Does the extended parallel process model fear appeal theory explain fears and barriers to prenatal physical activity?

BACKGROUND: Few studies have looked at the impact of fear on exercise behavior during pregnancy using a fear appeal theory. It is beneficial to understand how women receive the message of safe exercise during pregnancy and whether established guidelines have any influence on their decision to exercise. Using the extended parallel process model (EPPM), we explored women's fears about prenatal physical activity. METHODS: We conducted a prospective, cross-sectional study on the fears and barriers to prenatal exercise among a racially/ethnically diverse population of pregnant women. Participants were recruited from local prenatal clinics. Ninety females with a singleton pregnancy between 16 and 30 weeks gestation were enrolled in the study. The primary outcome measure was classification of risk behavior based on the EPPM theory. FINDINGS: Women who scored high on self-efficacy for exercising safely were more likely to exercise during pregnancy (adjusted odds ratio, 5.95; 95% CI, 1.39-25.39; P=.016) for at least 90 minutes per week. Participants who exercised at least 90 minutes per week during pregnancy scored higher on their perceived ability to control danger to the baby, as well as less susceptibility of harm and threat to baby of moderate exercise from prenatal exercise. CONCLUSIONS: More education and counseling on specific guidelines for safely exercising during pregnancy are needed. The EPPM framework has the potential to help improve health communications about exercise safety and guidelines between patients and health care professionals during pregnancy.

Physician-led, hospital-linked, birth care centers can decrease cesarean section rates without increasing rates of adverse events.

BACKGROUND: This study compares outcomes at a hospital-linked, physician-led, birthing center to a traditional hospital labor and delivery service. METHODS: Using de-identified electronic medical records, a retrospective cohort design was employed to evaluate 32,174 singleton births during 1998-2005. RESULTS: Compared with hospital service, birth care center delivery was associated with a lower rate of cesarean sections (adjusted Relative Risk = 0.73, 95% confidence interval 0.59-0.91; p < 0.001) without an increased rate of operative vaginal delivery (adjusted Relative Risk = 1.04, 95% confidence interval 0.97-1.13; p = 0.25) and a higher initiation of breastfeeding (adjusted Relative Risk = 1.28, 95% confidence interval 1.25-1.30; p ≤ 0.001). A maternal length of stay greater than 72 hours occurred less frequently in the birth care center (adjusted Relative Risk = 0.60, 95% confidence interval 0.55-0.66; p < 0.001). Comparing only women without major obstetrical risk factors, the differences in outcomes were reduced but not eliminated. Adverse maternal and infant outcomes were not increased at the birth care center. CONCLUSION: A hospital-linked, physician-led, birth care center has the potential to lower rates of cesarean sections without increasing rates of operative vaginal delivery or other adverse maternal and infant outcomes.

Improving cancer survivorship care: oncology nurses' educational needs and preferred methods of learning.

Oncology nurses are essential in all phases of cancer care; however, their role in survivorship care is unclear. To better understand the self-reported knowledge and educational needs on topics of survivorship care and oncology nurses' learning preferences, an online survey was conducted. Respondents self-reported knowledge level for 31 care topics, identified areas of most interest, topics needed to assist patients and address patient questions, and reported participation in continuing education and preferred learning methods. Knowledge was rated highest for topics of fatigue, anxiety, and fear of recurrence and lowest for issues related to finance, employment, and insurance. Nurses were most interested in late and long-term physical effects of cancer or treatment, managing emotional issues, cancer screening and surveillance, and complementary and alternative therapies. Study findings suggest that online learning methods would be feasible and well accepted by nurses to meet continuing education needs related to cancer survivorship.

Oncology nurses' perspectives on the state of cancer survivorship care: current practice and barriers to implementation.

PURPOSE/OBJECTIVES: to describe current survivorship care from the perspectives of oncology nurses. DESIGN: descriptive. SETTING: e-mail invitation to Web-based survey. SAMPLE: 399 Oncology Nursing Society members providing care for patients initially treated more than one year previously. METHODS: an online survey was used to evaluate current aspects of survivorship care. MAIN RESEARCH VARIABLES: practice settings, services provided, and barriers to delivering survivorship care. FINDINGS: few nurses (27%) worked in settings with a formal survivorship program. Several program components were provided significantly more often in outpatient settings, pediatric facilities, and workplaces with a formal survivorship program. At the transition from acute to follow-up care, the survivorship nursing care provided most often was scheduling for ongoing monitoring (71%) and the least likely was assistance for employment or legal issues (16%). The greatest barriers to providing survivorship care were lack of time and funding (46%). Among nurses new to oncology (fewer than five years), 49% indicated they lacked sufficient knowledge compared to 36% of nurses with more than five years of oncology experience. CONCLUSIONS: findings describe current aspects of survivorship care across practice settings. Nurses reported that the greatest barriers are lack of time, funding, and lack of knowledge about survivorship issues. IMPLICATIONS FOR NURSING: a need exists for education to enhance knowledge and skills of nurses who will provide survivorship care. Research is warranted to develop empirically supported guidelines and care-delivery models that address the barriers to providing survivorship services.

Comparison of focus groups on cancer and employment conducted face to face or by telephone.

Findings from telephone focus groups have not been compared previously to findings from face-to-face focus groups. We conducted four telephone focus groups and five face-to-face focus groups in which a single moderator used the same open-ended questions and discussion facilitation techniques. This comparison was part of a larger study to gain a better understanding of employment experiences after diagnosis of gynecologic cancer. Offering the telephone option made it easier to recruit women from rural areas and geographically distant cities. Interaction between participants occurred in both types of focus group. Content analysis revealed that similar elements of the employment experience after cancer diagnosis were described by telephone and face-to-face participants. Participants disclosed certain emotionally sensitive experiences only in the telephone focus groups. Telephone focus groups provide useful data and can reduce logistical barriers to research participation. Visual anonymity might help some participants feel more comfortable discussing certain personal issues.

Cancer-related tasks involving employment: opportunities for clinical assistance.

Many cancer survivors experience unmet psychosocial needs related to their jobs, and women often fare worse than men in this regard. However, little research exists on ways to assist patients with cancer in preventing or managing common job problems. We conducted focus groups and a survey among 73 women who were employed at the time of presentation of a gynecologic cancer. We compared the findings with existing recommendations and professional standards for occupational rehabilitation. Participants described different cancer-related employment tasks in three time periods: just after diagnosis, during primary treatment, and after primary treatment is completed. The more difficult tasks included communicating with supervisors and coworkers, determining company policies, applying for employer-sponsored benefits, handling finances, managing symptoms on returning to work, finding effective solutions to cancer-related job problems, leaving the job with dignity if too sick or if the job ended, and making career plans. The cancer care team may be able to help meet the psychosocial needs of employed cancer survivors by screening for job concerns, providing information, formulating a return-to-work plan, treating symptoms, consulting with professionals who have employment-related expertise, and giving other forms of assistance.

Employment and quality of survivorship among women with cancer: domains not captured by quality of life instruments.

BACKGROUND: Many quality of life instruments assess the amount of paid work in combination with role function at home in the same items and do not specifically assess social support in the workplace. The goal of this study was to obtain women's views on the relationship between employment and health-related quality of life. METHODS: A focus group and questionnaire study was conducted among 73 women with gynecologic cancer who were employed at diagnosis and 25 people who provided them with psychosocial support. RESULTS: The women held a variety of blue collar and white collar jobs at diagnosis. Employment provided a strong sense of accomplishment and a welcome distraction during treatment. The employment experience was described as distinct from role function at home. No one equated working more hours with better quality of life. Social support at work could be poor at the same time that support from family and friends grew stronger. CONCLUSIONS: The contribution to their quality of life that cancer survivors feel they receive from employment may not be linearly related to the quantity of their role function in the workplace. Employment-related items could be useful as an adjunct to standard quality of life measures.

Disparity in assisted reproductive technologies outcomes in black women compared with white women.

OBJECTIVE: To compare success rates in black and white women undergoing IVF. DESIGN: Retrospective cohort study. SETTING: Society for Assisted Reproductive Technology member clinics in 1999-2000 that performed >or=50 cycles of IVF and reported race/ethnicity in >95% of cycles. PATIENT(S): Women receiving 80,309 IVF cycles. INTERVENTION(S): IVF using nondonor embryos. MAIN OUTCOME MEASURE(S): Live-birth rate per cycle started. RESULT(S): Black, white, and other race/ethnicity women underwent 3666 (4.6%), 68,607 (83.5%), and 8036 (11.9%) IVF cycles, respectively. Spontaneous abortions were more common among black women. The live-birth rate was 26.3% (95% confidence interval [CI], 25.9%-26.7%) among white women compared with 18.7% (95% CI, 17.5%-20.1%) among black women (rate ratio, 1.41). After controlling for increased tubal and uterine factor infertility among blacks and other characteristics, black race was an independent risk factor for not achieving a live birth (adjusted relative risk, 1.21; 95% CI, 1.12-1.36 if no prior ART, and RR, 1.38; 95% CI, 1.20-1.57 if prior ART). For cryopreserved embryo cycles, live-birth rates were equivalent. CONCLUSION(S): Black women, who represented 7.8% of married reproductive-age women in the United States at that time, were underrepresented among IVF recipients. Race is a marker for prognosis that is not explained by characteristics available in the registry data set.

Reproductive disorders associated with pesticide exposure.

Exposure of men or women to certain pesticides at sufficient doses may increase the risk for sperm abnormalities, decreased fertility, a deficit of male children, spontaneous abortion, birth defects or fetal growth retardation. Pesticides from workplace or environmental exposures enter breast milk. Certain pesticides have been linked to developmental neurobehavioral problems, altered function of immune cells and possibly childhood leukemia. In well-designed epidemiologic studies, adverse reproductive or developmental effects have been associated with mixed pesticide exposure in occupational settings, particularly when personal protective equipment is not used. Every class of pesticides has at least one agent capable of affecting a reproductive or developmental endpoint in laboratory animals or people, including organophosphates, carbamates, pyrethroids, herbicides, fungicides, fumigants and especially organochlorines. Many of the most toxic pesticides have been banned or restricted in developed nations, but high exposures to these agents are still occurring in the most impoverished countries around the globe. Protective clothing, masks and gloves are more difficult to tolerate in hot, humid weather, or may be unavailable or unaffordable. Counseling patients who are concerned about reproductive and developmental effects of pesticides often involves helping them assess their exposure levels, weigh risks and benefits, and adopt practices to reduce or eliminate their absorbed dose. Patients may not realize that by the first prenatal care visit, most disruptions of organogenesis have already occurred. Planning ahead provides the best chance of lowering risk from pesticides and remediating other risk factors before conception.

Asian ethnicity is associated with reduced pregnancy outcomes after assisted reproductive technology.

OBJECTIVE: To determine whether success rates were similar in Asian and Caucasian women undergoing infertility treatment. DESIGN: Secondary data analysis and multivariate modeling. SETTING: Clinics reporting to the national Society for Assisted Reproductive Technology registry and a university-based clinic. PATIENT(S): Caucasian and self-identified Asian infertile women undergoing IVF. The study included 25,843 Caucasian and 1,429 Asian patients from the national registry; 370 Caucasian and 197 Asian patients were included from the site-specific clinic. INTERVENTION(S): In vitro fertilization. MAIN OUTCOME MEASURE(S): Pregnancy rate and live-birth rate. RESULT(S): Infertile Asian women differed only minimally from their Caucasian counterparts in baseline characteristics and treatment response. Yet Asian women had a decreased clinical pregnancy rate (odds ratio, 0.71; 95% confidence interval 0.64-0.80) and a decreased live-birth rate (odds ratio, 0.69; 95% confidence interval 0.61-0.77). Subsequent multivariate analysis demonstrated that Asian ethnicity was an independent predictor of poor outcome. CONCLUSION(S): After treatment, infertile Asian women have significantly fewer pregnancies than do Caucasian women. Multivariate analysis indicates that this discrepancy cannot be accounted for by differences in baseline characteristics or by response to current therapeutic interventions.

Use of a gestational carrier for a patient with recurrent adverse pregnancy outcomes from early onset severe pre-eclampsia.

OBJECTIVE: To describe the first reported case of gestational carrier treatment to prevent severe early onset pre-eclampsia. DESIGN: Case report. SETTING: A university-based reproductive endocrinology and infertility clinic and a tertiary care hospital. PATIENT(S): A 29-year-old woman and her husband with three consecutive pregnancies complicated by early onset severe pre-eclampsia causing fetal demises at 22 and 24 weeks gestation; a neonatal death at 25 weeks gestation; and life-threatening maternal hemolysis, elevated liver enzymes, and low platelets. INTERVENTION(S): An IVF procedure in the patient using her husband's sperm with the transfer of two embryos to a friend who offered to be a gestational carrier. MAIN OUTCOME MEASURE(S): Successful IVF cycle in the patient and uncomplicated pregnancy and delivery in the gestational carrier. RESULT(S): The gestational carrier achieved a pregnancy and progressed without complications to delivery of a healthy, 3.2-kg infant at 39 weeks gestation. CONCLUSION(S): The use of a gestational carrier deserves consideration as a treatment option in patients with poor reproductive histories because of early onset severe pre-eclampsia and hemolysis, elevated liver enzymes, and low platelets syndrome. This experience also suggests that development of pre-eclampsia may be in large part maternally rather than embryologically or paternally driven.

Preconception care and treatment with assisted reproductive technologies.

Couples with fertility problems seeking treatment with assisted reproductive technologies (ART) such as in vitro fertilization should receive preconception counseling on all factors that are provided when counseling patients without fertility problems. Additional counseling should address success rates and possible risks from ART therapies. Success rates from ART are improving, with the highest live birth rates averaging about 40% per cycle among women less than 35 years old. A woman's age lowers the chance of achieving a live birth, as do smoking, obesity, and infertility diagnoses such as hydrosalpinx, uterine leiomyoma, or male factor infertility. Singletons conceived with ART may have lower birth weights. Animal studies suggest that genetic imprinting disorders may be induced by certain embryo culture conditions. The major risk from ovarian stimulation is multiple gestation. About one-third of live-birth deliveries from ART have more than one infant, and twins represent 85% of these multiple-birth children. There are more complications in multiple gestation pregnancies, infants are more likely to be born preterm and with other health problems, and families caring for multiples experience more stress. Transferring fewer embryos per cycle reduces the multiple birth rate from ART, but the patient may have to pay for additional cycles of ART because of a lower likelihood of pregnancy.

Workgroup report: Implementing a national occupational reproductive research agenda--decade one and beyond.

The initial goal of occupational reproductive health research is to effectively study the many toxicants, physical agents, and biomechanical and psychosocial stressors that may constitute reproductive hazards in the workplace. Although the main objective of occupational reproductive researchers and clinicians is to prevent recognized adverse reproductive outcomes, research has expanded to include a broader spectrum of chronic health outcomes potentially affected by reproductive toxicants. To aid in achieving these goals, the National Institute for Occupational Safety and Health, along with its university, federal, industry, and labor colleagues, formed the National Occupational Research Agenda (NORA) in 1996. NORA resulted in 21 research teams, including the Reproductive Health Research Team (RHRT). In this report, we describe progress made in the last decade by the RHRT and by others in this field, including prioritizing reproductive toxicants for further study; facilitating collaboration among epidemiologists, biologists, and toxicologists; promoting quality exposure assessment in field studies and surveillance; and encouraging the design and conduct of priority occupational reproductive studies. We also describe new tools for screening reproductive toxicants and for analyzing mode of action. We recommend considering outcomes such as menopause and latent adverse effects for further study, as well as including exposures such as shift work and nanomaterials. We describe a broad domain of scholarship activities where a cohesive system of organized and aligned work activities integrates 10 years of team efforts and provides guidance for future research.

Impact of 1996 Residency Review Committee Obstetrics-Gynecology primary care requirements on residency training and surgical procedures.

OBJECTIVE: This study evaluated the impact of required primary care rotations in obstetrics-gynecology residency training after 1996. STUDY DESIGN: A questionnaire was sent to the 1994 to 2003 graduates from 1 residency program, and records of surgical procedures completed during residency were analyzed. RESULTS: Thirty-nine of 46 graduates participated in the study (response rate 85%). Required primary care training was associated with increased confidence in providing primary care (81.5% versus 54.5%, P = .12) but less agreement that obstetrics-gynecology is a primary care specialty (21.4% versus 45.5%, P = .23). Abdominal hysterectomies and vaginal hysterectomies per resident did not decrease (127 versus 113, P = 0.149, and 55 versus 48, P = .06, respectively). Adjusted for temporal trends, cesarean sections per resident decreased (366 versus 321, P = .009). CONCLUSION: Residents maintained adequate rates of major inpatient surgical procedures after implementation of required primary care training. There was a tendency for residents who graduated after 1996 to have less favorable attitudes about primary care.

Occupational exposures and reproductive health: 2003 Teratology Society Meeting Symposium summary.

Assuring reproductive health in the workplace challenges researchers, occupational safety and health practitioners, and clinicians. Most chemicals in the workplace have not been evaluated for reproductive toxicity. Although occupational exposure limits are established to protect 'nearly all' workers, there is little research that characterizes reproductive hazards. For researchers, improvements in epidemiologic design and exposure assessment methods are needed to conduct adequate reproductive studies. Occupational safety and health programs' qualitative and quantitative evaluations of the workplace for reproductive hazards may differ from standardized approaches used for other occupational hazards in that estimates of exposure intensity must be considered in the context of the time-dependent windows of reproductive susceptibility. Clinicians and counselors should place the risk estimate into context by emphasizing the limitations of the available knowledge and the qualitative nature of the exposure estimates, as well as what is known about other non-occupational risk factors for adverse outcomes. This will allow informed decision-making about the need for added protections or alternative duty assignment when a hazard cannot be eliminated. These policies should preserve a worker's income, benefits, and seniority. Applying hazard control technologies and hazard communication training can minimize a worker's risk. Chemical reproductive hazard training is required for workers by the Occupational Safety and Health Administration's Hazard Communication Standard. The National Institute for Occupational Safety and Health (NIOSH) has formed a National Occupational Research Agenda Team to promote communication and partnering among reproductive toxicologists, clinicians and epidemiologists, to improve reproductive hazard exposure assessment and management, and to encourage needed research.

Follicle-stimulating hormone and estradiol levels independently predict the success of assisted reproductive technology treatment.

OBJECTIVE: To evaluate the relationship between early follicular phase levels of FSH and E(2) and outcomes of therapy with assisted reproductive technologies (ART). DESIGN: Retrospective cohort study. SETTING: ART centers in the United States. PATIENT(S): Women receiving 19,682 ART procedures performed in 135 clinics. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Rates of clinical pregnancy, live birth delivery, and high ovarian response (>/=10 oocytes retrieved after stimulation). RESULT(S): The ratio of each FSH or E(2) value to the respective upper limit of normal value for the clinic was computed. Within each age group, rates of pregnancy, live birth, and high ovarian response decreased linearly as FSH levels increased. For example, among women 35 years of age and younger, pregnancy rates (PR) ranged from 41.1% (FSH ratio 0-0.5) to 18.5% (FSH ratio >2.0). The three outcomes exhibited a similar downward trend as E(2) ratios increased. When both hormone ratios were elevated, outcomes were least favorable. These relationships remained statistically significant after we adjusted for diagnosis, number of embryos transferred, previous births, previous ART therapy, and use of GIFT, zygote intrafallopian transfer (ZIFT), intracytoplasmic sperm injection (ICSI), or assisted hatching. CONCLUSION(S): The FSH and E(2) ratios predict ART success independent of age and other clinical prognostic factors.

Kansas office-based nurses' evaluation of patient tobacco cessation activities.

In this study, we examined the tobacco cessation efforts of nurses working in primary care settings. A 43-item questionnaire was mailed to 1,036 office-based nurses located throughout Kansas. With a response rate of 50.1%, 415 questionnaires were available for analysis. Although 89% of respondents encountered patients who smoked on a daily or weekly basis, only 51% reported documenting their patients' tobacco use, and 38% assessed patients' readiness to quit. Two thirds (66%) of nurses believed that tobacco management was part of their role but only 35% provided cessation advice, 23% recommended nicotine replacement therapy, and 14% provided coping techniques. Nurses cited barriers such as perceiving patients as disinterested or unmotivated to quit (65%) and having little time (55%), skills (32%), or knowledge (25%). Most (91%) agreed that they needed additional tobacco control education. Nurses who were advanced registered nurse practitioners or clinical nurse specialists were more likely to feel confident about their smoking cessation counseling skills compared to nurses with less education (66.7 vs. 31.2%, p =.010). Office-based nurses identified specific barriers that could be addressed through professional education about tobacco management.

Pregnancy during obstetrics and gynecology residency: effect on surgical experience.

OBJECTIVE: This study explored residents' views about pregnancy during residency and the effect leaves of absence had on the quantity of surgical procedures performed. STUDY DESIGN: Physicians who graduated from an obstetrics and gynecology residency between 1994 and 2002 were contacted by mail. Respondents completed a questionnaire and consented to use of the program's surgical database to obtain information regarding surgical procedures performed during their training. RESULTS: Thirty-one of the 41 eligible resident physicians returned the questionnaire and consent form (response rate, 75.6%). Among the 14 responding men, 2 had taken a total of three nonvacation, noneducational leaves. Among the 17 women respondents, there were 16 leaves associated with deliveries, and the nonvacation, noneducational leave for women who were pregnant was statistically longer than for other residents (median of 6 weeks compared with 0 weeks, P<.001). Most pregnancies were planned (27/29, 93.1%) and were delivered in the third or fourth year of training (11/16, 68.8%). Former residents listed several ways that the program accommodated pregnancy and were satisfied with the program. The mean number of procedures for women with deliveries compared with other residents were as follows: cesarean section, 315 versus 281 cases (P=.20); abdominal hysterectomy, 116 versus 102 cases (P=.08); laparoscopy, 87 versus 92 cases (P=.72); vaginal hysterectomy, 51 versus. 45 cases (P=.11). CONCLUSION: Pregnancy and delivery did not decrease surgical experience of four major procedures in this program, and pregnant physicians perceived appropriate support from their colleagues and the program administration.

Feasibility of maternity protection in early pregnancy.

Many countries have maternity protection laws for women who need job modification or medical leave during pregnancy. This approach will prevent birth defects only if maternal job changes can be made before the critical period of organogenesis, which begins at three weeks' gestation. The authors studied the gestational ages at which pregnant women working with chemicals, radiation, and noise presented for occupational safety and health consultations. The work setting promoted early presentation because the consultation was free, convenient, mandatory, and would not result in job loss. Among the 213 pregnant women evaluated between 1996 and 2000, most (89.5%) had their occupational safety evaluations in the first trimester. Although this sounds ideal, the mean gestational age at presentation was 7.5 weeks, and only 3.3% of occupational health evaluations were initiated by three weeks' gestation. Environmental and biological monitoring showed that none of the women was exposed over occupational limits. These data suggest that a workplace free from reproductive hazards needs to be provided before conception.

Clinical outcomes among recipients of donated eggs: an analysis of the U.S. national experience, 1996-1998.

OBJECTIVE: To evaluate the role of recipient age on the outcome of donor egg cycles. DESIGN: Retrospective cohort study of aggregated national cycles of donor egg therapy that are collected by Society for Assisted Reproductive Technology and the Centers for Disease Control and Prevention. SETTING: Assisted reproductive technology centers in the United States that report their results to the Centers for Disease Control and Prevention by way of the Society for Assisted Reproductive Technology. PATIENT(S): Recipients of embryos (17,339 cycles) derived from donated eggs between 1996 and 1998. INTERVENTION(S): None. MAIN OUTCOME MEASURE(S): Rates of implantation, clinical intrauterine pregnancy, pregnancy loss, and delivery based on the age of the recipient. RESULT(S): Success of donor egg therapy was remarkably constant among recipients aged 25 years through those in their late forties. At higher ages, declining rates of implantation, clinical pregnancy, and delivery were seen, along with small increases of pregnancy loss. During the course of the 3 years studied, fewer embryos were transferred and higher rates of implantation were observed. CONCLUSION(S): The success of donor egg therapy is unaffected by recipient age up to the later 40s, after which they begin to decline. Although recipient age per se is likely to be the major cause of this effect, other factors may contribute to this observation.