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PubMed2003

Maternal mortality and access to obstetric services in West Africa.

OBJECTIVES: Process evaluation has become the mainstay of safe motherhood evaluation in developing countries, yet the extent to which indicators measuring access to obstetric services at the population level reflect levels of maternal mortality is uncertain. In this study we examine the association between population indicators of access to obstetric care and levels of maternal mortality in urban and rural West Africa. METHODS: In this ecological study we used data on maternal mortality and access to obstetric services from two population-based studies conducted in 16 sites in eight West African countries: the Maternal Mortality and Obstetric Care in West Africa (MAMOCWA) study in rural Sénégal, Guinea-Bissau and The Gambia and the Morbidité Maternelle en Afrique de l'Ouest (MOMA) study in urban Burkina Faso, Côte d'Ivoire, Mali, Mauritanie, Niger and Sénégal. RESULTS: In rural areas, maternal mortality, excluding early pregnancy deaths, was 601 per 100,000 live births, compared with 241 per 100,000 for urban areas [RR = 2.49 (CI 1.77-3.59)]. In urban areas, the vast majority of births took place in a health facility (83%) or with a skilled provider (69%), while 80% of the rural women gave birth at home without any skilled care. There was a relatively close link between levels of maternal mortality and the percentage of births with a skilled attendant (r = -0.65), in hospital (r = -0.54) or with a Caesarean section (r = -0.59), with marked clustering in urban and rural areas. Within urban or rural areas, none of the process indicators were associated with maternal mortality. CONCLUSION: Despite the limitations of this ecological study, there can be little doubt that the huge rural-urban differences in maternal mortality are due, at least in part, to differential access to high quality maternity care. Whether any of the indicators examined here will by themselves be good enough as a proxy for maternal mortality is doubtful however, as more than half of the variation in mortality remained unexplained by any one of them.

Africa, Western↗
PubMed1998

Cost issues surrounding the use of computerized telemedicine for obstetric ultrasonography.

OBJECTIVE: The purpose of this study was to describe the cost implications of converting an established videotape review network for obstetric ultrasonography to one based on telemedicine technology. DESIGN: Retrospective review of fixed and non-fixed costs associated with interpreting obstetric ultrasound examinations using both videotape and telemedicine transmission. SUBJECTS: A network of three community offices transmitting 600 obstetric ultrasound examinations per month to a central tertiary level facility. METHODS: Sonographers at the community offices record ultrasound examinations onto videotape, which are then sent by courier to a central facility for interpretation. At the completion of this videotaped examination, sonographers repeat the ultrasound scan while transmitting real-time images over a telemedicine link to the central facility. Costs associated with the videotape review technique that can be avoided by converting to telemedicine interpretation were derived and compared with the fixed and non-fixed costs associated with establishing the telemedicine network. RESULTS: For this network, the fixed costs for establishing telemedicine are $101,750. Monthly non-fixed cost savings by eliminating videotape review include $1620 to $2700 for printing still images, $1200 for courier charges and $7000 for fewer repeat ultrasound examinations. Monthly non-fixed costs for the telemedicine network are $2415. Net monthly savings in non-fixed costs for a telemedicine network are therefore $7405 to $8585, which may pay for the initial fixed costs in 12 to 14 months. CONCLUSIONS: The high cost of a telemedicine network may be offset by possible savings in non-fixed costs compared with alternative systems for interpreting obstetric ultrasonography.

Costs and Cost Analysis↗
PubMed2002

Need for maternal critical care in obstetrics: a population-based analysis.

The purpose of this study was to note potential obstetric risk factors leading to maternal intensive care and to estimate the frequency, costs and outcomes of management. In a cross-sectional study of intensive care admissions in Kuopio from March 1993 to October 2000, 22 consecutive obstetric patients admitted to a mixed medical-surgical intensive care unit were followed. We recorded demographics, admitting diagnoses, APACHE II score, clinical outcomes and treatment costs. The overall need for maternal intensive care was 0.9 per 1000 deliveries during the study period. The mean age (+/-SD) of the patients was 31.7 (+/-6.6) years and the APACHE II score 10.8 (+/-6.2). The most common admission diagnoses were obstetric haemorrhage (73%) and pre-eclampsia-related complications (32%). The duration of ICU stay was 5.8 days (range 1-31) and one of the 21 patients died in the intensive care unit (4.5%). The total cost of intensive care was in the order of USD 5000 per patient. Very few obstetric patients develop complications requiring intensive care. Although several risk factors associated with maternal intensive care were documented, most cases occurred in low-risk women, which implies that the risk is relevant to all pregnancies. Long-term morbidity was rare, and collectively the outcome of intensive care was good. Further research is needed to determine effective approaches in prevention, such as uterine artery embolization.

Journal Article↗
PubMed1989

[Effect of obstetric-perinatal measures on mortality and early morbidity of premature infants weighing 500 to 1,500 grams].

In a retrospective analysis of perinatal influencing factors in 186 premature newborns of the Department of Gynaecology of the University of Erlangen covering the period from 1982-1987 with birth weights between 500 and 1500 grams, the mortality and early morbidity were analysed, as characterised by cerebral haemorrhages, respiratory distress syndrome and infections insofar, as they had been connected with the obstetrical approach and paediatric intensive-care treatment, 45 infants born in 1982/83 were compared with 141 infants, who had been subjected to a different treatment approach during 1984 to 1987. During the second period, there was a marked drop both in mortality and in the incidence of asphyxia-induced severe cerebral haemorrhage and of the respiratory distress syndrome. A shortened latency period after premature rupture of the amnion, and a more pronounced presence of a neonatologically experienced team of paediatricians were found to be significant obstetric liberal influencing factors in determining the need to perform Caesarean section. The triplication of the frequency of Caesarean section observed resulted in a 50% reduction in perinatal mortality and morbidity. Infants with pelvic presentation benefited most from the more liberal performance of Caesarean section, as did infants with vertex presentation. Shortening of the latency phase in premature rupture resulted in a marked reduction in infection morbidity and mortality. Therefore we conclude, that the frequently practised procrastination with the aim to await an improvement in lung maturity should be replaced by a more active obstetric management, avoiding both infection and birth trauma. Obstetric decisions should be based rather on prenatal estimation of weight than on the calculated gestational age. At present, the lowest birth weight associated with the expectation of a healthy life is considered to be 750 grams.

Asphyxia Neonatorum↗
PubMed2002

Length of hospital stay, obstetric conditions at childbirth, and maternal readmission: a population-based cohort study.

OBJECTIVE: We assessed the association between obstetric conditions, length of hospital stay for childbirth, and maternal readmission. STUDY DESIGN: A population-based cohort study was conducted on obstetric deliveries (N = 2,652,726) in Canada from 1989 to 1999. Women who were readmitted to the hospital because of obstetric causes within 60 days of initial discharge were identified. RESULTS: Among the readmitted cases, women with cesarean deliveries were more likely to be readmitted to the hospital in the first week after discharge than women with vaginal deliveries (53% vs 41%). After an adjustment for maternal age by means of a Cox regression model, the risk of maternal readmission after cesarean delivery was significantly increased by 21%, 18%, and 10% for mothers with a length of hospital stay of <or=2, 3, and 4 days, respectively, compared with mothers with a length of hospital stay of 5 days. Postpartum hemorrhage, major puerperal infection, and some hypertensive disorders were associated with an elevated risk for maternal readmission and were also the major causes of readmission. CONCLUSION: Short length of hospital stay and several obstetric conditions appear to increase the risk of readmission in women with cesarean birth.

Adolescent↗
PubMed2006

Angiographic embolization for obstetrical hemorrhage: effectiveness and follow-up outcome of fertility.

BACKGROUND: This study was undertaken to describe the results of angiographic embolization for obstetrical hemorrhage and the follow-up outcome of fertility. METHODS: Consecutive patients who received angiographic embolization for the management of obstetrical hemorrhage at a single tertiary center were included in this study. Medical records were reviewed to collect the clinical data and details on the procedure. Patients were interviewed by telephone to obtain the long-term outcomes for complications, menstruation, desire for conception, and subsequent pregnancies. RESULTS: Embolization was successful in 42 (86%) of 49 patients with obstetrical hemorrhage resulting from various causes. The main cause of hemorrhage was uterine atony (n=24). The success rate was significantly lower in cases with abnormal placentation than in other causes of hemorrhage (p<0.05). The procedure took an average of 45.6 min (range, 20-120 min). There were no major complications related to the procedure. We were able to follow-up 48 patients. Among 37 patients with preserved uteri, menstruation resumed spontaneously in 36 patients. Nine patients became pregnant, of which six gave birth to healthy babies and three ended in early miscarriage. CONCLUSIONS: Angiographic embolization is an effective noninvasive method for the management of obstetrical hemorrhage and a useful technique for preserving fertility.

Adult↗
PubMed2001

Maternal susceptibility locus for obstetric cholestasis maps to chromosome region 2p13 in Finnish patients.

BACKGROUND: Obstetric cholestasis, attributed to maternal hypersensitivity to estrogens, is a pregnancy-specific disorder characterized by pruritus and biochemical cholestasis in the second or third trimester of pregnancy. The pathophysiology of the disorder is incompletely understood, but the familial nature of the disease has long been recognized. Carriership of long-chain 3-hydroxyacyl-coenzyme A dehydrogenase (LCHAD) deficiency has been reported to be associated with an increased risk of obstetric cholestasis and the gene is located in the p23 region of chromosome 2. METHODS: On the basis of this information, we conducted population-based linkage disequilibrium (LD) screening to find potential cholestasis-associated loci on chromosome 2. The study was carried out in 47 unrelated control women and in 45 cholestatic women, eight of whom had a positive family history. RESULTS: During initial screening with chromosome 2-specific microsatellite markers, the tetranucleotide marker D2S1394 was found to be in LD in the 2p13 region. Screening this region with additional microsatellite markers revealed that the adjacent marker D2S1374 was also significantly associated with obstetric cholestasis, whereas no association was found with the markers located in the vicinity of the hydroxyacyl-CoA dehyrogenase/3-ketoacyl-CoA thiolase/enoyl-CoA hydratase, alpha subunit (HADHA) gene. CONCLUSIONS: Collectively, these data suggest that there may be a novel obstetric cholestasis-associated gene located in the vicinity of the 2p13 LD region.

3-Hydroxyacyl CoA Dehydrogenases↗
PubMed2001

Can cardiotocography prior to induction of labour predict obstetric intervention? A pilot study.

We set out to study the value of cardiotocography (CTG) performed before induction of labour for prolonged pregnancy in predicting obstetric intervention. This was a prospective observational study, based in a district general hospital. We studied 100 consecutive patients who underwent induction of labour for prolonged pregnancy. Cardiotocographs (CTGs) were performed before induction of labour on the tenth day after the estimated date of confinement (290 days). The CTGs were then reviewed without knowledge of the outcome of the induction of labour. Obstetric outcomes were then compared. The main outcome measures were the intrapartum presence or absence of meconium stained liquor and the necessity for obstetric intervention. Ninety per cent of CTGs were normal. There was no difference found between the two groups for operative delivery or the presence of meconium liquor. Caesarean section was more likely in the group with an abnormal CTG before induction of labour, but the possibility of this being due to chance is high in this study. There was one case of undiagnosed growth restriction in the abnormal CTG group. These results may be due to a true lack of difference in obstetric intervention between women with normal or abnormal CTGs prior to induction of labour or more probably an inability to detect a difference in our small study. These baseline data allow the calculations necessary for a more substantive trial.

Journal Article↗
PubMed1997

'Near-miss' obstetric enquiry.

A near-miss maternal mortality enquiry was performed at University College Obstetric Hospital, London, by reviewing retrospectively all 30 obstetric admissions to the intensive care unit (ITU) over a two-year period. The obstetric admission rate to ITU was 0.5 (95% CI 0.32-0.67%), or one per 200 women delivered. Haemorrhage and severe pre-eclampsia were the two commonest causes of admission. Sub-standard care was identified in 52% of cases. Blood loss was often massive ( 2000 ml), underestimated and required large volume transfusions (mean transfusion 6.4 units, range 1-24). Although there are problems with definitions, ascertainment and validity, 'near-miss' review is feasible. It is worthwhile for every hospital to carry out its own 'near-miss' enquiry using appropriate local criteria to identify potential areas for improvements. 'Near-misses' are more prevalent than deaths and are dominated by conditions that are amenable to treatment. They may be even more sensitive to improvement or deterioration in obstetric services than mortality data.

Journal Article↗
PubMed2000

Teenage pregnancy and ethnicity in The Netherlands: frequency and obstetric outcome.

OBJECTIVES: To study differences in frequency and obstetric outcome of teenage pregnancy (not ending in induced abortion) between the main ethnic groups in The Netherlands. DESIGN: A retrospective cohort study based on the 1990-93 birth cohort in the National Obstetric Registry. SUBJECTS: A total of 10,583 teenagers and 54,501 20-24-year-old women who had a singleton pregnancy and were primiparous. MAIN OBSTETRIC OUTCOME MEASURES: These were perinatal death occurring between the 16th week of pregnancy and 24 h after birth, preterm birth and operative delivery (vaginal extraction and Cesarean section). METHOD: Comparison of the frequency of teenage pregnancy between ethnic groups and by bivariate and multivariate analysis of the three outcome measures between the teenage groups, the teenage groups and ethnically related 20-24-year-old women, and the teenage groups and Dutch 22-24-year-old women. RESULTS: A total of 55.2% of pregnant teenagers had non-Dutch ethnicity compared to 13.8% of all pregnant women. Islamic-Mediterranean teenagers constituted the largest group, one in four of all primiparous Mediterranean women being younger than 20 years of age, followed by black teenagers. Except for Hindustani teenagers, perinatal death occurred in all non-Dutch teenage groups more frequently than in Dutch teenagers, but the differences were only significant for black teenagers (odds ratios of black compared to Dutch teenagers were 2.89 (95% confidence interval (CI) 1.89-4.4) and 1.53 (95% CI 1.19-1.98), respectively). Rates for preterm birth were higher in black and Asian than in Dutch teenagers, but the difference was only significant for black teenagers (odds ratio 1.53, 95% CI 1.19-1.98). Compared to ethnically related 20-24-year-old women, rates of perinatal death and preterm birth were significantly higher in Dutch, black and Asian teenagers and, for preterm birth only, in Mediterranean teenagers. Correction for preterm birth showed that only part of these differences in perinatal death could be explained by preterm birth. Vaginal extraction and Cesarean section occurred less frequently in teenagers than in ethnically related (and in Dutch) 20-24-year-old women. Mediterranean teenagers had the lowest Cesarean section rate and Blacks the lowest vaginal extraction rate. CONCLUSION: Teenage pregnancy in The Netherlands is much more common in minority ethnic groups than in the indigenous population, particularly among Islamic-Mediterraneans and Blacks. Obstetric outcomes vary considerably, these being best in Hindustani and poorest in black teenagers, and being worse in teenagers than in 20-24-year-old women. However, teenagers less often had assisted delivery.

Adolescent↗
PubMed1999

Epidemiological studies of obstetric ultrasound examinations in Denmark 1989-1990 versus 1994-1995.

BACKGROUND: The purpose of the study was to describe number, type, time and place for all obstetric ultrasound examinations that pregnant women in Denmark had performed during their pregnancies. Further, to compare these results with results from a similar national survey performed five years previously. METHODS: During a two-week period in February 1990 and a two-week period in May 1995, all delivery departments in Denmark (1990: 57/1995: 49) participated in two identical designed studies with the aim as described above. For all women who delivered in these periods variables were recorded from the women's case records and after interview. After the exclusion of 108/145 women without complete registrations, the material consisted of 2268/2315 women; approximately 3.7%/3.4% of all deliveries in Denmark 1990/1995. The chi2 and t-test were used for statistical analyses with a statistical significance level of 5%. RESULTS: Of all obstetric ultrasound examinations 99%/96% took place in hospitals. Twenty/seven percent of the women had no examination during their pregnancies. The mean number of obstetric ultrasound examinations was 1.5/1.9 for all women and 1.9/2.1 for women who had at least one examination. In total 40%/54% of the women were offered a screening examination. Women with an offer of screening had a mean number of examinations: 1.8/2.0 and women without an offer: 1.3/1.9 (1990: p<0.05; 1995: non-significant). CONCLUSION: The studies have shown an increasing number of women with an offer of ultrasound screening and in general an increased use of ultrasound examinations in obstetrics during the five year period 1990-1995 in Denmark.

Adult↗
PubMed2000

Obstetric prognosis in second pregnancy after preeclampsia in first pregnancy.

OBJECTIVE: To assess obstetric outcomes in women in their second pregnancy after preeclampsia in the first pregnancy. METHODS: We utilized population-based birth registry data of Kuopio University Hospital to investigate pregnancy outcome measures in 123 nonpreeclamptic parous women with prior preeclampsia and 21 women with repeat preeclampsia in their second pregnancy. The general obstetric population was used as a reference group in logistic regression. RESULTS: The development of recurrent preeclampsia in 15% of women is associated with adverse neonatal outcomes. A first preeclamptic pregnancy may offer protection against disease recurrence and a history of preeclampsia has no significant effects on birth weight, fetal distress, or prematurity rate. However, they have a higher rate of pregnancy-induced hypertension and abdominal deliveries, and, therefore, a greater proportion of newborns are referred to neonatal units for observation. CONCLUSIONS: Women in whom preeclampsia does not recur have good obstetric outcomes in their second delivery, almost comparable to that in the general obstetric population. A genetic susceptibility to preeclampsia alone has minor effects on pregnancy outcome in a second pregnancy if the disease does not recur.

Adolescent↗
PubMed2005

Aromatherapy for outpatients with menopausal symptoms in obstetrics and gynecology.

OBJECTIVE: To introduce Complementary and Alternative Medicine (CAM) into a hospital department of obstetrics and gynecology with the goal of achieving integrative medicine, the authors investigated the effectiveness of aromatherapy for outpatients with menopausal symptoms. LOCATION: The department of obstetrics and gynecology, St. Marianna University Hospital, Kawasaki, Japan. DESIGN: Participants in the aromatherapy trial received a 30 minute aromatherapy session performed by an aromatherapist that included a consultation, massage, and home care guidance. After they carried out approximately 1 month of home care, they received a second aromatherapy session. The patients' physical and mental health status was measured at the start and endpoint of the trial by use of the Kupperman index (KI), the self-rating depression scale, and consultation. SUBJECTS: Fifteen (15) outpatients (mean age, 54.3 +/- 7.4 years) with menopausal symptoms in the department of obstetrics and gynecology of St. Marianna University Hospital. RESULTS: The mean value of the KI score was significantly lowered after the aromatherapy trial from 31.4 +/- 6.8 to 22.9 +/- 6.1 (p = 0.001). CONCLUSION: This investigation shows that aromatherapy could be effective as a CAM method for menopausal symptoms in the setting of a hospital obstetrics and gynecology department.

Adult↗
PubMed2002

Obstetric outcome among women with unexplained infertility after IVF: a matched case-control study.

BACKGROUND: Infertility itself and also assisted reproductive treatment increase the incidence of some obstetric complications. Women with unexplained infertility are reported to be at an increased risk of intrauterine growth restriction during pregnancy, but not for other perinatal complications. METHODS: A matched case-control study was performed on care during pregnancy and delivery, obstetric complications and infant perinatal outcomes of 107 women with unexplained infertility, with 118 clinical pregnancies after IVF or ICSI treatment. These resulted in 90 deliveries; of these, 69 were singleton, 20 twin and one triplet. Two control groups were chosen from the Finnish Medical Birth Register, one group for spontaneous pregnancies (including 445 women and 545 children), matched according to maternal age, parity, year of birth, mother's residence and number of children at birth, and the other group for all pregnancies after IVF, ICSI or frozen embryo transfer treatment (FET) during the study period (including 2377 women and 2853 children). RESULTS: Among singletons, no difference was found in the mean birthweight, and the incidence of low birthweight (<2500 g) was comparable with that of the control groups. No differences were found in gestational duration, major congenital malformations or perinatal mortality among the groups studied. Among singletons in the study group, there were more term breech presentations (10.1%) compared with both spontaneously conceiving women and all IVF women (P < 0.01). The rate of pregnancy-induced hypertension was significantly lower among singletons in the study group (P < 0.05) compared with other IVF singletons. The multiple pregnancy rate was 23.3% in the study group. The obstetric outcome of the IVF twins was similar to both control groups. CONCLUSIONS: The overall obstetric outcome among couples with unexplained infertility treated with IVF was good, with similar outcome compared with spontaneous pregnancies and IVF pregnancies generally.

Adult↗
PubMedDate not supplied

Homocysteine--a pathophysiological cornerstone in obstetrical and gynaecological disorders?

Homocysteine, a product of the methionine cycle, is known to play an important role in cardiovascular diseases, neurological disorders and embryology, and in very important, fast growing fields concerning obstetrics and gynaecology. Therefore, we attempted an actual overview on possible obstetrical and gynaecological disorders as a consequence of an impaired methionine cycle. We tried to evaluate all mechanisms concerning homocysteine metabolism in order to look for hypothetical possibilities of therapeutic interventions. Using MEDLINE starting in January 1966, a search was conducted for articles published in which homocysteine was included as a subject heading or a text word. This search was also specified in combination with other key words such as obstetrics, pregnancy, gynaecology and cancer. Additional sources were identified through cross-referencing. All sources found were examined with regard to providing substantial information on our topic. The information obtained was divided into articles dealing with homocysteine and the methionine cycle itself, homocysteine and pregnancy, and homocysteine and hormones, including menopause, hormone replacement therapy and oral contraceptives. Another group was concerned with other special gynaecological aspects of the methionine cycle. We suggest that elevated concentrations of homocysteine could be a marker and perhaps a cause of, or contributive to, a wide range of obstetrical and gynaecological disorders.

Animals↗
PubMed1998

The impact of obstetric risk factors and socioeconomic characteristics on utilization of antenatal care.

BACKGROUND: The objective of the study is to assess the impact of obstetric risk status and defined risk factors on utilization of antenatal care in a Swedish county. METHODS: An area-based, population study was carried out with retrospective review of standardized patient records before (n = 2008) and after (n = 1874) the introduction of a reduced schedule for surveillance of pregnancy. For assessment of individual risk factors a multiple regression model is used. RESULTS: Overall the number of contacts per pregnancy decreased from 13.2 to 11.4. With the reduced routine programme the difference between low-risk and high-risk women increased from 1.1 to 2.7 visits on average. In the multiple regression model socioeconomic characteristics had little influence on the use of antenatal care. Previous obstetric complications increased compliance to the schedule after the programme change. Complications during current pregnancy were important for the number of extra visits planned by the staff. Self referrals were most influenced by symptoms but in-patient care was influenced by multiple factors. The total explanatory ability of the regression model was low for time of first visit to the antenatal care unit and referrals for ultrasound examinations. CONCLUSIONS: With a reduced routine programme the surveillance became better apportioned to obstetric risk. Even a combination of medical or obstetric risk factors with socioeconomic characteristics explain only part of the variation in utilization of antenatal care.

Adolescent↗
PubMed1998

What's new in local anaesthetics for obstetric anaesthesia?

Despite its efficacy, bupivacaine has never been considered to be the most suitable agent for achieving anaesthesia and analgesia in the obstetric patient. Ropivacaine is less cardiotoxic than bupivacaine and, at low concentrations, can produce analgesia with minimal motor block, attributes which make it potentially very suitable for use in obstetrics. However, further research is required to ultimately establish ropivacaine's place in obstetric anaesthesia and analgesia. Levobupivacaine, the L isomer of bupivacaine, is of similar potency to bupivacaine but has the advantage of being significantly less cardiotoxic than racemic bupivacaine, which suggests that it might ultimately replace racemic bupivacaine in obstetric practice.

Journal Article↗
PubMed2001

Severe obstetric morbidity.

Obstetric morbidity is an important marker of the quality of obstetric care. This review explores the definition, incidence and significance of obstetric morbidity. Some topical issues related to obstetric morbidity are discussed. In addition, the importance of long-term morbidity and violence against women is highlighted.

Eclampsia↗