Do general practitioner deliveries constitute a perinatal mortality risk?

Family practice obstetrics in a teaching hospital. Does a tertiary care environment make a difference?

OBJECTIVE

To determine referral rates, to study the nature of consultations with obstetricians, and to examine how both patient and physician characteristics affect referrals.

DESIGN

Case series. Retrospective review of hospital records.

SETTING

Victoria Hospital, a tertiary care centre affiliated with the University of Western Ontario in London, Ont.

PARTICIPANTS

Five hundred forty-two women admitted consecutively for delivery under the care of family physicians from October 1, 1990, to September 31, 1991.

OUTCOME MEASURE

The number and types of obstetrical consultations obtained for the study population.

RESULTS

Of the 50.7% of cases requiring consultation, half were delivered by obstetricians. The most common reasons for consultation were failure to progress in labour, induction of labour, posterior presentation, fetal distress, and pregnancy-induced hypertension. The most common reasons for obstetricians to attend delivery were to perform forceps rotations and cesarean sections.

CONCLUSIONS

Parity and risk classification were the two most important factors for predicting whether consultation would occur. The high rate of consultation in this study might relate to ease of access to consultation in a tertiary care environment. More study is needed to examine the reasons for consultation because it seems that some of the situations for which obstetricians were consulted could have been safely managed by family physicians.

The shift from home to institutional childbirth: a comparative study of the United Kingdom and The Netherlands

The British system of childbirth with a very low rate of home childbirth is compared to that in The Netherlands, a country with a relatively high percentage of home deliveries. The analysis explores three possible explanations: the structure of the health professions in both countries, the structure of their health systems, and the use of scientific information in guiding policy decisions on birth place. Differences in the professional status and training programs of midwives between The Netherlands and the United Kingdom affected the distribution of home versus institutional deliveries in the two countries. Reimbursement schemes in The Netherlands have been important in maintaining a high percentage of births at home in this country. In the United Kingdom centralized planning and the influence of medical thinking played major roles in accelerating the shift from home to hospital deliveries in the National Health Service.

Relation of family physician or specialist care to obstetric interventions and outcomes in patients at low risk: a western Canadian cohort study

To determine the relation of family physician or specialist care to intrapartum interventions and outcomes, we carried out a historical cohort study of 1456 obstetric patients at low risk admitted between Nov. 15, 1984, and Mar. 15, 1986, to a western Canadian teaching hospital. The patients were classified as being at low risk on admission by means of chart review. Family physicians and specialists were found to have similar rates for most of the interventions measured, although the interventions for which significantly different rates were found suggest a less interventionist style of intrapartum care by family physicians. There were no significant differences in maternal or neonatal outcomes except for a higher proportion of infants weighing less than 2500 g among primigravid women cared for by family physicians compared with those under the care of specialists. Self-selection of physician specialty by patients resulted in differences in the demographic characteristics of the two patient populations. The findings support the continued involvement of family physicians in the provision of obstetric care.

Topics for family medicine research in obstetrics

Primarily because of improvements in care of the low-birthweight neonate, Canada's neonatal mortality rates have declined significantly over the last 20 years. To make further improvement, research is now focused on the prevention of prematurity. However, benefits from the implementation of such research and the maintenance of the current neonatal mortality rate depend on the availability of obstetric care providers in rural areas. The recent trend among family physicians to drop the practice of obstetrics significantly jeopardizes access to obstetric care for inhabitants of rural areas, and a significant body of literature suggests that such declines in access will be accompanied by an increase in the neonatal death rate. A logical research agenda for rural family physicians would include the forecasting of the effect of the decrease in obstetric care manpower, follwed by the study of factors behind this trend, and the evaluation programs designed to prevent family physicians abandoning obstetric practice.

General practitioner obstetrics: does risk prediction work?

The effectiveness of antenatal risk prediction based on maternal characteristics at booking was examined among 5730 pregnant women booked in an integrated general practitioner obstetric unit over a seven-year period. High rates of transfer to consultant care were found especially for nulliparae. Apart from parity, maternal factors associated with transfer before labour were weight, smoking and social class. Factors associated with transfer in labour were maternal stature and marital status. Reasons for transfer were also identified. The validity of the present booking criteria, which were developed in the 1950s, is questioned.

Small hospital obstetrics: is small beautiful?

The number of deliveries in small Canadian hospitals over the last 15 years was reviewed. The two provinces with the highest percentage of deliveries in small hospitals had similar patterns of Perinatal Mortality Rates to the two provinces with the lowest percentage of small hospital deliveries. Birthweight specific mortality rates for newborns weighing greater than 2,500 grams was lower in small hospitals compared to larger hospitals in the provinces of Ontario, Newfoundland and Saskatchewan for 1985. In Ontario, for the year 1985, even when corrected for perinatal transfers and the home address of the mother, there were no significant differences in perinatal mortality between those hospitals with less than 400 births, those between 401 and 2,999 births and those with 3,000 or more births. Within the present Canadian system of perinatal regionalization, small hospital obstetrics is safe.

The case for small rural hospital obstetrics

Small obstetrical units can offer a very competitive quality of service as compared to large centres. They achieved this quality of service by transferring all high-risk deliveries to specialized regional centres with neonatal intensive care facilities (perinatal regionalization). The significant decrease in perinatal mortality over the past 20 years is a result of the superior care of low birth-weight infants, available in these large centres. It is not surprising that some people might project this superior performance to all weight categories. A review of the literature, however, shows that overall, small (level I) hospitals are as safe as larger centres. The authors discuss the means by which small, and often isolated, centres do as well as better equipped and more extensive centres with larger staffs.

Is obstetrics safe in small hospitals? Evidence from New Zealand's regionalised perinatal system

Perinatal mortality rates were determined for all public maternity hospitals in New Zealand for the years 1978-1981. Level 1 maternity hospitals-mostly small rural units staffed by general practitioners and midwives-had lower birth-weight-specific perinatal mortality rates in all but the lowest birth-weight categories than the better equipped hospitals to which they refer. This probably reflects the cautious antenatal practices of general practitioners, and the effective regionalisation of perinatal services in New Zealand. It is also possible that there is an advantage, particularly for normal birth-weight children, in being born in smaller obstetric units. There is no evidence that a satisfactory outcome depends on a minimum number of deliveries.