First birth Caesarean section and subsequent fertility: a population-based study in the USA, 2000-2008.

STUDY QUESTION: Is first birth Caesarean delivery associated with a lower likelihood of subsequent childbearing when compared with first birth vaginal delivery? SUMMARY ANSWER: In this study of US women whose first delivery was in 2000, those who had a Caesarean delivery were less likely to have a subsequent live birth than those who delivered vaginally. WHAT IS ALREADY KNOWN: Some studies have reported lower birth rates subsequent to Caesarean delivery in comparison with vaginal delivery, while other studies have reported no difference. STUDY DESIGN, SIZE, DURATION: We conducted a retrospective cohort study of 52 498 women who had a first singleton live birth in the State of Pennsylvania, USA in 2000 and were followed to the end of 2008 via Pennsylvania birth certificate records to identify subsequent live births during the 8- to 9-year follow-up period. PARTICIPANTS/MATERIALS, SETTING, METHODS: Birth certificate records of first singleton births were linked to the hospital discharge data for each mother and newborn, and linked to all birth certificate records for each mother's subsequent deliveries which occurred in 2000 to the end of 2008. Poisson regression models were used to evaluate the association between first birth factors and whether or not there was a subsequent live birth during the follow-up period. MAIN RESULTS AND THE ROLE OF CHANCE: Over an average of 8.5 years of follow-up, 40.2% of women with a Caesarean first birth did not have a subsequent live birth, compared with 33.1% of women with a vaginal first birth (risk ratio (RR): 1.21, 95% confidence interval (CI): 1.18-1.25). Adjustment for the demographic confounders of maternal age, race, education, marital status and health insurance coverage attenuated the RR to 1.16 (95% CI: 1.13-1.19). Specific pregnancy and childbirth-related complications associated with not having a subsequent live birth included diabetes-related disorders, abnormalities of organs and soft tissues of the pelvis, fetal abnormalities, premature or prolonged rupture of membranes, hypertensive disorders, amnionitis, fetal distress and other maternal health problems. However, adjustment for the pregnancy and childbirth complications had little effect on the RR of not having a subsequent live birth (RR = 1.15, 95% CI: 1.11-1.19). LIMITATIONS, REASONS FOR CAUTION: We were unable to distinguish between women who did not have a subsequent live birth and those who moved out of the state, which may have introduced a selection bias if those who had Caesarean births were more likely to emigrate than those who delivered vaginally. In addition we were unable to measure pre-pregnancy body mass index, weight gain during pregnancy and prior infertility, which would have been helpful in our efforts to reduce selection bias. WIDER IMPLICATIONS OF THE FINDINGS: The results of this study provide further corroboration of previous studies that have reported reduced fertility subsequent to Caesarean section in comparison with vaginal delivery. STUDY FUNDING/POTENTIAL COMPETING INTERESTS: This study was funded by the US National Institute of Child Health and Human Development (NICHD, R01-HD052990). No competing interests are declared.

Quality management in public and community health: examples from women's health.

Quality assessment and improvement activities are as relevant to the public health sector and community-based health care organizations as they are to the rest of the health care industry. This article provides a framework for the types of quality assessment and improvement approaches available to public health and community-based health care organizations and provides two examples drawn from the field of women's health. The first focuses on a population-based assessment of the performance of the health care system using indicators for the nation as a whole and for the states specifically in a women's health report card. The second focuses on measuring quality of care provided to clients of one type of safety-net organization, Title X family planning clinics. Either type of approach can serve as the basis for developing strategies for improving the performance of health care organizations.

Physician gender effects on preventive screening and counseling: an analysis of male and female patients' health care experiences.

BACKGROUND: Studies have documented that patients of female physicians receive higher levels of preventive services. However, most studies include patients of only one gender, examine mainly gender-specific screening services, and do not examine patient education and counseling. OBJECTIVES: This study tests both physician- and patient-gender effects on screening and counseling services received in the past year and considers effects of gender-matched patient-physician pairs. RESEARCH DESIGN: Multivariate analyses are conducted to assess direct and interactive (physician x patient) gender effects and to control for important covariates. SUBJECTS: Data are from the 1998 Commonwealth Fund Survey of Women's Health, a nationally representative sample of U.S. adults. The analytic sample includes 1,661 men and 1,288 women ages 18 and over. MEASURES: Dependent variables are measures of patient-reported screening and counseling services received, including gender-specific and gender-nonspecific services and counseling on general health habits and sensitive topics. RESULTS: Female physician gender is associated with a greater likelihood of receiving preventive counseling for both male and female patients. For female patients, there is an increased likelihood of receiving more gender-specific screening (OR = 1.36, P <0.05) and counseling (OR = 1.40, P <0.05). These analyses provide no evidence that gender-matched physician-patient pairs provide an additional preventive care benefit beyond the main effect of female physician gender. CONCLUSIONS: Female physician gender influences the provision of both screening and counseling services. These influences may reflect physicians' practice and communication styles as well as patients' preferences and expectations.

Gender and patient satisfaction in managed care plans: analysis of the 1999 HEDIS/CAHPS 2.0H Adult Survey.

This paper investigates gender differences in satisfaction, and in the variables associated with satisfaction, using the Consumer Assessment of Health Plans Study (CAHPS) adult questionnaire administered by the National Committee for Quality Assurance (NCQA) as part of HEDIS 1999. Data represent 97,873 men and women enrolled in 206 commercial managed care plans nationwide. Mean plan-level gender differences in satisfaction measures are small, with no consistent pattern of one gender being more satisfied than the other. Controlling for health plan, member, utilization, and selected HEDIS performance indicators, health plan characteristics account for the largest proportion of variance explained in satisfaction. Not-for-profit status and lower turnover of primary care providers are stronger determinants of women's than men's satisfaction. We conclude that it can be useful to analyze CAHPS scores by gender to identify areas for quality improvement in women's health care.

Managed care and women's health: access, preventive services, and satisfaction.

This paper examines insured women's access to health care, receipt of preventive services, and satisfaction with care by the types of health plans in which they are enrolled. Three types of plans are compared: managed care (HMOs and PPOs), fee-for-service with utilization controls, and traditional fee-for-service. For women who have been enrolled in their plans for at least one year, we find the same or better access to care in managed care plans as compared with other plans; receipt of more gender-specific clinical preventive services in managed care plans, but no differences among types of plans for non-gender-specific preventive services or counseling services; and lower satisfaction with care in managed care plans. The implications for practice and policy are discussed.

Ownership type and community benefits of women's health centers.

An important aspect of the changing health care system is the growth of women's health centers--organizations that design and deliver services to women. This growth has generated interest in the behavior of centers, especially because of increasing awareness of women's health issues. Using data from the 1994 National Survey of Women's Health Centers, the authors examined the association between ownership of centers and 12 measures of community benefits, and 296 nonprofit and 108 for-profit centers were compared. Overall, the nonprofits performed better than the for-profits in terms of serving underserved women, delivering comprehensive primary care services, providing training for health professionals and education services for clients and the community, and involving the community in center governance. Among women's health centers, the results show that ownership matters, and indicate the importance of supporting providers who serve the underserved and developing a standard of community benefits.

Improving cervical cancer screening in hospital settings.

BACKGROUND: Identifying opportunities to offer cervical cancer screening to underscreened women is important for increasing early detection. Maryland law mandates offering Pap tests during hospital admissions. We examined organizational and physician attitudes and practices regarding inpatient screening, to identify mechanisms for increasing the law's effectiveness. METHODS: We analyzed state admission data, a hospital administrators telephone survey, and a mailed survey of Maryland primary and specialty care physicians, to identify overall patterns and subgroup differences regarding screening. RESULTS: Overall, we found significant concern regarding cancer, and evidence of policies and procedures for screening. However, most hospitals and providers offered screening without assessing clinical need or including persuasive recommendations. Providers with significantly less engagement in preventive assessment and screening included medical and surgical subspecialists and non-primary care providers. Providers to African-American and Medical Assistance women were also less likely to have knowledge, attitudes, and practices conducive to inpatient screening. CONCLUSIONS: Adequate support and infrastructure for preventive screening exist within hospitals. Adding clinical assessment and persuasive education could in crease the impact of these mechanisms, and improve prevention among underscreened inpatient populations.

Delivery of primary care services among family planning centers: a response to managed care?

Previous case studies indicate that some family planning centers are transforming themselves into providers of primary care services, in part as a strategy to attract managed care contracts. Data for 98 family planning centers from the 1994 National Survey of Women's Health Centers and supplementary sources are used to explore the factors associated with managed care contracting. Although some organizational-level factors are predictive, no cross-sectional association was found between providing primary care and managed care contracting, which suggests family planning centers are not using primary care as a major contracting strategy.

The trends in health care delivery for women: challenges for medical education.

The author discusses four key trends in the U.S. health care delivery system that affect how women's health care is delivered: the restructuring of primary care, particularly in the context of managed care organizations; initiatives in quality assessment; changes in patterns of health insurance coverage; and threats to the health care safety net. She concludes that medical educators need to link training to these changes in the health care delivery system to prepare physicians to work effectively for women's health in the changing system and to help bring about appropriate, needed transformations of the institutions in which women's health care is provided. Specific recommendations for medical educators are given after the discussion of each trend.

Women's health centers: are the National Centers of Excellence in Women's Health a new model?

This paper describes the characteristics of the clinical centers of the first 12 National Centers of Excellence (CoE) in Women's Health, designated by the U.S. Department of Health and Human Services Office on Women's Health between 1996 and 1997. These centers are compared with 56 hospital-sponsored primary care women's health centers identified in the 1994 National Survey of Women's Health Centers, the only source of nationally representative data on primary care women's health centers. While analysis demonstrates that some organizational and clinical attributes of primary care women's health centers were in evidence before the CoE program was initiated, the CoE centers demonstrate further integration of clinical services with research and medical training in women's health, and the delivery of services to a more diverse population of women.

Gender and patient satisfaction with primary care: tuning in to women in quality measurement.

This study analyzes the relationship between patient gender and satisfaction with primary care visits, using 1999 survey data on 1691 women and 760 men making primary care visits at multiple sites affiliated with a large academic health system designated as a National Center of Excellence in Women's Health (COE). The main findings are that in multivariate analyses controlling for patient and visit characteristics, different aspects of the content of primary care visits are important to women and men. Women's overall satisfaction with visits is more dependent than men's on informational content, continuity of care, and multidisciplinarity. Men's overall satisfaction is more dependent on the personal interest shown in them by providers. No differences in satisfaction are found between those seen in sites affiliated with the COE and other primary care sites within the health system that are not core sites of the COE. We conclude that quality improvement and research in women's primary care could benefit from gender analysis of patient satisfaction data and from more gender-sensitive patient satisfaction measures.

Women's satisfaction with primary care: a new measurement effort from the PHS National Centers of Excellence in Women's Health.

This paper describes efforts by the National Centers of Excellence in Women's Health to develop a woman-specific primary care satisfaction instrument suitable for quality improvement and research.

Measuring quality in women's health care: issues and recent developments.

This article provides a discussion of some key quality issues in women's health care and of some recent developments in quality measurement in women's health. The work of the Women's Health Measurement Advisory Panel of the National Committee for Quality Assurance is described to illustrate some challenges and avenues for development of quality measures that address key health concerns of women and reflect their perspectives. The development of quality measures in women's health is essential for quality reporting that is meaningful for women, for quality improvement efforts within health care organizations, and for research to identify the conditions that optimize quality in women's health care.

The implications of affiliations between Catholic and non-Catholic health care organizations for availability of reproductive health services.

Four case studies of successfully negotiated affiliations between Catholic and non-Catholic organizations reveal the strategies employed to address a range of reproductive health services.

PIP: This article summarizes multiple case studies on decision-making with regard to reproductive health services in affiliations between Catholic and non-Catholic organizations. A database on the number and types of affiliations was compiled during 1990-1996 to provide a national profile of such organizations. Findings of case studies revealed that affiliations between Catholic and non-Catholic health care organizations are diverse in structure, motivated by market and financial issues, and display diverse strategies with regards to reproductive health services. In addition, strategies for providing more comprehensive women's health care were evident in 3 of the 4 case studies. Availability of contraceptive services, female and male sterilization, and infertility services generally was unchanged as a result of affiliations. This shows that affiliations themselves did not significantly affect policies or practices with regards to their provision. Successful negotiations between Catholic and non-Catholic partners involve explicit strategies concerning reproductive health services, some of which curtail specific services and some of which enhance services. Finally, policy-makers have an important role in ensuring that communities receive full disclosure of the nature of affiliations and their possible impact on availability of services.

The accuracy of substituted judgments in patients with terminal diagnoses.

BACKGROUND: Patients' loved ones often make end-of-life treatment decisions, but the accuracy of their substituted judgments and the factors associated with accuracy are poorly understood. OBJECTIVE: To assess the accuracy of judgments made by surrogate decision makers; ascertain the beliefs, practices, and clinical and sociodemographic factors associated with accuracy of surrogates' decisions; assess the preferences of patients for life-sustaining treatments; and compare differences in accuracy across diagnoses. DESIGN: Cross-sectional paired interviews. SETTING: Outpatient practices of three university hospitals. PATIENTS: 250 patients with terminal diagnoses of congestive heart failure, AIDS, amyotrophic lateral sclerosis, lung cancer, and chronic obstructive pulmonary disease (50 patient-surrogate pairs in each group) and 50 general medical patients and their surrogates. MEASUREMENTS: The accuracy of surrogate predictions was measured by using scales based on 10 potential treatments in each of three hypothetical clinical scenarios. RESULTS: Preferences varied according to mode of treatment and scenario. On average, surrogates made correct predictions in 66% of instances. Accuracy was better for the permanent coma scenario than for the scenarios of severe dementia or coma with a small chance of recovery (P < 0.001). In a binary logit model, the accuracy of substituted judgments was positively associated with the patient having spoken with the surrogate about end-of-life issues (odds ratio [OR], 1.9 [95% CI, 1.6 to 2.3]), the patient having private insurance (OR, 1.4 [CI, 1.1 to 1.7]), the surrogate's level of education (OR, 1.5 [CI, 1.2 to 1.9]), and the patient's level of education (OR, 1.7 [CI, 1.4 to 2.2]). Accuracy was negatively associated with the patient's belief that he or she would live longer than 10 years (OR, 0.6 [CI, 0.5 to 0.7]), surrogate experience with life-sustaining treatment (OR, 0.4 [CI, 0.3 to 0.5]), surrogate participation in religious services (OR, 0.67 [CI, 0.50 to 0.91]), and a diagnosis of heart failure (OR, 0.6 [CI, 0.5 to 0.8]). Age, ethnicity, marital status, religion, and advance directives were not associated with accuracy. CONCLUSIONS: The accuracy of substituted judgments is associated with multiple clinically apparent patient and surrogate factors. This information can help clinicians identify conditions under which substituted judgments are likely to be accurate or inaccurate and can help target populations for education designed to improve the accuracy of surrogate decision making.

Provision of mental health services in women's health centers.

Women's health centers are often associated with a comprehensive model of health care that treats the "whole woman." Using data from a nationwide study of 467 women's health centers, we explored how the ideal of comprehensive care was implemented with respect to mental health services. Specifically, we examined the rates of screening and treatment for a subset of mental health and behavioral and social problems in women's health centers and the structural, staffing, philosophical, and patient factors associated with the provision of services. Across 12 services, the overall rates of provision ranged from 7.7% for screening for dementing disorders to 27.6% for smoking cessation counseling and treatment. In a series of logistic regressions, center type (primary care) and having a mental health staff person were consistently associated with service provision; other important variables were having a high percentage of women using the center as their usual source of care and having a belief in women-centered care. Findings indicate that the majority of women using women's health centers do not receive services in a comprehensive care environment that includes key mental health services.

Characteristics of current hospital-sponsored and nonhospital birth centers.

OBJECTIVES: (1) To describe contemporary birth centers in terms of the population served, organizational and financial characteristics, services provided, mission and philosophy, and planning and marketing techniques. (2) To compare hospital-sponsored and nonhospital models with regard to the above characteristics. METHOD: Data from the National Survey of Women's Health Centers conducted in 1994 are analyzed using t-tests and chi-square tests. RESULTS: Contemporary birth centers serve a diverse population of women and provide a range of clinical and nonclinical services. Birth centers are both hospital-sponsored and nonhospital, with the former growing at a faster rate. Compared to hospital-sponsored centers, nonhospital centers serve a larger proportion of uninsured women, provide a broader range of clinical services, and are more committed to women-centered care. Centers utilize different marketing methods and are involved in a number of organizational changes to better position themselves in the changing health care environment. CONCLUSIONS: Birth centers offer an attractive option to consumers and are a viable model for delivering women-centered care. Given that all "birth center" facilities do not share the same philosophy and service mix, women need to have some assurance of what a "birth center" will, and will not, provide.