Rate of Second and Third Trimester Weight Gain and Preterm Delivery Among Underweight and Normal Weight Women.

Objectives Low gestational weight gain (GWG) in the second and third trimesters has been associated with increased risk of preterm delivery (PTD) among women with a body mass index (BMI) < 25 mg/m(2). However, few studies have examined whether this association differs by the assumptions made for first trimester gain or by the reason for PTD. Methods We examined singleton pregnancies during 2000-2008 among women with a BMI < 25 kg/m(2) who delivered a live-birth ≥28 weeks gestation (n = 12,526). Women received care within one integrated health care delivery system and began prenatal care ≤13 weeks. Using antenatal weights measured during clinic visits, we interpolated GWG at 13 weeks gestation then estimated rate of GWG (GWGrate) during the second and third trimesters of pregnancy. We also estimated GWGrate using the common assumption of a 2-kg gain for all women by 13 weeks. We examined the covariate-adjusted association between quartiles of GWGrate and PTD (28-36 weeks gestation) using logistic regression. We also examined associations by reason for PTD [premature rupture of membranes (PROM), spontaneous labor, or medically indicated]. Results Mean GWGrate did not differ among term and preterm pregnancies regardless of interpolated or assumed GWG at 13 weeks. However, only with GWGrate estimated from interpolated GWG at 13 weeks, we observed a U-shaped relationship where odds of PTD increased with GWGrate in the lowest (OR 1.36, 95 % CI 1.10, 1.69) or highest quartile (OR 1.49, 95 % CI 1.20, 1.85) compared to GWGrate within the second quartile. Further stratifying by reason, GWGrate in the lowest quartile was positively associated with spontaneous PTD while GWGrate in the highest quartile was positively associated with PROM and medically indicated PTD. Conclusions Accurate estimates of first trimester GWG are needed. Common assumptions applied to all pregnancies may obscure the association between GWGrate and PTD. Further research is needed to fully understand whether these associations are causal or related to common antecedents.

Investigating Implausible Gestational Age and High Birthweight Combinations.

BACKGROUND: Birth certificate data overestimate national preterm births because a high percentage of last menstrual period (LMP) dates have errors. Study goals were to determine: (i) To what extent errors in transfer of birthweight and LMP date from medical records to birth certificates contribute to implausibly high birthweight-for-gestational-age births; (ii) What percentage of implausible births would be resolved if the clinical estimate (CE) from birth certificates were used instead of LMP-based gestational age, and with what degree of certainty; and (iii) Of those not resolved, what percentage had a medical explanation. METHODS: Medical records and birth certificates for all singleton infants with implausibly high birthweight-for-gestational-age based on LMP delivered in the Kaiser Permanente Northwest system in Oregon during 1998-2007 were examined. Percentages of implausible records resolved under various scenarios were calculated. RESULTS: A total of 100 births with implausibly high birthweight-for-gestational age combinations were identified. When LMP date and birthweight from medical records were used instead of from birth certificates, 31% of births with implausible combinations were resolved. Substituting the CE on the birth certificate for the LMP date resolved 92%. Of the latter, the clinician's gestational age estimate in the medical record was obtained in early pregnancy in 72%. Five of the eight births with unresolved implausible combinations were to mothers with diabetes; the remaining three had no documented medical explanation. CONCLUSIONS: In this study, use of the birth certificate CE rather than the LMP resulted in a clinically reliable reclassification for the majority of implausible birthweight-for-gestational age deliveries.

Associations of Gestational Weight Gain with Preterm Birth among Underweight and Normal Weight Women.

Studies report increased risk of preterm birth (PTB) among underweight and normal weight women with low gestational weight gain (GWG). However, most studies examined GWG over gestational periods that differ by term and preterm which may have biased associations because GWG rate changes over the course of pregnancy. Furthermore, few studies have specifically examined the amount and pattern of GWG early in pregnancy as a predictor of PTB. Within one integrated health care delivery system, we examined 12,526 singleton pregnancies between 2000 and 2008 among women with a body mass index <25 kg/m(2), who began prenatal care in the first trimester and delivered a live-birth >28 weeks gestation. Using self-reported pregravid weight and serial measured antenatal weights, we estimated GWG and the area under the GWG curve (AUC; an index of pattern of GWG) during the first and second trimesters of pregnancy (≤28 weeks). Using logistic regression adjusted for covariates, we examined associations between each GWG measure, categorized into quartiles, and PTB (<37 weeks gestation). We additionally examined associations according to the reason for PTB by developing a novel algorithm using diagnoses and procedure codes. Low GWG in the first and second trimesters was not associated with PTB [aOR 1.11, (95% CI 0.90, 1.38) with GWG <8.2 kg by 28 weeks compared to pregnancies with GWG >12.9]. Similarly, pattern of GWG was not associated with PTB. Our findings do not support an association between GWG in the first and second trimester and PTB among underweight and normal weight women.

Pregnancy-related mortality in the United States, 2006-2010.

OBJECTIVE: To update national population-level pregnancy-related mortality estimates and examine characteristics and causes of pregnancy-related deaths in the United States during 2006-2010. METHODS: We used data from the Pregnancy Mortality Surveillance System and calculated pregnancy-related mortality ratios by year and age group for four race-ethnicity groups: non-Hispanic white, non-Hispanic black, Hispanic, and other. We examined causes of pregnancy-related deaths by pregnancy outcome during 2006-2010 and compared causes of pregnancy-related deaths since 1987. RESULTS: The 2006-2010 pregnancy-related mortality ratio was 16.0 deaths per 100,000 live births (20,959,533 total live births). Specific race-ethnicity pregnancy-related mortality ratios were 12.0, 38.9, 11.7, and 14.2 deaths per 100,000 live births for non-Hispanic white, non-Hispanic black, Hispanic, and other race women, respectively. Pregnancy-related mortality ratios increased with maternal age for all women and within all age groups, non-Hispanic black women had the highest risk of dying from pregnancy complications. Over time, the contribution to pregnancy-related deaths of hemorrhage, hypertensive disorders of pregnancy, embolism, and anesthesia complications continued to decline, whereas the contribution of cardiovascular conditions and infection increased. Seven of 10 categories of causes of death each contributed from 9.4% to 14.6% of all 2006-2010 pregnancy-related deaths; cardiovascular conditions ranked first. CONCLUSION: Relative to previous years, during 2006-2010, the U.S. pregnancy-related mortality ratio increased as did the contribution of cardiovascular conditions and infection to pregnancy-related mortality. Although the identification of pregnancy-related deaths may be improving in the United States, the increasing contribution of chronic diseases to pregnancy-related mortality suggests a change in risk profile of the birthing population. LEVEL OF EVIDENCE: II.

Maternal mortality and morbidity in the United States: where are we now?

This article provides a brief overview of the work conducted by the Division of Reproductive Health at the Centers for Disease Control and Prevention on severe maternal morbidity and mortality in the United States. The article presents the latest data and trends in maternal mortality and severe maternal morbidity, as well as on maternal substance abuse and mental health disorders during pregnancy, two relatively recent topics of interest in the Division, and includes future directions of work in all these areas.

Health care utilization in the first year of life among small- and large- for-gestational age term infants.

The objective of the study was to assess if small- and large-for gestational age term infants have greater health care utilization during the first year of life. The sample included 28,215 singleton term infants (37-42 weeks) without major birth defects delivered from 1998 through 2007 and continuously enrolled at Kaiser Permanente Northwest for 12 months after delivery. Birth weight for gestational age was categorized into 3 levels: <10th percentile (SGA), 10-90th percentile (AGA), >90th percentile (LGA). Length of delivery hospitalization, re-hospitalizations and sick/emergency room visits were obtained from electronic records. Logistic regression models estimated associations between birth weight category and re-hospitalization. Generalized linear models estimated adjusted mean number of sick/emergency visits. Among term infants, 6.2 % were SGA and 13.9 % were LGA. Of infants born by cesarean section, SGA infants had 2.7 higher odds [95 % 1.9, 3.8] than AGA infants of staying ≥5 nights during the delivery hospitalization; of those born vaginally, SGA infants had 1.5 higher adjusted odds [95 % 1.1, 2.1] of staying ≥4 nights. LGA compared to AGA infants had higher odds of re-hospitalization within 2 weeks of delivery [OR 1.25, 95 % CI 0.99, 1.58] and of a length of stay ≥4 days during that hospitalization [OR 2.6, 95 % CI 1.3, 5.0]. The adjusted mean number of sick/emergency room visits was slightly higher in SGA (7.8) than AGA (7.5) infants (P < .05). Term infants born SGA or LGA had greater health care utilization than their counterparts, although the increase in utilization beyond the initial delivery hospitalization was small.

Health care utilisation in the first year of life among infants of mothers with perinatal depression or anxiety.

BACKGROUND: Limited information is available on associations between maternal depression and anxiety and infant health care utilisation. METHODS: We analysed data from 24 263 infants born between 1998 and 2007 who themselves and their mothers were continuously enrolled for the infant's first year in Kaiser Permanente Northwest. We used maternal depression and anxiety diagnoses during pregnancy and postpartum to categorise infants into two depression and anxiety groups and examined effect modification by timing of diagnosis (pregnancy only, postpartum only, pregnancy and postpartum). Using generalised estimating equations in multivariable log-linear regression, we estimated adjusted risk ratios (RR) between maternal depression and anxiety and well baby visits (<5 and ≥ 5), up to date immunisations (yes/no), sick/emergency visits (<6 and ≥ 6) and infant hospitalisation (any/none). RESULTS: Infants of mothers with perinatal depression or anxiety were as likely to attend well baby visits and receive immunisations as their counterparts (RR = 1.0 for all). Compared with no depression or anxiety, infants of mothers with prenatal and postpartum depression or anxiety, or postpartum depression or anxiety only were 1.1 to 1.2 times more likely to have ≥ 6 sick/emergency visits. Infants of mothers with postpartum depression only had marginally increased risk of hospitalisation (RR = 1.2 [95% confidence interval 1.0, 1.4]); 70% of diagnoses occurred after the infant's hospitalisation. CONCLUSIONS: An understanding of the temporality of the associations between maternal depression and anxiety and infant acute care is needed and will guide strategies to decrease maternal mental illness and improve infant care for this population.

A system-based intervention to improve postpartum diabetes screening among women with gestational diabetes.

OBJECTIVE: We sought to determine whether our process improvement program led to increased postpartum diabetes screening rates among women with gestational diabetes mellitus (GDM). STUDY DESIGN: In early 2009, we conducted obstetrics department staff education sessions, revised GDM patient care protocols, and developed an electronic system to trigger reminder calls to patients who had not completed diabetes mellitus screening by 3 months postpartum. We then evaluated the rates of postpartum glucose test order entry and completion for women with GDM delivering from July 2009 through June 2010 (n = 179) and July 2007 through June 2008 (n = 200). RESULTS: After the program's implementation, the proportion of women receiving an order for a postpartum glucose test within 3 months of delivery increased from 77.5-88.8% (P = .004), and test completion increased from 59.5-71.5% (hazard ratio, 1.37; 95% confidence interval, 1.07-1.75). CONCLUSION: Rates of postpartum diabetes testing can be improved with system changes and reminders.

Extent of maternal morbidity in a managed care population in georgia.

BACKGROUND: Although maternal deaths are among the most tragic events related to pregnancy, they are uncommon in the US and, therefore, inadequate indicators of a woman's pregnancy-related health. Maternal morbidity has become a more useful measure for surveillance and research. Traditional attempts to monitor maternal morbidity have used hospital discharge data, which include data only on complications that resulted in hospitalisation, underestimating the frequency and scope of complications. METHODS: To obtain a more accurate assessment of morbidity, we applied a validated computerised algorithm to identify pregnancies and pregnancy-related complications in a defined population enrolled in a health maintenance organisation in the south-eastern US. We examined the most common morbidities by pregnancy outcome and maternal characteristics. RESULTS: We identified 37 741 pregnancies; in half (50.7%), at least one complication occurred. The five most common were urinary tract infections, anaemia, mental health conditions, pelvic and perineal complications, and obstetrical infections. Complications were more likely in women with low socio-economic status (SES), and among non-Hispanic Black women compared with non-Hispanic White women. Multivariable models stratified by race/ethnicity indicated that in pregnancies among non-Hispanic White women, low SES had a modest effect on the odds of having preexisting medical conditions [adjusted odd ratio (AOR) 1.3 [95% confidence interval (CI) 1.2, 1.5]] or having any morbidity (AOR 1.3 [95% CI 1.2, 1.4]). Low SES had little effect on complications among non-Hispanic Black women. CONCLUSION: Our findings suggest that comprehensive health insurance coverage may lessen the unfavourable impact of socio-economic disadvantage on the risk of maternal morbidity.

Race, ethnicity, and nativity differentials in pregnancy-related mortality in the United States: 1993-2006.

OBJECTIVE: To compare trends in and causes of pregnancy-related mortality by race, ethnicity, and nativity from 1993 to 2006. METHODS: We used data from the Pregnancy Mortality Surveillance System. For each race, ethnicity, and nativity group, we calculated pregnancy-related mortality ratios and assessed causes of pregnancy-related death and the time between the end of pregnancy and death. RESULTS: Race, ethnicity, and nativity-related minority women contributed 40.7% of all U.S. live births but 61.8% of the 7,487 pregnancy-related deaths during 1993-2006. Pregnancy-related mortality ratios were 9.1 and 7.5 deaths per 100,000 live births among U.S.- and foreign-born white women, respectively, and slightly higher at 9.6 and 11.6 deaths per 100,000 live births for U.S.- and foreign-born Hispanic women, respectively. Relative to U.S.-born white women, age-standardized pregnancy-related mortality ratios were 5.2 and 3.6 times higher among U.S.- and foreign-born black women, respectively. However, causes and timing of death within 42 days postpartum were similar for U.S.-born white and black women with cardiovascular disease, cardiomyopathy, and other pre-existing medical conditions emerging as chief contributors to mortality. Hypertensive disorders, hemorrhage, and embolism were the most important causes of pregnancy-related death for all other groups of women. CONCLUSION: Except for foreign-born white women, all other race, ethnicity, and nativity groups were at higher risk of dying from pregnancy-related causes than U.S.-born white women after adjusting for age differences. Integration of quality-of-care aspects into hospital- and state-based maternal death reviews may help identify race, ethnicity, and nativity-specific factors for pregnancy-related mortality. LEVEL OF EVIDENCE: III.

Early term delivery and health care utilization in the first year of life.

OBJECTIVE: To assess health care utilization during the first year of life among early term-born infants. STUDY DESIGN: We assessed health care utilization of 22420 singleton term infants (37-42 weeks gestational age [GA]) without major birth defects, fetal growth restriction, or exposure to diabetes or hypertension in utero, delivered between 1998 and 2007 and continuously enrolled at Kaiser Permanente Northwest for 12 months after delivery. GA, duration of delivery hospitalization, and postdelivery rehospitalizations and sick/emergency room visits in the first year of life were obtained from electronic medical records. Logistic regression models were used to estimate associations between GA and number of hospitalizations and length of stay. Generalized linear models were used to estimate the adjusted mean number of sick/emergency visits. RESULTS: Overall, 20.9% of term infants were born early. Infants delivered vaginally at 37 weeks GA had a 2.2 greater odds (95% CI, 1.6-3.1) of staying 4 or more days compared with those born at 39-40 weeks GA. Similar association was found among infants delivered by cesarean delivery at 37 or 38 weeks GA. Infants born at 37 weeks GA had increased odds of being rehospitalized within 2 weeks of delivery (OR, 2.6; 95% CI, 1.9-3.6). The adjusted mean number of sick/emergency room visits was higher for infants born at 37 and 38 weeks GA than for those born at 39-40 weeks GA (8.1, 7.7, and 7.3, respectively; P < .0001). CONCLUSIONS: Early term-born infants had greater health care utilization during their entire first year of life than infants born at 39-40 weeks GA.

Newborn size among obese women with weight gain outside the 2009 Institute of Medicine recommendation.

OBJECTIVE: To estimate risk of delivering macrosomic, large-for-gestational-age and small-for-gestational-age neonates in obese women with gestational weight gain outside the 2009 Institute of Medicine recommendation (11-20 pounds). METHODS: In a retrospective cohort study, we evaluated 2,080 obese women (body mass index 30 or higher) with singleton pregnancies that resulted in term live births within one health maintenance organization between 2000 and 2005; women with diabetes or hypertensive disorders were excluded. Gestational weight gain was categorized as less than 0, 0 to less than 11, 11-20 (referent), greater than 20-30, greater than 30-40, and greater than 40 pounds and as above, below, or within Institute of Medicine recommendations. We conducted multivariable logistic regression to estimate the odds of large for gestational age and small for gestational age (birth weights greater than the 90th percentile and less than the 10th percentile for gestational age, respectively) and macrosomia (greater than 4,500 g) adjusting for potential confounders. RESULTS: Eighteen percent gained below, 25% within, and 57% above Institute of Medicine recommendations. Prevalence of macrosomia, large for gestational age, and small for gestational age were 4.3%, 19.8%, and 4.3%, respectively. Compared with weight gain of 11-20 pounds, weight gain above recommendations did not significantly decrease small-for-gestational-age risk but was associated with increased odds of macrosomia (adjusted odds ratio [OR] 3.36; 95% confidence interval [CI] 1.74-6.51; 6.0% compared with 2.1%) and large for gestational age (adjusted OR 1.80; 95% CI 1.36-2.38; 23.8% compared with 16.6%). Weight gain below recommendations was associated with increased odds of small for gestational age (adjusted OR 3.94; 95% CI 2.04-7.61; 8.8% compared with 2.7%) and decreased odds of large for gestational age (adjusted OR 0.56; 95% CI 0.37-0.84; 11.2% compared with 16.6%). CONCLUSION: Regarding small for gestational age and large for gestational age, there is no benefit of weight gain above Institute of Medicine recommendations. Weight gain below recommendations decreases large for gestational age but increases small-for-gestational-age risk. LEVEL OF EVIDENCE: II.

Excessive gestational weight gain and postpartum weight retention among obese women.

OBJECTIVE: To evaluate the incremental effect of weight gain above that recommended for term pregnancy (15 pounds) on postpartum weight retention at 1 year among obese women. METHODS: In a retrospective cohort study, we identified 1,656 singleton gestations resulting in live births among obese women (body mass index at or above 30 kg/m) between January 2000 and December 2005 in Kaiser Permanente Northwest. Pregnancy weight change (last available predelivery weight minus weight at pregnancy onset) was categorized as less than 0, 0-15, greater than 15 to 25, greater than 25 to 35, and greater than 35 pounds. Postpartum weight change (weight at 1 year postpartum minus weight at pregnancy onset) was defined as less than 0, 0-10, and greater than 10 pounds. RESULTS: Total gestational weight gain was -33.2 (weight loss) to +98.0 pounds (weight gain). Nearly three fourths gained greater than 15 pounds, and they were younger and weighed less at baseline than women who gained 15 pounds or less. Pregnancy-related weight change showed a significant relationship with postpartum weight change. For each pound gained during pregnancy, there was a 0.4-pound increase above baseline weight at 1 year postpartum. In adjusted logistic regression models, the risk of a postpartum weight greater than 10 pounds over baseline was twofold higher for women gaining greater than 15 to 25 pounds compared with women gaining 0-15 pounds (odds ratio [OR] 2.18, 95% confidence interval [CI] 1.54-3.10), fourfold higher for women gaining greater than 25 to 35 pounds (OR 3.91, 95% CI 2.75-5.56), and almost eightfold higher for women gaining greater than 35 pounds (OR 7.66, 95% CI 5.36-10.97). CONCLUSION: Incremental increases in gestational weight gain beyond the current recommendation for obese women substantially increase the risk of weight retention at 1 year postpartum. LEVEL OF EVIDENCE: II.

Postpartum screening for diabetes after a gestational diabetes mellitus-affected pregnancy.

OBJECTIVE: To estimate trends in postpartum glucose testing in a cohort of women with gestational diabetes mellitus (GDM). METHODS: A validated computerized algorithm using Kaiser Permanente Northwest automated data systems identified 36,251 live births or stillbirths from 1999 through 2006. The annual percentage of pregnancies complicated by gestational diabetes with clinician orders for and completion of a fasting plasma glucose (FPG) test within 3 months of delivery was calculated. Logistic regression with generalized estimating equations was used to test for statistically significant trends. RESULTS: The percentages of pregnancies affected by GDM increased from 2.9% in 1999 to 3.6% in 2006 (P<.01). Clinician orders for postpartum tests increased from 15.9% in 1999 to 79.3% in 2004 (P<.01), and then remained stable through 2006. Completed FPG tests increased from 9.0% in 1999 to 57.8% in 2004 (P<.01), and then remained stable through 2006. No oral glucose tolerance tests were ordered. From 2004 to 2006, the practice site where women received care was the factor most strongly associated with the clinician order, but it was not predictive of test completion. Among women with clinician orders, those who were Asian or Hispanic or who attended the 6-week postpartum examination were more likely to complete the test than their counterparts. CONCLUSION: Postpartum glucose testing in women with GDM-affected pregnancies increased over time. However, even in recent years, 42% of women with GDM-affected pregnancies failed to have a postpartum FPG test, and no test was ordered for 21% of GDM-affected pregnancies.

Maternal morbidity rates in a managed care population.

OBJECTIVE: To identify and estimate prevalence rates of maternal morbidities by pregnancy outcome and selected covariates during the antepartum, intrapartum, and postpartum periods in a defined population of pregnant women. METHODS: We used electronic data systems of a large, vertically integrated, group-model health maintenance organization (HMO) to develop an algorithm that searched International Classification of Diseases, 9th Revision, Clinical Modification, codes for 38 predetermined groups of pregnancy-related complications among women enrollees of this HMO between January 1, 1998, and December 31, 2001. RESULTS: We identified 24,481 pregnancies among 21,011 women. Although prevalence and type of morbidity varied by pregnancy outcome, overall, 50% of women had at least one complication. The most common complications were anemia (9.3%), urinary tract infections (9.0%), mental health conditions (9.0%), hypertensive disorders (8.5%), and pelvic and perineal trauma (7.0%). CONCLUSION: A range of mild-to-severe pregnancy complications were identified using linked inpatient and outpatient databases. The most common complications we found usually do not require hospitalization so would be missed in studies that use only hospitalization data. Our data allowed examination of a broad scope of conditions and severity. These findings increase our understanding of the extent of maternal morbidity. LEVEL OF EVIDENCE: II.

Association between obesity during pregnancy and increased use of health care.

BACKGROUND: In the United States, obesity during pregnancy is common and increases obstetrical risks. An estimate of the increase in use of health care services associated with obesity during pregnancy is needed. METHODS: We used electronic data systems of a large U.S. group-practice health maintenance organization to identify 13,442 pregnancies among women 18 years of age or older at the time of conception that resulted in live births or stillbirths. The study period was between January 1, 2000, and December 31, 2004. We assessed associations between measures of use of health care services and body-mass index (BMI, defined as the weight in kilograms divided by the square of the height in meters) before pregnancy or in early pregnancy. The women were categorized as underweight (BMI <18.5), normal (BMI 18.5 to 24.9), overweight (BMI 25.0 to 29.9), obese (BMI 30.0 to 34.9), very obese (BMI 35.0 to 39.9), or extremely obese (BMI > or =40.0). The primary outcome was the mean length of hospital stay for delivery. RESULTS: After adjustment for age, race or ethnic group, level of education, and parity, the mean (+/-SE) length of hospital stay for delivery was significantly (P<0.05) greater among women who were overweight (3.7+/-0.1 days), obese (4.0+/-0.1 days), very obese (4.1+/-0.1 days), and extremely obese (4.4+/-0.1 days) than among women with normal BMI (3.6+/-0.1 days). A higher-than-normal BMI was associated with significantly more prenatal fetal tests, obstetrical ultrasonographic examinations, medications dispensed from the outpatient pharmacy, telephone calls to the department of obstetrics and gynecology, and prenatal visits with physicians. A higher-than-normal BMI was also associated with significantly fewer prenatal visits with nurse practitioners and physician assistants. Most of the increase in length of stay associated with higher BMI was related to increased rates of cesarean delivery and obesity-related high-risk conditions. CONCLUSIONS: Obesity during pregnancy is associated with increased use of health care services.

Development of an algorithm to identify pregnancy episodes in an integrated health care delivery system.

OBJECTIVE: To develop and validate a software algorithm to detect pregnancy episodes and maternal morbidities using automated data. DATA SOURCES/STUDY SETTING: Automated records from a large integrated health care delivery system (IHDS), 1998-2001. STUDY DESIGN: Through complex linkages of multiple automated information sources, the algorithm estimated pregnancy histories. We evaluated the algorithm's accuracy by comparing selected elements of the pregnancy history obtained by the algorithm with the same elements manually abstracted from medical records by trained research staff. DATA COLLECTION/EXTRACTION METHODS: The algorithm searched for potential pregnancy indicators within diagnosis and procedure codes, as well as laboratory tests, pharmacy dispensings, and imaging procedures associated with pregnancy. PRINCIPAL FINDINGS: Among 32,847 women with potential pregnancy indicators, we identified 24,680 pregnancies occuring to 21,001 women. Percent agreement between the algorithm and medical records review on pregnancy outcome, gestational age, and pregnancy outcome date ranged from 91 percent to 98 percent. The validation results were used to refine the algorithm. CONCLUSIONS: This pregnancy episode grouper algorithm takes advantage of databases readily available in IHDS, and has important applications for health system management and clinical care. It can be used in other settings for ongoing surveillance and research on pregnancy outcomes, pregnancy-related morbidities, costs, and care patterns.

Vaginal douches and other feminine hygiene products: women's practices and perceptions of product safety.

OBJECTIVE: Use of vaginal douche products has been linked with a variety of reproductive health problems; nonetheless, the practice of douching persists. The goals of this study were to 1) determine the use of vaginal douches and other feminine hygiene products, 2) ascertain how safe women think vaginal douche products are, and 3) evaluate women's readiness to stop douching. METHODS: A random-digit-dial computer-assisted telephone survey was conducted among US women between the ages of 18 and 44. RESULTS: Of the 2,602 women interviewed, 11.8% (n = 307) engaged in regular douching (White: 9.1%; African American: 27.7%; Hispanic: 15.0%). Women who douched, compared to women who did not douche, used other feminine hygiene products significantly more often (vaginal sprays [ p < .0001], wipes/towelettes [ p < 0.01], vaginal powder [ p < 0.0001] and bubble bath for feminine cleansing [ p < 0.001]). Women who douched also were more likely than nondouchers to agree with the statement, "Douche products are safe to use; otherwise they wouldn't be on the market" (70.3% vs. 33.4%, respectively; p < 0.0001). Nearly all women (90.0%) who douched had no intention to discontinue the practice. CONCLUSION: Compared with women who do not douche, women who douche use other feminine hygiene products at a much higher rate and also believe that douche products are safe. Women who douche will remain resistant to stopping the practice without innovative interventions. Given that most women start douching in adolescence, teens should be targeted for prevention efforts.

From mortality to morbidity: the challenge of the twenty-first century.

Although maternal mortality has been the traditional measure used to evaluate the status of women's health in pregnancy, the Division of Reproductive Health at the Centers for Disease Control and Prevention has expanded beyond its surveillance of pregnancy mortality to explore pregnancy morbidity. Working with a variety of partners, we are looking at several questions. What is pregnancy morbidity, its spectrum and prevalence? What are the most serious complications of pregnancy? Are there differences in the severity of complications between white and black women? What conditions should be monitored and by what methods? Answers to these questions should help us understand why some groups of women experience a greater risk of death from pregnancy, but also help us to enlarge the scope of our concern for the health of women before, during, and after pregnancy.