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

Abstract

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.

Pregnant mothers out of the perinatal regionalization's reach

“…The high frequency of out-born infants in this report is similar to findings reported by Samuelson et al 15 They found that patients living away from subspecialized centers in Georgia had a higher risk for delivering their VLBW infants outside these centers, potentially subjecting the infants to additional morbidity and mortality. 15 Distance of the maternal residence from a subspecialty center was reported to be associated with birth of VLBW infants in level I nurseries in other population based studies.…”

“…15 Distance of the maternal residence from a subspecialty center was reported to be associated with birth of VLBW infants in level I nurseries in other population based studies. 15,17,23 Obviously, distance to care may present a larger impediment to women with less social capital (e.g. low income, transportation or community resources).…”

“…Type of maternal insurance coverage, maternal age, marital status, level of education and race were reported as factors associated with less reliable use of perinatal services and birth outside the subspecialty centers. 5,12,13,15,16 We used infants' qualification for Medicaid insurance as a marker for maternal financial status. Insurance coverage and these other markers of perinatal care under utilization, in our study, were not associated with birth hospital level.…”

“…11 Previous reports have described multiple barriers to adequate utilization of perinatal services related to population characteristics, geographic factors and system delivery elements. 9,[12][13][14][15][16][17] However, the US Department of Health and Human Services 18 cited little progress in these population-based objectives, and identified geographic areas and underserved populations for targeted interventions. 18 We conducted a study of the back transport process in a regionalized perinatal care system regarding utilization of health care services and found that about half of VLBW infants were outborn.…”

Hospital Factors and Nontransfer of Small Babies: A Marker of Deregionalized Perinatal Care?

“…Independent of hospital level, other hospital factors remained significantly associated with nontransfer of <1250 g infants in the 19 infants less than 1250 g were to be transferred to Level III perinatal centers when born at a Level I or Level II hospital, and also when born at a Level II þ hospital if the Level II þ hospital's exception status did not include infants less than 1250 g. Based on the data presented here, the rate of nontransfer of these infants was 40.4%, with the highest overall rates of nontransfer occurring among infants weighing 1000-1249 g. While the mortality rates among nontransferred versus transferred infants were not examined in the current study, previous studies have demonstrated that the risk of death is higher for infants less than 2000 g, 11,21 infants less than 1500 g, 18,22 and infants less than 1250 g 13 born at Levels I and II centers rather than tertiary care centers. In addition, in a study of perinatal regionalization in Illinois from 1991 to 1993, 23 a lower proportion of VLBW infants (<1500 g) transferred out was associated with an increase in neonatal mortality.…”