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PubMedDate not supplied

Alaska's obstetrical delivery systems: a descriptive epidemiologic study.

Delivery of obstetrical care in rural Alaska can be very challenging, due to remoteness, lack of medical resources and transportation difficulties. This descriptive study looks at what the current delivery systems for obstetrical care in Alaska are. Alaska's obstetrical delivery systems can be divided into three basic systems. 1) Full comprehensive obstetrical care limited only by lack of neonatal ICU capability. 2) Cesarean delivery capable, but with limited resources. 3) Low risk vaginal deliveries with no cesarean delivery capability except by transports approaching 6 hours. This study raises questions about which system is most effective for which communities. Further studies need to be undertaken to better understand how to provide effective obstetrical care in rural and bush Alaska at an acceptable risk, and at reasonable cost.

Alaska↗
PubMed2001

Obstetrical deliveries associated with maternal malignancy in California, 1992 through 1997.

OBJECTIVE: This study aims to characterize the rate of occurrence and nature of outcomes associated with obstetrical deliveries in women with malignant neoplasms among 3,168,911 women who delivered in California in 1992 through 1997. DESIGN: The study is a population-based retrospective review of infant birth and death certificates and maternal and neonatal discharge records. Cases of malignant neoplasms associated with obstetrical delivery were attributed to 1 of 3 categories, depending on the earliest documented hospital discharge diagnosis, as follows: "prenatal" if the diagnosis was first documented by hospitalization within 9 months preceding delivery, "at delivery" if the diagnosis was established from the delivery hospitalization, or "postpartum" if the diagnosis was first documented by hospitalization within 12 months after delivery. METHODS: Computer-linked infant birth and death certificates and maternal and neonatal discharge records were used to identify cases and outcomes. Cases of malignant neoplasms were identified by using International Classification of Diseases, Ninth Revision codes (140-208). Noninvasive neoplasms and carcinoma in situ neoplasms were excluded. In analysis of outcomes, the Mantel-Haenszel estimate for adjusted odds ratios was used. RESULTS: Among 3,168,911 obstetrical deliveries over the 6-year span, a total of 2247 cases of primary malignancy were identified. The observed rate of occurrence for primary malignant neoplasms was 0.71 per 1000 live singleton births. Most cases (53.3%) were first documented in the postpartum period as follows: prenatal, 587 cases (0.18 per 1000); at delivery, 462 cases (0.15 per 1000); and postpartum, 1198 cases (0.38 per 1000). The most frequently documented primary malignant neoplasms associated with obstetrical delivery were breast cancer (423 cases, 0.13 per 1000), thyroid cancer (389 cases, 0.12 per 1000), cervical cancer (266 cases, 0.08 per 1000), Hodgkin's disease (172 cases, 0.05 per 1000), and ovarian cancer (123 cases, 0.04 per 1000). Odds ratios for a variety of demographic factors identified maternal age as the most significant risk factor for development of malignant neoplasms (age greater than 40 vs 20-25, odds ratio 5.7, CI 4.6-6.9). Age-adjusted odds ratios for maternal cancer of any type suggested significantly elevated risks for cesarean delivery (odds ratio 1.4, CI 1.3-1.6), blood transfusion (odds ratio 6.2, CI 4.5-8.5), hysterectomy (odds ratio 27.4, CI 20.8-36.1), and maternal postpartum hospital stay greater than 5 days (odds ratio 30.6, CI 27.9-33.6), but not for postpartum maternal death (odds ratio 0.8, CI 0.6-1.0). Odds ratios also suggested significantly elevated risks for premature newborn (odds ratio 2.0, CI 1.8-2.2), very low birth weight (odds ratio 2.9, CI 2.2-3.8), and newborn hospital stay longer than 5 days (odds ratio 2.6, CI 2.4-3.0), but not for neonatal death (odds ratio 1.6, CI 0.8-3.1) or infant death (odds ratio 1.2, CI 0.5-3.3). However, several types of malignant neoplasms did confer significant elevations in risk for neonatal death. Hospital charges for both maternal and neonatal care were significantly elevated in the maternal malignant neoplasm group. CONCLUSION: A lower than expected occurrence rate of obstetrical delivery associated with maternal malignancy was seen when compared with previously published hospital-based reports. Malignant neoplasms associated with obstetrical delivery were most frequently first documented in the postpartum period. Maternal and neonatal morbidity were significantly increased, yet the risk of in-hospital maternal death was not significantly elevated. A significant increase in risk of neonatal death for infants of mothers with cervical cancer was found.

Adult↗
PubMed2003

Cancer associated with obstetric delivery: results of linkage with the California cancer registry.

OBJECTIVE: This study provides revised population-based measurements for the occurrence rates of cancer associated with obstetric delivery and examines perinatal and cancer-related outcomes within the group of women with 4,846,505 obstetric deliveries in California, inclusive of the years 1991 through 1999. STUDY DESIGN: This observational study used a population-based retrospective review of cases identified as a result of computer linkage of maternal/neonatal hospital discharge and birth/death records with case files in the California Cancer Registry (CCR). The effect of timing of cancer diagnosis on clinical outcomes was studied by dividing the cases into three groups as follows: "prenatal" for cancer diagnosis within 9 months before delivery, "at delivery" for cancer diagnosis during delivery hospitalization, and "post partum" for cancer diagnosis within 12 months after delivery. Computerized records for 4,846,505 obstetric patients and 4,906,920 newborn infants comprising the linked vital statistics birth/patient discharge database (VS/PDD) were used to identity-match cases within the CCR case files. Cases of malignant disease were categorized into 22 anatomic or histologic subgroups. Perinatal clinical outcomes including preterm delivery, prolonged neonatal hospital stay, stillbirth, neonatal death, frequency of first trimester prenatal care, and cesarean delivery were analyzed by use of International Classification of Diseases, 9th Revision, Clinical Modification codes from the VS/PDD. Clinical cancer outcomes including cancer stage and vital status on follow-up were drawn from CCR records. Statistical comparisons for trends were performed with the Cochran-Armitage test, outcomes comparisons with the Fisher exact test, and survival comparisons were performed with the Cox proportional hazard model. RESULTS: Among 4,846,505 obstetric deliveries, 4,539 cases of invasive malignancy were identified for an observed occurrence rate of 0.94 per 1000 births. Sixty-four percent of the cases occurred post partum; cancers of the breast, thyroid, cervix, along with malignant melanoma, and Hodgkin's disease accounted for 64% of the cases. The timing of cancer diagnosis affected clinical outcomes: for all cancer cases as a group, the most favorable perinatal and cancer outcomes occurred in women whose cancer diagnosis was made 6 to 9 months before delivery (6% of cases). The most unfavorable perinatal and cancer outcomes were associated with cancer diagnosis made 0 to 3 months before delivery (14% of cases). For women whose cancer was diagnosed post partum, perinatal outcomes were minimally affected by the presumed existence of occult cancer at the time of obstetric delivery. CONCLUSION: The use of computer-linkage to the CCR files enhanced identification of cases of maternal malignancy associated with obstetric delivery. Cancer diagnosis was associated with approximately 1 in 1000 deliveries. Most cases were diagnosed after delivery and were comprised predominantly of cancers of the breast, thyroid, cervix, malignant melanoma, and Hodgkin's disease. A small group of women (approximately 1 per 5000 deliveries) are seen within a few months before delivery or at delivery with malignant disease, many of whom have rapidly progressing disease and may require high-risk perinatal and oncology services.

Breast Neoplasms↗
PubMed2001

Obstetrical delivery of the HIV-positive woman: legal and ethical considerations.

Every year, thousands of perinatally HIV-infected children are born, resulting in debate about appropriate HIV treatment and interventions for pregnant women. Recent medical studies endorse the use of the cesarean delivery to reduce vertical (mother to infant) transmission of HIV. In addition to medical questions, this practice raises legal and ethical considerations for the attending physician. In the context of AIDS prevention, the potential exists for reasoned and well-informed decision making to give way to encouragement, and even duress, in cases where a woman refuses recommended surgical delivery. However, in such cases, the role of the physician should remain as that of an informed educator and counselor, enabling the patient to exercise her autonomy and personal choice within her social and cultural context.

Cesarean Section↗
PubMed2005

[Obstetric delivery and risk of neonatal mortality in Goiânia in 2000, Brazil].

OBJECTIVE: To determine factors associated to vaginal delivery and increased neonatal mortality in cohort studies of newborns. METHODS: A retrospective cohort study was carried out using linkage data from the Information System on Live Births and Mortality Data System database, which included all newborns in Goiânia for the year 2000. A stratified analysis of delivery routes and maternity hospitals by risk factors of neonatal mortality was conducted through the calculation of relative risk at a 5% significance level. Statistical analyses were carried out using the Chi-square test at a 5% significance level. RESULTS: Vaginal deliveries were more commonly seen than cesarean sections in situations where there was an increased risk of neonatal mortality. Public hospitals, where vaginal deliveries predominated, were sought by the majority of those pregnant women with an increased risk of neonatal mortality. Private hospitals, not affiliated to the public-funded Brazilian Healthcare System (SUS) and where the incidence of cesarean section was as high as 84.9%, opted for vaginal delivery in situations of greater risk, such as extreme prematurity and very-low-birth-weight infants. CONCLUSIONS: The association between vaginal delivery and increase neonatal mortality resulted from a selection bias due to the distribution of pregnant women in the hospital network. In addition, this selection bias also resulted from an almost universal preference for cesarean sections in low-risk pregnancies as opposed to vaginal delivery for pregnancies with an increased risk of neonatal mortality.

Brazil↗
PubMedDate not supplied

Do increases in payments for obstetrical deliveries affect prenatal care?

Raising fees is one of the primary means that State Medicaid Programs employ to maintain provider participation. While a number of studies have sought to quantify the extent to which this policy retains or attracts providers, few have looked at the impact of these incentives on patients. In this study, the authors used Medicaid claims data to examine changes in volume and site of prenatal care among women who delivered babies after the Maryland Medicaid Program raised physicians fees for deliveries 200 percent at the end of its 1986 fiscal year. Although the State's intent was to stabilize the pool of nonhospital providers who were willing to deliver Medicaid babies, it was also hoped that women would benefit through greater access to prenatal care, especially care rendered in a nonhospital setting. The authors' hypotheses were that (a) the fee increase for obstetrical deliveries would result in an increase in prenatal visits by women on Medicaid, and (b) the fee increase would lead to a shift in prenatal visits from hospital to community based providers. The data for Maryland's Medicaid claims for the fiscal years 1985 through 1987 were used. Comparisons were made in the average number of prenatal visits and the ratio of hospital to nonhospital prenatal visits before and after the fee increase. Data for continuously enrolled women who delivered in the last 4 months of each fiscal year were analyzed for between and within year differences using Student's t-test and ANOVA techniques. The findings indicate very little overall change in either the amount or location of prenatal care during the year after the large fee increase for deliveries.Though significant increases in the number of prenatal visits occurred for women who lived outside of Baltimore City, it is difficult to attribute these changes solely to the fee increase. Where an effect was observed, it appeared to be greatest in non urban areas of the State, probably because coordination of care by fewer Medicaid providers is more common in such areas.The findings do not support the hypotheses that raising fees for obstetrical deliveries uniformly increase community-based prenatal care. Instead, the findings suggest that tying fee increases for obstetrical deliveries to the amount of prenatal care provided for each patient may be the best way of increasing the commitment of Medicaid obstetrical providers to give their patients more comprehensive perinatal care.

Adult↗