First birth Caesarean section and subsequent fertility: a population-based study in the USA, 2000-2008.

STUDY QUESTION: Is first birth Caesarean delivery associated with a lower likelihood of subsequent childbearing when compared with first birth vaginal delivery? SUMMARY ANSWER: In this study of US women whose first delivery was in 2000, those who had a Caesarean delivery were less likely to have a subsequent live birth than those who delivered vaginally. WHAT IS ALREADY KNOWN: Some studies have reported lower birth rates subsequent to Caesarean delivery in comparison with vaginal delivery, while other studies have reported no difference. STUDY DESIGN, SIZE, DURATION: We conducted a retrospective cohort study of 52 498 women who had a first singleton live birth in the State of Pennsylvania, USA in 2000 and were followed to the end of 2008 via Pennsylvania birth certificate records to identify subsequent live births during the 8- to 9-year follow-up period. PARTICIPANTS/MATERIALS, SETTING, METHODS: Birth certificate records of first singleton births were linked to the hospital discharge data for each mother and newborn, and linked to all birth certificate records for each mother's subsequent deliveries which occurred in 2000 to the end of 2008. Poisson regression models were used to evaluate the association between first birth factors and whether or not there was a subsequent live birth during the follow-up period. MAIN RESULTS AND THE ROLE OF CHANCE: Over an average of 8.5 years of follow-up, 40.2% of women with a Caesarean first birth did not have a subsequent live birth, compared with 33.1% of women with a vaginal first birth (risk ratio (RR): 1.21, 95% confidence interval (CI): 1.18-1.25). Adjustment for the demographic confounders of maternal age, race, education, marital status and health insurance coverage attenuated the RR to 1.16 (95% CI: 1.13-1.19). Specific pregnancy and childbirth-related complications associated with not having a subsequent live birth included diabetes-related disorders, abnormalities of organs and soft tissues of the pelvis, fetal abnormalities, premature or prolonged rupture of membranes, hypertensive disorders, amnionitis, fetal distress and other maternal health problems. However, adjustment for the pregnancy and childbirth complications had little effect on the RR of not having a subsequent live birth (RR = 1.15, 95% CI: 1.11-1.19). LIMITATIONS, REASONS FOR CAUTION: We were unable to distinguish between women who did not have a subsequent live birth and those who moved out of the state, which may have introduced a selection bias if those who had Caesarean births were more likely to emigrate than those who delivered vaginally. In addition we were unable to measure pre-pregnancy body mass index, weight gain during pregnancy and prior infertility, which would have been helpful in our efforts to reduce selection bias. WIDER IMPLICATIONS OF THE FINDINGS: The results of this study provide further corroboration of previous studies that have reported reduced fertility subsequent to Caesarean section in comparison with vaginal delivery. STUDY FUNDING/POTENTIAL COMPETING INTERESTS: This study was funded by the US National Institute of Child Health and Human Development (NICHD, R01-HD052990). No competing interests are declared.

Cervical cancer screening practices among older women: results from the Maryland Cervical Cancer Case-Control Study.

Considerable evidence shows a large proportion of older women have either never had a Pap test or have significant gaps in their history of cervical cancer screening. Differences in health care utilization patterns by age, cohort differences in use of medical subspecialities, and provider reluctance to perform cancer screening within the general medical care encounter have been suggested as reasons for underscreening. Our study conducted in 1985 documents prior health care utilization patterns of 153 cases of Maryland women with invasive cervical cancer compared with a matched control group. Analysis within three age groups showed that cases were significantly less likely to have ever had a Pap test or to receive regular Pap testing, primarily due to differences in medical care utilization patterns. Never having an obstetrician-gynecology visit, a recent (less than 3 years) internist visit, or not having any out-patient visit were significant risk factors. Other risks included older age at first Pap test, reporting not being told to have routine Pap tests, and not using contraceptives. In a multiple logistic regression analysis, recent out-patient visits and lifetime use of an obstetrician-gynecologist remained significant after adjusting for age interactions with recent Pap test history, underscoring the importance of medical care utilization patterns for screening of cancer of the uterine cervix among the elderly.

Physician practices in the diagnosis of dementing disorders.

Because there are both treatable and untreatable causes of dementia, the physician's ability to conduct (or refer a patient for) a differential diagnosis could have a profound effect on health outcomes for patients and on health care costs. This study was undertaken to assess physician practices with regard to the diagnosis of dementing disorders. Data from 53 physicians (a response rate of 48%) in several specialties were obtained from a self-administered mail questionnaire. Results indicate that the majority of physicians provided history taking, physical examination, and neurological examination. Physicians were more likely to refer patients for psychiatric and neuropsychological examinations than to provide these services themselves. The results also point to deficiencies in two key areas: the use of formal, published diagnostic criteria, and the use of mental status and cognitive function tests. Over 75% of physicians surveyed did not use either DSM-III or NINCDS-ADRDA diagnostic criteria, and 42% of physicians did not provide any mental status tests themselves. The need for continuing education to close knowledge gaps is emphasized.

Utilization of obstetrician-gynecologists and prevention of cervical cancer.

In a case-control study, we examined health care utilization histories to determine whether Papanicolaou tests provided by an obstetrician-gynecologist, as opposed to other providers, are more protective of cervical cancer. Women with cervical cancer were less likely than matched controls to have had regular Papanicolaou test screening, to have received a Papanicolaou test within the last five years, or to have obtained a Papanicolaou test from an obstetrician-gynecologist. After controlling for traditional risk factors, we found that receiving any Papanicolaou tests within the last five years from an obstetrician-gynecologist was more protective than receiving Papanicolaou tests from other providers, although the difference did not attain statistical significance. Among both cases and controls, younger women and women who had used prescription contraceptives were more likely to have had a recent Papanicolaou test by an obstetrician-gynecologist. The results support the importance of regular Papanicolaou test screening among older women and suggest that the obstetrician-gynecologist helps prevent cervical cancer by providing continuity of screening services.

Sex differences in the practice patterns of recently trained obstetrician-gynecologists.

Sex differences in practice patterns, as modified by family roles, are investigated in a national survey of 1420 active obstetrician-gynecologists who graduated from medical school between 1974 and 1979. Women are more likely than men to be practicing in multispecialty groups, and men are more likely than women to be practicing in obstetrics-gynecology partnerships. On average, men and women report working over 60 hours per week. In all practice arrangements except academic medicine, women work fewer total hours per week, although the differences are small and translate into significantly fewer patient encounters than men in only two practice arrangements: partnerships and multispecialty groups. When marital status and presence of children under age 18 are controlled, significant sex differences in hours worked remain only for married respondents with children. Family roles have an opposite effect on hours of work reported by men and women, decreasing the number of hours worked by women and increasing the number worked by men.

Ownership type and community benefits of women's health centers.

An important aspect of the changing health care system is the growth of women's health centers--organizations that design and deliver services to women. This growth has generated interest in the behavior of centers, especially because of increasing awareness of women's health issues. Using data from the 1994 National Survey of Women's Health Centers, the authors examined the association between ownership of centers and 12 measures of community benefits, and 296 nonprofit and 108 for-profit centers were compared. Overall, the nonprofits performed better than the for-profits in terms of serving underserved women, delivering comprehensive primary care services, providing training for health professionals and education services for clients and the community, and involving the community in center governance. Among women's health centers, the results show that ownership matters, and indicate the importance of supporting providers who serve the underserved and developing a standard of community benefits.

Job satisfaction among hospital nurses: a longitudinal study.

Data from a two-wave panel study of staff nurses in two hospitals are used to assess the relative importance of several types of independent variables as determinants of job satisfaction. Both organizational and nonorganizational determinants are examined, with the formed including both perceptual and structural measures. Job satisfaction is measured in two ways using both Overall and Multi-Facet indicators. The independent variables were measured five months before the dependent variables were measured in order to attenuate contamination problems. Findings indicate that perceptions of job and nursing unit attributes, particularly autonomy and task delegation, predict satisfaction most strongly. In addition, a nurse's own characteristics are found to be more important than either structural attributes of nursing units or job characteristics in predicting job satisfaction.

The impact of unit-based self-management by nurses on patient outcomes.

OBJECTIVE: Patients discharged from a self-managed nursing unit are compared with patients from traditionally managed units on postdischarge outcomes. DATA SOURCES AND STUDY SETTING: Primary data were collected on patients discharged from eight nursing units in three clinical areas in one hospital from August through November 1990. STUDY DESIGN: A case series of eligible patients discharged from four self-managed nursing units (n = 140) are compared with patients from four matched traditionally managed units (n = 138) on postdischarge outcomes: perceived health status, perceived functional status, needs for care, unmet needs for care, unplanned health care visits, and readmissions to the hospital within 31 days of discharge. DATA COLLECTION METHODS: Patients were interviewed by telephone at approximately two weeks postdischarge, and data from hospital records were merged with interview data. PRINCIPAL FINDINGS: Bivariate and multiple logistic regression analyses showed no significant effects (either positive or negative) of self-managed units on the postdischarge outcomes studied. CONCLUSIONS: Self-managed nursing units, previously shown to improve nurses' work satisfaction and retention, have no impact on patient postdischarge outcomes.

The trends in health care delivery for women: challenges for medical education.

The author discusses four key trends in the U.S. health care delivery system that affect how women's health care is delivered: the restructuring of primary care, particularly in the context of managed care organizations; initiatives in quality assessment; changes in patterns of health insurance coverage; and threats to the health care safety net. She concludes that medical educators need to link training to these changes in the health care delivery system to prepare physicians to work effectively for women's health in the changing system and to help bring about appropriate, needed transformations of the institutions in which women's health care is provided. Specific recommendations for medical educators are given after the discussion of each trend.

Physician gender and the physician-patient relationship: recent evidence and relevant questions.

Despite criticisms of the quality of health care for women and considerable research on sex differences in illness behavior and utilization of health services, little research has addressed the potential impact of physician gender on the physician-patient relationship and its outcomes. With the entry of more women into the medical profession, opportunities to investigate effects of physician gender will increase. A theoretical rationale for expecting physician gender to affect the key dimensions of the interactive physician-patient relationship (communication of information, affective tone, negotiative quality) and its outcomes (satisfaction, compliance, health status) is presented. Physician gender might impact on the relationship through three mechanisms: sex differences among physicians, particularly with respect to sex-role attitudes; patients' different expectations of male and female physicians; or increased status congruence between physician and patient in same-sex, as compared to opposite-sex, physician-patient dyads. Recent research related to these topics is discussed and found to support the plausibility of these mechanisms of potential gender effects. Some methodological suggestions for future research are presented, including the suggestion that future research identify specific conditions under which physician gender effects might be more salient.

KIE: The authors hypothesize that physician gender could have an effect on patient satisfaction, compliance, and health status through the mechanisms of the physician patient relationship. They review the literature on three aspects of this relationship: physicians' sex role attitudes, patients' differing expectations of male and female physicians, and communication and rapport in same-sex versus opposite-sex physician patient interactions. They conclude that recent research supports the plausibility of their hypothesis and suggest methods for identifying specific conditions where the importance of physician gender might be demonstrated.

Managed care and women's health: access, preventive services, and satisfaction.

This paper examines insured women's access to health care, receipt of preventive services, and satisfaction with care by the types of health plans in which they are enrolled. Three types of plans are compared: managed care (HMOs and PPOs), fee-for-service with utilization controls, and traditional fee-for-service. For women who have been enrolled in their plans for at least one year, we find the same or better access to care in managed care plans as compared with other plans; receipt of more gender-specific clinical preventive services in managed care plans, but no differences among types of plans for non-gender-specific preventive services or counseling services; and lower satisfaction with care in managed care plans. The implications for practice and policy are discussed.

Women's health centers: are the National Centers of Excellence in Women's Health a new model?

This paper describes the characteristics of the clinical centers of the first 12 National Centers of Excellence (CoE) in Women's Health, designated by the U.S. Department of Health and Human Services Office on Women's Health between 1996 and 1997. These centers are compared with 56 hospital-sponsored primary care women's health centers identified in the 1994 National Survey of Women's Health Centers, the only source of nationally representative data on primary care women's health centers. While analysis demonstrates that some organizational and clinical attributes of primary care women's health centers were in evidence before the CoE program was initiated, the CoE centers demonstrate further integration of clinical services with research and medical training in women's health, and the delivery of services to a more diverse population of women.

Delivery of primary care services among family planning centers: a response to managed care?

Previous case studies indicate that some family planning centers are transforming themselves into providers of primary care services, in part as a strategy to attract managed care contracts. Data for 98 family planning centers from the 1994 National Survey of Women's Health Centers and supplementary sources are used to explore the factors associated with managed care contracting. Although some organizational-level factors are predictive, no cross-sectional association was found between providing primary care and managed care contracting, which suggests family planning centers are not using primary care as a major contracting strategy.

Gender and patient satisfaction in managed care plans: analysis of the 1999 HEDIS/CAHPS 2.0H Adult Survey.

This paper investigates gender differences in satisfaction, and in the variables associated with satisfaction, using the Consumer Assessment of Health Plans Study (CAHPS) adult questionnaire administered by the National Committee for Quality Assurance (NCQA) as part of HEDIS 1999. Data represent 97,873 men and women enrolled in 206 commercial managed care plans nationwide. Mean plan-level gender differences in satisfaction measures are small, with no consistent pattern of one gender being more satisfied than the other. Controlling for health plan, member, utilization, and selected HEDIS performance indicators, health plan characteristics account for the largest proportion of variance explained in satisfaction. Not-for-profit status and lower turnover of primary care providers are stronger determinants of women's than men's satisfaction. We conclude that it can be useful to analyze CAHPS scores by gender to identify areas for quality improvement in women's health care.

The implications of affiliations between Catholic and non-Catholic health care organizations for availability of reproductive health services.

Four case studies of successfully negotiated affiliations between Catholic and non-Catholic organizations reveal the strategies employed to address a range of reproductive health services.

PIP: This article summarizes multiple case studies on decision-making with regard to reproductive health services in affiliations between Catholic and non-Catholic organizations. A database on the number and types of affiliations was compiled during 1990-1996 to provide a national profile of such organizations. Findings of case studies revealed that affiliations between Catholic and non-Catholic health care organizations are diverse in structure, motivated by market and financial issues, and display diverse strategies with regards to reproductive health services. In addition, strategies for providing more comprehensive women's health care were evident in 3 of the 4 case studies. Availability of contraceptive services, female and male sterilization, and infertility services generally was unchanged as a result of affiliations. This shows that affiliations themselves did not significantly affect policies or practices with regards to their provision. Successful negotiations between Catholic and non-Catholic partners involve explicit strategies concerning reproductive health services, some of which curtail specific services and some of which enhance services. Finally, policy-makers have an important role in ensuring that communities receive full disclosure of the nature of affiliations and their possible impact on availability of services.

Women's satisfaction with primary care: a new measurement effort from the PHS National Centers of Excellence in Women's Health.

This paper describes efforts by the National Centers of Excellence in Women's Health to develop a woman-specific primary care satisfaction instrument suitable for quality improvement and research.

Partner-specific condom use among adolescent women clients of a family planning clinic.

Because inconsistent condom use could put adolescent women at an increased risk for sexually transmitted diseases, it is important to understand when and with whom they use condoms. This study examined partner-specific condom use over time among adolescent women. The data were from a clinic-based, prospective study of 308 adolescent women who had at least one sex partner during a 6-month follow-up. Their condom use was examined with three types of partners: exclusive, nonexclusive primary, and nonexclusive secondary. Predictors of consistent condom use (using condoms 100% of the time with a specific partner) were explored in a multiple logistic regression analysis. Consistent condom use was more likely to occur in shorter relationships (less than 3 months) and with partners who preferred condoms for contraception. It was no more likely to occur with nonexclusive partners than with exclusive partners, and it was somewhat less likely to occur among consistent oral contraceptive users. These findings emphasize the importance of educating adolescent women to introduce and maintain condom use with all partners.

PIP: More than 50% of sexually active adolescents have more than 1 sex partner. Since the inconsistent use of condoms may place sexually active youths at increased risk of infection with sexually transmitted diseases, it is important to determine and understand when and with whom adolescents use condoms. Using 1988 interview data from a family planning clinic on 308 non-pregnant, unmarried women aged 11-18 years who had at least 1 sex partner over a 6-month follow-up period, this study investigated partner-specific condom use over time. 77% of respondents were Black, 89% urban, and of average age 16. Among those who had engaged in sexual intercourse by baseline, mean age at first intercourse was 14.5 years with an average 2.9 sex partners. 81.8% had 1 exclusive sex partner over the follow-up period and 58% had mothers who were themselves teenage mothers. Multiple logistic regression was used to analyze predictors that respondents would use condoms during 100% of sexual intercourse encounters with each of exclusive, nonexclusive primary, and nonexclusive secondary partners. Analysis revealed that consistent condom use was more likely to occur in relationships lasting less than 3 months and with partners who preferred condoms for contraception. Consistent condom use was no more likely to occur with nonexclusive partners than with exclusive partners, and was somewhat less likely to occur among consistent oral contraceptive users. These findings highlight the need to teach adolescents to begin and continue using condoms with all sex partners.

Women and health care communication.

Research bearing on the issue of gender differences in patient-provider communication is discussed, and recommendations for future research and for patient education and counseling are offered. Based on limited available evidence, women appear to receive more health care communications and more health information than men, possibly due to women's superior general communication skills. Provider gender may also affect the communication process, and congruence between patient and provider gender could produce more effective communication under some circumstances.

Communication between women and their health care providers: research findings and unanswered questions.

Although much research has been carried out on communication between health care providers and patients, relatively few studies have investigated the effects of patient or provider gender on the communication process or its outcomes. Women use health services more than men and are more likely than men to report being influenced by health information in the media. No studies are available showing that physicians hold biases about male and female patients that translate into different communication patterns with each sex. Recent studies of verbal communication between patients and primary health care physicians show that female patients tend to ask more questions than men. Evidence that physicians are more likely to withhold information from female patients is not conclusive. Some evidence has been found that female physicians interrupt their patients less often than male physicians, provide more verbalizations of empathy, and provide clearer explanations in response to patients' concerns. Female physician-patient dyads might be expected to improve communication under certain circumstances.

Cancer screening services for the elderly.

The reported practices and recommendations of primary care physicians with regard to cancer screening of elderly patients (65 years and older) were studied in a 1987 survey of 400 Maryland physicians. More than 90 percent of physicians in four specialties studied reported providing digital rectal examinations, physical breast examinations, and mammography to the elderly. However, only 54 percent of obstetrician-gynecologists and 68 percent of general practitioners provided sigmoidoscopy, 70 percent of obstetrician-gynecologists provided stool guaiac slide tests, 74 percent of general practitioners provided breast self-exam instruction, and 79 percent of internists provided Pap tests. Physicians were asked what screening intervals they recommended for each test for asymptomatic elderly patients. These reports were compared with current American Cancer Society (ACS) recommendations. Large proportions of physicians in four specialties recommended sigmoidoscopy and mammography less often than the ACS recommended. More than 20 percent of physicians in the four specialties believed the elderly do not need routine sigmoidoscopy. Most physicians (90 percent or more) recommended Papanicolaou tests more often than the ACS recommended. Specialty and young physician age were the best predictors of physicians' overall adherence to ACS recommendations for cancer screening schedules.