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Arslan E, Einerson BD, Zhang J, Zhang J, Branch DW. The Effect of "Off Hours" on Maternal and Perinatal Outcomes in a Diverse U.S. Cohort. Am J Perinatol 2024; 41:89-97. [PMID: 34856608 DOI: 10.1055/s-0041-1740119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVE This study aimed to evaluate the "off-hour effect" on maternal and neonatal adverse events in a large cohort representing U.S. POPULATION STUDY DESIGN A secondary analysis of the Consortium on Safe Labor (CSL) dataset with 208,695 women and 229,385 deliveries was performed. The study included the deliveries of ≥23 gestational weeks from 19 hospitals in the United States from 2002 to 2008. Babies with congenital anomalies were excluded from neonatal outcomes. We compared maternal and neonatal outcomes of patients delivered during weekdays versus off hours (nights and weekends). The primary outcomes of the study were composite maternal and composite neonatal adverse events. The secondary outcomes were delivery type and individual maternal and neonatal adverse events including maternal death and perinatal mortality rate. Associations between off hours and all the outcomes were analyzed in bivariable and multivariable analyses. The same analyses were performed in strata by indication for admission (spontaneous labor or induction of labor). RESULTS Composite maternal adverse events (6.19 vs. 6.06%, p = 0.41) and maternal death (0.01 vs. 0.01%, p = 0.19) were not significantly different between off hours and weekday groups. In contrast, composite neonatal adverse events (6.91 vs. 5.84%, p < 0.001) and perinatal mortality rate (1.03 vs. 0.77%, p < 0.001) were higher in the off-hour group. After adjusting for confounding variables, only the composite neonatal outcome continued to be associated with off hours (adjusted odds ratio [aOR] = 1.10, 95% confidence interval [CI]: 1.04-1.16). Stratified analyses showed that the off-hour effect for the neonatal composite outcome was not present in those presenting in spontaneous labor (6.1 vs. 5.9%, p = 0.40). CONCLUSION Off-hour delivery was not associated with severe maternal morbidity and was only modestly associated with severe neonatal morbidity. This association was observed in women undergoing induction, not in those presenting in spontaneous labor. These data draw into question the existence of a clinically meaningful and correctable "off-hour effect" in obstetrics. KEY POINTS · The presence of a significant off-hour effect in obstetrics is still questionable.. · If the off-hour effect exists, it seems that not to be related with staffing issues.. · There is not a big difference for adverse events at off hours in spontaneously laboring patients..
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Affiliation(s)
- Erol Arslan
- Division of Maternal Fetal Medicine, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, University of Health Sciences, Van Training and Research Hospital, Van/Turkey
| | - Brett D Einerson
- Division of Maternal Fetal Medicine, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Intermountain Health Care, Murray, Utah
| | - Jingwen Zhang
- Ministry of Education, Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jun Zhang
- Ministry of Education, Shanghai Key Laboratory of Children's Environmental Health, Xinhua Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - D Ware Branch
- Division of Maternal Fetal Medicine, University of Utah Health Sciences, Salt Lake City, Utah
- Division of Maternal Fetal Medicine, Intermountain Health Care, Murray, Utah
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Kim S, Selya AS. Weekend delivery and maternal-neonatal adverse outcomes in low-risk pregnancies in the United States: A population-based analysis of 3-million live births. Birth 2022; 49:549-558. [PMID: 35233821 DOI: 10.1111/birt.12626] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 06/17/2020] [Accepted: 02/07/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Childbirth is the most common cause of hospital admission in the United States. Previous studies have shown that there might be a "weekend effect" in perinatal care, indicating that mothers and newborns whose deliveries occur during the weekends are at increased risk of having adverse outcomes. This study aims to isolate the association between the weekend delivery and maternal-neonatal adverse outcomes by investigating low-risk pregnancies in nationwide data. METHODS A population-based study of all low-risk pregnancies (in-hospital, nonanomalous, term, normal birthweight, and singleton) was conducted based on US national natality data in 2017. Four maternal outcomes (ICU admission, uterine rupture, blood transfusion, and perineal laceration) and three neonatal outcomes (5-minute Apgar <7, NICU admission, and neonatal death) were defined as adverse outcomes. Logistic regression analyses were conducted to determine the association, adjusting for 23 maternal and neonatal characteristics and risk factors. RESULTS Among 3 011 577 low-risk pregnancies, 6.0% were reported to have at least one of the maternal-neonatal adverse outcomes. Weekend deliveries were significantly associated with six maternal-neonatal adverse outcomes with an exception of neonatal death. In general, weekend deliveries were 1.13 times significantly as likely to have any of seven maternal-neonatal adverse outcomes than weekday deliveries (OR 1.13, 95% CI 1.11-1.14), being attributed to adverse outcomes of more than 4500 mother-newborn pairs. CONCLUSIONS Weekend delivery is a consistent risk factor for both mothers and babies at the national level. Furthermore, studies are needed about possible modifiable factors that mediate these associations to ensure safe childbirth regardless of the day of delivery.
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Affiliation(s)
- Sooyong Kim
- Department of Population Health, University of North Dakota School of Medicine & Health Sciences, Grand Forks, North Dakota, USA
| | - Arielle S Selya
- Department of Population Health, University of North Dakota School of Medicine & Health Sciences, Grand Forks, North Dakota, USA.,Behavioral Sciences Group, Sanford Research, Sioux Falls, South Dakota, USA.,Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
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Solis-Garcia G, Avila-Alvarez A, García-Muñoz Rodrigo F, Vento M, Sánchez Tamayo T, Zozaya C. Time at birth and short-term outcomes among extremely preterm infants in Spain: a multicenter cohort study. Eur J Pediatr 2022; 181:2067-2074. [PMID: 35147746 DOI: 10.1007/s00431-022-04404-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/29/2021] [Accepted: 01/31/2022] [Indexed: 11/25/2022]
Abstract
UNLABELLED The first hours after birth entail a window of opportunity to decrease morbidity and mortality among extremely preterm infants. The availability of staff and its tiredness vary depending on the timing and day of the week. We hypothesized that these circumstances may impact neonatal outcomes. We have conducted a multicenter cohort study with data obtained from the Spanish neonatal network database SEN1500, where staff doctors are in the house 24/7. The main study exposure was the time of birth; secondary exposures were cumulative work hours from the medical and nurses' shifts and day of the week. The primary outcome was survival to hospital discharge. Secondary outcomes included common preterm infants' in-hospital complications. Univariate and multivariate analysis adjusting for potential confounders was performed. All extremely preterm infants (N = 8798) born between 2011 and 2019 were eligible; 35.7% of them were admitted during the night shift. No differences were found between day and night births regarding survival or morbidity. No differences were found between weekdays and weekends or when considering cumulative worked hours in the shifts. Infants born during the night shift were more likely to be intubated at birth (OR 1.20, CI95% 1.06-1.37), receive surfactant (OR 1.24, CI95% 1.08-1.44), and having anemia requiring transfusion (OR 1.23, CI 95% 1.08-1.42). CONCLUSION the time of birth did not seem to affect mortality and morbidity of extremely preterm infants. WHAT IS KNOWN • The first hours after birth in extremely preterm infants are a very valuable opportunity to decrease mortality and morbidity. • Time and day of birth have long been linked to outcomes in preterm infants, with night shifts and weekends classically having higher rates of mortality and morbidity. WHAT IS NEW • In this study, no differences were found between day and night births regarding survival or major morbidity. • Infants born during the night shift were more likely to be intubated at birth, receive surfactant and having anemia requiring transfusion.
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Affiliation(s)
- Gonzalo Solis-Garcia
- Division of Neonatology, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada.
| | - Alejandro Avila-Alvarez
- Department of Paediatrics, Neonatal Unit, Complexo Hospitalario Universitario A Coruña, Institute for Biomedical Research A Coruña, Coruña, Spain
| | - Fermín García-Muñoz Rodrigo
- Division of Neonatology, Complejo Hospitalario Universitario Insular Materno-Infantil, Las Palmas de Gran Canaria, Spain
| | - Máximo Vento
- Division of Neonatology, Hospital Universitari I Politècnic La Fe, Health Research Institute La Fe, Valencia, Spain
| | - Tomás Sánchez Tamayo
- Neonatology Department, Malaga Regional Hospital, Malaga Biomedical Research Institute-IBIMA, Malaga, Spain
| | - Carlos Zozaya
- Division of Neonatology, Hospital Universitario La Paz, Madrid, Spain
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Cambonie G, Theret B, Badr M, Fournier P, Combes C, Picaud JC, Gavotto A. Birth during on-call period: Impact of care organization on mortality and morbidity of very premature neonates. Front Pediatr 2022; 10:977422. [PMID: 36061390 PMCID: PMC9433924 DOI: 10.3389/fped.2022.977422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 08/01/2022] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The evidence that risks of morbidity and mortality are higher when very premature newborns are born during the on-call period is inconsistent. This study aimed to assess the impact of this situation among other determinants of outcomes, particularly newborn characteristics and care organization. METHODS Observational study including all infants born < 30 weeks' gestation in a French tertiary perinatal center between 2007 and 2020. On-call period corresponded to weekdays between 6:30 p.m. and 8:30 a.m., weekends, and public holidays. The primary endpoint was survival without severe morbidity, including grade 3-4 intraventricular hemorrhage (IVH), cystic periventricular leukomalacia, necrotizing enterocolitis, severe bronchopulmonary dysplasia (BPD), and severe retinopathy of prematurity. The relationship between admission and outcome was assessed by an adjusted odds ratio (aOR) on the propensity of being born during on-call period and expressed vs. weekday. Secondary analyses were carried out in extremely preterm newborns (<27 weeks' gestation), in cases of early death (within 7 days), and before (2007-2013, 51.5% of the cohort) vs. after (2014-2020, 48.5% of the cohort) the implementation of a pediatrician-nurse team dedicated to newborn care in the delivery room. RESULTS A total of 1,064 infants [27.9 (26.3; 28.9) weeks, 947 (760; 1,147) g] were included: 668 during the on-call period (63%) and 396 (37%) on weekdays. For infants born on weekdays, survival without severe morbidity was 54.5% and mortality 19.2%. During on-call, these rates were 57.3% [aOR 1.08 (0.84-1.40)] and 18.4% [aOR 0.93 (0.67-1.29)]. Comparable rates of survival without severe morbidity [aOR 1.42 (0.87-2.34)] or mortality [aOR 0.76 (0.47-1.22)] were observed in extremely preterm infants. The early death rate was 6.4% on weekdays vs. 8.2% during on-call [aOR 1.44 (0.84-2.48)]. Implementation of the dedicated team was associated with decreased rates of mortality [aOR 0.57 (0.38, 0.85)] and grade 3-4 IVH [aOR 0.48 (0.30, 0.75)], and an increased rate of severe BPD [aOR 2.16 (1.37, 3.41)], for infants born during on-call. CONCLUSION In this cohort, most births of very premature neonates occurred during the on-call period. A team dedicated to newborn care in the delivery room may have a favorable effect on the outcome of infants born in this situation.
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Affiliation(s)
- Gilles Cambonie
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France.,Pathogenesis and Control of Chronic Infection, INSERM UMR 1058, University of Montpellier, Montpellier, France
| | - Bénédicte Theret
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
| | - Maliha Badr
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
| | - Patricia Fournier
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
| | - Clémentine Combes
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
| | - Jean-Charles Picaud
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
| | - Arthur Gavotto
- Department of Neonatal Medicine, Arnaud de Villeneuve Hospital, Montpellier University Hospital Centre, University of Montpellier, Montpellier, France
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Rizzolo A, Shah PS, Bertelle V, Makary H, Ye XY, Abenhaim HA, Piedboeuf B, Beltempo M. Association of timing of birth with mortality among preterm infants born in Canada. J Perinatol 2021; 41:2597-2606. [PMID: 34050244 DOI: 10.1038/s41372-021-01092-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 03/31/2021] [Accepted: 04/30/2021] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To assess the association between time of birth and mortality among preterm infants. STUDY DESIGN Population-based study of infants born 22-36 weeks gestation (GA) in Canada from 2010 to 2015 (n = 173 789). Multivariable logistic regression models assessed associations between timing of birth and mortality. RESULT Among infants 22-27 weeks GA, evening birth was associated with higher mortality than daytime birth (adjusted odds ratio [AOR] 1.14, 95% CI 1.01-1.29). Among infants 28-32 weeks GA and 33-36 weeks GA, night birth was associated with lower mortality than daytime birth (AOR 0.75, 95% CI 0.59-0.95; AOR 0.78, 95% CI 0.62-0.99, respectively). Sensitivity analysis excluding infants with major congenital anomaly revealed that associations between hour of birth and mortality among infants born 28-32 and 33-36 weeks GA decreased or were not statistically significant. CONCLUSION Higher mortality among extremely preterm infants during off-peak hours may suggest variations in available resources based on time of day.
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Affiliation(s)
- Angelo Rizzolo
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada
| | - Prakesh S Shah
- Departments of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
| | - Valerie Bertelle
- Department of Pediatrics, University of Sherbrooke, Sherbrooke, QC, Canada
| | - Hala Makary
- Department of Pediatrics, Dr. Everett Chalmers Hospital, Fredericton, NB, Canada
| | - Xiang Y Ye
- Maternal-infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Haim A Abenhaim
- Department of Obstetrics and Gynecology, Jewish General Hospital, McGill University, Montreal, QC, Canada
| | - Bruno Piedboeuf
- Department of Pediatrics, Université Laval, Quebec, QC, Canada
| | - Marc Beltempo
- Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.
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Joensuu J, Saarijärvi H, Rouhe H, Gissler M, Ulander VM, Heinonen S, Mikkola T. Maternal childbirth experience and time of delivery: a retrospective 7-year cohort study of 105 847 parturients in Finland. BMJ Open 2021; 11:e046433. [PMID: 34135044 PMCID: PMC8211041 DOI: 10.1136/bmjopen-2020-046433] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To explore how the time of delivery influences childbirth experience. DESIGN A retrospective cohort study. SETTING Childbirth in the four Helsinki and Uusimaa Hospital District hospitals, Finland, from 2012 to 2018. PARTICIPANTS 105 847 childbirths with a singleton live fetus. MAIN OUTCOME MEASURES Childbirth experience measured by Visual Analogue Scale (VAS). RESULTS The major difference in average childbirth experience measured by VAS was between primiparas (8.03; 95% CI 8.01 to 8.04) and multiparas (8.47; 95% CI 8.45 to 8.48). Risk ratio (RR) of the low VAS (≤5) was 2.3 when primiparas were compared with multiparas. Differences in VAS between distinct periods were found in two stages: annual and time of day. The decrease in VAS from 2012-2016 to 2017-2018 in primiparas was from 7.97 (95% CI 7.95 to 7.99) to 7.80 (95% CI 7.77 to 7.83) and from 2014-2016 to 2017-2018 in multiparas from 8.60 (95% CI 8.58 to 8.61) to 8.49 (95% CI 8.47 to 8.52). Corresponding RRs of low VAS were 1.3 for primiparas and 1.2 for multiparas. Hourly differences in VAS were detected in primiparas between office hours 08:00-15:59 (7.97; 95% CI 7.94 to 7.99) and other times (night 00:00-07:59; 7.91; 95% CI 7.88 to 7.94; and evening 16:00-23:59; 7.90; 95% CI 7.87 to 7.92). In multiparas differences in VAS were detected between evening (8.52; 95% CI 8.50 to 8.54) and other periods (night; 8.56; 95% CI 8.54 to 9.58; and office hours; 8.57; 95% CI 8.55 to 8.59). CONCLUSION The maternal childbirth experience depended on the time of delivery. Giving birth during the evening led to impaired childbirth experience in both primiparas and multiparas, compared with delivery at other times. The impact of labour induction on childbirth experience should be further examined. The reorganisation of delivery services and the reduction of birth preparations might affect annual VAS. VAS is a simple method of measuring the complex entity of childbirth experience, and our results indicate its ability to capture temporal variation.
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Affiliation(s)
- Johanna Joensuu
- Faculty of Management and Business, Tampere University, Tampere, Finland
- Department of Obstetrics and Gynaecology, Helsinki University Hospital, Helsinki, Finland
| | - Hannu Saarijärvi
- Faculty of Management and Business, Tampere University, Tampere, Finland
| | - Hanna Rouhe
- Department of Obstetrics and Gynaecology, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Mika Gissler
- Information, Finnish Institute of Health and Welfare, Helsinki, Finland
- Division of Family Medicine, Karolinska Institute Department of Neurobiology, Care Sciences and Society, Huddinge, Sweden
| | - Veli-Matti Ulander
- Department of Obstetrics and Gynaecology, Helsinki University Hospital, Helsinki, Finland
| | - Seppo Heinonen
- Department of Obstetrics and Gynaecology, Helsinki University Hospital, Helsinki, Finland
- Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | - Tomi Mikkola
- Department of Obstetrics and Gynaecology, Helsinki University Hospital, Helsinki, Finland
- Folkhälsän Research Center, Biomedicum, Helsinki, Finland
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Toyokawa S, Hasegawa J, Ikenoue T, Asano Y, Jojima E, Satoh S, Ikeda T, Ichizuka K, Takeda S, Tamiya N, Nakai A, Fujimori K, Maeda T, Masuzaki H, Suzuki H, Ueda S. Weekend and off-hour effects on the incidence of cerebral palsy: contribution of consolidated perinatal care. Environ Health Prev Med 2020; 25:52. [PMID: 32912144 PMCID: PMC7488476 DOI: 10.1186/s12199-020-00889-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 08/27/2020] [Indexed: 11/25/2022] Open
Abstract
Objective This study estimated the effects of weekend and off-hour childbirth and the size of perinatal medical care center on the incidence of cerebral palsy. Methods The cases were all children with severe cerebral palsy born in Japan from 2009 to 2012 whose data were stored at the Japan Obstetric Compensation System for Cerebral Palsy database, a nationally representative database. The inclusion criteria were the following: neonates born between January 2009 and December 2012 who had a birth weight of at least 2000 g and gestational age of at least 33 weeks and who had severe disability resulting from cerebral palsy independent of congenital causes or factors during the neonatal period or thereafter. Study participants were restricted to singletons and controls without report of death, scheduled cesarean section, or ambulance transportation. The controls were newborns, randomly selected by year and type of delivery (normal spontaneous delivery without cesarean section and emergency cesarean section) using a 1:10 case to control ratio sampled from the nationwide Japan Society of Obstetrics and Gynecology database. Results A total of 90 cerebral palsy cases and 900 controls having normal spontaneous delivery without cesarean section were selected, as were 92 cerebral palsy cases and 920 controls with emergent cesarean section. A significantly higher risk for cerebral palsy was found among cases that underwent emergent cesarean section on weekends (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.06–2.81) and during the night shift (OR 2.29, 95% CI 1.30–4.02). No significant risk was found among normal spontaneous deliveries on weekends (OR 1.63, 95% CI 0.97–2.73) or during the quasi-night shift (OR 1.26, 95% CI 0.70–2.27). Regional perinatal care centers showed significantly higher risk for cerebral palsy in both emergent cesarean section (OR 2.35, 95% CI 1.47–3.77) and normal spontaneous delivery (OR 2.92, 95% CI 1.76–4.84). Conclusion Labor on weekends, during the night shift, and at regional perinatal medical care centers was associated with significantly elevated risk for cerebral palsy in emergency cesarean section.
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Affiliation(s)
- Satoshi Toyokawa
- Department of Public Health, Graduate School of Medicine, The University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-0033, Japan. .,Department of the Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.
| | - Junichi Hasegawa
- Department of the Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan.,Department of Obstetrics and Gynecology, St. Marianna University School of Medicine, Kanagawa, Japan
| | | | - Yuri Asano
- Department of the Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan
| | - Emi Jojima
- Department of the Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan
| | - Shoji Satoh
- Maternal and Perinatal Care Center, Oita Prefectural Hospital, Oita, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University Graduate School of Medicine, Mie, Japan
| | - Kiyotake Ichizuka
- Department of Obstetrics and Gynecology, Showa University Northern Yokohama Hospital, Kanagawa, Japan
| | - Satoru Takeda
- Department of Obstetrics and Gynecology, Juntendo University, Tokyo, Japan
| | - Nanako Tamiya
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Akihito Nakai
- Department of Obstetrics and Gynecology, Nippon Medical School, Tokyo, Japan
| | - Keiya Fujimori
- Department of Obstetrics and Gynecology, Fukushima Medical University, Fukushima, Japan
| | | | - Hideaki Masuzaki
- Department of Obstetrics and Gynecology, University of Nagasaki, Nagasaki, Japan
| | - Hideaki Suzuki
- Department of the Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan
| | - Shigeru Ueda
- Department of the Japan Obstetric Compensation System for Cerebral Palsy, Japan Council for Quality Health Care, Tokyo, Japan
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Williams V, Jaiswal N, Chauhan A, Pradhan P, Jayashree M, Singh M. Time of Pediatric Intensive Care Unit Admission and Mortality: A Systematic Review and Meta-Analysis. J Pediatr Intensive Care 2019; 9:1-11. [PMID: 31984150 DOI: 10.1055/s-0039-3399581] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/03/2019] [Indexed: 01/21/2023] Open
Abstract
The aim of this study was to determine the association between the time of admission (day, night, and/or weekends) and mortality among critically ill children admitted to a pediatric intensive care unit (PICU). Electronic databases that were searched include PubMed, Embase, Web of Science, CINAHL (Cumulative Index of Nursing and Allied Health Literature), Ovid, and Cochrane Library since inception till June 15, 2018. The article included observational studies reporting inhospital mortality and the time of admission to PICU limited to patients aged younger than 18 years. Meta-analysis was performed by a frequentist approach with both fixed and random effect models. The GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach was used to evaluate the quality of evidence. Ten studies met our inclusion criteria. Five studies comparing weekday with weekend admissions showed better odds of survival on weekdays (odds ratio [OR]: 0.77; 95% confidence interval [CI]: 0.60-0.99). Pooled data of four studies showed that odds of mortality were similar between day and night admissions (OR: 0.93; 95% CI: 0.77-1.13). Similarly, three studies comparing admission during off-hours versus regular hours did not show better odds of survival during regular hours (OR: 0.77; 95% CI: 0.57-1.05). Heterogeneity was significant due to variable sample sizes and time period. Inconsistency in adjusting for confounders across the included studies precluded us from analyzing the adjusted risk of mortality. Weekday admissions to PICU were associated with lesser odds of mortality. No significant differences in the odds of mortality were found between admissions during day versus night or between admission during regular hours and that during off-hours. However, the evidence is of low quality and requires larger prospective studies.
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Affiliation(s)
- Vijai Williams
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Nishant Jaiswal
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India.,Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Anil Chauhan
- Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Pranita Pradhan
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Muralidharan Jayashree
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India
| | - Meenu Singh
- Department of Pediatrics, Postgraduate Institute of Medical Research and Education, Chandigarh, India.,Department of Telemedicine, Postgraduate Institute of Medical Research and Education, Chandigarh, India
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Shawer S, Rowbotham S, Heazell A, Kelly T, Vause S. Impact of consultant obstetric presence on serious incidents. INTERNATIONAL JOURNAL OF HEALTH GOVERNANCE 2019. [DOI: 10.1108/ijhg-12-2018-0079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Many organisations, including the Royal College of Obstetricians and Gynaecologists, have recommended increasing the number of hours of consultant obstetric presence in UK National Health Service maternity units to improve patient care. St Mary’s Hospital, Manchester implemented 24-7 consultant presence in September 2014. The paper aims to discuss these issues.
Design/methodology/approach
To assess the impact of 24-7 consultant presence upon women and babies, a retrospective review of all serious clinical intrapartum incidents occurring between September 2011 and September 2017 was carried out by two independent reviewers; disagreements in classification were reviewed by a senior Obstetrician. The impact of consultant presence was classified in a structure agreed a priori.
Findings
A total of 72 incidents were reviewed. Consultants were directly involved in the care of 75.6 per cent of cases before 24-7 consultant presence compared to 96.8 per cent afterwards. Negative impact due to a lack of consultant presence fell from 22 per cent of the incidents before 24-7 consultant presence to 9.7 per cent after implementation. In contrast, positive impact of consultant presence increased from 14.6 to 32.3 per cent following the introduction of 24-7 consultant presence.
Practical implications
Introduction of 24-7 consultant presence reduced the negative impact caused by a lack of, or delay in, consultant presence as identified by serious untoward incident (SUI) reviews. Consultant presence was more likely to have a positive influence on care delivery.
Originality/value
This is the first assessment of the impact of 24-7 consultant presence on the SUIs in obstetrics.
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Eze P, Lawani LO, Ukaegbe CI, Anozie OB, Iyoke CA. Association between time of delivery and poor perinatal outcomes -An evaluation of deliveries in a tertiary hospital, South-east Nigeria. PLoS One 2019; 14:e0217943. [PMID: 31181101 PMCID: PMC6557521 DOI: 10.1371/journal.pone.0217943] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 05/21/2019] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Nigeria account for a significant proportion of adverse perinatal outcome. Nigerian studies assessing impact of time of delivery on perinatal outcome are scarce. This study evaluates any associations between time of delivery and perinatal outcome. METHODS This was a cross-sectional study at the Federal Teaching Hospital, Abakaliki from 01 January 2016 to 30 June 2018. Data were analysed with IBM SPSS version 25.0. RESULTS A total of 4,556 deliveries were analysed. Majority (72.2%) delivered on week days and 27.8% on weekends. Over 90% had 1st and 5th minutes Apgar scores ≥7. There was statistical difference in NICU admission between morning and evening hours (p = 0.009) but not between morning and night hours (p = 0.795). ENND during evening was twice higher (1.2%) than morning (0.5%); p = 0.047 and night hours (0.6%); p = 0.623.There was no difference in the risk of fresh stillbirths between morning and evening (p = 0.560), as well as morning and night hours (p = 0.75), there was also no difference in fresh stillbirths between week days and weekends (p = 0.895). There was no difference in low Apgar scores at 1st minute between morning and evening (p = 0.053) and night (p = 0.221), and between weekdays and weekends (p = 0.524). Similarly, there was no difference in low 5th minute Apgar scores between morning and evening (p = 0.165) and night (p = 0.944), as well as between week days and weekends (p = 0.529). However, ENND was twice (p = 0.085) and 1.3 times higher (p = 0.526) for evening and night hours respectively, while there was no difference between weekends and week days (p = 0.652). CONCLUSION NICU admission and ENND were commoner during evening hours. However, work hours did not affect the rate of stillbirth and low Apgar scores during weekdays and weekends. It is pertinent for each obstetric unit to identify and modify factors responsible for unfavourable outcomes during various shifts, with the aim of improving perinatal health.
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Affiliation(s)
- Paul Eze
- Medicins Sans Frontieres (MSF), OCBA, Barcelona, Spain
| | - Lucky Osaheni Lawani
- Department of Obstetrics & Gynecology, Federal Teaching Hospital, Abakaliki, Ebonyi State, Nigeria
- * E-mail:
| | | | | | - Chukwuemeka Anthony Iyoke
- Department of Obstetrics & Gynecology, University of Nigeria Teaching Hospital, Enugu, Enugu State, Nigeria
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Liu LY, Miller ES, Yee LM. Association between time of day and performance, indications, and outcomes of obstetric interventions among nulliparous women delivering at term. J Perinatol 2019; 39:808-813. [PMID: 30911083 DOI: 10.1038/s41372-019-0353-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE The objective of this study is to determine whether there is an association between delivery time and obstetric interventions, as well as maternal and perinatal outcomes. STUDY DESIGN Retrospective cohort study of nulliparous women delivering singleton, vertex, live births at ≥37 weeks gestation at a single center from 2014 to 2015. Nighttime deliveries were designated as those occurring between 18:00 and 05:59 h. The primary outcomes were obstetrical interventions (cesarean delivery, operative vaginal delivery, episiotomy). Secondary outcomes included indications for operative deliveries, as well as maternal and perinatal outcomes. RESULTS Of 7691 women eligible for inclusion, 3707 (48.2%) delivered during the nighttime. Women who experienced nighttime deliveries had no demographic or clinical differences compared with women delivering during the daytime. Women delivering during the nighttime had greater odds of cesarean delivery (OR 1.27, 95% CI 1.14-1.43) and operative vaginal delivery (OR 1.83, 95% CI 1.20-2.78). Women who delivered at night were also more likely to have neonates with a 5 min Apgar score <7 (OR 1.59, 95% CI 1.08-2.32) and umbilical artery pH < 7.0 (OR 1.76, 95% CI 1.18-2.63). There were no differences observed in any of the other outcomes examined. CONCLUSIONS Delivery during the nighttime is associated with alterations in some obstetric interventions and perinatal outcomes.
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Affiliation(s)
- Lilly Y Liu
- Department of Obstetrics and Gynecology, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | - Emily S Miller
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Lynn M Yee
- Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Moussa H, Hosseini Nasab S, Fournie D, Ontiveros A, Alkawas R, Chauhan S, Blackwell S, Sibai B. The impact of time of delivery on gestations complicated by preterm premature rupture of membranes: daytime versus nighttime. J Matern Fetal Neonatal Med 2018; 32:3319-3324. [PMID: 29631461 DOI: 10.1080/14767058.2018.1463363] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Background: Perinatal death, in particular intrapartum stillbirth and short-term neonatal death, as well as neonatal short-term and long-term morbidity have been associated with the time of day that the birth occurs. Indeed, evening and nighttime deliveries were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Impact of shift change, as well as time of day delivery have been extensively studied in the context of maternal and neonatal complications of cesarean delivery, however, no studies were previously performed on timing of delivery and its effect on the outcome of pregnancies complicated by preterm premature rupture of membranes. Objective: Our objective was to compare obstetric, neonatal as well as long-term outcomes between women delivered in the daytime versus nighttime, in singleton gestations whose pregnancies were complicated by preterm premature rupture of membranes. Study design: This was a secondary analysis of a trial of the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network "A Randomized Clinical Trial of the Beneficial Effects of Antenatal Magnesium Sulfate for the Prevention of Cerebral Palsy." For this analysis, the time of delivery was divided into the daytime, from 07:01 to 19:00, and the nighttime, from 19:01 to 07:00. Epidemiological, obstetric characteristics as well as neonatal and long-term outcomes were compared between deliveries occurring during the daytime versus the nighttime periods. Inclusion criteria consisted of singleton gestations diagnosed with preterm premature rupture of membranes (PPROM). Multifetal gestations and pregnancies with preterm labor without preterm premature rupture of membranes were excluded. Results: A total of 1752 patients met inclusion criteria, 881 delivering during the daytime, while 871 during the nighttime. There were no differences in demographic maternal variables. There were no differences in the number of patients receiving steroids and the doses of steroids. Antibiotic prophylaxis was also equal in both groups. Postpartum endometritis, chorioamnionitis, and the latency to delivery were also equivalent between both the groups. Cesarean delivery for distress was the only different outcome, more prevalent in daytime deliveries (157 (44.7%) versus 108 (35.9%) of the nighttime ones p = .02). Neonatal adverse outcomes as well as long-term outcomes were similar between the two groups. Conclusions: In the setting of delivery at a tertiary care center, and in the era of universal use of steroids, and latency antibiotics for the management of preterm premature of membranes, there is no marked difference in pregnancy, neonatal as well as long-term outcomes for infants delivered in the daytime versus nighttime.
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Affiliation(s)
- Hind Moussa
- a OBGYN , University of Cincinnati College of Medicine , Cincinnati , OH , USA
| | - Susan Hosseini Nasab
- b Obstetrics and Gynaecology , McGovern Medical School at The University of Texas Health Science Center at Houston , Houston , TX , USA
| | - David Fournie
- c Department of Mathematics , Columbia University , New York , NY , USA
| | - Alejandra Ontiveros
- d OBGYN , University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Rim Alkawas
- e University of Texas Health Science Center at Houston , Houston , TX , USA
| | - Suneet Chauhan
- f Department of Obstetrics, Gynaecology and Reproductive Sciences, Lyndon B . Johnson General Hospital , Houston , TX , USA
| | - Sean Blackwell
- g Department of Obstetrics, Gynaecology & Reproductive Sciences , University of Texas Health Science Center , Houston , TX , USA
| | - Baha Sibai
- h Obstetrics and Gynaecology , University of Texas Health Science Center , Houston , TX , USA
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Henderson J, Kurinczuk JJ, Knight M. Resident consultant obstetrician presence on the labour ward versus other models of consultant cover: a systematic review of intrapartum outcomes. BJOG 2017; 124:1311-1320. [PMID: 28244641 PMCID: PMC5574016 DOI: 10.1111/1471-0528.14527] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Several key policy documents have advocated 24-hour consultant obstetrician presence on the labour ward as a means of improving the safety of birth. However, it is unclear what published evidence exists comparing the outcomes of intrapartum care with 24-hour consultant labour ward presence and other models of consultant cover. OBJECTIVES To collate and critically appraise evidence of the effect of continuous resident consultant obstetrician cover on the labour ward on outcomes of intrapartum care compared with other models of consultant cover. SEARCH STRATEGY Studies were included which quantitatively compared intrapartum outcomes for women and babies where continuous resident consultant obstetric cover was provided with other models of consultant cover. SELECTION CRITERIA Quantitative studies within healthcare systems with mixed obstetric-midwifery models of care. DATA COLLECTION AND ANALYSIS Two researchers independently screened titles and full-text publications, extracted data and assessed the quality of included studies. Meta-analysis was performed using REVIEW MANAGER 5.3. MAIN RESULTS About 1508 publications were screened resulting in two papers, three conference abstracts and one letter being included. All were single-site time-period comparison studies. The quality of studies overall was poor with significant risk of bias. The only significant finding in meta-analysis related to instrumental deliveries, which occurred more frequently when there was on-call consultant cover (unadjusted risk ratio 1.14; 95% CI 1.04-1.24). CONCLUSION No reliable evidence of the effects of 24-hour resident consultant presence on the labour ward on intrapartum outcomes was identified. TWEETABLE ABSTRACT More robust research is needed to assess intrapartum outcomes with resident consultant labour ward presence.
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Affiliation(s)
- J Henderson
- National Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - JJ Kurinczuk
- National Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
| | - M Knight
- National Perinatal Epidemiology UnitNuffield Department of Population HealthUniversity of OxfordOxfordUK
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14
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Mgaya A, Hinju J, Kidanto H. Is time of birth a predictor of adverse perinatal outcome? A hospital-based cross-sectional study in a low-resource setting, Tanzania. BMC Pregnancy Childbirth 2017; 17:184. [PMID: 28606111 PMCID: PMC5469024 DOI: 10.1186/s12884-017-1358-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 05/26/2017] [Indexed: 12/25/2022] Open
Abstract
Background Inconsistent evidence of a higher risk of adverse perinatal outcomes during off-hours compared to office hours necessitated a search for clear evidence of an association between time of birth and adverse perinatal outcomes. Methods A cross-sectional study conducted at a tertiary referral hospital compared perinatal outcomes across three working shifts over 24 h. A checklist and a questionnaire were used to record parturients’ socio-demographic and obstetric characteristics, mode of delivery and perinatal outcomes, including 5th minute Apgar score, and early neonatal mortality. Risks of adverse outcomes included maternal age, parity, referral status and mode of delivery, and were assessed for their association with time of delivery and prevalence of fresh stillbirth as a proxy for poor perinatal outcome at a significance level of p = 0.05. Results Off-hour deliveries were nearly twice as likely to occur during the night shift (odds ratio (OR), 1.62; 95% confidence interval (CI), 1.50–1.72), but were unlikely during the evening shift (OR, 0.58; 95% CI, 0.45–0.71) (all p < 0.001). Neonatal distress (O.R, 1.48, 95% CI; 1.07–2.04, p = 0.02), early neonatal deaths (OR, 1.70; 95% CI, 1.07–2.72, p = 0.03) and fresh stillbirths (OR, 1.95; 95% CI, 1.31–2.90, p = 0.001) were more significantly associated with deliveries occurring during night shifts compared to evening and morning shifts. However, fresh stillbirths occurring during the night shift were independently associated with antenatal admission from clinics or wards, referral from another hospital, and abnormal breech delivery (OR 1.9; 95% CI, 1.3–2.9, p = 0.001, for fresh stillbirths; OR, 5.0; 95% CI 1.7–8.3, p < 0.001, for antenatal admission; OR, 95% CI, 1.1–2.9, p < 0.001, for referral form another hospital; and OR 1.6; 95% CI 1.02–2.6, p = 0.004, for abnormal breech deliveries). Conclusion Off-hours deliveries, particularly during the night shift, were significantly associated with higher proportions of adverse perinatal outcomes, including low Apgar score, early neonatal death and fresh stillbirth, compared to morning and evening shifts. Labour room admissions from antenatal wards, referrals from another hospital and abnormal breech delivery were independent risk factors for poor perinatal outcome, particularly fresh stillbirths.
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Affiliation(s)
- Andrew Mgaya
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania. .,Department of Women's and Children's Health, International Maternal and Child Health, Academic Hospital, Uppsala, Sweden.
| | - Januarius Hinju
- Department of Obstetrics and Gynaecology, Benjamin Mkapa referral Hospital, Dodoma, Tanzania
| | - Hussein Kidanto
- Department of Obstetrics and Gynaecology, Muhimbili National Hospital, P.O. Box 65000, Dar es Salaam, Tanzania.,Department of Women's and Children's Health, International Maternal and Child Health, Academic Hospital, Uppsala, Sweden.,Department of Obstetrics and Gynaecology, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
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Bhanji F, Topjian AA, Nadkarni VM, Praestgaard AH, Hunt EA, Cheng A, Meaney PA, Berg RA. Survival Rates Following Pediatric In-Hospital Cardiac Arrests During Nights and Weekends. JAMA Pediatr 2017; 171:39-45. [PMID: 27820606 PMCID: PMC6159879 DOI: 10.1001/jamapediatrics.2016.2535] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Nearly 6000 hospitalized children in the United States receive cardiopulmonary resuscitation (CPR) annually. Little is known about whether the survival of these children is influenced by the time of the event (eg, nighttime or weekends). Differences in survival could have important implications for hospital staffing, training, and resource allocation. OBJECTIVE To determine whether outcomes after pediatric in-hospital cardiac arrests differ during nights and weekends compared with days/evenings and weekdays. DESIGN, SETTING, AND PARTICIPANTS This study included a total of 354 hospitals participating in the American Heart Association's Get With the Guidelines-Resuscitation registry from January 1, 2000, to December 12, 2012. Index cases (12 404 children) from all children younger than 18 years of age receiving CPR for at least 2 minutes were included. Data analysis was performed in December 2014 and June 2016. We aggregated hourly blocks of time, using previously defined time intervals of day/evening and night, as well as weekend. Multivariable logistic regression models were used to examine the effect of independent variables on survival to hospital discharge. We used a combination of a priori variables based on previous literature (including age, first documented rhythm, location of event in hospital, extracorporeal CPR, and hypotension as the cause of arrest), as well as variables that were identified in bivariate generalized estimating equation models, and maintained significance of P ≤ .15 in the final multivariable models. MAIN OUTCOMES AND MEASURES The primary outcome measure was survival to hospital discharge, and secondary outcomes included return of circulation lasting more than 20 minutes and 24-hour survival. RESULTS Of 12 404 children (56.0% were male), 8731 (70.4%) experienced a return of circulation lasting more than 20 minutes, 7248 (58.4%) survived for 24 hours, and 4488 (36.2%) survived to hospital discharge. After adjusting for potential confounders, we found that the rate of survival to hospital discharge was lower during nights than during days/evenings (adjusted odds ratio, 0.88 [95% CI, 0.80-0.97]; P = .007) but was not different between weekends and weekdays (adjusted odds ratio, 0.92 [95% CI, 0.84-1.01]; P = .09). CONCLUSIONS AND RELEVANCE The rate of survival to hospital discharge was lower for pediatric CPR events occurring at night than for CPR events occurring during daytime and evening hours, even after adjusting for many potentially confounding patient-, event-, and hospital-related factors.
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Affiliation(s)
- Farhan Bhanji
- Centre for Medical Education and Department of Pediatrics, McGill University, Montreal, Quebec, Canada2Royal College of Physicians and Surgeons of Canada, Ottawa, Ontario, Canada
| | - Alexis A. Topjian
- Departments of Anesthesia and Critical Care Medicine and of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania4University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Vinay M. Nadkarni
- Departments of Anesthesia and Critical Care Medicine and of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania4University of Pennsylvania Perelman School of Medicine, Philadelphia
| | | | - Elizabeth A. Hunt
- Departments of Anesthesiology and Critical Care Medicine and of Pediatrics, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam Cheng
- Department of Pediatrics, Alberta Children’s Hospital, Calgary, Alberta, Canada
| | - Peter A. Meaney
- Departments of Anesthesia and Critical Care Medicine and of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania4University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Robert A. Berg
- Departments of Anesthesia and Critical Care Medicine and of Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania4University of Pennsylvania Perelman School of Medicine, Philadelphia
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Knight HE, van der Meulen JH, Gurol-Urganci I, Smith GC, Kiran A, Thornton S, Richmond D, Cameron A, Cromwell DA. Birth "Out-of-Hours": An Evaluation of Obstetric Practice and Outcome According to the Presence of Senior Obstetricians on the Labour Ward. PLoS Med 2016; 13:e1002000. [PMID: 27093698 PMCID: PMC4836717 DOI: 10.1371/journal.pmed.1002000] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 03/10/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Concerns have been raised that a lack of senior obstetricians ("consultants") on the labour ward outside normal hours may lead to worse outcomes among babies born during periods of reduced cover. METHODS AND FINDINGS We carried out a multicentre cohort study using data from 19 obstetric units in the United Kingdom between 1 April 2012 and 31 March 2013 to examine whether rates of obstetric intervention and outcome change "out-of-hours," i.e., when consultants are not providing dedicated, on-site labour ward cover. At the 19 hospitals, obstetric rotas ranged from 51 to 106 h of on-site labour ward cover per week. There were 87,501 singleton live births during the year, and 55.8% occurred out-of-hours. Women who delivered out-of-hours had slightly lower rates of intrapartum caesarean section (CS) (12.7% versus 13.4%, adjusted odds ratio [OR] 0.94; 95% confidence interval [CI] 0.90 to 0.98) and instrumental delivery (15.6% versus 17.0%, adj. OR 0.92; 95% CI 0.89 to 0.96) than women who delivered at times of on-site labour ward cover. There was some evidence that the severe perineal tear rate was reduced in out-of-hours vaginal deliveries (3.3% versus 3.6%, adj. OR 0.92; 95% CI 0.85 to 1.00). There was no evidence of a statistically significant difference between out-of-hours and "in-hours" deliveries in the rate of babies with a low Apgar score at 5 min (1.33% versus 1.25%, adjusted OR 1.07; 95% CI 0.95 to 1.21) or low cord pH (0.94% versus 0.82%; adjusted OR 1.12; 95% CI 0.96 to 1.31). Key study limitations include the potential for bias by indication, the reliance upon an organisational measure of consultant presence, and a non-random sample of maternity units. CONCLUSIONS There was no difference in the rate of maternal and neonatal morbidity according to the presence of consultants on the labour ward, with the possible exception of a reduced rate of severe perineal tears in out-of-hours vaginal deliveries. Fewer women had operative deliveries out-of-hours. Taken together, the available evidence provides some reassurance that the current organisation of maternity care in the UK allows for good planning and risk management. However there is a need for more robust evidence on the quality of care afforded by different models of labour ward staffing.
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Affiliation(s)
- Hannah E. Knight
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
- * E-mail:
| | - Jan H. van der Meulen
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Ipek Gurol-Urganci
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Gordon C. Smith
- Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom
| | - Amit Kiran
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Steve Thornton
- Department of Obstetrics and Gynaecology, University of Exeter Medical School, Exeter, United Kingdom
| | - David Richmond
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - Alan Cameron
- Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom
| | - David A. Cromwell
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
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Timing of induction of labor and association with nighttime delivery: a retrospective cohort. J Perinatol 2015; 35:1011-4. [PMID: 26491850 DOI: 10.1038/jp.2015.135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2015] [Revised: 09/11/2015] [Accepted: 09/22/2015] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To assess the risk of nighttime delivery associated with timing and method of labor induction. STUDY DESIGN We reviewed records of 692 patients undergoing full, late or post-term labor induction at two large hospitals. Primary independent variables were start time (morning or evening) and method (prostaglandin or oxytocin). Relative risk was assessed for the primary outcome of nighttime delivery. RESULT Two hundred and ninety-seven (42.9%) patients experienced nighttime delivery. The relative risk of nighttime delivery adjusted for age in multiparous women using oxytocin in the morning compared with oxytocin inductions in the evening was 0.31 (95% confidence interval (CI): 0.22 to 0.45). Among nulliparous women in the same group, the adjusted relative risk was 0.65 (95% CI: 0.36 to 1.19). For prostaglandin inductions, there was no difference in the risk of nighttime delivery based on timing of the induction in the evening (relative risk: 0.89; 95% CI: 0.71 to 1.10). CONCLUSION The method used and the time at which induction is started affect risk of nighttime delivery. For multiparous patients receiving oxytocin, morning induction carries lower risk of nighttime delivery. For prostaglandins, timing of initiation did not affect risk of nighttime delivery.
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Miller H, Goetzl L, Wing DA, Powers B, Rugarn O. Optimising daytime deliveries when inducing labour using prostaglandin vaginal inserts. J Matern Fetal Neonatal Med 2015; 29:517-22. [PMID: 25758619 PMCID: PMC4776722 DOI: 10.3109/14767058.2015.1011117] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE To determine induction start time(s) that would maximise daytime deliveries when using prostaglandin vaginal inserts. METHODS Women enrolled into the Phase III trial, EXPEDITE (clinical trial registration: NCT01127581), had labour induced with either a misoprostol or dinoprostone vaginal insert (MVI or DVI). A secondary analysis was conducted to determine the optimal start times for induction by identifying the 12-h period with the highest proportion of deliveries by parity and treatment. RESULTS Optimal start times for achieving daytime deliveries when using MVI appear to be 19:00 in nulliparae and 23:00 in multiparae. Applying these start times, the median time of onset of active labour would be approximately 08:30 for both parities and the median time of delivery would be the following day at approximately 16:30 for nulliparae and 12:00 (midday) for multiparae. Optimal start times when using DVI appear to be 07:00 for nulliparae and 23:00 for multiparae. Using these start times, the median time of onset of active labour would be the following day at approximately 04:00 and 11:50, and the median time of delivery would be approximately 13:40 and 16:10, respectively. CONCLUSIONS When optimising daytime deliveries, different times to initiate induction of labour may be appropriate depending on parity and the type of retrievable prostaglandin vaginal insert used.
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Affiliation(s)
- Hugh Miller
- a Watching Over Mothers & Babies Foundation , Tucson , AZ , USA
| | - Laura Goetzl
- b Department of Obstetrics, Gynecology and Reproductive Sciences , Temple University , Philadelphia , PA , USA
| | - Deborah A Wing
- c Department of Obstetrics and Gynecology , University of California , Irvine, Orange , CA , USA .,d Miller Children's and Women's Hospital , Long Beach , CA , USA
| | - Barbara Powers
- e Independent Consultant , Phoenixville , PA , USA , and
| | - Olof Rugarn
- f Ferring Pharmaceuticals , Copenhagen , Denmark
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Reference ranges of amniotic fluid index in late third trimester of pregnancy: what should the optimal interval between two ultrasound examinations be? J Pregnancy 2015; 2015:319204. [PMID: 25685558 PMCID: PMC4312643 DOI: 10.1155/2015/319204] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 11/18/2014] [Accepted: 11/20/2014] [Indexed: 11/18/2022] Open
Abstract
Background. Amniotic fluid index (AFI) is one of the major and deciding components of fetal biophysical profile and by itself it can predict pregnancy outcome. Very low values are associated with intrauterine growth restriction and renal anomalies of fetus, whereas high values may indicate fetal GI anomalies, maternal diabetes mellitus, and so forth. However, before deciding the cut-off standards for abnormal values for a local population, what constitutes a normal range for specific gestational age and the ideal interval of testing should be defined. Objectives. To establish reference standards for AFI for local population after 34 weeks of pregnancy and to decide an optimal scan interval for AFI estimation in third trimester in low risk antenatal women. Materials and Methods. A prospective estimation of AFI was done in 50 healthy pregnant women from 34 to 40 weeks at weekly intervals. The trend of amniotic fluid volume was studied with advancing gestational age. Only low risk singleton pregnancies with accurately established gestational age who were available for all weekly scan from 34 to 40 weeks were included in the study. Women with gestational or overt diabetes mellitus, hypertensive disorders of the pregnancy, prelabour rupture of membranes, and congenital anomalies in the foetus and those who delivered before 40 completed weeks were excluded from the study. For the purpose of AFI measurement, the uterine cavity was arbitrarily divided into four quadrants by a vertical and horizontal line running through umbilicus. Linear array transabdominal probe was used to measure the largest vertical pocket (in cm) in perpendicular plane to the abdominal skin in each quadrant. Amniotic fluid index was obtained by adding these four measurements. Statistical analysis was done using SPSS software (Version 16, Chicago, IL). Percentile curves (5th, 50th, and 95th centiles) were constructed for comparison with other studies. Cohen's d coefficient was used to examine the magnitude of change at different time intervals. Results. Starting from 34 weeks till 40 weeks, 50 ultrasound measurements were available at each gestational age. The mean (standard deviation) of AFI values (in cms) were 34 W: 14.59 (1.79), 35 W: 14.25 (1.57), 36 W: 13.17 (1.56), 37 W: 12.48 (1.52), 38 W: 12.2 (1.7), and 39 W: 11.37 (1.71). The 5th percentile cut-off was 8.7 cm at 40 weeks. There was a gradual decline of AFI values as the gestational age approached term. Significant drop in AFI was noted at two-week intervals. AFI curve generated from the study varied significantly when compared with already published data, both from India and abroad. Conclusion. Normative range for AFI values for late third trimester was established. Appreciable changes occurred in AFI values as gestation advanced by two weeks. Hence, it is recommended to follow up low risk antenatal women every two weeks after 34 weeks of pregnancy. The percentile curves of AFI obtained from the present study may be used to detect abnormalities of amniotic fluid for our population.
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Harmsen L, Schaaf H. Adverse outcomes of (post-)term births and differences in professional organisational contexts: an integral descriptive system approach. BMJ Open 2014; 4:e006083. [PMID: 25416058 PMCID: PMC4244403 DOI: 10.1136/bmjopen-2014-006083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE The development and application of an integral descriptive model for monitoring and evaluation of patient flows and adverse outcomes of childbirth related to distinct categories of professional organisational contexts. SETTING After categorisation of the individual professional contexts in which deliveries take place, the resulting framework has been superimposed on the 2002-2010 database of the Netherlands Perinatal Registry. PARTICIPANTS All Dutch hospitals and almost all first-line midwife practices recorded 1,469,955 (post-)term births from which only the patients with a spontaneous onset of labour (n=1,120,508) were included in a study on the quality of obstetric care outside office hours. MAIN OUTCOME MEASURES For the performance of professional organisational contexts the difference in relative incidence of perinatal death or Apgar score <7 between the related patient groups and the reference patient groups has been used. These differences have been expressed as risk ratio (RR) with a 95% CI. RESULTS Only the group of patients who started labour spontaneously under the supervision of the first-line midwife shows a proportional distribution over the parts of the day. In all other groups the distribution of patients is disproportional. The perinatal mortality rate declines by about 30% in the successive periods. This decline concerns mainly those patients who gave birth outside office hours. CONCLUSIONS The complexity and the dynamics of the obstetric care system make it virtually impossible to demonstrate fixed patterns in the relationships between the separate contextual factors and the (adverse) outcomes of births. To generate useful knowledge, it is necessary to evaluate changes in the obstetric care system periodically and systematically. Thus, the longitudinal application of the model demonstrated that the differences in perinatal mortality rate between the parts of the day have disappeared in recent years.
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Affiliation(s)
- Loes Harmsen
- Department of Obstetrics and Gynaecology, Deventer Hospital, Deventer, The Netherlands
| | - Hans Schaaf
- Independent Researcher and Management Consultant, JHS Healthcare, Tilburg, The Netherlands
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Siddiqui I, Whittingham B, Meadowcroft K, Richardson M, Cooper JC, Belcher J, Morris E, Ismail KMK. Developing Objective Metrics for Unit Staffing (DOMUS) study. BMJ Open 2014; 4:e005398. [PMID: 25217367 PMCID: PMC4163650 DOI: 10.1136/bmjopen-2014-005398] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Safe midwifery staffing levels on delivery suites is a priority area for any maternity service. Escalation policies are tools that provide an operational response to emergency pressures. The aim of this study was to assess the feasibility of using a scoring system to contemporaneously assess the required staffing level based on demand and use this to determine delivery suite escalation level and utilise the information generated regarding clinical activity (Demand) and staffing levels (Capacity) to generate unit-specific calculation for the actual number of midwifery staff required. SETTING A maternity unit of a university-affiliated tertiary referral hospital. DESIGN Over a 12-month period, specifically designed scoring sheets were completed by delivery suite shift co-ordinators four times a day (04:00, 10:00, 16:00 and 22:00). Based on the dependency score (Demand) and the number of midwifery staff available (Capacity), an escalation level was determined for each shift. The 80th centile of the demand was used to determine optimal capacity. RESULTS A total of 1160 scoring sheets were completed. Average staff number throughout the year on any shift was 7 (range 3-11). Average dependency score was 7 (range 1-14). The 80th centile for demand was calculated to be 11. CONCLUSIONS This study stresses the importance and usefulness of a simple tool that can be used to determine the level of escalation on delivery suite based on an objective scoring system and can also be used to determine the appropriate staffing on delivery suite.
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Affiliation(s)
- I Siddiqui
- University Hospital of North Staffordshire NHS Trust, Stoke, UK
| | - B Whittingham
- University Hospital of North Staffordshire NHS Trust, Stoke, UK
| | - K Meadowcroft
- University Hospital of North Staffordshire NHS Trust, Stoke, UK
| | - M Richardson
- University Hospital of North Staffordshire NHS Trust, Stoke, UK
| | - J C Cooper
- University Hospital of North Staffordshire NHS Trust, Stoke, UK
| | - J Belcher
- Department of Primary Care Sciences, Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, Keele, UK
| | - E Morris
- Norfolk and Norwich University Hospital NHS Foundation Trust, Norwich, UK
| | - K M K Ismail
- College of Medical & Dental Sciences, Birmingham centre for Women's and Children's Health, School of Clinical & Experimental Medicine, University of Birmingham, Birmingham, UK Birmingham Women's NHS Foundation Trust, Birmingham, UK
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Daripa M, Caldas HMG, Flores LPO, Waldvogel BC, Guinsburg R, de Almeida MFB. Perinatal asphyxia associated with early neonatal mortality: populational study of avoidable deaths. REVISTA PAULISTA DE PEDIATRIA 2014; 31:37-45. [PMID: 23703042 DOI: 10.1590/s0103-05822013000100007] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2012] [Accepted: 09/10/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To compare the epidemiological profile of avoidable early neonatal deaths associated with perinatal asphyxia according to region of death in the State of São Paulo, Brazil. METHODS Population-based cohort study including 2,873 avoidable deaths up to six days of life associated with perinatal asphyxia from January 2001 to December 2003. Perinatal asphyxia was considered if intrauterine hypoxia, birth asphyxia, or meconium aspiration syndrome were written in any line of the original Death Certificate. Epidemiological data were also extracted from the Birth Certificate. RESULTS During the three years, 1.71 deaths per 1,000 live births were associated with perinatal asphyxia, which corresponded to 22% of the early neonatal deaths. From the 2,873 avoidable deaths, 761 (27%) occurred in São Paulo city; 640 (22%), in the metropolitan region of São Paulo city; and 1,472 (51%), in the countryside of the state. In the first two regions, deaths were more frequent in public hospitals, among newborns with gestational age of 36 weeks or less, and among babies weighing less than 2500g. In the countryside, mortality was more frequent in philanthropic hospitals, in term newborns and in neonates weighing over 2500g. Most of these neonates were born during daytime in their hometown and died at the same institution in which they were born within the first 24 hours after delivery. Meconium aspiration syndrome was related to 18% of the deaths. CONCLUSIONS Perinatal asphyxia is a frequent contributor to the avoidable early neonatal death in the state with the highest gross domestic product per capita in Brazil, and it shows the need for specific interventions with regionalized focus during labor and birth care.
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Snowden JM, Cheng YW, Kontgis CP, Caughey AB. The association between hospital obstetric volume and perinatal outcomes in California. Am J Obstet Gynecol 2012; 207:478.e1-7. [PMID: 23174387 DOI: 10.1016/j.ajog.2012.09.029] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2012] [Revised: 09/10/2012] [Accepted: 09/26/2012] [Indexed: 10/27/2022]
Abstract
OBJECTIVE We sought to analyze the association between hospital obstetric volume and perinatal outcomes in California. STUDY DESIGN This was a retrospective cohort study of births occurring in California in 2006. Hospitals were divided into 4 obstetric volume categories. Unadjusted rates of neonatal mortality and birth asphyxia were calculated for each category, overall and among term deliveries with birthweight >2500 g. Multivariable logistic regression was used to control for confounders. Deliveries in rural hospitals were analyzed separately using different volume categories. RESULTS Prevalence of asphyxia increased with decreasing hospital volume overall and among term, non-low-birthweight infants, from 9/10,000 live births at highest-volume hospitals to 18/10,000 live births at the lowest-volume hospitals (P < .001). Similar trends were observed in rural hospitals, with rates increasing from 7-34/10,000 live births in low-volume rural hospitals (P < .001). CONCLUSION These findings provide evidence for an inverse association between hospital obstetric volume and birth asphyxia.
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Gijsen R, Hukkelhoven CWPM, Schipper CMA, Ogbu UC, de Bruin-Kooistra M, Westert GP. Effects of hospital delivery during off-hours on perinatal outcome in several subgroups: a retrospective cohort study. BMC Pregnancy Childbirth 2012; 12:92. [PMID: 22958736 PMCID: PMC3496693 DOI: 10.1186/1471-2393-12-92] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2011] [Accepted: 08/23/2012] [Indexed: 11/29/2022] Open
Abstract
Background Studies have demonstrated a higher risk of adverse outcomes among infants born or admitted during off-hours, as compared to office hours, leading to questions about quality of care provide during off-hours (weekend, evening or night). We aim to determine the relationship between off-hours delivery and adverse perinatal outcomes for subgroups of hospital births. Methods This retrospective cohort study was based on data from the Netherlands Perinatal Registry, a countrywide registry that covers 99% of all hospital births in the Netherlands. Data of 449,714 infants, born at 28 completed weeks or later, in the period 2003 through 2007 were used. Infants with a high a priori risk of morbidity or mortality were excluded. Outcome measures were intrapartum and early neonatal mortality, a low Apgar score (5 minute score of 0–6), and a composite adverse perinatal outcome measure (mortality, low Apgar score, severe birth trauma, admission to a neonatal intensive care unit). Results Evening and night-time deliveries that involved induction or augmentation of labour, or an emergency caesarean section, were associated with an increased risk of an adverse perinatal outcome when compared to similar daytime deliveries. Weekend deliveries were not associated with an increased risk when compared to weekday deliveries. It was estimated that each year, between 126 and 141 cases with an adverse perinatal outcomes could be attributed to this evening and night effect. Of these, 21 (15-16%) are intrapartum or early neonatal death. Among the 3100 infants in the study population who experience an adverse outcome each year, death accounted for only 5% (165) of these outcomes. Conclusion This study shows that for infants whose mothers require obstetric interventions during labour and delivery, birth in the evening or at night, are at an increased risk of an adverse perinatal outcomes.
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Affiliation(s)
- Ronald Gijsen
- Centre for Public Health Forecasting, National Institute for Public Health and the Environment, PO Box 1, Bilthoven, BA, 3720, The Netherlands.
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Twins born over weekends: are they at risk for elevated infant mortality? Arch Gynecol Obstet 2012; 286:1349-55. [PMID: 22797696 DOI: 10.1007/s00404-012-2463-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2012] [Accepted: 07/03/2012] [Indexed: 10/28/2022]
Abstract
OBJECTIVE To assess the impact of the day of birth on twin mortality in a population sample. METHODS We analyzed weekend versus weekday twin births from the United States national twin birth data for the periods 1989-2002. We computed adjusted hazard ratios (HR) and 95% confidence intervals (CI) to assess the association between infant mortality and weekday of birth using the Cox proportional hazards model. RESULTS The crude rates for all types of mortality were found to be significantly higher for twins born on weekends than on weekdays. After adjustment, only post-neonatal mortality risk was higher on weekends as compared to weekdays [Hazards ratio (HR)=1.19, CI: 1.04, 1.36]. Twins of white mothers were at greater risk for neonatal death (HR=1.16, CI: 1.08, 1.24) but were less likely to experience post-neonatal death (HR=0.68, CI: 0.64, 0.76) as compared to twins of black mothers. We found an interaction between maternal age and weekday of birth. Twins born on weekends to teenage mothers (age<18) had a 35% greater risk for neonatal death (HR=1.35, CI: 1.06, 1.71) while those born on weekends to older mothers did not show elevated risk for any of the mortality indices. CONCLUSION Increased risks for post-neonatal death are significantly higher amongst twins born on weekends as compared to weekdays. Further research is required to identify the detailed differences in structure and procedures that result in the disadvantage associated with weekend birth.
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Woodhead N, Lindow S. Time of birth and delivery outcomes: A retrospective cohort study. J OBSTET GYNAECOL 2012; 32:335-7. [DOI: 10.3109/01443615.2012.664586] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Resnick S, Jacques A, Patole S, Simmer K. Does after-hours in-house senior physician cover improve standard of care and outcomes in high-risk preterm neonates? A retrospective cohort study. J Paediatr Child Health 2011; 47:795-801. [PMID: 21426436 DOI: 10.1111/j.1440-1754.2011.02028.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
AIM To compare the standard of care and outcomes to discharge for inborn high-risk preterm (gestation <32 weeks) neonates admitted to the neonatal intensive care unit (NICU) before and after adopting an after-hours in-house senior physician cover roster (ISPCR). The ISPCR involved the presence of a consultant neonatologist or neonatal fellow in the NICU until 11 pm. METHODS This was a retrospective analysis of prospectively collected data for 12 months before (1 February 2002 to 31 January 2003, epoch 1) and after (1 April 2003 to 31 March 2004, epoch 2) adopting the ISPCR. Short-term neonatal outcomes, including mortality and morbidity such as intraventricular haemorrhage, retinopathy of prematurity, necrotising enterocolitis and chronic lung disease, were examined. The standard of acute care, including admission temperature, correct positioning of tubes and lines, and preventable ventilatory complications in the first 8 h following admission, was also compared. RESULTS The numbers (235 in epoch 1, 245 in epoch 2), demographic characteristics and severity of illness (CRIB score) of neonates admitted to the NICU was comparable between epochs. Overall neonatal outcomes did not show significant improvement after adopting an ISPCR, nor were they improved for after-hours admissions in the presence of senior in-house physicians. The standard of acute care was also not significantly different. Minor improvements, such as earlier administration of surfactant, were noted in epoch 2. CONCLUSIONS Adoption of an ISPCR was not associated with any significant change in the standard of acute care and short-term outcomes for inborn neonates <32 weeks' gestation.
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Affiliation(s)
- Steven Resnick
- Neonatology Clinical Care Unit, King Edward Memorial Hospital for Women, Perth, Western Australia, Australia.
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Starting time for induction of labor and the risk for night-time delivery. SEXUAL & REPRODUCTIVE HEALTHCARE 2011; 2:113-7. [DOI: 10.1016/j.srhc.2011.05.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2011] [Revised: 04/25/2011] [Accepted: 05/04/2011] [Indexed: 11/22/2022]
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Wu YW, Pham TN, Danielsen B, Towner D, Smith L, Johnston SC. Nighttime delivery and risk of neonatal encephalopathy. Am J Obstet Gynecol 2011; 204:37.e1-6. [PMID: 21074140 DOI: 10.1016/j.ajog.2010.09.022] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2010] [Revised: 06/30/2010] [Accepted: 09/20/2010] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The objective of the study was to determine the relationship between nighttime delivery and neonatal encephalopathy (NE). STUDY DESIGN The design of the study was a retrospective population-based cohort of 1,864,766 newborns at a gestation of 36 weeks or longer in California, 1999-2002. We determined the risk of NE associated with nighttime delivery (7:00 (PM) to 6:59 (AM)). RESULTS Two thousand one hundred thirty-one patients had NE (incidence 1.1 per 1000 births). Nighttime delivery was associated with increased NE (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.03-1.20), birth asphyxia (OR, 1.18; 95% CI, 1.08-1.29), and neonatal seizures (OR, 1.17; 95% CI, 1.07-1.28). In adjusted analyses, nighttime delivery was an independent risk factor for NE (OR, 1.10; 95% CI, 1.01-1.21), as were severe intrauterine growth retardation (OR, 3.8; 95% CI, 3.1-4.8); no prenatal care (OR, 2.0; 95% CI, 1.4-2.9); primiparity (OR, 1.5; 95% CI, 1.4-1.7); advanced maternal age (OR, 1.3; 95% CI, 1.16-1.45); and infant male sex (OR, 1.3; 95% CI, 1.2-1.4). CONCLUSION Future studies of time of delivery may generate new strategies to reduce the burden of NE.
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Bell EF, Hansen NI, Morriss FH, Stoll BJ, Ambalavanan N, Gould JB, Laptook AR, Walsh MC, Carlo WA, Shankaran S, Das A, Higgins RD. Impact of timing of birth and resident duty-hour restrictions on outcomes for small preterm infants. Pediatrics 2010; 126:222-31. [PMID: 20643715 PMCID: PMC2924191 DOI: 10.1542/peds.2010-0456] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
OBJECTIVE The goal was to examine the impact of birth at night, on the weekend, and during July or August (the first months of the academic year) and the impact of resident duty-hour restrictions on mortality and morbidity rates for very low birth weight infants. METHODS Outcomes were analyzed for 11,137 infants with birth weights of 501 to 1250 g who were enrolled in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network registry in 2001-2005. Approximately one-half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessments at 18 to 22 months were completed for 4508 infants. Mortality rate, short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth. RESULTS There was no effect of the timing of birth on mortality rate and no impact on the risks of short-term morbidities except that the risk of retinopathy of prematurity (stage > or =2) was higher after the introduction of duty-hour restrictions and the risk of retinopathy of prematurity requiring operative treatment was lower for infants born during the late night than during the day. There was no impact of the timing of birth on neurodevelopmental outcome except that the risk of hearing impairment or death was slightly lower among infants born in July or August. CONCLUSION In this network, the timing of birth had little effect on the risks of death and morbidity for very low birth weight infants, which suggests that staffing patterns were adequate to provide consistent care.
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Affiliation(s)
- Edward F. Bell
- Department of Pediatrics, University of Iowa, Iowa City, Iowa
| | | | | | | | | | - Jeffrey B. Gould
- Department of Pediatrics, Stanford University, Palo Alto, California
| | - Abbot R. Laptook
- Department of Pediatrics, Brown University, Providence, Rhode Island
| | - Michele C. Walsh
- Department of Pediatrics, Case Western Reserve University, Cleveland, Ohio
| | - Waldemar A. Carlo
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | | | - Abhik Das
- RTI International, Rockville, Maryland
| | - Rosemary D. Higgins
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, Maryland
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Pasupathy D, Wood AM, Pell JP, Fleming M, Smith GCS. Time of birth and risk of neonatal death at term: retrospective cohort study. BMJ 2010; 341:c3498. [PMID: 20634347 PMCID: PMC2904877 DOI: 10.1136/bmj.c3498] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To determine the effect of time and day of birth on the risk of neonatal death at term. DESIGN Population based retrospective cohort study. SETTING Data from the linked Scottish morbidity records, Stillbirth and Infant Death Survey, and birth certificate database of live births in Scotland, 1985-2004. SUBJECTS Liveborn term singletons with cephalic presentation. Perinatal deaths from congenital anomalies excluded. Final sample comprised 1,039,560 live births. MAIN OUTCOME MEASURE All neonatal deaths (in the first four weeks of life) unrelated to congenital abnormality, plus a subgroup of deaths ascribed to intrapartum anoxia. RESULTS The risk of neonatal death was 4.2 per 10,000 during the normal working week (Monday to Friday, 0900-1700) and 5.6 per 10 000 at all other times (out of hours) (unadjusted odds ratio 1.3, 95% confidence interval 1.1 to 1.6). Adjustment for maternal characteristics had no material effect. The higher rate of death out of hours was because of an increased risk of death ascribed to intrapartum anoxia (adjusted odds ratio 1.7, 1.2 to 2.3). Though exclusion of elective caesarean deliveries attenuated the association between death ascribed to anoxia and delivery out of hours, a significant association persisted (adjusted odds ratio 1.5, 1.1 to 2.0). The attributable fraction of neonatal deaths ascribed to intrapartum anoxia associated with delivery out of hours was 26% (95% confidence interval 5% to 42%). CONCLUSIONS Delivering an infant outside the normal working week was associated with an increased risk of neonatal death at term ascribed to intrapartum anoxia.
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Affiliation(s)
- Dharmintra Pasupathy
- Department of Obstetrics and Gynaecology, University of Cambridge, and NIHR Cambridge Comprehensive Biomedical Research Centre, Cambridge CB2 2SW
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de Graaf JP, Ravelli ACJ, Visser GHA, Hukkelhoven C, Tong WH, Bonsel GJ, Steegers EAP. Increased adverse perinatal outcome of hospital delivery at night. BJOG 2010; 117:1098-107. [PMID: 20497413 DOI: 10.1111/j.1471-0528.2010.02611.x] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether delivery in the evening or at night and some organisational features of maternity units are related to perinatal adverse outcome. DESIGN A 7-year national registry-based cohort study. SETTING All 99 Dutch hospitals. POPULATION From nontertiary hospitals (n = 88), 655 961 singleton deliveries from 32 gestational weeks onwards, and, from tertiary centres (n = 10), 108 445 singleton deliveries from 22 gestational weeks onwards. METHODS Multiple logistic regression analysis of national perinatal registration data over the period 2000-2006. In addition, multilevel analysis was applied to investigate whether the effects of time of delivery and other variables systematically vary across different hospitals. MAIN OUTCOME MEASURES Delivery-related perinatal mortality (intrapartum or early neonatal mortality) and combined delivery-related perinatal adverse outcome (any of the following: intrapartum or early neonatal mortality, 5-minute Apgar score below 7, or admission to neonatal intensive care). RESULTS After case mix adjustment, relative to daytime, increased perinatal mortality was found in nontertiary hospitals during the evening (OR, 1.32; 95% CI, 1.15-1.52) and at night (OR, 1.47; 95% CI, 1.28-1.69) and, in tertiary centres, at night only (OR, 1.20; 95% CI, 1.06-1.37). Similar significant effects were observed using the combined perinatal adverse outcome measure. Multilevel analysis was unsuccessful; extending the initial analysis with nominal hospital effects and hospital-delivery time interaction effects confirmed the significant effect of night in nontertiary hospitals, whereas other organisational effects (nontertiary, tertiary) were taken up by the hospital terms. CONCLUSION Hospital deliveries at night are associated with increased perinatal mortality and adverse perinatal outcome. The time of delivery and other organisational features representing experience (seniority of staff, volume) explain hospital-to-hospital variation.
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Affiliation(s)
- J P de Graaf
- Division of Obstetrics and Prenatal Medicine, Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, the Netherlands
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Numa A, Williams G, Awad J, Duffy B. After-hours admissions are not associated with increased risk-adjusted mortality in pediatric intensive care. Intensive Care Med 2007; 34:148-51. [PMID: 17943272 DOI: 10.1007/s00134-007-0904-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2006] [Accepted: 09/23/2007] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the influence of time of admission on risk-adjusted mortality and length of stay for nonelective patients admitted to a pediatric intensive care unit (ICU) without 24-h per day in-house intensivist coverage. DESIGN Data analyzed came from a comprehensive, prospectively collected ICU database. SETTING A 12-bed pediatric ICU located in a university-affiliated tertiary referral children's hospital. PATIENTS Subjects consisted of 4,456 consecutive nonelective patients admitted over a 10-year period (1997-2006). INTERVENTIONS None. MEASUREMENTS AND RESULTS Patients were categorized according to time of admission to the ICU as either in-hours (0800-1800 Monday-Friday and 0800-1200 on weekends), when an intensivist is present in the ICU, or after-hours (all other times), when intensivists attend only on an as-needed basis. Multivariate logistic regression was used to assess the effect of time of admission on outcome after adjustment for severity of illness using the Paediatric Index of Mortality (PIM). Patients admitted after hours had a lower risk-adjusted mortality than those admitted during normal working hours, with an odds ratio for death of 0.712 (95% confidence interval 0.518-0.980, p = 0.037). Length of stay was also significantly shorter for patients admitted after hours (44.05h vs. 50.0h, p = 0.001). CONCLUSIONS A lack of in-house intensivist presence is not associated with any increase in mortality or length of stay for patients admitted to our pediatric ICU; on the contrary, after-hours admission in this cohort was associated with a decreased risk-adjusted mortality and a shorter length of stay.
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Affiliation(s)
- Andrew Numa
- Intensive Care Unit, Sydney Children's Hospital, High St., 2031, Randwick, Australia.
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Badr LK, Abdallah B, Balian S, Tamim H, Hawari M. The chasm in neonatal outcomes in relation to time of birth in Lebanon. Neonatal Netw 2007; 26:97-102. [PMID: 17402601 DOI: 10.1891/0730-0832.26.2.97] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023]
Abstract
PURPOSE The purpose of this study was to investigate the relationship between the time of birth and the mortality and morbidity of infants admitted to neonatal intensive care units. DESIGN This prospective, cohort study examined the records of women and infants admitted to the NICUs of four hospitals in Beirut, Lebanon, between July 1, 2002, and June 30, 2003. The hospitals selected were university affiliated and had a large number of deliveries (5,152 total for the year 2002-2003). MAIN OUTCOME VARIABLES Neonatal mortality and morbidity for infants admitted to the NICU were evaluated in relation to time of birth. RESULTS For the whole sample, mortality was higher for infants born during the night shift than for those born during the day shift. Mortality, morbidity, and brain asphyxia rates were also higher for infants born during the night shift and admitted to the NICU. Maternal risk factors and delivery complications were nor consistently higher on the night shift.
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Profit J, McCormick MC, Escobar GJ, Richardson DK, Zheng Z, Coleman-Phox K, Roberts R, Zupancic JAF. Neonatal intensive care unit census influences discharge of moderately preterm infants. Pediatrics 2007; 119:314-9. [PMID: 17272621 PMCID: PMC3151170 DOI: 10.1542/peds.2005-2909] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The timely discharge of moderately premature infants has important economic implications. The decision to discharge should occur independent of unit census. We evaluated the impact of unit census on the decision to discharge moderately preterm infants. DESIGN/METHODS In a prospective multicenter cohort study, we enrolled 850 infants born between 30 and 34 weeks' gestation at 10 NICUs in Massachusetts and California. We divided the daily census from each hospital into quintiles and tested whether discharges were evenly distributed among them. Using logistic regression, we analyzed predictors of discharge within census quintiles associated with a greater- or less-than-expected likelihood of discharge. We then explored parental satisfaction and postdischarge resource consumption in relation to discharge during census periods that were associated with high proportions of discharge. RESULTS There was a significant correlation between unit census and likelihood of discharge. When unit census was in the lowest quintile, patients were 20% less likely to be discharged when compared with all of the other quintiles of unit census. In the lowest quintile of unit census, patient/nurse ratio was the only variable associated with discharge. When census was in the highest quintile, patients were 32% more likely to be discharged when compared with all of the other quintiles of unit census. For patients in this quintile, a higher patient/nurse ratio increased the likelihood of discharge. Conversely, infants with prolonged lengths of stay, an increasing Score for Neonatal Acute Physiology II, and minor congenital anomalies were less likely to be discharged. Infants discharged at high unit census did not differ from their peers in terms of parental satisfaction, emergency department visits, home nurse visits, or rehospitalization rates. CONCLUSIONS Discharges are closely correlated with unit census. Providers incorporate demand and case mix into their discharge decisions.
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Affiliation(s)
- Jochen Profit
- Harvard Newborn Medicine Program, Children's Hospital Boston and Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA.
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Urato AC, Craigo SD, Chelmow D, O'Brien WF. The association between time of birth and fetal injury resulting in death. Am J Obstet Gynecol 2006; 195:1521-6. [PMID: 16723102 DOI: 10.1016/j.ajog.2006.03.084] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2005] [Revised: 02/10/2006] [Accepted: 03/19/2006] [Indexed: 11/29/2022]
Abstract
OBJECTIVE In obstetrics, the care of patients in labor or with emergencies takes place day and night. Birth-related injury is among the worst of obstetric outcomes. This study sought to examine the relationship between time of birth and fetal injury resulting in death. STUDY DESIGN The Birth-Related Neurologic Injury Compensation Association (NICA) is a Florida organization that pays for the care of infants >2500 g with birth-related brain or spinal cord injury resulting in permanent impairment. We conducted a case-control study using all deaths from the NICA database from 1989 to 2002. Data were collected on the antepartum, intrapartum, and postpartum care of the mother and fetus/child. Time of birth was identified for all cases and compared with a randomly selected control group of 1000 births in 1996 from Florida. RESULTS Eighty deaths were identified in the NICA database of 447 total cases. Of the 80 cases, 36/80 (45%) were born from 11 pm to 8 am. Of the 999 controls (1 certificate sealed for adoption) 281 (28.1%) were born from 11 pm to 8 am. This yields an odds ratio of 2.09 (95% CI 1.29-3.40) for the association of nighttime birth with fetal injury resulting in death. CONCLUSION Fetuses sustaining injuries resulting in death were more than twice as likely as controls to have been born from 11 pm to 8 am. Further studies are needed to determine the factors that affect this association and what changes might need to be made to optimize care regardless of time of day or night.
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Affiliation(s)
- Adam C Urato
- Department of Obstetrics and Gynecology, University of South Florida/Tampa General Hospital, Tampa, FL, USA
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Dodd JM, Crowther CA, Robinson JS. Morning compared with evening induction of labor: a nested randomized controlled trial. A nested randomized controlled trial. Obstet Gynecol 2006; 108:350-60. [PMID: 16880306 DOI: 10.1097/01.aog.0000227746.35565.d9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To test the hypothesis that commencing induction of labor in the morning more closely reflects the physiologic timing of onset of labor and is associated with fewer women who remain undelivered 24 hours after cervical ripening and induction begins. METHODS This was a nested randomized clinical trial, conducted between April 2001 and December 2004. Pregnant women at more than 36+6 weeks gestation with a cephalic presentation who were scheduled for prostaglandin induction of labor were eligible to participate. Women were randomly assigned to either admission in the morning (0800 hours) or admission in the evening (2,000 hours). The primary outcome measures were vaginal birth not achieved in 24 hours, uterine hyperstimulation with associated fetal heart rate changes, and cesarean delivery. RESULTS A total of 620 women were entered in the trial, with 280 women in the morning admission group and 340 women in the evening admission group. There were no statistically significant differences between the timing of admission for induction and the primary trial outcomes. However, women admitted in the morning were less likely to require oxytocin infusion (morning admission 126 of 280 [45.0%] compared with evening admission 184 of 340 [54.1%]; relative risk 0.83, 95% confidence interval 0.70-0.97; P=.022). Nulliparous women admitted in the morning were less likely to require operative vaginal birth (morning admission 10 of 62 [16.1%] compared with evening admission 28 of 82 [34.2%]; relative risk 0.47, 95% confidence interval 0.25-0.90; P=.015). CONCLUSION For women who require induction of labor, consideration should be given to admission in the morning rather than admission in the evening. CLINICAL TRIAL REGISTRATION Australian Clinical Trials Registry, www.actr.org.au, 12606000156583.
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Affiliation(s)
- Jodie M Dodd
- The Department of Obstetrics and Gynaecology, the University of Adelaide, North Adelaide, South Australia, Australia.
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Wu YW, Croen LA, Shah SJ, Newman TB, Najjar DV. Cerebral palsy in a term population: risk factors and neuroimaging findings. Pediatrics 2006; 118:690-7. [PMID: 16882824 DOI: 10.1542/peds.2006-0278] [Citation(s) in RCA: 144] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE The purpose of this work was to study risk factors and neuroimaging characteristics of cerebral palsy in term and near-term infants. PATIENTS AND METHODS Among a cohort of 334,339 infants > or = 36 weeks' gestation born at Kaiser Permanente Medical Care Program in northern California in 1991-2003, we identified infants with cerebral palsy and obtained clinical data from electronic and medical charts. Risk factors for cerebral palsy among infants with different brain abnormalities were compared using polytomous logistic regression. RESULTS Of 377 infants with cerebral palsy (prevalence: 1.1 per 1000), 273 (72%) received a head computed tomography or MRI. Abnormalities included focal arterial infarction (22%), brain malformation (14%), and periventricular white matter abnormalities (12%). Independent risk factors for cerebral palsy were maternal age > 35, black race, and intrauterine growth restriction. Intrauterine growth restriction was more strongly associated with periventricular white matter injury than with other neuroimaging findings. Nighttime delivery was associated with cerebral palsy accompanied by generalized brain atrophy but not with cerebral palsy accompanied by other brain lesions. CONCLUSIONS Cerebral palsy is a heterogeneous syndrome with focal arterial infarction and brain malformation representing the most common neuroimaging abnormalities in term and near-term infants. Risk factors for cerebral palsy differ depending on the type of underlying brain abnormality.
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Affiliation(s)
- Yvonne W Wu
- Department of Neurology, University of California, 350 Parnassus Ave, Suite 609, San Francisco, California 94143-0137, USA.
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Abdel-Latif ME, Bajuk B, Oei J, Lui K. Mortality and morbidities among very premature infants admitted after hours in an Australian neonatal intensive care unit network. Pediatrics 2006; 117:1632-9. [PMID: 16651317 DOI: 10.1542/peds.2005-1421] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To assess risk-adjusted early (within 7 days) mortality and major morbidities of newborn infants at < 32 weeks' gestation who are admitted after office hours to a regional Australian network of NICUs where statewide caseload is coordinated and staffed by on-floor registrars working in shift rosters. We hypothesize that adverse sequelae are increased in these infants. DESIGNS We conducted a database review of the records of infants (n = 8654) at < 32 weeks' gestation admitted to a network of 10 tertiary NICUs in New South Wales and the Australian Capital Territory from 1992 to 2002. Multivariate logistic regression analysis was performed to adjust for case-mix and significant baseline characteristics. OUTCOMES Sixty-five percent of infants were admitted to the NICUs after hours. These infants did not have an increase in early neonatal mortality or major neonatal sequelae compared with their office-hours counterparts. Admissions during late night hours after midnight or fatigue risk periods before the end of a medical 12-hour shift were not associated with higher early mortality. Risk factors significantly predictive of early neonatal death were lack of antenatal steroid treatment, Apgar score < 7 at 5 minutes, male gender, gestation age, and being small for gestation. CONCLUSIONS Current staffing levels, specialization, and networking are associated with lower circadian variation in adverse outcomes and after-hours admission to this NICU network and have no significant impact on early neonatal mortality and morbidity.
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Abstract
OBJECTIVE To assess what independent influence, if any, weekend or evening admission to a pediatric intensive care unit (PICU) staffed 24 hrs/day, 7 days/wk by in-house, board-certified pediatric intensivists might have on mortality. DESIGN AND PATIENTS A retrospective study of 5,968 consecutive admissions to the PICU from August 1996 to December 2003 for patients aged 0 days to 21 yrs. SETTING A single, 14-bed, multidisciplinary PICU at an academic medical center. MEASUREMENTS Standardized mortality ratios of observed-to-predicted mortality were derived with their corresponding p values. Multivariate logistic regression was used to test the independent effect of weekend admission, weekend discharge/death, and evening PICU admission on mortality for the entire sample and, separately, for only emergency admissions, controlling for other significant predictor variables or interaction terms. RESULTS Overall, crude mortality was significantly higher on the weekend (weekday, 2.2%; weekend, 5.0% [p = .0000]) and in the evening (day, 2.1%; evening, 3.8% [p = .0004]). Assessing the entire sample using multivariate logistic regression, neither weekend admission (p = .146), weekend discharge/death (p = .348), nor evening PICU admission (p = .711) showed a significant relationship with mortality controlling for other significant factors. Limiting the scope to the emergency admissions subset, neither weekend admission (p = .135), weekend discharge/death (p = .278), nor evening PICU admission (p = .867) were significant predictors of mortality. Weekend and evening admissions differed in important ways from weekday and daytime admissions, making simple comparisons of crude mortality rates inappropriate. Weekend and evening admissions were more likely to be emergency, nonoperative patients; have a lower Pediatric Risk of Mortality III score but have a higher overall predicted mortality risk; and differ in the distributions of patients by primary diagnosis. CONCLUSIONS Using multivariate logistic regression to control for important clinical differences, neither weekend admission, weekend discharge/death, nor evening admission had a significant independent effect on mortality risk in the entire sample or for the emergency patient subset. Our findings are consistent with previous work demonstrating the benefit of intensive care units staffed 24 hrs/day, 7-days/wk by in-house, board-certified intensivists.
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Affiliation(s)
- Eric D Hixson
- From the Quality Institute, Cleveland Clinic Health System, Cleveland, OH, USA
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Abstract
OBJECTIVE To assess whether mortality is increased in the United States in infants born at night, we compared case-mix adjusted neonatal mortality for low- and high-risk infants born during the daytime (7 am to 6 pm), early night (7 pm to 12 am), and late night (1 am to 6 am). METHODS California linked birth-death certificate data on 3,363,157 infants, weighing more than 500 g and born without lethal congenital anomalies in 1992-1999, were analyzed. Logistic regression, adjusting for birth weight, gender, prenatal care initiation, maternal hypertension, eclampsia, diabetes, and placental abruption/previa, was used to estimate the relationship between neonatal mortality and time of birth. RESULTS The overall neonatal mortality was 2.08 deaths per 1,000 live births. Neonatal mortality was 1.88 for daytime births, increasing to 2.37 for early night and 2.31 for late night births. After adjusting for case mix, early night births had a 12% increase and late night births a 16% increase in the odds of neonatal death, an excess that accounts for 9.6% of all neonatal deaths. Mortality was increased for night births that were less than 1,500 g or more than 1,500 g, singletons or multiples, and those delivered vaginally or by cesarean. The increased risk was identified in hospitals that provide intermediate, community, and regional neonatal intensive care, but not in hospitals that provide primary care. CONCLUSION Identifying the causal factors and reducing the increased burden of mortality for infants born at night should be a major priority for perinatal medicine.
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Affiliation(s)
- Jeffrey B Gould
- Division of Neonatal and Developmental Medicine, Stanford University, Palo Alto, California 94304, USA.
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Wu YW, Backstrand KH, Zhao S, Fullerton HJ, Johnston SC. Declining diagnosis of birth asphyxia in California: 1991-2000. Pediatrics 2004; 114:1584-90. [PMID: 15574618 DOI: 10.1542/peds.2004-0708] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE Birth asphyxia is recognized as an important cause of neonatal morbidity and mortality. Whether advances in perinatal care have altered the incidence of birth asphyxia is unknown. We determined the incidence of birth asphyxia diagnoses made over a 10-year period in California. METHODS In a population-based retrospective cohort study of 5,364,663 live births, we determined the incidence and case fatality of birth asphyxia between 1991 and 2000. Using a statewide administrative hospital discharge database, we identified all newborn admissions that generated a diagnosis of birth asphyxia (International Classification of Diseases, Ninth Revision, Clinical Modification codes 768.5, 768.6, or 768.9) or a diagnosis that overlaps with birth asphyxia, such as congenital encephalopathy or fetal distress. We determined incidence and in-hospital case fatality rates adjusted for birth weight and demographic characteristics and stratified by associated perinatal complications. RESULTS The 24 330 newborns who received a diagnosis of birth asphyxia yielded a population incidence of 4.5 per 1000 live births. Black ethnicity (relative risk [RR]: 1.3; 95% confidence interval [CI]: 1.2-1.3), male gender (RR: 1.2; 95% CI: 1.1-1.2), and low socioeconomic status (RR: 1.2; 95% CI: 1.1-1.2) all were associated with increased risk. The diagnosis of birth asphyxia decreased by 91% from 14.8 to 1.3 per 1000 live births during the study years. This decrease could not be explained by an increased diagnosis of overlapping conditions. Overall case fatality was 4%, and the majority of deaths in infants >2000 g occurred in the presence of congenital anomalies, cord abnormalities, or maternal hemorrhage. In newborns <2000 g, case fatality was highest in the presence of chorioamnionitis (48%). CONCLUSION The diagnosis of birth asphyxia has decreased dramatically in recent years. The factors that are responsible for this decline are unclear and deserve additional investigation.
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Affiliation(s)
- Yvonne W Wu
- Department of Neurology, University of California, San Francisco, Box 0136, 500 Parnassus Ave, Room 411, San Francisco, CA 94143-0136, USA.
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Obi-Osius N, Misselwitz B, Karmaus W, Witten J. Twin frequency and industrial pollution in different regions of Hesse, Germany. Occup Environ Med 2004; 61:482-7. [PMID: 15150386 PMCID: PMC1763650 DOI: 10.1136/oem.2003.008342] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To investigate whether twinning occurs more frequently in residents in the vicinity of a toxic waste incinerator (TWI). METHODS Within a longitudinal environmental study that addressed child health second grade school children and their parents were recruited. The proportion of twinning in the TWI region was compared with two comparison areas. In a second confirmatory investigation, birth records for the years 1994-97 from the Hessian Perinatal Survey (HEPS) were accessed to determine whether the incidence of twinning was higher in regions around the TWI compared to adjacent reference areas. RESULTS In the environmental study, 61.5% of the children and 95% of their mothers participated. In mothers, twinning was 5.3% in the TWI region compared to 1.6% and 2.3% in the comparison regions. The proportion of mothers with fertility assessment/treatment was 5.7%, 8.3%, and 0% respectively. The prevalence of twinning was not significantly higher (4.5%) in mothers with treatment compared to mothers without (3.7%). From the HEPS, data of 20 603 births was analysed. The incidence of twins was significantly higher in areas which surround the TWI and other industries (1.4-1.6 per 100 births) compared to births in reference areas (0.8 per 100). CONCLUSIONS Twinning rates may be associated with exposure to industrial pollution. Future environmental health studies that consider multiple births as an outcome are warranted. These should also investigate whether the incidence of monozygotic or dizygotic twinning may be associated with industrial pollution.
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Affiliation(s)
- N Obi-Osius
- Epidemiological Working Group of the Ministry of Environment and Health and the Institute for Medical Biometry and Epidemiology, University Hospital Hamburg-Eppendorf, Germany.
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Arias Y, Taylor DS, Marcin JP. Association between evening admissions and higher mortality rates in the pediatric intensive care unit. Pediatrics 2004; 113:e530-4. [PMID: 15173533 DOI: 10.1542/peds.113.6.e530] [Citation(s) in RCA: 86] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Previous research investigating the relationship between the time of admission and mortality rates has yielded inconsistent results and has not been conducted in the pediatric intensive care unit (PICU) patient population. OBJECTIVE To determine whether an association between the time of admission (weekday versus weekend and daytime versus evening) and the risk of death exists among pediatric patients included in a cohort of children admitted to a national sample of PICUs. DESIGN/METHODS We analyzed retrospectively a cohort of consecutive admissions to 15 PICUs included in the Pediatric Intensive Care Unit Evaluations database. The odds of death were analyzed by using mixed-effects, multivariate, logistic regression, with clustering at the hospital level. The primary independent variables were admission to the PICU on a weekend and admission to the PICU during evening hours. The severity of illness was adjusted by using the Pediatric Risk of Mortality III probability of death score. PATIENTS All 20,547 emergency PICU admissions made between May 1995 and December 2001 were included in the analyses. MAIN OUTCOME MEASURES The primary outcome was death within 48 hours after admission to the PICU. RESULTS Pediatric patients admitted to the PICU during evening hours had higher odds of death (odds ratio [OR]: 1.28; 95% confidence interval [CI]: 1.00-1.62) than did those admitted during daytime hours. Subgroup analyses revealed higher odds of death among patients admitted with shock (OR: 4.09; 95% CI: 1.65-10.1), with congenital cardiovascular disease (OR: 3.90; 95% CI: 1.37-11.1), or after cardiac arrest (OR: 1.80; 95% CI: 1.04-3.13). There was no association between mortality rates and the day of admission (weekend admissions versus weekday admissions). CONCLUSIONS An increased risk of death exists for some pediatric patients admitted to the PICU during evening hours. It remains necessary to determine whether this finding results from differences in the structure of care, processes of care, or both.
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Affiliation(s)
- Yeseli Arias
- Department of Pediatrics, University of California, Davis, Sacramento, California 95817, USA
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Minkoff H, Powderly KR, Chervenak F, McCullough LB. Ethical Dimensions of Elective Primary Cesarean Delivery. Obstet Gynecol 2004; 103:387-92. [PMID: 14754712 DOI: 10.1097/01.aog.0000107288.44622.2a] [Citation(s) in RCA: 73] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Cesarean deliveries are among the most common surgical procedures performed in the United States. Recent publications demonstrate the reduced risks of these operations and describe their potential benefits to both mothers and children. Recent surveys show that a substantial minority of obstetricians would accede to patients' requests for elective primary cesarean delivery, and some of these professionals would prefer that mode of delivery for themselves or their partners. However, scant attention has been paid to the ethical underpinnings of surgery by choice in these circumstances or ethically justified criteria for determining the role of patient choice in elective surgery generally. We define and elaborate upon the role of beneficence-, autonomy-, and justice-based considerations in these deliberations. We conclude that beneficence-based clinical judgment still favors vaginal delivery. Additionally, we have no confidence that either offering or performing elective cesarean delivery is consistent with substantive-justice-based considerations and conclude that there is no autonomy-based obligation to offer cesarean delivery in an ethically and legally appropriate informed consent process. Physicians should respond to patient-initiated requests for such procedures with a thorough informed consent process and request that the woman reconsider to ensure that her autonomy is being meaningfully exercised. In such cases, implementing a woman's request is ethically permissible.
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Affiliation(s)
- Howard Minkoff
- Department of Obstetrics and Gynecology at Maimonides Medical Center, 967 48th Street, Brooklyn, NY 11219, USA.
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Castelló A, Verdú F. The working day in medicine: lessons from the air. HOSPITAL MEDICINE (LONDON, ENGLAND : 1998) 2003; 64:416-8; discussion 419-20. [PMID: 12886852 DOI: 10.12968/hosp.2003.64.7.2310] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
This article discusses whether it would be wrong to explain a mistake involving medical responsibility on the basis of an opinion that the professional was not in the optimum physical or mental state at the moment the mistake took place.
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Affiliation(s)
- Ana Castelló
- Department of Legal Medicine, College of Medicine and Odontology, University of Valencia EG, 46010 Valencia, Spain
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Stephansson O, Dickman PW, Johansson ALV, Kieler H, Cnattingius S. Time of birth and risk of intrapartum and early neonatal death. Epidemiology 2003; 14:218-22. [PMID: 12606889 DOI: 10.1097/01.ede.0000037975.55478.c7] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Previous studies have found that infants born at night and during weekends and holidays have an increased risk of perinatal mortality. However, these associations may be confounded by the distribution of high-risk deliveries according to time of birth. METHODS We undertook a population-based cohort study of 694,888 singleton births without elective cesarean section in Sweden between 1991 and 1997. We estimated relative risks of intrapartum and early neonatal death according to the hour, day and month of delivery. Estimated risk ratios were adjusted for gestational age, birth weight for gestational age, malformations, induction of labor, breech presentations and year of birth. RESULTS Infants of high-risk deliveries were more often delivered during daytime (8:00 am to 7:59 pm). Compared with infants born during daytime, infants born at night were at increased risk of early neonatal death (adjusted risk ratio = 1.28; 95% confidence interval = 1.13-1.46), but not intrapartum death (1.05; 0.71-1.54). If this association is causal, 12% of early neonatal deaths can be attributed to the increased risk among nighttime births. There was no association of weekend or holiday births with risks of intrapartum or early neonatal death. CONCLUSIONS Infants born at night may be at increased risk of early neonatal death.
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Affiliation(s)
- Olof Stephansson
- Department of Medical Epidemiology, Karolinska Institute, Stockholm, Sweden.
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Abstract
This is a literature review onperinatal mortality focusing its evitability. A Medline and Lilacs (Latin-America and Caribbean) search was conducted for the 90s. There are few research studies on this subject in Brazil due to the great number of underreported fetal deaths and the low quality information provided in death certificates. Different proposals for perinatal death classification are presented. Most are based on grouping the underlying causes of deaths in a functional system in order to facilitate the analysis. In the Wigglesworth classification system, one of the most recommended methods, deaths are related to the different stages of care for pregnant women and children, evidencing the possibilities of their prevention. The evitability approach of perinatal deaths in Brazil is highly recommended, as mortality rates are still very high and most of the deaths are considered avoidable. Premature deaths could be avoided improving the quality of health care. Besides improving the medical assistance, the organization of health care regarding pre-natal, birth and neonatal care must also be better developed to ensure access to qualified assistance.
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Affiliation(s)
- Sônia Lansky
- Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, MG, Brasil.
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Heller G, Richardson DK, Schnell R, Misselwitz B, Künzel W, Schmidt S. Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990-1999. Int J Epidemiol 2002; 31:1061-8. [PMID: 12435785 DOI: 10.1093/ije/31.5.1061] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND While agreement exists about the benefits of regionalization for high-risk births, little evidence exists regarding regionalization of low-risk births. The objective of this study was to investigate the impact of regionalization on neonatal survival focussed on low-risk births. METHODS Data from the perinatal birth register of Hesse, 1990-1999 were used comprising detailed information about 582,655 births covering more than 95% of all births in Hesse. Outcome events were death during labour or within the first 7 days of life (early-neonatal death). Mortality rates and corresponding 95% CI were calculated according to hospital volume measured by births per year and birthweight categories. RESULTS Birthweight-specific mortality rates were lowest in large delivery units and highest in smaller delivery units. This gradient was especially pronounced within low-risk births and was also confirmed in several logistic regression models adjusting for additional risk factors. A more than threefold mortality risk was observed in hospitals with <500 births/year compared with hospitals with >1,500 births/year (odds ratio = 3.48; 95% CI: 2.64-4.58). Further trend analyses indicated that prenatal prevention programmes and the increasing usage of modern prenatal diagnostic procedures have not reduced this gradient in recent years. CONCLUSIONS This analysis presents an urgent public policy issue of whether such elevated risk in smaller delivery units is acceptable or if further consolidation of birthing units should be considered to reduce early-neonatal mortality.
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Affiliation(s)
- Günther Heller
- Institute of Medical Sociology & Social Medicine, Medical Centre of Methodology and Health Research, University of Marburg, Germany.
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