Pregnancy and Parenthood During Medical School.

PURPOSE: The stress of pregnancy and parenthood during the intense educational experience of medical school could increase the risk of student burnout. Because 9.2 percent of U.S. medical students are parents by graduation, it would seem prudent to include this topic in wellness programs and policies. The purpose of this study was to determine the effects of pregnancy and parenthood on medical students. METHOD: This was a cross-sectional, internet survey distributed to all four classes of medical students at the University of South Dakota Sanford School of Medicine during the 2016-2017 academic year. The survey determined self-reported pregnancy and parenthood information, knowledge of a medical school pregnancy policy, and policy recommendations. RESULTS: More than 85 percent of the 194 respondents recommended that the following elements be included in an institutional policy: process for arranging parental leave, how leave time might affect graduation, how missed requirements could be made up, and how to request special accommodation or leave. Twenty-nine of the respondents (15 percent) were parents or currently pregnant. Eight pregnancies during medical school were associated with complications, including three miscarriages. Of the 18 students who reported maternity or paternity leave, 13 (72 percent) and 10 (56 percent) would have extended their leave time if it did not delay graduation or only reduced their number of elective rotations, respectively. No student would choose to extend leave if it would delay graduation. CONCLUSIONS: This survey is the first of its kind investigating pregnancy and parenthood in medical students attending a U.S. medical school. Students want schools to provide clear, well-defined guidelines, scheduling flexibility and administrators who are approachable and understanding of their individual circumstances.

Medicare charge-receipt data: results for South Dakota.

BACKGROUND: The 2013 release of 2011 financial information by the Centers for Medicare and Medicaid Services (CMS) caused concern because some hospitals had charges that appeared to be exorbitantly high compared to reimbursement rates. METHODS: Charges and receipts for South Dakota were compared to national data. The study was restricted to nine discharge codes likely to be seen by an adult hospitalist service. RESULTS: South Dakota hospitals had a lower charge-to-receipt ratio than the national average (p < 0.01). The average ratio in South Dakota was 2.74 compared to 3.75 nationally. South Dakota charged 29 percent less for these discharge codes and received 3 percent lower reimbursement than the national average. CONCLUSIONS: The relatively low charge-to-receipt ratio and low charges in South Dakota are encouraging. Unfortunately, the only South Dakotans likely to be asked to pay full charges are the uninsured, who thus face bills that are much higher than insurance companies pay for the insured population. This leaves uninsured patients and hospitals with trying to negotiate discounts or waivers on an individual basis, which is an inefficient and problematic approach for both parties.

Vaccinating through a lifetime: adult priorities.

Vaccination strategies for adults have recently been updated to include newer vaccine products and to reflect the changing epidemiology of vaccine-preventable diseases in adults. New products include vaccines against shingles and the human papillomavirus, and a combination vaccine which contains an acellular pertussis component (Tdap). In some cases, existing vaccines have been re-formulated to provide alternate routes of delivery, as is the case with the influenza vaccine, or more effective formulations, as is the case with the meningococcal vaccine. Vaccine strategies for adults are designed to respond to existing, emerging, or re-emerging infectious diseases in populations at risk. This includes the resurgence of pertussis and recent evidence showing that diabetics are at increased risk for hepatitis B. Unfortunately, large portions of the adult population do not receive recommended vaccinations. As a result, more adults die from vaccine-preventable diseases than die from motor vehicle accidents. Strategies to improve vaccine coverage include public education campaigns and making some vaccines available in nontraditional settings such as retail stores or workplaces. Within health care settings, successful strategies have included the use of standing orders, automatic reminders for physicians using the electronic health record and recall/reminder letters for patients. Appropriate use of adult vaccines plays a key role in prevention of disease and the provision of high-quality care.

Time from pregnancy recognition to prenatal care and associated newborn outcomes.

OBJECTIVE: To examine the relationship between newborn outcomes and late prenatal care initiation after recognition of pregnancy. DESIGN: Secondary data analysis of the Pregnancy Risk Assessment and Monitoring System (PRAMS) data for the United States. SETTING: Twenty-nine states. PARTICIPANTS: Women of childbearing age (135,623) who resided in 29 states in the PRAMS study who received prenatal care and had live births. METHODS: Population-based survey from 2000 through 2004 that examined four newborn outcomes: prematurity, low birth weight (LBW), admission into Neonatal Intensive Care Unit (NICU), and infant mortality. RESULTS: The average time lag (difference between the time of pregnancy recognition and initiation of prenatal care) for the study was 3.2 weeks (99% CI [3.12, 3.21]). Women who recognized their pregnancies before 6 weeks had a longer lag time (3.5 weeks, 99% CI [3.43, 3.53]) than women who recognized their pregnancies later (2.1 weeks, 99% CI [1.96, 2.15]). After adjusting for confounders including the timing of pregnancy recognition, longer time lag was associated with reduced risks of prematurity (odds ratio [OR]=0.99, 99% Confidence Interval [CI] [0.97, 1.00], p<.01), LBW (OR=0.98, 99% CI [0.97, 0.99], p<.01) and NICU admission (OR=0.99, 99% CI [0.98, 1.00], p<.01) but not with infant mortality (OR=1.00, 99% CI [0.95, 1.05], p>.01). CONCLUSION: Average time lag from pregnancy recognition to prenatal care was not associated with poor newborn outcomes once results were adjusted for time of pregnancy recognition and other confounders.

Scheduling the first prenatal visit: office-based delays.

OBJECTIVE: The purpose of this study was to evaluate the office-based component of delayed entry into prenatal care. STUDY DESIGN: Phone numbers for all obstetrics offices in a single state were obtained from a commercial list. A research assistant who posed as a newly pregnant, fully insured woman asked each clinic when she should come in for her first prenatal visit. RESULTS: Information was provided by 239 of the 279 (86%) offices. The recommended appointment times ranged from immediately (4 weeks of gestation) to 10.6 weeks, which averaged 6.37 weeks. Twenty-five percent of clinics recommended a first appointment at >/=8 weeks. Scheduling calls were not a source of prenatal advice: <5% of clinics asked about smoking, alcohol, or medical condition; 88% of clinics did not mention vitamins. CONCLUSION: Office-based delays in scheduling the first prenatal visit occur in a substantial proportion of clinics, even for fully insured women. There is a need for a standard source of advice in early pregnancy.

Time of pregnancy recognition and prenatal care use: a population-based study in the United States.

BACKGROUND: A woman who does not recognize her pregnancy early may not initiate prenatal care early. This study examined the relationship between the time of pregnancy recognition and the time of initiation of prenatal care, and the number of prenatal visits among women of childbearing age. METHODS: This study analyzed the Pregnancy Risk Assessment and Monitoring System (PRAMS) data for the United States. The analysis sample was representative of resident women of childbearing age in 29 U.S. states who had live births within 2 to 6 months before being contacted. The data were weighed to reflect the complex survey design of the PRAMS, and binary and multinomial logistic regressions were used for the analyses. RESULTS: Most (92.5%) of the 136,373 women in the study had recognized their pregnancy by 12 weeks of gestation, and 80 percent initiated prenatal care within the first trimester. Early pregnancy recognition was associated with significantly increased odds of initiating prenatal care early (OR = 6.05, p < 0.01), after controlling for sociodemographic and prior birth outcome data, and was also associated with lower odds of having fewer than the recommended number of prenatal visits and higher odds of having more than the recommended prenatal visits (OR: <11 visits = 0.71 and >15 visits = 1.17, p < 0.01). CONCLUSIONS: Early pregnancy recognition was associated with improved timing and number of prenatal care visits. Promotion of early pregnancy recognition could be a means of improving birth outcomes by encouraging and empowering women to access prenatal care at a critical point in fetal development.

Late recognition of pregnancy as a predictor of adverse birth outcomes.

OBJECTIVE: We examined the relationship between the time of recognition of pregnancy and birth outcomes, such as premature births, low birthweight (LBW), admission to the neonatal intensive care unit (NICU), and infant mortality. STUDY DESIGN: A secondary analysis was performed using the Pregnancy Risk Assessment and Monitoring System (PRAMS) multistate data from 2000-2004. The sample consisted of 136,373 women who had a live childbirth. Analysis involved multiple logistic regression models, appropriately weighted for point and variance estimation to reflect the complex survey design of the PRAMS using STATA 9.2 (Stata Corp, College Station, TX). RESULTS: Approximately 27.6% recognized their pregnancy late (after 6 weeks of gestation). Late recognition was significantly associated with an increased odds of having premature births (odds ratio [OR], 1.09; 99% confidence interval [CI], 1.01-1.19), LBW (OR, 1.08; 99% CI, 1.01-1.15), and NICU admissions (OR, 1.12; 99% CI, 1.03-1.21). CONCLUSION: These results provide a rationale and an impetus for developing interventions that promote early recognition of pregnancy.

Utilization of home pregnancy testing among women at risk for unintended pregnancy.

PURPOSE: We sought to determine whether a brief intervention increased home pregnancy test utilization among women at risk for unintended pregnancy. METHODS: The intervention included education, consultation with a nurse, and the provision of a free home pregnancy test kit. Participants were 35 women aged 18-39 years from a Medicaid population who were having unprotected intercourse and who were not trying to conceive. The women received education on pregnancy testing and the importance of early recognition of pregnancy. All women received a free home pregnancy test kit. The main outcome measures were pregnancy test use and appropriateness of use. MAIN FINDINGS: During the 3-month follow-up period, 62% of participants used the home pregnancy test kit, which was approximately 3 times higher than the self-reported testing rate before the study (p < .001). The most common reason for use was a late period (median 5 days late when test was done). Women also purchased additional kits to confirm the initial test result (median 2 kits per episode of use). CONCLUSION: The intervention increased utilization of home pregnancy test kits among women at risk of unintended pregnancy. All study participants used the test appropriately. These results can serve as a framework for interventions to improve early pregnancy recognition.

Why women risk unintended pregnancy.

BACKGROUND: To reduce unintended pregnancy, it is necessary to understand why women have unprotected intercourse when they do not desire pregnancy. METHODS: We devised a survey of 42 potential reasons why women have unprotected intercourse based on the responses of a focus group we had previously convened. We administered the survey to women between the ages of 18 and 39 years who were visiting primary care clinics and were not trying to get pregnant. RESULTS: Of the 151 respondents, 84 (56%) were having unprotected intercourse. Women gave an average of 9 reasons for having unprotected intercourse. The most common reasons fell into 3 categories: lack of thought/preparation (87% of respondents), being in a long-term or strong relationship (70%), and concerns about side effects of contraception (80%). Eighty-three of the 84 women (99%) chose at least 1 of these categories. CONCLUSION: Basing survey questions on focus group responses provided important insights into the reasons women risk unintended pregnancy. A deeper understanding of this issue is critical to reducing unintended pregnancy.

Self-testing for pregnancy among women at risk: a randomized controlled trial.

BACKGROUND: The timing of pregnancy recognition affects early pregnancy and the timing of prenatal care. Little research has been done on how to make women at risk more alert to the possibility of pregnancy. DESIGN: The study was an RCT performed and analyzed between 2006 and 2007. SETTING/PARTICIPANTS: Participants were low-income, adult women who were having unprotected intercourse and were not actively trying to conceive. INTERVENTION: Women in the intervention group received a free home-pregnancy test kit and were able to order more kits as needed. Six-month follow-up information was obtained. MAIN OUTCOME MEASURES: The main outcome measures were suspicion and testing for pregnancy. RESULTS: Ninety-one percent of the 198 participants completed the study. Women in the intervention group suspected pregnancy 2.3 times during the 6-month period compared to 1.2 times for women in the control group (p<0.0001). Women in the intervention group tested for pregnancy 93% of the time when they suspected pregnancy. Women in the control group tested for pregnancy only 64% of the time when they suspected pregnancy (p<0.0001). CONCLUSIONS: Women who were having unprotected intercourse were more likely to suspect and test for pregnancy if they were supplied with a free home-pregnancy test kit.

Risk drinking and contraception effectiveness among college women.

Risk drinking, especially binge drinking, and unprotected sex may co-occur in college women and increase the risks of STI exposure and pregnancy, but the relationships among these behaviors are incompletely understood. A survey was administered to 2012 women of ages 18-24 enrolled in a public urban university. One-quarter of the college women (23%) drank eight or more drinks per week on average, and 63% binged in the past 90 days, with 64% meeting criteria for risk drinking. Nearly all sexually active women used some form of contraception (94%), but 18% used their method ineffectively and were potentially at risk for pregnancy. Forty-four percent were potentially at risk for STIs due to ineffective or absent condom usage. Ineffective contraception odds were increased by the use of barrier methods of contraception, reliance on a partner's decision to use contraception, and risk drinking, but were decreased by the use of barrier with hormonal contraception, being White, and later age to initiate contraception. In contrast, ineffective condom use was increased by reliance on a partner's decision to use condoms, the use of condoms for STI prevention only, and by risk drinking. Thirteen percent of university women were risk drinkers and using ineffective contraception, and 31% were risk drinkers and failing to use condoms consistently. Risk drinking is related to ineffective contraception and condom use. Colleges should promote effective contraception and condom use for STI prevention and consider coordinating their programs to reduce drinking with programs for reproductive health. Emphasizing the use of condoms for both pregnancy prevention and STI prevention may maximize women's interest in using them.

Reasons for unprotected intercourse: analysis of the PRAMS survey.

OBJECTIVES: This study was conducted to identify reasons why women had unprotected intercourse that led to an unintended pregnancy. METHODS: As part of the Pregnancy Risk Assessment Monitoring System (PRAMS) survey, women with a recent unintended viable pregnancy were asked after the birth why they had not used birth control. RESULTS: Of 7856 respondents, 33% felt they could not get pregnant at the time of conception, 30% did not really mind if they got pregnant, 22% stated their partner did not want to use contraception, 16% cited side effects, 10% felt they or their partner were sterile, 10% cited access problems and 18% selected "other." Latent class analysis showed seven patterns of response, each identifying strongly with a single reason. CONCLUSIONS: Almost half of women with viable unintended pregnancies ending in a birth felt they could not/would not get pregnant at the time of conception. Most women identified with a single reason for having unprotected intercourse.

Global warming and infectious disease.

Global warming has serious implications for all aspects of human life, including infectious diseases. The effect of global warming depends on the complex interaction between the human host population and the causative infectious agent. From the human standpoint, changes in the environment may trigger human migration, causing disease patterns to shift. Crop failures and famine may reduce host resistance to infections. Disease transmission may be enhanced through the scarcity and contamination of potable water sources. Importantly, significant economic and political stresses may damage the existing public health infrastructure, leaving mankind poorly prepared for unexpected epidemics. Global warming will certainly affect the abundance and distribution of disease vectors. Altitudes that are currently too cool to sustain vectors will become more conducive to them. Some vector populations may expand into new geographic areas, whereas others may disappear. Malaria, dengue, plague, and viruses causing encephalitic syndromes are among the many vector-borne diseases likely to be affected. Some models suggest that vector-borne diseases will become more common as the earth warms, although caution is needed in interpreting these predictions. Clearly, global warming will cause changes in the epidemiology of infectious diseases. The ability of mankind to react or adapt is dependent upon the magnitude and speed of the change. The outcome will also depend on our ability to recognize epidemics early, to contain them effectively, to provide appropriate treatment, and to commit resources to prevention and research.

Reducing alcohol-exposed pregnancy risk in college women: initial outcomes of a clinical trial of a motivational intervention.

A significant number of college women are at risk for alcohol-exposed pregnancy (AEP) owing to binge drinking paired with using contraception ineffectively. This article describes a randomized controlled trial of a one-session motivational interviewing-based intervention to reduce AEP risk among college women and presents 1-month outcomes demonstrating the early impact of this intervention. There were 228 female students from a mid-Atlantic urban university enrolled in the trial. Eligibility criteria were being in the age range of 18-24 years and being at risk for AEP. Risk for AEP was defined as having sexual intercourse with a man in the past 90 days while using contraception ineffectively (no use, incorrect use of an effective method, or use of an ineffective method only); drinking at risky levels was defined as engaging in at least one binge in the past 90 days or consuming an average of eight standard drinks per week. One-month outcome data were available for 212 of the 228 enrolled women (a follow-up rate of 93%), with complete data available for 105 women assigned to the control condition and 94 assigned to the intervention condition. At 1-month follow-up, 15% of the control subjects and 25% of the intervention women reported no risk drinking, a significant difference favoring the intervention group. Significantly fewer control subjects (48%) used effective contraception at 1-month follow-up as compared with intervention women (64%), chi(2)(1) = 5.1, p < .03. Significantly more intervention women (74%) were no longer at risk for AEP at 1 month as compared with control subjects (54%), chi(2)(1) = 8.15, p < .005. Factors that were associated with continued AEP risk at 1-month follow-up were a higher number of standard drinks per day consumed in the month prior to baseline (odds ratio, 1.1) and assignment to the control condition (odds ratio, 2.9). The risks of unintended pregnancy and AEP among drinking women in college merit greater prevention efforts. The results of this study show the promise of one preventive intervention that warrants additional study.