Evaluation of different approaches to obstetric care: Part 1

Ethnicity and obstetric performance in Singapore

The influence of ethnicity on obstetric performance in Singapore was assessed by retrospective analysis of all deliveries in the National University Hospital over a 7-year period. Malay mothers were younger, shorter, less educated, of higher parity, were more likely to have had no antenatal care, and had the highest incidence of premature labour. However, mothers of Indian origin had the smallest babies, the highest incidence of low birth weight and significantly higher perinatal mortality rates. Chinese mothers fared better than their Malay and Indian counterparts in all parameters assessed. The ethnic origin of the mother has an important bearing on perinatal performance. This emphasises the importance of designing appropriate strategies to improve perinatal health in the different ethnic groups.

The shift from home to institutional childbirth: a comparative study of the United Kingdom and The Netherlands

The British system of childbirth with a very low rate of home childbirth is compared to that in The Netherlands, a country with a relatively high percentage of home deliveries. The analysis explores three possible explanations: the structure of the health professions in both countries, the structure of their health systems, and the use of scientific information in guiding policy decisions on birth place. Differences in the professional status and training programs of midwives between The Netherlands and the United Kingdom affected the distribution of home versus institutional deliveries in the two countries. Reimbursement schemes in The Netherlands have been important in maintaining a high percentage of births at home in this country. In the United Kingdom centralized planning and the influence of medical thinking played major roles in accelerating the shift from home to hospital deliveries in the National Health Service.

Perinatal data reliability in a large teaching obstetric unit

In this inter-rater agreement study of antenatal and neonatal variables collected in a large teaching obstetric unit, information routinely collected by hospital staff was compared with that collected by a specially trained physician and a social worker. Agreement between the two sources of data was evaluated using kappa statistics and intraclass correlation coefficients. Excellent agreement was observed for some variables such as maternal and newborn anthropometric measures, and previous birthweight, but there was poor agreement for others such as indicators of physical activity, work during pregnancy and blood pressure measures. Some of the limitations are due to problems in phrasing questions, patients' recall, interviewer bias and abstracting data. We recommend that epidemiological studies should always include a reliability component, proper standardization of personnel and instruments and include, when published, validity data and examples of questions used.

Obstetric management and outcome related to maternal characteristics

Presented are the results of a logit analysis of the variations in birth management and outcome, other than birth weight, associated with socioeconomic and physical maternal characteristics at a London teaching hospital. Previous studies have not attempted to discriminate rigorously between the effects of correlated explanatory variables. Logit analysis overcomes this problem by systematically measuring the independent effect of each maternal characteristic on each type of management and outcome, holding the effects of all other maternal characteristics constant. The results show that, in quantitative terms, parity and age have the greatest effects on both management and birth outcome. Stature is also an important factor for certain types of management, and ethnicity, occupation, and prenatal class attendance have some significant effects. In contrast to the literature on the determinants of birth weight, the smoking habit of the mother had no significant effect when all other factors were controlled for.

Ethnic differences in the distribution of normally formed singleton stillbirths

The normally formed singleton stillbirth deliveries occurring in Dudley Road Hospital in 1979, 1980 and 1981 were classified according to the primary aetiology. There was a higher than normal stillbirth rate in the Indian group which was almost entirely accounted for by the increased number of stillbirths falling into the 'intrauterine death before labour' group.

Prediction of small-for-dates infants by measurement of symphysial-fundal-height

A standard chart of symphysial-fundal height from 20 to 40 weeks of pregnancy was derived from measurements in 103 women who were delivered of infants weighing between the 25th and 90th centile for gestation. The chart was used to predict birth weight in a group of 138 high-risk patients. Thirty (73.1 per cent) of 41 infants with birth weight for gestation less than 10th centile could be detected by this one clinical measurement. A single measurement was most accurate for detecting low birth weight for gestation at 32 to 33 weeks. It is suggested that symphysial-fundal height measurements should be made routinely on all antenatal patients and that each obstetric unit should derive its own standard curves.

Analysis of ethnic differences in perinatal statistics

The 3996 mothers delivered at Dudley Road Hospital, Birmingham, in 1979 were analysed for their ethnic origins. Social classes IV and V predominated in all groups. A high proportion of Indian mothers fell into the low-risk group based on age and parity but had the highest stillbirth and perinatal mortality rates (15.1 and 27.5/1000 respectively) and infants of low mean birth weight (2986 g). Elderly and multiparous mothers were characteristic of the Pakistani and Bangladeshi groups. Young, primiparous mothers were more common among the West Indians and Europeans, in whom the stillbirth and perinatal mortality rates were low; infants in the European group had a mean birth weight higher than in any other group (3231 g). From these findings ethnic origin of the mother is apparently an important factor in perinatal mortality.

Caesarean-section rates in Australia: a population-based audit

Caesarean-section rates are increasing rapidly in Australia, and in many other Western countries. Private health-fund data for each State of Australia show marked differences in caesarean-section rates between States. Comparison between Western Australia and South Australia showed that these differences could be related to the proportion of specialist obstetricians per capita in each of the States. Although stillbirth rates are lower in the States with high caesarean-section rates, perinatal mortality rates, which include stillbirths, are not significantly different between States. Since the populations of Australian States are reasonably homogeneous, justification for performing more caesarean sections must be questioned.

Perinatal death: audit and classification

Two hundred and thirteen perinatal deaths occurred in a population of 10,539 deliveries over a 4-year period. The associated obstetric complications and circumstances were analysed. The majority of perinatal deaths occurred in fetuses in whom there was a serious malformation, or whose birth weight was less than 800 g. Of the 110 deaths which occurred in normal babies weighing 800 g or more, 54 were antepartum, 5 were intrapartum, and 51 were neonatal. The clinical features surrounding these deaths were classified, and their implications discussed.

A review of the use of Barton's forceps for the rotation of the fetal head from the transverse position

The technique of use of Barton's forceps is described. A series of 248 patients in a 4-year period has been assessed to determine the safety of the instrument. It is concluded that the forceps can be used with safety for both mother and baby under pudendal block anaesthesia, in mid-cavity and low-cavity deliveries.

A critique of Priorities for Health and Personal Social Services in England

Priorities for Health and Personal Social Services in England was prepared by the Department of Health and Social Security (DHSS) as a basis for consultation about its intended policies during the period 1975–1976 to 1979–1980. The decision of the DHSS to engage in consultation with interested parties is, of course, to be welcomed. However, the Priorities document leaves much to be desired both in terms of the quality and quantity of information provided and in its treatment of the pressing issues affecting the health and personal social services. Many of the areas labeled as priorities show no increase in the proportion of the budget devoted to them; some, in fact, show a definite reduction. Other so-called “growth areas” show such low rates of expansion that they will barely keep pace with the needs of the increasing number of elderly in the population.

Many Area Health Authorities are reducing services in acute specialties, despite long waiting lists and the fact that over 80 percent of admissions of elderly patients are to acute wards. Thus, such cuts are likely to increase even further the demand for geriatric facilities. Many of the areas designated for expansion by the DHSS are largely under the financial control of local government, which is in many cases reducing these services. The most rapid rise in expenditure will be on pharmaceuticals. This will account for the largest increase within the primary care system, leaving little room for any improvements in the service.

In an associated document, Prevention and Health: Everybody's Business, the DHSS attempts to demonstrate that specific preventive measures have been the most important factors in major changes of disease patterns and ignores the importance of secular changes. There is no discussion of the relationship between social structure and both disease and delivery of care; instead, the focus is on individuals changing their life-style as a result of being provided with the appropriate information. There is already evidence that this approach yields poor results and that alternative strategies are needed. Unfortunately, the DHSS seems unable to provide leadership for their development.

These two documents give little hope that genuinely new initiatives will come from the DHSS. Whatever the initial intentions behind their publication, it now seems unlikely that “consultation” will prove to be anything more than a smokescreen behind which cutbacks in services can occur. True consultation implies availability of accurate information about the health and personal social services, together with a program of public education far more comprehensive than that which is currently envisaged.

Home and hospital confinement in Newcastle upon Tyne, 1960 to 1969

During the decade 1960 to 1969, perinatal mortality rates in Newcastle upon Tyne fell in parallel with national trends, in association with a marked reduction of domiciliary midwifery. Analysis of the records of women booked for confinement at home or in specialist hospitals showed that the reduction of mortality occurred with unexpected uniformity in both categories, in low risk as well as high risk patients, and in all causes of mortality except congenital malformations. It could not be attributed to improvements in maternal characteristics nor to increased size of babies at birth. The most probably explanation seems to be a combination of many improvements in the quality of care, with increased awareness of risks, better selection of high-risk groups, and improved supervision and management throughout. There is no indication that single factor in obstetric management, such as more intervention during labour, had a dominant effect.

Evaluation of different approaches to obstetric care: Part II

The obstetric management and outcome of normal patients presenting to two obstetric teams working in the Cardiff Maternity Hospital are compared over a five-year period. One team induced labour with amniotomy and oxytocin infusion three times more frequently than the other. No advantage or disadvantage of this practice was demonstrated using various measures of perinatal morbidity and mortality. The implications of these findings are discussed together with those of two previously reported observational studies. The need for experimental research in perinatal medicine is stressed.