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Volume 5, No. 6, June/July 2007
Features
American College of Obstetricians and Gynecologists
Endometrial ablation. ACOG Practice Bulletin No. 81
Summary of Recommendations and Conclusions
The following recommendations and conclusions are based on good and consistent scientific evidence (Level A):
- For women with normal endometrial cavities, resectoscopic endometrial ablation and nonresectoscopic endometrial ablation systems appear to be equivalent with respect to successful reduction in menstrual flow and patient satisfaction at 1 year following index surgery.
- Resectoscopic endometrial ablation is associated with a high degree of patient satisfaction but not as high as hysterectomy.
The following recommendations and conclusions are based on limited or inconsistent scientific evidence (Level B):
- Hysterectomy rates associated with both resectoscopic endometrial ablation and nonresectoscopic endometrial ablation are at least 24% within 4 years following the procedure.
- Women undergoing endometrial ablation with previous or concomitant laparoscopic sterilization are at low risk for the development of cyclic or intermittent pelvic pain subsequent to the procedure.
- Patient satisfaction and reduction in menstrual blood flow after endometrial ablation in women with normal endometrial cavities is similar to that experienced by women using the levonorgestrel-secreting intrauterine system.
The following recommendations and conclusions are based primarily on consensus and expert opinion (Level C):
- Patients who choose endometrial ablation should be willing to accept normalization of menstrual flow, not necessarily amenorrhea, as an outcome.
- Premenopausal patients undergoing endometrial ablation should be counseled to use appropriate contraception.
- in women with endometrial cavities that exceed device limitations.
- The endometrium of all candidates for endometrial ablation should be sampled, and histopathologic results should be reviewed before the procedure.
- Women with endometrial hyperplasia or uterine cancer should not undergo endometrial ablation.
- Performance of nonresectoscopic endometrial ablation in patients with prior classic cesarean delivery or transmural myomectomy may increase the risk of damage to surrounding structures. If endometrial ablation is to be performed in such patients, it may be best to perform resectoscopic endometrial ablation with laparoscopic monitoring. Safety of nonresectoscopic endometrial ablation in women with low transverse cesarean delivery has not been adequately studied.
- For resectoscopic endometrial ablation, it is recommended that a fluid management and monitoring system that provides “real-time” output of fluid balance be used.
Endometrial ablation. ACOG Practice Bulletin No. 81. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1233–48.
Seeking and Giving Consultation
ABSTRACT: Consultations usually are sought when practitioners with primary clinical responsibility recognize conditions or situations that are beyond their level of expertise or available resources. One way to maximize prompt, effective consultation and collegial relationships is to have a formal consultation protocol. The level of consultation should be established by the referring practitioner and the consultant. The referring practitioner should request timely consultation, explain the consultation process to the patient, provide the consultant with pertinent information, and continue to coordinate overall care for the patient unless primary clinical responsibility is transferred. The consultant should provide timely consultation, communicate findings and recommendations to the referring practitioner, and discuss continuing care options with the referring practitioner.
Seeking and Giving Consultation. ACOG Committee Opinion No. 365. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1255–9.
Disruptive Behavior
ABSTRACT: Disruptive behavior may have a negative effect on patient care. Consequently, it is important that a systematic process be in place to discourage, identify, and remedy episodes of disruptive behavior.
Disruptive Behavior. ACOG Committee Opinion No. 366. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007; 109:1261–2.
Patents, Medicine, and the Interests of Patients
ABSTRACT: Many basic scientists and clinicians support the right to obtain and enforce patents on drugs, diagnostic tests, medical devices, and most recently, genes. Although those who develop useful drugs, diagnostic and screening tests, and medical technologies have the right to expect a fair return for their efforts and risks, current interpretations of patent law have the potential to impede rather than promote scientific and medical advances. Policies regarding the patenting of scientific inventions, discoveries, and improvements must balance the need for the open exchange and use of information with the need to make the pursuit of such knowledge financially rewarding.
Patents, Medicine, and the Interests of Patients. ACOG Committee Opinion No. 364. American College of Obstetricians and Gynecologists. Obstet Gynecol 2007;109:1249–53.
American Family Physician**
Therapies for Overactive Bladder- Nonpharmacologic vs. Anticholinergic
Clinical Question: Cochrane Briefs
How do nonpharmacologic therapies compare with anticholinergic medications in patients with overactive bladder (i.e., urinary urgency)?
Evidence-Based Answer
Anticholinergic medications are more effective than bladder training in reducing the number of voids per day. Combining an anticholinergic medication with bladder training is more effective than either therapy alone.
Practice Pointers
Overactive bladder can be associated with urge incontinence, urinary frequency, and nocturia. Causes of chronic bladder irritation include urinary tract infection; pelvic surgery; estrogen deficiency; diabetes; multiple sclerosis; medications (e.g., neuroleptics, diuretics); cerebral ischemia; dementia; and overflow incontinence.1
The most common treatments for overactive bladder are anticholinergic medications, bladder training, pelvic floor muscle training, biofeedback, and electric stimulation of the detrusor muscles. Compared with placebo, persons taking anticholinergic medications for overactive bladder have about five fewer trips to the bathroom and four fewer leakage episodes per week. Patients taking anticholinergic medications also report modest improvements in quality of life.2
This Cochrane review included randomized or quasi-randomized controlled trials that compared anticholinergic medications with nonpharmacologic therapies for overactive bladder or urinary urge incontinence in adults. Thirteen trials (1,770 total participants treated for three to 12 weeks) were identified; however, most trials were small and protocols varied, making it difficult to draw many firm conclusions.
Bladder training was the most effective nonpharmacologic treatment studied. Six trials (288 total participants) compared anticholinergic medications (4 mg of tolterodine [Detrol], 45 mg of propantheline [Pro-Banthine], or 5 to 45 mg of oxybutynin [Ditropan] daily). Overall, anticholinergic medications improved symptoms compared with bladder training alone (relative risk = 0.73; 95% confidence interval, 0.59 to 0.90). Combining bladder training with an anticholinergic medication improved symptoms compared with either treatment alone. Patients receiving combined treatment had about 5 percent fewer voids per day, and about 15 percent of patients reported a greater change from baseline in the sensation of urgency.
No trials of pelvic floor muscle training or surgery were found. No significant difference between anticholinergic medications and electrostimulation was found. About one third of patients taking anticholinergic medications experienced adverse effects such as dry mouth, headache, constipation, dizziness, decreased visual acuity, and tachycardia.
Alhasso AA, et al. Anticholinergic drugs versus non-drug active therapies for overactive bladder syndrome in adults. Cochrane Database Syst Rev 2006;(4):CD003193.
http://www.aafp.org/afp/20070501/cochrane.html
Exercise Is an Effective Intervention in Overweight and Obese Patients
Clinical Scenario: Cochrane for Clinicians
A 52-year-old overweight man with hypertension and diabetes has made some dietary changes, but he has not initiated an exercise program for weight loss. He wonders if exercise will really make a difference.
Clinical Question
How effective is exercise in reducing body weight and improving cardiac risk factors in overweight or obese patients?
Evidence-Based Answer
Exercise leads to a weight loss of 1 lb, 2 oz to 16 lb, 12 oz (0.5 to 7.6 kg), compared with a 3-oz (0.1-kg) weight loss to a weight gain of 1 lb, 9 oz (0.7 kg) with no treatment. Patients participating in higher-intensity exercise lose 3 lb, 5 oz (1.5 kg) more than those participating in low-intensity exercise. Regardless of whether the patient loses weight, exercise improves diastolic blood pressure and triglyceride, high-density lipoprotein, and glucose levels. When a low-calorie diet is compared with exercise alone, a low-calorie diet leads to more weight loss (6 lb, 3 oz to 29 lb, 16 oz [2.8 to 13.6 kg] versus 1 lb, 2 oz to 16 lb, 12 oz). However, trials with three to 12 months of follow-up show that participants who combine a low-calorie diet with exercise lose 2 lb, 7 oz (1.1 kg) more than those who only diet.
Shaw K, Gennat H, O'Rourke P, Del Mar C. Exercise for overweight or obesity. Cochrane Database Syst Rev 2006;(4):CD003817.
http://www.aafp.org/afp/20070501/cochrane.html
Evaluation and Treatment of Acute Low Back Pain (See Patient Education)
Acute low back pain with or without sciatica usually is self-limited and has no serious underlying pathology. For most patients, reassurance, pain medications, and advice to stay active are sufficient. A more thorough evaluation is required in selected patients with "red flag" findings associated with an increased risk of cauda equina syndrome, cancer, infection, or fracture. These patients also require closer follow-up and, in some cases, urgent referral to a surgeon. In patients with nonspecific mechanical low back pain, imaging can be delayed for at least four to six weeks, which usually allows the pain to improve. There is good evidence for the effectiveness of acetaminophen, nonsteroidal anti-inflammatory drugs, skeletal muscle relaxants, heat therapy, physical therapy, and advice to stay active. Spinal manipulative therapy may provide short-term benefits compared with sham therapy but not when compared with conventional treatments. Evidence for the benefit of acupuncture is conflicting, with higher-quality trials showing no benefit. Patient education should focus on the natural history of the back pain, its overall good prognosis, and recommendations for effective treatments. Am Fam Physician 2007;75:1181-8, 1190-2.
http://www.aafp.org/afp/20070415/1181.html
Restless Legs Syndrome: Pramipexole (Mirapex)
Pramipexole (Mirapex) is a non-ergot selective dopamine receptor agonist that has been used since 1997 for the treatment of idiopathic Parkinson's disease. It is now labeled for the treatment of moderate to severe restless legs syndrome (RLS),1 which is defined as having symptoms at least two to three days per week for at least three months and having a baseline score higher than 15 on the 40-point International Restless Legs Syndrome Study Group Rating Scale.2
Bottom Line
Although many patients with RLS do not need pharmacologic therapy, pramipexole is one option for treating moderate to severe symptoms. As with other agents used to manage RLS, potentially serious adverse reactions are possible. Am Fam Physician 2007;75
http://www.aafp.org/afp/20070415/steps.html
AHRQ
AHRQ breastfeeding evidence review
Breastfeeding and Maternal and Infant Health Outcomes in Developed Countries.
It can be downloaded at AHRQ Publications Clearinghouse at AHRQPubs@ahrq.hhs.gov or by calling the Clearinghouse at 800-358-9295.
Ask A Librarian: Diane Cooper, M.S.L.S. / NIH
Quick Check for Drugs and Lactation
When you need to know if a drug you prescribe is safe for breastfeeding mothers, here is a new and easy to use database to check.
LactMed is a peer-reviewed database of drugs to which breastfeeding mothers may be exposed. LactMed is part of the National Library of Medicine’s Toxicology Data Network (TOXNET) and contains over 450 drug records. Data include information on the levels of drugs in the breast milk and infant blood, and possible adverse effects on the nursing infant. There are suggested alternatives to those drugs when available. All data are derived from the scientific literature and fully referenced.
LactMed can be accessed using the Health Services Research Library website at http://hsrl.nihlibrary.nih.gov
Find PubMed in the left panel and click.
Once you are in PubMed, click on TOXNET located on their left panel.
Next, select LactMed from the list. In the search box, enter the drug you are interested in.
Sample Record for Prozac (abbreviated for space)
DRUG LEVELS AND EFFECTS:
SUMMARY OF USE DURING LACTATION:
The average amount of drug in breast milk is higher with fluoxetine than
with most other SSRIs and the active metabolite, norfluoxetine, is
detectable in the serum of most breastfed infants during the first 2
months postpartum and a few thereafter…….
DRUG LEVELS:
Fluoxetine is metabolized to norfluoxetine which has antidepressant
activity that is considered to be equal to fluoxetine. In a pooled analysis of serum levels from published studies and 1unpublished case, the authors found that 20 mothers taking an average daily dosage of 28 mg (range 10 to 80 mg) had an average milk fluoxetine
level of 76 mcg/L (range 23 to 189 mcg/L)…
EFFECTS IN BREASTFED INFANTS:
Colic, decreased sleep, vomiting and watery stools occurred in a 6-day-old
breastfed infant probably caused by maternal fluoxetine…….
POSSIBLE EFFECTS ON LACTATION:
Fluoxetine has caused increased prolactin levels and galactorrhea in
nonpregnant, nonnursing patients. The clinical relevance of
these findings in nursing mothers is not known. …….
AAP CATEGORY (comment from the American Academy of Pediatrics)
Effect on nursing infant is unknown but may be of concern.
ALTERNATE DRUGS TO CONSIDER:
Nortriptyline
REFERENCES:
1. Weissman AM, Levy BT, Hartz AJ et al. Pooled analysis of antidepressant levels in lactating mothers, breast milk, and nursing infants. Am J Psychiatry. 2004;161:1066-9.
2. Kristensen JH, Ilett KF, Hackett LP et al. Distribution and excretion of fluoxetine and norfluoxetine in human milk. Br J Clin Pharmacol. 1999;48:521-7
LactMed can be accessed using the Health Services Research Library website at http://hsrl.nihlibrary.nih.gov
Breastfeeding - Suzan Murphy, PIMC
Long-Term Breastfeeding among Native American Women
Available for purchase the two versions of the “video features Native American women telling in their own words of their experience in learning and teaching breastfeeding in the context of community and family tradition. The discussions include: New mothers' questions, managing at the hospital, working and breastfeeding, sexuality, birth control, attitudes towards extended nursing, fathers' roles, tandem nursing, and more.
http://www.glitc.org/pages/bfvideo.html
Systematic review and meta-analysis confirms long-term positive effects of breastfeeding
The World Health Organization's Department of Child and Adolescent Health, in collaboration with the epidemiology unit in the University of Pelotas, Brazil, conducted this systematic review and meta-analysis of studies to assess the association between breastfeeding and blood pressure, diabetes and related indicators, serum cholesterol, overweight and obesity, and intellectual performance. Two reviewers independently evaluated study quality, using a standardized protocol, and disagreement was resolved by consensus rating. Subjects who were breastfed experienced lower mean blood pressure and total cholesterol, as well as higher performance in intelligence tests. Prevalence of overweight/obesity and type-2 diabetes was lower among breastfed subjects. All effects were statistically significant but for some outcomes their magnitude was relatively modest.
This review confirms what has been widely known for years; that breastfeeding helps infants achieve the highest attainable standard of health.
http://www.who.int/child-adolescent-health/New_Publications
/NUTRITION/ISBN_92_4_159523_0.pdf
FAQs - Breastfeeding and maternal illness
Is breastfeeding okay if mom the gets sick? Most of the time, the answer is yes. The following review is from CDC and references listed below.
When breastfeeding is not recommended:
- The baby is diagnosed with galactosemia, a rare genetic metabolic disorder occurring in 1 in
47,000 births. There is little data on the prevalence of galactosemia in AI/AN
communities.
- The baby’s mother:
- Has been infected with or recently exposed to the human immunodeficiency virus (HIV)
- Is taking antiretroviral medications
- Has untreated, active tuberculosis
- Is infected with human T-cell lymphotropic virus type I or type II
- Is using or is dependent upon an illicit drug
- Is taking prescribed cancer chemotherapy agents, such as antimetabolites that interfere with DNA replication and cell division
- Is undergoing radiation therapies; however, such nuclear medicine therapies require only a temporary interruption in breastfeeding
What about stomach flu?
Yes, moms with diarrhea from food and water sources can keep breastfeeding. The recommendations to increase fluid intake and use oral rehydration salts work well with breastfeeding.
If medication is needed consider kaolin-pectin (Kaopectate) or loperamide (Immodium, Maalox) . Both are described by the American Academy of Pediatrics (AAP) as “usually compatible with breastfeeding,” with kaolin-pectin being preferable to loperamide.
Avoid suggesting anitdiarrheal medications that have bismuth subsalicylate compounds (Pepto-Bismol). They are considered by both AAP and Hale to be of concern because the baby can absorb significant levels of salicylates and pose a theoretical risk of Reye’s syndrome.
For more information go to www.cdc.gov travelers’ health.
Can a mom breastfeed if she contracts hepatitis A?
Yes, she can continue and gamma globulin treatment is compatible with breastfeeding. Encourage the mom to use effective hand washing techniques and food safety recommendations to protect her baby, whether she is breastfeeding or bottle-feeding.
What if she has hepatitis B (HBV) ?
Is it safe for a mom infected with HBV to breastfeed her baby right after birth?
Yes. HBV transmission through breastfeeding was not reported. CDC recommends:
- All babies born to HBV-infected moms need to receive hepatitis B immune globulin and the
first dose of hepatitis B vaccine within 12 hours of birth, the second dose of vaccine at
aged 1–2 months, and the third dose at aged 6 months.
- The infant needs to be tested after completing the vaccine series, at aged 9–18 months to
confirm that the vaccine worked and the infant is not infected with HBV through exposure
to the mother’s blood during the birth process.
What if the mom’s nipples are cracked and bleeding?
Like hepatitis C, both viruses are spread by infected blood. There is not enough data to make recommendations at this point. Until more information is available, the wisest course is to encourage the mom to temporarily interrupt breastfeeding her baby until she is healed. Although sore nipples seem to last forever, they usually heal quickly, often within 24 hours. It is helpful to pump and dump during this time. Since both hepatitis b and c are resilient viruses, it would be prudent to discard the breast pump when through.
What about HBV vaccinations for a breastfeeding mom?
It is okay for a breastfeeding mom to receive HBV vaccinations. The vaccines contain noninfectious HBsAg particles and are given to newborns also.
For more information, refer to CDC. A Comprehensive Immunization Strategy to Eliminate Transmission of Hepatitis B Virus Infection in the United States. MMWR, Recommendations and Reports, December 23, 2005 / 54(RR16);1-23
What about mom with hepatitis C (HCV) – is it safe for her to breastfeed?
Yes, like HBV, there is no evidence that breastfeeding spreads HCV.
What if the mom in infected with HCV and has cracked and bleeding nipples?
See recommendations above for HBV and cracked and bleeding nipples.
For more information, refer to CDC. Recommendations for prevention and control of Hepatitis C virus (HCV) infection and HCV-related chronic disease. MMWR, October 16, 1998, 47(RR-19):1–39.
What if a mom becomes infected with West Nile Virus, is it safe for her to breastfeed her baby?
So far, there is no evidence that it is harmful for a mom infected with West Nile Virus to breastfeed infant. In According to CDC, there have been 4 documented cases of West Nile Virus transmission through breast milk (1 in 2002 and 3 in 2003) with no recognizable illness in the baby. As a result, CDC recommends that moms with West Nile Virus illness continue breastfeeding because the benefits of breast milk are thought to outweigh the theoretical risk of harm to the baby.
For more information go to http://www.cdc.gov/ncidod/dvbid/westnile/
Resources
American Academy of Pediatrics' Breastfeeding and the Use of Human Milk, available at:
http://aappolicy.aappublications.org/cgi/content/abstract/pediatrics;115/2/496
American Academy of Pediatrics Committee on Drugs. (2001) The transfer of drugs and other chemicals into human milk. Pediatrics 108:776-789.
Department of Health and Human Services, Centers of Disease Control and Prevention, www.cdc.gov
Hale, T. (2006) Medications and Mothers’ Milk. 12 th edition. Amarillo, TX: Pharmasoft Publishing.
Lawrence RA, Lawrence R. (2005) Breastfeeding: A guide for the medical professional, 6th Edition. St. Louis: Mosby.
Need fast information about drugs and breastfeeding? Go to Lactnet at www.toxnet.nlm.nih.gov
Other
RCT of very early mother-infant skin-to-skin contact and breastfeeding status
Conclusion: Very early skin-to-skin contact enhanced breastfeeding success during the early postpartum period. No significant differences were found at 1 month.
Moore ER, et al Randomized controlled trial of very early mother-infant skin-to-skin contact and breastfeeding status. J Midwifery Womens Health. 2007;52(2):116-125.
and
http://www.medscape.com/viewarticle/555315?src=mp
CCC Corner Digest
Nicely laid out hard copy - A compact digest of last month’s CCC Corner
Highlights include
Social Change Might Save More Lives Than Medical Advances
New HPV Brochures for Clinicians, CDC
More stillbirths after previous cesarean delivery
Young women with CIN: Any treatment increases preterm delivery - LEEP
Public Opinion vs. Science Concerning Sex Education
New Guideline for Screening Mammography for Women 40 to 49 Yrs
Premature Rupture of Membranes, Practice Bulletin
Quick Check for Drugs and Lactation
Breastfeeding - it’s all about synergy
Extended OCP Regimen; Acceptable Breakthrough Bleeding
Must See Website: Indian Health Service HIV-AIDS Program
Ethics of medicine with economically vulnerable populations: 2nd in series
Do you walk around your vehicle before getting in it? You should
Which Indian Health facilities lead the U.S. in national benchmarks?
Emergence of a range of nonhormonal treatments for vasomotor symptoms
Ultrasound affects mice brains in negative ways
BTL: Nearly 1/2 of women under 25 yo request information on reversal
Two summer programs for high school students
Calcium Supplementation May Not Benefit Healthy Children
Preconception counseling for women with DM and HTN: Which meds?
Electronic Health Record (EHR) Implementation: Worth the effort?
HIV/AIDS among AI/AN Fact Sheet
New recommendations for gestational weight gain may be required
Weaving it all together: 2007 Behavioral Health Conference
May newsletter here
http://www.ihs.gov/MedicalPrograms/MCH/M/obgyn0507.cfm
If you want a copy of the CCC Digest mailed to you each month, please contact nmurphy@scf.cc
Domestic Violence – Denise Grenier, Rachel Locker
The failure to protect Indigenous women from sexual violence in the USA
The Amnesty International report entitled “Maze of Injustice – The failure to protect Indigenous women from sexual violence in the USA” is an important and timely reminder for all individuals and agencies that provide services to American Indian and Alaska Native (AI/AN) women. The Amnesty International report calls attention to the disproportionate impact on Indian women, focusing on three disparate communities that vary with respect to law enforcement, jurisdiction, and health care and support services. This report helps remind us that no one is immune from sexual violence.
The Indian Health Service (IHS) and our health care providers need to be aware of the prevalence of sexual assault and the need to address acute injuries as well as the long term negative health effects of sexual violence. As a result of this report, the IHS will help develop a prototype policy on sexual assault that can be used by facilities to help ensure the provision of best practices and culturally appropriate medical and supportive care for victims.
The health care response to intimate partner violence (IPV) has been improved by the existence of policies and procedures at all IHS facilities. Screening for IPV has improved as well, with aggregate national rates exceeding Agency targets. IPV policies and procedures, screening and education for health care providers are the result of Agency clinical performance measures developed to improve care.
The Indian Health Service and the Administration for Children and Families (ACF) jointly fund activities at twenty IHS, Tribal and Urban facilities to help improve the health care response to domestic violence. This work is led by multi-disciplinary teams of health service staff and tribal and community domestic violence advocates. The IHS-ACF project seeks to build a sustainable response to domestic violence that prioritizes safety and autonomy for victims and provides outreach and education, utilizing the experience and commitment of community members. Partners in this collaborative effort include the Family Violence Prevention Fund (FVPF), Mending the Sacred Hoop Technical Assistance (MSHTA) Project and Sacred Circle. MSHTA and Sacred Circle specialize in developing sexual assault and domestic violence policies and programs in Indian Country.
Sexual assault has long been recognized as a dynamic of domestic violence. In response to the alarming statistics of sexual assault experienced by AI/AN women, several of the project sites, including the Cherokee Indian Hospital and Zuni Comprehensive Community Health Center, have trained sexual assault nurse examiners (SANE) who are on call and available for emergency room care. For other sites, identifying and cooperating with pre-existing sexual assault community resources have been key to strengthening their response. At the Kanza Health Center in Oklahoma, the Dearing House, a nearby child advocacy center, was instrumental in improving exams for pediatric/adolescent sexual assault cases identified in the clinic. The Warm Springs Health and Wellness Center’s Domestic Violence team leaders collaborated with the local Victims of Crime office to assist high school students in the production of a film about sexual assault against children and teens. This effort complements the efforts at the Warm Springs facility and community hospital where SANE nurses are available for follow-up. Both institutions maintain policies and procedures on sexual assault. Many of the domestic violence project sites expanded their work beyond the walls of the health care facility, and the focus has increasingly moved toward prevention.
The experience of the IHS-ACF project sites demonstrates that chances for success for improving the health care response to domestic violence are greatest when health care teams and local domestic violence advocacy groups collaborate in the delivery of services to women. This model of care can be combined with existing best practices to improve the health care response to victims of sexual assault. Clinical guidelines have been shown to improve the quality of care for a number of health conditions, such as type 2 diabetes. Similarly, the incorporation of guidelines and policies concerning domestic violence and sexual assault will strengthen the ability of our providers and health care system to address sexual violence against American Indian and Alaska Native women. Our expectation should be that the health care response will be consistently safe, professional, timely, accessible, culturally and personally respectful, and coordinated with law enforcement and legal and community services. We must not re-victimize women who seek care in our hospitals and clinics.
IHS-ACF Domestic Violence Project
Project Faculty, IHS and FVPF
Sexual Violence Resources:
Amnesty International: Native American and Alaska Native Women
http://www.amnestyusa.org/Womens_Human_Rights/Join_Voices_with_Native_
American_and_Alaska_Native_Women/page.do?id=1021163&n1=3&n2=39&n3=1410
Amnesty Internation, home page
www.AmnestyUSA.org
Mending the Sacred Hoop Technical Assistance (MSHTA) Project
www.msh-ta.org
Sexual Assault Forensic Examiner Technical Assistance
www.safeta.org
National Sexual Violence Resource Center
www.ncvrc.org
National Protocol for Sexual Assault Medical Forensic Examinations,
September 2004
http://www.ncjrs.gov/pdffiles1/ovw/206554.pdf
Southwest Center for Law and Policy -
free legal training and technical assistance to tribal communities and to organizations
and agencies serving Native people:
www.swclap.org
Tribal Law and Policy Institute - education, research, training,
and technical assistance programs which promote the enhancement of justice in
Indian country and the health, well-being, and culture of Native peoples.
www.tlpi.org
Other
Physical and sexual abuse in adulthood are associated with complaints concerning general and reproductive health and a poor sex life
CONCLUSION: Abusive experiences were common in gynecologic outpatients. Women with abusive experiences had ill health and poor sexual life more often than the controls. In contrast to the results of previous studies, most of the women did not want to be asked about abuse by their gynecologist. LEVEL OF EVIDENCE: II
Pikarinen
U, et al Experiences of Physical and Sexual Abuse and Their Implications
for Current Health. Obstet Gynecol. 2007 May;109(5):1116-1122
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=retrieve&db
=pubmed&list_uids=17470592&dopt=Abstract
WH Pregnancy and DV education online session
Excerpts
– Video vignettes and text walk you through a 15 minute session with a WH client, mom with child in pediatric setting, adolescent clients and considerations in screening gay and lesbian clients - with audio, patient interviews and Q&A:
“Physical Abuse during Pregnancy”
In a 1996 review, in studies that asked about violence more than once during personal interviews or asked later in pregnancy, the prevalence of physical abuse during pregnancy ranged from 7.4% to 20.1%. The results of this review indicated that abuse during pregnancy occurs more frequently than gestational diabetes or preeclampsia. Even more disturbing: Homicide is the second leading cause of traumatic death for pregnant and postpartum women in the United States accounting for 31% of maternal injury deaths.
AND the maternal child dyad
“Effects of IPV on Children” In families in which IPV occurs, it is not only the woman's life that is at risk; identifying and intervening on behalf of battered women is perhaps one of our most effective ways to prevent child abuse as well. The effects of IPV can also adversely affect the mental and physical development of children from infancy into adulthood. Infants who have witnessed violence have eating and sleeping problems, decreased responsiveness to adults, and increased crying.
Exposure to violence increases the likelihood of children experiencing the following:
FTT
HA
Bed wetting
Speech disorders
Vomiting and diarrhea
Furthermore, the effects of such exposure follow the child throughout his or her life. A 1998 study reported the following risks in persons with 4 or more adverse childhood experiences: 4- to 12-fold risk for alcoholism, drug abuse, depression, and suicide attempts as well as a 2- to 4-fold risk of smoking, poor self-rated health, having 50 or more sexual intercourse partners, and sexually transmitted diseases. Finally the many resources include patient and provider information, CME slides, etc. http://www.medscape.com/viewarticle/553333_3
Domestic
Violence and Your Patient's Health: Asking the Right Questions
http://www.medscape.com/viewprogram/6760?src=mp
Elder Care News
Gynecologic Assessment of the Elderly Patient
Review physiologic changes associated with aging, normal and abnormal physical findings, symptoms and conditions commonly encountered, and age-specific aspects of pelvic examination
http://www.medscape.com/viewarticle/554398
Family Planning
Reasons for unprotected intercourse
RESULTS: Of 7856 respondents, 33% felt they could not get pregnant at the time of conception, 30% did not really mind if they got pregnant, 22% stated their partner did not want to use contraception, 16% cited side effects, 10% felt they or their partner were sterile, 10% cited access problems and 18% selected "other." Latent class analysis showed seven patterns of response, each identifying strongly with a single reason. CONCLUSIONS: Almost half of women with viable unintended pregnancies ending in a birth felt they could not/would not get pregnant at the time of conception. Most women identified with a single reason for having unprotected intercourse.
Nettleman MD, Chung H, Brewer J, et al. 2007. Reasons for unprotected intercourse: Analysis of the PRAMS survey. Contraception 75(5):361-366.
Adolescent sexual behavior and strategies for reducing early pregnancy and childbearing
With One Voice 2007: America's Adults and Teens Sound Off About Teen Pregnancy assesses public opinion on adolescent pregnancy. The survey is the fifth in a series of nationally representative surveys conducted by the National Campaign to Prevent Teen Pregnancy that have asked adolescents (ages 12-19) and adults (ages 20 and older) a consistent, core set of questions about adolescent pregnancy and related issues.
Topics include parental and other adult influence; abstinence and contraception; regret, virginity, older partners, and attitudes about adolescent sex; gender differences; religion; social norms and beliefs; and media. Data are presented in charts and, where available, results from previous surveys (2001-2006) are included. A description of the survey methodology and a summary are also provided. The survey is intended to provide insights for policymakers, program administrators, families, and others about adolescent pregnancy and factors that influence adolescents' decisions about sex. http://www.teenpregnancy.org/resources/data/pdf/WOV2007_fulltext.pdf
Effect of Medicaid Family Planning Expansions on Unplanned Births
Overall, Medicaid family planning expansions led to lower birth rates, The authors found that
* Average annual birthrates were significantly lowered by income-based expansions; a statistically significant effect of postpartum expansions was not found.
* Significant maternal and infant health care cost offsets were identified in all income-expansion states for which data are available.
Theses health care cost offsets exceeded total program costs in most cases.
Overall, our results suggest that both types of Medicaid family planning expansions either yield financial benefits to states or, at the very least, are cost neutral. The experience of these early family planning expansions should be a guide for other states considering family planning benefit expansions.
Lindrooth RC, McCullough JS. 2007. The effect of Medicaid family planning expansions on unplanned births. Women's Health Issues 17(2):66-74. http://www.jiwh.org/content.cfm?sectionid=84&IssueSelected=137
Guidelines for Selection of Contraception in Women with Rheumatic Diseases
http://www.medscape.com/viewprogram/6990?sssdmh=dm1.265392&src=nlcmealert
Featured Web Site David Gahn, IHS MCH Portal Web Site Content Coordinator
MCHB Launches Web Site to Increase Awareness of Perinatal Depression
Depression During and After Pregnancy: A Resource for Women, Their Families, and Friends contains tips on identifying depression in mothers and offers steps to help treat it successfully. The Web site was launched by the Health Resources and Services Administration's Maternal and Child Health Bureau to increase awareness among women and health professionals of the impact and pervasiveness of perinatal depression.
Selected topics include steps a woman can take if she believes she is at risk of, or is experiencing, perinatal depression. A section of the Web site is devoted to information for families and friends.
A list of print and electronic resources is also provided.
http://www.mchb.hrsa.gov/pregnancyandbeyond/depression
An accompanying 22-page booklet is also available at ftp://ftp.hrsa.gov/mchb/pregnancyandbeyond/depression.pdf
Frequently asked questions
Q. What are the Unnecessary Tests done in Obstetrics and Gynecology?
A. Here are a few examples
1.) Unnecessary Testing by Clinicians and Independent Companies
Certain once-broadly accepted monitoring tests that were used routinely have not been supported by outcome data. Examples from obstetric practice include electronic fetal heart rate monitoring and fetal pulse oximetry. Routine electronic fetal heart rate monitoring has not been demonstrated to decrease the rate of cerebral palsy, but has been linked to increases in the overall rate of cesarean delivery. It has also been determined that routine use of fetal pulse oximetry is not associated with either reduced rates of cesarean delivery or improvement in the condition of newborns.[ Although these tests are not recommended for routine assessment, they remain in use in many hospitals in the United States.
Other monitoring tests may be misused. One example of this is fetal ultrasonography. Although it is helpful in estimating gestational age, identifying twin pregnancies, and detecting genetic anomalies, the American College of Obstetrics and Gynecology (ACOG) position is that routine ultrasonographic screening during pregnancy is not mandatory. They deem routine use reasonable when requested by a patient. Most women in the United States undergo at least 1 or 2 ultrasounds during pregnancy; this level of exposure has never been associated with significant risk and use may provide significant benefits. However, some expectant couples have followed the lead of actors Tom Cruise and Katie Holmes and purchased (for costs ranging between $15,000 and $200,000) their own ultrasound machines, which they use daily.
There are some data (mostly from other vertebrates) suggesting that prolonged and frequent use of fetal ultrasound can cause abnormalities in fetal brain development, behavior, and body weight. Even though such findings have not been substantiated in humans, the US Food and Drug Administration (FDA) considers promotion, selling or leasing of ultrasound equipment for the purpose of making "keepsake fetal videos" an unapproved use of a medical device. Such use may also violate state laws and regulations.
Risks of Unnecessary Testing
Before considering a full-body scan or other non-proven screening test, individuals should be made aware of the potential risks. False-positive test results are extremely common among individuals with no signs or symptoms of disease; multiple tests increase the likelihood of false-positive results. Such alarming, yet incorrect test results, can lead to further unnecessary investigations, additional patient costs, heightened anxiety, and risk to future insurability. Conversely, true positive results can lead to the over diagnosis of conditions that would not have become clinically significant, thus leading to further risky interventions.
Examples of potentially harmful screening methods and possible outcomes include:
- Pelvic ultrasounds on asymptomatic women to search for ovarian cancer could lead to unnecessary laparoscopies and biopsies, with attendant complications; and
- Screening all current and former smokers in the United States for lung cancer with a CT scan would identify more than 180 million lung nodules, the vast majority of which would be benign. Millions of patients with nodules could needlessly undergo invasive needle lung biopsies and/or removal of parts of their lungs, resulting in many cases of impaired breathing, pneumothorax, hemorrhage, infection, and even death.
Even commonly recommended tests carry a sometimes large risk of a false-positive result. For example, among women in their early 40s with abnormal mammograms, it was shown that approximately 57 women without cancer underwent further diagnostic workup for every 1 woman found to have a malignancy.
On the other hand….Evidence-based Screening
Space limitation precludes a thorough discussion of an evidence-based approach to screening tests, but this section provides a brief overview of criteria for appropriate screening. Tests to screen for disease in the pre-symptomatic stages should meet certain criteria before being recommended. These criteria include:
- The disease being screened for must be reasonably common and have a significant effect on either duration or quality of life;
- Acceptable, effective treatment must exist, and the condition must have an asymptomatic period during which detection and treatment can improve outcome;
- Treatment during the asymptomatic period must be superior to treatment once symptoms occur; and
- The screening test must be safe, affordable, and have adequate sensitivity (i.e., the test is usually positive in those with disease) and specificity (the test is usually negative in those without disease).
Examples of gynecologic- or obstetrically-related screening tests meeting these criteria include Pap smears, mammography, oral glucose tolerance testing during pregnancy, and universal testing of newborns for certain congenital disorders. Other general tests of proven value include blood pressure monitoring for those older than 21 years of age, cholesterol tests for those 35 to 65 years of age, and abdominal ultrasounds for persons (especially men) with coronary risk factors and/or positive family history to screen for abdominal aortic aneurysms.
Regrettably, many well-established screening tests are underused, especially among nonwhites, those of lower socioeconomic status (SES), and those with inadequate or no health insurance. Such underuse has been clearly linked with increased risk for adverse outcome. For example, SES differences in access to and use of screening mammography have been associated with advanced stage at time of breast cancer diagnosis and lower survival rates, especially among African-Americans. SES differences in the use of prenatal testing for trisomy 21 have also been associated with disparities in the live-birth prevalence of Down syndrome. Because incidence of this disease does not vary according to SES, it has been demonstrated that early prenatal diagnosis leads to a higher rate of elective termination of pregnancy by individuals of higher SES
Causes and Consequences of the Unwarranted Use of Costly and Unscientific (Yet Profitable) Screening Modalities?
http://www.medscape.com/viewarticle/552964?src=mp
Indian Child Health Notes - Steve Holve, Pediatrics Chief Clinical Consultant
June / July 2007
Acute pain relief in children
Pertussis: Secular Trends in the United States
Persistence of racial disparities in fatal injuries to very young children
http://www.ihs.gov/MedicalPrograms/MCH/M/ChPedNotes.cfm
Information Technology
Brigg Reilley / John Redd, HQW
How can we improve HIV screening in pregnancy? Preliminary GPRA Related Results
As you read the following, think about the classic ‘3 things you should take away from a presentation,’
1.) Prenatal HIV screening is the responsibility of all clinics whether we like it or not
2.) Most service units have a prenatal HIV screening problem, but we are not aware of it
3.) There are gaps that that staff can identify and fix, improving both actual screening rates and reported screening rates.
In some clinics, there can be a ‘not my job’ syndrome.
People say things along the lines of: 1) We refer the women out anyway; 2) We don’t have an HIV counselor, and it’s not my role to counsel and 3) What if it IS positive? We can’t do anything about it anyway.
All of these reasons are essentially irrelevant – and, as noted below, the successful small clinics assume responsibility for the first few PN visits, which includes getting the lab panels done, even if the woman will eventually be referred out.
Background
Current national standards of care for prenatal care specifically recommend that all pregnant women be routinely screened for a variety of diseases for which early detection is beneficial to the mother or child. Routine infectious disease screening includes tests for HIV, syphilis, gonorrhea, chlamydia, and hepatitis B surface antigen. Early detection of HIV is critical because it can reduce the risk of mother-to-child transmission from approximately 25% with no intervention to less than 1% with intervention.
National IHS policy is that prenatal HIV screening in IHS should be conducted on all women in IHS through “opt-out” testing. The IHS 2005 Executive Summary states “The Indian Health Service has issued guidance recommending universal prenatal HIV testing using the “opt-out” approach. In “opt-out” testing, HIV tests are included in the standard battery of prenatal tests and women are informed that an HIV test is being conducted and that they have a right to refuse it. Information regarding HIV is included as part of a patient’s prenatal education. As more practitioners adopt opt-out testing, prenatal HIV screening rates should increase.”
IHS considers prenatal HIV screening an important indicator of the quality of care provided by the Agency. As a result, HIV screening during prenatal care is one of the core Government Performance and Results Act (GPRA) measurements, with the IHS goal being to reach 100%. GPRA considers a service unit ‘responsible’ for HIV screening if there is >1 visit during the time frame of pregnancy.
For the most recent year, GPRA statistics show that percentage of IHS prenatal patients tested during pregnancy for HIV varies considerably by IHS Area, from 17% to 84%. The national IHS rate is about 65%.
Clearly, these rates can and should improve.
The IHS Division of Epidemiology & Disease Prevention Prenatal HIV Screening Project
In response to these results, IHS, through the Minority AIDS Initiative and the IHS Division of Epidemiology & Disease Prevention, has funded the ongoing IHS Prenatal HIV Screening Project. In brief, this is the methodology of this phase of the project:
Charts that were considered ‘misses’ by GPRA (i.e. prenatal care but no HIV screening) are being reviewed in 20 IHS sites (thus far, charts have been reviewed at 12 sites) across the country. The misses were identified by running a simple logic (a set of commands that we can give to any service unit that is interested).
In general, most service units have said they are sure that they have tested every prenatal patient for HIV, and usually express surprise at their low GPRA scores.
Results
These results are part of an ongoing study and are considered preliminary.
The two main categories of ‘misses’ as 1) data and 2) clinical. Sites that have < 80% reported HIV screening rates generally have some sort of data or clinical gap in screening, or often both.
On the clinical side, the main misses were:
not using opt-out, including still using a consent form
not testing at all, mainly among women who are late presenters, or skip appointments, or have otherwise ‘non-routine’ prenatal care, although it is arguable that this group is actually at highest risk
a provider determining that an HIV test is not needed because there are ‘no risk factors’ or -carrying over an HIV test from a previous pregnancy
assuming that the test was done (or will be done) at the previous (or next) service unit to see the patient.
In the data category, the main errors were:
not entering HIV tests results from a contract lab into the facility’s computer
not entering HIV tests results done by an another facility
not entering HIV test refusals into the facility’s computer
(note: to enter refusals in the EHR takes a couple extra steps, which should be fixed in the next version).
Preliminary Recommendations to IHS Service Units
Review the policy of universal prenatal HIV testing via “opt-out” with all clinicians, whether or not they usually see prenatal patients.
Run the SU’s patient list to find charts that are misses and ‘diagnose’ the SU’s gaps.
Bundle HIV and the other routine prenatal ID serum tests into a “prenatal panel” that can be ordered in one step by clinicians. Tests done ‘a la carte’ result in greater misses for HIV and other IDs, especially in patients with complications and missed appointments.
Perform prenatal testing before transferring to a higher level of care. Small facilities should remember that GPRA will consider them responsible for prenatal HIV testing if the patient is seen by them. Transfers out with no lab tests done, and with no follow up to obtain results on test done elsewhere, result in low scores.
Make prenatal opt-out HIV screening absolutely routine, both in policy and in practice. Sites with lower scores tend to ‘bottleneck’ testing in a way that makes it an exceptional event rather than the rule. For example, a provider may be unable to test without a specific consent form (and the form isn’t easily available), and without using a specific person to obtain consent (and that person isn’t in clinic today). These reasons for low testing rates are no longer acceptable in the world of universal prenatal opt-out HIV screening.
OB/GYN CCC Editorial comment:
Act now: Make HIV screening a routine test in pregnancy
Brigg Reilley and John Redd emphasize that the above results are just part of an ongoing investigation, but felt strongly in the importance of this data to allow a preliminary release. The full analysis will follow.
In the meantime, there are clear ‘provider related’ and ‘system related’ obstacles to routine prenatal HIV screening and documentation that can be addressed now. Pending the final results, these simple statements are true:
All pregnant patients should be educated about and offered HIV screening in pregnancy
HIV screening in pregnancy is your responsibility. Don’t wait for the next provider or facility to do perform the screening
HIV screening in pregnancy is a routine part of care. It does not need a separate written consent and can be ‘bundled’ in with the other initial prenatal labs
Many of the patients who miss the initial screen, e.g., due to missed appointments etc… are those patients at highest risk. Please continue to try to obtain the HIV screen right up to and including the time of delivery.
Other Resources:
Division of Epidemiology and Disease Prevention
http://www.ihs.gov/medicalprograms/epi/index.cfm
International Health Update: Claire Wendland, Madison, WI
Social context of maternal deaths and morbidity
Fair warning: the three pieces I’m recommending here are not freely available online. But all should be available through your librarian, and for providers who are interested in the social context of maternal deaths and morbidity, they are well worth seeking out.
A northern Nigerian proverb tells us “the world is a pregnant woman” – suggesting that life, like pregnancy, is uncertain and perilous. But why is it so much more perilous in some places than others? Biomedical and public health perspectives on the problem have tended to identify shortfalls in clinical care, and have led to interventions designed to improve skills training: not long ago the training of TBAs was the flavor of the day, and more recently the focus has shifted to the improvement of emergency obstetric care in health centers. Anthropologists Craig Janes and Lewis Wall (also an Ob/Gyn) bring a different perspective to their studies of pregnancy-related mortality in the disparate settings of Nigeria and Mongolia, both arguing that rising maternal death rates reflect not just health sector deficiencies, but larger social upheavals and overarching economic structures.
In Mongolia, for example, herders have been organized since the 13th century into collective structures – first feudal, then socialist – that regulated access to valued resources including land, livestock and water (and under the socialists, health care and education). These collective structures were rapidly dismantled when Mongolia initiated the so-called “shock therapy” program of economic reforms in 1990. Food shortages, widespread unemployment and localized famine, growing inequality, and deterioration of the public health sector rapidly followed. Though this initial shock has now stabilized, reproductive health and maternal mortality statistics continue to be poorer than they were under socialism. Women, Janes suggests, appear to be particularly vulnerable to the economic stresses occasioned by de-collectivization, household food insecurity, and migration, in part because the deconstruction of the collective has isolated women – economically and socially – at the single-household level.
Nigeria has had similar problems with a deteriorating public health sector and economy. Wall’s article demonstrates how highly patriarchal social and religious structures compound these national problems, resulting in rising rates of maternal death, obstetric fistula disease and perhaps even peripartum cardiomyopathy. Where women depend on powerful men for both the social permission and the economic resources required to travel to the hospital, tragedy can all too easily follow.
For a more intimate narrative take on issues of gender, maternity and risk in North Africa, consider Kris Holloway’s new book Monique and the Mango Rains. Holloway was a Peace Corps volunteer in Mali 1989-1991, where she worked closely with Monique Dembele, a Malian community health worker and midwife. Monique had minimal training and even more minimal facilities but a burning drive to improve health care -- and particularly childbirth safety -- in a rural village. This nicely written, extremely accessible book (requiring no clinical background to enjoy) neither pathologizes nor romanticizes Malian village life, and deals in a fair and approachable way with issues of sexuality and patriarchy.
All three of these readings challenge conventional medical wisdom by suggesting that a narrow focus on improving one or another aspect of formal health sector care -- absent an understanding of and attention to the larger social and political contexts of women’s lives -- will not be enough to substantially reduce maternal deaths in the Third World.
Resources
Holloway K. Monique and the Mango Rains: Two Years with a Midwife in Mali. Longview, IL: Waveland Press, 2007
Wall LL. Dead mothers and injured wives: the social context of maternal morbidity and mortality among the Hausa of northern Nigeria. Studies in Family Planning 29(4):341-359, 1998
Janes CR, Chuluundorj O. Free markets and dead mothers: the social ecology of maternal mortality in post-socialist Mongolia. Medical Anthropology Quarterly 18(2):230-257, 2004
MCH Alert
Progress toward meeting Healthy People 2010 Maternal, Infant, and Child objectives
Healthy People 2010 Midcourse Review: Maternal, Infant and Child Health highlights results from an assessment of progress toward achieving the Healthy People (HP) 2010 maternal, infant, and child health goals and objectives through the first half of the decade. The purpose of the midcourse review, which was led by the Centers for Disease Control and Prevention and the Health Resources and Services Administration, is to assess data trends; consider new science and available data; and, if appropriate, revise the objectives to ensure that HP 2010 remains current, accurate, and relevant to public health priorities. Topics include modifications to objectives and sub-objectives, progress toward Healthy People 2010 targets, progress toward elimination of health disparities, opportunities and challenges, and emerging issues.
http://www.healthypeople.gov/data/midcourse/pdf/FA16.pdf
Mental disorders and nicotine dependence among pregnant women
These data suggest that cigarette use and nicotine dependence are not uncommon among women who are pregnant in the United States, with more than one in four pregnant women using cigarettes during pregnancy, and approximately one in ten having a diagnosis of nicotine dependence. The authors found that
* Among pregnant women in the United States, 21.7% reported that they smoked cigarettes and 12.4% met criteria for nicotine dependence.
* Among pregnant women who smoked cigarettes, 45.1% met criteria for at least one mental disorder; among pregnant women with nicotine dependence, 57.5% met criteria for at least one mental disorder.
* After adjustment for differences in demographic characteristics and co-morbid mental disorders, the associations between major depressive disorder, dysthymia, and panic disorder remained significantly associated with nicotine dependence among pregnant women.
Results suggest an urgent need for smoking cessation and nicotine dependence treatment and that mental health outreach programs might be indicated in conjunction with prenatal care, especially in underserved areas.
Goodwin RD, Keyes K, Simuro N. 2007. Mental disorders and nicotine dependence among pregnant women in the United States. Obstetrics and Gynecology 109(4):875-883. http://www.greenjournal.org/cgi/content/abstract/109/4/875
MCH Headlines: Judy Thierry HQE
Improve the system - Improve the care: Underpinnings
The title of the American Native Women’s Health and Maternity Care Conference to be held August 15 - 17, 2007 at the Marriott - Louisiana, Blvd., Albuquerque, NM has as one of its three objectives to “outline the underpinnings of an optimal WH and MCH health care system /environment in the ITU”.
Underpinnings like a foundation, like the joists in a floor are about strength and unity.
Underpinnings like the lining of a coat or jacket provide durability, form and fit.
The 18.5 credit 2.5 day conference is YOUR conference. Workgroups, professional reports and updates, state of the art practice across ITU’s and plenary discussions from national leaders and women’s health advocates are designed to ‘fit’ your practice and the community you serve.
Wanda Jones, Deputy Assistant Secretary, Office for Women’s Health (OWH) Department of Health and Human Services will identify the challenges for Women’s Health in 2007 and the strategies for addressing those issues. She will describe OWH mission and initiatives impacting on AIAN women (underserved, women of color, health disparities and citizens of sovereign nations). http://www.4women.gov/owh/about/welcome.cfm
Ms. Stacy Bohlen, Executive Director National Indian Health Board will provide remarks on NIHB’s educational and advocacy role, the key partnerships and collaborations that support American Indian and Alaska Native women and their families and communities. Recent testimony by a board member requested increased support for diabetes and chronic disease. http://www.nihb.org/index.php
Empowering women is a precept of Centering Pregnancy R. Evidence based group prenatal care taken up by Zuni, Chinle, Kayenta and Tuba, among other practice communities will present a paradigm shift in care that is client centered, founded on building trust among the women. http://www.centeringpregnancy.com/
A pre-meeting training on Monday and Tuesday will take place at the Marriot – please contact judith.thierry@ihs.gov if you are interested.
Special Care Program at PIMC presented by Judy Whitecrane, CNM serves A/OD at risk pregnant women ‘where they are at’ in a sensitive, confidential and behaviorally integrated health care approach.
Provider Self Care? Terese Grant from the Center on Human Development and Disability, University of Washington will engage participants in appreciating the importance of a system that values self-care, respite, retreats, networking and day-to-day support of staff who work with high-risk women.
“Improve the System – Improve the Care” planning committee has designed many workshops and plenary objectives to address the effects of violence on AIAN women and the clinical and community response. Domestic Violence and Sexual Assault strategies and potential alternatives for serving victims of sexual assault in direct Tribal and urban Indian locations will be addressed by - Connie Monahan, New Mexico Statewide Sexual Assault Nurse Examiner (SANE) Coordinator.
Please join us
Native Women’s Health and MCH Conference, 2007
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Drive It Right Kits
Talking to teens about safe driving to 19,000 high schools across the country. Drive it Right, Talking to teens about safe driving is arriving at schools across the country just in time to incorporate them into National Youth Traffic Safety Month projects.
Allstate Insurance Company has a limited amount of Drive it Right, Talking to teens about safe driving kits available to NOYS member organizations on a first request basis.
These materials include Educator Resource Materials, a poster, and a supporting video. NOYS has previewed this resource and supports the content and use of the materials to address youth traffic safety.
16 page work book with questionnaires divided into:
# LICENSE TO TEACH – FOR teachers
# LICENSE TO DRIVE - STUDENTS
• It’s Your Road
Introduction and background information on driving issues
that affect teens.
• Crash Test
A list of questions to gauge teens pre-existing knowledge and
attitudes about teen driving issues and to spark genuine dialogue.
• What’s It Worth?
Checklist of what teens could lose by driving carelessly.
• Split-second Decision
Real world, driving-related scenarios to make teens think about
how they would react.
• Simple Tips to Stay Alive
Quick tips to help students improve their driving habits.
• What Are You Going to Do About It?
Ideas for teen-directed initiatives they could implement during
your Teen Safe Driving Campaign.
• Tips for Creating a Drive It Right Pledge
Culminating pledge that students will create and sign, promising
to keep themselves and their friends safe.
www.discoveryschool.com/100days Contact Sandy Spavone atsspavone@noys.org
Have you heard of: “oral health risk assessment”…“fluoride varnish”…“early childhood caries”…“the Baby bottle tooth decay germ -aka Streptococcus mutans?
While most of these terms are part of our clinical vocabulary we still have long way to go to reduce and prevent caries in infants and young children. In the coming months ten American Indian and Alaska Native communities will be getting an oral health check-up – training that is!
Dentists from academic and private practice will be supporting pediatricians, dentists, dental hygienists, and oral health community stakeholders who submitted applications on how they wanted to work with their communities in early childhood oral health. Sites will receive $2,000 in free in-kind consultation services for onsite technical assistance.
The American Academy of Pediatrics’ Oral Health Initiative along with the Bright Futures Educational Center is providing these awards in partnership with the Indian Health Service Maternal and Child Health Program and the Division of Oral Health. Preceptors will be making their way for a one-day training designed by the individual sites. Proposed plans include updates with WIC, Head Start Programs, primary care providers, oral health providers and community dental consultants to refresh their early childhood oral health knowledge and skills. Components of the one-day preceptorship will include how to: conduct oral health risk assessments, oral health exams, apply varnish and learn how to expand community and parent participation in this number one infectious disease. The preceptorships will build upon existing activities bringing up-to-date information on infant and toddlers oral health.
The ten awardees’ coordinating the preceptorships and visiting preceptors are:
- Chinle Comprehensive Health Care Facility, Chinle, AZ - Kristi Nix, MD - Jay Shirley, DMD Marietta, Georgia
- Consolidated Tribal Health Project, Inc. Redwood Valley, CA - Mary Ann Gonzalez, DDS - Leslee Singleton Huggins, BS, DDS, MS , Tyler, TX
- Fort Defiance Indian Hospital: Fort Defiance, AZ – Michael Bartholomew, MD - Ronald Winder, DDS, Tulsa, Oklahoma
- Gallup Indian Medical Center, Gallup, NM - Kevin Sweeney, MD - Adriana Segura-Donly DDS, MS, San Antonio, Texas
- Oneida Dental Clinic: Oneida, WI - Barb Ayres, RDH - Kavita Kohli, DDS, New York, N.Y.
- Pine Ridge Indian Hospital - Delores Starr - Hakan Koymen, DDS, MS, Perry Hall, MD
- Port Gamble S’Klallam Health Department: Kingston, WA - Dorie Salem-Soule, RDH - Rama Oskouian, DMD, Woodville, WA
- Seminole Tribe of Florida: Hollywood. FL - Kerri Cook-Descheene, Dental Prevention Coordinator - Jonathan Shenkin, DDS, MPH , Bangor, ME
- Tulalip Indian Health Clinic: Tulalip, WA - Marion Fulkomer, MD - Rama Oskouian, DMD, Woodville, WA
- White Earth Health: Ogema, MN - Karry Cassidy, Hygiene Supervisor - TBA
Interested in applying for the second round?
Contact Wendy Nelson at Wnelson@aap.org for an application.
Newly completed Pregnancy and Postpartum Quitline Toolkit
For a one per person hard copy of the Quitline Toolkit sent to you (include your mailing address) Email Lauren DiBiaseldibiase@schsr.unc.edu
Online availability at http://www.helppregnantsmokersquit.org/
K-12 Oral Health Education Curriculum
The Missouri Dept. of Health and Senior Services has completed a K-12 Oral Health Education Curriculum power point presentation series. The presentations can be downloaded free-of-charge by clicking on the grade(s) specific icons. These presentations can be used by school health nurses or teachers, as well as by other health care/child care professionals, in conjunction with their health curriculum. The presentations are available online at: http://www.dhss.mo.gov/oralhealth/OralHealthEducation.html
American Academy of Pediatrics on state mandated benefits for childhood vaccinations
AI/AN CHILDREN are covered under VACCINES FOR CHILDREN (VFC). THIS CHART IS HELPFUL TO SEE THE Larger SAFTY NET
http://cme.kff.org/Key=12433.7c.F.C.PFdksq
2005 - State by state AIAN % population breakout State ranking http://factfinder.census.gov/servlet/GRTTable?_bm=y&-geo_id=01000US&
-_box_head_nbr=R0203&-ds_name=ACS_2005_EST_G00_&-_lang=en&-format=US-30&-_sse=on
National Children's Study - by county: It is Pregnant
women who are enrolled and their offspring followed for 2 decades
http://www.nationalchildrensstudy.gov/about/locations/
Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death Data Set
Objectives—This report presents 2004 period infant mortality statistics from the linked birth/infant death data file by a variety of maternal and infant characteristics. The linked file differs from the mortality file, which is based entirely on death certificate data.
Methods—Descriptive tabulations of data are presented and interpreted. Excluding rates by cause of death, the infant mortality rate is now published with two decimal places.
Results—The U.S. infant mortality rate was 6.78 infant deaths per 1,000 live births in 2004 compared with 6.84 in 2003. Infant mortality rates ranged from 4.67 per 1,000 live births for Asian and Pacific Islander mothers to 13.60 for non-Hispanic black mothers. Among Hispanics, rates ranged from 4.55 for Cuban mothers to 7.82 for Puerto Rican mothers. Infant mortality rates were higher for those infants whose mothers were born in the 50 States and the District of Columbia, were unmarried, or were born in multiple births. Infant mortality was also higher for male infants and infants born preterm or at low birth weight. The neonatal mortality rate declined from 4.63 in 2003 to 4.52 in 2004 while the postneonatal mortality rate was essentially unchanged. Infants born at the lowest gestational ages and birth weights have a large impact on overall U.S. infant mortality. More than one-half (55 percent) of all infant deaths in the United States in 2004 occurred to the 2 National Vital Statistics Reports, Vol. 55, No. 14, May 2, 2007 2 percent of infants born at less than 32 weeks of gestation. Still, infant mortality rates for late preterm (34–36 weeks of gestation) infants were three times those for term (37–41 week) infants. The three leading causes of infant death—Congenital malformations, low birthweight, and SIDS—taken together accounted for 45 percent all infant deaths. Results from a new analysis of preterm-related causes of death show that 36.1 percent of infant deaths in 2004 were due to preterm-related causes. The preterm-related infant mortality rate for non-Hispanic black mothers was 3.3 times higher, and the rate for Puerto Rican mothers was 75 percent higher than for non-Hispanic white mothers.
Infant Mortality Statistics from the 2004 Period Linked Birth/Infant Death Data Set by T.J. Mathews, M.S., and Marian F. MacDorman, Ph.D., Division of Vital Statistics
http://www.cdc.gov/nchs/data/nvsr/nvsr55/nvsr55_14.pdf
Trends in Preterm-Related Infant Mortality by Race and Ethnicity: United States, 1999-2004 Objectives—This report examines trends in preterm-related causes of infant death in the United States by maternal race and ethnicity.
Methods—A grouping of preterm-related causes of infant death was created by identifying causes of death that were a direct cause or consequence of preterm birth.
Cause-of-death categories were considered to be preterm-related when 75% or more of total infant deaths attributed to that cause were born preterm, and the cause was
considered to be a direct consequence of preterm birth based on a clinical evaluation and review of the literature. Trends in preterm-related causes of death were
examined by maternal race and ethnicity.
Results—In 2004, 36.1% of all infant deaths in the United States were preterm related, up from 34.5% in 1999. The preterm-related infant mortality rate for non-
Hispanic black mothers was 3.3 times higher and the rate for Puerto Rican mothers was 75% higher than for non-Hispanic white mothers. The preterm-related infant
mortality rate for non-Hispanic black mothers was higher than the total infant mortality rate for non-Hispanic white, Mexican, and Asian or Pacific Islander (API)
mothers.
Discussion—The leveling off of the U.S. infant mortality decline since 2000 has been attributed in part to an increase in preterm and low birthweight (LBW) births.
Continued tracking of this group of preterm-related causes of infant death will improve our understanding of trends in infant mortality and perinatal health in the
United States .
Trends in Preterm-Related Infant Mortality by Race and Ethnicity: United States, 1999-2004 by Marian F. MacDorman, Ph.D., Division of Vital Statistics; William M. Callaghan, M.D., M.P.H., Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion; T.J. Mathews, M.S.; Donna L. Hoyert, Ph.D.; and Kenneth D. Kochanek, M.A., Division of Vital Statistics, National Center for Health Statistics
http://www.cdc.gov/nchs/products/pubs/pubd/hestats/infantmort99-04/infantmort99-04.htm
Kids Count Tables: Child and youth demographics – by race, by state, health, economic
Annie E. Casey Foundation has launched a new and improved website
IF YOU ARE DRAFTING ANY PROPOSAL YOU WANT TO REFERENCE THIS WEBSITE FOR COMPARISON DATA.
- CHILD WELFARE - National Foster Care Month focuses national attention on the needs of children and youth in foster care. The campaign encourages more citizens to get involved -- whether as their foster parents, volunteers, mentors, or employers, or in other ways. The Annie E. Casey Foundation and its direct services agency, Casey Family Services, are among the partner organizations involved in promoting stable and permanent family connections for children.
- COMMUNITY CHANGE
- ECONOMIC SECURITY
- EDUCATION
- HEALTH
- JUVENILE JUSTICE
- SPECIAL INTEREST AREAS.
New Resource for Children’s Health Information
SCHIP and child health coverage by state, with state to state comparisons, state to US comparisons lacks AIAN specifics. Statehealthfacts.org now includes a children’s health section that offers customized fact sheets for each state, a directory of all children’s health topics on the site, and the latest children’s health research from KCMU and headlines from kaisernetwork.org
http://cme.kff.org/Key=12433.7c.P.C.Mzc7Px
Definitions: Persons of Hispanic origin may be of any race; all other racial/ethnic groups are non-Hispanic.
"Other" includes Asian-Americans, Pacific Islanders, American Indians, Aleutians, Eskimos and persons of "Two or More Races".
These groups have been combined due to their small populations in many states which prevent meaningful statistical analyses of the groups individually.
The distribution of the U.S. population by Race/Ethnicity is: White, 195,289,747 (66.7%), Black, 35,539,912 (12.1%), Hispanic, 43,077,106 (14.7%), American Indian, 1,654,861 (0.6%), Asian-Americans and Pacific Islanders, 12,915,910 (4.4%), and Two or More Races, 4,469,902 (1.5%).
Two charts from fact sheet:
http://www.kff.org/medicaid/upload/7610.pdf
Link to the AAP Government Affairs “state by state” LEGISLATION REPORT
TOC FOR your specific interests. When sessions convene / adjourn / governor / state budgets /… to booster seats to guns to helmets to…tobacco.
http://www.aap.org/advocacy/statelegrpt.pdf
Birth characteristics single and multirace women
Medical Mystery Tour
Which Indian Health facilities lead the entire U.S. in national obstetric benchmarks?
You saw the above question last month in the May CCC Corner.
Here is the rest of the story…
First, let me tell you two characteristics common to both facilities. Both have strong certified nurse midwife programs and both are 638 facilities, e.g., operated by tribal Boards under Self Determination legislation.
….and now the envelope please….the winners are… the Tuba City obstetrical care unit and the Alaska Native Medical Center obstetrical care unit.
Tuba City was recognized for cesarean delivery rate just under 14 percent – lowest in the State of Arizona for Arizona Perinatal Trust Level II Nurseries
and
Alaska Native Medical Center was recognized for best practice in five categories of the American College of Nurse- Midwives (ACNM) 2005 Benchmarking Program for facilities its size.
The categories included:
Successful vaginal after cesarean rate 84.1% (63 attempted VBACs)
Intact perineum 84.1% (1352 vaginal births)
Patients with prenatal care by 12 weeks 86.9% (1488 births)
Lowest pitocin induction rate 5.4% (1488 births)
Cesarean delivery rate 9.1% (1488 births)
As no one staff category can accomplish the above in isolation, so I would like to offer congratulations to the entire staffs at both facilities for a job well done.
Now, how can we translate that success to other Indian Health sites?
The easiest way to start that process is to hear directly from the staff themselves. We have arranged to have members of their staff present at the upcoming 2007 National Indian Women’s Health and MCH Conference in Albuquerque, NM August 15- 17, 2007 so you can hear for yourselves.
The theme of the 2007 National Indian Women’s Health and MCH Conferenceis “Improve the System: Improve the Outcome” so it will explore how we can all work together to raise the AI/AN health status to the highest possible status.
There will be national benchmark organizations (Institute for Healthcare Improvement, American College of Nurse- Midwives, American College of Obstetricians and Gynecologists, Kaiser Family Foundation, etc…), internationally known speakers, and a rather extensive clinical Program.
The meeting is only every 3 years, so you and a team from your facility should try your best to attend. You can either use your local facility funds, because there is a program review function, or use your CME /CEU funds. In addition, limited scholarships are available.
2007 National Indian Women’s Health and MCH Conference
http://www.ihs.gov/MedicalPrograms/MCH/F/CN01.cfm#Aug07
Background
About Benchmarking
Benchmarking is a method for comparing your facilities care processes to those of the practices in the field that demonstrate the best outcomes. Identifying "best practices" through benchmarking allows all who participate in the process to improve and adapt the care they provide in order to obtain superior outcomes: high satisfaction, patient safety, effectiveness and efficiency.
One Example: ACNM
The purpose of the American College of Nurse- Midwives (ACNM) Benchmarking Program is to provide a midwifery-specific mechanism to improve and maintain the superior quality of midwifery care provided to women and children by promoting member awareness of "best practices." To facilitate this, members are encouraged to participate in benchmarking their practice against other midwifery practices in the country.
ACNM Benchmarking Program
http://www.acnm.org/education.cfm?id=842
Another Example:
Tuba City Regional Health Care Corporation leads the way with healthy childbirth model Tuba City Regional Health Care Corporation birth by cesarean delivery is just under 14 percent – lowest in the State of Arizona for Arizona Perinatal Trust Level II Nurseries, according to latest data. Certified nurse mid-wife/obstetrician model practiced is favored by the World Health Organization Citing its collaborative certified nurse mid-wife/obstetrician model for childbirth, Tuba City Regional Health Care Corporation reported the lowest birth by cesarean delivery rate in Arizona among Arizona Perinatal Trust Level II Nurseries for the year 2005 – just 13.9 percent. The national average is approximately 33%. For most mothers in labor arriving at the Tuba City obstetrical care unit (OCU), everything is considered normal, healthy and natural until signs show otherwise. Midwives care for patients in the OCU 24 hours per day. Obstetricians are always available when anything abnormal begins to occur during labor, or for high-risk pregnancies. The World Health Organization recommends the certified nurse mid-wife/obstetrician model utilized at Tuba City Hospital. A cesarean delivery is the birth of a baby by surgery. The doctor makes an incision in the belly and uterus and then removes the baby. A c-section is usually performed when a vaginal delivery would lead to medical complications; although nationwide it is becoming increasingly more common to have an elective c-section when there is no contra-indication to having a vaginal birth. While sometimes necessary, a c-section is major abdominal surgery, carrying with it a considerable list of risks, such as bleeding, infection, damage to nearby organs such as the bowel or the bladder, scar tissue formation, and a higher risk in future pregnancies. When a c-section is necessary, it can be a life saving technique for both mother and infant. Another factor increasing the rates of c-section births is the belief that ‘once a c-section, always a c-section.’ Often, pregnant women who have had a previous c-section aren’t necessarily aware that in some facilities they can still choose to have a natural vaginal birth. The risks from Vaginal Birth After C-section (VBAC) delivery are low, but are slightly higher than for a repeat c-section delivery – this finding is from a study by the National Institute of Child Health and Human Development of the National Institutes of Health. “We are strong advocates for VBAC at this facility for appropriate candidates, and we have an excellent success rate with no known uterine ruptures over the last 10 years,” said Dr. Amanda Leib, TCRHCC OB/GYN Chief. In 2006, among 28 mothers who chose to try to have VBACs at Tuba City Hospital, there was an 82% success rate. 24 women had successful vaginal births, and 4 underwent c-sections. “The decision for c-section is usually made between the doctor, certified nurse mid-wife and patient. There are many reasons why women wind up having c-sections, and the events leading to such a decision vary depending on the situation,” said Dr. Leib. Some reasons the c-section rate is low at Tuba City Hospital are that we offer VBACs, we have a certified nurse mid-wife/obstetrician model which allows more one-on-one attention during labor and delivery than at other facilities, and that we are very involved with our high risk patients. We believe in active management before fetal problems occur.” Barbara Orcutt, CNM, MSN, Director of Nurse Mid-wives at Tuba City Hospital has been a certified nurse mid-wife for 29 years. She remarked, “I’ve been associated with numerous practices and hospitals in various parts of the country, and the acceptance of certified nurse mid-wifery here is wonderful. We have a close working relationship with our obstetricians and we are valued.” Certified nurse mid-wives deliver all of the vaginally born babies at Tuba City Hospital, and are involved in the labor of women who eventually do have c-sections. There are 5 certified nurse mid-wives currently practicing at Tuba City Hospital. In addition to following traditional ways, the OB/Gyn Department is scheduled and run in such a manner that both patient and provider will very often see a familiar face when a woman is in labor. Certified nurse mid-wives staff the OCU 24 hours a day, and they work 12-hour shifts so there is continuity with any one patient with a large block of time.
Our schedules are structured as such that we don’t think in terms of ‘It’s Friday afternoon and I’d better get her delivered before the weekend,’” said Orcutt. Dr. Leib continued, “We regularly review our c-section rate and individual c-sections as a department, looking for ways we can improve and offer even better patient care.”
Pregnant women considering a c-section, with no clear medical reason for it, should know that the procedure is not without risk, Canadian doctors caution in a report in February 2007. Dr. Shiliang Liu with the Public Health Agency in Ottawa, Canada, and colleagues, report that the rate of severe complications, such as major bleeding, infection and blood clots, is three times higher overall in women having a planned c-section compared with women who have a natural birth. The researchers used a Canadian database to look at the outcomes of 46,766 women who underwent what doctors deemed to be a low-risk, c-section delivery and nearly 2.3 million women who underwent planned vaginal delivery between April 1991 and March 2005. Liu’s team found that the rate of severe complications in the planned cesarean group was 27.3 cases per 1,000 deliveries, compared with 9.0 per 1,000 deliveries in the planned vaginal delivery group. This data adds to a growing body of evidence suggesting that primary elective c-section birth may place both the mother and newborn at greater risk for complications. In 2005 there were 546 live births at Tuba City Hospital, of which 471 were vaginal deliveries. Of the 546, 75 were c-section deliveries – 40 of which were primary c-sections (first time c-sections