Opportunities for maternal transport for delivery of very low birth weight infants.

OBJECTIVE: To assess frequency of very low birth weight (VLBW) births at non-level III hospitals. STUDY DESIGN: Retrospective cohort study using linked California birth certificate and discharge data of 2008 to 2010 for deliveries of singleton or first-born infant of multiple gestations with birth weight 400 to 1500 g. Delivery rates by neonatal level of care were obtained. Risk of delivery at non-level III centers was estimated in univariable and multivariable models. RESULTS: Of the 1 508 143 births, 13 919 (9.2%) were VLBW; birth rate at non-level III centers was 14.9% (8.4% in level I and 6.5% in level II). Median rate of VLBW births was 0.3% (range 0 to 4.7%) annually at level I and 0.5% (range 0 to 1.6%) at level II hospitals. Antepartum stay for >24 h occurred in 14.0% and 26.9% of VLBW births in level I and level II hospitals, respectively. CONCLUSION: Further improvement is possible in reducing VLBW infant delivery at suboptimal sites, given the window of opportunity for many patients.

Neonatal mortality among low birth weight infants during the initial months of the academic year.

OBJECTIVE: Proper management of very low weight (<1500 g) infants requires specific expertise. During July and August, pediatric interns start new rotations and advance in responsibilities by postgraduate level. We test the hypothesis that low weight births in teaching hospitals exhibit increased neonatal mortality during the initial training months. STUDY DESIGN: Population-based cohort of 5184 very low weight and 15 232 moderately low weight infants in California from 19 regional teaching hospitals with medical training programs. Logistic regression methods controlled for both individual covariates and temporal patterns in neonatal mortality. RESULT: We found no difference in neonatal mortality between very low weight infants born in teaching hospitals during July and August and those born in other months (adjusted odds ratio (AOR): 0.98, 95% confidence interval (CI), 0.78 to 1.23). Investigation of moderately low birth weight infants also indicated no increased neonatal mortality. CONCLUSION: Infants most likely to die in the neonatal period do not appear to be at elevated risk of neonatal mortality during July and August.

Manifestations of poverty and birthrates among young teenagers in California zip code areas.

CONTEXT: Given that many communities are implementing community-wide initiatives to reduce teenage pregnancy or childbearing, it is important to understand the effects of a community's characteristics on adolescent birthrates. METHODOLOGY: Data from the 1990 census and from California birth certificates were obtained for zip codes in California. Regression analyses were conducted on data from zip code areas with at least 200 females aged 15-17 between 1991 and 1996, to predict the effects of race and ethnicity marital status, education, employment, income and poverty, and housing on birthrates among young teenagers. RESULTS: In bivariate analyses, the proportion of families living below poverty level within a zip code was highly related to the birthrate among young teenagers in that zip code (r=.80, p<.001). In multivariate analyses, which controlled for some of the correlates of family poverty level, the proportion of families living below poverty level remained by far the most important predictor of the birthrate among young teenagers (b=1.54), followed by the proportion of adults aged 25 or older who have a college education (b=-0.80). Race and ethnicity were only weakly related to birthrate. In all three racial and ethnic groups, poverty and education were significantly related to birthrate, but the effect of college education was greater among Hispanics (b=-2.98) than among either non-Hispanic whites (b=-0.53) or blacks (b=-1.12). Male employment and unemployment and female unemployment were highly related to the birthrate among young teenagers in some racial or ethnic groups, but not in others. CONCLUSIONS: Multiple manifestations of poverty, including poverty itself, low levels of education and employment, and high levels of unemployment, may have a large impact upon birthrates among young teenagers. Addressing some of these issues could substantially reduce childbearing among young adolescents.

Newborn discharge timing and readmissions: California, 1992-1995.

CONTEXT: Hospital stays for newborns and their mothers after uncomplicated vaginal delivery have decreased from an average of 4 days in 1970 to 1.1 days in 1995. Despite the lack of population-based research on the quality-of-care implications of this trend, federal legislation passed in 1996 mandated coverage for 48-hour hospital stays after uncomplicated vaginal delivery. OBJECTIVE: To assess the impact of very early discharge (defined as discharge on the day of birth) on the risk of infant readmission during the neonatal period in a California healthy newborn population. DESIGN: Retrospective cohort study, based on a linked dataset consisting of the birth certificate, newborn, and maternal hospitalization record, and linked infant readmission records for all healthy, vaginally delivered, and routinely discharged California newborns from 1992 to 1995. OUTCOME MEASURES: Very early discharge and infant readmission during the first 28 days of life. RESULTS: The percentage of infants discharged very early or early (after a 1-night stay) increased from 71% in 1992 to 85% in 1995. The percentage of infants discharged very early increased from 5.0% in 1992 to 5.7% in 1993 and 7.0% in 1994, then decreased to 6.7% in 1995. Characteristics that have been previously associated with suboptimal pregnancy outcomes were found to decrease the likelihood of very early discharge, eg, maternal complications, primiparity, and Hispanic, African American, South East Asian, or other Asian race/ethnicity. The rate of readmission in the neonatal period initially decreased from 27.6 infants per 1000 in 1992 to 25.67 infants per 1000 in 1994, then increased to 30.2 infants per 1000 in 1995. For infants discharged early, no statistically significant increase in the risk of readmission was observed, compared with infants discharged after a 2+-night stay. The adjusted odds ratio (OR) for readmission was statistically significantly higher for infants who were discharged very early, compared with infants discharged early (OR: 1.27), first order births (OR: 1.21), infants born to mothers who experienced complications (OR: 1.11), infants with Medicaid insurance (OR: 1.23), and infants born to mothers who received adequate plus prenatal care (OR: 1.15). The risk was statistically significantly lower for female infants (OR: 0.75). The proportion of infants rehospitalized for dehydration and low-risk infections over the 4 study years combined was statistically significantly higher in infants discharged very early (4.37 per thousand and 10.30 per thousand, respectively), compared with infants discharged early (3.59 per thousand and 8.16 per thousand, respectively) or after a 2+-night stay (2.91 per thousand and 7.95 per thousand, respectively). The proportion of infants rehospitalized for dehydration increased statistically significantly from 2.89 per thousand in 1992 to 4.52 per thousand in 1995. CONCLUSIONS: One-night stays with adequate antenatal and postnatal care outside the hospital do not increase the risk of readmission for healthy, vaginally delivered infants born in California. However, the decision to discharge infants on the day of birth should be applied conservatively because of the increased risk of infant readmission associated with very early discharge.

Preventing early-onset group B streptococcal sepsis: strategy development using decision analysis.

OBJECTIVE: To evaluate recommended strategies for prevention of early-onset group B streptococcal infections (EOGBS) with reference to strategies optimized using decision analysis. METHODS: The EOGBS attack rate, prevalence and odds ratios for risk factors, and expected effects of prophylaxis were estimated from published data. Population subgroups were defined by gestational age, presence or absence of intrapartum fever or prolonged rupture of membranes, and presence or absence of maternal group B streptococcus (GBS) colonization. The EOGBS prevalence in each subgroup was estimated using decision analysis. The number of EOGBS cases prevented by an intervention was estimated as the product of the expected reduction in attack rate and the number of expected cases in each group selected for treatment. For each strategy, the number of residual EOGBS cases, cost, and numbers of treated patients were calculated based on the composition of the prophylaxis group. Integrated obstetrical-neonatal strategies for EOGBS prevention were developed by targeting the subgroups expected to benefit most from intervention. RESULTS: Reductions in EOGBS rates predicted by this decision analysis were smaller than those previously estimated for the strategies proposed by the American Academy of Pediatrics in 1992 (32.9% vs 90.7%), the American College of Obstetricians and Gynecologists in 1992 (53.8% vs 88.8%), and the Centers for Disease Control and Prevention in 1996 (75.1% vs 86.0%). Strategies based on screening for GBS colonization with rectovaginal cultures at 36 weeks or on use of a rapid test to screen for GBS colonization on presentation for delivery, combining intrapartum prophylaxis for selected mothers and postpartum prophylaxis for some of their infants, would require treatment of fewer patients and prevent more cases (78.4% or 80.1%, respectively) at lower cost. CONCLUSIONS: No strategy can prevent all EOGBS cases, but the attack rate can be reduced at a cost <$12 000 per prevented case. Supplementing intrapartum prophylaxis with postpartum ampicillin in a few infants is more effective and less costly than providing intrapartum prophylaxis for more mothers. Better intrapartum screening tests offer the greatest promise for increasing efficacy. Integrated obstetrical and neonatal regimens appropriate to the population served should be adopted by each obstetrical service. Surveillance of costs, complications, and benefits will be essential to guide continued iterative improvement of these strategies.

Very low birth weight births at non-NICU hospitals: the role of sociodemographic, perinatal, and geographic factors.

PURPOSE: The purpose of this study was to assess the extent of variation in the percentage of very low birth weight (VLBW) infants born at perinatal Level 1 hospitals (no Neonatal Intensive Care Unit [NICU]) across California's nine geographic Perinatal regions. The role of sociodemographic, perinatal, and geographic factors was also assessed. METHODS: Multivariate analysis of California birth certificate files between 1989 and 1993, for 24,094 live-born infants weighing between 500 and 1499 gm, was conducted to identify factors associated with delivery at a Level 1 hospital. Analyses specific for race and ethnicity were also conducted for Hispanic, African American, and white cohorts. RESULTS: In the 5-year study period, 1989 through 1993, 10.5% (24,094) of all live-born VLBW infants were delivered in Level 1 hospitals. Significant variation across regions was evident, ranging from a regional low of 3.1% to a high of 24.3%. After controlling for multiple factors, the odds of delivering at a Level 1 hospital were decreased for African Americans and South East Asians and increased in Hispanic women as compared with white non-Hispanic women. For all women, less then adequate prenatal care, living in a 50% to 75% urban zip code, and living greater then 25 miles from the nearest NICU significantly increased the odds of VLBW delivery at a Level 1 hospital. For Hispanics, teen pregnancy and having two or more prior infant deaths increased the odds, whereas Medi-Cal as the payer source for delivery and two or more pregnancy complications decreased the odds of a Level 1 VLBW delivery. After taking these factors into account, when compared with Los Angeles, the odds of inappropriate delivery site ranged from 0.37 to 2.75 across California's nine geographic perinatal regions. Of this variation, 78% could be accounted for by the percentage of total births that delivered at a region's Level 1 hospitals. CONCLUSION: The overall state average of 10.5% deliveries of VLBW at Level 1 hospitals, although close to the 10% national objective for the year 2000, did not indicate the wide variation seen across California's nine geographic regions. Risk-adjusted regional differences in the likelihood of inappropriate delivery site for the high-risk VLBW infants suggest that reaching the Healthy People 2000 objective will require further strengthening of California's perinatal regional networks, especially in those regions where a high percentage of total births deliver at Level 1 hospitals.

Small-area analysis: targeting high-risk areas for adolescent pregnancy prevention programs.

CONTEXT: Traditional methods of identifying areas in need of adolescent pregnancy prevention programs may miss small localities with high levels of adolescent childbearing. METHODS: Birthrates for 15-17-year-olds were computed for all California zip codes, and the zip codes with birthrates in the 75th percentile were identified. Panels of local experts in adolescent pregnancy reviewed these "hot spots" for accuracy and grouped them into potential project areas, based on their demographics, geography and political infrastructure. RESULTS: In all, 415 zip codes exceeded the 75th-percentile cut-off point of 62.8 births per 1,000, and 210 of them differed significantly from the state average of 44.5 per 1,000 for 15-17-year-olds. While all had high adolescent birthrates, they varied greatly in racial and ethnic mix, poverty and educational attainment, and certain perinatal measures such as inadequate prenatal care and repeat pregnancy. CONCLUSIONS: The use of zip code-level data holds promise for more effective program planning and intervention.

PIP: Traditional methods of identifying areas in need of adolescent pregnancy prevention programs may overlook small localities with high levels of adolescent childbearing in communities and counties where this is not a universal problem. The present study assessed the potential of a "geomapping" approach based on measurement of the number of births occurring to teens 15-17 years old in each California (US) zip code in 1992-94. A total of 415 zip codes with teen birth rates in excess of the state's 75th percentile cut-off point (62.8 births/1000) were identified. 210 of these zip codes, accounting for 96% of all births to 15-17 year olds in the 75th-percentile zip codes, differed significantly (p 0.01) from the state average of 44.5 births/1000 15-17 year olds. 178 (85%) of these 210 "hot spots" also included birth rates exceeding the third quartile among teens 10-14 and/or 18-19 years old. Panels of local experts reviewed these "hot spots" for accuracy and grouped them into 82 potential project areas on the basis of demographics, geography, and political infrastructure. Although there was substantial variation, localities with the highest teen birth rates tended to be characterized by minority overrepresentation, poverty, and poor prenatal care coverage. In addition to identifying areas with unmet need, this approach encourages community participation in program development.

Racial disparities in outcomes of military and civilian births in California.

OBJECTIVE: To examine racial disparities in prenatal care utilization, birth weight, and fetal and neonatal mortality in a population for whom financial barriers to health care services are minimal. STUDY-DESIGN: Using linked birth, fetal death, and infant death certificate files, we examined prenatal care utilization, birth weight distribution, and fetal and neonatal mortality rates for all white and black births occurring in military hospitals in California from January 1, 1981, to December 31, 1985. These patterns were compared with the experience of their civilian counterparts during the same time period. RESULTS: Black mothers had higher percentages of births occurring in teenaged and unmarried mothers than did white mothers in military and civilian populations. First-trimester prenatal care initiation was lower for blacks in the military (relative risk, 0.79; 95% confidence interval, 0.75-0.82) and civilian (relative risk, 0.51; 95% confidence interval, 0.50-0.52) populations. However, the scale of the disparity in prenatal care utilization was significantly smaller (P < .001) in the military group. Rates of low birth weight and fetal and neonatal mortality among blacks were elevated in the military and civilian groups. However, the racial disparity in low birth weight was significantly smaller in the military group (P < .01 and P < .001, respectively). CONCLUSIONS: In populations with decreased financial barriers to health care, racial disparities in prenatal care use and low birth weight were reduced. However, the persistence of significant disparities suggests that more comprehensive strategies will be required to ensure equity in birth and neonatal outcome.

Socioeconomic differences in rates of cesarean section.

Increasing cesarean-section rates have focused attention on variations in the use of this procedure that appear to be independent of medical indication. We investigated the relation between the rate of primary cesarean section and socioeconomic status in a cohort of 245,854 singleton infants born to non-Hispanic white, black, Asian-American, and Mexican-American residents of Los Angeles County, California. On the basis of birth-certificate data for 1982 and 1983, a significant relation, independent of maternal age, parity, or birth weight, was found between the rates of primary cesarean section and socioeconomic status. Women who lived in census tracts with a median family income of more than $30,000 had a primary cesarean-section rate of 22.9 percent, as compared with 13.2 percent among women residing in areas with a median family income under $11,000. In women between the ages of 18 and 34, the incidence of reported complications of pregnancy or childbirth in the lowest-income group was 10.9 percent, as compared with 17.4 percent in the highest-income group (accounting for 42 percent of the difference in the rate of primary cesarean section between groups); the rate of primary cesarean section in the presence of complications in these two groups was 65.4 percent and 79.3 percent (accounting for 17 percent of the difference); and the primary rate in the absence of reported complications in these two groups was 6.4 percent and 10.5 percent (accounting for 41 percent of the difference). The rates of primary cesarean section were highest among non-Hispanic whites (20.6 percent), intermediate among Asian Americans (19.2 percent) and blacks (18.9 percent), and lowest among Mexican Americans (13.9 percent). Significant socioeconomic differences in these rates were observed in all four groups (P less than 0.01). We conclude that the rates of primary cesarean section vary directly with socioeconomic status and that this association cannot be accounted for by differences in maternal age, parity, birth weight, race, ethnic group, or complications of pregnancy or childbirth.

Socioeconomic differentials and neonatal mortality: racial comparison of California singletons.

The median family income of the zip code of maternal residence was used to estimate the presence and determine the extent of socioeconomic differentials in the neonatal mortality rates of a cohort of 401,399 white and of 66,577 black Californian singletons born from 1982 to 1983. The neonatal mortality rate in the white infants increased from 3.99 in mothers residing in zip codes with a median family income greater than $25,000 to 12.1 for mothers residing in zip codes with a median family income less than $11,000. With decreasing socioeconomic status there was also a significant increase in the percentage of white infants weighing less than 2,500 g (percentage of low birth weight increased from 3.75 to 8.33) and weighing less than 1,500 g (percentage of very low birth weight increased from 0.56 to 1.46). When the source of the socioeconomic difference in white neonatal mortality was partitioned, 77.4% was due to deterioration in the birth weight distribution and 22.6% to deterioration in the birth weight-specific mortality rates. For the black cohort, the neonatal mortality rate increased from 5.9 in the most, to 9.0 in the least affluent strata. Although decreasing residential median family income was associated with an increase in the percent low birth weight (8.19 v 12.86), the percentage of very low birth weight was not significantly different (1.59 v 2.10). When the source of the differential in black neonatal mortality was partitioned, only 29% was due to deterioration of the birth weight distribution, whereas 71% was secondary to less favorable birth weight-specific mortality rates.(ABSTRACT TRUNCATED AT 250 WORDS)