Association between pregnancy affected by vaginal bleeding and women's mortality: A cohort study.

OBJECTIVE: To investigate the association between vaginal bleeding (VB) in pregnancy and women's mortality, using VB-unaffected pregnancies, terminations and miscarriages as comparators. DESIGN: Observational cohort study. SETTING: Nationwide registries of Denmark linked at an individual level. POPULATION OR SAMPLE: 1 354 181 women and their 3 162 317 pregnancies (1979-2017), including 70 835 VB-affected pregnancies and comparators: 2 236 359 VB-unaffected pregnancies ending in childbirth; 589 697 terminations; and 265 426 miscarriages. METHODS: We followed pregnancies until the earliest date of woman's death, emigration or end of data. MAIN OUTCOME MEASURES: All-cause and cause-specific mortality rates per 10 000 person-years (PY) and hazard ratios (HRs) with 95% confidence intervals (CIs) adjusted using Cox proportional hazards regression for age, calendar year, pre-existing chronic conditions and socio-economic factors. RESULTS: There were 2320 deaths from any cause among women following VB-affected pregnancy (mortality rate 15.2, 95% CI 14.6-15.9 per 10 000 PY); 55 030 deaths following VB-unaffected pregnancy (mortality rate 12.7, 95% CI 12.6-12.8); 27 500 deaths following a termination (mortality rate 21.9, 95% CI 21.6-22.1), and 10 865 deaths following a miscarriage (mortality rate 19.2, 95% CI 18.8-19.6). For comparison of VB-affected versus VB-unaffected pregnancies, associations with all-cause (HR 1.14, 95% CI 1.09-1.19), natural causes (HR 1.15, 95% CI 1.09-1.22) and non-natural causes (HR 1.27, 95% CI 1.08-1.48) mortality were attenuated in a sensitivity analysis of pregnancies recorded in 1994-2017 (HR 1.00, 95% CI 0.90-1.12, HR 0.98, 95% CI 0.85-1.14 and HR 1.04, 95% CI 0.72-1.51, respectively). Contrasts with remaining comparators did not suggest increased risks of all-cause, natural or non-natural mortality causes. CONCLUSION: We found no evidence of an increased risk of women's mortality following VB-affected versus VB-unaffected pregnancy, termination or miscarriage.

Using medico-legal claims for quality improvement in maternity care: application and revision of an NHSLA coding taxonomy.

OBJECTIVE: To validate the NHSLA maternity claims taxonomy at the level of a single maternity service and assess its ability to direct quality improvement. DESIGN: Qualitative descriptive study. SETTING: Medico-legal claims between 1 January 2000 and 31 December 2016 from a maternity service in metropolitan Melbourne, Australia. POPULATION: All obstetric claims and incident notifications occurring within the date range were included for analysis. METHODS: De-identified claims and notifications data were derived from the files of the insurer of Victorian public health services. Data included claim date, incident date and summary, and claim cost. All reported issues were coded using the NHSLA taxonomy and the lead issue identified. MAIN OUTCOME MEASURES: Rate of claims and notifications, relative frequency of issues, a revised taxonomy. RESULTS: A combined total of 265 claims and incidents were reported during the 6 years. Of these 59 were excluded, leaving 198 medico-legal events for analysis (1.66 events/1000 births). The costs for all claims was $46.7 million. The most common claim issues were related to management of labour (n = 63, $17.7 million), cardiotocographic interpretation (n = 43, $24.4 million), and stillbirth (n = 35, $656,750). The original NHSLA classification was not sufficiently detailed to inform care improvement programmes. A revised taxonomy and coding flowchart is presented. CONCLUSIONS: Systematic analysis of obstetric medico-legal claims data can potentially be used to inform quality and safety improvement. TWEETABLE ABSTRACT: New taxonomy to target health improvement from maternity claims based on NHSLA Ten Years of Maternity Claims.