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Record linkage was used to identify births in 1974 to patients who had received contraceptive services from public family planning clinics in metropolitan Atlanta. The record linkage methodology is described. Results indicated that patient educational level, age. contraceptive choice, and race were the factors most associated with subsequent patient fertility. Black teenage patients experienced the highest fertility. Patients age 20 years and over with some education beyond high school experienced approximately one-third the fertility of less-educated patients. The program effectiveness of the IUD and the Pill was substantially better than that of foam and condoms. Excluding teenagers, the program effectiveness of the IUD was better than the Pill, Changes in family planning services for high-risk patients may help them achieve their- fertility control objectives. Linking family planning clinic records to official birth records as described in this study can help determine clinic success in meeting patient objectives. Other applications of record linkage are discussed briefly. [ABSTRACT FROM AUTHOR]

In its 1988 report, The Future of Public Health, the Institute of Medicine stated that schools of public health had become "somewhat isolated" for public health practice. Since then a great deal has been done to address this issue by the academic community, state and local public health practice agencies, foundations, and federal health agencies. This commentary reviews their most important actions and identifies some unresolved issues.

The Cancer and Steroid Hormone Study, a multicenter, population-based, case-control study of ovarian, breast, and endometrial cancer in women 20 to 54 years of age, permitted the diagnoses of contributing pathologists to be compared with those of a panel of three gynecologic pathologists. A diagnosis of ovarian cancer was made by contributing pathologists on 477 subjects. Agreement between the two groups of pathologists was 97% for primary epithelial ovarian cancer and 89% for primary nonepithelial ovarian malignancies. Agreement on diagnosis of major cellular subtypes of ovarian malignancy ranged between 73% for endometrioid cancer and 100% for clear cell carcinomas. We conclude that the diagnosis of pathologic features of primary ovarian cancer is highly predictable. Nonetheless, diagnosis by histologic type varies sufficiently that a review process should be considered for clinical or investigative decisions involving specific histologic diagnoses of ovarian cancer.

Five deaths associated with the use of an intrauterine contraceptive device (IUD) were reported during the first half of 1973 through a nationwide mail survey of physicians whose practices were likely to be involved with intrauterine contraception. Four of the five reported deaths involved serious infections, and two of these four occurred in relation to a pregnancy. Use of an IUD prior to death ranged from seven months to 3 1/2 years. The mortality attributable to IUDs is estimated to be lower than that attributable to combination oral contraceptives.

One hundred six women were reported to have died from abortions (55 legal, 10 illegal, and 41 spontaneous) in the United States from 1975 through 1977. In reviewing these deaths, the authors developed a new approach to mortality studies. A catalogue was compiled of behavioral factors (including actions by physicians, patients, communities, and institutions) that in the authors' judgment increased the risk of death from abortion. The proportion of abortion deaths to which each behavioral risk factor contributed was determined. Of the 199 different behavioral factors, 5 contributed to more than 10% of legal abortion deaths, 5 to more than 10% of illegal abortion deaths, and 3 to more than 10% of spontaneous abortion deaths. The most frequent factors involved were delay in obtaining a legal abortion until 13 weeks' gestation or later, incomplete abortion, and inappropriate choice of antibiotics for septic abortion. Assessing the proportion of abortion deaths to which each factor contributed can help identify which factors deserve priority in prevention.

Widespread publicity in the mass media about the dangers of leaving an IUD in place in a pregnant uterus was apparently more effective than traditional scientific publication and drug package inserts in getting doctors to remove devices from pregnant patients. This suggests that such publicity could be effective in improving clinical practice and the public health in other instances, such as getting doctors to prescribe and women to request birth control pills with lower doses of estrogen, and persuading women to obtain early rather than the riskier midtrimester abortions.

In 1978 and 1979, two women in the United States were reported to have died from electrical complications following sterilization with unipolar coagulating devices. Both deaths followed apparent bowel injuries occurring at the time of sterilization. Numerous reports have documented the electrical accidents associated with unipolar electrocoagulation. Because unipolar electrocoagulation has greater risk for these complications than alternative sterilization techniques, without proved greater benefits, we question the need for continuing its use in female sterilization.

The Center for Disease Control (CDC), Atlanta, Georgia implemented an eight-month prospective surveillance system in 24 hospitals distributed among states with and without public funding for abortion. Out of 3,157 visits for abortion-related complications, only 10 women gave a history of non-physician or self-induced abortion and none were Medicaid recipients. The small number of hospitals located in non-funded states and the smaller numbers of women served in these hospitals than in the funded states limited the power of out study. Women living along the Texas-Mexico border appeared more likely to have complications after illegal abortions than women from other areas of the country.

Abortions by dilatation and evacuation after the 12th menstrual week of pregnancy are said to be both hazardous and impractical. To evaluate this hypothesis, we compared the safety and feasibility of 6213 abortions by this means and 8662 induced by intra-amniotic instillation of saline during the 13th to the 20th week of pregnancy. Abortions by dilatation and evacuation had a lower rate for major complica-tions (0.69 vs. 1.78 per cent; P is less than 0.001) and lower rates for treatment of complications, including antibiotic administration (2.22 vs. 5.65 per cent; P is less than 0.001), blood transfusion (0.19 vs. 0.91 per cent; P is less than 0.001), and curettage or manual evacuation of the uterus (0.98 vs. 34.10 per cent; P is less than 0.001). Such abortions also had a lower rate for failure of the method to produced abortion (0.11 vs. 2.52 per cent; P is less than 0.001). Although large, randomized trials are required to determine the appropriate role of mid-trimester abortion by this means, this method appears safe and practical through the 20th week of pregnancy.

The relative safety of suction curettage abortions performed with either local or general anesthesia has not been clearly established. To compare the safety of these two anesthetic techniques, we studied 36,430 women who received local anesthetics and 17,725 who received general anesthetics for this operation in the United States from 1971 through 1975. The aggregated major complication rates for the two groups were similar, but there were significant differences between local and general anesthesia for specific complications and treatments. Local anesthesia was associated with higher rates of febrile and convulsive morbidity; however, general anesthesia was associated with higher rates of hemorrhage, cervical injury, and uterine perforation. Both anesthetic techniques appear to be safe, with similar degrees of overall safety, although each is associated with a different spectrum of complications.

Neonatal mortality examined by place and circumstances of delivery in North Carolina during 1974 through 1976 with attention given to home delivery. Planned home deliveries by lay-midwives resulted in three neonatal deaths per 1,000 live births; planned home deliveries without a lay-midwife, 30 neonatal deaths per 1,000 live births; and unplanned home deliveries, 120 neonatal deaths per 1,000 live births. The women babies were delivered by lay-midwives were screened in county health departments and found to be medically at low risk of complication, despite having demographic characteristics associated with high-risk of neonatal mortality. Conversely, the women delivered at home without known prenatal screening or a trained attendant had low-risk demographic characteristics but experienced a high rate of neonatal mortality. Planning, prenatal screening, and attendant-training were important in differentiating the risk of neonatal mortality in this uncontrolled, observational study.

Six abortion-related deaths associated with the use of prostaglandin F2alpha were reported through the Center for Disease Control's surveillance of abortion deaths between 1972 and 1975. Prostaglandin may have had only indirect association with these deaths. The patients' ages ranged from 16 to 38 years, their length of gestation ranged from 15 to 24 menstrual weeks, four were white, and three were nulliparous. Four patients had pre-existing conditions that increased their risks and contributed to their death. The estimated death-to-case rate for prostaglandin F2alpha was 10.5 per 100,000 abortions. Although lower than the rate for intra-amniotic saline instillation, this death-to-case rate is only an approximation. The relative safety of intra-amniotic prostaglandin F2alpha as a second-trimester abortifacient, compared to saline, remains to be established.

Women with long-term use of oral contraception (OC) are at increased risk of developing a serious, though nonmalignant, liver tumor--hepatocellular ademona (HCA)--according to a case-control study conducted by the Center for Disease Control (CDC) in collaboration with the Armed Forces Institute of Pathology (AFIP). The tumor is sometimes fatal, deaths usually being due to sudden rupture and hemorrhage. This study suggests that, in addition to long-term OC use, a women's age and the hormonal potency of the OC she uses affect her changes of developing HCA. Women 27 years old and older who have used OC with high hormonal potency for 7 or more years are at the greatest risk.

Data gathered by the Center for Disease Control (CDC) through epidemiologic surveillance of deaths associated with legal abortions performed from 1972 through 1975 are analyzed by the type of procedure and the gestational age of the patients. Analysis shows that deaths increase at higher gestational ages and that the risk of death from abortion is highest with hysterotomy and hysterectomy and lowest with suction curettage. Second trimester instillation procedures are associated with higher rates of mortality than first trimester curettage procedures, even when dilatation and evacuation at 13-15 weeks' gestation is included as a curettage procedure. A case history of a patient who died as a result of legal abortion demonstrates that while legal abortion is a safe surgical procedure, some of the deaths that still occur can be prevented.

Family planning has become an important issue in modern life. The physician must be prepared to advise patients on the advantages and risks of both old and new methods and to determine which method is most acceptable and will therefore be most effective.

We reviewed the neonatal outcome of 3,369 infants who weighed less than or equal to 1500 grams and who were born in Georgia during the years 1974--76. We matched 1,465 of these infants with a death certificate registered in the State's Vital Records. Upon review of the hospital records of the remaining infants, we identified 453 infants that died during the neonatal period without a death certificate being registered. Subsequently, we compared the hospital death registries for 1977 in Georgia and death certificates registered in Vital Records during 1977. We identified an additional 236 infants who died without a death certificate being registered. Forty per cent of these infants weighed greater than 1500 grams. Two major procedural errors regarding the filing of death certificates in Georgia at the local level contributed to this 21 per cent underregistratioon of neonatal deaths in 1974--77. The underregistration occurred disproportionately for rural areas, for unmarried mothers, and for Black infants. The reason for underregistration included failure of hospitals and morticians to file death certificates with the county registrars.

Between August 7 and October 14, 1977, Clostridium perfringens organisms were isolated from endometrial and/or blood specimens from 3 women who had been hospitalized in McAllen, Texas, after having had illegal induced abortions. One of the women died of clostridial septicemia. A single abortionist was suspected in these 3 cases. The authors investigated the illnesses of these 3 women and those of 6 other women who were hospitalized at some time from January through October 1977 after having had illegal abortions but did not identify a common abortionist. The patient who died was a Medicaid-eligible woman who had had an abortion performed by a nonphysician after public funding of abortion was restricted in Texas as of August 5, 1977. The authors examined the medical records of all 230 women hospitalized in McAllen General Hospital with abortion complications from 1977 through January 1978. The local effect of restriction of public funds for abortion was to be studied. The incidence of women admitted to the hospital with febrile abortion complications after August 5, 1977, did not differ from that of women admitted from January 1 through August 4, 1977. However, the incidence of hospitalization of Medicaid-eligible women with abortion-related complications was greater after August 5 than it was in the earlier period.

From July 1975 through December 1979, the Georgia Department of Protective Services Central Registry recorded population-based data on confirmed, non-confirmable, and ruled-out child abuse reports. We propose that reporting biases are reflected in the differential characteristics of confirmed and ruled-out reports of child abuse. Characteristics, households, or groups equally or more prevalent in the latter category cannot necessarily be considered associated with increased risk of child abuse, even if they are represented in the confirmed abuse population more than in the general public. Important examples of factors or categories for which an association was suggested in other studies but which are not supported by this analysis are: urban residence, teenage motherhood, infancy, and mothers and other female perpetrators. These are conditions or categories associated with greater surveillance; therefore, risk assessment is not possible using the data in this registry. Certain households do appear to be at increased risk for child abuse. These include large families, families without a biological mother or biological father, and families ever needing Aid to Families with Dependent Children (AFDC). This increased risk, however, is slight. Improved surveillance requires identification of reporting biases. A comparison of confirmed and ruled-out reports is an inexpensive and system-specific step toward achieving this aim.

Homicide rates for infants dropped suddenly between 1967 and 1969. The abrupt nature of this decline suggested the change was artifactual. Investigation suggests that two classification revisions instituted at this time were causes of this decline: changes in related codes set forth in the Eighth Revision of the International Classification of Diseases, Adapted, and revision of the standard certificate of death in 1968. Infant homicides may have been disproportionately underrecorded after 1968. (Am J Public Health 1983; 73:195-197.)

In 1983, the State Epidemiologists in 46 States completed a survey questionnaire describing the professional qualifications, training, and experience of State health department epidemiologists and the scope of participation by the State Epidemiologists and their staffs in public health programs. The survey identified 224 State health department epidemiologists (estimated U.S. ratio 1.1 per million population). A State health department epidemiologist was most often male (80 percent), frequently (57 percent) was a physician, had an average age of 41 years, and had worked as an epidemiologist for 9 years. Participation in public health programs (either by supervising or providing consultation) by the State Epidemiologists and their staffs focused mainly on general epidemiology and communicable disease programs; fewer than half had participated in programs relating to the health of women and children, chronic diseases, injuries, or in other programs directed towards preventing premature mortality. Recently, the State Epidemiologists have been trying to broaden their activities into these areas; however, the demands created by the acquired immunodeficiency syndrome (AIDS) will mostly likely slow this process. Based on the overall findings and collective experience, it was concluded that State health departments have too few epidemiologists to address the wide variety of important public health problems facing our communities. It was proposed that each State health department have at least four epidemiologists (including one or more physician epidemiologists) and at least one master's level biostatistician and that the epidemiologists-per-population ratio not be less than 1 per million.

A case-control study of hepatocellular adenoma (HCA), a serious though nonmalignant liver tumor, was conducted by the Center for Disease Control and the Armed Forces Institute of Pathology (AFIP). Interviews with 79 women with HCA and with 220 age- and neighborhood-matched controls were completed. Limited information was obtained on nine additional patients who had died. Women with HCA and hemorrhage have a greater risk of morbidity and death than those with other symptoms. Increasing duration of OC use increases the risk of HCA. Use of OCs with high hormonal potency and age over 30 years may further increase a woman's risk of HCA. Long-term users of OCs have an estimated annual incidence of HCA of 3 to 4 per 100,000.

Homicide is a major cause of pediatric mortality. National law enforcement data were analyzed to characterize and differentiate neonaticide, infanticide, filicide, and overall child homicide. Results include the following: Neonaticides often involved parents or unidentified perpetrators and occurred proportionately more in rural areas than did other types of child homicide. Infanticide appeared to be one end of the spectrum of child homicide and not a distinct entity. Filicide rates were higher for sons than daughters and the crime was committed by more fathers than mothers. Overall child homicide predominately involved young male offenders who were acquaintances of the victim. At remarkably early ages, homicide characteristics began to resemble those of adult homicide. Further research in this area should attempt to gain detailed information concerning the child, his family, and their social network. Pediatricians should be actively involved in determining risk factors for child homicide and in screening children for risk when these factors are determined.

Using a national sample of hospital discharges, we found identical seasonal patterns for spontaneous abortions and conceptions but no significant seasonal variation in the rate of spontaneous abortions per 1,000 conceptions. The differences between our findings and those of previous investigators of spontaneous abortion may reflect our more comprehensive definition of spontaneous abortion, our more complete estimate of the monthly number of conceptions, and our more rigorous statistical analysis. The periodic regression analysis (PRA) reported in our study may be useful in other studies that monitor short-term trends.

We studied the effects of cesarean section on neonatal mortality for breech infants and low--birth weight vertex infants using data from the Georgia neonatal surveillance network on 392,241 singleton deliveries between 1974 and 1978. The risk of neonatal death for breech infants weighing 4,000 g or less delivered vaginally was significantly higher than the risk for those delivered by cesarean section. The lower the birth weight, the higher the risk for a vaginal breech delivery. For breech infants weighing 1,000 to 2,500 g, the risk was almost 21/2 times greater for a vaginal delivery v a cesarean delivery. The best outcome for high-risk vertex infants weighing 1,000 to 1,500 g was for those delivered by cesarean section in a tertiary perinatal center. An increase in the cesarean section rate may be associated with increased neonatal survival; however, the benefits must be weighed against the costs of an increased maternal mortality and morbidity.

Previous studies of the association between cigarette smoking and endometrial cancer have yielded inconsistent results. There is some evidence that this discrepancy may be explained by differences in menopausal status between the groups of women studied. We addressed the issue of the effects of postmenopausal smoking on endometrial cancer risk using data from the Cancer and Steroid Hormone Study, a multicenter, population-based, case-control study of gynecologic cancers in the United States. We found that smoking after natural menopause is associated with a 70% reduced risk of endometrial cancer among estrogen users and a 50% reduced risk among nonusers of estrogen. These findings are consistent with previously proposed biologic effects of smoking on estrogen metabolism, which may have important clinical implications.

Published reports disagree on the risks of intraamniotic prostaglandin F2alpha (PGF2alpha) for midtrimester abortion. To evaluate the safety and efficacy of intraamniotic PGF2alpha, we compared 1241 PGF2alpha and 10,013 saline abortions performed during the 13th to the 24th menstrual week. The results were reported in the Joint Program for the Study of Abortion/CDC, a multicenter prospective study. PGF2alpha abortions required less time (P less than .001) but had higher rates of major complications (P less than .01), antibiotic and operative treatment of complications (P less than .001), and readmission to a hospital (P less than .001). These findings challenge the current contention that PGF2alpha is safer than saline as an abortifacient.

This analysis of the Cancer and Steroid Hormone Study, a multicenter, population-based case control investigation of hormone use by women of reproductive age and endometrial, breast, and ovarian cancer shows that cigarette smoking is not associated with either an increased or a decreased risk of endometrial cancer. This study included 437 women with endometrial cancer and 3200 control subjects, all of whom were between the ages of 20 and 54 years at the time of interview. The absence of any alteration of the risk of endometrial cancer and smoking was found consistently no matter which variable was used as a measure of smoking--ever or never smoked cigarettes, former or current smoking, light or heavy smoking, or age smoking began.

At hospitals in three cities where public funding for legal abortions had been restricted, we reviewed the records of women with complications of all types of abortions. We compared the number of complications in the year before funding restriction with the number in the following year, during restriction. For complications of illegal and spontaneous abortions, we found no significant change in either the number or proportion of publicly funded hospitalizations. For complications of legal abortions, we found a decrease in both the number and proportion of publicly funded hospitalizations. For poor women, it appears that restriction of public funding for legal abortions has not markedly increased the number of illegal abortions, but has reduced the number of legal abortions, especially those at later gestational ages, which would have cost more and been at greater risk of complications.

To evaluate the intrauterine device as a risk factor for mortality associated with spontaneous abortion, we analyzed all deaths from spontaneous abortions reported in the period 1972-1974. Women dying from spontaneous abortions with a device in place were more likely to be young, white and married than those not wearing a device. Risk of death from spontaneous abortion was over 50 times greater for women who continued their pregnancy with a device in place than for those who did not. The Dalkon shield carried an increased risk of death, as compared to other devices, even after rates were adjusted for duration of use. However, pregnant women with either a loop or a coil in place also had a higher risk of dying from spontaneous abortion than those without any device. The results support the clinical recommendation that any device should be removed when pregnancy is first diagnosed.

In a mail survey of physicians likely to be involved with intrauterine contraception in the United States and Puerto Rico, 49.2% of the physicians responded, describing 3,502 unduplicated reports of hospitalizations related to the use of intrauterine contraceptive devices (IUDs) during the first six months of 1973. We estimate from this response that approximately 7,900 IUD-related hospitalizations occurred during that period. Interviews with a probability sample of nonrespondents demonstrated that their IUD complication experience was not substantially different from that reported through the mail survey. Estimates of the number of IUDs worn in 1973 permit rate calculations of three to ten IUD-related hospitalizations per 1,000 woman-years of IUD use. The rate of hospitalizations attributable to the IUD is probably higher that that attributable to combination oral contraceptives.

In the United States, the three principal methods of abortion for patients at 13 or more menstrual weeks' gestation are intraamniotic instillation of saline or prostaglandin F2alpha (PGF2alpha) and dilatation and evacuation (D&E). The relative safety of these methods, however, has not been established. This report compares the three methods using data on 17467 abortions collected by the Joint Program for the Study of Abortion under the auspices of the Center for Disease Control (JPSA/CDC). Abortion by D&E was found to be significantly safer than abortion by saline instillatin (p less than 0.001), and abortion by saline instillation was significantly safer than by PGF2alpha (p less than 0.01). Moreover, midtrimester D&E is both safe and practical; it is a direct and rapid procedure which can be performed on an outpatient basis. Although PGF2alpha accelerated the time required for abortion, it also significantly increased serious morbidity.

Classification errors of dependent variables can distort the results of observational studies. To reduce misclassification from our multicentre observational study of abortion complications, we extended the methodology of Lawrence and Greenwald for use in situations of unequal sample sizes and implemented both an office review and a field review. We reabstracted 424 reported complications and a random sample of 364 reported non-serious cases from 12 institutions participating in our study. In total, 30 per cent of the reported serious complications turned out to be misclassified: the office review detected 74 per cent of the total number of misclassifications with the remainder found in the field review. Because, with our particular data base, we estimated expending only 15 per cent of the total resources with our office effort, this represented the most cost-efficient approach to reducing classification errors. By eliminating the false positives from our study, we forced the specificity to 1.00 which produced both an unbiased estimate of the relative risk and an increase of 4 per cent to 63 per cent in the power of our study.

Homicide is one of the five leading causes of death for all persons 1-44 years of age. Over half of the homicides occurring in 1979 did not involve the perpetration of another crime. The authors have defined these as primary homicides and suggest that these deaths require the formulation of public health and social services prevention strategies. An epidemiologic assessment of primary homicides in the United States for 1976 through 1979 showed the following. Sixty per cent of primary homicides were male victim/male offender events; 40% involved a female as a victim and/or as an offender. Three per cent of primary homicides were female victim/female offender events; 97% involved a male as a victim and/or as an offender. Primary homicides involving female victims or offenders were more frequently intrafamilial than those involving males, but rates of intrafamilial homicides by males were greater than those involving females. The preponderance of all primary homicides occurred between acquaintances, but the relationship between victim and offender varied with age, sex, and race. The weapons used varied with the victim's and offender's age, sex, and race, and with the relationship between victim and offender. Based on the described patterns, prevention measures should be divided into three broad areas: intrafamilial violence, extrafamilial violence, and male patterns of aggression. Key target populations for the first area include females, rural households, and the very young or very old. A key target population for the second area is teenage males.

In 1979, over 20,000 people in the United States were victims of homicide, but public health agencies have not yet defined their role in its prevention. Role definition might begin with differentiating various forms of homicide, so the authors used data on all homicides reported by law enforcement agencies for 1976-1979 to determine whether homicides that did not occur during the perpetration of another crime (primary homicides) differ from those that occurred during the perpetration of another crime (secondary homicides). Primary and secondary homicide rates were highest in the South and West, respectively. The relative risk for Standard Metropolitan Statistical Areas (SMSAs) compared with non-SMSAs was 2.4 for secondary homicide but only 1.3 for primary homicide. It was found that 17% of primary homicides and 3% of secondary homicides had a female offender. Primary homicides were more frequently intersexual and intraracial than were secondary homicides. Victim and offender ages were similar to one another in primary homicides and dissimilar in secondary ones. Over 75% of primary homicides involved family members or acquaintances, compared to only 24% of secondary homicides. The authors conclude that primary and secondary homicides are epidemiologically dissimilar, and they suggest that public health concern should focus on primary homicide. Prevention and intervention measures should concentrate on discussed target populations. Techniques might include stress reduction and conflict avoidance.

From 1973 through 1978, the Center for Disease Control identified ten deaths caused by ruptured ectopic pregnancy after attempted legal abortions for those pregnancies. The women ranged in age from 18 to 31 years, seven were black, three were white, and five were nulliparous. The estimated gestational age was 16 menstrual weeks or earlier. In seven cases tissue obtained at abortion was sent for outside microscopic pathological examination; attempts to contact four of the patients when no products of conception were found were unsuccessful. An important factor in preventing fatal ectopic pregnancy for women who have legal abortions is the identification of products of conception at the time of the abortion procedure while the patient is still available for reexamination and recurretage.