PURPOSEIn 1999 the American College of Obstetricians and Gynecologists (ACOG) adopted more-restrictive guidelines for vaginal birth after cesarean delivery (VBAC). This study assesses trends in VBAC in California and compares neonatal and maternal mortality rates among women attempting VBAC delivery or undergoing repeat cesarean delivery before and after this guideline revision.
METHODSThe 1996 through 2002 California Birth Statistical Master Files were used to identify 386,232 California residents who previously gave birth by cesarean delivery and had a singleton birth planned in a California hospital.RESULTS Attempted VBAC deliveries decreased signifi cantly from 24% before to 13.5% after guideline revision (P <.001). Neonatal mortality rates per 1,000 live births for attempted VBAC deliveries were not different from repeat cesarean delivery rates among neonates weighing ≥1,500 g in either the study periods 1996 to 1999 or 2000 to 2002. Neonatal mortality rates for attempted VBAC deliveries were higher for repeat cesarean deliveries among neonates weighing <1,500 g in the same periods (attempted VBAC: 1996(attempted VBAC: -1999.2; 95% Poisson confi dence interval [CI], 197.7-308.6;2000 CI, 254.3-419.4; repeat cesarean delivery: 1996-1999 CI, 48.3-69.9;2000). Maternal death rates per 100,000 live births for attempted VBAC deliveries were similar for both periods (1996-1999 CI, 0.1-11.0;2000 CI, 1.0-30.6).CONCLUSIONS Neonatal and maternal mortality rates did not improve despite increasing rates of repeat cesarean delivery during the years after the ACOG 1999 VBAC guideline revision. Women with infants weighing ≥1,500 g encountered similar neonatal and maternal mortality rates with VBAC or repeat cesarean delivery.
The authors discuss the growing need for primary care residents to learn how to care for patients of many cultural backgrounds. To effectively learn the needed skills, residents must incorporate insights from areas outside medicine. The authors focus on three such areas: cultural competency, public health, and community-oriented primary care. Regarding cultural competency, the authors make clear that on the one hand, physicians must be trained to be sensitive to cultural differences and patterns, but on the other, they cannot be expected to know the many cultures of their patients in depth. They discuss the Core Curriculum Guidelines on Culturally Sensitive and Competent Health Care created by the Society of Teachers of Family Medicine. Regarding community-oriented primary care (COPC), a process introduced from Europe in 1982, the authors state that one of its key elements is to provide accessible care to diverse and often underserved populations. However, various factors have kept COPC, and the federally funded community health centers that address the concerns of COPC, from having the widespread effects they could have. Regarding public health, the authors review the various services and orientations of public health and show how these help foster care for diverse populations. The authors then briefly describe their own residency program and its work with diverse populations. They conclude by emphasizing the importance for residents of learning the principles and practices embodied in cultural competency, public health, and COPC in order to effectively communicate with their patients.
Prophylactic treatment with commercially available E. purpurea capsules did not significantly alter the frequency of upper respiratory tract symptoms compared with placebo use.
Census data from the residency graduate's high school predicted rural practice and practice in a proportionally high minority community, but not in a federally designated medically underserved area.
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