therapy should remain a first treatment option for women with on-going or worsening continence symptom identified at follow-up afteranal sphincter injury.

670 Racial disparities in perinatal mortalityat 40, 41 and 42 weeks of gestationAnita C.J. Ravelli1, Jelle Schaaf2, Martine Eskes3, Esteriekde Miranda4, Ameen Abu Hanna1, Ben Willem J. Mol51Academic Medical Center, Medical Informatics, Amsterdam, Netherlands,2Academic Medical Center, Obstetrics and Gynecology, Amsterdam,Netherlands, 3Academic Medical Center, Medical Informatics, Amsterdam,Netherlands, 4Academic Medical Center, Obstetrics & Gynaecology,Amsterdam, Netherlands, 5Academic Medical Center, Obstetrics& Gynecology, Amsterdam, NetherlandsOBJECTIVE: Normal duration of pregnancy has long been thought tohave a uniform distribution over all different racial groups. We hy-pothesize that the normality of pregnancy duration is race specific,which urges the need of a tailored approach of the management postterm pregnancy.STUDY DESIGN: We used data from the nation wide Perinatal RegistryNetherlands from 1999 till 2008. All singleton infants born from 400/7 weeks of gestation onwards without congenital anomalies of thefour main racial groups were included. We used logistic regressionanalysis to assess both crude and adjusted perinatal mortality, which isa combination of fetal and neonatal mortality within 7 days after birth.RESULTS: The overall perinatal mortality was 1586 in 755,615 infants;2.1 per 1000. Perinatal mortality risk was 1.9 per 1000 at 40 weeks andincreased to 2.4 at 41 weeks and 2.3 at 42 weeks, which was signifi-cantly different from 40 weeks (p�0.001). Overall, the South Asian,African/Creole and Mediterranean women had increased risk of peri-natal mortality compared to Caucasian women (adjusted odds ratios2.5 95% CI 1.5-4.2, 1.8 95% CI 1.2-2.8 and 1.6 95% CI 1.3-2.1, respec-tively). South Asian and African women delivered earlier than Cau-casian women (p�0.001). South Asian women had significantly in-creased risks of perinatal mortality especially at 41 weeks of gestation(9.2 per 1000). African/Creole women risks were increased at both 40and 41 weeks (2.6 and 4.4 per 1000 respectively). Mediterraneanwomen had significantly increased risk of perinatal mortality at both41 and 42 weeks (4.3 and 2.7 per 1000 respectively). When the analysiswas restricted to spontaneous onset of labor the same patternsemerged (see figure).CONCLUSION: South Asian, African/Creole and Mediterranean womenhave increased risk of perinatal mortality from 40 weeks onwards.South Asian and African/Creole have a shorter duration of pregnancyas compared to Caucasian women. These data suggest that inductionof labor for post term pregnancy should be considered at a youngergestational age for non-Caucasian women.

671 Prevalence of and risk factors for pica amongpregnant women in Chhattisgarh, IndiaAdeline Boatin1, Blair Wylie2, Mrigendra Pal Singh3, NeeruSingh3, Kojo Yeboah-Antwi4, Davidson Hamer4

1Massachusetts General Hospital, OB/GYN, Boston, MA, 2MassachusettsGeneral Hospital, Department of Obstetrics and Gynecology, Boston, MA,3National Institute for Malaria Research Field Station, National Institutefor Malaria Research Field Station, Madhya Pradesh, India, 4Centerfor Global Health and Development, Center for GlobalHealth and Development, Boston, MAOBJECTIVE: Pica refers to the ingestion or craving for nonfood itemssuch as soil, clay or chalk. Reported prevalence in pregnancy has var-ied widely (e.g., 0.02% Denmark; 74% Kenya). Studies have demon-strated an association between pica and iron deficiency anemia al-though whether pica is a cause or consequence remains uncertain. Anincrease in parasitic infections, electrolyte disturbances and gastroin-testinal complications has also been linked with pica. We sought todetermine the prevalence of pica, identify risk factors, and evaluate theassociation with anemia among pregnant women in India.STUDY DESIGN: In 2 districts in Chhattisgarh, India, 2386 pregnantwomen were enrolled during routine antenatal visits over 12 months(2007-08) to assess malaria prevalence. Information about pica wascollected and blood was obtained by fingerstick for hemoglobin (Hgb)determination.RESULTS: Approximately one-quarter (637/2386, 27%) of the subjectsreported the consumption of chalk, mud-pot or raw rice during preg-nancy. Moderate to severe anemia (Hgb � 9 g/dL) was quite commonin the population (23%) but significantly higher among those withpica (30.9% vs 20.5%, p �0.0001). Risk factors for pica included feweryears of education (p �0.001), engagement in agricultural work(p�0.01), and membership among historically disadvantaged castes(Scheduled Caste, Scheduled Tribals) (p�0.0001). In addition, picawas more frequent among women who chewed tobacco comparedwith those who did not (46.5% vs 24.6%, p�0.0001). Age, parity,home ownership, use of iron supplements, malaria parasitemia,chronic disease, and smoking were not associated with pica.CONCLUSION: Pica was relatively common among this cohort of Indianpregnant women and significantly associated with anemia. Identifiedrisk factors suggest a link with socioeconomic status. Given these find-ings, further observational and qualitative research is needed to clarifymaternal behaviors and the potential impact of pica on maternal andfetal health.

672 Does health care system distrust influenceutilization of prenatal care services?Caroline Kelly1, Brittany A. Verhelst1, Sarah E. Gearhart1,Joanna E. Adamczak1, Sindhu K. Srinivas1

1University of Pennsylvania Perelman School of Medicine,Maternal and Child Health Research Program, Departmentof Obstetrics and Gynecology, Philadelphia, PAOBJECTIVE: Racial disparities are evident among many obstetrical out-comes. Studies show that blacks have lower trust in the health caresystem and this is associated with worse health status in multiple dis-ease states, likely due to interference with seeking medical care andadherence. Our objective was to evaluate whether health care systemdistrust (HCSD) influences utilization of prenatal care (PNC) ser-vices.STUDY DESIGN: We performed a prospective cohort study of womenobtaining PNC at the Hospital of the University of Pennsylvania be-tween October 2009 and June 2011. Participants completed a vali-dated 9-item questionnaire (score 9-45) on HCSD during a prenatalvisit (PNV) prior to 16 weeks gestation. Data on PNV and emergencyroom (ER) visits was collected via electronic medical record abstrac-tion. Associations between distrust scores and measures of PNC uti-lization were analyzed using Spearman correlation, chi-square analy-ses and student’s T-tests.

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RESULTS: 418 women completed the questionnaire. The mean HCSDscore was 21.3 (SD 5.4). Mean scores were higher for blacks thannon-blacks (22 vs. 20.3, p�0.001). The distrust score was not associ-ated with receipt of care in the first trimester (p�0.76) or compliancewith antenatal testing (p�0.14). There was a trend toward a higherHCSD score being associated with a lower number of PNV (p�0.07).The distrust score was associated with the number of times a patientdid not attend a scheduled appointment (p�0.009). Patients withHCSD scores in the highest quartile had nearly two fold greater oddsof missing at least one scheduled PNV (OR�1.95 [1.29-2.96],p�0.002). Subjects with higher distrust scores were also more likely topresent to the ER for care (OR�1.48 [0.99-2.22], p�0.06). Not show-ing up for scheduled care was positively associated with total ER visits(p�0.001).CONCLUSION: HCSD is associated with a lower show rate for scheduledPNV and with greater ER visits. Exploring reasons for distrust and healthsystems based approaches to improving trust may improve care delivery,adherence and outcomes. ACOG Bayer Healthcare Grant (Srinivas).

673 Maternal dietary patterns during pregnancyand associated nutrient intakesCiara McGowan1, Jennifer Walsh2, Jacinta Byrne1,Michael Foley3, Fionnuala McAuliffe4

1UCD Obstetrics & Gynaecology, School of Medicine and Medical Science,Dublin, Ireland, 2National Maternity Hospital, Obstetrics and Gynaecology,Dublin, Ireland, 3UCD Obstetrics and Gynaecology, School of Medicine andMedical Science, Dublin, Ireland, 4UCD Obstetrics and Gynaecology,School of Medicine and Medical Science, Dublin, IrelandOBJECTIVE: Pregnancy is the most important stage of a womens lifecycle where nutrition is essential for an optimum pregnancy outcome.Dietary pattern analysis is becoming a popular method of determin-ing habitual dietary patterns during pregnancy. Cluster analysis is onetechnique that can be used to identify clusters or groups of subjectswith similar dietary characteristics. The aim of this study was to ex-amine the dietary patterns among pregnant women using cluster anal-ysis and to explore their relationship with maternal nutrient intakes.STUDY DESIGN: Two hundred and fifteen pregnant women were re-cruited from the antenatal clinic at the National Maternity Hospital,Dublin, Ireland. All participants completed a 3 day food diary duringeach trimester of pregnancy. Dietary data were entered into NetWISPversion 3.0 (Tinuviel software, Llanfechell, Anglesey, UK) and anal-ysed using k-means cluster analysis in PASW statistics version 18.0(SPSS Inc., Chicago, IL, USA). One way ANOVA test was used tocompare nutrient intakes between clusters.RESULTS: Two major dietary patterns were identified when all 3 trimes-ters of pregnancy were combined: healthy and western. Women consum-ing a healthy pattern were significantly older in age and had lower BMI(p�0.001). Energy intake was similar in both clusters. Women consum-ing a healthy pattern had significantly greater intakes of vitamin C, folate,iron and calcium and significantly lower intakes of fat and saturated fat asa percentage of total energy (p � 0.001).CONCLUSION: Healthy dietary patterns in pregnancy are associatedwith better nutrient intakes. Dietary pattern analysis which capturestotal dietary intake may be superior to other methods of nutritionalassessment and could contribute to the development of healthy eatingguidelines for pregnancy.

674 Decision making in prenatal screening; money mattersE.J. (Joanne) Verweij1, Diederik Veersema2,Eva Pajkrt3, Monique Haak4

1Leiden University Medical Center, Department of Obstetrics, Leiden,Netherlands, 2Synergos, Ultrasound Obstetrics and Gynaecology, Eindhoven,Netherlands, 3Academic Medical Center, Department of Obstetrics andGynaecology, Amsterdam, Netherlands, 4Leiden University Medical Center,Department of Obstetrics and Gynaecology, Leiden, NetherlandsOBJECTIVE: Multiple factors influence pregnant women in their decisionto accept or decline prenatal screening. The combined test (CT), consist-ing of maternal serum screening and nuchal translucency (NT) measure-

ment identifies women at risk for trisomy 21, 18 or 13. In the Netherlandseveryone is insured and every pregnant woman has to be informed aboutthe CT. The costs (150 euro) of the CT are, however, only reimbursed forwomen �36 years. The 20 week anomaly scan is covered by insurance foreveryone. The aim of our study was to determine the influence of with-drawal of reimbursement on the uptake of the CT.STUDY DESIGN: In an ultrasound center designated to service a geo-graphical area, the CT and 20 week scan were performed for free to tryout the system before the national introduction of both tests between2004 and March 2007. After this period the insurance companies sud-denly stopped paying for the CT in women � 36 years, according tothe national screening program design. The difference in number ofwomen opting for the CT 20 months before and after April 2007 wasstudied. The monthly number of 20 week anomaly scans, performedin the same ultrasound center, was used as a reference.RESULTS: There was a significant decline (p�0.001) of NT scans (fig.1) after April 2007. The mean number of NT’s was 381 (range 319-445) and 247 (range 205-318), before and after April 2007, respec-tively. The total number of 20 week scans in the same ultrasoundcenter remained stable (p�0.15).CONCLUSION: Money matters as we observed a significant reduction inCT with the introduction of a national screening program. Althoughcounselling of the health-care provider might have changed simulta-neously, the financial impact on the uptake of the CT should not beunderestimated. Furthermore the fact that women � 36 years have topay personally in a fully insurance-covered health care system mightact as a sign from the government that the CT is not important forpregnant women. Policy makers and health insurance companiesshould reconsider if the introduction of personal costs in a nationalscreening program is ethical.

675 Adolescent pregnancy is associatedwith reduced final adult heightJaimey Pauli1, Allen Kunselman2, Christy Stetter3,Thomas Lloyd2, William Dodson4, Richard Legro4

1Penn State - Milton S. Hershey Medical Center, Division of Maternal FetalMedicine, Hershey, PA, 2Penn State College of Medicine, Public HealthSciences, Hershey, PA, 3Penn State College of Medicine, Public HealthSciences, Hershey, PA, 4Penn State - Milton S. Hershey MedicalCenter, Division of Reproductive Endocrinology, Hershey, PAOBJECTIVE: Adolescent mothers are at increased risk compared toadult women for complications of pregnancy, with one proposedmechanism being a competition between the still-growing motherand her fetus for resources. There are conflicting data in the literatureabout whether maternal growth halts during an adolescent preg-nancy, and there are very few studies examining the final outcome of

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