When Delaware Gov. Jack Markell took office in 2009, he vowed to bring more opportunities to residents of his state. What was standing in their way, the governor found, was a higher rate of unintended pregnancy than anywhere else in the U.S. So he took actions to reduce unintended pregnancies in the state.

Delaware is making long-acting reversible contraception available at low or no cost to women of childbearing age, thanks in part to a partnership with the nonprofit organization Upstream USA, which trains health care providers and health centers to offer intrauterine devices and birth control implants.

Markell told The Nation’s Health that in his eyes, all other types of opportunities — such as pursuing education, building a career, saving money to buy a home and having healthy birth outcomes — were influenced by whether or not people were able to decide when and how to build their families. A March Guttmacher Institute fact sheet showed that in 2010, Delaware had 62 unintended pregnancies for every 1,000 women ages 15-44 in 2010. The rate was the highest in the nation and accounted for 57 percent of all births in the state.

“I pretty quickly came to the conclusion that this is the most important thing that we can do to help more Delawareans reach their potential,” Markell said.

So with the help of Upstream, Delaware invested $1.75 million in state funding, as well as $13 million in philanthropic giving, to reshape the way Delaware residents access family planning. The initiative, called Delaware Contraceptive Access Now, started not with community education, but with billing.

For many women, one of the best and easiest times to insert an intrauterine device is right after delivering a baby. However, in Delaware, as with many states, the medical reimbursement system did not cover IUD insertion after delivery. Instead, providers had to schedule insertion for their patients’ follow-up well-woman visits, four to six weeks after delivery. The drop-off in seeing patients was substantial, as it cost more money for the women seeking care and there was no medical reason for it.

“These are barriers we find in health care all around the entire country,” Mark Edwards, co-founder of Upstream, told The Nation’s Health. “Health centers were worried about losing money. When you help them understand how to bill and code properly, they break even at a minimum, maybe even make a little money.”

In the last two years or so, Upstream staff have been training Delaware health care workers in all aspects of providing IUDs and implants. Licensed medical providers are taught proper insertion and removal of the devices. Front-of-office staff and health care providers learn best practices on how to counsel patients about their birth control options. And billing staff are advised on coding and billing in order to keep the devices affordable. The coverage is not limited to Medicaid patients or certain insurance providers; all providers in the state are covered, from community health centers to private practice and hospitals. As of late July, Edwards said more than 550 Delaware health care staff had received Upstream training.

Staff at Nemours Alfred I. DuPont Hospital for Children in Wilmington, Delaware, were trained by Upstream staff in February. Krishna White, MD, MPH, chief of the hospital’s division of adolescent medicine and pediatric gynecology, said that the hospital has already seen the positive effects of offering LARC to its adolescent patients.

The American College of Obstetricians and Gynecologists recommends LARC as a first line of defense for teens looking to prevent pregnancy. IUDs and implants are the most effective forms of reversible birth control, according to the Centers for Disease Control and Prevention. However, short-acting contraceptives such as condoms and birth control pills are both more popular with teens and less effective.

An April 2015 study from CDC found that less than 5 percent of teens using birth control choose LARC, and many of them know little about the option.

“The majority of patients we see are young women coming in for reproductive concerns,” White told The Nation’s Health. “It’s critically important for teens, who may not be able to make it into another office, or might change their mind. It’s best to provide it for them at the moment they want it.”

While Delaware is working to make LARC available to residents, it is not alone. Colorado’s Family Planning Initiative, which helps Title X clinics offer low- to no-cost IUDs to teens and women who want them, helped lower the state’s teen birth and abortion rates by 48 percent each from 2009 to 2014, according to the Colorado Department of Public Health and Environment. The program has also been associated with better birth outcomes, according to a study published in the September 2015 issue of APHA’s American Journal of Public Health.

Thanks to the program, one in three patients of Title X clinics, which are federally funded to provide family planning options, now uses long-acting reversible contraceptives for their family planning methods, said Jody Camp, MPH, family planning section manager at the Colorado Department of Public Health and Environment.

Along with state support and funding from both state and philanthropic donations, Camp said the media helped in making the program successful in Colorado.

“It’s been so helpful in normalizing our work,” Camp told The Nation’s Health.“They can speak to people on both sides of the aisle. It’s really helped to gain a better understanding about LARC, not necessarily as a tool for birth control, but a tool for economic self-sufficiency. I do believe that’s what (worked) in our favor when we asked the legislature for additional funding.”

Another contributing factor to success, however, is the financial payoff for states. Colorado estimated that its LARC program saved the state $49 million to $111 million in Medicaid birth-related costs. While Delaware’s program is still new, Markell noted that healthy Medicaid births cost the state approximately $12,000, and unhealthy births cost even more.

Upstream’s Edwards said he hopes that more states, cities and clinics will enact programs to make LARC more accessible to those who want it.

“This is really an opportunity to demonstrate that this kind of investment can reduce unintended pregnancies and improve birth outcomes…improve opportunities and also save a lot of money,” he said.

To learn more about the Delaware program, visit www.upstream.org/delawarecan.

• Copyright The Nation’s Health, American Public Health Association

Why Talk to My Family?

Your family members can benefit from knowing about your BRCA1or BRCA2 mutation.  Talk to your family members about your mutation, so they will know that

• BRCA1 and BRCA2 mutations are passed through families.
• A person with a BRCA1 or BRCA2 mutation is more likely to get breast, ovarian, and other cancers.
• Genetic counseling and testing for BRCA1 and BRCA2 mutations can provide information about their risk.
• If they choose to be tested, they should be tested for the same mutation that you have.
• Steps can be taken to prevent breast and ovarian cancer or find it earlier.

View the full resource here.

Carrie K. Shapiro-Mendoza, PhD1; Wanda D. Barfield, MD1; Zsakeba Henderson, MD1; Arthur James, MD2; Jennifer L. Howse, PhD3; John Iskander, MD4; Phoebe G. Thorpe, MD4 (View author affiliations)

Preterm birth (delivery before 37 weeks and 0/7 days of gestation) is a leading cause of infant morbidity and mortality in the United States. In 2013, 11.4% of the nearly 4 million U.S. live births were preterm; however, 36% of the 8,470 infant deaths were attributed to preterm birth (1). Infants born at earlier gestational ages, especially <32 0/7 weeks, have the highest mortality ( Figure) and morbidity rates. Morbidity associated with preterm birth includes respiratory distress syndrome, necrotizing enterocolitis, and intraventricular hemorrhage; longer-term consequences include developmental delay and decreased school performance. Risk factors for preterm delivery include social, behavioral, clinical, and biologic characteristics ( Box). Despite advances in medical care, racial and ethnic disparities associated with preterm birth persist. Reducing preterm birth, a national public health priority (2), can be accomplished by implementing and monitoring strategies that target modifiable risk factors and populations at highest risk, and by providing improved quality and access to preconception, prenatal, and interconception care through implementation of strategies with potentially high impact.

Most preterm births are spontaneous and can occur with intact membranes (40%–45% of preterm births) or after preterm premature rupture of membranes (25%–30% of preterm births) (3). The etiology of preterm labor is poorly understood; prevailing theories include infectious and inflammatory processes. Intrauterine infection and inflammation might account for up to 40% of preterm births, but in many instances, the cause might be subclinical and difficult to detect (3,4). Maternal or fetal complications can often result in preterm birth because of medically indicated induction of labor or cesarean delivery (30%–35% of preterm births) (3). Growing awareness of the complications of prematurity has prompted careful evaluation of the indications for and timing of delivery (5).

For more accurate estimates of the preterm birth rate, CDC’s National Center for Health Statistics transitioned from using the date of last normal menstrual period to the obstetric estimate of gestation at delivery, starting with 2014 births and revising data back to 2007 (6).* Based on the historical last normal menstrual period measure, the U.S. preterm birth rate increased 21%, from 10.6% in 1990 to 12.8% in 2006 (7). Since 2007, the first year that data using the obstetric estimate of gestation at delivery were available, the overall rate declined, from 10.4% in 2007 to 9.6% in 2014. However, declines have been disproportionate across racial and ethnic groups (6). In 2014, non-Hispanic black (black) women had the highest preterm birth rate (13.2%), followed by American Indians or Alaska Natives (AI/AN) (10.2%), Hispanics (9.4%), non-Hispanic whites (whites) (8.9%), and Asian/Pacific Islanders (API) (8.5%). Compared with the preterm birth rate among whites, the rates of preterm birth among blacks and AI/AN were 1.5 and 1.1, respectively (6).

Declines in infant mortality (53%) since the 1980s have been largely attributed to increasing preterm survival, owing to improvements in neonatal intensive care and treatments for lung immaturity. Infant mortality rates (deaths in children aged <12 months per 1,000 live births) declined from 12.6 in 1980 (8) to 5.96 in 2013 (1).† Despite these declines, racial and ethnic disparities persist. In 2013, the infant mortality rate among black infants (11.2) was 2.2 times higher than that among white infants (5.1). Rates of preterm-related infant mortality§ (per 1,000 live births) provide further evidence of racial and ethnic disparities and highlight the importance of reducing preterm births. Black women have the highest rates of preterm-related infant mortality (4.9), followed by AI/AN women (2.0), Hispanic women (1.8), white women (1.6), and API women (1.5) (1).

Read the full article here.

Shapiro-Mendoza CK, Barfield WD, Henderson Z, et al. CDC Grand Rounds: Public Health Strategies to Prevent Preterm Birth. MMWR Morb Mortal Wkly Rep 2016;65:826–830. DOI: http://dx.doi.org/10.15585/mmwr.mm6532a4

Only you can give your baby protection against whooping cough before your little one is even born. Talk to your doctor or midwife about getting the Tdap vaccine during your third trimester.

Whooping cough is a serious disease that can be deadly for babies. Unfortunately, babies can't get vaccinated and start building protection against whooping cough until they are two months old. The good news is that you can avoid this gap in protection by getting the whooping cough vaccine (called Tdap) during the third trimester of your pregnancy. By doing so, you pass antibodies to your baby before birth. These antibodies help protect your baby in the first few months of life.

You Need a Whooping Cough Vaccine during Each Pregnancy

Learn why Laura decided to get the whooping cough vaccine in her 3rd trimester and how her baby girl was born with some protection against the disease.
Also available on YouTube.

CDC recommends pregnant women get the whooping cough vaccine between 27 and 36 weeks of each pregnancy. This recommendation is supported by the American College of Obstetricians and Gynecologists  and the American College of Nurse-Midwives, healthcare professionals who specialize in caring for pregnant women. The goal is to give babies some short-term protection against whooping cough in early life.

The amount of antibodies you have from the whooping cough vaccine will decrease over time. That is why it's important for pregnant women to get a whooping cough vaccine during each pregnancy so that each baby has the benefit of getting the greatest number of protective antibodies. Getting the whooping cough vaccine while pregnant is the best way to help protect your baby from whooping cough in the first few months of life.

Whooping Cough Vaccine during Pregnancy Is Safe for Your Baby

Getting the whooping cough vaccine while you are pregnant is very safe for you and your baby. The most common side effects include redness, swelling, pain, and tenderness where the shot is given, body-ache, fatigue, or fever. Severe side effects are extremely rare. You cannot get whooping cough from the whooping cough vaccine. Learn more about safety and side effects.

Whooping Cough Is Making a Comeback

Whooping cough is a very contagious illness that is on the rise.

There are many factors contributing to this increase, but one key reason is that today's vaccines, while safe and effective, do not last as long as we would like. However, getting vaccinated is still the best way to prevent whooping cough and its complications.

View the latest U.S. whooping cough numbers.

Young Babies Are at Highest Risk

When babies—even healthy babies—catch whooping cough, the symptoms can be very serious because their immune systems are still developing. They can get pneumonia (a lung infection), and many have trouble breathing.

About half of babies who get whooping cough end up in the hospital. The younger the baby is when he gets whooping cough, the more likely it is that he will need to be treated in the hospital. Every year in the United States, up to 20 babies die from whooping cough, with most deaths in those too young to be protected by their own whooping cough vaccine.

More Information 

E-Cigarettes and Pregnancy is a free, online interactive presentation on electronic nicotine delivery systems and their potential health effects during and after pregnancy, and discusses effective tobacco cessation treatments.

The training is eligible for continuing education and Maintenance of Certification Part IV credit.

Learn more about continuing education.

The ABOG MOC standards now allow participation in ABOG-approved Simulation Courses to meet the annual Improvement in Medical Practice (Part IV) MOC requirement. This course has been approved to meet ABOG Improvement in Medical Practice requirements for 2016. Please review the 2016 MOC Bulletin for further information.

This computer program is protected by copyright law and international treaties. Unauthorized reproduction or distribution of this program or any portion of it may result in severe civil and criminal penalties, and will be prosecuted to the maximum extent possible under the law. This is subject to license agreements with Dartmouth College, and is not to be copied or used except as specified in such agreement. Some materials in this program are from copyrighted publications and products owned by others. Refer to the publication data included in bibliographic citations, and the copyright notices in the original published form of the contained publications, all of which are incorporated herein by reference.

The Inside Knowledge campaign raises awareness of the five main types of gynecologic cancer: cervical, ovarian, uterine, vaginal, and vulvar. Inside Knowledge encourages women to pay attention to their bodies, so they can recognize any warning signs and seek medical care.

New television and radio public service announcements in English and Spanish feature actress Cote de Pablo, talking about her own cervical cancer scare, and sharing advice for other women. And check out the new posters telling Cote’s story, as well as our Behind-the-Scenes videos from filming!

Inside Knowledge also has new TV and radio PSAs that highlight gynecologic cancer symptoms. The PSAs encourage women to learn the symptoms, and pay attention to what their bodies are telling them.

Lesser-known conditions and diseases affect the health or safety of millions of women or girls each year. Learn about some of them and what you can do.

1. Asthma occurs more often in women than men. Older adults, women, and African Americans are more likely to die due to asthma.

• Women with asthma should always try to avoid asthma triggers.
• Known asthma triggers include pollen, mold and tobacco smoke.
• Know your triggers and learn how to avoid them.
• Work with your doctor to develop an asthma action plan that will help you take your medications correctly and avoid your asthma triggers.

2. Heavy menstrual bleeding, lasting more than seven days or very heavy, affects more than 10 million American womeneach year. That is about one out of every five women.

• A bleeding disorder may be the cause of heavy menstrual bleeding.
• Talk to your doctor or nurse if you have heavy menstrual bleeding to determine if you need testing.
• Learn about possible causes, including the signs and symptoms of a bleeding disorder.

3. About 27 million women in the U.S. have a disability , a condition of the body or mind that makes it more difficult to do certain activities and interact with the world around them.

• More than 50% of women older than 65 are living with a disability. The most common cause of disability for women isarthritis or rheumatism.

• Women with disabilities need the same general health care as women without disabilities, and they may also need additional care to address their specific needs. However, research shows that many women with disabilities may not receive regular health screenings, like mammograms or a Pap test, as recommended.

• Learn about tools and health resources for women with disabilities.

4. Infertility affects about 6% of married women ages 15-44. Also, about 12% of women 15 - 44 years of age in the U.S. have difficulty getting pregnant or carrying a pregnancy to term, regardless of marital status.

• Infertility is defined as not being able to get pregnant after one year of unprotected sex.
• Several things increase a woman's risk of infertility, including age, smoking, excessive alcohol use, extreme weight gain or loss, or excessive physical or emotional stress that results in the absence of a menstrual period.
• Infertility may be treated medically, surgically, or using assisted reproductive technology depending on the underlying cause.
• Assisted Reproductive Technology, also known as ART, includes all fertility treatments in which both eggs and sperm are handled.
• Learn more about what you can do to be healthy before, during, and after ART treatment. Resources are available for patients preparing for infertility treatment and pregnancy.

5. Bacterial vaginosis (BV) is the most common vaginal infection in women ages 15-44.

• BV is an infection caused when too much of certain bacteria change the normal balance of bacteria in the vagina. In the United States an estimated 21.2 million (29.2%) women ages 14–49 have BV.
• The cause of BV is unknown. BV is linked to an imbalance of "good" and "harmful" bacteria that are normally found in a woman's vagina.
• Basic prevention steps that may help to lower your risk of developing BV include not having sex, limiting the number of sex partners you have, and not douching.

6. Sex Trafficking is a serious public health problem that affects the well-being of individuals, families, and communities. The majority of victims are women and girls.

• Sex trafficking is defined as "the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act" by the Trafficking Victims Protection Act of 2000  .
• Consequences can be immediate and long term, including physical problems and relationship problems, psychological concerns  , and chronic health outcomes.
• Learn about what communities and groups can do to prevent trafficking.

7. About 19 women die every day as a result of drug overdoses involving prescription opioids.

• Women are more likely to have chronic pain, be prescribed opioid pain relievers, and use them for longer time periods than men.
• Addiction to prescription opioids is the strongest risk factor for heroin addiction, and heroin use has increased among women.
• Women should discuss all medications they are taking with their doctor and use prescriptions only as directed. Get help for substance abuse problems (1-800- 662-HELP); call Poison Help (1-800-222-1222) for questions about medicines, or see your pharmacist.

Soluble corn fiber (SCF) is a nondigestible carbohydrateused in foods and beverages such as cereals, baked goods, candy, dairy products, frozen foods, carbonated beverages, and flavored water.

SCF helps create packaged food products that have lower sugar contents, while providing a valuable source of dietary fiber.

Evidence suggests that SCF has many of the same health benefits associated with intact dietary fiber found in grains, vegetables, legumes, and fruit. SCF may improve intestinal regularity and has prebiotic properties. Moreover, SCF supports healthy blood glucose control and supports bone health by increasing calcium absorption.

The daily recommended fiber intake for adults in the United States is 25 grams for women and 38 grams for men. However, most Americans consume around half of the recommended amount. Fiber-enriched foods help bridge the shortage of fiber in the diet without significantly increasing calorie content.

In the new research, the team aimed to evaluate how the dose of SCF affected calcium absorption, bone properties, and gut microbiome in adolescent and postmenopausal women.

"We are looking deeper in the gut to build healthy bone in girls and help older women retain strong bones during an age when they are susceptible to fractures," says Connie Weaver, distinguished professor and head of nutrition science.

"Soluble corn fiber, a prebiotic, helps the body better utilize calcium during both adolescence and postmenopause. The gut microbiome is the new frontier in health," she adds.

Tate & Lyle Ingredients America LLC funded the research, and they produce Promitor Dietary Fiber, which is a soluble prebiotic fiber made from corn that is labeled as "soluble corn fiber" or "maltodextrin" on the packaging.

Findings from the study on postmenopausal women were published in American Journal of Clinical Nutrition, while the findings on adolescent women were published in Journal of Nutrition.

Weaver and colleagues found that after prebiotic fiber passes through the gut for the microbes in the lower gut to digest, the SCF is broken down into short-chain fatty acids, which assist in the maintenance bone health.

Supplementation helped build and preserve bone

In the postmenopausal study, 14 healthy postmenopausal women consumed 0 grams, 10 grams, or 20 grams of SCF every day for 50 days. The women in the groups that received 10 grams and 20 grams - amounts that are found in supplement form - displayed bone calcium retention improvement by 4.8 percent and 7 percent, respectively.

"If projected out for a year, this would equal and counter the average rate of bone loss in a post-menopausal woman," says Weaver, an expert in mineral bioavailability, calcium metabolism, botanicals and bone health.

In the adolescent study, 28 girls aged between 11-14 years old consumed either 0 grams, 10 grams, or 20 grams of SCF every day for 4 weeks, while maintaining their regular diet. The females in both the 10 gram and 20 gram SCF groups saw an increase in calcium absorption by around 12 percent, which would build 1.8 percent more skeleton per year.

Gastrointestinal symptoms were minimal in both studies and the same was seen in the control groups.

"Most studies looking at benefits from soluble corn fiber are trying to solve digestion problems, and we are the first to determine that this relationship of feeding certain kind of fiber can alter the gut microbiome in ways that can enhance health," Weaver said. "We found this prebiotic can help healthy people use minerals better to support bone health."

Few people meet the daily recommended intake of 1,200 milligrams of calcium for healthy bone mass.

Weaver says that while SCF can help people better utilize calcium for bone health, this finding does not mean the recommendation to drink milk and follow a well-balanced diet should be ignored. SCF can, however, help individuals that are not consuming the whole recommended amount of dairy.

"Calcium alone suppresses bone loss, but it doesn't enhance bone formation. These fibers enhance bone formation, so they are doing something more than enhancing calcium absorption."

Connie Weaver

Further studies by the team will examine the mechanisms behind how SCF boosts calcium absorption and retention, and if the prebiotic fiber benefits the body in other ways.

Read about how a diet high in fiber alters bacteria to protect against food allergies.

Written by Hannah Nichols

With concerns over a continued Zika outbreak growing, the Food and Drug Administration has given Roche Holdings emergency approval to use one of its Zika blood testing kits.

The approval, which lasts as long as the emergency is ongoing, will allow for testing of the virus through Roche's LightMix Zika rRT-PCR test, which has not been approved by the FDA yet.

The test uses the company's LightCycler 480 Instrument II or cobas z 480 Analyzer to search for Zika. The systems, found in specialist laboratories, can help detect the virus which can be more easily be found in blood samples. The disease can also be found in urine. On its site Roche says the cobas z 480 can process 384 samples per day.

The Roche emergency approval is the latest in the FDA's search to more quickly identify and contain the virus. The agency had previously approved nine other systems for detecting Zika since February under similar emergency use authorizations. It approved two systems that help detect the disease, one from InBios International and another from Luminex Corporation, earlier this month.

On Friday the FDA announced that all blood donations in the U.S. needed to be scanned for Zika, which over the last few weeks has spread into Florida and Puerto Rico.

Since officials revealed its presence in the state earlier this month over 40 people in the Miami-Dade and Palm Beach counties in Florida have been diagnosed with the virus.

The FDA updated its guidance due to the potential serious health consequences of Zika to pregnant women and children born to women exposed to the virus during pregnancy. The Zika virus is transmitted primarily by the Aedes mosquito but can also be spread by sexual contact. Although most people infected with the virus never develop symptoms, an infection during pregnancy can cause serious birth defects and is associated with other adverse pregnancy outcomes, the FDA warns.

Contributing: Doyle Rice 

New CDC downloads available:

ZIKA VIRUS TESTING FOR ANY PREGNANT WOMAN NOT LIVING IN AN AREA WITH ZIKA - Download

When to test for Zika Virus - Download