Endomyocardial biopsy--helpful in differential diagnosis between myocarditis and dilated cardiomyopathy. A case report

OBJECTIVES: Inadequate prenatal care is thought to be a major modifiable risk factor for preterm birth, the leading cause of neonatal mortality. To improve high-risk women's financial access to prenatal care, the U.S. Medicaid program underwent major expansions during the 1980s. We evaluated these expansions over the nine-year period 1983 to 1991 in Tennessee to determine their effects on Medicaid enrollment, use of prenatal care, and preterm birth. METHODS: We used linked birth certificates, Medicaid data, and U.S. Census files to identify 610,056 singleton births to African-American or Caucasian women in Tennessee whose last menstrual period was between 1983 and 1991. These were classified by maternal characteristics to identify groups with the greatest postexpansion increases in Medicaid enrollment, which should have benefited most from the policy changes. Study outcomes were Medicaid enrollment by delivery, enrollment in the first trimester, inadequate prenatal care (modified Kessner index), and preterm (< 37 weeks) birth. We calculated the changes (delta expressed as births per 100) between 1983 and 1991 in percentages of births with each of these outcomes. RESULTS: The expansions led to pronounced increases in maternal Medicaid enrollment by delivery (21% of births in 1983 to 51% by 1991) and in the first trimester (from 10% to 37%). Married women with < 12 years of education, < 25 years of age, and < $12,500 mean neighborhood incomes (group 1) had the greatest increase, where enrollment and first-trimester enrollment increased from 24% to 86% and 7% to 68%, respectively. In group 1, the percentages of births with inadequate maternal use of prenatal care decreased substantially, from 12.8% in 1983 to 6.4% in 1991, a reduction of 6.4 births per 100 (95% confidence intervals [CI] = -7.6, -5.3). However, the preterm birth rate did not decrease (9.1% in 1983, 9.4% in 1991, change of 0.3[-0.7 to 1.2] births per 100). For other births, there were lesser increases in Medicaid enrollment, correspondingly lesser decreases in inadequate use of prenatal care, but no reductions in preterm birth rates. CONCLUSIONS: In Tennessee, the Medicaid expansions materially increased enrollment and use of prenatal care among high-risk women, but did not reduce the likelihood of preterm birth.     

Identification of multiprotein complexes containing DNA replication factors by native immunoblotting of HeLa cell protein preparations with T-antigen-dependent SV40 DNA replication activity

Adequate prenatal care has been linked to improved birth outcomes in general populations but has not been assessed in HIV-infected women. We examined longitudinal claims files and vital statistics records for women in the New York State Medicaid HIV/AIDS data base delivering a singleton from 1985 through 1990. Adequacy of the self-reported number of prenatal visits was assessed by the Kessner index. In logistics models, we estimated the association of prenatal care, illicit drug use, and other maternal characteristics with three outcomes; low birth weight, preterm birth, and small-for-gestational-age. Of 2,254 singletons delivered by this HIV-infected cohort, 28% were low birth weight, 23% were preterm birth, and 20% were small for gestational age. Two-thirds had inadequate prenatal care. Non-drug users had 57 and 26% lower adjusted odds of low birth weight and preterm delivery than drug users. The adjusted odds of low birth weight and preterm birth for women with an adequate number of prenatal visits were, respectively, 48 and 21% lower than for women with inadequate care. Adequate prenatal care was also associated with a 43% reduction in the odds of small-for-gestational-age. An adequate number of prenatal visits by women in this HIV cohort was associated with a significant reduction in all three adverse birth outcomes, but most had inadequate prenatal care. These data support strengthening efforts to bring pregnant, HIV-infected women into care.     

The changing pattern of prenatal care utilization in the United States, 1981-1995, using different prenatal care indices

CONTEXT: Two measures traditionally used to examine adequacy of prenatal care indicate that prenatal care utilization remained unchanged through the 1980s and only began to rise slightly in the 1990s. In recent years, new measures have been developed that include a category for women who receive more than the recommended amount of care (intensive utilization). OBJECTIVE: To compare the older and newer indices in the monitoring of prenatal care trends in the United States from 1981 to 1995, for the overall population and for selected subpopulations. Second, to examine factors associated with receiving intensive utilization. DESIGN: Cross-sectional and trend analysis of national birth records. SETTING: The United States. SUBJECTS: All live births between 1981 and 1995 (N=54 million). MAIN OUTCOME MEASURES: Trends in prenatal care utilization, according to 4 indices (the older indices: the Institute of Medicine Index and the trimester that care began, and the newer indices: the R-GINDEX and the Adequacy of Prenatal Care Utilization Index). Multiple logistic regression was used to assess the risk of intensive prenatal care use in 1981 and 1995. RESULTS: The newer indices showed a steadily increasing trend toward more prenatal care use throughout the study period (R-GINDEX, intensive or adequate use, 32.7% in 1981 to 47.1 % in 1995; the Adequacy of Prenatal Care Utilization Index, intensive use, 18.4% in 1981 to 28.8% in 1995), especially for intensive utilization. Women having a multiple birth were much more likely to have had intensive utilization in 1995 compared with 1981 (R-GINDEX, 22.8% vs 8.5%). Teenagers were more likely to begin care later than adults, but similar proportions of teens and adults had intensive utilization. Intensive use among low-risk women also increased steadily each year. Factors associated with a greater likelihood of receiving intensive use in 1981 and 1995 were having a multiple birth, primiparity, being married, and maternal age of 35 years or older. CONCLUSIONS: The proportion of women who began care early and received at least the recommended number of visits increased between 1981 and 1995. This change was undetected by more traditional prenatal care indices. These increases have cost and practice implications and suggest a paradox since previous studies have shown that rates of preterm delivery and low birth weight did not improve during this time.     

The perinatal situation in France. Trends between 1981 and 1995

OBJECTIVES: Assess the main indicators of health status and medical practice at delivery and to determine the feasibility of a routine national survey. POPULATION AND METHOD: A survey conducted in 1995 concerned all live births and stillbirths occurring within one week. The sample included 13,147 women in metropolitan France. The results were compared with those of earlier national perinatal surveys. RESULTS: Since 1981, the perinatal situation in France has shown a rise in maternal age at delivery, development of prenatal care (particularly the number of visits), and an increase in the number of procedures at delivery, notably induction. The preterm delivery calculated for all births has remained unchanged: 5.6% in 1981 and 5.9% in 1995, but the proportion of infants weighing less than 2500 g has increased from 5.2% to 6.2%. CONCLUSION: The 1995 national perinatal survey in France, based on all births during one week and involving minimal data collection has provided a representative sample of births and information well adapted to surveillance of the main health and medical practice parameters. This type of survey should become routine and serve as a basic element for epidemiological surveillance.     

Geographic patterns of low birth weight in Hawaii

This study examines areal variations in low birth weight, using the census tract as the unit of analysis. Reports from the 1980 U.S. census were used to develop summary indicators of environmental and socio-economic conditions, including poverty, employment, education and crowding, for 155 census tracts in the state of Hawaii. Maternal socio-demographic, prenatal care utilization, and medical risk indicators and low birth weight percentages for resident, single live births were extracted from the Hawaii 1979-1987 vital record live birth files and aggregated by census tract. Multiple regression analysis was used to develop a model that predicted 61% of the variation among census tracts in the percentage of low birth weight. Patterns of low birth weight were primarily associated with ethnic patterns of maternal residence and single marital status. There was no association between inadequate prenatal care and low birth weight at the census tract level.     

1988 National Maternal and Infant Health Survey: methods and response characteristics

OBJECTIVES: The 1988 National Maternal and Infant Health Survey (NMIHS) was conducted by the National Center for Health Statistics to study factors related to poor pregnancy outcome, such as adequacy of prenatal care; inadequate and excessive weight gain during pregnancy; maternal smoking, drinking, and drug use; and pregnancy and delivery complications. METHODS: The NMIHS is a nationally representative sample of 11,000 women who had live births, 4,000 who had late fetal deaths, and 6,000 who had infant deaths in 1988. Questionnaires were mailed to mothers based on information from certificates of live birth, reports of fetal death, and certificates of infant death. Information supplied by the mother, prenatal care providers, and hospitals of delivery was linked with the vital records to expand knowledge of maternal and infant health in the United States. RESULTS: The response rates in all three components of the NMIHS differed according to the mothers' characteristics. Mothers were more likely to respond if they were 20-39 years of age, were white, were married, had fewer than four children, entered prenatal care early, had more prenatal visits, had more years of education, or resided in the Midwest Region. The percent of respondents was lower for teenage mothers, mothers of races other than white, and mothers with four or more children, little prenatal care, or fewer years of education. Mothers whose infants weighed less than 2,500 grams were less likely to respond in the live-birth and infant-death components than mothers whose infants weighed 2,500 grams or more. CONCLUSIONS: The NMIHS will provide an invaluable tool for researchers and practitioners seeking solutions to perinatal and obstetric problems.     

Talon cusp in permanent dentition associated with other dental anomalies: review of literature and reports of seven cases

A longitudinally linked data set for Georgia was used to identify characteristics, including previous prenatal care use and complications at the first birth, associated with prenatal care use in the second pregnancy among 8,224 African-American women. More than 70% of the women who were < 25 years of age at their first birth (younger women) and almost 40% of women who were > or = 25 years at their first birth received inadequate care with at least one of their first two births. Women who received inadequate care in their first pregnancy were more likely to receive inadequate care in their second pregnancy than women who received adequate care in their first pregnancy. Younger women with a history of a stillbirth, neonatal death, or vacuum extraction were less likely to receive inadequate care in their subsequent pregnancy. Although this study was not able to evaluate the content of prenatal care, it suggested that many African-American women may not receive sufficient care to prevent adverse pregnancy outcomes. Women who receive inadequate care in their first pregnancy must be targeted for interventions that help them overcome economic, situational, or attitudinal barriers to receiving adequate care in their next pregnancy.     

Significance of philosophy, bio-mathematics, biometry and model theory for medicine]

STUDY OBJECTIVE: Poor attendance to antenatal visits was studied to identify risk factors and to analyse the association with adverse pregnancy outcome. DESIGN: All poor attenders and a sample of good attenders were compared within three groups of women: women < 20 years, French women > or = 20 years, and foreigners > or = 20 years. SETTING: 20 French districts including 85,000 births from January to June 1993. SUBJECTS: 848 poor attenders and 759 good attenders. Poor attenders made fewer than four antenatal visits or began care during or after the sixth month. Good attenders made at least four visits and began care before the sixth month. MAIN RESULTS: 1.1% of the women were poor attenders. Risk factors for poor attendance were single status and lack of health insurance in the group under 20; young age, high parity, and single status in the French group aged over 20; and single status and lack of health insurance in the foreign group aged over 20. For poor attenders, the odds ratios for preterm delivery were 5.8 (95% CI: 3.2, 10.5) among French women and 3.3 (95% CI: 1.5, 7.4) among foreign women with health insurance. Poor attendance was not associated with poor pregnancy outcome in the group under 20, and among foreign women over 20 without health insurance, but both groups had high rates of preterm delivery and low birth weight. CONCLUSION: Lack of health insurance is an important barrier to health care during pregnancy. Poor antenatal care is an important risk factor for adverse pregnancy outcome among women who have easy access to health care services.     

Tetanus immunization status and predictors of immunity in older family practice outpatients

370 deaths out of 1141 hospitalized cases of newborns aged 0-28 days were retrospectively analyzed in the Tantigou pediatric hospital of Dapaong, situated 645 km from Lome in northern Togo, in 1984-1985 and 1994-1995. A decreasing trend in neonatal mortality was noted: 42.5% and 27.6% respectively. Major causes of death were prematurity or low birth weight, sepsis, hypoxia conditions. The attendance of pregnant women at health information centres seems to be improving, but the neonatal mortality rate remaining high, the implementation of primary health care/Bamako Initiative resulting especially aiming at better prenatal care for pregnant women must be sustained.     

Racial disparity in pregnancy outcomes: analysis of black and white teenage pregnancies

The pregnancies of black women are complicated by adverse outcomes such as prematurity and low birth weight at twice the rate of complications in pregnancies of white women. Although the cause of this racial disparity is unknown, it is most likely multifactorial. The disparity in outcomes has been found in many studies despite implementation of controls for the factors of age, socioeconomic status, and access to health care. We hypothesized that the increased incidence of adverse outcomes may be strongly affected by adequacy of prenatal care. We investigated the effects of comprehensive prenatal care delivered at the University of North Carolina-Chapel Hill Teenage Obstetric Clinic. The gestational age at the onset of prenatal care and the mean number of prenatal visits were the same for black and white teenagers. Among 183 teenagers we found no significant difference between black and white pregnancies for the outcomes of premature labor, premature delivery, fetal death, neonatal mortality, or hypertensive diseases. The mean gestational age at delivery was 38.3 weeks and 39.1 weeks for black and white women, respectively. The mean birth weight was 3126 gm and 3272 gm for black and white women, respectively. There was a trend (p < 0.09) toward more low birth weight infants in white women: 7% for black infants and 12% for white infants. We believe that comprehensive prenatal care significantly lessens the racial disparity in pregnancy outcomes between black and white adolescent women.     

Estimated gains in birth weight associated with reductions in smoking during pregnancy

OBJECTIVE: To compare the estimated effect on birth weight of reductions in maternal cigarette consumption and urinary cotinine during pregnancy. STUDY DESIGN: An observational study of 641 women with complete data on cigarette consumption, urinary cotinine and infant birth weight. Correlation and regression analyses were used to examine relationships between birth weight, cigarette consumption and urinary cotinine at first and last prenatal visits. RESULTS: Correlations of cigarette consumption and urinary cotinine with infant birth weight were -.23 and -.30 (first visit) and -.26 and -.31 (last visit); all P values were < .001. The regression equation relating urinary cotinine concentrations at first and last visits to infant birth weight explained a significantly larger proportion of the variability in birth weight than the equation relating cigarette consumption at these visits to infant birth weight, 11% vs. 7%, P = .04. Among continuing smokers, both equations predicted gains in birth weight in association with reductions in cigarette consumption, but quitting smoking before the first visit was associated with the most weight gain. As compared to the average infant birth weight of a woman who smoked 20 cigarettes per day throughout pregnancy, the estimated gain in birth weight would be 105 g if she cut down by 10 cigarettes per day after the first visit, 210 g if she quit after this visit and 310 g if she quit before the first visit. CONCLUSION: For women still smoking at their first prenatal visit, infant birth weight is already compromised, but subsequent reductions in cigarette consumption are associated with gains in birth weight. For women who cannot quit smoking, these reductions need to be substantial if increases in birth weight of > 100 g are to be achieved.     

Medicaid managed care and the marketplace

In 1994 and 1995, Tennessee, Hawaii, Rhode Island, and Oklahoma began massive expansions of Medicaid managed care, growing from three health plans covering a few enrollees to 27 plans covering the great majority a year later. Some firms aggressively pursued expansion, while others had very limited business objectives. Although established insurers often dominated the Medicaid markets, newly developed firms, some provider-sponsored, were also important. Despite the relatively low Medicaid capitation rates in the 1996-97 period, Medicaid plans in three states had an average 1% net profit margin.     

Perinatal mortality in breech presentation sibships

OBJECTIVE: To compare perinatal mortality in breech presentation delivered vaginally and by cesarean in individual births and in sibships. METHODS: A national, population registry-based study, 1967-1994, was conducted, with maternal record linkage of sibships, comprising the first to the third birth of a mother. The main outcome was perinatal mortality. Odds ratios of perinatal mortality were calculated and adjusted by logistic regression analysis. RESULTS: The overall relative perinatal mortality was 4.3 (95% confidence interval [CI] 4.1, 4.5) in breech compared with nonbreech presentation and 5.4 (95% CI 4.7, 6.2) in vaginal compared with cesarean delivery. The relative perinatal mortality in breech compared with nonbreech presentation was lowest in birth order one compared with birth orders two and three. In breech vaginal delivery compared with cesarean delivery, the opposite effect of birth order was found. The highest perinatal mortality was found in a current breech presentation of a sibship with no previous breech births. In birth subsequent to breech births, perinatal mortality was more or less independent of current presentation, without respect to delivery method. The increased perinatal mortality in breech presentation is explained partly by its association with other risk factors for perinatal death. CONCLUSION: Women with recurring breech presentation represent a lower risk of adverse perinatal outcome. This might be explained by a biologic mechanism or by increased quality of antenatal care. An increased mortality in subsequent nonbreech siblings after a breech presentation was surprising.     

Evaluation of long-term follow-up of glomerular function in renal transplant recipients

The determinants and outcomes of unwanted pregnancies were explored in a prospective study of 1454 women who delivered in Moscow, Russia, during 1984-85. Mothers were interviewed during their postpartum hospital stay and again 3 years later. 131 women (9%) demonstrated a negative attitude toward their pregnancy. Another 72 women (5%) had a negative attitude initially, but developed positive feelings over the course of the pregnancy. The percentage of unwanted pregnancies was 2.9 times greater among unmarried women (14.9%) than married women (5.1%). Poor marital relationships, inadequate living conditions, tobacco/alcohol use, and low per capita income were found significantly more often among women with unwanted pregnancies. Significantly more infants of mothers with unwanted than wanted pregnancies had infants who were premature (28.3% vs. 9.5%) and low birth weight, but there was no significant difference in neonatal complications. Mothers of unwanted infants also were more likely to delay prenatal care and attend infrequently and, once the child was born, made fewer visits to the pediatrician. Even if unwanted pregnancy has no adverse medical sequelae, being unwanted should be considered a psychosocial risk factor with implications for a child's development.     

Health care characteristics associated with women's satisfaction with prenatal care

OBJECTIVES: The objective of this study was to explore the relation between prenatal care characteristics and satisfaction among Medicaid recipients. METHODS: African-American (n = 75) and Mexican-American (n = 26) nonadolescent primiparous pregnant women who had at least three prenatal care visits participated in a 25-minute telephone survey that asked them about satisfaction with prenatal care (art of care, technical quality, physical environment, access, availability and efficacy); prenatal care characteristics (practitioner attributes, service availability, and features of the delivery of care); and, personal characteristics (sociodemographics, health status and behaviors, and pregnancy-related variables). Univariate and multivariable analyses were conducted to explore the relations between personal characteristics and satisfaction and between care characteristics and satisfaction. RESULTS: For the overall sample, the following prenatal care characteristics were associated with increased satisfaction: having procedures explained by the provider, short waiting times at the prenatal care site, the availability of ancillary services, and reporting that the prenatal care practitioner was male. When examining the data by ethnicity, whether the provider explained procedures was the most important determinant of satisfaction for both African-American and Mexican-American women. CONCLUSIONS: Knowledge of the care characteristics that impact low-income pregnant women's satisfaction can be utilized to alter service delivery to increase use of prenatal care and ultimately to improve perinatal outcomes.     

Effects of long-term pravastatin treatment on spermatogenesis and on adrenal and testicular steroidogenesis in male hypercholesterolemic patients

STUDY OBJECTIVE: To determine if there are significant differences in birth outcomes and survival for infants delivered by certified nurse midwives compared with those delivered by physicians, and whether these differences, if they exist, remain after controlling for sociodemographic and medical risk factors. DESIGN: Logistic regression models were used to examine differences between certified nurse midwife and physician delivered births in infant, neonatal, and postneonatal mortality, and risk of low birthweight after controlling for a variety of social and medical risk factors. Ordinary least squares regression models were used to examine differences in mean birthweight after controlling for the same risk factors. STUDY SETTING: United States. PATIENTS: The study included all singleton, vaginal births at 35-43 weeks gestation delivered either by physicians or certified nurse midwives in the United States in 1991. MAIN RESULTS: After controlling for social and medical risk factors, the risk of experiencing an infant death was 19% lower for certified nurse midwife attended than for physician attended births, the risk of neonatal mortality was 33% lower, and the risk of delivering a low birthweight infant 31% lower. Mean birthweight was 37 grams heavier for the certified nurse midwife attended than for physician attended births. CONCLUSIONS: National data support the findings of previous local studies that certified nurse midwives have excellent birth outcomes. These findings are discussed in light of differences between certified nurse midwives and physicians in prenatal care and labour and delivery care practices. Certified nurse midwives provide a safe and viable alternative to maternity care in the United States, particularly for low to moderate risk women.     

Early impact of new health care legislation on the pediatric surgical experience of surgical residents

On January 1, 1994, Tennessee implemented TennCare, an insurance program for the state's medically uninsured and those who were previously covered by Medicaid. To determine how this change has affected the pediatric surgical experience of residents in training, we reviewed our institution's operative case logs from the first quarter of 1994 and compared them with logs for the first quarter of the years 1990 through 1993. Cases were classified according to urgency and necessity of surgical procedures. No significant change was noted in the number of patients having operations for the most necessary or urgent conditions, such as solid tumors or appendicitis. In contrast, the number of elective operations, principally for hernias, decreased significantly during the same period. While Tennessee's legislative change apparently has not affected the volume of urgent surgical cases, it has significantly decreased surgical residents' elective pediatric surgical experience.     

Prenatal maternal stress and prematurity: A prospective study of socioeconomically disadvantaged women.

Developed and tested a biopsychosocial model of birth weight and gestational age at delivery using structural equation modeling procedures. The model tested the effects of medical risk and prenatal stress on these indicators of prematurity after controlling for parity. Ss were 130 women (aged 18–42 yrs) of low socioeconomic status (SES) interviewed throughout pregnancy in conjunction with prenatal care visits to a public clinic. Ss also completed an abbreviated version of the Perceived Stress Scale (S. Cohen et al; see record 1984-24885-001) and the State form of the State-Trait Anxiety Inventory. Lower birth weight was predicted by earlier delivery and by prenatal stress. Earlier delivery was predicted by medical risk and by prenatal stress. Parity was not related to time of delivery or to birth weight. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Architecture. HOTELIA, an innovative concept

This article focuses on adolescent pregnancy and birth issues in the US. Although the birth rate among adolescents aged 10-19 years in New Jersey declined to 9609 infants per year in 1994, a decline of 7% from 1990, there remain concerns about the welfare of the mother and fetal development. Adolescent birth rates in New Jersey are higher for Black youths compared to White youths (100/1000 births vs. 25.4/1000). During 1990-94, births to girls aged 10-14 years increased from 241 to 284. There are many reasons for teenage pregnancy: abuse or coercion, peer pressure, misinformation, defiant behavior, person whims, and need for success through pregnancy. Pregnant teens frequently do not receive adequate prenatal care, maintain good nutrition, and/or refrain from unhealthy habits such as cigarette smoking, alcohol drinking, and/or drug use. The lack of prenatal care until late pregnancy may be due to lack of health insurance coverage or money for transportation. Teenagers have higher rates of premature births. Fetal development may be impaired due to lack of a proper maternal diet with a sufficient amount of folic acid, iron and protein, or food intake. Teenagers have twice the rate of spina bifida. Girls need to know the facts about the risk of premature birth and low birth weight associated with their cigarette smoking during pregnancy. Girls should be asked to reduce smoking to 3-5 cigarettes per week by the next visit and to stop entirely by the following visit. Teenagers need reinforcement in adopting the right eating patterns and curbing undesirable habits. Prenatal care should be comprehensive. The evidence suggests that fetal development is hampered by the competition for resources between the mother and fetus. Health care professionals must provide contraceptives and education; most hope that the repetitive cycle of repeat pregnancy and poverty does not continue.