Utah Women's Health Review - UHR Volume 12 SUPPLEMENT (2007)

UH Review Utah's Health: An Annual Review Special Supplement: Women's Health in Utah June 2007 Utah's Health: An Annual Review Special Supplement on Women's Health Editorial Advisory Board Patricia Aikins Murphy, CNM, DrPH College of Nursing Laurie Baksh, MPH Department of Health Susanne Cusick, BS Utah Health Research Network Caren J. Frost, PhD, MPH College of Social Work Anke-Peggy Holtorf, PhD, MBA College of Pharmacy Shaheen Hossain, PhD Department of Health Mary McFarland, BA Eccles Health Sciences Library Michael Varner, MD School of Medicine Editorial Coordinator Emogene Grundvig, MSW College of Social Work Special thanks to Emogene fo r helping to fo rm a t and edit the fin a l version but also fo r w ritin g a number o f reports. COEDP Program Coordinator Leanne Johnston School of Medicine Liaison with Utah's Health Brooke Elizabeth Musat Peer Reviewers Patricia Aikins Murphy College of Nursing Laurie Baksh Department of Health Joanna Bettmann College of Social Work Caren Frost College of Social Work Shaheen Hossain Utah Department of Health Yvette LaCoursiere School of Medicine Angie Stefaniak Center For Public Policy Michael Varner School of Medicine Acknowledgements Thank you to all the Department o f Health personnel who p rovid ed assistance to many authors in locating data fo r their reports. Thank you to Dean Jannah H. Mather, Ph.D. o f the College o f Social Work fo r making Ms. Grundvig available to this project. Thank you to Dr. Richard Sperry f o r his support o f this project. UTAH'S HEALTH: An Annua l Review Volume 12: Supplement Women's Health in Utah http://uuhsc.utah.edu/coe/womenshealth uThe University of Utah National Center of Excellence in Women's Health Demonstration Project Region VIII Promote ■ Prevent ■ Protect Utah Department of Health Utah's Health: An Annual Review - Special Supplement: Women's Health in Utah The University of Utah National Center o f Excellence In Womens Health Demonstration Project Region VIII University o f Utah Health Sciences Center 30 North 1900 East Room 2B-111, Salt Lake City, Utah 84132 © 2007 The University of Utah. AH Rights Reserved I am pleased to announce the publication of the Women's Health supplement to the Utah's Health Review. Women's Health provides a current profile of women's health issues in our state. Dating from pioneer times, Utah has had a long tradition of commitment to women's health. Early women providers were remarkable: Martha Hughes Cannon was one of the first physicians in the state and also the first woman state senator. Ellis R. Shipp, the first obstetrician in Utah, also founded a school for obstetrics and nurse midwives. Romania Rose Prat Penrose not only established health care for women and children, but was also the first trained ophthalmologist in Utah. Today, we have no less of a commitment to women's health. The University of Utah's National Center of Excellence in Women's Health Demonstration Project, in collaboration with the Utah State Department of Health, has produced a comprehensive report detailing women's health issues in Utah. This report provides a collection of current data on some of the most pressing health challenges facing women and their families today. Women's Health will aid in identifying priorities for research and health care services in Utah. Within the pages of the Women's Health supplement are numerous data reports on women's health. Topics include cancer, domestic violence, mental health, abortion, cardiovascular disease, and reproductive health. Also included in the review is a collection of original research articles. Highlighted are diverse topics such as the consequences of obesity, headache, sexual abuse, prescription drug use among Medicaid patients, induction of labor, periodontal disease, etc. A study of the impact of immigrants on our health care system underscores new challenges that face our state. Health disparities can only be remedied if they are recognized. This report provides in formation to help track the health behaviors, risk factors, and health care utilization practices of women in Utah. Much of our ability to generate accurate data for the promotion of health research, policy development, and health care reforms to benefit the citizens of Utah comes from our state's online Indicator-Based Information Query System (IBIS). We are proud of the continued collaboration between the University of Utah and the Utah Department of Health that has produced the information contained within these monographs. So, it is with great excitement that we offer the 2007 Women's Health supplement to the Utah Health Review to you to read, share, discuss, analyze, and utilize. David N. Sundwall, MD Executive Director Utah D epartment of Health Utah Department of Health Utah's National Center of Excellence in Women's Health Demonstration Project is proud to work with the Utah State Health Department to produce a supplementary volume on Women's Health in the State of Utah to accompany the annual Utah's Health Review. The National Centers of Excellence in Women's Health were founded by the Office on Women's Health in the United States Department of Health and Human Services in 1996 to promote women's health across the life span. The model promotes a dynamic change in women's health by linking academic programs across medical specialties and disciplines to improve clinical care for women, promote research in women's health issues, improve education for health care providers, encourage programs to serve the under served, and promote women to leadership positions in Academic Health Centers. The University of Utah joined the program in 2005 and immediately partnered with all of the Schools in the Health Sciences as well as many of the Colleges on Main Campus, and with the State Health Department's Women and Child Health Division to achieve a multi-disciplinary thrust to improve the health of women in our State. Our goal is to connect women to wellness. The symbol that we have chosen is a woman holding the "eternal knot"-one of the auspicious symbols of the inter-connectivity of all things-including health. We see this supplement as a beginning. While there are obvious gaps in our knowledge, we have tried to assemble topics that are timely and helpful. We hope that this report will spur further interest and collaborations across our State institutions and Universities to increase understanding of the complexity of issues facing the health of women of Utah. The research working group of the Center of Excellence - under the skillful guidance of Patricia Aikins Murphy, CNM, DrPH, FACNM who holds The Annette Poulson Cumming Endowed Chair in Women's and Reproductive Health, College of Nursing - has produced an excellent start at benchmarking women's health in 2007 for the State of Utah. This report brings up further needs for data collection and it is our hope to produce periodic updates on the state of health of the women of Utah. Kathleen Digre, MD Director, On behalf of Region VIII National Center of Excellence in Women's Health Demonstration Project, University of Utah Yvette LaCoursiere, MD, MPH Co-Director, CoE, Director of Outreach Patricia Aikins Murphy, CNM, DrPH, FACNM, Director o f Research Lynne Durrant PhD, College of H ealth, Co-Director of Outreach Jennifer Van Horn, MD, School o f Medicine, Co-Director of Clinical Services Leissa Roberts, CN!M, Co-Director of Clinical Services Stephanie Richardson, RN, PhD, Director of Professional Education Kirtly Jones MD, Co-Director o f Professional Education Nicole Mihalopoulos, MD, MPH, Director of Adolescent Girls Health Nancy Lombardo, MLS, Sally Patrick, T. Elizabeth Workman, MLIS, Eccles H ealth Sciences Library Leanne Johnston, CoE Coordinator Michael Varner, MD Evaluator Editor's Note We are pleased to release this special supplement on women's health in Utah as part of the 12th volume of Utah's Health: An Annual R ev iew : Special Supplement on Women's Health in Utah. The editorial board and contributors represent an interdisciplinary group of students, faculty, researchers from the University of Utah, personnel from the Utah Department of Health, and interested advocates for women's health. This special supplement speaks to the interest in and dedication to women's health that can be found within our state. This supplement has three sections: Original R esearch an d R eview s touch on a variety of topics that impact women's health, from obesity to prescription drug use to headaches and reproductive health issues. The Special Topics section addresses the impact of immigrants on the health care system. Because data on women immigrants and their impact on the state's health care system are difficult to find, this paper is not specific to the women of Utah. However it provides background that can easily be extrapolated to suggest the effects of immigration within the state. Information about the health of refugee women is similarly difficult to obtain; the brief data page represents initial efforts to collate information from a variety of agencies serving this community in Utah. We hope that this preliminary presentation of issues and data will encourage interested parties in the state to begin the process of collecting comprehensive data to address this topic. The Women's Health Data Reports look at a variety of topics that reflect women's health concerns. We have tried in assembling these pages to go beyond typical emphasis on physical health conditions and have also included aspects of social health that impact Utah women's lives. Some important topics, such as osteoporosis and bone health, are missing because of the difficulty in finding data to describe them. Others may be missing because of limitations of space and authorship; such topics will be periodically addressed on the University of Utah National Center of Excellence in Women's Health Demonstration Project's website at http://uuhsc.utah.edu/coe/womenshealth/. Many deserve credit for this effort. It would not have been possible without the successful partnership between the University of Utah National Center of Excellence in Women's Health Demonstration Project and the Utah Department of Health, the hard work of the editorial board, and the dedication of the contributors. We are grateful to the editorial board of Utah's Health: An Annual R ev iew for the opportunity to provide our women's health supplement for this year's review. We hope to continue this work on a regular basis, and plan future volumes that will address specific issues in women's health, such as health of Latina and Native American women, as well as special topics such as aging and adolescent health. Patricia Aikins Murphy, CNM., DrPH and the Editorial Advisory Board Authors and Contributors Patricia Aikins Murphy, CNM DrPH, is an Associate Professor in the College of Nursing and the director of research for the National Centers of Excellence in Women's Health Demonstration Project at the University of Utah. Jose Abarca, BSW, is a graduate student in the College of Social Work and a Research Assistant with the Utah Criminal Justice Center. Laurie Baksh, MPH, is the PRAMS Data Manager at the Utah Department of Health. Susan Baggaley, MS, FNP, is in the Department of Neurology at the University of Utah and has a research interest in headaches. Janelle Bassett, RN, is a doctoral student in the College of Nursing. Craig Beck is a student in the traditional baccalaureate program at the University of Utah College of Nursing. Lois Bloebaum, BSN, MPA, is the Manager of the Reproductive Health Program in the Maternal and Child Health Bureau at the Utah Department of Health. Diana Brixner, RPh, PhD, is currently Associate Professor and Chair of the Department of Pharmacy Practice at the University of Utah College of Pharmacy in Salt Lake City. She is also Executive Director of the Pharmacotherapy Outcomes Research Center, affiliated with the University of Utah Health Sciences Center Kirsten D. Bradley, BS, is a graduate of the Health Promotion and Education program and first-year medical student at the University of Utah. Stephanie Chambers, BS, is a medical student and co-president of the Women's Health Interest Group at the University of Utah School of Medicine. Kristin G. Cloyes, PhD, RN, is an Assistant Professor in the College of Nursing and faculty member of the Utah Criminal Justice Center. Susanne Cusick, BS, is the research manager for the Utah Health Research network. Kathleen Digre, MD, is a Professor of Neurology and Ophthalmology, an adjunct professor of Obstetrics & Gynecology, and the Director of the National Center of Excellence in Women's Health Demonstration Project at the University of Utah Jane M. Dyer, CNM, FNP, MS, MBA, is an Assistant Professor in the College of Nursing and the Director of the Nurse Midwifery and Women's Health Nurse Practitioner Program. Caren J. Frost, PhD, MPH is a Research Associate Professor in the College of Social Work. She is Director of International Social Work Education and Chair of the Health Domain for the Masters of Social Work Program. Dianne Fuller, RN, MSN, FNP-C is an Assistant Professor at the University of Utah College of Nursing and Executive Director of Salt Lake Sexual Assault Nurse Examiners. Emogene Grundvig, MSW, recently received her Master of Social Work from the University of Utah. Her previous educational and work experiences have been in criminal justice, and she currently specializes in the treatment of sexual offenders, and victims of abuse. Candace Hayden, CCRC, BS, is a full time graduate student in the Master of Science in Public Health program at the University of Utah as well as a Clinical Research Coordinator at the Huntsman Cancer Institute. Holly Hilton, BS, is a graduate assistant for the Center of Public Policy and Administration and a graduate student in the Master's of Public Policy program at the University of Utah. Anke-Peggy Holtorf, PhD MBA, is a Visiting Assistant Professor at the College of Pharmacy in the Pharmacotherapy Outcomes Research Center. Shaheen Hossain, PhD, is the Maternal and Child Health Epidemiologist and Manager of the Data Resources Program in the Maternal and Child Health Bureau at the Utah Department of Health. Srichand Jasti, M.E., M.Stat., is an Associate Instructor, in the College of Nursing at University of Utah Brent Jeffries, Pharm.D. Candidate, is a student of the University of Utah College of Pharmacy. Sarah E Johnson, BS, is a pre-medical student at the University of Utah, with a strong interest in women's health policy and contraceptive access. Jason Kidde, MS, is an Exercise Specialist in the Skeletal Muscle Exercise Research Facility, University of Utah, Division of Physical Therapy D. Yvette LaCoursiere, MD, MPH, is an Assistant Professor in the Department of Obstetrics and Gynecology and Deputy Director and Director of Community Outreach and Public Education for the National Center of Excellence in Women's Health Demonstration Project at the University of Utah. Joanne LaFleur, PharmD, MSPH, is a Research Assistant Professor in the University of Utah College of Pharmacy in the Department of Pharmacotherapy. Timothy E. Lane, BS, LEHS, is the Manager of the Sexually Transmitted Disease Control Program, Utah Department of Health. Barbara A. Larsen, MPH, RD, is the Program Manager for the Heart Disease and Stroke Prevention Program at the Utah Department of Health. Robin Marcus, PT, PhD, is a Clinical Associate Professor in the Division of Physical Therapy, and a BIRCWH Scholar in the Department of Obstetrics and Gynecology at the University of Utah. Angeni Marque, BS, is a Research Analyst in Data Resources Program, Maternal and Child Health Bureau at the Utah Department of Health. CarrieAnn McBeth, PharmD, is a Clinical Pharmacist at the University of Utah Drug Regimen Review Center . JoAnne McGarry is the PRAMS Operations Manager at the Utah Department of Health Bruce P. Murray, PhD, FACHE, CAE, is the Program Manager for Family Dental Plan, Bureau of Clinical Services, Division of Health Systems Improvement, at the Utah Department of Health. Sally M. Patrick, M.L.S., is the Outreach Librarian for the Spencer S. Eccles Health Sciences Library and Project Director for Utahealthnet, a National Library of Medicine funded project creating a gateway to consumer health information for Utah. Jennifer Paynter is a student in her last semester in the traditional baccalaureate nursing program at the University of Utah. Robert Satterfield, MStat, is an Epidemiologist in Data Resources Program, Maternal and Child Health Bureau at the Utah Department of Health. David Servatius works as a research data analyst for the University of Utah Drug Regimen Review Center (DRRC) and Pharmacotherapy Outcomes Research Center. Sara Ellis Simonsen, RN, MSPH , is a Research Associate and doctoral student in the Public Health Program at the University of Utah. Lori Smith, LCSW, is a Children's Mental Health Promotion Specialist at the Bureau of Maternal and Child Health, Child Adolescent and School Health Program, Utah Department of Health. Joseph Stanford, MD, MPSH, is Associate Professor in the Public Health Program at the University of Utah and Director of the Family Medicine Research Fellowship. Steven Steed, DDS, is the State Dental Director of the Oral Health Program in the Maternal and Child Health Bureau at the Utah Department of Health. Angie Stefaniak, MPA, is program manager for the Master of Public Policy program and a policy analyst for the Center for Public Policy and Administration at The University of Utah. Nan Streeter, MS, RN , is the Director of the Bureau of Maternal and Child Health at Utah Department of Health. Gretchen Tietjen, MD, is Professor and Chair of Neurology at the University of Toledo College of Medicine. She is interested in the long term effects of maltreatment on women's health. J. Anne Tumsatan, BA, is an undergraduate student at the University of Utah. The Utah Sexual Assault Safety Project is a coalition of health and advocacy groups in the state that is concerned with treatment and care of victims of sexual assault. Michael Varner, MD, is a Professor of Obstetrics and Gynecology in the Division of Maternal Fetal Medicine at the University of Utah. Richard O. Woodward, DDS, is a practicing dentist for Family Dental Plan, Bureau of Clinical Services, Division of Health Systems Improvement, at the Utah Department of Health. T. Elizabeth Workman, MLIS, is Associate Librarian at the Spencer S. Eccles Health Sciences Library, University of Utah. Karen Zinner, MPH, is a Data Analyst in Data Resources Program, Maternal and Child Health Bureau at the Utah Department of Health. Table of Contents Introductions David Sundwall, MD, Director, Utah DOH iii Kathleen Digre, MD, and the CoE Women's Health Demo Project iv Editor's Note v Original Research and Reviews Consequences of Obesity on Women's Health 2 Yvette D. LaCoursiere, MD, MPH Headache and Sexual Abuse in Women in a Headache Clinic in Utah 9 Stephanie Chambers, BS; Kathleen Digre, MD; Srichand Jasti, ME, MStat; Susan Baggaley, MS, FNP; Gretchen Tietjen, MD Labor Induction Trends in Utah and a Comparison of Maternal and Neonatal Outcomes among Induced Deliveries without an Identified Medical Indication 22 Shaheen Hossain, PhD; Nan Streeter, MS, RN; Robert Satterfield, MStat; Lois Bloebaum, MPA; Angeni Marque, BS Periodontal Disease and the Risk ofAdverse Pregnancy Outcomes: Part I: A Review of Current Literature 34 Bruce P. Murray, PhD, FACHE, CAE; Shaheen Hossain, PhD; Richard O. Woodward, DDS; Robert Satterfield, MStat; Karen Zinner, MPH. Periodontal Disease and the Risk ofAdverse Birth Outcomes: Part II: The Results of a Pilot Study 45 Shaheen Hossain, PhD; Bruce P. Murray, PhD; Robert Satterfield, MStat; Richard O. Woodward, DDS; Karen Zinner, MPH; Nan Streeter, MS, RN; Steven Steed, DDS; Lois Bloebaum, MPA; Angeni Marque, BS Prescription Drug Use by Women and Men in Utah Medicaid 57 Anke-Peggy Holtorf, PhD, MBA; Joanne LaFleur, PharmD, MSPH; David Servatius; Brent Jeffries, PharmD Candidate; Diana Brixner, RPh, PhD Table of Contents Special Topics: Focus on Immigrants and Refugees The Impact of Preventive Care: Public Health Policy Affecting Undocumented Immigrants 72 Kirsten D. Bradley, BS Female Refugee Health Status in Utah, 2007 82 Jennifer Paynter Women's Health Data Reports Utah and U.S. Women's General Demographics | Karen Zinner 86 Utah Women and Cardiovascular Disease Stroke in Women | Susanne Cusick, Barbara Larsen 88 Heart Disease in Women | Barbara Larsen 91 Cholesterol Awareness | Craig Beck 94 Statin Treatment of Diabetic Patients in Utah Medicaid | Anke-P. Holtorf, Joanne LaFleur, David 97 Servatius, Brent Jeffries, CarrieAnn McBeth, Diana Brixner Utah Women and Cancer Breast Cancer | Candace Hayden 100 Cervical Cancer | Candace Hayden 102 Colorectal Cancer | Candace Hayden 104 Endometrial Cancer | Candace Hayden 106 Lung Cancer | Candace Hayden 109 Ovarian Cancer | Candace Hayden 111 Utilization of Mammogram Screening and Pap Tests | Karen Zinner 113 Utah Women and Mental Health Depression among Older Women | Emogene Grundvig 116 Mental Illness and Women | Lori Smith 119 Postpartum Depression | Joanne McGarry 123 Suicide | Emogene Grundvig 126 Suicide in Later Years | Emogene Grundvig 128 Women, Incarceration and Serious Mental Illness in Utah State Prison System | Kristin G. Cloyes, Jose 130 Abarca, Emogene Grundvig, Janelle Bassett Table of Contents Utah Women and Perinatal Health Race and Low Birth Weight in Utah | Jane M. Dyer 134 Preterm Birth | Sara Ellis Simonsen, Michael Varner 137 Prenatal Care in the First Trimester | Karen Zinner 140 Obesity and Pregnancy | Laurie Baksh 143 Fetal Deaths | Shaheen Hossain 145 Maternal Mortality | Lois Bloebaum 147 Utah Women and Reproductive Health Unintended Pregnancy | Laurie Baksh 149 Adolescent Births | Karen Zinner 151 Infertility in Utah, 2004 - 2005 | Joseph Stanford, Sara Ellis Simonsen, Laurie Baksh 153 Access to Contraceptives in Utah | Sarah E. Johnson 158 Abortion | Holly Hilton 160 Emergency Contraception in Utah | Angie Stefaniak 163 Chlamydia and Gonorrhea | J. Anne Tumsatan, Timothy E. Lane 166 Utah Women and Violence Rape and Sexual Violence against Women in Utah | Dianne Fuller, Emogene Grundvig 169 Appropriate Services for Rape Victims in Utah Hospitals | Patricia Murphy for the Utah Sexual Assault 171 Safety Project Dating Violence | Emogene Grundvig 173 Elder Abuse | Emogene Grundvig 175 Domestic Violence | Emogene Grundvig 177 Utah Women and Health Risk Factors Obesity in Women | Laurie Baksh 179 Insurance Coverage among Utah Women | Lois Bloebaum 181 Falls and Fall-Related Injuries | Jason Kidde, Robin Marcus 184 Smoking | Karen Zinner 187 Chronic Alcohol Consumption | Karen Zinner 189 HIV/AIDS | J. Anne Tumsatan 191 Women and Diabetes | Lois Bloebaum 194 Women's Health Information and Services 197 T. Elizabeth Workman, Sally Patrick Utah's Health: An Annual Review | Special Supplement: Women's Health in Utah Original Research and Reviews Utah Department of Health 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Consequences of Obesity on Women's Health Yvette D. LaCoursiere, MD, MPH CORRESPONDENCE: Department of Obstetrics & Gynecology University of Utah Obesity among women of reproductive age is a major health threat in the United States and contributes to the overall morbidity, mortality and costs associated with overweight and obesity. In the year 2000, 117 billion dollars in health care costs and 300,000 deaths were attributed to obesity (Allison, Fontaine, Manson, Stevens, & VanItallie, 1999; Centers for Disease Control and Prevention). Body mass index (BMI), the most commonly used measure to define obesity, is calculated by dividing a woman's weight in kilograms by her height in meters squared. The International Obesity Task Force defined overweight and obesity using the following classification of body mass index (BMI, defined as kg/m2): <19 underweight, 19-24.9 normal weight, 25-29.9 overweight, 30­34.9 class I obesity, 35-39.9 class II obesity, and >40 class III obesity. (International Obesity Task Force, 1998) Using this classification system, over 127 million American adults are overweight (BMI>25), 60 million are obese (BMI>30), and 9 million are severely obese (BMI>40) (American Obesity Association). For the first time in over twenty years the number of obese women nationwide did not increase; however the majority of adult American women are still overweight or obese (Ogden et al., 2006). In 2003-2004, 62% of women were overweight or obese, 33% were obese, and 7% were severely obese (Ogden et al., 2006). This is significantly higher than the NHANES data from 1988-94, where the rates were 50%, 26%, and 4.0 % respectively (Flegal, Carroll, Kuczmarski, & Johnson, 1998; Flegal, Carroll, Ogden, & Johnson, 2002). Overweight and obesity have long been known to increase the risk and severity of many chronic diseases including type 2 diabetes mellitus, cardiovascular disease, hypertension and arthritis (Field et al., 2001). Table 1 provides a list of the major morbidities associated with obesity. While this list of health consequence associated with obesity is extensive, the most dire consequence, mortality, is also increased. The Nurses' Health Study prospectively studied over 116,000 women who were disease free at enrollment for 24 years. All cause and disease specific mortality increased in this population with increasing BMI, even after controlling for age, smoking, family history, menopausal status, activity and alcohol consumption (Hu et al., 2004). Obese women, when compared to lean women, are more likely to suffer from endometrial cancer, breast cancer, stress urinary incontinence, gall bladder disease and depression (American Obesity Association, 2002). Also, they are less likely to participate in health care maintenance activities, such as mammograms and gynecologic exams, which may delay the identification of disease and may worsen prognosis (Fontaine, Heo, & Allison, 2001). 2 Obesity © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Table 1 Morbidities Associated with Obesity Type II Diabetes Renal Cancer Cardiovascular Disease Gallbladder Disease Hypertension Stress Urinary Incontinence Hyperlipidemia Menstrual Irregularities Arthritis Carpal Tunnel Syndrome Postmenopausal Breast Cancer Sleep Apnea Endometrial Cancer Asthma Gastrointestinal Cancer Depression and poor QOL There has been little attention paid to the complications of obesity in women of reproductive age. While obesity complications of pregnancy have been studied, significantly less attention has been paid to postpartum and long­term complications in these women. (The paucity of research during the puerperium is not limited to obese women.) National studies which identify trends in body mass indices, including the National Health and Nutrition Examination Survey (NHANES) and the Behavioral Risk Factor Surveillance System specifically exclude pregnant women from their analyses (Flegal et al., 2002; Freedman, Khan, Serdula, Galuska, & Dietz, 2002). Several studies have shown that obese pregnant women are at increased risk for adverse pregnancy outcomes including gestational diabetes, pre-eclampsia, macrosomia, fetal anomalies, intrauterine fetal demise, early neonatal death, induction, cesarean delivery, postpartum hemorrhage, and infection (Cnattingius, Bergstrom, Lipworth, & Kramer, 1998; Ehrenberg, Dierker, Milluzzi, & Mercer, 2002; Jensen et al., 2003; Lu et al., 2001; Sebire et al., 2001; Watkins, Rasmussen, Honein, Botto, & Moore, 2003). To explore the impact of overweight and obesity during pregnancy in Utah, birth certificate data from 1991 to 2001 were analyzed. Maternal obesity, as defined by the proportion of women with a BMI greater than 30 at delivery has increased nearly 40% over this past decade in Utah (D.Y. LaCoursiere, Bloebaum, Duncan, & Varner, 2004). (See figure 1). A similar increase in the percent of women who were overweight (BMI >25) or obese (BMI >30) prior to pregnancy has also been identified (D.Y. LaCoursiere et al., 2004). In 2001, 40.2% of women were overweight or obese before delivery. The attributable fraction of cesarean delivery in the overweight and obese was 0.388 (95% CI: 0.369 - 0.407) (D. Y. LaCoursiere, Bloebaum, Duncan, & Varner, 2005). This means that after controlling for other factors, nearly 40% of cesarean deliveries in the overweight and obese are due to increased maternal weight. Statewide, among all women having a cesarean in 2001, 1 in 7 is attributable to © 2007 The University of Utah. All Rights Reserved Obesity 3 2007 UTAH'S HEALTH: AN ANNUAL REVIEW overweight and obesity. Cesarean delivery rates are shown in figure 2 for women with and without risk factors of diabetes and hypertension. Increases in preeclampsia have also been seen with the rise in maternal overweight and obesity over this same decade (see figure 3). While much of the above information reflects poor outcomes associated with a woman's weight before pregnancy, excess maternal weight gain during pregnancy also increases the risk of adverse outcomes. The chance of Cesarean delivery, preeclampsia and birth weight over 4000 grams all increase with excessive maternal weight gain in pregnancy. 22 In fact, 40% of women who gain over 35 lbs during their pregnancy are delivered by primary Cesarean delivery (see figure 4). Utah data have also been used to investigate the association between obesity and postpartum depressive symptoms. To do so we explored the Pregnancy Risk Assessment Monitoring System (PRAMS), a project sponsored by the Centers for Disease Control and Prevention (CDC). PRAMS is a population-based survey of maternal attitudes and experience from preconception through the postpartum period. (Centers for Disease Control and Prevention). The Utah Department of Health (UDOH) participates in this project. One of the questions pertains to the woman's postpartum mood. She is asked "In the months after your delivery, would you say that you were- Not depressed at all, A little depressed, Moderately depressed, Very Depressed, Very depressed and had to get help?" The response to this question and questions pertaining to stressors were stratified by prepregnancy body mass index. There were 3,439 women included in the analysis. Among overweight and obese women, there was a trend toward more partner associated stress (p=0.057) and they were more likely to report emotional (p<0.001) and traumatic stress (p<0.001). When stratified by BMI categories, the prevalence of moderate or greater depressive symptoms increases at the extremes of BMI (figure 4). After controlling for marital status and income, prepregnancy obesity (BMI>30) was associated with greater than moderate postpartum depressive symptoms (adjusted odds ratio 1.53 [95% CI:1.15 - 2.02]) (D. Y. Lacoursiere, Baksh, Bloebaum, & Varner, 2006). While limited in its evaluation of depressive symptoms, this database supports the possibility that obese women could be at greater risk for maternal stressors and postpartum depression. Currently a larger prospective study, funded by the National Institutes of Health, is being conducted in our state. There have been recent studies presenting interesting information on obesity and breast feeding (Oddy et al., 2006) (Li et al., 2005). Increased prepregnancy BMI is associated with shorter breastfeeding duration (Oddy et al., 2006). Maternal obesity and short duration of breast feeding are additive risk factors for childhood overweight (Li et al., 2005). Recently, biologic data support this epidemiologic association between obesity and short duration of breastfeeding. Increased prepregnancy BMI predicts a lower prolactin response to suckling at 48 hours. Prolactin is responsible for stimulating milk production and thus a decrease in responsiveness could lead to a diminished ability to make milk and perhaps contribute to breastfeeding discontinuation (Rasmussen & Kjolhede, 2004). These studies lead to the possibility that an intervention to improve prepregnancy BMI and or maternal weight gain might improve a woman's ability to breastfeed. 4 Obesity © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Overweight and obesity significantly impact women's health. It affects two-thirds of all women nationwide. . Rates of overweight and obesity during pregnancy are increasing in Utah. Data from our state suggest that it is likewise influencing women's reproductive health outcomes. Overweight and obese Utah women are more likely to have gestational diabetes, preeclampsia, Cesarean delivery postpartum depression and large babies. Information also supports that overweight and obese women have more difficulty continuing to breastfeed. Maternal weight during pregnancy not only effects the woman's outcome, but also that of her child. While information is needed to prevent the untoward effects of increased BMI in women, even more data are necessary on primary prevention of obesity. Figure 1. Overweight and Obesity before Pregnancy, 1991-2001. Figure 2. Cesarean delivery rates by BMI strata and risks of Diabetes and Hypertension © 2007 The University of Utah. All Rights Reserved Obesity 5 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Figure 3. Incidence of preeclampsia, prevalence of BMI>25 and the attributable fraction of preeclampsia secondary to BMI>25. 35 30 25 20 15 10 I I £------5------5- I I 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 O Incidence o f Preeclampsia (%) O Prevalence o f Prepregnancy BMI >25 (%) ♦ AF PreEclampsia from BMI >25 Figure 4. Outcomes by Pregnancy Weight Gain 5 0 6 Obesity © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Figure 5. Percent with Postparum Depressive Symptoms by BMI Strata References Allison, D. B., Fontaine, K. R., Manson, J. E., Stevens, J., & Vanltallie, T. B. (1999). Annual deaths attributable to obesity in the United States. Jama, 282(16), 1530-1538. American Obesity Association. AOA fact sheets. from http://www.obesity.org/subs/fastfacts.obesity_US.shtml American Obesity Association. (2002). Obesity In The U.S. AOA fact sheets. from http://www.obesity.org/subs/fastfacts/obesity_women.shtml Centers For Disease Control and Prevention. Reproductive Health Information Sources, surveillance and research, pregnancy risk assessment monitoring system. http://www.cdc.gov/reproductivehealth/srv_prams.htm#1. Centers for Disease Control and Prevention. Preventing chronic diseases: investing wisely in health. Preventing obesity and chronic diseases through good nutrition and physical activity. http://www.cdc.gov/nccdphp/pe_factsheets/pe_pa.htm. Cnattingius, S., Bergstrom, R., Lipworth, L., & Kramer, M. S. (1998). Prepregnancy weight and the risk of adverse pregnancy outcomes. N Engl J Med, 338(3), 147-152. Ehrenberg, H. M., Dierker, L., Milluzzi, C., & Mercer, B. M. (2002). Prevalence of maternal obesity in an urban center. Am J Obstet Gynecol, 187(5), 1189-1193. Field, A. E., Coakley, E. H., Must, A., Spadano, J. L., Laird, N., Dietz, W. H., et al. (2001). Impact of overweight on the risk of developing common chronic diseases during a 10-year period. Arch Intern Med, 161(13), 1581-1586. Flegal, K. M., Carroll, M. D., Kuczmarski, R. J., & Johnson, C. L. (1998). Overweight and obesity in the United States: prevalence and trends, 1960-1994. Int J Obes Relat Metab Disord, 22(1), 39-47. Flegal, K. M., Carroll, M. D., Ogden, C. L., & Johnson, C. L. (2002). Prevalence and trends in obesity among U.S. adults, 1999-2000. Jama, 288(14), 1723-1727. Fontaine, K. R., Heo, M., & Allison, D. B. (2001). Body weight and cancer screening among women. J Womens Health Gend Based Med, 10(5), 463-470. © 2007 The University of Utah. All Rights Reserved Obesity 7 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Freedman, D. S., Khan, L. K., Serdula, M. K., Galuska, D. A., & Dietz, W. H. (2002). Trends and correlates of class 3 obesity in the United States from 1990 through 2000. Jama, 288(14), 1758-1761. Hu, F. B., Willett, W. C., Li, T., Stampfer, M. J., Colditz, G. A., & Manson, J. E. (2004). Adiposity as compared with physical activity in predicting mortality among women. N Engl J Med, 351(26), 2694-2703. International Obesity Task Force. (1998). Managing the global epidemic of obesity. Report of the WHO consultation on obesity, World Health Organization. Geneva. Jensen, D. M., Damm, P., Sorensen, B., Molsted-Pedersen, L., Westergaard, J. G., Ovesen, P., et al. (2003). Pregnancy outcome and prepregnancy body mass index in 2459 glucose-tolerant Danish women. Am J Obstet Gynecol, 189(1), 239-244. Lacoursiere, D. Y., Baksh, L., Bloebaum, L., & Varner, M. W. (2006). Maternal body mass index and self-reported postpartum depressive symptoms. Matern Child Health J, 10(4), 385-390. LaCoursiere, D. Y., Bloebaum, L., Duncan, J. D., & Varner, M. V. (2004). Population-based trends in maternal obesity, Utah 1991-2001. J Soc Gynecol Investig, 11(2 Supplement), 191a. LaCoursiere, D. Y., Bloebaum, L., Duncan, J. D., & Varner, M. W. (2005). Population-based trends and correlates of maternal overweight and obesity, Utah 1991-2001. Am J Obstet Gynecol, 192(3), 832-839. Li, C., Kaur, H., Choi, W. S., Huang, T. T., Lee, R. E., & Ahluwalia, J. S. (2005). Additive interactions of maternal prepregnancy BMI and breast-feeding on childhood overweight. Obes Res, 13(2), 362-371. Lu, G. C., Rouse, D. J., DuBard, M., Cliver, S., Kimberlin, D., & Hauth, J. C. (2001). The effect of the increasing prevalence of maternal obesity on perinatal morbidity. Am J Obstet Gynecol, 185(4), 845-849. Oddy, W. H., Li, J., Landsborough, L., Kendall, G. E., Henderson, S., & Downie, J. (2006). The association of maternal overweight and obesity with breastfeeding duration. J Pediatr, 149(2), 185-191. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United States, 1999-2004. Jama, 295(13), 1549-1555. Rasmussen, K. M., & Kjolhede, C. L. (2004). Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum. Pediatrics, 113(5), e465-471. Sebire, N. J., Jolly, M., Harris, J. P., Wadsworth, J., Joffe, M., Beard, R. W., et al. (2001). Maternal obesity and pregnancy outcome: a study of 287,213 pregnancies in London. Int J Obes Relat Metab Disord, 25(8), 1175-1182. Watkins, M. L., Rasmussen, S. A., Honein, M. A., Botto, L. D., & Moore, C. A. (2003). Maternal obesity and risk for birth defects. Pediatrics, 111(5 Part 2), 1152-1158. 8 Obesity © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Headache and Sexual Abuse in Women in a Headache Clinic in Utah Stephanie Chambers, BS; Kathleen Digre, MD; Srichand Jasti, ME, MStat; Susan Baggaley, MS, FNP; Gretchen Tietjen, MD* Center of Excellence Women's Health University of Utah, *Medical University of Ohio CORRESPONDENCE: Kathleen Digre, MD Director, National Centers of Excellence in Women's Health Demonstration Proj'ect University of Utah [e-mail] Abstract Headache is a common disorder in women and chronic daily headache is also more common in women. Childhood sexual abuse has been found to be frequent among women who have disabling headache. We wished to determine the frequency of sexual abuse as well as other forms of abuse in a headache clinic in Utah. Methods: Patients filled out a questionnaire using a personal digital assistant (PDA). Patients also completed depression and somatic symptom severity measures. Results: Two-hundred twenty-two women completed the study. The majority of the women had migraine, over half had chronic daily headache. Sexual abuse in childhood was reported in 34% of women; physical abuse was reported in 32% of women, and emotional abuse in 26%. Of those reporting sexual abuse, 41% of women reported occurrences before they were 12 years and 82% reported occurrences as adolescents less than 20 years. Risk for abuse did not follow socio-economic level, number of headaches, but was more prevalent in women with a lower level of education. Depression was common in over one-half of the patients and women who were abused had an increase in depressive indicators. Multiple somatic symptoms were more common in abused women. Migraine headaches occurred in 85.6% of the patients; 43.7% had daily migraine headaches. Some form of violence was experienced by 63.1% of the women. Conclusion: A reported history of abuse is common among women seen in a headache clinic. Clues to identifying women who have been abused are present when there are increased somatic symptoms and depression. Practitioners should be aware that abuse is common and address this with women with headache. Introduction Headache is a common disorder in women. In fact, almost twenty percent of all women in the population suffer from migraine (Lipton, Stewart, Diamond, Diamond & Reed, 2001). About 4% of the adult population suffers from some sort of chronic daily headache; however, women again share the burden of daily headache twice as often as men (Scher, Stewart, Liberman & Lipton, 1998; Stewart & Lipton, 1993; Silberstein and Lipton, 2000). © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 9 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Sexual abuse in childhood has been estimated to occur in 15-25% of women (Leserman, 2005; Howard, 1995). These women are found to have more chronic complaints (pelvic pain, irritable bowel syndrome), use more health care resources (Walker et al., 1999b; Hilden 2004), have more physical symptoms and have an increase in life­time health problems (Leserman, 2005; Walker et al., 1999a; Roberts, 1996). There is evidence to suggest that a history of childhood sexual abuse may also increase the severity of headache as well as lead to increase in other pain and depression (Felitti, 1991; Domino & Haber, 1997; Emiroglu, Kurul, Akay, Miral & Dirik, 2004). We sought to find the frequency of sexual abuse among women visiting a headache specialty clinic in Utah. Methods The study was approved by the IRB. All participants were women seen for evaluation and treatment of headache in the University of Utah Headache Clinic. All participants were examined and diagnosed by specialists in headache (KBD, SB). Women patients who met the following criteria were invited to participate: 1) primary headache disorder defined by the International Classification of Headache Disorders (2004) 2) women over 18 years of age; 3) willingness and ability to perform a self-administered questionnaire on a Personal Digital Assistant (PDA). Women were excluded from the study if they were not able to complete the questionnaire on the PDA or if they were unable to read English. The patient's diagnosis and the average number of headache days per month over the previous three months were entered by the headache specialist. The electronic questionnaire was designed with Pendragon® Forms 3.2 computer software (Pendragon Software Corporation, Libertyville, IL). Patients responded to questions on the following topics: age, race, household income, highest educational level attained, age of onset of headaches, impact of headaches on daily life, severity of current depression, and somatic symptoms. The questionnaire collected information on physical abuse, sexual abuse, and ‘fear for life' (emotional abuse) in time periods: childhood years (<12 years old), teenage years (13 to 20 years old), adulthood (>21 years old) and current (within the past year). The participants were asked if they had been the recipient of other abusive behaviors such as: threats, aggression, intimidation, isolation, and coercion. They were also asked if they had stress due to fear of threats or felt they were at risk for future abuse. The participants were asked whether they had witnessed 1) abusive behavior between adults, and 2) drug/alcohol abuse by adults in their childhood home. The questionnaire also included a disability scale, the Headache Impact Test (HIT-6) (Kosinski et al., 2003) that produces a score ranging from 36 to 78. In this test, there are four levels of disability based on the HIT-6 scores: ‘little or no impact' for scores less than 49, ‘some impact' for scores 50-55, ‘substantial impact' for scores 56-59, ‘very severe impact' for scores more than 60. Determination of current (over the prior two weeks) depression was performed using the Personal Health Questionnaire 9 (PHQ-9) (Kroenke, Spitzer & Williams, 2001), that produces a score ranging from 0 to 27. Five 10 Headache And Sexual Abuse © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW levels of depression severity exist based on the PHQ-9 scores: ‘minimal' for scores 0-4, ‘mild' for scores 5-9, ‘moderate' for scores 10-14, ‘moderately severe' for scores 15-19, and ‘severe' for scores 20 and above. The type and severity of current somatic symptoms (over the prior 4 weeks) was assessed using Personal Health Questionnaire 15 (PHQ-15) (Kroenke, Spitzer & Williams, 2002). The symptoms include: joint or limb pain, dizziness, headaches, back pain, abdominal pain, chest pain, breathing trouble, fainting, gas or indigestion, sleeping trouble, palpitations, menstrual problems, diarrhea (constipation), and sexual pain/problems. In this test, 15 symptoms were graded by the patient as ‘not bothered at all' (scored as 0), ‘bothered a little' (scored as 1), or ‘bothered a lot' (scored as 2). The PHQ-15 reveals four levels of somatic symptom severity: ‘minimal' for 0-4, ‘low' for 5-9, ‘medium' for 10-14, and ‘high' for 15-30. Table 1. Demographics of Headache Clinic Population Compared to the State of Utah Population Headache Clinic Population* Women of Utah Population+ Average Age 40.8 27.8 Race Caucasian 206/222 92.8% 86.1%** Other 16/222 7.2% 13.9%** Highest Educational Less than High School 7/220 3.2% ** %.91. 1 Attainment High School 65/220 29.5% Some college 51/220 23.2% 65.7%** College and post-grad 97/220 44.1% 22.3%** Annual Household Income++ Less than $20,000 21/209 9.6% 10.8%*** 120,000-150,000 62/209 29.7% 44.1%*** $50,000-$ 100,000 86/209 41.1% 33.9%*** Over $100,000 40/209 19.1% 11.1%*** Average Household number*** 3.2 3.1 *number of women reporting each demographic varies **women over the age of 25 +Institute for Women's Policy Research. Available online at http://www.iwpr.org/States2004/PDFs/Utah.pdf. Accessed February 15, 2007. ++Governor's Office for Planning and Budget. Available online at http://governor.utah.gov/dea/census/stateofutah/utah.pdf. Accessed February 15, 2007; general Utah population (not specific to women) Patients took about 15 minutes to answer the questions. A security code was entered at the end of the survey, uploaded data to a central database using the PDA, and synchronized to a central database through a Pendragen © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 11 2007 UTAH'S HEALTH: AN ANNUAL REVIEW SyncServe computer software. The database was kept at the University of Toledo, Ohio which was the primary site for the study. Data for Utah were transferred to SPSS for analysis. Chi-square test, t-test, and regression were used for analysis. This study was part of a multi-centered study. Only the data from Utah are presented here. Previous publications of the aggregate data include Tietjen et al. (2007). Results There were 222 women who participated in this study. The ages were 18-72 with a mean age of 40.8. The majority of the women were Caucasian. The vast majority, 97%, had attained high school graduation and many, 44%, had attained a baccalaureate degree or higher. Sixty percent of the women had household incomes more than $50,000 and only 10% had incomes less than $20,000. The number of people in a household ranged from 1­12; the average household size was 3.2. See Table 1 for demographic data and its comparison to the demographic Figure 1. Headache Severity and Disability (HIT-6) 180 n------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------ 160 - 140 - 120 - o 100 - 80 60 40 20 49 or less, Little or no im pact 50-55, Some impact 56-59, Substantial im pact 60 or more, V e ry severe im pact 0 information of women from the State of Utah. The headache clinic population and the female Utah population were found not to significantly differ on race and average number of household members. But the cohort did differ on age (t=16.351, p<0.001), education (%2=8.309, p<0.01), and income (x2=66.611, p<0.001). It was found 12 Headache And Sexual Abuse © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW that, on average, the headache clinic sample was significantly older, more educated, and had higher income levels than the female Utah population. Some statistics representing only women were unavailable. For these demographic variables (i.e. income and average household number), information from the general Utah population was used for comparison. The primary headache type was most frequently migraine (190/222, 85.6%), and less frequently: tension-type (5/222, 2.3%), post-traumatic (12/222, 5.4%), and other (15/222, 6.6%). Headaches occurred less than 15 days per month in 101/222 (45.5%) patients and more than 15 days per month in 121/222 (54.5%) patients. Severe headaches were found in 170/222 (76.6%) patients as defined by the HIT-6 test score of over 60. The average HIT-6 score was 63 and the range of scores was 48-76. See figure 1. The women reported their headaches to begin between the ages of 1 and 61 years with a mean of 21.5 years. Headaches beginning before the age of 20 were experienced by 105 (47.3%) women. Moderate to severe depression, as determined by the PHQ-9 score of 15 or greater, occurred in 84 (37.8%) women. Minimal or no depression, indicated by a PHQ-9 score of 0-4, occurred in 76 (34.2%) women. See figure 2. Figure 2. Depression Severity (PHQ-9) 80 ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- 70 60 | 50 0S. ti cc 0- 40 *6 1Z 30 20 10 0 0 thru 4, minimal 5 thru 9, mild 10 thru 14, moderate 15 thru 19, moderately 20 or greater, severe severe Somatic symptoms were highly prevalent in this group; 161 (72.5%) women had somatic symptoms that the PHQ-15 determined were of medium or high severity. See figure 3. © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 13 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Thirty-four (15.3%) women currently or in the past abused drugs or alcohol; 13/34 (38.2%) of these women recalled alcohol or drug abuse to be present in their childhood homes. Some type of violent behavior was reported by 140 (63.1%) women-this includes physical, sexual, and emotional abuse, other abusive behaviors, or had witnessed violent behaviors. Fifty-four (54.3%) of these women reported a personal previous history of sexual abuse (76/140). Figure 3. Somatic Symptoms (PHQ-15) 100 Physical abuse (as defined as being hit, punched, slapped, kicked, bitten, grabbed choked, by a family member, current or former spouse, or significant other) occurred in 71 (32%) women. These 71 women indicated that they had been physically abused at different ages, so there was a total of 106 reports of abuse. The physical abuse occurred at 12 years of age or younger (29.2%), 13-20 years of age (38.7%), 21 years of age or older (13.5%). Only 3.8% reported current physical abuse. See figure 4. Sexual abuse was reported to occur in 76 (34.2%) of women. These 76 women indicated that they had been sexually abused at different ages, so there was a total of 107 reports of abuse. The sexual abuse occurred at 12 years of age or younger (41.1%), 13-20 years of age (39.3%), 21 years of age or older (15.9%); rarely was there current sexual abuse (1.9%). See figure 4. Emotional Abuse/Fear for life (as defined by being hurt or frightened so badly by a family member that they feared for their life) occurred in 57 (25.7%) women. These 57 women indicated that they had been emotionally 14 Headache And Sexual Abuse © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW abused at different ages, so there was a total of 73 reports of abuse. The emotional abuse occurred at 12 years of age or younger (21.9%), 13-20 years of age (34.2%), 21 years of age or older (38.4%); current emotional abuse occurred in 5.5% of the 57 women. See figure 4. Figure 4. Age at which Abuse Occurred 90 no violence 12 y/o 13-20 y/o 21 y/o within past year One hundred and one (45.5%) women reported no sexual, physical or emotional abuse. While patients with a history of physical or sexual abuse showed no statistical increase in headache frequency when compared to patients with no history of physical abuse and sexual abuse, patients with a history of emotional abuse showed an increase in headache frequency when compared to patients with no history of emotional abuse (%2=13.553, p<0.001). Women with a history of physical, sexual, or emotional abuse usually reported more than one type of abuse. Of the women who had physical, sexual, and/or emotional abuse 55/121 (45.5%) had witnessed abusive behavior between adults in their childhood home, whereas 18/10 (18.0%) who had never had abuse, had witnessed abusive behavior in their childhood home. See figure 5. Figure 5. Reports of more than one kind of abuse in a Headache Clinic Population © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 15 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Other abusive behaviors (independent of physical, sexual, or emotional abuse) were reported by 107 women. In response to questions about these other abusive behaviors, women reported they had been: threatened (51; 45.5%), shown aggression (44; 19.8%); harassed (42; 18.9%); intimidated (71; 31.98%), isolated (53; 23.9%), and controlled/coerced (52; 23.4%). Table 2 compares the samples of women with no history of physical, sexual, or emotional abuse (N=101) and the sample of women with a history of physical, sexual, and/or emotional abuse (N=121). The two groups did not differ significantly in age, race, income, number of household members, and headache frequency. The sub-sample of women with a history of physical, sexual and/or emotional abuse had significantly different education levels when compared to those who did not experience any abuse (X2=10.732, p=0.013). Table 3 shows the results of linear regression models to fit the somatic symptom severity score (PHQ-15), the depression score (PHQ-9), and the headache-related disability score (HIT-6). The PHQ-15 score (somatic symptoms) is significantly associated to sexual abuse, emotional abuse, income level and headache frequency. Higher PHQ-15 scores are observed for participants who have had a history of sexual Table 2. Demographics of Physical, Sexual, and Emotional Abuse No history of physical, sexual, or emotional abuse N=101 History of physical, sexual, or emotional abuse N=121 P Values Age Average 41.5 40.3 .432 Race Caucasian 95% 90.9% Non- .331 caucasian 5.0% 9.1% Education* Less than hs 3.0% 3.3% .013 High school 18.8% 38.0% Some college 21.8% 24.0% College and post-grad 45.5% 34.7% Household members 1 9.9% 8.3% .772 2 34.7% 31.4% 3-5 47.5% 53.7% >5 7.9% 6.6% Annual Household Income <20 K 8.9% 9.9% .154 20-50 K 21.8% 33.1% 50-100 K 44.6% 33.9% >100 K 20.8% 15.7% Headache freq <15 d 49.5% 42.2% .201 >15 d 50.5% 57.9% *(P<0.05) 16 Headache And Sexual Abuse © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW and/or emotional abuse and also for those who experience more than 15 headaches a month. The PHQ-15 score seems to be negatively related to income level (i.e., higher income level relates to lower PHQ-15 score) after controlling for all other factors. The PHQ-9 score (depression) is significantly associated to emotional abuse, income level, and headache frequency. The presence of emotional abuse, increasing income levels, and increasing headache frequency result in higher PHQ-9 scores; this is quantified by the parameter estimates shown in Table 4. Although sexual abuse was not found to be significantly associated with PHQ-9 at the 0.05 level (p=0.056), it was very close to the significance value and we have chosen to leave this factor in. Again, as with the PHQ-15, the PHQ-9 is negatively associated with income level. The HIT-6 score was found to be significantly associated only with age and headache frequency. Age was negatively related to the HIT-6 score (i.e., older women show lower HIT-6 scores). The headache frequency seemed to be the major predictor of the HIT-6 score. Table 3. Significant Correlations between PHQ-15, PHQ-9, and HIT-6 Dependent Variables Predictors Coefficient Estimates Adjusted R2 PHQ-15 Sexual Abuse 2.348** 0.223 Emotional Abuse 2.210* Income Level -0.712* Headache Frequency 3.654*** Constant 6.749*** PHQ-9 Sexual Abuse 1.195**** 0.161 Emotional Abuse 1.417* Income Level -0.712* Headache Frequency 3.654*** Constant 11.655*** HIT-6 Age -0.083** Headache Frequency 4.303*** 0.174 Constant 64.048*** *P<0.05 **P<0.01 ***p<0.001 ****p<0.06 Physical abuse was not significantly related to PHQ15, PHQ_9, or the HIT-6. Discussion This study shows that a large number of women in a sub-specialty headache clinic in Utah have had sexual, physical and/or emotional abuse. Sexual abuse was the most frequent at 34%. Most of the sexual abuse occurred before the age of 20. The estimated rate of sexual abuse in the general population is 15-25% (Scher, Stewart, © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 17 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Liberman & Lipton, 1998). In chronic headache patients at a specialty clinic, Utah appears to be above this average. Sexual abuse is known to be associated with a poor health status (Leserman, 2005; Walker et al., 1999 as well as more physical symptoms (Tietjen et al., 2007), and a higher utilization of health resources and increased cost to society (Walker et al., 1999). In addition, sexual abuse has been found to be associated with other forms of abuse (physical and emotional) (Dong et al., 2004). In our cohort of 140 patients with some type of abuse, it was common to have other forms as well. We found that almost 21% of the abused women reported all three forms of abuse (sexual, physical and emotional). As noted in other studies, sexual abuse can occur in any socioeconomic group and education (Swahnberg et al., 2004). In our population, women were from a higher socioeconomic status and had more high school or college experience than our general Utah population. Headache has been reported to be a major symptom seen in patients who have had sexual abuse. In fact, in one large study of abused women, chronic daily headaches were more than twice as common as in women who were not abused (Felitti, 1991). Early childhood sexual abuse is associated with more headache than in those who have sexual abuse in adulthood (Golding 1999). Chronic headache is associated with depression since 38% of our population had moderate to severe depression. In our population, depression was more severe in those who have had sexual or emotional abuse. Juang, Wang, Fuh, Lu, and Chen (2004) found that physical abuse in childhood tended to increase the likelihood of chronic daily headache in adolescence. Romans, Belaise, Martin, Morris and Raffi (2002) reported that headache and migraine were definitely correlated with adult physical abuse. Krantz and Ostergren (2000) showed that physical abuse was associated with headache and that women who had physical abuse in childhood or adulthood had an increased likelihood of multiple somatic symptoms In our study, physical abuse was neither associated with headache nor multiple somatic symptoms. Depression is strongly associated with migraine in patients without abuse. In fact, the prevalence of depression among patients with migraine is 14.7/100,000 vs those who do not have migraine (7/100,000) (Hamelsky & Lipton, 2006). Merikangas, Angst, and Isler (1990) and Breslau et al. (2000) and Breslau et al. (2003) found that those with migraine had three times the incidence of depression than those without migraine. Shared genetic and neuro-biologic factors may link migraine and depression (Silberstein, 2001). Walling et al. (1994a) and Walling et al. (1994b) found that early childhood physical abuse predicted depression, anxiety and somatization. Other studies have also found that women experiencing violence have a significantly higher rate of depression (Nicolaidis, Curry, McFarland & Gerrity, 2004). Depression associated with abuse has also been found to be associated with morbid obesity (Felitti, 1991). Depression was found in 38% of our patients. Depression was increased in our patients with sexual and emotional abuse. 18 Headache And Sexual Abuse © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW An increase in multiple somatic complaints is similar to other studies of women with all forms of abuse (Tietjen et al., 2007; Krantz & Ostergren, 2000). In our study, 96 (80%) of 120 abused women had a ‘medium' or ‘high' level multiple somatic complaints. This finding suggests that women with multiple somatic complaints should also be queried about forms of abuse. Our headache clinic population is similar in several demographics to the state of Utah. The clinic and general population were not significantly different in race and average number of household members. The clinic patients were significantly more educated (%2=41.611, p<0.001) and had significantly higher incomes (%2=30.02, p<0.001) than the general population of the state of Utah. Nevertheless, our study shows that headaches and abuse affects a wide range of individuals even those who are more educated and of higher economic fortune. We would make the following recommendations for practitioners who see women who have chronic headache. First, the practitioner should ask about abuse in childhood. Recently two questions were found to predict sexual abuse: (a) "When I was growing up, people in my family hit me so hard that it left me with bruises or marks" and (b) "When I was growing up, someone tried to touch me in a sexual way or tried to make me touch them." (Thombs, Bernstein, Ziegelstein, Bennett & Walker, 2007) These questions had sensitivity 85% and specificity of 88% in predicting sexual abuse. Further, women with multiple chronic health symptoms should also be queried about abuse. Despite many articles about the importance of querying for abuse, only 21% of women with a history of abuse presenting to medical clinics are asked about it (Pearse, 1994). Treatment for women with headache who have been abused has not been extensively studied. Cognitive behavioral approaches are most frequently used and have the most evidence for success (Leserman, 2005). Behavioral and cognitive therapy are more efficacious in some cases than medications (Payne & Colletti, 1991). Psychotherapy (Martsolf & Draucker, 2005), group therapy (Kessler, White & Nelson, 2003; Talbot et al., 1999), and even inpatient treatment (Stalker, Palmer, Wright & Gebotys, 2005) have been used. No single therapy has been found to be superior, however. In general, finding a single medication that completely stops headache is almost impossible. However, every attempt to reduce the migraine headache with standard preventive medications such as beta blockers, calcium channel blockers, and anti-convulsants should be attempted (Goadsby, Lipton & Ferrari, 2002). The reason for emotional abuse causing increased rates of headache is not clear. Clearly more work is needed to understand the pathophysiology of increased headache in women with all forms of abuse and to determine the best treatment of these disabling headaches. There are limitations to our study. We do not address any type of abuse in men. We are using a highly specialized population (those going to a headache clinic) so our findings may not be generalizable to all headache © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 19 2007 UTAH'S HEALTH: AN ANNUAL REVIEW patients. The study also relied on the woman's recollection of abuse. Nevertheless, this study gives us insight into some women visiting a chronic headache clinic in Utah. References Breslau, N., Schultz, L.R., Stewart, W.F., Lipton, R.B., Lucia, V.C., Welch, K.M. (2000). Headache and maj'or depression: is the association specific to migraine? Neurology 54(2), 308-13. Breslau, N., Lipton, R.B., Stewart, W.F., Schultz, L.R., Welch, K.M. (2003). Comorbidity of migraine and depression: investigating potential etiology and prognosis. Neurology 60(8), 1308-1312. Domino, J.V., Haber, J.D. (1987). Prior physical and sexual abuse in women with chronic headache: clinical correlates. Headache 27(6), 310-314. Dong, M ., Anda, R.F., Felitti, J.J, Dube, S.R., Williamson, D.F., Thompson, T.J., et al. (2004). The interrelatedness of multiple forms of childhood abuse, neglect, and household dysfunction. Child Abuse and Neglect 28(7), 771-784. Emiroglu, F.N., Kurul, S., Akay, A., Miral, S., Dirik, E. (2004). Assessment of child neurology outpatients with headache, dizziness, and fainting. Journal of Child Neurology (5), 332-336. Felitti, V.J., Long-term medical consequences of incest, rape, and molestation. (1991). Southern Medical Journal 84(3), 328-331. Golding, J.M. (1999). Sexual assault history and headache: five general population studies. Journal of Nervous and Mental Disease 187(10), 624-629. Goadsby, P.J., Lipton, R.B., Ferrari, M.D. (2002). Migraine--current understanding and treatment. New England Journal of Medicine 346(4), 257-270. Hamelsky, S.W., Lipton, R.B. (2006). Psychiatric comorbidity of migraine. Headache 46(9), 1327-33. Headache Classification Subcommittee of the International Headache Society. (2004). The International Classification of Headache Disorders: 2nd edition. Cephalalgia 24 (Supplement 1), 9-160. Howard, F.M. (1995). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics and Gynecology 85(1), 158-159. Hilden, M., Schei, B., Swahnberg, Kl, Halmesmaki, E., Langhoff-Roos, J. et al. (2004). A history of sexual abuse and health: a Nordic multicentre study. British Journal of Obstetrics and Gynecology 111(10),1121-1127. Juang, K.D., Wang, S.J., Fuh, J.L, Lu, S.R., Chen, Y.S., (2004). Association between adolescent chronic daily headache and childhood adversity: a community-based study. Cephalalgia 24(1), 54-59. Kessler, M.R., White, M.B., Nelson, B.S. (2003). Group treatments for women sexually abused as children: a review of the literature and recommendations for future outcome research. Child Abuse and Neglect 27(9), 1045-1061. Krantz G., Ostergren, P.O., (2000). The association between violence victimisation and common symptoms in Swedish women. Journal of Epidemiology and Community Health 54(11), 815-821. Kosinski, M., Bayliss, M.S., Bj'orner, J.B., Ware, J.E. Jr., Garber, W.H., Batenhorst, A., et al. (2003). A six-item short-form survey for measuring headache impact: the HIT-6. Quality of Life Research 12(8), 963-974. Kroenke, K., Spitzer, R.L., Williams, J.B. (2001). The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine 16(9), 606-613. Kroenke, K., Spitzer, R.L., Williams, J.B. (2002). The PHQ-15: validity of a new measure for evaluating the severity of somatic symptoms. Psychosomatic Medicine 64(2), 258-266. Leserman, J. (2005). Sexual abuse history: prevalence, health effects, mediators, and psychological treatment. Psychosomatic Medicine 67(6), 906-915. 20 Headache And Sexual Abuse © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Lipton, R.B., Stewart, W.F., Diamond, S., Diamond, M.L., Reed, M. (2001). Prevalence and burden of migraine in the United States: data from the American Migraine Study II. Headache, 41(7), 646-657. Martsolf, D.S., Draucker, C.B. (2005). Psychotherapy approaches for adult survivors of childhood sexual abuse: an integrative review of outcomes research. Issues in Mental Health Nursing 26(8), 801-825. Merikangas K.R., Angst, J., Isler H. (1990). Migraine and psychopathology. Results of the Zurich cohort study of young adults. Archives of General Psychiatry 47(9), 849-853. Nicolaidis, C., Curry, M., McFarland, B., Gerrity, M. (2004). Violence, mental health, and physical symptoms in an academic internal medicine practice. Journal of General Internal Medicine 19(8), 819-827. Payne, T.J., Colletti, G. (1991). Treatment of a 15-year-old girl with chronic muscle-contraction headache using implosive therapy. British Journal of Medical Psychology 64(Pt 2), 173-177. Pearse, W.H. (1994). The Commonwealth Fund Women's Health Survey: selected results and comments. Womens Health Issues 4(1), 38-47. Roberts, S.J. (1996). The sequelae of childhood sexual abuse: a primary care focus for adult female survivors. Nurse Practitioner 21, 42-52. Romans, S., Belaise, C., Martin, J., Morris, E., Raffi, A. (2002). Childhood abuse and later medical disorders in women. An epidemiological study. Psychotherapy and Psychosomatics 71(3),141-150. Scher, A.I., Stewart, W.F., Liberman, J., Lipton, R.B. (1998). Prevalence of frequent headache in a population sample. Headache 38(7), 497-506. Silberstein, S.D., Lipton, R.B. (2000). Chronic daily headache. Current Opinion in Neurology. 13(3), 277-283. Silberstein, S.D. (2001). Shared mechanisms and comorbidities in neurologic and psychiatric disorders. Headache 41(Supplement 1), S11- S17. Stalker, C.A., Palmer, S.E., Wright, D.C., Gebotys, R. (2005). Specialized inpatient trauma treatment for adults abused as children: a follow-up study. American Journal of Psychiatry 162(3), 552-559. Stewart, W.F., Lipton, R.B. (1993). Migraine headache: epidemiology and health care utilization. Cephalalgia 13 (Supplement 12), 41-46. Swahnberg, K., Wijma, B., Schei, B., Hilden, M., Irminger, K., Wingern, G.B. (2004). Are sociodemographic and regional and sample factors associated with prevalence of abuse? ACTA Obstetricia et Gynecoloica Scandinavica 83(3), 276-288. Talbot, N.L., Houghtalen, R.P, Duberstein, P.R., Cox, C., Giles, D.E., Wynne, L.C. (1999). Effects of group treatment for women with a history of childhood sexual abuse. Psychiatric Services 50(5), 686-692. Thombs, B.D., Bernstein, D.P., Ziegelstein R.C., Bennett, W., Walker, E.A. (2007). A brief two-item screener for detecting a history of physical or sexual abuse in childhood. General Hospital Psychiatry 29(1), 8-13. Tietjen, G.E., Brandes, J.L., Digre, K.B., Baggaley, S., Martin, V., Recober, A., et al. (2007) High prevalence of somatic symptoms and depression in women with disabling chronic headache. Neurology 68(2), 134-140. Walker, E.A., Gelfand, A., Katon, W.J., Koss, M.P., Von Korff, M., Bernstein, D., et al. (1999a). Adult health status of women with histories of childhood abuse and neglect. American Journal of Medicine 107(4), 332-339. Walker, E.A., Unutzer, J., Rutter, C., Gelfand, A., Saunders, K., VonKorff, M., et al. (1999b). Costs of health care use by women HMO members with a history of childhood abuse and neglect. Archives of General Psychiatry 56(7), 609-613. Walling, M.K., O'Hara, M.W., Reiter, R.C., Milburn, A.K., Lilly, G., Vincent, S.D. (1994a). Abuse history and chronic pain in women: II. A multivariate analysis of abuse and psychological morbidity. Obstetrics and Gynecology 84(2), 200-206. Walling, M.K., Reiter, R.C., O'Hara, M.W., Milburn, A.K., Lilly, G., Vincent, S.D. (1994b). Abuse history and chronic pain in women: I. Prevalences of sexual abuse and physical abuse. Obstetrics and Gynecology 84(2), 193-199. © 2007 The University of Utah. All Rights Reserved Headache And Sexual Abuse 21 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Labor Induction Trends in Utah and a Comparison of Maternal and Neonatal Outcomes among Induced Deliveries without an Identified Medical Indication Shaheen Hossain, PhD, Nan Streeter, MS, RN, Robert Satterfield, MStat, Lois Bloebaum, BSN, MPA, Angeni Marque, BS CORRESPONDENCE: Shaheen Hossain, Ph.D. Program Manager Data Resources Program, MCH Bureau PO Box 142001 Salt Lake City, Utah, 84114-2001 [phone] [e-mail] Abstract Induction of labor is a valuable obstetric procedure when indicated by a medical or clinical condition. However, strong debate surrounds the issue of non-medical inductions that are conducted for convenience, and whether or not the benefits outweigh the risks. This research focuses on trends in induction and assesses maternal and neonatal outcomes associated with labor induction, specifically those inductions conducted without identifiable medical indications. In this study, Utah birth certificate records from 1992 to 2005 were used to examine trends. Maternal and neonatal outcomes related to the induction of labor without an identified indication were assessed using only 2005 birth certificate data. When comparing neonatal outcomes, induced and non-induced deliveries were quite similar. However, nulliparous women with induced labor were significantly more likely to have instrumental procedures used to assist with vaginal delivery compared to the non-induced group (22.8% vs. 17.7 %). It is the recommendation of this study that women receive a complete disclosure of the risks and benefits associated with the induction of labor before undergoing this obstetric procedure. Future studies are needed to understand why Utah's induction rate is higher than the national rate. Introduction Induction of labor is a valuable obstetric procedure when initiated for a medical reason. For several clinical conditions, the decision to induce labor may be appropriate and lifesaving for mother and child. Although induction of labor has been practiced for many years, the procedure has become more widely used in recent years. Nationally and in Utah, induction rates doubled between 1992 and 2005. However, large proportions of inductions are performed in the absence of any medical or obstetric indication and are considered "elective." 22 Labor Induction Trends © 2007 The University of Utah: All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW According to the American College of Obstetricians and Gynecologists (ACOG), induction of labor is undertaken when, in the opinion of the physician, the risks of delivery to the mother or the fetus or both, are less than the risk of continuing the pregnancy (ACOG, 1999). Controversy exists regarding the potential benefit of elective induction at term. Proponents of elective induction argue that they are avoiding potential adverse outcomes associated with postdates, preeclampsia and term intrauterine fetal death of unknown causes (Martin et al., 1978). It was suggested by Macer et al. (1992) that elective induction allows for better planning by the physician, patients, and their families. The anxiety of some women may be reduced by the assurance that their personal physician may be present during the birth of their child. Others advocate elective induction to allow for daytime deliveries with a rested patient and optimal perinatal medical care personnel (Smith et al., 1984). Those opposing elective induction would argue that not only is it generally not recommended by ACOG, but also it is an unnecessary and unnatural process (Macer et at., 1992). There is concern over inducing labor before fetal lung maturity has been achieved (ACOG, 1999). A number of studies have examined the associations between elective induction and pregnancy outcomes. Although inconsistent, the results are compatible with an association between elective induction and increased risk of cesarean delivery. Some studies have observed this increased risk among all women (Prysak et al., 1998; Glantz, 2005) while others have observed it only among nulliparous women (Seyb et al, 1999; Dublin et al, 2000). Many studies have found that patterns of labor progression differ between women who are induced and those who are not (Hoffman et al., 2006; Vahratian et al., 2005). A higher rate of instrumental delivery has also been observed among induced women compared to those experiencing spontaneous labor (Dublin et al., 2000; Smith et al., 1984). Women who were induced tended to receive greater numbers of intrapartum interventions, such as epidural anesthesia, compared to women experiencing spontaneous labor (Glantz, 2005; Smith et al., 1984). Some research has calculated higher than average length of stay in maternity units among induced women (Vrouenraets et al., 2005; Glantz, 2005), as well as higher delivery costs (Maslow et al., 2000). Other studies found no adverse impact associated with the induction of labor. Smith et al. (1984) found that when careful patient selection is made by an experienced clinician, planned delivery does not jeopardize the outcomes of either the mother or fetus compared to spontaneous labor. This result was similar to that of Cole et al. (1975) who found no evidence that elective induction of labor increased fetal or maternal morbidity. The purpose of this study was to assess maternal and neonatal outcomes associated with the induction of labor among low risk women who lacked identifiable indications for induction at term. © 2007 The University of Utah. All Rights Reserved Labor Induction Trends 23 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Methods Data Sources To examine induction trends, Utah birth certificate records from 1992 through 2005 were used. Induction of labor was measured by birth certificate item ‘induction' and identifies all deliveries where induction of labor was attempted, regardless of whether the induction was successful. On the birth certificate record, induction is defined as the initiation of uterine contractions before the spontaneous onset of labor by medical and/or surgical means for the purpose of delivery. Excluded from the study were records of births where stimulation or augmentation of a previously established labor was indicated. The birth certificate does not distinguish between elective and indicated inductions, but it does contain information on most of the medical indications related to induction. Induction rates per 100 live births in Utah were compared with overall U.S. rates. Maternal and neonatal outcomes related to the induction of labor without an identified indication were assessed using only 2005 birth certificate data. Study Selection Criteria The study included women with singleton births clinically estimated to be between 38-40 completed weeks' gestation. The clinical estimate of gestational age on the birth record is defined as the age in total weeks completed from the last menstrual period date to the date of delivery. Gestational age parameters 38-40 weeks were selected based on a review of the parameters used in recent induction research to identify a low-risk group. The study was also limited to women who gave birth in a hospital. In order to define infants in vertex presentation, women with breech/malpresentations were excluded. To further limit the study to low-risk women, records with one or more listed medical risk factors for pregnancy were excluded. Many of the risk factors in the birth certificate records are recognized by ACOG as indications for induction, and include: pregnancy induced hypertension, premature rupture of membrane, Rh sensitization, acute or chronic lung disease, chronic hypertension, polyhydramnios/oligohydramnios, pre-existing diabetes, gestational diabetes, renal disease, and eclampsia. Examination of previous pregnancy history resulted in the removal of women with previous preterm, macrosomic, or SGA infants, since history of such conditions may point toward an increased risk for similar complications. The remaining group was further reduced to exclude those with certain complications of pregnancy. The complications excluded for were: placenta previa, abruptio placenta, umbilical cord prolapse, incompetent cervix, uterine bleeding, cephalopelvic disproportion, and genital herpes. Several of these listed complications are defined by ACOG as contraindications for induction, and, as such, disqualify the subjects from being considered ‘low risk'. Women diagnosed as febrile were excluded from the study on the basis of the suggestion that the condition could be considered a proxy for "chorioamnionitis", which is also a recommended indication for induction by ACOG (MacDorman et al., 2002). The final step in defining the study population was to remove all birth records where the mother was indicated to have had any previous cesarean delivery. This 24 Labor Induction Trends © 2007 The University of Utah: All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW final study population was divided into two groups: those induced and those non­induced, in order to compare maternal and neonatal outcomes. The flowchart of selection of study participants is presented in Figure 1. Study Participants During 2005, there were 51,517 resident births in Utah. Of these, only 38,153 women who delivered at a hospital with a single infant in vertex presentation in the gestational age range of 38-40 weeks were initially included for this study. The application of exclusion criteria resulted in a total of 14,809 women as the final study population. Among these, 5,945 women had labor induced and were compared with 8,864 non-induced women. Outcomes Maternal outcome was measured in terms of incidence of cesarean and instrumental delivery. Instrumental delivery was defined as any use of either forceps or vacuum during a vaginal delivery. Neonatal outcomes of interest included birth weight, Apgar scores at 1 and 5 minutes, the presence of moderate/heavy mecon-ium, birth injury, fetal distress, hyaline mem-brane disease/ RDS, or assisted ventilation. Statistical Analysis The analyses performed included descriptive summary statistics, chi square, t-test, and regression. Multivariate logistic regression mod-els were developed to estimate the effect of induction on the risk of cesarean and instrumental delivery while adjusting for potential confounders. Adjusted odds ratios (OR) with 95% confidence interval were generated from regression models. All analyses were performed using SAS version 9.1 (SAS Institute Inc., Cary, NC, USA). Figure 1: Selection of Study Participants Have One or More Have No Risk Factors J. © 2007 The University of Utah. All Rights Reserved Labor Induction Trends 25 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Results Trend Data The overall induction (indicated and non-indicated) rate in Utah increased from 16.4% in 1992 to 35.3% in 2005. This represents a 115% increase. Utah's rate is significantly higher than the national average (33.6% vs. 21.2%, 2004 data). The trends in induction rates in Utah and the U.S. are presented in Figure 2. Figure 2: Induction Rates, Utah vs. United States, 1992-2005 Y e a r Data source: Utah Birth Certificate Data 1992-2005, Office of Vital Records and Statistics, Utah Department of Health. Center for Disease Control and Prevention, National Center for Health Statistics, Births: Final Data for 2004. National Vital Statistics Reports, Vol. 55, No.1 (September 29, 2006). Assessment of Outcomes Characteristics of Participants Shown in Table 1 are selected maternal characteristics of women who underwent induction of labor compared with those whose labor was not induced. Women with induced labor were slightly older and had more education compared to the non-induced group. A difference was also noted in the proportion of nulliparous women, which was lower in the induction group compared with the non-induction group (30.3% vs. 42.2%). The induction group had a higher proportion of married women compared to the non-induced group (87.4% vs. 82.1%). Induction of Labor and Maternal Outcomes The primary maternal outcomes measured in this study were the risk of cesarean section or instrumental delivery associated with labor induction. A comparison of induced and non-induced women delivering infants by various modes is presented in Table 2. 26 Labor Induction Trends © 2007 The University of Utah: All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Tablel: Characteristics of Women by Induction Status Induced Labor* (n=5945) Non-Induced Labor (n=8864 ) No. % No. % Maternal Age <20 years old 312 5.2 702 7.9 20-34 years old 5231 88.0 7606 85.8 >35 years old 402 6.8 556 6.3 Mean ± SD 26.7± 4.8f 26.0± 5.0 Education (yrs) 0 -11 462 7.9 1380 15.9 12 1765 30.2 2438 28.1 >13 3612 61.9 4860 56.0 Mean ± SD 13.7± 2.1¥ 13.3± 2.7 Parity Nulliparous 1800 30.3¥ 3727 42.2 Multiparous 4136 69.7 5107 57.8 Marital Status Married 5197 87.4 7278 82.1 Unmarried 748 12.6¥ 1 585 17.9 Gestational Age 38 weeks 1013 17.0 2746 31.0 39 weeks 3412 57.4¥ 3754 42.4 40 weeks 1520 25.6 2364 26.7 Mean ± SD 39.1±0.7 38.9±0.8 Numbers may not sum to total due to missing numbers. Education and parity had missing values. •Induced labor in the absence of an identified indication. f p < .05 ¥ p < .001 Table 2: Comparison of Mode of Delivery Induced Labor* Non-Induced Labor No. % No. % P Value Primary cesarean section 246 4.1 517 5.8 <.001 Instrumental Vaginal Delivery 594 10.4 832 10.0 NS Forceps 193 3.4 331 4.0 NS Vacuum 404 7.1 524 6.3 NS NS = not statistically significant * Induced labor in the absence of an identified indication. This study revealed slight differences in cesarean rates between the induced and non-induced group. The primary c-section rate for the induction group was significantly lower compared to the non-induced group (4.1% vs. 5.8%, p< .001). Overall, the use of instruments associated with vaginal delivery was similar in both groups (10.4% vs. 10.0%). However, when analyzed by parity, nulliparous women in the induction group had a significantly higher instrumental delivery rate compared to the nulliparous in the non-induced group (22.8% vs. 17.7%, p<.001; see Table 3). © 2007 The University of Utah. All Rights Reserved Labor Induction Trends 27 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Table 3: Mode of Delivery by Parity Induced Labor* Non-Induced Labor No. % No. % P Value Nulliparous Primary cesarean section 196 10.9 391 10.5 NS Instrumental vaginal delivery 366 22.8 590 17.7 < .001 Multiparous Primary cesarean section 50 1.2 122 2.4 < .001 Instrumental vaginal delivery 227 5.6 240 4.8 NS NS = not statistically significant * Induced labor in the absence of an identified Since instrumental delivery among nulliparous women was correlated with birth weight and maternal age, as well as induction, we used a logistic regression model to adjust for these potentially confounding characteristics. Instrumental delivery was designated as the dependent variable in the logistic model, with group (induction vs. non-induction) as an independent variable, and birth weight and maternal age as covariates. The odds ratio for instrumental delivery adjusted for these confounding factors is shown in Table 4. The nulliparous women in the induced group were 1.36 times more likely to experience instrumental delivery compared to the nulliparous women in the non-induced group, regardless of maternal age or newborn's birth weight. Table 4: Risk of Instrumental Delivery among Nulliparous Women Related to Induction Crude Odds Adjusted for Adjusted for Adjusted for All Ratio Birth Weight Maternal Age Instrumental Vaginal Delivery 1.38 (1.19 - 1.59)* 1.36 (1.17-1.57)* 1.38 (1.19 - 1.60)* 1.36 (1.18 - 1.58)* *95% confidence interval Neonatal Characteristics Neonatal characteristics at birth are presented in Table 5. The average neonatal weight at birth in the labor induction group was 3,416 grams compared with 3,365 grams in the non-induced group (p<.05). In the induced group, a higher proportion of newborns were macrosomic (> 4,000 g) compared to newborns in the non-induced group (6.5% vs. 5.8%, p <.05). The prevalence of low birth weight (<2,500 g) neonates were slightly lower in the induced group compared to the non-induced group (0.6% vs. 1.0%, p<.05). There were no significant differences in Apgar scores of less than 7 at either 1 or 5 minutes between the induced and non-induced groups. 28 Labor Induction Trends © 2007 The University of Utah: All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Table 5: Neonatal Characteristics at Birth Induced Labor* (n=5945) Non-Induced Labor (n=8864) Neonatal birth weight (g) Mean ± SD 3415.6 ± 376.2f 3364.9 ± 390.8 Low birth weight <2500 g 0.6%f 1.0% Macrosomic > 4000 g 6.5%f 5.8% Apgar Score <7 At 1 minute 5.3% 5.9% At 5 minutes 0.4% 0.4% * Induced labor in the absence of an identified indication. f p<.05 Neonatal Outcomes Neonatal outcomes associated with induction are provided in Table 6. The proportion of newborns with birth injury did not differ significantly between the induced and non-induced group (1.1% vs. 1.3%). This study observed that meconium staining occurred more frequently among the non-induced group compared to the induced group (7.1% vs. 3.6%, p<.001). No significant difference in the proportion of newborns with hyaline membrane disease/RDS, assisted ventilation, or fetal distress was observed. Table 6: Neonatal Outcomes Associated with Induction of Labor Induced Labor* Non-Induced Labor No. % No. % P Value Birth injury 66 1.1 118 1.3 NS Meconium, moderate/heavy 21 5 3.6 625 7.1 <.001 Hyaline membrane disease/RDS 30 0.5 37 0.4 NS Assisted ventilation (<30 min.) 11 0.2 12 0.1 NS Assisted ventilation (>30 min.) 6 0.1 18 0.2 NS Fetal distress 421 7.1 570 6.4 NS NS = not statistically significant * Induced labor in the absence of an identified indication. Time and Day of Delivery In 2005, the majority of induced deliveries (80%) occurred between 8 AM and 8 PM, compared to 60% among the non-induced (see Table 7). Women who had labor induced were also more likely to deliver on weekdays (Monday - Friday) compared to the weekend, with a preponderance Tuesday - Thursday (see Figure 3). Table 7: Time of Delivery © 2007 The University of Utah. All Rights Reserved Labor Induction Trends 29 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Table 7: Time of Delivery Time of Day Induced* Non-Induced ___________________________________________ %_____________________________ % 8 am - 12 pm 20.5 23.8 12 pm - 4 pm 36.4 19.0 4 pm - 8 pm 23.7 16.8 8 pm - 12 am 9.3 11.1 12 am - 4 am 7.0 17.1 4 am - 8 am 3.2 12.2 *Induced labor in the absence of an identified indication. Figure 3: Delivery by Day of the Week □ N o n -In d u c e d Labor □ Induced Labor Sun day Mo n day T u esday We d n e s d a y Th u rsd ay Friday Day o f the We e k Saturday 25 1 9 . 8 1 9 . 8 20 1 7 . 1 1 5 . 8 1 6 . 0 1 5 . 1 1 5 . 3 1 4 . 6 1 4 . 5 1 4 . 3 1 3 . 4 1 2 . 8 6 . 6 5 . 0 5 0 Discussion Induction rates are increasing rapidly both locally and nationally. Increases were seen among women with documented medical indications as well as among women with elective inductions (Yeast et al., 1999). Explanation of the dramatic increase in the incidence of labor induction is certainly complex and may be comprised of numerous contributing factors (Rayburn et al., 2002; Zhang et al., 2002). A suggested primary reason for the rising usage of induction centers on the ability it provides to plan the timing of birth for the physician, patient, and family. Other explanations include the increasing availability of effective cervical ripeners and medical liability concerns associated with continued expectant management, particularly post-term (Rayburn et al., 2002). In addition, the ability to more accurately determine the gestational age of the neonate, and more sophisticated techniques of antepartum fetal surveillance may also contribute to the rising induction rate (Yeast et al., 1999). In assessing maternal outcomes using 2005 birth certificate data, this study found that the cesarean delivery rate was lower among the induced group compared to the non-induced group. This finding is consistent with the 30 Labor Induction Trends © 2007 The University of Utah: All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW findings of Cole et al. (1975). However, other previous studies have documented an increased rate of cesarean delivery with elective induction, particularly among the nulliparous (Macer et al., 1992; Smith et al., 1984; Yudkin et al., 1979). In this study instrumental delivery rates did not differ between the induced and non-induced groups overall. This parallels the finding of Cole et al. (1975), where forceps use was similar in both groups of women, those induced and those experiencing spontaneous labor. Their study also found that the use of epidurals is more commonly associated with elective induction than with women experiencing spontaneous labor. Therefore, it has been hypothesized that it may be epidural analgesia rather than induction that is the causal factor explaining the higher incidence of instrumental delivery among induced women. Wigton et al. (1994) also noted that patients receiving epidurals were more likely to require instrumental delivery. When they controlled for the influence of epidurals, in their analysis, they found no difference in instrumental delivery rates between induced and non-induced groups. This study was unable to control for epidural use because of the unavailability of data. While no differences in instrumental delivery rates were observed in this study between the induced and non-induced groups, when parity was introduced, an increased risk of instrumental delivery was observed among nulliparous women (OR = 1.36, 95% CI 1.18 - 1.58). This is of concern since research has documented a link between instrumental delivery and maternal morbidity such as soft tissue injury/discomfort, maternal hematoma, and pelvic floor injury. Vacuum extraction may also "result in significant fetal injury if misused;", problems such as cephalohematoma, subgaleal hematoma, intracranial hemorrhage, hyperbilirubinemia, and retinal hemorrhage may result (ACOG, 2000). Comparison of neonatal outcomes showed that women with induced labor without an identified indication had, on the average, infants with higher birth weights. These findings are in accordance with those of Macer et al. (1992). In this study no association was observed between induction of labor and birth injury. However, previous studies, particularly research done by Dublin et al. (2000), found birth injuries were more common among infants born to women whose labors were induced. The greater prevalence of meconium staining among the non­induced group in this study population, was consistent with the findings of previous studies (Dublin et al., 2000; Smith et al., 1984), who found that meconium was present much less frequently in the electively induced group. The findings of no association between induction and low Apgar scores (<7) were also consistent with previous studies (Dublin et al., 2000; Macer et al., 1992; Smith et al., 1984). Overall, in this study, the neonatal outcomes between the induced and non-induced groups were similar. This study found that the majority of induced women were delivered on weekdays in the afternoon or early evening hours. By contrast, the deliveries of non-induced or spontaneously laboring women were distributed evenly over the 24-hour period. These findings parallel those reported in other studies (Macer et al., 1992; Smith © 2007 The University of Utah. All Rights Reserved Labor Induction Trends 31 2007 UTAH'S HEALTH: AN ANNUAL REVIEW et al., 1984). In this study women who had labor induced were found to be more likely to deliver on weekdays. This may support the hypothesis that a primary attraction of induction is the opportunity it provides to choose a convenient delivery time. Several limitations may be noted in this study. The birth certificate contains information on maternal medical risk factors, labor complications, and induction of labor, however, it does not distinguish between elective induction and medically indicated induction. This study assumed that women without medical risk factors and certain selected labor complications may be defined as low-risk, healthy women undergoing induction. It is possible that women may have had other mitigating factors not reported on the birth certificates, such as joint pain, back pain, edema, indigestion, distance from hospital, or psychosocial issues that influenced the physician's decision for induction. Such information may be present in medical charts or in other medical records. Another limitation is that some information of potential interest in assessing induction of labor is not included in birth certificate data. This information includes items such as Bishop's score for cervical ripening, the different methods of induction, use of epidural analgesia, and length of labor. It is possible that the associations observed in this study between the induction of labor and various maternal and neonatal outcomes may be linked with particular methods of induction only, as mentioned by Dublin et al. (2000). There were also no intrapartum or postpartum complications recorded on the birth certificate, such as hemorrhage, laceration, etc. Incomplete information regarding medical history remains an important limitation of this study and warrants caution in the interpretation of these findings. It is possible that there were other differences between women with induced labor and those with non-induced labor that were unable to be measured in this study. In conclusion, overall maternal and neonatal outcomes were not adversely affected by induction among low-risk women who lacked an identified indication. However, induction was associated with increased risk for instrumental delivery among nulliparous women in this study. Therefore, it is recommended that all women receive full disclosure of the benefits and risks associated with induction before undergoing this obstetric procedure. Further studies need to be undertaken as Utah's induction rate is significantly higher than the national rate. References American College of Obstetricians and Gynecologists, (ACOG). (June 2000). Operative vaginal delivery. ACOG Practice Bulletin, Clinical Management Guidelines for Obstetrician-Gynecologists. No. 17. pp. 417-424. American College of Obstetricians and Gynecologists, (ACOG). (1999). Induction and augmentation of labor. ACOG Technical Bulletin. No. 10, 562-568. Cole, R.A.; Howie, P.W.; Macnaughton, M.C. (1975, April 5). Elective induction of labor. The Lancet. 767-770. Dublin, S; Lydon-Rochelle, M.; Kaplan, R.C.; Watts, D.H.; Critchlow, C.W. (October 2000 ). Maternal and neonatal outcomes after induction of labor without an identified indication. American Journal of Obstetrics and Gynecology, Vol. 183(4): 986-994. 32 Labor Induction Trends © 2007 The University of Utah: All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Glantz, J.C. (April 2005). Elective induction vs. spontaneous labor association and outcomes. Journal of Reproductive Medicine. Vol. 50(4), 235-240. Hoffman, M.K.; Vahratian, A.; Sciscione, A.C.; Troendle, J.F.; Zhang, J.. (2006, May). Comparison of labor progression between induced and noninduced multiparous women. Obstetrics & Gynecology. Vol. 107(5), 1029-1034. Macer, J.A.; Macer, C.L.; Chan, L.S. (1992). Elective induction versus spontaneous labor: A retrospective study of complications and outcome. American Journal of Obstetrics and Gynecology. Vol. 166, 1690-1697. MacDorman, M.F.; Mathews, T.J.; Martin, J.A.; Malloy, M.F. (2002). Trends and characteristics of induced labour in the United States, 1989-98. Paediatric and Perinatal Epidemiology . Vol. 16, 263-273. Martin, D.H.; Thompson, W .; Pinkerton, J.H.M.; Watson, J.D. (1978). A randomized controlled trial of selective planned delivery. British Journal of Obstetrics and Gynecology. Vol. 85, 109-113. Prysak, M .; Castronova, F.C. (1998, July). Elective induction versus spontaneous labor: A case-control analysis of safety and efficacy. Obstetrics and Gynecology. Vol. 92, No. 1, 47-52. Rayburn, W.F.; Zhang, J. (2002, July). Rising rates of labor induction: Present concerns and future strategies. Obstetrics and Gynecology. Vol. 100, No. , 164-167. Seyb, S.T.; Berka, R.J.; Socol, M.L.; Dooley, S.L.. (1999). Risk of cesarean delivery with elective induction of labor at term in nulliparous women. Obstetrics & Gynecology. Vol. 94: 600-607. Smith, L.P.; Nagourney, B.A.; McLean, F.H.; Usher, R.H. (1984, March). Hazards and benefits of elective induction of labor. American Journal of Obstetrics & Gynecology. Vol. 148(5), 579-585. Vahration, A.; Zhang, J.; Troendle, J.F.; Sciscione, A.C.; Hoffman, M.K. (2005, April). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstetrics & Gynecology. Vol. 105(4), 698-704. Vrouenraets, F.P.J.M.; Roumen, F.J.M.E.; Dehing, C.J.G.; Van den Akker; Aarts, M.J.B.; Scheve, E.J.T. (2005, April). Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Obstetrics & Gynecology. Vol.105(4), 690-697. Wigton, T.R.; Wolk, B.M. (1994, January). Elective and routine induction of labor. The Journal of Reproductive Medicine. Vol. 39, No. 1, 21-26. Yeast, J.D.; Jones, A.; Poskin, M. (1999). Induction of labor and the relationship to cesarean delivery: A review of 7001 consecutive inductions. American Journal of Obstetrics and Gynecology. Vol. 180, No. 3, Part 1, 628-633. Yudkin, P.; Frumar, A.M.; Anderson, A.B.M.; Turnbull, A.C. (1979, April). A retrospective study of induction of labour. British Journal of Obstetrics and Gynaecology. Vol. 86, No. 4, 257-265. Zhang, J.; Yancey, M.K.; Henderson, C.E. (2002). U.S. national trends in labor induction, 1989-1998. Journal of Reproductive Medicine. Vol. 4, 120-124. Acknowledgements We thank Brenda Ralls PhD, Sharon Talboys, MPH, Karen Zinner, MPH, and Tara Johnson, MS for their valuable comments about data analysis and interpretations. © 2007 The University of Utah. All Rights Reserved Labor Induction Trends 33 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Periodontal Disease and the Risk of Adverse Pregnancy Outcomes Part I: A Review of Current Literature Bruce P. Murray, PhD, FACHE, CAE, Shaheen Hossain, PhD, Richard O. Woodward, DDS, Robert Satterfield, MStat, Karen Zinner, MPH CORRESPONDENCE Bruce P. Murray, Ph.D., FACHE, CAE Program Administrator - Family Dental Plan Utah Department of Health Division of Health Systems Improvement Bureau of Clinical Services P.O. Box 142002 Salt Lake City, UT 84114-2002 [phone]; Fax: [phone] [e-mail] Abstract During the last decade numerous investigators have studied the posited relationship between periodontal disease in pregnant women and adverse pregnancy outcomes such as premature labor, pre-term deliveries, small-for-gestational age infants, early or late miscarriages, low birth weights and pre-eclampsia. This article presents the results of a comprehensive literature review of these investigations as well as other articles containing similar summaries or commentaries about the studies. The review objective was to ascertain and summarize what the investigators have concluded about this topic. Articles were obtained from the authors' files, references provided in other publications, articles shared by colleagues, and articles listed in PubMed©, many of which were obtained through interlibrary loans at the University of Utah, Salt Lake City, Utah. The authors identified 67 initial articles. Of those 67, 39 contained original empirical data. Twenty-three of the 39 disclosed positive associations, 5 disclosed no associations, 7 revealed mixed associations (both positive and no associations depending on the variables analyzed). Another 4 articles analyzed, in a preliminary sense, the role of pathogens as potential causal explanations for positive associations. The remaining articles contained summaries or commentaries about previously reported data or impending studies. Despite all of the research that has occurred, clearly there still isn't sufficient evidence to conclude or explain definitively a causal relationship between periodontitis in pregnancy and adverse pregnancy outcomes. The only definitive conclusion that can be reached is that there is a lot of evidence that women who have had adverse pregnancy outcomes have more of a tendency to have periodontitis than those who do not. 34 Periodontal Disease I © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Introduction The topic of the posited relationship between periodontal disease (periodontitis) in pregnant women and adverse pregnancy outcomes (premature labor, pre-term deliveries, small-for-gestational age infants, early or late miscarriages, low birth weights and eclampsia or preeclampsia) has received a lot of attention among researchers. During the last decade numerous investigators1-67 have reported or commented on the results of studies focusing on the topic. The majority of the empirical studies (at least twenty-three 3-4,10,15,19,22,26,28-29,34,36-38,40,43,47-48,56,58,62,64­65,67), which include a range of methodological approaches and interventions, from prospective case-control studies to retrospective, non case-control studies using convenience samples, demonstrate to one degree or another a positive association between the presence of periodontal disease in pregnant mothers and diverse adverse pregnancy outcomes. This paper is devoted to a comprehensive literature review of the articles pertaining to this topic. Methodology for Literature Review Studies analyzed for inclusion in this literature review were identified from various sources: (1) Personal files of the authors. (2) References listed by previous investigators in their published articles. (3) Articles shared among colleagues. (4) Articles listed through PubMed©, a service of the National Library of Medicine and the National Institutes of Health. Copies of many of the articles were obtained through an interlibrary loan service of the University of Utah, Eccles Health Sciences Library, Salt Lake City, Utah. The current authors read and examined the articles with the objectives of determining their contents in order to categorize them, i.e., empirical vs. non-empirical, positive associations, no associations, mixed results, summaries of previous studies; and to summarize the key findings and significance of disclosed associations. The current authors believe that the literature reviewed in this paper represents a relatively comprehensive list of studies pertaining to the topic as reported in the scientific literature over the last decade. No attempts were made to eliminate any particular periodicals except for those that may have been published in a foreign language for which English translations were locally unavailable. Table 1 is a numerical summary of the articles reviewed. Table 1: Summary of Number of Articles Reviewed Articles initially identified 67 Articles containing original empirical data 39 Articles with empirical data disclosing positive associations 23 Articles with empirical data disclosing no associations 5 Articles with empirical data disclosing mixed associations 7 Articles analyzing causal mechanisms via the role o f pathogens 4 Articles containing summaries or commentaries about previously reported data or impending studies 28 © 2007 The University of Utah. All Rights Reserved Periodontal Disease I 35 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Results This section delineates the results of the literature review. Literature is summarized in three categorical areas derived from the review process: (1) Studies Reporting Positive Associations; (2) Studies Reporting No Associations; (3) Studies Reporting Mixed or Equivocal Findings or Summaries of Previous Research Findings. Studies Reporting Positive Associations Possibly the first evidence of a positive relationship was reported in 1996 by Offenbacher, et al.67 A case-control study of 124 pregnant or postpartum mothers, divided into case (preterm low birth weight or PLBW ) and control (normal birth weight or NBW) groups, disclosed worse periodontal disease among the former than the latter. The authors concluded that periodontal disease is a statistically significant risk factor for PLBW. Other studies were reported in 1998. Davenport, et al.,65 examined the relationship between maternal periodontal disease and PLBW. In their case-control study of 177 subjects, it was found that the extent and severity of periodontal disease were higher than predicted and may have reflected elevations in gingival inflammation associated with pregnancy. Dasanayake,62 in a 1:1 matched case-control study of 55 pairs of pregnant women, in which control variables were introduced, found that mothers of LBW infants were shorter, less educated, married to men of lower occupational status, had less healthy areas of gingival and more areas with bleeding and calculus, and gained less weight during pregnancy. The author concluded that poor periodontal health of the mother is a potential risk factor for LBW. In another study of 1,313 pregnant women, Jeffcoat, et al.,58 found that the data showed an association between the presence of periodontal disease at 24 weeks' gestation and subsequent preterm birth. In 2001, Offenbacher, et al.,56 again reported on another five-year prospective study of 814 pregnant women. Their aim was to determine whether maternal periodontitis contributed to the risk for prematurity and growth restriction in the presence of traditional obstetric risk facts. The investigators concluded that the study provided evidence that periodontitis and incident progression are significant contributors to obstetric risk for preterm delivery, low birth weight and low weight for gestational age. Lopez, et al.,48 conducted a randomized controlled study of 400 Chilean pregnant women with periodontal disease, randomly assigning 200 to an experimental group and 200 to a control group. They found that the incidence of PLBW in the treatment group was 1.8% and in the control group was 10.1%. In fact, periodontal disease was the strongest factor related to PLBW. Other factors significantly associated with PLBW were less than six pre-natal visits and maternal low weight gain. 36 Periodontal Disease I © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW In 2002, Riche, et al.,47 reported on their study of 1,020 women, 47 of whom had preeclampsia. They found a strong association between periodontal disease status at enrollment and rate of premature delivery observed among preeclamptic women after adjusting for major risk factors, including maternal race, age, marital status, and use of WIC (women, infants', children's' program) or food stamp services. To determine if maternal periodontal disease is associated with the development of preeclampsia, Boggess, et al.,40 studied 1,115 healthy pregnant women. After adjusting for other risk factors, they observed that active maternal periodontal disease during pregnancy is associated with an increased risk for the development of preeclampsia. In the ensuing years, other studies have followed. Jeffcoat, et al.,38 conducted a pilot study of 366 women, randomized to one of three treatment groups, and compared with an untreated reference group of 723 pregnant women. They noted that performing scaling and root planing in pregnant women may reduce preterm birth. Radnai, et al.,36 conducted a case-control study of postpartum women, 41 in a case group and 44 in a control group. A significant association was found between preterm birth and early localized peridontitis of patients. A study by Goepfert, et al.,34 of a convenience sample of 59 women who experienced a spontaneous preterm birth (SPB) at <32 weeks gestation, versus a control group of 36 women who experienced an indicated preterm birth at <32 weeks gestation, versus 44 women who experienced an uncomplicated term birth (TB) was revealing. The SPB group had significantly more extensive periodontitis that the TB group. Moreover, after controlling for maternal age, race, education, insurance status, parity, history of a SPB and smoking, women with severe periodontitis were almost three times as likely to experience a SPB as those without severe periodontitis. In 2005, Marin, et al.,26 reported on a study of 152 pregnant women, divided into three groups: healthy, gingivitis and periodontitis. They concluded that periodontal disease in normal Caucasian pregnant women, older than 25 years, is statistically associated with a reduction in infant birth weight. Another study by Moliterno, et al.,22 of 151 mothers, 76 in a case group and 75 in a control group, relying upon data from hospital registration records, indicated that periodontitis was a risk factor for low birth weight, similar to other risk factors already recognized by obstetricians. Coming on the research scene again, Lopez, et al.,19 reported the results of a randomized control trial of 870 pregnant women from Santiago, Chile. A treatment group of 580 women received periodontal treatment before 28 weeks gestation. A control group of 290 women received periodontal treatment after delivery. The treatment group had significantly reduced PTLBW. © 2007 The University of Utah. All Rights Reserved Periodontal Disease I 37 2007 UTAH'S HEALTH: AN ANNUAL REVIEW More recently in 2006, Sadatmansouri, et al.,10 reported the results of clinical trial research of 30 pregnant women (18-35 years of age) with moderate to severe periodontitis, 15 of which receive periodontal treatments and 15 of which did not receive treatments. The authors concluded that periodontal therapy results in a reduction in the PLBW rate. Results of a prospective study were published by Offenbacher, et al.4 They studied 1,020 pregnant women who received antepartum and postpartum periodontal examinations. It was found that maternal periodontal disease increased relative risk for preterm or spontaneous preterm births. In fact, periodontal disease progression during pregnancy was found to be a predictor of more severe adverse pregnancy outcome of very preterm birth, independent of traditional obstetric, periodontal and social domain risk factors. Boggess, et al.,3 also studied prospectively 1,017 women, risk ratio adjusted for age, smoking, drugs, marital and insurance status and preeclampsia. Their conclusion was that moderate or severe periodontal disease in early pregnancy is associated with delivery of a small-for-gestation-age infant. Studies Reporting No Associations At least five 6,21,23,35,42 of the empirical studies reported disclose no evidence of relationships between periodontal disease in pregnant women and adverse pregnancy outcomes. Davenport, et al.,42 reported in 2002 the results of a case-control study of 236 pregnant women cases and a daily random sample of 507 controls. They found no evidence for an association between PLBW and periodontal disease. They concluded that the results do not support a specific drive to improve periodontal health of pregnant women as a means of improving pregnancy outcomes. In 2004, Moore, et al.,35 completed and reported a prospective study of 3,738 women. They found no significant relationships between the severity of periodontal disease and either preterm or LBW. They observed, however, that there did "appear" to be a correlation between poorer periodontal health and those that experienced a late miscarriage. The major conclusion of the study was that there was no association between either preterm birth or LBW and periodontal disease in the study population. A study was also conducted by Noack, et al.,23 and reported in 2005. Of 59 pregnant women with a high risk of LBW (suffering from preterm contractions) versus 42 women with no preterm contractions and infants appropriate for date and weight, there were no significant differences between the groups in any aspects of the studied periodontitis parameters. Periodontitis was not noted to be a detectable risk factor for PLBW in pregnant women. 38 Periodontal Disease I © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW Also reported in 2005 was a study by Lunardelli and Peres.21 They tested the potential link between periodontal disease in pregnant women and LBW or prematurity. Relying on a population-based, cross-sectional study of 449 parturients in Southern Brazil, they found no association between the variables. Michalowicz, et al.,6 sought to study the effect of nonsurgical periodontal treatment on preterm birth. Their 2006 reported study of 823 women included random assignment of 413 patients to a treatment group which received scaling and root planning, compared to 410 patients in a control group which received no treatment. The authors concluded that treatment of periodontitis improves periodontal health and is safe, but does not significantly alter the rates of preterm birth, LBW or fetal growth restriction. Studies Reporting Mixed or Equivocal Findings or Summaries of Previous Research Findings The remainder of the published articles we analyzed,1-2,5,7-9,11-14,16-18,20,24-25,27,30-33,39,41,44-46,49,50-53,55,57,59,60-61,63 both empirical and nonempirical reveal mixed findings, focus in a preliminary sense on the study of the role of antigens or pathogens in explaining the relationship, or provide summary commentary (from other literature reviews) about conclusions derived from studies already conducted. For example, Farrell, et al.,11 reported mixed findings in their prospective study of 1,793 women reported never previously smoking. There was, in fact, an association between some measures of periodontal disease and late miscarriage, but no association between periodontitis and preterm birth or LBW in the study population. In an earlier study Moreu, et al.,24 based on examinations of 96 pregnant women in first, second and third trimester of pregnancy, observed mixed findings. They reported that periodontal disease is a significant risk factor for LBW but not for pre-term delivery. Buduneli, et al.,27 evaluated the possible link between periodontal infections and PLBW for post-partum women with low socioeconomic characteristics. They found no statistically significant differences between the cases and the controls regarding dental and periodontal parameters. Bacterial load scores, however, were significantly higher in the controls than in the cases. Similarly, but conversely, Mitchell-Lewis, et al.,53 in a study of 213 pregnant women, with 74 assigned to a treatment group and 90 to a non treatment group, found mixed results. They observed no differences in clinical periodontal status between the two groups. However, PLBW mothers had significantly higher levels of certain bacteria. Some studies are beginning to identify potential pathogens (organisms) and the potential roles they may play in fostering the relationship. Hill (1998),66 examined the effects of a complex of bacterial vaginosis microbes and their impact of PLBW. The study provided evidence associating maternal periodontal disease with PLBW taken with the isolation of F. nucleatum, Capnocytophaga, and other oral species from amniotic fluid. © 2007 The University of Utah. All Rights Reserved Periodontal Disease I 39 2007 UTAH'S HEALTH: AN ANNUAL REVIEW Dasanayake, et al.,52 studied 448 women, predominantly African American and socioeconomically homogeneous, using case and control groups. Their data showed that LBW deliveries were associated with a higher maternal serum antibody level against P. gingivalis at mid-trimester. The association remained significant after controlling for smoking, age lgG levels against other selected periodontal pathogens, and race. One analytical study in 2001 by Madianos, et al.,55 of 812 deliveries from a cohort study of pregnant mothers presented measures of maternal periodontal infection using whole chromosomal DNA probes to identify 15 periodontal organisms within maternal periodontal plaque sampled at delivery. A conclusion was proffered: the high prevalence of elevated fetal lgM to C. rectus among premature infants raises the possibility that this specific maternal oral pathogen may serve as a primary fetal infectious agent eliciting prematurity. A study reported in 2006 by Yiping, et al.,9 or 34 pregnant women also provided some direct evidence of oral-utero microbial transmission. The authors stated that their observations suggested a Bergeyella strain identified in the patient's intrauterine infection originated from the oral cavity. Some of the reported studies mentioned previously have engendered commentary about the reliability and validity of the investigations, some of it controversial about whether some of the results from different studies are in conflict, or and about the need for more skillful appraisals of the methodologies used in the analyses. One commentator, Ahearne,31 suggested that "the concept of evidence based dentistry is an honorable one, but the reality is that it can become very confusing for the practicing dentist when different studies ask the same question but come up with different answers." Ahearne first referred to the study by Moore, et al.,35 in which no positive relationship was found between periodontal disease and pre-term birth or LBW. Secondly, he noted that the very same month Radnai, et al.,36 asked a very similar question and came to the conclusion that peridontitis was an important risk factor for pre-term birth. The conclusion of the letter was that "if the difference in the outcomes of the studies is due to the difference in the populations studied then, surely it raises some questions about the validity of clinical trials in general." In a follow-up research letter, Beckett, et al.,25 using "a systematic process of critical appraisal, discovered that one of the studies contained a far more reliable evidence source than the other." They recommended that "practitioners must develop critical appraisal skills. It is important not to fall into the trap of assuming because a paper is published in a referred journal, it must be sound. . . ." One interesting study contained an insightful meta analysis of previous research. Khader and Ta'ani,29 in a methodologically sophisticated review of previous studies, utilizing independently abstracted data from the studies, found that periodontal diseases in the pregnant mother significantly increases the risk of subsequent pre­term birth or LBW. Their conclusion was based on two previous case-control studies and three prospective 40 Periodontal Disease I © 2007 The University of Utah. All Rights Reserved UTAH'S HEALTH: AN ANNUAL REVIEW cohort studies that met prestated meta analysis inclusion criteria. Another interesting conclusion was reached: "there is no convincing evidence, on the basis of existing case-control and prospective studies, that treatment of periodontal disease will reduce the risk of pre-term birth." Conclusions The majority of reported studies indicate a positive association between periodontitis in pregnant mothers and adverse pregnancy outcomes. Although a plethora of research has already occurred, clearly there still isn't sufficient evidence, however, to conclude a causal relationship between the presence of periodontitis and adverse pregnancy outcomes. The only definitive conclusion that can be reached is that there is a lot of evidence of a positive association of periodontitis with adverse pregnancy outcomes. In other words, those women who have had adverse pregnancy outcomes have more of a tendency to have periodontitis than those who do not. This fact is evident even when various control variables are analyzed as potential explanations or reasons for the relationship. The precise mechanisms or chemical processes that would establish a definitive causal relationship have not yet been unequivocally identified. Further research to identify and isolate causal mechanisms or processes still needs to be undertaken. It would be wise to conduct a prospective case-control study in which an adequate sample of subjects is included, and multiple regression is applied to assess the independent contributions (amount of variance accounted for) of various variables that are known to predispose to adverse pregnancy outcomes. Despite the lack of conclusive causal explanations, proper prophylaxes should still be encouraged. There isn't any evidence to suggest that proper prophylaxes won't be beneficial to pregnant women, and it is likely more prudent to err on the side of prevention rather than doing nothing. References 1. Bobetsis, Y.A., Barros, S.P., & Offenbacher, S. (2006). Exploring the relationship between periodontal disease and pregnancy complications. J Am Dent Assoc 137 (Suppl. 2), 7S-13S. 2. Douglass, C.W. (2006). Risk assessment and management of periodontal disease. J Am Dent Assoc 137 (Suppl. 3), 27S-32S. 3. Boggess, K.A., Beck, J.D., Murtha, A.P., Moss, K. & Offenbacher, S. (2006). Maternal periodontal disease in early pregnancy and risk for a small-for-gestational-age infant. Am J Obstet & Gynecol 194, 1316-22. 4. Offenbacher, S., Boggess, K.A., Murtha, A.P., Jared, H.L., Lieff, S., McKaig, R.G., Mauriello, S.M., Moss, K.L., & Beck, J.D. (2006). Progressive periodontal disease and risk of very preterm delivery. Am J Obstet & Gynecol 107, 29-36. 5. Goldenberg, R.L., & Culhane, J.F. (2006, Nov.). Preterm birth and periodontal disease. N Engl J Med 355(18), 1925-27. 6. Michalowicz, B.S., Hodges, J.S., DiAngelis, A.J., Lupo, V.R., Novak, M.J., Ferguson, J.E