The impact of hospital obstetric volume on maternal outcomes in term, non–low-birthweight pregnancies

Snowden, Jonathan M.; Cheng, Yvonne W.; Emeis, Cathy; Caughey, Aaron B.

doi:10.1016/j.ajog.2014.09.026

Cited by 55 publications

(61 citation statements)

References 30 publications

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“…9,20,34 Additionally, prior research indicating greater risk of maternal morbidity (such as postpartum hemorrhage) and postpartum complications in low-volume rural settings may influence clinical recommendations or personal decisions regarding delivery location. 35–37 Indeed, our findings show higher rates of non-local childbirth among rural women whose local hospital has 460 births or fewer each year (Table 3). Future research on personal and clinical decision-making around delivery location may elucidate both medical and non-medical reasons for these patterns.…”

Section: Commentmentioning

confidence: 60%

Location of childbirth for rural women: implications for maternal levels of care

Kozhimannil

Casey

Hung

et al. 2016

American Journal of Obstetrics and Gynecology

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BACKGROUND A recent American College of Obstetricians and Gynecologists and Society for Maternal Fetal Medicine consensus statement on levels of maternity care lays out designations that correspond to specific capacities available in facilities that provide obstetric care. Pregnant women in rural and remote areas receive particular attention in discussions of regionalization and levels of care, owing to the challenges in assuring local access to high-acuity services when necessary. Currently, approximately half a million rural women give birth each year in US hospitals, and whether and which of these women give birth locally is crucial for successfully operationalizing maternal levels of care. OBJECTIVES To characterize rural women who give birth in non-local hospitals and measure local hospital characteristics and maternal diagnoses present at childbirth that are associated with non-local childbirth. STUDY DESIGN This was a repeat cross-sectional analysis of administrative hospital discharge data for all births to rural women in nine states in 2010 and 2012. Multivariate logistic regression models were used to predict the odds of childbirth in a non-local hospital (at least 30 road miles from the patient's residence). We examined patient age, race/ethnicity, payer, rurality, clinical diagnoses (diabetes, hypertension, hemorrhage during pregnancy, placental abnormalities, malpresentation, multiple gestation, preterm delivery, prior cesarean delivery, and a composite of diagnoses that may require maternal-fetal medicine consultation), as well as local hospital characteristics (birth volume, neonatal care level, ownership, accreditation, and system affiliation). RESULTS The rate of non-local childbirth among 216,076 rural women was 25.4%. It varied significantly by primary payer (Adjusted Odds Ratio [95% Confidence Interval]=0.76 [0.68,0.86]) for Medicaid vs. private insurance) and by clinical conditions including multiple gestation (1.82 [1.58,2.1]), preterm deliveries (2.41 [2.17,2.67]), and conditions which may require maternal fetal medicine services or consultation (1.28 [1.22,1.35]). Rural women whose local hospital did not have a neonatal intensive or intermediate care unit had nearly double the odds of giving birth at a non-local hospital (1.94 [1.64,2.31]). CONCLUSION Approximately 75% of rural women gave birth at local hospitals; rural women with preterm births and clinical complications, as well as those without local access to higher-acuity neonatal care, were more likely to give birth in non-local hospitals. However, after controlling for clinical complications, rural Medicaid beneficiaries were less likely to give birth at non-local hospitals, implying a potential access challenge for this population.

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Section: Commentmentioning

confidence: 60%

Location of childbirth for rural women: implications for maternal levels of care

Kozhimannil

Casey

Hung

et al. 2016

American Journal of Obstetrics and Gynecology

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“…14 This data set has been used broadly to track maternal/child health outcomes and to assess the quality of obstetric care. 15, 16 The database includes patient discharge data (including diagnosis and procedure codes) for antepartum admissions in the 9 months prior to delivery, and linked maternal/infant admissions in the year after delivery, as well as data from the US Standard Certificate of Live Birth. Details of data linkage and quality control are described in detail elsewhere.…”

Section: Methodsmentioning

confidence: 99%

“…The maternal characteristics included in this main-term model were race/ethnicity (non-Hispanic black, Hispanic, or Asian-American, compared with the referent category of non-Hispanic white), advanced maternal age (≥35 years), educational attainment (≥12 years vs <12), parity (nulliparous vs multiparous), insurance status (public/none vs private) and initiation of prenatal care in the first trimester. Hospital characteristics in the model were teaching hospital (defined as the presence of obstetrics–gynaecology residents on obstetric rotations) and hospital birth volume (defined using previously published categories for annual birth volume: 16 <1200 births per year, 1200–2399 births, 2400–3599 births and ≥3600 annual births).…”

Section: Methodsmentioning

confidence: 99%

A ‘busy day’ effect on perinatal complications of delivery on weekends: a retrospective cohort study

et al. 2016

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Objective To evaluate whether busy days on a labour and delivery unit are associated with maternal and neonatal complications of childbirth in California hospitals, accounting for weekday/weekend births. Design This is a population-based retrospective cohort study. Setting Linked vital statistics/patient discharge data for California births between 2009 and 2010 from the Office of Statewide Health Planning and Development. Participants All singleton, cephalic, non-anomalous California births between 2009 and 2010 (N=724 967). Main outcomes The key exposure was high daily obstetric volume, defined as giving birth on a day when the number of births exceeded the hospital-specific 75th percentile of daily delivery volume. Outcomes were a range of maternal and neonatal complications. Results Several maternal and neonatal complications were increased on high-volume days and weekends following adjustment for maternal demographics, annual hospital birth volume and teaching hospital status. For example, compared with low-volume weekdays, the odds of Apgar <7 on low-volume weekend days and high-volume weekend days were 11% (adjusted OR (aOR) 1.11, CI 1.03 to 1.21) and 29% higher (aOR 1.29, CI 1.10 to 1.52), respectively. High volume was associated with increased odds of neonatal seizures on weekdays (aOR 1.33, CI 1.01 to 1.71) and haemorrhage on weekends (aOR 1.11, CI 1.01 to 1.22). After accounting for between-hospital variation, weekend delivery remained significantly associated with increased odds of Apgar score <7, neonatal intensive care unit admission, prolonged maternal length of stay and the odds of neonatal seizures remained increased on high-volume weekdays. Conclusions Our findings suggest that weekend delivery is a consistent risk factor for a range of perinatal complications and there may be variability in how well hospitals handle surges in volume.

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“…For the unadjusted analyses, delivery volume was classified into one of four categories: 50 to 500 deliveries (very low volume), 501 to 1000 deliveries (low volume), 1001 to 2000 deliveries (medium volume), and >2000 (high volume). Prior analyses have used varying obstetric volume cutoffs; 28,29 the volume categories used in this analysis were chosen because they represent easily interpretable and clinically meaningful distinctions in obstetric volume.…”

Section: Methodsmentioning

confidence: 99%

Hospital delivery volume, severe obstetrical morbidity, and failure to rescue

Friedman

Ananth

Huang

et al. 2016

American Journal of Obstetrics and Gynecology

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Background In the setting of persistently high risk for maternal mortality and severe obstetric morbidity, little is known about the relationship between hospital delivery volume and maternal outcomes. Objective The objectives of this analysis were (i) to determine maternal risk for severe morbidity during delivery hospitalizations by hospital delivery volume in the United States; and (ii) to characterize, by hospital volume, the risk for mortality in the setting of severe obstetrical morbidity – a concept known as failure to rescue. Study Design This cohort study evaluated 50,433,539 delivery hospitalizations across the United States from 1998 to 2010. The main outcome measures were (i) severe morbidity defined as a composite of any one of fifteen diagnoses representative of acute organ injury and critical illness, and (ii) failure to rescue, defined as death in the setting of severe morbidity. Results The prevalence of severe morbidity rose from 471.2 to 751.5 cases per 100,000 deliveries from 1998 to 2010, an increase of 59.5%. Failure to rescue was highest in 1998 (1.5%), decreased to 0.6% in 2007, and rose to 0.9% in 2010. In models adjusted for comorbid risk and hospital factors, both low and high annualized delivery volume were associated with increased risk for failure to rescue and severe morbidity. However, the relative importance of hospital volume for both outcomes compared to other factors was relatively small. Conclusions While low and high delivery volume are associated with increased risk for both failure to rescue and severe maternal morbidity, other factors, in particular characteristics of individual centers, may be more important in determining outcomes.

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The impact of hospital obstetric volume on maternal outcomes in term, non–low-birthweight pregnancies

Cited by 55 publications

References 30 publications

Location of childbirth for rural women: implications for maternal levels of care

Location of childbirth for rural women: implications for maternal levels of care

A ‘busy day’ effect on perinatal complications of delivery on weekends: a retrospective cohort study

Hospital delivery volume, severe obstetrical morbidity, and failure to rescue

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