OBJECTIVE To test the association of elective induction of labor at term compared with expectant management and maternal and neonatal outcomes. METHODS This was a retrospective cohort study of all deliveries without prior cesarean delivery in California in 2006 using linked hospital discharge and vital statistics data. We compared elective induction at each term gestational age (37–40 weeks) as defined by The Joint Commission with expectant management in vertex, non-anomalous, singleton deliveries. We used multivariable logistic regression to test the association of elective induction and cesarean delivery, operative vaginal delivery, maternal third- or fourth-degree lacerations, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, hyperbilirubinemia, and macrosomia (birth weight greater than 4,000 g) at each gestational week, stratified by parity. RESULTS The cesarean delivery rate was 16%, perinatal mortality was 0.2%, and neonatal intensive care unit admission was 6.2% (N=362,154). The odds of cesarean delivery were lower among women with elective induction compared with expectant management across all gestational ages and parity (37 weeks [odds ratio (OR) 0.44, 95% confidence interval (CI) 0.34–0.57], 38 weeks [OR 0.43, 95% CI 0.38–0.50], 39 weeks [OR 0.46, 95% CI 0.41–0.52], 40 weeks [OR 0.57, CI 0.50–0.65]). Elective induction was not associated with increased odds of severe lacerations, operative vaginal delivery, perinatal death, neonatal intensive care unit admission, respiratory distress, shoulder dystocia, or macrosomia at any term gestational age. Elective induction was associated with increased odds of hyperbilirubinemia at 37 and 38 weeks of gestation and shoulder dystocia at 39 weeks of gestation. CONCLUSION Elective induction of labor is associated with decreased odds of cesarean delivery when compared with expectant management

ObjectiveTo propose an antenatal care classification for measuring the continuum of health care based on the concept of adequacy: timeliness of entry into antenatal care, number of antenatal care visits and key processes of care.MethodsIn a cross-sectional, retrospective study we used data from the Mexican National Health and Nutrition Survey (ENSANUT) in 2012. This contained self-reported information about antenatal care use by 6494 women during their last pregnancy ending in live birth. Antenatal care was considered to be adequate if a woman attended her first visit during the first trimester of pregnancy, made a minimum of four antenatal care visits and underwent at least seven of the eight recommended procedures during visits. We used multivariate ordinal logistic regression to identify correlates of adequate antenatal care and predicted coverage.FindingsBased on a population-weighted sample of 9 052 044, 98.4% of women received antenatal care during their last pregnancy, but only 71.5% (95% confidence interval, CI: 69.7 to 73.2) received maternal health care classified as adequate. Significant geographic differences in coverage of care were identified among states. The probability of receiving adequate antenatal care was higher among women of higher socioeconomic status, with more years of schooling and with health insurance.ConclusionWhile basic antenatal care coverage is high in Mexico, adequate care remains low. Efforts by health systems, governments and researchers to measure and improve antenatal care should adopt a more rigorous definition of care to include important elements of quality such as continuity and processes of care.

INTRODUCTION Little is known about the relationship between disability and mode of delivery. Prior research has indicated elevated risk of cesarean delivery among women with certain disabilities, but has not examined patterns across multiple types of disability or by parity. OBJECTIVE To determine whether physical, sensory, or intellectual and developmental disabilities are independently associated with primary cesarean delivery. METHODS We conducted a retrospective cohort study of all deliveries in California 2000–2010 using linked birth certificate and hospital discharge data. We identified physical, sensory, and intellectual and developmental disabilities using ICD-9 codes. We used logistic regression to examine the association of these disabilities and primary cesarean delivery, controlling for socio-demographic characteristics and co-morbidities and stratified by parity. RESULTS In our sample, 0.45% (20,894/4,610,955) of deliveries were to women with disabilities. A larger proportion of women with disabilities were nulliparous, had public insurance, and had co-morbidities (e.g., gestational diabetes) compared with women without disabilities (p<0.001 for all). The proportion of primary cesarean in women with disabilities was twice that in women without disabilities (32.7% versus 16.3%, p<0.001; aOR = 2.05; 95% CI = 1.94–2.17). The proportion of deliveries by cesarean was highest among women with physical disabilities due to injuries compared with women without disabilities (57.8% versus 16.3%, p<0.001; aOR = 6.83; 95%CI = 5.46–8.53). CONCLUSION Women across disability subgroups have higher odds of cesarean delivery, and there is heterogeneity by disability type. More attention is needed to this population to ensure better understanding of care practices that may impact maternal and perinatal outcomes.

Objective To compare perinatal outcomes between elective induction of labor (eIOL) and expectant management in obese women. Design Retrospective cohort study. Setting Deliveries in California in 2007. Population Term, singleton, vertex, nonanomalous deliveries among obese women (n=74,725). Methods Women who underwent eIOL at 37 weeks were compared with women who were expectantly managed at that gestational age. Similar comparisons were made at 38, 39, and 40 weeks. Results were stratified by parity. Chi-square tests and multivariable logistic regression were used for statistical comparison. Main Outcome Measures Method of delivery, severe perineal lacerations, postpartum hemorrhage, chorioamnionitis, macrosomia, shoulder dystocia, brachial plexus injury, respiratory distress syndrome. Results The odds of cesarean delivery were lower among nulliparous women with eIOL at 37 weeks (odds ratio [OR] 0.55, 95% confidence interval [CI] 0.34–0.90) and 39 weeks (OR 0.77, 95% CI 0.63–0.95) compared to expectant management. Among multiparous women with a prior vaginal delivery, eIOL at 37 (OR 0.39, 95% CI 0.24–0.64), 38 (OR 0.65, 95% CI 0.51–0.82), and 39 weeks (OR 0.67, 95% CI 0.56–0.81) was associated with lower odds of cesarean. Additionally, eIOL at 38, 39, and 40 weeks was associated with lower odds of macrosomia. There were no differences in the odds of operative vaginal delivery, lacerations, brachial plexus injury, or respiratory distress syndrome. Conclusions In obese women, term eIOL may decrease the risk of cesarean delivery, particularly in multiparas, without increasing the risks of other adverse outcomes when compared with expectant management. Tweetable Abstract Elective induction of labor in obese women does not increase risk of cesarean or other perinatal morbidities.

The purpose of this secondary analysis was to identify the meaning of normalization for parents of a child with a chronic genetic condition. The sample was comprised of 28 families (48 parents), selected to reflect two groups: Normalization Present (NP) and Normalization Absent (NA). Constant comparison analysis was used to identify themes characterizing parents' perceptions of the meaning of normalization. The meanings parents attributed to normalization reflected their evaluation of condition management, parenting role, and condition impact, with parents in the NP and NA groups demonstrating distinct patterns of meaning. These meaning patterns are discussed as an outcome of normalization. Providers can play a pivotal role in helping families achieve normalization by providing guidance on how to balance condition management with normal family life.

Background Approximately 12% of women of reproductive age have some type of disability. Very little is known about sexual and reproductive health issues among women with disabilities, including what proportion of women with disabilities experience pregnancy. Data on pregnancy are important to inform needs for preconception and pregnancy care for women with disabilities. Objective The purpose of this study was to describe the occurrence of pregnancy among women with various types of disability and with differing levels of disability complexity, compared to women without disabilities, in a nationally representative sample. Study Design We conducted cross-sectional analyses of 2008–2012 Medical Expenditure Panel Survey annualized data to estimate the proportion of women ages 18–44 with and without disabilities who reported a pregnancy during one year of their participation on the survey panel. We used multivariable logistic regression to test the association of pregnancy with presence, type, and complexity of disability, controlling for other factors associated with pregnancy. Results Similar proportions of women with and without disabilities reported a pregnancy (10.8% vs. 12.3%, with 95% confidence intervals overlapping). Women with the most complex disabilities (those that impact activities such as self-care and work) were less likely to have been pregnant (AOR=0.69, 95%CI=0.52–0.93), but women whose disabilities only affected basic actions (seeing, hearing, movement, cognition) did not differ significantly from women with no disabilities. Conclusion Women with a variety of types of disabilities experience pregnancy. Greater attention is needed to the reproductive healthcare needs of this population in order to ensure appropriate contraceptive, preconception, and perinatal care.

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BackgroundDespite Britain, Colombia, and some Mexican states sharing a health exception within their abortion laws, access to abortion under the health exception varies widely. This study examines factors that result in heterogeneous application of similar health exception laws and consequences for access to legal abortion. Our research adds to previous literature by comparing implementation of similar abortion laws across countries to identify strategies for full implementation of the health exception.MethodsWe conducted a cross-country comparative descriptive study synthesizing data from document and literature review, official abortion statistics, and interviews with key informants. We gathered information on the use and interpretation of the health exception in the three countries from peer-reviewed literature, court documents, and grey literature. We next extracted public and private abortion statistics to understand the application of the law in each setting. We used a matrix to synthesize information and identify key factors in the use of the law. We conducted in-depth interviews with doctors and experts familiar with the health exception laws in each country and analyzed the qualitative data based on the previously identified factors.ResultsThe health exception is used broadly in Britain, somewhat in Colombia, and very rarely in Mexican states. We identified five factors as particularly salient to application of the health exception in each setting: 1) comprehensiveness of the law including explicit mention of mental health, 2) a strong public health sector that funds abortion, 3) knowledge of and attitudes toward the health exception law, including guidelines for physicians in providing abortion, 4) dissemination of information about the health exception law, and 5) a history of court cases that protect women and clarify the health exception law.ConclusionsThe health exception is a valuable tool for expanding access to legal abortion. Differences in the use of the health exception as an indication for legal abortion result in wide access for women in Britain to nearly no access in Mexican states. Our findings highlight the difference between theoretical and real access to legal abortion. The interpretation and application of the health exception law are pivotal to expanding real access to abortion.