Validation study: evaluation of the metrological quality of French hospital data for perinatal algorithms

OBJECTIVE

The aim of our validation study was to assess the metrological quality of hospital data for perinatal algorithms on a national level.

DESIGN

Validation study.

SETTING

This was a multicentre study of the French medicoadministrative database on perinatal indicators.

PARTICIPANTS

In each hospital, we selected 150 discharge abstracts for delivery (after 22 weeks of gestation), in 2014, and their corresponding medical records. Overall, 22 hospitals were included.

INTERVENTIONS

A single investigator performed blind data collection from medical records in order to compare data from discharge abstracts with data from medical records. Finally, 3246 discharge abstracts were studied.

PRIMARY AND SECONDARY OUTCOME MEASURES

Seventy items, including maternal and delivery characteristics and maternal morbidity, were collected for each delivery stay.

RESULTS

The concordance rate of maternal age at delivery was 94.8% (95% CI 93.8 to 95.4). Combining the two forms of pre-existing diabetes, the algorithm presented a PPV of 65.9% and a sensitivity of 75.7%. The concordance rate of gestational age at delivery was 91.8% (90.9 to 92.7). Regarding gestational diabetes, the PPV was 80.8% (79.4 to 82.2) and the sensitivity was 79.5% (78.1 to 80.9). Regardless of the algorithm explored, the PPV for vaginal delivery was over 99%. For the diagnosis codes corresponding to immediate postpartum haemorrhage, the PPV was 77.7% (76.3 to 79.1) and the sensitivity was 75.5% (74.0 to 77.0). The algorithm for stillbirth presented a PPV of 89.4% (88.3 to 90.5) and a sensitivity of 95.4% (94.7 to 96.1).

CONCLUSIONS

This first national validation study of many perinatal algorithms suggests that the French national hospital database is an appropriate data source for epidemiological studies, except for some indicators which presented low PPV and/or sensitivity.

[Medical-social characteristics of maternal deaths in a Mayan community of Yucatan, Mexico]

OBJECTIVE

To describe clinical and sociodemographic characteristics of maternal deaths occurred from 1997 to 2001, so as the access and availability of services of health, in the municipality of Chemax, Yucatan, Mexico.

MATERIAL AND METHODS

Acts and certificates of death of women born in the municipality of Chemax were reviewed. The maternal deaths were classified in direct and indirect obstetrical deaths, according to criteria of the International Statistical Classification of Diseases and Related Health Problems (tenth revision). The knowledge of the women on risks in the pregnancy, childbirth and the postpartum period was explored indirectly in the relatives, as well as perceptions of these last ones on the death. The time passed between the search of aid and the attention was calculated.

RESULTS

Nine cases of maternal deaths were registered during 1997-2001 period, two of which were findings of the study. The principal cause was the obstetric hemorrhage. The 9 women spoke Mayan an 5 understood in addition the Spanish. The women did not know the obstetrical risks. The perceptions of the relatives on the deaths were bound to myths, lack of information and medical attention. The minimum time of transfer for the attention of the childbirth was of 10 minutes and the maximum of 2 hours. For the attention of the complications, eigth women were transferred to a hospital outside their locality.

CONCLUSIONS

The hemorrhage postpartum was the leading cause of maternal death in Chemax. Sociodemographic factors and of access to the health services, characterized to the maternal deaths in this community. Something similar could be happening in other communities very marginalized of Yucatan.

Antifungal prophylaxis to prevent neonatal candidiasis: a survey of perinatal physician practices

BACKGROUND

Bloodstream infections with Candida species have a high mortality rate in very low birth weight infants. Preliminary data suggest that prophylaxis with fluconazole reduces the incidence of colonization and invasive Candida infections in high-risk, very low birth weight neonates. The extent of antifungal prophylaxis use to prevent neonatal candidemia is unknown.

METHODS

We surveyed a 20% random sample of the members of the American Academy of Pediatrics Section on Perinatal Pediatrics. We collected information on prophylactic agents used, indications for use, and rationale for reported practices.

RESULTS

A total of 219 (47%) of 469 members sampled responded; 3 clinicians who did not provide care to very low birth weight infants were excluded. Antifungal prophylaxis use was reported by 73 (34%) respondents. Agents used included intravenous fluconazole (66%), oral nystatin (59%), and intravenous amphotericin B (21%). Decreased birth weight or early gestational age was the most frequent indication to start prophylaxis (57 [78%]). Respondents who did not use antifungal prophylaxis compared with respondents who used fluconazole prophylaxis were significantly more likely to have concerns about (1) the emergence of antifungal resistance, (2) unclear criteria on which to base the decision to start prophylaxis, and (3) the need for clarification of the role of surveillance cultures.

CONCLUSIONS

Although preliminary data suggest that fluconazole is efficacious to prevent candidemia in a subset of neonates, this practice is not used widely by clinicians who care for very low birth weight infants. Additional efficacy studies should address the emergence of antifungal resistance or clarification of criteria to initiate prophylaxis, including the role of surveillance cultures.

Association between childhood sleep problems and perinatal factors, parental mental distress and behavioral problems

The aim of this study was to examine the effect of age, gender and perinatal risk factors on the risks for sleep problems, and investigate the relation between childhood sleep problems and children's behavioral syndromes and parental mental distress in early and middle childhood. We recruited a representative sample of 1391 children, ages 4-9, from nine kindergartens and three elementary schools by using a multistage sampling method. Parents of child participants completed a questionnaire including perinatal risk factors, sleep habits and problems, the Child Behavior Checklist (CBCL) and the Chinese Health Questionnaire (CHQ). A mixed model was used for data analysis to address cluster effect from the same classes and schools. Results showed that boys suffered from more sleep problems than girls. Early insomnia, sleep terrors and enuresis decreased with ages, but sleepwalking increased with ages. Perinatal exposure to alcohol, coffee and non-prescribed medication, vaginal bleeding, artificial delivery, first-born order and higher parental CHQ score (> or =4) were significantly associated with several childhood sleep problems. In addition, children with sleep problems had higher T-scores of the eight behavioral syndromes derived from the CBCL. Our findings indicated that the childhood sleep problems were associated with perinatal risk factors, parental psychopathology and children's behavioral problems.

The value of the perinatal and neonatal autopsy

The postmortem historically has been considered a valuable diagnostic exercise which contributes to medical knowledge. Despite this, there has been a significant reduction in autopsy rates throughout the developed world. This audit was a retrospective study of autopsy reports of stillbirths and neonates [corrected] greater than 500 grams over a five year period from 1995 to 1999. The audit was performed to assess the impact of autopsy on the current practice of perinatal medicine. The audit compared the final pathological diagnosis to the clinical diagnosis. The pathological diagnosis was categorised as (I) diagnostic, (II) confirmative, (III) unexplained. The recurrence risk estimates as a result of necropsy were also identified, as were any additional findings that were felt to be relevant but did not belong to any of the above categories. A total of 262 perinatal deaths (including stillbirths) and neonatal deaths greater than 500 grams birth weight were recorded during this period. The autopsy rate was 81%. The 213 autopsies performed were assessed, of which 76 (36%) were found to be diagnostic, 108 (51%) confirmatory, and 29 (13%) were unexplained or revealed no new findings. Change in recurrence risk estimates was identified in 24 (11%) and additional relevant information was obtained in 38 (18%). There were a number of cases where an unexpected diagnosis was made as a result of autopsy; these diagnoses included a respiratory chain disorder in a twenty nine week infant, and an occult necrotising enterocolitis presenting with severe haemolysis post transfusion in a preterm infant. The perinatal post mortem examination remains an indispensable part of clinical management. It contributes to medical education and quality assurance. It can aid in the identification of inheritable diseases and provide information for accurate parental counseling.

[Prenatal health in 2002-2003. Survey of medical practice. Results from the Audipog sentinel network]

Perinatal health survey has been ensured for 10 years by the AUDIPOG Sentinel Network (AUDIPOG, Association of Users of Computerized Files in Perinatology, Obstetrics and Gynecology). It was created, in 1994, by a group of birth specialists having the same concern for a common system of perinatal health survey and assessment of medical practices. Every year, the network includes about 100 voluntary maternity units pooling data about pregnant women and their newborns. To date, the AUDIPOG database comprises 180,000 births gathered between 1994 and 2003, including 78,287 births for the 2002 and 2003 period. The use of a standardization method of the rates makes it possible to provide valid estimations at the national level. This report presents the perinatal health indicators in 2002-2003 and confirms a very alarming situation: the rate of preterm births has not decreased since 1999 (7.1% of births) and high prematurity (< 33 weeks of gestation) affects 1.6% of newborns. Only 65% of high premature infants are born in care level III maternity units, while the figure of 80% has been reached as soon as 1999 and has not stopped to decrease since. The rate of cesarean section keeps on increasing, reaching 18.7% including 9.6% before the beginning of labour. The AUDIPOG network constitutes a continuous, and in real time, perinatal health survey and also a tool to assess medical practices. Members of the Audipog network can log in to the common data base, using the AUDIPOG website (http://audipog.inserm.fr), in order to find answers to their own questionnings and to compare their practices with the external reference formed by the network: such an access represents an innovating method of self-assessment of medical practices and quality control.

Effect of ethnicity on mortality of very low birthweight infants in Israel

BACKGROUND

Multiple demographic, genetic, and environmental factors differ between Muslim and Jewish infants in Israel.

OBJECTIVE

To evaluate whether, after adjustment for perinatal factors associated with mortality, excess mortality occurs in very low birthweight (VLBW) Muslim compared with Jewish infants.

DESIGN

The Israel National VLBW infant database includes data on 99% of all VLBW births in Israel. The study population comprised 5015 Jewish and 1549 Muslim VLBW infants of more than 23 weeks gestation, born between 1995 and 1999. The Mantel-Haenszel test was used for stratified analysis and logistic regression analysis to assess the effect of ethnic origin on mortality.

RESULTS

The death rate was significantly higher among Muslim infants (22.7% v 17.2%; crude odds ratio 1.42; 95% confidence interval 1.24 to 1.63). Excess mortality in Muslims occurred mainly in the 32-33 week (8.0% v 2.8%) and >33 week (14.7% v 4.7%) gestational age groups, and in birthweight groups of 1000-1249 g (17.6% v 9.3%) and 1250-1500 g (9.1% v 3.6%). In VLBW infants without congenital malformations, there was a significantly higher risk of mortality among Muslim infants (odds ratio 1.28; 95% confidence interval 1.04 to 1.57) compared with Jewish infants, after adjustment for gestational age, birth weight, small for gestational age, prenatal care, prenatal steroid treatment, plurality, mode of delivery, and Apgar score.

CONCLUSIONS

Excess mortality was present among Muslim VLBW infants without congenital malformations. Perinatal factors associated with increased risk of mortality were more prevalent in the Muslim VLBW population. The pattern of disparities suggests inadequate access to, or utilisation of, effective perinatal technology in the Muslim population in Israel.

Neonatal outcomes and quality of care in level II perinatal centers supported by a children's hospital-medical school level III program

OBJECTIVE

Eight Level II perinatal centers developed contracts with the children's hospital to provide consultative neonatal patient care, education, and administrative support. The purpose of the present study was to evaluate infant outcomes and quality of care during a 3-year period of the program, 1994 to 1996.

STUDY DESIGN

Neonatal mortality rates were determined for the 18,703 live births. Quality of care was assessed for 30 infants who died at the Level II centers and 315 infants transferred to the children's hospital.

RESULTS

The neonatal mortality rate was 2.2/1000 live births. Quality-of-care issues primarily involved 80 "drop-in" deliveries </=32 weeks' gestation and seven-term infants with perinatal asphyxia. Enhanced neonatal care at the Level II special care nurseries was evident from procedures performed and the clinical course of 1382 infants not transferred.

CONCLUSION

Further improvement is possible with comprehensive prenatal care avoiding deliveries <32 weeks' gestation and improved response to acute intrapartum emergencies.

Perinatal management of fetal cardiac anomalies in a specialized obstetric-pediatrics center

Perinatal teams dealing with fetal heart disease frequently wonder which pregnancies might be terminated, and when delivery should take place in a specialized surrounding. We present a retrospective study of 229 fetuses, in which prenatal ultrasound showed a cardiac anomaly not compatible with a standard maternity ward delivery. One hundred nineteen pregnancies were terminated (group I) while 110 pregnancies led to the birth of a live baby (group II). Pathology in group I was discovered earlier than in group II (24 vs. 29.3 weeks' gestation; p <0.01), and associated malformations or chromosomal anomalies were much more frequent in group I (80/119 vs. 9/110; p <0.001). Among live born babies, three infants with transposition of the great arteries underwent Rashkind atrioseptostomy in the delivery room. With a minimum follow-up of 12 months, 69 children (63%) have undergone surgery. Among 92 survivors (1 child is lost to follow-up), 78 (71%) are asymptomatic and 14 symptomatic. Early prenatal diagnosis of fetal heart anomalies significantly facilitates prenatal work-up and perinatal care. We present the types of pathology having led to termination and define the situations in which children are at risk of perinatal hemodynamic compromise.

Defining the relationship between obstetricians and maternal-fetal medicine specialists

OBJECTIVE

The purpose of this study was to determine how frequently general obstetricians refer pregnant patients to maternal-fetal medicine specialists in the presence of the clinical indications specified as appropriate for referral or consultation by the 1996 statement of the Society of Perinatal Obstetricians.

STUDY DESIGN

A questionnaire was mailed to 400 randomly selected general obstetricians across the United States. The obstetricians were asked how often they refer their high-risk pregnant patients to maternal-fetal medicine specialists in the presence of (1) a need for diagnostic or therapeutic procedures, (2) medical/surgical disorders, (3) healthy gravid women with high-risk fetuses, and (4) conditions that necessitate admission for reasons other than delivery. Response categories for each individual procedure/high-risk condition included "always," "frequently," "infrequently," "never," and "not applicable."

RESULTS

Overall, 55% of the responses indicated referral (always or frequently) to maternal-fetal medicine specialists for procedures or in the presence of high-risk conditions. More than 75% of the obstetricians always or frequently refer to maternal-fetal medicine specialists for most diagnostic/therapeutic procedures and for the following high-risk conditions: acute fatty liver, portal hypertension, pulmonary hypertension, transplantations, fetal hydrops, fetal anomaly/cytogenetic abnormality, fetal supraventricular tachycardia or congenital heart block, isoimmunization, and twin-to-twin transfusion syndrome.

CONCLUSION

Most of the conditions for which >75% of the obstetricians refer to maternal-fetal medicine are rarely seen in practice. Comprehensive ultrasound examination is the only commonly encountered clinical situation that >75% of the general obstetricians refer to maternal-fetal medicine specialists.

[Current developments in the German Perinatal Survey. Modular analysis tools operating on a database platform]

The introduction of the modified data set for quality assurance in obstetrics (formerly perinatal survey) in Lower Saxony and Bavaria as early as 1999 saw the urgent requirement for a corresponding new statistical analysis of the revised data. The general outline of a new data reporting concept was originally presented by the Bavarian Commission for Perinatology and Neonatology at the Munich Perinatal Conference in November 1997. These ideas are germinal to content and layout of the new quality report for obstetrics currently in its nationwide harmonisation phase coordinated by the federal office for quality assurance in hospital care. A flexible and modular database oriented analysis tool developed in Bavaria is now in its second year of successful operation. The functionalities of this system are described in detail.

Antenatal transfer of rural women to perinatal centres. High Risk Obstetric and Perinatal Advisory Working Group

The aim of this study was to describe antenatal transfers of rural women to perinatal centres, and among transferred women, to assess the use of selected evidence-based therapies and determine the predictors of preterm and imminent births. The clinical records of rural women antenatally transferred to perinatal centres in NSW and the ACT during 1997-1998 were reviewed. Of 453 rural antenatal transfers, 408 (90%) were emergency transfers. Increasing remoteness was associated with increased rates of antenatal transfer but not with a lower probability of giving birth. Of all transferred women, 64% delivered; 58% of preterm transfers delivered preterm and of those delivering preterm, 76% delivered within 7 days. Although the main reason for antenatal transfer was the possibility of preterm birth, women presenting with preterm contractions only were less likely to deliver preterm (OR = 0.2, 95% CI 0.1-0.4) or < or = 7 days (OR = 0.3, 95% CI 0.2-0.5) than women with any other presenting symptoms. The overall usage of effective interventions (antenatal steroids, antibiotics for PPROM and beta-mimetic tocolysis to delay birth) among antenatally transferred rural women was high, but there is room for increased uptake prior to transfer.

Administrative data for quality improvement

This article discusses the use of administrative data for quality improvement in perinatal and neonatal medicine. We review the nature of administrative data and focus on hospital discharge abstract data as the primary source of hospital- and community-based assessments. Although discharge abstract data lack the richness of primary data, these data are the most accessible comparative data source for examining all patients admitted to a hospital. When aggregated to the state level as occurs in more than 30 states, hospital discharge data reflects hospital utilization and outcomes for an entire geographic population at the state and community level. This article reviews some of the weaknesses of administrative data and then focuses how these data can be used for hospital- and community-based assessment of perinatal care citing as examples the measures of perinatal process and outcome used by the National Perinatal Information Center in its Quality/Efficiency Reports for member hospitals and a study of perinatal high-risk care in the State of Florida. The use of discharge abstract data for performance measurement at either the hospital or the system level requires a thorough understanding of how to select a patient group, its characteristics, the intervention, and the outcomes relevant to that patient group. In the perinatal arena, the National Perinatal Information Center has selected and presents those measures that rely on data items shown to be the most reliable based on validity studies and clinician opinion, delineation of the intervention, and the measurement of what occurred. As hospitals respond to the recent pressures of the Joint Commission on Accreditation of Healthcare Organizations and other quality assurance entities, the accuracy of the discharge data will improve. With accepted caution, these data sets are invaluable to researchers studying comparative populations over time or across large geographic areas.

The labor-adjusted cesarean section rate--a more informative method than the cesarean section "rate" for assessing a practitioner's labor and delivery skills

OBJECTIVE

Our purpose was to determine the benefits of an acuity-adjusted labor management tool.

STUDY DESIGN

A retrospective review was performed of all deliveries at Good Samaritan Regional Medical Center in Phoenix, Arizona, for a 1-year period from Jan. 1 to Dec. 31, 1994. All physicians with > or = 20 deliveries were included in the analysis. Patients with indications for which most practitioners would perform a cesarean delivery were removed from consideration. Physicians were then compared with respect to labor management in the remaining patients without relative contraindications to vaginal delivery.

RESULTS

The total number of deliveries (n = 6062) was performed by 47 attending obstetricians, 9 perinatologists, an obstetrics-gynecology clinic, and a family practice clinic. The "raw" cesarean section rate was 20.1%. Those at high risk for cesarean delivery (n = 534) were excluded, leaving 684 cesarean sections performed in 5528 patients (12.4%) who were appropriate to labor. Differences were observed between the nulliparous cesarean section rate (16%) compared with that for parous patients (10.1%) (p < 0.0001 by Fisher's exact test (two-tailed) but not between attending obstetrician-gynecologists (12.4%) and perinatologists (13.8%) (not significant).

CONCLUSION

A labor-adjusted cesarean section rate is more appropriate than just "raw" data. Medical, obstetric, and fetal factors affect a "raw" rate that is out of the control of the obstetrician. This method of assessing the labor and delivery skills of each practitioner and hospital would allow meaningful comparison with others.

Interobserver variability of sonographically determined second-trimester nuchal skinfold thickness measurements

Twenty physicians experienced in fetal sonographic evaluation obtained fetal nuchal skinfold thickness measurements in each of five pregnant women between 16 and 18 weeks' gestation. A random effects analysis of variance model was used to explore the sources of variation in the set of measurements, to determine the interobserver variability of sonographically measured second-trimester nuchal skinfold thickness. It was possible to obtain 96 measurements. Four measurements (all in the same patient) were deemed unobtainable due to fetal position. All recorded measurements were between 1.7 and 4.5 mm. The means (and ranges) for the five patients were 2.7 (1.7-3.6), 2.9 (2.0-4.5), 2.7 (2.0-4.0), 3.3 (2.2-4.0), and 2.7 (1.8-4.0) mm. The standard deviation for interobserver variability, caused by the combined effect of physician and machine imprecision, was 0.56 mm and the overall coefficient of variation was 19.8%. Interpatient differences were statistically significant (p = 0.004). Interphysician differences were not (p = 0.11). We conclude that experienced physician sonographers using high-resolution ultrasound equipment are able to obtain second-trimester nuchal skinfold thickness measurements within 1.1 mm of the estimated true value with 95% probability.

The birth survey in Germany--education and quality control in perinatology

Perinatal mortality in Germany fell during the past four decades from 5% in 1955 to 0.5-0.6% in 1992. This decrease was achieved by organisational health improvements: movement from home to hospital deliveries, mother protection law, guiding principles for prenatal care, pregnancy passport, regionalisation of high risk cases; and medical achievements: fetal monitoring before and during labor, ultrasound technics and neonatal intensive care units with neonatal monitoring, PEEP ventilation and surfactant application. This movement has been supported in the last decade by the implementation of a perinatal survey, starting in Munich, Bavaria in 1975 and distributed, since 1980, over all the states of Germany. The perinatal review is a birth data assessment on a voluntary basis, which provides the opportunity to compare the data with the mean of the participating hospitals. It is therefore an instrument for selfeducation and selfcontrol. It is also used for analysing long-term trends (i.e. caesarean section rate) and for estimating implemented obstetrical managements (i.e. corticosteroid treatment) on a large data pool. Perinatal reviews support the goal to keep the perinatal mortality low or even to achieve a further decrease.

[Quality assurance exemplified by perinatology and surgery]

Quality assurance encompasses all activities which are necessary to obtain a demanded quality of medical care. Typically, a quality assurance process ("monitoring- and evaluation-process") includes the following steps: systematic observation of quality of medical care using quality indicators, assessment of quality by comparison with standards and recognizing problems, analysis of the most important problem, realization of appropriate problem solving strategies and evaluation, if the problem is successfully solved through the corrective action. The quality assurance programs in perinatology and surgery--established in all the states of the Federal Republic of Germany--support the hospitals in the application of this quality assurance process. Uniform documentation and preparation of quality relevant information (lists of complications, profiles, charts, etc.) help the hospitals to perform a self-evaluation, to recognize problems and to verify the elimination of the problems. Hence, comparisons with local results and with results of other hospitals are possible.

Training in perinatal care--management of patients in labour

Training in perinatal care involves many different areas, and care around the time of labour forms a core part of training. Our senior residency programme involves 6 months supervised work in the labour ward. During this period, management of spontaneous, induced and augmented labour, methods of fetal monitoring and pain relief are taught. A log book and a check list are maintained to ensure the necessary manipulative and operative obstetric procedures have been followed. Limited scanning experience is provided to enable management of emergencies such as APH, multiple pregnancies, etc. Preparation and presentation of monthly statistics become a responsibility. Daily neonatal ward rounds are performed so that neonatal morbidity in relation to obstetric events are correlated. This exercise provides adequate knowledge to prognosticate and counsel patients whose babies are low birthweight or have malformations. Two to three new research projects are entrusted to trainees in order to acquire skills in writing research protocols, applications for research grants and later to enter research and write manuscripts. Discussion regarding research, working protocols and management problems are carried out after the daily ward rounds. Relevant reference papers or chapters are read, discussed and compiled in a file for further reading and for the benefit of other residents in training. This posting is followed or preceded by 6 months posting in ultrasound, high risk, medical disorder, diabetic and endocrine clinics. They also manage the antenatal and postnatal wards during these 6 months. At the end of 1 year training those interested in fetomaternal medicine do a further 2 years training in these areas at an advanced level.

The Flemish Centre for the Study of Perinatal Epidemiology and its registry

The Flemish Centre for the Study of Perinatal Epidemiology was formally established in 1986. Its objectives are the promotion of perinatal epidemiology and the study of maternal and perinatal mortality and morbidity. One of the means to accomplish these objectives was the creation of a databank of perinatal medicine. The registry at present covers almost 80% of all deliveries in Flanders. The registry indicates a maternal death rate of 5.8/100,000 living births whereas the Belgian official national statistics indicate a maternal death rate of 2.8/100,000. This means that either the matter is under reported at the national level or there is a real problem in the Flemish part of the country. The perinatal death rate varies among the participating services form 3.9 to 22.4%.

Use of diagnostic ultrasound, X-ray examinations, and electronic fetal monitoring in perinatal medicine

Obstetrical technologies such as electronic fetal monitoring (EFM) and selected diagnostic imaging procedures can be integral components of perinatal care. The Center for Devices and Radiological Health, a unit within the Food and Drug Administration, collaborated with the National Center for Health Statistics in the design and conduct of a National Maternal and Infant Health Survey to collect information from prenatal care providers, hospitals, and mothers on the use of EFM, diagnostic ultrasound, and x-ray examinations during pregnancy, labor, and delivery. A pretest, conducted some months before the survey began, showed that 78.8% of the pregnancies surveyed received a diagnostic ultrasound examination during pregnancy. Approximately 58.3% of the ultrasound-exposed mothers had two or more such examinations. Approximately 10.1% of the ultrasound examinations were performed in the first trimester of pregnancy, 57.0% in the second trimester, and 32.9% in the third trimester. The most common indication for an ultrasound examination was to establish dates or gestational age. Approximately 15.3% of the pregnancies surveyed received an x-ray examination. Approximately 74.6% of the pregnancies were monitored with EFM during labor. External EFM was used alone during 54.9% of the labors and along with internal EFM during 19.7% of the labors. The implications of these pretest findings are discussed, along with a review of the medical literature on the safety and effectiveness of these medical device technologies.

[Evaluation of perinatal policy. Result of a survey about birth in Pays de Loire]

A survey was undertaken in 3 French departments of the Pays de Loire from January 1, 1986 to December 31, 1986. Among the 32,876 neonate (NN) population, the authors studied the 2,753 NN who were hospitalized and a control group of 1,458 NN representative of the population of 30,123 NN who were not hospitalized. Socioeconomic patterns of mothers, of their pregnancies and deliveries were studied in both groups. The control group was compared with the data obtained in 1981 at the national level and in 1982 at the local level. This group was used as a reference for the study of hospitalized NN. Intrauterine growth retardation rate was 2.4%, prematurity rate 4.6% of live births, very premature rate (as defined by a gestational age less than 32 weeks) was 0.45% of births. Among the group of hospitalized NN, which represent 8.5% of the general population, the NN were regrouped according to Cullen's classification and their care load estimated according to the Omega score. Thus 2 subgroups were defined: the 2,298 ordinarily hospitalized (Cullen's classes I and II) and the 455 severely sick NN (classes III and IV) i.e. 1.3% of births. One third of the severely ill NN were very prematures. The 2 other thirds presented with respiratory (24%), infectious (24%), malformative (19%) or neurological (13%) diseases. Lengths of stay and Omega scores varied according to the causes for hospitalizations and were inversely correlated with gestational ages (p less than 0.001). Neonatal mortality was 3.3 p. 1,000 births and rate of stillbirths 6.5 p. 1,000.

Using logistic regression in perinatal epidemiology: an introduction for clinical researchers. Part 1: Basic concepts

Logistic regression is a statistical modelling technique which may be applied to estimate the simultaneous effect of a set of predictors (e.g. gestational age, birthweight) on the risk of a certain outcome variable (e.g. neonatal death) which can take either one of two possible values (yes/no, alive/dead) or in the situation where one wants to estimate the effect of a particular risk factor (e.g. sex) while adjusting (correcting) for the effect of other risk factors (e.g. gestational age). Since this situation often occurs both in medical or epidemiological research and in daily practice it is important to have a flexible and readily interpretable technique to predict risk of mortality and morbidity. Since the logistic regression technique is a powerful and widely applicable tool which is appearing more and more often in the epidemiological literature, a basic understanding of this technique becomes necessary for the clinical researcher. In this paper we explain logistic regression to medical researchers who do not have any particular statistical background. Part 1 covers the basic concepts. Part 2 will describe the actual representation of the basic concepts in a logistic framework.

Analysis of a maternal transport service within a perinatal region

In 1979, the State of Illinois legislated regionalization of perinatal care. Analysis of perinatal statistics from the Loyola University Perinatal Center from 1979 to 1986 supports: (1) increasing numbers of maternal and neonatal transports, with the number of maternal transports exceeding the number of neonatal transports since 1982; (2) increasing proportion of low birthweight and very low birthweight infants delivered at the perinatal center; (3) a decrease in the number of infants less than 1500 gm sent as neonatal transports; and (4) increasing proportion of neonatal transports with a birthweight greater than 2500 gm. With the change in utilization by local physicians, the perinatal center has expanded its obstetric and neonatal service areas and hired additional staff to meet the increased demand for its services. The perinatal mortality rate for the region has decreased from 1981 to 1986.

Peer review through perinatal statistics

The purpose here is to demonstrate that perinatal statistics serve as a powerful tool for peer review, thereby improving the standard of maternity care. These data were used as an instrument for peer review, first by comparing perinatal mortality between one country and another. More detailed statistics, rapidly fed back to the delivery units, acted as a strong inducement to practitioners at all levels who wanted to do at least as well as their neighbors. Examples are given from Sweden, Scotland and Germany.

Perinatal data reliability in a large teaching obstetric unit

In this inter-rater agreement study of antenatal and neonatal variables collected in a large teaching obstetric unit, information routinely collected by hospital staff was compared with that collected by a specially trained physician and a social worker. Agreement between the two sources of data was evaluated using kappa statistics and intraclass correlation coefficients. Excellent agreement was observed for some variables such as maternal and newborn anthropometric measures, and previous birthweight, but there was poor agreement for others such as indicators of physical activity, work during pregnancy and blood pressure measures. Some of the limitations are due to problems in phrasing questions, patients' recall, interviewer bias and abstracting data. We recommend that epidemiological studies should always include a reliability component, proper standardization of personnel and instruments and include, when published, validity data and examples of questions used.