Janet H. Muri

Specialty newborn care: trends and issues.

OBJECTIVE: This report explores the availability of neonatal special care services in the US and examines the variation in those services from both the staffing and service perspectives.STUDY DESIGN: The American Hospital Association survey of hospitals and a special national survey of hospitals with special care services were used as data sources to describe changes in the status of high-risk care between 1983 and 1997. The latter survey had a 69% response rate and was a collaborative effort among the March of Dimes, the Maternal and Child Health Bureau, the American Hospital Association, the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, Ross Labs, and the National Perinatal Information Center (NPIC).RESULTS: The study found that across all regions of the US, the special care supply has expanded. However, the study shows wide variation in medical staffing even among those hospitals offering the most intensive services; 25% had no physician in-house coverage 24 hr/d.CONCLUSION: Wide availability of high-risk newborn care is not problematic and suggests an oversupply; however, differential physician staffing raises issues regarding the need for more standardized care.

Use of high-technology care among women with high-risk pregnancies in the United States.

Objective: Infant mortality has been reduced dramatically with the development of perinatal regionalized high-technology care. Our objective was to assess use of high technology care among women with high-risk pregnancies in the urban and rural United States. Methods: The 1988 National Maternal and Infant Health Survey was linked to the 1988 American Hospital Association survey of all obstetrical hospitals. Hospitals were classified into five levels of care based on services and staffing. Women were classified as having high-risk pregnancies using two definitions: (1) gestational age <34 weeks and birthweight <1500 g (High Risk I) and (2) the first definition or an antenatal high-risk medical diagnoses (High Risk II). Analyses assessed the proportion of high-risk women delivering in appropriate locations in the rural and urban United States and explored how personal characteristics, insurance status, and use and source of prenatal care influenced where high-risk women delivered. Results: 71.2% of High Risk I and 55.9% of High Risk II women delivered in a high-technology facility (Level IIA or III). Fifty percent of HRI rural women delivered in tertiary high-technology hospitals and 39% of HRII rural women delivered in a high-technology hospital. High-risk urban women were two to three times more likely to deliver in a high-technology facility compared to their rural counterparts. The multivariate analysis showed that Black high-risk women were more likely to deliver in a high-technology setting and that receipt of prenatal care in a private setting lowered the odds of delivering in a high-technology setting when other factors were controlled. Conclusions: In an era where regionalized perinatal care was not threatened by managed care, a large proportion of high-risk women received care in less than optimal settings. Rural high-risk women delivered in high-technology hospitals less often than their urban counterparts. The multivariate analyses implied that the potential barriers to care may be more important among those considered more socially advantaged, who may be more at the mercy of managed care. The current reimbursement environment, which discourages referral to specialists and high-technology care, could result in less access today.

The effect of labour induction on the risk of caesarean delivery: using propensity scores to control confounding by indication.

To use propensity score methods to control for confounding by indication in the association between labour induction and caesarean delivery.

Changes in delivery methods at specialty care hospitals in the United States between 2006 and 2010

Objective:Given the increasing rates of labor induction and cesarean delivery, and efforts to reduce early term births, we examined recent trends in methods and timing of delivery.Study Design:We identified delivery methods and medical indications for delivery from administrative hospital discharge data for 231 691 deliveries in 2006 and 213 710 deliveries in 2010 from 47 specialty care member hospitals of the National Perinatal Information Center/Quality Analytic Services. In a subset of 17 hospitals, we examined trends by gestational age.Result:From 2006 to 2010, there was an 11% increase in labor induction and a 6% increase in cesarean delivery, largely due to repeat cesareans. There was a 4 per 100 reduction in early term births (37 to 38 weeks), mostly due to a decline in non-medically indicated interventional deliveries.Conclusion:We report a shift in deliveries at 38 weeks, which we believe may be attributed to efforts to actively limit non-medically indicated early term deliveries.

The Joint Commission's ORYX initiative: implications for perinatal nursing and care.

In 1986, the Joint Commission on Accreditation of Healthcare Organizations initiated the Agenda for Change, a new era in its accreditation process, announcing that it would begin to incorporate outcome or performance indicators into its review of hospitals. The expanded focus, to include performance indicators, was in direct response to the rapidly changing health care environment. From 1987 to 1993, the Joint Commission tested five sets of indicators at more than 450 volunteer hospitals, hi February 1996, the Joint Commission announced the ORYX initiative. The article reviews the history of the Joint Commissions Agenda for Change and highlights the new ORYX initiative, with particular focus on the development of the perinatal indicators and the role of the perinatal nurse in meeting the ORYX requirements.

Public Health Data in Action: An Analysis of Using Louisiana Vital Statistics for Quality Improvement and Payment Reform

Introduction In 2012, the Louisiana (LA) Department of Health and Hospitals revised the LA birth certificate to include medical reasons for births before 39 completed weeks’ gestation. We compared the completeness and validity of these data with hospital discharge records. Methods For births occurring 4/1/2012–9/30/2012 at Woman’s Hospital of Baton Rouge, we linked maternal delivery and newborn birth data collected through the National Perinatal Information Center with LA birth certificates. Among early term births (37–38 completed weeks’ gestation), we quantified the reasons for early delivery listed on the birth certificate and compared them with ICD-9-CM codes from Woman’s discharge data. Results Among 4353 birth certificates indicating delivery at Woman’s Hospital, we matched 99.8% to corresponding Woman’s administrative data. Among 1293 early term singleton births, the most common reasons for early delivery listed on the birth certificate were spontaneous active labor (57.5%), gestational hypertensive disorders (15.3%), gestational diabetes (8.7%), and premature rupture of membranes (8.1%). Only 2.7% of births indicated “other reason” as the only reason for early delivery. Most reasons for early delivery had >80% correspondence with ICD-9-CM codes. Lower correspondence (35 and 72%, respectively) was observed for premature rupture of membranes and abnormal heart rate or fetal distress. Discussion There was near-perfect ability to match LA birth certificates with Woman’s Hospital records, and the agreement between reasons for early delivery on the birth certificate and ICD-9-CM codes was high. A benchmark of 2.7% can be used as an attainable frequency of “other reason” for early delivery reported by hospitals. Louisiana implemented an effective mechanism to identify and explain early deliveries using vital records.

Hospital differences in special care nursery use for newborns of gestational diabetic mothers

Abstract Objective: Relatively healthy newborns of mothers with gestational diabetes mellitus (GDM) sometimes receive unwarranted surveillance. We studied the relationship between hospital characteristics and special care nursery use and total length of stay among GDM deliveries. Methods: We identified GDM deliveries at 44 USA member hospitals of the National Perinatal Information Center from 2007 to 2011. To study low risk, relatively healthy newborns with presumed discretion in special care nursery use, we analyzed 43 444 singleton newborns with only minor or moderate complications and WHO were not preterm or low birthweight. Results: Among eligible newborns, 6% received special care, but this ranged from 1% to 16% across 44 hospitals studied. Unadjusted associations suggested special care nursery use was highest in academic teaching hospitals, the Midwest, hospitals with ≥40% Medicaid births, and hospitals with a high supply of special care nursery beds. However, after controlling for clustering within hospitals, there were no significant associations between hospital characteristics and special care nursery use or length of stay. Conclusions: Hospital-level variation in special care nursery use and length of stay of relatively healthy newborns of mothers with GDM is unexplained by hospital characteristics and suggests other operational or management factors impacting utilization of newborn care resources.