Cesarean delivery on maternal request in Israel: Maternity department policies and obstetricians' perspectives.

OBJECTIVE: This study aimed to describe Israeli maternity departments' policies regarding cesarean delivery on maternal request, and factors associated with obstetricians' support for cesarean delivery on maternal request in specific scenarios. METHODS: This multicenter cross-sectional study included 22 maternity department directors and 222 obstetricians from the majority of Israeli hospitals. Directors were interviewed and completed a questionnaire about their department's cesarean delivery on maternal request policy, and obstetricians responded to a survey presenting case scenarios in which women requested cesarean delivery on maternal request. The scenarios represented profiles referring to the following factors: maternal age, poor obstetric history, pregnancy complications, and psychological problems. The survey also included the obstetricians' socio-demographic information and questions about other issues associated with cesarean delivery on maternal request. The main outcome measures were department policies regarding cesarean delivery on maternal request and obstetricians' support for cesarean delivery on maternal request in specific cases. RESULTS: Policies were divided between allowing and prohibiting cesarean delivery on maternal request (n = 10 and 12, respectively), and varied regarding issues such as informed consent and pre-surgery consultation. Most of the obstetricians (96.5%) did not support cesarean delivery on maternal request in the "reference scenario" describing a young woman with no obstetric complications. Additional factors increased the rate of support. Support was greater among obstetricians aged > 45 (odds ratio = 2.11; 95% confidence intervals 1.33-3.36) and lower among females (odds ratio = 0.58; 95% confidence intervals 0.39-0.86). Obstetricians whose department policy was less likely to allow cesarean delivery on maternal request reported lower rates of support for cesarean delivery on maternal request in most cases. CONCLUSION: Policies and obstetricians' support for cesarean delivery on maternal request vary broadly depending on clinical profiles and physician characteristics. Department policy has an impact on obstetricians' support for cesarean delivery on maternal request. Health policy will benefit from a framework in which the organizations, physicians, and patients are consulted.

Type of Re-Hospitalization and Association with Neonatal Morbidities in Infants of Very Low Birth Weight.

BACKGROUND: Preterm infants are at high risk for long-term morbidities and an increased rate of re-hospitalization. OBJECTIVE: The aim of this study was to evaluate the type of re-hospitalization of very low birth weight (VLBW) infants, from infancy through adolescence, and to assess the association of neonatal morbidities with specific types of re-hospitalization. STUDY DESIGN: The study cohort comprised 6,385 VLBW infants who were registered with the Maccabi Healthcare Services (MHS) from their birth hospitalization. Data were collected for up to 18 years (median 10.7 years) following neonatal intensive care unit discharge. Hospitalization types were determined from the MHS coding. Neonatal morbidities included necrotizing enterocolitis (NEC), grades 3-4 intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), bronchopulmonary dysplasia (BPD), and retinopathy of prematurity (ROP). Adjusted hazard ratios (aHR) and 95% confidence intervals (CI) were calculated using the Cox proportional hazards model. RESULTS: Overall, 3,956 infants were re-hospitalized at least once and a total of 11,595 hospitalization types were identified. NEC, IVH, PVL, and BPD were associated with significantly higher aHRs for general pediatric (aHR 1.28-1.55), general surgical (aHR 1.18-1.46), and pediatric intensive care unit (aHR 1.57-2.04) hospitalizations. IVH and PVL were associated with significantly higher aHRs for orthopedic (aHR 2.12 and 4.88, respectively) and ophthalmology (1.76 and 4.02, respectively) hospitalizations. IVH was associated with a 14.2-fold higher aHR for neurosurgical admissions, and ROP with a 1.62-fold higher aHR for ophthalmology hospitalizations. CONCLUSION: Among VLBW infants, specific patterns of re-hospitalization types associated with major neonatal morbidities were identified as particularly high risks for orthopedic and ophthalmology hospitalizations in infants with IVH and PVL, and for intensive care admissions in infants with NEC and BPD.

The effect of body mass index (BMI) and gestational weight gain on adverse obstetrical outcomes in pregnancies following assisted reproductive technology as compared to spontaneously conceived pregnancies.

OBJECTIVE: To compare the effect of pre-pregnancy body mass index (BMI) and inappropriate gestational weight gain (GWG) on adverse obstetrical outcomes among women undergoing assisted reproductive technology (ART) treatments as compared to spontaneously-conceived (SC) pregnancies. METHODS: This prospective cohort study included 1058 pregnant women from two medical centres; 504 women who conceived following ART treatments and 554 who conceived spontaneously. The women were recruited at 8 weeks of gestation and follow-up telephone interviews were conducted 6 weeks after delivery. Obstetrical outcomes included pregnancy hypertension, gestational diabetes (GD), low birth weight (LBW) (<2500g) and small for gestational age (SGA). Multivariate analyses were used to assess the effect of pre-pregnancy BMI and inappropriate GWG on these obstetrical outcomes adjusted for risk factors. RESULTS: The effect of pre-pregnancy BMI and inappropriate GWG on adverse obstetrical outcomes did not differ between ART and SC pregnancies. Pre-pregnancy obesity was found to be associated with increased risk for pregnancy hypertension (OR=2.16; 95%CI 1.16-4.03), GD (OR=2.89; 95%CI 1.61-5.17), caesarian section (OR=1.77; 95%CI 1.10-2.85) and SGA (OR=1.91; 95%CI 1.05-3.46). GWG below recommendations was associated with increased risk for GD (OR=1.73; 95%CI 1.06-2.82) and SGA (OR=1.69; 95%CI 1.17-2.40) while GWG above recommendations was associated with increased risk for pregnancy hypertension (OR=1.77; 95%CI 1.02-3.06). CONCLUSIONS: Pre-pregnancy obesity and inappropriate GWG were associated with adverse obstetrical outcomes in both ART and SC pregnancies. Emphasis should be given on the importance of an optimal pre-pregnancy BMI and appropriate GWG during pregnancy.

The mortality of very low birth weight infants: the benefit and relative impact of changes in population and therapeutic variables.

OBJECTIVE: Very low birth weight (VLBW, ≤1500 g) infants' mortality rates have decreased markedly. We aimed to quantify the relative contribution of changes in the distribution of population characteristics and changes in specific mortality rates on the decline in mortality rates of VLBW infants. STUDY DESIGN: A population-based observational study of the Israel national VLBW infant database. The study population comprised singleton VLBW infants of 24-32 weeks' gestation born during the epochs 1995-2000 (n = 3728) and 2006-2010 (n = 3246). The Kitagawa methodology was applied to determine the contribution of changes in demographic and perinatal characteristics and changes in specific mortality rates on the decline in mortality between the periods. RESULTS: During the study epochs, VLBW infant mortality rates decreased from 19.7 to 13.8%. Of the 5.9% decrease in mortality, 60.6% was attributed to the decrease in specific mortality rates and 39.4% to changes in the proportions of population characteristics and therapies, predominantly early initiation of prenatal care (8.1%), antenatal steroids (25.1%), and cesarean delivery (8.1%). For most of the demographic and perinatal categories considered the relative contribution of changes in their proportions was <3%, whereas >97% could be attributed to changes in the specific mortality rates for these characteristics. CONCLUSIONS: The decrease in preterm VLBW infant mortality was attributable predominantly to changes in variable specific mortality rates whereas changes in the proportions of demographic, perinatal risk factors, and therapies had a limited impact on VLBW infant mortality. Future assessment of determinants of VLBW infant mortality data should be dissected by discriminatory models.

Knowledge of risk factors and prevention of osteoporosis: the Israeli women's health at midlife study.

Wide disparities in knowledge of risk factors and prevention of osteoporosis were demonstrated among midlife Israeli minority women (Arabs and immigrants from the former USSR) compared to Jewish long-time residents. Women who believed osteoporosis to be a serious disease and those who felt susceptible to it reported better knowledge. PURPOSE: The main goals of this study were to assess knowledge of risk factors and preventive measures for osteoporosis in middle-aged women and to evaluate the relationship of knowledge to personal risk factors and personal perceptions about osteoporosis. METHODS: Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJRs), immigrants from the former Soviet Union, and Arab women. The survey instrument included five knowledge statements related to the risk after menopause, the risk of smoking, family history of fractures, decreased risk by physical activity, and by use of medications. RESULTS: The findings indicated wide disparities in knowledge about risk factors and preventive behavior of osteoporosis between the two minority groups (immigrants from the former Soviet Union and Arab women) and the majority group of midlife Israeli women. Knowledge of osteoporosis was related to perceived severity of the disease and partly to perceived susceptibility to osteoporosis. Past diagnosis of osteoporosis, current or past smoking status, and BMI were unrelated to knowledge in multivariate analyses. CONCLUSIONS: There is a need to improve knowledge of osteoporosis especially among less educated and minority women. Subjective perception of risk was more strongly related to knowledge than actual risk factors and should be targeted in public campaigns. The efforts should be aimed at strengthening women's perception of their own susceptibility to osteoporosis and of the severity of this disease.

Population-based study on antenatal corticosteroid treatment in preterm small for gestational age and non-small for gestational age twin infants.

OBJECTIVES: To assess the associations between antenatal corticosteroid use (ACU), mortality and severe morbidities in preterm, twin neonates and compare these between small for gestational age (SGA) and non-SGA twins. MATERIALS AND METHODS: Population-based study using data collected by the Israel National Very Low Birth Weight infant database from 1995 to 2012, comprising twin infants of 24-31 weeks' gestation, without major malformations. Univariate and multivariable logistic regression analyses were performed. RESULTS: Among the 6195 study twin infants, 784 were SGA. Among SGA neonates, ACU were associated with decreased mortality (23.9% vs. 39.2%, p < 0.0001) and composite adverse outcome including mortality or severe neonatal morbidity (43.8% vs. 56.8%, p = 0.0015), similar to the effect in non-SGA neonates (mortality 13.0% vs. 24.5%, p < 0.0001; composite outcome 34.2% vs. 44.8%, p < 0.0001). In the multivariable logistic regression analyses, ACU were associated with an almost 50% reduced mortality risk among SGA twin neonates (OR = 0.52, 95% CI 0.31-0.88) similar to the effect in non-SGA twin neonates (OR = 0.56, 95% CI 0.45-0.70), Pinteraction = 0.69. Composite adverse outcome risk was also reduced in SGA (OR = 0.78, 95% CI 0.50-1.23) and non-SGA groups (OR = 0.78, 95% CI 0.65-0.95), Pinteraction = 0.95. CONCLUSIONS: ACU should be considered in all mothers with twin gestation, at risk for preterm delivery at 24-31 weeks, in order to improve perinatal outcome.

Rehospitalization Through Childhood and Adolescence: Association with Neonatal Morbidities in Infants of Very Low Birth Weight.

OBJECTIVE: To evaluate the impact of major neonatal morbidities on the risks for rehospitalization in children and adolescents born of very low birth weight. STUDY DESIGN: An observational study was performed on data of the Israel Neonatal Network linked together with the Maccabi Healthcare Services medical records. After discharge from the neonatal intensive care unit, 6385 infants of very low birth weight born from 1995 to 2012 were registered with Maccabi Healthcare Services and formed the study cohort. Multivariable negative binomial regression models were calculated to estimate the adjusted relative risk (aRR) and 95% CI for hospitalization. RESULTS: Up to 18 years following discharge, 3956 infants were hospitalized at least once. The median age of follow-up was 10.7 years with total of follow-up of 67 454 patient years and 10 895 hospitalizations. The risks for rehospitalization were increased significantly for each of the neonatal morbidities: surgical necrotizing enterocolitis (NEC), aRR 2.71 (95% CI 2.08-3.53), intraventricular hemorrhage grades 3-4, 2.13 (1.85-2.46), periventricular leukomalacia (PVL), 1.83 (1.58-2.13), bronchopulmonary dysplasia, 1.94 (1.72-2.17), and retinopathy of prematurity stages 3-4, 1.59 (1.36-1.85). During the first 4 years, children with surgically treated NEC, intraventricular hemorrhage, PVL, or bronchopulmonary dysplasia had 1.5- to 2.5-fold greater risks for hospitalization compared with those without the specific morbidity. In the 11th-14th and 15th-18th years, respectively, surgically treated NEC was associated with a 3.05 (1.32-7.04) and 3.26 (0.99-10.7) aRR for hospitalization, and PVL was associated with a 2.67 (1.79-3.97) and 3.47 (2.03-5.92) aRR for hospitalization. CONCLUSIONS: Specific major neonatal morbidities as well as the number of morbidities were associated with excess risks of rehospitalization through childhood and adolescence.

Cultural Disparities in the Use of Prescription and Nonprescription Medications Among Midlife Women in Israel.

The study aimed to examine differences in medication use among midlife women from different cultural origins and to identify socio-demographic, health, and lifestyle characteristics associated with prescribed and non-prescribed medication use. Face-to-face interviews with women aged 45-64 years were conducted during 2004-2006 within three population groups: long-term Jewish residents (LTJR), immigrants from the former Soviet Union after 1989, and Arab women. The survey instrument included current use of medications and way of purchasing (with/without prescription). The level of prescribed and non-prescribed medication use was categorized as taking none, taking 1-2, and taking 3 or more medications. The rates of medication use were 59.5% for prescribed medication and 47% for non-prescribed medications. Differences between the minority groups and LTJR were observed mainly for cardiovascular, vitamins, supplements, and hormonal medications. The analyses showed significantly lower use of prescribed medications among immigrants and of non-prescribed medications among Arab women after taking into account health and socioeconomic indicators. Increased use of prescribed and non-prescribed medications was associated with worse health status and older age. Education was associated with increased use of non-prescribed medications. The disparities in pharmaceutical care may be linked to barriers in access to health care and to cultural preferences among minorities.

Sexual lifestyle among young adults with type 1 diabetes.

BACKGROUND: Sexual lifestyles including sexual activity, problems, satisfaction, and the formation and maintenance of relationships are greatly affected by physical health. Data are limited regarding the sexual lifestyle of adolescents and young adults with type 1 diabetes mellitus (T1DM). Fear of hypoglycemic episodes during sexual intercourse and intimacy issues can impact individuals with T1DM. The aim of this study was to assess sexual lifestyles of individuals with T1DM. METHODS: Fifty-three patients with T1DM, 27 (51%) males, mean ± SD age 27.9 ± 8.3 years completed the Hypoglycemia Fear Survey-II and the Sex Practices and Concerns questionnaire. RESULTS: Thirty-seven (70%) reported they never or almost never had concerns in their sexual lifestyles that were related to their diabetes. None experienced severe hypoglycemia during sex, but 21 (40%) reported occasional mild hypoglycemic events. More than two-thirds do not take any measures to prevent hypoglycemia before sex (decreasing insulin dose, snacks, and measuring blood glucose levels). Fear of hypoglycemia during sex was reported by 18 (35%); those who reported increased fear experienced mild hypoglycemic events during sex (61.1% vs 26.5%, P = .01), were singles (94.4% vs 64.7%, P = .02), and had higher scores on the Worries subscale of the Hypoglycemia Fear Survey-II (42.8 ± 12.8 vs 34.9 ± 10.5, P = .04) compared with those who did not. CONCLUSIONS: Among young people with T1DM, most do not have concerns regarding sex that are related to their diabetes, and most do not take specific measures before or after sex. One-third, however, fear of hypoglycemia during sex, mostly singles and those who experienced hypoglycemia in the past. Caregivers should be aware and address these concerns. Copyright © 2016 John Wiley & Sons, Ltd.

Possible risk for cancer among children born following assisted reproductive technology in Israel.

BACKGROUND: Among children conceived by assisted reproductive technology (ART), increased risk of adverse birth outcomes has been observed, including multiple births, preterm births, and congenital malformations. Regarding cancer among ART-conceived children, findings are discrepant. METHODS: This is a historical cohort of 9,042 ART-conceived children and 211,763 spontaneously conceived (SC) children born from 1997 through 2004. The median duration of follow-up was 10.6 years (interquartile range 9.0-12.3) in the ART group and 9.3 years (interquartile range 8.0-10.6) in the SC group. The cohort database was linked with the Israel National Cancer Registry updated until December 31, 2011 using each child's personal identification number. RESULTS: Twenty-one cases of cancer were identified in the ART group (2.2 per 10,000 person-years), as compared to 361 cancer cases in the SC group (1.8 per 10,000 person-years). The relative risk (RR) for overall cancer in the ART group compared to the SC group adjusted for maternal characteristics was 1.18 (95% confidence interval [CI] 0.80-1.75). ART children had a significantly increased risk for specific cancers, although based on small number of cases, including two cases of retinoblastoma (RR 6.18, 95% CI 1.22-31.2), as well as four cases of renal tumors (RR 3.25, 95% CI 1.67-6.32). CONCLUSION: A statistically significant increased risk for two pediatric cancers was found. However, for overall types of cancer the risk estimate was elevated but not statistically significant. Further studies with larger sample size and longer follow-up time are warranted in order to either confirm or refute these findings.