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Current events in Obstetrics & Gynecology, updates on new web site features and links to other web sites of interest to ObGyns.
Saturday, August 01, 2015

Biggs et al. California family planning health care providers’ challenges to the same-day long-acting reversible contraception provision

Why should you read about this topic?

To learn how to reduce the number of office visits before LARC can be provided

What were the authors trying to do?

Determine the proportion of times LARC was provided with only one visit and the reasons why more than one visit was required

Who participated and in what setting?

California Family PACT practice sites (N=636) in 2011

What was the study design?

Survey

What were the main outcome measures?

Whether a practice site offered same-day insertion of an IUD or contraceptive implant

What were the results?

Of those with onsite provision, 59% required at least two visits to insert an IUD and 47% required two visits to place an insert.  The major reasons for requiring more than one visit were screening, clinic flow, and scheduling.

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths: large number of diverse practice sites surveyed. Weaknesses: unvalidated survey; no evaluation of actual practice; no analysis of characteristics of non-respondents.

What does the study contribute for your practice?

The easiest way to increase the proportion of same-day LARC insertions seems to be not waiting for STI tests in asymptomatic women.


Saturday, July 25, 2015

Waldenstrom et al. Advanced maternal age and stillbirth risk in nulliparous and parous women

Why should you read about this topic?

In order to understand risks for stillbirth you need to dissect the effect of maternal age and parity

What were the authors trying to do?

Investigate the association between advanced maternal age and risk for stillbirth

Who participated and in what setting?

All women at least 25 years old with singleton pregnancies (N=1,804,442) at least 28 weeks delivering in Sweden from 1990-2011

What was the study design?

Retrospective evaluation of the Swedish Medical Birth Register, a population-based registry

What were the main outcome measures?

Stillbirth

What were the results?

Stillbirth rates increased with advancing maternal age.  Rates were 0.27% in the 25-29 years group increasing to 0.53% in the >40 years group.  This association was largely driven by nulliparous women.

What is the most interesting image in the paper?

Figure 1

What were the study strengths and weaknesses?

Strengths:  large sample size, population-based; sound strategy for development of models to adjust for confounders and explore possible mechanisms; careful control for interactions. Weaknesses: stillbirths between 20 and 27 weeks were not included; large amount of missing data for some covariates.

What does the study contribute for your practice?

Advanced maternal age is associated with stillbirth risk, particularly in nulliparous women.


Monday, July 13, 2015
Elizabeth Deans, MD
Elizabeth Deans, MD
Family Planning Fellow
Emory University School of Medicine
 
Abortion is safe. This message is simple, clear, but not new. Yet, given the current political climate and attacks on abortion access under the pretense of “safety,” I applaud that we have yet another study demonstrating the safety of abortion. The Centers for Disease Control and Prevention’s study by Zane et al in the August 2015 issue of Obstetrics & Gynecology reports that during 1998-2010, there were approximately 16.1 million abortion procedures and only 108 abortion-related deaths for an overall abortion mortality rate of 0.7 deaths per 100,000 legal induced-abortion procedures. This rate is much less than the mortality rate for pregnancies that end in live birth (8.8 deaths per 100,000 live-births).1 Twenty of the 108 deaths were from abortions completed for severe medical conditions in which pregnancy was life-threatening. Thus, for women without life-threatening pregnancies, there were 88 deaths.
 
Although death from an abortion is very rare, it is less rare when the procedure is performed at later gestational ages. Abortion mortality was the lowest at 0.3 deaths per 100,000 procedures performed at or before 8 weeks and the highest at 6.7 deaths per 100,000 procedures performed at or beyond 18 weeks of gestation. The authors conclude that “improved access to abortion services at lower-risk, early gestational ages will lower abortion mortality even more.”1 Thus, if women’s safety is truly considered a priority, women should have easier access to early abortion procedures.
 
Unfortunately, improving access to abortion at early gestational ages has not been a legislative priority. According to the American Civil Liberties Union, 43 states have introduced more than 330 abortion restrictions in the first quarter of 2015.2 North Carolina just extended its mandatory waiting period to 72 hours3 and more than half of clinics in Texas and the last remaining clinic is Mississippi are at risk of closing as the Supreme Court considers these states’ restrictive laws.4 Women are being forced to wait longer and drive farther for an abortion, where already in 2011, 89% of U.S. counties had no abortion clinics.5 To surpass these additional barriers, the extra time away from work, longer travel, and additional child care costs make these restrictions financially burdensome.
 
Additionally, this study describes another important mortality trend. The abortion mortality rate for black women is 1.1 deaths per 100,000 abortions compared to 0.4 deaths per 100,000 abortions for white women. This disparity is not explained by gestational age differences, and is consistent for the maternal mortality rate from all pregnancy-related deaths.6 These health care inequities are complex, deeply rooted in our history, and deserve continued public health focus. Unfortunately, many states hostile to abortion access are also home to high concentrations of black communities.7 The Guttmacher Institute defines “hostile” as states with 4 to 10 major abortion restrictions.8 Black women should not be dying at triple the rates of white women from pregnancy-related (including abortion-related) deaths, nor should they face barriers to care because of where they live.
 
The American College of Obstetricians and Gynecologists (ACOG) acknowledges that abortion care is an essential part of medical care for women and supports eliminating barriers to abortion.9 In its policy on abortion, ACOG states that if a woman decides to have an abortion, it should be performed as safely and early as possible. Additionally, ACOG opposes regulations that delay or inhibit abortion.10
 
Abortion is safe. As obstetrician-gynecologists striving to provide quality care to women, we must keep that message clear and facilitate access to comprehensive women’s healthcare.

 
References:
 
  1. Zane S, Creanga AA, Berg CJ, Pazol K, Suchdev DB, Jamieson DJ, Callaghan WM. Abortion-related mortality in the United States: 1998-2010, Obstet Gynecol 2015;126:258–65.
  2. American Civil Liberties Union. Federal court decision will force most Texas abortion clinics to close. Available at: https://www.aclu.org/news/federal-court-decision-will-force-most-texas-abortion-clinics-close. Retrieved June 22, 2015. 
  3. WRAL. NC House approves three-day abortion waiting period. Available at: http://www.wral.com/nc-house-approves-three-day-abortion-waiting-period/14601698/. Retrieved June 22, 2015.
  4. Denniston L. Court blocks Texas abortion law. SCOTUS blog. Available at: http://www.scotusblog.com/2015/06/court-blocks-texas-abortion-law/, Retrieved June 30, 2015.
  5. Jones RK, Jerman J. Abortion incidence and service availability in the United States, 2011. Perspect Sex Reprod Health 2014;46:3-14.
  6. Creanga AA, Berg CJ, Syverson C, Seed K, Bruce FC, Callaghan WM. Pregnancy-related mortality in the United States, 2006-2010. Obstet Gynecol 2015;125:5-12.
  7. Rastogi S, Johnson TD, Hoeffel EM, Drewery MP. The Black Population: 2010, 2010 Census Briefs. U.S. Census Bureau. Available at: https://www.census.gov/prod/cen2010/briefs/c2010br-06.pdf, Retrieved June 22, 2015.
  8. Nash E, Gold RB, Rowan A, Rathbun G, Vierboom Y. Laws affecting reproductive health and rights: 2013 state policy review, New York: Guttmacher Institute, 2014, Available at: http://www.guttmacher.org/statecenter/updates/2013/statetrends42013.html.  Retrieved June 27, 2015.
  9. Increasing access to abortion. Committee Opinion No. 613. American College of Obstetricians and Gynecologists. Obstet Gynecol 2014;124:1060-5.
  10. Abortion Policy. College Statement of Policy, as issued by the College Executive Board. Revised and approved November 2014. http://www.acog.org/-/media/Statements-of-Policy/Public/sop069.pdf?dmc=1&ts=20150623T1254257641, accessed June 22, 2015.

Saturday, June 27, 2015

Main et al. National partnership for maternal safety: consensus bundle on obstetric hemorrhage

Why should you read about this topic?

Obstetric hemorrhage is the most frequent cause of maternal morbidity and preventable maternal mortality

What were the authors trying to do?

Outline critical clinical practices that should be implemented in every maternity unit

Who participated and in what setting?

Multidisciplinary work groups of the National Partnership for Maternal Safety

What was the study design?

Consensus development by representatives of eight different professional organizations including ACOG

What were the main outcome measures?

The safety bundle was organized into 4 domains: readiness; recognition and prevention; response; and reporting and system learning

What is the most interesting image in the paper?

Box 1

What does the study contribute for your practice?

A framework for quality improvement processes for obstetric hemorrhage


Saturday, June 20, 2015

Lappen et al. Outcomes of term induction in trial of labor after cesarean delivery: analysis of a modern obstetric cohort

Why should you read about this topic?

With current cesarean delivery rates of 30+% we need updated induction TOLAC outcomes

What were the authors trying to do?

Evaluate the outcomes of induction of labor in women attempting TOLAC compared with outcomes in women awaiting spontaneous onset of labor

Who participated and in what setting?

Women (N=6,033) with term singleton pregnancies and history of one prior cesarean delivery attempting TOLAC at 19 hospitals across the US between 2002 and 2008

What was the study design?

Secondary analysis of Consortium on Safe Labor study

What were the main outcome measures?

Failed TOLAC

What were the results?

Compared with expectant management, induction of labor was associated with a higher risk of failed TOLAC at 37-39 weeks but not at 40 weeks.  Induction was associated with an increased risk of composite maternal morbidity at 39 weeks and NICU admission at 37 weeks. 

What is the most interesting image in the paper?

Table 2

What were the study strengths and weaknesses?

Strengths: expectant management comparison group; large number of observed deliveries; racially and ethnically diverse patient population; reasonable adjustment for confounding variables. Weaknesses: retrospective study;

What does the study contribute for your practice?

Induction of labor at term in women with one prior cesarean delivery is associated with an increased risk of failed TOLAC.

About the Author

William C. Dodson, MD
William C. Dodson, MD, is Professor of Obstetrics and Gynecology and Director of the Division of Reproductive Endocrinology and Infertility at Penn State College of Medicine. He completed his fellowship in reproductive endocrinology at Duke University. His research and clinical areas of focus include treatment of infertility, especially ovulation induction. He was previously on the Editorial Board of Obstetrics & Gynecology and has served as the Consultant Web Editor for Obstetrics & Gynecology since 2008.