Awareness of the Maternal Health Benefits of Lactation Among U.S. Pregnant Individuals.

INTRODUCTION: We assessed awareness of the maternal health benefits of lactation among a sample of nulliparous pregnant individuals in the United States, identified variables associated with awareness of these benefits, and examined whether awareness of these benefits impacts breastfeeding attitudes or intentions. METHODS: We administered a web-based survey to nulliparous U.S.-born individuals carrying a singleton gestation of at least 28 weeks. We assessed awareness of the maternal health benefits of lactation using 10 items to create a summative score. We examined variation in awareness of these benefits by demographic characteristics, health insurance, and personal or family health history and used multivariable models to estimate associations between awareness of the maternal health benefits of lactation and breastfeeding intentions. RESULTS: Of the 675 individuals invited to complete surveys, 451 (67%) responded. Only 50% were aware that breastfeeding lowers maternal risk of breast cancer; fewer were aware that breastfeeding lowers the risk of ovarian cancer (35%), diabetes (27%), and hypertension and heart disease (26%). Awareness of the maternal benefits of lactation did not vary by age or race/ethnicity. However, significant regional variation was noted. In multivariable models, scores of awareness of the maternal health benefits of breastfeeding were significantly associated with intentions to breastfeed for at least 12 months (adjusted odds ratio, 1.23; 95% confidence interval, 1.11, 1.37). CONCLUSIONS: Efforts to increase awareness of the maternal health benefits of lactation are still needed. Increasing awareness of the maternal health benefits of lactation may strengthen intentions to breastfeed as recommended.

Tobacco and Cannabis Use During and After Pregnancy in California.

OBJECTIVES: As the social and legal acceptance of cannabis use grows, health professionals must understand and mitigate the impact of cannabis use in the perinatal period. Here we compare the prevalence of tobacco and cannabis use during and after pregnancy in California, a state that recently legalized cannabis use. METHODS: Measures of tobacco and cannabis use during and after pregnancy were obtained from California's Maternal and Infant Health Assessment, an annual population-based survey of California resident women with a live birth. To allow analysis of county-level variation, we pooled data from the 35 counties with the largest numbers of births from 2017 to 2019. RESULTS: Cannabis use was more than twice as common as cigarette smoking among pregnant women (4.9% vs. 2.1%) in California. This difference was even more pronounced in some counties; for example, in Los Angeles, cannabis use was four times more prevalent than cigarette use. Either during or soon after birth, 7.3% of women in California reported cannabis use. Of those who smoked tobacco cigarettes prior to pregnancy, 73% quit before their third trimester of pregnancy, though 33.0% of these women reported a post-partum relapse in cigarette use. CONCLUSIONS: States that have legalized cannabis must attend to the increasing prevalence of perinatal cannabis use, as well as concurrent use with tobacco and other substances. Efforts to support cannabis cessation should draw from successful public health approaches in tobacco control.

Perceived Contraceptive Counseling Quality Among Veterans Using VA Primary Care: Data from the ECUUN Study.

BACKGROUND: High-quality contraceptive counseling is critical to support Veterans' reproductive autonomy and promote healthy outcomes. OBJECTIVE: To describe perceived quality of contraceptive counseling in Veterans Health Administration (VA) primary care and assess factors associated with perceived high- and low-quality contraceptive counseling. DESIGN: Cross-sectional study using data from the Examining Contraceptive Use and Unmet Need in women Veterans (ECUUN) national telephone survey. PARTICIPANTS: Veterans aged 18-44 who received contraceptive services from a VA primary care clinic in the past year (N=506). MAIN MEASURES: Perceived quality of contraceptive counseling was captured by assessing Veterans' agreement with 6 statements regarding provider counseling adapted from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey. High-quality counseling was defined as a top score of strongly agreeing on all 6 items; low-quality counseling was defined as not agreeing (neutral, disagreeing, or strongly disagreeing) with >3 items. We constructed two multivariable models to assess associations between patient-, provider-, and system-level factors and perceived high-quality (Model 1) and perceived low-quality counseling (Model 2). KEY RESULTS: Most participants strongly agreed that their providers listened carefully (74%), explained things clearly (77%), and spent enough time discussing things (71%). Lower proportions strongly agreed that their provider discussed more than one option (54%), discussed pros/cons of various methods (44%), or asked which choice they thought was best for them (62%). In Model 1, Veterans who received care in a Women's Health Clinic (WHC) had twice the odds of perceiving high-quality counseling (aOR=1.99; 95%CI=1.24-3.22). In Model 2, Veterans who received care in a WHC (aOR=0.49; 95%CI=0.25-0.97) or from clinicians who provide cervical cancer screening (aOR=0.49; 95%CI=0.26-0.95) had half the odds of perceiving low-quality counseling. CONCLUSIONS: Opportunities exist to improve the quality of contraceptive counseling within VA primary care settings, including more consistent efforts to seek patients' perspectives with respect to contraceptive decisions.

Special Considerations for Women of Reproductive Age on Anticoagulation.

Anticoagulation poses unique challenges for women of reproductive age. Clinicians prescribing anticoagulants must counsel patients on issues ranging from menstruation and the possibility of developing a hemorrhagic ovarian cyst to teratogenic risks and safety with breastfeeding. Abnormal uterine bleeding affects up to 70% of young women who are treated with anticoagulation. As such, thoughtful clinical guidance is required to avoid having young women who are troubled by their menses, dose reduce, or prematurely discontinue their anticoagulation, leaving them at increased risk of recurrent thrombosis. Informed by a review of the medical literature, we present current recommendations for assisting patients requiring anticoagulation with menstrual management, prevention of hemorrhagic ovarian cysts, and avoiding unintended pregnancy. The subdermal implant may be considered a first-line option for those requiring anticoagulation, given its superior contraceptive effectiveness and ability to reliably reduce risk of hemorrhagic ovarian cysts. All progestin-only formulations-such as the subdermal implant, intrauterine device, injection, or pills-are generally preferred over combined hormonal pills, patch, or ring. Tranexamic acid, and in rare cases endometrial ablation, may also be useful in managing menorrhagia and dysmenorrhea. During pregnancy, enoxaparin remains the preferred anticoagulant and warfarin is contraindicated. Breastfeeding women may use warfarin, but direct oral anticoagulants are not recommended given their limited safety data. This practical guide for clinicians is designed to inform discussions of risks and benefits of anticoagulation therapy for women of reproductive age.

Comparative effectiveness of hysteroscopic and laparoscopic sterilization for women: a retrospective cohort study.

OBJECTIVE: To compare real-world effectiveness of hysteroscopic to laparoscopic sterilization. DESIGN: Retrospective cohort of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical variables to examine the poststerilization pregnancy rates. SETTING: Clinics, hospitals. PATIENT(S): Women aged 18-50 years with Medicaid claims between January 1, 2008, and August 31, 2014. INTERVENTION(S): Hysteroscopic or laparoscopic sterilization procedure. MAIN OUTCOME MEASURE(S): Poststerilization pregnancy measured by pregnancy-related claims. RESULT(S): Among women with hysteroscopic (n = 5,906) or laparoscopic (n = 23,965) sterilization, poststerilization pregnancy claims were identified for 4.74% of women after hysteroscopic sterilization and 5.57% after laparoscopic sterilization. The pregnancy rates decreased over time after either procedure. Twelve months after the procedure, the crude incidence of pregnancy claims was higher for hysteroscopic sterilization than for laparoscopic sterilization (3.26 vs. 2.61 per 100 woman-years), but the propensity-weighted adjusted incidence rate ratio was 1.06 (95% confidence interval [CI], 0.85-1.26). Between 13 and 24 months after the procedure, there were fewer pregnancies for women after hysteroscopic sterilizations than for those after laparoscopic sterilizations (adjusted incidence rate ratio, 0.63 [95% CI, 0.45-0.88]), with no statistically significant differences in later years. The cumulative pregnancy rates 5 years after sterilization were lower with hysteroscopic sterilization than with laparoscopic sterilization (6.26 vs. 7.22 per 100 woman-years; propensity-weighted, adjusted risk ratio, 0.76 [95% CI, 0.62-0.90]). The poststerilization pregnancy rates varied by age and race/ethnicity. CONCLUSION(S): The pregnancy rates after female sterilization are higher than expected, whether performed hysteroscopically or laparoscopically. These findings are reassuring that the effectiveness of hysteroscopic sterilization was not inferior to laparoscopic sterilization. CLINICAL TRIAL REGISTRATION NUMBER: NCT03438682.

Patient-Centered Safety Outcomes After Hysteroscopic Compared With Laparoscopic Sterilization.

OBJECTIVE: To evaluate the real-world safety of hysteroscopic compared with laparoscopic surgical sterilization. METHODS: We conducted a retrospective cohort study of Medicaid claims for hysteroscopic or laparoscopic sterilization procedures performed in California, 2008-2014, among women aged 18-50 years. After excluding postpartum procedures, we applied log-linear (Poisson) event-history regression models for clustered person-period data, weighted for propensity to receive either sterilization procedures, and adjusted for sociodemographic and clinical characteristics that may affect outcomes of interest to patients and physicians. We assessed the following outcomes: procedural complications, additional surgical procedures (eg, hysterectomy), repeat sterilization procedures, pelvic pain, pelvic inflammatory disease (PID), abdominal pain, nonabdominal pain, and abnormal uterine bleeding. RESULTS: We identified 5,906 women who had undergone hysteroscopic and 23,965 who had undergone laparoscopic sterilization. After adjusting for sociodemographic and health history, women who had hysteroscopic sterilization were less likely to have claims for procedural complications (eg, transfusion, P<.001) on the day of surgical sterilization and additional surgical procedures (eg, hysterectomy, P=.002 at day 2-3 months postprocedure) than laparoscopic sterilization. Claims for a repeat attempt at sterilization were more common after hysteroscopic sterilization within 1 year (adjusted incident rate ratio 3.48, 95% CI 2.69-4.27) and within 5 years (adjusted incident rate ratio 2.32, 95% CI 1.84-2.79) than laparoscopic sterilization. Claims for pelvic pain (adjusted incident rate ratio 0.77, 95% CI 0.65-0.92 at 2 years), abdominal pain (adjusted incident rate ratio 0.80, 95% CI 0.68-0.93 at 7-12 months), and PID (adjusted incident rate ratio 0.55, 95% CI 0.33-0.93 at 2 years) were less common after hysteroscopic than laparoscopic sterilization. Although abnormal uterine bleeding claims were more common after hysteroscopic than laparoscopic sterilization up to 12 months postprocedure (adjusted incident rate ratio 1.37, 95% CI 1.06-1.77 at 7-12 months), there were no significant differences between methods 1 year after the procedure. CONCLUSION: Compared with laparoscopic sterilization, hysteroscopic sterilization was followed by more claims for repeat sterilization procedures and abnormal uterine bleeding, but fewer procedural complications and fewer claims for pelvic or abdominal pain. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov, NCT03438682.

Alcohol Screening During US Primary Care Visits, 2014-2016.

BACKGROUND: Unhealthy alcohol use is a significant health issue for the US population. The US Preventive Services Task Force (USPSTF) recommends screening adults 18 years or older for unhealthy alcohol use during primary care visits. OBJECTIVES: To evaluate alcohol screening among ambulatory visits made by US adult primary care patients and identify characteristics predictive of alcohol screening. DESIGN: A series of cross-sectional analysis of the National Ambulatory Medical Care Survey (NAMCS) data collected from 2014 to 2016 was used to examine US primary care providers' use of alcohol screening questionnaires and delivery of counseling on alcohol use. PARTICIPANTS: A total of 19,213 visits made by patients aged 18 years or older to a US primary care physician trained in family medicine or internal medicine. MAIN MEASURES: Administration of a validated alcohol screening questionnaire and counseling/education on alcohol use. Variation in alcohol screening by patient demographic characteristics, reason for office visit, length of office visit, chronic medical conditions, evaluation by assigned primary care physician, new patient to practice, and region. KEY RESULTS: Alcohol screening with a validated questionnaire occurred during 2.6% (95% Cl: 0.9%, 4.3%) of visits. Alcohol counseling, provided either by the physician or by referral, was documented in 0.8% (95% Cl: 0.3%, 1.3%) of visits. Screening was significantly more likely if patients were seen by their assigned primary care physician (adjOR 4.38 (95% Cl: 1.41, 13.61)), a new patient to the practice (adjOR 4.18 (95% Cl: 2.30, 7.79)), or had several chronic medical conditions (adjOR 3.40 (95% Cl: 1.48, 7.78)). Patients' sex, race/ethnicity, age group, or length of appointment time was not associated with screening for unhealthy alcohol use. CONCLUSIONS: Screening for unhealthy alcohol use using a validated questionnaire is uncommonly performed during US primary care visits. Interventions or incentives may be needed to increase uptake of USPSTF alcohol screening recommendations.

Hormonal Contraception and Risk of Thromboembolism in Women With Diabetes.

OBJECTIVE: To investigate safety of hormonal contraception with regard to thromboembolic events in women with type 1 or 2 diabetes. RESEARCH DESIGN AND METHODS: We used data from 2002-2011 in Clinformatics Data Mart to identify women in the U.S., 14-44 years of age, with an ICD-9-CM code for diabetes and a prescription for a diabetic medication or device. We examined contraceptive claims and compared time to thromboembolism (venous thrombosis, stroke, or myocardial infarction) among women with diabetes dispensed hormonal contraception using a modification of Cox regression to control for age, smoking, obesity, hypertension, hyperlipidemia, diabetic complications, and history of cancer; we excluded data for 3 months after women gave birth. RESULTS: We identified 146,080 women with diabetes who experienced 3,012 thromboembolic events. Only 28% of reproductive-aged women with diabetes had any claims for hormonal contraception, with the majority receiving estrogen-containing oral contraceptives. Rates of thromboembolism were highest among women who used the contraceptive patch (16 per 1,000 woman-years) and lowest among women who used intrauterine (3.4 per 1,000 woman-years) and subdermal (0 per 163 woman-years) contraceptives. Compared with use of intrauterine contraception, progestin-only injectable contraception was associated with increased risk of thromboembolism (12.5 per 1,000 woman-years; adjusted hazard ratio 4.69 [95% CI 2.51-8.77]). CONCLUSIONS: The absolute risk of thromboembolism among women with type 1 or 2 diabetes using hormonal contraception is low. Highly effective, intrauterine and subdermal contraceptives are excellent options for women with diabetes who hope to avoid the teratogenic effects of hyperglycemia by carefully planning their pregnancies.

Suboptimal breastfeeding in the United States: Maternal and pediatric health outcomes and costs.

The aim of this study was to quantify the excess cases of pediatric and maternal disease, death, and costs attributable to suboptimal breastfeeding rates in the United States. Using the current literature on the associations between breastfeeding and health outcomes for nine pediatric and five maternal diseases, we created Monte Carlo simulations modeling a hypothetical cohort of U.S. women followed from age 15 to age 70 years and their children from birth to age 20 years. We examined disease outcomes using (a) 2012 breastfeeding rates and (b) assuming that 90% of infants were breastfed according to medical recommendations. We measured annual excess cases, deaths, and associated costs, in 2014 dollars, using a 2% discount rate. Annual excess deaths attributable to suboptimal breastfeeding total 3,340 (95% confidence interval [1,886 to 4,785]), 78% of which are maternal due to myocardial infarction (n = 986), breast cancer (n = 838), and diabetes (n = 473). Excess pediatric deaths total 721, mostly due to Sudden Infant Death Syndrome (n = 492) and necrotizing enterocolitis (n = 190). Medical costs total $3.0 billion, 79% of which are maternal. Costs of premature death total $14.2 billion. The number of women needed to breastfeed as medically recommended to prevent an infant gastrointestinal infection is 0.8; acute otitis media, 3; hospitalization for lower respiratory tract infection, 95; maternal hypertension, 55; diabetes, 162; and myocardial infarction, 235. For every 597 women who optimally breastfeed, one maternal or child death is prevented. Policies to increase optimal breastfeeding could result in substantial public health gains. Breastfeeding has a larger impact on women's health than previously appreciated.

Women's health 2016: An update for internists.

Internists are called upon on a daily basis to address a range of women's health issues. Staying up to date with the evidence in this wide field can be challenging. This article reviews important studies published in 2015 and early 2016 pertinent to urinary tract infection, osteoporosis, ovarian cancer screening, and contraception.

Same-day intrauterine device placement is rarely complicated by pelvic infection.

PURPOSE: To compare rates of pelvic inflammatory disease (PID) among women who did and did not receive an intrauterine device (IUD) the day they sought emergency contraception (EC) or pregnancy testing. METHODS: Women, 15 to 45 years of age, who sought EC or pregnancy testing from an urban family planning clinic completed surveys at the time of their clinic visit (August 22, 2011, to May 30, 2013) and 3 months after their clinic visit. The surveys assessed contraceptive use and symptoms, testing, and treatment for sexually transmitted infections (STI) and PID. We reviewed the medical records of participants who reported IUD placement within 3 months of enrollment and abstracted de-identified electronic medical record (EMR) data on all women who sought EC or pregnancy testing from the study clinic during the study period. FINDINGS: During the study period, 1,060 women visited the study clinic; 272 completed both enrollment and follow-up surveys. Among survey completers with same-day IUD placement, PID in the 3 months after enrollment was not more common (1/28 [3.6%]; 95% CI, 0%-10.4%) than among women who did not have a same-day IUD placed (11/225 [4.9%]; 95% CI, 2.7%-8.6%; p = .71). Chart review and EMR data similarly showed that rates of PID within 3 months of seeking EC or pregnancy testing were low whether women opted for same-day or delayed IUD placement. CONCLUSIONS: Same-day IUD placement was not associated with higher rates of PID. Concern for asymptomatic STI should not delay IUD placement, and efforts to increase the uptake of this highly effective reversible contraception should not be limited to populations at low risk of STI.

Infant feeding in America: enough to break a mother's heart?

Cardiovascular disease is a leading cause of death of women around the world. Diet, exercise, smoking cessation, and blood pressure control are all recognized as key elements of preventing cardiovascular disease. Infant feeding has received less attention, but the studies reviewed here indicate that lactation may also play an important role in determining women's future risk of heart disease. A growing body of literature indicates that mothers who prematurely discontinue lactation face increased risk of visceral adiposity, hypertension, hyperlipidemia, diabetes, and subclinical cardiovascular disease, as well as cardiovascular morbidity and mortality. Breastfeeding is not always easy, but neither is dieting, exercise, smoking cessation, or treating hypertension. In order to effectively fight heart disease, efforts are needed to promote all aspects of a healthy lifestyle, which for women includes breastfeeding their babies.

Racial disparities in human papillomavirus vaccination: does access matter?

PURPOSE: To examine the association between race/ethnicity and human papillomavirus (HPV) vaccine initiation and to determine how access to health care influences this relationship. METHODS: We used nationally representative data from the National Survey of Family Growth to assess HPV vaccine initiation in 2,168 females aged 15-24 years. A series of regression analyses were performed to determine the independent effect of race/ethnicity on HPV vaccine initiation after controlling for sociodemographic variables and health care access measures. Age-stratified regression analyses were also performed to assess whether the relationship between race/ethnicity and HPV vaccine initiation differed among females aged 15-18 and 19-24 years. RESULTS: There were significant racial/ethnic disparities in HPV vaccination; United States (US)-born Hispanics, foreign-born Hispanics, and African-Americans were less likely to have initiated vaccination than were whites (p < .001). Adjusting for sociodemographic characteristics attenuated the disparity for both US-born and foreign-born Hispanics (adjusted odds ratio [AOR], .76; 95% confidence interval [CI], .50-1.16; and AOR, .67; 95% CI, .37-1.19) but not for African-Americans (AOR, .47, 95% CI, .33-.66). Adding health care access measures further attenuated the disparity for US-born and foreign-born Hispanics (AOR, .85, 95% CI, .54-1.34; and AOR, .84, 95% CI, .45-1.55). However, African-Americans remained less likely than whites to have initiated vaccination (AOR, .49, 95% CI, .36-.68). These racial/ethnic trends were similar for females aged 15-18 and 19-24 years. CONCLUSIONS: Lower rates of HPV vaccination among African-American females do not appear to be explained by differential access to health care. More research is necessary to elucidate factors contributing to HPV vaccination in this population.

Cost analysis of maternal disease associated with suboptimal breastfeeding.

OBJECTIVE: To estimate the U.S. maternal health burden from current breastfeeding rates both in terms of premature death as well as economic costs. METHODS: Using literature on associations between lactation and maternal health, we modeled the health outcomes and costs expected for a U.S. cohort of 15-year-old females followed to age 70 years. In 2002, this cohort included 1.88 million individuals. Using Monte Carlo simulations, we compared the outcomes expected if 90% of mothers were able to breastfeed for at least 1 year after each birth with outcomes under the current 1-year breastfeeding rate of 23%. We modeled cases of breast cancer, premenopausal ovarian cancer, hypertension, type 2 diabetes mellitus, and myocardial infarction considering direct costs, indirect costs, and cost of premature death (before age 70 years) expressed in 2011 dollars. RESULTS: If observed associations between breastfeeding duration and maternal health are causal, we estimate that current breastfeeding rates result in 4,981 excess cases of breast cancer, 53,847 cases of hypertension, and 13,946 cases of myocardial infarction compared with a cohort of 1.88 million U.S. women who optimally breastfed. Using a 3% discount rate, suboptimal breastfeeding incurs a total of $17.4 billion in cost to society resulting from premature death (95% confidence interval [CI] $4.38-24.68 billion), $733.7 million in direct costs (95% CI $612.9-859.7 million), and $126.1 million indirect morbidity costs (95% CI $99.00-153.22 million). We found a nonsignificant difference in number of deaths before age 70 years under current breastfeeding rates (4,396 additional premature deaths, 95% CI -810-7,918). CONCLUSIONS: Suboptimal breastfeeding may increase U.S. maternal morbidity and health care costs. Thus, investigating whether the observed associations between suboptimal breastfeeding and adverse maternal health outcomes are causal should be a research priority.

Progestin-only contraceptive pill use among women in the United States.

BACKGROUND: Progestin-only contraceptive pills (POPs) offer a safe and effective contraceptive option, particularly for women at increased risk of venous thromboembolism. However, the prevalence of POP use among women in the United States is unknown. STUDY DESIGN: We analyzed population-based data from 12,279 women aged 15-44 years in the National Survey of Family Growth. Data were collected continuously from 2006 to 2010 by in-person, computerized household interviews. Analyses describe POP use across sociodemographic and reproductive characteristics and thromboembolic risk profiles. RESULTS: Overall, 0.4% of all reproductive-aged women in the United States currently use POPs. POP use was higher among parous, postpartum and breastfeeding women than their counterparts (all p values<.001). Women at higher risk of thromboembolism (older, obese, diabetic or smoking women) had similar proportions of POP use as women without those risks. CONCLUSION: POPs are rarely used by US women. While data on chronic disease were limited, our results suggest that relatively few women with increased risk of thromboembolism are considering POPs when choosing an oral contraceptive.

Racial disparities in awareness of the human papillomavirus.

BACKGROUND: Human papillomavirus (HPV) is the most common sexually transmitted infection in the United States yet is one of the least recognized among the general public. HPV awareness may be relatively low among minority women. Because HPV awareness is associated with uptake of the HPV vaccine, it is critical to assess HPV awareness in the population and identify any racial/ethnic gaps. METHODS: This study used nationally representative data collected by the National Survey of Family Growth between July 2007 and December 2008. A multivariable logistic regression model was used to determine the independent effect of race/ethnicity on HPV awareness while controlling for sociodemographic and clinical confounders in a sample of 4088 women. Stratified multivariable analysis was also conducted to assess the relationship between race/ethnicity and HPV awareness among women in different age groups. RESULTS: After adjusting for confounders, Hispanic and black women overall were significantly less likely to have heard of HPV compared to white women (odds ratio [OR] 0.39, 95% confidence interval [CI] 0.29-0.54 and OR 0.39, 95% CI 0.29-0.54, respectively). Black women aged 15-18 and Hispanic women aged 19-26 had particularly low rates of HPV awareness (OR 0.17, 95% CI 0.07-0.43 and OR 0.18, 95% CI 0.11-0.30, respectively) compared to white women of the same ages. CONCLUSIONS: Hispanic and black women have significantly lower levels of HPV awareness than white women. Targeted educational efforts will be important to improve HPV awareness and associated preventive health measures to avoid HPV-related morbidity and mortality.

Lactation and maternal risk of type 2 diabetes: a population-based study.

BACKGROUND: Lactation has been associated with improvements in maternal glucose metabolism. METHODS: We explored the relationships between lactation and risk of type 2 diabetes in a well-characterized, population-representative cohort of women, aged 40-78 years, who were members of a large integrated health care delivery organization in California and enrolled in the Reproductive Risk factors for Incontinence Study at Kaiser (RRISK), between 2003 and 2008. Multivariable logistic regression was used to control for age, parity, race, education, hysterectomy, physical activity, tobacco and alcohol use, family history of diabetes, and body mass index while examining the impact of duration, exclusivity, and consistency of lactation on risk of having developed type 2 diabetes. RESULTS: Of 2233 women studied, 1828 were mothers; 56% had breastfed an infant for > or =1 month. In fully adjusted models, the risk of type 2 diabetes among women who consistently breastfed all of their children for > or =1 month remained similar to that of women who had never given birth (odds ratio [OR] 1.01; 95% confidence interval [CI], 0.56-1.81). In contrast, mothers who had never breastfed an infant were more likely to have developed type 2 diabetes than nulliparous women (OR 1.93; 95% CI, 1.14-3.27) [corrected]. Mothers who never exclusively breastfed were more likely to have developed type 2 diabetes than mothers who exclusively breastfed for 1-3 months (OR 1.52; 95% CI, 1.11-2.10). CONCLUSIONS: Risk of type 2 diabetes increases when term pregnancy is followed by <1 month of lactation, independent of physical activity and body mass index in later life. Mothers should be encouraged to exclusively breastfeed all of their infants for at least 1 month.

Pregnancy intention and health behaviors: results from the Central Pennsylvania Women's Health Study cohort.

OBJECTIVE: Our objective was to determine whether intention for future pregnancy affects selected preconception health behaviors that may impact pregnancy outcomes. METHODS: Analyses are based on data from a population-based cohort study of women ages 18-45 residing in Central Pennsylvania. A subsample of 847 non-pregnant women with reproductive capacity comprise the analytic sample. We determined the associations between intention for future pregnancy and the pattern in the following health behaviors over a 2-year period: nutrition (fruit and vegetable consumption), folic acid supplementation, physical activity, binge drinking, smoking, and vaginal douching. Multivariable analyses controlled for pregnancy-related variables, health status, health care utilization, and sociodemographic variables. RESULTS: At baseline, 9% of women were considering pregnancy in the next year, 37% of women were considering pregnancy some other time in the future, and 53% of women were not considering future pregnancy. In multivariable analyses, there were no associations between intention for future pregnancy and maintaining healthy behavior or improving behavior for any of the seven longitudinal health behaviors studied. CONCLUSIONS: The importance of nutrition, folic acid supplementation, physical activity, avoiding binge drinking, not smoking, and avoiding vaginal douching in the preconception period needs to be emphasized by health care providers and policy makers.