Medical care patterns at the onset of insulin-dependent diabetes mellitus: association with severity and subsequent complications.

The hospitalization of a child at the onset of insulin-dependent diabetes mellitus (IDDM) has become routine in many parts of the world, although controversy exists about its necessity. We examined the patterns of medical care use and the prognosis for acute complications after diagnosis for children with newly diagnosed IDDM in Colorado from 1978 to 1982. We reasoned that if children cared for entirely in outpatient settings at diagnosis had no more frequent acute complications after diagnosis than hospitalized children, we would be encouraged to further explore other potential benefits of outpatient care at onset. Twelve percent of 305 children studied statewide received only outpatient care during the first 2 wk after diagnosis, and, prognostically, their subsequent hospitalization and ketoacidosis rates were 2-3.7 times lower than those of children who received any inpatient care. No differences were noted for severe insulin reaction rates. Children classified as "severe" at onset, or with parents of lower education and income, or aged 10-14 yr at onset, regardless of care setting, had 2-4 times higher subsequent acute complication rates after onset than children without these characteristics. These findings, together with data on nights hospitalized and average length of stay in hospital at onset, suggest that a 42% reduction in total nights hospitalized could occur if children with "mild" or "normal" severity at onset were treated largely in the outpatient setting.

Complications and recovery from laparoscopy-assisted vaginal hysterectomy compared with abdominal and vaginal hysterectomy.

OBJECTIVE: To complete a systematic review of the published literature comparing complications, postoperative recovery time, and costs following laparoscopy-assisted vaginal hysterectomy, total abdominal hysterectomy (TAH), and vaginal hysterectomy. DATA SOURCES: We searched MEDLINE and several bibliographies, identifying all reports using the term "laparoscopy-assisted hysterectomy" published from 1989 to September 1995. METHODS OF STUDY SELECTION: We excluded case reports, letters, and reports of laparoscopy-assisted vaginal hysterectomy procedures used for radical cancer surgery, sex-change operations, total laparoscopic hysterectomy, or supracervical hysterectomy. TABULATION, INTEGRATION, AND RESULTS: Cases identified included 3112 laparoscopy-assisted vaginal hysterectomies, 1618 TAHs, and 690 vaginal hysterectomies. Laparoscopy-assisted vaginal hysterectomy cases compared with TAH cases demonstrated significantly greater incidence of bladder injury (1.8% for laparoscopy-assisted vaginal hysterectomy versus 0.4% for TAH; P = .01), significantly longer operating room time (115 minutes, standard deviation [SD] 37 minutes, for laparoscopy-assisted vaginal hysterectomy versus 87 minutes, SD 18 minutes, for TAH; P < .001), and significantly shorter hospitalization (49 hours, SD 16 hours, for laparoscopy-assisted vaginal hysterectomy versus 79 hours, SD 20 hours, for TAH; P < .001). Use of analgesia was consistently less for laparoscopy-assisted vaginal hysterectomy and return to full activity was always sooner when compared to TAH. Cost for the new procedure was higher in seven out of 11 studies, but when disposable instruments and hospital length of stay are considered, the remaining four studies reported a lower cost for laparoscopy-assisted vaginal hysterectomy. CONCLUSION: Although laparoscopy-assisted vaginal hysterectomy involves a shorter hospital stay, speedier postoperative recovery, and less analgesia use, there is also a higher rate of bladder injury and lengthier surgery. These outcomes must be weighed when choosing an intervention.

Does reducing the number of prenatal office visits for low-risk women result in increased use of other medical services?

OBJECTIVE: To determine whether a schedule of fewer prenatal visits than traditional for women with low-risk pregnancies lead to additional medical services outside prescribed prenatal care. METHODS: In a randomized, controlled trial conducted within a group-model health maintenance organization, we studied 2328 pregnant women judged to be a low risk of adverse perinatal outcomes. After risk assessment and consent, women were assigned to an experimental (nine visits) or a control (14 visits) schedule, with additional visits if requested either by providers after identifying risks or by women seeking additional services. We recorded whether women underwent maternal serum alpha-fetoprotein screening, obstetric ultrasound examinations at 15-24 weeks' gestation, hematocrit testing after 20 weeks, and diabetic screening. We also noted visits to nonobstetric care providers or our emergency care center, telephone calls, and hospitalizations. RESULTS: We found no significant differences between the two groups for prenatal blood tests, visits to nonobstetric providers or to the emergency care center, telephone calls from patients, or hospital admissions. A significantly greater percentage of women underwent ultrasound examinations at 15-24 weeks in the control group compared with the experimental group (57.3% and 53.1%, respectively; P = .045). CONCLUSION: The reduction in prenatal visits achieved using the experimental schedule was not accompanied by an increase in the use of other medical services compared with the routine schedule. The use of the schedule proposed by the Expert Panel on the Content of Prenatal Care improved the efficiency of delivery of prenatal care to low-risk women.

Short- and long-term risks after exposure to diagnostic ultrasound in utero.

A total of 425 children exposed to diagnostic ultrasound at three Denver hospitals during the period May, 1968, through August, 1972, and 381 matched control children were studied for adverse effects at birth and again at a special examination between seven and 12 years of age. Apgar scores, gestational age, head circumference, birth weight, length, congenital abnormalities, neonatal infection, and congenital infection were measured at birth. At seven to 12 years of age, measurements included conductive and nerve measurements of hearing, visual acuity and color vision, cognitive function, behavior, and a complete and detailed neurologic examination. No biologically significant differences between exposed and unexposed children were found.

Assisted reproductive interventions and multiple birth.

OBJECTIVE: To investigate the contributions of ovulation-inducing drugs and assisted reproductive technologies to multiple birth. METHODS: This historic prospective study was conducted in a cohort of 13,151 women who delivered after 20 weeks' gestation between October 1996 and December 1999. The study setting was a Colorado health maintenance organization. Cases were women who were pregnant as a result of exposure to treatment with either assisted reproductive technologies or ovulation induction in the absence of assisted reproductive technologies. The main outcome measure was multiple birth. RESULTS: There was a significant association between assisted conception and multiple birth. Compared with women with naturally conceived pregnancies, there was a 25-fold likelihood (95% confidence interval 18, 35, P <.001) of multiple birth among women exposed to any of those treatments. In the total cohort the proportion of multiple births attributable to those treatments was 33%. After adjusting for the use of assisted conception and other covariates, we found no association between advanced maternal age and multiple birth. CONCLUSION: In this cohort, assisted reproductive interventions were strongly associated with multiple birth. Although a higher proportion of older women sought assisted reproductive technologies, we did not find an independent relationship between advanced maternal age and multiple birth. The increasing number of multiple births attributable to assisted conception raises public health concerns regarding multiple gestation-related maternal and infant morbidities.

Effect of routine weekly cervical examinations at term on premature rupture of the membranes: a randomized controlled trial.

OBJECTIVE: The purpose of this study was to determine whether routine antepartum cervical examinations at term are associated with premature rupture of membranes (PROM). METHODS: This was a randomized controlled trial conducted at a health maintenance organization in metropolitan Denver. The subjects were 604 term gravidas randomized to a no examination or examination group. Exclusions included preterm labor, third-trimester bleeding, cerclage, multiple pregnancy, history of PROM (rupture before the onset of labor), and planned induction or cesarean. In the no examination group, routine examinations (without clinical indication) were not performed. In the examination group, weekly examinations were performed from 37 weeks until delivery. RESULTS: No statistically significant difference in PROM or prolonged PROM (more than 6 hours) was observed between those unexposed and those exposed to routine cervical examinations at term. In addition, there were no differences between the groups in other relevant outcomes including cesarean delivery, induction, augmentation, chorioaminionitis, or neonatal infectious morbidity. CONCLUSION: In our population, there is no association between routine weekly antepartum cervical examinations at term and PROM or other study end points.

Intrauterine resuscitation with tocolysis. An alternate month clinical trial.

Fifty patients were compared for the purpose of investigating the usefulness of intrauterine resuscitation with tocolysis (IURT). Terbutaline was given, as an intravenous bolus, to 31 women in labor in whom fetal distress was diagnosed and urgent delivery by cesarean section was indicated. In alternate months, a control group of 19 women with similar diagnoses was urgently delivered after standard interventions such as maternal positioning, oxygen administration, hydration, and discontinuation of oxytocin. Improvement in perinatal outcome was shown in infants after IURT. Apgar scores were less than 7 in 42% of the study group and in 71% of the control group at 1 minute (P = .04). Five-minute Apgar scores less than 7 occurred in 7% of the study group and 24% of the control group. A low venous pH was seen in 55% of the control group compared with 29% of the infants resuscitated with terbutaline. Estimated maternal blood loss and hematocrit change was not different in the two groups. Maternal blood pressure and pulse changes following IURT were modest and of doubtful significance. We conclude that intravenous terbutaline administered as a bolus injection at the time of fetal distress in labor improves infant outcome as evidenced by more vigorous Apgar scores and less acidemia without significant adverse physiologic effects on the mother.

Are there health risks in using risking systems? The case of perinatal risk assessment.

Health risk management is receiving widespread public and professional attention. Relationships between risks and health effects are often assumed to be real and taken for granted. While health risk assessments are increasingly conducted, they are sometimes not well grounded and frequently poorly studied. Knowledge of the sensitivity, specificity and predictive value of risk factors in clearly identified target populations is required if appropriate interventions are to be designed. 'Risking systems' are often comprised of risk factors which have little predictive usefulness. In the field of perinatal medicine, the identification of risk factors has a long history. The changing risk status of pregnant women during the prenatal period, in labor, and at the time of delivery poses problems for the research and clinician who rely on risking systems to characterize the likelihood of adverse events. Currently used risking systems, antepartum and intrapartum, are not sufficiently robust for this task. The assignment of a high risk status often results in overcalling a problem and a cascade of technological interventions may follow. In the current climate of 'managing' pregnancies, a thoughtful review of the quality of risking systems is required. Are we being over-risked and over-served?

The effects of internal electronic fetal heart rate monitoring on maternal and infant infections in high-risk pregnancies.

A controlled prospective study of the effects of fetal monitoring on mothers and infants was conducted at Denver General Hospital, Denver, Colorado. A total of 690 high-risk patients in labor were randomly assigned to one of three groups; auscultation alone, electronic fetal monitoring and electronic fetal monitoring with the option to obtain a scalp pH sample. Maternal and neonatal infectious morbidity after vaginal or cesarean delivery was unchanged with internal fetal monitoring. Despite frequent antibiotic prophylaxis (95% cesarean section v. 11% vaginal), cesarean section was the most significant factor associated with increased maternal puerperal infectious morbidity (13.75% cesarean section v. 3.9% vaginal). Although hours of labor, hours of rupture of membranes, hours of internal catheter, number of exams and presence of meconium were not associated with increased maternal infection, prolonged hours of internal catheter usage greater than 8 hours and prolonged rupture of membranes greater than 12 hours were associated with increased antibiotic usage in the neonate.

Oral intake policies on labor and delivery: a national survey.

STUDY OBJECTIVE: To examine current policies on oral intake during labor among hospitals throughout the United States. DESIGN AND SETTING: Anonymous questionnaire survey distributed to the directors of anesthesia and obstetrics departments of 740 hospitals. Completed surveys were then grouped by number of deliveries performed each year. MEASUREMENTS AND MAIN RESULTS: A total of 2,265 surveys were distributed. Of that number, 902 (33% response rate) surveys, representing 740 U.S. hospitals, were returned. Of the surveys returned, 419 surveys were received from obstetricians and 401 surveys were received from anesthesiologists. Oral intake during labor is limited primarily to clear liquids, although hospitals with fewer deliveries allow significantly more oral intake during latent phase than do hospitals with larger services. Allowing nonclear liquids or solid foods is uncommon in either phase of labor, regardless of hospital size. CONCLUSIONS: The results give an indication of oral intake policies used by labor and delivery units in the United States, and they may be helpful for obstetric services that are in the process of developing their own policies.

Low-birthweight prevention programs: the enigma of failure.

BACKGROUND: Low birthweight is the primary cause of neonatal morbidity and mortality in the United States. The purpose of our study was to identify factors associated with the effectiveness and apparent ineffectiveness of comprehensive, multicomponent, prenatal care programs for preventing low birthweight. METHODS: We reviewed obstetric, pediatric, and public health program evaluations, research reports, and commentaries, published in the English language literature, over the last four decades that pertained to the efficacy of prenatal care for preventing low birthweight. RESULTS: The heterogeneous nature of the services delivered and the lack of consistency in the definition of variables made it impossible to use rigorous, quantitative techniques to summarize this evaluation of the literature. Two general limitations of research design that emerged from our reviews were the focus on clusters of commonly associated risk factors, which has blurred the causal pathways linking specific risk factors to low birthweight, and the failure to examine process variables. These two methodologic problems have led investigators to erroneous conclusions that overstate the significance of negative intervention outcomes. The success and failure of low-birthweight prevention programs has rarely been examined in relation to evidence that the intervention actually modified the targeted risk factors. CONCLUSIONS: Few rigorous evaluations of well-designed programs have been conducted. Without an improvement in intervention designs and evaluation studies, recommendations to support or curtail the funding of comprehensive, multicomponent prenatal care services are inappropriate. Rigorously obtained evidence of the costs and benefits of approaches to the prevention of low birthweight are sorely needed.

Fetal gender differences in preterm birth: findings in a North American cohort.

A higher incidence of preterm birth (PTB) and premature rupture of membranes (PROM) has been observed among women delivering male newborns compared with female newborns in different populations. Some authors have speculated that this higher incidence of PTB may be related to the relatively greater weight at lower gestational age of male newborns compared with female newborns. Others have suggested that the greater incidence of PTB and PROM is caused by an increased vulnerability to infection in women carrying males. To understand possible pathogenic factors leading to PTB further, we examined the association between PTB and infant gender in a cohort of North American women. In addition, incidences of PROM, chorioamnionitis, and postpartum endometritis were analyzed for women delivering males versus females. Overall, males were more likely than females to deliver at 33 to 36 weeks' gestation (OR = 1.21; 95% CI: 1.02-1.42). This increase in PTB among males was not accompanied by an increased number of males with low birthweight; rather, males were less likely than females to weigh between 2000 and 2499 gm (OR = 0.71; 95% CI: 0.60-0.84). The difference in PTB by gender could not be explained by an increased occurrence of PROM, chorioamnionitis, endometritis, or other infection-linked processes. Our findings suggest that shorter gestation in males in this population may be related to their relatively increased size and birthweight. Male gender-associated factors that predispose to infection-mediated preterm birth may play greater roles in populations at higher risk for reproductive tract infection during pregnancy.

Rehospitalizations and outpatient contacts of mothers and neonates after hospital discharge after vaginal delivery.

OBJECTIVE: Our purpose was to determine whether length of hospital stay after vaginal delivery as determined by the discharging physician is associated with rehospitalizations or increased outpatient contacts by mothers and neonates and to assess the impact of home health care visits. STUDY DESIGN: An inception cohort study of all rehospitalizations and outpatient contacts of mothers and neonates after vaginal delivery at St. Joseph Hospital, Denver, Colorado, was done from January 1, 1994, to September 30, 1995. All Kaiser Permanente mother-neonate pairs in which the delivery was vaginal (excluding those with multiple gestations or birth weight < 2500 g) were included. Length of initial hospital stay was divided into three time periods: < or = 24 hours, 25 to 48 hours, and > 48 hours. The Colorado Kaiser Permanente Perinatal Database was used to identify perinatal and demographic factors that might have increased health care use. Additional information was sought in administrative databases, bill records, and inpatient charts. Mothers were followed up for 6 weeks and neonates for 28 days after delivery. Home care visits were provided to more than half the mothers and neonates by means of a standardized protocol. The main outcome measures were rehospitalizations and outpatient visits for mothers and neonate, controlling for home care visits. RESULTS: A total of 4323 mother-neonate pairs were identified. For the mothers, a longer initial hospital stay (> 48 hours) was significantly associated with both readmission (P < .01) and increased outpatient care use (P = .01) in the 6-week postpartum period. Thirty-five mothers (.81%) were rehospitalized by 6 weeks. Maternal factors associated with increased outpatient contacts were preeclampsia, preterm delivery, and instrument delivery. Sixty-seven neonates (1.55%) were readmitted to the hospital. Home care visits reduced the need for both readmissions and outpatient visits. CONCLUSIONS: For mothers in this cohort a longer initial hospital stay was significantly associated with hospital readmission and increased outpatient care in the postpartum period. Further analysis revealed that mothers with recognized potential and observed problems were rarely discharged in < or = 24 hours. We did not find statistically significant problems among neonates that were related to the length of their initial hospital stay. Those neonates receiving home care were less likely to require hospital readmission and less likely to seek outpatient care. It is unlikely that a single discharge policy will be appropriate for all mothers and neonates.

A controlled trial of the differential effects of intrapartum fetal monitoring.

A controlled prospective study of the differential effects of intrapartum fetal monitoring on mothers and infants has been conducted at Denver General Hospital, Denver, Colorado. A total of 690 high-risk obstetric patients in labor were randomly assigned to one of three monitoring groups--auscultation, electronic fetal monitoring alone, or electronic monitoring with the option to scalp sample. There were no differences in immediate infant outcomes in any measured category (Apgar scores, cord blood gases, neonatal death, neonatal morbidity, nursery course) among the three groups. There were no differences in rates of infant or maternal infections. The cesarean section rate was markedly increased in the electronically monitored groups, especially in the electronically monitored alone (18%) as compared with the auscultated (6%) (P less than 0.005). In this controlled trial electronic monitoring did not improve neonatal outcomes and the mothers were at increased risk of cesarean section.

Facts versus values: why legislators vote against injury control laws.

BACKGROUND: Control of motor vehicle-related injuries depends upon passage of mandatory safety belt and other injury control laws. Unfortunately, state legislators often oppose these laws. METHODS: In 1988, a 62-item questionnaire was mailed to the 97 Colorado legislators who voted on a 1987 safety belt law to identify factors (knowledge, experiences, attitudes, and beliefs) associated with "yes" and "no" votes. To test for associations between these attributes and the legislators' recorded votes, odds ratios (OR) and 95% confidence intervals (CIs) were calculated. A stepwise logistic regression identified independent predictors of "vote." RESULTS: Fifty-three (55%) of the legislators responded. Responders and nonresponders were demographically similar. "Vote" was not associated with age; sex; having young children in the family; perceived injury risk; recent traffic tickets; family or personal crash experience; or knowledge of the fatality risk reductions attributable to wearing safety belts. Ninety-six percent of the legislators knew that safety belts reduce the risk of death and 87% believed a safety belt law would save lives. The strongest predictors of a "yes" vote were impression that constituents favored the law (OR = 31, CI 95 = 3.5, 270); belief that a mandatory safety belt law will save lives (OR = 20, CI 95 = 2.1, 203); and "extreme" importance paid in the voting decision to effectiveness of the law in reducing deaths (OR = 19, CI 95 = 3.5, 107). Legislators who considered restrictions on individual freedoms an "extremely" important decision criterion were 43 times (CI 95 = 7, 267) more likely to vote "no." In the logistic model only extreme importance assigned to individual freedoms (beta = 3.7; OR = .025; p = 0.002) and policy effectiveness (beta = +3.1; OR = 22; p = 0.01) predicted "vote." The logistic model correctly predicted 90% of legislators' votes. CONCLUSIONS: In this study the strongest predictors of voting behavior were concern for individual freedoms, perceived constituents' support and attention paid to policy effectiveness. Those seeking to persuade legislators to vote for mandatory safety belt laws must pay attention to attitudes and values in addition to scientific facts.

The influence of breast surgery, breast appearance, and pregnancy-induced breast changes on lactation sufficiency as measured by infant weight gain.

We conducted a prospective study of the associations between several biologic and surgical breast factors and the onset of lactation in 319 healthy, motivated, primiparous women who were breastfeeding term, healthy, appropriate for gestational age or large for gestational age infants. During the last trimester of pregnancy subjects' breasts were examined for surgical incisions, size, symmetry, and nipple protuberance, and women estimated their prenatal breast enlargement. At two visits in the first two weeks postpartum, infants were weighted naked, and mothers reported the magnitude of postpartum breast engorgement when their milk came in. Breastfeeding was evaluated at each visit, and interventions were recommended for problems, with emphasis on maximizing milk yield. Lactation was deemed sufficient when an exclusively breastfed infant achieved an average weight gain of 28.5 g or more per day between the two visits. Infants gaining less than 28.5 g per day with breast milk exclusively, and those requiring formula supplement returned for a third visit at or before 21 days of age, when final lactation outcome was assessed based on weight gain between the second and third visits. Within three weeks postpartum 85 percent of the mothers achieved sufficient lactation, whereas 15 percent had persistent milk insufficiency despite intensive intervention. Of the study population, 6.9 percent had undergone previous breast surgery. Women with periareolar breast incisions were nearly 5 times more likely to have lactation insufficiency than were those without surgery (relative risk [RR] = 4.55; 95 percent confidence interval [CI] = 2.21-9.43; P less than 0.001). Insufficient lactation was significantly associated with minimal prenatal breast enlargement (P less than 0.02) and minimal postpartum breast engorgement when milk came in (P less than 0.001). Although not statistically significant, women with inverted nipples were more likely to have lactation insufficiency compared with those with normal nipples (RR = 2.94; 95% CI 1.05-8.20; P = .07). The findings from this study indicate that certain biologic and surgical breast variables are associated with lactation insufficiency.

Nifedipine for treatment of preterm labor: a historic prospective study.

OBJECTIVES: The purpose of this study was to ascertain whether adverse fetal and/or neonatal effects occurred during nifedipine treatment of preterm labor and to assess maternal tolerance of nifedipine therapy in patients intolerant of a beta-sympathomimetic agent. STUDY DESIGN: We undertook historic prospective review of medical records of 102 women admitted to an antepartum ward for treatment of preterm labor who received nifedipine. Data were collected regarding maternal side effects, fetal surveillance, and neonatal outcome. RESULTS: The number and severity of reported maternal side effects were significantly reduced when patients were switched from terbutaline to nifedipine. No discontinuance of nifedipine occurred because of maternal side effects. Fetal surveillance testing and neonatal outcome data failed to reveal deleterious in utero effects of nifedipine. CONCLUSIONS: Nifedipine was a well-tolerated and safe tocolytic in this population and warrants further investigation.

Obstetric anesthesia work force survey, 1981 versus 1992.

BACKGROUND: In 1981, with support from the American Society of Anesthesiologists and the American College of Obstetricians and Gynecologists, anesthesia and obstetric providers were surveyed to identify the personnel and methods used to provide obstetric anesthesia in the United States. The survey was expanded and repeated in 1992 with support from the same organizations. METHODS: Comments and questions from the American Society of Anesthesiologists Committee on Obstetrical Anesthesia and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice were added to the original survey instrument to include newer issues while allowing comparison with data from 1981. Using the American Hospital Association registry of hospitals, hospitals were differentiated by number of births per year (stratum I, > or = 1,500 births; stratum II, 500-1,499 births; stratum III, < 500 births) and by U.S. census region. A stratified random sample of hospitals was selected. Two copies of the survey were sent to the administrator of each hospital, one for the chief of obstetrics and one for the chief of anesthesiology. RESULTS: Compared with 1981 data, there was an overall reduction in the number of hospitals providing obstetric care (from 4,163 to 3,545), with the decrease occurring in the smallest units (56% of stratum III hospitals in 1981 compared with 45% in 1992). More women received some type of labor analgesia and there was a 100% increase in the use of epidural analgesia. However, regional analgesia was unavailable in 20% of the smallest hospitals. Spinal analgesia for labor was used in 4% of parturients. In 1981, obstetricians provided 30% of epidural analgesia for labor; they provided only 2% in 1992. Regional anesthesia was used for 78-85% (depending on strata) of patients undergoing cesarean section, resulting in a marked decrease in the use of general anesthesia. Anesthesia for cesarean section was provided by nurse anesthetists without the medical direction of an anesthesiologist in only 4% of stratum I hospitals but in 59% of stratum III hospitals. Anesthesia personnel provided neonatal resuscitation in 10% of cesarean deliveries compared with 23% in 1981. CONCLUSIONS: Compared with 1981, analgesia is more often used by parturients during labor, and general anesthesia is used less often in patients having cesarean section deliveries. In the smallest hospitals, regional analgesia for labor is still unavailable to many parturients, and more than one half of anesthetics for cesarean section are provided by nurse anesthetists without medical direction by an anesthesiologist. Obstetricians are less likely to personally provide epidural analgesia for their patients. Anesthesia personnel are less involved in newborn resuscitation.

Effect of frequency of prenatal care visits on perinatal outcome among low-risk women. A randomized controlled trial.

OBJECTIVES: In 1989, the Expert Panel on the Content of Prenatal Care established guidelines on the timing and content of prenatal care, including a schedule consisting of fewer prenatal visits than traditionally provided, for women at low risk of adverse perinatal outcomes. We tested the hypothesis that there are no significant increases in adverse perinatal outcomes when low-risk women are seen in a prenatal care visit schedule of fewer visits than routinely advised. DESIGN: Randomized controlled trial. SETTING: Group-model health maintenance organization. PATIENTS: A total of 2764 pregnant women, judged to be at low risk of adverse perinatal outcomes. INTERVENTIONS: Following risk assessment, participants were randomly assigned to an experimental schedule (nine visits) or a control schedule (14 visits) with additional visits as indicated or as desired by the patient. MAIN OUTCOME MEASURES: Preterm delivery, preeclampsia, cesarean delivery, low birth weight and patient's satisfaction with care. RESULTS: On average, there were 2.7 fewer visits observed in the experimental group than in the control group. There were no significant increases in the main outcomes of the experimental group; preterm delivery (relative risk [RR], 1.08; 95% confidence interval [CI], 0.92 to 1.27; P = .19), preeclampsia (RR, 0.94; 95% CI, 0.78 to 1.14, P = .74), cesarean delivery (RR, 1.04; 95% CI, 0.93 to 1.17; P = .25), and low birth weight (RR, 0.94; 95% CI, 0.78 to 1.12; P = .76). There were no differences between the two groups in patients' satisfaction with quality of prenatal care. CONCLUSION: In this study, good perinatal outcomes and patient satisfaction were maintained when the prenatal visit schedule proposed by the Expert Panel on the Content of Prenatal Care was observed.

Women's reasons for not seeking prenatal care: racial and ethnic factors.

Our objective was to determine if there were differences in the reasons for not seeking early prenatal care among low-income black, Hispanic, and white women who had four or fewer prenatal care visits or care only in the third trimester, and who gave birth at Denver General Hospital in Colorado. Data were gathered from 606 women (48% Hispanic, 26% black, 26% white) after delivery, using a 188-item questionnaire and abstracted medical charts. The most important reasons for not seeking early prenatal care were attitudinal (47%), financial (26%), and structural and system problems (8.5%). Financial reasons were more important to white than to black or Hispanic women, and attitudinal reasons were more important to black and Hispanic than to white women. The analysis showed that education and marital status were sometimes confounding variables. Clear differences in reasons for not seeking prenatal care were reported by women of dissimilar racial and ethnic groups in this public hospital. Cultural variations in women's views should be taken into account in developing programs intended to improve prenatal care and pregnancy outcome in Denver.