BACKGROUND The rate of unintended pregnancy in the United States increased slightly between 2001 and 2008 and is higher than that in many other industrialized countries. National trends have not been reported since 2008.
METHODS We calculated rates of pregnancy for the years 2008 and 2011 according to women’s and girls’ pregnancy intentions and the outcomes of those pregnancies. We obtained data on pregnancy intentions from the National Survey of Family Growth and a national survey of patients who had abortions, data on births from the National Center for Health Statistics, and data on induced abortions from a national census of abortion providers; the number of miscarriages was estimated using data from the National Survey of Family Growth.
Despite the fact that we KNOW how to prevent pregnancies in the United States, rates of unintended pregnancies have been shockingly high. In 2008, more than half of pregnancies in the US were unintended. Think about that. Fifty-one percent of all pregnancies were unintended. Interestingly, things had been getting worse from 2001 to 2008. Why? I’ll let you insert your own explanation. I have one, but it’s not evidence-based.
But in 2011, things looked better. Only 45% of pregnancies were unintended. However, even in 2011, rates of unintended pregnancies are highest among those who are 15-19 years old (75%) and 20-24 years old (59%). They’ve also higher among those below the poverty line (60%).
We’re the United States, people. This is a fixable problem. When you compare us to the rest of the world, we look more like Northern Africa than Europe:
BACKGROUND The risk of antepartum stillbirth at term is higher among women 35 years of age or older than among younger women. Labor induction may reduce the risk of stillbirth, but it also may increase the risk of cesarean delivery, which already is common in this older age group.
METHODS We conducted a randomized, controlled trial involving primigravid women who were 35 years of age or older. Women were randomly assigned to labor induction between 39 weeks 0 days and 39 weeks 6 days of gestation or to expectant management (i.e., waiting until the spontaneous onset of labor or until the development of a medical problem that mandated induction). The primary outcome was cesarean delivery. The trial was not designed or powered to assess the effects of labor induction on stillbirth.
I’ve written about how giving birth in the hospital is associated with higher rates of induction and c-sections. But does the induction cause the c-section? To the RCT!
This was a randomized controlled trial of first-time pregnant women who were at least 35 years old. They were randomly assigned to labor induction in the 39th week of pregnancy, or to expectant management – which means watch and only induce if there’s a medical problem. The main outcome of interest was c-section.
More than 600 women were randomized, and there were no significant differences between the groups. Overall, 32% of those in the induction group had a c-section, versus 33% in the expectant-management froup. There was, therefore, no difference. If you’re interested, there was also no difference in the percentage of women who had a vaginal delivery using forceps (38% of induction and 33% of expectant-management).
The study wasn’t powered for other outcomes, but there were still no differences in maternal or infant deaths, adverse outcomes, or womens’ experiences.
The rates of c-section were high overall compared to other countries (about a third of women). But there’s no evidence to be found there that it’s induction that’s causing that to happen.
I was on vacation recently, and I’m behind. This was Monday’s Healthcare Triage, based on my recent post on the CDC’s recommendations for alcohol and pregnancy:
I feel like a lot of my blogging has been reactive this week. Someone says something, people get outraged, ask me what I think, and then I wind up here. So be it.
The CDC weighed in on alcohol and pregnancy yesterday. This should be relatively straightforward. It’s pretty widely believed that if a fetus is exposed to alcohol while in utero, it has a greater-than-zero risk of developing fetal alcohol syndrome. FASD is a collection of issues which include low birth weight and growth, and problems with organs such as the heart, kidney, and brain. Kids with FASD can have learning disabilities, communication issues, and a lower IQ. The problems can last a lifetime.
That said, there are a number of holes in our knowledge base that make preventing this difficult. No one knows how much alcohol is needed in utero for a child to develop FASD. No one knows when the exposure makes a difference. No one knows why some women can binge drink during pregnancy and have a normal child while others might drink much, much less and have a child with problems.
The American Academy of Pediatrics’s solution has been to declare that no amount of alcohol is safe during pregnancy, that there is no time during pregnancy that women can drink, and that no type of alcohol is ok. Although that’s not as widely accepted in other parts of the world, it’s felt like women in the US took that in stride without too much controversy. I know women who choose to drink the occasional glass of wine during pregnancy, but most women I know seem to abstain altogether during pregnancy.
Clearly, I don’t know a random selection of Americans, though. According to the CDC, about 10% of pregnant women report some alcohol use and about 3% report binge drinking in the last month. Pregnant women most likely to drink are 35-44 years old, not married, and college graduates. Those who report binge drinking in the last month say they did so between 4 and 5 times, more even than nonpregnant women.
I’m a “rate limiting step” guy. If we want to prevent FASD, starting with these women (who aren’t rare) might be a good start. Expanding to those who are still drinking alcohol might be the next place to go. But the CDC decided to go whole hog and recommend that no women who might possibly become pregnant should drink. This includes, of course, pretty much all women who have yet to go through menopause:
More than 3 million US women are at risk of exposing their developing baby to alcohol because they are drinking, having sex, and not using birth control to prevent pregnancy. About half of all US pregnancies are unplanned and, even if planned, most women do not know they are pregnant until they are 4-6 weeks into the pregnancy. This means a woman might be drinking and exposing her developing baby to alcohol without knowing it. Alcohol screening and counseling helps people who are drinking too much to drink less. It is recommended that women who are pregnant or might be pregnant not drink alcohol at all.
The subtitle of this article is, “Why take the risk?” and it’s part of a genre of “won’t somebody think of the children?” that leads to the “if just one child can be saved” thinking that winds up with the conclusion that all women should just be plugged into Matrix-style birthing chambers once they hit puberty, until they hit menopause. That’s clearly how you prevent anything from happening to a baby in utero, ever. Do I need to bring up cars? We do things every day, EVERY DAY, which increase the risk of death to children.
You need to weigh risks and benefits. What is the prevalence of FADS? Even the CDC can’t decide. In their Data & Statistics section, they say that some records can identify 0.2 to 1.5 infants with FADS for every 1000 births. A more recent study found 0.3 out of 1000 kids 7-9 years of age has FADS. Other in-person assessments found that 6-9 per 1000 kids might have a FADS.
Moreover, their other infographic says that women who drink too much have a higher risk of injuries/violence, sexually transmitted diseases, and unintended pregnancy. That has caused the blogosphere to lose its s#$t, and I can’t blame them. The alcohol doesn’t CAUSE these things, and the CDC knows it. This is an association, and it’s part of a pathway, but the way they went about talking about it is being interpreted as victim blaming.
Why couldn’t the CDC just say that drinking too much causes you to lose control of your decision-making skills, which can lead to regret? For that matter, why is this part of the FASD discussion at all? It comes across as fear mongering about alcohol, period. If we go this route, why not just go back to Prohibition in an attempt to prevent FADS?
I get what the CDC is trying to say here. They’re saying that women can become pregnant if they’re having sex and not on birth control (true). Many women are pregnant and don’t know they are (true). If we want to limit the chance of a baby having FADS, we should try and limit the number of women who drink, thinking they’re not pregnant when they are (true). So women should think about being sexually active without birth control while they are still drinking alcohol in their life.
Unfortunately, that message didn’t get across. But before I blame the CDC completely, let me add that I don’t find the coverage by many in the media to be fair. Instead of trying to inform the public, talking about how the proper message should be getting across, too many are quick to use this as a “gotcha” moment to attack the CDC for their communication skills.
If we want to reduce FADS, and get the most bang for our buck, it’s worth starting with the too-many women who binge drink while they’re pregnant. Their fetuses are likely at highest risk. It’s probably worth talking to women who drink at all during pregnancy, to tell them we don’t know the amount or time that alcohol is safe, so that they can make an informed decision about drinking. It’s even worth telling women who are sexually active without birth control that if they think they might be pregnant, they should stop drinking.
Going beyond that with moralizing, shaming, complicating, and embellishing tactics likely doesn’t help.
The following originally appeared on The Upshot (copyright 2016, The New York Times Company).
Many medical students are taught this adage: “When you hear hoofbeats, think of horses, not zebras.” It means that we, as physicians, need to remember that common things are common, and that we shouldn’t immediately focus on the rare or esoteric.
As a pediatrician, for instance, I have to constantly remind myself that the vast, vast majority of children are healthy. Just because I encounter mostly sick children in the clinic doesn’t mean otherwise. I see a skewed population.
Recently, a new study comparing the safety of home or birth-center deliveries with hospital deliveries led to headlines proclaiming that babies not born in hospitals were significantly more likely to die. I have no trouble believing that’s the case.
That’s the zebra, though.
There are a number of people in the United States who would rather have their baby at home. I’m going to lay all of my cards (and biases) here on the table: I recoil at this thought. Why? Because pretty much the worst things I saw in residency occurred with a home birth. I can’t help myself. I hear home birth, and I think of zebras.
I, and my wife, feared the deaths of our babies during delivery so much that we chose in-hospital births. Our zeal to minimize that specific risk outweighed any other considerations. If faced with the decision again, I don’t doubt we’d choose the same. But that doesn’t mean everyone prioritizes risks the same way.
Women should also know that if they’re in the hospital, they are more likely to get an induction, augmentation or other labor-related procedure. They’re more likely to get a cesarean section. Their children are more likely to be admitted to the intensive care unit and spend time separated from them after birth. It’s perfectly rational for parents to accept a statistically significant, but relatively rarer, higher risk of one bad outcome to avoid another.
Home births are gaining in popularity. In Britain, about 10 percent of births don’t happen in a hospital. The Centers for Disease Control and Prevention estimates that in 2012, more than 53,000 births took place out of the hospital in the United States. More than 35,000 took place at home, the rest at dedicated birth centers. Out-of-hospital births are a small percentage of overall deliveries, about 1.36 percent, but the rate has been increasing since 2004, when they were about 0.8 percent. In some states, like Alaska (6 percent), Montana (3.9 percent) and Oregon (3.8 percent), out-of-hospital births are even more common.
In Oregon, data is recorded on birth certificates that allows researchers to know which births were planned for the home and which were planned for the hospital. They can compare outcomes.
In 2012 and 2013, researchers found that the rate of perinatal death was significantly higher for births planned at home: 3.9 versus 1.8 per 1,000. That would be an additional death for each 500 births at home. At-home births were also associated with an increased risk of neonatal seizures.
However, the risk of admission to an intensive care unit was significantly lower for those born at home. I recently wrote an editorial in JAMA Pediatrics discussing how increased neonatal intensive care use is a possible example of supply-induced care. In other words, those facilities might sometimes be used because they exist and need to be filled, not because infants need them.
In the hospital, you’re also more likely to get a procedure. More than 30 percent of women with planned in-hospital births had labor induced, versus 1.5 percent of those with planned at-home births. Almost 25 percent of those who planned to deliver in the hospital had a cesarean section versus 5.3 percent of those who planned to deliver at home.
It’s important to remember that the rates of severe morbidity (permanent harm or significant temporary harm) and death in women are 27 per 1,000 for planned (or “low-risk”) C-section deliveries versus 9 per 1,000 for planned vaginal deliveries. C-sections are probably more common in the United States than they need to be, and being in the hospital increases your chance of getting one, and the risks that come with it.
Unfortunately, the choice of birth location has become a charged debate in this country. In Britain, on the other hand, the medical system seems to have been adopting a more holistic view. The National Institute for Health and Care Excellence (NICE) released guidelines just over a year ago that recommended that health care providers explain to women at low risk of complications that home birth is a safe and acceptable option.
In fact, for British women who have given birth before and are at low risk, NICE recommends that providers explain that birth out of the hospital carries no differences in risk and is associated with higher rates of normal vaginal deliveries and lower rates of intervention.
In addition, there are “protocols and mechanisms” in place to coordinate care between home births and the hospital. An editorial in the New England Journal of Medicine last year noted that almost half of first-time mothers in Britain who intend to give birth out of the hospital wind up doing so in the hospital — and that this might be looked at as a sign of systemic success, not failure. If things don’t go well at home, everyone is prepared and ready to make the transfer because home and hospital delivery systems work closely together. The British safety net works.
The medical profession has a case that in-hospital births carry a lower risk of death, but many women still might be better off delivering elsewhere. A system could be created in which parents’ values and priorities are recognized, while also ensuring that more intensive care is available when needed.
Just because zebras exist doesn’t mean that horses can’t.
Importance The association between the use of antidepressants during gestation and the risk of autism spectrum disorder (ASD) in children is still controversial. The etiology of ASD remains unclear, although studies have implicated genetic predispositions, environmental risk factors, and maternal depression.
Objective To examine the risk of ASD in children associated with antidepressant use during pregnancy according to trimester of exposure and taking into account maternal depression.
Design, Setting, and Participants We conducted a register-based study of an ongoing population-based cohort, the Québec Pregnancy/Children Cohort, which includes data on all pregnancies and children in Québec from January 1, 1998, to December 31, 2009. A total of 145 456 singleton full-term infants born alive and whose mothers were covered by the Régie de l’assurance maladie du Québec drug plan for at least 12 months before and during pregnancy were included. Data analysis was conducted from October 1, 2014, to June 30, 2015.
Exposures Antidepressant exposure during pregnancy was defined according to trimester and specific antidepressant classes.
Main Outcomes and Measures Children with ASD were defined as those with at least 1 diagnosis of ASD between date of birth and last date of follow-up. Cox proportional hazards regression models were used to estimate crude and adjusted hazard ratios with 95% CIs.
Researchers used a big database of pregnancies and children from 1998-2009 in Quebec. There were more than 145,000 full-term infants in the cohort. They then looked at whether a mother’s use of antidepressants in pregnancy was associated with a later diagnosis of autism in their children. Exposure to antidepressants was defined as having at least one prescription filled during pregnancy or at a time that would overlap with pregnancy. They controlled for a host of mom’s variables, including sociodemographic characteristics, and history of psychiatric and chronic physical conditions. They controlled for baby things as well.
They found that, after adjusting for confounders including maternal psychiatric conditions, that the use of antidepressants during the second and/or third trimester was associated with an increased risk (Hazard ratio 1.87) of a child later being diagnosed with autism. Cue the scary headlines.
Now, let’s break this down.
In the entire cohort of 145,456 kids, 0.7% of them had ASD. That’s actually on the low side. Of course, some of the kids in the cohort were still too young to be reliably diagnosed. Moreover, they excluded any prematurely born kids from this analysis, and premies are at an increased risk of autism.
Let’s talk numbers first, though. Of the 145,456 kids born into this cohort, only 4724 were exposed to antidepressants. The other 140,732 were not. Of the 4724 exposed to antidepressants, 46 developed an ASD and 4678 did not. Of course, 1008 kids who were not exposed to an antidepressant were diagnosed with an ASD, too.
Antidepressants in the first trimester were not found to be significantly related to the risk of an ASD, though. Of those 46 kids, only 31 were exposed to an antidepressant in the second or third trimester.
In other words, the headline finding is a comparison between the kids who were never exposed to antidepressants and got ASD (1008/145,456) versus the kids who were exposed to antidepressants in the second or third trimester and got ASD (31/2532). Those calculate to 0.7% and 1.2%. The adjusted relative risk increase was 87% when taking into account person-years. The absolute increase is 0.5%. If you accept this at face value, the NNH is therefore about 200. The vast majority of kids who were exposed to antidepressents in the second and/or third trimester did not develop an ASD.
Further, only SSRIs were shown to be related when looking at classes of drugs individually. They all do have different mechanisms after all. There were 22 kids exposed to SSRIs in the second and/or third trimester who developed ASD (out of the 145,456 kids).
The point of laying out these numbers is to show you that this isn’t a problem of epidemic proportions. At the end of the day, this study hinges on a small number of children. That doesn’t mean the findings aren’t robust or that they aren’t real. But you have to place things in context. The mothers are theoretically getting a benefit from these drugs, or they wouldn’t be on them. Those benefits need to be weighed against risks.
And anyone who says that “any risk is too big when it comes to a child” needs to answer for cars.
We also need to consider this finding in context. There have been a number of studies in this area. This study showed an association between maternal use of SSRIs and a lower risk for preterm birth and many adverse outcomes. Depression in moms in general has been shown to be associated with low birth weight, preterm birth, and being small for gestational age. This case-control study found antidepressant use wasn’t linked to ASD, but that it might be to ADHD.
I didn’t tout any of those studies as truth when they were published any more than I would this one. It’s a data point, and we should adjust our priors accordingly.
Finally, there are limitations to this work. They did adjust for the presence of depression in mothers, but not necessarily the severity. It’s possible that the most severe cases were treated with antidepressants, and that’s what’s related to ASD in kids, not the drugs. It’s possible that mothers presceibed antidepressants are more plugged into the health system, and their kids were more likely to get a diagnosis of ASD than those whose mothers aren’t as plugged in. It’s possible that just filling a prescription is not a great marker for actual antidepressant use in pregnancy. It’s possible the premies might have made a difference if they were included. It’s possible something else is at play that we are all missing.
Here’s the tl;dr: This was a statistically significant finding, but from a relatively small group of children regardless of the size of the entire cohort. It’s only significant for SSRIs and in the second and/or third trimester, which is 22 kids total. The absolute risk increase was only 0.5%. There are limitations to the study, and other studies have found different results. My take home would be that this deserves more work and attention, and that any potential harms from the antidepressants should be weighed against the known benefits for these pregnant moms. They should discuss that with their physicians.
Frustrating pundit-scolds all over the country, the CDC reports:
Monitoring sexual activity and contraceptive use among U.S. adolescents is important for understanding differences in their risk of pregnancy. In 2013, the U.S. birth rate for teenagers aged 15–19 dropped 57% from its peak in 1991, paralleling a decline in the teen pregnancy rate.
But… but… but… the culture! The sexting! The Internet! The twerking! The depravity!
The percentage of male and female teenagers who had sexual intercourse at least once has declined in the 25-year period of 1988 to 2013. This decline was greater for male teenagers than female teenagers. According to the most recent data from 2011–2013, by age 19, roughly two of three never-married teenagers have had sexual intercourse. The majority of male and female teenagers used a method of contraception at first sexual intercourse. The methods teenagers most often used were the condom, withdrawal, and the oral contraceptive pill. Female teenagers who used a method of contraception at first sexual intercourse were less likely to have had a birth in their teen years than those who did not use a method of contraception at first intercourse.
It’s so lazy to continue to pretend that the kids these days are just the worst. Or that boys are sex-crazed. Or that teaching kids about contraception is a bad idea. But, you know, keep on scolding I guess.
How dangerous is heading a soccer ball? Who’s mandating the HPV vaccine in the US? And how many women are drinking while pregnant in Ireland, Australia, New Zealand, and the UK? This is Healthcare Triage News.
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03/08/2016
Aaron Carroll
