Obstetrics

The United States recorded its highest-ever birth rate in 2007, with increases in births across every age and race group, according to preliminary data released by the National Center for Health Statistics.

More than 4.3 million babies were born in 2007, the report said, corresponding to a general fertility rate of 69.5 births per 1,000 women—the highest fertility level since 1990.

The 2007 birth rate surpassed the previous record holder, set during the post-World War II baby boom,” said Stephanie Ventura, chief of the center's department of reproductive statistics. “Previously, the country's highest-ever birth rate occurred in 1957, but of course, there are a lot more women of childbearing years in the United States now. The actual fertility rate of 2.1 children per woman [over a lifetime] is just about half of what it was in the baby boom years.”

Teens, unmarried women, and older women all had more babies in 2007 than they did in previous years, Ms. Ventura said in an interview.

“The teen birth rate went up for the second year in a row. We have had an overall increase of 5% since 2005,” although it's too soon to say if this trend represents a reversal of the 34% decline in births to teens aged 15–19 reported between 1991 and 2005.

Births to unmarried women made up 40% of the total births during 2007, Ms. Ventura said, a historic level. “This really is a trend and has been increasing since 2002 at a pretty good clip.” The year 2007 also boasted the highest number of births ever in this group (1.7 million), and the highest birth rate ever in this group (53/1,000 women).

The increase among unmarried women occurred in all age groups, not just among teenagers. “Unmarried mothers used to be synonymous with teen mothers, but not any more,” Ms. Ventura said. “Sixty percent of births to women in their early 20s were to unmarried mothers, as were almost one-third of births to women in their later 20s.” In fact, the largest increase in nonmarital births occurred among women aged 25–39 years. “I think the social stigma of being an unwed mother has pretty much disappeared,” she said. However, about 40% of these births were to women in cohabitation relationships.

About a third of births in the United States in 2007 were by C-section, said Joyce Martin, an epidemiologist with the center. “This is the 11th straight year that we have had an increase in the cesarean section rate,” she said in an interview. “Our data show an increase in the rate of primary C-sections and a decline in the rate of vaginal birth following C-section.”

The increase follows a trend of decreasing C-sections in the early to mid-1990s. Since 1996, the rate has risen 50%. The increase has been spread over all age and race groups, she added.

Preterm births declined 1% in 2007, to a rate of 13%. “Historically, we have seen small declines in the preterm rate followed by large increases, so it's too early to predict whether this heralds the beginning of a trend,” she commented. “We are certainly hopeful, particularly because we saw large, but not significant, declines in both preterm and low-birth weight babies.”

Another positive sign was that the declines in preterm and low-birth-weight babies were spread across the country, not driven by a few states. “The decline was also concentrated among late preterm births, a group that had risen quite dramatically in recent years. … Again, it's too soon to say what might be causing this change,” Dr. Martin said.

The full report is available at www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

The United States recorded its highest-ever birth rate in 2007, with increases in births across every age and race group, according to preliminary data released by the National Center for Health Statistics.

More than 4.3 million babies were born in 2007, the report said, corresponding to a general fertility rate of 69.5 births per 1,000 women—the highest fertility level since 1990.

The 2007 birth rate surpassed the previous record holder, set during the post-World War II baby boom,” said Stephanie Ventura, chief of the center's department of reproductive statistics. “Previously, the country's highest-ever birth rate occurred in 1957, but of course, there are a lot more women of childbearing years in the United States now. The actual fertility rate of 2.1 children per woman [over a lifetime] is just about half of what it was in the baby boom years.”

Teens, unmarried women, and older women all had more babies in 2007 than they did in previous years, Ms. Ventura said in an interview.

“The teen birth rate went up for the second year in a row. We have had an overall increase of 5% since 2005,” although it's too soon to say if this trend represents a reversal of the 34% decline in births to teens aged 15–19 reported between 1991 and 2005.

Births to unmarried women made up 40% of the total births during 2007, Ms. Ventura said, a historic level. “This really is a trend and has been increasing since 2002 at a pretty good clip.” The year 2007 also boasted the highest number of births ever in this group (1.7 million), and the highest birth rate ever in this group (53/1,000 women).

The increase among unmarried women occurred in all age groups, not just among teenagers. “Unmarried mothers used to be synonymous with teen mothers, but not any more,” Ms. Ventura said. “Sixty percent of births to women in their early 20s were to unmarried mothers, as were almost one-third of births to women in their later 20s.” In fact, the largest increase in nonmarital births occurred among women aged 25–39 years. “I think the social stigma of being an unwed mother has pretty much disappeared,” she said. However, about 40% of these births were to women in cohabitation relationships.

About a third of births in the United States in 2007 were by C-section, said Joyce Martin, an epidemiologist with the center. “This is the 11th straight year that we have had an increase in the cesarean section rate,” she said in an interview. “Our data show an increase in the rate of primary C-sections and a decline in the rate of vaginal birth following C-section.”

The increase follows a trend of decreasing C-sections in the early to mid-1990s. Since 1996, the rate has risen 50%. The increase has been spread over all age and race groups, she added.

Preterm births declined 1% in 2007, to a rate of 13%. “Historically, we have seen small declines in the preterm rate followed by large increases, so it's too early to predict whether this heralds the beginning of a trend,” she commented. “We are certainly hopeful, particularly because we saw large, but not significant, declines in both preterm and low-birth weight babies.”

Another positive sign was that the declines in preterm and low-birth-weight babies were spread across the country, not driven by a few states. “The decline was also concentrated among late preterm births, a group that had risen quite dramatically in recent years. … Again, it's too soon to say what might be causing this change,” Dr. Martin said.

The full report is available at www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

The United States recorded its highest-ever birth rate in 2007, with increases in births across every age and race group, according to preliminary data released by the National Center for Health Statistics.

More than 4.3 million babies were born in 2007, the report said, corresponding to a general fertility rate of 69.5 births per 1,000 women—the highest fertility level since 1990.

The 2007 birth rate surpassed the previous record holder, set during the post-World War II baby boom,” said Stephanie Ventura, chief of the center's department of reproductive statistics. “Previously, the country's highest-ever birth rate occurred in 1957, but of course, there are a lot more women of childbearing years in the United States now. The actual fertility rate of 2.1 children per woman [over a lifetime] is just about half of what it was in the baby boom years.”

Teens, unmarried women, and older women all had more babies in 2007 than they did in previous years, Ms. Ventura said in an interview.

“The teen birth rate went up for the second year in a row. We have had an overall increase of 5% since 2005,” although it's too soon to say if this trend represents a reversal of the 34% decline in births to teens aged 15–19 reported between 1991 and 2005.

Births to unmarried women made up 40% of the total births during 2007, Ms. Ventura said, a historic level. “This really is a trend and has been increasing since 2002 at a pretty good clip.” The year 2007 also boasted the highest number of births ever in this group (1.7 million), and the highest birth rate ever in this group (53/1,000 women).

The increase among unmarried women occurred in all age groups, not just among teenagers. “Unmarried mothers used to be synonymous with teen mothers, but not any more,” Ms. Ventura said. “Sixty percent of births to women in their early 20s were to unmarried mothers, as were almost one-third of births to women in their later 20s.” In fact, the largest increase in nonmarital births occurred among women aged 25–39 years. “I think the social stigma of being an unwed mother has pretty much disappeared,” she said. However, about 40% of these births were to women in cohabitation relationships.

About a third of births in the United States in 2007 were by C-section, said Joyce Martin, an epidemiologist with the center. “This is the 11th straight year that we have had an increase in the cesarean section rate,” she said in an interview. “Our data show an increase in the rate of primary C-sections and a decline in the rate of vaginal birth following C-section.”

The increase follows a trend of decreasing C-sections in the early to mid-1990s. Since 1996, the rate has risen 50%. The increase has been spread over all age and race groups, she added.

Preterm births declined 1% in 2007, to a rate of 13%. “Historically, we have seen small declines in the preterm rate followed by large increases, so it's too early to predict whether this heralds the beginning of a trend,” she commented. “We are certainly hopeful, particularly because we saw large, but not significant, declines in both preterm and low-birth weight babies.”

Another positive sign was that the declines in preterm and low-birth-weight babies were spread across the country, not driven by a few states. “The decline was also concentrated among late preterm births, a group that had risen quite dramatically in recent years. … Again, it's too soon to say what might be causing this change,” Dr. Martin said.

The full report is available at www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_12.pdf

Consumption of solid food while in labor is safe for most women, according to the results of a large randomized trial.

It's been common practice to deny food to women in labor. Clinicians have worried that if general anesthesia were to be required for an emergency cesarean section, a woman might aspirate food into her lungs. As a result, even as recently as 2007, the American Society of Anesthesiologists recommended that laboring patients not be allowed solid food.

But in a study of 2,426 women, Dr. Geraldine O'Sullivan, consultant anesthetist at St. Thomas's Hospital, London, and her colleagues found that eating a low-fat, low-residue diet had no effect on the rate of spontaneous vaginal delivery, the duration of labor, the cesarean delivery rate, or the incidence of vomiting. In addition, the babies born to women permitted to eat solid foods were just as healthy as the babies born to women who were restricted to consuming water and ice (BMJ 2009;338:b784).

A total of 2,426 women with a mean age of 29 years were studied. All women in the study were giving birth for the first time, all pregnancies were uncomplicated, and all babies were singletons. The study was large enough to detect a difference as small as 6.7% in the rate of spontaneous vaginal delivery. The investigators agreed that a difference of this magnitude would be clinically as well as statistically significant.

Instead, they found no statistically significant differences on any measure. The rate of normal vaginal delivery was 44% in both groups. Instrumental delivery was 27% in the eating group and 26% in the water-only group. Cesarean sections were necessary in 30% of the women in the eating group and 30% of the women in the water-only group. A total of 35% of the women in the eating group vomited, compared with 34% of the women in the water-only group. And the mean length of labor was 597 minutes in the eating group, compared with 612 minutes in the water-only group.

Dr. William Camann, director of obstetric anesthesiology at Brigham andWomen's Hospital in Boston and past president of the Society for Obstetric Anesthesia and Perinatology, pointed out that the findings of this study didn't answer the question posed in regard to obstetric anesthesia safety concerns. The investigators didn't report whether any of the cesarean section patients received general anesthesia.

“The reason that pulmonary aspiration is so low is probably because the majority of obstetric patients nowadays have regional anesthesia during elective or emergent cesarean sections instead of general anesthesia, rather than [because] oral intake is restricted during labor, although we don't know this for sure. At our hospital only about 2%–3% of cesarean sections are done under general anesthesia.

“We don't really know whether liberalization of oral intake during labor will have adverse consequences or not. And we probably never will because the incidence of pulmonary aspiration is so low that it would take a study enrolling a huge number of women to achieve the statistical power necessary to get that evidence,” he said in an interview.

“Labor is not scheduled and predictable, like elective surgery. Although inevitably some women will end up having cesarean deliveries, this is highly likely to be done under regional anesthesia. There has to be a balance between patient comfort and patient safety, but with regard to oral intake in labor, this balance is hard to define,” Dr. Camann noted.

Not all of the women in the eating group actually ate solid food, and not all of the women in the water-only group avoided eating. Among the 1,219 women in the eating group, 71% actually ate, and the remainder either drank only water or had no oral intake. Among the 1,207 women in the water-only group, 20% failed to adhere to the protocol and ate some solid food.

The women ate a variety of foods, including fruit juice, soup, cereal, biscuits, fruits, chocolate, toast, vegetable stew, Danish pastry, sandwiches, hamburgers, chicken, and rice.

Denying solid food to women in labor became common after a 1946 study showing pulmonary acid aspiration, called Mendelson's syndrome, in some women who had eaten. But the risk of this has decreased in recent years. Anesthesiologists are more likely to use regional than general anesthesia for cesarean deliveries. In addition, it's common to prescribe proton pump inhibitors or H2 receptor blockers for women undergoing operative births.

Dr. Camann noted that there have been changes to the guidelines over the years, allowing for clear liquid intake of beverages such as juices, tea, and sports drinks during labor. “In fact, obstetric patients should drink something with electrolytes in it rather than just water to avoid water intoxication, which has been known to occur.”

The investigators stated that they had no conflicts of interest related to the study. Dr. Camann also reported no conflicts of interest.

Consumption of solid food while in labor is safe for most women, according to the results of a large randomized trial.

It's been common practice to deny food to women in labor. Clinicians have worried that if general anesthesia were to be required for an emergency cesarean section, a woman might aspirate food into her lungs. As a result, even as recently as 2007, the American Society of Anesthesiologists recommended that laboring patients not be allowed solid food.

But in a study of 2,426 women, Dr. Geraldine O'Sullivan, consultant anesthetist at St. Thomas's Hospital, London, and her colleagues found that eating a low-fat, low-residue diet had no effect on the rate of spontaneous vaginal delivery, the duration of labor, the cesarean delivery rate, or the incidence of vomiting. In addition, the babies born to women permitted to eat solid foods were just as healthy as the babies born to women who were restricted to consuming water and ice (BMJ 2009;338:b784).

A total of 2,426 women with a mean age of 29 years were studied. All women in the study were giving birth for the first time, all pregnancies were uncomplicated, and all babies were singletons. The study was large enough to detect a difference as small as 6.7% in the rate of spontaneous vaginal delivery. The investigators agreed that a difference of this magnitude would be clinically as well as statistically significant.

Instead, they found no statistically significant differences on any measure. The rate of normal vaginal delivery was 44% in both groups. Instrumental delivery was 27% in the eating group and 26% in the water-only group. Cesarean sections were necessary in 30% of the women in the eating group and 30% of the women in the water-only group. A total of 35% of the women in the eating group vomited, compared with 34% of the women in the water-only group. And the mean length of labor was 597 minutes in the eating group, compared with 612 minutes in the water-only group.

Dr. William Camann, director of obstetric anesthesiology at Brigham andWomen's Hospital in Boston and past president of the Society for Obstetric Anesthesia and Perinatology, pointed out that the findings of this study didn't answer the question posed in regard to obstetric anesthesia safety concerns. The investigators didn't report whether any of the cesarean section patients received general anesthesia.

“The reason that pulmonary aspiration is so low is probably because the majority of obstetric patients nowadays have regional anesthesia during elective or emergent cesarean sections instead of general anesthesia, rather than [because] oral intake is restricted during labor, although we don't know this for sure. At our hospital only about 2%–3% of cesarean sections are done under general anesthesia.

“We don't really know whether liberalization of oral intake during labor will have adverse consequences or not. And we probably never will because the incidence of pulmonary aspiration is so low that it would take a study enrolling a huge number of women to achieve the statistical power necessary to get that evidence,” he said in an interview.

“Labor is not scheduled and predictable, like elective surgery. Although inevitably some women will end up having cesarean deliveries, this is highly likely to be done under regional anesthesia. There has to be a balance between patient comfort and patient safety, but with regard to oral intake in labor, this balance is hard to define,” Dr. Camann noted.

Not all of the women in the eating group actually ate solid food, and not all of the women in the water-only group avoided eating. Among the 1,219 women in the eating group, 71% actually ate, and the remainder either drank only water or had no oral intake. Among the 1,207 women in the water-only group, 20% failed to adhere to the protocol and ate some solid food.

The women ate a variety of foods, including fruit juice, soup, cereal, biscuits, fruits, chocolate, toast, vegetable stew, Danish pastry, sandwiches, hamburgers, chicken, and rice.

Denying solid food to women in labor became common after a 1946 study showing pulmonary acid aspiration, called Mendelson's syndrome, in some women who had eaten. But the risk of this has decreased in recent years. Anesthesiologists are more likely to use regional than general anesthesia for cesarean deliveries. In addition, it's common to prescribe proton pump inhibitors or H2 receptor blockers for women undergoing operative births.

Dr. Camann noted that there have been changes to the guidelines over the years, allowing for clear liquid intake of beverages such as juices, tea, and sports drinks during labor. “In fact, obstetric patients should drink something with electrolytes in it rather than just water to avoid water intoxication, which has been known to occur.”

The investigators stated that they had no conflicts of interest related to the study. Dr. Camann also reported no conflicts of interest.

Consumption of solid food while in labor is safe for most women, according to the results of a large randomized trial.

It's been common practice to deny food to women in labor. Clinicians have worried that if general anesthesia were to be required for an emergency cesarean section, a woman might aspirate food into her lungs. As a result, even as recently as 2007, the American Society of Anesthesiologists recommended that laboring patients not be allowed solid food.

But in a study of 2,426 women, Dr. Geraldine O'Sullivan, consultant anesthetist at St. Thomas's Hospital, London, and her colleagues found that eating a low-fat, low-residue diet had no effect on the rate of spontaneous vaginal delivery, the duration of labor, the cesarean delivery rate, or the incidence of vomiting. In addition, the babies born to women permitted to eat solid foods were just as healthy as the babies born to women who were restricted to consuming water and ice (BMJ 2009;338:b784).

A total of 2,426 women with a mean age of 29 years were studied. All women in the study were giving birth for the first time, all pregnancies were uncomplicated, and all babies were singletons. The study was large enough to detect a difference as small as 6.7% in the rate of spontaneous vaginal delivery. The investigators agreed that a difference of this magnitude would be clinically as well as statistically significant.

Instead, they found no statistically significant differences on any measure. The rate of normal vaginal delivery was 44% in both groups. Instrumental delivery was 27% in the eating group and 26% in the water-only group. Cesarean sections were necessary in 30% of the women in the eating group and 30% of the women in the water-only group. A total of 35% of the women in the eating group vomited, compared with 34% of the women in the water-only group. And the mean length of labor was 597 minutes in the eating group, compared with 612 minutes in the water-only group.

Dr. William Camann, director of obstetric anesthesiology at Brigham andWomen's Hospital in Boston and past president of the Society for Obstetric Anesthesia and Perinatology, pointed out that the findings of this study didn't answer the question posed in regard to obstetric anesthesia safety concerns. The investigators didn't report whether any of the cesarean section patients received general anesthesia.

“The reason that pulmonary aspiration is so low is probably because the majority of obstetric patients nowadays have regional anesthesia during elective or emergent cesarean sections instead of general anesthesia, rather than [because] oral intake is restricted during labor, although we don't know this for sure. At our hospital only about 2%–3% of cesarean sections are done under general anesthesia.

“We don't really know whether liberalization of oral intake during labor will have adverse consequences or not. And we probably never will because the incidence of pulmonary aspiration is so low that it would take a study enrolling a huge number of women to achieve the statistical power necessary to get that evidence,” he said in an interview.

“Labor is not scheduled and predictable, like elective surgery. Although inevitably some women will end up having cesarean deliveries, this is highly likely to be done under regional anesthesia. There has to be a balance between patient comfort and patient safety, but with regard to oral intake in labor, this balance is hard to define,” Dr. Camann noted.

Not all of the women in the eating group actually ate solid food, and not all of the women in the water-only group avoided eating. Among the 1,219 women in the eating group, 71% actually ate, and the remainder either drank only water or had no oral intake. Among the 1,207 women in the water-only group, 20% failed to adhere to the protocol and ate some solid food.

The women ate a variety of foods, including fruit juice, soup, cereal, biscuits, fruits, chocolate, toast, vegetable stew, Danish pastry, sandwiches, hamburgers, chicken, and rice.

Denying solid food to women in labor became common after a 1946 study showing pulmonary acid aspiration, called Mendelson's syndrome, in some women who had eaten. But the risk of this has decreased in recent years. Anesthesiologists are more likely to use regional than general anesthesia for cesarean deliveries. In addition, it's common to prescribe proton pump inhibitors or H2 receptor blockers for women undergoing operative births.

Dr. Camann noted that there have been changes to the guidelines over the years, allowing for clear liquid intake of beverages such as juices, tea, and sports drinks during labor. “In fact, obstetric patients should drink something with electrolytes in it rather than just water to avoid water intoxication, which has been known to occur.”

The investigators stated that they had no conflicts of interest related to the study. Dr. Camann also reported no conflicts of interest.

Many physicians think it's no big deal to schedule elective deliveries before 39 weeks' gestation—contrary to guidelines—but their minds and practices can be changed with concerted effort, according to a study at nine hospitals.

In a 5-year program, reeducation of physicians and nurses on the hazards of early-term elective delivery, combined with policing of their practices, reduced the rate of early elective deliveries from 28% of all elective deliveries in 1999–2000 to less than 10% within 6 months of program initiation. After 6 years with the program in place, the near-term elective delivery rate remained less than 3%, Dr. Bryan T. Oshiro and his associates reported (Obstet. Gynecol. 2009;113:804–11).

Those improvements did not come easily. It wasn't enough to remind physicians of American College of Obstetricians and Gynecologists guidelines recommending that elective deliveries not be performed before 39 weeks' gestation. Nor were their minds changed by national data showing greater perinatal morbidity in infants delivered before 39 weeks, including 8- to 23-fold higher incidences of severe respiratory distress syndrome with deliveries at 38 or 37 weeks, respectively.

The medical staff argued that their local patients were healthier than those reported in the literature. The physicians wanted to maintain autonomy in managing the timing of delivery. Nursing staff did not want to be responsible for enforcing a policy against early elective deliveries, which would put them in adversarial relationships with the doctors. “It was not until internal or local neonatal morbidity data were presented that significant initial buy-in by the medical staff was seen,” reported Dr. Oshiro of Loma Linda (Calif.) University.

The team who developed and administered the program within the Intermountain Healthcare network of hospitals in Utah and Southeast Idaho collected and presented data showing that their rate of neonatal ICU admissions for normal pregnancies increased from 3.3% for deliveries at 39 weeks to 4.5% for elective deliveries at 38 weeks and 8.9% for deliveries at 37 weeks. The rate of ventilator use for deliveries without complications increased from 0.3% for deliveries at 39 weeks to 0.5% for deliveries at 38 weeks and 1.4% for deliveries at 37 weeks. The in-hospital data were key to obtaining staff buy-in.

Concerns that delaying elective deliveries might increase morbidity were allayed by follow-up data showing significant declines in the rates of postpartum anemia, meconium aspiration, Apgar scores less than 5 at 1 minute, and cesarean deliveries due to fetal distress in infants delivered at 39–41 weeks' gestation in the period after the program was started, compared with the pre-program era. The rate of preeclampsia increased slightly, the study found.

Intermountain Healthcare is a vertically integrated health care system with 21 hospitals. The nine hospitals in the study use an electronic records system that allows identification and tracking of elective deliveries.

To overcome strong initial opposition to the program, the program managers conducted extensive education of the staff at each hospital. Physicians who wanted to schedule an early-term elective delivery were required to obtain permission from their hospital's ob.gyn. department chair or the attending perinatologist so that nursing staff would not have to be the ones enforcing the new policy. A new brochure helped explain the policy on early-term elective deliveries to patients.

Clinical program leaders monitor performance systemwide, at each facility, and for each practitioner, and regularly discuss the results with each hospital and sometimes with individual physicians. Hospital administrators were motivated to help the program succeed because part of their compensation depended on meeting the goal of decreasing early-term elective deliveries.

“They've done a really nice job showing that if you do bring attention to it, you can improve your rates” of elective delivery at appropriate gestational ages, Dr. Catherine Spong of the National Institute of Child Health and Human Development commented in an interview.

Requiring physicians to get permission for early elective deliveries “would make it more difficult for someone to just go ahead and deliver early,” she added.

The proportion of U.S. deliveries of live infants that occur between 37 and 38 weeks' gestation has increased to nearly 18% in the past decade. Separate data have shown that approximately one-third of elective repeat cesarean deliveries are performed before 39 weeks. The rate of late preterm deliveries (between 34 and 37 weeks' gestation) and the indications for those deliveries also have changed, Dr. Spong said. All of these “probably should be more closely evaluated.”

The majority of obstetric providers in the Intermountain Healthcare system are community physicians, most of whom could choose to do deliveries at nearby competing hospitals. “Thus we feel that this program could work in other hospitals and in other areas of the country,” the investigators concluded.

The authors and Dr. Spong reported no conflicts of interest related to this study.

Many physicians think it's no big deal to schedule elective deliveries before 39 weeks' gestation—contrary to guidelines—but their minds and practices can be changed with concerted effort, according to a study at nine hospitals.

In a 5-year program, reeducation of physicians and nurses on the hazards of early-term elective delivery, combined with policing of their practices, reduced the rate of early elective deliveries from 28% of all elective deliveries in 1999–2000 to less than 10% within 6 months of program initiation. After 6 years with the program in place, the near-term elective delivery rate remained less than 3%, Dr. Bryan T. Oshiro and his associates reported (Obstet. Gynecol. 2009;113:804–11).

Those improvements did not come easily. It wasn't enough to remind physicians of American College of Obstetricians and Gynecologists guidelines recommending that elective deliveries not be performed before 39 weeks' gestation. Nor were their minds changed by national data showing greater perinatal morbidity in infants delivered before 39 weeks, including 8- to 23-fold higher incidences of severe respiratory distress syndrome with deliveries at 38 or 37 weeks, respectively.

The medical staff argued that their local patients were healthier than those reported in the literature. The physicians wanted to maintain autonomy in managing the timing of delivery. Nursing staff did not want to be responsible for enforcing a policy against early elective deliveries, which would put them in adversarial relationships with the doctors. “It was not until internal or local neonatal morbidity data were presented that significant initial buy-in by the medical staff was seen,” reported Dr. Oshiro of Loma Linda (Calif.) University.

The team who developed and administered the program within the Intermountain Healthcare network of hospitals in Utah and Southeast Idaho collected and presented data showing that their rate of neonatal ICU admissions for normal pregnancies increased from 3.3% for deliveries at 39 weeks to 4.5% for elective deliveries at 38 weeks and 8.9% for deliveries at 37 weeks. The rate of ventilator use for deliveries without complications increased from 0.3% for deliveries at 39 weeks to 0.5% for deliveries at 38 weeks and 1.4% for deliveries at 37 weeks. The in-hospital data were key to obtaining staff buy-in.

Concerns that delaying elective deliveries might increase morbidity were allayed by follow-up data showing significant declines in the rates of postpartum anemia, meconium aspiration, Apgar scores less than 5 at 1 minute, and cesarean deliveries due to fetal distress in infants delivered at 39–41 weeks' gestation in the period after the program was started, compared with the pre-program era. The rate of preeclampsia increased slightly, the study found.

Intermountain Healthcare is a vertically integrated health care system with 21 hospitals. The nine hospitals in the study use an electronic records system that allows identification and tracking of elective deliveries.

To overcome strong initial opposition to the program, the program managers conducted extensive education of the staff at each hospital. Physicians who wanted to schedule an early-term elective delivery were required to obtain permission from their hospital's ob.gyn. department chair or the attending perinatologist so that nursing staff would not have to be the ones enforcing the new policy. A new brochure helped explain the policy on early-term elective deliveries to patients.

Clinical program leaders monitor performance systemwide, at each facility, and for each practitioner, and regularly discuss the results with each hospital and sometimes with individual physicians. Hospital administrators were motivated to help the program succeed because part of their compensation depended on meeting the goal of decreasing early-term elective deliveries.

“They've done a really nice job showing that if you do bring attention to it, you can improve your rates” of elective delivery at appropriate gestational ages, Dr. Catherine Spong of the National Institute of Child Health and Human Development commented in an interview.

Requiring physicians to get permission for early elective deliveries “would make it more difficult for someone to just go ahead and deliver early,” she added.

The proportion of U.S. deliveries of live infants that occur between 37 and 38 weeks' gestation has increased to nearly 18% in the past decade. Separate data have shown that approximately one-third of elective repeat cesarean deliveries are performed before 39 weeks. The rate of late preterm deliveries (between 34 and 37 weeks' gestation) and the indications for those deliveries also have changed, Dr. Spong said. All of these “probably should be more closely evaluated.”

The majority of obstetric providers in the Intermountain Healthcare system are community physicians, most of whom could choose to do deliveries at nearby competing hospitals. “Thus we feel that this program could work in other hospitals and in other areas of the country,” the investigators concluded.

The authors and Dr. Spong reported no conflicts of interest related to this study.

Many physicians think it's no big deal to schedule elective deliveries before 39 weeks' gestation—contrary to guidelines—but their minds and practices can be changed with concerted effort, according to a study at nine hospitals.

In a 5-year program, reeducation of physicians and nurses on the hazards of early-term elective delivery, combined with policing of their practices, reduced the rate of early elective deliveries from 28% of all elective deliveries in 1999–2000 to less than 10% within 6 months of program initiation. After 6 years with the program in place, the near-term elective delivery rate remained less than 3%, Dr. Bryan T. Oshiro and his associates reported (Obstet. Gynecol. 2009;113:804–11).

Those improvements did not come easily. It wasn't enough to remind physicians of American College of Obstetricians and Gynecologists guidelines recommending that elective deliveries not be performed before 39 weeks' gestation. Nor were their minds changed by national data showing greater perinatal morbidity in infants delivered before 39 weeks, including 8- to 23-fold higher incidences of severe respiratory distress syndrome with deliveries at 38 or 37 weeks, respectively.

The medical staff argued that their local patients were healthier than those reported in the literature. The physicians wanted to maintain autonomy in managing the timing of delivery. Nursing staff did not want to be responsible for enforcing a policy against early elective deliveries, which would put them in adversarial relationships with the doctors. “It was not until internal or local neonatal morbidity data were presented that significant initial buy-in by the medical staff was seen,” reported Dr. Oshiro of Loma Linda (Calif.) University.

The team who developed and administered the program within the Intermountain Healthcare network of hospitals in Utah and Southeast Idaho collected and presented data showing that their rate of neonatal ICU admissions for normal pregnancies increased from 3.3% for deliveries at 39 weeks to 4.5% for elective deliveries at 38 weeks and 8.9% for deliveries at 37 weeks. The rate of ventilator use for deliveries without complications increased from 0.3% for deliveries at 39 weeks to 0.5% for deliveries at 38 weeks and 1.4% for deliveries at 37 weeks. The in-hospital data were key to obtaining staff buy-in.

Concerns that delaying elective deliveries might increase morbidity were allayed by follow-up data showing significant declines in the rates of postpartum anemia, meconium aspiration, Apgar scores less than 5 at 1 minute, and cesarean deliveries due to fetal distress in infants delivered at 39–41 weeks' gestation in the period after the program was started, compared with the pre-program era. The rate of preeclampsia increased slightly, the study found.

Intermountain Healthcare is a vertically integrated health care system with 21 hospitals. The nine hospitals in the study use an electronic records system that allows identification and tracking of elective deliveries.

To overcome strong initial opposition to the program, the program managers conducted extensive education of the staff at each hospital. Physicians who wanted to schedule an early-term elective delivery were required to obtain permission from their hospital's ob.gyn. department chair or the attending perinatologist so that nursing staff would not have to be the ones enforcing the new policy. A new brochure helped explain the policy on early-term elective deliveries to patients.

Clinical program leaders monitor performance systemwide, at each facility, and for each practitioner, and regularly discuss the results with each hospital and sometimes with individual physicians. Hospital administrators were motivated to help the program succeed because part of their compensation depended on meeting the goal of decreasing early-term elective deliveries.

“They've done a really nice job showing that if you do bring attention to it, you can improve your rates” of elective delivery at appropriate gestational ages, Dr. Catherine Spong of the National Institute of Child Health and Human Development commented in an interview.

Requiring physicians to get permission for early elective deliveries “would make it more difficult for someone to just go ahead and deliver early,” she added.

The proportion of U.S. deliveries of live infants that occur between 37 and 38 weeks' gestation has increased to nearly 18% in the past decade. Separate data have shown that approximately one-third of elective repeat cesarean deliveries are performed before 39 weeks. The rate of late preterm deliveries (between 34 and 37 weeks' gestation) and the indications for those deliveries also have changed, Dr. Spong said. All of these “probably should be more closely evaluated.”

The majority of obstetric providers in the Intermountain Healthcare system are community physicians, most of whom could choose to do deliveries at nearby competing hospitals. “Thus we feel that this program could work in other hospitals and in other areas of the country,” the investigators concluded.

The authors and Dr. Spong reported no conflicts of interest related to this study.

A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.

By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).

ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.

However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).

The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.

The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.

An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.

Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.

With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.

“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.

The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.

Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.

“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.

Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.

“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.

The investigators added that in the future, “individual provider induction rates may be monitored and evaluated, especially if the induction rates and subsequent cesarean birth rates are excessive.”

A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.

By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).

ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.

However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).

The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.

The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.

An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.

Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.

With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.

“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.

The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.

Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.

“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.

Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.

“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.

The investigators added that in the future, “individual provider induction rates may be monitored and evaluated, especially if the induction rates and subsequent cesarean birth rates are excessive.”

A large maternity hospital markedly decreased its excessive rate of labor inductions simply by strictly enforcing American College of Obstetricians and Gynecologists's recommendations for averting inappropriate inductions.

By requiring physicians to justify ordering elective labor inductions that might be deemed inappropriate, the hospital cut the overall rate of inductions by one-third, decreased the rate of inductions performed before 39 weeks by 64%, and reduced the rate of cesarean delivery among nulliparas undergoing induction by 60%, reported Dr. John M. Fisch and his associates at Magee-Womens Hospital (Obstet. Gynecol. 2009;113:797–803).

ACOG 2004 guidelines permit elective inductions only after 39 weeks, advise that the procedure be done in nulliparas only if the Bishop score is 8 or more (and in multiparas only if the Bishop score is 6 or more), and do not allow the use of cervical ripening. These guidelines were immediately implemented at Magee-Womens Hospital, a tertiary care center with 36 ob.gyn. residents and more than 100 practicing physicians caring for both clinic and private patients.

However, an audit of actual practice there between 2004 and 2005 showed little adherence to the guidelines and minimal improvement in the “unacceptably high” rate of inductions (28% in 2003).

The hospital then began a program to enforce the recommendations. The process for scheduling an induction was computerized, allowing data on all inductions to be monitored easily. This allowed program overseers to track individual physician patterns of delivery, and to discover that some physicians induced more than 30% of their deliveries while others did not induce at all.

The number of induction slots was reduced from 13 to 8, and staff in charge of scheduling inductions were instructed to remind physicians to adhere to ACOG's induction guidelines if they were not doing so. These staff also were empowered to involve the nurse manager or the medical director of the birth center in any inductions that did not meet ACOG criteria.

An audit form was attached to the front of the chart of every patient who presented to the labor and delivery unit for induction, and information such as gestational age, stated reasons for induction, attending physician, parity, Bishop score, and delivery outcomes was tracked.

Inductions that went forward even though they did not meet the criteria were reviewed by a multidisciplinary team each month and discussed with the attending physician. Peer review was performed, and letters sent from the vice president of medical affairs were included in the physicians' permanent recredentialing files.

With this enforcement, the overall induction rate decreased from 25% in 2004 to 17% in 2007. The rate of inductions at less than 39 weeks fell from 12% to 4%, and the rate of cesarean deliveries among nulliparas who had been induced dropped from 35% to 14%.

“Initial reaction to the guidelines ranged from skeptical to hostile, as physicians objected to oversight of their medical decision making,” Dr. Fisch and his colleagues noted.

The hospital sidestepped much of this resistance by presenting this program not as an effort to reduce inductions but as an effort to improve maternal and fetal outcomes by adhering to ACOG standards. Also, “due to the sensitive nature of altering physician practice patterns within such a large group of practitioners,” the task force that implemented the program was carefully chosen and included stakeholders from several disciplines.

Other obstacles were overcome by negotiation. For example, physicians initially resisted cooperating with the induction scheduler, who reminded them of the ACOG recommendations whenever they attempted to schedule an induction and brought in the director of the nursing unit or, if necessary, the medical director of the birth center. “This process evolved over time to the point where an attending will go directly to the medical director if they feel that approval will be needed to schedule an induction,” the researchers noted.

“A major strength of this study is its applicability for use at other institutions faced with an unacceptably high induction rate. … This article provides a blueprint for the development and implementation of a program” to reduce the risks associated with labor induction, which include infection, cesarean delivery, and neonatal ICU admission.

Noting that women who have induced labor spend more time in the hospital and incur greater costs for care than do those with spontaneous labor, Dr. Fisch and his associates calculated that their program has likely averted 71 unnecessary inductions and 5 unnecessary cesarean births per month.

“This accounts for 284 more hours in the hospital and a cost of $29,235 more per month,” which “translates into a total cost savings of 3,408 hours and $350,820 per year,” they said.

The investigators added that in the future, “individual provider induction rates may be monitored and evaluated, especially if the induction rates and subsequent cesarean birth rates are excessive.”

SAN FRANCISCO — For treatment of acne or rosacea in pregnancy, think first, and last, of azelaic acid gel 15% twice daily, Dr. Joseph Bikowski advised.

“It is pregnancy category B. It's the Rice Crispies and Corn Flakes of therapy; you can eat the stuff. It's the one thing you can use for acne and rosacea in pregnancy where you'll never do any harm, and you may do some good,” Dr. Bikowski said in a therapeutic pearls session at the annual meeting of the American Academy of Dermatology.

Other treatments for acne and/or rosacea are rated categories C through X, creating potential medicolegal exposure in the event of a bad pregnancy outcome, he noted. And although other formulations of azelaic acid are also rated category B, azelaic acid gel 15% (Finacea) is less irritating, said Dr. Bikowski, a dermatologist in private practice in Sewickley, Pa.

Dr. Bikowski disclosed that he is a consultant to and on the speakers bureau for Intendis Inc., which markets Finacea.

SAN FRANCISCO — For treatment of acne or rosacea in pregnancy, think first, and last, of azelaic acid gel 15% twice daily, Dr. Joseph Bikowski advised.

“It is pregnancy category B. It's the Rice Crispies and Corn Flakes of therapy; you can eat the stuff. It's the one thing you can use for acne and rosacea in pregnancy where you'll never do any harm, and you may do some good,” Dr. Bikowski said in a therapeutic pearls session at the annual meeting of the American Academy of Dermatology.

Other treatments for acne and/or rosacea are rated categories C through X, creating potential medicolegal exposure in the event of a bad pregnancy outcome, he noted. And although other formulations of azelaic acid are also rated category B, azelaic acid gel 15% (Finacea) is less irritating, said Dr. Bikowski, a dermatologist in private practice in Sewickley, Pa.

Dr. Bikowski disclosed that he is a consultant to and on the speakers bureau for Intendis Inc., which markets Finacea.

SAN FRANCISCO — For treatment of acne or rosacea in pregnancy, think first, and last, of azelaic acid gel 15% twice daily, Dr. Joseph Bikowski advised.

“It is pregnancy category B. It's the Rice Crispies and Corn Flakes of therapy; you can eat the stuff. It's the one thing you can use for acne and rosacea in pregnancy where you'll never do any harm, and you may do some good,” Dr. Bikowski said in a therapeutic pearls session at the annual meeting of the American Academy of Dermatology.

Other treatments for acne and/or rosacea are rated categories C through X, creating potential medicolegal exposure in the event of a bad pregnancy outcome, he noted. And although other formulations of azelaic acid are also rated category B, azelaic acid gel 15% (Finacea) is less irritating, said Dr. Bikowski, a dermatologist in private practice in Sewickley, Pa.

Dr. Bikowski disclosed that he is a consultant to and on the speakers bureau for Intendis Inc., which markets Finacea.

Pregnant women and new mothers with any type of diabetes appear to have twice the risk of developing perinatal depression as do those without diabetes, according to an analysis of Medicaid records.

This finding is consistent with reports showing a doubling of the odds of depression among adults with diabetes in the general population, said Katy Backes Kozhimannil of Harvard Medical School, Boston, and her associates.

The researchers explored a possible link between diabetes and depression in the perinatal period using a Medicaid database on 11,024 low-income women who gave birth in New Jersey between 2004 and 2006. A total of 657 of these women had diabetes, comprising 57 with nongestational diabetes who were taking insulin, 254 with nongestational diabetes who were not taking insulin, 163 with gestational diabetes who were taking insulin, and 183 with gestational diabetes who were not taking insulin.

Both prenatal and postpartum depression were twice as prevalent among the women who had diabetes than among those who did not. This association did not vary by diabetes classification.

After the data were controlled to account for the effects of age, race, and preterm delivery, women with diabetes still had nearly double the chance (odds ratio 1.9) of developing depression during the perinatal period (15%) than those without diabetes (8%).

“When cesarean delivery was included in the regression models in addition to the other covariates, the results remained virtually unchanged,” Ms. Kozhimannil and her colleagues wrote (JAMA 2009;301:842–7).

The findings were the same in the large subset of women who had no indication of depression before delivery. Those with diabetes had nearly twice the risk of developing new onset depression during the postpartum period. Perinatal depression is underdiagnosed and therefore inadequately treated. These findings should “encourage health care providers to pay particular attention to managing the mental health concerns of women with diabetes during pregnancy and the postpartum period,” the researchers said.

They noted that the design of this study did not allow them to determine whether the link between diabetes and perinatal depression is causal.

Pregnant women and new mothers with any type of diabetes appear to have twice the risk of developing perinatal depression as do those without diabetes, according to an analysis of Medicaid records.

This finding is consistent with reports showing a doubling of the odds of depression among adults with diabetes in the general population, said Katy Backes Kozhimannil of Harvard Medical School, Boston, and her associates.

The researchers explored a possible link between diabetes and depression in the perinatal period using a Medicaid database on 11,024 low-income women who gave birth in New Jersey between 2004 and 2006. A total of 657 of these women had diabetes, comprising 57 with nongestational diabetes who were taking insulin, 254 with nongestational diabetes who were not taking insulin, 163 with gestational diabetes who were taking insulin, and 183 with gestational diabetes who were not taking insulin.

Both prenatal and postpartum depression were twice as prevalent among the women who had diabetes than among those who did not. This association did not vary by diabetes classification.

After the data were controlled to account for the effects of age, race, and preterm delivery, women with diabetes still had nearly double the chance (odds ratio 1.9) of developing depression during the perinatal period (15%) than those without diabetes (8%).

“When cesarean delivery was included in the regression models in addition to the other covariates, the results remained virtually unchanged,” Ms. Kozhimannil and her colleagues wrote (JAMA 2009;301:842–7).

The findings were the same in the large subset of women who had no indication of depression before delivery. Those with diabetes had nearly twice the risk of developing new onset depression during the postpartum period. Perinatal depression is underdiagnosed and therefore inadequately treated. These findings should “encourage health care providers to pay particular attention to managing the mental health concerns of women with diabetes during pregnancy and the postpartum period,” the researchers said.

They noted that the design of this study did not allow them to determine whether the link between diabetes and perinatal depression is causal.

Pregnant women and new mothers with any type of diabetes appear to have twice the risk of developing perinatal depression as do those without diabetes, according to an analysis of Medicaid records.

This finding is consistent with reports showing a doubling of the odds of depression among adults with diabetes in the general population, said Katy Backes Kozhimannil of Harvard Medical School, Boston, and her associates.

The researchers explored a possible link between diabetes and depression in the perinatal period using a Medicaid database on 11,024 low-income women who gave birth in New Jersey between 2004 and 2006. A total of 657 of these women had diabetes, comprising 57 with nongestational diabetes who were taking insulin, 254 with nongestational diabetes who were not taking insulin, 163 with gestational diabetes who were taking insulin, and 183 with gestational diabetes who were not taking insulin.

Both prenatal and postpartum depression were twice as prevalent among the women who had diabetes than among those who did not. This association did not vary by diabetes classification.

After the data were controlled to account for the effects of age, race, and preterm delivery, women with diabetes still had nearly double the chance (odds ratio 1.9) of developing depression during the perinatal period (15%) than those without diabetes (8%).

“When cesarean delivery was included in the regression models in addition to the other covariates, the results remained virtually unchanged,” Ms. Kozhimannil and her colleagues wrote (JAMA 2009;301:842–7).

The findings were the same in the large subset of women who had no indication of depression before delivery. Those with diabetes had nearly twice the risk of developing new onset depression during the postpartum period. Perinatal depression is underdiagnosed and therefore inadequately treated. These findings should “encourage health care providers to pay particular attention to managing the mental health concerns of women with diabetes during pregnancy and the postpartum period,” the researchers said.

They noted that the design of this study did not allow them to determine whether the link between diabetes and perinatal depression is causal.

SAN DIEGO — The risk of neonatal morbidity, particularly of respiratory distress syndrome, is significantly higher for infants born between 34 and nearly 37 weeks' gestation than for those born at term, an analysis of Centers for Disease Control and Prevention data showed.

“We used to think that the lungs of a neonate are mature by 34 weeks, but we found out that's not always the case,” Dr. Amy Flick said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. “If a neonate is [at] 34 weeks' gestational age and is fine, there should be no reason to deliver; you could be risking a bad outcome.”

To compare neonatal morbidity for infants born at 34–36.9 weeks' gestation with that for infants born at 37–42 weeks, and to compare pregnancy outcomes for women in the two groups, Dr. Flick and her associates analyzed data from the 2004 CDC national birth registry. The researchers performed a secondary analysis using 2004 National Center for Health Statistics birth statistical files.

Compared with women whose infants were born at term, the women who bore infants in the late preterm period had significantly higher rates of hypertension (1.8% vs. 0.8%), preeclampsia (7.8% vs. 3.2%), preterm premature rupture of membranes (5.1% vs. 1.2%), and diabetes (5.2% vs. 3.4%), said Dr. Flick of the department of obstetrics and gynecology at the University of Miami.

The risk of neonatal composite morbidity was significantly higher in the late preterm group than in infants born at term (8.9% vs. 3.3%). Logistic regression analysis revealed that infants in the late preterm group were also 5.3 times more likely to have respiratory distress syndrome, 3.7 times more likely to require assisted ventilation, and 1.6 times more likely to have a 5-minute Apgar score of less than 7.

The risks and benefits of even late preterm deliveries must be presented to patients in a comprehensive manner along with input from neonatologists, the investigators concluded. They also called for further studies, including longer follow-up of late preterm infants.

Dr. Flick acknowledged certain limitations of the study, including its retrospective design and the fact that data came from birth certificates.

SAN DIEGO — The risk of neonatal morbidity, particularly of respiratory distress syndrome, is significantly higher for infants born between 34 and nearly 37 weeks' gestation than for those born at term, an analysis of Centers for Disease Control and Prevention data showed.

“We used to think that the lungs of a neonate are mature by 34 weeks, but we found out that's not always the case,” Dr. Amy Flick said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. “If a neonate is [at] 34 weeks' gestational age and is fine, there should be no reason to deliver; you could be risking a bad outcome.”

To compare neonatal morbidity for infants born at 34–36.9 weeks' gestation with that for infants born at 37–42 weeks, and to compare pregnancy outcomes for women in the two groups, Dr. Flick and her associates analyzed data from the 2004 CDC national birth registry. The researchers performed a secondary analysis using 2004 National Center for Health Statistics birth statistical files.

Compared with women whose infants were born at term, the women who bore infants in the late preterm period had significantly higher rates of hypertension (1.8% vs. 0.8%), preeclampsia (7.8% vs. 3.2%), preterm premature rupture of membranes (5.1% vs. 1.2%), and diabetes (5.2% vs. 3.4%), said Dr. Flick of the department of obstetrics and gynecology at the University of Miami.

The risk of neonatal composite morbidity was significantly higher in the late preterm group than in infants born at term (8.9% vs. 3.3%). Logistic regression analysis revealed that infants in the late preterm group were also 5.3 times more likely to have respiratory distress syndrome, 3.7 times more likely to require assisted ventilation, and 1.6 times more likely to have a 5-minute Apgar score of less than 7.

The risks and benefits of even late preterm deliveries must be presented to patients in a comprehensive manner along with input from neonatologists, the investigators concluded. They also called for further studies, including longer follow-up of late preterm infants.

Dr. Flick acknowledged certain limitations of the study, including its retrospective design and the fact that data came from birth certificates.

SAN DIEGO — The risk of neonatal morbidity, particularly of respiratory distress syndrome, is significantly higher for infants born between 34 and nearly 37 weeks' gestation than for those born at term, an analysis of Centers for Disease Control and Prevention data showed.

“We used to think that the lungs of a neonate are mature by 34 weeks, but we found out that's not always the case,” Dr. Amy Flick said in an interview during a poster session at the annual meeting of the Society for Maternal-Fetal Medicine. “If a neonate is [at] 34 weeks' gestational age and is fine, there should be no reason to deliver; you could be risking a bad outcome.”

To compare neonatal morbidity for infants born at 34–36.9 weeks' gestation with that for infants born at 37–42 weeks, and to compare pregnancy outcomes for women in the two groups, Dr. Flick and her associates analyzed data from the 2004 CDC national birth registry. The researchers performed a secondary analysis using 2004 National Center for Health Statistics birth statistical files.

Compared with women whose infants were born at term, the women who bore infants in the late preterm period had significantly higher rates of hypertension (1.8% vs. 0.8%), preeclampsia (7.8% vs. 3.2%), preterm premature rupture of membranes (5.1% vs. 1.2%), and diabetes (5.2% vs. 3.4%), said Dr. Flick of the department of obstetrics and gynecology at the University of Miami.

The risk of neonatal composite morbidity was significantly higher in the late preterm group than in infants born at term (8.9% vs. 3.3%). Logistic regression analysis revealed that infants in the late preterm group were also 5.3 times more likely to have respiratory distress syndrome, 3.7 times more likely to require assisted ventilation, and 1.6 times more likely to have a 5-minute Apgar score of less than 7.

The risks and benefits of even late preterm deliveries must be presented to patients in a comprehensive manner along with input from neonatologists, the investigators concluded. They also called for further studies, including longer follow-up of late preterm infants.

Dr. Flick acknowledged certain limitations of the study, including its retrospective design and the fact that data came from birth certificates.

Women who are overweight or obese at the time of conception are at increased risk for a postterm delivery, but that risk can be reduced if they restrict their pregnancy weight gain to a normal range, according to findings from a large database study.

Birth injury, meconium aspiration, cesarean delivery, and other complications have been linked to delivery beyond term, explained Dr. Donna R. Halloran, a St. Louis University pediatrician who presented the study results at the Southern regional meeting of the American Federation for Medical Research in New Orleans.

Researchers examined birth records linked to hospital discharge data for term singleton infants born at 42 weeks' gestation or beyond in Missouri over a 6-year period, collecting data on 8,542 postterm births to mothers without a history of diabetes, chronic hypertension, or a previous cesarean section.

After adjustment for maternal ethnicity, age, education, parity, tobacco history, Medicaid status, and infant sex, the odds of a postterm delivery were substantially elevated among mothers who were overweight (adjusted odds ratio, 1.12) or obese (adjusted odds ratio, 1.19) if they were overweight or obese at the time they became pregnant.

“The obesity epidemic is clearly having a detrimental impact on the health of this country, and pregnant women are no exception,” she said in an interview following the meeting. “Unfortunately, most women do not get preconceptual care.

“What we were pleased to find was that even if you are overweight or obese when the pregnancy begins, gaining an appropriate amount of weight (versus too much weight) reduces your risk of certain complications, specifically a postterm delivery.”

Indeed, this potential revision of risk occurred regardless of prepregnancy weight, whereas women gaining more than the recommended weight during pregnancy were 1.24 times more likely to be delivered post term.

Institute of Medicine (IOM) guidelines recommend a pregnancy weight gain of 28–40 pounds if a woman has a BMI of less than 19.8 kg/m₂, 25–35 pounds for women with BMIs between 19.8 kg/m₂ and 26 kg/m₂, and 15–25 pounds for a woman with a prepregnancy BMI of 26 kg/m₂ or greater.

Unfortunately, overweight and obese women in the Missouri study were more likely than thinner women to exceed IOM weight guidelines during pregnancy.

More than half of the 91,843 women with prepregnancy BMIs between 25 kg/m₂ and 29.9 kg/m₂ gained more than the amount recommended by the IOM, and 44% of the 31,147 with BMIs greater than 30 kg/m₂ gained more than 25 pounds during pregnancy.

About 20% of these women were delivered post term if they were nulliparous and nearly 15% if they were multiparous, the study showed.

Physicians can help to reverse the trend of increasing postterm deliveries, even among women who are overweight or obese at conception, said Dr. Halloran.

“There are safe ways to stay healthy and limit weight gain during pregnancy.” She pointed to several studies demonstrating the effectiveness of patient education and guidance about healthy eating, exercise, and the risks associated with excessive weight gain.

Ironically, one study conducted at the University of Pittsburgh suggested less may be more with regard to interventions with overweight women, Dr. Halloran said (Int. J. Obes. Relat. Metab. Disord. 2002;26:1494–502).

In this randomized controlled study, increasingly intensive interventions as women gained weight during pregnancy were effective in limiting the percentage of normal-weight women who exceeded IOM weight guidelines, but in overweight women, 32% more exceeded weight guidelines in the intervention group than in the control group.

A simpler series of interventions was found to be effective with both overweight and normal-weight lower-income women in preventing excessive gestational weight gain, in a study from Cornell University (Am. J. Obstet. Gyn. 2004;19:530–6).

The methods used were intentionally designed to be reasonable to implement in clinical practice, and included monitoring of and education about gestational weight gain by health care professionals during prenatal visits and a series of educational mailings sent to patients with healthy eating and exercise tips, a self-monitoring guide, and a monthly motivational newsletter.

Dr. Donna R. Halloran noted that the risk of postterm delivery can be reduced if overweight/obese women restrict their pregnancy weight gain to a normal range. SAINT LOUIS UNIVERSITY

Women who are overweight or obese at the time of conception are at increased risk for a postterm delivery, but that risk can be reduced if they restrict their pregnancy weight gain to a normal range, according to findings from a large database study.

Birth injury, meconium aspiration, cesarean delivery, and other complications have been linked to delivery beyond term, explained Dr. Donna R. Halloran, a St. Louis University pediatrician who presented the study results at the Southern regional meeting of the American Federation for Medical Research in New Orleans.

Researchers examined birth records linked to hospital discharge data for term singleton infants born at 42 weeks' gestation or beyond in Missouri over a 6-year period, collecting data on 8,542 postterm births to mothers without a history of diabetes, chronic hypertension, or a previous cesarean section.

After adjustment for maternal ethnicity, age, education, parity, tobacco history, Medicaid status, and infant sex, the odds of a postterm delivery were substantially elevated among mothers who were overweight (adjusted odds ratio, 1.12) or obese (adjusted odds ratio, 1.19) if they were overweight or obese at the time they became pregnant.

“The obesity epidemic is clearly having a detrimental impact on the health of this country, and pregnant women are no exception,” she said in an interview following the meeting. “Unfortunately, most women do not get preconceptual care.

“What we were pleased to find was that even if you are overweight or obese when the pregnancy begins, gaining an appropriate amount of weight (versus too much weight) reduces your risk of certain complications, specifically a postterm delivery.”

Indeed, this potential revision of risk occurred regardless of prepregnancy weight, whereas women gaining more than the recommended weight during pregnancy were 1.24 times more likely to be delivered post term.

Institute of Medicine (IOM) guidelines recommend a pregnancy weight gain of 28–40 pounds if a woman has a BMI of less than 19.8 kg/m₂, 25–35 pounds for women with BMIs between 19.8 kg/m₂ and 26 kg/m₂, and 15–25 pounds for a woman with a prepregnancy BMI of 26 kg/m₂ or greater.

Unfortunately, overweight and obese women in the Missouri study were more likely than thinner women to exceed IOM weight guidelines during pregnancy.

More than half of the 91,843 women with prepregnancy BMIs between 25 kg/m₂ and 29.9 kg/m₂ gained more than the amount recommended by the IOM, and 44% of the 31,147 with BMIs greater than 30 kg/m₂ gained more than 25 pounds during pregnancy.

About 20% of these women were delivered post term if they were nulliparous and nearly 15% if they were multiparous, the study showed.

Physicians can help to reverse the trend of increasing postterm deliveries, even among women who are overweight or obese at conception, said Dr. Halloran.

“There are safe ways to stay healthy and limit weight gain during pregnancy.” She pointed to several studies demonstrating the effectiveness of patient education and guidance about healthy eating, exercise, and the risks associated with excessive weight gain.

Ironically, one study conducted at the University of Pittsburgh suggested less may be more with regard to interventions with overweight women, Dr. Halloran said (Int. J. Obes. Relat. Metab. Disord. 2002;26:1494–502).

In this randomized controlled study, increasingly intensive interventions as women gained weight during pregnancy were effective in limiting the percentage of normal-weight women who exceeded IOM weight guidelines, but in overweight women, 32% more exceeded weight guidelines in the intervention group than in the control group.

A simpler series of interventions was found to be effective with both overweight and normal-weight lower-income women in preventing excessive gestational weight gain, in a study from Cornell University (Am. J. Obstet. Gyn. 2004;19:530–6).

The methods used were intentionally designed to be reasonable to implement in clinical practice, and included monitoring of and education about gestational weight gain by health care professionals during prenatal visits and a series of educational mailings sent to patients with healthy eating and exercise tips, a self-monitoring guide, and a monthly motivational newsletter.

Dr. Donna R. Halloran noted that the risk of postterm delivery can be reduced if overweight/obese women restrict their pregnancy weight gain to a normal range. SAINT LOUIS UNIVERSITY

Women who are overweight or obese at the time of conception are at increased risk for a postterm delivery, but that risk can be reduced if they restrict their pregnancy weight gain to a normal range, according to findings from a large database study.

Birth injury, meconium aspiration, cesarean delivery, and other complications have been linked to delivery beyond term, explained Dr. Donna R. Halloran, a St. Louis University pediatrician who presented the study results at the Southern regional meeting of the American Federation for Medical Research in New Orleans.

Researchers examined birth records linked to hospital discharge data for term singleton infants born at 42 weeks' gestation or beyond in Missouri over a 6-year period, collecting data on 8,542 postterm births to mothers without a history of diabetes, chronic hypertension, or a previous cesarean section.

After adjustment for maternal ethnicity, age, education, parity, tobacco history, Medicaid status, and infant sex, the odds of a postterm delivery were substantially elevated among mothers who were overweight (adjusted odds ratio, 1.12) or obese (adjusted odds ratio, 1.19) if they were overweight or obese at the time they became pregnant.

“The obesity epidemic is clearly having a detrimental impact on the health of this country, and pregnant women are no exception,” she said in an interview following the meeting. “Unfortunately, most women do not get preconceptual care.

“What we were pleased to find was that even if you are overweight or obese when the pregnancy begins, gaining an appropriate amount of weight (versus too much weight) reduces your risk of certain complications, specifically a postterm delivery.”

Indeed, this potential revision of risk occurred regardless of prepregnancy weight, whereas women gaining more than the recommended weight during pregnancy were 1.24 times more likely to be delivered post term.

Institute of Medicine (IOM) guidelines recommend a pregnancy weight gain of 28–40 pounds if a woman has a BMI of less than 19.8 kg/m₂, 25–35 pounds for women with BMIs between 19.8 kg/m₂ and 26 kg/m₂, and 15–25 pounds for a woman with a prepregnancy BMI of 26 kg/m₂ or greater.

Unfortunately, overweight and obese women in the Missouri study were more likely than thinner women to exceed IOM weight guidelines during pregnancy.

More than half of the 91,843 women with prepregnancy BMIs between 25 kg/m₂ and 29.9 kg/m₂ gained more than the amount recommended by the IOM, and 44% of the 31,147 with BMIs greater than 30 kg/m₂ gained more than 25 pounds during pregnancy.

About 20% of these women were delivered post term if they were nulliparous and nearly 15% if they were multiparous, the study showed.

Physicians can help to reverse the trend of increasing postterm deliveries, even among women who are overweight or obese at conception, said Dr. Halloran.

“There are safe ways to stay healthy and limit weight gain during pregnancy.” She pointed to several studies demonstrating the effectiveness of patient education and guidance about healthy eating, exercise, and the risks associated with excessive weight gain.

Ironically, one study conducted at the University of Pittsburgh suggested less may be more with regard to interventions with overweight women, Dr. Halloran said (Int. J. Obes. Relat. Metab. Disord. 2002;26:1494–502).

In this randomized controlled study, increasingly intensive interventions as women gained weight during pregnancy were effective in limiting the percentage of normal-weight women who exceeded IOM weight guidelines, but in overweight women, 32% more exceeded weight guidelines in the intervention group than in the control group.

A simpler series of interventions was found to be effective with both overweight and normal-weight lower-income women in preventing excessive gestational weight gain, in a study from Cornell University (Am. J. Obstet. Gyn. 2004;19:530–6).

The methods used were intentionally designed to be reasonable to implement in clinical practice, and included monitoring of and education about gestational weight gain by health care professionals during prenatal visits and a series of educational mailings sent to patients with healthy eating and exercise tips, a self-monitoring guide, and a monthly motivational newsletter.

Dr. Donna R. Halloran noted that the risk of postterm delivery can be reduced if overweight/obese women restrict their pregnancy weight gain to a normal range. SAINT LOUIS UNIVERSITY

Maternal obesity is associated with a significantly increased risk of fetal structural anomalies, including neural tube defects and cardiac malformations, according to a meta-analysis.

The risk for some of these anomalies also was elevated among women who were overweight but not obese. Future studies should investigate whether there is a dose-response relationship between maternal weight and risk of structural abnormalities, said Katherine J. Stothard, Ph.D., and her associates at Newcastle University, Newcastle upon Tyne, England (JAMA 2009;301:636–50).

The researchers reviewed 39 relevant articles in the English literature and performed a meta-analysis of 18 of those that were the most scientifically sound, excluding studies with fewer than 150 cases of a particular congenital anomaly and studies of abnormalities that were chromosomal or syndromic in origin.

The investigators included cases in which pregnancies were terminated when congenital anomalies were discovered.

Compared with mothers at recommended body weights, obese mothers were nearly twice as likely to have a pregnancy affected by neural tube defects, including spina bifida and anencephaly. Their risk ranged from 1.2 to 1.7 times to have a fetus with a cardiovascular anomaly such as a septal defect, a facial malformation such as cleft palate or cleft lip, or other anomalies including anorectal atresia, hydrocephaly, and limb reduction.

Some types of anomalies could not be examined in this meta-analysis because the studies of those defects were not sufficiently powered to detect significant effects.

However, the literature review showed that the association with maternal obesity approached significance for omphalocele, craniosynostosis, and simultaneous multiple anomalies.

Both neural tube defects and cardiac anomalies also were more likely to occur in mothers who were overweight but not frankly obese. Future studies should assess structural congenital anomalies across “the complete range of [body mass index],” Dr. Stothard and her associates said.

“It is notable that many of the congenital anomalies implicated in this review have similar developmental timing and responsiveness to folic acid, suggesting a common underlying etiology,” they added.

Dr. Stothard received funding from BDF Newlife.

Maternal obesity is associated with a significantly increased risk of fetal structural anomalies, including neural tube defects and cardiac malformations, according to a meta-analysis.

The risk for some of these anomalies also was elevated among women who were overweight but not obese. Future studies should investigate whether there is a dose-response relationship between maternal weight and risk of structural abnormalities, said Katherine J. Stothard, Ph.D., and her associates at Newcastle University, Newcastle upon Tyne, England (JAMA 2009;301:636–50).

The researchers reviewed 39 relevant articles in the English literature and performed a meta-analysis of 18 of those that were the most scientifically sound, excluding studies with fewer than 150 cases of a particular congenital anomaly and studies of abnormalities that were chromosomal or syndromic in origin.

The investigators included cases in which pregnancies were terminated when congenital anomalies were discovered.

Compared with mothers at recommended body weights, obese mothers were nearly twice as likely to have a pregnancy affected by neural tube defects, including spina bifida and anencephaly. Their risk ranged from 1.2 to 1.7 times to have a fetus with a cardiovascular anomaly such as a septal defect, a facial malformation such as cleft palate or cleft lip, or other anomalies including anorectal atresia, hydrocephaly, and limb reduction.

Some types of anomalies could not be examined in this meta-analysis because the studies of those defects were not sufficiently powered to detect significant effects.

However, the literature review showed that the association with maternal obesity approached significance for omphalocele, craniosynostosis, and simultaneous multiple anomalies.

Both neural tube defects and cardiac anomalies also were more likely to occur in mothers who were overweight but not frankly obese. Future studies should assess structural congenital anomalies across “the complete range of [body mass index],” Dr. Stothard and her associates said.

“It is notable that many of the congenital anomalies implicated in this review have similar developmental timing and responsiveness to folic acid, suggesting a common underlying etiology,” they added.

Dr. Stothard received funding from BDF Newlife.

Maternal obesity is associated with a significantly increased risk of fetal structural anomalies, including neural tube defects and cardiac malformations, according to a meta-analysis.

The risk for some of these anomalies also was elevated among women who were overweight but not obese. Future studies should investigate whether there is a dose-response relationship between maternal weight and risk of structural abnormalities, said Katherine J. Stothard, Ph.D., and her associates at Newcastle University, Newcastle upon Tyne, England (JAMA 2009;301:636–50).

The researchers reviewed 39 relevant articles in the English literature and performed a meta-analysis of 18 of those that were the most scientifically sound, excluding studies with fewer than 150 cases of a particular congenital anomaly and studies of abnormalities that were chromosomal or syndromic in origin.

The investigators included cases in which pregnancies were terminated when congenital anomalies were discovered.

Compared with mothers at recommended body weights, obese mothers were nearly twice as likely to have a pregnancy affected by neural tube defects, including spina bifida and anencephaly. Their risk ranged from 1.2 to 1.7 times to have a fetus with a cardiovascular anomaly such as a septal defect, a facial malformation such as cleft palate or cleft lip, or other anomalies including anorectal atresia, hydrocephaly, and limb reduction.

Some types of anomalies could not be examined in this meta-analysis because the studies of those defects were not sufficiently powered to detect significant effects.

However, the literature review showed that the association with maternal obesity approached significance for omphalocele, craniosynostosis, and simultaneous multiple anomalies.

Both neural tube defects and cardiac anomalies also were more likely to occur in mothers who were overweight but not frankly obese. Future studies should assess structural congenital anomalies across “the complete range of [body mass index],” Dr. Stothard and her associates said.

“It is notable that many of the congenital anomalies implicated in this review have similar developmental timing and responsiveness to folic acid, suggesting a common underlying etiology,” they added.

Dr. Stothard received funding from BDF Newlife.