Onset and persistence of postpartum depression in an inner-city maternal health clinic system.

OBJECTIVE: Postpartum depressive disorders lead to maternal disability and disturbed mother-infant relationships, but information regarding the rates of major depressive disorder in minority women is noticeably lacking. The goal of this study was to determine whether the risk factors for and rate of postpartum major depressive disorder in a predominantly African American and Hispanic clinic population would be similar to those reported for Caucasian women. METHOD: Investigators systematically screened all women scheduled for their first postpartum visit on selected days at four publicly funded inner-city community maternal health clinics in Dallas County (N=802). A multistage screening process included the Edinburgh Postnatal Depression Scale, the Inventory of Depressive Symptomatology, and the Structured Clinical Interview for DSM-IV for a maximum of three assessments during the initial 3-5-week postpartum period. RESULTS: The estimated rate of major depressive disorder during the postpartum period among women in this setting was between 6.5% and 8.5%. Only 50% of the depressed women reported onset following birth. Bottle-feeding and not living with one's spouse or significant other were associated with depression at the first evaluation; persistent depressive symptoms were linked with the presence of other young children at home. Greater severity of depressive symptoms at first contact predicted major depressive disorder several weeks later. CONCLUSIONS: Rates of postpartum depression among Latina and African American postpartum women are similar to epidemiologic rates for Caucasian postpartum and nonpostpartum women. As previously shown for Caucasian women, major depressive disorder in many Latina and African American postpartum women begins before delivery, revealing the need to screen pregnant women for depression.

Medical assessment and legal outcome in child sexual abuse.

OBJECTIVE: To examine the relationship of behavioral symptoms, interview disclosures, and physical examination findings with changing legal outcomes in child sexual abuse. DESIGN: Retrospective case series. SETTING: Hospital- and community-based multidisciplinary child abuse evaluation teams in the same county in 2 periods. PATIENTS: Children ages 0 to 17 years referred for evaluation of sexual abuse. MAIN OUTCOME MEASURES: Substantiation by child protective services, issuance of a warrant by law enforcement authorities, and criminal penalties were compared with reported changes in behavior, disclosure by the child, and physical evidence on examination. RESULTS: Among 497 children evaluated in 1991-1992 and 1995-1996, those with a positive examination finding were 2.5 times more likely to result in a criminal prosecution with a finding of perpetrator guilt (P<.001). Similar rates of disclosure, positive examination findings, child protective services substantiation, and warrant issuance were noted in the 2 periods. Decreasing rates of guilt determination and increasing criminal penalties were identified in 1995-1996 (P<.002). Disclosure of child sexual abuse during medical assessment was significantly associated with a positive physical examination finding, child protective services substantiation, and issuance of a warrant, but not a finding of guilt or criminal penalty. CONCLUSIONS: Medical assessment plays an important role in the overall community response to child sexual abuse. While behavioral symptoms and disclosure are important in medical treatment and child protective services investigation, positive physical findings are associated with a finding of guilt. There is a trend toward less finding of guilt and more years of criminal penalty that is not explained by case characteristics.

Potential barriers to the removal of Norplant among family planning clinic patients.

OBJECTIVES: This study examined the prevalence and effects of potential barriers to removal of levonorgestrel implants (Norplant) among low-income women. METHODS: A sample of 687 women who received Norplant at hospital-based family planning clinics were interviewed before Norplant insertion and 6 months after Norplant insertion (or at Norplant removal if removal occurred earlier). Those who continued to use Norplant were reinterviewed at 2 years or at removal. RESULTS: In a multivariate analysis, only 1 of the 4 potential barriers--cost--significantly impeded Norplant discontinuation. CONCLUSIONS: Family planning clinics need to make clear that they follow a policy of Norplant removal on demand, regardless of the patient's ability to pay.

Condom use among women choosing long-term hormonal contraception.

CONTEXT: Women who rely on long-term hormonal contraception may neglect to use condoms, and thus increase their risk of contracting sexually transmitted diseases, including AIDS. METHODS: Data from a prospective, multisite study were collected to examine the probability of condom use among 1,073 new users of either the contraceptive implant or injectable; users were interviewed when they accepted their method and again six months to one year later. Multivariate logistic regression analyses identified factors that significantly predicted the likelihood of dual method use. RESULTS: Condom use dropped markedly among women who adopted long-term hormonal contraception. The proportion who always used condoms in the previous three months fell from 21% at the time of adoption to 11% at follow-up. Among women with one sexual partner, this decrease was from 20% to 10%; however, among those with more than one partner, use increased from 25% to 31%. The factors significantly predicting dual method use included previous condom use (odds ratio of 2.5), receipt of AIDS-specific counseling (odds ratio of 1.6), the perception of being at some risk of AIDS at baseline (odds ratio of 1.4) and having had more than one sexual partner over the study period (odds ratio of 5.4). In addition, injectable users, teenagers and black women were more likely than other women to use condoms with their hormonal method. CONCLUSIONS: Although condom use among all women declined markedly once they initiated long-term hormonal contraception, frequency of condom use varied by subgroup and was associated with several factors. Most importantly, women with more than one sexual partner and those who received a message during counseling on the need to continue using condoms were more likely than others to use condoms in conjunction with the implant or injectable.

PIP: Concerns have been raised that women who use long-term hormonal contraceptive methods to prevent pregnancy will fail to protect themselves from sexually transmitted diseases (STDs), including AIDS, through concomitant condom use. This possibility was investigated in a prospective (1993-94), multi-site US (Pittsburgh, Pennsylvania; Dallas, Texas; and New York, New York) study of 1073 new users of either contraceptive implants or Depo-Provera. The mean age of study participants was 23 years; 63% were Hispanic, 24% Black, and 13% White. Overall, the proportion of women who always used condoms in the previous 3 months dropped from 21% at the time of method initiation to 11% at follow-up 6-12 months after enrollment. However, use increased from 25% to 31% among women with more than 1 sexual partner. Significant predictors of dual method use included previous condom use (odds ratio (OR), 2.5); receipt of AIDS-specific counseling (OR, 1.6); the perception, at baseline, of being at some risk of AIDS (OR, 1.4); and more than 1 sexual partner during the study period (OR, 5.4). In addition, injectable users, teenagers, and Black women were more likely than other women to use condoms with their hormonal method. These findings have important implications for family planning programs, especially the need for counseling on the continued importance of condom use for STD prevention when pregnancy is prevented by non-barrier methods.

Depressive symptoms and Depo-Provera.

Women enrolled in a multicenter prospective study were evaluated to identify any possible relationship between depressive symptoms and the use of contraceptives. Women choosing Depo-Provera (n = 495) were evaluated before starting these contraceptives and were reinterviewed 1 year later. Women who continued the method had lower depressive symptom scores at baseline than did the women who discontinued the method or who were lost to follow-up. Among the continuing Depo-Provera users, the depressive symptom scores improved slightly at 1 year (7.4 vs 6.7). Those subjects with the highest (i.e., worst) scores at enrollment demonstrated improved scores at follow-up.

PIP: The product labeling for Depo-Provera cites depression as an infrequent side effect. Previous research on this topic has documented self-reported depression or mood changes in 1-5% of Depo-Provera users. These studies were limited, however, by a lack of measurement of baseline depression. In the present study, 495 new acceptors of Depo-Provera enrolled in a broader prospective cohort study conducted at three US hospitals (Texas, Pennsylvania, New York) were interviewed at enrollment and again after 12 months of use. Included in both the initial and follow-up questionnaires were six questions on depressive symptoms in the past month taken from the Mental Health Inventory. At 12 months, 172 women were still using Depo-Provera, 221 had discontinued the method, and 102 were lost to follow-up. Women who were still using Depo-Provera at 12 months had lower depressive symptom scores at baseline than women who discontinued use or were lost to follow-up. Between baseline and the 12-month follow-up, the mean depression score dropped from 7.4 to 6.7 among continuing users and remained steady at 8.0 among discontinuers. The mean depression score in the quintile of women with the highest depression scores at baseline also decreased after 12 months of use, from 15.4 to 9.5. These results suggest that Depo-Provera use is not likely to exacerbate symptoms in women with pre-existing depression.

Depressive symptoms and Norplant contraceptive implants.

Women enrolled in a multicenter prospective study were evaluated to identify any possible relationship between depressive symptoms and the use of contraceptive implants. Women choosing Norplant implants (n = 910) were evaluated before starting this contraceptive and were reinterviewed at 6 months and 2 years. Women who continued the method had lower depressive symptom scores before initiating Norplant implants than did the women who discontinued the method or who were lost to follow up. Among the continuing Norplant implant users, the mean scores were similar before starting Norplant and at 6 months (7.9 vs 7.7). The strongest overall predictor of the depressive symptom score was relationship satisfaction. At 24 months, the subgroup of continuing users with decreased relationship satisfaction had an increase in depressive symptom score, but those with stable or improved relationships had stable depressive symptom scores. The subjects with the highest (i.e., worst) scores at enrollment demonstrated improved scores during follow-up. These results are reassuring for women who are concerned that Norplant use may adversely affect their mood.

PIP: Although depression is cited in the Norplant contraceptive implant product labeling as a rare side effect, previous evaluations of this association have not included baseline measurement of mood. To assess this association more systematically, the present study followed a cohort of 910 new Norplant acceptors recruited from three urban hospitals in the US (Texas, Pennsylvania, New York) for 24 months. Included in both the initial and follow-up questionnaires were six questions drawn from the Mental Health Inventory on depressive symptoms in the past month. At the end of the study period, 293 women were still using Norplant, 295 had discontinued use, and 138 were lost to follow-up. Women who continued with Norplant for 2 years had significantly lower depression scores at baseline than women who discontinued use or were lost to follow-up. Among continuing Norplant users, mean depressive symptom scores were similar before starting Norplant and after 6 months of use (7.9 and 7.7, respectively). The strongest overall predictor of the depression score was relationship satisfaction. At 24 months, the subgroup of continuing users with decreased relationship satisfaction had an increase in depression score, while those with no change or improved relationships had stable scores. The mean depression score of the quintile of women most depressed at enrollment improved during the study period from 15.4 to 11.0, dispelling concerns that Norplant exacerbates pre-existing depression. Only 4.4% of discontinuers cited mood changes as a reason for terminating Norplant use and there were no cases of psychiatric hospitalization. These findings suggest that concern about possible mood changes is not a reason to withhold Norplant.

Injectable contraceptive discontinuation and subsequent unintended pregnancy among low-income women.

OBJECTIVES: This study investigated rates of discontinuation of the recently introduced injectable contraceptive depot medroxyprogesterone acetate (DMPA) and postdiscontinuation rates of unprotected intercourse and unintended pregnancy. METHODS: A sample of 402 low-income, urban, minority women were interviewed when they initiated DMPA use and 12 months later. RESULTS: The 12-month life-table discontinuation rate was 58%, with half of the discontinuers stopping after only one injection. Menstrual changes and other side effects were the most frequently cited reasons for discontinuation. Approximately half of the discontinuers at risk for unintended pregnancy either did not make the transition to another contraceptive or used contraception only sporadically. The cumulative unintended pregnancy rate by 9 months postdiscontinuation was 20%. CONCLUSIONS: DMPA initiators were at substantial risk for unintended pregnancy because most quickly discontinued use and did not make the transition to consistent use of another contraceptive.

Determinants of early implant discontinuation among low-income women.

The determinants of contraceptive implant discontinuation within six months of insertion were examined among 786 low-income women attending family planning clinics in three U.S. cities. The six-month cumulative life-table discontinuation rate was 7.6%. Menstrual side effects were the most common reasons given for early implant removal, although women who discontinued use were no more likely than those who continued with the method to report menstrual irregularities. Women who opted for early removal were more likely than those who continued with the method to experience headaches, hair loss, weight gain and arm infection. Logistic regression analysis indicates that dissatisfaction with prior contraceptive methods, a partner who wants a child within the next two years, perceived pressure from health care providers to choose the implant, exposure to negative media coverage and the number of implant side effects significantly predict early implant discontinuation. Women's social and demographic characteristics, Medicaid status and motivation to avoid an unplanned pregnancy were not significantly related to early removal.

PIP: This study examines early contraceptive implant discontinuation among low-income clinic patients in Dallas, New York, and Pittsburgh and the impact of negative media coverage of Norplant in the press. Interviews were conducted among 786 women during 1993-94 at baseline, prior to insertion, and 6 months later. The explanatory logistic model included sociodemographic characteristics of users, motivation to avoid unintended pregnancy, satisfaction with previous contraceptive methods, and negative media coverage of a method of birth control. The sample population included only 55% who had completed high school, 22% who were currently employed, and 94% with at least one prior pregnancy. 70% had had at least one unintended pregnancy. 29% had experienced two or more unintended pregnancies. 8% had had no live births. 60% of the women were adolescents at the time of their first birth. The cumulative life table 6-month discontinuation rate was 7.6% (58 women out of 786). The removal rate was 1.02 during month 2, 1.55 during month 3, and almost 1.50 during months 4-6. 28% had the implant removed due to menstrual side effects, 19% complained of headaches, and 10% had some arm discomfort. 9% experienced weight changes and early removal. 7% discontinued use due to mood changes, and 5% stated hair loss, chest pains, or negative media reports as the reasons. About 75% of discontinuers and continuers reported side effects due to less regular menstrual periods. Discontinuers were more likely than continuers to report headaches, hair loss, weight gain, and the perception of long-term health problems. Discontinuers were more likely to report arm infection. Among the 33% exposed to intense negative media coverage, only 15% discontinued use. Findings suggest that counselors should explore the fertility desires of a woman and her spouse and refrain from promoting a specific method.

Beliefs about Norplant implants among low income urban women.

This study documents the counseling experiences and beliefs about Norplant implants that are held by an ethnically diverse sample of low income clinic patients in the United States. Virtually all implant acceptors, but only about half of those choosing other contraceptives, receive information about the Norplant system during clinic-based counseling. Exposure to group counseling and to a film regarding Norplant implants are associated with high levels of knowledge among acceptors. Several important patterns emerge in comparing the beliefs of patients choosing the Norplant system with those of patients choosing other methods of birth control. Substantial proportions of the latter group adhere to several inaccurate beliefs about the method, associating its use with: long-term health problems, problems for future babies, future fertility problems, infection, and high cost. These outcomes in particular, as well as several others described, should be systematically addressed and reviewed in contraceptive counseling.

Beliefs about Depo-Provera among three groups of contraceptors.

This article examines the beliefs about Depo-Provera held by three groups of contraceptors utilizing urban family planning clinics in the United States (n = 836). Patients choosing Depo-Provera, oral contraceptives, and Norplant were asked about their beliefs regarding Depo-Provera in the following four domains: effectiveness in preventing pregnancy, convenience, side-effects, and risk to health; and also for their perceptions regarding the physical discomfort and cost associated with the method. Findings reveal that patients choosing the pill and Norplant give Depo-Provera significantly lower ratings for both convenience and effectiveness than do Depo-Provera acceptors. Given the documented effectiveness of Depo-Provera, this is a potential cause for concern. Moreover, Norplant and pill choosers are most likely to hold inaccurate beliefs regarding both the cost of Depo-Provera, and certain side-effects associated with its use. Although more than half of all patients believe the Depo-Provera would cause menstrual changes and weight gain, it is noteworthy that the proportions are not higher, given their known association with the method. Knowledge about the likelihood of these side-effects is essential, particularly for those choosing Depo-Provera. Implications for physicians, counselors, and other family planning professionals are discussed.

A preliminary report of Norplant implant insertions in a large urban family planning program.

During the 21-month period between August 1, 1991, and April 30, 1993, 2,358 women received Norplant system insertions in either Parkland Memorial Hospital or the Dallas Maternal Health and Family Planning clinics. Forty-three percent of these women were teenagers with 14% 16 years of age or less. Overall, 431 patients received Norplant implants insertions postpartum prior to discharge from the hospital. To date, 138 Norplant systems have been removed, with the proportion of contraceptive implant removals among teenagers being essentially the same as that in more mature women. Of the reasons given by women discontinuing the Norplant system, an unanticipated high incidence of pain in the arm containing the implants, hair loss, and mood changes were noted. We have found the Norplant system to be a highly effective and highly acceptable contraceptive method for a large number of indigent women.

PIP: Between August 1991 and April 1993, in Texas, family planning specialists analyzed prospective data on 2358 women who underwent Norplant system insertions at either the Division of Maternal Health and Family Planning clinics of the University of Texas Southwestern Medical Center or at Parkland Memorial Hospital. The household income of about 90% of the women was at or below the poverty level. Health workers counseled each woman expressing interest in Norplant individually so the women understood the risks, benefits, and side effects. The women had access to health workers via telephone, clinic appointment, or clinic walk-in visits when they had questions and concerns. At the time of insertion, 43% of the women were no older than 19 years of age. 14% were 16-years-old or younger. 63% of the 431 women who received Norplant immediately after delivery were no more than 19-years-old. 74% of all the women had at least one concern about Norplant. The leading concern was pain at the time of insertion (32.1%) followed by weight changes (14.8%), and menstrual changes (12.2%). As of August 1993, only 138 (5.85%) of the women requested removal (adolescents = 40%). The reasons for removal included irregular bleeding (41.3%), headache (22.5%), pain in the arm with Norplant (18.1%), weight gain (14.5%), hair loss (10.1%), mood changes (8%), and desire for pregnancy (8%). The researchers had not anticipated the high incidence rates of arm pain, hair loss, and mood changes. These findings suggested that Norplant is an acceptable longterm contraceptive method. Other studies showed that it is also very effective.

Prenatal care evaluation and cohort analyses.

The value of prenatal care has been obscured by multiple factors, including the limitations of birth certificate data, large socioeconomic disparities between women who seek prenatal care and those who do not, and the "preterm delivery bias", ie, the reduced pregnancy duration and opportunity for prenatal care among women who give birth prematurely. Perinatal mortality and morbidity (neonatal intensive care unit admission; ventilator therapy) were carefully assessed in an indigent population (28,838 deliveries at Parkland Memorial Hospital). To avoid the preterm delivery bias, a cohort of all women whose pregnancy reached a specific week of gestation was identified and their prenatal care status (zero vs one or more visits) by that week was related to pregnancy outcome. Separate cohorts were defined at 26, 30, 34, 38, and 42 weeks. Prenatal care was associated with improved pregnancy outcomes in only the 34-, 38-, and 42-week cohorts (P less than .01). Findings suggest substantial benefit from prenatal care after 30 weeks' gestation but not from early prenatal care. Unfortunately, it may not be possible to assess prenatal care accurately in observational studies even if cohort analyses are used. Clinical trials are needed to assess the effects of strategies for increasing or improving prenatal care, especially in early pregnancy.

Physician extender services in family planning agencies: issues in Medicaid reimbursement.

PIP: The US Social Security Amendments of 1972 mandated the inclusion of family planning services in state Medicaid plans, authorized 90% of reimbursements for family planning care, and imposed financial penalties for failure to provide these services to Medicaid-eligible clients. On the other hand, many states have retrictive policies regarding Medicaid reimbursements to family planning agencies for services provided by physician extenders (e.g.s nurse practitioners and physician assistants). There is concern that such restrictions greatly reduce accessibility to family planning services. Reasons that hae been suggested as causes of such restrictive policies include physician concern over loss of income, the uncertain status of physician extenders in some states, a fear that this step will lead to a demand for reiimbursement for the services of other allied health care providers such as social workers, and concern that care for the indigent will lead to an expensive increase in state reimbursement for family planning services. However, a review of relevant federal law and regulations indicates that Medicaid reimbursement for services provided to eligible patients by physician extenders has never been prohibited or discouraged. Physician supervision is required in reimbursement cases, but this does not mean that a physician must be on the premises while services are delivered. The Medicaid program actually allows significant latitude in establishing administrative policies and procedures. Rather, problems faced by family planning agencies in receiving Medicaid reimbursements for physician extenders' services are due to restrictions in state laws and staff misinterpretations of policy. Research has demonstrated that physcian extenders can contribute significantly to cost effectiveness, while providing types of care in localities such as rural areas that physicians tend to avoid. Given the importance of family planning services to Medicaid-eligible clients, unwarranted policy restrictions contrary to congressional intent should be eliminated.^ieng

Differences on Bayley's infant behavior record for a sample of high-risk infants and their controls.

3 groups of high-risk newborns and their controls were assessed at 92 weeks post-conceptional age using Bayley's Infant Behavioral Record (IBR). The 3 groups of high-risk infants were those who weighed 1,500 grams or less at birth and required no ventilator therapy, those weighing 1,500 grams or less at birth who required ventilator therapy, and newborns weighing more than 1,500 grams at birth who required ventilator therapy. Controls were healthy term infants matched for 7 socioeconomic and demographic variables. The first principal component of the IBR ratings for the 3 groups of high-risk infants and the controls were similar. All 3 groups of high-risk infants received less desirable IBR ratings on most items than their controls. In addition, there were some differences among high-risk groups; ventilated infants regardless of birth weight received the lowest ratings reflecting overall performance on the IBR, very low birthweight, ventilated newborns were more likely to receive ratings characterizing an overly active infant with a short attention span, and very low birth-weight, never-ventilated infants were most likely to be rated as happy but passive and delayed. The differences between the high-risk infants and controls in large part resulted from infants who were also delayed in terms of their mental and motor development.

Risk of uterine perforation among users of intrauterine devices.

Since 1965 there has been a substantial increase in the number of women in the United States who use the intrauterine contraceptive device (IUD). A collaborative multicenter case--control study was conducted to examine uterine perforation and uterine incarceration as well as several other suspected complications related to use of an IUD. To determine which attributes of the IUD and which user characteristics contribute to the risk of uterine perforation and incarceration, the authors analyzed 32 women with uterine perforation requiring transperitoneal removal, 106 women with uterine incarceration of an IUD which was removed transcervically, and 497 controls. Most important, women who were lactating at the time of IUD insertion were 10 times as likely to have had a uterine perforation as women with at least 1 live birth but who were not lactating at the time of insertion. An incarcerated IUD resulting in a difficult removal was 2.3 times as likely among women lactating at the time of insertion compared to women not lactating at the time of insertion. The likelihood of both uterine perforation and uterine incarceration were unchanged regardless of the type of IUD used.

Impact of government regulations on two management and clinical information systems in a medical school environment.

Administrative and legal requirements and, in particular, federal and state government health care assistance and social services program regulations all combine to add complexity to the management and operation of ambulatory and inpatient health programs. This paper describes how constantly changing government regulations and differences in interpretations and definitiions have been expensive, time-consuming and sometimes detrimental to health care delivery for two large management and clinical computer-based information systems.

An automated clinic management system for a family planning network.

The medical information, financial, and logistic aspects of a comprehensive computer-based Appointment, Registration, Information System, and Evaluation (ARISE) are analyzed for the management of a family planning program serving 30,000 patients annually. An overview of the existing computer system network is presented with descriptions of the interactive master patient index, the batch appointment process, the management statistics package, and Department of Health, Education, and Welfare (HEW) reporting. Emphasis is placed on the financial management control system which includes 1) procedures for third-party submission of claims for payment, in particular Titles IVA, XX, and XIX (Social Security Act), together with discussion of related administrative requirements; 2) technics of auditing data integrity including systematic sampling of collected data; and 3) the process of billing and receipts collection. Methodology and implementation aspects of ARISE may have wide applicability to other family planning and similarly structured clinical programs.