Objective

To estimate trends and risk factors for cesarean delivery for twins in the United States.

Methods

This was a cross-sectional study in which we calculated cesarean rates for twins from 1995 to 2008 using National Center for Health Statistics data. We compared cesarean rates by year and for vertex vs. breech presentation. The order of presentation for a given twin pair could not be determined from the available records and therefore analysis was based on individual discrete twin data. Multivariable logistic regression was used to estimate independent risk factors, including year of birth and maternal factors, for cesarean delivery.

Results

Cesarean rates for twin births increased steadily from 53.4% to 75.0% in 2008. Rates rose for the breech twin category (81.5% to 92.1%) and the vertex twin category (45.1% to 68.2%). The relative increase in cesarean rate for preterm and term infants was similar. After risk adjustment, there was an average increase noted in cesarean delivery of 5% each year during the study period (risk ratio 1.05, 95% confidence interval 1.04, 1.05).

Conclusions

Cesarean delivery rates for twin births increased dramatically from 1995 to 2008. This increase is significantly higher than that which could be explained by an increase in cesarean delivery for breech presentation of either the presenting or second twin.

Objectives

To estimate risk factors for premature infants not receiving antenatal steroids in a population-based cohort and to determine whether the gains of a quality improvement collaborative project on antenatal steroid administration were sustained long-term.

Methods

Clinical data for premature infants born in 2005-2007 were obtained from the California Perinatal Quality Care Collaborative, which collects data on more than 90% of neonatal admissions in California. Eligible infants had a birth weight of less than 1500 grams or gestational age less than 34 weeks born at a Collaborative hospital. These data were linked to administrative data from California Vital Statistics. Socio-demographic and medical risk factors for not receiving antenatal steroids were determined. We also examined the effect of birth hospital participation in a prior quality improvement collaborative project. A random effects logistic regression model was used to determine independent risk factors.

Results

Of 15,343 eligible infants, 23.1% did not receive antenatal steroids in 2005-2007. Hispanic mothers (25.6%), mothers younger than age 20 (27.6%), and those without prenatal care (52.2%) were less likely to receive antenatal steroids. Mothers giving birth vaginally (26.8%) and mothers with a diagnosis of “fetal distress” (26.5%) were also less likely to receive antenatal steroids. Rupture of membranes prior to delivery, and multiple gestations were associated with higher likelihood of antenatal steroid administration. Hospitals who participated in a quality improvement collaborative in 1999-2000 had higher rates of antenatal steroid administration (85% vs. 69%, p < 0.0001).

Conclusion

A number of eligible mothers do not receive antenatal steroids. Quality improvement initiatives to improve antenatal steroid administration could target specific high-risk groups.

OBJECTIVE:

To evaluate the effectiveness of the California Perinatal Quality Care Collaborative quality-improvement model using a toolkit supplemented by workshops and Web casts in decreasing nosocomial infections in very low birth weight infants.

DESIGN:

This was a retrospective cohort study of continuous California Perinatal Quality Care Collaborative members' data during the years 2002–2006. The primary dependent variable was nosocomial infection, defined as a late bacterial or coagulase-negative staphylococcal infection diagnosed after the age of 3 days by positive blood/cerebro-spinal fluid culture(s) and clinical criteria. The primary independent variable of interest was voluntary attendance at the toolkit's introductory event, a direct indicator that at least 1 member of an NICU team had been personally exposed to the toolkit's features rather than being only notified of its availability. The intervention's effects were assessed using a multivariable logistic regression model that risk adjusted for selected demographic and clinical factors.

RESULTS:

During the study period, 7733 eligible very low birth weight infants were born in 27 quality-improvement participant hospitals and 4512 very low birth weight infants were born in 27 non–quality-improvement participant hospitals. For the entire cohort, the rate of nosocomial infection decreased from 16.9% in 2002 to 14.5% in 2006. For infants admitted to NICUs participating in at least 1 quality-improvement event, there was an associated decreased risk of nosocomial infection (odds ratio: 0.81 [95% confidence interval: 0.68–0.96]) compared with those admitted to nonparticipating hospitals.

CONCLUSIONS:

The structured intervention approach to quality improvement in the NICU setting, using a toolkit along with attendance at a workshop and/or Web cast, is an effective means by which to improve care outcomes.

Aim

To investigate the relationship between low Apgar score and neonatal mortality in preterm neonates.

Methods

Infant birth and death certificate data from the U.S. National Center for Health Statistics for 2001-2002 were analyzed. Primary outcome was 28 day mortality for 690,933 neonates at gestational ages 24-36 weeks. Mortality rates were calculated for each combination of gestational age and five-minute Apgar score. Relative risks of mortality, by high vs. low Apgar score, were calculated for each age.

Results

Distribution of Apgar scores depended on gestational age, the youngest gestational ages having higher proportions of low Apgar scores. Median Apgar score ranged from 6 at 24 weeks, to 9 at 30-36 weeks gestation. The relative risk of death was significantly higher at Apgar scores 0-3 vs. 7-10, including at the youngest gestational ages, ranging from 3.1 (95% confidence interval 2.9, 3.4) at 24 weeks to 18.5 (95% confidence interval 15.7, 21.8) at 28 weeks.

Conclusion

Low Apgar score was associated with increased mortality in premature neonates, including those at 24 to 28 weeks gestational age, and may be a useful tool for clinicians in assessing prognosis and for researchers as a risk prediction variable.

Pay-for-performance initiatives in medicine are proliferating rapidly. Neonatal intensive care is a likely target for these efforts because of the high cost, available databases, and relative strength of evidence for at least some measures of quality. Pay-for-performance may improve patient care but requires valid measurements of quality to ensure that financial incentives truly support superior performance. Given the existing uncertainty with respect to both the effectiveness of pay-for-performance and the state of quality measurement science, experimentation with pay-for-performance initiatives should proceed with caution and in controlled settings. In this article, we describe approaches to measuring quality and implementing pay-for-performance in the NICU setting.

OBJECTIVE

To examine the impact of birth at night, on the weekend, and during July or August – the first months of the academic year – and the impact of resident duty-hour restrictions on mortality and morbidity of VLBW infants.

METHODS

Outcomes were analyzed for 11,137 infants with birth weight 501–1250 grams enrolled in the NICHD Neonatal Research Network registry 2001–2005. Approximately half were born before the introduction of resident duty-hour restrictions in 2003. Follow-up assessment at 18–22 months was completed for 4,508 infants. Mortality (7-day and 28-day), short-term morbidities, and neurodevelopmental outcome were examined with respect to the timing of birth: night vs day, weekend vs weekday, and July or August vs other months, and after vs before implementation of resident duty-hour restrictions.

RESULTS

There was no effect of hour, day, or month of birth on mortality and no impact on the risks of short-term morbidities except the risk of ROP requiring operative treatment was lower for infants born during the late night hours than during the day. There was no impact of timing of birth on neurodevelopmental outcome except the risk of hearing impairment or death was slightly lower among infants born in July or August compared with other months. The introduction of resident and fellow duty-hour restrictions had no impact on mortality or neurodevelopmental outcome. The only change in short-term morbidity after duty-hour restrictions were introduced was an increase in the risk of ROP (stage 2 or higher).

CONCLUSION

In this network of academic centers, the timing of birth and the introduction of duty-hour restrictions had little effect on the risks of mortality and morbidity of VLBW infants, suggesting that staffing patterns were adequate to provide consistent care.

Objective

To determine if cesarean delivery for breech has increased in the United States.

Study Design

We calculated cesarean rates for term singletons in “breech / malpresentation” from 1997–2003 using National Center for Health Statistics data. We compared rates by socio-demographic groups and state. Multivariable logistic regression models were constructed to see if factors associated with cesarean delivery differed over time.

Results

Breech cesarean rates increased overall from 83.8% to 85.1%. There was a significant increase in rates for most socio-demographic groups. There was little to no increase for mothers < 30 years. There was wide variability in rates by state, 61.6%–94.2% in 1997. Higher breech incidence correlated with lower cesarean rates, suggesting potential state bias in reporting breech.

Conclusion

In the United States, breech infants are predominantly born by cesarean. There was a small increase in this trend from 1998 to 2002. There is wide variability by state, which is not explained by socio-demographic patterns, and may be due to reporting differences.