PUBLIC HEALTH BRIEFS
Apparently many respondents chose an unlicensed midwife because they were unable to locate a licensed provider who would attend an out-of-hospital birth. This is consistent with the finding that women attended by unlicensed midwives are more likely to reside in rural counties than their counterparts attended by licensed midwives or certified nursemidwives. Shared religious beliefs was another reason cited for the choice of birth attendant. It was later learned that some unlicensed midwives regard their practice as a ministry to serve fellow churchwomen. That two-thirds of mothers attended by unlicensed midwives paid a fee for service suggests that in most cases this was a professional relationship, not simply one friend helping another. Technically, unlicensed midwives who charge a fee are practicing illegally. However, because they are responding to the needs of particular groups of women, they are likely to continue to practice in spite of legal
prohibitions. Legislation prohibiting unlicensed midwives from practicing is rarely enforceable.2 Indeed, the real effect of such legislation has been to force unlicensed midwives to work in secret or to prevent them from seeking education and training.23 Providing an avenue to legal midwifery practice may be a more appropriate course of action so long as competence, equivalent to other licensed providers, can be demonstrated. REFERENCES 1. Joint Study Group of the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives: Maternity Care in the World. Hampshire, England: C.M. Printing Services, 1976. 2. Owen M: Laws and policies affecting the training and practice of traditional birth attendants. Int Digest Health Legis 1983; 34:441-475. 3. World Health Organization: Report of the Consultation on Approaches for Policy Development for Traditional Health Practitioners, Including Traditional Birth Attendants. Geneva: WHO, 1985; 18.
Occupational Physical Activity and other Risk Factors for Preterm Birth among US Army Primigravidas GILBERT RAMIREZ, DRPH, RICHARD M. GRIMES, PHD, JOHN F. ANNEGERS, PHD, BARRY R. DAVIS, MD, PHD, AND CARL H. SLATER, MD Abstract: We examined the relation of occupational physical activity to the risk of preterm birth among US Army active-duty primigravidas between 1981 and 1984 using 604 cases (preterm deliveries; < 37 weeks gestation) and 6,070 controls (term and post-term deliveries). Women employed in the highest physical activity levels had increased odds of preterm delivery ranging from 1.69 to 1.75. The relation was not changed by adjustment for the effects of age, marital status, socioeconomic status, or education. Missing data suggest cautious interpretation. (Am J Public Health 1990; 80:728-729).
Introduction
Relatively few studies have examined the relation between physical activity on the job and the risk of preterm birth, and the findings have been mixed. In a French case-control study, risk of preterm birth was related to the number of sources of occupational fatigue and with a workweek longer than 40 hours.' This finding was not confirmed in a case-control study in New Haven, Connecticut;2 decreased risk of preterm birth was seen among women participating in sports or physical fitness exercises during pregnancy. Address reprint requests to Gilbert Ramirez, DrPH, Assistant Professor, Graduate Program in Allied Health Research, Lavaca Hall West, Southwest Texas State University, San Marcos, TX 78666-4616. Dr. Ramirez is a Major (Ret), US Army. All co-authors are from the University of Texas Health Science Center, School of Public Health, Houston, Texas. This paper, submitted to the Journal September 7, 1988, was revised and accepted for publication August 25, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
728
The population of US Army active-duty gravidas presents an unusual opportunity to study the relation between preterm birth and occupational physical activity because of its large size and homogeneity, and because US Army military occupational specialties (MOS) had undergone physical demand assessments. Methods In 1977, entry level specialties for enlisted personnel were categorized by maximum upper body strength requirements as required for "combat conditions" performance (see Appendix).3 This physical activity measure was not a specific measure of actual physical activity during pregnancy. Data for this study were obtained from Patient Administration Systems and Biostatistics Activity, Fort Sam Houston, Texas for length of gestation (from maternal and infant inpatient records) and from US Army Military Personnel Center, Alexandria, Virginia for physical activity and other demographic data (from fiscal year personnel files). Each subject was assigned to her MOS physical activity level during pregnancy using the fiscal year corresponding to her mid-gestation date. US Army policy forbids the reassignment of women during pregnancy. The population of US Army active-duty gravidas delivering at US Army medical treatment facilities numbered 22,450 during the four-year period 1981-84. This period was chosen because of differences in coding schema for inpatient records prior to 1981; data for deliveries after 1984 were incomplete at the time of this study. Eligibility criteria for the study sample included primiparity, singleton delivery, and enlisted paygrade status. Officer occupations had not been assessed for physical demand requirements. Cases were defined as preterm deliveries (- 37 weeks gestation); controls included term and post-term deliveries. AJPH June 1990, Vol. 80, No. 6
PUBLIC HEALTH BRIEFS
Risk factors studied included age, race, pay grade, length of military service, marital status, education, occupational aptitude score, job skill level, and type of military unit. The latter two variables were included to control for the initial focus of the MOS physical demand analysis: "entry level skills in a combat environment." Military duties performed in a field unit closely resemble how they would be performed in a combat environment. The occupational aptitude score was included since it is also used to determine MOS eligibility. Odds ratios were computed for each separate risk factor. The dose-response relation between occupational physical activity and preterm birth was assessed with the Mantel test for trend.4 We also fitted a logistic regression model and estimated population attributable risk.5
Results Of the 22,450 US Army active-duty deliveries between 1981-84, 20,684 were to enlisted women. Of these, 20,218 were single live births. Using the mothers' Social Security Numbers (SSN), 12,911 of the 20,218 (64 percent) maternal inpatient records could be matched to infants' inpatient records. Seventy-two percent (9,262) of these matched records met the primiparity criterion. Using the maternal SSN, 7,821 were matched with personnel records. Of these, 1,147 records could not be used due to MOS data entry errors. The remaining sample of 6,674 included 604 cases and 6,070 controls. Odds ratios for each risk factor are presented in Table 1. Risk factors for preterm birth included the two highest TABLE 1-Estimates of Relative Risk for Preterm Birth Risk Factors Physical demand Low Medium Moderately Heavy Heavy Very Heavy (p-value, trend: 0.0056) Age (years) -20 50
*Occasional: 20% but < 80% of the ffme Constant: >80% of the time
1. Mamelle N, Laumon B, Lazar P: Prematurity and occupational activity during pregnancy. Am J Epidemol 1984; 119:309-322. 2. Berkowitz GS, Kelsey JL, Holford TR, Berkowitz RL: Physical activity and the risk of spontaneous preterm delivery. J Reprod Med 1983; 28:581-588. 3. Women in the Army Policy Review Group. Women in the Army policy review. Washington, DC: Department of the Army, 1982. 4. Schlesselman JJ: Case-control studies. Design, conduct, analysis. New York: Oxford University Press, 1982; 200-206. 5. Kleinbaum DG, Kupper LL, Morgenstern H: Epidemiologic Research. Principles and quantitative methods. London: Lifetime Learning Publications, 1982; 160-164, 434-435. 6. Fox ME, Harris RE, Brekken AL: The active-duty military pregnancy: A new high-risk category. Am J Obstet Gynecol 1977; 129:705-707. 7. Hauth JC, Gilstrap III LC, Brekken AL: The effect of 17a-hydroxyprogesterone caproate on pregnancy outcome in an active-duty military population. Am J Obstet Gynecol 1983; 146:187-190.
Pawtucket Heart Health Program Point-of-Purchase Nutrition Education Program in Supermarkets MARY K. HuNT, MPH, RD, R. CRMUG LEFEBVRE, PHD, MARY LYNNE HIXSON, MA, RD, STEPHEN W. BANSPACH, PHD, ANNLOUISE R. ASSAF, PHD, AND RIcHARD A. CARLETON, MD Abstract: Point-of-purchase nutrition education in supermarkets is one intervention strategy of the Pawtucket Heart Health Program, a community cardiovascular disease prevention program in Pawtucket, Rhode Island. Using consumer intercept interviews, awareness of shelf labels and their effect on purchase behavior have been continuously evaluated. Between 1984 and 1988, the percent of shoppers who could identify correct labels increased from 11 percent to 24 percent (95% confidence intervals of difference: 7,17). The percent who reported they were encouraged to purchase the identified foods increased from 36 percent to 54 percent (95% CI of difference: 5,41). (Am J Public Health 1990; 80:730-731.)
Introduction Because 57 percent of the adult population has blood cholesterol levels that put them at moderate or high risk for cardiovascular disease (CVD),1 many Americans need to change their dietary intake of saturated fat and cholesterol to reduce their blood cholesterol level and CVD risk. To reach this large number of people, Blackburn and Kottke delineate the need for population strategies.2,3 The Pawtucket Heart Health Program, a comprehensive community heart disease prevention study,4-7 developed the "Four Heart Program," a point-of-purchase (POP) nutrition education program in supermarkets and restaurants, as one of its From the Division of Health Education, Memorial Hospital of Rhode Island, Pawtucket, RI. Address reprint requests to Mary Lynne Hixson, MA, RD, Pawtucket Heart Health Program, Memorial Hospital of RI, Ill Brewster St., Pawtucket, RI 02860. Additional affiliations of the co-authors are: Department of Community Health, Brown University, Providence, RI (Lefebvre, Banspach, Assaf); and the Division of Cardiology, Memorial Hospital of Rhode Island, and Department of Medicine, Brown University (Dr. Carleton). This paper, submitted to the Journal August 8, 1989, was revised and accepted for publication December 20, 1989. C 1990 American Journal of Public Health 0090-0036/90$1.50
730
population strategies. We report the results of a study of consumer awareness of the supermarket program and its influence on self-reported purchase behavior. Methods The Four Heart supermarket program was started in three supermarkets owned by two different companies and one small family-owned market in 1983-84. The name, Four Heart, represents foods that are tasty and contain less fat, cholesterol, and sodium. The basis of the program is the placement of brand-specific shelf labels next to the unit price tags of qualifying foods. Original multi-colored shelf labels that identified products low in sodium, fat, and/or calories were replaced in 1986 with labels of uniform color with the messages: "low-fat", "low-sodium", "low-fat, low-sodium", and "fat ratio OK." Collateral and support materials include signs with health messages in areas where shelf labels cannot be applied; "Look for the Labels" posters with lucite holders for brochures; free recipe cards; periodic promotions such as contests and blood pressure and cholesterol screening, counseling and referral events (SCORES); and training of store and department managers and of lay volunteers as program monitors. Criteria used to determine the eligibility of foods for these labels were adapted from the Minnesota Heart Health Program8 and Food and Drug Administration (FDA) food labeling regulations and recommendations9'10 Whereas FDA-sponsored descriptive programs labeled all products in the store that met their nutrient criteria,11'12 we were interested in studying a more prescriptive program. Only those foods included in meal pattern recommendations based on the US Dietary Guidelines for Americans'3 are labeled. Consumer intercept interviews were conducted at approximately yearly intervals over four years in two supermarkets from two chains. Interviews were administered in a similar manner across all stores and time periods. AJPH June 1990, Vol. 80, No. 6
Apparently many respondents chose an unlicensed midwife because they were unable to locate a licensed provider who would attend an out-of-hospital birth. This is consistent with the finding that women attended by unlicensed midwives are more likely to reside in rural counties than their counterparts attended by licensed midwives or certified nursemidwives. Shared religious beliefs was another reason cited for the choice of birth attendant. It was later learned that some unlicensed midwives regard their practice as a ministry to serve fellow churchwomen. That two-thirds of mothers attended by unlicensed midwives paid a fee for service suggests that in most cases this was a professional relationship, not simply one friend helping another. Technically, unlicensed midwives who charge a fee are practicing illegally. However, because they are responding to the needs of particular groups of women, they are likely to continue to practice in spite of legal
prohibitions. Legislation prohibiting unlicensed midwives from practicing is rarely enforceable.2 Indeed, the real effect of such legislation has been to force unlicensed midwives to work in secret or to prevent them from seeking education and training.23 Providing an avenue to legal midwifery practice may be a more appropriate course of action so long as competence, equivalent to other licensed providers, can be demonstrated. REFERENCES 1. Joint Study Group of the International Federation of Gynecology and Obstetrics and the International Confederation of Midwives: Maternity Care in the World. Hampshire, England: C.M. Printing Services, 1976. 2. Owen M: Laws and policies affecting the training and practice of traditional birth attendants. Int Digest Health Legis 1983; 34:441-475. 3. World Health Organization: Report of the Consultation on Approaches for Policy Development for Traditional Health Practitioners, Including Traditional Birth Attendants. Geneva: WHO, 1985; 18.
Occupational Physical Activity and other Risk Factors for Preterm Birth among US Army Primigravidas GILBERT RAMIREZ, DRPH, RICHARD M. GRIMES, PHD, JOHN F. ANNEGERS, PHD, BARRY R. DAVIS, MD, PHD, AND CARL H. SLATER, MD Abstract: We examined the relation of occupational physical activity to the risk of preterm birth among US Army active-duty primigravidas between 1981 and 1984 using 604 cases (preterm deliveries; < 37 weeks gestation) and 6,070 controls (term and post-term deliveries). Women employed in the highest physical activity levels had increased odds of preterm delivery ranging from 1.69 to 1.75. The relation was not changed by adjustment for the effects of age, marital status, socioeconomic status, or education. Missing data suggest cautious interpretation. (Am J Public Health 1990; 80:728-729).
Introduction
Relatively few studies have examined the relation between physical activity on the job and the risk of preterm birth, and the findings have been mixed. In a French case-control study, risk of preterm birth was related to the number of sources of occupational fatigue and with a workweek longer than 40 hours.' This finding was not confirmed in a case-control study in New Haven, Connecticut;2 decreased risk of preterm birth was seen among women participating in sports or physical fitness exercises during pregnancy. Address reprint requests to Gilbert Ramirez, DrPH, Assistant Professor, Graduate Program in Allied Health Research, Lavaca Hall West, Southwest Texas State University, San Marcos, TX 78666-4616. Dr. Ramirez is a Major (Ret), US Army. All co-authors are from the University of Texas Health Science Center, School of Public Health, Houston, Texas. This paper, submitted to the Journal September 7, 1988, was revised and accepted for publication August 25, 1989. © 1990 American Journal of Public Health 0090-0036/90$1.50
728
The population of US Army active-duty gravidas presents an unusual opportunity to study the relation between preterm birth and occupational physical activity because of its large size and homogeneity, and because US Army military occupational specialties (MOS) had undergone physical demand assessments. Methods In 1977, entry level specialties for enlisted personnel were categorized by maximum upper body strength requirements as required for "combat conditions" performance (see Appendix).3 This physical activity measure was not a specific measure of actual physical activity during pregnancy. Data for this study were obtained from Patient Administration Systems and Biostatistics Activity, Fort Sam Houston, Texas for length of gestation (from maternal and infant inpatient records) and from US Army Military Personnel Center, Alexandria, Virginia for physical activity and other demographic data (from fiscal year personnel files). Each subject was assigned to her MOS physical activity level during pregnancy using the fiscal year corresponding to her mid-gestation date. US Army policy forbids the reassignment of women during pregnancy. The population of US Army active-duty gravidas delivering at US Army medical treatment facilities numbered 22,450 during the four-year period 1981-84. This period was chosen because of differences in coding schema for inpatient records prior to 1981; data for deliveries after 1984 were incomplete at the time of this study. Eligibility criteria for the study sample included primiparity, singleton delivery, and enlisted paygrade status. Officer occupations had not been assessed for physical demand requirements. Cases were defined as preterm deliveries (- 37 weeks gestation); controls included term and post-term deliveries. AJPH June 1990, Vol. 80, No. 6
PUBLIC HEALTH BRIEFS
Risk factors studied included age, race, pay grade, length of military service, marital status, education, occupational aptitude score, job skill level, and type of military unit. The latter two variables were included to control for the initial focus of the MOS physical demand analysis: "entry level skills in a combat environment." Military duties performed in a field unit closely resemble how they would be performed in a combat environment. The occupational aptitude score was included since it is also used to determine MOS eligibility. Odds ratios were computed for each separate risk factor. The dose-response relation between occupational physical activity and preterm birth was assessed with the Mantel test for trend.4 We also fitted a logistic regression model and estimated population attributable risk.5
Results Of the 22,450 US Army active-duty deliveries between 1981-84, 20,684 were to enlisted women. Of these, 20,218 were single live births. Using the mothers' Social Security Numbers (SSN), 12,911 of the 20,218 (64 percent) maternal inpatient records could be matched to infants' inpatient records. Seventy-two percent (9,262) of these matched records met the primiparity criterion. Using the maternal SSN, 7,821 were matched with personnel records. Of these, 1,147 records could not be used due to MOS data entry errors. The remaining sample of 6,674 included 604 cases and 6,070 controls. Odds ratios for each risk factor are presented in Table 1. Risk factors for preterm birth included the two highest TABLE 1-Estimates of Relative Risk for Preterm Birth Risk Factors Physical demand Low Medium Moderately Heavy Heavy Very Heavy (p-value, trend: 0.0056) Age (years) -20 50
*Occasional: 20% but < 80% of the ffme Constant: >80% of the time
1. Mamelle N, Laumon B, Lazar P: Prematurity and occupational activity during pregnancy. Am J Epidemol 1984; 119:309-322. 2. Berkowitz GS, Kelsey JL, Holford TR, Berkowitz RL: Physical activity and the risk of spontaneous preterm delivery. J Reprod Med 1983; 28:581-588. 3. Women in the Army Policy Review Group. Women in the Army policy review. Washington, DC: Department of the Army, 1982. 4. Schlesselman JJ: Case-control studies. Design, conduct, analysis. New York: Oxford University Press, 1982; 200-206. 5. Kleinbaum DG, Kupper LL, Morgenstern H: Epidemiologic Research. Principles and quantitative methods. London: Lifetime Learning Publications, 1982; 160-164, 434-435. 6. Fox ME, Harris RE, Brekken AL: The active-duty military pregnancy: A new high-risk category. Am J Obstet Gynecol 1977; 129:705-707. 7. Hauth JC, Gilstrap III LC, Brekken AL: The effect of 17a-hydroxyprogesterone caproate on pregnancy outcome in an active-duty military population. Am J Obstet Gynecol 1983; 146:187-190.
Pawtucket Heart Health Program Point-of-Purchase Nutrition Education Program in Supermarkets MARY K. HuNT, MPH, RD, R. CRMUG LEFEBVRE, PHD, MARY LYNNE HIXSON, MA, RD, STEPHEN W. BANSPACH, PHD, ANNLOUISE R. ASSAF, PHD, AND RIcHARD A. CARLETON, MD Abstract: Point-of-purchase nutrition education in supermarkets is one intervention strategy of the Pawtucket Heart Health Program, a community cardiovascular disease prevention program in Pawtucket, Rhode Island. Using consumer intercept interviews, awareness of shelf labels and their effect on purchase behavior have been continuously evaluated. Between 1984 and 1988, the percent of shoppers who could identify correct labels increased from 11 percent to 24 percent (95% confidence intervals of difference: 7,17). The percent who reported they were encouraged to purchase the identified foods increased from 36 percent to 54 percent (95% CI of difference: 5,41). (Am J Public Health 1990; 80:730-731.)
Introduction Because 57 percent of the adult population has blood cholesterol levels that put them at moderate or high risk for cardiovascular disease (CVD),1 many Americans need to change their dietary intake of saturated fat and cholesterol to reduce their blood cholesterol level and CVD risk. To reach this large number of people, Blackburn and Kottke delineate the need for population strategies.2,3 The Pawtucket Heart Health Program, a comprehensive community heart disease prevention study,4-7 developed the "Four Heart Program," a point-of-purchase (POP) nutrition education program in supermarkets and restaurants, as one of its From the Division of Health Education, Memorial Hospital of Rhode Island, Pawtucket, RI. Address reprint requests to Mary Lynne Hixson, MA, RD, Pawtucket Heart Health Program, Memorial Hospital of RI, Ill Brewster St., Pawtucket, RI 02860. Additional affiliations of the co-authors are: Department of Community Health, Brown University, Providence, RI (Lefebvre, Banspach, Assaf); and the Division of Cardiology, Memorial Hospital of Rhode Island, and Department of Medicine, Brown University (Dr. Carleton). This paper, submitted to the Journal August 8, 1989, was revised and accepted for publication December 20, 1989. C 1990 American Journal of Public Health 0090-0036/90$1.50
730
population strategies. We report the results of a study of consumer awareness of the supermarket program and its influence on self-reported purchase behavior. Methods The Four Heart supermarket program was started in three supermarkets owned by two different companies and one small family-owned market in 1983-84. The name, Four Heart, represents foods that are tasty and contain less fat, cholesterol, and sodium. The basis of the program is the placement of brand-specific shelf labels next to the unit price tags of qualifying foods. Original multi-colored shelf labels that identified products low in sodium, fat, and/or calories were replaced in 1986 with labels of uniform color with the messages: "low-fat", "low-sodium", "low-fat, low-sodium", and "fat ratio OK." Collateral and support materials include signs with health messages in areas where shelf labels cannot be applied; "Look for the Labels" posters with lucite holders for brochures; free recipe cards; periodic promotions such as contests and blood pressure and cholesterol screening, counseling and referral events (SCORES); and training of store and department managers and of lay volunteers as program monitors. Criteria used to determine the eligibility of foods for these labels were adapted from the Minnesota Heart Health Program8 and Food and Drug Administration (FDA) food labeling regulations and recommendations9'10 Whereas FDA-sponsored descriptive programs labeled all products in the store that met their nutrient criteria,11'12 we were interested in studying a more prescriptive program. Only those foods included in meal pattern recommendations based on the US Dietary Guidelines for Americans'3 are labeled. Consumer intercept interviews were conducted at approximately yearly intervals over four years in two supermarkets from two chains. Interviews were administered in a similar manner across all stores and time periods. AJPH June 1990, Vol. 80, No. 6
