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

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

Occupational health characteristics of women on dairy farms in Pennsylvania.

Women play a significant role in Pennsylvania production agriculture, thereby exposing themselves to occupational health risks. The goal of this cross-sectional study was to assess the incidence of health conditions with a possible zoonotic origin in this underserved population. A written survey was sent to a stratified, random sample of dairy farms in Pennsylvania (n = 3709) using a modified version of the Dillman method. In addition to demographic data, the survey was used to collect information on the occurrence of zoonotic diseases, gastrointestinal illnesses, respiratory problems, dermatoses, and women's reproductive health issues. Of the 624 respondents, 10.4% (n = 65) reported that they had contracted a disease from an animal. Interestingly, only 9 respondents indicated that they had suffered from foodborne illnesses in the past year including salmonellosis (n = 1), campylobacteriosis (n = 1), and gastroenteritis due to Escherichia coli (n = 1). A risk factor associated with difficulty breathing was the lack of use of a breathing mask, whereas ventilation in the free stall area appeared to offer a protective effect. Difficulty breathing was reported by 9.8% (n = 61) of the respondents. Risk factors associated with skin disorders included raising fruits and/or vegetables, raising swine, and not wearing gloves when milking. The findings of the study suggest that many of the illnesses and conditions could have been acquired by working with dairy animals and their environment. Based on the findings of this study, additional investigations on the causes and prevention of these illnesses are warranted.

Occupational health behaviors and habits of women on dairy farms in Pennsylvania.

The goal of this study was to determine what tasks women perform, behaviors that could result in exposure to zoonotic disease, and preventative measures practiced by women on dairy farms. A written survey was sent to a stratified, random sample of dairy farms in Pennsylvania (n = 3709) using a modified version of the Dillman method. The tasks most commonly performed by the respondents (n = 624) included milking (70.8%), feeding (60.6%), and cleaning stalls (42.6%). The use of personal protective equipment was infrequent. Gloves were always worn when milking by 32.7%. More respondents, 96.5%, changed their clothes at least sometimes before working in the barn as compared to when leaving the barn. Handwashing was always performed by 86.7% after assisting with delivering calves, whereas 71.1% always washed their hands after milking. Eating and drinking in the barn were practiced by 45.0% and 72.0%, respectively. Veterinary obstetric drugs were administered by 28.2% of the respondents. Most of the respondents, 89.7%, indicated that they felt they had minimal to no risk of contracting a disease from the animals with which they worked.

Reason for visit: is migrant health care that different?

PURPOSE: The purpose of this pilot study was to determine the reasons for which migrant agricultural workers in Pennsylvania seek health care. METHODS: Participants were individuals 14 years of age and over, actively involved in agricultural labor and presenting for medical care at 6 migrant health care centers. Bilingual health care providers randomly selected and interviewed the participants. FINDINGS: The most commonly reported reason for visiting the health care provider was for physical examination. The most frequent acute problems were related to the musculoskeletal and integumentary systems. Frequently cited problems in the medical history were hypertension, musculoskeletal/back pain, and gastrointestinal conditions. Most medications being taken were for cardiovascular or pain-related problems. CONCLUSIONS: These results suggest that migrant workers present with medical problems that are similar to those of the general primary care population. Many problems were recurrent and represented common chronic medical conditions.

Survey of health needs and concerns of rural Pennsylvanians.

INTRODUCTION: This survey was undertaken to determine the most important health and safety needs of farmers and rural citizens of Pennsylvania. METHODS: In June of 2004, a one-page questionnaire was distributed by mail to 32,700 members of the Pennsylvania Farm Bureau as an attachment to their monthly newsletter. RESULTS: The lack of affordable health care insurance was overwhelmingly cited as the most important unmet health care need (73%). No other issue was chosen by more than 10 percent of respondents. This lack of affordable health insurance was also cited as the most important health or safety problem to be addressed in the respondent's communities (71%). When asked the most important health or safety problem affecting them as individuals or their community, the respondents chose "no major problem or need" as the most frequent response (46%). The issue of affordable health insurance was not an option for this question. The predominant concern regarding the lack of affordable health insurance was consistent across all regions of the Commonwealth and for farmers as well as residents of all community sizes sampled. DISCUSSION: This study would indicate that the lack of affordable health insurance is the preeminent health and safety issue for many Pennsylvania farmers and rural citizens.

Policy and organizational issues in agromedicine: a survey of 2001 NAAC meeting attendees.

The field of agromedicine faces numerous policy and organizational development challenges as it enters the 21st Century. To gauge these, the authors surveyed attendees of the 14th Annual Meeting of the North American Agromedicine Consortium (NAAC) in Charleston, South Carolina, in November 2001. Survey questions dealt with agromedicine policy issues, organizational/programmatic issues, the agromedicine core areas, the usefulness of state reports at the meeting, and important policy, organizational and programmatic issues that were missing from, or insufficiently covered at the meeting. While respondents clearly saw serious obstacles facing agromedicine as it continues to develop, they also felt that the NAAC and the profession served important roles in furthering education, research and client service.