcomes of pregnancy; pulmonary embolism was the leading cause of death following the delivery of a live birth. Future studies aimed at developing strategies to reduce the risk of maternal deaths in the United States should use enhanced surveillance and collect more information about each death, which would allow for better understanding of factors associated with maternal mortality.

Characteristics of U.S. women having abortions, 1987

In 1987, as in earlier years, women having abortions were predominantly white (65 percent), younger than 25 (59 percent), and unmarried (82 percent). A majority had no previous live births (53 percent), and most had no previous abortions (58 percent). About half the abortions were performed before nine weeks of gestation, and 97 percent were curettage procedures, usually suction curettage. Comparisons with 1980 data reveal a six percent decline in the U.S. abortion rate after changes in age, race and marital status within the population are controlled for; however, the decline occurred only among the white population and not among minority races. Among teenagers aged 15-19, the abortion rate declined slightly for whites and increased for minorities. The rate also increased among women younger than age 15.

Maternal mortality in the United States, 1979-1986

To understand better the epidemiology and to describe the causes of maternal death, we reviewed all identified maternal deaths in the United States and Puerto Rico for 1979-1986. The overall maternal mortality ratio for the period was 9.1 deaths per 100,000 live births. The ratios increased with age and were higher among women of black and other minority races than among white women for all age groups. The causes of death varied for different outcomes of pregnancy; pulmonary embolism was the leading cause of death after a live birth. Unmarried women had a higher risk of death than married women. The risk of death increased with increasing live-birth order, except for primiparas. In order to develop strategies to reduce the risk of maternal death in the United States, future studies should include expanded information about each death, which will allow better understanding of factors associated with maternal mortality.

Abortion surveillance, 1986-1987

Since 1980, the number of legal abortions reported to CDC has remained fairly stable, varying each year by less than 3%. In 1986, 1,328,112 abortions were reported; in 1987, that number increased by approximately 2% to 1,353,671. The abortion ratio for 1986 was 354 legally induced abortions per 1,000 live births; the ratio for 1987 was 356 per 1,000. The national abortion rate was 23/1,000 females ages 15-44 years for 1986 and 24/1,000 females ages 15-44 years in 1987. Abortion ratios were higher among women of black and other minority races and among women less than 15 years of age. Women undergoing legally induced abortions tended 1) to be young, white, and unmarried, 2) to have had no previous live births, and 3) to be having the procedure for the first time. In 1987, approximately half of all abortions were performed before the eighth week of gestation, and greater than 85% were performed during the first trimester of pregnancy (less than 13 weeks of gestation).

Abortion surveillance, United States, 1984-1985

Since 1983, the number of legal abortions reported to CDC increased by 5% to 1,333,521 in 1984; in 1985, that number decreased by less than 1% to 1,328,570. The national abortion rate was the same for both years-24 per 1,000 females ages 15-44 years. The abortion ratio for 1984 was 364 legally induced abortions per 1,000 live births; the ratio for 1985 was 354 per 1,000. Abortion ratios were higher among women of black and other minority races and among women younger than 15 years of age. Women undergoing legally induced abortions tended 1) to be young, white, and unmarried, 2) to have had no previous live births, and 3) to be having the procedure for the first time. Curettage was the procedure used in 96% of the reported cases. Eleven deaths were associated with legally induced abortions in 1984, and six in 1985. The case-fatality rate in 1985 was 0.5 deaths per 100,000 legally induced abortions, down from the 0.8 per 100,000 reported in 1983 and 1984. Overall, since 1980, the numbers and rates of abortion have had only slight year-to-year fluctuations. The steady increase in the percentage of repeat abortions since 1972 reflects the ongoing availability of legal abortions. Since the beginning of CDC's abortion mortality surveillance, the number of deaths related to legal abortions has decreased 75%, from 24 deaths in 1972 to six deaths in 1985.

Pregnancy-associated deaths due to AIDS in the United States

From 1981 to 1988, eighty percent of all women with the acquired immunodeficiency syndrome (AIDS) reported to the Centers for Disease Control were of reproductive age. Six pregnancy-associated deaths due to AIDS in this country have been reported in the medical literature. We identified 20 unpublished cases of women who died of AIDS during or within one year after termination of pregnancy. Analysis showed that these women were mostly black or Hispanic, half were intravenous drug abusers, and most died of Pneumocystis carinii pneumonia. Each pregnancy had an obstetric complication, primarily preterm delivery. The interval between diagnosis of AIDS and the death of these women ranged from one day to 15 months, with a mean interval of 113 days. Multiple reporting sources increased case detection and should be used for future investigations. Prospective case-control studies are needed to determine any further relationship between pregnancy complications and AIDS.

Maternal mortality surveillance, United States, 1980-1985

To better define the incidence, causes, and risk factors associated with maternal deaths, the Division of Reproductive Health, Center for Chronic Disease Prevention and Health Promotion, CDC, coordinated a study by the Maternal Mortality Collaborative, a Special Interest Group of the American College of Obstetricians and Gynecologists (ACOG). In 1983, this group established voluntary surveillance of maternal deaths for the years 1980-1985. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 39% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Overall, women over 30 years of age had a higher risk of dying than did younger women. For each age group, women of black and other races who were 30 years and older having the highest risk. The leading causes of maternal deaths were embolism, hypertension in pregnancy, sequelae from ectopic pregnancy, hemorrhage, cerebrovascular accidents, and anesthesia complications. Of the 111 nonmaternal deaths, 90 (82%) were attributed to unintentional or intentional injuries. As a result of the success of this voluntary reporting system, the Division of Reproductive Health initiated National Pregnancy Mortality Surveillance in January 1988.

Maternal mortality in the United States: report from the Maternal Mortality Collaborative

To better define the incidence, causes, and risk factors associated with maternal deaths, the Maternal Mortality Collaborative in 1983 initiated national voluntary surveillance of maternal mortality. The Maternal Mortality Collaborative reported 601 maternal deaths from 19 reporting areas for 1980-1985, representing a maternal mortality ratio of 14.1 per 100,000 live births. Overall, 37% more maternal deaths were reported by the Maternal Mortality Collaborative than by the National Center for Health Statistics for these reporting areas. Older women and women of black and other races continued to have higher mortality than younger women and white women. The five most common causes of death for all reported cases were embolism, nonobstetric injuries, hypertensive disease of pregnancy, ectopic pregnancy, and obstetric hemorrhage. Compared with national maternal mortality for 1974-1978, ratios were lower for all causes except for indirect causes, anesthesia, and cerebrovascular accidents. Fatal injuries among pregnant women are not commonly reported to maternal mortality committees. As maternal mortality from direct obstetric causes continues to decline, clinicians will need to emphasize preventing deaths from nonobstetric causes.