Risk factors for not delivering in a level III unit before 32 weeks of gestation: results from a population-based study in Paris and surrounding districts in 2003

Choosing a maternity hospital: a matter of travel distance or quality of care?

BACKGROUND

The choice of a hospital should be based on individual need and accessibility. For maternity hospitals, this includes known or expected risk factors, the geographic accessibility and level of care provided by the hospital. This study aims to identify factors influencing hospital choice with the aim to analyze if and how many deliveries are conducted in a risk-appropriate and accessible setting in Bavaria, Germany.

METHODS

This is a cross-sectional secondary data analysis based on all first births in Bavaria (2015-18) provided by the Bavarian Quality Assurance Institute for Medical Care. Information on the mother and on the hospital were included. The Bavarian Index of Multiple Deprivation 2010 was used to account for area-level socioeconomic differences. Multiple logistic regression models were used to estimate the strength of association of the predicting factors and to adjust for confounding.

RESULTS

We included 195,087 births. Distances to perinatal centers were longer than to other hospitals (16 km vs. 12 km). 10% of women with documented risk pregnancies did not deliver in a perinatal center. Regressions showed that higher age (OR 1.03; 1.02-1.03 95%-CI) and risk pregnancy (OR 1.44; 1.41-1.47 95%-CI) were associated with choosing a perinatal center. The distances travelled show high regional variation with a strong urban-rural divide.

CONCLUSION

In a health system with free choice of hospitals, many women chose a hospital close to home and/or according to their risks. However, this is not the case for 10% of mothers, a group that would benefit from more coordinated care.

Risk factors for very preterm delivery out of a level III maternity unit: The EPIPAGE-2 cohort study

BACKGROUND

Regionalisation programmes aim to ensure that very preterm infants are born in level III units (inborn) through antenatal referral or transfer. Despite widespread knowledge about better survival without disability for inborn babies, 10%-30% of women deliver outside these units (outborn).

OBJECTIVE

To investigate risk factors associated with outborn deliveries and to estimate the proportion that were probably or possibly avoidable.

METHODS

We used a national French population-based cohort including 2205 women who delivered between 24 and 30⁺⁶  weeks in 2011. We examined risk factors for outborn delivery related to medical complications, antenatal care, sociodemographic characteristics and living far from a level III unit using multivariable binomial regression. Avoidable outborn deliveries were defined by pregnancy risk (obstetric history, antenatal hospitalisation) and time available for transfer.

RESULTS

25.0% of women were initially booked in level III, 9.1% were referred, 49.8% were transferred, and 16.1% had outborn delivery. Risk factors for outborn delivery were gestational age <26 weeks (adjusted relative risk (aRR) 1.37, 95% confidence interval (CI) 1.13, 1.66), inadequate antenatal care (aRR 1.39, 95% CI 1.10, 1.81), placental abruption (aRR 1.66, 95% CI 1.27, 2.17), and increased distance to the closest level III unit ((aRR 2.79, 95% CI 2.00, 3.92) in the 4th versus 1st distance quartile). Among outborn deliveries, 16.7% were probably avoidable, and 25.6% possibly avoidable, which could increase the proportion of inborn deliveries between 85.9% and 92.9%. Avoidable outborn deliveries were mainly associated with gestational age, intrauterine growth restriction, preterm premature rupture of membranes, and haemorrhage, but not distance.

CONCLUSIONS

Our study identified some modifiable risk factors for outborn delivery; however, when regionalised care relies heavily on antenatal transfer, as it does in France, only some outborn deliveries may be prevented. Earlier referral of high-risk women will be needed to achieve full access to tertiary care.

Extremely and Very Preterm Deliveries in a Maternity Unit of Inappropriate Level: Analysis of Socio-Residential Factors

PURPOSE

To analyze the socio-residential factors associated with extremely and very preterm deliveries occurring in non-level 3 maternity units in France.

MATERIALS AND METHODS

This is a population-based observational retrospective study using national hospital data from 2012 to 2014. A generalized estimating equations regression model was used to study the characteristics of women who delivered very preterm and the socio-residential risk factors for not delivering in a level 3 maternity unit at 24-31+6d weeks of gestation.

RESULTS

Among deliveries resulting in live births and without contraindication to in-utero transfer, we identified 9198 extremely or very preterm deliveries; 2122 (23.1%) of these were managed in a non-level 3 unit. Our study showed that young maternal age (women under 20 years at delivery) was associated with the risk of giving birth prematurely in a non-level 3 maternity, and particularly in a level 1 maternity unit (adjusted relative risk, 1.53; 95% CI 1.09-2.16). Living more than 30 minutes away from the closest level 3 unit increased the risk of delivering very preterm in a level 1 or 2 unit. Living in an urban area or urban periphery increased the risk of giving birth in a level 2 maternity unit (adjusted relative risk, 1.53; 95% CI 1.28-1.83 and 1.42; 95% CI 1.17-1.71, respectively).

CONCLUSION

This study shows that young pregnant women living more than 30 minutes from a level 3 hospital have an increased risk of delivering in a maternity unit that is not equipped to deal with premature births. The risk also increases with an urban place of residence when the delivery occurs in a level 2 unit. A clearer understanding of the population at risk of delivering prematurely in a non-level 3 maternity could lead to improvements in structuring healthcare to encourage earlier management and better support.

Evaluation of the birthplace of newborns with gestational age less than 34 weeks according to the complexity of the Neonatal Unit in maternity hospitals linked to the "Rede Cegonha": Brazil, 2016-2017

This study aims to evaluate the birthplace of preterm infants with less than 34 gestational weeks at birth by type of neonatal care service in maternity hospitals of the "Rede Cegonha" and estimate the maternal factors associated with the inadequate place of birth for gestational age. This national cross-sectional study was performed in 2016/2017 to evaluate health establishments with the Rede Cegonha's action plan. Information was analyzed from 303 puerperae and the respective health establishments of their births. Newborns were classified by gestational age at birth (<30 and 30-33 weeks) and health establishments as hospitals with neonatal intensive care service, hospitals with intermediate neonatal care service, and hospitals without neonatal care service. Ministerial Ordinance N° 930/2012 was used to classify the birthplace as appropriate for the newborn's gestational age. Preterm birth prevalence was 37.3 at less than 30 weeks' gestation and 66.8 at 30-33 weeks. Birth in inappropriate services for the newborn's gestational age occurred in 6.3%, with significant regional and social differences. Inequalities in access to neonatal care for preterm infants persist in the "Rede Cegonha" despite advances.

Extremely premature infants: How does death in the delivery room influence mortality rates in two level 3 centers in France?

OBJECTIVES

Mortality rates of very preterm infants may vary considerably between healthcare facilities depending on the neonates' place of inclusion in the cohort study. The objective of this study was to compare the mortality rates of live-born extremely preterm neonates observed in two French tertiary referral hospitals, taking into account the occurrence of neonatal death both in the delivery room and in the neonatal intensive care unit (NICU).

METHODS

Retrospective observational study including all pregnancy terminations, stillbirths and live-born infants within a 22- to 26-week ^0/6 gestational age range was registered by two French level 3 university centers between 2009 and 2013. The mortality rates were compared between the two centers according to two places of inclusion: either the delivery room or the NICU.

RESULTS

A total of 344 infants were born at center A and 160 infants were born at center B. Among the live-born neonates, the rates of neonatal death were similar in center A (54/125, 43.2%) and center B (33/69, 47.8%; P=0.54). However, neonatal death occurred significantly more often in the delivery room at center A (31/54, 57.4%) than at center B (6/33, 18.2%; P<0.001). Finally, the neonatal death rate of live-born very preterm neonates admitted to the NICU was significantly lower in center A (25/94, 26.6%) than in center B (27/63, 42.9%; P=0.03).

CONCLUSIONS

This study points out how the inclusion of deaths in the delivery room when comparing neonatal death rates can lead to a substantial bias in benchmarking studies. Center A and center B each endorsed one of the two models of preferential place of neonatal death (delivery room or NICU) detailed in European studies. The reasons behind the two different models and their impact on how parents perceive supporting their neonate need further investigation.

Factors associated with late detection of critical congenital heart disease in newborns

OBJECTIVES

Critical congenital heart disease (CCHD) was recently added to the US Recommended Uniform Screening Panel for newborns. This study assessed whether maternal/household and infant characteristics were associated with late CCHD detection.

METHODS

This was a statewide, population-based, retrospective, observational study of infants with CCHD born between 1998 and 2007 identified by using the Florida Birth Defects Registry. We examined 12 CCHD conditions that are primary and secondary targets of newborn CCHD screening using pulse oximetry. We used Poisson regression models to analyze associations between selected characteristics (eg, CCHD type, birth hospital nursery level [highest level available in the hospital]) and late CCHD detection (defined as diagnosis after the birth hospitalization).

RESULTS

Of 3603 infants with CCHD and linked hospitalizations, CCHD was not detected during the birth hospitalization for 22.9% (n = 825) of infants. The likelihood of late detection varied by CCHD condition. Infants born in a birth hospital with a level I nursery only (adjusted prevalence ratio: 1.9 [95% confidence interval: 1.6-2.2]) or level II nursery (adjusted prevalence ratio: 1.5 [95% confidence interval: 1.3-1.7]) were significantly more likely to have late-detected CCHD compared with infants born in a birth hospital with a level III (highest) nursery.

CONCLUSIONS

After controlling for the selected characteristics, hospital nursery level seems to have an independent association with late CCHD detection. Thus, perhaps universal newborn screening for CCHD could be particularly beneficial in level I and II nurseries and may reduce differences in the frequency of late diagnosis between birth hospital facilities.

Levels of neonatal care

Provision of risk-appropriate care for newborn infants and mothers was first proposed in 1976. This updated policy statement provides a review of data supporting evidence for a tiered provision of care and reaffirms the need for uniform, nationally applicable definitions and consistent standards of service for public health to improve neonatal outcomes. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care.

Improving perinatal regionalization for preterm deliveries in a Medicaid covered population: initial impact of the Arkansas ANGELS intervention

OBJECTIVE

To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001-2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice.

DATA SOURCES

A dataset of linked Medicaid claims and birth certificates for the time period by clustering Medicaid claims by pregnancy episode. Pregnancy episodes were linked to residential county-level demographic and medical resource characteristics. Deliveries occurring before 35 weeks gestation (n=5,150) were used for analysis.

STUDY DESIGN

Logistic regression analysis was used to examine time trends and individual, county, and intervention characteristics associated with delivery at hospitals with NICU, and delivery at the academic medical center.

PRINCIPAL FINDINGS

Perceived risk, age, education, and prenatal care characteristics of women affected the likelihood of use of the NICU. The perceived availability of local expertise was associated with a lower likelihood that preterm infants would deliver at the NICU. ANGELS did not increase the overall use of NICU, but it did shift some deliveries to the academic setting.

CONCLUSION

Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.

[Is it possible to prevent preterm births outside of level-3 maternity wards? Experience of Greater Lyon perinatal network]

OBJECTIVE

The main objective of this study was to calculate the percentage of preterm births before 28 weeks gestational age (weeks GA) outside level-3 maternity wards and determine how many could have been prevented.

METHODS

This was an observational, multicenter, retrospective cohort study, which included all the deliveries that occurred between 24 and 27 weeks GA + 6 days in the Greater Lyon perinatal network (France) occurring between first of March 2008 and first of March 2009. In utero transfers (IUTs) and newborn transfers (NBTs) which were carried out outside the network, medical abortions, and foetal deaths in utero were excluded. The duration between patient's arrival in the level 1 and 2 maternity and birth was compared at the 97(th) percentile of the mother's transfer time in level-3 maternity. Births that occurred outside of level-3 maternity wards were considered avoidable each time the first duration was more than the second.

RESULTS

During the study period, 113 infants were born alive between 24 and 27 weeks GA+6 days in the network. They were all included in the study. Ninety were born in a level-3 maternity ward and 23 were born in level-1 and 2 maternity wards (20%). There were 35 requests for IUT and 28 were carried out (80%). In 65% of non-level 3 births, no IUT was requested. In 17% of cases, an IUT request could have prevented births in level 1/2 maternity wards. If twin pregnancies had been transferred to a level-3 maternity ward, 26% of non-level 3 births would have been avoided. If all high-risk pregnancies had been transferred to a level-3 maternity ward, 40% of non-level 3 births would have been avoided.

DISCUSSION AND CONCLUSION

Any time a pregnant woman is hospitalized in a type 1/2 maternity ward before 28 weeks GA, doctors should consider an in utero transfer to a level-3 maternity ward. It may be possible to lower the birth-rate of non-level 3 births by a targeted increase in in utero transfers and by transferring high-risk pregnancies to a level-3 maternity ward.

Increasing VLBW deliveries at subspecialty perinatal centers via perinatal outreach

OBJECTIVES

To test the hypothesis that the promotion of national guidelines recommending the transfer of high-risk mothers to subspecialty perinatal centers reduces mortality and morbidity through the reduction of preterm infants delivered at nontertiary maternity hospitals.

METHODS

After implementation of hospital-based educational and communication programs emphasizing the importance of maternal transfer to subspecialty perinatal centers, we conducted a population-based cohort study of all live births delivered at maternity hospitals in greater Cincinnati from 2003 through 2007 (n = 1825). Birth weights measured between 500 and 1499 g and gestational ages were less than 32 weeks. Risk-adjusted outcomes were measured by multivariate logistic regression in 2 stages. We compared these findings with those from a similar study conducted at our institution that included infants with birth weights less than 1500 g born between September 1, 1995, and December 31, 1997 (n = 848). The primary outcome was the percentage decrease in infants born with very low birth weights at nontertiary centers compared with our previous study.

RESULTS

The number of infants born with birth weights less than 1500 g and at less than 32 weeks' gestation delivered at hospitals without tertiary perinatal and neonatal care decreased from 25% to 11.8% between the 2 study periods. The odds of death or major morbidity for infants born with very low birth weights at nontertiary perinatal centers is 3 times that of infants born at subspecialty perinatal centers after controlling for demographic variations (odds ratio: 3.05 [95% confidence interval: 2.1-4.4]).

CONCLUSIONS

Local promotion of national guidelines by neonatologists coincided with a significant reduction in the percentage of infants born with birth weights less than 1500 g and at less than 32 weeks' gestation who were not delivered at subspecialty perinatal centers, and, at 88.2%, this nearly achieves the Healthy People 2010 objective to deliver 90% of infants born with very low birth weights in subspecialty perinatal centers.

Access to level III perinatal care for pregnancies of very short duration (<32 weeks)

AIMS

To evaluate to which extent pregnancies of very short duration (<32 weeks' gestation) are concentrated in level III centers.

METHODS

Area-based study in the 57 maternity units of the Lazio Region (Italy), years 2003-2004, including: 1012 live births (gestational age 22-31 weeks), 261 fetal losses (22-31 weeks) and 209 induced abortions (22-25 weeks). Variables associated with access to a level III unit were evaluated through multivariable logistic regression models.

RESULTS

83.7% of all pregnancies <32 weeks (88.8% of live births, 71.6% of fetal losses and 75.1% of induced abortions) were admitted to a level III perinatal center; 23.4% of live newborns, delivered in a level III hospital, were subsequently transferred to a same level facility. The probability that a fetal loss was not treated in a level III perinatal unit was higher for women without pregnancy complication, with lower education level, and living outside the metropolitan area.

CONCLUSIONS

Regionalization of perinatal care in Lazio is not satisfactory. Concentration of high-risk deliveries in level III centers is good, but in utero transfer is insufficient. This study can help to define the effectiveness of different organizational systems on access to locally available perinatal facilities and to optimize general organizational patterns of perinatal care.

Very preterm birth: who has access to antenatal corticosteroid therapy?

We describe the administration of antenatal corticosteroid therapy (ACT) for liveborn very preterm neonates in a population-based study. A total of 790 very preterm neonates (between 24 and 31 full weeks of gestation) were included in this regionally defined population of very preterm neonates in France. The main outcome measure was non-access to ACT. Data were analysed using logistic and polytomous models to control for neonatal and sociodemographic characteristics, mechanisms of very preterm birth and neonatal network organisation. As compared with level III, births in levels I-II maternity units were closely related to non-access to ACT (60.1% vs. 8.8%), but not to pregnancy follow-up (19.7% vs. 17.8%). Only 6.3% of very preterm neonates that benefited from antepartum referral did nor receive ACT. Births associated with rupture of membranes and gestational hypertension were significantly more often transferred to level-III units (73.8% and 68.3% respectively) than those due to maternal bleeding and spontaneous labour (57.0% and 50.7% respectively), and the neonates had a lower probability of not receiving ACT (8.5%, 11.5%, 23.0%, 31.2% respectively). Very preterm neonates referred in utero to a level-III unit came from a more favourable socio-economic environment. Non-access to ACT was more often observed in neonates born to 14- to 24-year-old mothers, smokers, of low socio-economic status, and preterm birth resulting from maternal bleeding or spontaneous labour. These data from a French regional study show that access to ACT is not only explained by practitioners' support of recommendations. In our population-based study, ACT access was related to socio-economic factors and to the mechanisms of very preterm birth. Improving the rate of access to ACT should take these organisational, medical and socio-economic dimensions into account.

[Very preterm birth: is maternal anesthesia a risk factor for neonatal intubation in the delivery room?]

OBJECTIVE

To assess the risk of tracheal intubation at birth in very premature neonates related to the type of maternal anesthesia in case of elective cesarean.

POPULATION AND METHODS

All 219 live-born very premature neonates (28-32 weeks of gestation), delivered after an elective cesarean in the 27 maternity wards of 2 French semi-rural neonatal networks. Eighty-three percent (182/219) were delivered in level III maternity wards in university hospitals.

RESULTS

Of the very preterm neonates, 33.3% (73/219) were intubated in the delivery room, either for respiratory distress syndrome or a low APGAR score. Very preterm neonates delivered after maternal general anesthesia were more often intubated than those delivered after spinal anesthesia (48.7% vs 25.2%; OR: 2.8; 95% CI: 1.8-5.1). The risk of intubation related to maternal general anesthesia remained statistically significant after an adjustment for gestational age, fetal growth retardation, respiratory distress syndrome, type of maternity ward, and a propensity score that took into account maternal sociodemographic characteristics and the causes of very preterm birth (aOR: 3.4; 95% CI: 1.4-8.2). The risk of intubation related to general anesthesia was lower after adjusting for the 5-min APGAR score (aOR: 2.8; 95% CI: 1.0-7.3).

CONCLUSION

Very preterm neonates delivered after cesarean with general anesthesia require tracheal intubation in the delivery room more often than those delivered with spinal anesthesia. This study cannot assess a causal link between anesthesia and the need for neonatal intubation. However, neonatologists have to be aware of the type of maternal anesthesia because it may interfere with the non-invasive ventilation support policy of the very preterm neonate.

Organisation of obstetric services for very preterm births in Europe: results from the MOSAIC project

OBJECTIVE

To study the impact of the organisation of obstetric services on the regionalisation of care for very preterm births.

DESIGN

Cohort study.

SETTING

Ten European regions covering 490 000 live births.

POPULATION

All children born in 2003 between 24 and 31 weeks of gestation.

METHOD

The rate of specialised maternity units per 10 000 total births, the proportion of total births in specialised units and the proportion of very preterm births by referral status in specialised units were compared.

MAIN OUTCOME MEASURE

Birth in a specialised maternity unit (level III unit or unit with a large neonatal unit (at least 50 annual very preterm admissions).

RESULTS

The organisation of obstetric care varied in these regions with respect to the supply of level III units (from 2.3 per 10 000 births in the Portuguese region to 0.2 in the Polish region), their characteristics (annual number of deliveries, 24 hour presence of a trained obstetrician) and the proportion of all births (term and preterm) that occur in these units. The proportion of very preterm births in level III units ranged from 93 to 63% in the regions. Different approaches were used to obtain a high level of regionalisation: high proportions of total deliveries in specialised units, high proportions of in utero transfers or high proportions of high-risk women who were referred to a specialised unit during pregnancy.

CONCLUSION

Consensus does not exist on the optimal characteristics of specialised units but regionalisation may be achieved in different models of organisation of obstetric services.