The relationship between neonatal mortality and hospital level.

BACKGROUND. The relative safety of the small obstetrics unit compared with that of the larger or more technologically sophisticated units remains controversial. The purpose of this study was to examine the relationship between neonatal mortality and the level of perinatal services present in the hospital of birth. METHODS. Logistic regression was used to model neonatal mortality as a function of race, weight, and hospital level. Hospitals were classified into five categories using the volume of deliveries and the level of perinatal services available. RESULTS. Both black and white infants born at Level I-A hospitals who weighed less than 2250 (5 lb) fared worse than those born at Level III hospitals. There were no other statistically significant differences between the remaining hospital levels at any weight, although there was a trend toward improved mortality for white babies weighing less than 1500 g (3 lb, 5 oz) born at Level III centers. Level II-B hospitals, which also had neonatal intensive care available, did not demonstrate this trend. RESULTS. The results of this study support the safety of facilities with lower levels of care for delivery of normal birthweight infants and the need for continued centralized delivery of higher levels of care for high-risk patients.     

Trends in Rural and Urban Deliveries and Vaginal Births: California 1998‐2002

ABSTRACT: Context: Pregnant women in rural areas may give birth in either rural or urban hospitals. Differences in outcomes between rural and urban hospitals may influence patient decision making. Purpose: Trends in rural and urban obstetric deliveries and neonatal and maternal mortality in California were compared to inform policy development and patient and provider decision making in rural health care settings. Methods: Deliveries in California hospitals identified by the California Department of Health Services, Birth Statistical Master Files for years 1998 through 2002 were analyzed. Three groups of interest were created: rural hospital births to all mothers, urban hospital births to rural mothers, and urban hospital births to urban mothers. Findings: Of 2,620,096 births analyzed, less than 4% were at rural hospitals. Neonatal death rates were significantly higher in babies born to rural mothers with no pregnancy complications who delivered a normal weight baby vaginally at an urban hospital compared to urban mothers delivering at an urban hospital (0.2 [CI 0.2‐0.4] deaths per 1,000 births versus 0.1 [CI 0.1‐0.1]). Logistic regression analysis showed that delivery in a rural hospital was a protective factor compared to urban mothers delivering in an urban hospital, with an odds ratio of 0.8 (CI 0.6‐0.9). Maternal death rates were not different. Conclusions: Rural obstetric services in this period showed favorable neonatal and maternal safety profiles. This information should reassure patients considering a rural hospital delivery, and aid policy makers and health care providers striving to ensure access to obstetric services for rural populations.     

Do all hospitals need cesarean delivery capability? An outcomes study of maternity care in a rural hospital without on-site cesarean capability

OBJECTIVES: We analyzed perinatal outcomes at a rural hospital without cesarean delivery capability. STUDY DESIGN: This was a historical cohort outcomes study. POPULATION: The study population included all pregnant women at 20 weeks or greater of gestational age (n = 1132) over a 5-year period in a predominantly Native American region of northwestern New Mexico. OUTCOMES MEASURED: The outcomes studied included perinatal mortality, neonatal morbidity, obstetric emergencies, intrapartum and antepartum transfers, and cesarean delivery rate. We did a detailed case review of all obstetric emergencies and low-Apgar-score births at Zuni-Ramah Hospital and all cesarean deliveries for fetal distress at referral hospitals. RESULTS: Of the 1132 women in the study population, 64.7% (n = 735) were able to give birth at the hospital without operative facilities; 25.6% (n = 290) were transferred before labor; and 9.5% (n = 107) were transferred during labor. The perinatal mortality rate of 11.4 per 1000 (95% confidence interval, 5.1-17.8) was similar to the nationwide rate of 12.8 per 1000 even though Zuni-Ramah has a high-risk obstetric population. No instances of major neonatal or maternal morbidity caused by lack of surgical facilities occurred. The cesarean delivery rate of 7.3% was significantly lower than the nationwide rate of 20.7% (P <.001). The incidence of neonates with low Apgar scores (0.54%) was significantly lower than the nationwide rate (1.4%). The incidence of neonates requiring resuscitation (3.4%) was comparable to the nationwide rate (2.9%). CONCLUSIONS: The presence of a rural maternity care unit without surgical facilities can safely allow a high proportion of women to give birth closer to their communities. This study demonstrated a low level of perinatal risk. Most transfers were made for induction or augmentation of labor. Rural hospitals that do not have cesarean delivery capability but are part of an integrated perinatal system can safely offer obstetric services by using appropriate antepartum and intrapartum screening criteria for obstetric risk.     

Maternal characteristics associated with place of delivery and neonatal mortality rates among very-low-birthweight infants,Georgia

To determine whether the Healthy People 2000 objective to deliver very-low-birthweight (VLBW) infants at subspecialty perinatal care centres was met, and if improvements in the regional perinatal care system could reduce neonatal mortality further for 2010, we examined place of delivery for VLBW infants, associated maternal characteristics and the potential impact on neonatal mortality. We used linked birth and death records for the 1994-96 Georgia VLBW (i.e. 500-1499 g) birth cohorts. Among 4770 VLBW infants, 77% were delivered at hospitals providing subspecialty perinatal care. The strongest predictor of birth hospital level was the mother's county of residence, defined using three levels: residence in a county with a subspecialty hospital, residence in a county adjacent to one with such a hospital or residence in a non-adjacent county. Eighty-nine per cent of infants born to women who resided in counties with subspecialty care hospitals delivered at such hospitals, compared with 53% of infants born to women who resided in a non-adjacent county. Women were also more likely to deliver outside subspecialty care if they had less than adequate prenatal care [adjusted odds ratio (AOR) 1.5, P-value = 0.0001]. The neonatal mortality rate varied by level of perinatal care at the birth hospital from 132.1/1000 to 283/1000 live births, with the highest death rate for infants born at hospitals offering the lowest level of care. Assuming that the differences in mortality were due to care level of the birth hospital, potentially 16-23% of neonatal deaths among VLBW infants could have been prevented if 90% of infants born outside subspecialty care were delivered at the recommended level. These findings suggest that a state's support of strong, collaborative, regional perinatal care networks is required to ensure that high-risk women and infants receive optimal health care. Improved access to recommended care levels should further reduce neonatal mortality until interventions are identified to prevent VLBW births.     

Challenge of reducing perinatal mortality in rural Congo: findings of a prospective, population-based study

Each year, an estimated six million perinatal deaths occur worldwide, and 98% of these deaths occur in low- and middle-income countries. These estimates are based on surveys in both urban and rural areas, and they may underrepresent the problem in rural areas. This study was conducted to quantify perinatal mortality, to identify the associated risk factors, and to determine the most common causes of early neonatal death in a rural area of the Democratic Republic of the Congo (DRC). Data were collected on 1,892 births. Risk factors associated with perinatal deaths were identified using multivariate analysis with logistic regression models. Causes of early neonatal deaths were determined by physician-review of information describing death. The perinatal mortality rate was 61 per 1,000 births; the stillbirth rate was 30 per 1,000 births; and the early neonatal death rate was 32 per 1,000 livebirths. Clinically-relevant factors independently associated with perinatal death included: low birthweight [odds ratio (OR)=13.51, 95% confidence interval (CI) 7.82-23.35], breech presentation (OR)=12.41; 95% CI 4.62-33.33), lack of prenatal care (OR=2.70, 95% CI 1.81-4.02), and parity greater than 4 (OR=1.93 95% CI 1.11-3.37). Over one-half of early neonatal deaths (n=37) occurred during the first two postnatal days, and the most common causes were low birthweight/prematurity (47%), asphyxia (34%), and infection (8%). The high perinatal mortality rate in rural communities in the DRC, approximately one-half of which is attributable to early neonatal death, may be modifiable. Specifically, deaths due to breech presentation, the second most common risk factor, may be reduced by making available emergency obstetric care. Most neonatal deaths occur soon after birth, and nearly three-quarters are caused by low birthweight/prematurity or asphyxia. Neonatal mortality might be reduced by targeting interventions to improve neonatal resuscitation and care of larger preterm infants.     

The regionalization of perinatal care in Wales and Washington State.

OBJECTIVES. The purpose of this study was to compare perinatal regionalization and neonatal mortality in Wales and Washington State. METHODS. The 28 hospitals in Wales and the 80 hospitals in Washington State that offered maternity services and the 218,326 births that occurred in these hospitals in 1989 and 1990 were studied. Surveys were used to identify the neonatal technology and the referral policies of each hospital, and linked data from birth and death certificates were used to examine birthweight-specific neonatal mortality rates for all babies born in these hospitals. RESULTS. Welsh district general hospitals (broadly equivalent to Level II perinatal centers in the United States) have more sophisticated neonatal technology than their Washington State counterparts and appear less likely to refer small or preterm babies to regional or subregional centers. Neonatal mortality rates were quite similar in the two settings. CONCLUSIONS. Perinatal care in Wales appears to be less regionalized than in a similar region in the United States. The relative lack of perinatal regionalization in Wales may contribute to duplication and underutilization of expensive neonatal technologies. National health care systems do not, in and of themselves, lead to optimal regionalization of services.     

农村地区县妇幼保健院助产服务现状及优势分析

目的:调查农村地区不同类别助产机构产科服务提供情况及服务能力,对县妇幼保健院助产服务现状和优势进行分析。方法:在全国随机抽取44个地市全部助产服务机构2010年产科服务情况进行问卷调查,重点对农村地区(县和县级市)中不同类型助产机构进行分析。结果:农村助产服务机构中县妇幼保健院占6.5%,县妇幼保健院产科床位数占辖区产科总床位数的18.1%,分娩数量占辖区分娩量的42.9%,平均每个县妇幼保健院年分娩为1 259人,高于县级综合性医院和其他医疗机构。县妇幼保健院中能提供综合产科和综合新生儿科服务的比例最高分别为85.3%、61.9%,高于县级综合性医院83.1%、59.4%,并明显高于其他医疗机构32.4%、19.3%。结论:县妇幼保健院是农村地区助产服务的主要力量之一,与其他助产机构相比,县妇幼保健院在助产服务提供数量和能力方面都具有一定优势。应进一步加强对妇幼保健机构的规范化建设,以保证其职能的履行。     

The relation of obstetrical volume and nursery level to perinatal mortality.

We investigated the relation of hospital delivery volume and nursery technology level to perinatal outcome in 226,164 White singleton births in Washington State, 1980-83. Level III facilities (neonatal intensive care unit) were defined by the state licensing commission. We defined the Level II (intermediate) and Level I (normal newborn) facilities using published criteria. Infants under 2000 gm born in Level III facilities had half the risk of perinatal death compared to those born in a Level I or II facility. No significant improvement was noted among level or volume groupings for normal birthweight infants. A loglinear regression model of hospital perinatal death rates showed that when birthweight and maternal risk were controlled, obstetrical volume added minimal explanatory power to level of nursery care.     

Dar es Salaam perinatal care study: needs assessment for quality of care

OBJECTIVE: Poor obstetric care in low income countries has been attributed to a wide range of factors. We conducted a perinatal care needs assessment in Dar es Salaam health institutions to assess the factors underlying the present poor perinatal outcome. METHODS: A cross sectional study was conducted in 2005 in all four public hospitals and all five public health centres purposively selected, and in six dispensaries selected using simple random sampling method. WHO Safe Motherhood needs assessment instruments were used to assess structural, systemic and process needs for quality perinatal care. Health care providers, administrators and clients were interviewed about perinatal care services in their respective health institutions. RESULTS: The majority (72%) of all deliveries in Dar es Salaam took place in the four available public hospitals. The potential coverage of comprehensive and basic emergency obstetric care (EmOC) services were 360% and 350% of the United Nations minimum recommended health institution categories per 500,000 population respectively. The coverage for health centres and dispensaries based on Tanzanian standards were 20% and 24% respectively. Two of the hospitals did not provide theatre and blood transfusion services for 24 hours per day. Two public health centres did not provide delivery services at all and 83% of the dispensaries had poorly established obstetric services. There was only one public neonatal unit that served as a referral institution for all sick newborns delivered in public health institutions in the region. CONCLUSION: This paper reveals the state of inadequate infrastructure, equipments and supplies for perinatal care in Dar es Salaam public health institutions. A major investment is needed to establish new public infrastructure for maternal and neonatal care, upgrade and optimize use of the existing ones, and improve supply of essential material resources in order to achieve the Millennium Development Goals set for maternal and child survivals by 2015.     

Associations Between Hospital Maternal Service Level and Delivery Outcomes

ObjectiveThis study explored the associations between delivery hospital self-reported level of maternal service, as defined by the American Hospital Association, and both maternal and neonatal outcomes among women at high maternal risk, as defined by the Obstetric Comorbidity Index.MethodsThis was a secondary analysis of linked delivery hospitalization discharge and vital records data for women experiencing singleton births in Georgia from 2008 to 2012. The need for maternal transfer was defined using a sample-specific cut-off of the risk score calculated using the Obstetric Comorbidity Index. Outcomes included poor maternal outcome (severe maternal morbidity or death), maternal length of stay, preterm delivery, low birth weight, and perinatal death. The analysis was completed using hierarchical logistic regression with a two-level model considering hospital level of maternal service and controlling for maternal race and transfer status.ResultsIn these data, there was no difference in the odds of a poor maternal or neonatal outcome according to delivery hospital level of maternal care; however, delivery at a hospital with maternal service level III was associated with a higher odds of an extended length of stay.ConclusionsFor this group of pregnant women in need of maternal transfer, delivery hospital self-reported level of maternal care was not associated with the odds of poor maternal or neonatal outcomes. This study supports the need for improved definitions of hospital level of maternal services.     

Type of delivery attendant, place of delivery and risk of early neonatal mortality: analyses of the 1994-2007 Indonesia Demographic and Health Surveys

Access to skilled birth attendants and emergency obstetric care are thought to prevent early neonatal deaths. This study aims to examine the association between the type of delivery attendant and place of delivery and early neonatal mortality in Indonesia. Four Indonesia Demographic and Health Surveys from 1994, 1997, 2002/2003 and 2007 were used, including survival information from 52?917 singleton live-born infants of the most recent birth of a mother within a 5-year period before each survey. Cox proportional hazards regression models were used to obtain the hazard ratio for univariable and multivariable analyses. Our study found no significant reduction in the risk of early neonatal death for home deliveries assisted by the trained attendants compared with those assisted by untrained attendants. In rural areas, the risk of early neonatal death was higher for home deliveries assisted by trained attendants than home deliveries assisted by untrained attendants. In urban areas, a protective role of institutional deliveries was found if mothers had delivery complications. However, an increased risk was associated with deliveries in public hospitals in rural areas. Infants of mothers attending antenatal care services were significantly protected against early neonatal deaths, irrespective of the urban or rural setting. An increased risk of early neonatal death was also associated with male infants, infants whose size at birth was smaller than average and/or infants reported to be born early. A reduced risk was observed amongst mothers with high levels of education. Continuous improvement in the skills and the quality of the village midwives might benefit maternal and newborn survival. Efforts to strengthen the referral system and to improve the quality of delivery and newborn care services in health facilities are important, particularly in public hospitals and in rural areas.     

Risk factors for neonatal mortality in rural areas of Bangladesh served by a large NGO programme

Neonatal deaths account for about half of all deaths among children under 5 years of age in Bangladesh, making prevention a major priority. This paper reports on a study of neonatal deaths in 12 areas of Bangladesh served by a large NGO programme, which had high coverage of reproductive health outreach services and relatively low neonatal mortality in recent years. The study aimed to identify the main factors associated with neonatal mortality in these areas, with a view to developing appropriate strategies for prevention. A case-control design was adopted for collection of data from mothers whose children, born alive in 2003, died within 28 days postpartum (142 cases), or did not (617 controls). Crude and adjusted odds ratios (AOR) were calculated as estimates of relative risk for neonatal death, using 'neighbourhood' controls (241) and 'non-neighbourhood' controls (376). A similar proportion of case and control mothers had received NGO health education and maternal health services. The main risk factors for neonatal death among 122 singleton babies, based on the two sets of controls, were: complications during delivery [AOR, 2.6 (95% CI: 1.5-4.5) and 3.1 (95% CI: 1.8-5.3)], prematurity [AOR, 7.2 (95% CI: 3.6-14.4) and 8.3 (95% CI: 4.2-16.5)], care for a sick neonate from an unlicensed 'traditional healer' [AOR, 2.9 (95% CI 0.9-9.5 and 5.9 (95% CI: 1.3-26.3)], or care not sought at all [AOR, 23.3 (95% CI: 3.9-137.4)]. The strongest predictor of neonatal death was having a previous sibling not vaccinated against measles [AOR, 5.9 (95% CI: 2.2-15.5) and 12.0 (95% CI: 4.5-31.7)]. The findings of this study indicate the need for identification of babies at high risk and early postpartum interventions (40.2% of the deaths occurred within 24 hours of delivery). Relevant strategies include special counselling during pregnancy for mothers with risk characteristics, training birth attendants in resuscitation, immediate postnatal check-up in the home for high-risk babies identified at delivery, advice for mothers on appropriate care-seeking for sick babies, improving the capacity of sub-district hospitals for emergency obstetric and newborn care, and promotion of institutional deliveries.     

Neonatal mortality clusters: a new tool for classifying neonatal outcomes.

BACKGROUND: A method for assessing general hospital neonatal care performance is needed that is simple, is easy to use, and requires minimal data. METHODS: All neonatal deaths in Washington State obstetric hospitals from 1980 to 1983 were assigned to 10 mutually exclusive neonatal mortality clusters, a new classification method derived from information available on the death certificate. RESULTS: More than one-third (35.3 percent) of all neonatal deaths fell within one of the seven clusters considered to represent potentially preventable causes of death. The rate of possibly preventable deaths was much higher in level III hospitals than in level II or level I hospitals, a finding similar to that observed in other states using different analytic approaches. CONCLUSIONS: Neonatal mortality clusters offer a less complex method of classifying neonatal deaths and assessing hospital performance than other currently used techniques.     

Men's Perceptions of Delivery Care in Rural Malawi: Exploring Community Level Barriers to Improving Maternal Health

In this cross-sectional survey with qualitative components (n = 389), we explored how husbands perceive delivery care in rural Malawi. Most husbands decide on maternal health care seeking, believe in antenatal care, and prefer institutional delivery. Men acknowledge that their unfaithfulness and violence can harm the pregnancy. Most husbands feel responsible for birth preparedness, but poor availability and unforeseeable transport costs hinder care seeking in pregnancy complications. Our findings suggest that innovative birth preparedness and transport interventions that involve men, as well as the extension of antenatal care (ANC) services to men, can help overcome obstacles to improving maternal health at the community level.     

中澳探索农村地区建立新生儿窒息复苏有效机制试点项目效果评估

目的提高项目地区县级医疗机构产儿科人员新生儿窒息复苏能力,在试点地区建立包括政策、规章、人员和资金支持在内的医疗机构新生儿窒息复苏工作的长效机制。方法在中澳卫生与艾滋病项目确定的4个项目县开展项目活动。为实现项目目标,项目组计划实施了省级师资培训班、县级定期复训,建立院内新生儿窒息复苏领导小组制度,开展国家级和省级督导与评估,举办专家研讨会及经验交流会等22项子活动。项目结束后,采用随机对照的研究方法,选择4个对照县进行调查并与干预县进行比较。结果①政策影响方面:干预县新生儿科医生参加高危分娩术前讨论、分娩现场等待分娩、参加新生儿窒息病例评审等制度建立率均在90%以上,对照县均低于55%。项目省将中澳项目所引进的知识、管理制度和经验扩展到全省范围,产生深远的影响。②能力建设方面:干预县和对照县医务人员新生儿复苏知识平均得分分别为(9.19±1.18)分和(8.40±1.52)分(t=3.922,P<0.001),自信心平均得分分别为(57.33±2.50)分和(54.09±8.19)分(t=3.541,P=0.001);对照县医务人员"快速评估的四项内容"、"羊水污染且无活力是否需要立即气管内吸引胎粪"等核心知识的回答,正确率均低于70%,且均显著低于干预县。③临床效果方面:干预县新生儿窒息发生率由8.83%降至5.99%(χ2=11.300,P=0.001),因窒息死于分娩现场率由27.60/10万降至5.03/10万(χ2=3.142,P=0.076);对照县这两个率的变化均无统计学意义。结论中澳项目在政策影响、能力建设和临床效果等方面取得了显著成绩,不仅提高了医务人员新生儿窒息复苏的技术能力和自信心水平,降低新生儿窒息发生率和死亡率,而且促成项目省出台了一系列降低新生儿死亡的政策、规章和制度,以项目为契机促进妇幼卫生工作的全面发展和提高。     

Management of outbreaks of methicillin-resistant Staphylococcus aureus infection in the neonatal intensive care unit: a consensus statement.

OBJECTIVE: In 2002, the Chicago Department of Public Health (CDPH; Chicago, Illinois) convened the Chicago-Area Neonatal MRSA Working Group (CANMWG) to discuss and compare approaches aimed at control of methicillin-resistant Staphylococcus aureus (MRSA) in neonatal intensive care units (NICUs). To better understand these issues on a regional level, the CDPH and the Evanston Department of Health and Human Services (EDHHS; Evanston, Illinois) began an investigation. DESIGN: Survey to collect demographic, clinical, microbiologic, and epidemiologic data on individual cases and clusters of MRSA infection; an additional survey collected data on infection control practices. SETTING: Level III NICUs at Chicago-area hospitals. PARTICIPANTS: Neonates and healthcare workers associated with the level III NICUs. METHODS: From June 2001 through September 2002, the participating hospitals reported all clusters of MRSA infection in their respective level III NICUs to the CDPH and the EDHHS. RESULTS: Thirteen clusters of MRSA infection were detected in level III NICUs, and 149 MRSA-positive infants were reported. Infection control surveys showed that hospitals took different approaches for controlling MRSA colonization and infection in NICUs. CONCLUSION: The CANMWG developed recommendations for the prevention and control of MRSA colonization and infection in the NICU and agreed that recommendations should expand to include future data generated by further studies. Continuing partnerships between hospital infection control personnel and public health professionals will be crucial in honing appropriate guidelines for effective approaches to the management and control of MRSA colonization and infection in NICUs.     

Access to neonatal intensive care for low-birthweight infants: the role of maternal characteristics.

OBJECTIVES. This study assessed the impact of mother's race, insurance status, and use of prenatal care on very low birthweight infant delivery in or transfer to hospitals with neonatal intensive care units (ICUs). METHODS. Multivariate analysis of Alabama vital statistics records between 1988 and 1990 for infants weighing 500 to 1499 g was conducted, comparing hospital of birth and maternal and infant transfer status, and controlling for infant birthweight and for maternal pregnancy history and demographic characteristics. RESULTS. With other factors adjusted for, non-White mothers with early prenatal care were more likely than White mothers to deliver their very low birthweight infants in hospitals with neonatal ICUs without transfer. Among the mothers who presented first at hospitals without such facilities, those who had late prenatal care were less likely than those with early care to be transferred to hospitals with neonatal ICUs before delivery. Medicaid coverage increased the likelihood of antenatal transfer for White women. Likelihood of infant transfer was not associated with these maternal characteristics. CONCLUSIONS. Maternal race, prenatal care use, and insurance status may influence the likelihood that very low birthweight infants will have access to neonatal intensive care. Interventions to improve perinatal regionalization should address individual and system barriers to the timely referral of high-risk mothers.     

Status of maternal and new born care at first referral units in the state of West Bengal

A study was conducted in 12 First Referral Units (FRUs), selected through multistage sampling, from 6 districts of West Bengal. Infrastructure facilities, record keeping, referral system and MCH indicators related to newborn care were documented. Data was collected by review of records, interview and observation using a pre-designed proforma. Inadequate infrastructure facilities (e.g. no sanctioned posts of specialists, no blood bank at rural hospitals declared as First Referral Units etc.); poor utilization of equipment like neonatal resuscitation sets, radiant warmer etc, lack of training of the service providers were evident. Records/registers were available but incomplete. Referral system was found to be almost nonexistent. Most of the deliveries (86.1%) were normal delivery. Deliveries (87.71%) and immediate neonatal resuscitation (94.9%) were done mostly by nursing personnel. Institution based maternal, perinatal and early neonatal mortality rates were found to be 5.6, 62.4 and 25.2 per 1000 live births respectively. Eclampsia (48.9%), hemorrhage (17.7%), puerperal sepsis (7.1%) were reported to be major causes of maternal mortality. Common causes of early neonatal mortality were birth asphyxia (54.3%), sepsis (14.6%) and prematurity/LBW (12.4%).     

Children and pregnant women.

A review of the literature of the 1980s reveals that women living in rural American are at risk for receiving inadequate prenatal and maternal care. Documented risk factors include poverty and concomitant lack of medical insurance, residence in the most restrictive Medicaid states, and loss of local services including the closure of obstetric units of rural hospitals and the decision by local physicians to discontinue obstetrics. A prominent factor in a physician's decision to stop providing maternity care is the escalating cost of medical liability insurance; however, other forces are also at work, including interference with personal and family activities, disruption of other aspects of professional life (e.g., office schedule), inadequate reimbursement, and an inability to keep up with advancing technology. A research agenda for the 1990s should be consistent with previous recommendations and must stimulate the development of new programs that will induce the maximum number of providers to again offer high quality perinatal care to rural women. Other items on the 1990s research agenda include: (1) the clarification of the impact of lost perinatal services in rural areas, (2) the effects of travel time and distance on perinatal outcomes and cost of care, (3) the effect of loss of obstetric services on other health care services for women and children, and (4) comparisons of regionalized versus centralized systems for the provision of perinatal services.     

Mortality risk after intrauterine and after neonatal transport

In a Dutch national collaborative study of 1338 newborn infants born in 1983 with a gestational age of less than 32 weeks and (or) a birth weight of less than 1500 g, a comparison was made of maternal transport to university perinatal centres and delivery in local general hospitals on the one hand, and neonatal transport to those centres and treatment in regional general hospitals on the other. The mortality risk was investigated by means of logistic regression analysis. The results show that maternal transport was accompanied by a statistically significantly lower mortality risk. The mortality risk after neonatal transport, compared with that after treatment in regional hospitals, was also lower although not significantly. Mortality risk after neonatal transport was significantly associated with increasing transportation distance. The results of the study confirm that referral by maternal transport offers the best prospects for high risk preterm babies.