Good outcome of teenage pregnancies in high-quality maternity care

BACKGROUND: Teenage pregnancies have been associated with fetal growth restriction, low birth weight, preterm birth and neonatal mortality. These could be due to biological immaturity, lifestyle factors or inadequate attendance to maternity care. The objective of this study was to assess the relationship between young age of the mother and pregnancy risk factors and adverse pregnancy outcome in conditions of high-quality maternity care used by almost the entire pregnant population. METHODS: We analysed a population-based database of 26,967 singleton pregnancies during 1989-2001. Only 185 of these mothers were under 18 years old. Data were collected using a self-administered questionnaire at 20 weeks of pregnancy and clinical records of pregnancy, delivery and newborn child. The information covered maternal risk factors, pregnancy characteristics and obstetric outcomes. Odds ratios (ORs) for adverse pregnancy outcomes in teenage compared with older mothers were obtained from multiple logistic regression models. RESULTS: Teenage mothers smoked, were unemployed and had anaemia or chorioamnionitis more often than older mothers. On the other hand, they were overweight and had maternal diabetes less often than adults. Teenage mothers had as many instrumented deliveries (OR 0.70; 95% confidence interval 0.39-1.27) but fewer Caesarean sections (0.62; 0.39-0.97) than adults. We found no evidence for increased risk of preterm delivery, fetal growth restriction, low birth weight, or fetal or perinatal death in teenage mothers. CONCLUSIONS: These results suggest that increased risks for adverse pregnancy outcomes in teenage pregnancies can most probably be overcome by means of high-quality maternity care with complete coverage.     

Use of prenatal screening tests in Finland

This study examines the availability of prenatal screening testssuch as ultrasound, amniocentesis, chorionic villus samplingand serum screening in Finnish maternity care and estimatespossible future trends. In Finland, municipalities are responsiblefor organizing maternity care in their area. Questionnaireswere sent to a random sample of 100 municipalities (responserate 99%) and to all Finnish public hospitals with obstetricor gynaecological departments (response rate 100%). Ultrasoundscreening examinations and amniocentesis and chorionic villussampling were put into use in Finland as soon as they were technicallyavailable. These screening techniques have diffused widely andare accessible throughout most of the country. There existssome variation with regard to the timing and number of ultrasoundexaminations and to which age group amniocentesis and chorionicvillus sampling are offered. A tendency to decentralize prenatalscreening test locations, in particular in the case of ultrasound,was found. Most professionals were comfortable with currentscreening systems and, if some change was wished for, it mostoften was a wish to increase screening activity. Regardlessof many controversial issues, prenatal screening has becomean established practice in Finland.     

Primary care and genetic services. Health care in evolution

The demand for services for predicting, diagnosing, and managing genetic diseases or diseases with a genetic component is likely to increase faster than the availability of services from medical geneticists and genetic counselors. Health care systems may also impose limitations on referrals to these specialists. If genetic problems are not to be missed and excessive referrals are to be avoided, non-geneticist practitioners will have to recognize when genetic problems should be considered, and initiate diagnosis and even management. Primary-care-centred systems offer the greatest potential for maximizing overall cost-effectiveness, by reducing the demand for specialty services not essential for improving health. But primary-care-centred systems may pose a risk of underdetection and undermanagement of genetic problems if practitioners are not actively supported by information and other educational networks. Several models for dealing with these challenges are presented, including algorithms that aid in recognizing genetic problems.     

Delayed prenatal care and the risk of low birth weight delivery

To determine if the timing of prenatal care is associated with low birth weight delivery after adjusting for sociodemographic and behavioral risk factors, we performed a retrospective cross-sectional study of singleton births to white (2,945,595) or African-American (552,068) women in the United States in 1996. When adjusted for race, maternal age, educational level attained, and the use of alcohol and tobacco during pregnancy, women beginning care in the 2nd (adjusted RR = 0.85; 95% CI: 0.83–0.86) and 3rd trimesters (RR = 0.87; 95% CI: 0.84–0.91) had a reduced risk of low birth weight compared to women beginning care in the 1st trimester. Our findings suggest that no benefit exists for early initiation of prenatal care for reducing the risk of low birth weight. Findings related to differences in low birth weight among women who start prenatal care later are likely due to sociodemographic differences that may influence access to early care.     

Inequality in medical care in Israel: Arabs and Jews in the Jerusalem district of the General Sick Fund

Background: Differences in health and health services use amongdifferent ethnic groups within populations have been alwaysa major concern in democratic societies. Past research has documentedthe gaps both in health and in services utilization betweenthe Israell Arab and Jewish populations. Methods: This paperstudies the 1993 utilization of health services by a sampleof 70,000 Arabs and Jews insured by the General Sick Fund (Clalit),the biggest sick fund in Israel, in the Jerusalem district.The Arab population consists of Palestinian residents of greaterEast Jerusalem and Israell Arabs, offering a unique opportunityto study the health care use of the three population groups.Results: The results show that, while the mean annual cost ofcare per user is the same for Jews and Arabs, Arabs insureesare dramatically less likely to use medical services, controllingfor age, gender, income, chronic conditions and settlement size.This was found true for both ambulatory and in-patient careand, in particular, for elderly persons. The Israell Arabs arethe most intensive users of care compared to the Jews and thePalestinians. Conclusion: The gaps in utilization can be attributedto differences in accessibility, traditionalism and social andcultural assets. Early findings following the implementationof the National Health Insurance Law in 1995 indicate that somedifferences in accessibility to and use of medical servicesbetween Arabs and Jews have been reduced. The founding of thePalestinian Authority Council will hopefully further enhancethe use of medical care and the health state of the Palestinianpopulation.     

Continuous quality improvement in primary health care: A five year project

Background: The aim of the study was to determine the feasibilityof a programme of continuous quality improvement (CQI) in threeprimary care teams (PCTs) and to test the effectiveness of correspondenceanalysis (CA) in identifying factors contributing to qualityperformance. Methods: A CQI task force was responsible for coordinatingall aspects of the programme. Six domains of performance weredefined, each having one or more indicators. The statisticalanalysis included comparison of proportions and, in addition,CA was used to further identify which factors were contributingto a performance below the standard. Results: In the domainof infant care, two of the three PCTs reached the 100% goalon immunisation coverage. The third PCT did not attain the standard(85%). However, through CA it was possible to identify the subpopulationat risk. The proportion of pregnant women accessing pre-natalcare during the first trimester increased from the initial 20to 66% (p<0.001). Physicians' compllance with pre-natal careprotocol increased from 70 to 93% (p<0.05). Performance relatedto recording of home health care visits in medical historiesdid not improve at all, nor did the providers reach the standardfor continuing education. The medical records Information improvedfor alcohol and tobacco consumption, allergies (p<0.05),and blood pressure (p<0.05). The patients' satisfaction wasgreater with doctors than nurses. Conclusions: This experienceindicates the feasibllity and benefits of a comprehensive CQIprogramme at the primary care level. CA is considered a usefulstatistical method for locating factors contributing to qualityperformance.     

Utilization of prenatal care in poorer and wealthier urban neighbourhoods in Turkey

BACKGROUND: The objectives of this study are to identify the individual- and neighbourhood-level determinants of utilization of prenatal care, and to identify self-reported reasons for not receiving prenatal care in Turkey. METHODS: A household-based cluster sample of 1249 women who had a child less than two years old were interviewed in five Turkish cities. Multilevel regression analysis was run to predict the influences of individual- and neighbourhood-level characteristics on utilization of prenatal care. RESULTS: Utilization of prenatal care and the quality of the care received were found to be significantly lower in poorer neighbourhoods. Using multilevel regression analysis (two levels), educational level, income, parity and having health insurance were found to be individual-level determinants, while quality of care offered and stability of the local population were found to be neighbourhood-level determinants of utilization of prenatal care. The most frequent self-reported reason for receiving no prenatal care was 'not having any complaint', and the second was 'insufficient financial resources'. CONCLUSION: There was a big difference between poor and wealthy neighbourhoods in utilization of prenatal care. This difference was partly due to a contextual effect of neighbourhood status; but mostly due to individual-level variables. Improving the quality of prenatal care may increase not only the benefits of prenatal care, but also its utilization, especially in the public sector. Health and social policies have to take into account diversity among individuals and neighbourhoods in the course of efforts to improve service quality.     

重度子痫前期孕产妇产前血压与妊娠结局的关系

目的探讨重度子痫前期孕产妇不同程度的产前血压与妊娠结局的相关性。方法选取广州医科大学附属第三医院2016年7月1日至2018年6月30日收治的177例重度子痫前期孕产妇作为研究对象,按照产前血压分为高血压1组和高血压2组(高血压1组:收缩压为160~179mm Hg和/或舒张压为100~109mm Hg;高血压2组:收缩压≥180mm Hg和/或舒张压≥110mmHg),回顾性分析两组患者一般临床资料。结果①高血压2组的发病孕周、分娩孕周早于高血压1组(t值分别为2.14、3.06,均P <0.05)。②高血压2组的HELLP综合征发生率高于高血压1组(χ~2=4.66,P <0.05)。③高血压2组患者的胎儿早产、胎儿生长受限、出生并发症发生率及围产儿结局、低体重儿及新生儿转新生儿重症监护室(NICU)发生率均显著高于高血压1组(χ~2值分别为6.64、8.85、11.07、7.06,均P <0.05)。结论重度子痫前期患者不良妊娠结局的发生率随着产前血压升高而增加。     

Quantile effects of prenatal care utilization on birth weight in Argentina

The effects of prenatal care utilization on birth weight (BW) may vary by unobserved fetal health endowments. This heterogeneity will be masked by estimating the effects at BW mean but can be evaluated by estimating the effects at BW quantiles as fetal health endowment is a strong correlate with the BW quantile order. We estimated the effects of prenatal care visits and delay before prenatal care initiation, on BW mean and quantiles using a sample of infants from Argentina. Self‐selection into prenatal care was modeled using 2SLS and instrumental variable quantile regression. Results suggest that the ‘mean’ effect of prenatal care utilization largely underestimates the effects at lower BW quantiles. About 35 and 77 g increase in BW mean and 0.1 quantile respectively, per visit and about 30 and 139 g decrease in BW mean and 0.1 quantile respectively, per week delayed, were estimated. Ignoring self‐selection into prenatal care resulted in underestimation of mean and quantile effects. Results highlight the limitation of analyses focused on ‘mean effects’ in the presence of treatment heterogeneity and emphasize the importance of identifying women at risk for having infants at lower BW quantiles as they may benefit most from earlier and more intensive prenatal care. Copyright © 2009 John Wiley & Sons, Ltd.     

Prenatal drug use and the production of infant health

We estimate the effect of illicit drug use during pregnancy on two measures of poor infant health: low birth weight and abnormal infant health conditions. We use data from a national longitudinal study of urban parents that includes postpartum interviews with mothers, hospital medical record data on the mothers and their newborns, and information about the neighborhood in which the mother resides. We address the potential endogeneity of prenatal drug use. Depending on how prenatal drug use is measured, we find that it increases low birth weight by 4-6 percentage points and that it increases the likelihood of an abnormal infant health condition by 7-12 percentage points.     

Age and quality of in-hospital care of patients with heart failure

BACKGROUND: Elderly patients may be at risk of suboptimal care. Thus, the relationship between age and quality of care for patients hospitalized for heart failure was examined. METHODS: A cross-sectional study based on retrospective chart review was performed among a random sample of patients hospitalized between 1996 and 1998 in the general internal medicine wards, with a principal diagnosis of congestive heart failure, and discharged alive. Explicit criteria of quality of care, grouped into three scores, were used: admission work-up (admission score); evaluation and treatment during the stay (evaluation and treatment score); and readiness for discharge (discharge score). The associations between age and quality of care scores were analysed using linear regression models. RESULTS: Charts of 371 patients were reviewed. Mean age was 75.7 (+/-11.1) years and 52% were men. There was no relationship between age and admission or readiness for discharge scores. The evaluation and treatment score decreased with age: compared with patients less than 70 years old, the score was lower by -2.6% (95% CI: -7.1 to 1.9) for patients aged 70 to 79, by -8.7% (95% CI: -13.0 to -4.3) for patients aged 80 to 89, and by -19.0% (95% CI: -26.6 to -11.5) for patients aged 90 and over. After adjustment for possible confounders, this relationship was not significantly modified. CONCLUSIONS: In patients hospitalized for congestive heart failure, older age was not associated with lower quality of care scores except for evaluation and treatment. Whether this is detrimental to elderly patients remains to be evaluated.     

Ethnic differences in rates of infant mortality and sudden infant death in Sweden, 1978-1990

This study examined ethnic differences in infant mortality rates(IMRs) and rates of sudden infant death syndrome (SIDS) amongSwedish and immigrant women between 1978 and 1990 in Sweden.The study population comprised 1,265,942 single live birthsto women between the ages of 15 and 44 years in Sweden. Datafrom 3 registers In Sweden were linked to obtain medical andsociodemographic information for each mother and child in thestudy. Logistic regression analyses were employed to assessethnic differences in infant mortality and SIDS while controllingfor relevant confounders. This study revealed no ethnic differencesin IMRs. There were also no ethnic differences in the mortalityrates due to SIDS, except for immigrant women from SoutheastAsia and the Pacific Islands who experienced significantly higherrates of SIDS than Swedish women. This study shows that, ingeneral, the IMRs and mortality rates due to SIDS are not aserious public health problem among immigrant women in Swedenand suggests several reasons why this is the case.     

Use of health services and home care before and after conversion of nursing home residences into private flats: Cross sectional consumer health surveys

The aim of this article is to describe the attitude to a changeof nursing home residences into private flats and the use ofservices by elderly persons before and after a major intervention(in 1986) in the service-delivery organization in the DanishMunicipality of Skaevinge. In this intervention, the rooms ofa nursing home were converted into health care centre flats.Former nursing home residents were again living in private flats.Their pensions, which formerly paid for their upkeep in thenursing home, were now paid directly to them. The study is basedon cross-sectional consumer health surveys. A total of 155 elderlypersons participated in ‘before and after’ interviewswhich took place in 1985 and 1987. During the first survey,52% of the elderly persons were positive towards conversionof the nursing home; in the second survey, this figure roseto 76%. There was a significant increase in provision of homehelp from 10 to 37%, home nursing from 11 to 30% and healthadvice in general. Due to the integration of the former nursinghome staff with the home care area, staff now work as interdisciplinaryteams both inside and outside the new health care centre.     

The incidence of spina bifida in Sweden 1973-2003: the effect of prenatal diagnosis

BACKGROUND: Many studies have been conducted on the accuracy of prenatal ultrasound diagnosis of foetal CNS-malformations. These studies were mostly hospital-based or, sometimes, multicentre studies. We present here a population-based study of the prenatal diagnosis of spina bifida in Sweden over a period of 31 years. METHODS: We compared the number of newborns with spina bifida and the elective terminations because of the prenatal diagnosis of spina bifida for different periods. RESULTS: The rate of spina bifida among newborns diminished gradually from 0.55 per 1000 to 0.29 per 1000 during the study period. In M county the rate of spina bifida at birth decreased very rapidly and from 1993 onwards was about half of that in the rest of the country. CONCLUSION: There has been a decline in the rate of spina bifida at birth. This decline can be seen earlier in the southern part of the country, M county. The decline is probably, to a great extent, a consequence of prenatal ultrasound screening.     

Severity measurement using a generic instrument: A feasibility study in ambulatory care involving patients with diabetes or asthma

The object of the study was to assess the performance of a genericseverity measure [the Duke severity of illness (DUSOI) scale]in ambulatory care in the UK. This was done in 2 settings. First,all 181 patients with non-insulin-requiring diabetes mellitusattending a single general practice had 4 retrospective ratingsof severity of illness, 2 before and 2 after training of therater. Secondly, a convenience sample of 232 patients with non-insulin-requiringdiabetes mellitus and 376 patients with asthma from 57 generalpractices and 7 hospitals in the north of England had a singlerating of severity of illness and completed a questionnaireon functional health status. From the first setting we estimatedthe test-retest reliability of the rating of severity: the intradasscorrelation coefficient for the 2 ratings before training was0.72 and after it was 0.85. Training increased diagnosis identificationby 0.91 (95% Cl: 0.72–1.1) diagnoses per patient. Fromthe second setting we estimated the concurrent validity of theDUSOI scale as assessed by correlation with the functional healthstatus measures. For 42% of patients with diabetes their diabeteswas rated as their most severe diagnosis; for 85% of patientswith asthma their asthma was rated as their most severe diagnosis.For patients with asthma the DUSOI scores correlated with physicalhealth domains. For patients with diabetes similar correlationswere much weaker. We conclude that the DUSOI scale is capableof reliable use and has concurrent validity. However, it requiresfurther evaluation to fully establish its utility in UK ambulatorycare.     

The impact of prenatal care on birthweight: the case of Uruguay

This study analyzes prenatal care and birthweight in Uruguay. These data are unique since they represent a population of urban, poor women who gave birth in a health care system that provides both prenatal and obstetric care free of charge. This study finds a positive effect of increased prenatal care use on birthweight and evidence of bias in OLS estimates, similar to studies that use US data. The results highlight the usefulness of existing methodologies for estimating the effect of prenatal care on birthweight and the importance of extending these methodologies to data from countries other than the US.     

Cross-sectional survey of hospital HIV/AIDS care in Catalonia, 1990

In 1991, a survey of 42 acute-care hospitals was carried outin Catalonia to obtain information related to hospital carefor HIV/AIDS patients during 1990. Thirty-eight hospitals responded;the mean length of stay of the 1,527 patients admitted withAIDS was 21 days. The six largest hospitals of the metropolitanarea of Barcelona treated 67% of them. Overall there were 179(12%) ‘terminal’ AIDS patients. Six per cent ofinternal medicine beds overall were occupied by AIDS patients,but this figure rose to 22% in large hospitals. The estimatedcost for AIDS in-patient care during 1990 was nearly £26 million. The major concentration of AIDS patients in fewinstitutions and the demand on beds for HIV/AIDS patients ishaving an impact on the acute hospital care system. If presentHIV/AIDS care demands prevail, we conclude that some unnecessaryacute hospital care might be mitigated if comprehensive, coordinatedhealth and social programmes are developed.     

What did your baby eat yesterday?: Social factors and infant feeding practices

This paper presents data on the feeding of 354 young childrenin the Midlands and the South of England in 1987–9. Thedata were collected by means of a postal questionnaire completedby mothers. Considerable geographical and social variation ininfant feeding practices is shown to exist. Social factors significantlyrelated to diet are household income, housing tenure and quality,the presence of other children in the household, household amenities,mothers' feelings of control, and partners' domestic help. Theimplications of these findings for current policy guidelinesconcerning parental feeding of young children are explored,as are the ways in which they contribute to the debate aboutthe merits of personal health education versus those of attendingto environmental and material constraints on the promotion ofthe public health.     

Adolescent smoking in pregnancy and birth outcomes

INTRODUCTION: Cigarette smoking amongst pregnant adolescents is a preventable risk factor associated with low birthweight (<2,500 g), preterm birth (<37 weeks) and infant mortality. The aim of this study was to compare birth outcomes of adolescents who smoke during pregnancy with those who do not and to construct their birthweight-for-gestational-age curves. METHODS: A retrospective cohort analysis of 534 adolescents (10 cigarettes daily had babies with larger birthweight reduction (P = 0.001). CONCLUSION: Almost half of all adolescents smoked during their pregnancy. Birthweight-for-gestational-age curves of smoking adolescents showed a marked fall-off in weight from 36 weeks of gestation, and at least 10% of adolescent smokers showed fetal growth restriction from before 32 weeks of gestation.     

The effect of prenatal care on birthweight: a full-information maximum likelihood approach

This paper uses a full-information maximum likelihood estimation procedure, the Discrete Factor Method, to estimate the relationship between birthweight and prenatal care. This technique controls for the potential biases surrounding both the sample selection of the pregnancy-resolution decision and the endogeneity of prenatal care. In addition, we use the actual number of prenatal care visits; other studies have normally measured prenatal care as the month care is initiated. We estimate a birthweight production function using 1993 data from the US state of Texas. The results underscore the importance of correcting for estimation problems. Specifically, a model that does not control for sample selection and endogeneity overestimates the benefit of an additional visit for women who have relatively few visits. This overestimation may indicate 'positive fetal selection,' i.e., women who did not abort may have healthier babies. Also, a model that does not control for self-selection and endogenity predicts that past 17 visits, an additional visit leads to lower birthweight, while a model that corrects for these estimation problems predicts a positive effect for additional visits. This result shows the effect of mothers with less healthy fetuses making more prenatal care visits, known as 'adverse selection' in prenatal care.