The cost of prematurity: quantification by gestational age and birth weight

OBJECTIVE: To determine gestational age- and birth weight-related pregnancy outcomes and resource use associated with prematurity in surviving neonates. METHODS: A data set linking birth certificates with maternal and newborn hospital discharge records from hospitals in California (from January 1, 1996, to December 31, 1996) was examined for all singleton deliveries by gestational age (weekly, from 25 to 38 weeks) and birth weight (by 250-g increments from 500 to 3000 or more g). Records were examined for respiratory distress syndrome (RDS), use of mechanical ventilation, length of hospital stay in days, and hospital costs. RESULTS: As expected, RDS, ventilation, length of hospital stay, and costs per case decreased exponentially with increasing gestational age and birth weight. Specifically, neonatal hospital costs averaged 202,700 dollars for a delivery at 25 weeks, decreasing to 2600 dollars for a 36-week newborn and 1100 dollars for a 38-week newborn. Neonatal costs were 224,400 dollars for a newborn at 500-700 g, decreasing to 4300 dollars for a newborn at 2250-2500 g and 1000 dollars for a birth weight greater than 3000 g. For each gestational age group from 25 to 36 weeks, total neonatal costs were similar, despite increasing case numbers with advancing gestational age. Neonatal RDS and need for ventilation were significant at 7.4% and 6.3%, respectively, at 34 weeks' gestation. Significant "excess" costs were found for births between 34 and 37 weeks' gestational age when compared with births at 38 weeks. CONCLUSION: Prematurity, whether examined by gestational age or birth weight, is associated with significant neonatal hospital costs, all of which decrease exponentially with advancing gestational age. Because total costs for each gestational age group from 25 to 36 weeks were roughly the same (38,000,000 dollars), opportunity for intervention to prevent preterm delivery and decrease costs is potentially available at all preterm gestational ages.     

The cost-effectiveness of gestational diabetes screening including prevention of type 2 diabetes: application of a new model in India and Israel

Abstract

Objective: Gestational diabetes mellitus (GDM) is associated with elevated risks of perinatal complications and type 2 diabetes mellitus, and screening and intervention can reduce these risks. We quantified the cost, health impact and cost-effectiveness of GDM screening and intervention in India and Israel, settings with contrasting epidemiologic and cost environments.

Methods: We developed a decision-analysis tool (the GeDiForCE?) to assess cost-effectiveness. Using both local data and published estimates, we applied the model for a general medical facility in Chennai, India and for the largest HMO in Israel. We computed costs (discounted international dollars), averted disability-adjusted life years (DALYs) and net cost per DALY averted, compared with no GDM screening.

Results: The programme costs per 1000 pregnant women are $259?139 in India and $259?929 in Israel. Net costs, adjusted for averted disease, are $194?358 and $76?102, respectively. The cost per DALY averted is $1626 in India and $1830 in Israel. Sensitivity analysis findings range from $628 to $3681 per DALY averted in India and net savings of $72?420–8432 per DALY averted in Israel.

Conclusion: GDM interventions are highly cost-effective in both Indian and Israeli settings, by World Health Organization standards. Noting large differences between these countries in GDM prevalence and costs, GDM intervention may be cost-effective in diverse settings.     

上海市2000-2009年孕产妇死亡情况分析

目的 通过对上海市孕产妇死亡资料的分析,了解孕产妇系统管理中的问题,为提出有效的干预措施降低孕产妇死亡率提供科学依据.方法 采用回顾性分析的方法,对上海市2000至2009年孕产妇死亡病例资料及评审结果、WHO十二格表分类进行分析.结果 (1)活产数变化:上海市活产总数从2000年的84 898例上升到2009年的187 335例,10年增加了120.7%.其中外地户籍来上海分娩者近10年有大幅度增长,已从2000年的26.5%上升到2009年的54.8%,期间增长了4.6倍.(2)孕产妇死亡率及其构成比:2000至2009年上海市活产数共1 279 010例,其中孕产妇死亡262例,死亡率为20.48/10万(262/1 279 010).上海市户籍者死亡率为8.09/10万(55/680 005);外地户籍者死亡率为34.56/10万(207/599 005).(3)不同广籍死亡率变化趋势:从2000年的21.2/10万降至2009年的9.61/10万.上海市户籍者孕产妇死亡率除2003至2004年外基本稳定在10.00/10万以下;外地户籍者孕产妇死亡率下降明显,2002年高达77.42/10万,而到了2009年已下降到11.69/10万.(4)孕产妇死因构成比及顺位:262例孕产妇死亡前5位的死因顺位依次为产科出血(69例,26.3%)、妊娠期高血压疾病(27例,10.3%)、妊娠合并心脏疾病(24例,9.2%)、妊娠合并肝脏疾病(17例,6.5%)、羊水栓塞和异位妊娠(均为15例,5.7%).(5)2000至2009年前后两个5年孕产妇主要死因变化:上海市户籍者的异位妊娠、妊娠期高血压疾病和妊娠合并心脏疾病的死因变化较大,其中异位妊娠死亡率从第一个5年的1.36/10万下降到第二个5年的0.26/10万;妊娠合并心脏疾病从第一个5年的1.36/10万下降到第二个5年的0.52/10万;妊娠期高血压疾病从第一个5年的0上升到第二个5年的0.78/10万.外地户籍者孕产妇的产科出血、异位妊娠、妊娠期高血压疾病死亡率下降显著,作为首位死因的产科出血从第一个5年的21.85/10万下降到第二个5年的5.47/10万;异位妊娠从第一个5年的4.37/10万下降到第二个5年的0.68/10万;而妊娠期高血压疾病从第一个5年的6.87/10万下降到第二个5年的2.96/10万.(6)直接产科原因与间接产科原因的死亡:262例死亡孕产妇中,直接产科原因导致的死亡141例(53.8%);而间接产科原因导致的死亡121例(46.2%).(7)产科出血死亡率的变化:2000至2009年的10年间,上海市孕产妇产科出血死亡率呈逐年下降趋势,从2000年的10.6/10万下降至2009年的1.7/10万.(8)孕产妇死亡病例的评审结果:262例死亡孕产妇经上海市级专家评审后结果分为3类,Ⅰ类(可避免死亡)41例(15.6%),Ⅱ类(创造条件可以避免死亡)66例(25.2%),Ⅲ类(不可避免死亡)155例(59.2%).55例上海市户籍死亡孕产妇中,Ⅰ类17例(30.9%),Ⅱ类14例(25.5%),Ⅲ类24例(43.6%);207例外地户籍死亡孕产妇中,Ⅰ类24例(11.6%),Ⅱ类52例(25.1%),Ⅲ类131例(63.3%).(9)WHO十二格表分类:从死亡孕产妇的知识技能、态度、资源和管理方面分析上海市户籍和外地户籍孕产妇死亡原因的影响因素显示,上海市户籍死亡者中以医疗保健机构的知识技能问题占主要原因(80.0%);外地户籍死亡者中以个人家庭的知识技能和态度为主要原因,分别为54.1%和40.1%.结论 (1)近10年上海市孕产妇死亡率(尤其是外地户籍孕产妇死亡率)逐年显著下降,结果提示上海市对孕产妇的系统管理措施有效.(2)产科出血虽然跃居10年孕产妇死因的首位,但呈显著下降的趋势;30%～40%的孕产妇死亡可创造条件加以避免.(3)但随着孕产妇死因构成比的变化及服务需求的提高,探索新的服务与管理模式以保障母婴安康更显得十分必要.

Abstract：

Objectives To find problems in the systematic management of maternal health and to provide evidence for developing effective interventions to reduce maternal mortality in Shanghai. Methods Every maternal death from 2000 to 2009 was audited by experts and relevant informations were collected and analyzed retrospectively. Results ( 1 ) Number of live births. The number of live births in Shanghai rised from 84 898 in 2000 to 187 335 in 2009, which increased by 120. 7%. Notably, the number of live births of migrating people increased 4. 6 times. In 2000, it took up 25.5% and in 2009, it rose to 54. 8%. ( 2 )Maternal mortality ratio (MMR) and its composition. The total live births from 2000 to 2009 was 1 279 010,among which there were 262 maternal deaths, with average maternal mortality of 20. 48 per 100 000 live birth (262/1 279 010). For Shanghai residents, the MMR was 8.09 per 100 000 live births (55/680 005 ),while the MMR of migrating people was 34. 56 per 100 000 live births ( 207/599 005 ). ( 3 ) Trends of MMR. The MMR declined from 21.2 per 100 000 live births in 2000 to 9.61 per 100 000 live births in 2009. The MMR of Shanghai residents maintained below 10 per 100 000 live births with exception of year 2003 and 2004. The MMR of migrating people declined sharply. In 2002 it was 77.42 per 100 000 live births, and in 2009 it decreased to 11. 69 per 100 000 live births. (4)The composition of causes of maternal deaths and rank order. The top 5 causes of deaths were obstetric hemorrhage (69 cases, 26. 3% of the total deaths), pregnancy induced hypertension (27 cases, 10. 3% of the total deaths), heart diseases (24 cases,9. 2% of the total deaths), liver diseases ( 17 cases, 6. 5% of the total deaths), amniotic fluid embolism and ectopic pregnancy ( 15 cases respectively, 5.7% of the total deaths). ( 5 ) The changes of causes between the first 5 years and the latter 5 years. The MMR of ectopic pregnancy, heart diseases and pregnancy induced hypertension changed significantly in Shanghai residents. The MMR of ectopic pregnancy decreased from 1.36 per 100 000 live births in the first 5 years to 0. 26 per 100 000 live births in the latter 5 years. The MMR of heart diseases decreased from 1.36 per 100 000 live births to 0. 52 per 100 000 live births. While the MMR of pregnancy induced hypertension increased from 0 to 0. 78 per 100 000 live births. For migrating population, the MMR of obstetric hemorrhage, ectopic pregnancy and pregnancy induced pregnancy deceased significantly. As the primary cause, the MMR of obstetric hemorrhage deceased from 21.85 per 100 000 live births in the first 5 years to 5.47 per 100 000 live births in the second 5 years. The MMR of ectopic pregnancy decreased from 4. 37 per 100 000 live births to 0. 68 per 100 000 live births. And the MMR of pregnancy induced hypertension decreased from 6. 87 per 100 000 live births to 2. 96 per 100 000 live births.(6) Direct obstetric causes and indirect obstetric causes of maternal deaths. Among the 262 deaths,141 cases (53. 8% ) were due to Direct obstetric causes and 121 (46. 2% ) were due to indirect obstetric causes. (7)The trend of MMR of obstetric hemorrhage. The MMR of obstetric hemorrhage declined from 10. 6 per 100 000 live births in 2000 to 1.7 per 100 000 live births in 2009. ( 8 ) The results of maternal death audit. The results of maternal death audit were classified into 3 categories: 41 cases ( 15.6% )belonged to the first category, i. e, avoidable deaths; 66 cases (25.2%) belonged to the second category,i. e, avoidable when creating some conditions; and 155 cases (59. 2% ) belonged to the third category,which means not avoidable. Among 55 deaths of Shanghai residents, 17 cases (30. 9% ) belonged to the first category, 14 cases (25.5%) belonged to the second, and 24 cases (43.6%) belonged to the third category. Among 207 deaths of migrating population, 24 cases (11.6%) belonged to the first category,52 cases (25. 1% ) belonged to the second, and 131 cases (63.3%) belonged to the third category. (9)WHO twelve-grid classification of maternal deaths. The factors, including attitude, knowledge and skills, resources and management of the dead people and their families, the medical institutes and social supportive departments were integrated and analyzed. It showed that the main reason of maternal deaths of Shanghai residents was poor knowledge and skills of medical staffs, accounting for 80. 0% of the deaths. While the main reasons of maternal deaths of migrating people were poor knowledge and skills, inappropriate attitude of the dead people and their families, which took up 54. 1% and 40. 1% respectively. Conclusions The MMR in Shanghai declined continuously from 2000 to 2009, especially for migrating population which reflected the interventions of maternal management in Shanghai were effective. Though obstetric hemorrhage was the first top cause of maternal death during past 10 years, it declined Sharply. 30% to 40% maternal deaths were avoidable if some conditions were created. However, in order to adapt the changes of main causes of maternal deaths and accomplish increasing service requirements, it is necessary to develop new service and management mode.     

Association between rising professional liability insurance premiums and primary cesarean delivery rates

OBJECTIVE: To estimate the association between changes in Illinois professional liability premiums for obstetrician-gynecologists and singleton primary cesarean delivery rates. METHODS: Data from the National Center for Health Statistics were used to identify all singleton births between 37 weeks and 44 weeks of gestation occurring in Illinois from 1998 through 2003. Primary cesarean delivery rates for women delivered between 37 weeks and 44 weeks of gestation per 1,000 gravid women eligible to have a primary cesarean delivery were calculated for each Illinois county. The annual medical professional liability premium for each county in Illinois was represented by the reported professional liability insurance rate charges (adjusted to 2004 dollars) from the ISMIE Mutual Insurance Company. Separate analyses were conducted for nulliparous and multiparous women. The independent association between county-level primary cesarean delivery rates and the previous year's insurance premiums was evaluated using linear regression models. RESULTS: During the study period, 817,521 women were eligible for inclusion in the analysis. The county-level mean primary cesarean delivery rate increased from 126 to 163 per 1,000 (P<.001) eligible women, whereas the mean annual medical professional liability insurance premiums also rose significantly (from $60,766 in 1997 to $83,167 in 2002, P<.001). Multivariable analyses demonstrated that for each annual $10,000 insurance premium increase, the primary cesarean delivery rate increased by 15.7 per 1,000 for nulliparous women. This association also was evident for multiparous women, who had an increase in cesarean deliveries of 4.7 per 1,000 for every $10,000 increase. CONCLUSION: Higher rates of primary cesarean delivery are associated with increased medical professional liability premiums for obstetrician-gynecologists in Illinois. LEVEL OF EVIDENCE: II.     

Placenta previa in singleton and twin births in the United States, 1989 through 1998: a comparison of risk factor profiles and associated conditions

OBJECTIVE: The purpose of this study was to compare risk factor profiles for placenta previa between singleton and twin live births. STUDY DESIGN: This cohort study was based on United States natality data files (1989 through 1998) and comprised 37,956,020 singleton births and 961,578 twin births. Women who were diagnosed with placenta previa were included only if they were delivered by cesarean delivery. Risk factors for placenta previa that were examined included sociodemographic (age, gravidity, education, marital status, and race), behavioral (prenatal care, smoking, and alcohol use), previous preterm birth, and medical and obstetric factors. Effect modification between maternal age and gravidity and the dose-response relationship with number of cigarettes smoked/day on placenta previa risk were also evaluated. RESULTS: The rate of placenta previa was 40% higher among twin births (3.9 per 1,000 live births, n = 3,793 births) than among singleton births (2.8 per 1,000 live births, n = 104,754 births). Comparison of risk factors for placenta previa between the singleton and twin births revealed fairly similar risk factor profiles. Compared with primigravid women <20 years old, the risk for placenta previa increased by advancing age and by increasing number of pregnancies among both singleton and twin births. The number of cigarettes smoked per day also showed a dose-response trend for placenta previa risk in the two groups. CONCLUSION: The increased rate of placenta previa among twin births underscores the need to monitor carefully such pregnancies with heightened suspicion and awareness for the development of this condition.     

Maternal outcomes associated with planned primary cesarean births compared with planned vaginal births

OBJECTIVE: To compare the outcomes and costs associated with primary cesarean births with no labor (planned cesareans) to vaginal and cesarean births with labor (planned vaginal). METHODS: Analysis was based on a Massachusetts data system linking 470,857 birth certificates, fetal death records, and birth-related hospital discharge records from 1998 and 2003. We examined a subset of 244,088 mothers with no prior cesarean and no documented prenatal risk. We then divided mothers into two groups: those with no labor and a primary cesarean (planned primary cesarean deliveries-3,334 women) and those with labor and either a vaginal birth or a cesarean delivery (planned vaginal-240,754 women). We compared maternal rehospitalization rates and analyzed costs and length of stay. RESULTS: Rehospitalizations in the first 30 days after giving birth were more likely in planned cesarean (19.2 in 1,000) when compared with planned vaginal births (7.5 in 1,000). After controlling for age, parity, and race or ethnicity, mothers with a planned primary cesarean were 2.3 (95% confidence interval [CI] 1.74-2.9) times more likely to require a rehospitalization in the first 30 days postpartum. The leading causes of rehospitalization after a planned cesarean were wound complications (6.6 in 1,000) (P<.001) and infection (3.3 in 1,000). The average initial hospital cost of a planned primary cesarean of US dollars 4,372 (95% C.I. US dollars 4,293-4,451) was 76% higher than the average for planned vaginal births of US dollars 2,487 (95% C.I. US dollars 2,481-2,493), and length of stay was 77% longer (4.3 days to 2.4 days). CONCLUSION: Clinicians should be aware of the increased risk for maternal rehospitalization after cesarean deliveries to low-risk mothers when counseling women about their choices. LEVEL OF EVIDENCE: II.     

Falling incidence of hypoxic-ischaemic encephalopathy in term infants.

OBJECTIVE: To examine trends in the incidence of hypoxic-ischaemic encephalopathy over a 13-year period. DESIGN: A retrospective analysis of medical records of all infants admitted in the years 1976-1980 and 1984-1988. SETTING: A large non-teaching district health authority in central England. SUBJECTS: Infants admitted to a district general hospital neonatal unit with clinical features of hypoxic-ischaemic encephalopathy. MAIN OUTCOME MEASURES: Incidence of three grades of hypoxic-ischaemic encephalopathy, handicap and mortality. RESULTS: During the first 5-year period the overall incidence of hypoxic-ischaemic encephalopathy was 7.7 per 1000 live births with 2.6 per 1000 live births being severely affected (grades II and III). In the second 5-year period the overall incidence was 4.6 per 1000 live births with 1.8 per 1000 live births being severely affected. The difference in the overall rate is statistically significant. Of the infants with severe encephalopathy 61% had Apgar scores below 4 at 1 min and 60% were born by instrumental or operative delivery. CONCLUSIONS: The fall in incidence of hypoxic-ischaemic encephalopathy has occurred during a period of falling perinatal mortality rate. It was instructive to find that infants born vaginally and without obstetric intervention formed a larger fraction of the severely affected infants in the later period.     

The impact of medical legal risk on obstetrician-gynecologist supply

OBJECTIVE: To evaluate the effects of medical legal risk on practice location of obstetrician-gynecologists. METHODS: We used the American College of Obstetricians and Gynecologists (ACOG) Membership Record to determine the number of Fellows and Junior Fellows by state. We obtained state malpractice premiums from the Medical Liability Monitor and state birth rates from the National Center for Health Statistics. The American Medical Association (AMA) "Crisis" and ACOG "Red Alert" designations, as well as state malpractice premium levels, were used to approximate malpractice risk. We examined the changes in state births to obstetrician-gynecologist rates from 1995 to 2003 by using the Student t test and Mann-Whitney tests. Comparisons were made between states of different risk levels. RESULTS: We found no significant difference in the percentage changes in births per Fellow or births per Junior Fellow between AMA "Crisis" and remaining states, nor between ACOG "Red Alert" and Safe states. The percentage changes in births per Fellow were similar in the 10 highest-premium states and the 10 lowest-premium states. The percentage increase in births per Junior Fellow in the 10 highest-premium states was significantly greater than the 10 lowest-premium states (median 28.5% versus 5.0%, P = .03). CONCLUSION: Malpractice premiums appear to influence practice location of new obstetrician-gynecologists. Neither the AMA designation of "Crisis" nor the ACOG designation of "Red Alert" had supply implications in the analysis. More research on the interaction of malpractice rates and obstetrician-gynecologist supply is needed for informed decisions regarding malpractice premium management.     

Fetal malformations associated with breech delivery. Implications for obstetric management

Among 1,411 breech deliveries at the Soroka Medical Center, Beer-Sheva, Israel, there were 116 cases of congenital anomalies (8.2 %). Forty-nine fetuses (3.47%) exhibited major congenital anomalies and 67 (4.7%), minor ones. The incidence of chromosomal anomalies was 0.63% (1 per 159 births) as compared with 0.25% in the general population. The frequency distribution indicated that most of the fetuses with congenital abnormalities weighed 2,000 gm or more. In view of the high incidence of chromosomal aberrations and major congenital anomalies among fetuses with breech presentation, it seems desirable to consider ultrasonographic assessment and chromosomal analysis during the last trimester of pregnancy.     

The impact of prenatal care on fetal and neonatal death rates for uninsured patients: a "natural experiment" in West Virginia.

A three-county program in southern West Virginia was developed by an obstetric practice to deliver prenatal care to a population of uninsured patients. Between January 1984 and December 1986, 1331 (29.4%) of 4534 patients were delivered at a level 2 hospital after prenatal care within the clinic program. The hospital-wide fetal death ratio declined from 11.8 to 7.2 per 1000 live births during the years of clinic operation, a statistically significant reduction (P = .02). Uninsured patients experienced a statistically significant reduction in fetal death ratio during the program, from 35.4 to 7.0 per 1000 live births (P = .02), whereas those covered by medical assistance did not experience a reduction. Privately insured patients also had a significant decrease, from 10.0 to 3.1 per 1000 live births (P less than .001). The increasing operating expense, mainly due to rising malpractice insurance premiums, required suspension of the program in December 1986. The fetal death ratio returned to 10.3 deaths per 1000 live births in 1987. Factors that varied significantly during the "clinic" phase included: higher rates of cesarean, diagnosed maternal hypertension, and diabetes mellitus; and lower rates of premature rupture of membranes and non-white population. Other factors, including age over 35 years, postdatism, incidence of twins, incidence of lethal congenital anomalies, and single marital status, did not vary significantly before, during, or after the clinic program. This study identified a high-risk population of patients who did not qualify for medical assistance coverage and were de facto "uninsured." The results suggest that prenatal care for this high-risk population of uninsured patients can reduce the fetal death rate.     

Termination of pregnancy: attitudes and behavior of women in a traditional society

OBJECTIVES: The Bedouin Arabs, a Muslim traditional ethnic minority in Israel, are faced with difficult choices when offered prenatal diagnosis as part of the universally provided prenatal care in Israel. This paper is to examine attitudes towards and practice of pregnancy termination, following an unfavorable prenatal diagnosis. METHODS: Semistructured interviews with 83 women were conducted to study attitudes. Data from the Soroka Medical Center, where all births in the area take place, were used to assess the rate of terminations of pregnancies following a diagnosis of a chromosomal anomaly. RESULTS: While divided on the question of termination, many women believed that a second medical opinion is needed, preferably from an Arab physician. The reasons for termination are both child- and mother-related. Opposing termination is based on both the suspicion that the diagnosis might be wrong and on religious reasons. Between 1995 and 1999, 686 Bedouin women had undergone amniocentesis (2.4% of all pregnancies). Six of 11 pregnancies with the diagnosis of a trisomy were terminated (54.5%). All cases in which a trisomy was terminated were trisomy 21. CONCLUSIONS: Culturally acceptable prenatal diagnostic services for Muslim populations should be based on early testing, and should involve Muslim physicians and religious authorities.     

The health care costs of cervical human papillomavirus--related disease

OBJECTIVE: The purpose of this study was to examine the health care costs of cervical human papillomavirus-related disease in a US health care setting. STUDY DESIGN: We conducted an observational cohort study using 1997 through 2002 administrative and laboratory records from 103,476 female enrollees of the Kaiser Permanente Northwest health plan (Portland, Ore). We examined the cost per case and annual cost per 1000 enrollees for cervical human papillomavirus-related events. RESULTS: A cervical examination with a normal routine papanicolaou smear incurred costs of 57 dollars (95% CI, 57-57). Costs that were associated with abnormal routine screening diagnoses ranged from 299 dollars for atypical squamous cells (95% CI, 245-352) to 2349 dollars for high-grade squamous intraepithelial lesion (95% CI, 1,047-3,650). The costs of histologically confirmed cervical intraepithelial neoplasia ranged from 1026 dollars for cervical intraepithelial neoplasia 1 (95% CI, 862-1191) to 3235 dollars for cervical intraepithelial neoplasia 3 (95% CI, 2051-4419); a cost of 376 dollars (95% CI, 315-436) was associated with false-positive test results. At the level of the health plan, overall annual cervical cancer prevention and treatment costs were 26,415 dollars per 1000 female enrollees, with routine cervical cancer screening accounting for expenditures of 16,746 dollars per 1000 female enrollees, cervical intraepithelial neoplasia accounting for expenditures of 4535 dollars per 1000 female enrollees, cervical cancer accounting for expenditures of 2629 dollars per 1000 female enrollees, and false-positive test results accounting for expenditures of 2394 dollars per 1000 female enrollees. CONCLUSION: These are the first direct estimates of both individual and population level costs of cervical human papillomavirus-related disease in a general US health care setting. Routine cervical cancer screening comprises nearly two thirds of total annual cervical human papillomavirus-related health care costs, with 10% of expenditures dedicated to the treatment of invasive cervical cancer, 17% to the management of cervical precancers, and 9% to dealing with false-positive Papanicolaou test results.     

Still births – eight years experience at Aga Khan University Hospital Karachi,Pakistan

Objectives.?To examine the possible etiological causes of still births during 8 years of clinical experience at a tertiary referral center, The Aga Khan University Hospital Karachi Pakistan. In addition, to compare demographic and medical risk factors along with analysis of cause of fetal death in different groups.

Material and Methods.?This was a retrospective cohort study, conducted at the Aga Khan University Karachi, Pakistan over a period of 8-year period between January 2000 and January 2008. We reviewed 287 medical records of all women who had intrauterine fetal demise during study time period.

Results.?The prevalence of still births at our institution was 6.6?±?2.1 per 1000 total births. Congenital anamolies, maternal hypertension, and fetal growth restrictions were the three main causes of still births. About half of still births were among unbooked pregnant women. More than 90% of occurred during the ante natal period while 10% were intrapartum. Majority of stillborns were in macerated state when delivered.

Conclusion.?Most of still births were due to known causes such as hypertension, congenital anomalies, and fetal growth restriction. Improvement in the management of hypertension and diagnosis of congenital anomalies is necessary. Results of the analysis urge on the need for antenatal care and compliance for follow-ups.     

The effect of obstetric management and factors beyond clinical control on maternal mortality rates at the Chicago Maternity Center from 1959 to 1963

This 5 year survey of maternal mortality rates covers 16,087 consecutive births, 89 per cent at home and 11 per cent in a hospital. Nonsurvival is related to medical indigency, race, exogenous obesity, lack of prenatal care, grandmultiparity, and absence of medical attendants at delivery. The total number of deaths was 9.5 per 10,000 live births. Four of 7 direct deaths were catastrophic emergencies, unregistered or medically unattended, and left no choice for management. A review of management revealed that among 412 cesarean sections, there were 2 deaths, each direct (0.5 per cent). Of 1,316 operative vaginal deliveries, there were 441 major manipulative procedures with no related death. High risk is inherent in a medically indigent population; the related high loss at cesarean section, in contrast to the patients' excellent tolerance for delivery from below, makes it mandatory that trainees acquire the judgment and skill necessary in the use of major manipulative vaginal procedures.     

Mortality of full-term infants during the first month of life in a tertiary care hospital.

OBJECTIVE: The neonatal mortality rate is disproportionately influenced by preterm infants and does not reflect the rate in full-term infants. Our objectives were to estimate the full-term neonatal mortality rate and to identify causes of death in full-term infants during the first month of life. STUDY DESIGN: A retrospective study of full-term infant deaths during a 6-year period from 2000 to 2005, in a tertiary medical center. RESULT: During the study period there were 44,703 full-term births and 31 deaths, representing a mortality rate of 0.69 per 1,000 live births. The main cause of death was congenital anomalies (64.5%), specifically cardiac anomalies. Other causes were chromosomal anomalies or syndromes (12.9%), labor complications (12.9%), infections (3.2%), congenital diseases (3.2%) and metabolic disorders (3.2%). CONCLUSION: The mortality rate of full-term infants may be lower than previous estimates. Efforts aimed at decreasing mortality among full-term infants should focus on prenatal diagnosis.     

Cost-effectiveness analysis of prenatal population-based fragile X carrier screening

OBJECTIVE: To investigate the cost-effectiveness of a widespread prenatal population-based fragile X carrier screening program. STUDY DESIGN: A decision tree was designed comparing screening versus not screening for the fragile X mental retardation protein 1 premutation in all pregnant women. Baseline values included a prevalence of fragile X mental retardation protein 1 premutations of 3.3 per 1000, a premutation expansion rate of 11.3%, and a 99% sensitivity of the screening test. The cost of the screening test was varied from 75 US dollars to 300 US dollars. A sensitivity analysis of the probabilities, utilities, and costs was performed. RESULTS: The screening strategy would lead to the identification of 80% of the fetuses affected by fragile X annually. Assuming the cost of 95 US dollars per test and only one child, the program would be cost effective at 14,858 US dollars per quality-adjusted life-year. The screening strategy remained cost effective up to 140 US dollars per test and 1 child per woman or for 2 children per woman up to a cost of 281 US dollars per test. CONCLUSION: Population-based screening for the fragile X premutation may be both clinically desirable and cost effective. Prospective pilot studies of this screening modality are needed in the prenatal setting.     

Intussusception in Taiwanese children: analysis of incidence, length of hospitalization and hospital costs in different age groups.

BACKGROUND AND PURPOSE: This study investigated the characteristics of intussusception in Taiwanese children of different age groups, including the incidence, length of hospitalization and hospital costs. METHODS: Children with a diagnosis of intussusception who were hospitalized from 1999 through 2001 were identified from a nationwide health insurance claims database. The incidence of intussusception was calculated by age, gender, and season. Length of hospitalization and hospital costs were also analyzed. RESULTS: A total of 6988 cases of intussusception were identified in Taiwan from 1999 to 2001. Among them, 4859 cases occurred in children below 15 years of age. The average incidence among children below age 15 years was 34.5 per 100,000, with a peak incidence of 118.8 per 100,000 observed among children younger than 24 months old. The highest incidence of intussusception in Taiwanese children occurred between 12 and 24 months of age. According to the data for patients below 15 years of age hospitalized for intussusception in year 2000, males were more likely to be affected than females (61.3% vs 38.7%). Intussusception-related hospitalizations were rare in infants in the first few months of life, increased in those 6 to 12 months old, and peaked among children 1 to 3 years old. Among the 952 patients with intussusception admitted to hospitals in 2000, 297 (31.2%) received surgery, incurring higher median medical costs (New Taiwan Dollars [NT dollars] 42,265 or US dollars 1234) and longer median hospital stay (6.2 days) than the 655 patients who did not require surgery (NT dollars 6290 or US dollars 185 for hospitalization of 2.4 days). CONCLUSIONS: The study found that the incidence of intussusception peaked in the second year of life in Taiwanese children. There was also a male predominance and lack of seasonal variation in incidence.     

Physician- and midwife-attended home births Effects of breech,twin, and post-dates outcome data on mortality rates

The effect of attending breech, twin, and post-date pregnancies on home birth outcomes was assessed. The same form was used to collect data on a convenience sample of 4,361 home births attended by apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981. Data sets were compared to find 1,000 pairs of pregnant women, one from each group, who were matched for age, sex, socioeconomic status, race, and medical risk. The perinatal mortality rate for the midwife-attended births was 14 per 1,000 (three fetal deaths before labor, six intrapartum fetal deaths, and five neonatal deaths). The perinatal mortality rate for births attended by family physicians was five per 1,000 (one fetal death before labor, two intrapartum fetal deaths, and two neonatal deaths). The difference was statistically significant; however, the differences disappeared when cases involving post-dates, twin, or breech deliveries were eliminated from the sample. Although the data are more than a decade old, they support the premise that outcomes for low-risk home births are comparably good whether attended by physicians or midwives. However, the findings do raise questions about the safety of attending high-risk births at home.     

PHYSICIAN- AND MIDWIFE-ATTENDED HOME BIRTHS: Effects of Breech,Twin, and Post-Dates Outcome Data on Mortality Rates

The effect of attending breech, twin, and post-date pregnancies on home birth outcomes was assessed. The same form was used to collect data on a convenience sample of 4,361 home births attended by apprentice-trained midwives from 1970 to 1985 and 4,107 home births attended by family physicians from 1969 to 1981. Data sets were compared to find 1,000 pairs of pregnant women, one from each group, who were matched for age, sex, socioeconomic status, race, and medical risk. The perinatal mortality rate for the midwife-attended births was 14 per 1,000 (three fetal deaths before labor, six intrapartum fetal deaths, and five neonatal deaths). The perinatal mortality rate for births attended by family physicians was five per 1,000 (one fetal death before labor, two intrapartum fetal deaths, and two neonatal deaths). The difference was statistically significant; however, the differences disappeared when cases involving post-dates, twin, or breech deliveries were eliminated from the sample. Although the data are more than a decade old, they support the premise that outcomes for low-risk home births are comparably good whether attended by physicians or midwives. However, the findings do raise questions about the safety of attending high-risk births at home.