RAND-University of Pittsburgh Health Institute

Women's Health


The RUPHI-MWRI Women’s Health Pilot Grant Program provides funding for pilot studies that focus on any aspect of health at any time in a woman’s lifespan

Funding Period

March 1, 2008 - March 1, 2009


University of Pittsburgh Investigator RAND Investigator Title of Project
Katherine Wisner, MD Sandraluz Lara-Cinisomo, PhD Latina Postpartum Depression: Defining Terms and Treatment
Bimla Schwartz, MD, MPH Tamara Dubowitz, PhD Interest in Intrauterine Contraception Among Women Requesting Emergency Contraception or Pregnancy Testing
Janet Catov, PhD Matthias Schonlau, PhD Severity of Preterm Birth and Maternal Sub-Clinical Cardiovascular Disease

Final Reports

Interest in Intrauterine Contraception among Women Requesting Emergency Contraception or Pregnancy Testing

Eleanor Bimla Schwarz, MD, MS, University of Pittsburgh
Tamara Dubowitz, ScD, RAND

Summary of work

We have completed 2 analyses of the survey data that we were able to collect thanks to these grant funds. The first of these publications was picked up by Reuters and resulted in international coverage of our work. Click here for more information.

Publication: Schwarz EB, Kavanaugh M, Douglas E, Dubowitz T, Creinin MD.

Interest in intrauterine contraception among seekers of emergency contraception and pregnancy testing. Obstet Gynecol. 2009 Apr;113(4):833-9. PMID: 19305327

Specific aim: This study estimated interest in use of intrauterine contraception among women seeking emergency contraception (EC) or walk-in pregnancy testing.

Methods: We surveyed 412 women who requested EC or pregnancy testing at four family planning clinics in Pittsburgh, PA. The 41-item survey assessed knowledge of, attitudes towards, and interest in using intrauterine contraception (IUD). Data were analyzed using 2 and Fisher’s exact tests and multivariable logistic regression methods.

Findings: The response rate was 85%. Twelve percent (95% CI 9%-15%) of women surveyed expressed interest in same-day insertion of an IUD and 22% (95% CI 18%-26%) wanted more information about IUDs. Interest in same-day IUD insertion increased with higher education level, prior unwanted pregnancy, and experience with barriers to use of contraception.

Conclusions: Same-day IUD insertion may be a reasonable way to increase the use of highly-effective contraception among women seeking EC or walk-in pregnancy testing

Publication: Kavanaugh M, Schwarz EB. Prospective assessment of pregnancy intentions using a single-item vs. multi-item measure. Perspe Sex Repro Health. In press.

Specific aim: To compare the utility of a single-item vs. multi-item measure in prospectively assessing women’s pregnancy intentions. Methods: Women ages 15-44 awaiting pregnancy test results at family planning clinics in Pittsburgh, PA completed a survey containing both single and multi-item measures of pregnancy intentions. Chi-square analyses were used to examine the data.

Results: The survey completion rate was 83% (249/300). Responses to the single-item measure closely paralleled the multi-item classifications for non-ambivalent women: few women indicated that they were trying (11%) or planning (20%) for pregnancy while approximately a third of the sample were not trying (31%) or planning (36%) for pregnancy, per the single-item and multi-item measures, respectively. The single-item measure categorized more women as ambivalent about pregnancy (58%) than did the multi-item measure (44%). Of women categorized as ambivalent by the single-item measure, 38% were also categorized as ambivalent by the multi-item measure. Overall, 68% of responses to the two measures were concordant. With both measures, greater proportions of women who were not planning or trying for pregnancy indicated that they planned to have an abortion if their test was positive.

Conclusions: Prospective assessment of pregnancy intention with either a single or multi-item measure may allow for less-biased assessment of pregnancy plans. The multi-item measure may reduce the number of women categorized as ambivalent and allow more targeted contraceptive and pre-conception counseling interventions.

Plans for future work

Having demonstrated that up to 30% of women seeking emergency contraception or pregnancy testing would be interested in same-day insertion of an IUD if this service were available I plan to propose a larger project designed to demonstrate the feasibility, safety, and efficacy of same-day insertion of highly effective reversible contraceptives (which include IUDs and contraceptive implants). In an effort to identify clinical sites willing to participate in such a project, I have spoken with the leaders of Adagio Health (which provides family planning services at 70 sites in 23 counties of western Pennsylvania). They have expressed enthusiasm about such a project and together we are working to identify a number of clinics that will be good sites to work. Ideally, if we can identify enough sites, I hope to conduct a cluster randomized trial to assess rates of unintended pregnancy, sexually transmitted infection, and pelvic inflammatory disease, in the 1-2 years after women visit a study clinic.

Potential funding agencies:

HHS PAR-08-999 http://www.hhs.gov/opa/news/sdi_032508.pdf

AHRQ PA-09-070 http://grants.nih.gov/grants/guide/pa-files/PA-09-070.html

We feel that this proposal would fit with one of the IOM’s tope 25 priority areas. Specifically: Compare the effectiveness of innovative strategies for preventing unintended pregnancies (e.g., over-the-counter access to oral contraceptives or other hormonal methods, expanding access to long-acting methods for young women, providing free contraceptive methods at public clinics, pharmacies, or other locations).


Names of Pitt and RAND co-investigators on the new grant:

E. Bimla Schwarz, MD, MS, Mitch Creinin, MD, and if we can find a way to look at neighborhood effects that will draw on her strengths, possibly Tamara Dubowitz.

Severity of Preterm Birth and Maternal Sub-Clinical Cardiovascular Disease

Janet M. Catov, PhD, MS, University of Pittsburgh
Matthias Schonlau, PhD, RAND

Preterm birth, the most prevalent pregnancy complication in the U.S., is the leading cause of infant morbidity and mortality and rates are increasing. Until recently, preterm birth was thought to have no long term maternal health consequences. Emerging epidemiologic evidence, however, indicates that women with preterm births not complicated by preeclampsia have a 2 to 3-fold higher risk for CVD death compared to those with term births. The relation of spontaneous preterm birth (PTB) severity, subtypes and recurrence to maternal CVD risk, however, has not been studied. Early PTB is strongly related to infection and inflammation even when measured before mid-gestation, and the earlier the PTB the higher the risk of recurrence in subsequent pregnancies. Thus, some factors such as inflammation may antedate conception, increase risk for PTB, and persist post partum. Inflammation has also been related to CVD risk in women, and women with early or recurrent sPTB may be at particularly elevated risk for CVD later in life.

Aim 1. To relate a history of sPTB to subclinical evidence of cardiovascular disease using non-invasive measures of arterial stiffness, carotid artery plaque and vessel thickness, and endothelial dysfunction. We compared 119 women who delivered preterm (<37 weeks) following pregnancies not complicated by preeclampsia or growth restriction to 237 women with uncomplicated term births (≥37 weeks). All women delivered at Magee-Womens Hospital in Pittsburgh, PA and those with diabetes or hypertension before the index birth were excluded. Women underwent B-mode carotid ultrasound to determine the mean of average IMT across 8 carotid artery segments (common carotid, bulb, and internal carotid) 8 years (SD 1.7) post partum. Covariates were assessed via a structured interview, and gestational age of the index birth was determined from medical records (based mainly on prenatal ultrasound). Women were, on average, 37 years old (SD 7.5) at measurement. Effects of gestational age of index birth on IMT were evaluated with multiple linear regression. The mean IMT for women with term vs. preterm births was not different (0.56 vs. 0.58 mm, p=0.10). When gestational age of the index birth was evaluated continuously, however, important differences in IMT were detected. As the gestational age of the index birth decreased, IMT increased (beta= -0.004, p<0.01, Figure 1). After adjustment for race, age, BMI, and smoking this relationship was attenuated but remained significant (beta= -0.002, p=0.05). Eight years post partum, carotid IMT appeared to increase as gestational age of a previous birth decreased. Early atherosclerosis following PTB may be a mechanism linking PTB to future cardiovascular disease.

Aim 2. To evaluate the severity and recurrence of preterm births and maternal cardiovascular disease risk. We related preterm birth, severity (earlier gestational age at delivery) and recurrence (2 or more) among women who gave birth between 1973 and 1983 in Denmark (n=427,765) to maternal CVD morbidity and mortality from 1977 to 2006. Birth data were linked to CVD hospitalizations and deaths identified in national registers via ICD codes, and data were analyzed using Cox proportional hazards regression models. Women with a prior PTB had excess CVD after adjustment for age, parity, and education (HR 1.36 [95% CI 1.31, 1.41], Figure 2). This was only modestly attenuated when women with preeclampsia or small for gestational age births were excluded, and the relationship was stronger for CVD mortality (HR 1.98 [1.73, 2.26]). Recurrent PTB was associated with higher CVD morbidity compared to women with one PTB, and this was particularly evident for ischemic events (HR 1.78 [1.40, 2.27] vs. 1.22 [1.09, 1.36]. Risk was similarly elevated among women with early vs. moderate PTB. The associations between PTB and risk of atherosclerosis (HR 4.11, [3.28, 5.14]) and thrombosis (HR 2.23, [1.34, 3.74]) were particularly high. Sensitivity analysis suggested that confounding by smoking only partly explained these associations. Associations between PTB and maternal CVD could reflect a common underlying predisposition related to both conditions.

Conclusions: Women with early preterm births appear to have evidence of atherosclerosis 8 years post partum, and those with recurrent preterm births have excess cardiovascular disease risk after 28 years of follow up. Associations with ischemic disease, atherosclerosis and thrombosis were particularly elevated among women with two or more preterm births. Our results support the possibility that preterm births may mark women at increased risk for cardiovascular disease, and suggest that atherosclerosis may link these conditions. These data were presented at the American Heart Association Epidemiology and Prevention Conference (March 2009) and are currently being drafted as manuscripts.

Next steps: Our pilot data support two NIH grant applications. An RC1 Challenge Grant was submitted in April, 2009 to study atherogenic factors early in pregnancy among women with and without subsequent preterm births. An R01 slated for October 2009 submission will evaluate the cardiovascular risk and carotid artery remodeling among women with and without a preterm birth 10 years post partum. This will be a collaborative project between the University of Pittsburgh, RAND, and Michigan State University.

Latin Postpartum Depression: Defining Terms and Treatment

Sandraluz Lara-Cinisomo, PhD, RAND
Katherine Wisner, MD, University of Pittsburgh

Specific Aims: Postpartum depression is a significant mental health condition that may lead to serious health and mental health outcomes for mothers and their children. There has been a growth in the number of studies examining treatment options including the use of antidepressants and psychotherapy. However, most of the studies have focused on white women and, to a lesser extent, African-American mothers. This means we still do not know the treatment preferences of Hispanic women. It is vital that we first determine these preferences if we are to effectively treat Hispanic mothers suffering with or at risk for postpartum depression. At address this gap, we conducted a pilot qualitative study with Hispanic mothers from two Pennsylvania regions to identify treatment preferences and to establish guidelines for implementing their preferred mental health treatments.

Methods: Five focus group interviews were conducted with prenatal and postpartum Hispanic women and Hispanic male partners. Participants were recruited at approved medical and community settings. Participants were approached by the PI and/or their health care provider and were invited to participate in the study. Focus groups were conducted in Spanish and English and moderated by the PI and a standardized interview protocol available in Spanish and English was used to guide the interviews. Five areas of inquiry guided the interviews: Defining depression and postpartum depression, Treatment Preferences, Barriers to Treatment, and Suggestions for treatment delivery. Focus group discussions were audio taped with the participants’ consent and transcribed verbatim. Spanish focus groups were translated during transcription by a professional translator. Demographic data was collected using a survey after each focus group interview. Each focus group took approximately 60 to 90 minutes to complete.

The unit of analysis was the focus group. The PI and two members of the research team not familiar with the interview and study objective independently coded the transcripts based on the areas of inquiry provided in the interview protocol. The research team member individually identified salient themes in the data that are relevant to areas of inquiry then discussed them as a team to reach a consensus. Following the team consensus, the transcripts were codes using the final schemes.

Findings: Based on our analysis of the focus group data, we found that three primary “symptoms of depression” were reported: crying, irritability, and withdrawal. In coping with these symptoms, we found that three primary approaches including the use of social supports, such as talking to family, friends, and trusted health care providers. However, participants made it clear that they did not perceive conversations with their health care provider as a form of formal psychotherapy. Instead, participants said they considered their provider as friends. Using distraction (i.e., focus on a task), such as focusing on a happy event (e.g., baby smiling) or engaging in a hobby was also reported as a coping strategy among participants. Withdrawing from others by isolating oneself was also a commonly reported coping strategy. Respondents said they preferred to experience their symptoms alone, in the privacy of their own room and away from others including family and friends, which is an interesting contrast to seeking social support.

With regard to treatment preferences, participants had a hierarchy for treating their symptoms. Respondents across focus groups said their first line of defense would be to use own coping (e.g., seek social support, distraction), followed by relying on an in-home worker, such as a promotora or home visiting nurse. A third, yet less desirable approach would be to seek help from a mental health profession. However, there were a number of misconceptions about what a mental health provider can do to help. There were also a number of fears associated with seeking professional mental health care, such as feeling pressured to take antidepressants or losing custody of their child. The use of antidepressants as a treatment option was not endorsed or embraced by the vast majority of focus group participants. However, participants said they would be more willing to take antidepressants after the birth of their child than during pregnancy.