Preeclampsia associated with chronic hypertension among African-American and White women.

OBJECTIVE: To examine the racial differences in preeclampsia/eclampsia (preeclampsia) associated with chronic hypertension among African-American and White women. METHODS: Using hospital discharge summary records from the National Hospital Discharge Survey from 1988 to 1996, we conducted a case-control study to assess the risk of preeclampsia among women with chronic hypertension in two separate identical models: one for African-American and another for White women. Cases were pregnant women who developed preeclampsia. Controls were women without preeclampsia. The main exposure was chronic hypertension. Logistic regression was used to derive odds ratios (OR) and 95% confidence intervals (CI) and to assess interaction between hypertension and preeclampsia. Population attributable risk percent associated between chronic hypertension and preeclampsia was calculated for each ethnic group. RESULTS: Preeclampsia was more than eleven times likely among women with chronic hypertension compared to normotensive women for both African-American (OR = 12.4, 95% CI = 10.2-15.2) and White women (OR = 11.3, 95% CI = 9.7-13.2). Among African-American women, we found an interaction between chronic hypertension and region on preeclampsia. The effect of region magnified the risk of preeclampsia associated with chronic hypertension in general for African-American women, but the effect was lower for the Southern region (OR = 8.9, 95% CI = 6.4-12.3). We also found that the point estimate of population attributable risk percent of preeclampsia attributable to chronic hypertension was significantly higher for African-American women (10.3, 95% CI = 8.6-12.5) compared to White women (5.3, 95% CI = 4.7-6.4). CONCLUSION: The more than eleven-fold higher risk of preeclampsia among both African-American and White women with chronic hypertension compared to normotensive women underscores the potential risk of chronic hypertension for adverse pregnancy outcomes. Furthermore, the two-fold higher population attributable risk percent of preeclampsia among African-American compared to White women quantifies the burden of preeclampsia attributable to chronic hypertension, and indicates a greater opportunity for prevention.

Racial and ethnic differences in access to medical care.

The authors' review of the health services literature since the release of the landmark Report of the Secretary's Task Force Report of Black and Minority Health in 1985 revealed significant differences in access to medical care by race and ethnicity within certain disease categories and types of health services. The differences are not explained by such factors as socioeconomic status (SES), insurance coverage, stage or severity of disease, comorbidities, type and availability of health care services, and patient preferences. Under certain circumstances when important variables are controlled, racial and ethnic disparities in access are reduced and may disappear. Nonetheless, the literature shows that racial and ethnic disparities persist in significant measure for several disease categories and service types. The complex challenge facing current and future researchers is to understand the basis for such disparities and to determine why disparities are apparent in some but not other disease categories and service types.

Factors related to noncompliance with screening mammogram appointments among low-income African-American women.

Despite current mammography recommendations, screening rates among African-American women are suboptimal. The purpose of this case-control study was to identify the psychological, demographic, and health care system barriers to screening mammography use among low-income African-American women. A total of 574 women with screening mammogram appointments at an urban hospital were interviewed to determine the predictors of mammogram appointment noncompliance. Predictor variables included: demographics; breast cancer knowledge, attitudes, beliefs, and screening practices; and type of health care provider making the referral. Age was inversely related to mammogram appointment noncompliance. Relative to women 40 to 49 years old, women 70 years of age and older were the least likely to miss their appointments (odds ratio [OR], 0.3; 95% confidence interval [CI], 0.2, 0.5). Women referred for mammography by a physician's assistant or nurse practitioner were less likely to miss their appointments than women referred by a physician (OR, 0.3; 95% CI, 0.1, 0.8). Embarrassment, lack of breast symptoms, and forgetfulness also contributed to noncompliance. Key demographic, attitudinal, and health care system factors hinder low-income African-American women from obtaining screening mammograms. These findings have significant health education and policy implications for health care delivery to women in this population.

Determining cost savings from attempted cephalic version in an inner city delivering population.

The use of external cephalic version (ECV) is increasingly seen as an important clinical management strategy for breech presentation infants. Currently, 75% of women with breech presentation at term undergo Cesarean delivery risking adverse outcomes and incurring higher costs. ECV, if successful, reduces the rate of breech presentation at delivery and the need for Cesarean delivery. Data from an inner-city population of delivering women were examined to determine the effectiveness of ECV among these minority, low income women. Hospital clinical and Medicaid claims data for 679 deliveries with breech presentation were studied. Decision tree analysis indicated ECV was successful for 48% of those attempted. Based on amounts billed Medicaid, attempting ECV reduced the use of resources by a little over $3,000 per delivery. Sensitivity analysis showed, however, that the savings may be as low as $906. Multivariate analysis confirmed the independent effect of attempting ECV on the probability of Cesarean delivery.

Maternal hypertension and spontaneous preterm births among black women.

OBJECTIVE: To examine effects of maternal hypertension on spontaneous preterm birth (birth at less than 37 weeks' gestation) among black women. METHODS: Using hospital discharge summary records from the National Hospital Discharge Survey between 1988 and 1993, we conducted a case-control study to assess the risk of spontaneous preterm birth among black women with chronic hypertension preceding pregnancy and pregnancy-induced hypertension. Logistic regression was used to derive odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: Preterm births were almost two times more likely for women with pregnancy-induced hypertension (OR = 1.8; 95% CI, 1.5, 2.2), more than 1.5 times more likely for women with chronic hypertension preceding pregnancy (OR = 1.6; 95% CI, 1.3, 2.1), and more than four times more likely for women with pregnancy-aggravated hypertension (OR = 4.4; 95% CI, 2.9, 6.7) compared with normotensive women. Preterm births also were associated significantly with antepartum hemorrhage, poor fetal growth, marital status, and source of payment. The odds of preterm birth by maternal hypertension were increased among women with chronic hypertension and genitourinary infection, whereas the odds of preterm birth were reduced among women with pregnancy-induced hypertension and genitourinary infection. CONCLUSION: These findings are important in demonstrating the relation between type of hypertension in pregnancy and preterm birth. The relationships between maternal hypertension and preterm birth need to be further investigated to provide some guidelines in the management of hypertension in pregnancy and assessment of prenatal care compliance for black women, particularly when genitourinary infection is present.

Maternal hypertension and associated pregnancy complications among African-American and other women in the United States.

OBJECTIVE: To characterize maternal hypertension and related pregnancy complications among African-American and other women in the United States. METHODS: Using data from the National Hospital Discharge Survey, we analyzed the incidence and clinical spectrum of maternal hypertension among African-American women who delivered in hospital during 1988-1992. Maternal hypertension consisted of pregnancy-induced hypertension and chronic hypertension preceding pregnancy, including pregnancy-aggravated hypertension. Pregnancy-induced hypertension included preeclampsia, eclampsia, and transient hypertension. Incidence rates (per 1000 deliveries) and 95% confidence intervals (CI) were calculated by type of hypertension and demographic characteristics. Risk ratios and 95% CIs for adverse pregnancy outcomes among women with hypertension were also calculated. RESULTS: The overall incidence of all causes of maternal hypertension was 64.2, and of chronic hypertension preceding pregnancy it was 25.0 per 1000 deliveries among African-American women, an excess of 15.6 and 14.5 cases per 1000 deliveries, respectively, compared with rates for other women. The risks of preterm delivery and inadequate fetal growth were similarly increased for all hypertensive women, regardless of race. However, hypertensive African-American women were at a threefold greater risk of pregnancies complicated by antepartum hemorrhage, an association that was not observed, in other women. Development of preeclampsia and eclampsia irrespective of race was about four times higher among women with chronic hypertension preceding pregnancy than among those without chronic hypertension. CONCLUSION: The excess incidence of maternal hypertension, particularly chronic hypertension, may contribute to adverse maternal and fetal pregnancy outcomes and the disparity in outcomes observed between African-American and other women in the U.S. These findings provide a specific focus for further clinical outcomes research and assessment of prenatal management in African-American women.

Determinants of black/white differences in colon cancer survival.

BACKGROUND: Blacks have lower survival rates for colon cancer than whites, possibly related to more advanced stages of disease at diagnosis and to socioeconomic differences between blacks and whites. While the black/white difference in colon cancer survival is well documented, the few studies that have investigated this difference have been limited by the modest number and type of explanatory factors that were considered. PURPOSE: We analyzed data from the National Cancer Institute Black/White Cancer Survival Study to determine 1) what characteristics might contribute to the racial difference in colon cancer survival and 2) if a survival disparity remained between black and white patients after adjustment was made for these characteristics. METHODS: This prospective study included 454 blacks and a stratified random sample of 521 whites, aged 20-79 years, with cancer of the colon diagnosed from January 1, 1985, through December 31, 1986, and who were residents of the metropolitan areas of Atlanta, New Orleans, and San Francisco/Oakland. Follow-up was truncated on December 31, 1990. Cox proportional hazards regression was used to estimate the death rate among blacks relative to that among whites after adjustment for potential explanatory factors, including sociodemographic factors, concurrent (comorbid) medical conditions, stage at diagnosis, tumor characteristics, and treatment. All P values were calculated from two-tailed tests of statistical significance. RESULTS: After adjustment for age, sex, and geographic area, the black-to-white mortality hazard ratio (HR) was 1.5 (95% confidence interval [CI] = 1.2-1.9), indicating that the risk of death among black patients was 50% higher than that among white patients. Further adjustment for stage reduced the excess cancer mortality to 20% (HR = 1.2; 95% CI = 1.0-1.5), decreasing the overall racial difference in excess mortality from 50% to 20% or to a 60% reduction in excess mortality. Although adjustment for poverty reduced the excess mortality by 20%, adjusting for both stage and poverty did not further reduce the racial difference. Among patients with stages II and III disease, blacks had lower survival rates than whites (HR = 1.8; 95% CI = 1.0-3.1 and HR - 1.5; 95% CI = 1.0-2.3, respectively). Among those patients with metastatic disease (stage IV), survival was similar for whites and blacks. CONCLUSIONS: Stage at diagnosis accounted for more than half of the excess colon cancer mortality observed among blacks. Poverty and other socioeconomic conditions, general health status, tumor characteristics, and general patterns of treatment did not further explain the remaining survival disadvantage among blacks. IMPLICATIONS: Because the racial disparity was confined to earlier stages, future studies should investigate whether blacks have more advanced disease at diagnosis and whether less aggressive treatment is provided because of understanding.

Age-specific patterns of association between breast cancer and risk factors in black women, ages 20 to 39 and 40 to 54.

Data from the 1980 to 1982 population-based Cancer and Steroid Hormone case-control study of women 20 to 54 years old afforded the opportunity to investigate risk factors for breast cancer among black women younger than 40 years (177 patients and 137 control subjects) and to compare the results to black women 40 to 54 years old (313 patients and 348 control subjects). Information on exposure variables was obtained by in-person interviews. The logistic regression results indicated that the risk of breast cancer among black women younger than 40 years was nearly three times greater for those who used oral contraceptives for more than 10 years relative to never-users (odds ratio, 2.8; 95% confidence interval, 1.2 to 6.8) and more than four times greater for severely obese women (body mass index > or = 32.30 kg/m2) relative to women whose relative weights were less than 24.90 kg/m2. Patterns of association for the two age groups were similar for surgical menopausal, age at first full-term pregnancy, and multiple births, but differed for age at menarche.

PIP: In this case control study among Black American women, the findings showed that differences in breast cancer risk between Black women aged 20-39 years and Black women aged 40-54 years are related to age at menarche, oral contraceptive use, and family history of breast cancer. An inverse relationship was found with age at menarche and a positive relationship with duration of oral contraceptive use among women 20-39 years. The logistic model with all variables included revealed that increased risk was related to an increasing Body Mass Index (BMI) as an adult, lack of breast feeding under the age of 25 years, and the duration of oral contraceptive use among women aged under 40 years. BMI had a stronger impact among women aged under 40 years when BMI at age 18 years was included. Both age groups showed reduced risk with surgical menopause. The final logistic regressions indicated that younger women with menarche at under the age of 12 years had 50% less breast cancer risk than younger women with menarche at 14 years or older. Severely obese younger women had four times the breast cancer risk as women weighing under 24.90 kg/m squared. For women who used oral contraceptives for 10 years or more, the adjusted odds ratio was 2.8 compared to never-users. This finding was unique. Age at initiation of use was unrelated. Results suggested that older women with a family history of breast cancer or with menarche at 13 years and younger had a higher relative risk; early age at menarche was a protection against breast cancer only among younger women. Breast feeding before the age of 25 years may affect risk of breast cancer among women under 40 years of age. Education was unrelated. The findings indicate the importance of examining within race differences by sociocultural differences and reproductive life style choices. Data were obtained from the CASH study by the Centers for Disease Control on 490 women aged 20-54 years who had been diagnosed with primary breast cancer between December 1, 1980 and December 31, 1982 and 485 controls.

Breast cancer risk factors among Hispanic women.

Studies of risk factor differences between racial and ethnic groups within a population may be most valuable in delineating the etiology of breast cancer. Most studies of breast cancer risk factors have been conducted only among white women. We could not find any epidemiologic studies that investigated risk factors for breast cancer occurrence among Hispanic women. The Cancer and Steroid Hormone Study provided the opportunity to investigate risk factors for breast cancer among Hispanic women aged 20 to 54 years in a population-based case-control study of 148 case and 167 control subjects. The final multiple logistic regression analysis indicated that women who had a first-degree relative (mother or sister) with breast cancer were nearly twice as likely to have had breast cancer compared to women with no family history (OR = 1.89; 95% CI 1.10-3.16). Expected patterns of association between breast cancer and number of full-term pregnancies, age at first full-term birth, and benign breast disease, although not statistically significant, were observed. Unexpectedly, the results also suggested a reduced risk of breast cancer among Hispanic women associated with early age at menarche. These factors require further evaluation in larger studies among specific Hispanic subgroups.

Breast cancer risk factors among black women and white women: similarities and differences.

To further explore whether breast cancer risk factors are the same for black women and white women, the authors investigated several biologic, cultural, and social factors in a 1980-1982 case-control study of non-Hispanic black subjects (490 cases, 485 controls) and non-Hispanic white subjects (3,934 cases, 3,901 controls) aged 20-54 years. Logistic regression analyses indicated that blacks and whites shared four risk factors at a comparable magnitude (age at first full-term birth, parity, surgical menopause, and history of benign breast disease). For two observed risk factors, the magnitude (breast feeding) and pattern (family history of breast cancer) of the relation were different in blacks and whites. The relative risks of breast cancer among black women who had first-degree relatives (odds ratio (OR) = 1.61) and second-degree relatives (OR = 1.71) with breast cancer were similar, whereas the relative risk among white women who had first-degree relatives (OR = 2.16) was distinctly larger than for those who had second-degree relatives (OR = 1.44) with breast cancer. The relation of early age at menarche appeared negligible for blacks although significant for whites aged 12 and under (OR = 1.26). The results also indicated that natural menopause, oral contraceptive use, and cigarette smoking may have different, and more complex, relations to breast cancer among blacks and whites.

Survey of graduates of the Epidemic Intelligence Service as an approach to enhancing ethnic diversity among the nation's epidemiologists.

A survey was conducted to improve the recruitment, training, and retention of epidemiologists in the Epidemic Intelligence Service (EIS) Program of the Centers for Disease Control. The authors compared minority graduates of the program and nonminority graduates in several areas: reasons for application, degree of satisfaction, appropriateness of preparation for epidemiologic practice, and current professional activities. A closed-ended questionnaire was mailed to all 87 minority graduates from the program during the period 1970-88, and to 172 randomly selected nonminority graduates. Of 259 graduates surveyed, 234 or 90.3 percent returned the questionnaire--89.6 percent of minority graduates and 90.7 percent of nonminority graduates. Virtually all graduates were satisfied with their EIS experience (95.2 percent), have encouraged others to apply (96.1 percent), and are the most frequent sources of initial contact of prospective officers (38.2 percent). Most EIS graduates (71.2 percent) were still working in epidemiology. Compared with the nonminority graduates, the minority graduates were more likely to be women and to be single. Minority graduates were less likely than non minorities to hold academic appointments (44.2 percent versus 60.0 percent) and less likely to work in academic settings as their primary job (11.5 percent versus 18.7 percent). At the same time, minority graduates were more likely to have learned of the EIS Program from academic advisors (32.1 percent versus 19.4 percent). Graduates express high levels of satisfaction with the EIS Program and continue to practice epidemiology following graduation. Few differences between the minority and nonminority graduates were found. Because fewer minority graduates are in academic settings to serve as mentors or role models, alternative recruitment methods must be developed to sustain a high level of interest among minority groups in the EIS Program.

Ten-year changes in birthweight distributions of black and white infants, South Carolina.

The birthweight distributions of Black and White infants in South Carolina were compared for the paired-year periods 1975-76 and 1985-86. No discernible changes in birthweight distributions between the two time periods were observed especially among Black infants. The distributions among White infants reflected an overall improvement in birthweight most noticeably above 2500g.

Cigarette smoking, herpes simplex virus type 2 infection, and cervical abnormalities.

In a case-control study, we investigated the relation of cigarette smoking and genital herpes virus infection to cervical abnormalities. Although cases and controls differed according to several factors, multiple logistic analyses indicated that age, education, and cigarette smoking were the only independent risk factors for histologically confirmed disease. Relative risk estimates were 1.92 and 3.68 for past and current smokers, respectively. The results indicated that smoking and genital herpes infection did not interact in the risk of cervical abnormality.