Suboptimal care and perinatal mortality in ten European regions: methodology and evaluation of an international audit.

BACKGROUND: A European concerted action (the EuroNatal study) investigated differences in perinatal mortality between countries of Europe. This report describes the methods used in the EuroNatal international audit and discusses the validity of the results. METHODS: Perinatal deaths between 1993 and 1998 in regions of ten European countries were identified. The categories of death chosen for the study were singleton fetal deaths at 28 or more weeks of gestational age, all intrapartum deaths at 28 or more weeks of gestational age and neonatal deaths at 34 or more weeks of gestational age. Deaths with major congenital anomalies were excluded. An international audit panel used explicit criteria to review all cases, which were blinded for region. Subjective interpretation was used in cases of events or interventions where explicit criteria did not exist. Suboptimal factors were identified in the antenatal, intrapartum and neonatal periods, and classified as 'maternal/social', due to 'infrastructure/service organization', or due to 'professional care delivery'. The contribution of each suboptimal factor to the fatal outcome was listed and consensus was reached on a final grade using a procedure that included correspondence and plenary meetings. RESULTS: In all regions combined, 90% of all known or estimated cases in the selected categories were included in the audit. In total, 1619 cases of perinatal death were audited. Consensus was reached in 1543 (95%) cases. In 75% of all cases, the grade was based on explicit criteria. In the remaining cases, consensus was reached within subpanels without reference to predefined criteria. There was reasonable to good agreement between and within subpanels, and within panel members. CONCLUSIONS: The international audit procedure proved feasible and led to consistent results. The results that relate to suboptimal care will need to be studied in depth in order to reach conclusions about their implications for assessing the quality of perinatal care in the individual regions.

The reliability of perinatal and neonatal mortality rates: differential under-reporting in linked professional registers vs. Dutch civil registers.

Official Dutch perinatal mortality rates are based on birth and death certificates. These civil registration data are not detailed enough for international comparisons or extensive epidemiological research. In this study, we linked and extrapolated three national, incomplete, professional registers from midwives, obstetricians and paediatricians, containing detailed perinatal information. This linkage and extrapolation resulted in one detailed professional database which is representative of all Dutch births and from which gestational age-specific perinatal mortality rates could be calculated. The reliability of these calculated mortality rates was established by comparing them with the rates derived from the national civil registers. The professional database reported more perinatal deaths and fewer late neonatal deaths than the civil registers. The under-reporting in the civil registers amounted to 1.2 fewer perinatal deaths per 1000 births and was most apparent in immature newborns. We concluded that under-reporting of perinatal and neonatal deaths depends on the data source used. Mortality rates for the purpose of national and international comparison should, therefore, be defined with caution. This study also demonstrated that combining different incomplete professional registers can result in a more reliable database containing detailed perinatal information. Such databases can be used as the basis for extensive perinatal epidemiological research.

The hour of birth: comparisons of circadian pattern between women cared for by midwives and obstetricians.

OBJECTIVE: To examine the difference, if any, between midwives' care and obstetricians' care in the circadian pattern of the hour of birth in spontaneous labour and delivery. DESIGN: A descriptive study comparing the circadian pattern of the hour of birth between women cared for by a midwife or an obstetrician. SETTING: Data were derived from the Perinatal Database of the Netherlands (LVR), comprising 83% of all births under midwives' care and 75% of all births under obstetricians' care. SUBJECTS: 57,871 women receiving midwives' care and 31,999 women receiving obstetricians' care with spontaneous labour and spontaneous delivery. MAIN OUTCOME MEASURES: Differences in the circadian rhythms between women receiving midwives' care and obstetricians' care. FINDINGS: There was a difference in the circadian pattern of the hour of birth between midwives' and obstetricians' care. Peak times differed 5.43 hours (CI 4.23-7.03) for primiparous and 3.34 hours (CI 3.00-4.08) for multiparous women between the midwives' group and the obstetricians' group. CONCLUSION: This study demonstrates a remarkable difference in circadian pattern of the hour of birth between midwives' care and obstetricians' care. In obstetricians' care the duration of normal labour appears to be prolonged, presumably by an increased level of stress. In normal birth the care of midwives is preferable.

Practice variation of test procedures reportedly used in routine antenatal care in The Netherlands.

BACKGROUND: Pregnant women are encouraged to book for antenatal care. However, little is known about the contents of antenatal care, in particular regarding various test procedures. The present descriptive study was conducted to assess the variation in standard test procedures in antenatal care in The Netherlands. METHODS: A nationwide structured survey by mailed questionnaire was carried out among specialist obstetricians and midwives in The Netherlands. Representatives of each obstetric practice registered with the Dutch Society of Obstetrics and Gynecology (n=132) and a sample of midwives registered with the Dutch Society of Midwives (n=394) were invited to report the standard policy of tests routinely used for antenatal care in their own setting. Furthermore, they were asked to report their views on the potential impact of the antenatal care program on pregnancy outcome. RESULTS: Complete information was available from 105 specialist obstetricians (80%) and 281 midwives (71%). The assessment of maternal blood pressure and weight are reportedly the commonest procedures routinely conducted during the antenatal period. However, within each profession reported definitions and implications of abnormal findings vary markedly, especially in the fields of identification and management of hypertensive disorders in pregnancy. Serial examination of the cervix is not standard policy among both groups. With respect to laboratory tests, considerable intra- and interprofessional variations are reported, in particular those for maternal serum glucose, rubella antibody titer and urinary dipstick for glucose and protein. As to standard ultrasound policies, wide intra- and interprofessional variations are noted. Seventy-two specialist obstetricians (68%) and 92 midwives (33%) routinely estimate the duration of gestation by ultrasound in pregnant women (p<0.001). A fetal anomaly scan at about 18-20 weeks' gestation is routinely offered to pregnant women by 31 specialist obstetricians (30%) and 44 midwives (16%) (p<0.01); 29 obstetricians (28%) and 11 midwives (4%) reportedly use ultrasound in all pregnant women for the detection of fetal growth restriction (p<0.001). Overall, midwives have a more optimistic view about the impact of antenatal care on pregnancy outcome than obstetricians. CONCLUSIONS: Although the standard package of antenatal care provided by both specialist obstetricians and midwives in The Netherlands seems to be relatively uniform, wide intra- and interprofessional variations exist with respect to (1) the application of tests in terms of recommendations to test some or all pregnant women, (2) defining normal from abnormal and (3) potential implications of abnormal findings.