Differences in fertility patterns between urban and rural women in Washington State, 1983-1984 to 1993-1994.

We use data on Washington State abortions and births for 1983-1984 and 1993-1994 to analyze trends for urban and rural women, using the demographic measures total abortion and total fertility rates. These express pacing of childbearing in a single number which is simple to calculate and interpret, and is age-standardized. We find significant urban-rural differences. Total abortion rates decline and total fertility rates increase in both areas. However, the relative magnitudes of pacing decreases in abortions for rural women and increases in births for urban women are striking. The demographic measures are useful interpretive tools, and can be applied to a broad range of questions.

Reproductive health services in rural Washington State: scope of practice and provision of medical abortions, 1996-1997.

OBJECTIVES: This study explored reproductive health care in rural Washington State, reasons given by providers for not offering abortions, and providers' willingness to use medical abortifacients. METHODS: Physicians, midwives, nurse practitioners, and physician assistants in rural Washington completed an inventory of reproductive health services that they provide, whether and why they do not perform abortions, and whether they would use medical abortifacients. RESULTS: Of the respondents, 89.2% reported providing reproductive health care. Only 1.2% reported performing surgical abortions, and 26.1% indicated that they would probably prescribe medical abortifacients. CONCLUSIONS: Few providers offer surgical abortions in rural Washington. Greater numbers report a willingness to prescribe medical abortifacients.

Medical students' attitudes toward abortion and other reproductive health services.

BACKGROUND AND OBJECTIVES: The continued availability of legal abortions in the United States depends on the willingness of future physicians to provide this procedure. This paper explores the attitudes toward abortion issues of first- and second-year medical students at a large regional primary care-oriented medical school. METHODS: We anonymously surveyed 286 first- and second-year medical students at the University of Washington. RESULTS: The response rate to the written survey was 76.6%. Women were slightly overrepresented among the respondents. The majority of students supported the broad provision of reproductive health services; 58.1% felt that first-trimester abortions should be available to patients under most circumstances. Of the 43.4% of students who anticipated a career in family practice, most expected to provide abortions in their future practices. Older students and women were more likely to support the provision of abortion services. CONCLUSIONS: Despite continuing pressure on abortion providers, most first- and second-year medical students at a fairly typical state-supported medical school intend to incorporate this procedure into their future practices.

PIP: This paper investigated the attitude toward abortion and other reproductive health services of first- and second-year medical students at the Seattle campus of the University of Washington, a large regional primary care-oriented medical school, in 1996-97. A total of 219 (76.6%) students responded. The majority of the students support the availability of a broad range of reproductive health services including abortion; 58.1% felt that first-trimester abortions should be available to patients under most circumstances. Of the 43.4% of students who anticipated a career in family practice, most expected to provide abortions in their future practices. Moreover, older students and women were more likely to support the provision of abortion services. This study concludes that despite the continuing pressure on abortion providers, most first- and second-year medical students at a fairly state-supported medical school intend to incorporate this procedure into their future practices.

Abortion services in rural Washington State, 1983-1984 to 1993-1994: availability and outcomes.

CONTEXT: Fewer rural health providers offer abortion services than a decade ago. It is unknown how the reduction in service availability has affected women's pregnancy outcomes, the extent to which they must travel to obtain an abortion or whether abortions are delayed as a result. METHODS: Population, birth and fetal death data, as well as pregnancy termination reports, obtained from Washington State were used to calculate abortion rates and ratios and birthrates for Washington residents in 1983-1984 and in 1993-1994. Residence of abortion patients was classified by county only, and location of providers was recorded as large urban county, small urban county, large rural county or small rural county. Distances that women traveled to obtain an abortion were calculated. Chi-square tests were used to compare urban and rural rates and ratios within time periods, and to compare changes that occurred between time periods. RESULTS: Birthrates and abortion rates decreased for both rural and urban Washington women between 1983-1984 and 1993-1994, but the magnitude of the decrease was greater for rural women. The rural abortion rate fell 27%, from 14.9 abortions per 1,000 women to 10.9 per 1,000, while the urban rate dropped 17%, from 21.8 to 18.2 per 1,000. The decline in the abortion rate was larger for adolescents than it was for other age-groups. In rural areas, the abortion rate decreased from 16.5 per 1,000 adolescents aged 10-19 in 1983-1984 to 10.8 per 1,000 in 1993-1994, while it declined from 23.3 per 1,000 to 16.9 per 1,000 in urban areas. From the earlier to the later time period, rural women traveled on average 12 miles farther each way to obtain an abortion, and the proportion who obtained the procedure in a rural county decreased from 25% to 3%. In the earlier time period, 62% of rural women traveled 50 miles or more to obtain an abortion, compared with 73% in 1993-1994. From 1983-1984 to 1993-1994, the proportion of rural women who traveled out of state for an abortion increased from 8% to 14%. The proportion of rural women terminating their pregnancy after the first trimester increased from 8% in 1983-1984 to 15% in 1993-1994. CONCLUSION: Rural Washington women are traveling farther and more often to urban and out-of-state locations for abortion services, and are obtaining their abortions at a later gestational age, which is associated with a decade-long decline in the number of abortion providers.

PIP: The availability and outcome of abortion services as of 1983-84 and 1993-94 in rural Washington State were investigated. The population data include birth, fetal death and pregnancy termination which came from the vital statistics data compiled by Washington State. Results showed that birth rates and abortion rates decreased throughout the state from 1983-84 to 1993-94. The magnitude of the drop in abortion rates was significantly greater in rural than in urban women (p 0.01). The rural abortion rate fell 27% compared with a 17% drop in the urban rate. The declination in the abortion rate was larger for adolescents than other age groups. The abortion rate for adolescents aged 10-19 years dropped 35% in rural areas and 28% in urban areas. 12 miles increased the distance that rural women traveled to obtain abortion. The proportion of rural women having abortions decreased significantly from 25% to 3%. During 1983-84, 62% traveled 50 miles to obtain abortion compared with 73% in 1993-94. In both time periods, the proportion of rural women who traveled out of state for an abortion increased from 8% to 14%. Furthermore, the proportion of women terminating their pregnancy after the first trimester increased from 8% in 1983-84 to 15% in 1993-94. More work is needed to understand the relationships among provider availability, other factors influencing decision-making and pregnancy outcomes.

Family planning service provision in rural areas: a survey in Washington State.

CONTEXT: Women in rural areas are highly dependent on public clinics for family planning services, yet little information has been collected on rural family planning providers, especially on their funding and operation. METHODS: All 31 family planning clinic sites in rural Washington State were surveyed about their sponsorship, staffing, service provision and population coverage. RESULTS: Clinic sites were located in 25 of the 53 discrete rural health service areas of Washington State. While the three wealthiest areas had clinics, eight of the poorest areas had no clinics. Eight clinics were Planned Parenthood affiliates, eight were private freestanding clinics and 15 were local health department sites. Clinic sites were small (with the equivalent of 2.4 full-time staff members, on average) and offered a mean of 18 of 43 potential reproductive and women's health care services; general primary care services were rarely provided. Only one clinic offered abortions. CONCLUSION: Family planning clinics in rural Washington State offer an important but limited number of services. Many rural areas have no local family planning clinic. Given these clinics' reliance on federal and state funding, decreased public support might seriously impair family planning provision in rural areas.

PIP: This study explored the range of services available in 3 types of family planning (FP) clinic centers in rural Washington state: Planned Parenthood clinics (8), private freestanding clinics (8), and local health department clinics (15). Comparisons were made of staffing, funding, patient volume, range of services, service area, and availability of abortion services. All 31 FP clinics completed the questionnaire in 1995. Most providers were nurse practitioners, physician assistants, or registered nurses who were supervised by a medical physician. Local health departments had the largest staffs (3.5 full-time staff). Private clinics averaged 1.8 staff, and Planned Parenthood clinics averaged 1.2 staff. 25 clinics reported a mean of 809 clients, or 131 clients/1000 women aged 15-44 years. 9 of 43 possible reproductive health services were unavailable. Of a designated total of 34 core, discretionary, and rare services, clinics provided a mean of 18 services. Only 1 clinic provided abortions. Availability of services did not vary by type of clinic. Cost and lack of trained providers were reasons for lack of service expansion. Local community opposition and lack of trained providers were the most common reasons for absence of abortion services. Women were referred to abortion services 20-200 miles away. 36% would prescribe mifepristone if it were available. Federal funds and state funds, which comprised almost 50% of funding, varied by clinic type. Areas with the lowest socioeconomic status were less likely to have FP clinics. Findings demonstrate that FP clinics provide an important but limited scope of services to rural women.

How well do birth certificates describe the pregnancies they report? The Washington State experience with low-risk pregnancies.

OBJECTIVES: Birth certificates are a major source of population-based data on maternal and perinatal health, but their value depends on the accuracy of the data. This study assesses the validity of information recorded on the birth certificates for women in Washington State who were considered to be low risk at entry into care. METHODS: Birth certificates were matched to data abstracted from prenatal and intrapartum clinic and hospital records of a sample of 1937 Washington State obstetrical patients who were considered to be low risk at the beginning of their pregnancies. Accuracy of a variety of pregnancy characteristics (e.g., complications, procedures) on the birth certificate was analyzed using percentage agreement and sensitivity with record abstracts as the "gold standard." Next, we weighted the data from each source to produce estimates of pregnancy characteristics in the population. We compared these estimates from the two data sources to see whether they provide similar pictures of this subpopulation. RESULTS: Missing data for specific items on the birth certificates ranged from 0% to 24%. The birth certificate accurately captured gravidity and parity, but was less likely to report prenatal and intrapartum complications. The population estimates of the two data sources were significantly different. CONCLUSIONS: Because birth certificates significantly underestimated the complications of pregnancies, number of interventions, number of procedures, and prenatal visits, use of these data for health policy development or resource allocation should be tempered with caution.

Interspecialty differences in the obstetric care of low-risk women.

OBJECTIVES: This study examined differences among obstetricians, family physicians, and certified nurse-midwives in the patterns of obstetric care provided to low-risk patients. METHODS: For a random sample of Washington State obstetrician-gynecologists, family physicians, and certified nurse-midwives, records of a random sample of their low-risk patients beginning care between September 1, 1988, and August 31, 1989, were abstracted. RESULTS: Certified nurse-midwives were less likely to use continuous electronic fetal monitoring and had lower rates of labor induction or augmentation than physicians. Certified nurse-midwives also were less likely than physicians to use epidural anesthesia. The cesarean section rate for patients of certified nurse-midwives was 8.8% vs 13.6% for obstetricians and 15.1% for family physicians. Certified nurse-midwives used 12.2% fewer resources. There was little difference between the practice patterns of obstetricians and family physicians. CONCLUSIONS: The low-risk patients of certified nurse-midwives in Washington State received fewer obstetrical interventions than similar patients cared for by obstetrician-gynecologists or family physicians. These differences are associated with lower cesarean section rates and less resource use.

An early preceptorship and medical students' beliefs, values, and career choices.

BACKGROUND AND OBJECTIVES: Curriculum influence on career choice is difficult to determine. In this study we explored the impact of a summer rural/underserved preceptorship on the residency choices of participants and on the beliefs and attitudes of participating students about rural underserved primary care practices. METHODS: Two data sets are used to examine the Rural/Underserved Opportunities Program (R/UOP). Matriculation and residency selection information is analyzed to compare R/UOP participants with nonparticipants. Second, a survey eliciting beliefs and attitudes about various career choices was given to participants before and after the experience and to a sample of non-participating classmates matched for age, race, and ethnicity. RESULTS: At matriculation, R/UOP participants gave higher rankings to primary care specialties as possible career choices. They were more likely to be matched in a primary care residency than nonparticipants. R/UOP participants expressed belief in more differences between urban and rural practice than did nonparticipants. They maintained their higher attitudes towards rural practice. CONCLUSIONS: R/UOP supports preexisting beliefs and positive attitudes towards rural underserved primary care careers. Participating students do not have large differences at entry into medical school. They are more likely to select primary care residencies, compared with nonparticipants.

Rural and urban differences in physician resource use for low-risk obstetrics.

OBJECTIVE: To explore the hypothesis that rural obstetricians (OBs) and family physicians (FPs) utilized fewer resources during the care of the low-risk women who initially booked with them than did their urban counterparts of the same specialties. DATA SOURCES/STUDY DESIGN: A stratified random sample of Washington state rural and urban OBs and FPs was selected during 1989. A participation rate of 89 percent yielded 209 participating physicians. The prenatal and intrapartum medical records of a random sample of the low-risk patients who initiated care with the sampled providers during a one-year period were abstracted in detail and analyzed with the physician as the unit of analysis. Complete data for 1,683 patients were collected. Resource use elements (e.g., urine culture) were combined by standardizing them with average charge data so that aggregate resource use could be analyzed. Intraspecialty comparisons for resource use by category and overall were performed. FINDINGS/CONCLUSIONS: Results show that rural physicians use fewer overall resources in caring for nonreferred low-risk-booking obstetric patients than do their urban colleagues. Resource use unit expenditures showed the hypothesized pattern for both specialties for total, intrapartum, and prenatal care with the exception of FPs for prenatal care. Approximately 80 percent of the resource units used by each physician type were related to hospital care. No differences were shown in patterns of care for most clinically important aspects of care (e.g., cesarean delivery rates), and no evidence suggested that outcomes differed. The overall differences were due to specific components of care (e.g., fewer intrapartum hospital days and less epidural anesthesia).

Do women choose their obstetric providers based on risks at entry into prenatal care? A study of women in Washington State.

OBJECTIVE: To study risk factors in a large population of women over a broad geographic area as they entered obstetric care, and to assess how they distributed themselves among the specialties. METHODS: Data from 1 year were gathered through a retrospective chart review of all women initiating care with randomly selected urban and rural obstetricians, urban and rural family physicians, and urban certified nurse midwives. RESULTS: The majority of women had at least one risk factor at entry into care. When a scoring system was applied to the data, 13.5% of the women were designated "high risk," which is consistent with findings of other studies. However, women did not distribute themselves to provider types according to risk. Higher-risk women were more likely to choose family physicians, especially in rural areas. Much of this difference can be attributed to young maternal age, late entry into care, and lack of health insurance or Medicaid sponsorship. CONCLUSION: These findings suggest that economics and geography are more likely to influence a woman's initial choice of provider than medical and obstetric risk.

Evaluation of oral rehydration therapy in Matiguas, Nicaragua.

Use of oral rehydration salts is an effective tool to decrease deaths due to diarrheal dehydration. Following concerted educational efforts to introduce oral rehydration therapy, Nicaragua reported a significant decrease in deaths of young children from diarrhea and dehydration over a 5-year period. Further decline in the mortality rate has not occurred, however, and factors that would affect usage and impact are poorly understood. A health survey was administered in 155 randomly selected homes in Matiguas, Nicaragua, in July 1990. Caretakers of children were asked about their knowledge, attitudes, and practices in treating diarrhea in children younger than age 5. They were also asked to demonstrate their knowledge of mixing World Health Organization oral rehydration salts packets. Ninety percent of the respondents said they used oral rehydration therapy. The major reason quoted for not using it was dislike of the taste. Of the three-quarters willing to mix the oral rehydration salts, 62 percent prepared the solution correctly and 38 percent incorrectly. Knowledge about diarrhea and the role of oral rehydration therapy was high in this population, and those with this knowledge were more likely to use it. Respondents who learned to mix the oral rehydration salts at the health center had more years of education and were more likely to mix the salts correctly. In this study, there is a positive association between contact with the health center and correct use of the rehydration salts. The relationship of this association with morbidity and mortality needs further research.

Depression after childbirth.

BACKGROUND AND METHODS: Depression following childbirth is an illness occurring in 10 to 20 percent of women in the year postpartum. Researchers have debated whether postpartum depression is a different illness from depression at other times. We critically review the literature on postpartum depression, as distinguished from postpartum blues and psychosis. RESULTS: Problems with definition, study design, and the validity of the diagnosis have hampered investigation. Studies do not clearly distinguish postpartum depression from major depression occurring at other times CONCLUSIONS: Depression after childbirth is probably the same illness as depression at other times. It is not known whether biological and psychological factors unique to the puerperium alter the expression of the illness. Nonetheless, physicians caring for women and infants should learn to screen for, diagnose, and treat depression in women after childbirth.