Breast cancer among young U.S. women in relation to oral contraceptive use.

BACKGROUND: While most studies have found no association between oral contraceptive use and breast cancer, several studies of younger women have reported an association with long-term oral contraceptive use. PURPOSE. We studied the relationship of patterns of oral contraceptive use to breast cancer risk among younger women. These women have had oral contraceptives available their entire reproductive lives and are now entering the breast cancer-prone years. METHODS: A population-based, case-control study of breast cancer was conducted in three counties in western Washington State among women born in 1945 or later, ages 21-45. Case patients were 747 women with breast cancer diagnosed in 1983-1990 and identified through the Seattle-Puget Sound Surveillance, Epidemiology, and End Results cancer registry. Control subjects were 961 women identified by random-digit telephone dialing. Subjects were interviewed in person, using pictures of brands of oral contraceptives and calendars of life events as recall aids. RESULTS: There was no increased incidence of breast cancer associated with ever having used oral contraceptives. Because only 8% of this cohort had never used oral contraceptives, short-term users (< 1 year) were combined with never users as the reference group for further analyses. A small increased risk of breast cancer was associated with long duration of oral contraceptive use (odds ratio for > or = 10 years = 1.3; 95% confidence interval [CI] = 0.9-1.9; P for trend = .03), particularly among women aged 35 years or younger (odds ratio for > or = 10 years = 1.7; 95% CI = 0.9-3.1). Breast cancer was also modestly related to oral contraceptive use early in reproductive life (odds ratio for use within 5 years of menarche = 1.3; 95% CI = 1.0-1.8; P for trend = .04) and to use of high-progestin-potency oral contraceptives for at least 1 year (odds ratio = 1.5; 95% CI = 1.1-2.1). These associations were adjusted for age, age at menarche, term pregnancy, induced abortion, and family history of breast cancer. The associations were not further confounded by case-control differences in education, religion, breast feeding of offspring, or infertility; in oral contraceptive contraindications, indications, or complications; or in measures of breast cancer detection such as mammography or breast biopsy. CONCLUSIONS: Long-term oral contraceptive use among young women or use beginning near menarche may be associated with a small excess breast cancer risk, possibly due to susceptibility to genetic damage in breast epithelial cells at ages of high breast cell proliferative activity. IMPLICATIONS: Future studies should investigate whether the patterns of risk we reported are present as this cohort ages.

PIP: A case control study was conducted in Washington among 21-45 year old white women from King, Pierce, and Snohomish counties (i.e., Seattle metropolitan area) to examine the relationship between oral contraceptive (OC) use and breast cancer. The 747 cases were diagnosed with invasive breast cancer between January 1983 and April 1990. The researchers combined short term OC users with never users since just 8% of all subjects had never used OCs. They controlled for age, age at menarche, term pregnancy, induced abortion, and family history of breast cancer. Longterm use (i.e., =or 10 years) of OCs was associated with a small increased risk of breast cancer (odds ratio [OR] = 1.3; p for trend = 0.03), especially among women not older than 35 years (OR = 1.7). This finding was consistent with results of other studies. OC use early in reproductive life (i.e., within 5 years of menarche) was also associated with a moderate increase in breast cancer (OR = 1.3; p for trend = 0.04). Breast cancer risk was also elevated among women who used high progestin potency OCs (as defined by the Dickey method for classifying OC potency) for at least 1 year (OR = 1.5). Case control differences in education, religion, breast feeding of children, or infertility; in OC contraindications, indications, complications; or in measures of breast cancer detection (e.g., mammography or breast biopsy) did not confound the associations. An association between breast cancer and long term OC use among young women and OC use beginning close to menarche suggest that puberty, a time when breast epithelial cells are undergoing considerable proliferative activity, are susceptible to genetic damage. Further research is needed to determine whether the aforementioned patterns of breast cancer risk continues as the cohort becomes older.

Contraceptive and reproductive risks for cervical dysplasia in southwestern Hispanic and non-Hispanic white women.

BACKGROUND: Various contraceptive practices and reproductive factors have been associated with cervical neoplasia in case-control studies worldwide. METHODS: To investigate contraceptive and reproductive risk factors associated with high-grade cervical dysplasia in southwestern Hispanic and non-Hispanic white women, we carried out a clinic-based case-control study among university-affiliated clinic attendees. RESULTS: Oral contraceptive use ever (odds ratio [OR] = 0.4, 95% confidence interval [CI]: 0.2-0.9) and past diaphragm use (OR = 0.3, 95% CI: 0.1-0.8) were protective for dysplasia in analyses adjusted for age, ethnicity, sexual behaviour, and for cervical papillomavirus (HPV) infection. After further adjustment for Pap smear screening interval, oral contraceptive use ever remained protective for dysplasia. Vaginal deliveries were strongly associated with dysplasia with > 2 vaginal deliveries associated with a 3.9-fold increase in risk after adjustment for age, ethnicity, sexual behaviour, and HPV infection. Using logistic regression models to simultaneously control for effects of multiple factors as potentially related to cervical dysplasia, we found low educational attainment, cervical HPV infection, cigarette smoking, history of any sexually transmitted disease, and having one or more vaginal deliveries to be associated with dysplasia; oral contraceptive use and past diaphragm use also remained protective for high-grade cervical dysplasia in these regression analyses. CONCLUSIONS: The data suggest that use of oral contraceptives (ever) and past diaphragm use are protective for high-grade cervical dysplasia among Hispanic and non-Hispanic white women in New Mexico. The clinic-based perspective of this research (versus population-based studies) may help explain some of these findings.

When children have children: the teen pregnancy predicament.

Despite developments in contraceptive technology and changes in societal norms, adolescent pregnancy remains a key issue for politicians, social scientists, health care providers, and educators. The adolescent's access to contraception and abortion services continues to spark legal debate. The implications of research call for the development of innovative programs to address larger issues, such as poverty and limited access to health care, in the management and prevention of adolescent pregnancies. Clinical interventions, such as school-linked clinics to provide contraception and prenatal care programs to reduce perinatal morbidity, have varied in their approaches and their subsequent success.

PIP: The birthrate among both white and African-American US young women 15-19 years old declined steadily from 89.1 live births per 1000 women (LB/1000) in 1960 to 51.3 LB/1000 in 1985, as a result of the availability of contraception and abortion. The rate has since risen to 62.1 LB/1000 in 1991. In contrast, the birthrate among unmarried young women 15-19 years old increased from 15.3 LB/1000 in 1960 to 42.5 LB/1000 in 1990. The birthrate among white unmarried adolescents more than tripled over the past three decades. The Johns Hopkins University School of Public Health revealed a rise in overall sexual activity from 28% in 1972 to 50% in 1979 in interviews of a national sample of 15-19 year olds. After the Supreme Court decision in Roe v. Wade, 232,440 abortions were performed in 1973 to 15-19 year olds and that number rose to 444,780 by 1980. Title IX of the Civil Rights Act prohibited the exclusion of girls from schools on the basis of pregnancy. In 1977 the Supreme Court struck down a statute that prohibited the sale of nonprescription contraceptives to minors under 16. Reports by the Centers for Disease Control and Prevention identified 1,559,110 legal abortions in 1987, of which 26.1% were to women younger than 20 years old. The adolescent seeking an abortion faces clinical disclosure and parental consent. According to a 1985 poll, 85% of Americans approve of sex education. Nearly 60% of 12-17 year olds surveyed in 1986 said that they had taken a course or had a class on sex education. However, in a 1988 survey of over 4000 public school teachers, only 84% of teachers were in programs that included sexual decision making, abstinence, and birth control methods. Adolescent childbearing may represent normative behavior for those coping with the stress of poverty. Adolescent pregnancy is associated with low birthweight, preterm labor and delivery, poor maternal weight gain, hypertension, anemia, and sexually transmitted diseases.

The prevalence, risks, and management of Chlamydia trachomatis infections in fertile and infertile patients from the high socioeconomic bracket of the South African population.

OBJECTIVE: The main objective of the study was to evaluate the prevalence of Chlamydia trachomatis endocervicitis in an infertile population. DESIGN: Forty consecutive patients were enrolled in the study group and 41 in the control group. SETTING: The study was undertaken in the Department of Obstetrics and Gynaecology of the University of the Orange Free State, Bloemfontein, Republic of South Africa. PATIENTS: Infertile white females, visiting an infertility clinic in an academic hospital and fertile white female patients visiting an antenatal clinic. INTERVENTIONS: Endocervical swabs were taken, and monoclonal direct immunofluorescence for C. Trachomatis were done on each. MAIN OUTCOME MEASURES: A difference was expected between the prevalence of C. trachomatis infection in the fertile and infertile population. RESULTS: In the study group, 14(35.9%) positive, 25(64.1%) negative, and 1 fallout were obtained. In the control group, 3 patients (7.32%) tested positive. CONCLUSION: Although no correlation was found between C. trachomatis infection of the female genital tract and the clinical history, it showed a significant correlation with infertility. This justifies routine screening tests and antibiotic treatment of positive infertile couples. Analysis of cost-effectiveness showed that empirical treatment of new infertile couples is justified in some populations.

PIP: Health workers at the Department of Obstetrics and Gynecology of the University of the Orange Free State in Bloemfontein, South Africa enrolled 40 consecutive infertile white couples 41 consecutive pregnant white females into a case control study to determine the prevalence of Chlamydia trachomatis infections in an infertile population. Both groups were from the middle to upper socioeconomic class. Laboratory personnel used the monoclonal direct immunofluorescence test to each cervical cytology smear. They had to repeat the test on 5% of the smears. Prevalence of C. trachomatis in the study group stood much higher than it did in the control group (35.9% vs. 7.3%; p.002). No association existed between clinical history and presence of C. trachomatis in the fertile group. 19.5% of the fertile patients had taken antibiotics during the 3 months prior to the study. None reported earlier episodes of salpingitis and/or pelvic inflammatory disease. The researchers proposed a possible reason for the very high rate of C. trachomatis in infertile patients. Perhaps the infertile clinic only examined unresolved infertile cases who may have had an exceptionally high rate of C. trachomatis. The infertility clinic chose to treat all new couples with lymecycline because studies showed that it is always effective against C. trachomatis. Indeed this treatment proved to be the most beneficial at the lowest cost.

Blood pressure changes during pregnancy in Nigerian women.

The purpose of this longitudinal study was to determine the pattern of blood pressure during pregnancy in Nigerian women. The blood pressure of 189 women from early pregnancy and up to term, during labor and 24 h after delivery were monitored. The mean systolic, diastolic and mean arterial blood pressure were computed and the blood pressure readings were correlated with parity and selected anthropometric and socioeconomic variables. The results showed a decline in blood pressure levels during the mid-trimester of pregnancy with a progressive increase towards term. The highest blood pressures were recorded during the third stage of labor. The mean (+/- 2 SD) of blood pressure was 130/80 mmHg. There was no significant correlation of blood pressure with parity but there was a significant positive correlation with maternal age and Quetelex index after 30 weeks of gestation. As compared to Caucasian women, Nigerian women showed higher levels of diastolic blood pressures. We conclude that: (1) the higher incidence of gestational hypertension in African women may be due to higher levels of resting baseline blood pressures in the women, and (2) pregnant women in our population with persistent elevation of blood pressures above 130/80 mmHg should be closely monitored.

AIDS knowledge and risk behaviors among culturally diverse women.

This article reports results from a survey of women at risk for HIV infection. The sample (n = 620) included black (50.6%), white (28.7%), Hispanic (13.4%), and Haitian (5.0%) adult women from south Florida. Data concerning their AIDS knowledge, prevalence of risk behaviors, and perceived vulnerability are presented. Results indicate differences in certain knowledge areas and risk behaviors by race/ethnicity and a consistent incidence of unprotected sex with their main partners across all racial/ethnic groups.

PIP: Florida has the 3rd highest cumulative number of AIDs cases among states in the US, and 12% in Florida are women, which is 3% higher than the national average. The study describes the AIDs knowledge and sexual behavior of women at high risk of HIV infection in 1989 from Dade and Broward counties in Florida. As part of a 3-year project, it was designed to develop a cross sectional description of women at risk, and to develop and evaluate interventions aimed at perinatal AIDs prevention. 620 nonpregnant women were recruited from county jails and detention centers (59.3%), county health, STD, and family planning clinics (26%), alcohol/drug treatment centers (13.6%), and other (1.1%). The mean age of respondents was 28.9 years. 51% were never married, and 76% had 1-3 children. 45% were unemployed. 21% reported income from prostitution and 17% from illegal activity. 44% had ever engaged in prostitution. 83% had used an illegal substance of which 22% was IV drugs. 8.7% were seropositive. 71% received AIDs, STDs, contraception, and sexuality information from the mass media, and 59% from medical professionals and public health clinics. The limitations were the representatives of the sample, and the validity and reliability of the questionnaire. The results of AIDs knowledge, risk behavior, and vulnerability revealed that the majority were well informed about AIDs and HIV infection, with the exception of Haitians. The findings support treating Haitian women as a special population for AIDs prevention programs. Those 20 and 41 years tended to believe myths about AIDs and casual contact and perceived risk based on the appearance of an individual. 75% were unaware of bleach as a remedy for dirty needles. As a subcultural influence, people need more knowledge about safer drug use. Knowledge did not influence risky behavior. Transmission appears to be from heterosexual contact. A greater prevalence of sexual risk behavior was reported with main partners even though 75% agreed one couldn't trust lovers in reporting STDs. Program focus on prostitutes may have limited impact. Hispanics reported the greatest prevalence of risk behaviors, followed by whites, blacks, and Haitians. Over 40% of Hispanic and Haitian and 20% of black women reported intention to not use a condom with a seropositive partner. Economics and gender role norms are a great influence. There was a general lack of perceived vulnerability. Successful community and society level strategies involve continued education, sociocultural sensitivity, gender role issues, sexual decision making, and economic factors.

Modification of oral contraceptive relationships on breast cancer risk by selected factors among younger women.

In a case-control study of 1647 breast cancer cases and 1501 population controls under 45 years of age, potential modifying effects of other risk factors on the relationship of oral contraceptives to breast cancer were examined. Among the total series of study subjects, the relationship of extended pill usage was greater in non-white than white women. Oral contraceptive associations, however, did not appear to be substantially modified by other risk factors, including parity, body size, or family history of breast cancer (apart from a somewhat enhanced relationship among subjects who reported a sister with breast cancer. Further, oral contraceptive relationships did not vary by a history of benign breast disease, although the majority of subjects began pill usage prior to the development of benign breast disease. Among the women under the age of 35, in whom oral contraceptive relationships were heightened (over a twofold excess risk for use of 5 years or longer), pill relationships were less modified by race than in the total series. Although among these younger subjects there was no effect of pill usage in heavy women, and an enhanced relationship among heavier consumers of alcoholic beverages, these interactive effects were not statistically significant. The findings of this study generally support no substantial variation in oral contraceptive relationships by other breast cancer risk factors, although some further attention might be warranted regarding possible modifying effects of race, body size, type of relative with breast cancer, and alcohol consumption.

PIP: To assess the possible interactive effects of oral contraceptives (OCs) with selected breast cancer risk factors, a case-control study involving US women diagnosed with breast cancer before 45 years of age was conducted. All incident cases of breast cancer diagnosed among younger women during 1990-92 in Atlanta, Georgia, Seattle/Puget Sound, Washington, and five counties of central New Jersey were eligible. Controls were identified through random-digit dialing. The final sample consisted of 1647 cases and 1501 controls. Ever-use of OCs for 6 months or more was associated with a slightly elevated breast cancer risk (relative risk (RR), 1.3; 95% confidence interval (CI), 1.1-1.5), with a stronger association for women whose breast cancer was diagnosed prior to age 35 years (RR, 1.8; 95% CI, 1.2-2.7). Among women under age 35 years, the risk was highest among women who had used OCs for 5 or more years and for those who used them within the past 5 years. In general, study findings did not support extensive variations in the risk associated with OC use across most risk factors. However, there were some noteworthy variations. At ages 35-44 years, long-term OC use exerted stronger effects in African-American women (RR, 1.5; 95% CI, 0.9-2.6) and other non-White women (RR, 2.8; 95% CI, 1.2-6.6) than among White women (RR, 1.0; 95% CI, 0.8-1.3). Although there was no interaction between OC use and a family history of breast cancer, OC use by a woman with a sister with breast cancer elevated the cancer risk. Body size was inversely associated with breast cancer risk in OC users, while weekly consumption of 7 or more alcoholic drinks slightly raised this risk.

Multicenter trial of two monophasic oral contraceptives containing 30 mcg ethinylestradiol and either desogestrel or gestodene in Thai women.

The efficacy and acceptability of two third generation oral contraceptives in Thai women were evaluated in a prospective, open, group-comparative, randomized, multicenter trial of women asking for contraception. In six Family Planning Centers and Outpatient Gynaecological Clinics in urban areas in Thailand, 783 healthy women who were at risk for pregnancy and did not have contraindications to oral contraceptive use were randomly allocated to one of the two study groups. An oral contraceptive containing 30 mcg ethinylestradiol and 150 mcg desogestrel was given to 394 women and an oral contraceptive with the same amount of ethinylestradiol and 75 mcg gestodene to 389 women during 6 cycles. Criteria of cycle control, side effects and the presence and severity of acne vulgaris were assessed and blood pressure and body weight measured at pretreatment and after cycles 1, 3 and 6. Furthermore, the efficacy was evaluated after the last cycle. No pregnancies occurred with either of the contraceptives. The incidences of irregular bleeding and minor side effects in both groups were very low and decreased after an initial increase in the first cycle. Acne improved in both groups. Blood pressure and body weight remained unchanged. The two oral contraceptives were found to be effective and acceptable in Thai women. Compared to Caucasian women, the incidences of irregular bleeding and side effects were apparently lower in these Asian women. Furthermore, the effects of both oral contraceptives were comparable.

PIP: During October 1988-April 1990, clinicians randomly allocated 783 healthy women attending six family planning centers and outpatient gynecological clinics in urban areas of Thailand to either the group using a 30 mcg ethinyl estradiol (EE) combined oral contraceptive (OC) with 150 mcg desogestrel (DSG) (394 women) or an OC with 75 mcg gestodene (GSD) (389 women). Researchers aimed to evaluate the efficacy and acceptability of these two third-generation OCs. After six cycles of OC use, the continuation rate was 87.6% for DSG/EE and 85.9% for GSD/EE. No one from either group became pregnant. Women forgot to take the pills during 1.8% of the cycles with DSG/EE and 2% of the cycles with GSD/EE. Breakthrough bleeding was more common than spotting in both groups (0.8-5.4% vs. 0.6-2% for DSG/EE; 0.8-4.4% vs. 0-4.4% for GSD/EE), while in Caucasian women spotting was more common. Breakthrough bleeding and spotting rates were comparable in both groups. Irregular bleeding initially increased, then fell with time. Irregular bleeding for both OC groups was less common than it is in Northern European women. No one experienced any serious side effects. The most common minor side effects were nausea, headache, and breast tenderness. The incidences increased in the first cycle, then fell. They were comparable for both groups. Acne was less frequent after OC use (20.7% at baseline vs. 17.1% at 6 months for DSG/EE and 22% at baseline vs. 16.9% at 6 months for GSD/EE). Neither OC influenced the mean body weight or the mean blood pressure. These findings indicated that both OCs are very effective, provide excellent cycle control, and produce a low incidence of side effects. They also protect against acne.

Preliminary experience with Norplant in an inner city population.

Norplant, the five-year subdermal contraceptive system, is the first implantable contraceptive method approved for general use in the United States. We describe the preliminary experiences of 246 U.S. women who accepted Norplant between April, 1991 and September, 1991. Norplant was well accepted among this diverse general population. Intensive counselling about side effects, especially menstrual changes, is crucial for patient satisfaction. Although 48% of acceptors experienced menstrual cycle changes and 70% experienced at least one side effect, phone calls and unscheduled visits for problems were infrequent. Adequate counselling about side effects obviates the need for a routine follow-up visit one month after insertion.

PIP: Between April and October 1991 in Baltimore, Maryland, family planning providers tried to follow 246 13-42 year old women at a clinic at the Francis Scott Key (FSK) Medical Center for 3 months who accepted the levonorgestrel-releasing implant Norplant to evaluate its acceptability and effectiveness among a high-risk population. 56% of the women were Black and 41% White. 69% were single. Most were interval gynecologic patients (109), but many were postabortion patients (97). The providers could only follow 108 women. Reasons for unscheduled visits were insertion site tenderness, amenorrhea, and removal. At 1 month, 70 % had at least 1 side effect. 48% had irregular bleeding 1-2 months after insertion. Other side effects included headache (49%), acne (24%), weight gain (22%), increased appetite (19%), and dizziness (18.5%). The 24-hour telephone hotline had only received 38 problem calls, all of which were from FSK Norplant patients. More than 50% of the calls were about menstruation concerns. Reasons for removal included pressure to receive Norplant, increased acne, headaches and prolonged bleeding, and postinsertion site problems. 1 woman became pregnant, but it occurred before insertion. She underwent an abortion and continued to use Norplant. 78% of the women considered Norplant to be excellent and 14% considered it to be good. 95% would recommend it to others. 69% reported convenience to be the best thing about Norplant and 22% said it was pregnancy prevention. Worst things were irregular bleeding (26%) and progestin-related side effects (e.g., headaches and weight gain) (19%). 35% did not consider anything to be bad about Norplant. 64% had at least some apprehension before insertion, the major reasons being fear of needles (48%) and of pain (37%). Prior to insertion, just 37% were worried about potential side effects. The providers thought that the routine follow-up visit at 1 month was not cost-effective and provided no specific clinical benefit. They advocated adequate counseling about side effects to take the place of the follow-up visit.

Births to unmarried mothers: trends and obstetric outcomes.

PIP: This study examines trends in nonmarital childbearing among women who represent an inner-city urban population that includes high-risk privately insured mothers and a large number of indigent mothers. The study population includes data collected from a computerized database at the MetroHealth Medical Center in Cleveland, Ohio, during 1974-93, on 73,544 births. The subsample for the clinical analysis is based on 29,865 deliveries that occurred during 1987-93. Findings indicate that the proportion of deliveries to unmarried mothers increased by at least 20% over a 19-year period. The proportion of privately insured unmarried mothers increased from 6.7% to 27.3% during 1975-93. The proportion of staff-funded mothers increased from 63.5% to 77.5%. The proportion increased for all races, funding groups, and age groups. In the subsample of births during 1987-93, there were 51% Whites, 38% Blacks, 8% Hispanics, and 3% other. Only 15% had private medical insurance. 34.2% of births were to married mothers. 38% of births were to women who were smokers, 3.2% were alcohol users, and 15.4% were narcotic users. 15.4% were cesarean births. The infant mortality rate was 13/1000 live births. Unmarried mothers tended to be about four years younger than married mothers. Over 30% of unmarried mothers and only 10% of married mothers were teenagers. 48% of White mothers, 14% of Black mothers, 35% of Hispanic mothers, and 70% of mothers of other race were married at the time of delivery. The mean birth weight for unmarried mothers was 100 g less than for married mothers. Significant predictors of mothers' marital status were insurance status, race, age, and their interaction. The odds of unmarried status increased with younger age, delivery later in the study period, race, insurance pay status, and parity, which, when controlled for, showed Black and Hispanic mothers with increased odds of an unmarried status. Significantly more unmarried mothers had infants with thick meconium, premature delivery, and fetal distress among neonates.^ieng

School importance and dropout among pregnant adolescents.

PURPOSE: This study examined the relationship of psychological well-being, social support, and demographic variables to school importance and school dropout among pregnant teens. METHOD: Fifty-one Caucasians and 68 African-Americans (mean age = 16.7 years, mean weeks pregnant = 23) were recruited from two Baltimore area prenatal teen clinics. The adolescents completed questionnaires measuring depression, self-esteem, mastery, parental and friend support, demographic characteristics (i.e., age, marital status, ethnicity, socioeconomic status), school importance, and status. RESULTS: Most adolescents were enrolled in school or had graduated (69.7%), were receiving at least passing grades (78.7%), and perceived finishing high school as very important (76.7%). Blacks were more likely to say school was important (p < 0.001), were less likely to drop out (p < 0.01), and received higher grades (p < 0.01) than whites. Dropouts had lower family incomes than current school attenders and graduates (p < 0.05). One measure of psychological well-being (mastery, p < 0.01) was positively correlated with school importance. Social support did not correlate with school importance or dropout. CONCLUSIONS: These findings suggest that dropping out of school among pregnant teens may be more strongly related to sociocultural factors than to individual characteristics such as emotional support and psychological well-being. Overall, this study reveals a positive picture of educational continuation and performance during pregnancy, with most adolescents recognizing the importance of education and remaining in school.

PIP: This study examined the relationship of psychological well-being, social supports, and demographic factors to school importance and dropout status. Data were obtained from 51 White and 68 Black pregnant adolescents, aged 13-18 years, who volunteered after recruitment in two Baltimore, Maryland, prenatal clinics. Interviews were conducted during the second and third trimester of pregnancy. This study was based on systems theory that argues for multiple levels of analysis. The following instruments were relied on for scales: Procidano and Heller scales, the Brief Symptom Inventory, Rosenberg's scale, Pearlin and Schooler scales, and Hollinghead's 4-factor index. School importance was measured by a 4-item scale developed by Maton and Teti. 58.8% were currently enrolled in school, 10.9% had graduated, and 30% had dropped out. 16.4% of the dropouts had left due to pregnancy. Most reported that school was important. Whites were significantly more likely than Blacks to drop out. Blacks reported greater peer support and higher self-esteem. Mastery and school enrollment were each correlated with school importance. Self-esteem and depression were unrelated to school dropout status. Peer and parent support were unrelated to school importance or retention. Demographic factors were correlated with school importance and dropout status. SES was unrelated to school importance, but higher SES teens were less likely to drop out. Blacks valued school more, were less likely to drop out, and received higher grades. Policies should incorporate socioeconomic conditions as factors in school dropout status among pregnant adolescents.

Social factors predicting postpartum choice of Norplant among African-American and non-Hispanic white adolescents.

PURPOSE: This study was designed to determine the factors associated with Norplant choice for postpartum teens. METHODS: A total of 151 teenagers, ages 12-20 years, who delivered at the Medical Center of Delaware from July to December 1992, were offered insertion of Norplant within 48 h postpartum. A structured interview was conducted in the postpartum period after nondirective counseling sessions including a physical demonstration using anatomical models of various contraceptive methods. Student's t-tests, chi-square, and multivariate analyses were used. RESULTS: Eighty-six teenagers were African-American (mean age = 17.3 +/- 1.9 years) and 65 non-Hispanic white (NHW) (mean age = 18.3 +/- 1.5 years). The NHW teenagers were older (p < 0.001); the African-American teenagers were more likely to have Medicaid (49% vs. 14%; p < 0.001) and to have one or more friends who use Norplant (62% vs. 34%; p < 0.001). In multivariate analyses, NHW teenagers were more likely to choose Norplant if they had discussed their choice with a parent or guardian [adjusted odds ratio (AOR) = 14.6, 95% confidence interval (CI), 2.12-100.57]; had Medicaid funding (AOR = 12.1; 95% (CI), 10.6-91.34); and had any friends who used Norplant (AOR = 6.3; 95% (CI), 1.38-28.40). However, for African-American teenagers, the strongest predictor for choice of Norplant was number of prior children delivered. After two deliveries, there was a better than four-fold likelihood (AOR = 4.8; 95% (CI), 1.47-15.94) that African-American teenagers would choose Norplant. For the African-American teenagers, parental discussion, Medicaid status, and friends' use of Norplant were not as important as family size, but far greater percentages of the African-American teenagers had access to Medicaid funding and peers who used Norplant. CONCLUSIONS: NHW and African-American teenagers choose Norplant for different reasons. Lack of funding may have been a barrier to choosing Norplant. Discussions with parents and friends have a positive influence on choosing Norplant for NHW teenagers. African-American teenagers were more likely than NHW to have Medicaid coverage, and more frequently choose Norplant if the current birth was their third child.

PIP: 151 youths, aged 12-20 years, who delivered at the Medical Center of Delaware from July to December 1992, were offered insertion of Norplant within 48 hours postpartum. These young women were subsequently interviewed to determine which factors are associated with choosing to accept or not accept Norplant. 86 Black teenagers of mean age 17.3 years and 65 non-Hispanic Whites of mean age 18.3 years participated. The White teenagers were significantly older, 49% of Blacks and 14% of Whites had Medicaid, and 62% of Blacks and 34% of Whites had one or more friends who use Norplant. In multivariate analyses, the White teens were more likely to choose Norplant if they had discussed their choice with a parent or guardian, if they received Medicaid funding, and if they had any friends who used Norplant. The strongest predictor for choice of Norplant among Black teens was the number of prior children delivered. After 2 deliveries, there was an almost 5-fold likelihood that Black teenagers would choose Norplant. For the Black teens, parental discussion, Medicaid status, and friends' use of Norplant were not as important as family size, but larger proportions of the Black teens had access to Medicaid funding and peers who used Norplant.

Factors associated with elective Norplant removal in black and white women.

Premature removal of contraceptive implants (Norplant [levonorgestrel implants], Wyeth-Ayerst Laboratories, Philadelphia, Pennsylvania) is a cause of a sizable national medical expenditure in the United States. Understanding the factors that influence the decision to remove the implants and being able to predict which users are likely to elect discontinuation prematurely could provide useful information for counseling patients as they are considering contraceptive implants so that potentially enormous long-term savings could be achieved. This study surveyed 98 women who had Norplant inserted and removed between January 1991 and December 1994. Data were collected from chart review, and when necessary, a questionnaire was used to extract information not found in the chart. The chi-squared statistic and t-test were used to compare demographic variables. All but one subject received comprehensive pre-implant counseling. The main reason given for electively removing the Norplant prematurely was irregular menstrual bleeding (60%). Pre-implant counseling did not influence the decision for removal. These results indicate the importance of clarifying patients' doubts regarding menstrual bleeding irregularities during follow-up visits rather than relying on the information patients received during preimplant counseling.

PIP: Premature removal of contraceptive implants (Norplant) is a cause of a sizable national medical expenditure in the US. Understanding the factors that influence the decision to remove the implants and being able to predict which users are likely to elect discontinuation prematurely could provide useful information for counseling patients as they are considering contraceptive implants so that potentially enormous long-term savings could be achieved. This study surveyed 98 women who had Norplant inserted and removed between January 1991 and December 1994. Data were collected from chart review, and, when necessary, a questionnaire was used to extract information not found in the chart. The chi-squared statistic and t-test were used to compare demographic variables. All but one subject received comprehensive pre-implant counseling. The main reason given for electively removing the Norplant prematurely was irregular menstrual bleeding (60%). Pre-implant counseling did not influence the decision for removal. These results indicate the importance of clarifying patients' doubts regarding menstrual bleeding irregularities during follow-up visits rather than relying on the information patients received during pre-implant counseling.

Discrimination against breastfeeding: a racial/economic issue?

PIP: Black mothers in South Africa are more likely to breast feed than white mothers, and for a longer period of time. During hospital visits the author observed nurseries in which black mothers fed their children while white mothers did not. In the nurseries for white mothers there were many advertisements from formula companies promoting their products. Because of overcrowding black mothers are usually released 24 hours after birth. There are billboards advertising baby foods in the black areas also, and the cost of these foods is more than most can afford. Using these foods often leads to dehydration, and if the child is not treated in a rehydration center, it dies. Also, the family may suffer when money is used for the more costly formula when less expensive foods could feed the whole family. In the US many black women on welfare are given formula for their children, since many health workers and others are not interested in or ignorant of breastfeeding benefits. Compared to white South African women, fewer white women breastfeed, but they do it longer. There is also extensive promotion of gadgets to assist breast feeding mothers in the US including breast pumps, breast pads, and nipple shields. Some of these are in use in South Africa are just as useless there. In South Africa affluent white women do not breastfeed while in the US more do. In the US poor black women do not breastfeed while in South Africa they do. From these observations it appears that non-western health care systems are more supportive of breastfeeding than the western systems. One might examine the question of social class and racial issues involved, also.^ieng

Physical abuse, smoking, and substance use during pregnancy: prevalence, interrelationships, and effects on birth weight.

OBJECTIVE: To establish the singular and combined occurrence of physical abuse, smoking, and substance use (i.e., alcohol and illicit drugs) during pregnancy and its effect on birth weight. DESIGN: Prospective cohort analysis. SETTING: Urban public prenatal clinics. PARTICIPANTS: 414 African American, 412 Hispanic, and 377 white pregnant women. MAIN OUTCOME MEASURE(S): Occurrence of physical abuse was 16%; smoking, 29.5%; and alcohol/illicit drug use, 11.9%. Significant relationships existed between physical abuse and smoking for African American and white women. For African American women, 33.7% of women who were not abused smoked, versus 49.5% of women who were abused (chi 2 = 8.21; df = 1; p < 0.005). Alcohol/illicit drug use was 20.8% for nonabused women compared with 42.1% for abused women (chi 2 = 18.18; df = 1; p < 0.001). For white women, 46.6% of women who were not abused smoked, versus 59.6% of those who were abused (chi 2 = 5.22; df = 1; p < 0.005). As a triad, physical abuse, smoking, and alcohol/ illicit drug use were significantly related to birth weight (F[3, 1040] = 30.19, p < 0.001). CONCLUSIONS: Physical abuse during pregnancy is common, readily detected with a five-question screen, and associated with significantly higher use of tobacco, alcohol, and illicit drugs. Clinical protocols that integrate assessment and intervention for physical abuse, smoking, and substance use are essential for preventing further abuse and improving smoking and substance cessation rates.

PIP: Using a prospective cohort analysis, this study established the singular and combined occurrence of smoking, physical abuse, and substance use during pregnancy and its effect on birth weight among African American, Hispanic, and White women. The sample consisted of 1203 African American (n = 414), Hispanic (n = 412), and White (n = 377) pregnant women from urban public prenatal clinics in Houston and Baltimore. In the results, occurrence of physical abuse was 16%; smoking, 29.5%; and alcohol/illicit drug usage, 11.9%. Among African American and White women, significant relationships existed between physical abuse and smoking. About 33.7% of African American women, who were not abused, smoked compared with 49.5% of women who were abused. Alcohol/illicit drug use was 20.8% for nonabused women compared with 42.1% for abused women. Moreover, the three characteristics--physical abuse, smoking, and alcohol/illicit drug use--were significantly related to birth weight. The results indicate that abuse during pregnancy is associated with increased smoking, and use of alcohol and illicit drugs. Thus, clinical protocols integrating assessment and intervention for physical abuse, smoking, and substance use are needed to achieve healthy outcomes for pregnant women and their infants.

Reasons for condom utilization among high-risk adolescent girls.

Two hundred forty-eight adolescent girls responded to a list of 30 statements describing reasons for using and not using condoms. For 24 of the statements, most adolescents (> 70%) gave the same response regarding why they did or did not use condoms. Therefore, only the six remaining statements were used in further analyses. The relationship between the six statements and psychosexual history, condom use, and sexually transmitted disease (STD) history was examined. Those adolescent girls who had been sexually active longer were more likely to report lack of enjoyment as a reason that they did not use condoms (P < .03), and those adolescents who had been sexually active less time were more likely to report personal (P < .005) and partner (P < .0006) enjoyment of sex with condoms as a reason for using condoms. Longer relationships before intercourse were associated with having condoms available (P < .01) and partner insistence on their use (P < .02). Partner insistence on condom use was related to fewer episodes of sexually transmitted diseases (P = .03). These findings indicate the importance of relationship and partner variables in adolescent girls' perceptions of condom use.

PIP: At a clinic for urban adolescents in Cincinnati, Ohio, interviews were conducted with 248 sexually active female adolescents to determine reasons for using and not using condoms in relation to their psychosexual history. 80% were African-Americans; 20% were Caucasians. More than 70% of the adolescents answered 24 of 30 survey items the same way, so the researchers examined the relationship between the six remaining items and psychosexual history, condom use, and sexually transmitted diseases (STDs). Teens who had engaged in sexual intercourse for a shorter period of time were more likely to cite own and partner's enjoyment of sex with condoms as reasons they used condoms (p = 0.005 and 0.0006, respectively). Those who had been sexually active for a longer period were more likely to report that they did not use condoms because condoms interfered with pleasure (p = 0.03). Teens who said that they used condoms because their partners insisted on it tended to have been sexually active for a shorter period of time (p = 0.001) and had a longer relationship with their partner before engaging in sexual intercourse (p = 0.02). Teens who said that availability of condoms was a reason for using condoms were more likely to have a longer relationship before engaging in sexual intercourse (p = 0.01). Teens who said that they did not use condoms because condoms were not available tended to have a shorter relationship prior to sexual intercourse than their counterparts (p = 0.0001). Lack of enjoyment of sex with condoms and partner insistence on using condoms were associated with condom use at last intercourse (odds ratio [OR] = 3.098, p 0.0001, and OR = 2.799, p 0.0002, respectively). Partner insistence on condom use was associated with fewer episodes of STDs (OR = 1.668, p = 0.03). Use of oral contraceptives did not decrease condom use. These findings suggest that the relationship and partner affect adolescents' perceptions of condom use.

Females' perception of date rape: an examination of two contextual variables.

PIP: This study examined the role of perceived token resistance and previous sexual contact on women's ability to discriminate when a female wants her partner to stop his sexual advances. Participants included 101 White female undergraduate students and were randomly assigned to one of the four conditions: 1) perceived resistance with genital contact; 2) no resistance with genital contact; 3) perceived resistance with no genital contact; and 4) no resistance without genital contact. Subjects listened to an audiotaped date rape after being informed of the couple's sexual history based on the condition assigned to them. They were also informed that the couple had been on five previous dates, in which the man had manipulated the woman's breasts or genitals. In addition, the woman did not object to this contact, or the woman initially objected to the contact but subsequently stopped resisting contact. Participants in the perceived token resistance conditions took significantly longer to determine when the man should refrain from attempting further sexual contact. The findings of this study could be used to increase information on date rape, to educate individuals about the responses associated with date rape, and to reinforce rules concerning appropriate sexual behavior.^ieng

Attribution of control and teenage pregnancy.

PIP: In rural Appalachia in Tennessee, data on 13 female adolescents who had experienced a pregnancy (mean age=16 years, 7 months) were compared with those on 38 female adolescents who had not experienced a pregnancy (mean age-16 years, 4 months) to test the hypothesis that teenagers who experience a pregnancy have external attributions of control over their life events. The Nowicki-Strickland Locus of Control Scale for Children was administered to determine their beliefs about causes of events in their lives. All the girls were white and matched for socioeconomic status, housing, and cultural background. The mean attribution of control to external agents score stood at 14.5 for girls who had experienced a pregnancy compared with 12.7 for those who had not experienced a pregnancy, but the difference was not significant (p=.08).54% of the cases exhibited external attributional orientation compared with 16% of the controls (p.02). This finding concurred with that of earlier studies. The fact that not all the girls who had experienced a pregnancy had external attributional orientation suggested that it is not the only factor linked to adolescent pregnancy. Studies have not identified whether external attributional orientation is a causal factor or consequence of adolescent pregnancy. A 1980 study found that women who had shown more external locus of control scores during pregnancy and tended to castigate themselves had a high probability of postpartum depression. Another study indicated that rises in depression among adolescents were linked to prechange orientations toward external attributions of control. Practitioners should selectively pay attention to teenagers who have extreme attributional orientations since many teenagers carry their pregnancies to term and choose to rear their infants. These orientations appear to pose risks for the adolescent mother and her children.^ieng

Life threatening pulmonary embolus in a factor V Leiden carrier on oral contraceptives: a case report.

Venous thromboembolism is a serious, potentially lethal health problem affecting one per 1,000 people annually. Major surgery, the use of oral contraceptives, complicated pregnancy, fractures, and immobilization increase the risk of thrombosis. In addition to these factors, thrombosis is associated with inherited deficiencies of antithrombin III, protein C, and protein S. Together these do not account for more than five to 10% of the cases. Hereditary activated protein C resistance has been recognized as a basis for a majority of cases of familial thrombosis. It accounted for more than a 10 times higher number than that of other known genetic defects. We describe a case of a young female who presented with a pulmonary embolism and was discovered to have activated protein C resistance. This patient had a heterozygous mutation for factor V Leiden and was taking oral contraceptives. This report underlines: 1) increased risk of venous thrombosis in oral contraceptive users who carry factor V Leiden mutation associated with functional resistance to the normal anticoagulation activities of protein C; 2) most episodes occurring in the young are minor, but pulmonary embolus can occur; 3) the importance of identifying other affected members of the family; and 4) the importance of anticoagulation prophylaxis at times of enhanced risk, particularly during pregnancy, postpartum, and major surgery.

The incidence of extended households among middle-aged black and white women: estimates from a 15-year panel study.

PIP: Much has been written in recent years about changes in family and household structure in the US. Analyses based on census data or other cross sections indicate that fewer adults live in families, especially the nuclear family of husband, wife, and minor children. Analyses based on cross-sections also indicate the relative rarity of extended households, especially 3-generation families. In this descriptive analysis, data from the National Longitudinal Surveys of Mature Women are used to compare cross-section and 15-year estimates of the incidence of various types of extended households. Black and white women are analyzed separately and the estimates for the proportion of middle-aged women living in extended households are presented by marital status. Results show large differences between single-year and 15-year estimates of the incidence of extension. Overall, between 1/4 and 1/3 of white middle-aged women lived in extended households for some time over the 15-year period, and approximately 2/3 of black women experienced this household form for at least part of their middle years. The authors conclude that, contrary to popular and academic perceptions, extended families are a relatively common form of living arrangement for adults in this country, if only for short periods of time. This may be 1 indicator of the prevalence of the modified-extended family in the US.^ieng