Tubal sterilization in the United States, 1994-1996.

CONTEXT: Although the number and rate of tubal sterilizations, the settings in which they are performed and the characteristics of women obtaining sterilization procedures provide important information on contraceptive practice and trends in the United States, such data have not been collected and tabulated for manyyears. METHODS: Information on tubal sterilizations from the National Hospital Discharge Survey and the National Survey of Ambulatory Surgery was analyzed to estimate the number and characteristics of women having a tubal sterilization procedure in the United States during the period 1994-1996 and the resulting rates of tubal sterilization. These results were compared with those of previous studies to examine trends in clinical setting, in the timing of the procedure and in patient characteristics. RESULTS: In 1994-1996, more than two million tubal sterilizations were performed, for an average annual rate of 1 1.5 per 1,000 women; half were performed postpartum and half were interval procedures (i. e., were unrelated by timing to a pregnancy). All postpartum procedures were performed during inpatient hospital stays, while 96% of interval procedures were outpatient procedures. Postpartum sterilization rates were higher than interval sterilization rates among women 20-29 years of age; interval sterilization procedures were more common than postpartum procedures at ages 35-49. Sterilization rates were highest in the South. For postpartum procedures, private insurance was the expectedprimary source of payment for 48% and Medicaid was expected to pay for 41 %; for interval sterilization procedures, private insurance was the expected primary source of payment for 68% and Medicaid for 24%. CONCLUSIONS: Outpatient tubal sterilizations andprocedures using laparoscopy have increased substantially since the last comprehensive analysis of tubal sterilization in 1987, an indication of the effect of technical advances on the provision of this service. Continued surveillance of both inpatient and outpatient procedures is necessary to monitor the role of tubal sterilization in contraceptive practice.

Pregnancy-related mortality from preeclampsia and eclampsia.

OBJECTIVE: To examine the role of preeclampsia and eclampsia in pregnancy-related mortality. METHODS: We used data from the Centers for Disease Control and Prevention's Pregnancy Mortality Surveillance System to examine pregnancy-related deaths from preeclampsia and eclampsia from 1979 to 1992. The pregnancy-related mortality ratio for preeclampsia-eclampsia was defined as the number of deaths from preeclampsia and eclampsia per 100,000 live births. Case-fatality rates for 1988-1992 were calculated for preeclampsia and eclampsia deaths per 10,000 cases during the delivery hospitalization, using the National Hospital Discharge Survey. RESULTS: Of 4024 pregnancy-related deaths at 20 weeks' or more gestation in 1979-1992, 790 were due to preeclampsia or eclampsia (1.5 deaths/100,000 live births). Mortality from preeclampsia and eclampsia increased with increasing maternal age. The highest risk of death was at gestational age 20-28 weeks and after the first live birth. Black women were 3.1 times more likely to die from preeclampsia or eclampsia as white women. Women who had received no prenatal care had a higher risk of death from preeclampsia or eclampsia than women who had received any level of prenatal care. The overall preeclampsia-eclampsia case-fatality rate was 6.4 per 10,000 cases at delivery, and was twice as high for black women as for white women. CONCLUSION: The continuing racial disparity in mortality from preeclampsia and eclampsia emphasizes the need to identify those differences that contribute to excess mortality among black women, and to develop specific interventions to reduce mortality from preeclampsia and eclampsia among all women.

The check box: determining pregnancy status to improve maternal mortality surveillance.

OBJECTIVE: More than half of pregnancy-related deaths are not identified through routine surveillance methods. The purpose of this study was to evaluate the effectiveness of the pregnancy check box on death certificates in ascertaining pregnancy-related deaths. METHODS: Data derived from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System were used to identify states that included a check box on the death certificate in 1991 and 1992. Death certificates from those states were evaluated to determine the number and proportion of pregnancy-related deaths identified by a marked check box. Characteristics of death were also examined. RESULTS: Sixteen states and New York City included a check box or question specifically asking about pregnancy of the decedent. Of the 425 pregnancy-related deaths identified in the 17 reporting areas, 124 (29%) were determined to be pregnancy-related deaths only because of the pregnancy status information provided in the check box. The proportion of deaths identified only by a marked check box ranged from less than 5% for four states to 40% or more for seven states. CONCLUSIONS: The availability of pregnancy status information on death certificates is a simple and effective aid in ascertaining a pregnancy-related death, when no other indicators of pregnancy appear on the death certificate. Routine use of the pregnancy check box for all states would lead to substantially increased classification of maternal deaths and more accurate classification of the causes of and risk factors for maternal deaths.

Pregnancy-related mortality in the United States due to hemorrhage: 1979-1992.

OBJECTIVE: To study trends and examine risk factors for pregnancy-related mortality due to hemorrhage. METHODS: We analyzed pregnancy-related deaths from 1979-1992 from the National Pregnancy Mortality Surveillance System of the Centers for Disease Control and Prevention. Live-birth data used to calculate mortality ratios were obtained from published vital statistics. Deaths due to ectopic pregnancies were excluded. RESULTS: There were 763 pregnancy-related deaths from hemorrhage associated with intrauterine pregnancies, a ratio of 1.4 deaths per 100,000 live births. The pregnancy-related mortality ratio was higher for black women and those of other races than white women. The risk of pregnancy-related mortality increased with age. Abruptio placentae was the overall leading cause of pregnancy-related death due to hemorrhage. Leading causes of death differed by race, age group, and pregnancy outcome. CONCLUSION: Hemorrhage is the leading cause of pregnancy-related death in the United States. Black women have three times the risk of death of white women. In-depth investigations are needed to ascertain the risk factors associated with those deaths.

Pregnancy-related mortality in Hispanic women in the United States.

OBJECTIVE: To examine pregnancy-related mortality among Hispanic women in the United States. METHODS: We used data from the Centers for Disease Control and Prevention's ongoing Pregnancy Mortality Surveillance System to examine all reported pregnancy-related deaths (deaths during or within 1 year of pregnancy that were caused by pregnancy, its complications, or treatment) in states that reported Hispanic origin for 1979-1992. The pregnancy-related mortality ratio was defined as the number of pregnancy-related deaths per 100,000 live births. RESULTS: For the 14-year period, the overall pregnancy-related mortality ratio was 10.3 deaths per 100,000 live births for Hispanic women, 6.0 for non-Hispanic white women, and 25.1 for black women. In Hispanic subgroups, the pregnancy-related mortality ratio was 9.7 for Mexican women and ranged from 7.8 for Cuban women to 13.4 for Puerto Rican women. Pregnancy-induced hypertension was the leading cause of pregnancy-related death for Hispanic women overall. CONCLUSION: Pregnancy-related mortality ratios for Hispanic women were higher than those for non-Hispanic white women, but markedly lower than those for black women. The similarity in socioeconomic status between Hispanic and black women was not an indicator of similar health outcomes. Prevention of pregnancy-related deaths in Hispanic women should include investigation of medical and nonmedical factors and consider the heterogeneity of the Hispanic population.

Pregnancy-related mortality surveillance--United States, 1987-1990.

PROBLEM/CONDITION: The Healthy People 2000: National Health Promotion and Disease Prevention Objectives specifies goals of no more than 3.3 maternal deaths per 100,000 live births overall and no more than 5.0 maternal deaths per 100,000 live births among black women; as of 1990, these goals had not been met. In addition, race-specific differences between black women and white women persist in the risk for pregnancy-related death. REPORTING PERIOD COVERED: This report summarizes surveillance data for pregnancy-related deaths in the United States for 1987-1990. DESCRIPTION OF SYSTEM: The National Pregnancy Mortality Surveillance System was initiated in 1988 by CDC in collaboration with the CDC/American College of Obstetricians and Gynecologists Maternal Mortality Study Group. Health departments in the 50 states, the District of Columbia, and New York City provided CDC with copies of death certificates and available linked outcome records (i.e., birth certificates or fetal death records) of all identified pregnancy-related deaths. RESULTS: During 1987-1990, 1,459 deaths were determined to be pregnancy-related. The overall pregnancy-related mortality ratio was 9.2 deaths per 100,000 live births. The pregnancy-related mortality ratio for black women was consistently higher than for white women for every risk factor examined by race. The disparity between pregnancy-related mortality ratios for black women and white women increased from 3.4 times greater in 1987 to 4.1 times greater in 1990. Older women, particularly women aged > or =35 years, were at increased risk for pregnancy-related death. The gestational age-adjusted risk for pregnancy-related death was 7.7 times higher for women who received no prenatal care than for women who received "adequate" prenatal care. The distribution of the causes of death differed depending on the pregnancy outcome; for women who died following a live birth (i.e., 55% of the deaths), the leading causes of death were pregnancy-induced hypertension complications, pulmonary embolism, and hemorrhage. INTERPRETATION: Pregnancy-related mortality ratios for black women continued, as noted in previously published surveillance reports, to be three to four times higher than those for white women. The risk factors evaluated in this analysis confirmed the disparity in pregnancy-related mortality between white women and black women, but the reason(s) for this difference could not be determined from the available information. ACTIONS TAKEN: Continued surveillance and additional studies should be conducted to assess the magnitude of pregnancy-related mortality, to identify those differences that contribute to the continuing race-specific disparity in pregnancy-related mortality, and to provide information that policy makers can use to develop effective strategies to prevent pregnancy-related mortality for all women.

Abortion training in obstetrics and gynecology residency programs in the United States, 1991-1992.

According to a 1991-1992 survey of program directors of obstetrics and gynecology residency programs in the United States, the overall percentage of programs providing any training in first-trimester (70%) or second-trimester abortion (66%) has changed very little since 1985. However, the proportion of programs providing routine training in first-trimester abortion decreased from 23% in 1985 to 12% in 1991-1992, and the proportion providing routine training in second-trimester abortion declined from 21% to 7%. The majority of the programs that dropped routine abortion training continued to offer optional training, but residents in programs with optional training were less likely to receive training. More than 80% of programs in private, non-Catholic hospitals and public hospitals provided some form of abortion training in 1991-1992, but only 6% of programs in Catholic hospitals and no military programs did so. In 45% of programs offering abortion training, residents performed one or fewer abortions per week.