Homeless women's gynecological symptoms and use of medical care

Information is lacking on homeless women's gynecological symptoms and use of medical care for symptoms. This paper documents and explains gynecological symptoms and conditions and use of medical care in a probability sample of 974 reproductive-age (15-44) homeless women. Two-thirds of women reported symptoms during the previous year; 71 percent of those received medical care for their gynecological symptoms. Pregnancy, drug dependence, more episodes of homelessness, and general physical health symptoms were positively associated with a number of gynecological symptoms. Gynecological symptoms, younger age, better perceived health, and insurance coverage were positively associated with medical care; women reporting recent drug use and rape received less care. These findings support the importance of medical care and other treatment and support services for homeless women, including expanded care during pregnancy and substance abuse treatment. Health insurance coverage and an interruption in the cycle of homelessness also appear vital to women's health.

Lack of progress in labor as a reason for cesarean

OBJECTIVE

To estimate the prevalence of lack of progress in labor as a reason for cesarean delivery and to compare published diagnostic criteria with the labor characteristics of women with this diagnosis.

METHODS

We reviewed medical records and did a postpartum telephone survey to collect data from 733 women who delivered full-term, nonbreech infants by unplanned cesarean between March 1993 and February 1994. These were a subset of 2447 births sampled at delivery from 30 hospitals in Los Angeles County and Iowa. We measured the proportion of unplanned cesareans done for lack of progress in labor, the cervical dilatation at the time of cesarean, length of the second stage, and slope of the active phase among the women. We estimated the proportion of these cesareans that conformed to the ACOG criteria for the diagnosis of lack of progress.

RESULTS

Lack of progress was a reason for 68% of unplanned, vertex cesareans. At least 16% of the subjects who had cesareans for lack of progress were in the latent phase of labor according to ACOG criteria. The second stage was not prolonged in 36% of the women who delivered at 10 cm.

CONCLUSION

Lack of progress in labor is a dominant reason for cesarean delivery. Many cesareans are done during the latent phase of labor, and in the second stage of labor when it is not prolonged. These practices do not conform to published diagnostic criteria for lack of progress.

Development of a quality of care measurement system for children and adolescents. Methodological considerations and comparisons with a system for adult women

OBJECTIVES

To describe the development of a pediatric quality of care measurement system designed to cover multiple clinical topics that could be applied to enrollees in managed care organizations and to compare the development of this system with the concurrent development of a similar system for adult women.

DESIGN

Indicators were developed for 21 pediatric (ages 0-18 years) clinical topics and 20 adult (ages 17-50 years) women's clinical topics. Indicators were classified by the strength of evidence supporting them. A modified Delphi method was used to obtain validity and feasibility ratings from a pediatric expert panel and an adult women's expert panel. Indicators were categorized by type of care (preventive, acute, or chronic), function (screening, diagnosis, treatment, or follow up), and modality (history, physical examination, laboratory/radiology study, medication, other intervention, or other contact).

RESULTS

Of 557 pediatric and 391 adult women's proposed indicators, 453 (81%) and 340 (87%), respectively, were retained by the 2 expert panels. A lower percentage of final pediatric indicators than adult indicators were based on randomized, controlled trials and other rigorous studies (18% vs 40%, P < .001). The expert panels were more likely to retain indicators based on rigorous studies (93% retained) than on descriptive studies and expert opinion (81% retained, P < .001). A higher percentage of pediatric indicators than women's indicators were for preventive care (30% vs 11%, P < .001) and a lower percentage were for acute care (36% vs 49%, P < .001) or chronic care (34% vs 41%, P = .06).

CONCLUSIONS

This study contributes to the field of pediatric quality of care assessment by providing many more indicators than have been available previously and by documenting the strength of evidence supporting these indicators. Formal consensus methods are essential for the development of pediatric quality measures because the evidence base for pediatric care is more limited than for adult care.

Adjusting cesarean delivery rates for case mix

OBJECTIVES

(1) To describe the issues in developing a clinical predictor of cesarean delivery that could be used to adjust reported cesarean rates for case mix, and (2) to compare its performance to other, simpler predictors using clinical and statistical criteria.

DATA SOURCES

Singleton births greater than 2,500 grams in Washington State in 1989 and 1990 for whom mothers and infant hospital discharge records could be matched to birth certificate data.

DESIGN

Statistical analysis of retrospective merged hospital and birth certificate data, which were used to develop variables and models to predict the probability that any particular delivery would be a cesarean.

PRINCIPAL FINDINGS

Merged data led to better predictor variables than those based on one source. A simple four-category hierarchical classification into births with prior cesarean, breech but no prior cesarean, first birth, and other explains 30 percent of the variance in individual cesarean rates. The full clinical model fit the data well and explained 37 percent of the variance. Multiparas without serious complications comprised 35 percent of the mothers and averaged less than 2 percent cesareans. A hospital's predicted cesarean rate depends strongly on the proportion of its births that are first births.

CONCLUSION

Government and private agencies have reported cesarean rates as measures of hospital performance. Depending on data and resources available, both simple and complex measures of case mix can be used to adjust reported rates. These adjustments should not include all variables related to the rates. Proper adjustments may not alter hospital rankings greatly, but they will improve the validity and acceptability of the reports.

Research design and methods of quantitative synthesis of medical evidence

OBJECTIVE

To review the scientific principles, strengths, and limitations of research designs and methods of quantitative synthesis of medical evidence.

DATA SOURCES

We used MEDLINE to perform a systematic search for literature using the keywords research design, epidemiology, and biometry. Journals searched included six major journals in obstetrics and gynecology and three in general medicine. These sources were supplemented with texts and reviews from the general medical literature.

METHODS OF STUDY SELECTION

We reviewed the publications identified by our search and evaluated critically the relevant reports. We summarized objectives and scientific guidelines for the common research methodologies and outlined their advantages and disadvantages.

TABULATION, INTEGRATION, AND RESULTS

The standard of clinical research design is the randomized controlled trial (RCT), which, if performed with sufficient methodologic rigor, is least likely to have serious biases. Cohort, case-control, and cross-sectional studies are common observational studies used in reproductive health; such observational studies are more susceptible to biases that can distort the researcher's results and conclusions. Descriptive studies such as case series and case reports are often interesting as clinical vignettes but have limited scientific merit. Methods for quantitative synthesis of medical evidence, including meta-analysis, decision analysis, and cost-effectiveness analysis are being used with increased frequency in the reproductive health literature to summarize medical evidence.

CONCLUSION

Various research methods have their own inherent advantages and disadvantages. An understanding of the scientific principles of these methods will enable the clinician to evaluate medical evidence critically.

A family of arginal thrombin inhibitors related to efegatran

Three new tripeptide arginal thrombin inhibitors were shown to have potent anticoagulant and antithrombotic activity: D-MePhg-Pro-Arg-H (LY287045), D-1-Tiq-Pro-Arg-H (LY294291), and D-MePhe-Pro-Arg-H (Efegatran). Efegatran and the related arginals differ mechanistically from old and from new anticoagulant agents. As illustrated with x-ray diffraction analysis of crystals of the LY294291 complex with human thrombin, the family of arginals binds thrombin with the P3, P2, and P1 residues interacting with the putative S3, S2, and S1 fibrinogen-binding sites. A hemi-acetal bond at Ser 195 was shown to contribute to the tight-binding reversible competitive thrombin inhibition properties observed with the arginal family. Tight-binding Kass values from thrombin inhibition studies correlated with thrombin clottin inhibition potency. The thrombin time (TT) assay was prolonged twofold with 33 nM Efegatran, which demonstrated an apparent Kass value of 0.8 x 10(8) L/mol (for comparison, 17 nM hirudin was required to prolong the TT assay two-fold). There are empirical anticoagulant selectivity differences between Efegatran and hirudin, manifested by large activated partial thromboplastin time (aPTT)/TT effect ratios (30 to 55) found with the arginals, as compared to the small aPTT/TT effect ratio (2 to 3) found with hirudin. The underlying anticoagulant mechanism differences between the arginals and hirudin appear to be confined to the aPTT pathway and, therefore, might involve different effects toward thrombin feedback activation of factor VIII. The arginals did not substantially inhibit other coagulation factor serine proteases. Antithrombotic effects of Efegatran and the arginal family occur at low infusion doses in dogs and appear to correlate with effects on TT without requiring perturbation of the aPTT. Selectivity properties regarding the fibrinolytic enzymes were shown to be important for successful use of the arginals in vivo as adjunctive agents during tissue plasminogen activator (t-PA) thrombolysis. The data suggest that LY287045, LY294291, and Efegatran should be expected to be useful as antithrombotic adjuncts to thrombolytic therapy with t-PA, urokinase, or streptokinase and should be expected to spare endogenous fibrinolysis. Efegatran has been evaluated in phase I clinical studies and is currently under clinical investigation in phase II protocols as a new cardiovascular anticoagulant.

Reductions in cost and cesarean rate by routine use of external cephalic version: a decision analysis

OBJECTIVE

To describe currently accepted methods for managing the term breech pregnancy, and to predict the delivery outcomes and costs of each method.

METHODS

Literature review was used to derive four options for the peripartum management of the term breech pregnancy. Using decision-analysis techniques, we calculated the predicted delivery outcomes and costs associated with each option.

RESULTS

Applying external cephalic version to all term breech pregnancies without contraindications to labor or version, and allowing a trial of labor for eligible women who fail version, results in a 25% cesarean rate, at a cost of $8071 per case. Delivering unsuccessful versions by scheduled cesarean results in a 32% cesarean rate, at a cost of $8276 per case. In contrast, a strategy not using external version but allowing a trial of labor for those mothers who meet eligibility criteria results in a 63% cesarean rate, at a cost of $8755 per case. Routinely scheduling a cesarean when a breech is identified at term results in an 89% cesarean rate, at a cost of $9544 per case.

CONCLUSIONS

Although the liberal use of vaginal delivery for term breech pregnancies has been suggested as one way of lowering the cesarean rate, the addition of routine external cephalic version to the management strategy will result in more vaginal deliveries and lower costs than strategies that allow vaginal delivery but do not include an attempted cephalic version. Routine cesarean without attempted external cephalic version results in excessive operative deliveries.

A meta-analysis of infant outcomes after breech delivery

OBJECTIVE

To estimate the risks of neonatal morbidity and mortality associated with a trial of labor and with elective cesarean for the term breech infant.

DATA SOURCES

Using the terms "breech," "malpresentation," and "external cephalic version," we used the MEDLINE and Health Planning and Administration data bases to search the English-language literature from January 1981 to June 1993. The search was supplemented with a review of the reference lists of key articles and text chapters.

METHODS OF STUDY SELECTION

We included randomized trials or cohort studies that specified selection criteria for a vaginal delivery, provided detailed outcome data, and allowed for analysis by intended mode of delivery.

DATA EXTRACTION AND SYNTHESIS

Nine studies met the inclusion criteria. We pooled the weighted results from these studies to estimate the risks of birth injuries and perinatal death, and the risk differences between trial of labor and no trial of labor groups. The pooled risk for any injury was 1.00% after a trial of labor and 0.09% after elective cesarean. For any injury or death, the risk was 1.23% after a trial of labor and 0.09% after elective cesarean. The risk differences for injury and injury or death were 0.89 and 1.10%, respectively. These are significantly different from zero, suggesting an increased risk of injury and injury or death after a trial of labor.

CONCLUSION

When management decisions are made, the potential increased risk of neonatal morbidity after a trial of labor should be considered along with the increased maternal risk from cesarean delivery.