[Data collection of costs of oral health care delivery].
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Data Collection↗
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[Birthplace free-standing birth center -- perinatal data in comparison with clinic deliveries in Bavaria and Berlin].
QUESTION: The purpose of this investigation is to find any differences between important maternal and infantile perinatal data from a clinic and a birth center group. Is the perinatal and/or maternal mortality in the birth center group higher? What influence do different socioeconomic factors have on the clinic group? PATIENTS AND METHODS: We have carried out a retrospective comparison of the obstetric parameters from all birth center deliveries in the states Berlin and Bavaria for the years 1999 and 2000 (n = 3,060) and the perinatal data investigations of selected clinical groups of both states (n = 55,875). RESULTS: Objective parameters in both groups regarding week of potation at delivery, parity, age of pregnant women, infantile measures, primi- and multiparae and Apgar scales were comparable. There are significant differences in the delivery mode (spontaneous deliveries: birth centers > clinics; operative deliveries: birth centers < clinics), in blood loss over 1,000 ml (birth centers > clinics), in the episiotomy and perineal tear rate (birth centers < clinics), in the infantile transfer rate to a neonatology unit (birth centers < clinics) and in the frequency of necessary neonatological measures in the neonate (birth centers > clinics). The perinatal and maternal mortality in the groups were similar. Within the clinical group the socioeconomic status and a background of immigration had no significant influence on the perinatal data. CONCLUSION: The retrospective data show that the more "invasive" clinical obstetrics leads to a similar postnatal condition of the neonates in comparison to the birth house group. Further comparative studies over several years are necessary to make statements about the occurrence of rare risks and maternal mortality in the free-standing birth center groups.
Adult↗
Factors associated with hospital-specific cesarean birth rates.
The variation in hospital-specific cesarean birth rates was examined using a multiple regression analysis in a national data base of deliveries in 1977. This data base included 222,285 singleton births in 282 hospitals representing all regions of the United States. The 32 independent variables included measures of medical risk, technologic sophistication, demographic characteristics and economic incentives. The incidences of medical risk factors, nonwhite race and ratio of obstetricians to fertile women were associated positively with hospital-specific cesarean delivery rates. Participation in health maintenance organizations and numbers of deliveries were correlated negatively with those rates. Hospital-specific cesarean delivery rates were not associated with technologic sophistication, malpractice premiums or reimbursement differences between routes of delivery. Pay source stratified models explained 45-63% of the variation in the hospital-specific cesarean rates. Sensitivity analysis revealed that even a 50% change in the incidence of any independent variable would change the cesarean delivery rate by less than 2%.
Birth Rate↗
No obvious spatial clustering of twin births in Sweden between 1973 and 1990.
The aim of this work was to ascertain whether spatial clustering of twin deliveries occurred in Sweden between 1973 and 1990. Since 1973, the Medical Birth Registry (MBR) has gathered information on all births in Sweden. Between 1973 and 1990, there were 17,067 twin deliveries. The MBR records data on pregnancies, deliveries, and the neonatal period, including parturients' domicile. To test the hypothesis that atmospheric pollution from refuse incinerators increases the incidence of twin deliveries, the periods before and after the commissioning of 14 such plants were compared. There was no apparent increase in the number of parishes or municipalities having a relative excess of twin deliveries. In the vicinity of one plant, there was a significantly increased number of twin deliveries, whereas in another, there was a significant decrease. There was no spatial clustering when the incidences of twin delivery were compared among parishes, municipalities, and areas near incinerators.
Birth Rate↗
Transfecting neurons and glia in the rat using pH-sensitive immunoliposomes.
Immunoliposomes were constructed using antibody 5-113 (directed to an antigen on the external surface rat glial cells), the antibody Thy 1.1, and a non-immune antibody. The antibodies were conjugated to N-gluytaryl-phosphatidylethanolamine. Liposomes were constructed with these conjugated antibodies, other lipids and a beta-galactosidase plasmid under the control of the cytomegalovirus promoter. When immunoliposomes decorated with one of three different antibodies were injected into the brain or spinal cord of adult rats, the X-gal reaction product was observed in neurons, astrocytes and vascular elements. There was an increase in neuronal labeling when animals were injected with Thy 1.1 conjugated liposomes and there was an increase in glial labeling in animals injected with 5-113 liposomes. In spinal cords, the immunoliposomes appear to penetrate a substantial distance, transfecting neurons several centimeters from the site of delivery. These data suggest that immunoliposomes may provide an effective transfection system for gene delivery in the CNS.
Animals↗
Psychosocial predictors of disappointment with delivery and puerperal depression. A longitudinal study.
BACKGROUND: To examine the extent to which personality characteristics, depression, fear and anxiety about pregnancy and delivery, and socio-economic background, predict disappointment with delivery and the risk of puerperal depression. METHODS: Two hundred and eleven women filled in questionnaires measuring personality traits, socio-economic factors, and marital satisfaction once before and once after the 30th week of pregnancy, and 2 3 months after delivery, when obstetric data about pregnancy and delivery was also collected. RESULTS: The women who were disappointed with their delivery or suffered from puerperal depression had been more depressed already in early pregnancy. Regression analysis showed that the strongest predictors of disappointment with delivery were labor pain (increase in R2 = 0.14, p<0.001) and emergency Cesarean (increase in R2 = 0.18, p<0.001). Puerperal depression was predicted by depression (increase in R2 = 0.16, p<0.001), and by personal traits such as general anxiety, vulnerability and neuroticism (increase in R2 = 0.32, p<0.001), both before 30 weeks of pregnancy and prior to the delivery (for depression increase in R2 = 0.05, p<0.001, and for anxiety and vulnerability increase in R2 = 0.04, p<0.01). The strongest predictors were depression at both time points before delivery (beta = 0.51, p<0.001, and beta = 0.39, p<0.001). Pregnancy- and delivery-related anxiety prior to the delivery also predicted puerperal depression, but complications of the pregnancy and delivery did not. CONCLUSIONS: Depression in early pregnancy predicts disappointment with the delivery and is a strong predictor of puerperal depression.
Adolescent↗
Breech delivery at term in Denmark, 1982-92: a population-based case-control study.
The aim of the study was to determine the influence of intended mode of delivery on neonatal outcome in term breech delivery and to identify risk factors at intended vaginal delivery. Based on register data on all deliveries of non-malformed, singleton fetuses in breech presentation at term (n = 19,476) in Denmark, 1982-92, a review of medical records of all (n = 218) cases with Apgar score < 7 at 5 minutes, including intrapartum and early neonatal deaths and 412 controls, was performed. Planned vaginal delivery was associated with a 15 times greater risk of low Apgar score than elective Caesarean section. Low Apgar score was correlated with duration of second stage of labour, but not with age, parity, birthweight, induction, augmentation or duration of first stage of labour. In conclusion, a pre-labour decision on vaginal delivery was associated with a 15-fold increase in low Apgar score. Prediction of low Apgar score in women selected for vaginal delivery does not seem possible before the second stage of labour.
Apgar Score↗
Potential risk factors for vertical HIV-1 transmission in Catalonia, Spain: the protective role of cesarean section. The Working Group on HIV-1 Vertical Transmission in Catalonia.
OBJECTIVE: To evaluate the roles of certain potential risk factors on the vertical transmission of HIV-1. DESIGN: Prospective registry of infants born to HIV-1-infected women in Catalonia (north-east Spain) from 1987 to 1992. METHODS: A total of 599 infants, born in Catalan hospitals to 520 women who were identified as being HIV-1-infected during gestation or at delivery, were included. Data on mode of delivery, birth weight, gestational age and breast-feeding as well as the mother's age, her route of HIV-1 infection, clinical stage and p24 antigenaemia, were recorded. HIV-1 infection status of 489 (82%) of the infants was determined according to the criteria of the US Centers for Disease Control and Prevention. Risk estimates and odds ratio (OR) were calculated and logistic regression was performed. RESULTS: The overall rate of vertical transmission was 18.6% (95% confidence interval, 15.2-22.0%). Multivariate analyses revealed that Cesarean section was associated with a lower rate of vertical transmission (OR = 0.3; P = 0.001), as was maternal HIV-1 infection via injecting drug use (OR = 0.44; P = 0.02). Breast-feeding (OR = 6.9; P = 0.001), very low birth weight (< 1500 g; OR = 6.3; P = 0.001) and p24 antigenaemia (OR = 4.6; P = 0.04) were all related to increased risk. The crude rate of HIV-1 transmission was 6% among Cesarean births compared with 21% for infants born via vaginal deliveries. The population-attributable risk for vaginal deliveries was 61.7%. CONCLUSIONS: The results show a protective effect of Cesarean section in the absence of zidovudine prophylaxis. However, current research should be directed towards the individual and combined effects that antiretroviral agents and Cesarean section may have on mother-to-child HIV-1 infection.
Adult↗
Single pre-delivery symphysis-fundal height measurement as a predictor of birthweight and multiple pregnancy.
OBJECTIVE: To compare the value of different pre-delivery maternal indices for predicting birthweight, and to examine the usefulness of a single pre-delivery symphysis-fundal height measurement for the detection of low birthweight and twin pregnancy or macrosomia. DESIGN: Symphysis-fundal height measurements were gathered from 1509 women who had both a singleton delivery and available data of pre-delivery weight, height and mid-upper arm circumference, and from 73 women who had a twin delivery. SETTING: A district hospital in rural Tanzania. RESULTS: Symphysis-fundal height, pre-delivery weight and mid-upper arm circumference, respectively, explain 41%, 13% and 4% of the observed variation in birthweight. At a cut-off level of 30 cm for symphysis-fundal height, the detection rate for birthweight below 2500 g and 2000 g was 66% and 68%, respectively, and the false positive rate was 9% and 14%, respectively. At a cut-off level of 38 cm for symphysis-fundal height the detection rate for twin pregnancy or birthweight > or = 4000 g was 76%, and the false positive rate was 4%. CONCLUSION: Symphysis-fundal height was a better predictor of birthweight than maternal height, pre-delivery weight or mid-upper arm circumference. It seems justified to investigate the value of a simple tricoloured symphysis-fundal height measuring tape for use in antenatal care in developing countries at village level.
Adolescent↗
Labor experiences of childhood sexual abuse survivors.
This field study used the ethnographic method to describe and analyze the labor experiences of childhood sexual abuse survivors. The sample included seven sexual abuse survivors, five nurse-midwives, and three labor and delivery nurses. Data collection included in-depth interviews, participant observation in labor and delivery over a period of six years, and anecdotal material from the literature. Analysis followed Spradley's Developmental Research Sequence and included domain, taxonomic, componential and theme analysis. Women reported both forgetting and remembering abusive incidents, and described labor sensations reminiscent of sexual abuse. A heuristic for appraising labor styles suggestive of past sexual abuse includes fighting, taking control, surrendering, and retreating. These styles are considered extremes of women's reactions to labor and are directly linked to posttraumatic stress disorder. This study demonstrated that it is important for perinatal caregivers to understand the link between childhood sexual abuse and childbirth so that they can assist women to have a positive birth experience.
Child↗
Effects of increased red cell mass on subclinical tissue acidosis in hyaline membrane disease.
AIM: To determine whether there are subclinical deficits in oxygen delivery in ventilated premature neonates. METHOD: Ventilated premature neonates weighing less than 1500 g, who were transfused for anaemia or who were given colloids for clotting abnormalities (or oedema), were haemodynamically monitored during the first week of life. Calf muscle surface pH (pH) was measured in conjunction with peripheral limb blood flow by occlusion plethysmography. RESULTS: Packed red blood cell transfusions corrected a subclinical regional tissue acidosis (low tpH) without affecting arterial pH or limb blood flow. This observation also correlated with an increase in regional oxygen delivery. The data were also suggestive of a pattern of pathological, supply dependent, oxygen delivery and are similar to other observations made in adults with adult respiratory distress syndrome. CONCLUSIONS: Packed red blood cells increase regional oxygen delivery and tissue surface pH. In contrast, colloid infusion provided no substantial cardiovascular or metabolic benefit to these patients and should be avoided when oxygen delivery is at issue and when there may be leaky pulmonary capillaries.
Acidosis↗
Efficacy of external cephalic version: a review.
OBJECTIVE: To assess the efficacy of external cephalic version, including safety, cost-benefit analysis, and impact on the cesarean delivery rate. DATA SOURCES: A MEDLINE search was conducted to identify all articles published in English between 1980-1991 on external cephalic version. References were also cross-checked for all reports. METHODS OF STUDY SELECTION: We reviewed only those articles providing sufficiently detailed data to determine actual numbers of subjects. In cases of duplicate results, only the latest publication was used. Rates of successful version, cesarean delivery, and fetal and maternal complications were presented. DATA EXTRACTION AND SYNTHESIS: Among the United States trials, the success rate was approximately 65% (range 48-77%), and once version succeeded, almost all the fetuses stayed in the vertex position until birth. Among those in whom external version was performed, the mean cesarean delivery rate was 37%, compared with 83% in controls (P < .001). External version would also save 12.3% of the costs of delivering breech patients overall. CONCLUSION: External cephalic version is safe and cost-effective. It substantially reduces the cesarean delivery rate among breech presentations, decreases the risk related to breech delivery, and avoids cesarean delivery in subsequent pregnancies. However, external version will not have a major impact on the high overall cesarean birth rate.
Africa↗
Small uterine septum is an important risk variable for preterm birth.
OBJECTIVE(S): To evaluate whether a uterus with a small septum (arcuate uterus or class VI according to the American Fertility Society (AFS) classification) behaves similarly to a uterus with a larger septum (septate or subseptate uterus or AFS class V). STUDY DESIGN: Observational study included 826 singleton deliveries to 730 women with a history of hysteroscopic resection of the uterine septum. Data on deliveries were obtained from the National Perinatal Registry of Slovenia (NPIS). Multiple gestations were excluded. We analysed and compared perinatal outcomes before and after hysteroscopic resection in two groups of women: in women with a small uterine septum (Group A) and in those with a larger uterine septum (Group B). Data on the septum length were obtained during hysteroscopic resection by comparing the length of the 1.4-cm long yellow tip of the electric knife to the length of the resected septum. A small uterine septum was defined as having a length of 1.3-1.5 cm. RESULTS: The preterm birth rate in Group A (n=420) was 33.9% before and 7.2% after hysteroscopic resection (P<0.001); the preterm birth rate in Group B (n=406) was 36.5% before and 8.0% after hysteroscopic resection (P<0.001). The very preterm birth rate in Group A was 12.5% before and 3.1% after hysteroscopic resection (P<0.001); the very preterm birth rate in Group B was 15.0% before and 2.9% after hysteroscopic resection (P<0.001). After surgery, we registered a decreased need for neonatal intensive care, as well as a significant decrease in stillbirth and neonatal death rates in both groups of patients. CONCLUSION(S): Similarly to a large uterine septum, a small uterine septum or arcuate uterus is an important hysteroscopically preventable risk variable for preterm birth.
Female↗
Protein transduction by lipidic peptide dendrimers.
We investigated the potential of a new family of lipidic peptide dendrimers in protein transduction into cultured cells. Dendrimer-protein interaction was determined by gel retardation assays using purified recombinant protein. To assess intracellular protein delivery, two marker proteins were used: recombinant firefly luciferase and a Cy3-labeled monoclonal antibody to the c-myc proto-oncogene. Protein delivery was determined by luciferase assays and fluorescence microscopy, respectively. While there was minimal delivery of luciferase or antibody in the absence of the dendrimers, the latter increased protein delivery substantially. Luciferase delivery was concentration and cell type-dependent; the efficiency of delivery also varied with the number of terminal amino groups on the dendrimers. In previous reports, we showed that these dendrimers could be used for gene and drug delivery; the data we report herein suggest that they may also be capable of intracellular protein delivery. This finding has important implications for the use of these dendrimers in protein therapeutics and vaccinology.
Antibodies, Monoclonal↗
Variability in the learning experiences of family practice residents during an obstetrics rotation.
BACKGROUND AND OBJECTIVES: Residency rotations do not necessarily provide the same clinical experience to each resident. This study quantified and explained the variability in participation in deliveries by family practice residents during an obstetrics rotation at a community hospital. METHODS: We collected prospectively completed resident experience logs from 17 residents and information from the hospital Summary of Delivery forms for 1,166 deliveries. The data were analyzed using methods to account for within-supervisor correlation. RESULTS: Participation and delivery rates varied markedly. In stepwise conditional regression analysis, resident participation in deliveries was positively associated with prior resident involvement during the labor and negatively associated with occurrence of the delivery on the night shift and with male gender of the resident. Resident performance of delivery was positively associated with non-instrumented vaginal delivery, prior resident involvement during the labor, and patient multiparity and negatively associated with male resident gender. CONCLUSIONS: We found substantial variability in resident experience and identified several factors associated with increased resident experience. Variability of experience among residents in clinical rotations should be assessed to ensure that all residents receive adequate training.
Adult↗
Effect of epidural analgesia for labor on the cesarean delivery rate.
OBJECTIVE: To use meta-analysis to evaluate the effect of epidural analgesia on the cesarean delivery rate. DATA SOURCES: The MEDLINE data base was searched for articles published in English between January 1981 and April 1992. We also interviewed experts and conducted a bibliographic follow-up and manual review of recent journals published from April to July 1992. METHODS OF STUDY SELECTION: We excluded articles with irrelevant titles, and those case studies, book chapters, or articles that did not provide primary and relevant data. Two hundred thirty articles were read, including articles that reported on women of standard obstetric risk and on cesarean delivery rates for an epidural group and for a concurrent no-epidural group. These criteria yielded six studies for a primary analysis and two others for a secondary analysis. DATA EXTRACTION AND SYNTHESIS: The sample size of the epidural and no-epidural groups and the number of cesareans within each group were extracted. Tests of homogeneity were conducted. The pooled cesarean delivery risk difference as a result of epidural analgesia was estimated. The cesarean rate for women undergoing epidural analgesia was ten percentage points greater than for no-epidural women (P < .05). More than a nine percentage point increase was shown for cesarean deliveries for dystocia (P < .05), when pooling either all studies or only randomized studies. CONCLUSIONS: The results of this meta-analysis strongly support an increase in cesarean delivery associated with epidural analgesia. Further research should evaluate the balance between analgesia associated with the use of epidurals, and postpartum morbidity and costs associated with cesarean deliveries.
Analgesia, Epidural↗
The prediction of plasma and brain levels of 2,3,5,6-tetramethylpyrazine following transdermal application.
The purpose of this study was to construct a pharmacokinetic (PK) model and to determine PK parameters of 2,3,5,6-tetramethylpyrazine (TMP) after application of TMP transdermal delivery system. Data were obtained in Sprague-Dawley (SD) rats following a single dose of TMP transdermal delivery system. Blood samples were obtained at 0, 0.25, 0.5, 1, 2, 4, 6, 16, and 24 hours after the transdermal application. In the brain level study, 18 SD rats were divided into 6 groups. Three SD rats before and after transdermal application were culled and sacrificed at each of the following time intervals: 2, 4, 6, 16, and 24 hours after the TMP-TTS application. TMP concentrations in plasma and brain tissues were determined using high performance liquid chromatography and data were fitted using a zero-order absorption and a first-order-elimination 3-compartment PK model. Fitted parameters included 2 volumes of distribution (V1, V2) and 2 elimination rate constants (k10, k20). The elimination half-life for TMP in plasma and brain was 26.5 and 31.2 minutes, respectively. The proposed PK model fit observed concentrations of TMP very well. This model is useful for predicting drug concentrations in plasma and brain and for assisting in the development of transdermal systems.
Administration, Cutaneous↗
Interventions to prevent weight gain: a systematic review of psychological models and behaviour change methods.
OBJECTIVE: To identify and review published interventions aimed at the prevention of weight gain. DESIGN: A systematic review of published interventions aimed at the prevention of weight gain. METHODS: Search strategies-we searched eight databases, manually checked reference lists and contacted authors. Inclusion and exclusion criteria-studies of any design, in which participants were selected regardless of weight or age, were included. Interventions targeting a specific subgroup, multifactorial interventions, interventions aimed at weight loss, and those with an ambiguous aim were excluded. Data extraction-data were extracted on behaviours targeted for change, psychological model, behaviour change methods and modes of delivery, methodological quality, characteristics of participants, and outcomes related to body weight and self-reported diet and physical activity. Classification and validation-a taxonomy of behaviour change programmes was developed and used for classification of underlying model, behaviour change methods, and modes of delivery. The data extraction and subsequent classification were independently validated. RESULTS: Eleven publications were included, describing five distinct interventions in schools and four in the wider community. Where diet and physical activity were described, positive effects were usually obtained, but all were measured by self-report. Effects on weight were mixed but follow-up was generally short. Smaller effects on weight gain were found among low-income participants, students and smokers. Many participants in the community-based studies were overweight or obese. Study dropout was higher among thinner and lower-income subjects. CONCLUSION: Interventions to prevent weight gain exhibited various degrees of effectiveness. Definite statements about the elements of the interventions that were associated with increased effect size cannot be made as only one of the five studies that involved an RCT design reported a significant effect on weight. This intervention involved a correspondence programme and a mix of behaviour change methods including goal setting, self-monitoring and contingencies. Future interventions might be more effective if they were explicitly based on methods of behaviour change that have been shown to work in other contexts. Effective interventions would be more easily replicated if they were explicitly described. Effectiveness might be more precisely demonstrated if more objective measures of physical activity and diet were used, and if the follow-up was over a longer period. International Journal of Obesity (2000) 24, 131-143
Behavior Therapy↗