Women's health

Alternative perinatal care

In the past few years, several provincial governments have introduced midwife care in response to a perceived growing interest among Canadian women to deliver babies at home or in birthing centres. How large and enduring this trend will be remains a major question for those planning health care services for pregnant women. A new study shows that of 3,448 women aged 20-44 who responded to questions about perinatal care in the 1994 Population Health Survey, 21% said they would allow a nurse or midwife to deliver their baby, 85% would allow a nurse or midwife to provide postpartum care and 31% would go to a birthing centre rather than a hospital to deliver their baby.

The authors report that education, immigration status and language were all major influences on how willing mothers-to-be are to choose options other than delivery in hospital. [CMAJ 1999;161(6):708-9]

Elderly women's health needs ignored

Elderly women, who form Canada's fastest-growing population segment, are also its more ignored when it comes to health care research. A 65-year-old woman has a 50% chance of reaching age 85, yet there is little research on her unique health needs including bone loss, incontinence and falls. [CMAJ 1999;161(10):1309-10]

Hormone replacement therapy

Although many practice guidelines exist for hormone replacement therapy (HRT) and several physician surveys and articles have been published on the topic, there are few clear-cut recommendations on when to prescribe HRT.

Based on a study of 327 Ontario physicians, new research finds that the majority of Ontario physicians are familiar with published recommendations and follow them in their practices. The vast majority recognized the importance of HRT in addressing risks for osteoporosis (97.4%), coronary artery disease (CAD) (89.3%) and breast cancer (97.3%).

While these finding are reassuring, about 15% of respondents said they would prescribe combined HRT for women who have had a hysterectomy. This is of concern because questions about the long-term effects of progestin and its role in CAD are unanswered. [CMAJ 1999;161(6):695-8]

Infertility treatment ignored?

In 1993 the Royal Commission on New Reproductive Technologies recommended that Ontario discontinue coverage of in vitro fertilization (IVF) techniques for indications other than bilateral fallopian tube blockage because its effectiveness had not been rigorously evaluated. To address this restriction, researchers compared the outcomes of three groups of patients: 122 couples with male factor infertility treated by IVF with intracytoplasmic sperm injection (ICSI) of fresh sperm from ejaculate, 27 couples with obstructive azoospermia treated by IVF with ICSI of epididymal sperm, and 98 couples with bilateral fallopian tube blockage treated with conventional IVF. The authors found no difference in rates of implantation or pregnancy for the three groups and suggest that the commission's recommendation to discontinue coverage of IVF for indications other than tubal blockage be revised. [CMAJ 1999;161(11):1397-1401]

An accompanying editorial criticized the lack of progress since 1993 and suggests that most infertile Canadians are being denied reproductive choice. [CMAJ 1999;161(11):1411-12]

Maternal screening popularity declines in rural areas

The Ontario Maternal Screening Program (MSS) was launched as an Ontario-wide pilot project in 1993 to determine pregnant women's risk of carrying a fetus with Down's syndrome, trisomy 18 or an open neural tube defect. As a follow-up, researchers surveyed Ontario health care providers on their use of and opinions about MSS. The high response rate (86%) to the survey attests to the strength of attitudes about MSS held by family physicians, obstetricians and midwives. However, the survey discovered marked regional differences in MSS practices: 90% of respondents in the Central East region, which includes Toronto, said that they routinely offer MSS to all pregnant women in accordance with Ontario Ministry of Health recommendations, compared with only 71% of those in the Northwest region, which includes Thunder Bay, Kenora and Rainy River. The authors noted that abortion is available in 94% of Toronto hospitals but in only 30% of hospitals in northeastern Ontario. They suggest that providers who cared for 50 or more pregnant women a year were more likely to offer MSS routinely than those who felt patient characteristics affect the offering of MSS or that follow-up services were not readily available. [CMAJ 1999;161(4):381-5]

Reducing stillbirth rates

Randomized clinical trials show that post-term pregnant women and their babies are better off if labour is induced before 42 weeks. Researchers studied the management of post-term pregnancy in Canada between 1980 and 1995 to determine if this evidence had been translated into clinical practice. They found a marked increase in the proportion of births taking place at 41 weeks' gestation (from 11.9% in 1980 to 16.3% in 1995) and a decrease in the proportion at 42 or more weeks (from 7.1% in 1980 to 2.9% in 1995). They also found a significant reduction in the rate of stillbirths among babies delivered at 41 or more weeks' gestation, from 1.8 per 1000 total births in 1980 to 0.9 per 1000 total births in 1995. [CMAJ 1999;160(8):1145-9]

Sexual assault

In the first study to link medical findings in Canadian sexual assault cases to legal outcomes, researchers reviewed the charts of 95 sexual assault cases that had been examined by the BC Women's Sexual Assault Service in 1992 and for which a police report had been filed. They found that charges were more likely to be laid in cases with documented moderate to severe injury than in cases with mild or no physical injury. Other factors associated with charge laying included socioeconomic status above the group median, and an assailant who was known to the victim.

The authors suggest that it would be valuable to extend this line of research to learn more about the other variables that predict the laying of charges and, even more important, the securing of a conviction. [CMAJ 1999;160(11):1565-9]

Trends in preterm birth

Preterm birth rates in Canada (birth prior to 37 weeks' gestation) have increased slightly over the last decade, apparently contrasting with a dramatic reduction reported between the early 1970s and mid-1980s. Two researchers report, however, that historical reductions in preterm birth in Canada were due to inaccuracies in gestational age information in the 1970s. Graphical examination of the 1972 data indicates that true gestational age was rounded to the nearest lunar month (9 months or 36 weeks), and thus a number of term births were misclassified as premature in the earlier data set. The authors state that the recent increase in preterm birth rates in Canada parallels that of other industrialized countries and is likely explained by increased obstetric intervention and multiple births. [CMAJ 1999;161(11):1409]

Violence during pregnancy

A study of 543 women receiving prenatal services through the Saskatoon District public health system found that 31 (5.7%) had experienced physical abuse during pregnancy. The authors report that although women in all ethnic groups were affected, aboriginal women were at greater risk than nonaboriginal women and women whose partner had a drinking problem were 3.4 times more likely to suffer abuse. [CMAJ 1999;160(7):1007-11]

An accompanying editorial warns that prevalence rates found in the above study may underestimate the extent of the problem. The author called for action to move society toward developing programs for early detection and prevention of physical abuse during pregnancy. [CMAJ 1999;160(7):1022-23]