Trimester Care Research Articles

259 A comprehensive early pregnancy access clinic increases first trimester care in an underserved urban population

259 A comprehensive early pregnancy access clinic increases first trimester care in an underserved urban population

Call for Improved Fourth Trimester Care After Stillbirth

Women who experience stillbirths are at increased risk for severe maternal morbidity and mortality, which makes the postpartum period a critical time in which to address health conditions and prevent complications. However, research on the health care needs of women who experience stillbirths is scarce, and these women are often excluded from research on the postpartum period. Therefore, the purpose of this commentary is to identify gaps in the research on postpartum care after stillbirth, explain why current fourth trimester care guidelines in the United States are inadequate, and advocate for nursing research and practice to improve understanding of health care needs in the fourth trimester.

The Pregnant Surgical Patient

The most vulnerable time for a fetus is during embryogenesis in the first 8 to 10 weeks of pregnancy, when women may be unaware of their pregnancy. Once pregnancy is established, a standard approach to the pregnant patient is the optimal way to ensure medical and surgical decisions are made within the context of maintaining the safety of both mother and fetus. This review describes the approach to the pregnant patient for surgical conditions within the context of physiologic changes of the patient and fetus at each trimester, anesthesia and critical care in pregnancy, imaging and drugs safe for use in pregnancy, and nongynecologic surgery in the pregnant patient and specific surgical conditions. Tables outline the classification of abortion, the assessment of pregnancy viability, physiologic changes in pregnancy, laboratory changes in pregnancy, imaging modality and radiation dose, and antibiotics and safety in pregnancy. Figures include a diagram of types of hysterectomy, respiratory changes in pregnancy, and enlargement of the uterus. Algorithms outline the approach to abdominal pain in the pregnant patient and diagnosis and management of ectopic pregnancy. This review contains 5 figures, 6 tables, and 85 references.

Multiparous Black and Latinx Women Face More Barriers to Prenatal Care than White Women.

Women who are late to prenatal care miss opportunities for health interventions and are at increased risk for pregnancy-related complications. Black women have the lowest rates of first trimester care compared with White or Latinx women. We sought to describe barriers to prenatal care experienced by race/ethnicity in a multi-site, prospective cohort. We performed a secondary analysis of the Community Child Health Research Network Study, a multi-site prospective cohort study of pregnant women from 2008 to 2012. Women were recruited at the time of delivery and followed prospectively for 2years. Participants who experienced a repeat pregnancy in the 2-year follow-up period had a prospective assessment of prenatal care barriers. A multilevel mixed effects Poisson regression was performed to evaluate the association between race/ethnicity and number of prenatal barriers. Of the 298 participants in the sample, 43% of Black, 35% of Latinx, and 23% of White participants reported barriers to prenatal care. After adjustment for confounders, Black and Latinx women reported almost twice as many barriers to prenatal care as White women (adjusted rate ratio 1.89 [1.2, 3.0]; 2.00 [1.1, 3.8], respectively). In our analysis, multiparous Black and Latinx women reported encountering more barriers to prenatal care than White women. Additional reforms and policy change are needed at the clinic, local, and state levels to support women in accessing early quality prenatal care to achieve racial equity in prenatal care.

Improving 4th Trimester Care at Burlington Community Health Center [30A

INTRODUCTION: At Burlington Community Health Center (BCHC), many barriers prevent new mothers from returning to clinic for their 6-week postpartum visit (PPV). A significant amount of maternal care is being rendered by pediatricians. While baby is seen often in first months, mother is not often seen until 6-weeks postpartum. METHODS: Prenatal database compiled from BCHC patients who presented between 8/1/2016 and 7/31/2018. Clinic work-flow established for newborn visits at BCHC, in which a care manager used “Newborn Visit Checklists” to evaluate new mothers at newborn visit. Care manager scheduled a visit for the mother at 2- or 4-weeks postpartum. At that visit, the 6-week PPV (primary endpoint) was scheduled. RESULTS: 120 prenatals found in chart review, who served as the comparison group. Of these, 40% (n=48) returned to BCHC for 6-week PPV. Between 8/1/2018 and 9/28/2018, 14 newborns presented to BCHC; their 14 mothers served as the intervention group. Of the 14 mothers eligible for intervention, 43% (n=6) received care elsewhere. Of the 8 remaining BCHC patients, 100% (n=8) were scheduled for, 63% (n=5) showed up for a 2- or 4-week visit. Attendance rate at 6-week PPV was 89% (n=8), a 123% increase from baseline. CONCLUSION: Attendance rates at 6-week PPV were higher for mothers who had already been seen by their provider at 2- or 4-weeks postpartum. Seeing mothers earlier instead of waiting until 6-weeks postpartum allows them to address concerns with provider and connect with resources earlier, improving health for mother/baby dyad.

The Impact of a Parental Notification Requirement on Illinois Minors' Access to and Decision-Making Around Abortion

PurposeThis study aims to examine the impact of a parental notification (PN) requirement on the frequency, timing, and out-of-state travel of minors seeking abortion, as well as changes in who minors involve in their decision, support received, and decision certainty. MethodsWe analyzed administrative and medical records of 1,577 women obtaining an abortion before and after implementation of a PN requirement at one Illinois facility. Using multivariate regression within a difference-in-differences framework, we quantified changes in the number and timing of women seeking care, frequency of parental awareness and support, travel from out-of-state, decision certainty, and anticipated coping among minors 17 years and below compared with young adults (YAs) aged 18–20 years. ResultsA smaller proportion of abortions to women ages 20 years and under post-law were among minors (39%–33%, p = .017). Compared with YAs, minors experienced a larger increase in parental awareness (71%–93% [minors] vs. 53%–58% [YAs], p < .000]; however, parents' support for the decision was unchanged. The proportion of minors certain of their decision went from 77% pre-law to 71% post-law (p = .099) compared with 82% pre- and post-law among YAs (p = .798). Compared with YAs, a larger proportion of minors obtained second trimester care post-law if coming from another state (21%–31% [minors] vs. 23%–16% [YAs], p = .022). ConclusionsIllinois' PN requirement was associated with a decrease in the number of abortions among minors, delayed care for those from out-of-state, increased parental awareness of the pregnancy, and no change in parents' support.

Trends in Early Prenatal Care Among Women with Pre-Existing Diabetes: Have Income Disparities Changed?

Women with pre-existing diabetes are at high maternal risk for comorbidities and death, particularly when early prenatal care is not received. Low income is a known barrier to early prenatal care. It is unknown whether recent policies to expand access to prenatal care have reduced income disparities. We hypothesized that income disparities would be minimized and that the odds of receipt of first trimester prenatal care among women with pre-existing diabetes would become similar across income strata over time. Using the Colorado birth certificate registry from 2007 to 2014, receipt of prenatal care was assessed retrospectively in 2,497 women with pre-existing diabetes. Logistic regression was used to examine the association between high (>$50,000), medium ($25,000-50,000), and low (<$25,000) income strata and receipt of first trimester prenatal care by birth year, adjusted for demographics. High, medium, and low income represented 29.5%, 19.0%, and 51.5% of the cohort, respectively. Women with high income were more likely to receive first trimester care than women with low income from 2007 [adjusted odds ratio, 95% confidence interval: 2.16 (1.18, 3.96)] through 2013 [1.66 (1.01, 2.73)], but significant differences were no longer observed in 2014 [1.59 (0.89, 2.84)]. The likelihood of receiving first trimester prenatal care was not significantly different between medium- and low-income strata from 2007 [1.07 (0.66, 1.74)] through 2014 [0.77 (0.48, 1.23)]. From 2007 to 2013, women in Colorado with diabetes were more likely to receive early prenatal care if they were in the highest income stratum than in the lowest stratum. In 2014, receipt of first trimester care became equitable across all income strata. Future work should examine national patterns of income with receipt of prenatal care and outcomes among women with pre-existing diabetes.

Characteristics of Spontaneous Births Attended by Midwives and Physicians in US Hospitals in 2014.

This study compares characteristics and birth outcomes of women attended by certified nurse-midwives/certified midwives (midwives) and physicians in US hospitals in 2014. Data reported in 2014 on the 2003 version of the US birth certificate were examined. Spontaneous vaginal births attributed to midwives and physicians and occurring in hospitals were included. Demographic and risk profiles and adjusted odds ratios for maternal and newborn outcomes were compared by provider type. Midwives attended 294,604 (12.21%) and physicians attended 2,117,376 (87.79%) of all spontaneous vaginal births occurring in 47 states. Small but statistically significant differences (P < .05) were evident in most characteristics. Substantively, profiles were remarkably similar along all demographic and many medical risk variables. Age, race, and insurance status varied by less than 2 percentage points; education status and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation varied by less than one percentage point. Parity, body mass index, maternal weight gain, tobacco use, trimester care began, and average number of prenatal visits also varied by less than one to 2 percentage points. Midwives attended women with hypertension, diabetes, and infections in proportions similar to physicians. Physicians attended more women with preterm birth and multiple gestation. Midwives attended more women beyond 41 weeks' gestation. There were no differences in 5-minute Apgar scores, neonatal seizures, anomalous neonates, or those no longer living at the time of data collection. Third- or fourth-degree lacerations (odds ratio [OR], 0.81; 95% confidence interval [CI], 0.78-0.84), labor induction (OR, 0.76; 95% CI, 0.76-0.77), and epidural analgesia use (OR, 0.54; 95% CI, 0.53-0.54) were less likely in midwife-attended births. Birth at greater than 42 weeks' gestation was more likely (OR, 2.07; 95% CI, 1.97-2.17) among midwife-attended births. In 2014, midwives practicing in US hospitals attended women with a range of risks similar to those of women attended by physicians. Small but statistically significant differences were noted in most characteristics and should be controlled in comparative studies. This contrasts with earlier reports of midwives caring for disproportionately disadvantaged women compared to physicians.

Oregon’s Coordinated Care Organizations and Their Effect on Prenatal Care Utilization Among Medicaid Enrollees

Introduction Previous studies indicate that inadequate prenatal care is more common among women covered by Medicaid compared with private insurance. Increasing the proportion of pregnant women who receive early and adequate prenatal care is a Healthy People 2020 goal. We examined the impact of the implementation of Oregon's accountable care organizations, Coordinated Care Organizations (CCOs), for Medicaid enrollees, on prenatal care utilization among Oregon women of reproductive age enrolled in Medicaid. Methods Using Medicaid eligibility data linked to unique birth records for 2011-2013, we used a pre-posttest treatment-control design that compared prenatal care utilization for women on Medicaid before and after CCO implementation to women never enrolled in Medicaid. Additional stratified analyses were conducted to explore differences in the effect of CCO implementation based on rurality, race, and ethnicity. Results After CCO implementation, mothers on Medicaid had a 13% increase in the odds of receiving first trimester care (OR 1.13, CI 1.04, 1.23). Non-Hispanic (OR 1.20, CI 1.09, 1.32), White (OR 1.20, CI 1.08, 1.33) and Asian (OR 2.03, CI 1.26, 3.27) women on Medicaid were more likely to receive initial prenatal care in the first trimester after CCO implementation and only Medicaid women in urban areas were more likely (OR 1.14, CI 1.05, 1.25) to initiate prenatal care in the first trimester. Conclusion Following Oregon's implementation of an innovative Medicaid coordinated care model, we found that women on Medicaid experienced a significant increase in receiving timely prenatal care.

Prenatal Care in Oregon and Washington

In the prenatal period, women can have sustained contact with nurses and other clinicians, forming relationships that are likely to be health enhancing for both the woman and her unborn child. Yet, first trimester care use in Oregon dropped noticeably over the past decade. In comparison with Washington state, Oregon has not shown substantial recovery. The aim of this study was to explore potential reasons for the declining prenatal trend in Oregon. We collated county-level birth data from all Oregon and Washington counties from 2000 to 2010. A descriptive, observational, time-series regression analysis for both states assessed the influence of maternal determinants known to impact first trimester care utilization. In Oregon, two factors were significantly associated with declining first trimester care: Medicaid funding (p<.01) and maternal Hispanic ethnicity (p=.02). In Washington, there was no significant association between any assessed determinant and first trimester care. In Oregon, over the period of our study, women dependent on Medicaid and women of Hispanic origin were less likely to utilize first trimester care. A similar trend for these variables was not observed in Washington. At the time of our study, both states had different policy approaches, which may explain some of the observable patterns. Amid current healthcare reforms and rising immigration, our findings suggest the need for strong advocacy for those less able to access or utilize care.

Explaining Racial Differences in Prenatal Care Initiation and Syphilis Screening Among Medicaid-covered Pregnant Women

Sexually transmitted diseases and their outcomes disproportionately affect non-Hispanic Blacks who also receive later prenatal care. We used a sample of low-income pregnant women insured by Medicaid to assess racial disparities in the receipt of first trimester prenatal care and any as well as early (by 2nd trimester) syphilis screening. We used an older but unique file of linked 1995 Georgia Medicaid claims and Pregnancy Risk Assessment Monitoring System (PRAMS) births (n=1,096) to test the relative explanatory power of factors contained in administrative versus survey data. Using administrative data, we found non-Hispanic Blacks were less likely than non-Hispanic Whites to receive first trimester care but more likely to be screened. Adding in PRAMS survey data eliminated these differences. Having an outpatient department as usual source of care was a key factor. This may reflect unmeasured characteristics of minorities and their neighborhoods or differences in screening practices across provider settings.

Moving to Mandatory Medicaid Managed Care in Ohio

Understanding the impacts of Medicaid managed care on pregnant women is critical because Medicaid covers more than a third of all births nationally, many under managed care arrangements. We sought to examine the impacts of mandatory Health Maintenance Organization (HMO) enrollment on prenatal care use, smoking, and birth weight for Medicaid-covered pregnant women in Ohio. Impact estimates are derived from a pre-post design with a comparison group, using Ohio birth certificate data linked to Medicaid enrollment files. Between April 1993 and April 1995 is the baseline period and October 1997 to June 1998 is the post-period. The treatment group consists of deliveries in 6 counties that implemented mandatory HMO enrollment in the mid 1990s; the comparison group consists of deliveries in 4 counties with voluntary HMO enrollment. Medicaid-covered deliveries to 24,799 non-Hispanic white women with no college education living in Ohio. Seven outcomes are analyzed: first trimester care; last trimester or no care; adequate prenatal care; inadequate prenatal care; smoking during pregnancy; and birth weight. Our findings indicate that mandatory HMO enrollment in Ohio's Medicaid program had positive effects on prenatal care and led to reductions in maternal smoking. No effects were found on birth weight. Even with the improvements related to Medicaid managed care, rates of inadequate prenatal care and maternal smoking remain relatively high. Addressing the underlying risk factors that are facing poor women and further expanding public programs may be critical to achieving further progress.

Paternity establishment: variables associated with failed implementation

Paternity establishment for 90% of births to unwed mothers is a recent federal mandate designed to optimize parental rights and childhood benefits. Using a statewide database, this study examines the relationship between selected demographic and clinical variables and in-hospital paternity establishment. Vital statistics for the year 2000 were obtained pertaining to live birth deliveries in the state of Michigan. Data were developed by the Michigan Department of Community Health through linkage of state birth data files with a central paternity registry. Statistical comparisons were made of the frequency distributions of the study variables, using a normal approximation of binomial distribution. There were a total of 134,917 live births in Michigan during 2000. Of these, 46,057 (34.1%) were to unmarried women. The overall rate of in-hospital paternity establishment for these cases was 56% in 2000. A review of selected characteristics indicated a wide range of variability in the proportion of cases for which paternity is established. The following characteristics were significantly different ( P<0.05) from the overall average rate (56%) of paternity establishment in 2000: African American, 37.3%; less than high school education, 48.3%; birth weight under 1500 g, 44.8%; birth weight 1500–2499 g, 48.4%; no prenatal care, 30.1%; third trimester care, 37.9%; second trimester care, 47.3%; abnormal newborn, 53.2%; gestational age ≤37 weeks, 50.7%; age less than 20, 52.8%. A greater than average rate of paternity establishment was noted with first trimester care (61.3%), high school or greater education (60.7%), and non–African-American race (71.3%). In conclusion, key demographic and clinical variables limiting the successful establishment of paternity are readily identifiable. In order to achieve the legislative mandate of 90% success, strategies must be developed to improve overall paternity establishment, with special emphasis on these target populations. In addition, these data suggest that racial and ethnic factors are important determinants of paternity establishment in the state of Michigan.

Individual and Community Level Correlates of Prenatal Care in California

This event history analysis of the Perinatal Substance Exposure Study investigates individual and community level correlates of the timing of first prenatal care among pregnant women in California. Data were collected anonymously at the time of delivery and include demographic information from hospital records and urine samples which were tested for a battery of substances. Zip-code level data from the 1990 census were appended to each record to assess absolute community effects. A discrete-time hazard rate was estimated for each trimester in six nested models using logistic regression. Results suggest that: poor, non-White, younger, native born, Spanish-speaking, substance-using women in poorer neighborhoods were least likely to receive prenatal care. While a positive urine test for alcohol was not associated with prenatal care initiation; overall drug positives and tobacco positives (self-report) were. The optimal model, with interactions, estimates that women in poorer communities were less likely to receive prenatal care in the first trimester, but more likely to receive care in the third trimester. This pattern is similar for most of the time-varying covariates in that non-Whites, English speakers and younger women were less likely to receive first trimester care, but more likely to receive second and third trimester care.

Young, Minority and Disadvantaged Women Exhibit Least Favorable Pregnancy- Related Health Behavior

This article summarizes findings from an analysis of the 1988 US National Survey of Family Growth among 8450 women aged 15-44 years. The racial composition was 63% White 35% Black and 4% other racial groups. Fertility during 1984-88 included 16.2 million live births of which 98% were to women who had received some prenatal care. However only 65% received care initiated during the first trimester. 73% of women aged 25 years and older received early prenatal care. First trimester care included only 39% of women aged under 20 years and 60% of women aged 20-24 years. 46% of never married women and 69% of married women received early prenatal care. 55-56% of women with unwanted or mistimed pregnancies and 72% of women with planned pregnancies received early prenatal care. Early care was greater among women with more than a high school education women with household incomes at least 300% of the poverty level and women in managerial or professional occupations. Women with Medicaid coverage and inner city residents were less likely to receive early care. 54% of Blacks and 68% of Whites received early care. Racial and ethnic differences declined considerably among women who received later care or no care at all. 69% received care from a private physician. 20% received care from a non-hospital clinic. 11% received care from a hospital clinic. Only 42% of teenagers compared to 65-77% of older women received care privately. Private physician use was also less likely among never married women women with unwanted or mistimed pregnancies women with later or no care and among Black women. Women with low socioeconomic characteristics tended to receive less care from private physicians. 27% of women giving birth during 1984-88 smoked during some portion of the pregnancy. 17% smoked fewer than 15 cigarettes per day. 12% of Whites and only 6% of Blacks were heavy smokers. Smoking during pregnancy declined between the 1982 and 1988 surveys. 34% drank alcohol during their pregnancy. 15% drank at least once a month. Older women with higher socioeconomic status were more likely to be drinkers. 51% neither smoked nor drank. 12% smoke and drank. 7% of births were low birth weight. 66% had private insurance coverage.

Does Prenatal Care Decrease the Incidence and Cost of Neonatal Intensive Care Admissions?

This study was conducted to examine the potential effects of expanded Medicaid coverage for low income women. Statewide birth data for 1983 to 1985 were examined to determine the relationship between prenatal care and admissions to neonatal intensive care units (NICUs) and the costs of this care. An NICU sample was constituted from infants who were discharged live following more than 7 NICU days, were referred to an out of state tertiary center, or died following NICU admission. Inadequate care (no prenatal care, only last trimester care, or less than five visits) was received by 11% of the total birth cohort and by 18% of the infants in the NICU sample (p less than 0.001). Infants with inadequate care had a NICU admission rate of 5.10% versus 2.86% for those with adequate prenatal care (p less than 0.001). The hospital billings for infants in the NICU sample with inadequate care were significantly higher than were those for infants with adequate care (p less than 0.05). Assuming that economic resources limit access to prenatal care, the projection can be made that had all women with inadequate prenatal care received Medicaid-covered adequate prenatal care, expenditure for this care would yield more than a two to one return in savings in NICU costs.

Does prenatal care decrease the incidence and cost of neonatal intensive care admissions?

This study was conducted to examine the potential effects of expanded Medicaid coverage for low income women. Statewide birth data for 1983 to 1985 were examined to determine the relationship between prenatal care and admissions to neonatal intensive care units (NICUs) and the costs of this care. An NICU sample was constituted from infants who were discharged live following more than 7 NICU days, were referred to an out of state tertiary center, or died following NICU admission. Inadequate care (no prenatal care, only last trimester care, or less than five visits) was received by 11% of the total birth cohort and by 18% of the infants in the NICU sample (p less than 0.001). Infants with inadequate care had a NICU admission rate of 5.10% versus 2.86% for those with adequate prenatal care (p less than 0.001). The hospital billings for infants in the NICU sample with inadequate care were significantly higher than were those for infants with adequate care (p less than 0.05). Assuming that economic resources limit access to prenatal care, the projection can be made that had all women with inadequate prenatal care received Medicaid-covered adequate prenatal care, expenditure for this care would yield more than a two to one return in savings in NICU costs.

Barriers to adolescent prenatal care

It is estimated that over one-half of all adolescent mothers receive inadequate prenatal care. Our objectives were to explore the barriers to care as perceived by adolescents and to develop a model to identify adolescents at risk for inadequate care. Structured interviews were conducted with 101 adolescents less than 17 years of age who delivered infants at an urban university hospital between September 1988 and January 1989. All the interviews were conducted within 48 hr of delivery by a single investigator. The Maternal Health Services Index was used to divide subjects into those who received inadequate care (Group 1, n = 37) and those who received intermediate or adequate care (Group 2, n = 64). Both groups were predominantly black (99%), poor (mean Hollingshead score = 2), and unmarried (99%). Groups 1 and 2 differed ( p < 0.05) in 12 variables pertaining to beliefs about prenatal care and course during the pregnancy. Of the 12 variables, 7 comprised a stepwise logistic regression model designed to maximally differentiate Groups 1 and 2-negative attitudes towards physicians (20% vs 6%), perceived importance of first trimester care (78% vs 94%), confusion about available prenatal services (24% vs 5%), lack of health insurance (41% vs 16%), exposure to pregnant friends (76% vs 95%), mean gestational age at recognition of pregnancy (15 wks vs 11 wks), and desire for an adolescent-only prenatal clinic (78% vs 58%). The adjusted odds ratios of the variables ranged in declining order from 15.4 to 4.7. The attributable risks, or etiologic fractions, of the variables ranged in increasing order from 0.19 to 0.49. Receiver-operating characteristic curve analysis of the model demonstrated a curve area of 0.89 ± 0.04, significantly better than chance. We conclude that the model clarifies the barriers to care and helps identify pregnant adolescents who are likely to receive inadequate prenatal care.

Birth weight outcomes for repeat teenage pregnancy

To investigate the outcomes for repeat teenage pregnancy and the effect of interpregnancy interval on birth weight, birth certificate data were reviewed from all mothers under 26 years delivering their second baby during 1981–1983 at an urban teaching hospital. Initially, 409 mothers who had delivered their first baby at the same hospital were identified. Mothers were divided into three groups: mothers under 20 years for both births; mothers under 20 years for the first birth, with the second birth delayed until 20 to 25 years; and mothers 20–25 years for both births. Group 1 mothers had high but identical rates of low birth weight (17.5%) for both parities, high rates of very low birth weight infants (<1501 g), and no change in mean birth weight between the two pregnancies. Group 2 mothers were older at first birth and had better outcomes for first and second births than group 1 mothers. For group 1 mothers, the initiation of prenatal care was delayed at second pregnancy compared to first pregnancy (46% receiving first trimester care versus 59% at first delivery). In contrast, groups 2 and 3 showed improvement in accessing prenatal care for the second pregnancy. Interpregnancy interval had no influence on the birth weight of the second infant in any group.

The Need for Prenatal Care in the United States: Evidence from the 1980 National Natality Survey

Seventy-eight percent of U.S. mothers begin prenatal care during the first three months of pregnancy; 18 percent wait until the second three months; and five percent wait until the third trimester or receive no care at all. Patterns of prenatal care vary widely among population subgroups: Mothers younger than 18 and unmarried mothers are the least likely to obtain first-trimester care (49 percent and 56 percent, respectively), and the most likely to obtain care only in the third trimester or none at all (about 12 percent of each group). Women aged 18-19, blacks, Hispanics, poor women and women with little education also have disproportionately high levels of very late or no care (7-9 percent). Married, white, nonpoor women, in contrast, obtain the most timely prenatal care: In 1980, only two percent initiated care in the third trimester or received no care. Compared with this subgroup of women, the population as a whole has two times the risk of obtaining inadequate care. Unmarried women run the highest relative risk (five times the risk for married, white, nonpoor women), followed by teenagers, Hispanic women, women with little education, poor women and blacks (who have from three to more than four times the risk of the comparison group).