Chilean women's preferences regarding mode of delivery: which do they prefer and why?

OBJECTIVE: Caesarean section rates in Chile are reported to be as high as 60% in some populations. The purpose of this study was to determine pregnant Chilean women's preferences towards mode of delivery. DESIGN: Interviewer-administered cross-sectional survey. SETTING: Prenatal clinics in Santiago, Chile. Population Pregnant women in Santiago, Chile. METHODS: Of 180 women completing the questionnaire, 90 were interviewed at a private clinic (caesarean delivery rate 60%) and 90 were interviewed at a public clinic (cesarean delivery rate 22%). Data collected included demographics, preferred mode of delivery, and women's attitudes towards vaginal and caesarean deliveries. MAIN OUTCOME MEASURES: Mode of delivery preferences, perceptions of mode of delivery measured on a 1-7 Likert scale. RESULTS: The majority of women (77.8%) preferred vaginal delivery, 9.4% preferred caesarean section, and 12.8% had no preference. There was no statistical difference in preference between the public clinic (11% preferred caesarean) and the private clinic (8% preferred caesarean, P= 0.74). Overall, women preferring caesarean birth were slightly older than other groups (31.6 years, versus 28.4 years for women who preferred vaginal and 27.3 years for women who had no preference, P= 0.05), but there were otherwise no differences in parity, income, or education. On a scale of 1-7, women preferring caesarean birth rated vaginal birth as more painful, while women preferring vaginal birth rated it as less painful (5.8 versus 3.7, P= 0.003). Whether vaginal or caesarean, each group felt that their preferred mode of delivery was safer for their baby (P < 0.001). CONCLUSIONS: Chilean women do not prefer caesarean section to vaginal delivery, even in a practice setting where caesarean delivery is more prevalent. Thus, women's preferences is unlikely to be the most significant factor driving the high caesarean rates in Chile.

Organizational strategies to tackle health-care disparities in the USA.

US health policy is beginning to address health-care disparities, mainly in terms of racial/ethnic groups and access to care for vulnerable groups. Though not widespread, policies are engaging a wide range of organizations, including federal, state and local government, insurers, providers and philanthropic foundations. It initially seems strange that US health-care organizations (HCOs) are seeking to tackle disparities, as the system itself generates huge disparities. This article reviews the reasons underlying growing interest in disparities in the USA, examines the barriers and opportunities facing such initiatives and considers their likely impact. Demographic changes, efforts to widen access to care and to remedy health-care discrimination are the primary factors in driving these initiatives. HCOs (and others) are faced with implementation barriers including structural impediments of the health-care system, the limited extent to which the issue has permeated within HCOs, and data collection. Opportunities for progress can be garnered from the mounting evidence base, the various programmes being implemented, and emerging links with quality improvement initiatives. The USA is faced with ongoing efforts to keep the issue on the (policy and managerial) agenda, to integrate strategies into organizational systems and processes, and to monitor the effects of such strategies.

The impact of the use of the isolated echogenic intracardiac focus as a screen for Down syndrome in women under the age of 35 years.

OBJECTIVE: The purpose of this study was to determine the public health impact of the routine offering of amniocentesis to women under the age of 35 years who have an isolated fetal echogenic intracardiac focus on second trimester ultrasound scan. STUDY DESIGN: A decision analytic model was designed that compared the accepted standard of second trimester triple marker screen for Down syndrome to a policy in which amniocentesis with an isolated echogenic intracardiac focus on ultrasound in addition to the triple marker screen is offered to all women in the United States who are <35 years of age. A sensitivity of 20%, an echogenic intracardiac focus screen positive rate of 5%, and a risk of Down syndrome of 1:1000 were assumed. A sensitivity analysis was performed that varied the screen positive rate, the sensitivity of echogenic intracardiac focus for Down syndrome, and the prescreen risk for Down syndrome in the population. RESULTS: With the baseline sensitivities, rates, and risks, the use of isolated echogenic intracardiac focus as a screen would result in an additional 118,146 amniocenteses performed annually to diagnose 244 fetuses with Down syndrome. These amniocenteses would result in 582 additional miscarriages. It would be necessary to perform 485 amniocenteses that would result in 2.4 procedure-related losses for each additional Down syndrome fetus that was identified. CONCLUSION: Although the echogenic intracardiac focus appears to be associated with a small increased risk of Down syndrome, its use as a screening tool in low-risk populations would lead to a large number of amniocenteses and miscarriages to identify a small number of Down syndrome fetuses.

Preterm delivery in patients admitted with preterm labor: a prediction study.

OBJECTIVE: To develop a model for prediction of preterm delivery in patients treated with parenteral tocolysis using combinations of maternal demographic and clinical factors. METHODS: We performed a retrospective cohort study using a perinatal database to identify women admitted with preterm labor and treated with parenteral tocolysis from 1980 to 1994. We developed an explanatory model using multiple logistic regression to determine the effect of four variables (prior preterm delivery, substance abuse, maternal complications and third-trimester care) on the likelihood of preterm delivery. For the prediction model, we initially included these four variables and then removed them in a stepwise fashion to determine the combination of the variables that offered the greatest model sensitivity and specificity. RESULTS: A total of 900 women were identified for the study and 247 (27%) had a preterm delivery. In the explanatory model, prior preterm delivery (OR 2.4; 95% CI 1.5-3.6), substance abuse (OR 2.2; 95% CI 1.2-5.1), initiation of care in the third trimester (OR 2.0; 95% CI 1.3-2.8) and medical complications of pregnancy (OR 1.8; 95% CI 1.2-2.6) increased the likelihood of preterm delivery. For the prediction tool, a three-variable model (prior preterm delivery, substance abuse and initiation of care in the third trimester) had high specificity (98%) and modest negative predictive value (73%). CONCLUSIONS: A simple three-variable model can correctly identify 98% of women with preterm labor treated with parenteral tocolysis who will not deliver preterm. Patients with no prior history of preterm delivery, no substance abuse and initiation of prenatal care before the third trimester have a 73% probability of not delivering preterm.

Decision analysis of prenatal testing for chromosomal disorders: what do the preferences of pregnant women tell us?

Current guidelines recommend offering invasive testing for chromosomal disorders only to women who are aged 35 or older, or who are at similarly elevated risk (as determined by maternal serum and/or ultrasonographic screening). We conducted a decision analysis, using preference scores obtained from pregnant women, to determine whether current guidelines maximize the health-related quality of life of these women. If only miscarriage and chromosomal abnormalities are considered, the expected value of testing exceeds that of not testing for women 30 years of age or older. However, if a comprehensive range of relevant testing outcomes is considered, testing offers a higher expected value than not testing, regardless of age. Furthermore, patient preferences for specific testing outcomes play a much more substantial role in determining the course of action with the highest expected value than does the probability of any of the possible testing outcomes. The current age- and risk-based guideline for prenatal diagnosis does not maximize expected value and fails to appropriately consider individual patient preferences. For counseling purposes, how an individual values the presence and timing of fetal chromosomal information should be carefully understood.

Objective and subjective assessments of socioeconomic status and their relationship to self-rated health in an ethnically diverse sample of pregnant women.

A new measure of subjective socioeconomic status (SES) was examined in relation to self-rated physical health in pregnant women. Except among African Americans, subjective SES was significantly related to education, household income, and occupation. Subjective SES was significantly related to self-rated health among all groups. In multiple regression analyses, subjective SES was a significant predictor of self-rated health after the effects of objective indicators were accounted for among White and Chinese American women; among African American women and Latinas, household income was the only significant predictor of self-rated health. After accounting for the effects of subjective SES on health, objective indicators made no additional contribution to explaining health among White and Chinese American women; household income continued to predict health after accounting for subjective SES among Latinas and African American women.

Procedure-related miscarriages and Down syndrome-affected births: implications for prenatal testing based on women's preferences.

OBJECTIVE: To determine how pregnant women of varying ages, races, ethnicities, and socioeconomic backgrounds value procedure-related miscarriage and Down-syndrome-affected birth. METHODS: We studied cross-sectionally 534 sociodemographically diverse pregnant women who sought care at obstetric clinics and practices throughout the San Francisco Bay area. Preferences for procedure-related miscarriage and the birth of an infant affected by Down syndrome were assessed using the time trade-off and standard gamble metrics. Because current guidelines assume that procedure-related miscarriage and Down syndrome-affected birth are valued equally, we calculated the difference in preference scores for those two outcomes. We also collected detailed information on demographics, attitudes, and beliefs. RESULTS: On average, procedure-related miscarriage was preferable to Down syndrome-affected birth, as evidenced by positive differences in preference scores for them (time trade-off difference: mean = 0.09, median = 0.06; standard gamble difference: mean = 0.11, median = 0.02; P <.001 for both, one-sample sign test). There was substantial subject-to-subject variation in preferences that correlated strongly with attitudes about miscarriage, Down syndrome, and diagnostic testing. CONCLUSION: Pregnant women tend to find the prospect of a Down syndrome-affected birth more burdensome than a procedure-related miscarriage, calling into question the equal risk threshold for prenatal diagnosis. Individual preferences for those outcomes varied profoundly. Current guidelines do not appropriately consider individual preferences in lower-risk women, and the process for developing prenatal testing guidelines should be reconsidered to better reflect individual values.

Frequency of cervical smear abnormalities within 3 years of normal cytology.

OBJECTIVE: To compare cervical screening outcomes associated with age and three screening intervals, 1, 2, and 3 years. METHODS: We did a prospective cohort study comprising 128,805 women at community-based clinics throughout the United States who were screened for cervical cancer within 3 years of normal smears through the National Breast and Cervical Cancer Early Detection Program. We determined the incidence of cytologic abnormalities defined as atypical squamous cells of undetermined significance (ASCUS), low-grade squamous intraepithelial lesion (SIL), high-grade SIL, and suggestive of squamous cell cancer. RESULTS: Over the 3 years after normal smear results, the incidence of new smears interpreted as high-grade SIL or suggestive of squamous cell cancer (high-grade SIL or worse) was 66 of 10,000 for women under 30 years old, 22 of 10, 000 for those 30-49 years, 15 of 10,000 for those 50-64 years, and 10 of 10,000 for those over 65 years. Age-adjusted incidence rates of high-grade SIL or worse were similar for women screened at 9-12 months (25 of 10,000), 13-24 months (29 of 10,000), and 25-36 months (33 of 10,000) after normal smears (P =.46). Age-adjusted incidence rates of ASCUS, the most common cytologic abnormality, did not change (P =.36). Incidence of smears interpreted as low-grade SIL increased as time from the normal smear increased (P =.01). CONCLUSIONS: Within 3 years after normal cytology results, cervical smears interpreted as high-grade SIL or worse are uncommon, and the incidence rate is unrelated to the time since last normal smear. Optimal screening strategies for women with recent normal cytology results should be based on comprehensive modeling studies that incorporate the true risks and benefits of repetitive screening.

Ethnic differences in hormone replacement prescribing patterns.

OBJECTIVE: To determine whether prescription patterns of hormone replacement therapy (HRT) differ in African-American, Asian, Latina, Soviet immigrant, and white women. DESIGN: Retrospective review of computerized medical records. SETTING: The general internal medicine, family medicine, and gynecology practices of an academic medical center. PATIENTS: Women aged 50 years or older with at least one outpatient visit from January 1, 1992, to November 30, 1995. MEASUREMENTS AND MAIN RESULTS: Use of HRT was defined as documentation of systemic estrogen use. The main predictor variable was self-identified ethnicity. Age, diagnosis (coronary heart disease, hypertension, diabetes, osteoporosis, or breast cancer), and median income were included in the analysis. Of the 8,968 women (mean age, 65.4 years) included, 50% were white, 20% Asian, 15% African American, 9% Latina, and 6% Soviet immigrants. Whites (33%) were significantly more likely to be prescribed HRT than Asians (21%), African Americans (25%), Latinas (23%), or Soviet immigrants (6.6%), p < 0.01 for each. Multivariate analysis, comparing ethnic groups and controlling for confounding variables, showed that Asians (odds ratio [OR] 0.56; 95% confidence interval [CI] 0.49, 0.64), African Americans (OR 0.70; 95% CI 0.60, 0.81), Latinas (OR 0.70; 95% CI 0.58, 0.84), and Soviet immigrants (OR 0.14; 95% CI 0.10, 0. 20) were each less likely to be prescribed HRT than were white women. Although women with osteoporosis were more likely to receive HRT (OR 2.28; 95% CI 1.71, 2.99), those with coronary heart disease were not (OR 0.88; 95% CI 0.68, 1.09). CONCLUSIONS: Physicians at this medical center were more likely to prescribe HRT for white women and women with osteoporosis. Further study is needed to address whether these differences in HRT prescribing result in different health outcomes.

Preferences of women facing a prenatal diagnostic choice: long-term outcomes matter most.

Women aged 35 or older who wish to undergo prenatal diagnosis for chromosomal disorders are typically offered a choice between chorionic villus sampling or amniocentesis. These two tests are performed at different times and impose differing miscarriage risks. In deciding which test to use, therefore, women need to consider both short-term consequences (e.g. timing of pregnancy loss, should it occur) and long-term consequences (e.g. whether a pregnancy loss is followed by a future birth). We examined how women seeking prenatal diagnostic services value the outcomes of testing. We conducted a cross-sectional study of 72 women seeking genetic counselling at the University of California at San Francisco or Kaiser San Francisco. We measured preferences for outcomes (utilities) of prenatal diagnosis using the standard gamble metric. We also assessed demographics and attitudes via questionnaire. We observed no differences in mean utilities assigned to first- versus second-trimester pregnancy losses with similar long-term sequelae. Utilities for losses followed by future birth, however, were significantly higher than utilities for losses without future birth (range 0.91 to 0.93 versus 0.84 to 0.86, p<0.05 for all comparisons). In addition, we observed substantial variation in utilities across women. Long-term outcomes matter most to these women. In presenting prenatal diagnostic options to their patients, clinicians should include discussion of outcomes such as the likelihood of future birth in the event of a pregnancy loss. Furthermore, the substantial variation in utilities we observed suggests that future prenatal testing policies should account for the preferences of the individual woman.

Hormone replacement therapy for African American women: missed opportunities for effective intervention.

OBJECTIVES: Because of the potential benefits and risks of hormone replacement therapy (HRT), information about the efficacy of HRT in different groups of women is important to patients and providers. The objectives of this study were to review the evidence on the benefits and risks of HRT in African American women and to present a quantitative analysis of the potential reduction in mortality from osteoporotic fractures and coronary heart disease and the potential increase in risk of breast and endometrial cancer. METHODS: A MEDLINE search of English-language observational studies and clinical trials on the effects of HRT on osteoporotic fractures and coronary heart disease (CHD) was conducted for the time period from 1966 to September 1998. Using available CHD mortality data for African American women and white women, potential reductions in mortality with HRT were explored for African American and white women. RESULTS: In the 30 studies on CHD and HRT, African American women were known to comprise only 173 (0.1%) of 148,437 participants. In 11 studies of HRT and osteoporotic fractures, only 128 (0.4%) of 40,299 participants were known to be African American women. An analysis of CHD mortality by decade intervals indicated that African American women, aged 55 to 64, are more likely to die from CHD each year than white women. Despite a lower incidence of breast and endometrial cancer among African American women, the mortality rates of African American women with these cancers is higher compared with white women. CONCLUSIONS: With the higher underlying CHD mortality rate among African American women, HRT is an important potential preventive therapy. The absence of African American women and other non-white women from clinical studies of HRT makes it difficult to fully assess the risks and benefits of HRT in this group of women.

Who should be offered prenatal diagnosis? The 35-year-old question.

Prenatal diagnosis of chromosomal disorders is generally offered to women who will be 35 years or older at the time of delivery or who have been determined via serum screening to be at risk similar to that of a woman older than 35 years. This age threshold was based on 4 major rationales that reflect considerations of resources and effectiveness. In this paper, we explore the current screening recommendations and consider new information that calls the 35-years threshold into question. We conclude that guidelines regarding use of prenatal diagnosis account for the preferences of the individual patient as well as for individual risk.

Anaerobes in pelvic inflammatory disease: implications for the Centers for Disease Control and Prevention's guidelines for treatment of sexually transmitted diseases.

In preparing the 1998 sexually transmitted disease treatment guidelines of the Centers for Disease Control and Prevention, we reviewed evidence regarding the need to eradicate anaerobes when treating pelvic inflammatory disease (PID). Anaerobes are present in the upper genital tract during an episode of acute PID, with the prevalence dependent on the population under study. Vaginal anaerobes can facilitate acquisition of PID and cause tissue damage to the fallopian tube, either directly or indirectly through the host inflammatory response. Use of several broad-spectrum regimens appears to result in excellent clinical cure rates, despite the fact that some combinations fall short of providing comprehensive coverage of anaerobes. There are limited data on the long-term effects of failing to eradicate anaerobes from the upper genital tract. Concern that tissue damage may continue when anaerobes are suboptimally treated has prompted many experts to caution that therapeutic regimens should include comprehensive anaerobic coverage for optimal treatment of women with PID.

Can preference scores for discrete states be used to derive preference scores for an entire path of events? An application to prenatal diagnosis.

The authors conducted a study exploring whether preferences for sequences of events can be approximated by preferences for component discrete states. Visual-analog-scale (VAS) and standard-gamble (SG) scores for a subset of the possible sequences of events (path states) and component temporary and chronic outcomes (discrete states) that can follow prenatal diagnostic decisions were elicited from 121 pregnant women facing a choice between chorionic villus sampling and amniocentesis. For individuals, preference scores for path states could not be predicted easily from discrete-state scores. Mean path-state VAS scores, however, were predicted reasonably accurately by multiple regression models (R2 = 0.85 and 0.82 for two different anchoring schemes), with most measured scores lying within the 95% confidence intervals of the derived scores. It is concluded that, for individual patient decision making, preferences for path states should be elicited. When mean preference values for a population are sought, however, it may be reasonable to derive regression weights from a subset of respondents and then to apply those weights to preferences for discrete states elicited from a larger group.

Concurrent hysterectomy at bilateral salpingo-oophorectomy: benefits, risks, and costs.

OBJECTIVE: To evaluate the medical and economic consequences of concurrent hysterectomy at the time of bilateral salpingo-oophorectomy (BSO) for benign ovarian disease in peri- and postmenopausal women. METHODS: Decision analysis was used to compare the health outcomes and economic costs of performing BSO with concurrent hysterectomy versus BSO alone in theoretic cohorts of 10,000 women undergoing surgery for benign adnexal disease. A model was constructed incorporating probabilities of possible outcomes from the National Hospital Discharge Database, the National Cancer Institute SEER Program, and the literature. Data on associated costs were obtained from the California State Discharge Database, Medicare, and the literature. RESULTS: Performing concurrent hysterectomy in a cohort of 10,000 45-year-old women would prevent approximately 71 future deaths from gynecologic disease at a cost of five immediate deaths from the surgery. However, short-term complications are much more frequent in women undergoing hysterectomy. On average, hysterectomy at age 45 adds approximately 0.071 years of life expectancy; at age 55, it adds 0.026 years. The procedure results in cost savings of approximately $1913 per patient at age 45 and $1112 at age 55. CONCLUSION: Concurrent hysterectomy causes short-term morbidity, but appears to increase average life expectancy slightly among perimenopausal women and is cost-saving. Medical outcomes and economic consequences only marginally favor the procedure. Patient preferences for the potential outcomes should play a key role in determining the appropriateness of its use.

Acyclovir prophylaxis in late pregnancy to prevent neonatal herpes: a cost-effectiveness analysis.

OBJECTIVE: To compare the cost-effectiveness of oral acyclovir prophylaxis in late pregnancy to the current strategy of cesarean delivery for genital herpes lesions in the prevention of neonatal herpes transmission from mothers with recurrent genital infections. METHODS: Decision analysis was used to evaluate the clinical outcomes and direct costs of a prevention program from the health care payer's perspective. Probabilities were obtained from the literature and experts. Cost data were based on hospital costs and a cohort of herpes-infected neonates. RESULTS: Acyclovir prophylaxis during late pregnancy followed by cesarean delivery for genital lesions at delivery in women with recurrent genital herpes requires 1818 women to follow this strategy to prevent one neonatal infection and 7.4 women to take acyclovir to prevent one outbreak of genital herpes at delivery, at a cost (above no intervention) of over $493,000 per neonatal infection prevented, $1.1 million per neonatal death or disability prevented, and $1444 per maternal outbreak prevented. Cesarean delivery for genital herpes lesions requires 386 women with recurrent herpes to undergo cesareans to prevent one neonatal infection, at a cost of more than $1.3 million per neonatal infection prevented and more than $3 million per neonatal death or disability prevented. If acyclovir is given and herpes lesions still occur, the incremental cost of requiring cesarean delivery for these women over vaginal delivery with culture and follow-up of exposed infants is more than $1.4 million per neonatal infection prevented. CONCLUSION: Oral acyclovir prophylaxis in late pregnancy for women with recurrent genital herpes is more cost-effective than the current strategy of cesarean delivery for all women presenting with genital herpes lesions.

Racial-ethnic differences in prenatal diagnostic test use and outcomes: preferences, socioeconomics, or patient knowledge?

OBJECTIVE: To determine whether use of chorionic villus sampling and amniocentesis varies by racial-ethnic group and, if so, whether this variation is reflected in the prevalence of Down syndrome-affected births to women age 35 and older, the ages at which prenatal diagnosis is offered currently. METHODS: Medical charts of 238 women 35 years of age and older presenting for care at the University of California at San Francisco by 20 gestational weeks in 1993 and 1994 were reviewed to assess prenatal diagnostic test use. The prevalence of Down syndrome-affected births in California during 1983-1991 was obtained from the Birth Defects Monitoring Program. RESULTS: Latinas and African-American women were much less likely to undergo prenatal diagnosis than were whites and Asians. Odds ratio (OR) and 95% confidence intervals (CI), with white women serving as the reference group, were as follows: Asians 1.16 (0.57-2.36), Latinas 0.19 (0.08-0.43), and African-Americans 0.19 (0.04-0.49). Trends persisted, at diminished magnitude, after adjustment for socioeconomic characteristics: OR for Asians 1.77 (0.78-3.98) Latinas 0.28 (0.09-0.83) , and African-Americans 0.33 (0.10-1.10). Non-white women age 35 and older were significantly more likely than white women to give birth to a Down syndrome-affected infant: risk ratios for Asians 1.81 (1.61-2.03), Latinas 3.00 (2.74-3.28), and African-Americans 1.86 (1.63-2.11). CONCLUSION: Racial-ethnic differences exist in prenatal diagnostic test use and associated outcomes in women aged 35 and older. Socioeconomic factors are partially responsible; patient education and preferences may play a role.

The cost-effectiveness of prenatal carrier screening for cystic fibrosis.

OBJECTIVE: To evaluate the economic consequences of routinely offering cystic fibrosis-carrier screening to pregnant white women under 35 years of age. METHODS: Decision analysis was used to evaluate the health outcomes and medical costs of a screening program from the health care payer's perspective. Probabilities were taken from the literature; cost data were based on consultations with laboratory and hospital administrators. Sensitivity analysis was performed for key assumptions. RESULTS: If the test acceptance rate were 78% and the screening test identified 85% of carriers, a prenatal cystic fibrosis-carrier screening program would identify slightly more than half of the high-risk pregnancies in the population. For a cohort of one million pregnant women, it would cost $83 million. If the proportion of couples choosing abortion were 30% and the lifetime cost of medical care for cystic fibrosis were $243,650, the program would save $12 million in averted costs of medical care for cystic fibrosis, for a net cost of $71 million. Even after accounting for the savings in averted medical care for cystic fibrosis, the cost per high-risk pregnancy identified would be $82,000; the cost per unwanted cystic fibrosis birth averted would be $1.4 million. Results were sensitive to the cost and sensitivity of the screening test, but relatively insensitive to the test acceptance rate and therapeutic abortion rates between 50-100% among pregnancies identified with cystic fibrosis. CONCLUSION: A prenatal cystic fibrosis-carrier screening program would not save the health care payer money under most assumptions, but may be justified if the benefit of the early information provided to expectant parents is judged worth the cost.