Quality Of Perinatal Care Research Articles

Promoting antenatal steroid use for fetal maturation: Results from the California Perinatal Quality Care Collaborative

The California Perinatal Quality Care Collaborative (CPQCC) was formed to seek perinatal care improvements by creating a confidential multi-institutional database to identify topics for quality improvement (QI). We aimed to evaluate this approach by assessing antenatal steroid administration before preterm (24 to 33 weeks of gestation) delivery. We hypothesized that mean performance would improve and the number of centers performing below the lowest quartile of the baseline year would decrease. In 1998, a statewide QI cycle targeting antenatal steroid use was announced, calling for the evaluation of the 1998 baseline data, dissemination of recommended interventions using member-developed educational materials, and presentations to California neonatologists in 1999-2000. Postintervention data were assessed for the year 2001 and publicly released in 2003. A total of 25 centers voluntarily participated in the intervention. Antenatal steroid administration rate increased from 76% of 1524 infants in 1998 to 86% of 1475 infants in 2001 (P < .001). In 2001, 23 of 25 hospitals exceeded the 1998 lower-quartile cutoff point of 69.3%. Regional collaborations represent an effective strategy for improving the quality of perinatal care.

Mozambican Midwives' Views on Barriers to Quality Perinatal Care

Our purpose in this study was to explore the midwives' perception of factors obstructing or facilitating their ability to provide quality perinatal care at a central labor ward in Maputo. In-depth interviews were undertaken with 16 midwives and were analyzed according to grounded theory technique. Barriers to provision of quality perinatal care were identified as follows: (i) the unsupportive environment, (ii) nonempowering and limited interaction with women in labor, (iii) a sense of professional inadequacy and inferiority, and (iv) nonappliance of best caring practices. A model based on the midwives' reflections on barriers to quality perinatal care and responses to these were developed. Actions aimed at overcoming the barriers were improvising and identifying areas in need of change. Identified evading actions were holding others accountable and yielding to dysfunction and structural control. In order to improve perinatal care, the midwives need to see themselves as change agents and not as victims of external and internal causal relationships over which they have no influence. It is moreover essential that the midwives chose actions aiming at overcoming barriers to quality perinatal care instead of choosing evading actions, which might jeopardize the health of the unborn and newborn infant. We suggest that local as well as national education programs need to correspond with existing reality, even if they provide knowledge that surpasses the present possibilities in practice. Quality of intrapartum and the immediate newborn care requires a supportive environment, however, which in the context of this study presented such serious obstacles that they need to be addressed on the national level. Structural and administrative changes are difficult to target as these depend on national organization of maternal health care (MHC) services and national health expenditures.

Size of delivery unit and neonatal outcome in Sweden. A catchment area analysis

Quality of perinatal care was evaluated in relation to size of delivery unit and size of catchment area for deliveries. Neonatal outcome, measured as neonatal mortality, low Apgar scores at 5 min, and the occurrence of respiratory disorders and cerebral palsy was analyzed during a 15-year period from 1985 to 1999 inclusive. Figures were derived from the Swedish Medical Birth Registry and the Hospital Discharge Registry. Odds ratios were estimated for the different outcomes in relation to size of delivery unit (actual and estimated number of births) and the provision of a pediatric department at the hospital. Seven possible confounders were considered: year of birth, maternal age, parity, smoking during pregnancy, gestational age, parental cohabitation, and maternal body mass index. Neonatal mortality was significantly higher for infants in families living within the catchment area of the smallest units without a pediatric department. Small differences in the occurrence of respiratory disturbances and Apgar scores are probably due to diagnostic differences. There were no differences in the incidence of cerebral palsy. Neonatal mortality continued to decrease during the observation period. Differences were minor, pointing to a fairly homogeneous quality of perinatal care and an efficient referral system for risk pregnancies. Mortality continues to decrease in spite of a reduction in the number of units caring for deliveries.

Comparação da mortalidade neonatal em recém-nascidos de muito baixo peso ao nascimento, em maternidades do Município do Rio de Janeiro, Brasil

This study was a comparison of neonatal mortality rates in four maternity hospitals in the city of Rio de Janeiro, Brazil. The study population consisted of newborns with birth weight below 1,500 g. The research instrument was a questionnaire with data reported by the mother and collected from the patient record. For each maternity hospital the standardized mortality ratio (SMR) was calculated using the direct and indirect method, using the weight distribution of the National Institute of Child Health and Human Development Neonatal Research as the standard. The final sample consisted of 487 newborns. Standardizations by the direct and indirect method showed high mortality rates in all four institutions; those showing the largest number of newborns in the lowest weight brackets were those with the lowest SMR values. The lowest mortality ratio by weight bracket was in the 500 to 749 g group. The SMR results were inversely associated with the quantitative population of newborns in the lowest weight brackets. The mortality coefficients showed high rates, especially in the highest weight brackets. The results indicate deficient quality of perinatal care.

Risks of Stillbirth and Early Neonatal Death by Day of Week

Unless labor is timed for high-risk pregnancies or there are differences in the quality of perinatal care, births on different days of the week should have similar outcomes. Not many such studies have been done, but all of them point to a higher risk of stillbirth and/or early neonatal death for infants born on weekend days rather than on weekdays. The investigators, using a Canadian database of 3,239,972 births taking place in the years 1985 through 1998, sought associations between these outcomes and the day of the week at birth. These women represented all births recorded in Canada during the period under review except for Ontario. Births were 24% less frequent on weekend days than during the week. Stillbirth rates were lowest on Mondays and highest on Saturdays. Neonatal deaths were considerably more frequent among infants born on Saturdays and Sundays (Fig. 1), particularly those caused by asphyxia. These patterns were consistent throughout the review period. Cause-specific excess risks for stillbirth varied widely. Stillbirths resulting from congenital anomalies were much less frequent on weekend days than on weekdays. Cause-specific excess risks for early neonatal death also varied widely, ranging from +28% for asphyxia and immaturity to -3% for congenital anomalies. On logistic regression analysis, controlling for completed weeks of gestational age, there was no apparent excess risk of either stillbirth or early neonatal death on weekends. For preterm infants, the gestational age-specific risks of early neonatal death were similar or slightly lower for infants born on weekend days. Any excess risk of stillbirth or early neonatal death on weekend days in this Canadian study was much smaller than has been reported from other countries. The present findings suggest that, in Canada, accessibility to quality obstetric and neonatal care is maintained on weekends.

Responding to variations in mortality due to intrapartum asphyxia

The mortality rate due to intrapartum asphyxia is generally considered a good guide to the quality of perinatal care. Using a routine system of surveillance, we identified a six‐fold difference in mortality rate due to intrapartum asphyxia depending on the hospital of birth, with the lowest rate (95 per cent confidence intervals) of 0.25 (0.10, 0.64)/1,000 births and the highest rate of 1.59 (0.77, 3.27)/1,000 births. A framework of internal and external reviews of the clinical services was developed, that is able to tackle such clinical governance issues in a robust but sensitive manner. The outcome included specific improvements in service provision. The model is generally applicable and is thus suitable for use wherever such clinical governance issues are identified.

Infant mortality and low birth weight in cities of Northeastern and Southeastern Brazil.

To compare estimates of low birth weight (LBW), preterm birth, small for gestational age (SGA), and infant mortality in two birth cohorts in Brazil. The two cohorts were performed during the 1990s, in S o Lu s, located in a less developed area in Northeastern Brazil, and Ribeir o Preto, situated in a more developed region in Southeastern Brazil. Data from one-third of all live births in Ribeir o Preto in 1994 were collected (2,839 single deliveries). In S o Lu s, systematic sampling of deliveries stratified by maternity hospital was performed from 1997 to 1998 (2,439 single deliveries). The chi-squared (for categories and trends) and Student t tests were used in the statistical analyses. The LBW rate was lower in S o Lu s, thus presenting an epidemiological paradox. The preterm birth rates were similar, although expected to be higher in Ribeir o Preto because of the direct relationship between preterm birth and LBW. Dissociation between LBW and infant mortality was observed, since S o Lu s showed a lower LBW rate and higher infant mortality, while the opposite occurred in Ribeir o Preto. Higher prevalence of maternal smoking and better access to and quality of perinatal care, thereby leading to earlier medical interventions (cesarean section and induced preterm births) that resulted in more low weight live births than stillbirths in Ribeir o Preto, may explain these paradoxes. The ecological dissociation observed between LBW and infant mortality indicates that the LBW rate should no longer be systematically considered as an indicator of social development.

Neonatal mortality in weekend vs weekday births.

Increases in neonatal mortality for infants born on the weekend were last noted several decades ago. Although the current health care environment has raised concern about the adequacy of weekend care, there have been no contemporary evaluations of daily patterns of births, obstetric intervention, and case mix-adjusted neonatal mortality. To compare the neonatal mortality of infants born on weekdays and weekends. Case series of 1 615 041 live births (weight >or=500 g) in California between 1995-1997 to determine patterns of births, cesarean deliveries, and neonatal deaths. Analyses were stratified by birth weight and delivery method. To assess the role of weekend differences in case mix, observed and birth weight-adjusted odds ratios (ORs) for increased weekend mortality were estimated using logistic regression. Birth weight-adjusted neonatal mortality. There was a 17.5% decrease in births on weekends, accompanied by a decrease in the proportion of cesarean deliveries from 22% on weekdays to 16% on weekends. Weekend decreases in births were least pronounced in smaller infants, resulting in a weekend concentration of high-mortality, very low-birth-weight (<1500 g) births. Observed neonatal mortality increased from 2.80 per 1000 weekday births to 3.12 per 1000 weekend births (OR, 1.12; 95% confidence interval [CI], 1.05-1.19; P =.001) for all births, and from 4.94 to 6.85 (OR, 1.39; 95% CI, 1.25-1.55; P<.001) for cesarean deliveries. After adjusting for birth weight, the increased odds of death for infants born on the weekend were no longer significant. The provision of optimal care regardless of the day of week is an important goal for perinatal medicine. Comparing the neonatal mortality of infants born on weekdays and weekends provides a straightforward assessment of this goal. After controlling for birth weight, we found no evidence that the quality of perinatal care in California was compromised during the weekend.

Suboptimal care and perinatal mortality in ten European regions: methodology and evaluation of an international audit

Background: A European concerted action (the EuroNatal study) investigated differences in perinatal mortality between countries of Europe. This report describes the methods used in the EuroNatalinternational audit and discusses the validity of the results.Methods: Perinatal deaths between 1993 and 1998 in regions of ten European countries were identified. The categories of death chosenfor the study were singleton fetal deaths at 28 or more weeks of gestational age, all intrapartum deaths at 28 or more weeks of gestational age and neonatal deaths at 34 or more weeks of gestational age.Deaths with major congenital anomalies were excluded. An international audit panel used explicit criteria to review all cases, which were blinded for region. Subjective interpretation was used in casesof events or interventions where explicit criteria did not exist. Suboptimal factors were identified in the antenatal, intrapartum and neonatal periods, and classified as 'maternal/social', due to 'infrastructure/serviceorganization', or due to 'professional care delivery'. The contribution of each suboptimal factor to the fatal outcome was listed and consensus was reached on a final grade using a procedure that includedcorrespondence and plenary meetings.Results: In all regions combined, 90% of all known or estimated cases in the selected categories were included in the audit. In total, 1619 cases of perinataldeath were audited. Consensus was reached in 1543 (95%) cases. In 75% of all cases, the grade was based on explicit criteria. In the remaining cases, consensus was reached within subpanels without referenceto predefined criteria. There was reasonable to good agreement between and within subpanels, and within panel members.Conclusions: The international audit procedure proved feasible and led toconsistent results. The results that relate to suboptimal care will need to be studied in depth in order to reach conclusions about their implications for assessing the quality of perinatal care in theindividual regions.

Fundamental classification of perinatal death: Validation of a new classification system of perinatal death

Objective: To validate a newly introduced classification system for the registration of perinatal mortality. Design: Descriptive. Setting: Dutch Healthcare region Delft-Westland-Oostland (DWO). Material and methods: In a 10-years period (1983–1992), all cases of perinatal death with a birthweight above 500 g ( n=239) were included into the study. Six assessors: four gynaecologists and two paediatricians were asked to classify all cases using a classification model proposed by the authors. This model is based on the underlying cause of death using simple principles of obstetrical and neonatal pathology: birth trauma, infection, placenta or cord pathology, pathology of immune tolerance of mother and fetus, congenital malformation of the fetus and complications of a pre-viable delivery. Therefore, we used the term fundamental classification. The six assessors worked independently of each other in classifying all cases of perinatal death, were not involved in the original development of the system and were unaware of the results of the classification of their colleagues. Agreement beyond chance between assessors was calculated using kappa’s coefficient for multiple observers and multiple test results. Results: Overall kappa was 0.70 (95% confidence interval (C.I.) 0.68–0.72). Reproducibility was poor for the categories trauma and unclassifiable, fair for the categories infections and placental/cord pathology, and very good to excellent for the categories maternal immune system pathology, congenital malformations and complications of prematurity. Conclusions: The proposed system showed a good level of agreement and appeared to be simply applicable. It offers a good insight in the underlying cause of death with the possibility for recognising preventive factors in future pregnancies and will enable (inter)national comparisons in causes of perinatal death. A reliable uniform registration of perinatal death based on the underlying causes should be the basis for improvement of the quality of perinatal care.

Does perinatal mortality reflect the quality of perinatal care? Trends based on the Hessian perinatal survey

Mit den Daten der HEPE der Jahre 1990–1999 sollen die wesentlichen Entwicklungen der neonatalen Mortalitat und Morbiditat analysiert werden. Durch die Anderung des Personenstandsgesetzes 1994 schien die perinatale Mortalitat anzusteigen, insgesamt lasst sich jedoch eine rucklaufige Tendenz erkennen. Die Gruppe der sehr kleinen Fruhgeborenen spielt an der gesamten perinatalen Mortalitat und Morbiditat eine entscheidende Rolle. Die Analysen von zerebraler und pulmonaler Morbiditat sind als wesentliche prognostische Erkrankungen von hohem Interesse. Besonders die Zunahme des Anteils der Kinder <750 g bewirkt eine nahezu gleichbleibende Haufigkeit z. B. der IVH. Restriktiveres Beatmungsregime und Zunahme der pranatalen Kortikosteroide resultiert in einer rucklaufigen Rate maschineller Beatmung und BPD.

Neonatal and postneonatal mortality in Germany since unification

BACKGROUNDAfter unification, the gap in infant mortality rates between the two parts of Germany widened until 1996 before converging. The reasons for these changes have not, so far, been apparent.OBJECTIVESTo...

Quince años de mortalidad neonatal en un hospital de la Región Metropolitana

The neonatal mortality rate reflects the standard of living and quality of perinatal care. Neonatal mortality was analysed in the San Juan de Dios Hospital, Santiago, Chile, during a 15 year period from 1983 to 1997. During the study period 108,374 live infants were born, of them 1,190 have died. The neonatal mortality rate has significantly decreased from 15.3 in 1983 to 6.9 per 1000 live newborn infants in 1997. This decrease has been observed for each 500 g subgroup, mainly in babies between 1,000 and 1.499 g. Deaths occurred in 21% in the first hour and in 52% in the first day of life. Leading causes of death have been classified into major pathological subgroups, based on the suggestions of Wigglesworth et al. The most frequent causes of death were conditions associated with prematurity (45%), congenital malformations (21%), infections (17%), perinatal hypoxia (13%) and miscellaneous (4%). The overall and specific birth weight neonatal mortality rate have decreased due to several factors such as resident neonatologist since 1983, availability of single-use disposible materials available since 1990 and exogenous surfactant available in 1991 and 1994.

Using Employer Purchasing Power to Improve the Quality of Perinatal Care

Large employers have become increasingly involved in helping to set the agenda for quality measurement and improvement. Moreover, they are beginning to hold health care organizations accountable for their performance through marketplace incentives, including the public reporting of comparative quality data and the linkage of reimbursement to performance on quality measures. The Pacific Business Group on Health (PBGH) is an employer coalition that has been prominent in establishing models for collaborative quality measurement and improvement in the California marketplace. PBGH's involvement in quality stems from an environment in which purchasers were faced with high health care costs, yet virtually no information with which to assess the value their employees received from that care. Research indicating widespread variation in performance across health care organizations and seemingly limited oversight for quality of care within the industry has further motivated purchasers' efforts to better understand the quality of care being delivered to their em-ployees. Using the purchasing power of employers representing 2.5-million covered lives, PBGH endeavors to encourage the transition of the health care marketplace from one that competes solely on price to one that competes on price and quality. This entails collaborating with the health care industry to develop and publicly report valid performance data for use by both large employers and consumers of health care services. It also includes communicating to the marketplace purchasers' commitment to making purchasing decisions based on quality as well as cost. PBGH efforts to measure, report, and improve quality have been demonstrated by several undertakings in the perinatal care arena, including research to assess cesarean section rates and newborn readmission rates across California hospitals.employer coalition, purchaser, quality measurement, quality improvement, report cards, perinatal quality of care.

Monitoring systems to evaluate the quality of perinatal care.

Monitoring perinatal services is a complex and multifaceted matter. Case by case review has an immediate appeal because of the potential to identify simple clinical messages for practitioners, but interpretation is less straightforward than it might seem. Other non-experimental evaluations of perinatal care need to find ways of taking into account differences between hospitals, other than quality of care, which significantly influence outcome. These evaluations can be combined with the provision of information back to hospitals themselves from central health agencies. In addition to approaches using vital statistics and routinely collected data intermittent surveys of satisfaction with maternity care and preferences for care provide complementary information. The combination of several methods of monitoring perinatal services should enable hospitals and health planning agencies to work more effectively towards their shared goals.

Comparing hospital perinatal mortality rates: a quality improvement instrument.

This article describes the development of a reliable measurement instrument for the quality of perinatal care. The Hospital Perinatal Mortality Comparison (HPMC) predicts the expected perinatal mortality for individual hospitals, based on the perinatal mortality experienced in a group of similar newborns in a large reference population. Out of the 76 hospitals analyzed in 1990, 2 performed significantly better and 5 performed significantly worse than expected according to the logistic regression model. These results may lead to the identification of opportunities for improving the process of medical care in these hospitals.

Children and pregnant women.

A review of the literature of the 1980s reveals that women living in rural American are at risk for receiving inadequate prenatal and maternal care. Documented risk factors include poverty and concomitant lack of medical insurance, residence in the most restrictive Medicaid states, and loss of local services including the closure of obstetric units of rural hospitals and the decision by local physicians to discontinue obstetrics. A prominent factor in a physician's decision to stop providing maternity care is the escalating cost of medical liability insurance; however, other forces are also at work, including interference with personal and family activities, disruption of other aspects of professional life (e.g., office schedule), inadequate reimbursement, and an inability to keep up with advancing technology. A research agenda for the 1990s should be consistent with previous recommendations and must stimulate the development of new programs that will induce the maximum number of providers to again offer high quality perinatal care to rural women. Other items on the 1990s research agenda include: (1) the clarification of the impact of lost perinatal services in rural areas, (2) the effects of travel time and distance on perinatal outcomes and cost of care, (3) the effect of loss of obstetric services on other health care services for women and children, and (4) comparisons of regionalized versus centralized systems for the provision of perinatal services.

A longitudinal Study Comparing the Prenatal Care of Puerto Rican and White Woman

This study examined the effect of ethnicity on health-seeking attitudes and behavior, including patient compliance, use of the clinic, knowledge of childbirth, and the relationship between the patient and primary health care provider. Anthropologic techniques of observations and interviews were conducted longitudinally with 27 Puerto Rican women and 26 white women who received perinatal care at a tertiary-level hospital throughout the antepartum, intrapartum, and postpartum periods. Approximately 500 standardized and open-ended interviews and 150 observations of clinical interactions with resident physicians and nurse-midwives compared reproductive knowledge, beliefs, and practices. Results of this three-year study indicated that both groups of women were similar in age, years of education, and percentage receiving financial assistance. Puerto Rican women identified strongly as a separate ethnic group; all spoke Spanish and most were bilingual. Office visits and explanations from primary care providers were more important to women in both groups than information obtained from families, friends, or folk beliefs. Knowledge of pregnancy care procedures and childbirth, although limited, was no different between the groups. Long waits, depersonalized service, and a lack of continuity of care adversely affected patient and physician satisfaction and diminished effective doctor-patient interactions. This study suggests that differences in ethnic background do not necessarily adversely affect the delivery of reproductive health care. Indigent white and Puerto Rican women wanted the same thing: quality perinatal care and education.

A subsidized perinatal care program in a rural Colorado county.

A large number of medically indigent women in rural areas currently receive little or no prenatal care, raising major concerns regarding perinatal health. In Colorado, subsidized prenatal and labor/delivery programs have been instituted to address this problem. This article describes the implementation of two programs in one rural county. In these rural programs, private physicians, health department personnel, and social work staff at the local hospital collaborate to provide financial assistance, comprehensive health education, and quality medical care for eligible pregnant women. The identified benefits and barriers unique to the provision of quality perinatal care in rural settings are discussed.

42 IMPACT OF A DECLINING LOW BIRTHWEIGHT RATE ON PERINATAL MORTALITY AND INCIDENCE OF CEREBRAL PALSY

In infants 500 g or more born in a Norwegian County (Vestfold) 1970-84 (n= 34756), a significantly declining incidence of low birthweight (500-2499 g) occurred, from 5% 1970-79 to 4.1% 1980-84 (p < 0.01). The decline was stronger for infants 500-1499 g than for infants 1500-2499 g (31% vs. 13%; p < 0.01). Perinatal mortality decreased from 17 to 10.3 ‰ (p < 0.01), and the incidence of cerebral palsy (CP) from 2.8 to 1.7 ‰ (p = 0.07). Low birthweight infants were at increased risk for perinatal death and CP. Thus, 38% of the decline in perinatal mortality and 18.2% of the reduction of CP were attributable to the decline in low birthweight incidence. Changes in distribution of birthweights may be corrected for when quality of perinatal care is to be evaluated. Strategies for prevention of low birth weight may be important for reduction of perinatal mortality and handicaps related to low birthweight.