Relation between size of delivery unit and neonatal death in low risk deliveries: population based study

Busy day effect on adverse obstetric outcomes using a nationwide ecosystem approach: Cross-sectional register study of 601 247 hospital deliveries

OBJECTIVE

To study the busy day effect on selected neonatal adverse outcomes in different sized delivery hospitals and in the entire nationwide obstetric ecosystem.

DESIGN

A cross-sectional register study.

SETTING

The lowest and highest 10% of the daily delivery volume distribution were defined as quiet and busy days, respectively. The days between (80%) were defined as optimal delivery volume days. The differences in the incidence of selected adverse neonatal outcome measures were analysed between busy versus optimal days and quiet versus optimal days at the hospital category and for the entire obstetric ecosystem level.

POPULATION

A total of 601 247 singleton hospital deliveries between 2006 and 2016, occurred in non-tertiary (C1-C4, stratified by size) and tertiary level (C5) delivery hospitals.

METHODS

Analyses were performed by the methods of the regression analyses with crude and adjusted odds ratios including 99% CI.

MAIN OUTCOME MEASURES

Birth asphyxia.

RESULTS

At the ecosystem level, adjusted odds ratio for birth asphyxia was 0.81 (99% CI 0.76-0.87) on busy versus optimal days. Breakdown to hospital categories show that adjusted odds ratios for asphyxia on busy versus optimal days in non-tertiary hospitals (C3, C4) were 0.25 (99% CI 0.16-0.41) and 0.17 (99% CI 0.13-0.22), respectively, and in tertiary hospitals was 1.20 (99% CI 1.10-1.32).

CONCLUSIONS

Busy day effect as a stress test caused no extra cases of neonatal adverse outcomes at the ecosystem level. However, in non-tertiary hospitals busy days were associated with a lower and in tertiary hospitals a higher incidence of neonatal adverse outcomes.

Trends in Term Intrapartum Stillbirth in Norway

Importance

Fetal death during labor at term is a complication that is rarely studied in high-income countries. There is a need for large population-based studies to examine the rate of term intrapartum stillbirth in high-income countries and the factors associated with its occurrence.

Objective

To evaluate trends in term intrapartum stillbirth over time and to investigate the association between the trends and term intrapartum stillbirth risk factors from 1999 to 2018 in Norway.

Design, Setting, and Participants

This cohort study used data from the Medical Birth Registry of Norway from 1999 to 2018 to examine rates of term intrapartum stillbirth and risk factors associated with this event. A population of 1 021 268 term singleton pregnancies without congenital anomalies or antepartum stillbirths was included in analyses, which were performed from September 2022 to February 2023.

Exposure

The main exposure variable was time, which was divided into four 5-year periods: 1999 to 2003, 2004 to 2008, 2009 to 2013, and 2014 to 2018.

Main Outcomes and Measures

The primary study outcome was term intrapartum stillbirth. Risk ratios were calculated, and multivariable logistic regression analyses were conducted to identify factors associated with secular trends of term intrapartum stillbirth.

Results

The study population consisted of 1 021 268 term singleton births (maternal mean [SD] age, 29.72 [5.01] years; mean [SD] gestational age, 39.69 [1.27] weeks). During the study period, there were 95 term intrapartum stillbirths (0.09 per 1000 births). Maternal age, the proportion of individuals born in a country other than Norway, and the prevalence of gestational diabetes, labor induction, operative vaginal delivery, and previous cesarean delivery increased over the course of the study period. Conversely, the prevalence of infants large for gestational age, hypertensive disorder in pregnancy, and spontaneous vaginal delivery and the proportion of individuals who smoked decreased. The term intrapartum stillbirth rate decreased by 87% (95% CI, 68%-95%) from 0.15 per 1000 births in 1999 to 2008 to 0.02 per 1000 births in 2014 to 2018. Three in 4 term intrapartum stillbirths (70 of 95) occurred during intrapartum operative deliveries. The increased prevalence of older maternal age and obstetric risk factors were not associated with the variation in intrapartum stillbirth rates among the time periods. The prevalence of term intrapartum stillbirth was higher for individuals who gave birth in maternity units with fewer than 3000 annual births (adjusted odds ratio, 1.67; 95% CI, 1.07-2.61) than for those who gave birth in units with 3000 or more annual births.

Conclusions and Relevance

Findings of this study suggest that, despite increases in maternal and obstetric risk factors, term intrapartum stillbirth rates substantially decreased during the study period. Reasons for this decrease may be due to improvements in intrapartum care.

Consolidation of the perinatal care system and workload of obstetricians: an ecological study in Japan

Objectives

We examined the relationship between consolidation of delivery and the workload of obstetricians working at perinatal centers.

Methods

We conducted a descriptive analysis using perinatal care areas classified into three types (metropolitan, provincial, and rural). We calculated the Herfindahl-Hirschman Index (HHI) as an index of consolidation and the proportion of the deliveries at clinics as an indicator of the low-risk deliveries and the deliveries per center obstetrician as an indicator of obstetricians' workload. We used >150 deliveries yearly as an excess indicator. The correlation between the HHI and obstetricians' workload and the proportion of deliveries at clinics was examined using the Pearson correlation coefficient.

Results

The proportion of areas with  >150 deliveries yearly was higher in the consolidated areas. In provincial areas, obstetricians' workload was positively correlated with the HHI and was negatively correlated with the proportion of deliveries at clinics.

Conclusions

The obstetricians' workload may be increasing where more consolidation occurs. In provincial areas, the center obstetrician's workload could be reduced not only by consolidation but also by sharing the role of handling low-risk deliveries with clinics and hospitals with obstetric units other than perinatal centers.

Birth during off-hours: Impact of time of birth, staff´s seniority, and unit volume on maternal adverse outcomes-a population-based cross-sectional study of 87 065 deliveries

BACKGROUND

The aim of this study was to investigate whether time of birth, unit volume, and staff seniority impact the incidence of maternal complications in deliveries ≥34 + 0 gestational weeks.

METHODS

We conducted a population-based cross-sectional study of 87 065 deliveries occurring between 2004 and 2015 in ten public hospitals in Styria, Austria. A composite adverse maternal outcome measure of uterine atony, postpartum hysterectomy, postpartum bleeding, impaired wound healing, postpartum infections requiring antibiotic treatment, sepsis, or maternal death was used to compare outcomes by time of birth, unit volume, and staff seniority. Based on delivery data, generalized estimating equations (GEEs) were used to calculate the risk of maternal adverse outcomes.

RESULTS

Maternal adverse events occurred in 1.33% of deliveries. Incidence of maternal adverse events was highest for units with >1000 deliveries (adjusted OR 1.40; CI 95%: 1.16-1.69) and higher for perinatal centers (adjusted OR 1.35; CI 95%: 1.15-1.57) compared with reference units (500-1000 deliveries/year). Delivery during the daytime compared with the afternoon and nighttime did not affect the incidence of maternal complications (P = 0.765 and P = 0.136, respectively). Compared with resident-guided deliveries, the odds ratio for an adverse event was the same when a consultant attended the delivery (adjusted OR 1.13; CI 95%: 0.98-1.30) but lower in deliveries managed by midwives only (adjusted OR 0.21; CI 95%: 0.07-0.64).

CONCLUSION

Procedures performed during the night shift were not associated with increased complication rates. Delivery volume and high-volume centers were associated with the highest risk of maternal complications, and units with 500-1000 deliveries per year were the lowest. With increasing odds of pregnancy risks, these results change, and delivering in a high-volume center becomes at least as safe as delivering in a smaller unit.

Birth Volume and Geographic Distribution of US Hospitals With Obstetric Services From 2010 to 2018

IMPORTANCE

Timely access to clinically appropriate obstetric services is critical to the provision of high-quality perinatal care.

OBJECTIVE

To examine the geographic distribution, proximity, and urban adjacency of US obstetric hospitals by annual birth volume.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective population-based cohort study identified US hospitals with obstetric services using the American Hospital Association (AHA) Annual Survey of Hospitals and Centers for Medicare & Medicaid provider of services data from 2010 to 2018. Obstetric hospitals with 10 or more births per year were included in the study. Data analysis was performed from November 6, 2020, to April 5, 2021.

EXPOSURE

Hospital birth volume, defined by annual birth volume categories of 10 to 500, 501 to 1000, 1001 to 2000, and more than 2000 births.

MAIN OUTCOMES AND MEASURES

Outcomes assessed by birth volume category were percentage of births (from annual AHA data), number of hospitals, geographic distribution of hospitals among states, proximity between obstetric hospitals, and urban adjacency defined by urban influence codes, which classify counties by population size and adjacency to a metropolitan area.

RESULTS

The study included 26 900 hospital-years of data from 3207 distinct US hospitals with obstetric services, reflecting 34 054 951 associated births. Most infants (19 327 487 [56.8%]) were born in hospitals with more than 2000 births/y, and 2 528 259 (7.4%) were born in low-volume (10-500 births/y) hospitals. More than one-third of obstetric hospitals (37.4%; 10 064 hospital-years) were low volume. A total of 46 states had obstetric hospitals in all volume categories. Among low-volume hospitals, 18.9% (1904 hospital-years) were not within 30 miles of any other obstetric hospital and 23.9% (2400 hospital-years) were within 30 miles of a hospital with more than 2000 deliveries/y. Isolated hospitals (those without another obstetric hospital within 30 miles) were more frequently low volume, with 58.4% (1112 hospital-years) located in noncore rural areas.

CONCLUSIONS AND RELEVANCE

In this cohort study, marked variations were found in birth volume, geographic distribution, proximity, and urban adjacency among US obstetric hospitals from 2010 to 2018. The findings related to geographic isolation and rural-urban distribution of low-volume obstetric hospitals suggest the need to balance proximity with volume to optimize effective referral and access to high-quality perinatal care.

Association between travel time to delivery unit and unplanned out-of-hospital birth, infant morbidity and mortality: A population-based cohort study

INTRODUCTION

Over the last decade, a number of delivery units have been closed in Sweden, justified by both economic incentives and patient safety issues. However, concentrating births to larger delivery units naturally increases travel time for some parturient women, which may lead to unintended negative consequences. We aimed to investigate the association between travel time to delivery unit and unplanned out-of-hospital birth, and subsequent infant morbidity and mortality.

MATERIAL AND METHODS

We performed a population-based cohort study including 365 604 women in the Swedish Pregnancy Register, giving birth between 2014 and 2017. Modified Poisson regression was used to investigate the association between travel time from home address to actual delivery unit, based on geographic information system analysis, and risk of an unplanned out-of-hospital birth. Analyses were stratified by parity and urban/rural residence. Lastly, the associations between an unplanned out-of-hospital birth and severe infant morbidity, stillbirth, peripartum, perinatal and neonatal mortality were investigated.

RESULTS

Of those with an unplanned out-of-hospital birth (n = 2159), 65% had a travel time up to 30 minutes. A travel time between 31 and 60 minutes was associated with a doubled risk of unplanned out-of-hospital birth (adjusted risk ratio [RR] 1.96, 95% confidence interval [CI] 1.74-2.22) and women with a travel time of more than 1 hour had an adjusted RR of 3.19 (95% CI 2.64-3.86), compared with those with a travel time of <30 minutes. No difference in results was seen when stratified for parity and urban/rural residence. No association was found between unplanned out-of-hospital birth and severe infant morbidity. Significant associations were found in crude analyses for stillbirth (RR 1.85, 95% CI 1.09-3.13), peripartum (RR 1.93, 95% CI 1.18-3.16), perinatal (RR 2.03, 95% CI 1.28-3.23) and neonatal mortality (RR 3.08, 95% CI 1.27-7.46), although neonatal mortality was very rare (2.3/1000 out-of-hospital births). Similar effect estimates were found in the adjusted analyses, though no longer significant.

CONCLUSIONS

Although the majority of unplanned out-of-hospital births occurred in the group of women with a travel time of 0-30 minutes, increasing travel time to a delivery unit is associated with unplanned out-of-hospital birth, which may increase the risk of mortality.

Comparison of Two Telemedicine Delivery Modes for Neonatal Resuscitation Support: A Simulation-Based Randomized Trial

INTRODUCTION

Previous research has described technical aspects of telemedicine and the clinical impact of provider-to-patient telemedicine; however, little is known about provider-to-provider telemedical interventions.

OBJECTIVE

The primary aim of this study was to compare two telemedicine delivery modes on the quality of a simulated neonatal resuscitation. Our secondary aim was to evaluate the providers' task load.

METHODS

This was a prospective, single-center, randomized, simulation-based trial comparing a remote neonatal team leader ("teleleader") versus a remote consultant ("teleconsultant"). Participants resuscitated a simulated, apneic, and bradycardic neonate. Performance was assessed by video review and task load was measured by the self-reported NASA task load index (NASA-TLX) tool. In the teleleader group, one remote neonatal specialist assumed the role of team leader in the resuscitation. In the teleconsultant group, the same remote specialist assumed the role of teleconsultant.

RESULTS

Twenty-two participants were included in the analyses. The teleleader group was associated with a higher overall checklist score compared to teleconsultants (median score 68%, interquartile range [IQR]: 66-69 vs. 58%, IQR: 42-62; p = 0.016). No significant difference was seen in overall subjective workload as measured by the NASA-TLX tool. However, mental demand and frustration were significantly greater with teleconsultants compared to teleleaders (mean mental demand: 14.1 vs. 17.0 out of 21; frustration: 7.9 vs. 14.7 out of 21).

CONCLUSIONS

Simulated neonates randomized to teams with teleleaders received significantly better resuscitative care compared to those randomized to teams with teleconsultants. Mental demand and frustration were higher for providers in the teleconsultant compared to teleleader teams.

Impact of shortened length of stay for delivery on the required bed capacity in maternity services: results from forecast analysis on administrative data

BACKGROUND

We examine the implications of reducing the average length of stay (ALOS) for a delivery on the required capacity in terms of service volume and maternity beds in Belgium, using administrative data covering all inpatient stays in Belgian general hospitals over the period 2003-2014.

METHODS

A projection model generates forecasts of all inpatient and day-care services with a time horizon of 2025. It adjusts the observed hospital use in 2014 to the combined effect of three evolutions: the change in population size and composition, the time trend evolution of ALOS, and the time trend evolution of the admission rates. In addition, we develop an alternative scenario to evaluate the impact of an accelerated reduction of ALOS.

RESULTS

Between 2014 and 2025, we expect the number of deliveries to increase by 4.41%, and the number of stays in maternity services by 3.38%. At the same time, a reduction in ALOS is projected for all types of deliveries. The required capacity for maternity beds will decrease by 17%. In case of an accelerated reduction of the ALOS to reach international standards, this required capacity for maternity beds will decrease by more than 30%.

CONCLUSIONS

Despite an expected increase in the number of deliveries, future hospital capacity in terms of maternity beds can be considerably reduced in Belgium, due to the continuing reduction of ALOS.

Hospital-related, maternal, and fetal risk factors for neonatal asphyxia and moderate or severe hypoxic-ischemic encephalopathy: a retrospective cohort study

AIM

A previous large US study had documented an increased risk of asphyxia in small volume and rural hospitals. Our objective was to evaluate this in all hospitals in Alberta, a Canadian province.

METHODS

Retrospective cohort study of all singleton births ≥ 35-week gestation, in Alberta, from 2002-16 recorded in a perinatal database. Asphyxia was defined as intrapartum stillbirth or neonatal death from asphyxia or Neonatal Intensive Care Unit admission and at least two of the following: a. Apgar score of ≤ 5 at 10 minutes; b. mechanical ventilation or chest compressions for resuscitation within 10 minutes; c. cord pH < 7.00 (venous or arterial), or arterial base excess ≥ 12 at birth. Urban hospitals were defined as those serving a population of ≥ 50 000. Hospital volume was categorized by the following: urban: < 1200, 1200-2399, 2400-3600, > 3600 annual births and Rural: < 50, 50-599, 600-1699 annual births. Data on moderate-severe neonatal hypoxic-ischemic encephalopathy was also obtained from two provincial asphyxia databases for 2010-2016.

RESULTS

The overall rate of neonatal asphyxia was 2.28 per 1000 births for the study period and was 2.5/1000 in the urban hospitals and 1.35/1000 in the rural hospitals, OR: 1.86 95% CI (1.58, 2.19). The rate of moderate or severe neonatal hypoxic-ischemic encephalopathy was 0.9/1000 and was not associated with urban hospital birth; OR: 1.12 95%CI (0.82, 1.53) hospital volume was also not associated with asphyxia or moderate or severe neonatal hypoxic-ischemic encephalopathy.

CONCLUSIONS

This study observed similar rates of asphyxia and moderate or severe neonatal hypoxic-ischemic encephalopathy for rural and urban hospitals in Alberta and no association with hospital volume.

Use of Telemedicine to Improve Neonatal Resuscitation

Most newborn infants do well at birth; however, some require immediate attention by a team with advanced resuscitation skills. Providers at rural or community hospitals do not have as much opportunity for practice of their resuscitation skills as providers at larger centers and are, therefore, often unable to provide the high level of care needed in an emergency. Education through telemedicine can bring additional training opportunities to these rural sites in a low-resource model in order to better prepare them for advanced neonatal resuscitation. Telemedicine also offers the opportunity to immediately bring a more experienced team to newborns to provide support or even lead the resuscitation. Telemedicine can also be used to train and assist in the performance of emergent procedures occasionally required during a neonatal resuscitation including airway management, needle thoracentesis, and umbilical line placement. Telemedicine can provide unique opportunities to significantly increase the quality of neonatal resuscitation and stabilization in rural or community hospitals.

Increased risk of peripartum perinatal mortality in unplanned births outside an institution: a retrospective population-based study

BACKGROUND

Births in midwife-led institutions may reduce the frequency of medical interventions and provide cost-effective care, while larger institutions offer medically and technically advanced obstetric care. Unplanned births outside an institution and intrapartum stillbirths have frequently been excluded in previous studies on adverse outcomes by place of birth.

OBJECTIVE

The objective of the study was to assess peripartum mortality by place of birth and travel time to obstetric institutions, with the hypothesis that centralization reduces institution availability but improves mortality.

STUDY DESIGN

This was a national population-based retrospective cohort study of all births in Norway from 1999 to 2009 (n = 648,555) using data from the Medical Birth Registry of Norway and Statistics Norway and including births from 22 gestational weeks or birthweight ≥500 g. Main exposures were travel time to the nearest obstetric institution and place of birth. The main clinical outcome was peripartum mortality, defined as death during birth or within 24 hours. Intrauterine fetal deaths prior to start of labor were excluded from the primary outcome.

RESULTS

A total of 1586 peripartum deaths were identified (2.5 per 1000 births). Unplanned birth outside an institution had a 3 times higher mortality (8.4 per 1000) than institutional births (2.4 per 1000), relative risk, 3.5 (95% confidence interval, 2.5-4.9) and contributed 2% (95% confidence interval, 1.2-3.0%) of the peripartum mortality at the population level. The risk of unplanned birth outside an institution increased from 0.5% to 3.3% and 4.5% with travel time <1 hour, 1-2 hours, and >2 hours, respectively. In obstetric institutions the mortality rate at term ranged from 0.7 per 1000 to 0.9 per 1000. Comparable mortality rates in different obstetric institutions indicated well-functioning routines for referral.

CONCLUSION

Unplanned birth outside an institution was associated with increased peripartum mortality and with long travel time to obstetric institutions. Structural determinants have an important impact on perinatal health in high-income countries and also for low-risk births. The results show the importance of skilled birth attendance and warrant attention from clinicians and policy makers to negative consequences of reduced access to institutions.

Drivers of maternity care in high-income countries: can health systems support woman-centred care?

In high-income countries, medical interventions to address the known risks associated with pregnancy and birth have been largely successful and have resulted in very low levels of maternal and neonatal mortality. In this Series paper, we present the main care delivery models, with case studies of the USA and Sweden, and examine the main drivers of these models. Although nearly all births are attended by a skilled birth attendant and are in an institution, practice, cadre, facility size, and place of birth vary widely; for example, births occur in homes, birth centres, midwifery-led birthing units in hospitals, and in high intervention hospital birthing facilities. Not all care is evidenced-based, and some care provision may be harmful. Fear prevails among subsets of women and providers. In some settings, medical liability costs are enormous, human resource shortages are common, and costs of providing care can be very high. New challenges linked to alteration of epidemiology, such as obesity and older age during pregnancy, are also present. Data are often not readily available to inform policy and practice in a timely way and surveillance requires greater attention and investment. Outcomes are not equitable, and disadvantaged segments of the population face access issues and substantially elevated risks. At the same time, examples of excellence and progress exist, from clinical interventions to models of care and practice. Labourists (who provide care for all the facility's women for labour and delivery) are discussed as a potential solution. Quality and safety factors are informed by women's experiences, as well as medical evidence. Progress requires the ability to normalise birth for most women, with integrated services available if complications develop. We also discuss mechanisms to improve quality of care and highlight areas where research can address knowledge gaps with potential for impact. Evaluation of models that provide woman-centred care and the best outcomes without high costs is required to provide an impetus for change.

Neonatal outreach simulation

Numerous factors contribute to neonatal morbidity and mortality, and inexperienced providers managing crisis situations is one major cause. Simulation-based medical education is an excellent modality to employ in community hospitals to help refine and refresh resuscitation skills of providers who infrequently encounter neonatal emergencies. Mounting evidence suggests that simulation-based education improves patient outcomes. Academic health centers have the potential to improve neonatal outcomes through collaborations with community hospital providers, sharing expertise in neonatal resuscitation and simulation. Community outreach programs using simulation have been successfully initiated in North America. Two examples of programs are described here, including the models for curricular development, required resources, limitations, and benefits. Considerations for initiating outreach simulation programs are discussed. In the future, research demonstrating improved neonatal outcomes using outreach simulation will be important for personnel conducting outreach programs. Neonatal outreach simulation is a promising educational endeavor that may ultimately prove important in decreasing neonatal morbidity and mortality.

Centralized or decentralized perinatal surgical care for rural women: a realist review of the evidence on safety

BACKGROUND

The precipitous closure of rural maternity services in British Columbia (BC), Canada, and internationally has demanded a reevaluation of how to meet the perinatal surgical needs of rural women in accordance with the Triple Aim objectives of safety, cost-effectiveness, and satisfaction of all key stakeholders. There is emerging international evidence that General Practitioners with Enhanced Surgical Skills (GPESS) are a well-positioned health service solution due to their generalist nature in low-volume settings. A realist review was undertaken to evaluate international evidence on efficacious models of perinatal surgical care. This article presents findings of the safety of such practice, one discrete part of the full realist review.

METHODS

This paper was derived from a larger review, which used a realist review methodology to guide the approach, and adhered to the RAMESES quality standard for realist reviews. Seven academic databases were searched in December 2013, using year (1990) and language (English) limiters in keeping with a rapid review approach. Mining of bibliographies in addition to consultation with international experts led to further inclusion of academic and grey literature up to March 2014.

RESULTS

Two hundred fifty-four articles were originally identified; 119 articles were removed from consideration for lack of fit, resulting in the review of 191 articles from the peer reviewed and grey literature. Of these, 53 pertained to safety and are considered herein. Evidence on the safety of GPESS was consistent in the literature cited. Clinical, case study, and qualitative evidence demonstrates that perinatal surgical care is equally safe when provided by GPESS and specialist physicians.

CONCLUSION

Findings allow health planners to confidently build perinatal surgical services around the contribution of GPs with enhanced surgical skills and focus on educational, regulatory, and continuing professional development mechanisms to ensure their sustainability. Volume-to-outcomes associations are variable and inconclusive with regards to safety, suggesting the need for more evidence. These findings, and the attendant health services planning directions, are reassuring as they suggest the viability of local models of care where feasible.

Infant Outcomes After Elective Early-Term Delivery Compared With Expectant Management

OBJECTIVE

To compare the risk of neonatal morbidity and infant mortality between elective early-term deliveries and those expectantly managed and delivered at 39 weeks of gestation or greater.

METHODS

We conducted a population-based retrospective cohort study of 675,302 singleton infants born alive at 37-44 weeks of gestation from 2005 to 2009 in more than 125 birthing facilities in Florida. Data were collected from a validated, longitudinally linked maternal and infant database. The study population was categorized into exposure groups based on the timing and reason for delivery initiation-four subtypes of deliveries at 37-38 weeks of gestation and a comparison group of expectantly managed infants delivered at 39-40 weeks of gestation. Primary outcomes included neonatal respiratory morbidity, sepsis, feeding difficulties, admission to the neonatal intensive care unit (NICU), and infant mortality.

RESULTS

Neonatal outcome rates ranged from 6.0% for respiratory morbidities to 1.3% for both sepsis and feeding difficulties, and the infant mortality rate was 1.5 per 1,000 live births. When compared with infants expectantly managed and delivered at 39-40 weeks of gestation, those delivered after elective induction at 37-38 weeks of gestation did not have increased odds of neonatal respiratory morbidity, sepsis, or NICU admission but did experience slightly higher odds of feeding difficulty (odds ratio 1.18, 99% confidence interval 1.02-1.36). In contrast, infants delivered by elective cesarean at 37-38 weeks of gestation had 13-66% increased odds of adverse outcomes. Survival experiences were similar when comparing early inductions and early cesarean deliveries with the expectant management group.

CONCLUSION

The issues that surround the timing and reasons for delivery initiation are complicated and each pregnancy unique. This study cautions against a general avoidance of all elective early-term deliveries.

Applicability of the ReproQ client experiences questionnaire for quality improvement in maternity care

Background. The ReproQuestionnaire (ReproQ) measures the client's experience with maternity care, following the WHO responsiveness model. In 2015, the ReproQ was appointed as national client experience questionnaire and will be added to the national list of indicators in maternity care. For using the ReproQ in quality improvement, the questionnaire should be able to identify best and worst practices. To achieve this, ReproQ should be reliable and able to identify relevant differences. Methods and Findings. We sent questionnaires to 17,867 women six weeks after labor (response 32%). Additionally, we invited 915 women for the retest (response 29%). Next we determined the test-retest reliability, the Minimally Important Difference (MID) and six known group comparisons, using two scorings methods: the percentage women with at least one negative experience and the mean score. The reliability for the percentage negative experience and mean score was both 'good' (Absolute agreement = 79%; intraclass correlation coefficient = 0.78). The MID was 11% for the percentage negative and 0.15 for the mean score. Application of the MIDs revealed relevant differences in women's experience with regard to professional continuity, setting continuity and having travel time. Conclusions. The measurement characteristics of the ReproQ support its use in quality improvement cycle. Test-retest reliability was good, and the observed minimal important difference allows for discrimination of good and poor performers, also at the level of specific features of performance.

Selection and concentration of obstetric facilities in Japan: Longitudinal study based on national census data

AIM

A shortage of obstetricians with increased workload is a social problem in Japan. In response, the government and professional bodies have accelerated the 'selection and concentration' of obstetric facilities. The aim of this study was to evaluate the recent trend of selection and concentration.

METHODS

We used data on the number of deliveries and of obstetricians in each hospital and clinic in Japan, according to the Static Survey of Medical Institutions in 2005, 2008 and 2011. To evaluate the inter-facility equality of distribution of the number of deliveries, number of obstetricians and number of deliveries per obstetrician, Gini coefficients were calculated.

RESULTS

The number of obstetric hospitals decreased by 20% and the number of deliveries per hospital increased by 26% between 2005 and 2011. Hospital obstetricians increased by 16% and the average number of obstetricians per hospital increased by 19% between 2008 and 2011. Gini coefficient of deliveries has significantly decreased. In contrast, Gini coefficient of deliveries per obstetrician has significantly increased. The degree of increase in obstetricians and of decrease in deliveries per obstetrician was largest at the hospitals with the highest proportion of cesarean sections. The proportion of obstetric hospitals with the optimal volume of deliveries and obstetricians, as defined by Japan Society of Obstetrics and Gynecology, was 4% in 2008, and it had doubled to 8.1% 3 years later.

CONCLUSION

The selection and concentration of obstetric facilities is progressing rapidly and effectively in Japan.

Women's maternity care needs and related service models in rural areas: A comprehensive systematic review of qualitative evidence

BACKGROUND

Understanding the needs of rural women in maternity care and service models available to them is significant for the development of effective policies and the sustainability of rural communities. Nevertheless, no systematic review of studies addressing these needs has been conducted.

OBJECTIVES

To synthesise the best available evidence on the experiences of women's needs in maternity care and existing service models in rural areas.

METHODS

Literature search of ten electronic databases, digital theses, and reference lists of relevant studies applying inclusion/exclusion criteria was conducted. Selected papers were assessed using standardised critical appraisal instruments from JBI-QARI. Data extracted from these studies were synthesised using thematic synthesis.

FINDINGS

12 studies met the inclusion criteria. There were three main themes and several sub-themes identified. A comprehensive set of the maternity care expectations of rural women was reported in this review including safety (7), continuity of care (6) and quality of care (6), and informed choices needs (4). In addition, challenges in accessing maternity services also emerged from the literature such as access (6), risk of travelling (9) and associated cost of travel (9). Four models of maternity care examined in the literature were medically led care (5), GP-led care (4), midwifery-led care (7) and home birth (6).

CONCLUSION

The systematic review demonstrates the importance of including well-conducted qualitative studies in informing the development of evidence-based policies to address women's maternity care needs and inform service models. Synthesising the findings from qualitative studies offers important insight for informing effective public health policy.

The effects of designation and volume of neonatal care on mortality and morbidity outcomes of very preterm infants in England: retrospective population-based cohort study

OBJECTIVE

To examine the effects of designation and volume of neonatal care at the hospital of birth on mortality and morbidity outcomes in very preterm infants in a managed clinical network setting.

DESIGN

A retrospective, population-based analysis of operational clinical data using adjusted logistic regression and instrumental variables (IV) analyses.

SETTING

165 National Health Service neonatal units in England contributing data to the National Neonatal Research Database at the Neonatal Data Analysis Unit and participating in the Neonatal Economic, Staffing and Clinical Outcomes Project.

PARTICIPANTS

20 554 infants born at <33 weeks completed gestation (17 995 born at 27-32 weeks; 2559 born at <27 weeks), admitted to neonatal care and either discharged or died, over the period 1 January 2009-31 December 2011.

INTERVENTION

Tertiary designation or high-volume neonatal care at the hospital of birth.

OUTCOMES

Neonatal mortality, any in-hospital mortality, surgery for necrotising enterocolitis, surgery for retinopathy of prematurity, bronchopulmonary dysplasia and postmenstrual age at discharge.

RESULTS

Infants born at <33 weeks gestation and admitted to a high-volume neonatal unit at the hospital of birth were at reduced odds of neonatal mortality (IV regression odds ratio (OR) 0.70, 95% CI 0.53 to 0.92) and any in-hospital mortality (IV regression OR 0.68, 95% CI 0.54 to 0.85). The effect of volume on any in-hospital mortality was most acute among infants born at <27 weeks gestation (IV regression OR 0.51, 95% CI 0.33 to 0.79). A negative association between tertiary-level unit designation and mortality was also observed with adjusted logistic regression for infants born at <27 weeks gestation.

CONCLUSIONS

High-volume neonatal care provided at the hospital of birth may protect against in-hospital mortality in very preterm infants. Future developments of neonatal services should promote delivery of very preterm infants at hospitals with high-volume neonatal units.

Regionalization and local hospital closure in Norwegian maternity care--the effect on neonatal and infant mortality

OBJECTIVE

To study whether neonatal and infant mortality, after adjustments for differences in case mix, were independent of the type of hospital in which the delivery was carried out.

DATA

The Medical Birth Registry of Norway provided detailed medical information for all births in Norway.

STUDY DESIGN

Hospitals were classified into two groups: local hospitals/maternity clinics versus central/regional hospitals. Outcomes were neonatal and infant mortality. The data were analyzed using propensity score weighting to make adjustments for differences in case mix between the two groups of hospitals. This analysis was supplemented with analyses of 13 local hospitals that were closed. Using a difference-in-difference approach, the effects that these closures had on neonatal and infant mortality were estimated.

PRINCIPAL FINDING

Neonatal and infant mortality were not affected by the type of hospital where the delivery took place.

CONCLUSION

A regionalized maternity service does not lead to increased neonatal and infant mortality. This is mainly because high-risk deliveries were identified well in advance of the birth, and referred to a larger hospital with sufficient perinatal resources to deal with these deliveries.

Perinatal health inequalities and accessibility of maternity services in a rural French region: closing maternity units in Burgundy

Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.

Does facility based newborn care improve neonatal outcomes? A review of evidence

CONTEXT

Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality.

OBJECTIVE

To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes.

EVIDENCE ACQUISITION

Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered.

RESULTS

A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths.

CONCLUSIONS

Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

The association between hospital obstetric volume and perinatal outcomes in California

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.

Distance matters: a population based study examining access to maternity services for rural women

BACKGROUND

In the past fifteen years there has been a wave of closures of small maternity services in Canada and other developed nations which results in the need for rural parturient women to travel to access care. The purpose of our study is to systematically document newborn and maternal outcomes as they relate to distance to travel to access the nearest maternity services with Cesarean section capability.

METHODS

Study population is all women carrying a singleton pregnancy beyond 20 weeks and delivering between April 1, 2000 and March 31, 2004 and residing outside of the core urban areas of British Columbia. Maternal and newborn data was linked to specific geographic catchments by the B.C. prenatal Health Program. Catchments were stratified by distance to nearest maternity service with Cesarean section capability if greater than 1 hour travel time or level of local service. Hierarchical logistic regression was used to test predictors of adverse newborn and maternal outcomes.

RESULTS

49,402 cases of women and newborns resident in rural catchments were included. Adjusted odds ratios for prenatal mortality for newborns from catchments greater than 4 hours from services was 3.17 (95% CI 1.45-6.95). Newborns from catchments 2 to 4 hours, and 1 to 2 hours from services generated rates of 179 and 100 NICU 3 days per thousand births respectively compared to 42 days for newborns from catchments served by specialists.

CONCLUSIONS

Distance matters: rural parturient women who have to travel to access maternity services have increased rates of adverse prenatal outcomes.

Should births be centralised in higher level hospitals? Experiences from regionalised health care in Finland

OBJECTIVE

To describe: (i) trends in centralisation and unplanned out-of-hospital births; (ii) perinatal mortality by place of birth; and (iii) health and birth outcomes in areas served by hospitals of different levels.

DESIGN

Cross-sectional analysis of medical birth register data.

SETTING

Finland, from 1991 to 2008, and Uusimaa district from 2004 to 2008.

POPULATION

All births.

METHODS

In the hospital-based analysis, birthweight was adjusted by logistic regression. In the area-based analysis results were calculated according to where women lived, grouping them into areas served by different hospitals. The mother's background characteristics were adjusted for by logistic regression.

MAIN OUTCOME MEASURES

Place of birth, unplanned out-of-hospital birth, perinatal mortality, newborn outcomes, and birth procedures.

RESULTS

The number of birthing hospitals declined, the mean number of births per hospital increased, and more births, particularly high-risk births, occurred in university hospitals. Unplanned out-of-hospital births were rare, and their numbers increased in the 2000s, but regional differences declined. Perinatal mortality was higher in the university hospitals than in other hospitals, but after adjusting for birthweight, it was lower. Among children weighing more than 2500 g, mortality was similar for all hospital levels. In out-of-hospital births, perinatal mortality was much higher than in other children. The area-based analysis did not systematically show better or worse results for the areas served by lower level hospitals: after adjusting for the background characteristics of the mothers, all differences were found to be small.

CONCLUSIONS

The health and service data do not support the need to close down small hospitals in a regionalised system where there is a referral system that functions well.

Regionalization of care for obstetric hemorrhage and its effect on maternal mortality

OBJECTIVE

To examine factors that influence the morbidity and mortality of peripartum hysterectomy and analyze the effect of hospital volume on maternal mortality.

METHODS

We examined women who underwent peripartum hysterectomy at the time of cesarean delivery in a quality and resource utilization database. Procedure-associated intraoperative, perioperative, and postoperative medical complications, length of stay, intensive care unit use, and maternal mortality were analyzed. Hospitals were stratified into tertiles based on procedure volume and complications and compared using adjusted generalized estimating equations. Results are reported as odds ratios.

RESULTS

Maternal mortality among the 2,209 women who underwent peripartum hysterectomy was 1.2%. After adjusting for other clinical and demographic factors, perioperative mortality was 71% (odds ratio 0.29, 95% confidence interval 0.10-0.88) lower in women who underwent operation at high-volume hospitals compared with those treated at low-volume facilities. Hospital volume had no effect on the rates of intraoperative injuries, medical complications, length of stay, or transfusion. In contrast, compared with women treated at low-volume centers, patients who underwent operation at high-volume hospitals had a lower incidence of perioperative surgical complications (odds ratio 0.66, 95% confidence interval 0.47-0.93) and a lower rate of intensive care unit usage (odds ratio 0.53, 95% confidence interval 0.34-0.83).

CONCLUSION

Peripartum hysterectomy is associated with substantial morbidity and mortality. Maternal mortality is lower when the procedure is performed in high-volume hospital settings.

LEVEL OF EVIDENCE

II.

Increased adverse perinatal outcome of hospital delivery at night

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.

The impact on neonatal mortality of shifting childbirth services among levels of hospitals: Taiwan's experience

Background

There is considerable discussion surrounding whether advanced hospitals provide better childbirth care than local community hospitals. This study examines the effect of shifting childbirth services from advanced hospitals (i.e., medical centers and regional hospitals) to local community hospitals (i.e., clinics and district hospitals). The sample population was tracked over a seven-year period, which includes the four months of the 2003 severe acute respiratory syndrome (SARS) epidemic in Taiwan. During the SARS epidemic, pregnant women avoided using maternity services in advanced hospitals. Concerns have been raised about maintaining the quality of maternity care with increased demands on childbirth services in local community hospitals. In this study, we analyzed the impact of shifting maternity services among hospitals of different levels on neonatal mortality and maternal deaths.

Methods

A population-based study was conducted using data from Taiwan's National Health Insurance annual statistics of monthly county neonatal morality rates. Based on a pre-SARS sample from January 1998 to December 2002, we estimated a linear regression model which included "trend," a continuous variable representing the effect of yearly changes, and two binary variables, "month" and "county," controlling for seasonal and county-specific effects. With the estimated coefficients, we obtained predicted neonatal mortality rates for each county-month. We compared the differences between observed mortality rates of the SARS period and predicted rates to examine whether the shifting in maternity services during the SARS epidemic significantly affected neonatal mortality rates.

Results

With an analysis of a total of 1,848 observations between 1998 and 2004, an insignificantly negative mean of standardized predicted errors during the SARS period was found. The result of a sub-sample containing areas with advanced hospitals showed a significant negative mean of standardized predicted errors during the SARS period. These findings indicate that despite increased use of local community hospitals, neonatal mortality during the SARS epidemic did not increase, and even decreased in areas with advanced hospitals.

Conclusion

An increased use of maternity services in local community hospitals occurred during the SARS epidemic in Taiwan. However, we observed no increase in neonatal and maternity mortality associated with these increased demands on local community hospitals.

Regionalization and mortality in neonatal intensive care

This article examines the outcome data for very low birth weight infants in low-volume, mid-volume, and high-volume neonatal ICUs (NICUs) and argues for regionalization of NICU services on the basis of both medical outcomes and economic rationality. It recognizes some of the obstacles to regionalization of these services and presents ways to surmount them.

Impact of maternity unit closures on access to obstetrical care: the French experience between 1998 and 2003

As in many other countries, the number of maternity units has diminished substantially in France, raising concerns about the reduced accessibility of obstetric services. We describe here the impact of closures on distance and mean travel time between pregnant women's homes and maternity units. We used data from the 1998 and 2003 French National Perinatal Surveys and from vital registries to measure indicators of accessibility: straight-line distance to the nearest maternity unit, number of units within a 15-km radius and reported travel time to the unit for delivery. We analyzed these measures for all births, births in rural versus urban areas and according to regional rates of maternity closures. From 1998 to 2003, 20% of maternity units closed (reducing the number from 759 to 621) with regional variations in the rate of closure from 0.0% to 36.0%. Mean distance to the nearest maternity unit increased (6.6-7.2 km, p < 0.001). The proportion of women living more than 30 km from a maternity ward was low; but rose from 1.4% to 1.8%. The number of maternity units with a 15-km radius of the place of residence fell (median, 3 to 2). Differences were more marked in rural areas and in regions highly affected by closures. However, reported travel time did not increase and even declined slightly for women from urban areas and in regions moderately affected by the closures. As such, the closures do not appear to have had a negative impact on the geographic accessibility of maternity units. Pregnant women were faced with a reduction in the number of maternity units near their homes and our results suggest that they more often chose their maternity units based on proximity. A full assessment of the impact of closures on accessibility to obstetric services would require information on how these changes affected available choices for care during pregnancy and delivery.

Obstetrical volume and early neonatal mortality in preterm infants

OBJECTIVE

Regionalised perinatal care with antenatal transfer of high risk pregnancies to Level III centres is beneficial. However, levels of care are usually not linked to caseload requirements, which remain a point for discussion. We aimed to investigate the impact of annual delivery volume on early neonatal mortality among very preterm births.

METHODS

All neonates with gestational age 24-30 weeks, born 1991-1999 in Lower Saxony were included into this population-based cohort study (n = 5,083). Large units were defined as caring for more than 1,000 deliveries/year, large NICUs as those with at least 36 annual very low birthweight (<1,500 g, VLBW) admissions. Main outcome criterion was mortality until day 7. Adjusted Odds Ratios (adj. OR) and 95% confidence intervals (CI) were calculated based on generalised estimating equation models, accounting for correlation of individuals within units.

RESULTS

Within the first week of life, 20.6% of all neonates deceased; 10.2% were stillbirths, 3.7% died in the delivery unit, and 6.7% in the NICU. The crude OR for early neonatal mortality after having been delivered in a small delivery unit (excluding stillbirths) was 1.36 (95%CI 1.04-1.78; adj. OR 1.16 (0.82-1.63)). It increased to 1.96 (1.54-2.48; adj. OR 1.21 (0.86-1.70)) after the inclusion of stillbirths.

CONCLUSION

This study has shown a slight, but non-significant association between obstetrical volume and early neonatal mortality. In future studies the impact of caseload on outcome may become more evident when referring to high-risk patients instead of to the overall number of deliveries.

Hospital volume and neonatal mortality among very low birth weight infants

BACKGROUND

Very low birth weight infants (< 1500 g) are at increased mortality risk. Data on the impact of NICU volume are sparse, in comparison with those on the level of care. We hypothesized that neonatal mortality would be higher in small NICUs (< 36 very low birth weight admissions per year) than in large NICUs, with adjustment for volume of the delivery unit.

METHODS

We analyzed population-based data from a quality assurance program in Lower Saxony (Germany). Perinatal data for almost all very low birth weight infants born in 1991 to 1999 (n = 7745) were available. Analyses were restricted to infants born at 24 to 30 weeks (n = 4379). Data validation procedures, univariate data analyses, and logistic regression models based on general estimating equations were performed.

RESULTS

Neonatal mortality among infants admitted to NICUs was 12.2% in small NICUs and 10.2% in large NICUs. The mortality rate in small NICUs was increased significantly. Compared with infants from large delivery hospitals (> 1000 births per year) and large NICUs, the adjusted odds ratio was 1.94 for neonates for whom both units were small, 1.75 for those from large delivery units but small neonatal units, and 1.16 for those for whom only the NICU was large. Stratification according to gestational age revealed the greatest impact on mortality for infants of < 29 weeks.

CONCLUSIONS

Results suggest that creating larger perinatal centers may improve perinatal health care. The volume of the NICU was associated more strongly with 28-day mortality than was the volume of the delivery hospital, and it had the largest impact on survival for infants of < 29 weeks.

Does size matter? A population-based study of birth in lower volume maternity hospitals for low risk women

OBJECTIVE

To study the association between volume of hospital births per annum and birth outcome for low risk women.

DESIGN

Population-based study using the National Perinatal Data Collection (NPDC).

SETTING

Australia.

PARTICIPANTS

Of 750,491 women who gave birth during 1999-2001, there were 331,147 (47.14%) medically 'low risk' including 132,696 (40.07%) primiparae and 198,451 (59.93%) multiparae.

METHODS

The frequency of each birth and infant outcome was described according to the size of the hospital where birth took place. We investigated whether unit size (defined by volume) was an independent risk factor for each outcome factor using public hospitals with greater than 2000 births per annum as a reference point.

MAIN OUTCOME MEASURES

Rates of intervention at birth and neonatal mortality for low risk women in relation to hospitals with <100, 100-500, 501-1000, 1001-2000 and >2001 births per annum.

RESULTS

Neonatal death was less likely in hospitals with less than 2000 births per annum regardless of parity. For multiparous low risk women in hospitals of 100 and 500 births per annum compared with hospitals of >2000 births per annum the adjusted odds of neonatal mortality [adjusted odds ratio (AOR) 0.36; 99% confidence interval (CI) 0.14-0.93]. For low risk primiparous women in hospitals with less than 100 births per annum, there were lower rates of induction of labour (AOR 0.62; 99% CI 0.54-0.73); intrathecal analgesia/anaesthesia (AOR 0.34; 99% CI 0.28-0.42); instrumental birth (AOR 0.80; 99% CI 0.69-0.93); caesarean section after labour (AOR 0.59; 99% CI 0.49-0.72) and admission to a neonatal unit (AOR 0.15; 99% CI 0.10-0.22) and for low risk multiparous women in hospitals with less than 100 births per annum: induction (AOR 0.69; 99% CI 0.62-0.76); intrathecal analgesia/anaesthesia (AOR 0.32; 99% CI 0.29-0.36); instrumental birth (AOR 0.52; 99% CI 0.41-0.67); caesarean section after labour (AOR 0.41; 99% CI 0.33-0.52); and admission to a neonatal unit (AOR 0.09; 99% CI 0.07-0.12).

CONCLUSIONS

In Australia, lower hospital volume is not associated with adverse outcomes for low risk women.

Hospital Level of Care and Neonatal Mortality in Low- and High-Risk Deliveries

BACKGROUND

In high-risk births, the availability and concentration of neonatal resources in larger regional hospitals increases the chance of survival. The advantages of regionalization for low-risk deliveries are still unclear, but some studies have suggested that regionalization also is beneficial for low risk deliveries. The aim of the present study was to investigate both the relevance of regionalization and the concentration of neonatal resources as determinants of mortality in low- and high-risk deliveries in Sweden.

METHODS

Interhospital differences in 28-day neonatal mortality were analyzed distinguishing maternal and delivery factors from institutional ones. Using information from the Swedish Birth Register (1990-1995), we performed risk-stratified multilevel logistic regression analysis to study 691,742 births (first level) nested within the 66 Swedish hospitals with maternity wards (second level).

RESULTS

In low-risk deliveries, mortality decreased with improved access to neonatal resources. Mortality was lowest in larger regional hospitals with full access to neonatal care. This association remained unchanged after adjusting for patient mix. With regard to high-risk deliveries, mortality was higher in large county and regional hospitals than in small hospitals without access to neonatal care but, as expected, this increased risk disappeared after adjustment for patient mix.

CONCLUSIONS

Increased regionalization and concentration of neonatal resources for low-risk births is justified from a strictly medical point of view. From a public health perspective, closing small obstetrics units may prevent an appreciable number of deaths, but it would have only a very small impact on the risk of mortality from the individual's point of view. The cost-effectiveness of such a step remains to be analyzed from a health economics perspective.

Are we regionalized enough? Early-neonatal deaths in low-risk births by the size of delivery units in Hesse, Germany 1990-1999

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.

Deliveries in maternity homes in Norway: results from a 2-year prospective study

BACKGROUND

The study aims to report the short-term outcome for the mothers and newborns for all pregnancies accepted for birth at maternity homes in Norway.

METHODS

A 2-year prospective study of all mothers in labor in maternity homes, i.e. all births including women and newborns transferred to hospital intra partum or the first week post partum.

RESULTS

The study included 1275 women who started labor in the maternity homes in Norway; 1% of all births in Norway during this period. Of those who started labor in a maternity home, 1217 (95.5%) also delivered there while 58 (4.5%) women were transferred to hospital during labor. In the post partum period there were 57 (4.7%) transferrals of mother and baby. Nine women had a vacuum extraction, one had a forceps and three had a vaginal breech (1.1% operative vaginal births in the maternity homes). Five babies (0.4%) had an Apgar score below 7 at 5 min. There were two (0.2%) neonatal deaths; both babies were born with a serious group B streptococcal infection.

CONCLUSION

Midwives and general practitioners working in the districts can identify a low-risk population (estimated at 35%) of all pregnant women in the catchment areas who can deliver safely at the maternity homes in Norway. Only 4.5% of those who started labor in the maternity homes had to be transferred to hospital during labor.

Neonatal mortality rates in communities with small maternity units compared with those having larger maternity units

OBJECTIVE

To compare neonatal mortality in geographical areas where most deliveries occur in large hospitals with areas where a larger proportion of deliveries occur in small maternity units.

DESIGN

Population-based study using data from The Norwegian Medical Birth Registry.

SETTING

Records on all deliveries in Norway from 1967 to 1996, a total of 1.7 million births, were equipped with data on the size of the maternity units used by delivering women in that particular area.

MAIN OUTCOME MEASURE

Risk of neonatal death.

RESULTS

Women living in areas where the most frequently used delivery unit had less than 2000 annual deliveries had 1.2 fold the risk of experiencing neonatal death of their newborn (95% CI 1.1-1.3). The relative risk of neonatal death in geographical areas where more than 75% of deliveries occurred in units with more than 3000 annual births was 0.8 (95% CI 0.7-0.9) compared with areas where none delivered in such large units. The relative risk of neonatal death in areas where the most frequently used delivery units had less than 100 annual births was 1.4 (95% CI 1.1-1.7) compared with areas where units of more than 3000 annual births were the most frequently used. Differences in outcome could not be explained by differences in travelling distance to an urban centre where most referral delivery units are located, differences between rural and urban municipalities, or by differences in biological or socio-economic risk factors between municipalities.

CONCLUSIONS

We observed a small but significantly decreased neonatal mortality in areas where the great majority of births occurred in large hospitals.