Parental perceptions of the burden of genetic disease.

Parents who are carriers of genes that code for genetic disease face a complex decision regarding procreation. To investigate how parents perceive the potential effects of having a child with congenital defects and how such perceptions influence their reproductive decisions, 202 women accepting and 50 women rejecting amniocentesis after genetic counseling were followed in a 3-year longitudinal study. Using multiple correspondence analysis, we found that perceived burdens associated with hypothetical congenital abnormalities leading to prolonged illness or early death were considered the most serious, those related to physical handicap or facial abnormalities were perceived as least serious, while genetic defects causing mental retardation fell between. The parents were increasingly likely to accept amniocentesis the more they felt they would be unable to cope with the consequences of a genetic disease leading to prolonged illness or mental retardation (R = .23). Overall, the women who accepted amniocentesis were those who perceived the consequences of congenital malformation as most burdensome. The findings suggest that genetic counselors should not only explore parents' attitudes about specific congenital abnormalities, but also their perceptions of how they would cope with the medical and social consequences of the various genetic defects.

Risks for premature rupture of amniotic membranes.

The objective of this study was to test the hypothesis that diverse risk variables including infections during the index pregnancy independently increase the risk of preterm premature rupture of amniotic membranes (PROM) and preterm delivery without PROM. A case-control design was used to study women 15-45 years old who had preterm PROM, full-term PROM or preterm without PROM and were singly matched by age race and parity to controls who delivered full-term infants. The odds for preterm PROM was 6.0 times that of controls among women with intra-amniotic infection, 3.7 times among those with urinary tract and 7.6 times among women with gonorrhoea infections after controlling for the effects of exposure to cigarette smoke, having previous preterm and full-term PROM deliveries and antepartum bleeding that independently increased the odds. The odds for preterm births without PROM was 4.8 times that of controls among women with a previous preterm PROM birth, was significantly increased among those exposed to cigarette smoke or having antepartum bleeding, but not among those exposed to chlamydia infection. Even after adjusting for concomitant risk factors, women with preterm PROM births were more likely than their matched controls to have had infections.

Unfavorable outcome in penultimate pregnancy and premature rupture of membranes in successive pregnancy.

OBJECTIVES: Previous adverse obstetric events are known to influence the outcome of the succeeding pregnancy. We tested the hypothesis that preterm premature rupture of membranes (PROM), full-term PROM, and preterm delivery without PROM relate independently to the outcome of the immediately preceding pregnancy. METHODS: In a case-control study, 345 women 15-45 years old with preterm PROM, full-term PROM, or preterm delivery without PROM were singly matched by age, race, and parity to women having full-term delivery. Information about the penultimate pregnancy, household smoking, and sociodemographic variables were obtained during face-to-face interviews. Obstetric history, infections during pregnancy, and pregnancy complications abstracted from medical records were cross-checked with patient interview data. Penultimate pregnancy outcomes included full-term delivery, premature delivery, fetal loss or miscarriage, and planned abortion. RESULTS: Women having preterm PROM or preterm delivery without PROM in the index pregnancy were, respectively, 6.34 and 21.28 times more likely than controls to have had preterm delivery in the preceding pregnancy. A preceding fetal loss or miscarriage also increased 4.39-fold the risk for preterm PROM. Exposure to cigarette smoke, urinary tract infections, and vaginal bleeding during the index pregnancy independently increased the risk for preterm PROM. Women with full-term PROM did not differ significantly from controls in the outcomes of the penultimate pregnancy. CONCLUSION: Preterm delivery in the preceding pregnancy is associated with an increased risk for preterm delivery with or without PROM.

Using qualitative methods to evaluate health service delivery in three rural Colorado communities.

Qualitative and quantitative methods can be used simultaneously for hypothesis generation and testing. A pilot study was conducted in 1991 in three rural Colorado communities to clarify health service delivery problems related to cancer. The analysis focused on the perceptions of three types of respondents in each community related to whether cancer was a major problem, whether health services were adequate in their community, and what perceived solutions could be implemented. Respondents included community influentials, health care providers, and cancer patients or family members. Semistructured phone interviews were used to collect perceptions of these community members. Transcripts from the three communities were combined, coded, and tallied. Several distinct themes emerged from the analysis. These included: cancer was a major problem; public and provider education was needed; community systems and support to identify and solve health problems were lacking; medical networking needed to be expanded; transportation was a problem for remote communities; inability to pay for services was a problem for rural communities. Most respondents identified the problems as relevant to other chronic and acute diseases as well as cancer. This method identified the critical problems for the majority of the people without losing sight of the outlier responses.

Changing physician behavior to improve disease prevention.

Physicians often fail to provide nationally recommended preventive services for their patients. Addressing this, we have reviewed selected literature on changing physician behavior using the organizational construct of the "readiness for change" transtheoretical model. This model suggests that behavior evolves through stages from precontemplation, to contemplation, to preparation, to initiation, and to maintenance of change. Traditional continuing medical education may affect knowledge and beliefs, but rarely results in behavior change. However, motivational strategies such as practice feedback reports and influential peers can foster stage change. Successful interventions aimed at physicians preparing for change frequently use an office-system approach that targets not only physicians, but office staff and patients as well. Illustrating how the readiness to change model can guide the design and implementation of interventions, we describe strategies being used in a statewide randomized controlled trial to improve cancer prevention counseling and early detection by primary care physicians. The multistage interventions of Partners for Prevention include support from a medical liability carrier, a motivational videotape, a task-delineated office manual, chart flowsheets, patient activation forms, practice feedback reports, a designated prevention coordinator within each practice and regular telephone calls and office visits by project staff.

Previous pregnancy outcomes and subsequent risk of preterm rupture of amniotic sac membranes.

OBJECTIVE: To test the hypothesis that previous unfavourable pregnancy outcomes increase the risk for premature birth, with (PP) or without (PTB) premature rupture of the amniotic sac (PROM) at the index pregnancy and that multiple undesirable outcomes increase risk. DESIGN: Case control study. SETTING: Two university hospitals. SUBJECTS: Four hundred sixty-three women aged 15 to 45 years who were delivered preterm PROM, full term PROM and preterm without PROM matched with 463 women who delivered full term. All women included in the study had at least one previous pregnancy. OUTCOME MEASURES: Odds ratio of previous adverse pregnancy outcome among index cases. RESULTS: Compared with controls, PP cases had odds ratios of 95 for previous preterm birth, 186 for abortion and prematurity and 158 for fetal loss, abortion/prematurity after controlling for confounding variables. Compared with controls, PTB cases had an odds ratio of 96.5 for previous preterm delivery, 84 for abortion and prematurity, and 320 for fetal loss/abortion and prematurity after controlling for confounding variables. CONCLUSIONS: Previous preterm delivery, abortion and prematurity and fetal loss/abortion and prematurity all increase risk for subsequent preterm birth with or without PROM.

Coitus late in pregnancy: risk of preterm rupture of amniotic sac membranes.

OBJECTIVES: Coitus with or without orgasm in late pregnancy is inconsistently associated with preterm rupture of amniotic sac membranes. We tested the hypothesis that during late pregnancy sexual behaviors including sexual positioning relate to the occurrence of premature rupture of membranes. STUDY DESIGN: Women aged 15 to 45 years having preterm premature rupture of membranes, term premature rupture of membranes, or preterm delivery without premature rupture of membranes were matched singly by age, race, and parity to control women delivered of term infants. Information about six sexual activities, obstetric history, cervical infections, smoking during pregnancy, and sociodemographic information was obtained by face-to-face interview. RESULTS: Only the male superior position was significantly associated with preterm premature rupture of membranes (odds ratio 2.40, 95% confidence interval 1.16 to 4.97) and preterm delivery without premature rupture of membranes (odds ratio 1.82, confidence interval 1.02 to 3.25) after confounding variables were controlled for. No sexual positioning or sexual activities related significantly to term premature rupture of membranes. CONCLUSION: Most sexual positions and activities during late pregnancy are not associated with adverse pregnancy outcomes.

Adequacy of prenatal care and risk of pre term rupture of amniotic sac membranes.

Premature rupture of amniotic membranes (PROM) is associated with perinatal morbidity and mortality. A matched case-control study was undertaken to determine whether adequacy of prenatal care was associated with increased risk for PROM. Three study groups were defined, consisting of women delivering pre term with PROM, full term with PROM, and pre term without PROM. Cases were singly matched by race, age, and parity with women having full term deliveries without PROM. Data were collected by face-to-face structured interviews with eligible subjects and by medical records abstraction. Conditional multiple logistic regression indicated that among women with inadequate levels of prenatal care during pregnancy the risk for pre term PROM was 3.11 (CI = 1.10-8.78) and for pre term without PROM 2.18 (CI = 1.05-4.53) times higher than for their matched controls, even when adjusted for other sociodemographic, behavioral, index pregnancy, and medical history factors. We conclude that inadequate prenatal care may be a marker for less healthy behaviors, lifestyles, and environmental factors among women at increased risk for pre term delivery.

Dietary habits, prepregnancy weight, and weight gain during pregnancy. Risk of pre term rupture of amniotic sac membranes.

BACKGROUND: Premature rupture of amniotic sac membranes (PROM) is associated with perinatal morbidity and mortality. A matched case-control study was undertaken to determine whether dietary habits, prepregnancy weight, and weight gain during pregnancy were associated with increased risks for PROM. METHODS: Three study groups were defined, consisting of women delivering pre term with PROM (PP), full term with PROM (FP), and pre term without PROM (PWP). Cases were singly matched by race, age, and parity with women having full term deliveries without PROM. Data were collected by face-to-face structured interviews with eligible subjects and by medical records abstraction. RESULTS: Conditional multiple logistic regression indicated that during pregnancy, PP cases were significantly more likely to have gained less than 21 pounds (9.5 kg) (OR = 2.7, CI = 1.14-6.36) and were only half as likely as controls to have improved their diet (OR = 0.43, CI = 0.18-0.99) while controlling for cigarette smoking, urinary tract infection, chorioamnionitis, chlamydia, and a history of previous PROM. FP cases were significantly less likely than controls to have gained 31-40 pounds (14-18 kg) while pregnant (OR = 0.56, CI = 0.33-0.94) and were significantly more likely than controls to have a somewhat inadequate pregnancy diet (OR = 2.05, CI = 1.11-3.77) while controlling for a history of previous PROM. PWP cases were significantly less likely to have gained 31-40 pounds (14-18 kg) (OR = 0.42, CI = 0.21-0.84) or greater than 40 pounds (18 kg) (OR = 0.37, CI = 0.17-0.80) while pregnant or to have had adequate dairy products intake (OR = 0.60, CI = 0.36-0.99) while controlling for cigarette usage. CONCLUSION: Maternal dietary habits, weight gain during pregnancy, and supplement intake are associated with the occurrence of both pre term and full term PROM and pre term delivery without PROM.