Extreme hyperbilirubinemia and rescue exchange transfusion in California from 2007 to 2012.

OBJECTIVE: To evaluate the impact of statewide learning collaboratives that used national guidelines to manage jaundice on the serial prevalence of extreme hyperbilirubinemia (EHB, total bilirubin ⩾25 mg dl(-1)) and exchange transfusions introduced in California Perinatal Quality Care Collaborative (CPQCC) hospitals in 2007. STUDY DESIGN: Adverse outcomes were retrieved from statewide databases on re-admissions for live births ⩾35 weeks' gestation (2007 to 2012) in diverse CPQCC hospitals. Individual and cumulative select perinatal risk factors and frequencies were the outcomes measures. RESULTS: For 3 172 762 babies (2007 to 2012), 92.5% were ⩾35 weeks' gestation. Statewide EHB and exchange rates decreased from 28.2 to 15.3 and 3.6 to 1.9 per 100 000 live births, respectively. From 2007 to 2012, the trends for TB>25 mg dl(-1) rates were -0.92 per 100 000 live births per year (95% CI: -3.71 to 1.87, P=0.41 and R(2)=0.17). CONCLUSION: National guidelines complemented by statewide learning collaboratives can decrease or modify outcomes among all birth facilities and impact clinical practice behavior.

Estimating the quality of neonatal transport in California.

OBJECTIVE: To develop a strategy to assess the quality of neonatal transport based on change in neonatal condition during transport. STUDY DESIGN: The Canadian Transport Risk Index of Physiologic Stability (TRIPS) score was optimized for a California (Ca) population using data collected on 21 279 acute neonatal transports, 2007 to 2009, using models predicting (2/3) and validating (1/3) mortality within 7 days of transport. Quality Change Point 10th percentile (QCP10), a benchmark of the greatest deterioration seen in 10% of the transports by top-performing teams, was established. RESULT: Compared with perinatal variables (0.79), the Ca-TRIPS had a validation receiver operator characteristic area for prediction of death of 0.88 in all infants and 0.86 in infants transported after day 7. The risk of death increased 2.4-fold in infants whose deterioration exceeded the QCP10. CONCLUSION: We present a practical, benchmarked, risk-adjusted, estimate of the quality of neonatal transport.

Obstetric anal sphincter lacerations.

OBJECTIVE: To estimate the frequency of obstetric anal sphincter laceration and to identify characteristics associated with this complication, including modifiable risk factors. METHODS: A population-based, retrospective study of over 2 million vaginal deliveries at California hospitals was performed, using information from birth certificates and discharge summaries for 1992 through 1997. We excluded preterm births, stillbirths, breech deliveries, and multiple gestations. The main outcome measure was obstetric anal sphincter laceration (third and fourth degree). RESULTS: The frequency of anal sphincter lacerations was 5.85% (95% confidence interval [CI] 5.82, 5.88), decreasing significantly from 6.35% (95% CI 6.27, 6.43) in 1992 to 5.43% (95% CI 5.35, 5.51) in 1997 (P <.01). Using logistic regression analysis, we identified primiparity as the dominant risk factor (odds ratio [OR] for women with prior vaginal birth 0.15; 95% CI 0.14, 0.15). Birth weight over 4000 g was also highly significant (OR 2.17; 95% CI 2.07, 2.27). Lacerations occurred more often among women of certain racial and ethnic groups: Indian women (OR 2.5; 95% CI 2.23, 2.79) and Filipina women (OR 1.63; 95% CI 1.50, 1.77) were at highest risk. Episiotomy decreased the likelihood of third-degree lacerations (OR 0.81; 95% CI 0.78, 0.85), but increased the risk of fourth-degree lacerations (OR 1.12; 95% CI 1.05, 1.19). Operative delivery increased the risk of sphincter laceration, with vacuum delivery (OR 2.30; 95% CI 2.21, 2.40) presenting a greater risk than forceps delivery (OR 1.45; 95% CI 1.37, 1.52). CONCLUSION: Anal sphincter lacerations are strongly associated with primiparity, macrosomia, and operative vaginal delivery. Of the modifiable risk factors, operative vaginal delivery remains the dominant independent variable.

Adequacy of prenatal care among women with psychiatric diagnoses giving birth in California in 1994 and 1995.

OBJECTIVE: Although poor prenatal care is detrimental to maternal and infant health, few studies have assessed the adequacy of prenatal care among women with psychiatric diagnoses. This investigation examined the association between chart-recorded psychiatric and substance use diagnoses at the time of delivery and adequacy of prenatal care among all women delivering babies in California hospitals during 1994 and 1995. METHODS: The authors undertook an archival analysis of data from the California Health Information for Policy Project (CHIPP), which consists of linked hospital discharge and birth certificate data for 1,094,178 deliveries in 1994 and 1995. The associations between International Classification of Diseases, 9th Revision, Clinical Modification psychiatric and substance abuse diagnoses and level of prenatal care were examined. Logistic regression analyses were conducted to assess the association between maternal diagnostic category and inadequate prenatal care while controlling for payment source, age, education, race, marital status, and parity (previous births). RESULTS: Women who received psychiatric and substance use diagnoses demonstrated significantly increased risk of inadequate prenatal care compared with women without those diagnoses. CONCLUSIONS: Psychiatric diagnoses were associated with an increased risk of inadequate prenatal care; the association between psychiatric and substance use diagnoses and poor prenatal care persisted even after the analysis controlled for known risk factors. Future investigations will need to elucidate the processes of prenatal care for women with psychiatric disorders so that preventive interventions can be developed.