Background: Previous studies suggest that high risk and low birthweight babies have better outcomes if born in hospitals with level III neonatal intensive care units. Relations between obstetric care, particularly intrapartum interventions and perinatal outcomes, are less well understood, however. Objective: To investigate effects of obstetric, paediatric, and demographic factors on rates of hospital stillbirths and neonatal mortality. Methods: Cross sectional data on all 65 maternity units in all Thames Regions, 1994Regions, -1996, covering 540 834 live births and stillbirths. Hospital level analyses investigated associations between staffing rates (consultant/junior paediatricians, consultant/junior obstetricians, midwives), facilities (consultant obstetrician/anaesthetist sessions, delivery beds, special care baby unit, neonatal intensive care unit cots, etc), interventions (vaginal births, caesarean sections, forceps, epidurals, inductions, general anaesthetic), parental data (parity, maternal age, social class, deprivation, multiple births), and birthweight standardised stillbirth rates and neonatal mortality. Results: Unifactorial analyses showed consistent negative associations between measures of obstetric intervention and stillbirth rates. Some measures of staffing, facilities, and parental data also showed significant associations. Scores for interventional, organisational, and parental variables were derived for multifactorial analysis to overcome the statistical problems caused by high intercorrelations between variables. A higher intervention score and higher number of consultant obstetricians per 1000 births were both independently and significantly associated with lower stillbirth rates. Organisational and parental factors were not significant after adjustment. Only Townsend deprivation score was significantly associated with neonatal mortality (positive correlation). Conclusions: Birthweight adjusted stillbirth rates were significantly lower in units that took a more interventionalist approach and in those with higher levels of consultant obstetric staffing. There were no apparent associations between neonatal death rates and the hospital factors measured here.
We performed a cross-sectional study of all Thames maternity units, 1994-96, including 540,834 live and stillbirths. In contrast to recent media speculation, no association of caesarean section rates with midwifery staffing levels was found after adjustment for confounders. The only association with staffing was with levels of junior obstetric staffing, which could be a reflection of less experienced management of labour. Caesarean section rates were also associated positively with the levels of delivery beds, which could be a reflection of the closer monitoring of labour that may result from increased bed availability. Both caesarean section and instrumental vaginal delivery rates were associated with epidural rates, which was expected from the literature. Variations in epidural rates were mainly associated with variations in demographic case-mix, due possibly to patient demand. Demographic case-mix was also associated with instrumental vaginal deliveries but not the caesarean section rate.
This study investigates whether social class or a census-based deprivation score is a better predictor of stillbirth rates using data for 1993-5 for residents of South Thames (West) Region. Social class is routinely coded for 10% of live births and 100% of stillbirths. A Townsend deprivation score was assigned to each stillbirth and each live birth with a social class code, according to their electoral ward of residence. In unifactorial analyses of stillbirth rate the relationship was stronger with social class (P = 0.008) than with Townsend score (P = 0.11). Both relationships were strengthened by including those births recorded as social class 'other' ['other' vs. social class I odds ratio (OR) = 2.27, P < 0.001; lower vs. upper septile deprivation score OR = 1.45, P = 0.07)]. When social class and Townsend score were analysed together, the ORs for social class remained similar to before, but the Townsend ORs were reduced and non-significant overall. We conclude that social class, which is based on data on each individual, is a better predictor of stillbirth than Townsend score, which is based on data from the area of residence. We recommend further investigation of the stillbirth risk in the subgroups that make up the 'other' social class.
Adherence with current prophylactic antibiotic administration guidelines for cesarean delivery is not uniform. Education initiatives, regulatory maneuvers, and process improvement should be targeted at sites where anesthesiologists do not comply with current guidelines.
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