Comparison of obstetrician-gynecologists and family physicians regarding weight-related attitudes, communication, and bias.

OBJECTIVES: To assess physician perceptions regarding weight-related communication, quality of care, and bias in obstetrics-gynecology (OBGYN) and family physician (FP) practices. METHODS: A cross-sectional survey study based on a convenient sampling of OBGYN and FP was conducted. Physicians completed a 40-question survey assessing perceived obesity management and weight bias in caring for female patients with body mass index ≥25kg/m2. RESULTS: Reponses from 51 physicians (25 OBGYN and 26 FP) were received. There was no difference between specialties in satisfaction with care or level of confidence in treating patients with obesity. However, OBGYNs reported more negative perceptions of patients with obesity (mean score 19.2±3.3 vs. 15.0±4.0, p<0.001) and greater weight bias (11.8±2.0 vs. 9.7±2.5, p<0.01) compared to FPs. OBGYNs were also more likely to expect less favorable treatment outcomes (13.3±2.5 vs. 15.5±2.8. p<0.01). Physicians between 31-50 years old displayed a significantly higher perception of weight bias in their profession when compared to the reference 21-30year olds, and for each unit increase in self-reported BMI there was a 0.18 average increase in the composite score for perceived weight bias. CONCLUSIONS: OBGYN physicians reported significantly higher levels of weight bias than FP physicians, indicating a need for improved education in OBGYN training. CLINICAL TRIAL REGISTRATION: N/A.

Gender Differences in Eating Disorder Risk among NCAA Division I Cross Country and Track Student-Athletes.

PURPOSE: This study compared gender differences in eating disorder risk among NCAA Division I cross country and track distance running student-athletes. METHODS: Six hundred thirty-eight male and female student-athletes competing at distances of 800m or greater completed the Eating Disorder Screen for Primary Care (ESP). Scores on the ESP were used as the risk of eating disorders. RESULTS: Females screened positive at higher rates for risk of eating disorders than males on the ESP at a cutoff of 2 (sensitivity 90-100%, specificity 71%) with rates of 45.95% ± 3.03 and 13.66% ± 1.80, respectively. Females were also screened positive at higher rates than males at a stricter cutoff of 3 (sensitivity 81%, specificity 92%), with rates of 21.69% ± 2.50 compared to 4.64% ± 1.10, respectively. CONCLUSION: This study highlights that, among distance runners, both males and females are at risk of eating disorders, with females being at higher risk. It also emphasizes the need for screening for risk of eating disorders in this population.

US term stillbirth rates and the 39-week rule: a cause for concern?

BACKGROUND: More than a decade ago an obstetric directive called "the 39-week rule" sought to limit "elective" delivery, via labor induction or cesarean delivery, before 39 weeks 0 days of gestation. In 2010 the 39-week rule became a formal quality measure in the United States. The progressive adherence to the 39-week rule throughout the United States has caused a well-documented, progressive reduction in the proportion of term deliveries occurring during the early-term period. Because of the known association between increasing gestational age during the term period and increasing cumulative risk of stillbirth, however, there have been published concerns that the 39-week rule-by increasing the gestational age of delivery for a substantial number of pregnancies-might increase the rate of term stillbirth within the United States. Although adherence to the 39-week rule is assumed to be beneficial, its actual impact on the US rate of term stillbirth in the years since 2010 is unknown. OBJECTIVE: To determine whether the adoption of the 39-week rule was associated with an increased rate of term stillbirth in the United States. STUDY DESIGN: Sequential ecological study, based on state data, of US term deliveries that occurred during a 7-year period bounded by 2007 and 2013. The patterns of the timing of both term childbirth and term stillbirth were determined for each state and for the United States as a whole. RESULTS: A total of 46 usable datasets were obtained (45 states and the District of Columbia). During the 7-year period, there was a continuous reduction in all geographic entities in the proportion of term deliveries that occurred before 39 weeks of gestation. The overall rate of term stillbirth, when we compared 2007-2009 with 2011-2013, increased significantly (1.103/1000 vs 1.177/1000, RR 1.067, 95% confidence interval 1.038-1.096). Furthermore, during the 7-year period, the increase in the rate of US term stillbirth appeared to be continuous (estimated slope: 0.0186/1000/year, 95% confidence interval 0.002-0.035). Assuming 3.5 million term US births per year, and given 6 yearly "intervals" with this rate increase, it is possible that more than 335 additional term stillbirths occurred in the United States in 2013 as compared with 2007. In addition, during the 7-year period, there was a progressive shift in the timing of delivery from the 40th week to the 39th week. Absent this confounding factor, the magnitude of association between the adoption of the 39-week rule and the increase in rate of term stillbirth might have been greater. CONCLUSIONS: Between 2007 and 2013 in the United States, the adoption of the 39-week rule caused a progressive reduction in the proportion of term births occurring before the 39th week of gestation. During the same interval the United States experienced a significant increase in its rate of term stillbirth. This study raises the possibility that the 39-week rule may be causing unintended harm. Additional studies of the actual impact of the adoption of the 39-week rule on major childbirth outcomes are urgently needed. Pressures to enforce the 39-week rule should be reconsidered pending the findings of such studies.

Childhood eye examination.

Vision screening in children is an ongoing process, with components that should occur at each well-child visit. The purpose is to detect risk factors and visual abnormalities that necessitate treatment and to identify those patients who require referral to an ophthalmologist skilled in examining children. Screening can reveal conditions commonly treated in primary care and can aid in discussion of visual concerns with parents or caregivers. Vision screening begins with a review of family and personal vision history to identify risk factors requiring referral, including premature birth, Down syndrome, cerebral palsy, and a family history of strabismus, amblyopia, retinoblastoma, childhood glaucoma, childhood cataracts, or ocular or genetic systemic disease. Visual acuity measurement and external ocular examination are performed to recognize refractive error, childhood glaucoma, and various ocular conditions. Evaluation of fixation and alignment can identify amblyopia or strabismus. Red reflex examination is used to diagnose retinoblastoma, childhood cataracts, and other ocular abnormalities.

The active management of impending cephalopelvic disproportion in nulliparous women at term: a case series.

BACKGROUND: The Active Management of Risk in Pregnancy at Term (AMOR-IPAT) protocol has been associated in several studies with significant reductions of group cesarean delivery rate. Present within each of these studies were nulliparous women with risk factors for cephalopelvic disproportion. Risk factors for cephalopelvic disproportion in nulliparous women are especially important because they represent the precursors for the most common indication for primary cesarean delivery. CASES: Three examples of exposure of urban nulliparous women to the AMOR-IPAT protocol are presented. Each woman's risk factor profile for Cephalopelvic Disproportion (CPD) was used to estimate her Upper Limit of Optimal Time of Vaginal Delivery for CPD (UL-OTDcpd). Labor management and clinical outcomes for each case are presented. A simple table summarizing induction rates and birth outcome rates of exposed versus nonexposed nulliparous women is also presented. CONCLUSION: Because the mode of delivery of the first birth substantially impacts birth options in later pregnancies, the impact of AMOR-IPAT on nulliparous patients is particularly important. Determining the UL-OTDcpd in nulliparous patients, and carefully inducing each patient who has not entered labor by her UL-OTDcpd, may be an effective way of lowering rates of cesarean delivery in nulliparous women.

The association between increased use of labor induction and reduced rate of cesarean delivery.

AIM: An association was recently reported between a low cesarean section delivery rate and a method of obstetrical care that involved the frequent use of risk-guided prostaglandin-assisted preventive labor induction. We sought to confirm this finding in a subsequent group of pregnant women. METHODS: A retrospective cohort study design was used to compare the outcomes of 100 consecutively delivered women, who were exposed to the alternative method of care, with the outcomes of 300 randomly chosen women who received standard management. The primary outcome was group cesarean delivery rate. Secondary outcomes were rates of neonatal intensive care unit admission, low 1-minute Apgar score, low 5-minute Apgar score, and major perineal trauma. RESULTS: Women exposed to the alternative method of obstetrical care had a higher induction rate (59% vs. 16.3%, p < 0.001), a more frequent use of prostaglandins for cervical ripening (32% vs. 13%, p < 0.001), and a lower cesarean delivery rate (7% vs. 20.3%, p = 0.002). Exposed women did not experience higher rates of other adverse birth outcomes. CONCLUSIONS: Exposure to an alternative method of obstetrical care that used high levels of risk-driven prostaglandin-assisted labor was again associated with two findings: a lower group cesarean delivery rate and no increases in levels of other adverse birth outcomes. An adequately powered randomized controlled trial is needed to further explore this alternative method of care.

The active management of risk in multiparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes.

OBJECTIVE: To determine whether exposure of multiparous women to a high rate of preventive labor induction was associated with a significantly lower cesarean delivery rate. STUDY DESIGN: Retrospective cohort study involving 123 multiparous women, who were exposed to the frequent use of preventive labor induction, and 304 multiparous women, who received standard management. Rates of cesarean delivery and other adverse birth outcomes were compared in the 2 groups. Logistic regression controlled for confounding covariates. RESULTS: The exposed group had a lower cesarean delivery rate (adjusted odds ratio, 0.09; 0.8% vs 9.9%; P = .02) and a higher uncomplicated vaginal delivery rate (odds ratio, 0.53; 78.9% vs 66.4%; P = .01). Exposure was not associated with higher rates of other adverse birth outcomes. CONCLUSION: Exposure of multiparous women to a high rate of preventive labor induction was significantly associated with improved birth outcomes, including a very low cesarean delivery rate. A prospective randomized trial is needed to determine causality.

Active management of risk in nulliparous pregnancy at term: association between a higher preventive labor induction rate and improved birth outcomes.

OBJECTIVE: The objective of the study was to determine whether exposure of nulliparous women to a high rate of preventive labor induction was associated with improvement in birth health. STUDY DESIGN: A risk-scoring system was used to guide the frequent use of preventive labor induction in 100 nulliparous women. The birth outcomes of this group were compared with those of 352 nulliparous women who received usual care. Cesarean delivery was the primary study outcome. The Adverse Outcome Index and the rate of uncomplicated vaginal delivery were used to measure overall birth health. RESULTS: The exposed group experienced a higher labor induction rate (48% vs 23.6%; P < .001), a lower cesarean rate (9% vs 25.8%; adjusted odds ratio, 0.36; P = .02), and better composite birth outcomes. CONCLUSION: Exposure of nulliparous women to a high preventive induction rate was significantly associated with improvement in birth health. Prospective randomized trials are needed to further explore the utility of risk-guided preventive labor induction.

Active management of risk in pregnancy at term in an urban population: an association between a higher induction of labor rate and a lower cesarean delivery rate.

OBJECTIVE: The purpose of this study was to determine whether exposure to an alternative method of care, called the active management of risk in pregnancy at term, was associated with a lower group cesarean delivery rate. STUDY DESIGN: Active management of risk in pregnancy at term used risk factors for cesarean delivery to guide an increased use of labor induction. A retrospective cohort design was used to compare clinical outcomes of 100 pregnant women who were exposed to active management of risk in pregnancy at term to 300 randomly selected subjects who received standard management. RESULTS: The 2 groups had comparable levels of prenatal risk. The group exposed to the active management of risk in pregnancy at term exposure group encountered a higher induction rate (63% vs 25.7%; P < .001) and a lower cesarean delivery rate (4% vs 16.7%; P = .01). Findings were similar for both nulliparous and multiparous subgroups. Active management of risk in pregnancy at term exposure was not associated with higher rates of other major birth outcomes. CONCLUSION: Exposure to the active management of risk in pregnancy at term exposure was associated with a significantly lower group cesarean delivery rate. A prospective randomized trial that involved active management of risk in pregnancy at term exposure is needed to further explore this association.