Shielding device for endoscopic procedures during lower gastrointestinal endoscopy.

Objectives: The coronavirus pandemic significantly impacted endoscopic practice. During lower gastrointestinal endoscopy, infectious substances disseminate; therefore, we developed an infection control device (STEP-L) for lower gastrointestinal endoscopy and examined its usefulness. Methods: STEP-L wraps around the patient's buttocks and covers the endoscope. Using lower endoscopy training models, three endoscopists performed 18 colonoscopies with STEP-L (group S) and without (group C). Endoscopic insertion time and pigmented areas of ​​gloves and diapers after the examination were compared between both groups. Results: Insertion of the endoscope up to the cecum was possible in all 18 examinations. The insertion time to the cecum was 52.4 ± 19.0 s in group S and 53.9 ± 13.3 s in group C. The pigmented areas of the ​​gloves measured 39,108.0 ± 16,155.3 pixels in group C, but were significantly reduced to 2610.5 ± 4333.8 pixels in group S (p < 0.05). The pigmented areas of the diapers measured 2280.9 ± 3285.2 pixels in group C, but were significantly reduced to 138.0 ± 82.9 pixels in group S (p < 0.05). Conclusions: Using STEP-L does not change the insertion time, and is technically feasible. STEP-L significantly reduces the adhesion of virtual pollutants to the surroundings, suggesting that this device is useful for infection control during lower gastrointestinal endoscopy.

Prior Term Birth Decreases the Risk of Preterm Birth in a Subsequent Twin Gestation.

OBJECTIVE: The aim of the study is to examine the association between the risk of preterm delivery among women with twin pregnancies and their obstetric history. STUDY DESIGN: We designed a retrospective cohort study of live twin births in 2008 in the United States that delivered after 240/7 weeks. Women were categorized into nulliparas, multiparas with prior term delivery, and multiparas with prior preterm delivery. The incidence of preterm birth was compared using Chi-square test and multivariable logistic regression models. RESULTS: A total of 32,895 nulliparous and 64,701 multiparous women with twin pregnancies were included in the study. Of the multiparous women, 2,505 (4%) had a history of a prior preterm delivery. Multiparous women with prior term birth were more likely to deliver at term (: 43%): in the index twin pregnancy than nulliparous women (40%) and multiparous women with a prior preterm birth (21%; p < 0.001). Compared with nulliparous women, prior term birth was protective against preterm delivery (adjusted odds ratio [aOR] = 0.67 [95% confidence interval: 0.60-0.74] for delivery <28 weeks and aOR = 0.79 [0.71-0.77] for delivery <34 weeks). CONCLUSION: Among multiparous women with twins, a prior term delivery appeared to be protective against preterm delivery compared with nulliparous women with twins. KEY POINTS: · Prior term birth is protective against preterm birth in subsequent twin pregnancy.. · A prior term birth confers an OR of 0.66 for delivery prior to 28 weeks in twin pregnancies.. · A prior preterm birth renders a twin pregnancy nearly twice as likely to deliver before 28 weeks..

The association between nitroglycerin use and adverse outcomes in women undergoing cesarean delivery in the second stage of labor.

OBJECTIVE: To identify predictors of hysterotomy extension in women undergoing cesarean delivery (CD) in the second stage of labor, and whether use of nitroglycerin (NTG) during CD has a protective effect. METHODS: We conducted a retrospective cohort study of women undergoing CD in the second stage of labor from 2012 to 2015. Some women received NTG at the obstetrician's request. Logistic regression was used to examine the relationship between second stage duration and NTG administration on maternal and neonatal outcomes. RESULTS: Of the 391 women in the sample, 27% had an extension and 12% received NTG. Second stage ≥4 h was associated with a 2.14-fold higher risk of extension (95% CI 1.22-3.75), a 2.00-fold higher risk of hemorrhage (95% CI: 1.20-3.33) and 2.42-fold higher risk of blood transfusion during delivery hospitalization (95% CI: 0.99-5.91). Intravenous (IV) and sublingual-spray (SL-spray) NTG administration were not associated with an increased risk of hemorrhage or extension. SL-NTG was associated with 4.68-fold increased odds of 5-min Apgar <7 (95% CI 1.42-15.41) and 3.36-fold greater odds of NICU admission (95% CI 1.20-9.41). CONCLUSION: We found no evidence that NTG protects against extension, and SL-NTG use was associated with adverse neonatal outcomes. Clinical trials should be conducted to evaluate risk and benefits of NTG use.

Hypertension in dichorionic twin gestations: how is birthweight affected?

OBJECTIVE: To examine the association between hypertension (HTN) and discordant or small for gestational age (SGA) birthweights among dichorionic twin pregnancies. METHODS: Retrospective cohort of dichorionic twin pregnancies delivered at ≥24 0/7 weeks from 2002 to 2015. Women with HTN in pregnancy (gestational HTN or preeclampsia) and chronic HTN (cHTN) were compared to those with uncomplicated dichorionic pregnancies. Outcomes were any discordance (≥20% difference within each twin pair), discordance with at least one twin also SGA (≥20% discordance with at least one twin also SGA <10th percentile), and SGA alone of one or both twins (<5th and <10th percentile). RESULTS: 474 Dichorionic pregnancies were identified. Women with HTN in pregnancy had an adjusted odds ratio (aOR) of 2.68 (95% CI 1.48-4.87) for any discordance and 2.94 (1.57-5.48) for discordance with at least one twin also SGA. These aORs for women with cHTN were 4.65 (1.39-15.52) and 4.37 (1.21-15.76), respectively. Significant differences were not observed for SGA alone of one or both twins. CONCLUSION: Among dichorionic pregnancies, both women with HTN in pregnancy and cHTN demonstrated increased odds of any discordant growth, as well as discordance with concurrent SGA of at least one twin. Odds of these outcomes were greatest with cHTN.

Urinary Incontinence in Older Women: The Role of Body Composition and Muscle Strength: From the Health, Aging, and Body Composition Study.

OBJECTIVES: To evaluate prospective relationships between body composition and muscle strength with predominantly stress urinary incontinence (SUI) and urgency urinary incontinence (UUI) in older women. DESIGN: Prospective community-dwelling observational cohort study (Health, Aging, and Body Composition study). PARTICIPANTS: Women initially aged 70 to 79 recruited from Pittsburgh, Pennsylvania, and Memphis, Tennessee (N = 1,475). MEASUREMENTS: Urinary incontinence was assessed using structured questionnaires. Body mass index (BMI), grip strength, quadriceps torque, and walking speed were assessed using physical examination and performance testing. Appendicular lean body mass (ALM) and whole-body fat mass were measured using dual-energy X-ray absorptiometry. RESULTS: At baseline, 212 (14%) women reported at least monthly predominantly SUI and 233 (16%) at least monthly predominantly UUI. At 3 years, of 1,137 women, 164 (14%) had new or persistent SUI, and 320 (28%) had new or persistent UUI. Women had greater odds of new or persistent SUI if they demonstrated a 5% or greater decrease in grip strength, (adjusted odds ratio (AOR) = 1.60, P = .047) and lower odds of new or persistent SUI if they demonstrated a 5% or greater decrease in BMI (AOR = 0.46, P = .01), a 5% or greater increase in ALM corrected for BMI (AOR = 0.17, P = .004), or a 5% or greater decrease in fat mass (AOR = 0.53, P = .01). Only a 5% or greater increase in walking speed was associated with new or persistent UUI over 3 years (AOR = 1.54, P = .04). CONCLUSION: In women aged 70 and older, changes in body composition and grip strength were associated with changes in SUI frequency over time. In contrast, changes in these factors did not influence UUI. Findings suggest that optimization of body composition and muscle strength is more likely to modify risk of SUI than of UUI in older women.

The interaction between maternal race/ethnicity and chronic hypertension on preterm birth.

BACKGROUND: In both the biomedical and public health literature, the risk for preterm birth has been linked to maternal racial/ethnic background, in particular African-American heritage. Despite this well-documented health disparity, the relationship of comorbid conditions, such as chronic hypertension, to maternal race/ethnicity and preterm birth has received relatively limited attention in the literature. OBJECTIVE: The objective of the study was to evaluate the interaction between chronic hypertension and maternal racial/ethnic background on preterm birth. STUDY DESIGN: This is a retrospective cohort study of singleton pregnancies among women who delivered between 2002 and 2015 at the University of California, San Francisco. The associations of chronic hypertension with both spontaneous and medically indicated preterm birth were examined by univariate and multivariate logistical regression, adjusting for confounders including for maternal age, history of preterm birth, maternal body mass index, insurance type (public vs private), smoking, substance abuse, history of pregestational diabetes mellitus, and use of assisted reproductive technologies. The interaction effect of chronic hypertension and racial/ethnicity was also evaluated. All values are reported as odds ratios, with 95% confidence intervals and significance set at P = .05. RESULTS: In this cohort of 23,425 singleton pregnancies, 8.8% had preterm deliveries (3% were medically indicated preterm birth, whereas 5.5% were spontaneous preterm births), and 3.8% of women carried the diagnosis of chronic hypertension. Chronic hypertension was significantly associated with preterm birth in general (adjusted odds ratio, 2.74, P < .001) and medically indicated preterm birth specifically (adjusted odds ratio, 5.25, P < .001). When evaluating the effect of chronic hypertension within racial/ethnic groups, there was an increased odds of a preterm birth among hypertensive, African-American women (adjusted odds ratio, 3.91, P < .001) and hypertensive, Asian-American/Pacific Islander women (adjusted odds ratio, 3.51, P < .001) when compared with their nonhypertensive counterparts within the same racial/ethnic group. These significant effects were also noted with regard to medically indicated preterm birth for hypertensive African-American women (adjusted odds ratio, 6.85, P < .001) and Asian-American/Pacific Islander women (adjusted odds ratio, 9.87, P < .001). There was no significant association of chronic hypertension with spontaneous preterm birth (adjusted odds ratio, 0.87, P = .4). CONCLUSION: The effect of chronic hypertension on overall preterm birth and medically indicated preterm birth differs by racial/ethnic group. The larger effect of chronic hypertension among African-American and Asian/Pacific Islander women on medically indicated and total preterm birth rates raises the possibility of an independent variable that is not captured in the data analysis, although data regarding the indication for medically indicated preterm delivery was limited in this data set. Further investigation into both social-structural and biological predispositions to preterm birth should accompany research focusing on the effect of chronic hypertension on birth outcomes.

Clamp late and maintain perfusion (CLAMP) policy: delayed cord clamping in preterm infants.

OBJECTIVE: Randomized controlled trials have demonstrated that delayed umbilical cord clamping (DCC) in preterm infants results in improved neonatal outcomes, including increased hematocrit, and decreased rates of intraventricular hemorrhage (IVH) and packed red blood cell transfusions. We hypothesized that implementation of a DCC policy in preterm infants would result in similarly improved outcomes, despite initial clinician resistance. STUDY DESIGN: A DCC policy (30-60 s) for singleton infants <35 weeks gestation was implemented in September 2011. We conducted a pre-test/post-test analysis of neonatal outcomes among singletons delivered between 24 0/7 weeks and 34 6/7 weeks gestation from 2009 to 2013 (2 years pre-implementation and 2 years post-implementation). The primary outcomes were rates of policy compliance and four neonatal outcomes. RESULTS: Despite multiple routes of policy dissemination, DCC was attempted in only 49% of the deliveries. In spite of this, infants delivered post-policy implementation (n = 196) had a significant decrease in IVH, significant increase in initial hematocrits, and improved temperatures compared with infants delivered pre-implementation (n = 204). CONCLUSION: After implementation of a DCC policy, preterm singleton infants had improved temperatures, increased hematocrits and a decreased prevalence of IVH without significant differences in adverse outcomes, suggesting that the benefits of DCC outweighed the risks.

Predictors of impact of vaginal symptoms in postmenopausal women.

OBJECTIVE: This study aims to identify factors associated with greater impact of vaginal symptoms on the functioning and well-being of postmenopausal women. METHODS: Postmenopausal women who reported vaginal dryness, itching, irritation, or pain with sexual activity completed the multidimensional Day-to-day Impact of Vaginal Aging (DIVA) questionnaire and underwent assessment of multiple sociodemographic and clinical factors that have the potential to influence the impact of vaginal symptoms. Multivariable linear regression analyses examined relationships between selected participant characteristics and DIVA scale scores assessing symptom impact on activities of daily living, emotional well-being, self-concept and body image, and sexual functioning. RESULTS: Among 745 symptomatic participants, the mean (SD) age was 56 (9) years, and 66% were racial/ethnic minorities. Women with comorbid depression reported greater impact of vaginal symptoms on all dimensions of functioning and well-being measured by the DIVA questionnaire (11%-22% estimated increase in impact scores associated with every three-point increase in Hospital and Anxiety Depression Scale scores). Women with urinary incontinence also reported greater impact of vaginal symptoms on activities of daily living, emotional well-being, and self-concept and body image (27%-37% estimated increase in impact scores). Age, partner status, frequency of sexual activity, general health, and body mass index also predicted greater impact on at least one domain. CONCLUSIONS: Findings suggest that special efforts should be made to identify and treat vaginal symptoms in postmenopausal women known to have depression or urinary incontinence, as these women may experience greater impact of vaginal symptoms on multiple domains of functioning and quality of life.

Social media messaging in pregnancy: comparing content of Text4baby to content of free smart phone applications of pregnancy.

OBJECTIVE: Text4baby is the only free text-message program for pregnancy available. Our objective was to determine whether content differed between Text4baby and popular pregnancy smart phone applications (apps). METHODS: Researchers enrolled in Text4baby in 2012 and downloaded the four most-popular free pregnancy smart phone apps in July 2013; content was re-extracted in February 2014. Messages were assigned thematic codes. Two researchers coded messages independently before reviewing all the codes jointly to ensure consistency. Logistic regression modeling determined statistical differences between Text4baby and smart phone apps. RESULTS: About 1399 messages were delivered. Of these, 333 messages had content related to more than one theme and were coded as such, resulting in 1820 codes analyzed. Compared to smart phone apps, Text4baby was significantly more likely to have content regarding Postpartum Planning, Seeking Care, Recruitment and Prevention and significantly less likely to mention Normal Pregnancy Symptoms. No messaging program included content regarding postpartum contraception. CONCLUSIONS: To improve content without increasing text message number, Text4baby could replace messages on recruitment with messages regarding normal pregnancy symptoms, fetal development and postpartum contraception.

Bridging the gap: determinants of undiagnosed or untreated urinary incontinence in women.

BACKGROUND: More than a third of middle-aged or older women suffer from urinary incontinence, but less than half undergo evaluation or treatment for this burdensome condition. With national organizations now including an assessment of incontinence as a quality performance measure, providers and health care organizations have a growing incentive to identify and engage these women who are undiagnosed and untreated. OBJECTIVE: We sought to identify clinical and sociodemographic determinants of patient-provider discussion and treatment of incontinence among ethnically diverse, community-dwelling women. STUDY DESIGN: We conducted an observational cohort study from 2003 through 2012 of 969 women aged 40 years and older enrolled in a Northern California integrated health care delivery system who reported at least weekly incontinence. Clinical severity, type, treatment, and discussion of incontinence were assessed by structured questionnaires. Multivariable regression evaluated predictors of discussion and treatment. RESULTS: Mean age of the 969 participants was 59.9 (±9.7) years, and 55% were racial/ethnic minorities (171 black, 233 Latina, 133 Asian or Native American). Fifty-five percent reported discussing their incontinence with a health care provider, 36% within 1 year of symptom onset, and with only 3% indicating that their provider initiated the discussion. More than half (52%) reported being at least moderately bothered by their incontinence. Of these women, 324 (65%) discussed their incontinence with a clinician, with 200 (40%) doing so within 1 year of symptom onset. In a multivariable analysis, women were less likely to have discussed their incontinence if they had a household income < $30,000/y vs ≥ $120,000/y (adjusted odds ratio [AOR], 0.49, 95% confidence interval [CI], 0.28-0.86) or were diabetic (AOR, 0.71, 95% CI, 0.51-0.99). They were more likely to have discussed incontinence if they had clinically severe incontinence (AOR, 3.09, 95% CI, 1.89-5.07), depression (AOR, 1.71, 95% CI, 1.20-2.44), pelvic organ prolapse (AOR, 1.98, 95% CI, 1.13-3.46), or arthritis (AOR, 1.44, 95% CI, 1.06-1.95). Among the subset of women reporting at least moderate subjective bother from incontinence, black race (AOR, 0.45, 95% CI, 0.25-0.81, vs white race) and income < $30,000/y (AOR, 0.37, 95% CI, 0.17-0.81, vs ≥ $120,000/y) were associated with a reduced likelihood of discussing incontinence. Those with clinically severe incontinence (AOR, 2.93, 95% CI, 1.53-5.61, vs low to moderate incontinence by the Sandvik scale) were more likely to discuss it with a clinician. CONCLUSION: Even in an integrated health care system, lower income was associated with decreased rates of patient-provider discussion of incontinence among women with at least weekly incontinence. Despite being at increased risk of incontinence, diabetic women were also less likely to have discussed incontinence or received care. Findings provide support for systematic screening of women to overcome barriers to evaluation and treatment.

The Association of Expanded Access to a Collaborative Midwifery and Laborist Model With Cesarean Delivery Rates.

OBJECTIVE: To examine the association between expanded access to collaborative midwifery and laborist services and cesarean delivery rates. METHODS: This was a prospective cohort study at a community hospital between 2005 and 2014. In 2011, privately insured women changed from a private practice model to one that included 24-hour midwifery and laborist coverage. Primary cesarean delivery rates among nulliparous, term, singleton, vertex women and vaginal birth after cesarean delivery (VBAC) rates among women with prior cesarean delivery were compared before and after the change. Multivariable logistic regression models estimated the effects of the change on the odds of primary cesarean delivery and VBAC; an interrupted time-series analysis estimated the annual rates before and after the expansion. RESULTS: There were 3,560 nulliparous term singleton vertex deliveries and 1,324 deliveries with prior cesarean delivery during the study period; 45% were among privately insured women whose care model changed. The primary cesarean delivery rate among these privately insured women decreased after the change, from 31.7% to 25.0% (P=.005, adjusted odds ratio [OR] 0.56, 95% confidence interval [CI] 0.39-0.81). The interrupted time-series analysis estimated a 7% drop in the primary cesarean delivery rate in the year after the expansion and a decrease of 1.7% per year thereafter. The VBAC rate increased from 13.3% before to 22.4% afterward (adjusted OR 2.03, 95% CI 1.08-3.80). CONCLUSION: The change from a private practice to a collaborative midwifery-laborist model was associated with a decrease in primary cesarean rates and an increase in VBAC rates. LEVEL OF EVIDENCE: II.

Effect of stage of initial labor dystocia on vaginal birth after cesarean success.

OBJECTIVE: The objective of the study was to examine whether the stage of labor dystocia causing a primary cesarean delivery (CD) affects a trial of labor after cesarean (TOLAC) success. STUDY DESIGN: This was a retrospective cohort study of women who had primary CD of singleton pregnancies for first- or second-stage labor dystocia and attempted TOLAC at a single hospital between 2002 and 2014. We compared TOLAC success rates between women whose primary CD was for first- vs second-stage labor dystocia and investigated whether the effect of prior dystocia stage on TOLAC success was modified by previous vaginal delivery (VD). RESULTS: A total of 238 women were included; nearly half (49%) achieved vaginal birth after cesarean (VBAC). Women with a history of second-stage labor dystocia were more likely to have VBAC compared with those with first-stage dystocia, although this trend was not statistically significant among the general population (55% vs 45%, adjusted odds ratio, 1.4, 95% confidence interval, 0.8-2.5]). However, among women without a prior VD, those with a history of second-stage dystocia did have statistically higher odds of achieving VBAC than those with prior first-stage dystocia (54% vs 38%, adjusted odds ratio, 1.8 [95% confidence interval, 1.0-3.3], P for interaction = .043). CONCLUSION: Nearly half of women with a history of primary CD for labor dystocia will achieve VBAC. Women with a history of second-stage labor dystocia have a slightly higher VBAC rate, seen to a statistically significant degree in those without a history of prior VD. TOLAC should be offered to all eligible women and should not be discouraged in women with a prior second-stage arrest.

Variation in Women's Understanding of Prenatal Testing.

OBJECTIVE: To investigate women's understanding of prenatal testing options and of their own experience with screening, diagnostic genetic testing, or both. METHODS: This was a secondary analysis of data from a randomized controlled trial of enhanced information and values clarification regarding prenatal genetic testing in the absence of financial barriers to testing. Women in the third trimester of pregnancy were asked whether they had discussed prenatal genetic testing with their health care providers, whether they understood this testing was optional, and whether they had undergone testing during their pregnancy. Multivariable logistic regression models were fit to determine independent predictors of these outcomes. RESULTS: Data were available from 710 study participants. Discussions about screening tests were reported by 654 participants (92%); only 412 (58%) reported discussing diagnostic testing. That screening and diagnostic testing were optional was evident to approximately two thirds of women (n=470 and 455, respectively). Recall of actual tests undergone was correct for 626 (88%) for screening and for 700 (99%) for diagnostic testing. Racial, ethnic and socioeconomic variation existed in the understanding of whether screening and diagnostic tests were optional and in the correct recall of whether screening had been undertaken in the current pregnancy. In the usual care group, women receiving care in low-income settings were less likely to recall being offered diagnostic testing (adjusted odds ratio 0.23 [0.14-0.39]). CONCLUSION: Disparities exist in women's recall of prenatal genetic testing discussions and their understanding of their own experience. Interventions that explain testing options to women and help clarify their preferences may help to eliminate these differences.

The burden of nocturia among middle-aged and older women.

OBJECTIVE: To examine the prevalence, predictors, and effects of nocturia in women and evaluate overlaps with established urinary tract disorders. METHODS: This was a cross-sectional analysis of 2,016 women, aged 40 years and older, recruited from Kaiser Permanente Northern California from 2008 to 2012. Nocturia and other urinary symptoms were assessed using structured interviewer-administered questionnaires. Nocturia was defined as patient-reported nocturnal voiding of two or more times per night over a typical week. RESULTS: Thirty-four percent (n=692) reported nocturia, and 40% of women with nocturia reported no other urinary tract symptom. Women with nocturia were older (mean age 58 compared with 55 years) (odds ratio [OR] per 5-year increase 1.21, 95% confidence interval [CI] 1.12-1.31), more likely black (45%) (OR 1.75, 95% CI 1.30-2.35) or Latina (37%) (OR 1.36, 95% CI 1.02-1.83) compared with non-Latina white (30%), have worse depression (mean Hospital Anxiety and Depression Scale score 3.8 compared with 2.8) (OR per 1-point increase in Hospital Anxiety and Depression Scale score 1.08, 95% CI 1.04-1.12), and worse mobility (mean Timed Up-and-Go 11.3 compared with 10 seconds) (OR per 5-second increase in Timed Up-and-Go 1.29, 95% CI 1.05-1.58). Nocturia occurred more among women with hysterectomy (53% compared with 33%) (OR 1.78, 95% CI 1.08-2.94), hot flushes (38% compared with 32%) (OR 1.49, 95% CI 1.19-1.87), and vaginal estrogen use (42% compared with 34%) (OR 1.50, 95% CI 1.04-2.18). CONCLUSION: Nocturia is common in women and not necessarily attributable to other urinary tract disorders. Factors not linked to bladder function may contribute to nocturia risk, underlining the need for multiorgan prevention and treatment strategies. LEVEL OF EVIDENCE: II.

Prevalence and use of complementary health approaches among women with chronic pelvic pain in a prospective cohort study.

OBJECTIVE: The aim of this study was to examine the prevalence of and factors associated with use of complementary health approaches among women with chronic pelvic pain (CPP). DESIGN: We analyzed data from the Study of Pelvic Problems, Hysterectomy, and Intervention Alternatives, a prospective cohort study of women seeking care for noncancerous pelvic problems with intact uteri at enrollment. Among a subset of 699 participants who reported having CPP, we analyzed the prevalence of complementary health approaches used and associated patient sociodemographic and clinical characteristics, health-related quality of life, attitudes and beliefs, and conventional health care practices. RESULTS: At baseline, slightly over one-half (51%) of women with CPP used at least one complementary health approach in the past year, including acupuncture (8%), special foods or diets (22%), herbs (27%), and vitamins and minerals (29%). During follow-up surveys conducted annually for 4 years, a substantial proportion of women (44.8%) used complementary health approaches at more than half of the assessments. Users of complementary health approaches were more likely to undergo a hysterectomy or oophorectomy or to use gonadotropin-releasing hormone agonists or opioids during the study compared with nonusers. Women with CPP who used complementary health approaches also had more optimal health-related quality of life measured by the Pelvic Problem Impact Questionnaire (31.6 vs 25.6, P < 0.001). CONCLUSION(S): Many women with CPP consistently use complementary health approaches. The substantial interest in and high prevalence of complementary health approaches used alongside conventional medical approaches highlight the need for better understanding of multimodal approaches to address the complex condition of CPP.

Mode of delivery and postpartum depression: the role of patient preferences.

OBJECTIVE: The purpose of this study was to explore the relationship between strength of preference for vaginal delivery, delivery mode undergone, and postpartum depression. STUDY DESIGN: We conducted a secondary analysis of data from a longitudinal study of delivery-mode preferences. During an interview between 24-36 weeks of gestation, participants were asked whether they preferred vaginal or cesarean delivery; the strength of this preference was measured by the standard gamble metric. Depression was assessed antepartum and at 8-10 weeks and 6-8 months after delivery by using the Patient Health Questionnaire (PHQ-9). The primary outcome was PHQ-9 score at 8-10 weeks after delivery. We used multivariable regression analysis to assess the effect of strength of preference for vaginal delivery and delivery mode undergone on postpartum depression. RESULTS: Of 160 participants, 33.1% were nulliparous, and 30.6% had a previous cesarean delivery. Most of the participants (92.4%) preferred vaginal delivery, but the strength of preference varied substantially. The mean strength-of-preference score (0-1 scale; higher scores denote stronger vaginal delivery preference) was 0.658 (SD, ±0.352). A significant interaction emerged between the effects of delivery mode and vaginal delivery preference score on postpartum PHQ-9 score (P = .047). Specifically, a stronger preference for vaginal delivery was associated with higher PHQ-9 scores among women who underwent cesarean delivery (P = .027) but not among women who underwent vaginal delivery (P = .761). The interaction between delivery mode and vaginal delivery preference score was no longer significant at 6-8 months after delivery. CONCLUSION: Women who have a strong antepartum preference for vaginal delivery and deliver by cesarean may be at increased risk for depression in the early postpartum period.

Mode of delivery preferences in a diverse population of pregnant women.

OBJECTIVE: The objective of the study was to assess women's preferences for vaginal vs cesarean delivery in 4 contexts: prior cesarean delivery, twins, breech presentation, and absent indication for cesarean. STUDY DESIGN: This was a cross-sectional study of pregnant women at 24-40 weeks' gestation. After assessing stated preferences for vaginal or cesarean delivery, we used the standard gamble metric to measure the strength of these preferences and the time tradeoff metric to determine how women value the potential processes and outcomes associated with these 2 delivery approaches. RESULTS: Among the 240 participants, 90.8% had a stated preference for vaginal delivery. Across the 4 contexts, these women indicated that, on average, they would accept a 59-75% chance of an attempted vaginal birth ending in a cesarean delivery before choosing a planned cesarean delivery, indicating strong preferences for spontaneous, uncomplicated vaginal delivery. Variations in preferences for labor processes emerged. Although uncomplicated labor ending in vaginal birth was assigned mean utilities of 0.993 or higher (on a 0-1 scale, with higher scores indicating more preferred outcomes), the need for oxytocin, antibiotics, or operative vaginal delivery resulted in lower mean scores, comparable with those assigned to uncomplicated cesarean delivery. Substantially lower scores (ranging from 0.432 to 0.598) were obtained for scenarios ending in severe maternal or neonatal morbidity. CONCLUSION: Although most women expressed strong preferences for vaginal delivery, their preferences regarding interventions frequently used to achieve that goal varied. These data underscore the importance of educating patients about the process of labor and delivery to facilitate incorporation of informed patient preferences in shared decision making regarding delivery approach.

Two practice models in one labor and delivery unit: association with cesarean delivery rates.

OBJECTIVE: The objective of the study was to examine the association between labor and delivery practice model and cesarean delivery rates at a community hospital. STUDY DESGIN: This was a retrospective cohort study of 9381 singleton live births at 1 community hospital, at which women were provided labor and delivery care under 1 of 2 distinct practice models: a traditional private practice model and a midwife-physician laborist practice model. Cesarean rates were compared by practice model, adjusting for potential sociodemographic and clinical confounders. Statistical comparisons were performed using the χ(2) test and multivariable logistical regression. RESULTS: Compared with women managed under the midwife/laborist model, women in the private model were significantly more likely to have a cesarean delivery (31.6% vs 17.3%; P < .001; adjusted odds ratio [aOR], 2.11; 95% confidence interval [CI], 1.73-2.58). Women with nulliparous, term, singleton, vertex gestations also were more likely to have a cesarean delivery if they were cared for in the private model (29.8% vs 15.9%; P < .001; aOR, 1.86; 95% CI, 1.33-2.58) as were women who had a prior cesarean delivery (71.3% vs 41.4%; P < .001; aOR, 3.19; 95% CI, 1.74-5.88). CONCLUSION: In this community hospital setting, a midwife-physician laborist practice model was associated with lower cesarean rates than a private practice model.

Day-to-Day Impact of Vaginal Aging questionnaire: a multidimensional measure of the impact of vaginal symptoms on functioning and well-being in postmenopausal women.

OBJECTIVE: This study aims to develop a self-report questionnaire assessing the impact of vaginal dryness, soreness, itching, irritation, and pain on functioning and well-being in postmenopausal women. METHODS: Structured self-report items were developed to address the impact of vaginal symptoms on functioning and well-being based on findings from focus groups with racially/ethnically diverse, symptomatic postmenopausal women. Items were refined after cognitive interview pretesting and field-tested among symptomatic postmenopausal women enrolled in a multiethnic cohort study in California. Exploratory factor analysis (SAS PROC VARCLUS) and confirmatory factor analysis evaluated factor structure and eliminated poorly fitting items. Additional evidence of construct validity was obtained via examination of correlations with other measures of related constructs. Internal consistency and test-retest reliability were assessed using Cronbach α and correlation coefficients, respectively. RESULTS: For the 745 postmenopausal women who completed the draft questionnaire, the mean (SD) age was 56.2 (8.5) years, and 66% of the respondents were racial/ethnic minorities. The refined questionnaire included four multi-item scales addressing symptom impact on (1) activities of daily living, (2) emotional well-being, (3) sexual functioning, and (4) self-concept and body image. The four-factor model provided good approximate fit (comparative fit index, 0.987; standardized root-mean-square residual, 0.038). Correlations with other measures of symptom bothersomeness, sexual function, depression, and anxiety conformed to hypotheses. Cronbach α values ranged from 0.82 to 0.93. Intraclass coefficients ranged from 0.47 to 0.72. CONCLUSIONS: The Day-to-Day Impact of Vaginal Aging questionnaire is a new multidimensional self-report measure designed to facilitate evaluation of the impact of vaginal symptoms on postmenopausal women of diverse backgrounds.

Effect of enhanced information, values clarification, and removal of financial barriers on use of prenatal genetic testing: a randomized clinical trial.

IMPORTANCE: Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. OBJECTIVE: To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks' gestation (n = 710). INTERVENTIONS: A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). MAIN OUTCOMES AND MEASURES: The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks' gestation. RESULTS: Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret. CONCLUSIONS AND RELEVANCE: Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00505596.