6: Can differences in obstetric outcomes be explained by differences in the care provided?

Abstract

6 Can differences in obstetric outcomes be explained by differences in the care provided? William Grobman For the Eunice Kennedy Shriver National Institute of Health and Human Development, Maternal-Fetal Units Network, Bethesda, MD OBJECTIVE: Although many obstetric outcomes have been suggested as quality indicators, there is little direct evidence that institutional differences in these indicators are related to differences in the care provided. The objective of this study was to determine whether variation in the frequency of potential quality indicators could be related to differences in care. STUDY DESIGN: Data were obtained by trained abstractors, with ongoing data edits and audits, from all deliveries on 365 randomly selected days at 25 hospitals over a three-year period. Four outcome measures, selected a priori and rigorously defined, were chosen as potential quality indicators: severe postpartum hemorrhage (PPH), maternal peripartum infection (INF), perineal trauma (3rd or 4th degree laceration) at SVD (LAC), and a composite adverse neonatal outcome (NEO). Because the frequency of outcomes may be related to other patient, physician (e.g. years of experience), and institutional (e.g. in-house obstetrician 24 hours daily) factors, these characteristics were assessed for their associations with the above outcomes of interest through the use of hierarchical logistic regression, which was used to account for potential confounding and clustering of observations. Selected care processes were then placed into the model to assess whether these were independently associated with the outcomes. RESULTS: Data were collected on 115,502 women. After adjustment for patient, physician, and institutional characteristics, differential use of labor induction, cesarean delivery, and episiotomy, were associated with the outcomes of interest (Table). CONCLUSION: After controlling for differences in patients, physicians, and institutional factors, several care processes were found to be associated with variation in predefined adverse outcomes. These associations support the use of these outcomes as quality indicators, and also may suggest process measures that also are reasonable to use as quality indicators. 7 ROLO study: a randomized control trial of low glycemic index diet to prevent macrosomia in euglycemic women Jennifer Walsh, Rhona Mahony, Michael Foley, Fionnuala McAuliffe UCD Obstetrics and Gynaecology, School of Medicine and Medical Science, Dublin, Ireland OBJECTIVE: The macrosomic fetus is predisposed to a variety of adverse obstetric and neonatal outcomes, and significantly increases the risk of birth complications for the mother. In the long term, infants that are at the highest end of the distribution for weight are more likely to be obese in childhood. Eating primarily a high glycaemic carbohydrate diet can result in feto-placental overgrowth, excessive maternal weight gain and fetal macrosomia. Our hypothesis was that altering the source of maternal dietary carbohydrate could prevent macrosomia in euglycemic women. STUDY DESIGN: This is a randomised control intervention trial of 720 secundigravid women whose first baby was macrosomic (birth weight 4.0 Kg). Women were randomized to receive either no dietary intervention or a low glycemic index (GI) diet from early pregnancy. Those with pre-existing or previous gestational diabetes were excluded. The low GI group attended a small group dietetic session at 14-18 weeks’ gestation and continued the diet until term with written information and regular re-enforcement. The primary endpoint of the study was the difference in birth weight. Secondary outcomes included gestational weight gain and the development of glucose intolerance. RESULTS: There was no difference between the control and intervention groups in birthweight, customized birthweight centile or birthweight z-score. Fetal macrosomia recurred in 51% (n 184) of the intervention group and in 52 % (n 187) of controls. Women in the low GI group had significantly less gestational weight gain than those without any dietary intervention. (12.2kg vs 13.6kg p 0.01). The incidence of glucose intolerance was also significantly less in the low GI arm with 16.7% having a glucose challenge test result of 7.8 mmol/L compared with 23.4% of controls (p 0.04). CONCLUSION: Infant birthweight is a complex interplay of environmental and genetic factors. Despite a significant reduction in maternal gestational weight gain and glucose intolerance, a low GI diet in pregnancy has no effect on infant birthweight.