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Patients' attitudes associated with cesarean delivery on maternal request in an urban population
Residents’ Papers
www. AJOG.org
Patients’ attitudes associated with cesarean delivery on maternal request in an urban population Leo Pevzner, MD; Dena Goffman, MD; Margaret Comerford Freda, EdD, RN, FAAN; Ashlesha K. Dayal, MD OBJECTIVE: To explore patient attitudes related to cesarean delivery on maternal request (CDMR). STUDY DESIGN: Questionnaires were distributed to patients in mid-
trimester. Questions assessed patient demographics, knowledge, perceived risks, and attitudes about CDMR. RESULTS: Three hundred and fourteen questionnaires and 188 written
responses were used for analysis. Most patients (95%) did not believe that CDMR was advisable and felt that vaginal delivery (VD) was safer for both mother (93%) and baby (88%). Of patients who did not be-
C
ontroversy regarding elective primary cesarean delivery began earnestly in 1985, when Feldman and Friedman presented the argument for its use.1 In 1999, a Federation International of Gynecology and Obstetrics (FIGO) Committee concluded “performing cesarean section for non-medical reasons is ethically not justified.”2 Proponents for cesarean delivery on maternal request (CDMR) galvanized in 2000, led by W. Benson Harer, Jr, who suggested that CDMR and vaginal delivery (VD) are equally safe and advocated offering either option to women.3 Limited data regarding risks, benefits, women’s right to choose, and physicians’ motivation in performing surgery without a medical indication raises concern.4,5 The National Institutes of Health
From the Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center, Bronx, NY Received July 31, 2007; revised Sept. 7, 2007; accepted Oct. 1, 2007. Reprints: Ashlesha K. Dayal, MD, Department of Obstetrics, Gynecology and Women’s Health Montefiore Medical Center, 1825 Eashchester Road, Bronx, NY 10461; [email protected] 0002-9378/free © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.10.778
lieve CDMR was advisable, the most common explanations were classified into categories of “normal is better,” “risk of complications” (67%), only 1% of this group felt that the decision should be left up to the individual. Of the remaining patients (5%) who supported CDMR, 75% believed that the decision should be left up to the individual. CONCLUSION: The majority of women in our population do not think that CDMR is advisable.
Key words: cesarean delivery on maternal request, elective cesarean delivery
(NIH) convened a conference in 2006 which concluded that “Surveys of women . . . [and] health care providers . . . regarding CDMR will provide a basis for assessing the current extent of CDMR and attitudes about it.”6 The objective of our study was to explore women’s attitudes about CDMR in our urban population.
M ATERIALS AND M ETHODS This prospective cohort study was conducted at Montefiore Medical Center Bronx, NY, under protocol approved by the institutional review board. A questionnaire was developed to survey patients’ attitudes about CDMR. The survey consisted of 18 questions, including patient demographics, obstetric/surgical history, and attitudes regarding CDMR. All demographic and patient history questions were closed-ended questions. Questions addressing attitudes toward CDMR all began with a yes/no question, and patients were subsequently asked to elaborate with written responses. Anonymous surveys were distributed to mid-trimester patients between February 2007 and April 2007 who presented for their anatomy ultrasound at our largest outpatient ultrasound unit. The survey was in English and was selfadministered. Participation was voluntary and patients were only excluded if they declined to participate.
Statistical analysis was performed using NCSS (Number Cruncher Statistical System, v 2004; Kayesville, UT). Dichotomous variables were analyzed using the 2 analysis. P ⬍ .05 was considered significant. Subsequently, text was analyzed using content analysis techniques and the results represented by frequency within the text.7 As analysis proceeded, exhaustive categories were developed, and 6 final categories were obtained.
R ESULTS Of the 522 patients eligible to participate, 383 (73%) completed questionnaires; however, 314 were used in the final analysis due to incomplete data. A description of demographic data is presented in Table 1. Demographic data for patients who chose not to participate are unavailable. Our patients overwhelmingly (95%) believed that CDMR was not advisable and felt that VD is safer for mother (93%) and baby (88%; Table 2). Independent predictors for patients’ choice of CDMR were: being married (P ⫽ .01), belief that CDMR was advisable (P ⫽ .0), direct knowledge of another mother who received a CD (P ⫽ .003), or prior CD (P ⫽ .0). There were no significant differences between the responses of nulliparous and multiparous patients. Parous patients with a history of a prior CD compared to those with a history of VD
MAY 2008 American Journal of Obstetrics & Gynecology
e35
Residents’ Papers TABLE 1
Demographic characteristics Characteristic
Percent (N)
Age (range, mean)
16-41 (26.1)
...........................................................................................................
Race/ethnicity
..................................................................................................
Black
34% (102)
..................................................................................................
Hispanic
54% (163)
..................................................................................................
Non-Hispanic white and 12% (37) other
...........................................................................................................
Marital status
..................................................................................................
Single
58% (176)
Married
42% (129)
.................................................................................................. ...........................................................................................................
Education
..................................................................................................
High school diploma or 44% (135) higher
..................................................................................................
College or higher
56% (174)
...........................................................................................................
Hours worked
..................................................................................................
⬍20
40% (123)
20-40
37% (111)
⬎40
23% (71)
.................................................................................................. .................................................................................................. ...........................................................................................................
Insurance status
..................................................................................................
Medicaid
54% (167)
Private
46% (140)
.................................................................................................. ...........................................................................................................
Household income
..................................................................................................
⬍$50,000
69% (204)
⬎$50,000
31% (91)
.................................................................................................. ...........................................................................................................
Parity
..................................................................................................
Nulliparous
49% (152)
Multiparous
51% (158)
.................................................................................................. ...........................................................................................................
Personal history of CD
..................................................................................................
No
87% (269)
Yes
13% (40)
.................................................................................................. ...........................................................................................................
Know someone who had CD
..................................................................................................
No
66% (206)
Yes
34% (108)
.................................................................................................. ...........................................................................................................
Planned number of children
..................................................................................................
2 or more
55% (156)
3 or more
45% (130)
.................................................................................................. ...........................................................................................................
www.AJOG.org After responding to the question “Do you think CDMR is a good idea?,” 158/ 314 women provided a written response; some provided multiple responses for a total of 188. Written responses were more likely to be provided by women who: were college educated (P ⫽ .01), knew someone who had a CD (P ⬍ .0001), or believed that CDMR is a good idea (P ⫽ .02). Within text analysis, the 6 main themes expressed by our patients were: “normal/natural is better (63/188, 34%),” “risk of complications (54/188, 29%),” “cesarean should only be done for problems (25/188, 13%),” “the experience of childbirth shouldn’t be missed (17/188, 9%),” “cutting is bad and leaves scars (15/188, 8%),” and “it should be up to the individual (13/188, 7%).” Table 3 presents the frequency of elaborated responses to the question, “do you think 1 elective C/S is a good idea?” Of our patients who did not believe CDMR was advisable, the most common explanations were “Normal/ natural is better” (36%) and “risk of complications” (31%). Only 1% felt that the decision should be left up to the individual. On the contrary, while only 12 patients believed that CDMR was advisable, 75% of these believed that the decision should be left up to the individual. Representative comments in the “normal is better” group (34%) included: “ . . . let nature take its course . . . ,” “if you’re able to have a successful normal birth, you should . . . ” Women concerned about “risk of complications” (29%) wrote: “cesarean section is major surgery,” “exposing yourself to more germs and infection with surgery,” “infection and blood loss,” “the child does much better with a vaginal birth,” “the newborn can develop respiratory problems.”
CD, cesarean delivery. Pevzner. Patients’ attitudes associated with cesarean delivery on maternal request. Am J Obstet Gynecol 2008.
were more likely to believe CD to be safer for mother (P ⬍ .001) and baby (P ⬍ .001) and would be more likely to choose CDMR if offered a choice (P ⬍ .001). e36
C OMMENT CDMR is one of the most controversial topics in obstetrics,4,5 but a dearth of literature exists regarding patient attitudes.8-10 To our knowledge, this is the first study in the United States to address patient attitudes toward CDMR.
American Journal of Obstetrics & Gynecology MAY 2008
TABLE 2
Beliefs and attitudes Question and answer
Percent (N)
Do you think CDMR is a good idea?
..................................................................................................
No
95% (288)
Yes
5% (15)
.................................................................................................. ...........................................................................................................
Which do you think is safer for you?
..................................................................................................
VD
93% (283)
CD
7% (21)
.................................................................................................. ...........................................................................................................
Which do you think is safer for the baby?
..................................................................................................
VD
88% (272)
CD
12% (36)
.................................................................................................. ...........................................................................................................
How would you rather deliver?
..................................................................................................
VD
93% (286)
CD
7% (23)
.................................................................................................. ...........................................................................................................
CD, cesarean delivery; VD, vaginal delivery. Pevzner. Patients’ attitudes associated with cesarean delivery on maternal request. Am J Obstet Gynecol 2008.
Our study of women in an urban population demonstrated that most women have a preference for VD, and this concurs with available international literature. The sampling of our patients’ writings and analysis of their written responses presented in the results provides further insight about our patients’ attitudes towards CDMR. The recurrent themes, “normal/natural is better,” “risks of complications,” and “cesarean should only be done for problems,” seem to indicate that our patients lean towards traditional obstetric teachings on mode of delivery. Very few written responses offered that mode of delivery “should be left up to the individual.” The fact that our patient population is composed of 88% blacks or Hispanics must be acknowledged. To date, the few international studies addressing patient preferences and attitudes with regard to CDMR8-10 have not included this minority patient population. Patient ethnicity, socioeconomic status, and expectations clearly have a strong impact on attitudes regarding health-
Residents’ Papers
www.AJOG.org
TABLE 3
Qualitative content analysis response categories Do you think CDMR is a good idea? Response
Yes
No
Normal/natural is better
0
36% (63)
Risk of complications
8% (1) 31% (53)
........................................................................................................... ...........................................................................................................
Cesarean should only 17% (2) 13% (23) be done for problems
...........................................................................................................
The experience of childbirth should not be missed
0
Cutting is bad and leaves scars
0
10% (17)
...........................................................................................................
9% (15)
...........................................................................................................
It should be up to the 75% (9) individual
1% (2)
Pevzner. Patients’ attitudes associated with cesarean delivery on maternal request. Am J Obstet Gynecol 2008.
care issues, including CDMR. We appreciate that a similar survey administered in a different patient population may provide drastically different results; however, the insight provided
into the attitudes of the patients we serve is invaluable. Certainly, many unanswered questions remain about the risks, benefits, and attitudes toward CDMR. Future studies should be aimed at elucidating all of the above. Refining and validating our survey and using it to assess attitudes in our patients compared with other patient populations would be instructive. As we move forward, institutions may strive to evolve policy about CDMR. National and local policy should take into consideration not only patient attitude but also medical knowledge, experience, and available evidence. For now, patients and providers must jointly determine the mode of delivery. We must take into account not only provider bias but also patient attitudes, as we collaborate with our patients to make this important decision. f REFERENCES 1. Feldman GB, Friedman JA. Prophylactic cesarean section at term? N Engl J Med 1985;312:1264-7.
2. FIGO Committee for the Ethical Aspect of Human Reproduction and Women’s Health. Int J Gynaecol Obstet 1999;64:317-22. 3. Harer WB. Patient choice cesarean. ACOG clinical review. Washington, DC: American College of Obstetricians and Gynecologists; 2000. 4. Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med 2003;348: 946-50. 5. Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice cesarean: an evidencebased review. Obstet Gynecol Surv 2004; 59:601-16. 6. National Institutes of Health State-of-the-Science Conference statement: cesarean delivery on maternal request, March 27-29, 2006. Obstet Gynecol 2006;107:1389-97. 7. Morgan DL. Qualitative content analysis: a guide to paths not taken. Qual Health Res 1993;3:112-21. 8. Pakenham S, Chamberlain SM, Smith GN. Women’s views on elective primary caesarean section. J Obstet Gynaecol Can 2006;28: 1089-94. 9. Hildingsson I, Radestad I, Rubertsson C, Waldenstrom U. Few women wish to be delivered by caesarean section. BJOG 2002; 109:618-23. 10. Edwards GJ, Davies NJ. Elective caesarean section—the patient’s choice? Am J Obstet Gynecol 2001;21:128-9.
MAY 2008 American Journal of Obstetrics & Gynecology
e37
www. AJOG.org
Patients’ attitudes associated with cesarean delivery on maternal request in an urban population Leo Pevzner, MD; Dena Goffman, MD; Margaret Comerford Freda, EdD, RN, FAAN; Ashlesha K. Dayal, MD OBJECTIVE: To explore patient attitudes related to cesarean delivery on maternal request (CDMR). STUDY DESIGN: Questionnaires were distributed to patients in mid-
trimester. Questions assessed patient demographics, knowledge, perceived risks, and attitudes about CDMR. RESULTS: Three hundred and fourteen questionnaires and 188 written
responses were used for analysis. Most patients (95%) did not believe that CDMR was advisable and felt that vaginal delivery (VD) was safer for both mother (93%) and baby (88%). Of patients who did not be-
C
ontroversy regarding elective primary cesarean delivery began earnestly in 1985, when Feldman and Friedman presented the argument for its use.1 In 1999, a Federation International of Gynecology and Obstetrics (FIGO) Committee concluded “performing cesarean section for non-medical reasons is ethically not justified.”2 Proponents for cesarean delivery on maternal request (CDMR) galvanized in 2000, led by W. Benson Harer, Jr, who suggested that CDMR and vaginal delivery (VD) are equally safe and advocated offering either option to women.3 Limited data regarding risks, benefits, women’s right to choose, and physicians’ motivation in performing surgery without a medical indication raises concern.4,5 The National Institutes of Health
From the Department of Obstetrics & Gynecology and Women’s Health, Albert Einstein College of Medicine of Yeshiva University/Montefiore Medical Center, Bronx, NY Received July 31, 2007; revised Sept. 7, 2007; accepted Oct. 1, 2007. Reprints: Ashlesha K. Dayal, MD, Department of Obstetrics, Gynecology and Women’s Health Montefiore Medical Center, 1825 Eashchester Road, Bronx, NY 10461; [email protected] 0002-9378/free © 2008 Mosby, Inc. All rights reserved. doi: 10.1016/j.ajog.2007.10.778
lieve CDMR was advisable, the most common explanations were classified into categories of “normal is better,” “risk of complications” (67%), only 1% of this group felt that the decision should be left up to the individual. Of the remaining patients (5%) who supported CDMR, 75% believed that the decision should be left up to the individual. CONCLUSION: The majority of women in our population do not think that CDMR is advisable.
Key words: cesarean delivery on maternal request, elective cesarean delivery
(NIH) convened a conference in 2006 which concluded that “Surveys of women . . . [and] health care providers . . . regarding CDMR will provide a basis for assessing the current extent of CDMR and attitudes about it.”6 The objective of our study was to explore women’s attitudes about CDMR in our urban population.
M ATERIALS AND M ETHODS This prospective cohort study was conducted at Montefiore Medical Center Bronx, NY, under protocol approved by the institutional review board. A questionnaire was developed to survey patients’ attitudes about CDMR. The survey consisted of 18 questions, including patient demographics, obstetric/surgical history, and attitudes regarding CDMR. All demographic and patient history questions were closed-ended questions. Questions addressing attitudes toward CDMR all began with a yes/no question, and patients were subsequently asked to elaborate with written responses. Anonymous surveys were distributed to mid-trimester patients between February 2007 and April 2007 who presented for their anatomy ultrasound at our largest outpatient ultrasound unit. The survey was in English and was selfadministered. Participation was voluntary and patients were only excluded if they declined to participate.
Statistical analysis was performed using NCSS (Number Cruncher Statistical System, v 2004; Kayesville, UT). Dichotomous variables were analyzed using the 2 analysis. P ⬍ .05 was considered significant. Subsequently, text was analyzed using content analysis techniques and the results represented by frequency within the text.7 As analysis proceeded, exhaustive categories were developed, and 6 final categories were obtained.
R ESULTS Of the 522 patients eligible to participate, 383 (73%) completed questionnaires; however, 314 were used in the final analysis due to incomplete data. A description of demographic data is presented in Table 1. Demographic data for patients who chose not to participate are unavailable. Our patients overwhelmingly (95%) believed that CDMR was not advisable and felt that VD is safer for mother (93%) and baby (88%; Table 2). Independent predictors for patients’ choice of CDMR were: being married (P ⫽ .01), belief that CDMR was advisable (P ⫽ .0), direct knowledge of another mother who received a CD (P ⫽ .003), or prior CD (P ⫽ .0). There were no significant differences between the responses of nulliparous and multiparous patients. Parous patients with a history of a prior CD compared to those with a history of VD
MAY 2008 American Journal of Obstetrics & Gynecology
e35
Residents’ Papers TABLE 1
Demographic characteristics Characteristic
Percent (N)
Age (range, mean)
16-41 (26.1)
...........................................................................................................
Race/ethnicity
..................................................................................................
Black
34% (102)
..................................................................................................
Hispanic
54% (163)
..................................................................................................
Non-Hispanic white and 12% (37) other
...........................................................................................................
Marital status
..................................................................................................
Single
58% (176)
Married
42% (129)
.................................................................................................. ...........................................................................................................
Education
..................................................................................................
High school diploma or 44% (135) higher
..................................................................................................
College or higher
56% (174)
...........................................................................................................
Hours worked
..................................................................................................
⬍20
40% (123)
20-40
37% (111)
⬎40
23% (71)
.................................................................................................. .................................................................................................. ...........................................................................................................
Insurance status
..................................................................................................
Medicaid
54% (167)
Private
46% (140)
.................................................................................................. ...........................................................................................................
Household income
..................................................................................................
⬍$50,000
69% (204)
⬎$50,000
31% (91)
.................................................................................................. ...........................................................................................................
Parity
..................................................................................................
Nulliparous
49% (152)
Multiparous
51% (158)
.................................................................................................. ...........................................................................................................
Personal history of CD
..................................................................................................
No
87% (269)
Yes
13% (40)
.................................................................................................. ...........................................................................................................
Know someone who had CD
..................................................................................................
No
66% (206)
Yes
34% (108)
.................................................................................................. ...........................................................................................................
Planned number of children
..................................................................................................
2 or more
55% (156)
3 or more
45% (130)
.................................................................................................. ...........................................................................................................
www.AJOG.org After responding to the question “Do you think CDMR is a good idea?,” 158/ 314 women provided a written response; some provided multiple responses for a total of 188. Written responses were more likely to be provided by women who: were college educated (P ⫽ .01), knew someone who had a CD (P ⬍ .0001), or believed that CDMR is a good idea (P ⫽ .02). Within text analysis, the 6 main themes expressed by our patients were: “normal/natural is better (63/188, 34%),” “risk of complications (54/188, 29%),” “cesarean should only be done for problems (25/188, 13%),” “the experience of childbirth shouldn’t be missed (17/188, 9%),” “cutting is bad and leaves scars (15/188, 8%),” and “it should be up to the individual (13/188, 7%).” Table 3 presents the frequency of elaborated responses to the question, “do you think 1 elective C/S is a good idea?” Of our patients who did not believe CDMR was advisable, the most common explanations were “Normal/ natural is better” (36%) and “risk of complications” (31%). Only 1% felt that the decision should be left up to the individual. On the contrary, while only 12 patients believed that CDMR was advisable, 75% of these believed that the decision should be left up to the individual. Representative comments in the “normal is better” group (34%) included: “ . . . let nature take its course . . . ,” “if you’re able to have a successful normal birth, you should . . . ” Women concerned about “risk of complications” (29%) wrote: “cesarean section is major surgery,” “exposing yourself to more germs and infection with surgery,” “infection and blood loss,” “the child does much better with a vaginal birth,” “the newborn can develop respiratory problems.”
CD, cesarean delivery. Pevzner. Patients’ attitudes associated with cesarean delivery on maternal request. Am J Obstet Gynecol 2008.
were more likely to believe CD to be safer for mother (P ⬍ .001) and baby (P ⬍ .001) and would be more likely to choose CDMR if offered a choice (P ⬍ .001). e36
C OMMENT CDMR is one of the most controversial topics in obstetrics,4,5 but a dearth of literature exists regarding patient attitudes.8-10 To our knowledge, this is the first study in the United States to address patient attitudes toward CDMR.
American Journal of Obstetrics & Gynecology MAY 2008
TABLE 2
Beliefs and attitudes Question and answer
Percent (N)
Do you think CDMR is a good idea?
..................................................................................................
No
95% (288)
Yes
5% (15)
.................................................................................................. ...........................................................................................................
Which do you think is safer for you?
..................................................................................................
VD
93% (283)
CD
7% (21)
.................................................................................................. ...........................................................................................................
Which do you think is safer for the baby?
..................................................................................................
VD
88% (272)
CD
12% (36)
.................................................................................................. ...........................................................................................................
How would you rather deliver?
..................................................................................................
VD
93% (286)
CD
7% (23)
.................................................................................................. ...........................................................................................................
CD, cesarean delivery; VD, vaginal delivery. Pevzner. Patients’ attitudes associated with cesarean delivery on maternal request. Am J Obstet Gynecol 2008.
Our study of women in an urban population demonstrated that most women have a preference for VD, and this concurs with available international literature. The sampling of our patients’ writings and analysis of their written responses presented in the results provides further insight about our patients’ attitudes towards CDMR. The recurrent themes, “normal/natural is better,” “risks of complications,” and “cesarean should only be done for problems,” seem to indicate that our patients lean towards traditional obstetric teachings on mode of delivery. Very few written responses offered that mode of delivery “should be left up to the individual.” The fact that our patient population is composed of 88% blacks or Hispanics must be acknowledged. To date, the few international studies addressing patient preferences and attitudes with regard to CDMR8-10 have not included this minority patient population. Patient ethnicity, socioeconomic status, and expectations clearly have a strong impact on attitudes regarding health-
Residents’ Papers
www.AJOG.org
TABLE 3
Qualitative content analysis response categories Do you think CDMR is a good idea? Response
Yes
No
Normal/natural is better
0
36% (63)
Risk of complications
8% (1) 31% (53)
........................................................................................................... ...........................................................................................................
Cesarean should only 17% (2) 13% (23) be done for problems
...........................................................................................................
The experience of childbirth should not be missed
0
Cutting is bad and leaves scars
0
10% (17)
...........................................................................................................
9% (15)
...........................................................................................................
It should be up to the 75% (9) individual
1% (2)
Pevzner. Patients’ attitudes associated with cesarean delivery on maternal request. Am J Obstet Gynecol 2008.
care issues, including CDMR. We appreciate that a similar survey administered in a different patient population may provide drastically different results; however, the insight provided
into the attitudes of the patients we serve is invaluable. Certainly, many unanswered questions remain about the risks, benefits, and attitudes toward CDMR. Future studies should be aimed at elucidating all of the above. Refining and validating our survey and using it to assess attitudes in our patients compared with other patient populations would be instructive. As we move forward, institutions may strive to evolve policy about CDMR. National and local policy should take into consideration not only patient attitude but also medical knowledge, experience, and available evidence. For now, patients and providers must jointly determine the mode of delivery. We must take into account not only provider bias but also patient attitudes, as we collaborate with our patients to make this important decision. f REFERENCES 1. Feldman GB, Friedman JA. Prophylactic cesarean section at term? N Engl J Med 1985;312:1264-7.
2. FIGO Committee for the Ethical Aspect of Human Reproduction and Women’s Health. Int J Gynaecol Obstet 1999;64:317-22. 3. Harer WB. Patient choice cesarean. ACOG clinical review. Washington, DC: American College of Obstetricians and Gynecologists; 2000. 4. Minkoff H, Chervenak FA. Elective primary cesarean delivery. N Engl J Med 2003;348: 946-50. 5. Wax JR, Cartin A, Pinette MG, Blackstone J. Patient choice cesarean: an evidencebased review. Obstet Gynecol Surv 2004; 59:601-16. 6. National Institutes of Health State-of-the-Science Conference statement: cesarean delivery on maternal request, March 27-29, 2006. Obstet Gynecol 2006;107:1389-97. 7. Morgan DL. Qualitative content analysis: a guide to paths not taken. Qual Health Res 1993;3:112-21. 8. Pakenham S, Chamberlain SM, Smith GN. Women’s views on elective primary caesarean section. J Obstet Gynaecol Can 2006;28: 1089-94. 9. Hildingsson I, Radestad I, Rubertsson C, Waldenstrom U. Few women wish to be delivered by caesarean section. BJOG 2002; 109:618-23. 10. Edwards GJ, Davies NJ. Elective caesarean section—the patient’s choice? Am J Obstet Gynecol 2001;21:128-9.
MAY 2008 American Journal of Obstetrics & Gynecology
e37