Topographical Differences of Infant Mortality in Nepal.

Background Infant mortality is a major problem in Nepal, particularly in the mountainous region of the country. Objective To identify factors that contributes to the high rate of infant mortality in the mountain zone in Nepal. Method Data were derived from the 2011 Nepal Demographic and Health Survey (NDHS). Infant mortality was analyzed across three ecological zones in a sample of 5,306 live births in the five years preceding the survey. The contribution of risk factors to the excess infant mortality was assessed using multiple logistic regression. Result Infant mortality rate (deaths per 1000 live births) in the ecological zones were 59 (95% CI: 36, 81), 44 (35, 53), and 40 (33, 47) for the mountain, hill and terai zones, respectively. Women living in the mountain zone were more likely to report that distance to care was a "big problem" and had a greater risk of infant mortality compared to the terai zone (OR=1.42, 95% CI: 1.01, 2.02, p=0.04). This increased risk was observed only among births to mothers who perceived distance to the nearest health facility as a "big problem" (aOR=1.57, 95% CI: 1.01, 2.40, p=0.04) controlling for other risk factors. Conclusion These findings suggest that the higher Infant mortality rate (IMR) in the mountain zone was among the women who perceived distance to health facilities as a big problem. Improved accessibility to health services, particularly in this zone, is an essential strategy for reducing infant mortality in Nepal.

Utilization of primary health care facilities: lessons from a rural community in southwest Nigeria.

BACKGROUND: This study assessed service/organisational factors and clients' perceptions that influenced utilisation of Primary Health Care (PHC) facilities in a rural community in Nigeria. METHOD: A cross-sectional household survey in the community as well as key-informant interviews of opinion leaders and health care providers and participant observations of health facilities and utilisation pattern was used to collect data. RESULTS: Forty-four percent of respondents to the survey who were ill in the preceding six months visited a PHC facility for treatment, while others relied on self-medication/self-treatment. Education was positively associated with utilisation of PHC services (P<0.05). Maternal and child health (45.4%), prompt attention (23.0%), and appropriate outpatient (20.5%) services attracted respondents to use PHC services. Poor education about when to seek care, poverty, perceived high cost of PHC services, lack of drugs and basic laboratory services, and a regular physician on site at the facility were identified as barriers to utilisation. CONCLUSION: We conclude that community perceptions of poor quality and inadequacy of available services was responsible for low use of PHC services.

Utilization of Primary Health Care Facilities: Lessons from a Rural Community in Southwest Nigeria

Background: This study assessed service/organisational factors and clients' perceptions that influenced utilisation of Primary Health Care (PHC) facilities in a rural community in Nigeria. Method: A cross-sectional household survey in the community as well as key-informant interviews of opinion leaders and health care providers and participant observations of health facilities and utilisation pattern was used to collect data. Results: Forty-four percent of respondents to the survey who were ill in the preceding six months visited a PHC facility for treatment; while others relied on self-medication/self-treatment. Education was positively associated with utilisation of PHC services (P0.05). Maternal and child health (45.4); prompt attention (23.0); and appropriate outpatient (20.5) services attracted respondents to use PHC services. Poor education about when to seek care; poverty; perceived high cost of PHC services; lack of drugs and basic laboratory services; and a regular physician on site at the facility were identified as barriers to utilisation. Conclusion: We conclude that community perceptions of poor quality and inadequacy of available services was responsible for low use of PHC services

Quality of life and health-risk behaviors among adolescents.

PURPOSE: To assess the association between health-risk behaviors and self-perceived quality of life among adolescents METHODS: A sample of 2801 students (957 seventh and eighth graders and 1844 ninth through twelfth graders) completed the Teen Assessment Survey (TAP) and the surveillance module of the Youth Quality of Life Instrument (YQOL-S). TAP responses were used to determine health-risks related to tobacco use, alcohol use, illicit drug use, and high risk sexual behavior. Separate multivariate analyses of variance showed mean differences in contextual and perceptual items of the YQOL-S for each health-risk behavior. Differences among engagers (adolescents who often engage), experimenters (occasionally engage), and abstainers (never engage) in the health-risk behavior were evaluated by gender and junior/senior high school groups. RESULTS: In general, adolescent abstainers reported higher quality of life (QoL) than engagers and experimenters on YQOL-S items. Adolescents who engaged in multiple risk behaviors scored even lower than those who engaged in only one health-risk behavior. Experimenters tended to rate their QoL more similar to that of abstainers than to that of engagers. CONCLUSIONS: The framework of QoL proved useful in the evaluation of adolescents' engagement in health-risk behaviors. Additionally, assessing the areas of QoL that differ between the groups may provide information for planning interventions aimed at risk reduction among engagers and experimenters.

Ecological analysis of teen birth rates: association with community income and income inequality.

OBJECTIVES: To examine whether per capita income and income inequality are independently associated with teen birth rate in populous U.S. counties. METHODS: This study used 1990 U.S. Census data and National Center for Health Statistics birth data. Income inequality was measured with the 90:10 ratio, a ratio of percent of cumulative income held by the richest and poorest population deciles. Linear regression and analysis of variance were used to assess associations between county-level average income, income inequality, and teen birth rates among counties with population greater than 100,000. RESULTS: Among teens aged 15-17, income inequality and per capita income were independently associated with birth rate; the mean birth rate was 54 per 1,000 in counties with low income and high income inequality, and 19 per 1,000 in counties with high income and low inequality. Among older teens (aged 18-19) only per capita income was significantly associated with birth rate. CONCLUSIONS: Although teen childbearing is the result of individual behaviors, these findings suggest that community-level factors such as income and income inequality may contribute significantly to differences in teen birth rates.

Reproductive and sexual health benefits in private health insurance plans in Washington State.

CONTEXT: Although unintended pregnancy and sexually transmitted diseases (STDs) are considerable problems in the United States, private health insurance plans are inconsistent in their coverage of reproductive and sexual health services needed to address these problems. METHODS: A survey administered to a market-representative sample of 12 health insurance carriers in Washington State assessed benefit coverage for gynecologic services, maternity services, contraceptive services, pregnancy termination, infertility services, reproductive cancer screening, STD services, HIV and AIDS services, and sterilization, as well as for the existence of confidentiality policies. "Core" services in each category were defined based on U.S. Preventive Services Task Force and other recommendations. RESULTS: Of the 91 top-selling plans on which data were collected, 8% were indemnity plans, 14% were point-of-service plans, 21% were preferred-provider organization plans and 57% were health maintenance organization (HMO)-type products; they had a combined enrollment of 1.4 million individuals. Coverage of core services varied widely by type of plan. While a high proportion of plans covered core gynecologic, maternity, reproductive cancer screening, STD and HIV and AIDS services, nearly half of plans did not cover any kind of contraceptive method. Approximately 13% of female enrollees did not have core coverage for gyneco!ogic services, 19% for matemity services, 75% for contraception, 37% for sterilization and 53% for pregnancy termination; 98% of women and men were not covered for infertility treatment. Most carriers did not have specific policies for maintaining privacy of sensitive health information. Overall, benefit coverage was lower for indemnity, preferred-provider organization and HMO plans in Washington State than has previously been seen nationally. CONCLUSIONS: A sizable proportion of women and men in Washington State who rely on private-sector health insurance lack comprehensive coverage for key reproductive and sexual health services.

Association of lower continuity of care with greater risk of emergency department use and hospitalization in children.

CONTEXT: The benefits of continuity of pediatric care remain controversial. OBJECTIVE: To determine whether there is an association between having a continuous relationship with a primary care pediatric provider and decreased risk of emergency department (ED) visitation and hospitalization. DESIGN: Retrospective cohort study. Setting and Population. We used claims data from 46 097 pediatric patients enrolled at Group Health Cooperative, a large staff-model health maintenance organization, between January 1, 1993, and December 31, 1998, for our analysis. To be eligible, patients had to have been continuously enrolled for at least a 2-year period or since birth and to have made at least 4 visits to one of the Group Health Cooperative clinics. MAIN EXPOSURE VARIABLE: A continuity of care (COC) index that quantifies the degree to which a patient has experienced continuous care with a provider. MAIN OUTCOME MEASURES: ED utilization and hospitalization. RESULTS: Compared with children with the highest COC, children with medium continuity were more likely to have visited the ED (hazard ratio [HR]: 1.28 [1.20-1.36]) and more likely to be hospitalized (HR: 1.22 [1.09-1.38]). Children with the lowest COC were even more likely to have visited the ED (HR: 1.58 [1.49-1.66]) and to be hospitalized (HR: 1.54 [1.33-1.75]). These risks were even greater for children on Medicaid and those with asthma. CONCLUSIONS: Lower continuity of primary care is associated with higher risk of ED utilization and hospitalization. Efforts to improve and maintain continuity may be warranted.

Methodologic issues in pediatric outcomes research.

Clinicians, health services researchers, and third-party payers, among others, are justifiably interested in the outcomes of pediatric medical care and are, therefore, supportive of research in this area. Pediatric populations pose some unique methodologic challenges for health services researchers. To date, however, many of the approaches, models, and techniques used in pediatric outcomes research have been imported uncritically from experience with adult populations. As a result, some of the most interesting and salient aspects of pediatric outcomes research have yet to be fully developed. These include the following: 1) the problems posed by the dynamics of childhood development, 2) an emphasis on health supervision, 3) the need to see children within the context of a family system and to appreciate the interrelatedness of child health domains, 4) the measurement of the effects of interventions that span sectors, and 5) the paucity of available data sources. This article reviews these problematic areas and argues for a broad conceptual definition of pediatric health, a systems approach to assessing outcomes, and increased interdisciplinary collaboration.

Continuity and quality of care for children with diabetes who are covered by medicaid.

BACKGROUND: Poor and minority children with Type 1 diabetes mellitus are at increased risk of severe adverse outcomes as a result of their disease. However, little is known about the quality of care that these children receive and which factors are associated with better quality of care. OBJECTIVES: Our objectives were as follows: 1) to describe the utilization of services associated with quality of care for children with Type 1 diabetes mellitus who are covered by Medicaid and 2) to test the hypothesis that increased continuity of primary care is associated with better care for these children. DESIGN: Retrospective cohort study. METHODS: Washington State Medicaid claims data for 1997 were used to determine what proportion of children with diabetes had 1) an inpatient or outpatient diagnosis of diabetic ketoacidosis (DKA), 2) a glycosylated hemoglobin (HgA1c) level that had been checked, 3) a retinal examination, and 4) thyroid function studies. Continuity of care was quantified using a pre-established index. RESULTS: Two hundred fifty-two eligible patients were identified. During the observation year, 20% had an outpatient diagnosis of DKA, 6% were admitted with DKA, 43% visited an ophthalmologist, 54% had their HgA1c checked, and 21% had their thyroid function assessed. Children with high continuity of care were less likely to have DKA as an outpatient (0.30 [0.13-0.71]). Children with medium continuity of care and high continuity of care were less likely to be hospitalized for DKA (0.22 [0.05-0.87] and 0.14 [0.03-0.67], respectively). For preventive services utilization, high continuity of care was associated only with an increased likelihood of visiting an ophthalmologist (2.80 [1.08-3.88]). CONCLUSIONS: The quality of care for Medicaid children with diabetes can be substantially improved. Low continuity of primary care is an identifiable risk factor for DKA.

Pediatric deaths attributable to complex chronic conditions: a population-based study of Washington State, 1980-1997.

OBJECTIVES: Advances in medical technology and public health are changing the causes and patterns of pediatric mortality. To better inform health care planning for dying children, we sought to determine if an increasing proportion of pediatric deaths were attributable to an underlying complex chronic condition (CCC), what the typical age of CCC-associated deaths was, and whether this age was increasing. DESIGN: Population-based retrospective cohort from 1980 to 1997, compiled from Washington State annual censuses and death certificates of children 0 to 18 years old. MAIN OUTCOME MEASURES: For each of 9 categories of CCCs, the counts of death, mortality rates, and ages of death. RESULTS: Nearly one-quarter of the 21 617 child deaths during this period were attributable to a CCC. Death rates for the sudden infant death syndrome (SIDS), CCCs, and all other causes each declined, but less so for CCCs. Among infants who died because of causes other than injury or SIDS, 31% of the remaining deaths were attributable to a CCC in 1980 and 41% by 1997; for deaths in children 1 year of age and older, CCCs were cited in 53% in 1980, versus 58% in 1997. The median age of death for all CCCs was 4 months 9 days, with substantial differences among CCCs. No overall change in the age of death between 1980 to 1997 was found (nonparametric trend test). CONCLUSIONS: CCCs account for an increasing proportion of child deaths. The majority of these deaths occur during infancy, but the typical age varies by cause. These findings should help shape the design of support care services offered to children dying with chronic conditions and their families.

The association between greater continuity of care and timely measles-mumps-rubella vaccination.

OBJECTIVES: This study assessed whether greater continuity of care is associated with timely administration of measles-mumps-rubella (MMR) vaccination. METHODS: We studied 11,233 patients continuously enrolled in Group Health Cooperative (GHC) from birth to 15 months. We used a preestablished index to quantify continuity of care based on the number of primary care providers in relation to the number of clinic visits. MMR vaccination status at 15 months was assessed with automated immunization data systems at GHC. RESULTS: In a logistic regression model, both medium continuity (odds ratio [OR] = 1.20, 95% confidence interval [CI] = 1.08, 1.33) and high continuity (OR = 1.36, 95% CI = 1.22, 1.52) were associated with increased likelihood of being immunized by 15 months compared with patients in the lowest tercile of continuity of care. CONCLUSION: Greater continuity of care is associated with more timely immunization.

High-risk periods for childhood injury among siblings.

OBJECTIVE: To determine whether the risk of unintentional injury requiring emergency department (ED) or inpatient care in children is transiently increased over a 90-day period after injury to a sibling. DESIGN: Retrospective cohort. SETTING: King County, Washington. Participants. A total of 41 242 children 0 to 15 years of age continuously enrolled in Medicaid and living in King County during the period October 1, 1992 through September 30, 1993 (27 450 child-years). OUTCOME MEASURES: The outcome was an unintentional injury treated in the ED or inpatient setting. Incidence rates and hazard ratios were calculated for children whose sibling had been injured in the previous 90 days, compared with children without such exposure. Multivariate analysis was used to adjust for age, gender, race, sibling group size, and noninjury ED use. RESULTS: . There were 4921 injuries treated only in the ED and 82 hospital admissions. The incidence of ED treated injury was 305 per 1000 child-years among children whose sibling had been injured in the previous 90 days and 174 per 1000 child-years among children without this exposure (relative risk: 1.75; 95% confidence interval: 1.56-1.95). The incidence of injury-related hospitalization was 1.7 per 1000 child-years among children whose sibling had been injured in the previous 90 days, compared with 3.0 per 1000 child-years among children without this exposure (relative risk:.57; 95% confidence interval:.07-2.12). Injury risk peaked in the period 4 to 10 days after a sibling's injury and returned toward, but did not attain, baseline risk over the subsequent 21/2 months. The magnitude of this effect depended on the child's age; the relative risk of injury was higher among older children. CONCLUSIONS: Injuries treated in the ED or inpatient setting appear to cluster within sibling groups over brief periods of time. Shared social or environmental exposures may contribute to this clustering and may be amenable to targeted, time-limited prevention interventions.

A trade-off analysis of routine newborn circumcision.

BACKGROUND: The risks associated with newborn circumcision have not been as extensively evaluated as the benefits. OBJECTIVES: The goals of this study were threefold: 1) to derive a population-based complication rate for newborn circumcision; 2) to calculate the number needed to harm for newborn circumcision based on this rate; and 3) to establish trade-offs based on our complication rates and published estimates of the benefits of circumcision including the prevention of urinary tract infections and penile cancer. METHODS: Using the Comprehensive Hospital Abstract Reporting System for Washington State, we retrospectively examined routine newborn circumcisions performed over 9 years (1987-1996). We used International Classification of Diseases, Ninth Revision codes to identify both circumcisions and complications and limited our analyses to children without other surgical procedures performed during their initial birth hospitalization. RESULTS: Of 354, 297 male infants born during the study period, 130,475 (37%) were circumcised during their newborn stay. Overall 287 (.2%) of circumcised children and 33 (.01%) of uncircumcised children had complications potentially associated with circumcision coded as a discharge diagnosis. Based on our findings, a complication can be expected in 1 out every 476 circumcisions. Six urinary tract infections can be prevented for every complication endured and almost 2 complications can be expected for every case of penile cancer prevented. CONCLUSIONS: Circumcision remains a relatively safe procedure. However, for some parents, the risks we report may outweigh the potential benefits. This information may help parents seeking guidance to make an informed decision.

Is greater continuity of care associated with less emergency department utilization?

BACKGROUND: The benefits of continuity of care (COC) have not been firmly established for pediatric patients. OBJECTIVE: To assess whether greater COC is associated with lower emergency department (ED) utilization. SETTING: Outpatient teaching clinic at Children's Hospital and Regional Medical Center, Seattle, WA. PATIENTS: All 785 Medicaid managed care children ages 0 to 19 years followed at Children's Hospital and Regional Medical Center between 1993 to 1997 who had at least four outpatient visits. METHODS: Retrospective claims-based analysis. COC was quantified based on the number of different care providers in relation to the number of clinic visits. RESULTS: Attending COC was significantly greater than resident COC. In a multiple event survival analysis, compared with those patients in the lowest tertile of attending COC, those in the middle tertile had 30% lower ED utilization (hazard ratio 0.70 [0.53-0.93]) and those in the highest tertile had 35% lower ED use (hazard ratio 0.65 [0.50-0.80]). Resident COC was not significantly associated with ED use. CONCLUSION: Greater COC with attending physicians in outpatient teaching clinics is associated with lower ED utilization.

The effect of expanding Medicaid prenatal services on birth outcomes.

OBJECTIVES: Over 80% of US states have implemented expansions in prenatal services for Medicaid-enrolled women, including case management, nutritional and psychosocial counseling, health education, and home visiting. This study evaluates the effect of Washington State's expansion of such services on prenatal care use and low-birthweight rates. METHODS: The change in prenatal care use and low-birthweight rates among Washington's Medicaid-enrolled pregnant women before and after initiation of expanded prenatal services was compared with the change in these outcomes in Colorado, a control state. RESULTS: The percentage of expected prenatal visits completed increased significantly, from 84% to 87%, in both states. Washington's low-birthweight rate decreased (7.1% to 6.4%, P = .12), while Colorado's rate increased slightly (10.4% to 10.6%, P = .74). Washington's improvement was largely due to decreases in low-birthweight rates for medically high-risk women (18.0% to 13.7%, P = .01, for adults; 22.5% to 11.5%, P = .03, for teenagers), especially those with preexisting medical conditions. CONCLUSIONS: A statewide Medicaid-sponsored support service and case management program was associated with a decrease in the low-birthweight rate of medically high-risk women.

Analysis, assessment, and presentation of risk-adjusted statewide obstetrical care data: the StORQS II study in Washington State. Statewide Obstetrics Review and Quality System.

OBJECTIVE: To develop an effective, concise presentation of hospital-specific birth event and delivery-related complication rates, including significant deviations from expected rates calculated using risk-adjusted peer hospital data, for distribution to all Washington State hospitals with delivery services. DATA SOURCES: Complete data for calendar year 1993, including inpatient discharge records for mothers and newborns, birth certificates, and infant death records, for 74 hospitals from Washington state source files. STUDY DESIGN: Institutions were classified into four peer groups based on presence of neonatal intensive care units, number of births, and rural/urban location. Twenty-three clinical indicators of procedure (e.g., cesarean section) and complication rates were analyzed and presented. METHODS: For each indicator, observed and expected rates (adjusted within peer group for categorized baseline risk factors) were calculated and presented by institution. Effective graphic and numeric techniques for presenting significant deviations from expected rates were developed. Results were calculated in terms of numbers of events as well as rates. Approaches applicable to institutions with small numbers of deliveries were selected. PRINCIPAL FINDINGS: Exact confidence intervals (C.I.s) for event rates were superior to binomial or Poisson approximations for small hospitals. For calculating expected rates, indirect adjustment was used due to small numbers within risk factor categories. For all indicators, observed and expected rates along with 95 percent C.I.s for the true rate were presented graphically by institution for each peer group. Transforming C.I.s into "statistically acceptable ranges" allowed hospital personnel to assess their performance in terms of actual numbers of events as well as rates. CONCLUSIONS: Readily available statistical methods and straightforward descriptive approaches allow accurate presentation of outcomes for both large and small institutions.

Why don't women with diabetes plan their pregnancies?

OBJECTIVE: To determine why women with diabetes generally do not plan their pregnancies, consequently entering their pregnancies with poor blood glucose control and greatly increasing the risk of birth defects in their infants. RESEARCH DESIGN AND METHODS: A population-based sample of 85 women with diabetes diagnosed before the index pregnancy were recruited within 6 months postpartum from 15 hospitals in the state of Washington. Women with planned and unplanned pregnancies were compared using qualitative and quantitative analysis of personal interviews, self-administered questionnaires, and medical record review. RESULTS: Although most women (79%) knew they should optimize their blood glucose levels before conception, fewer than half (41%) of their pregnancies were planned. Women with planned pregnancies had significantly higher income and more education; were more likely to have private health insurance, to see an endocrinologist before pregnancy, to be happily married, and to be Caucasian; and were less likely to use tobacco. Most unplanned pregnancies were not contraceptive failures, but may have been consciously or subconsciously intended. Women with planned pregnancies generally described an ongoing and positive relationship with their health care providers. Women who felt that their doctors discouraged pregnancy were more likely to have an unplanned pregnancy than were women who had been reassured they could have a healthy baby. CONCLUSIONS: Many women with diabetes still perceive negative messages about pregnancies and become pregnant without optimal planning. We believe there are many opportunities for increasing the proportion of women with diabetes who plan their pregnancies, particularly in the areas of prepregnancy information, support that women are given, and the quality of the relationships they experience within the health care system. It is crucial that couples be reassured that with pre-conception glucose control, almost all women with diabetes can have healthy babies.

Comparison of length of stay for asthma by hospital type.

OBJECTIVE: To determine whether length of stay (LOS) for asthma admissions at a local university-affiliated children's hospital (UACH) is similar to that of community hospitals within the same county. METHODS: A retrospective analysis was performed using computerized hospital abstract records from 1989 through 1994. The study population was children 1 to 18 years old whose first or only hospitalization for a primary diagnosis of asthma occurred during the study period at either the UACH or one of the 17 community hospitals in King County, WA, that admit pediatric patients (n = 2491). Transfers and patients with chronic obstructive asthma or secondary diagnoses such as cystic fibrosis were not included in the study. Asthma patients were compared by sociodemographic and health risk characteristics such as age, sex, insurance status, and a comorbidity severity score. Differences between the two hospital populations were tested by chi2 and t tests. The effect of hospitalization at the UACH or the community hospitals on LOS was determined using analysis of covariance after adjusting for the sociodemographic and health risk covariates. RESULTS: Sixty-two percent (62%) of the asthma patients in the study population were discharged from the UACH. Compared with patients discharged from the community hospitals, the UACH patients were significantly younger, more often male, used public insurance, and resided in areas with lower median household incomes. The severity of comorbidities was not different between the two hospital groups. Overall, adjusted mean LOS was not significantly longer at the UACH (2.1 days) than at the community hospitals (2.0 days); however, adjusted mean LOS for specific subgroups, most notably poor children and those with public insurance, was significantly longer at the UACH. CONCLUSION: LOS for first or only asthma hospitalizations during 1989 through 1994 at the UACH was similar to local community hospitals within the same county. Specific subgroups of children were hospitalized for a longer period at the UACH, but children with private insurance and from areas with higher median household incomes had similar LOS, and presumably costs, at the UACH and the community hospitals.

Adolescent pregnancy and sexual risk-taking among sexually abused girls.

Data on 3,128 girls in grades eight, 10 and 12 who participated in the 1992 Washington State Survey of Adolescent Health Behaviors were used to analyze the association of a self-reported history of sexual abuse with teenage pregnancy and with sexual behavior that increases the risk of adolescent pregnancy. In analyses adjusting for grade level, respondents who had been sexually abused were 3.1 times as likely as those who had not been abused to say they had ever been pregnant; in multivariate analyses, respondents who had experienced abuse were 2.3 times as likely as others to have had intercourse but were not more likely than other sexually active respondents to have been pregnant. However, those with a history of sexual abuse were more likely to report having had intercourse by age 15 (odds ratio, 2.1), not using birth control at last intercourse (2.0) and having had more than one sexual partner (1.4). Thus, an association between sexual abuse and teenage pregnancy appears to be the result of high-risk behavior exhibited by adolescent girls who have been abused.

PIP: The association between a self-reported history of child sexual abuse and adolescent pregnancy was investigated in the 1992 Washington State (US) Survey of Adolescent Health Behaviors. Enrolled in the study were 3128 girls from 70 school districts in grades 8, 10, and 12. In these 3 grades, the prevalence of sexual abuse was 18%, 24%, and 28%, respectively. Sexual abuse was reported by 48% of students who had been pregnant at least once and 21% of those who had never been pregnant. After adjustment for grade level, girls who had been sexually abused were 3.1 times as likely to have ever been pregnant than those without such a history. In multivariate analysis controlled for other risk factors, sexually abused girls were 2.3 times more likely than others to have had sexual intercourse, but were not more likely than other sexually active girls to have been pregnant. However, those with a history of sexual abuse were more likely to have had intercourse by age 15 years (odds ratio (OR), 2.1), not to have used birth control at last intercourse (OR, 2.0), and to have had more than 1 sexual partner (OR, 1.4). These findings suggest that the association between sexual abuse and adolescent pregnancy results from the high-risk sexual behaviors of girls with an abuse history. Although the private nature of child sexual abuse impedes efforts at primary prevention, school counselors are urged to discuss child sexual abuse openly and target self-reported victims for pregnancy prevention.

Gestational diabetes is a herald of NIDDM in Navajo women. High rate of abnormal glucose tolerance after GDM.

OBJECTIVE: To estimate the rate of deterioration of glucose tolerance and evaluate risk factors for development of NIDDM in Navajo women with a history of gestational diabetes mellitus (GDM). RESEARCH DESIGN AND METHODS: A retrospective analysis of 111 GDM deliveries over a 4-year period, 1983-1987, was conducted in 1994 to determine glucose tolerance status. Patients who had not developed NIDDM were recalled for a 2-h glucose tolerance test (GTT). Tested and non-tested patients were compared, as estimate of conversion to NIDDM was calculated, and risk factors for NIDDM were evaluated. A life-table analysis was developed to estimate the probability of NIDDM after GDM. RESULTS: At the time of chart review, 32 patients (29%) had already been diagnosed with NIDDM. Of the patients, 79 were offered GTT testing, and 56 (71%) returned for follow-up; 15 were diagnosed with NIDDM and 17 with impaired glucose tolerance (IGT); 47 (42%) and 64 (58%) patients in the cohort had developed NIDDM or NIDDM/IGT at the conclusion of the study period. Patients who developed NIDDM had greater BMIs, parity, and infant weights. Fasting blood glucose > 5.83 mmol/l, GTT > 41.63 mmol/l, and recurrence of GDM were associated with later NIDDM. A life-table analysis estimated a 53% likelihood of having NIDDM at an 11-year follow-up; a second model, based only on patients with known NIDDM status, predicted a 70% rate of NIDDM at an 11-year follow-up. CONCLUSIONS: A high proportion of Navajo women with GDM progressed to NIDDM. Postpartum counseling and periodic GTTs are recommended.