[Two-year follow-up of infants born at 24 weeks gestation; first outcomes following implementation of the new 'Guideline for perinatal policy in cases of extreme prematurity']

OBJECTIVE

Since 2010 the guideline 'Guideline for perinatal policy in cases of extreme prematurity' has advised an active policy in infants born at 24 weeks gestation. We investigated how infants born at 24 and 25 weeks gestation in the first year following the implementation of the guideline had developed by the age of 2 years.

DESIGN

Retrospective national cohort study.

METHOD

The study population consisted of all surviving infants born in the Netherlands at 24 or 25 weeks gestation in the period from 1 October 2010 to 1 October 2011. At a corrected age of 2 years the children underwent a general physical and neurological examination, and their cognitive scores were determined on the 'Bayley scales of infant and toddler development' (Bayley III). Examinations took place in the 10 neonatal intensive care units (NICU's) in the Netherlands.

RESULTS

Of 185 extremely premature infants, 166 were admitted to a NICU. A total of 95 survived to a corrected age of 2 years; 78 (82%) children were examined. Their average cognitive score on the Bayley III scale was 88 (SD: 16). Among the children born at 24 weeks gestation, 20% had mild disabilities and 20% had moderate to severe disabilities. Among the children born at 25 weeks gestation, 17% had mild disabilities and 12% had moderate to severe disabilities.

CONCLUSION

Of the children born at 24 weeks gestation in the first year after the introduction of active policy in the Netherlands and surviving to 2 years of age (46%), more than half had developed without disabilities. This was comparable to children born at 25 weeks gestation. Of all children born at 24 weeks gestation, 25% survived to 2 years of age without disabilities.

Nairobi Newborn Study: a protocol for an observational study to estimate the gaps in provision and quality of inpatient newborn care in Nairobi City County, Kenya

INTRODUCTION

Progress has been made in Kenya towards reducing child mortality as part of efforts aligned with the fourth Millennium Development Goal. However, little advancement has been made in reducing mortality among newborns, which now accounts for 45% of all child deaths. The frequently unanticipated nature of neonatal illness, its severity and the high dependency of sick newborns on skilled care make the provision of inpatient hospital services one key component of strategies to improve newborn survival.

METHODS AND ANALYSES

This project aims to assess the availability and quality of inpatient newborn care in hospitals in Nairobi City County across the public, private and not-for-profit sectors and align this to the estimated need for such services, providing a description of the quantity and quality gaps between capacity and demand. The population level burden of disease will be estimated using morbidity incidence estimates from a literature review applied to subcounty estimates of population-adjusted births, providing a spatially disaggregated estimate of need within the county. This will be followed by a survey of neonatal services across all health facilities providing 24/7 inpatient newborn care in the county. The survey will include: a retrospective audit of admission registers to estimate the usage of facilities and case-mix of patients; a structural assessment of facilities to gain insight into capacity; a questionnaire to nursing staff focusing on the process of delivering key obstetric and neonatal interventions; and a retrospective case audit to assess adherence to guidelines by clinicians.

ETHICS AND DISSEMINATION

This study has been approved by the Kenya Medical Research Institute Scientific and Ethics Review Unit (SSC protocol No.2999). Results will be disseminated: to participating facilities through individualised reports and a joint workshop; to local and national stakeholders through meetings and a summary report; and to the international community through peer-review publication and international meetings.

Integrated Approach to Reduce Perinatal Adverse Events: Standardized Processes, Interdisciplinary Teamwork Training, and Performance Feedback

OBJECTIVE

To improve safety practices and reduce adverse events in perinatal units of acute care hospitals.

DATA SOURCES

Primary data collected from perinatal units of 14 hospitals participating in the intervention between 2008 and 2012. Baseline secondary data collected from the same hospitals between 2006 and 2007.

STUDY DESIGN

A prospective study involving 342,754 deliveries was conducted using a quality improvement collaborative that supported three primary interventions. Primary measures include adoption of three standardized care processes and four measures of outcomes.

DATA COLLECTION METHODS

Chart audits were conducted to measure the implementation of standardized care processes. Outcome measures were collected and validated by the National Perinatal Information Center.

PRINCIPAL FINDINGS

The hospital perinatal units increased use of all three care processes, raising consolidated overall use from 38 to 81 percent between 2008 and 2012. The harms measured by the Adverse Outcome Index decreased 14 percent, and a run chart analysis revealed two special causes associated with the interventions.

CONCLUSIONS

This study demonstrates the ability of hospital perinatal staff to implement efforts to reduce perinatal harm using a quality improvement collaborative. Findings help inform the relationship between the use of standardized care processes, teamwork training, and improved perinatal outcomes, and suggest that a multiplicity of integrated strategies, rather than a single intervention, may be essential to achieve high reliability.

Stillbirths and quality of care during labour at the low resource referral hospital of Zanzibar: a case-control study

BACKGROUND

To study determinants of stillbirths as indicators of quality of care during labour in an East African low resource referral hospital.

METHODS

A criterion-based unmatched unblinded case-control study of singleton stillbirths with birthweight ≥2000 g (n = 139), compared to controls with birthweight ≥2000 g and Apgar score ≥7 (n = 249).

RESULTS

The overall facility-based stillbirth rate was 59 per 1000 total births, of which 25 % was not reported in the hospital's registers. The majority of singletons had birthweight ≥2000 g (n = 139; 79 %), and foetal heart rate was present on admission in 72 (52 %) of these (intra-hospital stillbirths). Overall, poor quality of care during labour was the prevailing determinant of 71 (99 %) intra-hospital stillbirths, and median time from last foetal heart assessment till diagnosis of foetal death or delivery was 210 min. (interquartile range: 75-315 min.). Of intra-hospital stillbirths, 26 (36 %) received oxytocin augmentation (23 % among controls; odds ratio (OR) 1.86, 95 % confidential interval (CI) 1.06-3.27); 15 (58 %) on doubtful indication where either labour progress was normal or less dangerous interventions could have been effective, e.g. rupture of membranes. Substandard management of prolonged labour frequently led to unnecessary caesarean sections. The caesarean section rate among all stillbirths was 26 % (11 % among controls; OR 2.94, 95 % CI 1.68-5.14), and vacuum extraction was hardly ever done. Of women experiencing stillbirth, 27 (19 %) had severe hypertensive disorders (4 % among controls; OR 5.76, 95 % CI 2.70-12.31), but 18 (67 %) of these did not receive antihypertensives. An additional 33 (24 %) did not have blood pressure recorded during active labour. When compared to controls, stillbirths were characterized by longer admissions during labour. However, substandard care was prevalent in both cases and controls and caused potential risks for the entire population. Notably, women with foetal death on admission were in the biggest danger of neglect.

CONCLUSIONS

Intrapartum management of women experiencing stillbirth was a simple yet strong indicator of quality of care. Substandard care led to perinatal as well as maternal risks, which furthermore were related to unnecessary complex, time consuming, and costly interventions. Improvement of obstetric care is warranted to end preventable birth-related deaths and disabilities.

TRIAL REGISTRATION

This is the baseline analysis of the PartoMa trial, which is registered on ClinicalTrials.org ( NCT02318420 , 4th November 2014).

Recent Increases in the U.S. Maternal Mortality Rate: Disentangling Trends From Measurement Issues

OBJECTIVE

To develop methods for trend analysis of vital statistics maternal mortality data, taking into account changes in pregnancy question formats over time and between states, and to provide an overview of U.S. maternal mortality trends from 2000 to 2014.

METHODS

This observational study analyzed vital statistics maternal mortality data from all U.S. states in relation to the format and year of adoption of the pregnancy question. Correction factors were developed to adjust data from before the standard pregnancy question was adopted to promote accurate trend analysis. Joinpoint regression was used to analyze trends for groups of states with similar pregnancy questions.

RESULTS

The estimated maternal mortality rate (per 100,000 live births) for 48 states and Washington, DC (excluding California and Texas, analyzed separately) increased by 26.6%, from 18.8 in 2000 to 23.8 in 2014. California showed a declining trend, whereas Texas had a sudden increase in 2011-2012. Analysis of the measurement change suggests that U.S. rates in the early 2000s were higher than previously reported.

CONCLUSION

Despite the United Nations Millennium Development Goal for a 75% reduction in maternal mortality by 2015, the estimated maternal mortality rate for 48 states and Washington, DC, increased from 2000 to 2014; the international trend was in the opposite direction. There is a need to redouble efforts to prevent maternal deaths and improve maternity care for the 4 million U.S. women giving birth each year.

Applying a participatory approach to the promotion of a culture of respect during childbirth

Disrespect and abuse (D&A) during facility-based childbirth is a topic of growing concern and attention globally. Several recent studies have sought to quantify the prevalence of D&A, however little evidence exists about effective interventions to mitigate disrespect and abuse, and promote respectful maternity care. In an accompanying article, we describe the process of selecting, implementing, and evaluating a package of interventions designed to prevent and reduce disrespect and abuse in a large urban hospital in Tanzania. Though that study was not powered to detect a definitive impact on reducing D&A, the results showed important changes in intermediate outcomes associated with this goal. In this commentary, we describe the factors that enabled this effect, especially the participatory approach we adopted to engage key stakeholders throughout the planning and implementation of the program. Based on our experience and findings, we conclude that a visible, sustained, and participatory intervention process; committed facility leadership; management support; and staff engagement throughout the project contributed to a marked change in the culture of the hospital to one that values and promotes respectful maternity care. For these changes to translate into dignified care during childbirth for all women in a sustainable fashion, institutional commitment to providing the necessary resources and staff will be needed.

Time to Nurture Better Services

More government funding has been promised to increase specialist mental healthcare for mothers in the perinatal period but this is just part of the action required, writes Claire Read.

Enhancing Maternal and Perinatal Health in Under-Served Remote Areas in Sub-Saharan Africa: A Tanzanian Model

Background

In Tanzania, maternal mortality ratio (MMR), unmet need for emergency obstetric care and health inequities across the country are in a critical state, particularly in rural areas. This study was established to determine the feasibility and impact of decentralizing comprehensive emergency obstetric and neonatal care (CEmONC) services in underserved rural areas using associate clinicians.

Methods

Ten health centres (HCs) were upgraded by constructing and equipping maternity blocks, operating rooms, laboratories, staff houses and installing solar panels, standby generators and water supply systems. Twenty-three assistant medical officers (advanced level associate clinicians), and forty-four nurse-midwives and clinical officers (associate clinicians) were trained in CEmONC and anaesthesia respectively. CEmONC services were launched between 2009 and 2012. Monthly supportive supervision and clinical audits of adverse pregnancy outcomes were introduced in 2011 in these HCs and their respective district hospitals.

Findings

After launching CEmONC services from 2009 to 2014 institutional deliveries increased in all upgraded rural HCs. Mean numbers of monthly deliveries increased by 151% and obstetric referrals decreased from 9% to 3% (p = 0.03) in HCs. A total of 43,846 deliveries and 2,890 caesarean sections (CS) were performed in these HCs making the mean proportion of all births in EmONC facilities of 128% and mean population-based CS rate of 9%. There were 190 maternal deaths and 1,198 intrapartum and very early neonatal deaths (IVEND) in all health facilities. Generally, health centres had statistically significantly lower maternal mortality ratios and IVEND rates than district hospitals (p < 0.00 and < 0.02 respectively). Of all deaths (maternal and IVEND) 84% to 96% were considered avoidable.

Conclusions

These findings strongly indicate that remotely located health centres in resource limited settings hold a great potential to increase accessibility to CEmONC services and to improve maternal and perinatal health.

Impact of a labor and delivery safety bundle on a modified adverse outcomes index

BACKGROUND

The Obstetrics Adverse Outcomes Index was designed to measure the quality of perinatal care and includes 10 adverse events that may occur at or around the time of delivery. We hypothesized that adverse outcomes in the labor and delivery suite, including hypoxic ischemic encephalopathy, could be decreased with a combination of interventions, even among high-risk pregnancies.

OBJECTIVE

The objective of the study was to evaluate the impact of a labor and delivery care bundle on adverse obstetrics outcomes as measured by a modified Obstetrics Adverse Outcomes Index, Weighted Adverse Outcomes Index, and Severity Index.

STUDY DESIGN

This is a retrospective cohort study including all women who delivered at our academic, tertiary care institution over a 3 year period of time, before and after the implementation of an intervention to decrease adverse outcomes. Outcome measures consisted of previously reported indices that were modified including the addition of hypoxic ischemic encephalopathy. The adverse outcomes index is a percentage of deliveries with 1 or more adverse events, the weighted adverse outcomes index is the sum of the points assigned to cases with adverse outcomes divided by the number of deliveries, and the severity index is the sum of the adverse outcome scores divided by the number of deliveries with an identified adverse outcome. A segmented regression analysis was utilized to evaluate the differences in the level and trend of each index before and after our intervention using calendar month as the unit of analysis.

RESULTS

During the study period, 5826 deliveries met inclusion criteria. Comparing the pre- and postintervention periods, high-risk pregnancy was more common in the postintervention period (73.5% vs 79.4%, P < .001). Overall, there was a decrease in both the Modified Weighted Adverse Outcomes Index (P = .0497) and the Modified Severity Index (P = 0.01) comparing the pre- and postintervention periods; there was no difference in the Modified Adverse Outcomes Index (P = .43). For low-risk pregnancies, there was no significant difference in the levels for any of the measured indices over the study period (P = .61, P = .41, and P = .34 for the Modified Adverse Outcomes Index, Modified Weighted Adverse Outcomes Index, and Modified Severity Index, respectively). Among the high-risk pregnancies, the monthly Modified Weighted Adverse Outcomes Index decreased by 4.2 ± 1.8 (P = .03). The monthly Modified Severity Index decreased by 53.9 ± 17.7 points from the pre- to the postintervention periods (P = .01) and was < 50% of the predicted Modified Severity Index had the intervention not been implemented. The cesarean delivery rate was increasing prior to the intervention, but the rate was stable after the intervention, and the absolute rate did not differ between the pre- and the postintervention periods (28.4% vs 30.0%, P = .20).

CONCLUSION

Overall and for high-risk pregnancies, the implementation of the labor and delivery care bundle had a positive impact on the Modified Weighted Adverse Outcomes Index and Modified Severity Index but not the Modified Adverse Outcomes Index.

Improvement in perinatal care for extremely premature infants in Denmark from 1994 to 2011

INTRODUCTION

Major advances in perinatal care over the latest decades have increased the survival rate of extremely premature infants. Centralisation of perinatal care was implemented in Denmark from 1995. This study evaluates the effect of organisational changes of perinatal care on survival and morbidity of live-born infants with gestational ages (GA) of 22-28 weeks.

METHODS

Three cohort studies were included from 1994-1995, 2003 and 2011. Data from live-born infants were extracted regarding risk factors, survival, bronchopulmonary dysplasia (BPD), cystic periventricular leukomalacia (cPVL) and intraventricular haemorrhage grade 3-4 (IVH 3-4).

RESULTS

A total of 184, 83 and 127 infants were included from the cohorts. Delivery rates at level 3 Neonatal Intensive Care Unit (NICU) hospitals increased from 69% to 87%. Transfer rates to level 3 NICU almost doubled during the period. Survival rates were stationary, although a trend towards increased survival was observed for infants < 26 weeks. The frequency of infants receiving evidence-based treatment increased from 14% to 46%. IVH 3-4 rates were reduced from 21% to 12%, whereas BPD and cPVL rates did not change. Survival odds increased with higher gestational age and administration of surfactant.

CONCLUSIONS

Centralisation of treatment of extremely premature infants has been implemented because more children are being born at highly specialised perinatal centres. Care improved as more infants received evidence-based treatment. IVH 3-4 rates declined. A trend towards increased survival was observed for infants with a GA < 26 weeks.

FUNDING

none.

TRIAL REGISTRATION

not relevant.

Neonatal Near Miss: the need for a standard definition and appropriate criteria and the rationale for a prospective surveillance system

In Latin American, there is currently a regional action with the main purposes of putting the concept of severe neonatal morbidity in practice and formulating proposals for interventions. A general overview of neonatal health conditions, including morbidity and mortality, is provided to update regional knowledge on the topic. An example of the development and implementation of the concept of maternal near miss is also provided, followed by results from a systematic review covering all previously published studies on Neonatal Near Miss. Finally, some proposals for building a common concept on the topic and for launching a prospective surveillance study are presented. A Neonatal Near Miss is a neonate who had a severe morbidity (organ dysfunction or failure) but who survived this condition within the first 27 days of life. The pragmatic criteria recommended to be used are as follows: birth weight below 1700 g, Apgar score below 7 at 5 minutes of life and gestational age below 33 weeks. As a proxy for organ dysfunction, the following management criteria are also confirmed: parenteral therapeutic antibiotics; nasal continuous positive airway pressure; any intubation during the first 27 days of life; phototherapy within the first 24 h of life; cardiopulmonary resuscitation; the use of vasoactive drugs, anticonvulsants, surfactants, blood products and steroids for refractory hypoglycemia and any surgical procedure. Although this study starts from a regional perspective, this topic is clearly globally relevant. All nations, especially low and middle-income countries, could benefit from the proposed standardization.

Calculating Preference Weights for the Labor and Delivery Index: A Discrete Choice Experiment on Women's Birth Experiences

OBJECTIVE

The aim of this study was to calculate preference weights for the Labor and Delivery Index (LADY-X) to make it suitable as a utility measure for perinatal care studies.

METHODS

In an online discrete choice experiment, 18 pairs of hypothetical scenarios were presented to respondents, from which they had to choose a preferred option. The scenarios describe the birth experience in terms of the seven LADY-X attributes. A D-efficient discrete choice experiment design with priors based on a small sample (N = 110) was applied. Two samples were gathered, women who had recently given birth and subjects from the general population. Both samples were analyzed separately using a panel mixed logit (MMNL) model. Using the panel mixed multinomial logit (MMNL) model results and accounting for preference heterogeneity, we calculated the average preference weights for LADY-X attribute levels. These were transformed to represent a utility score between 0 and 1, with 0 representing the worst and 1 representing the best birth experience.

RESULTS

In total, 1097 women who had recently given birth and 367 subjects from the general population participated. Greater value was placed on differences between bottom and middle attribute levels than on differences between middle and top levels. The attributes that resulted in larger utility increases than the other attributes were "feeling of safety" in the sample of women who had recently given birth and "feeling of safety" and "availability of professionals" in the general population sample.

CONCLUSIONS

By using the derived preference weights, LADY-X has the potential to be used as a utility measure for perinatal (cost-) effectiveness studies.

Perinatal and maternal outcomes in planned home and obstetric unit births in women at 'higher risk' of complications: secondary analysis of the Birthplace national prospective cohort study

OBJECTIVE

To explore and compare perinatal and maternal outcomes in women at 'higher risk' of complications planning home versus obstetric unit (OU) birth.

DESIGN

Prospective cohort study.

SETTING

OUs and planned home births in England.

POPULATION

8180 'higher risk' women in the Birthplace cohort.

METHODS

We used Poisson regression to calculate relative risks adjusted for maternal characteristics. Sensitivity analyses explored possible effects of differences in risk between groups and alternative outcome measures.

MAIN OUTCOME MEASURES

Composite perinatal outcome measure encompassing 'intrapartum related mortality and morbidity' (intrapartum stillbirth, early neonatal death, neonatal encephalopathy, meconium aspiration syndrome, brachial plexus injury, fractured humerus or clavicle) and neonatal admission within 48 hours for more than 48 hours. Two composite maternal outcome measures capturing intrapartum interventions/adverse maternal outcomes and straightforward birth.

RESULTS

The risk of 'intrapartum related mortality and morbidity' or neonatal admission for more than 48 hours was lower in planned home births than planned OU births [adjusted relative risks (RR) 0.50, 95% CI 0.31-0.81]. Adjustment for clinical risk factors did not materially affect this finding. The direction of effect was reversed for the more restricted outcome measure 'intrapartum related mortality and morbidity' (RR adjusted for parity 1.92, 95% CI 0.97-3.80). Maternal interventions were lower in planned home births.

CONCLUSIONS

The babies of 'higher risk' women who plan birth in an OU appear more likely to be admitted to neonatal care than those whose mothers plan birth at home, but it is unclear if this reflects a real difference in morbidity. Rates of intrapartum related morbidity and mortality did not differ statistically significantly between settings at the 5% level but a larger study would be required to rule out a clinically important difference between the groups.

Perinatal experiences of Somali couples in the United States

OBJECTIVE

To explore the perspectives of Somali couples on care and support received during the perinatal period in the United States.

DESIGN

Descriptive phenomenology.

SETTING

A private room at the participants' homes or community center.

PARTICIPANTS

Forty-eight immigrant women and men from Somalia (26 women and 22 men) who arrived in the United States within the past 5 years and had a child or children born in their homelands or refugee camps and at least one child born in the United States. All of the participants resided in the Pacific Northwest.

METHODS

Semistructured individual interviews, interviews with couples, and a follow-up phone interview. Colaizzi's method guided the research process.

RESULTS

Data analysis revealed an overarching theme of Navigating through the conflicting values, beliefs, understandings and expectations that infiltrated the experiences captured by the three subthemes: (a) Feeling vulnerable, uninformed, and misunderstood, (b) Longing for unconditional respect and acceptance and (c) Surviving and thriving as the recipients of health care.

CONCLUSIONS

Integration of new Somali immigrant couples into the Western health care system can present many challenges. The perinatal experience for new Somali immigrant couples is complicated by cultural and language barriers, limited access to resources, and commonly, an exclusion of husbands from prenatal education and care. Nurses and other health care providers can play an important role in the provision of services that integrate Somali women and men into the plan of care and consider their culture-based expectations to improve childbirth outcomes.