Article

Pregnancy and risk of a traffic crash Response

Authors:
  • Sunnybrook Health Sciences Centre / Institute for Clinical Evaluative Sciences
To read the full-text of this research, you can request a copy directly from the authors.

Abstract

Introduction: Pregnancy causes diverse physiologic and lifestyle changes that may contribute to increased driving and driving error. We compared the risk of a serious motor vehicle crash during the second trimester to the baseline risk before pregnancy. Methods: We conducted a population-based self-matched longitudinal cohort analysis of women who gave birth in Ontario between April 1, 2006, and March 31, 2011. We excluded women less than age 18 years, those living outside Ontario, those who lacked a valid health card identifier under universal insurance, and those under the care of a midwife. The primary outcome was a motor vehicle crash resulting in a visit to an emergency department. Results: A total of 507,262 women gave birth during the study period. These women accounted for 6922 motor vehicle crashes as drivers during the 3-year baseline interval (177 per mo) and 757 motor vehicle crashes as drivers during the second trimester (252 per mo), equivalent to a 42% relative increase (95% confidence interval 32%-53%; p<0.001). The increased risk extended to diverse populations, varied obstetrical cases and different crash characteristics. The increased risk was largest in the early second trimester and compensated for by the third trimester. No similar increase was observed in crashes as passengers or pedestrians, cases of intentional injury or inadvertent falls, or self-reported risky behaviours. Interpretation: Pregnancy is associated with a substantial risk of a serious motor vehicle crash during the second trimester. This risk merits attention for prenatal care.

No full-text available

Request Full-text Paper PDF

To read the full-text of this research,
you can request a copy directly from the authors.

... Therefore, protecting the life of all children, including unborn fetuses, is of the highest priority, especially in Japan. A population-based, self-matched, longitudinal cohort analysis of the risk of motor vehicle collisions (MVCs) involving pregnant women drivers in Ontario suggested that the risk of a serious MVC significantly increased during the early second trimester of pregnancy [3]. Although the authors did not identify the reason for this increase, psychological and physiological changes during pregnancy were considered contributory factors. ...
... Pregnant women often suffer from nausea, vomiting, severe drowsiness, and back pain due to the secretion of human chorionic gonadotropin (hCG) and the enlargement of the uterus. These symptoms are considered common complaints of pregnancy, and their appearance is attributed to the occurrence of human error [3]. However, although the most common causes of MVCs involve driver human error, no studies have examined the relationship between common complaints in pregnancy and the risk of MVCs. ...
... This complaint is due to acute changes in normal movement or contraction of the uterus, especially in mid-to late-term pregnancy. This result supports a previous study of pregnant women drivers that found that the risk of serious MCVs significantly increased during the early second trimester [3]. This common pregnancy complaint could also influence cognition and decision-making processes. ...
Article
Full-text available
Pregnant women commonly report various health complaints during pregnancy, the occurrence of which is believed to cause human error. However, no study has examined the relationship between the occurrence of pregnancy complaints and the risk of motor vehicle collisions (MVCs). This study aimed to clarify the relationship between the frequency and severity of common pregnancy complaints and the occurrence of MVCs or near-miss incidents. We conducted a multicenter cross-sectional survey of 1000 pregnant women in Shiga Prefecture, Japan. The event group experiencing MVCs or near-miss incidents during pregnancy comprised 10.8% of respondents. The frequency of compression of the stomach or abdomen, tension and cramps in the lower abdomen, pelvic pain, irritability, depressed mood, distractedness, and hot flashes was significantly higher in the event group. The results of our multivariate logistic regression analysis revealed that tension and cramps in the lower abdomen, distractedness, and irritability were independent contributory factors to such events, with an odds ratio of 2.414, 1.849, and 1.746, respectively. Educating pregnant women to avoid driving when experiencing these symptoms would improve maternal and fetal safety.
... The Registered Persons Database was used to extract data on the patient's age, sex, socioeconomic status (quintiles), and home location (rural or urban). [41][42][43] On the basis of distributions, we categorized age into 2 groups as older (≥35 years) and younger (<35 years). This database derived socioeconomic status from the home postal code through Canadian Census data and the mean annual household income associated with a given postal code. ...
... This study found that patients undergoing bariatric surgery tend to have higher ambulance use and hospitalizations compared with other patients. 41 Emergency medicine physicians often typically focus on acute complications rather than the long-term mental health problems exacerbated after surgery. 58 This study suggests that a postoperative emergency visit could be an opportunity to screen for mental health in patients that have undergone bariatric surgery. ...
Article
Importance Self-harm behaviors, including suicidal ideation and past suicide attempts, are frequent in bariatric surgery candidates. It is unclear, however, whether these behaviors are mitigated or aggravated by surgery.Objective To compare the risk of self-harm behaviors before and after bariatric surgery.Design, Setting, and Participants In this population-based, self-matched, longitudinal cohort analysis, we studied 8815 adults from Ontario, Canada, who underwent bariatric surgery between April 1, 2006, and March 31, 2011. Follow-up for each patient was 3 years prior to surgery and 3 years after surgery.Main Outcomes and Measures Self-harm emergencies 3 years before and after surgery.Results The cohort included 8815 patients of whom 7176 (81.4%) were women, 7063 (80.1%) were 35 years or older, and 8681 (98.5%) were treated with gastric bypass. A total of 111 patients had 158 self-harm emergencies during follow-up. Overall, self-harm emergencies significantly increased after surgery (3.63 per 1000 patient-years) compared with before surgery (2.33 per 1000 patient-years), equaling a rate ratio (RR) of 1.54 (95% CI, 1.03-2.30; P = .007). Self-harm emergencies after surgery were higher than before surgery among patients older than 35 years (RR, 1.76; 95% CI, 1.05-2.94; P = .03), those with a low-income status (RR, 2.09; 95% CI, 1.20-3.65; P = .01), and those living in rural areas (RR, 6.49; 95% CI, 1.42-29.63; P = .02). The most common self-harm mechanism was an intentional overdose (115 [72.8%]). A total of 147 events (93.0%) occurred in patients diagnosed as having a mental health disorder during the 5 years before the surgery.Conclusions and Relevance In this study, the risk of self-harm emergencies increased after bariatric surgery, underscoring the need for screening for suicide risk during follow-up.
... As a result we might hypothesize that the relatively lower weight-adjusted dose given to our mostly overweight and obese study participants could have mitigated adverse drug effects. A previous study determined the incidence of adverse maternal effects among 225 women taking Diclectin® at the recommended (n = 123) or higher than recommended (n = 102) doses [21]. One-third (33.6%) of those women reported having adverse CNS effects (sleepiness, tiredness, and/or drowsiness) temporally related to the medication, a rate very similar to the present study (28.3%). ...
... dry mouth, dysrhythmia). In a recent population-based Canadian study, pregnant women in the first trimester of pregnancy, when NVP and the use of Diclegis® is at its peak, did not have a higher risk of car crushes , whereas there was a 46% increased risk in the second trimester, when most morning sickness has subsided and the drug is not used [21] . This may serve as a populationbased corroboration of the present results, showing that Diclegis® is not associated with measurable CNS depression. ...
Article
Full-text available
Nausea and vomiting of pregnancy (NVP) is the most common medical condition in pregnancy, affecting up to 80% of expecting mothers. In April 2013 the FDA approved the delayed release combination of doxylamine succinate and -pyridoxine hydrochloride (Diclegis®) for NVP, following a phase 3 randomized trial in pregnant women. The fetal safety of this medication has been proven by numerous studies. However, because it is the only FDA-approved medication for NVP that is likely to be used by a large number of pregnant women, its maternal safety is an important public health question. The Objective is to evaluate the maternal safety of doxylamine succinate -pyridoxine hydrochloride delayed-release preparation (Diclegis® as compared to placebo. We randomized women suffering from NVP to receive Diclegis® (n = 131) or placebo (n = 125) for 14 days at doses ranging from 2-4 tablets a day, based on a pre-specified titration protocol response to symptoms. Adverse events were collected through patient diaries, clinical examination and laboratory testing. Doxylamine succinate 10 mg and pyridoxine hydrochloride 10 mg use was not associated with an increased rate of any adverse event over placebo, including CNS depression, gastrointestinal or cardiovascular involvement. Doxylamine succinate-pyridoxine hydrochloride delayed release combination is safe and well tolerated by pregnant women when used in the recommended dose of up to 4 tablets daily in treating nausea and vomiting of pregnancy Clinical Trial Registration No: NCT00614445 .
... 3 The risk of adverse outcomes resulting from an MVC increases in the second trimester of pregnancy if the pregnant women were the driver 4 ; however, this does not appear to be the case for pregnant passengers or pedestrians. 5 A maternal mortality rate of 3.5 women per 100 000 is reported following MVCs in pregnant women. 6 Mechanisms of injury recorded within the pregnant population of the UK national trauma registry, the Trauma Audit and Research Network, saw an increased rate of vehicular collision in pregnant women when compared with the non-pregnant cohort. ...
... (3) method of sampling; (4) adequacy of follow-up; (5) if the outcomes were adequately ascertained and (6) if measurement or misclassification bias was minimised. Studies without these features or with unclear reporting were classified to have a high risk of bias. ...
Article
Full-text available
Objectives: To systematically review and quantify the effect of motor vehicle crashes (MVCs) in pregnancy on maternal and offspring outcomes. Design: Systematic review and meta-analysis of observational data searched from inception until 1 July 2018. Searching was from June to August 2018 in Medline, Embase, Web of Science, Scopus, Latin-American and Caribbean System on Health Sciences Information, Scientific Electronic Library Online, TRANSPORT, International Road Research Documentation, European Conference of Ministers of Transportation Databases, Cochrane Database of Systematic Reviews and Cochrane Central Register. Participants: Studies were selected if they focused on the effects of exposure MVC during pregnancy versus non-exposure, with follow-up to verify outcomes in various settings, including secondary care, collision and emergency, and inpatient care. Data synthesis: For incidence data, we calculated a pooled estimate per 1000 women. For comparison of outcomes between women involved and those not involved in MVC, we calculated ORs with 95% CIs. Where possible, we statistically pooled the data using the random-effects model. The quality of studies used in the comparative analysis was assessed with Newcastle-Ottawa Scale. Results: We included 19 studies (3 222 066 women) of which the majority was carried out in high-income countries (18/19). In population-level studies of women involved in MVC, maternal death occurred in 3.6 per 1000 (95% CI 0.25-10.42; 3 studies, 12 000 women; Tau=1.77), and fetal death or stillbirth in 6.6 per 1000 (95% CI 3.81-10.12; 8 studies, 47 992 women; I2=92.6%). Pooled incidence of complications per 1000 women involved in MVC was labour induction (276.43), preterm delivery (191.90) and caesarean section (166.65). Compared with women not involved in MVC, those involved had increased odds of placental abruption (OR 1.43, 95% CI 1.27-1.63; 3 studies, 1 500 825 women) and maternal death (OR 202.27; 95% CI 110.60-369.95; 1 study, 1 094 559 women). Conclusion: Pregnant women involved in MVC were at higher risk of maternal death and complications than those not involved. Prospero registration number: CRD42018100788.
... We characterize the six months preceding a birthday as " before " and the six months following a birthday as " after " in our statistical analysis. For example, an individual born August 21, 1996 and injured on August 1, 2012 was defined as 15 years old at the time of their crash but nearly 16 years old in statistical analysis[67][68]. We analyzed only crashes associated with the first identified birthday, therefore, the counts provided in our figures represent a subset of the total number of crashes that an individual might experience over their lifetime. ...
Article
Full-text available
Background Off-road vehicles are popular and thrilling for youth outside urban settings, yet sometimes result in a serious crash that requires emergency medical care. The relation between birthdays and the subsequent risk of an off-road vehicle crash is unknown. Methods We conducted a population-based before-and-after longitudinal analysis of youth who received emergency medical care in Ontario, Canada, due to an off-road vehicle crash between April 1, 2002, and March 31, 2014. We identified youth injured in an off-road vehicle crash through population-based health-care databases of individuals treated for medical emergencies. We included youth aged 19 years or younger, distinguishing juniors (age ≤ 15 years) from juveniles (age ≥ 16 years). Results A total 32,777 youths accounted for 35,202 emergencies due to off-road vehicle crashes within six months of their nearest birthday. Comparing the six months following a birthday to the six months prior to a birthday, crashes increased by about 2.7 events per 1000 juniors (18.3 vs 21.0, p < 0.0001). The difference equaled a 15% increase in relative risk (95% confidence interval 12 to 18). The increase extended for months following a birthday, was not observed for traffic crashes due to on-road vehicles, and was partially explained by a lack of helmet wearing. As expected, off-road crash risks did not change significantly following a birthday among juveniles (19.2 vs 19.8, p = 0.61). Conclusions Off-road vehicle crashes leading to emergency medical care increase following a birthday in youth below age 16 years. An awareness of this association might inform public health messages, gift-giving practices, age-related parental permissions, and prevention by primary care physicians.
... In high-income countries, injury is the most common cause of non-obstetric death among pregnant women. In the United States, an estimated one out of 12 pregnant women will experience an injury, 1 and one out of 25 may seek emergency care. 2 Motor vehicle crashes, intimate partner violence and falls are common causes of injury during pregnancy, [3][4][5][6][7] however improvements in seat belt use and traffic safety have reduced the risk of traffic-related injury among pregnant women. 4,8 Elevated risk of maternal mortality from violence (homicide and suicide) extended into the post-partum period in some high-income countries, 9,10 though rates of violence were not elevated in others. ...
Article
Full-text available
In high-income countries, injury is the most common cause of non-obstetric death among pregnant women. However, the injury risk during pregnancy has not been well characterized for many developing countries including Ghana. Our study described maternal and fetal outcomes after injury at the Komfo Anokye Teaching Hospital (KATH) in Kumasi, Ghana, and identified associations between the prevalence of poor outcomes and maternal risk factors. Methods: We conducted a cross-sectional study to identify pregnant women treated for injury over a 12-month period at KATH in Kumasi, Ghana. Descriptive statistics were used to characterize the population. We identified the association between poor outcomes and maternal risk factors using multivariable Poisson regression. Results: There were 134 women with documented pregnancy who sought emergency care for injury (1.1% of all injured women). The leading injury mechanisms were motor vehicle collision (23%), poisoning (21%), and fall (19%). Assault was implicated in 3% of the injuries. Eleven women (8%) died from their injuries. The prevalence of poor fetal outcomes: fetal death, distress or premature birth, was high (61.9%). One in four infants was delivered prematurely following maternal injury. After adjusting for maternal and injury characteristics, poor fetal outcomes were associated with pedestrian injury (adjusted prevalence ratio (aPR) 2.5, 95% CI 1.5–4.6), and injury to the thoraco-abdominal region (aPR 2.1, 95% CI 1.4–3.3). Conclusions: Injury is an important cause of maternal morbidity and poor fetal outcomes. Poisoning, often in an attempt to terminate pregnancy, was a common occurrence among pregnant women treated for injury in Kumasi. Future work should address modifiable risk factors related to traffic safety, prevention of intimate partner violence, and prevention of unintended pregnancies.
... Pregnant women in the second trimester have a higher risk of being in a serious motor vehicle crash (MVC) compared to that of pregnant women in the first or third trimester or non-pregnant women [1], and serious MVCs during pregnancy can result in fetal and neonatal deaths [2]. The incidence of fetal and neonatal death related to MVCs during pregnancy is at least 3.7 per 100,000 pregnancies [3]. ...
Article
Full-text available
Objective: Severe motor vehicle accidents involving pregnant women can result in fetal and neonatal death. We describe a case in which fetal death occurred due to relatively mild seatbelt injuries and present the characteristic magnetic resonance imaging (MRI) findings of the placenta. Case report: A 26-year-old primigravid woman at 20 weeks gestation was involved in an automobile accident. Although she suffered only a seatbelt injury, fetal death subsequently occurred. Contrast-enhanced MRI showed the region compressed by the seatbelt as a low-intensity band without enhancement, and serum alpha-fetoprotein and hemoglobin F levels were elevated. Conclusion: Careful monitoring, including blood and abdominal examinations, should be performed when pregnant women suffer seatbelt injuries.
... The majority of such studies (including ours) have confirmed that unintentional injury is a significant contributor to maternal and fetal mortality and morbidity, although the incidence and reported pregnancy outcomes have varied widely, largely depending on the data sources used to ascertain exposure (28,31,40,41). We are aware of no previous study that specifically examined risks among preterm births and gestational ageadjusted risks of neonatal mortality and morbidity. ...
Article
Full-text available
The sequelae of preterm births may differ, depending on whether birth follows an acute event or a chronic condition. In a population-based cohort study of 2,711,645 Canadian hospital deliveries from 2003 to 2012, 3,059 women experienced unintentional injury during pregnancy. We assessed the impact of the acute event on pregnancy outcome and on neonatal complications, such as nontraumatic intracranial hemorrhage, respiratory distress syndrome, intubation, and death. We adjusted for maternal age, parity, pregnancy conditions, and (for neonates) gestational age in logistic regression analyses. Injury was significantly associated with fetal mortality and early preterm delivery. For preterm infants born to injured women during the hospitalization for injury versus those born to noninjured women, the adjusted odds ratios were 2.25 (95% confidence interval (CI): 1.23, 4.17) for neonatal death, 2.44 (95% CI: 1.76, 3.37) for respiratory distress, 2.20 (95% CI: 1.26, 3.84) for nontraumatic intracranial hemorrhage, and 2.17 (95% CI: 1.60, 2.96) for intubation, despite more favorable fetal growth in those born to noninjured women (adjusted birth-weight-for-gestational-age z score: 0.154 vs. 0.024, P = 0.041; small-for-gestational-age rate: 4.5% vs. 9.5%, P = 0.001). Our findings suggest that adaptation to the suboptimal intrauterine environment underlying chronic causes of preterm birth may protect preterm infants from adverse sequelae.
... Thus, the authors concluded that 'pregnancy is associated with a substantial risk of a serious motor-vehicle crash during the second trimester, and this risk merits attention for prenatal care'. 8 Using a multicentre questionnaire survey targeting pregnant Japanese women in 2013, we have previously demonstrated that the incidence of motor vehicle accidents during pregnancy was 2.9%. 9 In a previous report from Sweden, motor vehicle crashes during pregnancy caused 1.4 maternal fatalities per 100 000 pregnancies and a fetus/neonate mortality rate of least 3.7 per 100 000 pregnancies. ...
Article
Full-text available
Objective To determine whether an educational leaflet had any effect on seat belt use, seat preference and motor vehicle accidents rate during pregnancy in Japan. Design Prospective, non-randomised control trial with a questionnaire survey. Setting Eight obstetric hospitals in Sapporo, Japan. Participants 2216 pregnant women, of whom 1105 received the leaflet (intervention group) and 1111 did not (control group). Interventions Distribution of an educational leaflet on seat belt use to women in the intervention group. Primary outcome measures The effect of an educational leaflet on seat belt use, each pregnant woman’s seat preference and the women’s rates of motor vehicle accidents rate during their pregnancies. To evaluate the effects, the intervention group’s responses to the questionnaires were compared with those of the control group. Results The proportion of subjects who always used seat belts during pregnancy was significantly higher in the intervention group (91.3%) than in the control group (86.7%; p=0.0005). Among all subjects, the percentage of women who preferred the driver’s seat was lower during pregnancy (27.0%) than before pregnancy (38.7%), and the percentage of women who preferred the rear seat was higher during pregnancy (28.8%) than before pregnancy (21.0%). These two rates did not differ between two groups. Seventy-one women (3.2%) reported experiencing a motor vehicle accident during pregnancy. The motor vehicle accident rate for the intervention group (3.3%) was similar to that for the control group (3.2%). Conclusions An educational seat belt leaflet was effective in raising the rate of consistent seat belt use during pregnancy, but it did not decrease the rate of motor vehicle accidents. The wearing of seat belts should be promoted more extensively among pregnant women to decrease rates of pregnancy-related morbidity and mortality from motor vehicle accidents.
... The advantage of this approach was to define an interval of time that might temporarily influence the decision to initiate testosterone treatment and that might not represent the patient's usual baseline condition. 61 The subsequent interval encompassed the first day after initiating testosterone and continued for 1 year forward. ...
Article
Background: Injury causes significant morbidity and mortality that is sometimes attributed to testosterone and violence. We hypothesized that prescribed testosterone might be associated with the subsequent risk of serious injury. Methods: We conducted a self-matched individual-patient exposure-crossover analysis comparing injury risks before and after initiation of testosterone. We selected adults treated with testosterone in Ontario, Canada, from October 1, 2012 to October 1, 2017 (enrollment) and continued until October 1, 2018 (follow-up). The primary outcome was defined as an acute traumatic event that required emergency medical care. Results: A total of 64,386 patients were treated with testosterone, of whom 89% were men with a median age of 52 years. We identified 34,439 serious injuries during the baseline interval before starting testosterone (584 per month) and 7,349 serious injuries during the subsequent interval after starting testosterone (565 per month). Rates of injuries were substantially above the population norm in both intervals with no significant increased risk after starting testosterone (relative risk = 1.00; 95% confidence interval: 0.96 to 1.04, P = 0.850). The unchanged risk extended to diverse patients, was observed for different formulations, and applied to all injury mechanisms. In contrast, testosterone treatment was associated with a 48% increased risk of a thromboembolic event (relative risk = 1.48; 95% confidence interval: 1.25 to 1.74, P < 0.001). Conclusions: Testosterone treatment was associated with a substantial baseline risk of serious injury that did not increase further after starting therapy. Physicians prescribing testosterone could consider basic safety reminders to mitigate injury risks.
... One pregnant patient diagnosed with Zika virus infection, for example, may provoke wide public attention, lead to excessive viral testing of pregnant women and result in underestimating more likely contributors to maternal morbidity including domestic violence, mental illness and traffic crashes. 2 Of course, a formal analysis of diagnostic possibilities for every case would demand substantial effort and, itself, does not guarantee a correct diagnosis. In addition, the availability heuristic often leads to the right diagnosis by providing a quick and easy guess. ...
... [4] Although the incidence of traffic accidents during pregnancy in Turkey is not known, the event rate of traffic accidents during pregnancy was 6.47 per 1000 cases in Canada. [5] The risk of stillbirth, preterm labor, uterine rupture, cesarean section, placental abruption, spontaneous abortion, and Pregnant women involved in traffic accidents should be managed according to maternal and fetal status. The management of a pregnant trauma patient warrants consideration of several issues specific to pregnancy, such as alterations in maternal physiology and anatomy, exposure to radiation and other possible teratogens, the need to assess fetal well-being, and conditions that are unique to a pregnancy and are related to trauma (Rh isoimmunization, placental abruption, and preterm labor). ...
Article
Background: This study aimed to show whether it is necessary to hospitalize pregnant women who have been involved in traffic accidents. Methods: Patients at a hospital in Istanbul, Turkey, who underwent traffic accidents between 2012 and 2018 were studied, and pregnant patients' files were evaluated. Demographic and obstetric features of patients, type of accident, type of trauma, Glasgow Coma Score, whether or not hospitalization were examined, the response of patients to hospitalization, and the obstetric and maternal results of accidents were assessed. Results: In the present study, 95 patients were included. Overall, hospitalization was recommended for 50 patients, but of these, 58% refused to be admitted. No patients who refused hospitalization had complications. Preterm labor was seen in 3.2% of patients, while 3.2% had a fetal loss and 5.3% had a placental abruption. Only one mother was lost (1.1%) due to sustaining multiple traumas in a traffic accident. Hospitalization was increasingly indicated with increasing gestational age, but other parameters had no effect on hospitalization. Conclusion: The likelihood that hospitalization was recommended for pregnant women involved in traffic accidents increased with gestational age. Patients with minor trauma who refused hospitalization had no complications.
... Möglicherweise kommen die Informationen der Hebammen nicht bei der Empfängerin an: der schwangeren Frau. Ein Erklärungsversuch hierfür wäre eventuell die in der Literatur häufig beschriebene Vergesslichkeit in der Schwangerschaft [37,42]. Viele Frauen beschreiben in ihrer Schwangerschaft eine verminderte Konzentrationsfähigkeit und Vergesslichkeit. ...
... These data have previously been used to estimate medical costs [10][11][12][13][14][15] and study traffic crashes. [16][17][18] ...
Article
Full-text available
Background: There is no reliable estimate of costs incurred by motorcycle crashes. Our objective was to calculate the direct costs of all publicly funded medical care provided to individuals after motorcycle crashes compared with automobile crashes. Methods: We conducted a population-based, matched cohort study of adults in Ontario who presented to hospital because of a motorcycle or automobile crash from 2007 through 2013. For each case, we identified 1 control absent a motor vehicle crash during the study period. Direct costs for each case and control were estimated in 2013 Canadian dollars from the payer perspective using methodology that links health care use to individuals over time. We calculated costs attributable to motorcycle and automobile crashes within 2 years using a difference-in-differences approach. Results: We identified 26 831 patients injured in motorcycle crashes and 281 826 injured in automobile crashes. Mean costs attributable to motorcycle and automobile crashes were $5825 and $2995, respectively (p < 0.001). The rate of injury was triple for motorcycle crashes compared with automobile crashes (2194 injured annually/100 000 registered motorcycles v. 718 injured annually/100 000 registered automobiles; incidence rate ratio [IRR] 3.1, 95% confidence interval [CI] 2.8 to 3.3, p < 0.001). Severe injuries, defined as those with an Abbreviated Injury Scale ≥ 3, were 10 times greater (125 severe injuries annually/100 000 registered motorcycles v. 12 severe injuries annually/100 000 registered automobiles; IRR 10.4, 95% CI 8.3 to 13.1, p < 0.001). Interpretation: Considering both the attributable cost and higher rate of injury, we found that each registered motorcycle in Ontario costs the public health care system 6 times the amount of each registered automobile. Medical costs may provide an additional incentive to improve motorcycle safety.
... Previously, a nationwide hospital-based database was analyzed, and the factors for pregnancy loss or for requiring surgery were determined [11][12][13]. Additionally, national or regional population-based databases have been used to study pregnant women who were involved in MVCs [3,[14][15][16][17]. However, these databases lack detailed information on vehicle collisions. ...
Article
Full-text available
To examine the factors that influence substantial injuries for pregnant women and negative fetal outcomes in motor vehicle collisions (MVCs), a retrospective analysis using the National Automotive Sampling System/Crashworthiness Data System was performed in Shiga University of Medical Science. We analyzed data from 736 pregnant women who, between 2001 and 2015, had injuries that were an abbreviated injury scale (AIS) score of one or more. The mean age was 25.9 ± 6.4 years and the mean gestational age was 26.2 ± 8.2 weeks. Additionally, 568 pregnant women had mild injuries and 168 had moderate to severe injuries. Logistic regression analysis revealed that seatbelt use (odds ratio (OR), 0.30), airbag deployment (OR, 2.00), and changes in velocity (21-40 km/h: OR, 3.03; 41-60 km/h: OR, 13.47; ≥61 km/h: OR, 44.56) were identified as independent predictors of having a moderate to severe injury. The positive and negative outcome groups included 231 and 12 pregnant women, respectively. Injury severity in pregnant women was identified as an independent predictor of a negative outcome (OR, 2.79). Avoiding moderate to severe maternal injuries is a high priority for saving the fetus, and education on appropriate seatbelt use and limiting vehicle speed for pregnant women is required.
... Moreover, patients cannot change the weather but can lessen crash risks by small changes in behavior added to informed system design, public education, traffic enforcement, vehicle engineering, and economic incentives (Appendixx7, http://links.lww.com/MD/B480). [94][95][96] Several illusions could contribute to a life-threatening crash in bright sunlight. Aerial perspective in bright light can make the approach speed of landscapes seem slow and lead drivers to compensate by accelerating faster. ...
Article
Full-text available
Bright sunlight may create visual illusions that lead to driver error, including fallible distance judgment from aerial perspective. We tested whether the risk of a life-threatening motor vehicle crash was increased when driving in bright sunlight. This longitudinal, case-only, paired-comparison analysis evaluated patients hospitalized because of a motor vehicle crash between January 1, 1995 and December 31, 2014. The relative risk of a crash associated with bright sunlight was estimated by evaluating the prevailing weather at the time and place of the crash compared with the weather at the same hour and location on control days a week earlier and a week later. The majority of patients (n = 6962) were injured during daylight hours and bright sunlight was the most common weather condition at the time and place of the crash. The risk of a life-threatening crash was 16% higher during bright sunlight than normal weather (95% confidence interval: 9–24, P < 0.001). The increased risk was accentuated in the early afternoon, disappeared at night, extended to patients with different characteristics, involved crashes with diverse features, not apparent with cloudy weather, and contributed to about 5000 additional patient-days in hospital. The increased risk extended to patients with high crash severity as indicated by ambulance involvement, surgical procedures, length of hospital stay, intensive care unit admission, and patient mortality. The increased risk was not easily attributed to differences in alcohol consumption, driving distances, or anomalies of adverse weather. Bright sunlight is associated with an increased risk of a life-threatening motor vehicle crash. An awareness of this risk might inform driver education, trauma staffing, and safety warnings to prevent a life-threatening motor vehicle crash. Level of evidence: Epidemiologic Study, level III.
... Outcomes were identified using validated diagnosis code algorithms in administrative databases ( Table I in the online-only Data Supplement). 3,9,21 The pedestrian injury category also included miscellaneous traffic incidents (eg, bicycle). We focused on traffic injuries and falls that resulted in an emergency department visit. ...
Article
Background and Purpose— We aimed to determine the long-term risks of a motor vehicle collision after a cerebrovascular event and whether the risks were similar after left- or right-hemispheric events. Methods— We used a population-based registry to identify patients diagnosed with a transient ischemic attack or stroke (hemorrhagic or ischemic) between 2003 and 2013 in Ontario, Canada. Hemispheric laterality was determined using radiological and clinical findings. We identified subsequent serious injuries involving the patient as a driver using linked administrative data. Secondary outcomes included serious injuries involving the patient as a pedestrian, as a passenger, or other traumatic events (fall, fracture, ankle sprain). We used proportional hazard models accounting for death as a competing risk to test the association of hemispheric laterality and outcomes with and without adjustment for age, sex, discharge modified Rankin Scale score, home location, and prior driving record. Patients were followed through to 2017. Results— Among 26 144 patients with hemispheric cerebrovascular events, 377 subsequent serious traffic injuries as a driver (2.2 per 1000 person-year) were identified over a median follow-up of 6.4 person-years. The rate did not differ by laterality (adjusted hazard ratio, 1.00; 95% CI, 0.82–1.23). The risk of a serious traffic injury as a pedestrian was significantly higher after a right-sided than left-sided event (adjusted hazard ratio, 1.27; 95% CI, 1.02–1.58). Subsequent risks for other traumatic injuries did not differ by laterality of cerebrovascular event. Conclusions— The risk of a serious traffic injury as a pedestrian is substantially higher after a right-hemispheric cerebrovascular event compared with a left-sided event. Walking should be promoted for exercise in survivors of a stroke or transient ischemic attack, but these vulnerable road users may benefit from additional poststroke rehabilitation to optimize safety.
Chapter
Latest discoveries in human sensory perception and AI offer endless opportunities in the field of research and development. The first chapter shows how to easily predict the future with a more scientific approach. The critical role of the magnetic sense is analyzed through the study of Tiffany & Co. and Jaeger-LeCoultre, and the future of mobility is assessed with Huawei Technologies.KeywordsMagnetic senseAIFuture of mobilityNavigateHaidinger’s brushTiffanyTeslaJaeger-LeCoultreADASMaglevPredictionInnovation roadmapMachine learningSensorsHuaweiBig dataBiomimicry
Article
Statistical analysis suggests that pregnant women are at greater risk of traffic incidents. Is “baby brain” to blame – or is this an outrageous insult? Donald Redelmeier and Sharon May investigate
Article
Full-text available
I read with great interest Redelmeier and colleagues’1 article on pregnancy and the risk of a traffic crash. The authors1 suggest that risk for a motor vehicle crash increases at the beginning of the second trimester of pregnancy and then subsides to baseline by the third trimester. The underlying assumption is that potential cognitive deficits or fatigue associated with the second trimester of pregnancy may account for this increased risk. However, a more obvious variable may account for these results. Adverse weather is a known factor in motor vehicle crashes, and crashes occur more frequently in the winter months. Similarly, the frequency of birth by month shows a trend toward a greater number of births in early and late summer. Counting backward, on average, most women will enter their second trimester during the winter months with the most adverse weather conditions, specifically January through March. In which month a crash occurs may be as, if not more, important than the stage of pregnancy.
Article
Motor vehicle accidents (MVAs) are a major contributor of worldwide morbidity and mortality; however, relatively little is known about the incidence and consequences of traffic accidents on pregnant women. Our aim is to compare rates and outcomes of motor vehicle collision-related accidents in pregnant women. We conducted a population-based retrospective cohort study using the Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2003 to 2011. The risk of different motor vehicle accidents and injuries were compared among pregnant and non-pregnant subjects using conditional logistic regression. We identified 5,936 cases of collision-related motor vehicle accidents in pregnancy and aged-matched them at a one-to-10 ratio to 59,360 nonpregnant women with collision-related motor vehicle accidents. As compared with nonpregnant women, pregnant women admitted after a motor vehicle accident suffered less severe injuries and consequently required fewer therapeutic interventions and a shorter hospital stay. Pregnant women who had a collision-related motor vehicle accident were however at increased risk of requiring genitourinary surgery (odds ratio [OR] 1.45, 95% confidence interval [CI] 1.24-1.69). When restricted to women with a fracture, pregnant women were even more likely to require genitourinary surgery (OR 2.93, 95% CI 2.32-3.71) as well as require a blood transfusion (OR 1.21, 95% CI 1.01-1.44). Pregnant women admitted to hospital after a collision-related motor vehicle accident tend to sustain less severe injuries compared with non-pregnant women. However, the influence of admissions for fetal monitoring, rather than maternal injury, cannot be determined from our dataset. Pregnant women who experienced a collision-related motor vehicle accident also require less surgical intervention, with the exception of genitourinary surgery, which may be indicative of more cesarean deliveries.
Article
Background: To compare the risks of a road traffic injury (RTI) crash among adults who were involved in high-risk gambling and those who did not gamble. Methods: We conducted a linked longitudinal cohort analysis of adult persons in large population survey conducted during 2007 and 2008 in Ontario, Canada. We used responses to Problem Gambling Severity Index to distinguish persons as nongamblers, no-risk, low-risk, or high-risk gamblers. All persons were subsequently monitored for a subsequent RTI crash as a driver, pedestrian, or bicyclist up to March 31, 2014, through health insurance databases. We estimated relative risks as rate ratios (RRs) with 95% confidence intervals (95% CIs). Results: In all, 30,652 adults were included, of whom 52% self-identified as gamblers, including 49% as no-risk gamblers, 2% as low-risk gamblers, and 1% as high-risk gamblers. During a median follow-up period of 6.8 years, 708 participants (2%) were involved in 821 RTI crashes. The absolute risks of an RTI were 6.4 per 1000 person-years (95% CI 3.7-10.4) in high-risk gamblers and 3.6 per 1000 person-years (95% CI 3.2-4.0) in nongamblers. The relative risks for RTI crashes were significantly higher in high-risk gamblers than in nongamblers (adjusted RR 1.68, 95% CI 1.03-2.76). The risks for RTI crashes as a driver were augmented in high-risk gamblers than in nongamblers (RR 1.97, 95% CI 1.13-3.43). Conclusions: We found an increased risk of an RTI crash among drivers who self-identified as high-risk gamblers. Further research exploring the underlying mechanisms of these associations might interest health professionals to monitor RTI risks in adults involved in high-risk gambling.
Article
Aim: This study was performed to determine the rate of pregnant occupants in motor vehicle accidents (MVA) and the frequency of seatbelt use in pregnancy in Japan. Methods: A questionnaire survey was conducted at seven centers located in Sapporo, targeting all 3952 women in gestational weeks 35-37 during the study period between June 2013 and January 2014. Information was collected on parity, driver's license, seatbelt use, seat preference, carrying Mother and Child Health Handbook when going out, and experience of occupant MVA during current pregnancy. Women who reported always using a seatbelt were classified as always seatbelt users (ASU). Results: A total of 2420 women who were given questionnaires provided responses (response rate, 61%). Seventy women (2.9%) reported having experienced an occupant MVA during the current pregnancy. MVA rate was significantly lower for ASU than non-ASU (2.6% [55/2097] vs 4.6% [15/323], respectively, P < 0.0001), and for ASU women preferring the rear seat than for other women (1.3% [6/451] vs 3.3% [64/1969], respectively, P = 0.0282). MVA rate tended to be lower for women preferring the rear seat than the front seat (1.7% [10/575] vs 3.3% [60/1845], respectively, P = 0.0637). The number of ASU, 94% (2286/2420) before pregnancy, decreased significantly to 87% (2097/2420) after the current pregnancy (P < 0.0001). Conclusion: The careful attitude of pregnant women toward driving safety may be associated with reduced risk of MVA in pregnancy. There is a need for an intensified campaign to promote seatbelt use among pregnant women.
Article
Background: Women are commonly advised to avoid driving following cesarean section (CS), however this advice is based upon little evidence. Aims: We aimed to assess a woman’s capacity to drive a car postbirth using a driving simulator to objectively examine driving behavior and competencies. Materials and methods: We conducted a pilot, prospective, randomized study from a tertiary referral hospital in Sydney, Australia. Postnatal women who were regular drivers and had given birth by vaginal delivery (VD), elective cesarean section (ElCS) or emergency cesarean section (EmCS) were randomized to early (2–3 weeks postbirth) or late (5–6 weeks postbirth) driver simulator testing. Driving performance was measured by reaction time to simulated impediments, awareness, attention, braking ability, traffic infringements and accidents. Analysis was by intention to treat. Outcomes were assessed using contingency analysis via two-sample t-tests and Wilcoxen rank-sum tests. Results: 66 women were randomized and 38 attended simulator testing (57.6%; 19 early, 19 late; 8 VD, 14 ElCS, 16 EmCS). There was no difference in reaction times, driver awareness, braking times, or traffic infringements by early versus late testing (all p > 0.05), nor by mode of birth (p > 0.05) amongst the women who completed driver testing. At 7–8 weeks, all women were driving, without accident. Conclusions: Although the study is limited by small sample size, there was no difference in driving capability by early versus late driving time since birth, nor by mode of birth. Further research is needed, but we cannot provide evidence to discourage well women from driving from 2–3 weeks postbirth.
Article
The article presents the results of a study devoted to the study of the perception of pregnant women — drivers of the road transport environment, its participants and themselves as a driver. The study was conducted on the basis of women’s consultations in Moscow, the respondents were 30 pregnant women drivers and 30 non — pregnant women drivers as a control group. The main purpose of the study was to identify the features of the perception of pregnant and non-pregnant women drivers themselves as a driver, road transport environment and its participants. To analyze the peculiarities of emotional and semantic representations of pregnant and non-pregnant women drivers, the following methods were used: “Personal differential”; “Unfinished sentences”; projective technique “I am a driver”. T student t — test was used to assess the differences between the perception of the driver by pregnant women drivers and non — pregnant women drivers. The results of the study suggest that there are significant differences between the perception of pregnant women as drivers and non — pregnant women drivers. To a greater extent, they are expressed in the increased emotionality of pregnant women, their immersion in their own condition and a more negative assessment of their driving skills.
Chapter
Aufgabe der Beschreibenden Statistik ist das Erkennen von Strukturen in einem gegebenen Datensatz. Dazu werden die erhobenen Phänomene bzw. die Eigenschaften des Datensatzes zunächst in Zahlen „übersetzt“.
Article
Im vorliegenden Beitrag wird anhand von exemplarischen Beispielen aufgeführt, welche Anforderungen an den kompetenzorientierten Umgang mit Statistik gestellt werden sollten und wie sich diese Anforderungen vor dem Hintergrund zunehmender Datenverfügbarkeit mit unterschiedlicher Strukturierungsform (Big Data) verändern. Insbesondere in Fächern, in denen die Statistikausbildung nicht zum Kerninhalt gehört, sollte vorrangig das „Denken in Daten(modellen)“ sowie die Interpretation und Bewertung von Ergebnissen statistischer Berechnungen gelehrt werden.
Article
Full-text available
Although statistical literacy has become a key competence in today’s data-driven society, it is usually not a part of statistics education. To address this issue, we propose an innovative concept for a conference-like seminar on the topic of statistical literacy. This seminar draws attention to the relevance and importance of statistical literacy, and moreover, students are made aware of the process of science communication and are introduced to the peer review process for the assessment of scientific papers. In the summer term 2020, the seminar was conducted as a joint project by the University of Hamburg, the University of Muenster and the Joachim Herz Foundation. In this paper, we present the concept of the seminar and our experience with this concept in the summer term 2020.
Article
Full-text available
Purpose Consensus is needed on conceptual foundations, terminology and relationships among the various self‐controlled “trigger” study designs that control for time‐invariant confounding factors and target the association between transient exposures (potential triggers) and abrupt outcomes. The International Society for Pharmacoepidemiology (ISPE) funded a working group of ISPE members to develop guidance material for the application and reporting of self‐controlled study designs, similar to Standards of Reporting Observational Epidemiology (STROBE). This first paper focuses on navigation between the types of self‐controlled designs to permit a foundational understanding with guiding principles. Methods We leveraged a systematic review of applications of these designs, that we term Self‐controlled Crossover Observational PharmacoEpidemiologic (SCOPE) studies. Starting from first principles and using case examples, we reviewed outcome‐anchored (case‐crossover [CCO], case‐time control [CTC], case‐case‐time control [CCTC]) and exposure‐anchored (self‐controlled case‐series [SCCS]) study designs. Results Key methodological features related to exposure, outcome and time‐related concerns were clarified, and a common language and worksheet to facilitate the design of SCOPE studies is introduced. Conclusions Consensus on conceptual foundations, terminology and relationships among SCOPE designs will facilitate understanding and critical appraisal of published studies, as well as help in the design, analysis and review of new SCOPE studies. This article is protected by copyright. All rights reserved.
Article
Full-text available
Women's economic situation is intimately linked with how successfully they negotiate their duties at work along with the burden of housework, childcare, and emotional work. Working women especially those who have caregiving responsibilities have to develop strategies to ensure that their day-time fixity constraints do not affect their work or promotions or opt out of the career ladder. Women also have to overcome physiological, cultural, and racial barriers that stop them from succeeding in their careers. Researchers agree that women's travel patterns are different from men but they have not asked how women are coping with the differences? How are the policymakers and transportation professionals addressing the constant struggle faced by women who must “juggle” work-life balance? We need more data to answer whether women regardless of income/race/ethnicity are able to complete their work and nonwork trips with comfort, convenience, and safety. We also need to find innovative solutions to mitigate spatial mismatch of work and home. Finally, it is time for transportation researchers to work closely with feminist scholars and geographers to address the policy gaps that are making it difficult for women to enjoy full time careers and thereby losing upward mobility.
Article
Full-text available
I read with great interest Redelmeier and colleagues’1 article on pregnancy and the risk of a traffic crash. The authors1 suggest that risk for a motor vehicle crash increases at the beginning of the second trimester of pregnancy and then subsides to baseline by the third trimester. The underlying assumption is that potential cognitive deficits or fatigue associated with the second trimester of pregnancy may account for this increased risk. However, a more obvious variable may account for these results. Adverse weather is a known factor in motor vehicle crashes, and crashes occur more frequently in the winter months. Similarly, the frequency of birth by month shows a trend toward a greater number of births in early and late summer. Counting backward, on average, most women will enter their second trimester during the winter months with the most adverse weather conditions, specifically January through March. In which month a crash occurs may be as, if not more, important than the stage of pregnancy.
Article
Full-text available
Human error due to risky behaviour is a common and important contributor to acute injury related to poverty. We studied whether social benefit payments mitigate or exacerbate risky behaviours that lead to emergency visits for acute injury among low-income mothers with dependent children. We analyzed total emergency department visits throughout Ontario to identify women between 15 and 55 years of age who were mothers of children younger than 18 years, who were living in the lowest socio-economic quintile and who presented with acute injury. We used universal health care databases to evaluate emergency department visits during specific days on which social benefit payments were made (child benefit distribution) relative to visits on control days over a 7-year interval (1 April 2003 to 31 March 2010). A total of 153 377 emergency department visits met the inclusion criteria. We observed fewer emergencies per day on child benefit payment days than on control days (56.4 v. 60.1, p = 0.008). The difference was primarily explained by lower values among mothers age 35 years or younger (relative reduction 7.29%, 95% confidence interval [CI] 1.69% to 12.88%), those living in urban areas (relative reduction 7.07%, 95% CI 3.05% to 11.10%) and those treated at community hospitals (relative reduction 6.83%, 95% CI 2.46% to 11.19%). No significant differences were observed for the 7 days immediately before or the 7 days immediately after the child benefit payment. Contrary to political commentary, we found that small reductions in relative poverty mitigated, rather than exacerbated, risky behaviours that contribute to acute injury among low-income mothers with dependent children.
Article
Full-text available
We sought to validate a case-finding algorithm for human immunodeficiency virus (HIV) infection using administrative health databases in Ontario, Canada. We constructed 48 case-finding algorithms using combinations of physician billing claims, hospital and emergency room separations and prescription drug claims. We determined the test characteristics of each algorithm over various time frames for identifying HIV infection, using data abstracted from the charts of 2,040 randomly selected patients receiving care at two medical practices in Toronto, Ontario as the reference standard. With the exception of algorithms using only a single physician claim, the specificity of all algorithms exceeded 99%. An algorithm consisting of three physician claims over a three year period had a sensitivity and specificity of 96.2% (95% CI 95.2%-97.9%) and 99.6% (95% CI 99.1%-99.8%), respectively. Application of the algorithm to the province of Ontario identified 12,179 HIV-infected patients in care for the period spanning April 1, 2007 to March 31, 2009. Case-finding algorithms generated from administrative data can accurately identify adults living with HIV. A relatively simple "3 claims in 3 years" definition can be used for assembling a population-based cohort and facilitating future research examining trends in health service use and outcomes among HIV-infected adults in Ontario.
Article
Full-text available
Teenage male drivers contribute to a large number of serious road crashes despite low rates of driving and excellent physical health. We examined the amount of road trauma involving teenage male youth that might be explained by prior disruptive behavior disorders (attention deficit hyperactivity disorder, conduct disorder, oppositional defiant disorder). We conducted a population-based case-control study of consecutive male youth between age 16 and 19 years hospitalized for road trauma (cases) or appendicitis (controls) in Ontario, Canada over 7 years (April 1, 2002 through March 31, 2009). Using universal health care databases, we identified prior psychiatric diagnoses for each individual during the decade before admission. Overall, a total of 3,421 patients were admitted for road trauma (cases) and 3,812 for appendicitis (controls). A history of disruptive behavior disorders was significantly more frequent among trauma patients than controls (767 of 3,421 versus 664 of 3,812), equal to a one-third increase in the relative risk of road trauma (odds ratio  =  1.37, 95% confidence interval 1.22-1.54, p<0.001). The risk was evident over a range of settings and after adjustment for measured confounders (odds ratio 1.38, 95% confidence interval 1.21-1.56, p<0.001). The risk explained about one-in-20 crashes, was apparent years before the event, extended to those who died, and persisted among those involved as pedestrians. Disruptive behavior disorders explain a significant amount of road trauma in teenage male youth. Programs addressing such disorders should be considered to prevent injuries.
Article
Full-text available
Exposure to ionizing radiation can be a source of anxiety for many pregnant women and their health care providers. An awareness of the radiation doses delivered by different techniques and the acceptable exposure thresholds can help both patients and practitioners. We describe exposure to radiodiagnostic procedures during pregnancy and suggest an approach to assess the potential risk.
Article
Full-text available
A review of experimental and correlational studies suggests that the aftereffects of stress on performance are due to a wide range of unpredictable, uncontrollable stressors including noise, electric shock, and bureaucratic stress. These effects are not limited to stressful situations that involve a lack of predictability and controllability over a distracting stimulus; they can also be induced by increased task demand. Interventions that increase personal control and/or stressor predictability are effective in reducing poststressor effects. There is also evidence for poststimulation effects on social behavior which generally involve an insensitivity toward others following stressor exposure. Studies of exposure to environmental stressors in naturalistic settings report effects similar to those found in laboratory settings. Several theories (e.g., psychic cost, learned helplessness, arousal) are examined. Some receive more support than others, but it is concluded that the reliability and generality of poststimulation effects have many causes. (86 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Article
Full-text available
Although the tragic events of September 11, 2001, are indelibly burnished into America’s consciousness, the equally tragic events of October 2001, November 2001, December 2001, January 2002, and all subsequent months attract little public note. In a typical month, more Americans are killed on our roads than were killed by the terrorists, If we could stimulate new approaches to the problems of risk in road traffic as we did about airline security after 9/11, every year we could save many times more lives than were lost that day. This can be achieved with far less reduction of mobility, convenience, freedom, or civil rights than was produced by our ongoing response to 9/11....
Chapter
The use of medications during pregnancy has become a concern since the thalidomide tragedy. However, although avoiding medications during pregnancy and breastfeeding may be desirable, it is often not possible. Medication use during pregnancy and postpartum is often necessary and unavoidable in chronic conditions such as asthma, diabetes mellitus, hypertension, epilepsy or depression. Women can also develop acute illnesses or pregnancy-induced complications that necessitate drug therapy. In addition, because approximately 50% of pregnancies are unplanned, women are frequently exposed to therapeutic drugs not necessarily intended to be used during pregnancy. Epidemiological studies have determined that two-thirds of all pregnant women use at least one prescription drug during pregnancy [1, 2]. However, in a review conducted in 2001 it was estimated that more than 90% of the drugs approved by the FDA between 1980 and 2000 had insufficient human pregnancy data to determine whether the benefits of treatment exceeded the risk to the embryo and/or fetus [3]. This reality highlights the growing need for more and better data regarding medication use during pregnancy and breastfeeding.
Article
Trauma attributable to motor vehicle collisions is a widespread cause of morbidity and death. Most Canadian patients will be in a serious collision at least once in their lifetime. Practising phys - icians might help prevent some death and morbidity using effective resuscitation in the aftermath of a crash, advocating general coun - termeasures toward road safety and issuing medical warnings to potentially unfit drivers, in addition to using unproven indirect strategies (see illustrative case in Box 3). The past half-century has shown an improvement of about 30%-50% in total traffic fatalities through a combination of interventions that each had modest effectiveness. The role for physicians in preventing collisions may expand given the shift in age demographics and ongoing advances in convenient and reliable motor vehicles.
Article
To introduce a new design that explores how an acute exposure might lead to a sustained change in the risk of a recurrent outcome. The exposure-crossover design uses self-matching to control within-person confounding due to genetics, personality, and all other stable patient characteristics. The design is demonstrated using population-based individual-level health data from Ontario, Canada, for three separate medical conditions (n > 100,000 for each) related to the risk of a motor vehicle crash (total outcomes, >2,000 for each). The exposure-crossover design yields numerical risk estimates during the baseline interval before an intervention, the induction interval immediately ahead of the intervention, and the subsequent interval after the intervention. Accompanying graphs summarize results, provide an intuitive display to readers, and show risk comparisons (absolute and relative). Self-matching increases statistical efficiency, reduces selection bias, and yields quantitative analyses. The design has potential limitations related to confounding, artifacts, pragmatics, survivor bias, statistical models, potential misunderstandings, and serendipity. The exposure-crossover design may help in exploring selected questions in epidemiology science.
Article
Background: Motor vehicle crashes are the leading cause of maternal injury-related mortality during pregnancy in the United States, yet pregnant women remain an understudied population in motor vehicle safety research. Methods: We estimated the risk of being a pregnant driver in a crash among 878,546 pregnant women, 16-46 years, who reached the 20th week of pregnancy in North Carolina (NC) from 2001 to 2008. We also examined the circumstances surrounding the crash events. Pregnant drivers in crashes were identified by probabilistic linkage of live birth and fetal death records and state motor vehicle crash reports. Results: During the 8-year study period, the estimated risk of being a driver in a crash was 12.6 per 1000 pregnant women. Pregnant women at highest risk of being drivers in serious crashes were 18-24 years old (4.5 per 1000; 95% confidence interval, CI,4.3, 4.7), non-Hispanic black (4.8 per 1000; 95% CI=4.5, 5.1), had high school diplomas only (4.5 per 1000; 95% CI=4.2, 4.7) or some college (4.1 per 1000; 95% CI=3.9, 4.4), were unmarried (4.7 per 1000; 95% CI=4.4, 4.9), or tobacco users (4.5 per 1000; 95% CI=4.1, 5.0). A high proportion of crashes occurred between 20 and 27 weeks of pregnancy (45%) and a lower proportion of crashes involved unbelted pregnant drivers (1%) or airbag deployment (10%). Forty percent of crashes resulted in driver injuries. Conclusions: NC has a relatively high pregnant driver crash risk among the four U.S. states that have linked vital records and crash reports to examine pregnancy-associated crashes. Crash risks were especially elevated among pregnant women who were young, non-Hispanic black, unmarried, or used tobacco. Additional research is needed to quantify pregnant women's driving frequency and patterns.
Article
We reviewed recent data on the prevalence, risk factors, complications and management of trauma during pregnancy. Using the terms "trauma" and "pregnancy" along with specified mechanisms of injury, we queried the Pubmed database for studies reported from January 1 (st), 1990 to May 1 (st), 2012. Studies with the largest number of patients for a given injury type and which were population-based and/or prospective were included. Case reports and case series were used only when more robust studies were lacking. A total of 1,164 abstracts were reviewed and 225 met criteria for inclusion. Domestic violence/intimate partner violence and motor vehicle crashes are the predominant causes of reported trauma during pregnancy. Management of trauma during pregnancy is dictated by its severity and should be initially geared towards maternal stabilization. Minor trauma can often be safely evaluated with simple diagnostic modalities. Pregnancy should not lead to under diagnosis or under treatment of trauma due to unfounded fears of fetal effects. More studies are required to elucidate the safest and most cost-effective strategies for the management of trauma in pregnancy.
Article
Background: Some clinical trials, laboratory experiments, and in vitro studies suggest that lipid-lowering medications predispose a person to traumatic injury. Methods: We used population-based administrative database analysis to study adults age 65 years or more over a 5-year interval (n = 1,348,259). Results: About 12% of the cohort received a prescription for a lipid-lowering medication and about 88% did not. The two groups had similar distributions of age, gender, and income. Overall, 2,557 (0.2%) were hospitalized for major trauma. Those who received a lipid-lowering medication were 39% less likely to sustain a major trauma than those who did not receive such medication (95% confidence interval, 29 to 47). Similar results were observed after adjustment for age, gender, and income; cardiac and neurologic medications; and lethality. No other cardiac or neurologic medication was associated with an apparent safety advantage. Conclusion: Lipid-lowering medications do not lead to a clinically important increase in the absolute risk of major trauma for elderly patients in the community.
Article
Physicians' warnings to patients who are potentially unfit to drive are a medical intervention intended to prevent trauma from motor vehicle crashes. We assessed the association between medical warnings and the risk of subsequent road crashes. We identified consecutive patients who received a medical warning in Ontario, Canada, between April 1, 2006, and December 31, 2009, from a physician who judged them to be potentially unfit to drive. We excluded patients who were younger than 18 years of age, who were not residents of Ontario, or who lacked valid health-card numbers under universal health insurance. We analyzed emergency department visits for road crashes during a baseline interval before the warning and a subsequent interval after the warning. A total of 100,075 patients received a medical warning from a total of 6098 physicians. During the 3-year baseline interval, there were 1430 road crashes in which the patient was a driver and presented to the emergency department, as compared with 273 road crashes during the 1-year subsequent interval, representing a reduction of approximately 45% in the annual rate of crashes per 1000 patients after the warning (4.76 vs. 2.73, P<0.001). The lower rate was observed across patients with diverse characteristics. No significant change was observed in subsequent crashes in which patients were pedestrians or passengers. Medical warnings were associated with an increase in subsequent emergency department visits for depression and a decrease in return visits to the responsible physician. Physicians' warnings to patients who are potentially unfit to drive may contribute to a decrease in subsequent trauma from road crashes, yet they may also exacerbate mood disorders and compromise the doctor-patient relationship. (Funded by the Canada Research Chairs program and others.).
Article
Adult immigrants are sometimes characterized as unsafe drivers and responsible for excess road crashes. We analyzed Canada's largest and most ethnically diverse province to assess whether recent immigrants had an increased risk of involvement as drivers in serious motor vehicle crashes. Overall, the study included 4,238,222 individuals followed for a median duration of 8.0 years. In total, 10,975 individuals were subsequently admitted to hospital as drivers involved in a crash, with a rate per 100,000 significantly lower among recent immigrants compared to long-term residents (158 vs 289, p<0.001). This difference was equal to a 45% relative reduction in the incidence of a crash (odds ratio=0.55, 95% confidence interval 0.52-0.58), persisted after adjustment for baseline characteristics (hazard ratio=0.61, 95% confidence interval 0.58-0.65), extended to extremes of crash severity, and was accentuated during initial years following immigration. These findings suggest that, contrary to popular opinion, recent immigrants are less prone to be drivers in serious motor vehicle crashes.
Article
Research has reported that pregnant women and mothers become forgetful. However, in these studies, women are not recruited prior to pregnancy, samples are not representative and studies are underpowered. The current study sought to determine whether pregnancy and motherhood are associated with brief or long-term cognitive deterioration using a representative sample and measuring cognition during and before the onset of pregnancy and motherhood. Women aged 20-24 years were recruited prospectively and assessed in 1999, 2003 and 2007. Seventy-six women were pregnant at follow-up assessments, 188 became mothers between study waves and 542 remained nulliparous. No significant differences in cognitive change were found as a function of pregnancy or motherhood, although late pregnancy was associated with deterioration on one of four tests of memory and cognition. The hypothesis that pregnancy and motherhood are associated with persistent cognitive deterioration was not supported. Previous negative findings may be a result of biased sampling.
Article
The aims of this study were to describe the prevalence, trends, and correlates of physical activity among a national sample of pregnant women. Using data collected from the 1999-2006 National Health and Nutrition Examination Survey, physical activity and sedentary behaviors were collected during interviews with 1280 pregnant women >/=16 years. Estimates were weighted to reflect the United States population. Overall 22.8% reported any transportation activity (i.e., to/from work/school), 54.3% reported any moderate to vigorous household activity, and 56.6% reported any moderate to vigorous leisure activity, all in the past month. Participation in any transportation and moderate to vigorous leisure activity was stable over time, while participation in any moderate to vigorous household activities and moderate leisure activities increased from 1999-2002 to 2003-06. Moderate to vigorous leisure activity was significantly higher among those in first trimester compared to third trimester, among non-Hispanic white participants compared to women from other race/ethnic groups, and among those with health insurance compared to those without. From 2003 to 2006, 15.3% of pregnant women reported watching 5 h or more of television or videos per day. These data could be used to monitor trends and set national goals for physical activity among pregnant women.
Article
A woman's life style choices before and during pregnancy have important implications for her unborn child, but information on behaviour can be unreliable when data are collected retrospectively. In particular there are no large longitudinal datasets that include information collected prospectively before pregnancy to allow accurate description of changes in behaviour into pregnancy. The Southampton Women's Survey is a longitudinal study of women in Southampton, UK, characterised when they were not pregnant and again during pregnancy. The objective of the analyses presented here is to describe the degree to which women comply with diet and life style recommendations before and during pregnancy, and changes between these time points. The analyses are based on 1490 women who delivered between 1998 and 2003 and who provided information before pregnancy and at 11 and 34 weeks' gestation. At each time point a trained research nurse ascertained smoking status and assessed food and drink consumption using a food frequency questionnaire. We derived the proportions of women who complied with recommendations not to smoke, to eat five portions of fruit and vegetables per day and to drink no more than four units of alcohol per week and 300 mg of caffeine per day.
Article
The aim of the study was to investigate the effect of spending one night without sleep on the performance of complex cognitive tasks, such as problem-solving, in comparison with a purely short-term memory task. One type of task investigated was immediate free recall, assumed to reflect the holding capacity of the working memory. The other type of task investigated was represented by syntactical reasoning and problem-solving tasks, assumed to reflect the processing (the mental transformation of input) and monitoring capacity of the working memory. Two experiments with a repeated-measures design were performed. Experiment 1 showed a significant decline in performance as a function of sleep loss on Raven's progressive matrices, a problem-solving task. No other main effect of sleep loss was found. Experiment 2 had a different order between tasks than Experiment 1 and the time without sleep was increased. A number-series induction task was also used in Experiment 2. A significant, negative effect of sleep loss in performance on Raven's progressive matrices was found in Experiment 2. The effects of sleep loss on the other tasks were nonsignificant. It is suggested that Raven's progressive-matrices task reflects the ability to monitor encoding operations (selective attention) and to monitor mental "computations".
Article
Two groups of women were studied to elicit their perceptions of cognitive changes during pregnancy. In the first phase of the study, 236 primiparous women were surveyed using a structured questionnaire three to five days after delivering their baby. Sixty-four percent of women reported changes in cognition during pregnancy. More changes were reported by the women who were older, better educated, married or living as married, had private health insurance and had attended an obstetrician during pregnancy. Phase 2 was designed to survey and assess the content (type, range and salience) of the cognitive changes. Forty-eight multigravid and primigravid women and two postpartum women were surveyed using a semi-structured questionnaire; 82% reported experiencing cognitive changes during pregnancy and postpartum, including difficulty in concentration, absentmindedness and short-term memory loss. It is argued that while prior research has associated altered mental functioning during pregnancy with psychiatric disturbance, this is not a necessary relationship. Education about cognitive changes during pregnancy may assist women to understand a common experience and to develop effective coping strategies.
Article
A case-control design involving only cases may be used when brief exposure causes a transient change in risk of a rare acute-onset disease. The design resembles a retrospective nonrandomized crossover study but differs in having only a sample of the base population-time. The average incidence rate ratio for a hypothesized effect period following the exposure is estimable using the Mantel-Haenszel estimator. The duration of the effect period is assumed to be that which maximizes the rate ratio estimate. Self-matching of cases eliminates the threat of control-selection bias and increases efficiency. Pilot data from a study of myocardial infarction onset illustrate the control of within-individual confounding due to temporal association of exposures.
Article
Major advances have been made in the identification and prevention of perinatal factors that lead to long-term handicap or neurologic deficits. When the infant or child exhibits a major handicap, scrutiny of the pregnancy management often occurs in an attempt to define the causal factors. The medical goal of this inquiry is to prevent injuries and, when possible, to eliminate these factors. In the litigious sense, any deviation from optimal, ideal care or any unusual observations, such as unusual or atypical fetal heart rate patterns, are often causally linked to the adverse outcome. There are at least four categories of major fetal injury that probably occur prior to labor. An awareness of, and a diligent search for, details will no doubt clarify the legitimate origins of many so-called birth injuries. Hence the common tendency to fixate on minor deviations and/or deficiencies of labor and delivery management as causing catastrophic injuries will be successfully challenged.
Article
To identify ways in which the safety of childbirth might be increased, we investigated the causes of death among the 886 women who died during pregnancy or within 90 days post partum ("maternal deaths") in Massachusetts from 1954 through 1985. The maternal mortality rate declined from 50 per 100,000 live births in the early 1950s to the current rate of 10 per 100,000 live births. Between one third and one half of the maternal deaths were considered to have been preventable. The leading causes of maternal death from 1954 through 1957 were infection, cardiac disease, pregnancy-induced hypertension, and hemorrhage. In contrast, from 1982 through 1985 the leading causes of death were trauma (suicide, homicide, and motor vehicle accidents) and pulmonary embolus. We observed a rapid increase in the frequency of death among women who received little or no antenatal care. From 1980 through 1984 the maternal mortality rate for white women was 9.6 per 100,000 live births, whereas for nonwhites it was 35 per 100,000 live births (relative risk, 2.9; 95 percent confidence limits, 2.5 and 3.2). Fifty percent of the nonwhite women who died during pregnancy or within 90 days post partum received little or no antenatal care, in contrast to only 15 percent of the white women. These data show that the leading causes of maternal death have changed markedly in Massachusetts during the past 30 years. Although the overall maternal mortality rate has declined sharply, further improvement may occur with better antenatal care and specific efforts to prevent trauma and pulmonary embolus.
Article
Implementing the recommended clinical practice guidelines for prenatal care can be difficult for busy practitioners because the guidelines are numerous and continually being revised. To develop a checklist outlining the current recommended activities for prenatal care to assist practitioners in providing evidence-based interventions to pregnant women. We reviewed guidelines for prenatal care from the Canadian Task Force on the Periodic Health Examination (CTFPHE) and from the report of the US Preventive Services Task Force (USPSTF). We searched MEDLINE for interventions commonly performed in pregnancy, but not reviewed by either task force. Interventions graded A or B are listed in bold type on the checklist. Interventions graded C by either task force or recommended by organizations not necessarily using the same rigorous criteria are listed in plain type. Recommended interventions are displayed along a time line under three headings: clinical maneuvers, investigations, and issues for discussion. Pilot testing by 12 practising physicians and 12 family practice residents showed that most respondents thought the checklist very useful. Providing a one-page checklist summarizing recommended clinical maneuvers, investigations, and topics for discussion should help physicians with implementing the many clinical practice guidelines for prenatal care.
Article
Many believe that informed consent makes clinical research ethical. However, informed consent is neither necessary nor sufficient for ethical clinical research. Drawing on the basic philosophies underlying major codes, declarations, and other documents relevant to research with human subjects, we propose 7 requirements that systematically elucidate a coherent framework for evaluating the ethics of clinical research studies: (1) value-enhancements of health or knowledge must be derived from the research; (2) scientific validity-the research must be methodologically rigorous; (3) fair subject selection-scientific objectives, not vulnerability or privilege, and the potential for and distribution of risks and benefits, should determine communities selected as study sites and the inclusion criteria for individual subjects; (4) favorable risk-benefit ratio-within the context of standard clinical practice and the research protocol, risks must be minimized, potential benefits enhanced, and the potential benefits to individuals and knowledge gained for society must outweigh the risks; (5) independent review-unaffiliated individuals must review the research and approve, amend, or terminate it; (6) informed consent-individuals should be informed about the research and provide their voluntary consent; and (7) respect for enrolled subjects-subjects should have their privacy protected, the opportunity to withdraw, and their well-being monitored. Fulfilling all 7 requirements is necessary and sufficient to make clinical research ethical. These requirements are universal, although they must be adapted to the health, economic, cultural, and technological conditions in which clinical research is conducted. JAMA. 2000;283:2701-2711.
Article
There is current interest in symptoms during pregnancy, but yet little is known about their prevalence and how often they are experienced across pregnancy. The reasons why some women experience more symptoms or experience them more often than others has received limited research attention. To document the prevalence and frequency of 27 pregnancy symptoms and to systematically investigate, cross-sectionally and prospectively, the effect of psychosocial factors on the prevalence and frequency of these symptoms, while controlling for biomedical factors. Four hundred and seventy-six nulliparous Scandinavian women who attended routine prenatal care in Uppsala county, Sweden, were studied six times during pregnancy (gestational weeks 10, 12, 20, 28, 32, and 36). The prevalence of symptoms was high, but only a smaller portion of these symptoms were experienced frequently. Psychological stress particularly contributed to the prevalence and frequency of concurrent symptoms and predicted symptoms up to 16 weeks later, independent of medical risk, smoking, and weight gain. Prevalence rates may be inflated, because many symptoms were experienced only 'occasionally' during each of the 4-week periods we sampled. By examining how frequently symptoms were experienced, we gained an indication of which symptoms are more likely to be bothersome or intrude upon daily activities. Psychosocial variables accounted for individual differences in symptom reports after taking biomedical factors into account. Attention to psychosocial variables in future studies will aid in our understanding of the etiology of pregnancy symptoms.
Article
Some clinical trials, laboratory experiments, and in vitro studies suggest that lipid-lowering medications predispose a person to traumatic injury. We used population-based administrative database analysis to study adults age 65 years or more over a 5-year interval (n = 1,348,259). About 12% of the cohort received a prescription for a lipid-lowering medication and about 88% did not. The two groups had similar distributions of age, gender, and income. Overall, 2,557 (0.2%) were hospitalized for major trauma. Those who received a lipid-lowering medication were 39% less likely to sustain a major trauma than those who did not receive such medication (95% confidence interval, 29 to 47). Similar results were observed after adjustment for age, gender, and income; cardiac and neurologic medications; and lethality. No other cardiac or neurologic medication was associated with an apparent safety advantage. Lipid-lowering medications do not lead to a clinically important increase in the absolute risk of major trauma for elderly patients in the community.
Article
Maternal and fetal trauma is an important cause of adverse fetal outcomes. However, systematic exclusion from US injury surveillance programs of even the most severe outcome, fetal/neonatal death, has led to a lack of understanding about frequency, causes, and prevention. To determine the rate of traumatic fetal deaths reported in state fetal death registries and the types of trauma and physiologic diagnoses associated with these deaths. Retrospective descriptive study of fetal death certificates from 1995 through 1997 obtained from 16 states, which accounted for 55% of US live births and approximately 15 000 fetal death registrations per year. Rate of fetal injury deaths, based on fetal death certificates coded with an underlying cause of death due to maternal injury at 20 weeks' gestation or later, by cause. During the 3-year study period, 240 traumatic fetal injury deaths were identified (3.7 fetal deaths per 100 000 live births). Motor vehicle crashes were the leading trauma mechanism (82% of cases; 2.3 fetal deaths per 100 000 live births), followed by firearm injuries (6% of cases) and falls (3% of cases). In 3 states, reported crash-related fetal deaths exceeded that of crash-related infant deaths. Placental injury was mentioned in 100 cases (42%) and maternal death was noted in 27 cases (11%). A peak rate of 9.3 fetal deaths per 100 000 live births was observed among 15- to 19-year-old women. Motor vehicle crashes are the leading cause of fetal deaths related to maternal trauma. Improved tracking of traumatic fetal injury deaths is important to stimulate and guide research and efforts to reduce the risks to women and fetuses from injury during pregnancy.
Article
A longitudinal study measured the performance of a group of 15 pregnant women on tests of verbal memory, divided attention, and focused attention on four occasions (second trimester, third trimester, 6 weeks post-partum, and 1 year post-partum) while at the same time obtaining self-assessment ratings of these cognitive functions. A group of 14 non-pregnant women was studied at equivalent intervals. The two groups of women did not differ in performance on the objective tests, and there was no change in performance over time except for an improvement in the measure of focused attention from the first to the final testing occasion. However, the self-assessment ratings showed that in the second trimester, the pregnant women rated themselves as more impaired than before compared with the non-pregnant women for all three cognitive abilities. To ensure that this difference was not due to the retrospective nature of the comparison of current with previous cognitive ability, a second longitudinal study compared 25 pregnant and 10 non-pregnant women using daily ratings over a period of 1 week on four occasions during pregnancy and the first year post-partum. Women in the third trimester of pregnancy reported mild impairments in their focused and divided attention ability and their ability to remember what they had read compared with the non-pregnant women. The results show that there are perceived cognitive impairments during pregnancy. It is suggested that these may be the result of mild impairments which are not revealed in objective tests because they can be overcome by conscious effort in short periods of testing. Alternatively, the perceptions may not be based on actual impairments but may result from depressed mood or expectations concerning the effect of pregnancy on cognition.
Article
Objectives: This article describes the design, sampling strategy, interviewing procedures, data collection and processing of the Canadian Community Health Survey (CCHS). Summary: Data collection for cycle 1.1 of the CCHS began in September 2000. This first cycle provides cross-sectional data at the regional level for 136 health regions; the first half of data collected for cycle 1.1 provides data for 133 health regions. In addition to the survey methods, this article reports the sample size and rates of proxy response and non-response for each province, for the first six months of cycle 1.1. A summary of methods used to impute values that were not provided by proxy respondents is provided. A discussion of survey errors and their sources follows.
Article
To assess the effect of maternal involvement in motor vehicle crashes on the likelihood of adverse pregnancy outcomes and to estimate the effect of seatbelt use in reducing the occurrence of those outcomes. Statewide motor vehicle crash, birth, and fetal death records from 1992 to 1999 were probabilistically linked. Logistic regression was used to compare the likelihood of adverse birth and fetal outcomes including low birth weight, prematurity, placental abruption, fetal distress, excessive bleeding, fetal death, and other complications among pregnant women in crashes and those not in crashes. Of 322,704 single live resident births, 8938 mothers (2.8%) experienced a crash during pregnancy. Pregnant women using seatbelts were not significantly more at risk for adverse fetal outcomes than pregnant women not in crashes. However, pregnant women who did not wear seatbelts during a crash were 1.3 times more likely to have a low birth weight infant than pregnant women not in a crash (95% confidence interval [CI] 1.0, 1.6) and twice as likely to experience excessive maternal bleeding than belted pregnant women in a crash (95% CI 1.0, 4.2). Forty-five of 2645 fetal deaths were linked to a motor vehicle crash, with unbelted pregnant women 2.8 times more likely to experience a fetal death than belted pregnant women in crashes (95% CI 1.4, 5.6). Pregnant women should be counseled to wear seatbelts throughout pregnancy and reduce crash risk.
Article
To examine factors affecting participation in obstetrics among obstetrician-gynecologists and changes in participation over time. Using physician billings from Ontario, Canada, from 1992/1993 to 2001/2002, we examined the impact of physician age, gender, practice location, and years of practice on participation in obstetrics with multiple logistic regression and repeated measures analyses. We also examined differences in practice patterns between obstetrics providers and nonproviders using linear and log-linear regressions. Obstetrics participation declined with age, from 96% among physicians under age 35, to 34% among those aged 65 and over (2001/2002 figures). Regressions demonstrated a lower likelihood of performing obstetrics in successive years (odds ratio [OR] 0.95 per year; 95% confidence interval [CI] 0.93, 0.98) and among physicians who were older (OR 0.91 per year of age; 95% CI 0.90, 0.93), female (OR 0.57; 95% CI 0.36, 0.91), and practicing in cities with medical schools (OR 0.58; 95% CI 0.44, 0.78). The crude obstetrics participation rate dropped from 82% to 77%, from 1992/1993 to 2001/2002. The physician age-sex-adjusted participation rate dropped from 80% in 1992/1993 to 77% in 2001/2002. Obstetrics providers had almost double the annual billings of nonproviders ($364,000 verus $187,000; P <.001), but more on-call days worked (105 versus 13; P <.001). Nonproviders of obstetrics derived more of their billings from outpatient visits, psychotherapy, and diagnostic tests. The likelihood of an obstetrics nonprovider resuming obstetrics was 1.1% per year. The proportion of obstetrician-gynecologists practicing obstetrics declined modestly in the last decade, partly because of more female physicians in the workforce who were less likely to practice obstetrics. Planners should consider these trends when estimating how many obstetrician-gynecologists to train to meet future societal needs. II-2
Article
Pregnant women represent a major challenge in trauma care because of the risks to both mother and child and because of the difficulties in following standard protocols. We analyzed data for all pregnant women admitted to the hospital in Canada over 7 years to test whether major trauma still clustered in the summer despite their aversion toward alcohol, recklessness, and extreme sports. A total of 2,618 pregnant women sustained major trauma. The prevalence of pregnancy was marginally lower in summer than in winter (decrease, 3%; 95% confidence interval, 2-4%), whereas the incidence of major trauma in pregnant women was significantly higher in summer than in winter (increase, 12%; 95% confidence interval, 3-21%; p = 0.005). No evidence of offsetting decreases in severity appeared in analyses of length of stay, number of surgical procedures, or mortality. We suggest that normal lifestyle choices contribute to an increased risk of major trauma during pregnancy and merit greater awareness throughout the year.