Sexually transmitted disease screening by United States obstetricians and gynecologists

OBJECTIVE: To assess compliance with practice guidelines and to determine the extent of missed opportunities for sexually transmitted disease (STD) prevention by describing screening practices of a national sample of obstetricians and gynecologists and comparing them to the practices of other specialists. METHODS: Physicians (n = 7300) in five specialties that diagnose 85% of STDs in the United States were surveyed. Obstetrics and gynecology (n = 647) was one of the five specialties. Besides providing demographic and practice characteristics, respondents answered questions about who they screen (nonpregnant females, pregnant females) and for which bacterial STDs (syphilis, gonorrhea, chlamydia). RESULTS: Responding obstetricians and gynecologists were most likely to be non-Hispanic white (75%), male (66%), and in their 40s (mode 43 years old). They saw an average of 90 patients per week during 47 hours of direct patient care. Approximately 95% practiced in private settings. Almost all (96%) screened some patients for at least one STD. Obstetricians and gynecologists screened women more frequently than other specialties, but no specialty screened all women or all pregnant women. CONCLUSION: Obstetricians and gynecologists screen women for STDs at a higher rate than other specialties represented in this study. Consistent with published guidelines, most obstetricians and gynecologists in our survey screened pregnant women for chlamydia, gonorrhea, and syphilis. Nonetheless, only about half of obstetricians and gynecologists screened nonpregnant women for gonorrhea or chlamydia, and fewer screen nonpregnant women for syphilis.     

Comparison of midwifery, family medicine, and obstetric patients' understanding of weight gain during pregnancy: a minority of women report correct counselling

ObjectiveWe hypothesized that differences in models of carebetween health care providers would result in variations inpatients’ reports of counselling. Our objective was to comparewhat women reported being advised about weight gain duringpregnancy and the risks of inappropriate weight gain according totheir type of health care provider.MethodsA cross-sectional survey was conducted using a selfadministeredquestionnaire at obstetric, midwifery, and familymedicine clinics in Hamilton, Ontario. Women were eligible toparticipate if they had had at least one prenatal visit, could readEnglish, and had a live, singleton pregnancy.ResultsThree hundred and eight women completed the survey,a 93% response rate. Care for 90% of the group was dividedapproximately evenly between midwives, family physicians, andobstetricians. A minority of women looked after by any of the typesof care providers reported being counselled correctly about howmuch weight to gain during pregnancy (16.3%, 10.3%, 9.2%, and5.7% of patients of midwives, family physicians, obstetricians, orother types of care providers, respectively, P = 0.349). A minorityof women with any category of care provider was planning to gainan amount of weight that fell within the guidelines or reportedbeing told that there were risks to themselves or their babies withinappropriate gain.ConclusionIn this study comparing reported counselling betweenpatients of obstetricians, midwives, family physicians, and otherhealth care providers, low rates of counselling about gestationalweight gain were universally reported. There is a common needfor more effective counselling.     

Can risk factor assessment replace universal screening for gonorrhea and Chlamydia in the third trimester?

The objective of this study is to determine whether risk factor (RF) screening can be used instead of routine third-trimester testing for gonorrhea and chlamydia in a clinic setting. We performed prospective analysis of women entering prenatal care over a 10-month period. Patients included received combined gonorrhea and chlamydia screening by DNA probe at the first prenatal visit and in the third trimester. RF examined included age <20, marital status, history of sexually transmitted disease (STD) or hepatitis, drug use and gestational age at entry into prenatal care. Only women with negative initial screens were included in univariate and multivariate analyses. Five hundred forty-two women fulfilled study criteria. Sixty percent had 1 RF; 35% had a history of STD. Third-trimester screens were positive in 4.1%. The absence of RF had a negative predictive value of 99.1%. The sensitivity and specificity of RF screening was 90.9 and 40.7%, respectively (p = 0.003). The model of best fit was obtained using any positive RF and teen as independent variables (relative risk 6.9, 95% confidence interval 1.6-29.6, p = 0.01). In an urban clinic population, comprehensive RF screening is effective in predicting women at low risk for STD in the third trimester after an initial negative test.     

Chlamydia screening in a Health Plan before and after a national performance measure introduction

OBJECTIVE: To evaluate chlamydia-screening policies, testing practices, and the proportion testing positive in response to the new Health Plan Employer Data and Information Set (HEDIS) chlamydia-screening performance measure in a large commercial health plan. METHODS: We interviewed health plan specialty departmental chiefs to describe interventions used to increase chlamydia screening and examined electronic medical records of 15- to 26-year-old female patients--37,438 from 1998 to 1999 and 37,237 from 2000 to 2001--who were classified as sexually active by HEDIS specifications to estimate chlamydia testing and positive tests 2 years before and after the HEDIS measure introduction. RESULTS: In January 2000, the obstetrics and gynecology department instituted a policy to collect chlamydia tests at the time of routine Pap tests on all females 26 years old or younger by placing chlamydia swabs next to Pap test collection materials. Other primary care departments provided screening recommendations and provider training. During 1998-1999, 57% of eligible female patients seen by obstetrics and gynecology exclusively and 63% who were also seen by primary care were tested for chlamydia; in 2000-2001 the proportions tested increased to 81% (P < .001) and 84% (P < .001). Proportions tested by other primary care specialists did not increase substantially: 30% in 1998-1999 to 32% in 2000-2001. The proportion of females testing positive remained high after testing rates increased: 8% during 1998-1999 and 7% during 2000-2001, and the number of newly diagnosed females increased 10%. CONCLUSION: After the obstetrics and gynecology department introduced a simple systems-level change in response to the HEDIS measure, the proportion of females chlamydia-tested and number of newly diagnosed females increased.     

A Descriptive Study of Women Presenting to an Obstetric Triage Unit With No Prenatal Care

ObjectiveTo describe women presenting to an obstetric triage unit with no prenatal care (PNC), to identify gaps in care, and to compare care provided to World Health Organization (WHO) standards.MethodsWe reviewed the charts of women who gave birth at Women’s Hospital in Winnipeg and were discharged between April 1, 2008, and March 31, 2011, and identified those whose charts were coded with ICD-10 code Z35.3 (inadequate PNC) or who had fewer than 2 PNC visits. Three hundred eighty-two charts were identified, and sociodemographic characteristics, PNC history, investigations, and pregnancy outcomes were recorded. The care provided was compared with WHO guidelines.ResultsOne hundred nine women presented to the obstetric triage unit with no PNC; 96 (88.1%) were in the third trimester. Only 39 women (35.8%) received subsequent PNC, with care falling short of WHO standards. Gaps in PNC included missing time-sensitive screening tests, mid-stream urine culture, and Chlamydia and gonorrhea testing. The mean maternal age was 26.1 years, and 93 women (85.3%) were multigravidas. More than one half of the women (51.4%) were involved with Child and Family Services, 64.2% smoked, 33.0% drank alcohol, and 32.1% used illicit drugs during pregnancy. Two thirds of the women (66.2%) lived in inner-city Winnipeg. Only 63.0% of neonates showed growth appropriate for gestational age. Two pregnancies ended in stillbirth; there was one neonatal death, and over one third of the births were preterm.ConclusionMost women who present with no PNC do so late in pregnancy, proceed to deliver with little or no additional PNC, and have high rates of adverse outcomes. Thus, efforts to improve PNC must focus on facilitating earlier entry into care. This would also improve compliance with WHO guidelines for continuing care. Treatment protocols could improve gaps in obtaining urine culture and in Chlamydia and gonorrhea testing.     

Birth Technology and Maternal Roles in Birth: Knowledge and Attitudes of Canadian Women Approaching Childbirth for the First Time

ObjectiveTo describe Canadian nulliparous women's attitudes to birth technology and their roles in childbirth.MethodsA large convenience sample of low-risk women expecting their first birth was recruited by posters in laboratories, at the offices of obstetricians, family physicians, and midwives, at prenatal classes, and through web-based advertising and invited to complete a paper or web-based questionnaire.ResultsOf the 1318 women completing the questionnaire, 95% did so via the web-based method; 13. 2% of respondents were in the first trimester, 39. 8% were in the second trimester, and 47. 0% in the third. Overall, 42. 6% were under the care of an obstetrician, 29 3% a family physician, and 28 1% a registered midwife The sample included mainly well-educated, middle-class women The planned place of giving birth ranged from home to hospital, and from rural centres to large city hospitals. Eighteen percent planned to engage a doula. Women attending obstetricians reported attitudes more favourable to the use of birth technology and less supportive of women's roles in their own delivery, regardless of the trimester in which the survey was completed Those women attending midwives reported attitudes less favourable to the use of technology at delivery and more supportive of women's roles Family practice patients' opinions fell between the other two groups. For eight of the questions, “I don't know” (IDK) responses exceeded 15%. These IDK responses were most frequent for questions regarding risks and benefits of epidural analgesia, Caesarean section, and episiotomy Women in the care of midwives consistently used IDK options less frequently than those cared for by physiciansConclusionsRegardless of the type of care provider they attended, many women reported uncertainty about the benefits and risks of common procedures used at childbirth. When grouped by the type of care provider, in all trimesters, women held different views across a range of childbirth issues, suggesting that the three groups of providers were caring for different populations with different attitudes and expectations     

Clinical Practice in Prevention of Neonatal HSV Infection: A Survey of Obstetrical Care Providers in Alberta

ObjectiveTo identify the current practice patterns of physicians providing prenatal care in Alberta with respect to prevention of neonatal herpes simplex virus (HSV) infection.MethodA 22-item questionnaire was mailed to all obstetricians and family physicians providing obstetrical care in Alberta. The questionnaire included demographic and practice details, and details of management of patients with a history or symptoms of HSV lesions, including practice in prescribing antiviral therapy, recommending elective Caesarean section, and ordering serology. Two reminders were mailed as necessary.ResultsResponses were received from 89 obstetricians (57%) and 94 family physicians (54%). Antiviral therapy was prescribed for the prevention of neonatal HSV infection in the third trimester by 97% of obstetricians versus 84% of family physicians (P = 0.007), with acyclovir being the most commonly prescribed agent. Caesarean section was offered “most of the time” to women with primary HSV infection in the third trimester by 65% of physicians, to women with prodromal symptoms during the intrapartum period by 57% (no significant differences between groups), and to women with HSV lesions by 92% of obstetricians and 82% of family physicians (P = 0.032). Women with a negative HSV history but whose partner had known HSV were offered serological testing “most of the time” by 30% of physicians (no significant difference between groups).ConclusionDespite the encouraging survey results, obstetrical providers should be encouraged to offer Caesarean section to women with a primary HSV infection in the third trimester and to offer serological testing in discordant couples. These simple strategies can help to prevent neonatal HSV infection and its long-term consequences.     

The Association of Inadequate and Intensive Prenatal Care With Maternal,Fetal, and Infant Outcomes: A Population-Based Study in Manitoba,Canada

ObjectiveLittle is known about how prenatal care influences health outcomes in Canada. The objective of this study was to examine the association of prenatal care utilization with maternal, fetal, and infant outcomes in Manitoba.MethodsThis retrospective cohort study conducted at the Manitoba Centre for Health Policy investigated all deliveries of singleton births from 2004-2005 to 2008-2009 (N = 67 076). The proportion of women receiving inadequate, intermediate/adequate, and intensive prenatal care was calculated. Multivariable logistic regression was used to examine the association of inadequate and intensive prenatal care with maternal and fetal-infant health outcomes, health care use, and maternal health-related behaviours.ResultsThe distribution of prenatal care utilization was 11.6% inadequate, 84.4% intermediate/adequate, and 4.0% intensive. After adjusting for sociodemographic factors and maternal health conditions, inadequate prenatal care was associated with increased odds of stillbirth, preterm birth, low birth weight, small for gestational age (SGA), admission to the NICU, postpartum depressive/anxiety disorders, and short interpregnancy interval to next birth. Women with inadequate prenatal care had reduced odds of initiating breastfeeding or having their infant immunized. Intensive prenatal care was associated with reduced odds of stillbirth, preterm birth, and low birth weight and increased odds of postpartum depressive/anxiety disorders, initiation of breastfeeding, and infant immunization.ConclusionInadequate prenatal care was associated with increased odds of several adverse pregnancy outcomes and lower likelihood of health-related behaviours, whereas intensive prenatal care was associated with reduced odds of some adverse pregnancy outcomes and higher likelihood of health-related behaviours. Ensuring women receive adequate prenatal care may improve pregnancy outcomes.     

Exploring Physicians’ Views and Values in Relation to Maternal Serum Screening

ObjectiveLittle is known about physician support for prenatal screening. We sought a better understanding of physicians’ values and opinions as they relate to prenatal screening, termination of affected pregnancies, and disability.MethodsSurveys were sent to all family physicians/general practitioners and obstetricians in Saskatchewan during May and June 2005.ResultsOf those physicians who responded, all obstetricians and 91% of family physicians reported offering maternal serum screening (MSS) to pregnant women in their practices. Of respondents who offered MSS to their patients, 87% of obstetricians and 72% of family physicians reported offering MSS to all pregnant women. Approximately one half of respondents agreed that they had enough knowledge to counsel a pregnant woman with a fetus affected by Down syndrome or spina bifida; 40% said the same about a fetus with trisomy 18. Twenty-six percent of physicians agreed that offering MSS was in conflict with their culture, religion, or personal value systems if it led to termination of pregnancy. One third of physicians reported having concerns about the increasing capacity for genetic testing of fetuses and the social, ethical, and clinical implications of such testing.ConclusionPhysicians held diverse views regarding prenatal screening, selective termination, and disability. Personal views and biases, in either direction, are relevant to our understanding of the clinical encounter and the ethical quandaries faced by practitioners. These value differences also may explain at least some of the variation in the use of MSS observed across the country, although the current study was not designed to make a causal link. There is a need to better understand how value differences affect the uptake of new reproductive technologies and the implications for health care policy and medical practice.     

A Practice Improvement Intervention Increases Chlamydia Screening Among Young Women at a Women's Health Practice

Annual chlamydia trachomatis screening of all sexually active women younger than age 26 is a recommended standard practice. Yet most women are not being tested. The author describes a successful practice change intervention to increase routine chlamydia screening rates in a women's health primary care setting. Screening rates increased from 53.4% to 76.1% following the intervention. Results suggest a combination of education, provider feedback, and clinic prompts can influence chlamydia screening behavior among providers.     

Trichomonas Vaginalis Infections Among Youth in Detention in the Southeastern United States

Most juvenile detention facilities do not screen for Trichomonas Vaginalis (TV) despite being the most common parasitic STI. We aimed to assess TV prevalence and risk factors among young women in a large urban juvenile detention center. We evaluated a retrospective cohort from April to December 2016. Youth submitted an intake urine sample for gonorrhea and chlamydia testing; we tested remnant urine for TV. Outcomes included prevalence of TV and risk factors for infection. A total of 1009 samples were collected, 374 from young women ages 13 – 17 years old. Among females, 8% tested positive for TV with co-infection of either gonorrhea, chlamydia or both occurring in 12/29 (41%) patients. Compared to youth without TV females with TV were more likely to be African American (76%) and report symptoms (41%) (p<0.05). In our study population, prevalence of TV was 8%. As nearly half of those with TV were asymptomatic, we recommend routine screening among this population.     

Beliefs and Perspectives of Women and Obstetrical Providers in Northern Ontario on Water Births

ObjectiveThis study sought to understand the beliefs and perspectives of women in northern Ontario and their obstetrical providers with respect to water birthing as access to this service is limited in this regionMethodsAll midwives, family physicians (FPs), and obstetricians providing labour and delivery services in northern Ontario were surveyed, as were a sample of labour and delivery nurses in the region and convenience samples of regional women.ResultsOf the 362 women who completed the survey (a 90.5% response rate), 81.8% (95% CI 77.5–85.4) believed water births to be safe, 40.9% (95% CI 35.9–46) were interested in having a water birth, and 76.5% (95% CI 71.8–80.5) wanted to have the option of a hospital-based water birth. Perceptions of water birth safety varied significantly by provider type (χ² P < 0.001) with 100% (95% CI 89.6–100) of midwives but 0% (95% CI 52.3–94.9) of obstetricians considering them to be safe. Perceptions of the specific risks and benefits of water birth also varied significantly by provider type, as did understanding of consumer interest. Reflecting these perceptions, 97.1% (95% CI 85.1–99.5) of midwives and 0% (95% CI 0–27.8) of obstetricians would consider assisting in or providing hospital-based water births.ConclusionsWomen in northern Ontario are interested in water birth and in having this service available in hospitals. However, given the widely divergent views of the professional groups providing labour and delivery care in the region, hospitals should be strongly encouraged to explore interprofessional development opportunities to enable patient-centred care in this context.     

Limitations in Correspondence Programs for Cervical Cancer Screening: Who Are the Women We Are Missing?

ObjectiveThis study sought to identify factors associated with gaps in the correspondence program and the characteristics of those women who are not reached with a mailed invitation to screening within an organized cervical cancer screening program.MethodsThis population-based, retrospective observational study examined the factors associated with failed correspondence mailings as part of the Ontario cervical cancer screening program. Administrative databases were used to identify eligible women who were overdue for screening or never screened yet did not receive an invitation to screening as a result of a failed mailing. These women were further characterized on the basis of age, affiliation with a primary care physician, and use of other health services (Canadian Task Force Classification II-2).ResultsA total of 1 350 425 women were eligible, of whom 1 064 637 had a successful mailing (78%). Women who were overdue for screening and who had a failed correspondence were more likely to be younger than 50 (72.5%) and associated with a primary care physician (61.2%), and 66.7% had three or more health care encounters in the preceding 3 years. Underscreened and never-screened women were also more likely to be younger than 50, but only 15% were associated with a primary care physician and only 18.2% had health care encounters in the previous 3 years.ConclusionThis is one of the first studies to evaluate the incidence of failed mailings within correspondence in organized screening programs. Women who are underscreened or never screened are infrequent users of health care services and tend not to have a primary care physician, thus making them less accessible to traditional outreach methods and at further risk of being non-compliant with screening.     

Maternal Mental Health in Assisted and Natural Conception: A Prospective Cohort Study

ObjectiveThis study sought to compare the pregnancy and postpartum self-reported mood and mental health status of women who conceived with assisted reproductive technology (ART) with those of women who conceived spontaneously.MethodsIn this prospective cohort study, 1176 pregnant women from prenatal clinics in the Ontario Birth Study were enrolled. In the pregnancy and the postpartum period, women who conceived with ART, including in vitro fertilization and intrauterine insemination, were compared with women who conceived spontaneously regarding depression and anxiety at 12–16 weeks and 24–28 weeks gestation and 6–10 weeks postpartum. The following main outcome measures were used: Edinburgh Postnatal Depression Scale, two-item Patient Health Questionnaire, State Trait Anxiety Inventory six-item scale, and two-item Generalized Anxiety Disorder scale (Canadian Task Force Classification II-2).ResultsWomen who conceived with ART demonstrated a decreased likelihood of depression compared with women who spontaneously conceived (SC) at 24–28 weeks gestation (Edinburgh Postnatal Depression Scale: ART 3.6% vs. SC 15%; P < 0.01; two-item Patient Health Questionnaire: ART 0.0% vs. SC 4.0%; P = 0.027), as well as decreased perceived stress (mean score: ART 3.25 vs. SC 4.02; P < 0.01). Women in the ART group also had a lower percentage of positive two-item Generalized Anxiety Disorder scores (ART 2.7% vs. SC 7.5%; P = 0.049). There was no difference in self-reported depression, anxiety, or perceived stress between groups at 12–16 weeks gestation or at 6–10 weeks postpartum.ConclusionWomen who conceived using ART reported decreased rates of depressive symptoms, perceived stress, and generalized anxiety during the second trimester of pregnancy compared with women who had SC pregnancies, and both groups experienced similar mental health status earlier in gestation and in the postpartum period.     

Human immunodeficiency virus counseling and testing practices among North Carolina providers

OBJECTIVE: To estimate the percentage of prenatal care providers who offer human immunodeficiency virus (HIV) testing to pregnant women, investigate how strongly testing is encouraged, and explore testing barriers. METHODS: Between January 2001 and March 2001, we sent surveys to 1381 prenatal care providers in North Carolina, comprised of obstetricians, family physicians who practice obstetrics, and nurse-midwives. A total of 653 questionnaires were returned. RESULTS: Overall, 95.5% of providers who responded reported recommending HIV testing to all pregnant patients. Only 69.2% strongly recommend testing, with obstetricians (73.4%) and family physicians (70.1%) doing so at higher rates than nurse-midwives (55.9%). Almost all respondents (96.9%) strongly recommend testing for women they perceive to be high risk, whereas 39.7% strongly recommend testing to women who have had an HIV test in the past 6 months. When women refuse testing, 48.1% of practitioners inquire about the reason, and 28.2% reoffer the test at a future prenatal appointment. The most significant testing barriers were treating an HIV-positive woman (18.4%) and informing a patient she is HIV positive (14.8%). Respondents report that low literacy and culturally appropriate patient education materials would be most helpful to them. CONCLUSION: Among respondents, most prenatal care providers report that they recommend HIV testing to all pregnant women. However, many respondents base their decision about how strongly to recommend HIV testing on an assessment of the woman's risk for HIV exposure. Significant barriers to offering HIV testing were associated with managing an HIV-positive patient. Providers were most in need of patient education materials.     

Blood Pressure Measurement for Hypertension in Pregnancy

ObjectiveAmbulatory BP monitoring (ABPM) has been proposed as a logical approach to overcoming many of the problems associated with clinical BP measurement. The extent of its use in diagnosing hypertension in pregnancy is unknown. The objective of this study was to identify the practices surrounding use of ABPM by practitioners to diagnose hypertension (HTN) and white coat hypertension (WCH) in pregnant women.MethodsWe mailed questionnaires to all obstetricians and family doctors practising obstetrics who were listed in the online medical directory of the College of Physicians and Surgeons of Alberta. Data were analyzed using SPSS.ResultsCompleted questionnaires were received from 81 obstetricians and 86 primary care physicians who manage hypertension in pregnancy. The majority of obstetricians (83%) and primary care physicians (79%) indicated that they “almost always” or “often” attempt to differentiate WCH from true HTN in pregnancy. The most popular method identified to differentiate WCH from true HTN in pregnancy was self (intermittent) home BP monitoring (78% of obstetricians and 69% of primary care physicians, P = 0.18). A minority of physicians in each group reported using ABPM to evaluate HTN in pregnancy, with significantly fewer obstetricians using ABPM diagnostically than primary care physicians (12% vs. 26%, P = 0.04).ConclusionObstetrical care providers in Alberta are aware that WCH is an issue among pregnant women. While ABPM is chosen in a minority of cases, both obstetricians and primary care physicians appear to have a strong preference to use self BP monitoring for further BP evaluation.     

Comparison of obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives and a private practice group of obstetricians in the same community

Objective: The purpose of this study was to compare the obstetric outcome of a primary-care access clinic staffed by certified nurse-midwives, supervised by a private practice group of four obstetricians, with the obstetric outcome of that group's private practice patients.Study design: A retrospective cohort study was performed. Obstetric outcome of 496 clinic patients was compared with that of 611 private patients in the same community from Aug. 1, 1991, to March 31, 1994.Results: Obstetric outcomes as measured by (1) perinatal morbidity and mortality, (2) Apgar score, (3) birth weights, and (4) prematurity rates were comparable between the two groups. Significant was the caesarean section rate of 13.1% (10.5% primary) for the clinic patients and 26.4% (18.5% primary) for the private patients and the high percentage (81.8%) of private patients who elected to have repeat cesarean sections.Conclusions: (1) Low-income, uninsured, and underinsured women who have access to excellent prenatal care with supervised certified nurse-midwives can have obstetric outcomes similar to women having prenatal care with private obstetricians. (2) Prenatal care with supervised certified nurse-midwives can reduce the cesarean section rate without compromising infant outcome. (3) Utilization of certified nurse-midwives supervised by obstetricians may provide the optimum model for perinatal care. Particularly for those women who are high risk because of social and economic factors and who are currently underserved.     

Impact of collaborative management and early admission in labor on method of delivery

OBJECTIVE: This study compared the effects of early admission in labor and perinatal care provider on delivery method. Higher spontaneous vaginal delivery rates for certified nurse midwives as compared with physicians have been reported in observational studies and randomized clinical trials. Certified nurse midwives, with their more expectant approach to labor management, would be expected to admit women later in labor than obstetricians. METHODS: Prospective cohort study of 2,196 low-risk pregnancies, with singleton, vertex infants admitted in spontaneous labor. Independent and joint effects of perinatal care provider and cervical dilation at admission on delivery method were evaluated. Confounding was addressed using restriction and multiple regression. RESULTS: Fewer (23.4%) women in collaborative care were admitted in early labor (< 4 cm cervical dilation) than women managed by obstetricians (95% CI = -27.6 to -19.2). Obstetrician care had 9% to 30% fewer spontaneous vaginal deliveries. Women admitted early in labor also had 6% to 34% fewer spontaneous vaginal deliveries. Evaluation of joint effects suggested that interaction between obstetrician provider and earlier admission increased the risk of operative delivery. CONCLUSION: Later admission in labor (at 4 cm or greater cervical dilation) and management of perinatal care by certified nurse midwives in collaboration with obstetricians increased the rate of spontaneous vaginal delivery in low-risk women.     

A study to determine the incidence and prevalence of newly discovered human immunodeficiency virus infection during the prenatal care period

OBJECTIVES: This study asked the following questions: 1) Does HIV testing in pregnancy identify women who previously were not known to be HIV positive? 2) When in pregnancy are women identified as HIV infected? 3) Does HIV seroconversion occur during the prenatal care period? METHODS: Medical records of 97 women from two primarily indigent care hospitals in Houston, TX who were found to be HIV positive at delivery were reviewed to determine if they had tested positive during the prenatal care period. Demographics and time of gestation of the prenatal testing also were recorded. The outcome measures were: 1) number of women found positive during prenatal care; 2) week of gestation at discovery of HIV positivity; and 3) number of women seroconverting between the initiation of prenatal care and delivery. RESULTS: Thirty women were known to be HIV positive prior to pregnancy. Fifty-six women were found to be positive during prenatal care and the seropositivity of 44 was discovered before the 34th week of pregnancy. Ten women were found to be positive at their first prenatal visit, which occurred after the 34th week. Date of testing was unknown for two women. Eleven women who received no prenatal care were found to be HIV positive at delivery. There were no seroconversions while women were under prenatal care. CONCLUSIONS: HIV testing at delivery did not find any HIV-positive women who had tested negative during prenatal care. Testing is very important for women who do not receive prenatal care. Making certain that high-risk women get into prenatal care also is very important.