Teenage birth rates declined substantially nationwide from 1990 to 1995 in the United States, according to a recent report from the National Vital Statistics System of the Centers for Disease Control and Prevention. The U.S. birth rate for teenagers in 1996 was 54.7 live births per 1000 women aged 15 to 19 years, down 4 percent from 1995 (56.8). The rate has declined steadily since 1991, when it was 62.1, an overall decline of 12 percent. These recent declines reverse the 24 percent rise in the teenage birth rate from 1986 to 1991. The rate for 1996 is still higher than it was during the early to mid-1950s (50–53 per 1000), however, when the rate was at its lowest point. Although black teenagers still have babies at almost twice the rate of whites, their birth rate declined 21 percent between 1991 and 1996, and is now at the lowest level ever reported. State-level teenage birth rates varied substantially in 1995, from 28.6 in Vermont to 105.5 in the District of Columbia. Other states with low rates included New Hampshire (30.6), Minnesota (32.4), North Dakota (33.5), and Maine (33.7). “What's significant is that these declines are in every state,” said Donna Shalala, Secretary of the U.S. Department of Health and Human Services. “I give a lot of credit to the African-American community, which has put out a clear consistent message from the churches, the schools, and all sorts of civic organizations, a drumbeat to young women that they should not become parents until they are truly ready to support a child” (Rochester Democrat & Chronicle, May 1, 1998:3A).

With a strong emphasis on breastfeeding for primary prevention, new “Recommendations to Prevent and Control Iron Deficiency in the United States” have been released by the Centers for Disease Control and Prevention (CDC), Department of Health and Human Services (MMWR 1998;47, April 3, No. RR-3). Iron deficiency is the most common known form of nutritional deficiency. Its prevalence is highest among young children and women of childbearing age, particularly pregnant women. In pregnant women it increases the risk for a preterm delivery and giving birth to a low-birthweight baby. Recommendations for primary prevention in infants and preschool children include the following:

Encourage breastfeeding of infants.

Encourage exclusive breastfeeding of infants (without supplementary liquid, formula, or food) for 4–6 months after birth.

When exclusive breastfeeding is stopped, encourage use of an additional source of iron (approximately (1 mg/kg per day of iron), preferably from supplementary foods.

For infants under 12 months who are not or partially breastfed, recommend only iron-fortified infant formula as a substitute for breastmilk.

For breastfed infants who receive insufficient iron from supplementary foods by age 6 months (i.e., < 1 mg/kg per day), suggest 1 mg/kg per day of iron drops.

For breastfed infants who were preterm or low birthweight, recommend 2–4 mg/kg per day of iron drops, starting at 1 month and continuing until 12 months after birth.

Encourage use of only breastmilk or iron-fortified infant formula for any milk-based part of the diet (e.g., in infant cereal) and discourage use of low-iron milks (e.g., cow's, goat's, and soy milk) until age 12 months.

Suggest that children aged 1–5 years consume no more that 24 oz of cow's, goat's, or soy milk each day.

Recommendations for primary and secondary prevention in pregnant women include the following:

Start oral, low-dose (30 mg/day) supplements of iron at the first prenatal visit.

Encourage pregnant women to eat iron-rich foods and foods that enhance iron absorption.

Pregnant women whose diets are low in iron are at additional risk for iron-deficiency anemia; guide these women in optimizing the dietary intake.

Screen for anemia at the first prenatal visit.

Electronic copies of the report can be obtained via the CDC's web site:, or a hard copy can be obtained by writing to the Division of Nutrition and Physical Activity, 4770 Buford Highway, NE, MS-K24, Atlanta, GA 30341–3717.

A bill designed to reduce the frequency of birth defects is expected to be signed by President Clinton (Nation's Health, April 1998:5). The bill directs the Centers for Disease Control and Prevention (CDC) to serve as a national clearinghouse for the collection and storage of data on birth defects. The measure provides funds for nonprofit groups to develop and implement birth defects prevention strategies, such as encouraging women of childbearing age to take the B-vitamin folic acid to prevent neural tube birth defects. States are encouraged to establish or improve data collection to aid the CDC in its efforts.

A recent United States study on RU-486 has found the drug highly effective and safe for terminating early pregnancies, laying the groundwork for the widespread use of the drug in the nation (Rochester Democrat & Chronicle, April 30, 1998:2A). The study, published in the New England Journal of Medicine, reported on 2015 women at 17 medical centers. It found that a combination of RU-486 and the already approved drug misoprostol was 92 percent effective in terminating pregnancies when used within the first 49 days after conception. The findings “confirm in the United States, with our ethnic groups and mix of women, that we have similar results to what was found in European trials,” said principal investigator Ann Robbins. “This is a safe and effective method for abortion in the United States.” U.S. Food and Drug Administration (FDA) approval cannot be completed, however, until a manufacturer is selected and the FDA inspects its facilities. A possible manufacturer has now been found, and sales are expected to begin in 1999.

Support for mothers to breastfeed in the workplace is provided in a bill recently introduced in the U.S. House of Representatives by Rep. Carolyn Maloney (D-N.Y.) (Nation's Health, May/June, 1998:14). According to Rep. Maloney, the courts have failed to interpret breastfeeding as a condition covered by the Pregnancy Discrimination Act. “Many women have been fired or discriminated against for using a breast pump to express breastmilk during the day, she said. “Some have been harassed on the job or had their pay withheld because they used lunchtime or other breaks to express milk.” The legislation would:

Clarify that a woman's right to breastfeed or express milk is protected under the Pregnancy Discrimination Act.

Encourage employers, through tax credits, to set up safe, private, sanitary, lactation-friendly environments.

Grant working women unpaid breaks adding up to as much as an hour a day for up to one year after the birth of a child to breastfeed or express milk.

Require the Food and Drug Administration to develop minimum quality standards for breast pumps.

Support a breastfeeding awareness campaign targeted to health professionals and the general public.

Expand breastfeeding promotion and education efforts through the federal Women, Infants and Children nutrition program.

Injuries to the anal sphincter during vaginal deliveries are surprisingly common and may cause fecal incontinence, according to national and international researchers reporting at the 1998 Annual Meeting of the American Society of Colon and Rectal Surgeons in San Antonio, Texas, May 2–7. They recommended that doctors should include questions about incontinence problems in routine postnatal follow-up examinations and, when forceps are used in delivery, refer mothers to a colon and rectal surgeon for follow-up. One-fifth of women suffered injuries to the anal sphincter muscle during vaginal deliveries, the researchers noted. Experts described anal sphincter damage in several studies from the United States and other countries. Dr Ylva Sahlin from Norway noted, “This is a hidden problem.” She said that in routine postnatal follow-up examinations patients are rarely asked specifically about incontinence problems, and they are unlikely to mention them without prompting. Scarring during the healing process can adversely affect the success of initial repairs to the sphincter, contributing to the high rate of incontinence in these cases. Standard therapies, including biofeedback and surgery, are effective in about 80 percent of cases, and new surgical procedures to repair or replace severely damaged anal sphincter muscles offer new hope to the remaining 20 percent. Many new treatment procedures that have been developed in Europe are gaining acceptance and being tested in the United States.

A newly appointed Task Force on Female Genital Mutilation/Female Circumcision by the American College of Obstetricians and Gynecologists (ACOG) plans an education program on the treatment of women who have undergone the procedure. In 1990 an estimated 168,000 girls and women who were living in the United States had undergone or were at risk for female genital mutilation; of these, 48,000 were younger than 18 years of age. The ACOG program will include an instructional slide-lecture kit for practicing physicians and for distribution to medical schools and ob-gyn residency programs. The kit will provide clinical information, and include topics on how to treat women who have had the procedure, how to talk to these women in a culturally sensitive manner, what complications to expect, how to deal with infibulated women who are pregnant, and when and where to refer women with emotional problems resulting from female genital mutilation. An informational brochure to be distributed to the entire fellowship is also planned.

The chances of blacks and women receiving a major diagnostic or therapeutic procedure while in the hospital is far less than for whites or men, according to a recent study (Ethnicity & Disease 1997;7:91–105). Black patients were less likely than their white counterparts to receive major therapeutic procedures for 37 of 77 conditions (48%). Women were less likely than men to receive major therapeutic procedures for 32 of 62 conditions (52%). Black women had a significantly lower rate of therapeutic procedures than white women for nearly all female reproductive system diseases. Blacks and women were less likely to receive a major diagnostic procedure for 21 and 26 percent of conditions, respectively. Studies on racial differences in procedure use show similar findings for hospitalization in the 1990s and mid-1980s. The authors concluded that this apparent variation by a patient's race or sex needs to be investigated.

Insurers that cover the new anti-impotence drug Viagra but do not pay for female contraception are guilty of “gender bias,” said the American College of Obstetricians and Gynecologists (ACOG) in a recent statement (Rochester Democrat & Chronicle, May 12, 1998:1A). “Pregnancy is a medical condition, just like impotence, and the cost benefit of preventing pregnancy is much greater than treating impotence,” said ACOG spokesperson, Dr Luella Klein of Emory University. Others disagree. Deacon Frank Clark of the Catholic Archdiocese of Philadelphia says that it is unfair to compare the two. “This pill helps men do something they should be able to do normally but can't because of a medical condition. Pregnancy isn't a medical condition; it's completely normal.” Many employer-sponsored insurance plans are covering Viagra for men but will not pay for women's birth control, placing an unfair financial burden on women, according to ACOG. Americans are divided over whether or not health plans should cover Viagra. In a recent USA Today/CNN/Gallup poll, 59 percent called the drug “a good thing for society as a whole,” but 50 percent said health plans should not pay for it. In a statement released recently, ACOG also supports a federal bill forcing insurers that offer prescription drug benefits to cover U.S. Food and Drug Administration-approved birth control.

“Changing times” are bringing to an end some cloth diaper laundry and delivery services around the country (Rochester Democrat & Chronicle, May 12, 1998:1A). After losing more than 85 percent of its customers since 1990, the only cloth diaper service in Rochester, New York, made its last pickup in May, and companies in Buffalo and Syracuse will also close. “It's kind of become a throwaway society,” said one owner from Syracuse. “People perceive paper diapers as being more convenient.” The reasons given are that most mothers work outside the home now, and disposable diapers, invented in the late 1960s, have become better and cheaper. Environmental groups touted the benefits of cloth diapers earlier this decade, but the message has waned. Caregivers at a Rochester day care center tried cloth diapers for about three years, beginning in 1989, but found the wetness soaked through clothes. “The disposables did the job better,” said the center's director. “More and more parents preferred disposables.”

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The Safe Motherhood Initiative is now in its eleventh year. The original sponsors of the initiative, after weighing the progress of the past decade, developed the following 10 action messages, which were the focus of the technical consultation on safe motherhood that took place in Columbo, Sri Lanka, in October 1997:

Establish safe motherhood as a human right.

Safe motherhood is a vital economic and social investment.

Empower women; ensure choices.

Delay marriage and first birth.

Every pregnancy faces risks.

Ensure skilled attendance at delivery.

Improve access to quality maternal health services.

Address unwanted pregnancy and unsafe abortion.

Measure progress.

Use the power of partnership.

Safe Motherhood now has its own site on the World Wide Web. The address of the home page is The Safe Motherhood website contains the fact sheets that are summarized in its newsletter, as well as much other information about making motherhood safer around the world. The Safe Motherhood newsletter is published three times a year, in English, Arabic, and French, by the Maternal and Newborn Health/Safe Motherhood Unit, Family and Reproductive Health, World Health Organization, 1211 Geneva 27, Switzerland. For a free subscription, please write to the above address.

A new peer-reviewed electronic journal was launched by the World Health Organization in March 1998. Its name is The WHO Reproductive Health Library, and it is a 3.5-inch computer diskette that contains reviews of controlled clinical trials on priority health topics, expert commentaries on the relevance for developing countries of the reviews, findings, and practical advice on the management of reproductive health problems. Its main purpose is to promote evidence-based care in the area of reproductive health by making available to health workers the most reliable and up-to-date medical information. It runs under the Windows operating system, with easy and rapid access to the data in it. Subscriptions are free of charge to health workers in developing countries. Others can access the reviews in the library through a paid subscription to The Cochrane Library, available from Update Software, Oxford, UK, and the American College of Physicians, Philadelphia, USA. For a copy of the WHO Reproductive Health Library, write to: HRP, World Health Organization, 1211 Geneva 27, Switzerland (Fax: 41-22-7914171; E-mail: khannaj\