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A study of the occurrence of gonorrhea in postpartum women
A study of the occurrence of gonorrhea in postpartum women MOHAMMAD MITWALLI AHMAD, M.D., DR.P.H. VESTAL W. PARRISH, JR., D.Sc. New Orleans, Louisiana This study concentrates upon the occurrence of gonorrhea in postpartum women who experienced a reproductive event in Charity Hospital of New Orleans and kept an appointment with the Louisiana Family Planning Clinic. The study period covered the four months from December, 1968, through March, 1969. To measure the frequency of gonorrhea, the Thayer-Martin culture medium was used. The agar plate was smeared with the rolling-Z technique and culture plates were then streaked, separating the colonies within the first hour. Findings from this study indicate that the average gonorrhea prevalence rate for these postpartum women was 7.4 per 100 women. Of the four months considered, December was the month when the gonorrhea prevalence rate was highest. In addition, from these data it would appear that those black postpartum women who have never been married, or have been married but are now separated, are young (24 years of age or less), and have zero parity should be classified as the highest risk group(s) for gonorrhea.
V E N E R E A L D I S E A S E has been and continues to be one of the major hazards to the health of societies since its recognition in the medieval ages. It has continued to be a substantial health problem because of a lack of ability to quickly locate, identify, and treat large segments of the population which act as reservoirs for the infection. 1 • 2
Despite the fact that gonorrhea is an infectious disease for which the agent and the mode of infection are known and against which there are very efficient methods of treatment, it has not been possible to eradicate it even in countries with well-organized health services. a-s Although an epidemiologic approach is time consuming and expensive, it is nevertheless essentiaL Screening programs conducted on women attending various clinics (i.e., antenatal, postpartum, family planning) would be commendable and are invaluable assets for gonorrhea control, giving a clue to the morbidity of the disease. 6 A nation-wide survey indicated that in New Orleans one in every 45 citizens was treated for infectious venereal disease during the fiscal year 1968. 7 The case rate of infectious venereal disease for New Orleans was 2,228 per 100,000 total population or about three times the national average of 765 per 100,000. New Orleans physicians reported an average of one in 123 cases of the social diseases to public health authorities. This is one reason why many sources of infection remain untreated and free to infect others.
From the Department of Obstetrics and Gynecology, University of Arkansas Medical Center, and the Department of Applied Health Sciences, Tulane School of Public Health and Tropical Medicine. The research on which the paper was based was partially supported by funds from the Department of Health, Education and Welfare, as well as from the Ford Foundation to the Tulane Center for Population and Family Studies. Some of these findings were included in a doctoral dissertation completed by Dr. Ahmad for his Dr.P.H. degree at Tulane School of Public Health and Tropical Medicine. Received for publication May 4, 1973. Revised july 10, 1973. Accepted August 1, 1973. Reprint requests: Dr. Vestal W. Parrish, Jr., Tulane University, School of Public Health and Tropical Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112.
368
Volume 118 Number 3
Gonorrhea in postpartum women
Table I. Outcome of the specimen cultures for the 1,129 study patients No. of Outcome Culture acceptable Culture contaminated* "No specimen received" No specimen taken Total
women
Per cent
1,036 27 1 65
91.8
1,129
100.1
2.4
0.1 5.8
*Growth of different kinds of fungi and other bacteria.
Study objectives This study was directed at the location of a possible reservoir of infection, namely, recently postpartum women. The study concentrated upon the occurrence of gonorrhea within a population of postpartum women who experienced a reproductive event (a live birth, multiple birth, stillbirth, infant death, premature birth, miscarriage, vesicular mole, or ectopic pregnancy) in the Charity Hospital of New Orleans and who kept an appointment with the Louisiana Family Planning Clinic in the time period December, 1968, through March, 1969. All these women were residents of Orleans Parish only. The study objectives for this report were focused on: ( 1) an estimate of the average prevalence of gonorrhea for this group of women during the study period, December, 1968, through March, 1969; ( 2) the prevalence of gonorrhea by date of entry into the study; ( 3) an analysis of the prevalence of gonorrhea for selected characteristics of the black segment of the study population selected. Material and methods Those women who accepted and kept an appointment in the Louisiana Family Planning Clinic were interviewed by nurses, attended a class in reproductive biology and family-planning methods, were offered a contraceptive method, and were given a general as well as gynecologic examination during their first visit. The initial postpartum visit to this clinic took place approximately four to six weeks after the occurrence of the reproductive event. The physical examination routinely included a Papanicolaou smear as
369
well as a smear from the endocervix for gonorrhea screening. 8 • 9 Measurement of frequency of gonorrhea was based upon the Thayer-Martin Selective Medium Technique. 10 - 15 The agar plate was smeared with the rolling-Z technique and culture plates were then streaked, separating the colonies within the first hour. 16 * Each plate was labelled with the woman's name, identification number, and date of inoculation. A data slip for each plate was completed by the nurse. This record included the name, address, Louisiana Family Planning Clinic identification number, age, sex, race, marital status, census tract number, parish of residence, and laboratory number. Specimens were forwarded to the Louisiana State Department of Health laboratory where all tests in this gonorrhea-screening program were performed. Three laboratory procedures were performed: the oxidase test, gram stain, and fluorescent-antibody stain. The results were reported, positive or negative, on the data slip and the laboratory entry sheet. This information was mailed back to the Louisiana Family Planning Clinic. After the Louisiana Family Planning Clinic staff received the foregoing results, this information was sorted into two groups: negative and positive. Charts were pulled for the positive cases and a home-visit card made, indicating the need of referral to the Health Clinic for gonorrhea treatment. One copy of the positive case slip was filed with the patient's chart. A second copy was marked with the census tract number and filed in census tract order. In negative cases, one copy was filed in the woman's medical chart and another filed with all the negative case slips in census tract order. Using the home-visit card information re*The procedure adopted took advantage of the existing facilities and services as well as complied with the requirements of the federal grant supporting the program. The Thayer-Martin medium was received by the Louisiana State Department of Health, Central Laboratory, in poured plates weekly by airmail from the manufacturers, Baltimore Bio· logical Laboratory, of Baltimore, Maryland. The plates were refrigerated at the State Health Department Laboratory until used. The culture plates were transported to Louisiana Family Planning Clinic as needed, where they were again
refrigerated until shortly before use.
370
February 1, 197+
Ahmad and Parrish
Am.
J. Obstet. Gynecol.
Table II. Monthly distribution of the results of the gonorrheal culture tests made with the Thayer-Martin selective medium culture Result
Dec. 1968
]an. 1969
Feb. 1969
March 1969
Number of positives Number of negatives
34 267
18
11
322
301 11.3
340 5.3
190 201
14 180 194
Total
Table III. Results of the 1,036 acceptable gonorrheal culture tests by race of patient Result
White
Number positive Number negative
2
Total
72 H 2.70
Black
Total
75 887
959
962 7.79
77 --
1,036 7.4
ferred to above, auxiliary workers located those patients with positive results and gave each an appointment to the New Orleans Venereal Disease Health Clinic. A home-visit card was sent to the Health Clinic for appointment information. After the set appointment date, the Health Clinic staff indicated on the home-visit card whether or not the patient kept her appointment and then returned it to the Family Planning Clinic. The charts for those patients who did not keep their appointments for treatment at the Health Clinic were marked for the nurse's attention on the patient's next visit to the Family Planning Clinic. At that time another attempt was made by the nurse to have the patient receive treatment at the Health Clinic. Results
During the four-month study period, 1,129 women were examined. Outcomes of the specimen cultures are indicated in Table I. Specimen cultures from 1,036 (91.8 per cent) women were acceptable for the gonorrhea tests. No specimen was taken from 65 ( 5.8 per cent); one (0.1 per cent) specimen was taken but results not returned; 27 ( 2.4 per cent) specimens were taken but the cultures >vere contaminated. Table II indicates that of the 1,036 women who had an acceptable culture, the gonorrhea test was positive for 7i women-a prevalence
5.5
7.2
Total
77 959 1,036
7.4
rate of 7.-t per !00 women for the study period. Trend analysis revealed that the prevalence rates by month when ordered from highest to lowest were: December. l 1.3: March, 7.2: February, 5.5; and January, 5.3. A chi-square test was used to determine significant differences in association for betweenmonth comparisons. Differences at the 0.05 level were accepted as significantly different. As indicated on Table II, there was a significant difference for December vs. January and December vs. February. To conserve space, a table is not presented. but such selected characteristics as source of unearned income, marital status, risk status, religion, education, present age, age at first pregnancy. parity, use of contraceptive method before attending the clinic, and whether or not the last pregnancy was planned were used as additional controls in an attempt to partially explain these between-month differences. None of these indicated a significant difference. Table III indicates that of the total 1,036 women with acceptable gonorrhea cultures, only 74 (seven per cent) were white. Only two ( 2. 70 per cent) of the H whites as opposed to 75 (7.79 per cent) of the 962 blacks were found to be positive. The chisquare test indicated no significant differences between whites and blacks. Selected characteristics of the 962 black women in the study population were studied in an effort to differentiate those women with a positive gonorrhea test from those with a negative test (Table IV). No significant difference was found between groups or subgroups when source of unearned income, risk status, religion, education, or types of termination for last pregnancy were considered. A trend analysis of the per cent positive on the gonorrhea test. however. indicates that
Volume 118 Number3
high-risk groups of black postpartum women tend to include those who do receive welfare (A.D.C.) and are not high-risk (as defined in Table IV) for negative pregnancy results but produced a stillbirth or miscarriage following their last pregnancy. The educational categories as grouped are more or less equal in percentage distribution. The same is not true, however, when marital status, present age, or parity are considered. Those women never married were found not significantly different from those ever married. However, when the ever married group is broken into three subgroups (married but separated, married with husband present, and widowed), between-group comparisons produce some interesting results. There was a significant difference when the never married women were compared with those who were married with husband in the home as well as when those women married but separated were compared with those married with husband in the home. But there was no significant difference when those widowed were compared with those married with husband in the home. When age was considered as a differentiating characteristic, the findings in Table IV reveal that the two younger age groups, 19 or less and 20 through 24, were significantly different from the oldest group of women 30 years of age or older. The group 25 through 29 years of age was not significantly different from any of the other age groups, while the groups 19 or less and 20 through 24 were not significantly different from each other. Parity as a differentiating characteristic for gonorrhea risk groups in black postpartum women could logically be seen as following the same trend set by age, since younger women tend to have a lower parity. Women with zero parity were significantly different from those with parity one through three as well as those with parity four or more. This was not true when women with parity one through three were compared with women with parity four or more. Comment
As indicated in the results concerned with between-month comparisons of positive vs.
Gonorrhea in postpartum women
371
Table IV. Gonorrhea rates for selected characteristics of the 962 black subjects
No.I
Characteristics 1. Source of unearned income Welfare (ADC) None Unknown 2. Risk status* Not a risk Definite risk 3. Religion Protestant Catholic 4. Education Less than 12 years of school Twelve years or more of school 5. Types of termination for last pregnancy Term live birth Premature live birth Stillbirth or miscarriage 6. Marital status Never married Ever married Married but separated Married with husband present Married but widowed 7. Present age (years) 19 or less 20-24 25-29 30 or more 8. Parity 0 1-3 4 or more
Total
posi- Per cent tive positive
165 774 23
17 57 1
10.30 7.36 4.35
450 512
40 35
8.88 6.83
757 202
61 14
8.05 6.93
640
50
7.81
319
25
7.83
790 128
58 12
7.34 9.37
40
5
12 .50
344 616
34 41
9.88 6.65
138
15
10.87t
425
24
5.64t
53
2
3.77t
322 343 152 145
28 31 11 5
8.70 9.03 7.23t 3.44t
8 742 212
3 62 10
*Definite risk: Should infer unfavorable direct and/or indirect obstetric causes of material and perinatal morbidity and should possess at least one of the following characteristics: {I) age under 16 or over 40, (2) parity six or more, (3) history of stillbirth or two or more miscarriages, (4) infant born alive but now dead, (5) history of two or more premature births, (6) history of toxemia of pregnancy, (7) history of cardiovascular-renal disease, (8) previous cesarean section.
tx i significant at 0.05 level.
negative gonorrheal culture tests, December was significantly different from January and February, with a higher portion of the patients seen during that month being positive. The selected characteristics introduced as additional controls in an attempt to partially
372
February l, 1974 Am.]. Obstet. Gynecol.
Ahmad and Parrish
explain these differences were found to be not significantly associated with the betweenmonth differences. Those women seen in December did tend, however, to be younger and have a higher parity. Then, too, a seasonal factor may be involved. Data from this study only suggest these possible influences. The small number of whites in the study population reflects the racial distribution indicative of the Charity Hospital patient population in New Orleans. Because of the small number of whites in the total study population and the chi-square test indicating no significant difference by race concerning the outcome of the gonorrheal culture tests, the more detailed analysis was focused on the black segment of the study population. The outcome of this analysis suggests that those black women never married as well as those married but separated are at a higher risk of contacting gonorrhea than is true of widows and women married with their husbands at home. Whether this means these high-risk groups are younger, less careful in their selection of sexual partners, or more prone to have
sexual relations with more than one partner is not clear. These data do support, however, that these two groups of black women are high-risk groups for gonorrhea. Data from this more detailed analysis further indicate the rank order of risk from highest to lowest by per cent positive for age groups to be: ( 1) 20 through 24 years of age, ( 2 ! 19 or less, ( 3) 25 through 29, and ( 4) 30 or more. Concerning parity, these data also indicate the rank order of risk from highest to lowest by per cent positive for parity groups to be: ( 1) zero, ( 2) one through three, and ( 3) four or more. Special recognition is given to Dr. Joseph D. Beasley (Chairman, Department of Applied Health Sciences, Tulane School of Public Health and Tropical Medicine), the New Orleans Family Planning Clinic staff, Miss Ethel Eaton (Lincoln Parish Project Biostatistician and Assistant Professor, Tulane School of Public Health and Tropical Medicine), Mrs. Irene Killen (Research Assistant), Mrs. Angie Weiler (Administrative Assistant), and Mis~ Cathy Joachim (Secretary) .
REFERENCES
1. Editorial: Iowa Med. Soc. 57: 376, 1967. 2. U. S. Department of Health, Education, and Welfare, Bureau of Disease Prevention and Environmental Control: Venereal Disease Program Report, 1967, pp. 2-28. 3. Danbolt, M.: Triangle 8: 2, 1967. 4. Fiumara, N. J., Appel, B., Hill, W., and Mescon, H.: N. Engl. J. Med. 260: 863, 1959. 5. WHO Expert Committee on Gonococcal Infection: World Health Organization Technical Report Series 262: 1-70, 1963. 6. Brown, W. J.: Report on VD Research Priorities of the American Social Health Association, January, 1969, pp. 71-73. 7. Today's VD Control Problem: The American Social Health Association, New York, January, 1969, pp. 25-61. 8. Brown, W. J., and Lucas, J. B.: In Tice's
9. 10. 11. 12.
13.
14. 15. 16.
Practice of Medicine, Hagerstown, Md., 1967, Roeber Medical Division, vol. III. Shapiro, L. H., and Lentz, J. W.: AM. J. 0BSTET. GYNECOL. 97: 968, 1967. Martin, J. E., Jr., Peacock, W. L., Jr., and Thayer, J.D.: J. Ven. Dis. 41: 199, 1965. Thayer, J. D.: J. Con£. Pub. Health Lab. Directors 26: 85, 1968. Thayer, J. D.: Neisseria gonorrhoeae--Culture Methods for Isolation and Identification, Atlanta, Ga., 1967, Venereal Disease Research Laboratory, Communicable Disease Center. Thayer, J. D., and Martin, J. E., Jr.: Pub. Health Rep. 81: 559, 1966. Thayer, J. D., and Moore, M. B.. Jr.: Med. Clin. North Am. 48: 755, 1964. Wende, R. D.: Pub. Health Lab. 22: 104, 1964. Martin, J. E.: Personal communication.
V E N E R E A L D I S E A S E has been and continues to be one of the major hazards to the health of societies since its recognition in the medieval ages. It has continued to be a substantial health problem because of a lack of ability to quickly locate, identify, and treat large segments of the population which act as reservoirs for the infection. 1 • 2
Despite the fact that gonorrhea is an infectious disease for which the agent and the mode of infection are known and against which there are very efficient methods of treatment, it has not been possible to eradicate it even in countries with well-organized health services. a-s Although an epidemiologic approach is time consuming and expensive, it is nevertheless essentiaL Screening programs conducted on women attending various clinics (i.e., antenatal, postpartum, family planning) would be commendable and are invaluable assets for gonorrhea control, giving a clue to the morbidity of the disease. 6 A nation-wide survey indicated that in New Orleans one in every 45 citizens was treated for infectious venereal disease during the fiscal year 1968. 7 The case rate of infectious venereal disease for New Orleans was 2,228 per 100,000 total population or about three times the national average of 765 per 100,000. New Orleans physicians reported an average of one in 123 cases of the social diseases to public health authorities. This is one reason why many sources of infection remain untreated and free to infect others.
From the Department of Obstetrics and Gynecology, University of Arkansas Medical Center, and the Department of Applied Health Sciences, Tulane School of Public Health and Tropical Medicine. The research on which the paper was based was partially supported by funds from the Department of Health, Education and Welfare, as well as from the Ford Foundation to the Tulane Center for Population and Family Studies. Some of these findings were included in a doctoral dissertation completed by Dr. Ahmad for his Dr.P.H. degree at Tulane School of Public Health and Tropical Medicine. Received for publication May 4, 1973. Revised july 10, 1973. Accepted August 1, 1973. Reprint requests: Dr. Vestal W. Parrish, Jr., Tulane University, School of Public Health and Tropical Medicine, 1430 Tulane Avenue, New Orleans, Louisiana 70112.
368
Volume 118 Number 3
Gonorrhea in postpartum women
Table I. Outcome of the specimen cultures for the 1,129 study patients No. of Outcome Culture acceptable Culture contaminated* "No specimen received" No specimen taken Total
women
Per cent
1,036 27 1 65
91.8
1,129
100.1
2.4
0.1 5.8
*Growth of different kinds of fungi and other bacteria.
Study objectives This study was directed at the location of a possible reservoir of infection, namely, recently postpartum women. The study concentrated upon the occurrence of gonorrhea within a population of postpartum women who experienced a reproductive event (a live birth, multiple birth, stillbirth, infant death, premature birth, miscarriage, vesicular mole, or ectopic pregnancy) in the Charity Hospital of New Orleans and who kept an appointment with the Louisiana Family Planning Clinic in the time period December, 1968, through March, 1969. All these women were residents of Orleans Parish only. The study objectives for this report were focused on: ( 1) an estimate of the average prevalence of gonorrhea for this group of women during the study period, December, 1968, through March, 1969; ( 2) the prevalence of gonorrhea by date of entry into the study; ( 3) an analysis of the prevalence of gonorrhea for selected characteristics of the black segment of the study population selected. Material and methods Those women who accepted and kept an appointment in the Louisiana Family Planning Clinic were interviewed by nurses, attended a class in reproductive biology and family-planning methods, were offered a contraceptive method, and were given a general as well as gynecologic examination during their first visit. The initial postpartum visit to this clinic took place approximately four to six weeks after the occurrence of the reproductive event. The physical examination routinely included a Papanicolaou smear as
369
well as a smear from the endocervix for gonorrhea screening. 8 • 9 Measurement of frequency of gonorrhea was based upon the Thayer-Martin Selective Medium Technique. 10 - 15 The agar plate was smeared with the rolling-Z technique and culture plates were then streaked, separating the colonies within the first hour. 16 * Each plate was labelled with the woman's name, identification number, and date of inoculation. A data slip for each plate was completed by the nurse. This record included the name, address, Louisiana Family Planning Clinic identification number, age, sex, race, marital status, census tract number, parish of residence, and laboratory number. Specimens were forwarded to the Louisiana State Department of Health laboratory where all tests in this gonorrhea-screening program were performed. Three laboratory procedures were performed: the oxidase test, gram stain, and fluorescent-antibody stain. The results were reported, positive or negative, on the data slip and the laboratory entry sheet. This information was mailed back to the Louisiana Family Planning Clinic. After the Louisiana Family Planning Clinic staff received the foregoing results, this information was sorted into two groups: negative and positive. Charts were pulled for the positive cases and a home-visit card made, indicating the need of referral to the Health Clinic for gonorrhea treatment. One copy of the positive case slip was filed with the patient's chart. A second copy was marked with the census tract number and filed in census tract order. In negative cases, one copy was filed in the woman's medical chart and another filed with all the negative case slips in census tract order. Using the home-visit card information re*The procedure adopted took advantage of the existing facilities and services as well as complied with the requirements of the federal grant supporting the program. The Thayer-Martin medium was received by the Louisiana State Department of Health, Central Laboratory, in poured plates weekly by airmail from the manufacturers, Baltimore Bio· logical Laboratory, of Baltimore, Maryland. The plates were refrigerated at the State Health Department Laboratory until used. The culture plates were transported to Louisiana Family Planning Clinic as needed, where they were again
refrigerated until shortly before use.
370
February 1, 197+
Ahmad and Parrish
Am.
J. Obstet. Gynecol.
Table II. Monthly distribution of the results of the gonorrheal culture tests made with the Thayer-Martin selective medium culture Result
Dec. 1968
]an. 1969
Feb. 1969
March 1969
Number of positives Number of negatives
34 267
18
11
322
301 11.3
340 5.3
190 201
14 180 194
Total
Table III. Results of the 1,036 acceptable gonorrheal culture tests by race of patient Result
White
Number positive Number negative
2
Total
72 H 2.70
Black
Total
75 887
959
962 7.79
77 --
1,036 7.4
ferred to above, auxiliary workers located those patients with positive results and gave each an appointment to the New Orleans Venereal Disease Health Clinic. A home-visit card was sent to the Health Clinic for appointment information. After the set appointment date, the Health Clinic staff indicated on the home-visit card whether or not the patient kept her appointment and then returned it to the Family Planning Clinic. The charts for those patients who did not keep their appointments for treatment at the Health Clinic were marked for the nurse's attention on the patient's next visit to the Family Planning Clinic. At that time another attempt was made by the nurse to have the patient receive treatment at the Health Clinic. Results
During the four-month study period, 1,129 women were examined. Outcomes of the specimen cultures are indicated in Table I. Specimen cultures from 1,036 (91.8 per cent) women were acceptable for the gonorrhea tests. No specimen was taken from 65 ( 5.8 per cent); one (0.1 per cent) specimen was taken but results not returned; 27 ( 2.4 per cent) specimens were taken but the cultures >vere contaminated. Table II indicates that of the 1,036 women who had an acceptable culture, the gonorrhea test was positive for 7i women-a prevalence
5.5
7.2
Total
77 959 1,036
7.4
rate of 7.-t per !00 women for the study period. Trend analysis revealed that the prevalence rates by month when ordered from highest to lowest were: December. l 1.3: March, 7.2: February, 5.5; and January, 5.3. A chi-square test was used to determine significant differences in association for betweenmonth comparisons. Differences at the 0.05 level were accepted as significantly different. As indicated on Table II, there was a significant difference for December vs. January and December vs. February. To conserve space, a table is not presented. but such selected characteristics as source of unearned income, marital status, risk status, religion, education, present age, age at first pregnancy. parity, use of contraceptive method before attending the clinic, and whether or not the last pregnancy was planned were used as additional controls in an attempt to partially explain these between-month differences. None of these indicated a significant difference. Table III indicates that of the total 1,036 women with acceptable gonorrhea cultures, only 74 (seven per cent) were white. Only two ( 2. 70 per cent) of the H whites as opposed to 75 (7.79 per cent) of the 962 blacks were found to be positive. The chisquare test indicated no significant differences between whites and blacks. Selected characteristics of the 962 black women in the study population were studied in an effort to differentiate those women with a positive gonorrhea test from those with a negative test (Table IV). No significant difference was found between groups or subgroups when source of unearned income, risk status, religion, education, or types of termination for last pregnancy were considered. A trend analysis of the per cent positive on the gonorrhea test. however. indicates that
Volume 118 Number3
high-risk groups of black postpartum women tend to include those who do receive welfare (A.D.C.) and are not high-risk (as defined in Table IV) for negative pregnancy results but produced a stillbirth or miscarriage following their last pregnancy. The educational categories as grouped are more or less equal in percentage distribution. The same is not true, however, when marital status, present age, or parity are considered. Those women never married were found not significantly different from those ever married. However, when the ever married group is broken into three subgroups (married but separated, married with husband present, and widowed), between-group comparisons produce some interesting results. There was a significant difference when the never married women were compared with those who were married with husband in the home as well as when those women married but separated were compared with those married with husband in the home. But there was no significant difference when those widowed were compared with those married with husband in the home. When age was considered as a differentiating characteristic, the findings in Table IV reveal that the two younger age groups, 19 or less and 20 through 24, were significantly different from the oldest group of women 30 years of age or older. The group 25 through 29 years of age was not significantly different from any of the other age groups, while the groups 19 or less and 20 through 24 were not significantly different from each other. Parity as a differentiating characteristic for gonorrhea risk groups in black postpartum women could logically be seen as following the same trend set by age, since younger women tend to have a lower parity. Women with zero parity were significantly different from those with parity one through three as well as those with parity four or more. This was not true when women with parity one through three were compared with women with parity four or more. Comment
As indicated in the results concerned with between-month comparisons of positive vs.
Gonorrhea in postpartum women
371
Table IV. Gonorrhea rates for selected characteristics of the 962 black subjects
No.I
Characteristics 1. Source of unearned income Welfare (ADC) None Unknown 2. Risk status* Not a risk Definite risk 3. Religion Protestant Catholic 4. Education Less than 12 years of school Twelve years or more of school 5. Types of termination for last pregnancy Term live birth Premature live birth Stillbirth or miscarriage 6. Marital status Never married Ever married Married but separated Married with husband present Married but widowed 7. Present age (years) 19 or less 20-24 25-29 30 or more 8. Parity 0 1-3 4 or more
Total
posi- Per cent tive positive
165 774 23
17 57 1
10.30 7.36 4.35
450 512
40 35
8.88 6.83
757 202
61 14
8.05 6.93
640
50
7.81
319
25
7.83
790 128
58 12
7.34 9.37
40
5
12 .50
344 616
34 41
9.88 6.65
138
15
10.87t
425
24
5.64t
53
2
3.77t
322 343 152 145
28 31 11 5
8.70 9.03 7.23t 3.44t
8 742 212
3 62 10
*Definite risk: Should infer unfavorable direct and/or indirect obstetric causes of material and perinatal morbidity and should possess at least one of the following characteristics: {I) age under 16 or over 40, (2) parity six or more, (3) history of stillbirth or two or more miscarriages, (4) infant born alive but now dead, (5) history of two or more premature births, (6) history of toxemia of pregnancy, (7) history of cardiovascular-renal disease, (8) previous cesarean section.
tx i significant at 0.05 level.
negative gonorrheal culture tests, December was significantly different from January and February, with a higher portion of the patients seen during that month being positive. The selected characteristics introduced as additional controls in an attempt to partially
372
February l, 1974 Am.]. Obstet. Gynecol.
Ahmad and Parrish
explain these differences were found to be not significantly associated with the betweenmonth differences. Those women seen in December did tend, however, to be younger and have a higher parity. Then, too, a seasonal factor may be involved. Data from this study only suggest these possible influences. The small number of whites in the study population reflects the racial distribution indicative of the Charity Hospital patient population in New Orleans. Because of the small number of whites in the total study population and the chi-square test indicating no significant difference by race concerning the outcome of the gonorrheal culture tests, the more detailed analysis was focused on the black segment of the study population. The outcome of this analysis suggests that those black women never married as well as those married but separated are at a higher risk of contacting gonorrhea than is true of widows and women married with their husbands at home. Whether this means these high-risk groups are younger, less careful in their selection of sexual partners, or more prone to have
sexual relations with more than one partner is not clear. These data do support, however, that these two groups of black women are high-risk groups for gonorrhea. Data from this more detailed analysis further indicate the rank order of risk from highest to lowest by per cent positive for age groups to be: ( 1) 20 through 24 years of age, ( 2 ! 19 or less, ( 3) 25 through 29, and ( 4) 30 or more. Concerning parity, these data also indicate the rank order of risk from highest to lowest by per cent positive for parity groups to be: ( 1) zero, ( 2) one through three, and ( 3) four or more. Special recognition is given to Dr. Joseph D. Beasley (Chairman, Department of Applied Health Sciences, Tulane School of Public Health and Tropical Medicine), the New Orleans Family Planning Clinic staff, Miss Ethel Eaton (Lincoln Parish Project Biostatistician and Assistant Professor, Tulane School of Public Health and Tropical Medicine), Mrs. Irene Killen (Research Assistant), Mrs. Angie Weiler (Administrative Assistant), and Mis~ Cathy Joachim (Secretary) .
REFERENCES
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