Home birth and short-stay delivery. Lessons in health care financing for providers of health care for women

The current restructuring of the U.S. health care delivery system is driven primarily by economic forces. Although primary care providers may understand the roles of technology and advocacy in fostering fundamental change, they may not be familiar with the issues related to financing of health care and, thus, may not fully appreciate the extent to which economic factors influence the character of their professional lives and the services they provide. Analysis of the loss of the home birth option in the 1950s provides a method for understanding and influencing the factors driving health care restructuring today. In examining short-stay delivery in the 1990s, this article also addresses ways in which managed health care systems may improve or restrict women's access to a variety of primary care services.     

An evaluation of the IFA-GC procedure in a low risk population

An automated indirect fluorescent antibody (IFA) test for gonococcal antibody was evaluated in 600 low risk females; 392 were prenatal patients from public and private clinics and 208 were apparently healthy females state employees in a multiphasic screening program. Clinical histories, physical examinations, and cervical cultures were obtained on all patients. The results of the cultures and serologic test were compared. Although the number of culture positive patients in the study was low, the lack of sensitivity of the IFA test in detecting gonococcal infection in these patients was disturbing. This observation and the number of apparent false positive IFA tests lead us to conclude that the automated IFA test for detection of gonorrhea shows promise, but we could not consider adopting the test in its present stage of development.     

Maternal risk factors in infants with very low birth weight

To determine whether maternal risk factors associated with the delivery of very low birth weight infants under 1501 g are different from those associated with low birth weight infants of 1501 to 2500 g, prenatal data on 12,247 deliveries were evaluated. The sample contained 302 very low birth weight infants. Maternal race, age, height, weight, gravidity, parity, past pregnancy performance, and pregnancy complications were analyzed. Factors related to very low birth weight but not to low birth weight infants were previous abortions, previous fetal deaths, and hypertensive vascular disease. Race, maternal height, and prepregnancy weight were not related to very low birth weight but were associated with an increase in low birth weight. There was no significant difference in the rate of very low birth weight or low birth weight by maternal age from 14 to 40 years. These results contradict the concept of a uniform set of predisposing factors for birth of all infants weighing 2500 g or less.     

First-trimester growth and the risk of low birth weight

BACKGROUND: Previous studies have demonstrated a correlation between first-trimester size and birth weight. It is not known, however, whether low birth weight is related to first-trimester growth. We sought to determine whether the risk of low birth weight and birth weight that was low for gestational age is related to the size of the embryo or the fetus in the first trimester. METHODS: From a data base of ultrasound records of more than 30,000 pregnancies, we identified women who had no important medical problems, a normal menstrual history, and a first-trimester ultrasound scan in which the crown-rump length of the embryo or fetus had been measured. We examined the relation between the outcome of 4229 pregnancies and the difference between the measured and the expected crown-rump length in the first trimester, expressed as equivalent days of growth. RESULTS: A first-trimester crown-rump length that was two to six days smaller than expected was associated with an increased risk (as compared with a normal or slightly larger than expected crown-rump length) of a birth weight below 2500 g (relative risk, 1.8; 95 percent confidence interval, 1.3 to 2.4), a birth weight below 2500 g at term (relative risk, 2.3; 95 percent confidence interval, 1.4 to 3.8), a birth weight below the fifth percentile for gestational age (relative risk, 3.0; 95 percent confidence interval, 2.0 to 4.4), and delivery between 24 and 32 weeks of gestation (relative risk, 2.1; 95 percent confidence interval, 1.1 to 4.0), but not with delivery between 33 and 36 weeks (relative risk, 1.0; 95 percent confidence interval, 0.7 to 1.5). CONCLUSIONS: Suboptimal first-trimester growth may be associated with low birth weight, low birth-weight percentile, and premature delivery.     

Association between hepatoblastoma and very low birth weight: a trend or a chance?

Nuchal vascular hamartoma was found in a newborn premature infant who presented with nonimmune hydrops fetalis, pulmonary hypoplasia due to bilateral pleural effusion and polyhydramnios in utero. The baby died 26 hours after birth despite maximal respiratory and circulatory support. Postmortem examination revealed a vascular hamartoma localized to the left posterolateral region of the neck. We suggest that nuchal vascular hamartoma may be associated with fetal hydrops, probably due to compromised lymph drainage.     

Is low birth weight a risk factor for development of non-insulin-dependent diabetes mellitus?

Different lines of evidence indicate that low birth weight and insufficient intrauterine nutrition may represent significant risk factors for the development of late onset non-insulin dependent diabetes mellitus (NIDDM). The evidence includes epidemiological studies, animal studies and metabolic studies of non-diabetic subjects with low birth weight. Insufficient intrauterine nutrition may induce a variety of abnormalities of metabolism in different tissues including muscle, liver, pancreas and adipose tissue; which can all in turn be related to known defects of glucose metabolism involved in the development of hyperglycaemia in NIDDM. Future studies should address the important question as to which roles genetics versus intrauterine and postnatal factors play in the etiology of late onset NIDDM in the general population. This may have important implications for which initiatives that should be applied to prevent NIDDM.     

Day-case or short-stay admission for arthroscopic knee surgery: a randomised controlled trial

Persons with various forms of albinism frequently have misrouting of their optic nerve fibers. Visual evoked potential (VEP) studies can confirm this because monocular stimulation tends to result in asymmetrical rather than symmetrical occipital response. This type of decussation abnormality is associated only with albinism. In the electroencephalogram (EEG) of normal subjects, unilateral eye opening or closing does not affect the frequency, reactivity, regulation, and symmetry of alpha rhythm. In contrast, in our study, 6 of 19 persons with oculocutaneous and ocular albinism responded to unilateral eye opening with contralateral disappearance or significant attenuation of their alpha rhythm. The most likely explanation of this phenomenon is that the visual pathway misrouting is complete or nearly complete in some children with albinism so that one rather than both occipital lobes receive visual information from each eye. This type of alpha behavior, like VEP studies, supports the diagnosis of albinism, and such testing can be easily performed during a routine EEG recording.     

Maternal risk factors for preterm birth and low birthweight in Cape Verde

BACKGROUND: Fifteen years after the implementation of an antenatal risk screening program in Cape Verde, the first assessment of an association between maternal obstetric characteristics and preterm birth or low birthweight (LBW) infants was undertaken. METHODS: A cohort of 353 systematically selected antenatal clinic attenders in the county of Praia, Cape Verde, was studied prospectively during the period October 1991 through December 1992. The cohort was followed past the perinatal period and information was obtained according to a pretested structured questionnaire. In the analysis of preterm birth and LBW, multiple logistic regression was listed to estimate the relative risks of ll background variables. RESULTS: The prevalence of preterm birth (<37 gestational weeks) was 12%, and the prevalence of LBW infants was 8%. Low birthweight (<2500 grams) was significantly associated with low maternal age (< or = 19 years, RR=3.7); nulliparity (RR=5.2) and obstetric history of previous LBW infant (RR-6.5). The risk of preterm birth was significantly increased if the woman had an obstetric history of hypertension or convulsions (RR=2.6). CONCLUSIONS: In the setting studied, teenage women and women with previous pregnancy hypertension should be given selective attention in antenatal care to achieve improved pregnancy outcome. Primary prevention is needed to lower the prevalence of teenage pregnancies.     

The dynamics of an infectious disease in a population with birth pulses

In December 1996, a questionnaire about farm management and parasite control measures in calves was sent to 956 randomly chosen dairy cattle farmers in The Netherlands. Another 150 farmers in the vicinity of Deventer who had vaccinated their calves in 1995 against lungworm were approached with the same questions. Our object was to investigate the consequences on worm control of the withdrawal of the lungworm vaccine from the market for reasons of possible BSE contamination of the vaccine. OF the returned questionnaires, 411 (43%) of the 'at random' group and 89 (59.3%) of the 'Deventer' group were valid. The most important data with regard to the farms of the 'at random' group (41) were: mean area 31.6 ha, mean number of calves 23, heifers 23 and milking cows 53. Sheep (mean 37) were present on 18.3% of the farms. With regard to management: 74.5% of the farmers turned the calves in their first year onto pasture, 25.5% kept them indoors. The average time on pasture was ca. 5 months. Rational grazing was practise on 81.4% of the farms, on 18.6% calves were set stocked. The first pasture of the calves was mown before turn-out on 72.9% of the farms. On 48.2% of these farms, calves were always moved to mown pastures. With regard to treatments: 33.8% of the farmers vaccinated their calves against lungworm in the years 1993, 1994 and 1995. Despite the withdrawal of the vaccine from the market in 1996, 7.2% of the farmers vaccinated their calves as recommended, with two doses, and 13.1% with a single dose. At turn-out, 41.5% of the farmers gave the calves a preventive anthelmintic treatment. Of these treatments, 66.9% were sustained of pulse release long acting device. During the grazing season, 36.6% of the farmers treated their calves. After housing 50.3% of the farmers gave a treatment. Signs of lungworm infection were noticed on 18.6% of the farms. Of the 'Deventer' group (89 farmers), 96.6% turned the calves out, Of these farmers, 86.0% had used the lungworm vaccine in 1995. In 1996, 52.7% of the farmers had vaccinated the calves:36.5% with a single dose and 16.2% with the double dose. Of the 35 farmers who did not vaccinate in 1996, 62.9% gave a preventive treatment at turn-out. Clinical signs of lungworm infection were not observed on the 12 farms which vaccinated the calves twice. On 11% of the farms which vaccinated once and on 14% of the farms which did not vaccinate, signs of lungworm infection were observed. It is concluded that more than 80% of Dutch dairy cattle farmers take appropriate measures to control gastrointestinal nematode and lungworm infections in calves in their first grazing season by grazing on aftermath, rotational grazing on mown pastures combined or not with preventive anthelmintic treatments. However, combinations of aftermath grazing and preventive treatment occurred on 30% of the farms. This may be overprotective and may prevent sufficient build up of immunity, causing worm problems at a later age. The withdrawal of the lungworm vaccine from the market did not cause a rise in lungworm problems. Some farmers did vaccinate, despite the withdrawal. The majority used other preventive treatment measures, mainly the application of long acting boli.     

Fetal growth velocity in the prediction of intrauterine growth retardation in a low risk population

Assignment of HLA-B types can be hampered by ambiguous reactivity of the typing sera resulting in inaccurate HLA-B assignments. In this study, 19 Korean samples exhibiting ambiguous serologic reactivities were characterized by DNA sequencing. Alleles identified from 7 samples were previously undetected in this population (B*1517, B*4101, B*4701, B*5001, and B*5106) and from 9 samples were common alleles in this population (B*4002, B*4003, B*4006, B*1501, B*1401, B*67012, and B*5401). Three samples were putative HLA-B homozygotes. Three major factors causing serologic ambiguity were identified: weak or false negative reactivity of typing sera (52.4%); cross or false positive reactivity of the sera (38.1%); and absence of information on the reaction patterns due to the lack of appropriate sera in the typing kit (e.g. B*4101 encoded molecule) or to the presence of recently characterized molecules (e.g. B*5106 encoded molecule) (9.5%). Overall, sequencing was helpful in clarifying ambiguous serologic reaction patterns improving the HLA typing for the Korean population.     

Poor periodontal health of the pregnant woman as a risk factor for low birth weight

1. It has been hypothesized that 5-HT1A autoreceptor antagonists may enhance the therapeutic efficacy of SSRIs and other antidepressants. Although early clinical trials with the beta-adrenoceptor/5-HT1 ligand, pindolol, were promising, the results of recent more extensive trials have been contradictory. Here we investigated the actions of pindolol at the 5-HT1A autoreceptor by measuring its effect on 5-HT neuronal activity and release in the anaesthetized rat. 2. Pindolol inhibited the electrical activity of 5-HT neurones in the dorsal raphe nucleus (DRN). This effect was observed in the majority of neurones tested (10/16), was dose-related (0.2-1.0 mg kg(-1), i.v.), and was reversed by the 5-HT1A receptor antagonist, WAY 100635 (0.1 mg kg(-1), i.v.), in 6/7 cases tested. 3. Pindolol also inhibited 5-HT neuronal activity when applied microiontophoretically into the DRN in 9/10 neurones tested. This effect of pindolol was current-dependent and blocked by co-application of WAY 100635 (3/3 neurones tested). 4. In microdialysis experiments. pindolol caused a dose-related (0.8 and 4 mg kg(-1), i.v.) fall in 5-HT levels in dialysates from the frontal cortex (under conditions where the perfusion medium contained 1 microM citalopram). In rats pretreated with WAY 100635 (0.1 mg kg(-1), i.v.), pindolol (4 mg kg(-1), i.v.) did not decrease, but rather increased 5-HT levels. 5. We conclude that, under the experimental conditions used in this study, pindolol displays agonist effects at the 5-HT1A autoreceptor. These data are relevant to previous and ongoing clinical trials of pindolol in depression which are based on the rationale that the drug is an effective 5-HT1A autoreceptor antagonist.     

Medical risk classification of dental patients in The Netherlands

This study centers on the general health of dental patients, evaluated on the basis of the physical status classification system of the American Society of Anesthesiologists (ASA). A total of 4,087 patients completed a risk-related, patient-administered questionnaire. On the basis of their medical data, a computerized ASA classification was determined for each patient: 63.3 percent were in ASA class I, 25.7 percent in class II, 8.9 percent in class III, and 2.1 percent in class IV. After verification and/or consultation with the physician, the dentist also determined the ASA class, and this was compared with the computerized outcome. The agreement expressed as a kappa value was 0.64; the computer result generally placed the patient in a higher category of medical risk. The computer-determined ASA classes differed among the various dental practices (chi 2 = 262.9; df = 138; P < .01). It is possible to estimate the risk class of dental patients on the basis of standardized medical information only; however, the definitive ASA class can only be determined after verification of the patient's reply or, in some cases, after consultation with a physician.     

Hospital experience and hospital mortality following partial pancreaticoduodenectomy in The Netherlands

OBJECTIVE: To analyse the effect of hospital experience on mortality after subtotal pancreaticoduodenectomy in the Netherlands. DESIGN: Retrospective evaluation. METHOD: Information on hospital mortality and pancreatic resection in 1994 and 1995 in the Netherlands was obtained from the National Medical Register. Subanalysis was carried out of surgical mortality by age and hospital experience. RESULTS: Approximately 50% of the pancreaticoduodenectomies in the Netherlands were performed in hospitals with limited experience (< 5 procedures per year). Hospital mortality was higher in small-volume hospitals than in hospitals with experience (> 25 procedures per year): in 1994 17.2 and 0% and in 1995 14.6 and 2.9%, respectively (p < 0.05). Mortality was higher in patients older than 70 years compared with patients younger than 55 (p < 0.05). CONCLUSION: There was a correlation between mortality after pancreaticoduodenectomy and hospital experience. Therefore these procedures should be performed in centres with experience.     

Factors in low birth weight

In this paper we compare the acute psychiatric wards in Hedmark county and the catchment area of Ullev?l hospital with regard to involuntary hospitalizations and admission rates for psychosis during the period 1989-94. In the former area the percentage of involuntary admissions decreased from 58% to 48% during the period, but in the Ullev?l catchment area it remained fairly stable at 85%. The latter area showed a higher percentage of involuntary hospitalizations for both psychotic and non-psychotic patients. The admission rate for psychotic patients was higher in the Ullev?l catchment area and tended to increase in the course of the study period. We relate our findings primarily to a higher incidence of psychiatric disorders in a city like Oslo. Structural differences in psychiatric and primary care, especially for long-term patients may also be a contributory factor.     

Comparison of remifentanil in combination with isoflurane or propofol for short-stay surgical procedures

There are few data in the literature that describe the use of remifentanil when administered as a component of an inhalation or total i.v. anaesthetic (TIVA) technique. We studied 251 male and female patients, aged 18-75 years, ASA I-II, undergoing inguinal hernia repair, arthroscopic knee surgery or varicose vein surgery of at least 30 min duration without premedication. Patients were randomized to receive a remifentanil loading dose of 1.0 microgram kg-1 followed by a continuous infusion of 0.5 microgram kg-1 min-1 in combination with isoflurane (end-tidal concentration 0.6%), (Group I, n = 115) or propofol (initial infusion rate 9 mg kg-1 h-1 reduced to 6 mg kg-1 h-1 after 10 min), (Group P, n = 118). The remifentanil infusion rate was reduced by 50%, 5 min after tracheal intubation. Intraoperative stresses were treated with a remifentanil bolus (1 microgram kg-1) followed by an increase in the remifentanil infusion rate. At the insertion of the last suture, the remifentanil infusion and concomitant anaesthetic were switched off simultaneously. Times to spontaneous respiration, adequate respiration and tracheal extubation were significantly shorter in group I compared with group P (6.4 min vs 7.6 min, P < 0.01; 7.6 min vs 9.3, P < 0.003; 7.8 min vs 9.5 min, P < 0.015). Overall mean systolic blood pressures during surgery were greater in group P compared with group I (P < 0.05) but the absolute differences were clinically insignificant (4-5 mm Hg).     

Low birth weight: some considerations in a Zambian population

A retrospective analysis of 2401 consecutive births revealed a lowbirth weight rate of 11.4 percent of all births and 14.2 percent all live borns. Sixty-five percent of late fetal and first week neonatal deaths were low birthweight babies. The cause of low birthweight labour was unknown in 48.2 percent of cases. The major known associations with low birthweight labour and delivery were twin birth, antepartum haemorrhage, premature rupture of the membranes and toxaemia of pregnancy. Nutritional factors were considered to be of significance in the incidence of low birthweight. The earlier attendance of mothers at ante-natal clinics and the availability of experienced medical and nursing personnel with adequate facilities are necessary for perinatal mortality to be significantly reduced in the low birthweight group.     

Neurodevelopmental outcome at age two years amongst very low birth weight infants: results from a district general hospital

SCOPE OF THE STUDY: We studied the possibility to examine position and determination of IOL and capsular bag supporting ring. PATIENTS AND METHODS: We showed in ten human eyes the identification of capsular bag supporting ring (PMMA, 12,5 mm open diameter) and intraocular lenses (IOL, 13,5 mm diameter) and haptics by ultrasound biomicroscopy in radar and limbus parallel scans 12 to 18 months post operation. RESULTS: Both alloplastic implantates show typical sceems of reflection and could be differentiated by ultrasoundbiomicroscopy. In eyes with zonulolysis up to 6 hours a good centration of capsular bag supporting ring and IOL had been seen, with more zonulolyses a slight subluxation could been shown. CONCLUSION: Ultrasound biomicroscopy is a good method to determine the position of intraocular lens and capsular bag supporting ring.     

Predictors of depressive symptom trajectories in mothers of preterm or low birth weight infants.

Predictors of maternal depression trajectories were examined longitudinally in families with an infant born preterm or at a low birth weight. A total of 181 mother–infant dyads enrolled in the study before the infant’s neonatal intensive care unit (NICU) discharge. Maternal depressive symptoms were assessed at 5 timepoints, and contextual variables and infant risks were assessed at NICU discharge. Hierarchical linear models revealed that mothers who experienced more risk factors reported more depressive symptoms just before their infant’s NICU discharge and showed less decline in depressive symptoms in the months immediately following the child’s birth. Although cumulative risks predicted depression trajectories, this effect appeared driven by maternal and family sociodemographic risks rather than infant risks. Addition of family support as a covariate in the multilevel models with a subsample of families revealed that social support and depression covaried across time. However, most of the findings regarding the association between risk and depression remained consistent, whereas the effects of maternal race and multiple birth were slightly attenuated. (PsycINFO Database Record (c) 2010 APA, all rights reserved)