U.S. Medical Eligibility Criteria for Contraceptive Use, 2024.

The 2024 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by persons who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and a meeting with national experts in Atlanta, Georgia, during January 25-27, 2023. The information in this report replaces the 2016 U.S. MEC (CDC. U.S. Medical Eligibility Criteria for Contraceptive Use, 2016. MMWR 2016:65[No. RR-3]:1-103). Notable updates include 1) the addition of recommendations for persons with chronic kidney disease; 2) revisions to the recommendations for persons with certain characteristics or medical conditions (i.e., breastfeeding, postpartum, postabortion, obesity, surgery, deep venous thrombosis or pulmonary embolism with or without anticoagulant therapy, thrombophilia, superficial venous thrombosis, valvular heart disease, peripartum cardiomyopathy, systemic lupus erythematosus, high risk for HIV infection, cirrhosis, liver tumor, sickle cell disease, solid organ transplantation, and drug interactions with antiretrovirals used for prevention or treatment of HIV infection); and 3) inclusion of new contraceptive methods, including new doses or formulations of combined oral contraceptives, contraceptive patches, vaginal rings, progestin-only pills, levonorgestrel intrauterine devices, and vaginal pH modulator. The recommendations in this report are intended to serve as a source of evidence-based clinical practice guidance for health care providers. The goals of these recommendations are to remove unnecessary medical barriers to accessing and using contraception and to support the provision of person-centered contraceptive counseling and services in a noncoercive manner. Health care providers should always consider the individual clinical circumstances of each person seeking contraceptive services. This report is not intended to be a substitute for professional medical advice for individual patients; when needed, patients should seek advice from their health care providers about contraceptive use.

Pregnancy Intention: Associations with Maternal Behaviors and Experiences During and After Pregnancy.

Background: The associations between levels of pregnancy intention and adverse behaviors or experiences during pregnancy and postpartum have not been well described. Materials and Methods: We used 2018 Pregnancy Risk Assessment Monitoring System data from 31 jurisdictions in the United States (n = 32,777) to estimate prevalence of inadequate prenatal care (PNC), inappropriate gestational weight gain, depression during pregnancy, intimate partner violence (IPV) during pregnancy, third trimester smoking, no breastfeeding, no postpartum visit, postpartum depressive symptoms, and postpartum smoking by categories of pregnancy intention: unwanted, ambivalent (i.e., unsure), mistimed (i.e., wanted later), or wanted (i.e., wanted then/sooner). Regression models estimated adjusted prevalence ratios (aPR) and 95% confidence intervals (CIs) of associations between pregnancy intention and maternal behaviors or experiences. Results: Approximately 16% of women reported pregnancy ambivalence. Women with pregnancy ambivalence (versus wanted pregnancies) had higher prevalence of all adverse maternal behaviors and experiences. Separate models found women with unwanted pregnancy (vs. ambivalent) had higher prevalence for depression during pregnancy (aPR: 1.40, 95% CI: 1.21-1.63), IPV (aPR: 1.75, 95% CI: 1.11-2.77), no breastfeeding (aPR: 1.22, 95% CI: 1.04-1.44), no postpartum visit (aPR: 1.28, 95% CI: 1.06-1.55), and postpartum depressive symptoms (aPR: 1.19, 95% CI: 1.00-1.42); Women with mistimed pregnancy (vs. ambivalent) had lower prevalence for inadequate PNC (aPR: 0.89, 95% CI: 0.81-0.98), third trimester smoking (aPR: 0.68, 95% CI: 0.57-0.80), no breastfeeding (aPR: 0.85, 95% CI: 0.74-0.98), and postpartum smoking (aPR: 0.83, 95% CI: 0.73-0.95). Discussion: The results emphasize the importance of recommended screening and care during the preconception, prenatal, and postpartum periods.

Required examinations and tests before initiating contraception: Provider practices from a national cross-sectional survey.

OBJECTIVE(S): We estimated the prevalence of requiring specific examinations or tests before providing contraception in a nationwide survey of family planning providers. STUDY DESIGN: We conducted a cross-sectional survey of public-sector health centers and office-based physicians providing family planning services across the United States in 2019 (n = 1395). We estimated the weighted proportion of providers (or their health center or practice) who required blood pressure measurement, pelvic examination (bimanual examination and cervical inspection), Papanicolaou (Pap) smear, clinical breast examination (CBE), and chlamydia and gonorrhea (CT/GC) screening before initiating hormonal or intrauterine contraception (IUC) for healthy women. We performed multivariable regression to identify factors associated with pelvic examination practices aligned with clinical recommendations; these recommendations classify examinations and tests as recommended or unnecessary before initiation of specific contraceptive methods. RESULTS: The overall response rate was 51%. Most providers required blood pressure measurement before initiating each method. Unnecessary CBE, Pap smears, and CT/GC screening were required by 14% to 33% of providers across methods. Fifty-two to 62% of providers required recommended pelvic examination before IUC placement; however, 16% to 23% of providers required unnecessary pelvic examinations before non-intrauterine hormonal method initiation. Factors associated with recommendation-aligned pelvic examination practices included having a higher proportion of patients using public funding (Medicaid or other assistance) and more recently completing formal clinical training. CONCLUSIONS: Almost half (47%) of providers did not require necessary pelvic examination before placing IUC. Conversely, many providers required unnecessary examinations and tests before contraception initiation for patients. IMPLICATIONS: Most providers required the few recommended examinations and tests for safe contraceptive provision. Reduction of unnecessary examinations and tests may reduce barriers to contraceptive access. There are also opportunities to increase use of recommended examinations, as up to 48% of providers did not require recommended pelvic examination before IUC.

Update: Characteristics of Patients in a National Outbreak of E-cigarette, or Vaping, Product Use-Associated Lung Injuries - United States, October 2019.

CDC, the Food and Drug Administration, state and local health departments, and other public health and clinical stakeholders are investigating a national outbreak of electronic-cigarette (e-cigarette), or vaping, product use-associated lung injury (EVALI) (1). As of October 22, 2019, 49 states, the District of Columbia (DC), and the U.S. Virgin Islands have reported 1,604 cases of EVALI to CDC, including 34 (2.1%) EVALI-associated deaths in 24 states. Based on data collected as of October 15, 2019, this report updates data on patient characteristics and substances used in e-cigarette, or vaping, products (2) and describes characteristics of EVALI-associated deaths. The median age of EVALI patients who survived was 23 years, and the median age of EVALI patients who died was 45 years. Among 867 (54%) EVALI patients with available data on use of specific e-cigarette, or vaping, products in the 3 months preceding symptom onset, 86% reported any use of tetrahydrocannabinol (THC)-containing products, 64% reported any use of nicotine-containing products, and 52% reported use of both. Exclusive use of THC-containing products was reported by 34% of patients and exclusive use of nicotine-containing products by 11%, and for 2% of patients, no use of either THC- or nicotine-containing products was reported. Among 19 EVALI patients who died and for whom substance use data were available, 84% reported any use of THC-containing products, including 63% who reported exclusive use of THC-containing products; 37% reported any use of nicotine-containing products, including 16% who reported exclusive use of nicotine-containing products. To date, no single compound or ingredient used in e-cigarette, or vaping, products has emerged as the cause of EVALI, and there might be more than one cause. Because most patients reported using THC-containing products before symptom onset, CDC recommends that persons should not use e-cigarette, or vaping, products that contain THC. In addition, because the specific compound or ingredient causing lung injury is not yet known, and while the investigation continues, persons should consider refraining from the use of all e-cigarette, or vaping, products.

Changes in US health care provider attitudes related to contraceptive safety before and after the release of National Guidance.

OBJECTIVE: The US Medical Eligibility Criteria for Contraceptive Use (USMEC) is the first national guidance containing evidence-based recommendations for contraception. We describe provider attitudes about contraceptive safety before and after the 2010 USMEC release. STUDY DESIGN: We conducted two cross-sectional mailed surveys using different nationwide samples of office-based physicians and Title X clinic providers before (2009-2010) and after (2013-2014) the USMEC release. We compared the proportion of providers reporting select contraceptive methods as safe for women with specific characteristics or medical conditions before and after the USMEC release and conducted multivariable logistic regression to adjust for provider characteristics. RESULTS: For the following select characteristics for which the USMEC classifies specific contraceptive methods as safe (Category 1 or 2), a significantly (p<.05) higher proportion of providers reported the method safe after versus before the USMEC release: intrauterine devices (IUDs) for adolescents (79.8% versus 60.2%), IUDs for women with HIV (72.4% versus 50.6%), depot medroxyprogesterone acetate (DMPA) for women with obesity (89.5% versus 76.1%), and DMPA for women with history of bariatric surgery (87.6% versus 73.9%). These differences remained significant after adjustment for provider characteristics. CONCLUSIONS: While we observed many positive changes in health care provider attitudes related to contraception safety after the USMEC release, gaps remain. Continuing education and evidence-based training for providers, and ensuring office and health center protocols address medical eligibility for contraception for the full range of characteristics included in the USMEC might bridge remaining gaps and increase delivery of high-quality contraception care. IMPLICATIONS: Gaps between evidence and provider attitudes remain that can inform future efforts to improve contraceptive service delivery.

Healthcare provider knowledge regarding oral contraception effectiveness for women with a history of bariatric malabsorptive procedures.

BACKGROUND: Clinical practice guidelines that recommend women avoid pregnancy immediately after bariatric surgery, highlighting the need for effective contraception. However, women with a history of malabsorptive bariatric procedures should generally not use oral contraceptives, as these procedures may decrease oral contraceptive effectiveness. OBJECTIVES: To identify provider characteristics associated with knowledge of combined oral contraceptive (COC) effectiveness. SETTING: United States. METHODS: We analyzed weighted survey data collected from national samples of public-sector health centers and office-based physicians who regularly provide family planning services (N = 2060). We asked providers about the effectiveness of COCs for women with a history of malabsorptive procedures compared with healthy women, giving them the response options of more/equally effective, less effective, and do not know. We used multinomial logistic regression to calculate adjusted odds ratios and 95% confidence intervals to identify characteristics associated with knowledge of COC effectiveness. RESULTS: Approximately 55% of providers correctly answered that COCs are less effective for women with malabsorptive procedures; 25% considered COCs more/equally effective, and 20% were uncertain. Among public-sector providers, the adjusted odds of uncertainty were significantly higher for those whose clinical focus was not reproductive health, for nurses versus advanced practice clinicians, and for providers working in clinics without Title X funding. For office-based physicians, adolescent medicine providers had higher odds of uncertainty versus obstetrician-gynecologists. Physicians practicing in settings classified as "other" (such as community health centers) had higher odds of considering COCs effective compared with those practicing in hospital or university clinics. CONCLUSIONS: Substantial proportions of surveyed providers had inadequate knowledge of COC effectiveness for women with a history of malabsorptive procedures.

Preconception Health Indicators for Public Health Surveillance.

OBJECTIVES: In response to an expressed need for more focused measurement of preconception health (PCH), we identify a condensed set of PCH indicators for state and national surveillance. METHODS: We used a systematic process to evaluate, prioritize, and select 10 PCH indicators that maternal and child health programs can use for surveillance. For each indicator, we assessed prevalence, whether it was addressed by professional recommendations, Healthy People 2020 objectives, or Centers for Disease Control and Prevention winnable battles, measurement simplicity, data completeness, and stakeholders' input. RESULTS: Fifty PCH indicators were evaluated and prioritized. The condensed set includes indicators that rely on data from the Pregnancy Risk Assessment Monitoring System (n = 4) and the Behavioral Risk Factor Surveillance System (n = 6). The content encompasses heavy alcohol consumption, depression, diabetes, folic acid intake, hypertension, normal weight, recommended physical activity, current smoking, unwanted pregnancy, and use of contraception. CONCLUSIONS: Having a condensed set of PCH indicators can facilitate surveillance of reproductive-aged women's health status that supports monitoring, comparisons, and benchmarking at the state and national levels.

Disparities in Preconception Health Indicators - Behavioral Risk Factor Surveillance System, 2013-2015, and Pregnancy Risk Assessment Monitoring System, 2013-2014.

PROBLEM/CONDITION: Preconception health is a broad term that encompasses the overall health of nonpregnant women during their reproductive years (defined here as aged 18-44 years). Improvement of both birth outcomes and the woman's health occurs when preconception health is optimized. Improving preconception health before and between pregnancies is critical for reducing maternal and infant mortality and pregnancy-related complications. The National Preconception Health and Health Care Initiative's Surveillance and Research work group suggests ten prioritized indicators that states can use to monitor programs or activities for improving the preconception health status of women of reproductive age. This report includes overall and stratified estimates for nine of these preconception health indicators. REPORTING PERIOD: 2013-2015. DESCRIPTION OF SYSTEMS: Survey data from two surveillance systems are included in this report. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based, landline and cellular telephone survey of noninstitutionalized adults in the United States aged ≥18 years that is conducted by state and territorial health departments. BRFSS is the main source of self-reported data for states on health risk behaviors, chronic health conditions, and preventive health services primarily related to chronic disease in the United States. The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing U.S. state- and population-based surveillance system administered collaboratively by CDC and state health departments. PRAMS is designed to monitor selected maternal behaviors, conditions, and experiences that occur before, during, and shortly after pregnancy that are self-reported by women who recently delivered a live-born infant. This report summarizes BRFSS and PRAMS data on nine of 10 prioritized preconception health indicators (i.e., depression, diabetes, hypertension, current cigarette smoking, normal weight, recommended physical activity, recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method) for which the most recent data are available. BRFSS data from all 50 states and the District of Columbia were used for six preconception health indicators: depression, diabetes (excluded if occurring only during pregnancy or if limited to borderline/prediabetes conditions), hypertension (excluded if occurring only during pregnancy or if limited to borderline/prehypertension conditions), current cigarette smoking, normal weight, and recommended physical activity. PRAMS data from 30 states, the District of Columbia, and New York City were used for three preconception health indicators: recent unwanted pregnancy, prepregnancy multivitamin use, and postpartum use of a most or moderately effective contraceptive method by women or their husbands or partners (i.e., male or female sterilization, hormonal implant, intrauterine device, injectable contraceptive, oral contraceptive, hormonal patch, or vaginal ring). Heavy alcohol use during the 3 months before pregnancy also was included in the prioritized set of 10 indicators, but PRAMS data for each reporting area are not available until 2016 for that indicator. Therefore, estimates for heavy alcohol use are not included in this report. All BRFSS preconception health estimates are based on 2014-2015 data except two (hypertension and recommended physical activity are based on 2013 and 2015 data). All PRAMS preconception health estimates rely on 2013-2014 data. Prevalence estimates of indicators are reported for women aged 18-44 years overall, by age group, race-ethnicity, health insurance status, and reporting area. Chi-square tests were conducted to assess differences in indicators by age group, race/ethnicity, and insurance status. RESULTS: During 2013-2015, prevalence estimates of indicators representing risk factors were generally highest and prevalence estimates of health-promoting indicators were generally lowest among older women (35-44 years), non-Hispanic black women, uninsured women, and those residing in southern states. For example, prevalence of ever having been told by a health care provider that they had a depressive disorder was highest among women aged 35-44 years (23.1%) and lowest among women aged 18-24 years (19.2%). Prevalence of postpartum use of a most or moderately effective method of contraception was lowest among women aged 35-44 years (50.6%) and highest among younger women aged 18-24 years (64.9%). Self-reported prepregnancy multivitamin use and getting recommended levels of physical activity were lowest among non-Hispanic black women (21.6% and 42.8%, respectively) and highest among non-Hispanic white women (37.8% and 53.8%, respectively). Recent unwanted pregnancy was lowest among non-Hispanic white women and highest among non-Hispanic black women (5.0% and 11.6%, respectively). All but three indicators (diabetes, hypertension, and use of a most or moderately effective contraceptive method) varied by insurance status; for instance, prevalence of current cigarette smoking was higher among uninsured women (21.0%) compared with insured women (16.1%), and prevalence of normal weight was lower among women who were uninsured (38.6%), compared with women who were insured (46.1%). By reporting area, the range of women reporting ever having been told by a health care provider that they had diabetes was 5.0% (Alabama) to 1.9% (Utah), and women reporting ever having been told by a health care provider that they had hypertension ranged from 19.2% (Mississippi) to 7.0% (Minnesota). INTERPRETATION: Preconception health risk factors and health-promoting indicators varied by age group, race/ethnicity, insurance status, and reporting area. These disparities highlight subpopulations that might benefit most from interventions that improve preconception health. PUBLIC HEALTH ACTION: Eliminating disparities in preconception health can potentially reduce disparities in two of the leading causes of death in early and middle adulthood (i.e., heart disease and diabetes). Public health officials can use this information to provide a baseline against which to evaluate state efforts to improve preconception health.

U.S. Medical Eligibility Criteria for Contraceptive Use, 2016.

The 2016 U.S. Medical Eligibility Criteria for Contraceptive Use (U.S. MEC) comprises recommendations for the use of specific contraceptive methods by women and men who have certain characteristics or medical conditions. These recommendations for health care providers were updated by CDC after review of the scientific evidence and consultation with national experts who met in Atlanta, Georgia, during August 26-28, 2015. The information in this report updates the 2010 U.S. MEC (CDC. U.S. medical eligibility criteria for contraceptive use, 2010. MMWR 2010:59 [No. RR-4]). Notable updates include the addition of recommendations for women with cystic fibrosis, women with multiple sclerosis, and women receiving certain psychotropic drugs or St. John's wort; revisions to the recommendations for emergency contraception, including the addition of ulipristal acetate; and revisions to the recommendations for postpartum women; women who are breastfeeding; women with known dyslipidemias, migraine headaches, superficial venous disease, gestational trophoblastic disease, sexually transmitted diseases, and human immunodeficiency virus; and women who are receiving antiretroviral therapy. The recommendations in this report are intended to assist health care providers when they counsel women, men, and couples about contraceptive method choice. Although these recommendations are meant to serve as a source of clinical guidance, health care providers should always consider the individual clinical circumstances of each person seeking family planning services. This report is not intended to be a substitute for professional medical advice for individual patients. Persons should seek advice from their health care providers when considering family planning options.

Contraceptive safety among women with cystic fibrosis: a systematic review.

BACKGROUND: With dramatic improvements in life expectancy for cystic fibrosis (CF) patients, contraception for women with CF has become an important issue. There are theoretical concerns that hormonal contraceptive use among women with CF may impact disease severity or risk for other adverse health outcomes, including thrombosis and poor bone health, as well as concerns that malabsorption or altered drug metabolism might impact contraceptive effectiveness. OBJECTIVE: To evaluate evidence on the safety and effectiveness of contraceptive methods among women with CF. SEARCH STRATEGY: We searched the PubMed database for all articles published from database inception through October 2015. SELECTION CRITERIA: We included studies that examined measures of disease severity, other health outcomes or indicators of contraceptive effectiveness among women with CF initiating or continuing a contraceptive method. RESULTS: Seven studies met our inclusion criteria. Three observational studies of fair to poor quality suggest that use of oral contraceptives (OCs) does not negatively impact CF disease severity, defined as changes in pulmonary function, number of exacerbations or need for intravenous antibiotics. Three small studies of poor quality reported on contraceptive failure among women with CF using combined hormonal contraceptives (combined OCs, patch or ring). One pregnancy was reported in a patch user out of 43 hormonal contraceptive users across all studies. One pharmacokinetic study reported that women with CF achieve steroid hormone plasma concentrations similar to healthy women after ingestion of combined OCs. CONCLUSIONS: Limited evidence suggests that hormonal contraceptive use does not negatively impact disease severity among women with CF and that hormonal contraceptive effectiveness is not impaired by CF. Studies were limited by small sample sizes and short duration of follow-up. No studies examined the effect of hormonal contraception on thrombosis or bone health among women with CF.

Core state preconception health indicators - pregnancy risk assessment monitoring system and behavioral risk factor surveillance system, 2009.

PROBLEM/CONDITION: Promoting preconception health can potentially improve women's health and pregnancy outcomes. Evidence-based interventions exist to reduce many maternal behaviors and chronic conditions that are associated with adverse pregnancy outcomes such as tobacco use, alcohol use, inadequate folic acid intake, obesity, hypertension, and diabetes. The 2006 national recommendations to improve preconception health included monitoring improvements in preconception health by maximizing public health surveillance (CDC. Recommendations to improve preconception health and health care-United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55[No. RR-6]). REPORTING PERIOD COVERED: 2009 for 38 indicators; 2008 for one indicator. DESCRIPTION OF SURVEILLANCE SYSTEMS: The Pregnancy Risk Assessment Monitoring System (PRAMS) is an ongoing state- and population-based surveillance system designed to monitor selected self-reported maternal behaviors, conditions, and experiences that occur shortly before, during, and after pregnancy among women who deliver live-born infants. The Behavioral Risk Factor Surveillance System (BRFSS) is an ongoing state-based telephone survey of noninstitutionalized adults aged ≥18 years in the United States that collects state-level data on health-related risk behaviors, chronic conditions, and preventive health services. This surveillance summary includes PRAMS data from 29 reporting areas (n = 40,388 respondents) and BRFSS data from 51 reporting areas (n = 62,875 respondents) for nonpregnant women of reproductive age (aged 18-44 years). To establish a comprehensive, nationally recognized set of indicators to be used for monitoring, evaluation, and response, a volunteer group of policy and program leaders and epidemiologists identified 45 core state preconception health indicators, of which 41 rely on PRAMS or BRFSS as data sources. This report includes 39 of the 41 core state preconception health indicators for which data are available through PRAMS or BRFSS. The two indicators from these data sources that are not described in this report are human immunodeficiency virus (HIV) testing within a year before the most recent pregnancy and heavy drinking on at least one occasion during the preceding month. Ten preconception health domains are examined: general health status and life satisfaction, social determinants of health, health care, reproductive health and family planning, tobacco and alcohol use, nutrition and physical activity, mental health, emotional and social support, chronic conditions, and infections. Weighted prevalence estimates and 95% confidence intervals (95% CIs)for 39 indicators are presented overall and for each reporting area and stratified by age group (18-24, 25-34, and 35-44 years) and women's race/ethnicity (non-Hispanic white, non-Hispanic black, non-Hispanic other, and Hispanic). RESULTS: This surveillance summary includes data for 39 of 41 indicators: 2009 data for 23 preconception health indicators that were monitored by PRAMS and 16 preconception health indicators that were monitored by BRFSS (one BRFSS indicator uses 2008 data). For two of the indicators that are included in this report (prepregnancy overweight or obesity and current overweight or obesity), separate measures of overweight and obesity were reported. All preconception health indicators varied by reporting area, and most indicators varied significantly by age group and race/ethnicity. Overall, 88.9% of women of reproductive age reported good, very good, or excellent general health status and life satisfaction (BRFSS). A high school/general equivalency diploma or higher education (social determinants of health domain) was reported by 94.7% of non-Hispanic white, 92.9% of non-Hispanic other, 91.1% of non-Hispanic black, and 70.9% of Hispanic women (BRFSS). Overall, health-care insurance coverage during the month before the most recent pregnancy (health-care domain) was 74.9% (PRAMS). A routine checkup during the preceding year was reported by 79.0% of non-Hispanic black, 65.1% of non-Hispanic white, 64.3% of other, and 63.0% of Hispanic women (BRFSS). Among women with a recent live birth (2-9 months since date of delivery), selected PRAMS results for the reproductive health and family planning, tobacco and alcohol use, and nutrition domains included several factors. Although 43% of women reported that their most recent pregnancy was unintended (unwanted or wanted to be pregnant later), approximately half (53%) of those who were not trying to get pregnant reported not using contraception at the time of conception. Smoking during the 3 months before pregnancy was reported by 25.1% of women, and drinking alcohol 3 months before pregnancy was reported by 54.2% of women. Daily use of a multivitamin, prenatal vitamin, or a folic acid supplement during the month before pregnancy was reported by 29.7% of women. Selected BRFSS results included indicators pertaining to the nutrition and physical activity, emotional and social support, and chronic conditions domains among women of reproductive age. Approximately one fourth (24.7%) of women were identified as being obese according to body mass index (BMI) on the basis of self-reported height and weight. Overall, 51.6% of women reported participation in recommended levels of physical activity per U.S. Department of Health and Human Services physical activity guidelines. Non-Hispanic whites reported the highest prevalence (85.0%) of having adequate emotional and social support, followed by other races/ethnicities (74.9%), Hispanics (70.5%), and non-Hispanic blacks (69.7%). Approximately 3.0% of persons reported ever being diagnosed with diabetes, and 10.2% of women reported ever being diagnosed with hypertension. INTERPRETATION: The findings in this report underscore opportunities for improving the preconception health of U.S. women. Preconception health and women's health can be improved by reducing unintended pregnancies, reducing risky behaviors (e.g., smoking and drinking) among women of reproductive age, and ensuring that chronic conditions are under control. Evidence-based interventions and clinical practice guidelines exist to address these risks and to improve pregnancy outcomes and women's health in general. The results also highlight the need to increase access to health care for all nonpregnant women of reproductive age and the need to encourage the use of essential preventive services for women, including preconception health services. In addition, system changes in community settings can alleviate health problems resulting from inadequate social and emotional support and environments that foster unhealthy lifestyles. Policy changes can promote health equity by encouraging environments that promote healthier options in nutrition and physical activity. Finally, variation in the preconception health status of women by age and race/ethnicity underscores the need for implementing and scaling up proven strategies to reduce persistent health disparities among those at highest risk. Ongoing surveillance and research in preconception health are needed to monitor the influence of improved health-care access and coverage on women's prepregnancy and interpregnancy health status, pregnancy and infant outcomes, and health disparities. PUBLIC HEALTH ACTION: Public health decision makers, program planners, researchers, and other key stakeholders can use the state-level PRAMS and BRFSS preconception health indicators to benchmark and monitor preconception health among women of reproductive age. These data also can be used to evaluate the effectiveness of preconception health state and national programs and to assess the need for new programs, program enhancements, and policies.

The effect of body mass index and weight change on epithelial ovarian cancer survival in younger women: a long-term follow-up study.

OBJECTIVE: The objective of this study was to assess the relationship between body mass index (BMI) and epithelial ovarian cancer survival among young women. METHODS: We conducted a cohort analysis of 425 women aged 20-54 years with incident epithelial ovarian cancer enrolled during 1980-1982 in Cancer and Steroid Hormone (CASH), a population-based, case-control study. Participants' vital status was ascertained though linkage with the Surveillance, Epidemiology and End Results (SEER) program. Using Cox proportional hazards models, we estimated adjusted hazard ratios (HR) and 95% confidence intervals (CI) for the association between survival and usual adult BMI, BMI at age 18, and weight change from age 18 to adult. RESULTS: During a follow-up of up to 17 years, 215 women died. Compared to women with an adult BMI in the lowest quartile (<20.7), women in the second (20.8-22.5), third (22.6-24.9), and fourth (≥25.0) quartiles were not at increased risk for death (HR 1.2, 95% CI 0.8-1.8; HR 1.1, 95% CI 0.7-1.6; and HR 0.9, 95% CI 0.6-1.4, respectively) (p trend=0.6). Similarly, neither age 18 BMI nor weight change were associated with ovarian cancer survival. CONCLUSIONS: Although elevated BMI is associated with increased ovarian cancer risk among young women, we found no evidence of its association with ovarian cancer survival in this population.

Associations between preconception counseling and maternal behaviors before and during pregnancy.

Preconception counseling (PCC) is a vital component of preconception care. Through counseling, providers educate and recommend strategies to improve health and birth outcomes for women of reproductive age. The objective of our analysis was to assess the associations between receipt of PCC and positive maternal behaviors before and during pregnancy. We analyzed 2004-2008 Pregnancy Risk Assessment Monitoring System data from Maine, New Jersey, Utah, and Vermont. Multivariable logistic regression was used to investigate the associations between receipt of PCC and prepregnancy daily multivitamin consumption, first-trimester entry into prenatal care, and cessation of smoking and drinking before pregnancy among women who smoked/drank in the 2 years preceding the survey, adjusting for a wide range of maternal characteristics. Overall, 32% of women reported receipt of PCC, with particularly low rates reported among women with an unintended pregnancy (14%) and no health insurance prior to pregnancy (14%). Receipt of PCC was associated with daily prepregnancy multivitamin consumption (adjusted odds ratio [AOR] = 4.4; 95% confidence interval [CI] = 4.0, 4.7), first-trimester entry into prenatal care for women with an intended pregnancy (AOR = 2.1; 95% CI = 1.8, 2.4), and drinking cessation before pregnancy among women who drank in the 2 years preceding the survey (AOR = 1.3; 95% CI = 1.2, 1.5). PCC was associated with positive maternal behaviors that increase the likelihood of a healthy woman, pregnancy, and infant. Unfortunately, less than one-third of women with a recent live birth reported receiving PCC. These data provide population-based evidence suggesting the value of PCC in the promotion of healthy maternal behaviors for women with intended or unintended pregnancies.

Intrauterine device use among women with ovarian cancer: a systematic review.

BACKGROUND: Fertility-sparing treatment may be an option for women with early stage ovarian cancer and certain tumor types. This systematic review evaluated the evidence on the safety of intrauterine device (IUD) use by women with ovarian cancer. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles relevant to IUD (copper or levonorgestrel-releasing) use and ovarian cancer published in any language from database inception through August 2009. We sought studies that examined outcomes among women using an IUD at or after ovarian cancer diagnosis. RESULTS: Of the 250 articles identified by our search strategy, none provided evidence (direct or indirect) regarding the safety of IUD use among women with ovarian cancer. CONCLUSIONS: No evidence on the safety of IUD use among women with ovarian cancer was identified. While there are some theoretical concerns that IUD use might affect monitoring of disease progression of sex cord-stromal tumors, or increase risk of pelvic infection or vaginal bleeding among women undergoing chemotherapy, we did not find any data to suggest that IUD use would lead to worsening of primary ovarian cancer.

Intrauterine device use among women with uterine fibroids: a systematic review.

BACKGROUND: There are concerns that intrauterine device (IUD) use by women with uterine fibroids might increase their uterine bleeding or risk for device expulsion. The objective of this systematic review was to evaluate evidence concerning the safety and effectiveness of IUD use among women with uterine fibroids. Key questions included whether IUD use is associated with increased risk for uterine bleeding among women with uterine fibroids and whether the presence of uterine fibroids is associated with an increased risk for device expulsion among IUD users. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles relevant to IUD (copper or levonorgestrel-releasing) use and uterine fibroids published in any language from database inception through June 2009. We used standard abstract forms and a grading system to summarize and assess the quality of the evidence. RESULTS: From 202 articles found in the database search, we identified 11 studies that met our inclusion criteria, all of which examined outcomes among users of the levonorgestrel-releasing IUD (LNG-IUD). Evidence from 10 of 11 noncomparative studies (Level II-3, fair) suggests that LNG-IUD use among women with fibroids does not increase menstrual bleeding, and results from all 11 showed that menstrual blood loss decreased among women who continued to use the LNG-IUD through the end of the study period. Overall, serum levels of hemoglobin, hematocrit and ferritin increased among LNG-IUD users in studies that assessed these outcomes. Several studies reported some occurrences of irregular bleeding. Findings from two cohort studies (Level II-2, fair to poor) showed rates of LNG-IUD expulsion to be higher among women with uterine fibroids (11% in each) than among women without uterine fibroids (0% and 3%); however, in one study the difference was not statistically significant, and in the other significance testing was not conducted. Six prospective noncomparative studies reported expulsion rates of 0-20% among women with uterine fibroids. CONCLUSIONS: Most women with uterine fibroids are likely to have less menstrual blood loss and higher serum levels of hemoglobin, hematocrit and ferritin after insertion of an LNG-IUD, despite some occurrences of irregular bleeding. LNG-IUD users with uterine fibroids may have higher rates of expulsion than those without fibroids.

Use of contraceptive methods among women with endometrial hyperplasia: a systematic review.

BACKGROUND: The objective of this systematic review is to evaluate the evidence for the safety of contraceptive use among women with endometrial hyperplasia. STUDY DESIGN: We searched the PubMed database for peer-reviewed articles published in any language from database inception through February 2009 concerning the safety of using any contraceptive method among women diagnosed with endometrial hyperplasia. We excluded case reports but included all other study designs. The quality of each individual piece of evidence was assessed using the United States Preventive Services Task Force grading system. RESULTS: We identified nine articles that met the criteria for review. Each study examined levonorgestrel intrauterine devices (LNG-IUDs); no studies were identified that examined other contraceptive methods. Overall, these studies suggest that LNG-IUD use is not associated with adverse health events among women diagnosed with endometrial hyperplasia. Disease regression with LNG-IUD use was observed in all women in seven studies, in 90% of women in one study, and in 67% of women in one study. Limitations of the studies include small sample sizes and lack of a comparison group or nonrandomized assignment to LNG-IUD. CONCLUSIONS: There is fair quality evidence indicating that use of the LNG-IUD is safe for women with endometrial hyperplasia and may have therapeutic benefits.

Contraceptive use among women with a history of bariatric surgery: a systematic review.

BACKGROUND: Weight loss after bariatric surgery often improves fertility but can pose substantial risks to maternal and fetal outcomes. Women who have undergone a bariatric surgical procedure are currently advised to delay conception for up to 2 years. STUDY DESIGN: We conducted a systematic review of the literature, from database (PubMed) inception through February 2009, to evaluate evidence on the safety and effectiveness of contraceptive use among women with a history of bariatric surgery. RESULTS: From 29 articles, five met review inclusion criteria. One prospective, noncomparative study reported 2 pregnancies among 9 (22%) oral contraceptive (OC) users following biliopancreatic diversion, and one descriptive study reported no pregnancies among an unidentified number of women taking OCs following laparoscopic adjustable gastric banding. Of two pharmacokinetic studies, one found lower plasma levels of norethisterone and levonorgestrel among women having had a jejunoileal bypass, as compared to nonoperated, normal-weight controls. The other study found no difference in plasma levels of D-norgestrel between women having a jejunoileal bypass of either 1:3 or 3:1 ratio between the length of jejunum and ileum left in continuity, but women with a 1:3 ratio had significantly higher plasma levels of D-norgestrel than extremely obese controls not operated upon. CONCLUSIONS: Evidence regarding OC effectiveness following a bariatric surgical procedure is quite limited, although no substantial decrease in effectiveness was identified from available studies. Evidence on failure rates for other contraceptive methods and evidence on safety for all contraceptive methods was not identified.

Dietary and physical activity behaviors of middle school youth: the youth physical activity and nutrition survey.

BACKGROUND: Obesity has become a national epidemic among youth. Declining physical activity and poor nutrition contribute to this epidemic. The purpose of this study was to obtain data on middle school students' physical activity and nutrition knowledge and practices. METHODS: The Youth Physical Activity and Nutrition Survey was developed and distributed to a probability sample of Florida public middle schools (n = 73) in spring 2003, producing data from 4,452 students in grades 6-8. RESULTS: Results showed that less than one fourth of youth met expert recommendations for daily fruit and vegetable intake and less than one fifth identified the daily fruit and vegetable serving recommendation. Less than half of students reported eating breakfast daily. More non-Hispanic black youth reported not engaging in vigorous or moderate physical activity during the previous 7 days, and more girls and Hispanic youth reported not attending any physical education classes during the average school week. CONCLUSION: These findings demonstrate that dietary and physical activity behaviors and knowledge among these middle school youth are setting the stage for the obesity epidemic to continue.

Preconception and interconception health status of women who recently gave birth to a live-born infant--Pregnancy Risk Assessment Monitoring System (PRAMS), United States, 26 reporting areas, 2004.

PROBLEM/CONDITION: In 2006, CDC published recommendations to improve health and health care for women before pregnancy and between pregnancies (CDC. Recommendations to improve preconception health and health care--United States: a report of the CDC/ATSDR Preconception Care Work Group and the Select Panel on Preconception Care. MMWR 2006;55[No. RR-6]). The Pregnancy Risk Assessment Monitoring System (PRAMS) provides data concerning maternal behaviors, health conditions, and experiences for women in the United States who have delivered a live birth. REPORTING PERIOD COVERED: 2004. DESCRIPTION OF SYSTEM: PRAMS is an ongoing, state- and population-based surveillance system designed to monitor selected maternal behaviors and experiences that occur before, during, and after pregnancy among women who deliver live-born infants in selected states and cities in the United States. PRAMS employs a mixed mode data-collection methodology; up to three self-administered questionnaires are mailed to a sample of mothers, and nonresponders are followed up with telephone interviews. Self-reported survey data are linked to selected birth certificate data and weighted for sample design, nonresponse, and noncoverage to create annual PRAMS analysis data sets that can be used to produce statewide estimates of perinatal health behaviors and experiences among women delivering live infants. This report summarizes data from 26 PRAMS reporting areas that collected data during 2004 and that had achieved overall weighted response rates of > or =70% and had weighted data available by the time the analysis was conducted in January 2007. Data are reported on indicators regarding 18 behaviors and conditions that are relevant to preconception (i.e., prepregnancy) health and health care and 10 that are relevant to interconception (i.e., postpartum) health and health care. The number of questions that were administered varied by site; certain questions were not asked for all reporting areas. RESULTS: With respect to preconception maternal behaviors and experiences, mean overall prevalence was 23.2% for tobacco use, 50.1% for alcohol use, 35.1% for multivitamin use at least four times a week, 53.1% for nonuse of contraception among women who were not trying to become pregnant, 77.8% for ever having a dental visit before pregnancy, 30.3% for receiving prepregnancy health counseling, 3.6% for experiencing physical abuse, and 18.5% for experiencing at least four stressors before pregnancy. With respect to preconception maternal health conditions, mean overall prevalence was 13.2% for women being underweight (body mass index [BMI]: <19.8), 13.1% for being overweight (BMI: 26.0-29.0), and 21.9% for being obese (BMI: > or =29.0). Mean overall prevalence was 1.8% for having diabetes, 6.9% for asthma, 2.2% for hypertension, 1.2% for heart problems, and 10.2% for anemia. Among women with a previous live birth, the mean overall prevalence of having a previous low birth weight infant was 11.6% and of having a previous preterm infant was 11.9%. With respect to interconception maternal behaviors and experiences, mean overall prevalence was 17.9% for tobacco use, 85.1% for contraceptive use, 15.7% for having symptoms of depression, and 84.8% for having social support. Mean overall prevalence was 7.5% for the most recent infant being born low birth weight, 10.4% for having a recent preterm infant, 89.3% for having a check-up, 89.0% for receiving contraceptive use counseling, 30.4% for having a dental visit, and 48.6% for receiving services from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Results varied by maternal age, race/ethnicity, pregnancy intention, and health insurance status. For certain risk behaviors and health conditions, mean overall prevalence was higher among women aged <20 years, black women, women whose pregnancies were unintended, and women receiving Medicaid; however, no single subgroup was consistently at highest risk for all the indicators examined in this report. INTERPRETATION: PRAMS results varied among reporting areas. The prevalence estimates in the majority of reporting areas and for the majority of indicators suggest that a substantial number of women would benefit from preconception interventions to ensure that they enter pregnancy in optimal health. The results also demonstrate disparities among age and racial/ethnic subpopulations, especially with respect to prepregnancy medical conditions and access to health care both before conception and postpartum. Differences also exist in health behaviors between women who reported intended and unintended pregnancies. PUBLIC HEALTH ACTION: Maternal and child health programs can use PRAMS data to monitor improvements in maternal preconception and interconception behaviors and health status. The data presented in this report, which were collected before publication of CDC's recommendations to improve preconception health and health care in the United States, can be used as a baseline to monitor progress toward improvements in preconception and interconception health following publication of the recommendations. These data also can be used to identify specific groups at high risk that would benefit from targeted interventions and to plan and evaluate programs aimed at promoting positive maternal and infant health behaviors, experiences, and reproductive outcomes. In addition, the data can be used to inform policy decisions that affect the health of women and infants.