Late preterm (34–36 weeks of gestational age (GA)), and early term (37–38 weeks GA) birth rates among singleton live births vary from 3% to 6% and from 15% to 31%, respectively, across countries, ...although data from low- and middle-income countries are sparse. Countries with high preterm birth rates are more likely to have high early term birth rates; many risk factors are shared, including pregnancy complications (hypertension, diabetes), medical practices (provider-initiated delivery, assisted reproduction), maternal socio-demographic and lifestyle characteristics and environmental factors. Exceptions include nulliparity and inflammation which increase risks for preterm, but not early term birth. Birth before 39 weeks GA is associated with adverse child health outcomes across a wide range of settings. International rate variations suggest that reductions in early delivery are achievable; implementation of best practice guidelines for obstetrical interventions and public health policies targeting population risk factors could contribute to prevention of both late preterm and early term births.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NLZOH, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UILJ, UL, UM, UPUK, ZAGLJ, ZRSKP
Background For every maternal death, >100 women experience severe maternal morbidity, which is a life-threatening diagnosis, or undergo a life-saving procedure during their delivery hospitalization. ...Similar to racial/ethnic disparities in maternal death, black women are more likely to experience severe maternal morbidity than white women. Site of care has received attention as a mechanism to explain disparities in other areas of medicine. Data indicate that black women receive care in a concentrated set of hospitals and that these hospitals appear to provide lower quality of care. Whether racial differences in the site of delivery contribute to observed black-white disparities in severe maternal morbidity rates is unknown. Objective The purpose of this study was to determine whether hospitals with high proportions of black deliveries have higher severe maternal morbidity and whether such differences contribute to overall black-white disparities in severe maternal morbidity. Study Design We used a published algorithm to identify cases of severe maternal morbidity during deliveries in the Nationwide Inpatient Sample of the Healthcare Cost and Utilization Project for 2010 and 2011. We ranked hospitals by their proportion of black deliveries into high black-serving (top 5%), medium black-serving (5% to 25% range), and low black-serving hospitals. We analyzed the risks of severe maternal morbidity for black and white women by hospital black-serving status using logistic regressions that were adjusted for patient characteristics, comorbidities, hospital characteristics, and within-hospital clustering. We then derived adjusted rates from these models. Results Seventy-four percent of black deliveries occurred at high and medium black-serving hospitals. Overall, severe maternal morbidity occurred more frequently among black than white women (25.8 vs 11.8 per 1000 deliveries, respectively; P < .001); after adjustment for the distribution of patient characteristics and comorbidities, this differential declined but remained elevated (18.8 vs 13.3 per 1000 deliveries, respectively; P < .001). Women who delivered in high and medium black-serving hospitals had elevated rates of severe maternal morbidity rates compared with those in low black-serving hospitals in unadjusted (29.4 and 19.4 vs 12.2 per 1000 deliveries, respectively; P < .001) and adjusted analyses (17.3 and 16.5 vs 13.5 per 1000 deliveries, respectively; P < .001). Black women who delivered at high black-serving hospitals had the highest risk of poor outcomes. Conclusion Most black deliveries occur in a concentrated set of hospitals, and these hospitals have higher severe maternal morbidity rates. Targeting quality improvement efforts at these hospitals may improve care for all deliveries and disproportionately impact care for black women.
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In countries with comparable levels of development and healthcare systems, preterm birth rates vary markedly--a range from 5 to 10% among live births in Europe. This review seeks to identify the most ...likely sources of heterogeneity in preterm birth rates, which could explain differences between European countries.
Multiple risk factors impact on preterm birth. Recent studies reported on measurement issues, population characteristics, reproductive health policies as well as medical practices, including those related to subfertility treatments and indicated deliveries, which affect preterm birth rates and trends in high-income countries. We showed wide variation in population characteristics, including multiple pregnancies, maternal age, BMI, smoking, and percentage of migrants in European countries.
Many potentially modifiable population factors (BMI, smoking, and environmental exposures) as well as health system factors (practices related to indicated preterm deliveries) play a role in determining preterm birth risk. More knowledge about how these factors contribute to low and stable preterm birth rates in some countries is needed for shaping future policy. It is also important to clarify the potential contribution of artifactual differences owing to measurement.
Stillbirths: ending preventable deaths by 2030 de Bernis, Luc, Dr; Kinney, Mary V, MSc; Stones, William, Prof ...
The Lancet (British edition),
02/2016, Volume:
387, Issue:
10019
Journal Article
Peer reviewed
Open access
Summary Efforts to achieve the new worldwide goals for maternal and child survival will also prevent stillbirth and improve health and developmental outcomes. However, the number of annual ...stillbirths remains unchanged since 2011 and is unacceptably high: an estimated 2·6 million in 2015. Failure to consistently include global targets or indicators for stillbirth in post-2015 initiatives shows that stillbirths are hidden in the worldwide agenda. This Series paper summarises findings from previous papers in this Series, presents new analyses, and proposes specific criteria for successful integration of stillbirths into post-2015 initiatives for women's and children's health. Five priority areas to change the stillbirth trend include intentional leadership; increased voice, especially of women; implementation of integrated interventions with commensurate investment; indicators to measure effect of interventions and especially to monitor progress; and investigation into crucial knowledge gaps. The post-2015 agenda represents opportunities for all stakeholders to act together to end all preventable deaths, including stillbirths.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK, ZRSKP
Objective To investigate the association between body temperature at admission to neonatal intensive care and in-hospital mortality in very preterm infants, stratified by postnatal age of death. ...Moreover, we assessed the association between admission temperature and neonatal morbidity. Study design In this cohort study from 19 regions in 11 European countries, we measured body temperature at admission for infants admitted for neonatal care after very preterm birth (<32 weeks of gestation; n = 5697) who were followed to discharge or death. Associations between body temperature at admission and in-hospital mortality and neonatal morbidity were analyzed by the use of mixed effects generalized linear models. The final model adjusted for pregnancy complications, singleton or multiple pregnancy, antenatal corticosteroids, mode of delivery, gestational age, infant size and sex, and Apgar score <7 at 5 minutes. Results A total of 53.4% of the cohort had a body temperature at admission less than 36.5°C, and 12.9% below 35.5°C. In the adjusted model, an admission temperature <35.5°C was associated with increased mortality at postnatal ages 1-6 days, (risk ratio 2.41; 95% CI 1.45-4.00), and 7-28 days (risk ratio 1.79; 1.15-2.78) but not after 28 days of age. We found no associations between admission temperature and neonatal morbidity. Conclusion Admission hypothermia after very preterm birth is a significant problem in Europe, associated with an increased risk of early and late neonatal death.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK, ZRSKP
IMPORTANCE: In an effort to improve the quality of care, several obstetric-specific quality measures are now monitored and publicly reported. The extent to which these measures are associated with ...maternal and neonatal morbidity is not known. OBJECTIVE: To examine whether 2 Joint Commission obstetric quality indicators are associated with maternal and neonatal morbidity. DESIGN, SETTING, AND PARTICIPANTS: Population-based observational study using linked New York City discharge and birth certificate data sets from 2010. All delivery hospitalizations were identified and 2 perinatal quality measures were calculated (elective, nonmedically indicated deliveries at 37 or more weeks of gestation and before 39 weeks of gestation; cesarean delivery performed in low-risk mothers). Published algorithms were used to identify severe maternal morbidity (delivery associated with a life-threatening complication or performance of a lifesaving procedure) and morbidity in term newborns without anomalies (births associated with complications such as birth trauma, hypoxia, and prolonged length of stay). Mixed-effects logistic regression models were used to examine the association between maternal morbidity, neonatal morbidity, and hospital-level quality measures while risk-adjusting for patient sociodemographic and clinical characteristics. MAIN OUTCOMES AND MEASURES: Individual- and hospital-level maternal and neonatal morbidity. RESULTS: Severe maternal morbidity occurred among 2372 of 115 742 deliveries (2.4%), and neonatal morbidity occurred among 8057 of 103 416 term newborns without anomalies (7.8%). Rates for elective deliveries performed before 39 weeks of gestation ranged from 15.5 to 41.9 per 100 deliveries among 41 hospitals. There were 11.7 to 39.3 cesarean deliveries per 100 deliveries performed in low-risk mothers. Maternal morbidity ranged from 0.9 to 5.7 mothers with complications per 100 deliveries and neonatal morbidity from 3.1 to 21.3 neonates with complications per 100 births. The maternal quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers were not associated with severe maternal complications (risk ratio RR, 1.00 95% CI, 0.98-1.02 and RR, 0.99 95% CI, 0.96-1.01, respectively) or neonatal morbidity (RR, 0.99 95% CI, 0.97-1.01 and RR, 1.01 95% CI, 0.99-1.03, respectively). CONCLUSIONS AND RELEVANCE: Rates for the quality indicators elective delivery before 39 weeks of gestation and cesarean delivery performed in low-risk mothers varied widely in New York City hospitals, as did rates of maternal and neonatal complications. However, there were no correlations between the quality indicator rates and maternal and neonatal morbidity. Current quality indicators may not be sufficiently comprehensive for guiding quality improvement in obstetric care.
Quality of Care and Disparities in Obstetrics Howell, Elizabeth A; Zeitlin, Jennifer
Obstetrics and gynecology clinics of North America,
03/2017, Volume:
44, Issue:
1
Journal Article
Peer reviewed
Open access
Growing attention is being paid to obstetric quality of care as patients are pressing the health care system to measure and improve quality. There is also an increasing recognition of persistent ...racial and ethnic disparities prevalent in obstetric outcomes. Yet few studies have linked obstetric quality of care with racial and ethnic disparities. This article reviews definitions of quality of care, health disparities, and health equity as they relate to obstetric care and outcomes; describes current efforts and challenges in obstetric quality measurement; and proposes 3 steps in an effort to develop, track, and improve quality and reduce disparities in obstetrics.
Stillbirth and in-hospital mortality rates associated with very preterm births (VPT) vary widely across Europe. International comparisons are complicated by a lack of standardized data collection and ...differences in definitions, registration, and reporting. This study aims to determine what proportion of the variation in stillbirth and in-hospital VPT mortality rates persists after adjusting for population demographics, case-mix, and timing of death.
Standardized data collection for a geographically defined prospective cohort of VPTs (22
-31
weeks gestation) across 16 regions in Europe. Crude and adjusted stillbirth and in-hospital mortality rates for VPT infants were calculated by time of death by using multinomial logistic regression models.
The stillbirth and in-hospital mortality rate for VPTs was 27.7% (range, 19.9%-35.9% by region). Adjusting for maternal and pregnancy characteristics had little impact on the variation. The addition of infant characteristics reduced the variation of mortality rates by approximately one-fifth (4.8% to 3.9%). The SD for deaths <12 hours after birth was reduced by one-quarter, but did not change after risk adjustment for deaths ≥12 hours after birth.
In terms of the regional variation in overall VPT mortality, over four-fifths of the variation could not be accounted for by maternal, pregnancy, and infant characteristics. Investigation of the timing of death showed that these characteristics only accounted for a small proportion of the variation in VPT deaths. These findings suggest that there may be an inequity in the quality of care provision and treatment of VPT infants across Europe.
Objective To assess the impact of being small for gestational age (SGA) on very preterm mortality and morbidity rates by using different birthweight percentile thresholds and whether these effects ...differ by the cause of the preterm birth. Study design The study included singletons and twins alive at onset of labor between 24 and 31 weeks of gestation without congenital anomalies from the Models of Organising Access to Intensive Care for very preterm births very preterm cohort in 10 European regions in 2003 (n = 4525). Outcomes were mortality, intraventricular hemorrhage grade III and IV, cystic periventricular leukomalacia, and bronchopulmonary dysplasia (BPD). Birthweight percentiles in 6 classes were analyzed by pregnancy complication. Results The mortality rate was higher for infants with birthweights <25th percentile when compared with the 50th to 74th percentile (adjusted odds ratio, 3.98 95% CI, 2.79-5.67 for <10th; adjusted odds ratio, 2.15 95% CI, 1.54-3.00 for 10th-24th). BPD declined continuously with increasing birthweight. There was no association for periventricular leukomalacia or intraventricular hemorrhage. Seventy-five percent of infants with birthweights <10th percentile were from pregnancies complicated by hypertension or indicated deliveries associated with growth restriction. However, stratifying for pregnancy complications yielded similar risk patterns. Conclusions A 25th percentile cutoff point was a means of identifying infants at higher risk of death and a continuous measure better described risks of BPD. Lower birthweights were associated with poor outcomes regardless of pregnancy complications.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPUK
Background Fetal growth restriction is defined using ultrasound parameters during pregnancy or as a low birthweight for gestational age after birth, but these definitions are not always concordant. ...Objective The purpose of this study was to investigate fetal and neonatal outcomes based on antenatal vs postnatal assessments of growth restriction. Study Design From the EPIPAGE 2 population-based prospective study of very preterm births in France in 2011, we included 2919 singleton nonanomalous infants 24–31 weeks gestational age. We constituted 4 groups based on whether the infant was suspected with fetal growth restriction during pregnancy and/or was small for gestational age with a birthweight <10th percentile of intrauterine norms by sex: 1) suspected with fetal growth restriction/small for gestational age 2) not suspected with fetal growth restriction/small for gestational age 3) suspected with fetal growth restriction/not small for gestational age and 4) not suspected with fetal growth restriction/not small for gestational age. We estimated relative risks of perinatal mortality and morbidity for these groups adjusting for maternal and neonatal characteristics. Results We found that 22.2% of infants were suspected with fetal growth restriction/small for gestational age, that 11.4% infants were not suspected with fetal growth restriction/small for gestational age, that 3.0% infants were suspected with fetal growth restriction/not small for gestational age, and that 63.4% infants were not suspected with fetal growth restriction/not small for gestational age. Compared with infants who were not suspected with fetal growth restriction/not small-for-gestational-age infants, small-for-gestational-age infants suspected and not suspected with fetal growth restriction had higher risks of stillbirth or termination of pregnancy (adjusted relative risk, 2.0 95% confidence interval, 1.6–2.5 and adjusted relative risk, 2.8 95% confidence interval, 2.2–3.4, respectively), in-hospital death (adjusted relative risk, 2.8 95% confidence interval, 2.0–3.7 and adjusted relative risk, 2.0 95% confidence interval, 1.5–2.8, respectively), and bronchopulmonary dysplasia (adjusted relative risk, 1.3 95% confidence interval, 1.2–1.4 and adjusted relative risk, 1.3 95% confidence interval, 1.1–1.4, respectively), but not severe brain lesions. Risks were not increased for infants suspected with fetal growth restriction but not small-for-gestational-age. Conclusion Antenatal and postnatal assessments of fetal growth restriction were not concordant for 14% of very preterm infants. In these cases, birthweight appears to be the more relevant parameter for the identification of infants with higher risks of adverse short-term outcomes.
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GEOZS, IJS, IMTLJ, KILJ, KISLJ, NUK, OILJ, PNG, SAZU, SBCE, SBJE, UL, UM, UPCLJ, UPUK, ZRSKP
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