Encyclopedia of Sociology Vol

restoring existing housing or for providing financial help for needy families, and so on. The observation of the effects of interventions on the variables of the housing needs model indicated whether the objective had been achieved and, if it had not, provided indications as to the most appropriate modifications to be applied to single variables in order to achieve the objective.

The second project was on the quality of the environment in daily life in Italian towns. The questions were the following: What type of environment is it? How can quality be defined? What is the current state of environmental quality? How can high environmental quality be achieved in the daily life of the town? To answer these questions, prediction was developed over the following stages: (1) Quality of the environment was defined according to people’s expectations in terms of services (number) and their spread or concentration in the town area, all placed in relation to individual and community values expressed by the local inhabitants. Surveys were carried out in each town by giving a questionnaire to 137 samples in as many communities, for a total of 33,000 interviewees. The result was the model of desired environmental quality for daily life as derived from subjective data converted into objective data. (2) This desired model was applied to each town (how many and what services existed and their location), which gave the model of environmental quality for daily life lived. (3) Observations were carried out on the context in which the above model was placed and the variables producing it, in order to identify the variables that influence the quality of the environment in it. These independent variables (clusters of multiple variables reduced in number by factor analysis and causally related to environmental quality through canonical analysis) represented the various features of community life: population, town territory, values, economic structure, social structure, local government, endogenous resources, exogenous resources, communications with the outside world, and so on. (4) The achievement of the desired environmental quality for daily life was explored by intervening on the variables that were causally most important for environmental quality (as they emerged from stage 3) and by simulating the effects that these interventions would have on environmental quality. This may entail further interventions on single variables until the

achievement of the desired environmental quality, which is the subject of the prediction.

A third project was the definition of task environments and their dynamics in agricultural production organizations. This research was basically exploratory in nature, concluding with normative assessments. The exploration was not carried out by inquiring into how company task environments are modified over time (an inquiry into process), because the starting theory (to be subjected to verification) was that proposed by Emery and Trist (1965), whereby task environments are modified as companies expand and become increasingly causally important and disruptive, introducing irrationality into the decisions companies have to make. In this research, then, predictive exploration was not based on the projection of variables into the future, but on the investigation of two situations (small-company and large-company task environments) and their comparison in accordance with the Emery–Trist theory, reconstructing the dynamics by comparing the two potential stages of a single company that grows from a small one into a large one (Gasparini 1983). By means of defining the role of the agricultural entrepreneur and his relations with the task environment organizations, synthesising these into a few factors (by factor analysis) and linking them through canonical analysis, task environments were identified and articulated according to their influential and direct relations with the company, according to contacts not generating real influences in that relations were based on sporadic contacts, and so on. One substantial difference emerged between small and large companies. In small companies, there are few influential relations and a great many casual and sporadic contacts. In large companies, the relational task environment is very rich in relations, influences, and dependency on company decisions; the structure of the sporadic contact task environment is by contrast marked by relational links that are weak and few and far between. This exploratory projection produced by the hypothetical transformation of a small company into a large one therefore showed a radical change in the functional and power relationships of the task environment. The identification of concrete relations and contacts and their respective influence clearly leads to the intention to intervene according to the normative objective, which in this case is a rethinking of

entrepreneurship, or an operational intervention in the agricultural economy to make sure that small and large entrepreneurs retain the power and responsibility assigned to them by the theory.

These three research examples show the great versatility of quantitative and objective techniques, that they need to be integrated with one another, and that they can be used in the exploratory dimension and some normative functions. These techniques are inextricably intertwined, as is exemplified by the fact that the exploratory dimension itself must be defined by reference to the criterion implicit in the normative dimension.

Leader’s Opinions and Qualitative Techniques. The methods and techniques based on leaders’ opinions, be they decision makers or experts in a particular field, are fundamentally qualitative in nature, that is, they are based on assessments that can be conventionally ordered in numerical values from which relations can then be highlighted. This can be done, as in the case of cross-impact analysis, but it should not be forgotten that the quantitative values manipulated are derived from percentages attributed intuitively to the occurrence of one event rather than another. Nevertheless, there are slightly differing degrees of formalization between these methods, and they are expressed in terms of their internal logic, reasoning experience that discriminates the more possible from the less possible, the ability to progressively refine judgments (the Delphi method), the compatibility between the reasoning and the context in which it is used, and the compatibility that has to give rise to the prediction for the phenomenon placed in the context.

This type of technique also contains scenarios, but they derive more from leaders’ judgments than from the (highly implicit) model at the basis of the issues at stake and therefore of the variables defining the features of the model itself.

These are thus methods that can be used for the study and prediction of phenomena whose details are not known and/or which are relatively new, which means that recourse is made to qualified individuals equipped, for one reason or another, to see their own knowledge and predictions through the prism of research experience or familiarity with decision-making processes. If such is the case, the next step might be to transform the

results of these subjective predictions into indicators and formal explanatory models, to be tested with exploratory methods and normative methods to obtain a (concrete) measurement of the projection or process required to achieve the predetermined objective–norm–criterion.

But it may also be the case that the simple results derived from these opinions are considered sufficient (expressed to various degrees of sophistication by means of in-depth interviews, the Delphi method, cross-impact analysis and the qualitative scenario), and this happens because, or probably because, the scientific component in the prediction is not held to be very important; it is considered as a set of rational instruments for reasoning about the plausibility of the prediction itself. Taking into account that these rationalized judgments come from policymakers (at the summit of the decision-making process) or opinion makers, this ascientific factor is even more worrisome.

In this case, the implicit conviction is that these are the players who will have a major role in the achievement of their own prediction—in which case, we are faced squarely with the principle of self-fulfilling prophecies.

Techniques in a Band of Abivalence. From Table 1 we still have to analyze the two intermediate bands in which predictive techniques are to be placed. Though these are conceptually different in some respects, they are also instrumentally contiguous, which in practice means that they often overlap, or are at least complementary, when being used. Objective qualitative methods indicate that phenomena are analyzed structurally with no measured data; methods that are quantitative but based on leaders’ opinions provide judgments strongly based on facts, or at least measurable data, which involves a strong tendency to apply leaders’ opinions to a concrete context.

Prediction techniques placed in these two bands of ambivalence are very similar to those devised for the predictive analysis of leaders’ opinions, but they rely heavily on a detailed knowledge of context. Thus they also make use not only of the Delphi method, cross-impact analysis, and scenarios, but also simulation in objective quantitative methods. However, the most typical of these two bands are relevance trees, science fiction, and tendency impact.

An example of predictive research in this context of ambivalence is condensed in what Igor Bestuzhev-Lada (1997) calls ‘‘technological prediction.’’ It comprises seven procedures that use methods which are both quantitative and qualitative, objective and subjective. The procedures are: program elaboration, construction and analysis of the starting model, construction and analysis of the predictive background model, exploratory prediction, normative prediction, prediction verification, and formulation of recommendations for a proper management of technological prediction. Indicators are often measured quantitatively, but their treatment and assessment are mostly qualitative.

In summary, the combination of the three criteria detailed in Table 1 indicates the following:

1.There are more specific techniques in the objective–quantitative methods and the leaders’ opinions–qualitative methods.

2.In the ambivalence band, methods that are typically objective and bound to opinion leaders tend to extend toward the quantitative and qualitative.

3.The exploratory and normative methods are not alternatives but are fairly well integrated with one another. An exploratory projection is implicit in the norma-

tive method, and the exploratory method requires a criterion that is able to be transformed into the desired predic- tion–norm.

4.Many methods are multivalent in prediction in that they are used to construct many types of prediction, but also in that they are technically versatile because they can be used with measured data and opinions alike. The most important example of this is the scenario.

5.The effectiveness of the methods varies according to the type of prediction in question. For short-term predic-

tions and those on a circumscribed subject, the quantitative–objective method is most effective. The longer the period involved and the broader the subject, the more effective are qualitative methods and methods based on leaders’ opinion. This means that a broad to medium to

long-term framework analyzed with qualitative methods contains specific shortterm subjects studied with mathematical formalization.

6.The scientific nature of prediction methods therefore varies with the variation of frames and times of reference, or at least there is a variation of the forms of expression of the scientific activities of description, explanation, and control.

From the above it thus emerges that the complexity of prediction of the future entails a multiplicity of studies because the future expresses itself in very different ways. This is why it is more than legitimate to speak in methodological terms of futures studies.

THE DISTRIBUTION OF FUTURES STUDIES IN TIME AND SPACE

It is well known that studying the future becomes a strongly felt need in times of transition. The rules of the past no longer hold, and the rules for the future do not yet exist or are still untried. In addition, globalization accentuates the need to build niches within which some form of autonomy may be regained. But what does niche autonomy mean when globalization bombards it with the upheaval external to it, upheaval which is therefore experienced as irrational?

This question gives rise to the need to predict and to achieve prediction through studies on the future or futures. It is hardly surprising that many public and private institutions have set up study centers for prediction. An indicator of this growth is provided by the large number of Web sites for such centers, which are being put together to form a Futures Studies Internet Society.

An ISIG study (Apuzzo et al. 1999) has found that worldwide two hundred and eight institutions working in futures studies have Web sites. Of these, one hundred and forty publish papers, one hundred and twenty-three provide links, sixty-nine publish their own journals on-line and conduct training, sixty-four advertise books, fifty-seven provide on-line shopping, forty-seven pass on chat news, thirty-eight make available projects, thirtyfour are concerned with software, and twentyeight deal with methods and techniques.

Most of the sites are American (one hundred and seventeen futures studies institutes) and only twenty-three are international; fourteen are in Britian; eleven in France; eight in Australia; six in Sweden; five in Canada; three each in Germany, Finland, Belgium, Norway, and Italy; two in Switzerland; and one each in Argentina, Denmark, Zaire, Austria, Israel, and Russia.

There can be no doubt that the future, especially in the United States, is strongly perceived as a subject requiring analysis. We have interpreted this as a way of finding autonomous futures for individual niches in the context of sweeping globalization. But it may also happen that despite this intention, the incipient Futures Studies Internet Society will accentuate the very standardization of feeling, thinking about, and planning the future that such great efforts are being made to curtail.

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ALBERTO GASPARINI

PREGNANCY AND PREGNANCY TERMINATION

Pregnancy is one of the most important events in a woman’s life. For many women, pregnancy defines, enhances, or determines their economic, social, or personal value. Pregnancy and childbearing can be highly desired for personal reasons, or to meet social expectations. In some circumstances, childlessness may be grounds for suspicion, divorce, or worse. Pregnancy in the wrong situation may be undesirable to an equivalent degree. Traditionally, the woman with an unacceptable pregnancy may be abandoned, lose her prospects for marriage, be forced into prostitution, or suffer an even worse fate. Other pregnancies, even though they occur within a socially sanctioned circumstance, may result in loss of opportunities for social or economic advancement. Control over the occurrence and outcome of pregnancy is integral to women’s control over their lives. This concept was strongly stated at the International Conference on Population and Development in Cairo in 1994.

Menarche, the first menstrual period, marks the beginning of a woman’s reproductive period, and menopause, the last menstrual period, marks the end. Menarche occurs between ages 8 and 14 for most well-nourished women, but may come later if there is malnutrition or chronic disease. If the first menstrual period follows ovulation (release of an egg or ovum from the ovary), the woman may be fertile before menarche has occurred. For most women, fertility increases rapidly in the first year after menarche, as ovulation becomes more regular, so that as many as 95 percent of women in their late teenage years may be fertile. Infertility in the first years after menarche may be due to malnutrition, malformations of the uterus and reproductive organs, hormone abnormalities

leading to anovulation, or genetic diseases. After the early twenties, fertility declines, as sexually transmitted diseases; endometriosis (occurrence in abnormal sites of tissue normally found in the lining of the uterus); and other inflammatory, infectious, and vascular diseases affect reproductive organs. Menopause occurs between ages 40 and 55 in most women, but most women over 40 are infertile, and very few live births occur to women over 45.

PREGNANCY

Pregnancy is typically divided into trimesters, which are uneven in length. Obstetricians invariably refer to ‘‘weeks’’ of pregnancy, meaning the number of weeks from last menstrual period, or when the last menstrual period should have occurred. The first trimester lasts from 3 to 12–14 weeks, the second from 12–14 to 24–26, and the third from 24–26 to delivery. The terminology is confusing, as menstrual age (the time since the last period) is not the same as gestational age (the time since fertilization, the union of the sperm and ovum). Therefore gestational age will be 2 weeks less than menstrual age. The system evolved in an era when many or most women could recall a last menstrual cycle, but few knew when conception or fertilization occurred. Now, more women may be aware of the date when conception occurred, and some pregnancies occur after assisted reproductive technologies (ART), when the time of fertilization may be known exactly. Either way, pregnancy itself begins immediately after implantation. This occurs about 3 weeks after the menstrual period and about 1 week after fertilization (therefore the first trimester starts at 3 weeks). A blood pregnancy test becomes positive within a day or two of implantation, and a urine test becomes positive a few days later. By the time the menses are missed, 4 weeks after the last menses, a urine pregnancy test will be positive if fertilization occurred at the expected time.

Between 10 percent and 40 percent of pregnancies result in spontaneous abortion in the first trimester. The wide variation in incidence reflects difficulty in recognizing very early abortion as well as differences in abortion rates among different age groups. Most spontaneous abortions are the result of chromosomal or developmental abnormalities of the pregnancy and are unavoidable; 1– 2 percent of pregnancies abort spontaneously in

the second trimester, often due to infection, and about 1 percent of pregnancies have serious anomalies. About 1 percent of pregnancies are ectopic, occurring outside of the uterus. Most ectopic pregnancies require medical or surgical treatment to avoid hemorrhage. Ectopic pregnancy is one of the major causes of maternal mortality; in the United States, it is still associated with about 10 percent of maternal deaths (Cunningham et al. 1997).

RESPONSE TO PREGNANCY

Women typically pass through several stages of reaction to pregnancy. The first reaction may be denial, particularly when the pregnancy is unwanted, or delight, when the pregnancy is wanted. Later, desired or planned pregnancy may still be accompanied by periods of ambivalence or anxiety (Affonso 1997). The concern may be about personal or work changes, financial stresses, health concerns, or concern about fetal health. At some point in the pregnancy, typically first or second trimester, the pregnancy is usually accepted. The fetus is visualized as a baby, and planning for birth and beyond ensues (Taylor 1980).

The pregnancy may not be accepted; the woman may choose to abort the pregnancy, or she may deny existence of the pregnancy, or she may never accept it even though she eventually gives birth. The lack of acceptance may follow a situation where abortion was unavailable; this may be an individual situation or a matter of political policy. During wartime, impregnation of ‘‘enemy’’ women (which may be accompanied by denial of abortion) is a form of terrorism (Swiss 1993).

Pregnancy itself does not impart any ability to deal with stress, nor does it decrease ability to manage stress. Women who have difficulty caring for themselves adequately when not pregnant, such as adolescents and women with severe psychiatric or developmental handicaps, may have difficulty caring for themselves while pregnant, to the detriment of the fetus. Pregnancy may be an incentive to stop self-abusive behavior such as drug use, but while pregnancy may be the motivating factor, it does not supply the emotional organization to change behavior. Domestic abuse of women does not usually stop with pregnancy; it often escalates (American College of Obstetricians and Gynecologists 1995b).

PREGNANCY AND BIRTHRATES

The pregnancy rate is the number of pregnancies occurring per 1,000 women of reproductive age (considered to be ages 15–45 inclusive), per year. The fertility rate is the number of all births (liveborn and stillborn) per 1,000 women age 15–45 per year; this is the birth rate for reproductive-age women. The term birthrate, unmodified, usually means the number of live births per 1,000 population (male and female of all ages).

Pregnancy rates increase during the teenage years and generally peak during the late twenties in most societies, before declining in the thirties and forties. Birthrates follow a similar trend, although the peak birthrate may occur later than the peak pregnancy rate, and the difference between pregnancy rates and birthrates is more pronounced at the extremes of reproductive life. At the beginning and the end of reproductive life more pregnancies are likely to be terminated by abortion.

More pregnancies than are wanted occur. Some are mistimed, occurring earlier than wanted, and some are unwanted at any time. In the United States, between 40 percent and 50 percent of pregnancies are unintended (Horton 1995; Henshaw 1998a). Overall, mistimed pregnancies are more frequent than unwanted pregnancies, but the relationship may be reversed in some groups, such as women over 40. Rates of unplanned pregnancy are generally lowest in countries with wide availability of effective contraception combined with public education, such as western Europe (Paul 1999). Unplanned pregnancy may occur because of contraceptive failure or non-use of contraception. In the United States noncontracepting women, about 8 percent of women at risk for unintended pregnancy, account for about 50 percent of unplanned pregnancies (Gold 1990).

Unplanned pregnancy may result in birth, spontaneous abortion, or induced abortion. The abortion ratio (ratio of pregnancies aborted to pregnancies occurring) in the United States for unplanned pregnancy is about 0.5 (Gold 1990). In other countries the rates may be lower, where unplanned pregnancies are accepted or abortion is not readily available, or higher, where unplanned pregnancy is not tolerated personally, socially, or economically (Henshaw et al. 1999).

Teenage pregnancy rates have been of concern because of adverse medical and economic outcomes, which are intertwined (Fraser et al. 1995). For most of the century, pregnancy rates for U.S. teenagers have been declining. Rates began to rise in the 1980s, reaching a recent high of 117 per 1,000 (women ages 15–19) in 1990 (Alan Guttmacher Institute 1999). By 1997 rates had declined about 10 percent to 97 per 1,000. Birthrates have shown a parallel decline from 60 per 1,000 to 54 per 1,000, and abortion rate declined as well.

In contrast to teenage women, women in their twenties have higher pregnancy and birthrates. Birthrates are currently about 110 per 1,000 women in this age group (National Center for Health Statistics 1999). Crude abortion rates are similar to those of adolescents, 20–30 per 1,000 women. Since adolescents have fewer pregnancies and births, the abortion ratio is higher than for women in their twenties or thirties. Overall, more than 40 percent of teenage pregnancies resulted in induced abortion. There are large variations in pregnancy, birth, and abortion rates by state, ethnic group, and age (Horton 1998). Nineteen-year-olds have a much higher pregnancy rate than 15-year- olds. Nonwhite and black teenage pregnancy rates are approximately twice those of white teenage rates. Nonwhite and younger teenagers are more likely to have induced abortions (National Center for Health Statistics 1999).

Comparison of birth and abortion rates can be cumbersome. Distribution of women’s age, ethnic group, geographic location, time of collection of statistics, event definition, and accuracy of reporting will affect rates.

CONDUCT OF PREGNANCY

A comprehensive discussion of pregnancy is outside the scope of this encyclopedia; for more complete information, an obstetrics textbook (e.g., Cunningham et al. 1997; Gabbe et al. 1996) should be consulted.

The first trimester of pregnancy is often accompanied by nausea and vomiting, which is typically short-lived but may be severe enough to interfere with daily activities. Some women have hyperemesis, vomiting which is severe enough to result in dehydration or even death; it is treated

with intravenous fluids, antinausea drugs, and sometimes intravenous feeding. Although a link between hyperemesis and ambivalence or anxiety about pregnancy has been postulated, the strength and the relevance of any such link is uncertain.

Women often note changes in food likes and dislikes, but there is no medical reason to restrict types of food. There are often cultural restrictions and prescriptions, and there is seldom any reason to interfere with custom. In the second half of pregnancy many women have heartburn, because of the pressure of the pregnancy on the bowel and stomach, and because of relaxation of the esophagus. Changes in diet or eating habits, or using antacids, may help.

Women need additional calories during the second 2 trimesters; the amount is about 300 kcal per day for most women, the equivalent of a modest sandwich. The additional calories should consist mostly of complex carbohydrates; most Americans have adequate protein intake. Women who receive protein supplements may have higher rates of preterm birth than women receiving carbohydrate supplements or no supplements at all. The U.S. Department of Agriculture administers a food supplement program called WIC (Women, Infants, and Children), which provides food to low-income pregnant and lactating women, infants, and children up to 5 years of age. Supplementation is associated with small decreases in the rate of low-birthweight delivery and a decrease in cost of caring for newborns (Merkatz 1990).

Folic acid, a vitamin, has been shown to decrease the incidence of neural tube defects, a complex of birth defects of the brain or spine. Since the neural tube fuses in the fifth menstrual week, often before pregnancy is noticed, women should take adequate folic acid before pregnancy (Czeizel and Dudas 1992; Rosenberg 1992). The recommended daily allowance of folic acid prior to pregnancy, 400 mg, is easily achieved with a well-balanced diet. Since bread and cereals are now fortified with folic acid, it is becoming harder to avoid adequate folic acid. However, residents of closed communities, producing their own food may not have access to fortified food. Overconsumption of most vitamins is harmless, and the excess is excreted in urine. However, fatsoluble vitamins may accumulate and reach levels

that are toxic to the fetus. Iron is useful for women who are anemic because of iron deficiency.

Prenatal medical care is available to most women in the United States through a patchwork of public and private funding (Alan Guttmacher Institute 1994). Public funding has increased over the last decades as it became evident that the cost of caring for low-birthweight infants could be decreased by providing prenatal care (Merkatz 1990). The relative importance of individual facets of prenatal care is not certain (e.g., Crane et al. 1994; Higby et al. 1993), and some usual practices are probably useless but are persistent (AAP and ACOG 1997; Merkatz 1990). Efforts to assess prenatal care are complicated by the observation that women who actively seek prenatal care have better outcomes than those who do not, even when the latter group receives the same care.

OUTCOMES OF PREGNANCY

A normal pregnancy lasts 38–42 menstrual weeks (term). Infants over 37 weeks are considered fullterm. Infants under 37 weeks are considered preterm. Low birthweight (or under 2,500 grams at birth), includes both preterm infants and full-term infants who weigh less than expected. The lowbirthweight rate is the percentage of births under 2,500 grams.

The low-birthweight rate is an indicator of maternal health and of the effectiveness of prenatal and intrapartum care. However, the low birthweight numbers may be affected by the definition of live births. In some locations, live births are considered to be births over 28 weeks and/or 750 or 1,000 grams. In the United States the usual definition is any birth over 500 grams or showing movement or cardiac activity after birth; birth of a fetus under 500 grams without movement is classified as a spontaneous abortion. However, the definition varies by state and some states have adopted 350 grams as the threshold (Horton 1998). A 350gram threshold will appear to raise the rate of low birthweight and the mortality rate of low-birthweight infants, as virtually no fetus born between 350 and 500 grams will survive (see ACOG 1995a).

Low birthweight is the leading cause of perinatal death. Perinatal deaths consist of antepartum deaths (in which the fetus dies before delivery), intrapartum death (in which the fetus dies during labor or

delivery), and neonatal deaths (in which a liveborn infant dies in the first 28 days). In contrast to the low-birthweight rate, which is usually expressed as a percentage, the death rate is usually expressed as the rate per thousand births (both live and stillbirths). Death rates vary according to policies on inclusion of the smallest fetuses and infants.

A viable fetus is a fetus that can survive outside the uterus. Viability may affect a decision to use an intrauterine treatment versus delivery and treatment of the infant. Viability has also played a role in some debates about abortion, as the gestational age of viability has decreased with advances in perinatal care.

For most healthy women, the physical stress of pregnancy is easily managed. Pregnancy is much more dangerous to women with underlying anemia, heart, or kidney disease, who cannot manage the necessary increase in blood supply and circulation, and to women who do not have adequate nutrition. Family planning, by allowing adequate nutrition before pregnancy and recovery between pregnancies, is critical to women’s health status during pregnancy (Alan Guttmacher Institute 1997). Women who are poorly nourished or ill have a much higher chance of delivering a lowbirthweight baby, who in turn is more likely to have chronic illnesses and disabilities.

Delivery has additional risks to all women. In the nineteenth century, with the best available care, maternal mortality was about 1 percent per pregnancy, and it remains at that level, or higher, in some parts of the world. It is estimated that each year 600,000 women die from pregnancy and childbirth (Berg et al. 1996; WHO 1998a). The three most common causes of morbidity and mortality are hemorrhage, infection, and pre-eclampsia (high blood pressure and blood vessel disease unique to pregnancy). Morbidity and mortality from all 3 of these situations are less likely where there are trained birth attendants (midwives or physicians) with access to a short list of medications (Rooks 1997). Relatively simple interventions may make a major difference in outcome (e.g., Wallace et al. 1994). In contrast, the incremental increase of complex technology is relatively small, although it may be dramatic in some situations. The widespread application of some technologies has been harmful by creating additional problems, such as interference with normal

Screening cost-effective in highprevalence populations.

Effective if antiretroviral drugs are available and safe alternatives to breastfeeding are available.

Data on effectiveness are conflicting.

Effective in high-prevalence groups; may not be cost-effective in lowprevalence groups.

Vaccination of most young women has reduced incidence.

In high-prevalence areas universal vaccination without screening is costefficient and simpler.

Can identify 90% of affected fetuses. 2-5% of women will need

additional testing

Can identify 60% of affected fetuses;

5% of women will need additional testing.

Table 1

labor by restriction of movement (Butler et al. 1993) or by diversion of resources from other beneficial programs.

Births are classified as spontaneous (vaginal), operative vaginal, or operative abdominal. Spontaneous birth includes births that are assisted by a birth attendant’s hands. Operative vaginal births include forceps and vacuum extractor (suction cup applied to the baby’s head); rates range from as low as 1 percent to 30 percent or higher in some settings. Operative abdominal births are ‘‘cesarean sections,’’ and rates vary widely. In western

Europe rates are generally 8–15 percent of total births. In the United States, rates had risen steadily for several decades before decreasing very slightly in the last several years to about 22 percent of all births (National Center for Health Statistics 1999). In some cities throughout the world there is a local demand for elective abdominal delivery as an alternative to labor, generally restricted to women who can afford to pay for the request. With such widely varying rates of operative intervention there is no consensus on optimal rates, although there are many opinions. For instance, there has been no decline in the rate of mental retardation in the

United States, although both fetal monitoring and operative delivery were purported to prevent at least some retardation (ACOG 1992; Rosen and Dickinson 1992).

After birth, women and babies do best when they are kept together and allowed to establish lactation (WHO 1998b). Separation of mother and baby as practiced in many hospitals is not only unpleasant, but inappropriate in terms of infection control and infant nutrition. The effect of labor and delivery routines on ‘‘bonding’’ or attachment has been debated; whether any simple intervention can influence parenting is questionable at this point. The social and educational support of trained lay women has measurable success in some studies on labor outcome and breastfeeding success (Rooks 1997). More intensive programs of pregnancy, delivery, and postpartum peer care have not been fully evaluated (O’Connor 1998).

TERMINATION OF PREGNANCY

Abortion is an event, other than a birth, that terminates a pregnancy. Abortion may be spontaneous, if it begins without intervention from the woman and without medical intervention, or induced, if some agent or procedure is used to cause the abortion. Induced abortion may also be classified as legal or illegal. Other terminology is neither uniform nor clear. Therapeutic abortion may refer to all legal induced abortions performed under medical supervision, or to those performed for medical indication such as severe illness in the woman. Spontaneous abortion may be classified as inevitable if it has not yet occurred but will occur, as incomplete if the pregnancy has been partially passed, or as complete if all tissue has been expelled or removed.

A viable pregnancy may refer to a pregnancy in which the baby is apparently healthy and growing; the pregnancy would be expected to continue if there were no intervention. A nonviable pregnancy will result in spontaneous abortion. Nonviable pregnancies are also called blighted ovum (which is technically incorrect since the ovum or egg has already divided), empty sac, or fetal demise. Abnormal pregnancies are sometimes detected by ultrasound or by blood testing, before there are any symptoms of spontaneous abortion.

Most abortions are requested because the pregnancy was unwanted, but there are other reasons, some of which are listed in Table 2.

In the United States, 90 percent of abortions occur in the first trimester; half of all women request abortion before 8 menstrual weeks. Ten percent of women request abortion after 12 weeks. Between 1 and 2 percent of all abortions performed are for fetal malformations; these are almost all second-trimester procedures. Fewer than 1 percent of abortions are performed in the third trimester. Generally, as the length of gestation increases, the cost of abortion increases, and the number of providers decreases (Gold 1990).

There are several types of procedures in use (for a more complete discussion, see Paul 1999). In the first trimester, there are both medical and surgical techniques. Surgical techniques consist of variations of suction curettage. In this procedure the cervix is stretched open if necessary; in very early pregnancy (fewer than 6 menstrual weeks) no opening may be necessary. The inside of the uterus is suctioned using a plastic tube and a vacuum created by an electric or manual pump. ‘‘Sharp’’ curettage, the traditional dilatation and curettage (D&C) is more traumatic and has been largely replaced by suction curettage.

Several medications are used for early medical abortion, depending on availability. Methotrexate is a medication that blocks folic acid, a vitamin. Several days later the woman takes a second drug, misoprostol (a prostaglandin drug), which makes the uterus contract and expel the pregnancy. The process is similar in both timing and feeling to a spontaneous abortion. The exact time sequence is difficult to predict; about 75 percent of women abort within 1 week. Vaginal bleeding occurs for a mean of about 10 days, but may last longer. The medication may fail to produce an abortion about 1 percent of the time, and about 1 percent of women need a suction curettage because of heavy bleeding. Methotrexate can be used up to 7 or 8 menstrual weeks, and is the most common agent in use in the United States, because it is FDA approved for other uses, and therefore easily available.

Mifepristone (formerly called RU 486) has been used in millions of women in China, France, Sweden, and the United Kingdom for medical