Physical and Organizational Job Stressors in Pregnancy and Associations With Primary Cesarean Deliveries.

OBJECTIVE: The aim of this study was to assess the relationship between exposure to physical and organizational job stressors during pregnancy and cesarean delivery. METHODS: We sampled 580 employed women in California who participated in a nested population-based case-control study of birth outcomes. Adjusted multivariate regression analyses estimated associations between heavy lifting, frequent bending, high noise, extreme temperature, prolonged standing and organizational stressors (shift work, inflexible schedules, effort-reward ratio), and primary cesarean (vs vaginal) delivery, controlling for covariates. RESULTS: Women occupationally exposed had higher odds of cesarean. Those exposed to daily manual lifting more than 15 pounds [adjusted odds ratio = 2.54; 95% confidence interval (95% CI) 1.21 to 5.32] and at least four physical job stressors (adjusted odds ratio = 3.49; 95% CI 1.21 to 10.09) had significantly elevated odds of cesarean delivery. Exposed morbid women experienced greater risk; risk was lower among those with schedule flexibility. CONCLUSION: Associations were found between modifiable exposure to physical job stressors during pregnancy and cesarean delivery.

The impact of male circumcision on HIV transmission.

PURPOSE: Adult male circumcision is currently being implemented as an HIV prevention strategy worldwide. We reviewed the literature on adult male circumcision in the prevention of HIV. MATERIALS AND METHODS: A MEDLINE search was used to identify current literature addressing HIV and male circumcision. The data from that literature were reviewed and summarized. RESULTS: Three randomized, controlled trials demonstrate that circumcising adult males reduces the incidence of HIV by 50% to 60%. Adult male circumcision does not seem to have an adverse impact on sexual function. Epidemiological and economic modeling suggests that adult male circumcision can potentially be a highly cost-effective strategy for HIV prevention. CONCLUSIONS: Safe, high quality, low cost adult male circumcision services should be made available to regions with a high HIV incidence as part of a comprehensive HIV prevention package.

Obstetric complications in women with diagnosed mental illness: the relative success of California's county mental health system.

OBJECTIVE: To examine disparities in serious obstetric complications and quality of obstetric care during labor and delivery for women with and without mental illness. DATA SOURCE: Linked California hospital discharge (2000-2001), birth, fetal death, and county mental health system (CMHS) records. STUDY DESIGN: This population-based, cross-sectional study of 915,568 deliveries in California, calculated adjusted odds ratios (AORs) for obstetric complication rates for women with a mental illness diagnosis (treated and not treated in the CMHS) compared with women with no mental illness diagnosis, controlling for sociodemographic, delivery hospital type, and clinical factors. RESULTS: Compared with deliveries in the general non-mentally ill population, deliveries to women with mental illness stand a higher adjusted risk of obstetric complication: AOR=1.32 (95 percent confidence interval [CI]=1.25, 1.39) for women treated in the CMHS and AOR=1.72 (95 percent CI=1.66, 1.79) for women not treated in the CMHS. Mentally ill women treated in the CMHS are at lower risk than non-CMHS mentally ill women of experiencing conditions associated with suboptimal intrapartum care (postpartum hemorrhage, major puerperal infections) and inadequate prenatal care (acute pyelonephritis). CONCLUSION: Since mental disorders during pregnancy adversely affect mothers and their infants, care of the mentally ill pregnant woman by mental health and primary care providers warrants special attention.

Sociodemographic predictors of prostate cancer risk category at diagnosis: unique patterns of significant and insignificant disease.

PURPOSE: We determined various sociodemographic predictors of prostate cancer risk category at presentation as assessed by serum prostate specific antigen, cancer grade and tumor stage. MATERIALS AND METHODS: We performed a retrospective cohort study of 5,939 patients enrolled in the CaPSURE national disease registry database between 1995 and 2007. Prostate cancer risk category was assigned as low, intermediate or high based on diagnostic prostate specific antigen, clinical grade and biopsy Gleason grade. Additionally, a group of men with low grade, limited volume tumors were identified as having clinically insignificant disease. The primary outcome was prostate cancer risk category at presentation. Treatment received vs active surveillance was analyzed as a secondary end point. RESULTS: Patients who were older, had lower levels of education and had Medicare with or without a supplement instead of private or Veteran's Affairs insurance were more likely to have intermediate and high risk disease than low risk disease. Nonwhite race was associated with high risk disease at presentation. Clinically insignificant disease was more common in men younger than 60 years, those with higher education and income, and those with private insurance. Logistic regression analysis suggested that younger age, higher education and income, and private insurance were related to insignificant disease being detected. Among men with insignificant disease younger age and private insurance were associated with immediate treatment with curative intent. CONCLUSIONS: Unique sociodemographic variables are associated with the clinical risk of prostate cancer at diagnosis and they may influence treatment decisions and outcomes. Patients with insignificant disease may be susceptible to overtreatment due to the indolent nature of the disease. Intermediate and high risk groups, which are associated with poorer outcomes, may be further endangered by late detection of the disease.

Maternity leave in the ninth month of pregnancy and birth outcomes among working women.

PURPOSE: The health effects of antenatal maternity leave have been scarcely evaluated. In California, women are eligible for paid benefits up to 4 weeks before delivery. We explored whether leave at > or =36 weeks gestation increases gestation and birthweight, and reduces primary cesarean deliveries among full-time working women. METHODS: Drawing from a 2002--2003 nested case-control study of preterm birth and low birthweight among working women in Southern California, we compared a cohort of women who took leave (n = 62) or worked until delivery (n = 385). Models weighted for probability of sampling were used to calculate hazards ratios for gestational age, odds ratios (OR) for primary cesarean delivery, and multilinear regression coefficients for birthweight. MAIN FINDINGS: Leave-takers were similar to non-leave-takers on demographic and health characteristics, except that more clerical workers took leave (p = .02). Compared with non-leave-takers, leave-takers had almost 4 times lower odds of cesarean delivery after adjusting for covariates (OR, 0.27; 95% confidence interval [CI], 0.08-0.94). Overall, there were no marked differences in length of gestation or mean birthweight. However, in a subgroup of women whose efforts outstripped their occupational rewards, gestation was prolonged (hazard ratio for delivery each day between 36 and 41 weeks, 0.56; 95% CI, 0.34-0.93). CONCLUSION: Maternity leave in late pregnancy shows promise for reducing cesarean deliveries and prolonging gestation in occupationally strained women.

Mexican women in California: differentials in maternal morbidity between foreign and US-born populations.

In the US, the majority of deaths and serious complications of pregnancy occur during childbirth and are largely preventable. We conducted a population-based study to assess disparities in maternal health between Mexican-born and Mexican-American women residing in California and to evaluate the extent to which immigrants have better outcomes. Mothers in these two populations deliver 40% of infants in the state. We compared maternal mortality ratios and maternal morbidities during labour and delivery in the two populations using linked 1996-98 hospital discharge and birth certificate data files. For maternal morbidities, we calculated frequencies and observed and adjusted odds (OR) ratios using pre-existing maternal health, sociodemographic characteristics and quality of health care as covariates. Approximately 19% of Mexican-born women suffered a maternal disorder compared with 21% of Mexican-American women (Observed OR = 0.89, [95% CI 0.88, 0.90]). Despite their lower education and relative poverty, Mexican-born women still experienced a lower odds of any maternal morbidity than Mexican-American women, after adjusting for covariates (OR = 0.92, [95% CI 0.90, 0.93]). These findings suggest a paradox of more favourable outcomes among Mexican immigrants similar to that found with birth outcomes. Nevertheless, the positive aggregate outcome of Mexican-born women did not extend to maternal mortality, nor to certain conditions associated with suboptimal intrapartum obstetric care.

Obstetric complications during labor and delivery: assessing ethnic differences in California.

PURPOSE: We sought to compare obstetric complications during labor and delivery among white non-Latina (white), black, Asian, and Latina women who delivered in California hospitals. Many intrapartum complications are preventable. METHODS: We used linked 1996-1998 state hospital discharge and birth certificate data to examine obstetric complications International Classification of Diseases, 9th Revision, Clinical Modification codes considered relevant for population surveillance. We compared the observed and adjusted odds of experiencing a complication among women of color, using white women as the reference group. FINDINGS: One out of 5 deliveries had >or=1 complication. White (21.3%) and Asian women (21.1%) had similar prevalence rates, whereas black women (24.2%) had higher and Latina women (19.6%) had lower rates. After adjusting for covariates, the odds of experiencing >or=1 complication was lower for Asians (odds ratio [OR] = 0.95; 95% confidence interval [CI] = 0.93, 0.96) and Latinas (OR = 0.97; 95% CI = 0.96, 0.98) than whites; the odds for black women remained elevated (OR = 1.25; 95% CI = 1.23, 1.27). Asian women stood a higher risk of deliveries with major lacerations, postpartum hemorrhage, and major puerperal infections. Rates for the latter complication were higher among all women of color. CONCLUSIONS: The burden of morbidity is high for all women, regardless of ethnicity. Yet, compared to white women, blacks suffer more aggregate morbidities, and Asians stand a high risk of all 3 intrapartum care-sensitive conditions. Furthermore, all women of color experience disproportionate rates of puerperal infections. Collective action is needed to reduce these disparities and improve maternal health.

Social disparities in maternal morbidity during labor and delivery between Mexican-born and US-born White Californians, 1996-1998.

OBJECTIVES: To assess maternal health disparities, we compared maternal morbidities during labor and delivery among Mexican-born and US-born White, non-Latina women residing in California. METHODS: This population-based study used linked hospital discharge and birth certificate data for 1996-1998 (862,723 deliveries). We calculated the frequency, and observed and adjusted odds ratios for obstetric complications. Covariates included maternal age, parity, education, prenatal care initiation and payment source, and hospital quality of care. RESULTS: Approximately 1 in 5 deliveries resulted in a obstetric complication. After control for covariates, Mexican-born women were significantly less likely to have 1 or more maternal morbidities than White, non-Latina women but more likely to have complications that reflect the quality of intrapartum care. CONCLUSIONS: Maternal morbidities during labor and delivery are a substantial burden for women in California. The favorable overall outcome of Mexican-born women over US-born White, non-Latinas is surprising given their lower educational attainment, relative poverty, and greater barriers to health care access. The favorable outcomes obscure vulnerabilities in those complications that are sensitive to the quality of intrapartum care.