Out-of-maternity deliveries in France: A nationwide population-based study

Sociodemographic characteristics of non-institutional births and the association with neonatal and infant mortality in Japan

OBJECTIVES

In this study, the association of non-institutional births with neonatal and infant mortality in Japan was investigated as well as sociodemographic characteristics of non-institutional births.

METHODS

The Vital Statistics data in Japan (the birth data from 2012 to 2021 and mortality data from 2012 to 2022) were used. Births were classified into three types based on the place of birth and birth attendant: institutional births, non-institutional births with a physician or a midwife, and non-institutional births without a physician or a midwife. Modified Poisson regression was used in order to investigate the association between the type of birth and neonatal and infant mortality and the association between sociodemographic characteristics and the type of birth.

RESULTS

A total of 9,422,942 births were used in the analysis. The results of regression analysis investigating an association between the type of birth and neonatal and infant mortality showed that non-institutional births were positively associated with neonatal and infant mortality regardless of the attendance of a physician or a midwife. Furthermore, the results of regression analysis investigating predictors of non-institutional births showed that factors such as non-urban regions, older maternal age groups, and unmarried status of mothers were positively associated with the two types of non-institutional births, and non-Japanese mother was positively associated with non-institutional births without a physician or a midwife.

CONCLUSIONS

Non-institutional births were a predictor of neonatal and infant mortality regardless of the attendance of a physician or midwife, and some sociodemographic characteristics have been proven to be predictors of non-institutional births.

Early antenatal risk factors for births before arrival: An unmatched case-control study

INTRODUCTION

Birth before arrival is associated with maternal morbidity and neonatal morbidity and mortality. Yet, timely risk stratification remains challenging. Our objective was to identify risk factors for birth before arrival which may be determined at the first antenatal appointment.

MATERIAL AND METHODS

This was an unmatched case-control study involving 37 348 persons who gave birth at a minimum of 22+0 weeks' gestation over a 5-year period from January 2014 to October 2019 (IRAS project ID 222260; REC reference: 17/SC/0374). The setting was a large UK university hospital. Data obtained on maternal characteristics at booking was examined for association with birth before arrival using a stepwise multivariable logistic regression analysis. Data are presented as adjusted odds ratios with 95% confidence intervals. Area under the receiver-operator characteristic curves (C-statistic) were employed to enable discriminant analysis assessing the risk prediction of the booking data on the outcome.

RESULTS

Multivariable analysis identified significant independent predictors of birth before arrival that were detectable at booking: parity, ethnicity, multiple deprivation, employment status, timing of booking, distance from home to the nearest maternity unit, and safeguarding concerns raised at booking by clinical staff. Our model demonstrated good discrimination for birth before arrival; together, the predictors accounted for 77% of the data variance (95% confidence interval 0.74-0.80).

CONCLUSIONS

Information gathered routinely at booking may discriminate individuals at risk for birth before arrival. Better recognition of early factors may enable maternity staff to direct higher-risk women towards specialized care services at an early point in their pregnancy, enabling time for clinical and social interventions.

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study

OBJECTIVE

To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn.

METHODS

All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI).

RESULTS

Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate.

CONCLUSIONS

Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

Time to onset of cardiovascular and cerebrovascular outcomes after hypertensive disorders of pregnancy: a nationwide, population-based retrospective cohort study

BACKGROUND

The increased maternal cardiocerebrovascular risk after a pregnancy complicated by hypertensive disorders of pregnancy, is well documented in the literature. Recent evidence has suggested a shorter timeframe for the development of these postnatal outcomes, which could have major clinical implications.

OBJECTIVE

This study aimed to determine the risk of and time to onset of maternal cardiovascular and cerebrovascular outcomes after a pregnancy complicated by hypertensive disorders of pregnancy.

STUDY DESIGN

This study included 2,227,711 women, without preexisting chronic hypertension, who delivered during the period 2008 to 2010: 37,043 (1.66%) were diagnosed with preeclampsia, 34,220 (1.54%) were diagnosed with gestational hypertension, and 2,156,448 had normotensive pregnancies. Hospitalizations for chronic hypertension, heart failure, coronary heart disease, cerebrovascular disease, and peripheral arterial disease were studied. A classical Cox regression was performed to estimate the average effect of hypertensive disorders of pregnancy over 10 years compared with normotensive pregnancy; moreover, an extended Cox regression was performed with a step function model to estimate the effect of the exposure variable in different time intervals: <1, 1 to 3, 3 to 5, and 5 to 10 years of follow-up.

RESULTS

The risk of chronic hypertension after a pregnancy complicated by preeclampsia was 18 times higher in the first year (adjusted hazard ratio, 18.531; 95% confidence interval, 16.520-20.787) to only 5 times higher at 5 to 10 years after birth (adjusted hazard ratio, 4.921; 95% confidence interval, 4.640-5.218). The corresponding risks of women with gestational hypertension were 12 times higher (adjusted hazard ratio, 11.727; 95% confidence interval, 10.257-13.409]) and 6 times higher (adjusted hazard ratio, 5.854; 95% confidence interval, 5.550-6.176), respectively. For other cardiovascular and cerebrovascular outcomes, there was also a significant effect with preeclampsia (heart failure: adjusted hazard ratio, 6.662 [95% confidence interval, 4.547-9.762]; coronary heart disease: adjusted hazard ratio, 3.083 [95% confidence interval, 1.626-5.844]; cerebrovascular disease: adjusted hazard ratio, 3.567 [95% confidence interval, 2.600-4.893]; peripheral arterial disease: adjusted hazard ratio, 4.802 [95% confidence interval, 2.072-11.132]) compared with gestational hypertension in the first year of follow-up. A dose-response effect was evident for the severity of preeclampsia with the averaged 10-year adjusted hazard ratios for developing chronic hypertension after early, preterm, and late preeclampsia being 10, 7, and 6 times higher, respectively.

CONCLUSION

The risks of cardiovascular and cerebrovascular outcomes were the highest in the first year after a birth complicated by hypertensive disorders of pregnancy. We found a significant relationship with both the severity of hypertensive disorders of pregnancy and the gestational age of onset suggesting a possible dose-response relationship for the development of cardiovascular and cerebrovascular outcomes. These findings call for an urgent focus on research into effective postnatal screening and cardiocerebrovascular risk prevention for women with hypertensive disorders of pregnancy.

Relationship between out-of-facility deliveries and distance and travel time to delivery facilities in Hokkaido, Japan: An ecological study

AIM

This study aimed to investigate the relationship between the distance and travel time from each municipality to the nearest delivery facilities in the other municipalities and the frequency of out-of-facility deliveries in Hokkaido.

METHODS

Vital statistics from 2016 to 2020 were used. For municipalities without delivery facilities, the distance and travel time from the town office of each municipality to the nearest delivery facility was measured using Google maps. Negative binomial regression with an offset term was used to calculate the relative risks (RRs) and 95% confidence intervals (CIs) of out-of-facility delivery for distance (<30, 30-59, ≥60 km), and travel time by car (<30, 30-59, and ≥60 min) from the town office to the nearest delivery facility compared with the presence of delivery facilities.

RESULTS

The overall rate of out-of-facility deliveries in Hokkaido was 2.1‰; in municipalities with delivery facilities, 1.8‰, and in municipalities without delivery facilities, 3.1‰. The adjusted RRs (95% CIs) for out-of-facility deliveries were significantly higher in municipalities with less than 30 km and travel time of less than 30 min to delivery facilities, 2.63 (1.34-5.17) and 2.76 (1.36-5.58), respectively, compared to municipalities with delivery facilities. However, the adjusted RR of out-of-facility delivery for municipalities ≥30 km was higher, although the difference was not significant.

CONCLUSIONS

Even in municipalities with a distance to delivery facilities of less than 30 km or travel time of less than 30 min, we should keep in mind the occurrence of out-of-facility deliveries.

Prise en charge périnatale du nouveau-né lors d’une naissance en milieu extrahospitalier

Les accouchements inopinés extrahospitaliers représentent environ 0,3 % des accouchements en France. La prise en charge du nouveau-né en préhospitalier par une équipe Smur fait partie de l’activité courante. L’évaluation initiale du nouveau-né comprend systématiquement la mesure de sa fréquence cardiaque (FC) et respiratoire (FR), l’appréciation de son tonus ainsi que la mesure de sa température axillaire. En cas de doute ou de transition incomplète un monitoring cardiorespiratoire sera immédiatement mis en place (FC, FR, SpO2). Nous faisons ici une mise au point sur les données connues et avons adapté les pratiques, si besoin, au contexte extrahospitalier, car la majeure partie des données rapportées dans la littérature concernent les prises en charge en maternité ou en milieu hospitalier. Nous abordons les points essentiels de la prise en charge des nouveau-nés, à savoir la réanimation cardiopulmonaire, le clampage tardif du cordon ombilical, la lutte contre l’hypothermie et l’hypoglycémie; ainsi que des situations particulières comme la prématurité, la conduite à tenir en cas de liquide méconial ou de certaines malformations congénitales. Nous proposons aussi quels peuvent être : le matériel nécessaire à la prise en charge des nouveau-nés en extrahospitalier, les critères d’engagement d’un renfort pédiatrique à la régulation ainsi que les méthodes de ventilation et d’abord vasculaire que l’urgentiste doit maîtriser. L’objectif de cette mise au point est de proposer des prises en charge les plus adaptées au contexte préhospitalier.

Cost analysis of planned out-of-hospital births in Italy

BACKGROUND AND AIM

In Italy, the main birthplace is a hospital, and only a few women choose an out-of-hospital setting. This study assessed the costs related to delivery in different birthplaces in Italy.

METHODS

The cost analysis considered direct and amortizable costs associated with mother-child care in physiological conditions. An analysis of the hospital births considered the Diagnoses-Related Groups 373 and 391. To estimate the cost of the births assisted privately by freelance midwives, an evaluation based on an experts' opinion was carried out.

RESULTS

Childbirth hospital care in Italy amounts to € 1832.00, and birth in an out-of-hospital setting accredited with the National Health System has a full cost of € 1345.19 in the 'maternity home' and € 909.60 at home. The average cost of the birth in 'private maternity homes' amounted to € 3260.00, while at-home births amounted to € 2910.00.

CONCLUSIONS

Any accreditation of out-of-hospital settings by the NHS would considerably reduce the waste of economic resources compared to hospital childbirth.

Suspected Labour as a Reason for Emergency Medical Services Team Interventions in Poland—A Retrospective Analysis

The purpose of this study was to present the characteristics of Emergency Medical Services (EMS) team responses to calls regarding suspected labour in out-of-hospital settings in Poland. We performed a retrospective analysis of EMS team interventions in cases of suspected onset of labour outside a hospital setting. The analysis included 12,816 EMS team responses to calls regarding women in suspected labour in the period between January 2018 and December 2019. The mean age of the patients studied was 28.24 years (SD = 6.47). The majority of patients were at term (76.36%) and in their second pregnancy (29.96%). EMS teams were most often dispatched in the summer (25.95%) and in urban areas (63.26%). Most EMS teams were basic (68.99%) and interventions most often took place between 19:00 and 06:59 (63.14%). Significant differences were observed between preterm and term pregnant women attended by EMS teams in terms of variables such as the age of the patient, number of previous labours, history of miscarriage, presence of vaginal bleeding, time of year, location of call, type and composition of EMS team dispatched, urgency code and time of call, duration of intervention, selected emergency medical procedures performed and test results.