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ORIGINAL RESEARCH |
From the Graduate School of Public Health, Department of Epidemiology and Biostatistics, San Diego State University, San Diego, California; Naval Health Research Center, San Diego, California; Department of Pediatrics, Division of Adolescent Medicine, and Department of Laboratory Medicine, University of California, San Francisco, California; and Navy Environmental Preventive Medicine Unit No. 5, San Diego, California.
Address reprint requests to: Anne Goldzier Thomas, PhDc, Naval Health Research Center, Operational Readiness Research Program, P.O. Box 85122, San Diego, CA 92186; E-mail: thomas{at}nhrc.navy.mil.
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ABSTRACT |
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METHODS: Participants were surveyed and urine was collected for pregnancy testing using standard laboratory methods and detection of C. trachomatis and N. gonorrhoeae infection by ligase chain reaction. Self-administered surveys facilitated collection of demographics, sexual behavior, including contraceptive use, sexual partners, sexually transmitted disease, and pregnancy history.
RESULTS: Among 299 of 314 participants, the prevalence of chlamydial infection was 4.7% and of pregnancy was 9.7%, with 48.3% of the pregnancies unplanned. Chlamydia trachomatis infection was univariately associated with having a new sex partner within the last 6 months, more sexual partners, single marital status, condom use, drinking until passing out or vomiting in the past 30 days (alcohol misuse), and current pregnancy. Unplanned pregnancy was univariately associated with young age, single marital status, inconsistent condom use, having a new sex partner within the last 6 months, and more recent sexual partners. Among the pregnant women, four (13.8%) were infected with C. trachomatis.
CONCLUSION: The high rates of chlamydial infection and unplanned pregnancy found in this population of employed young women with ready access to health care and health education underscore the challenge of enhancing reproductive health via compliance with effective contraceptive and sexually transmitted disease prevention methods. This is a challenge that remains unmet.
Inadequate use of barrier methods for sexually transmitted disease (STD) prevention and hormonal methods of contraception for pregnancy have contributed to epidemic rates of STDs and unplanned pregnancy in the United States1 and elsewhere.2 Genital Chlamydia trachomatis (C. trachomatis) infection, with sequelae of pelvic inflammatory disease, tubal infertility, and perinatal transmission,3 is the most common reportable bacterial disease in the United States. There were 607,602 cases of chlamydia reported to the Centers for Disease Control and Prevention in 1998,4 with costs estimated at $2 billion.5 Unplanned pregnancy is reported in approximately 56% of all pregnancies in the United States,1 and recent data from the United States National Survey of Family Growth indicate that approximately half of these terminate in abortion.6
With the licensure of urine-based nucleic acid amplification screening tests for C. trachomatis and Neisseria gonorrhoeae (N. gonorrhoeae),7–9 there have been a number of studies reporting rates of asymptomatic chlamydial and gonoccocal infections in general clinics,10 as well as in nonclinic-based population samples.11 Although unplanned pregnancy is recognized as another important adverse outcome of sexual behavior, there have been limited studies comparing both STDs and unplanned pregnancy in the same study group. Further, to our knowledge, there has not been a publication in which a population of healthy women was screened for current pregnancies that were characterized according to intendedness of pregnancy. The goal of this study was to apply urine-based ligase chain reaction for C. trachomatis and N. gonorrhoeae detection and urine-based pregnancy testing for Navy-enlisted women, and to compare the prevalence and epidemiologic correlates of these adverse reproductive outcomes.
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MATERIALS AND METHODS |
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All participants signed a consent form, approved by the Committee for the Protection of Human Subjects, Naval Health Research Center, San Diego. Participants completed a self-administered questionnaire that included demographics, STD and pregnancy history, 6-month history of sexual activity, and risk behaviors, as well as contraceptive use. A first-void urine sample, defined as the first 30–50 mL of micturition, was collected for pregnancy, chlamydial, and gonococcal diagnostic testing from all but 15 participants who were unable to provide a sample. All participants with a positive STD or pregnancy test were referred to the regional clinic for standard medical evaluation and treatment.12 This research was conducted in compliance with all applicable Federal Regulations governing the protection of human subjects in research.
An aliquot of the unspun urine was frozen to -70C and shipped on dry ice to the Department of Laboratory Medicine, University of California, San Francisco. Chlamydia trachomatis and N. gonorrhoeae were detected using LCx for C. trachomatis and N. gonorrhoeae assays (Abbott Laboratories, Abbott Park, IL). Urine-based pregnancy testing was performed using standard laboratory procedures at a Navy medical command.
Results are reported for 299 of 314 (95.2%) women surveyed for whom there were urine samples available for diagnostic testing. Frequencies of descriptive and risk characteristics of the population were tabulated. Contraceptive use analysis was limited to sexually active women who were defined as women reporting history of sexual activity ever and having at least one sexual partner within the prior 6 months. Current pregnancies, identified by urine screening, were categorized as planned or unplanned. An unplanned pregnancy was defined as a positive urine screen for pregnancy in a woman who either stated she was pregnant and reported the pregnancy as unintended or stated she was not pregnant and reported no intention of becoming pregnant within the next 6 months. Univariate statistics for chlamydial infection and pregnancy intention outcomes were performed using Pearson 
2, Fisher exact test, and Student t tests. Logistic regression was used to evaluate the association and predictive value of risk factors for chlamydial infection and unplanned pregnancy. All statistical analyses were performed using SAS statistical software (SAS 8.00 ed., 1999, SAS Institute, Inc., Cary, NC).
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RESULTS |
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. The women were generally young, and the majority were white. Approximately half of the population was single and all had completed high school, with 42.3% having at least some post-high school vocational or college education. Two of the women reported they had not "ever had sex" and were thus excluded from analysis of current sexual behavior. Of the sexually active participants, 30.0% reported that they had not used any method of birth control the last time they engaged in sexual intercourse.
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Chlamydia trachomatis infections were detected in 14 of 299 (4.7%, confidence interval [CI] 0.023, 0.071) of the women, whereas no N. gonorrhoeae infections were detected. Demographic characteristics and risk factors for chlamydial infection in univariate analyses are shown in Table 1
. No statistically significant associations were found between chlamydial infection and age, ethnicity, educational attainment, Navy command type (ship- or shore-based), age at first intercourse, ever being diagnosed with STD, or history of pregnancy.
In a multivariable logistic regression model of chlamydial infection, with covariates of misuse of alcohol and current pregnancy, the odds of being diagnosed with chlamydial infection were nearly five times higher for women who were currently pregnant, after adjustment for history of misuse of alcohol, defined as drinking until passing out or vomiting within the past 30 days (odds ratio [OR] 4.7, 95% CI 1.3, 16.7, Wald X2 = 5.7, P = .02). The odds of chlamydial infection were more than six times higher among women who reported misuse of alcohol, after adjustment for current pregnancy (OR 6.6, 95% CI 1.6, 27.8, Wald X2 = 6.6, P = .01, Table 2).
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. Women with unplanned pregnancies were generally unmarried, younger, had new or multiple sex partners, and reported more frequent although inconsistent use of condoms in the last 6 months. There were no statistically significant differences reported between the two pregnancy groups for educational attainment, history of previous pregnancy, command type, or misuse of alcohol.
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Univariable analysis of risk factors for current unplanned pregnancy compared with all others not currently having an unplanned pregnancy shows statistically significant differences as follows: marital status, P = .03; sex with a new partner in the last 6 months, P = .02; and age, P = .05. Using multivariable logistic regression with backwards selection, modeling current unplanned pregnancy, and starting with the univariably significant variables yields a model with one significant variable, marital status. Unmarried women are more than four times as likely as married women to report the intendedness of their pregnancy as unplanned (OR 4.1, 95% CI 1.1, 14.9, Wald X2 = 4.5, P = .03, Table 4).
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DISCUSSION |
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Misuse of alcohol and current pregnancy were the risk factors most strongly associated with chlamydial infection in the multivariable model. The significant association between chlamydial infection and pregnancy is particularly disturbing. Chlamydial infection places the women at reproductive risk, heralding potential perinatal morbidity for the infant from untreated chlamydial infection and possibly other undetected STDs. The association between misuse of alcohol and chlamydial infection supports associations seen in other studies linking STDs and alcohol abuse.13 Most studies examining the relationship between alcohol and STD, focusing generally on STD-related behaviors rather than STD prevalence, have found alcohol associated with a self-reported history of STDs14 and multiple partners.13,15–17 Future studies, using biologic STD outcomes, should further investigate the association of alcohol and STDs.
The substantial rates of unplanned pregnancy and asymptomatic chlamydial infection in this population of women with negligible barriers to health care and contraception are quite striking. Interestingly, in this study, the rates of these adverse outcomes do not seem to be linked to ship- versus shore-based environment. Access to health care has been cited as one of the important factors contributing to unplanned pregnancies and STDs in women in the civilian population, and it is a strategic target in the recommendations of the Institute of Medicine’s 1995 report on unplanned pregnancy.18 The military health care system with its geographic colocation of services, lack of fees for services or medications, and minimal waiting time for appointments provides an opportunity to assess the importance of these barriers. In light of the fact that all of the women had completed high school, and 43% had some courses beyond high school, it is assumed that there were no barriers to accessing health care because of educational deficiencies. Additionally, the military provides mandatory ongoing health education for all personnel emphasizing reducing unplanned pregnancies and maintaining sexual health. The high rates of STDs and unplanned pregnancies found in this population support the contention that complex behavioral factors contribute to unplanned pregnancy and STDs and warrant further study.
Because the risk of pelvic inflammatory disease, infertility, and ectopic pregnancy increases with repeated infections,19,20 early detection and treatment of chlamydial infections can substantially reduce personal and societal costs. This current study demonstrates the feasibility of applying noninvasive screening for STDs and pregnancy in nonclinic settings. Current Health Plan Employer Data and Information Set (HEDIS) guidelines for chlamydia call for screening of 15–26 year olds,21,22 and other studies11,23 have recommended age as a sole screening criteria. However, guidelines are still being formulated, and the finding in this study that more than 28% of those with chlamydial infection were older than 25 years of age highlights the need for population-specific guidelines.24
A 9.7% prevalence of pregnancy was found, with nearly half of these reported as unplanned. The only risk factor found to be significant for unplanned pregnancy was single marital status. There are few population-based studies of pregnancy prevalence and pregnancy intention in healthy young women with which to compare these rates. The proportion of unintended pregnancies was slightly higher than the 31% rate found in 1994 by the National Surveys of Family Growth.1,25 Previous military studies have also described rates of unplanned pregnancy from 55% in a population of pregnant Army personnel26 to 69% in younger pregnant Navy women in their first enlistment.27 Most published surveys of pregnancy intendedness, including the Family Growth Survey, have elicited information from women regarding previous pregnancies. This study measured intendedness at the time of current pregnancy, before the birth of the child, and thus the characterization of intendedness was less influenced by recall bias, and the mother’s attitude toward a child already born.
Limitations of this study include a small sample size and the cross-sectional study design, which does not permit assessment of causation, merely strength of association with risk factors. This is a population-based study of young female military personnel in which the women originate from all over the United States and its territories, which strengthens its comparison with other populations of young women.
The findings of high rates of asymptomatic chlamydial infection and unplanned pregnancy, in a population of healthy, well-educated, employed young women with ready access to health care, emphasizes the challenge of the recent directives in Healthy People 2010, which call for more effective and aggressive strategies to reduce STDs and unplanned pregnancy in United States adolescents.28 Currently, except for condoms, there are no "dual" purpose methods that both protect from STDs and unplanned pregnancy. Oral contraceptives provide effective protection for pregnancy but do not protect for STDs; barrier protection is more effective for STD prevention, but less effective for contraception. Effective strategies will require technologic advances in contraception and barrier protection, including dual-purpose products that can protect before, during, and after a potential unprotected event. Additionally, interventions will have to be developed to more effectively address the complex realities of interpersonal behavior and communication, sexual behavior, and substance misuse.
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Footnotes |
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Disclaimer: The views expressed in this article are those of the authors and do not reflect the official policy or position of the Department of the Navy, Department of Defense, or the United States Government.
Received April 13, 2001. Received in revised form July 16, 2001. Accepted August 2, 2001.
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REFERENCES |
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2. Gerbase AC, Rowley JT, Heymann DH, Berkley SF, Piot P. Global prevalence and incidence estimates of selected curable STDs. Sex Transm Infect 1998;74(Suppl 1):S12–6.
3. Chow JM, Yonekura ML, Richwald GA, Greenland S, Sweet RL, Schachter J. The association between Chlamydia trachomatis and ectopic pregnancy. A matched-pair, case-control study. JAMA 1990;263:3164–7.[Abstract]
4. Division of STD Prevention. Sexually Transmitted Disease Surveillance 1998 Supplement, Chlamydia Prevalence Monitoring Project. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention, 1999.
5. Institute of Medicine. The hidden epidemic: Confronting sexually transmitted diseases. Washington, DC: National Academy Press, 1996.
6. Henshaw SK. Unintended pregnancy in the United States. Fam Plann Perspect 1998;30:24–9, 46.[Medline]
7. Schachter J, Stamm WE, Quinn TC, Andrews WW, Burczak JD, Lee HH. Ligase chain reaction to detect Chlamydia trachomatis infection of the cervix. J Clin Microbiol 1994;32:2540–3.
8. Lee HH, Chernesky MA, Schachter J, Burczak JD, Andrews WW, Muldoon S, et al. Diagnosis of Chlamydia trachomatis genitourinary infection in women by ligase chain reaction assay of urine. Lancet 1995;345:213–6.[Medline]
9. Genec M, Meardh A. A cost-effectiveness analysis of screening and treatment for Chlamydia trachomatis infection in asymptomatic women. Ann Intern Med 1996;124:1–7.
10. Boyer CB, Shafer MA, Teitle E, Wibbelsman CJ, Seeberg D, Schachter J. Sexually transmitted diseases in a health maintenance organization teen clinic: Associations of race, partner’s age, and marijuana use. Arch Pediatr Adolesc Med 1999;153:838–44.
11. Munk C, Morrae SA, Kjaer SK, Poll PA, Bock JE, Meijer CJ, et al. PCR-detected Chlamydia trachomatis infections from the uterine cervix of young women from the general population: Prevalence and risk determinants. Sex Transm Dis 1999;26:325–8.[Medline]
12. Centers for Disease Control and Prevention. 1993 Sexually transmitted diseases treatment guidelines. MMWR 1993;42:1–102.[Medline]
13. Morrison TC, DiClemente RJ, Wingood GM, Collins C. Frequency of alcohol use and its association with STD/ HIV-related risk practices, attitudes and knowledge among an African-American community-recruited sample. Int J STD AIDS 1998;9:608–12.
14. Ericksen KP, Trocki KF. Behavioral risk factors for sexually transmitted diseases in American households. Soc Sci Med 1992;34:843–53.
15. Santelli JS, Brener ND, Lowry R, Bhatt A, Zabin LS. Multiple sexual partners among US adolescents and young adults. Fam Plann Perspect 1998;30:271–5.[Medline]
16. Anderson JE, Dahlberg LL. High-risk sexual behavior in the general population. Results from a national survey, 1988–1990. Sex Transm Dis 1992;19:320–5.[Medline]
17. Graves KL. Risky sexual behavior and alcohol use among young adults: Results from a national survey. Am J Health Promot 1995;10:27–36.[Medline]
18. Brown SS, Eisenberg L, eds. The best intentions: Unintended pregnancy and the well-being of children and families. Committee on Unintended Pregnancy, Division of Health Promotion and Disease Prevention, Institute of Medicine. Washington, DC: National Academy Press, 1995.
19. Hillis SD, Owens LM, Marchbanks PA, Amsterdam LF, Mac Kenzie WR. Recurrent chlamydial infections increase the risks of hospitalization for ectopic pregnancy and pelvic inflammatory disease. Am J Obstet Gynecol 1997;176: 103–7.[Medline]
20. Howell MR, Gaydos JC, McKee KT Jr, Quinn TC, Gaydos CA. Control of Chlamydia trachomatis infections in female Army recruits: Cost-effective screening and treatment in training cohorts to prevent pelvic inflammatory disease. Sex Transm Dis 1999;26:519–26.[Medline]
21. National Committee for Quality Assurance. HEDIS® 2000 Technical Specifications, Volume 2. Washington, DC: National Committee for Quality Assurance, 1999:68–70.
22. Mangione-Smith R, O’Leary J, McGlynn EA. Health and cost-benefits of chlamydia screening in young women. Sex Transm Dis 1999;26:309–16.[Medline]
23. Gaydos CA, Howell MR, Pare B, Clark KL, Ellis DA, Hendrix RM, et al. Chlamydia trachomatis infections in female military recruits. N Engl J Med 1998;339:739–44.
24. Miller WC, Hoffman IF, Owen-O’Dowd J, McPherson JT, Privette A, Schmitz JL, et al. Selective screening for chlamydial infection: Which criteria to use? Am J Prev Med 2000;18:115–22.[Medline]
25. Mosher WD, Bachrach CA. Understanding US fertility: Continuity and change in the National Survey of Family Growth, 1988–1995. Fam Plann Perspect 1996;28:4–12.[Medline]
26. Clark JB, Holt VL, Miser F. Unintended pregnancy among female soldiers presenting for prenatal care at Madigan Army Medical Center. Mil Med 1998;163: 444–8.[Medline]
27. Royle MH, Thomas P. Reducing unplanned pregnancies in the Navy. San Diego: Navy Personnel Research and Development Center, 1996:29.
28. Healthy People 2010. Washington, DC: US Department of Health and Human Services, 2000.
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