Ank, about unnplanned births outside an institutions and travel time to institution

Ellen

 

Am J Obstet Gynecol. 2017 Aug;217(2):210.e1-210.e12. doi: 10.1016/j.ajog.2017.03.033. Epub 2017 Apr 6.

Increased risk of peripartum perinatal mortality in unplanned births outside an institution: a retrospective population-based study.

Engjom HM1Morken NH2Høydahl E3Norheim OF4Klungsøyr K

Abstract

BACKGROUND:

Births in midwife-led institutions may reduce the frequency of medical interventions and provide cost-effective care, while larger institutions offer medically and technically advanced obstetric care. Unplanned births outside an institution and intrapartum stillbirths have frequently been excluded in previous studies on adverse outcomes by place of birth.

OBJECTIVE:

The objective of the study was to assess peripartum mortality by place of birth and travel time to obstetric institutions, with the hypothesis that centralization reduces institution availability but improves mortality.

STUDY DESIGN:

This was a national population-based retrospective cohort study of all births in Norway from 1999 to 2009 (n = 648,555) using data from the Medical Birth Registry of Norway and Statistics Norway and including births from 22 gestational weeks or birthweight ≥500 g. Main exposures were travel time to the nearest obstetric institution and place of birth. The main clinical outcome was peripartum mortality, defined as death during birth or within 24 hours. Intrauterine fetal deaths prior to start of labor were excluded from the primary outcome.

RESULTS:

A total of 1586 peripartum deaths were identified (2.5 per 1000 births). Unplanned birth outside an institution had a 3 times higher mortality (8.4 per 1000) than institutional births (2.4 per 1000), relative risk, 3.5 (95% confidence interval, 2.5-4.9) and contributed 2% (95% confidence interval, 1.2-3.0%) of the peripartum mortality at the population level. The risk of unplanned birth outside an institution increased from 0.5% to 3.3% and 4.5% with travel time <1 hour, 1-2 hours, and >2 hours, respectively. In obstetric institutions the mortality rate at term ranged from 0.7 per 1000 to 0.9 per 1000. Comparable mortality rates in different obstetric institutions indicated well-functioning routines for referral.

CONCLUSION:

Unplanned birth outside an institution was associated with increased peripartum mortality and with long travel time to obstetric institutions. Structural determinants have an important impact on perinatal health in high-income countries and also for low-risk births. The results show the importance of skilled birth attendance and warrant attention from clinicians and policy makers to negative consequences of reduced access to institutions.

Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

KEYWORDS:

access; availability; emergency obstetric and newborn care; health systems; perinatal mortality

 

 

From: A forum for discussion on midwifery and reproductive health research. <[log in to unmask]> On Behalf Of Pauline Dawson
Sent: Tuesday, October 22, 2019 10:50 AM
To: [log in to unmask]
Subject: Re: distance to hospital

 

Christine

 

A primary rural maternity unit is a lot less risky than being born in a private car on the side of the road. BBAs rise hugely when these units close and that's not good for anyone except the accountants. And that's only if they are considering short term costs.

 

Sorry.. getting away from the original question here. I'm just doing some work for a remote rural community whose unit has recently closed.

 

Pauline

 

On Tue, 22 Oct 2019, 21:43 McCourt, Christine, <[log in to unmask]> wrote:

Sarah Denham’s PhD looked at community maternity units in Scotland, which has considerable rural and remote areas. Outcomes were also found to be very good. I can’t remember whether she had much detail on transfer issues but quite possibly, so worth contacting her. I’m not sure whether she is on the list so I can try contacting her otherwise.

 

 Although England is a small and very urbanised country, the FMUs are mainly in the more rural areas and small. The birthplace findings reflect that as the study looked at things as they are. I find it curious that often people want to dismiss the findings re FMUs (very safe, very cost effective, & enhanced maternal safety) on the basis that their local unit is small and rural.

 

Perhaps we need to “take back control” (Brexit pun) of the language a bit and talk about MUs as a way of improving safety, as most of the discourse is focused on an implict assumption that they are more risky and the risk must be managed and mitigated. (Risk needs to be managed of course, but our cultural understandings of risk do not reflect the science with respect to childbirth.)

 

 

From: "[log in to unmask]" <[log in to unmask]> on behalf of "Sandall, Jane" <[log in to unmask]>
Reply to: "[log in to unmask]" <[log in to unmask]>, "Sandall, Jane" <[log in to unmask]>
Date: Tuesday, 22 October 2019 at 07:09
To: "[log in to unmask]" <[log in to unmask]>
Subject: Re: distance to hospital

 

CAUTION: This email originated from outside of the organisation. Do not click links or open attachments unless you recognise the sender and believe the content to be safe.

 

Is there anything in Australian birthplace? 

Jane sandall 

 

Please text me for urgent contact 07713743150

Sent from my iPhone

Professor Jane Sandall

King’s College, London

 

 

On 22 Oct 2019, at 00:33, Pauline Dawson <[log in to unmask]> wrote:

Thanks Christine,

 

I was just thinking that there might be observational studies where transfer time is related to outcomes for all that has occured in the last few years.

I know in the national maternal morbidity work that I was part of here delayed transfer was a factor in poor outcomes but we are talking numbers of hours. Also there is some Australian research where Born Before Arrival (BBA) is a measurement proxy but again very long distances there. These BBA data are around just getting to ANY maternity facility not transfers.

 

I have found a lot of the things you might want to study here in NZ eg transfer time and BBA aren't routinely collected in national datasets.

 

Fascinating conversation - thank you

 

Pauline

 

On Tue, Oct 22, 2019 at 11:59 AM McCourt, Christine <[log in to unmask]> wrote:

Pauline - to my knowledge no, and it would be a rather challenging thing to research.

 

The Birthplace data are the most detailed I can think of without searching systematically, but our findings showed particularly good outcomes from freestanding midwifery units and the distance/travel time to hospital was higher than that for home births.

We were not able to assess the actual time to get to hospital but the time to being assessed in hospital, as the data available didn’t allow the distinction to be made – how long women waited on arrival before being seen.

The median overall transfer time, including time spent arranging transfer, waiting for the ambulance to arrive, travel time and any wait before first assessment in the OU, was 60 minutes for transfers from FMUs and 49 minutes for transfers from home.

 

It seems likely that time to be seen on arrival in a well-functioning system would be related to urgency of reason for transfer.  In two cases of urgent transfer from FMU observed directly in the Birthplace qualitative case studies, the OU staff were ready to receive and take on care straight away having been briefed by a midwife by telephone. This is no doubt a benefit of having an integrated maternity system under the NHS, as compared with experiences in some countries.

 

The key source with details on transfers from Birthplace is this follow-on analysis paper:

 

Rachel E Rowe, John Townend, Peter Brocklehurst, Marian Knight, Alison Macfarlane, Christine McCourt, Mary Newburn, Maggie Redshaw, Jane Sandall, Louise Silverton and Jennifer Hollowell. Duration and urgency of transfer in births planned at home and in freestanding midwifery units in national prospective cohort study. BMC Pregnancy and Childbirth 2013, 13:224 http://www.biomedcentral.com/1471-2393/13/224

 

 

 

 

On 21/10/2019, 19:54, "A forum for discussion on midwifery and reproductive health research. on behalf of Pauline Dawson" <[log in to unmask] on behalf of [log in to unmask]> wrote:

 

    CAUTION: This email originated from outside of the organisation. Do not click links or open attachments unless you recognise the sender and believe the content to be safe.

   

    

    This is great data!

   

    Further to my email though I don't think anyone has found an optimal time?

    Am I wrong??

   

    Pauline

   

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    From: A forum for discussion on midwifery and reproductive health research.

   

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