A step towards better audit: The Robson Ten Group classification system for outcomes other than cesarean section.

INTRODUCTION: The Robson Ten Group Classification System is widely used for the audit of cesarean section (CS) rates. However, CS rate alone is a poor quality indicator and should be balanced with other obstetric endpoints. The aim of this study was to evaluate whether Swedish national data on obstetric outcomes other than CS, stratified by the Robson classification, could be analyzed in a useful way. MATERIAL AND METHODS: All births in Sweden from 2017 through 2020 recorded in the nationwide Swedish Pregnancy Register were categorized using the Robson classification with subdivision of some groups. Five outcomes were explored: CS, operative vaginal delivery, postpartum hemorrhage, obstetric anal sphincter injury (OASIS) and Apgar score <7 at 5 minuteutes. Rates of each outcome and contribution of each group to the total outcome rate were calculated. RESULTS: The largest Robson groups were nulliparous and multiparous women with single-term cephalic pregnancies, unscarred uterus and spontaneous labor. Intrapartum CS rates were highest for multiple pregnancies, women with induced labor after previous CS, and nulliparous women with induced labor. Nulliparous women and multiparous women with a previous CS with attempted vaginal birth had the highest operative vaginal delivery and OASIS rates. The postpartum hemorrhage rate was highest for multiple pregnancies and transverse lie, followed by prelabor CS in nulliparous and multiparous women with single-term cephalic pregnancies and unscarred uterus. The highest rates of Apgar score <7 at 5 minute were observed in preterm deliveries, multiple pregnancies, transverse lie and breech presentation. The largest contribution to the total CS rate was made by women with previous CS delivered by prelabor CS, and nulliparous women with induced or spontaneous labor. The largest contribution to all other outcomes was made by nulliparous women with spontaneous or induced labor and, notably, multiparous women with spontaneous labor and unscarred uterus. CONCLUSIONS: The Robson classification provides a useful framework for analyzing CS rates along with rates of operative vaginal delivery, OASIS, postpartum hemorrhage and low Apgar score. Parallel interpretation of several outcomes allows a systematic and multidimensional audit, helpful for families and healthcare professionals, and can be used for comparisons, assessment of trends and subpopulations.

Long-term effects of the nine-item list intervention on obstetric and neonatal outcomes in Robson group 1 - A time series study.

INTRODUCTION: The nine-item list, with organizational and cultural changes, was implemented at the delivery unit in Linköping, Sweden between 2007 and 2010, aiming at improving the quality of care by offering more women a safe and attractive vaginal delivery. The target group for the intervention was nulliparous women at term with spontaneous onset of labor and cephalic presentation (Robson group 1). The aim of this study was to evaluate pregnancy outcomes before, during, early post and late post introduction of the nine-item list. MATERIAL AND METHODS: Robson group 1 births (n = 12 763) from 2004 to 2018 were divided into four time periods; before the nine-item list (2004-2006), during introduction of the nine-item list (2007-2010), early post introduction of the nine-item list (2011-2014) and late post introduction of the nine-item list (2015-2018). The nine-item list consists of monitoring of obstetric results, midwife coordinator, risk classification of women, three midwife-competence levels, teamwork-the midwife, obstetrician and nurse working as a team with the common goal of a normal delivery, obstetric morning round, fetal monitoring skills and obstetric skills training. Perinatal outcomes before, during, early post and late post introduction were compared using a Student's t test for numerical variables and a Pearson chi-squared test for categorical variables. RESULTS: Apgar score <7 at 5 minutes, Apgar score <4 at 5 minutes and umbilical cord arterial pH <7 did not differ significantly between the four time periods. Between before introduction and early post introduction, instrumental vaginal delivery decreased from 19.8% to 12.2% and cesarean section from 9.6% to 4.5%. The late post introduction period showed a maintained effect with 10.7% instrumental deliveries and 3.9% cesarean sections. Obstetric anal sphincter injury grade III decreased instantly during the introduction of the nine-item list from 7.8% to 5.1% and thereafter remained unchanged. CONCLUSIONS: Implementation of the nine-item list increased the proportion of spontaneous vaginal deliveries by reducing the number of instrumental deliveries and cesarean sections without affecting the neonatal outcomes in nulliparous women with spontaneous onset of labor. The nine-item list intervention seems to provide long-term sustainable results.

Maternal obesity and risk of Down syndrome in the offspring.

OBJECTIVE: The objective of this article is to determine if maternal obesity is associated with an increased risk of Down syndrome in the offspring and whether the risk estimates for trisomy 21 based on combined screening is affected by maternal body mass index (BMI). METHODS: Study group I consisted of a nationwide cohort of 1 568 604 women giving birth; outcome was infants born with Down syndrome [Correction made here after initial online publication.]. Adjustment was made for maternal age. Study group II consisted of 10 224 women undergoing 1st trimester combined screening. Outcome was risk assessment for Down syndrome. All women were divided into six BMI groups, and outcomes were evaluated over the BMI strata with BMI 18.5 to 24.9 as reference and correcting for maternal age. RESULTS: Obese women had an increased risk for giving birth to an infant with Down syndrome compared with normal-weight women, BMI 30 to 34.9 odds ratio (OR) 1.31 [95% confidence interval (CI) 1.10-1.55], BMI 35 to 39.9 OR 1.12 (95% CI 0.82-1.53), BMI ≥ 40 OR 1.56 (95% CI 1.00-2.43). The observed and the expected numbers of women with a risk of Down syndrome >1/300 based on 1st trimester combined screen and maternal age were similar in each BMI group. CONCLUSION: Maternal obesity seems to increase the risk for Down syndrome births. The risk estimate for Down syndrome with 1st trimester combined screening is unaffected by BMI.

Impact of a standardized training program on midwives' ability to assess fetal heart anatomy by ultrasound.

BACKGROUND: Studies of prenatal detection of congenital heart disease (CHD) in the UK, Italy, and Norway indicate that it should be possible to improve the prenatal detection rate of CHD in Sweden. These studies have shown that training programs, visualization of the outflow tracts and color-Doppler all can help to speed up and improve the detection rate and accuracy. We aimed to introduce a more accurate standardized fetal cardiac ultrasound screening protocol in Sweden. METHODS: A novel pedagogical model for training midwives in standardized cardiac imaging was developed, a model using a think-aloud analysis during a pre- and post-course test and a subsequent group reflection. The self-estimated difficulties and knowledge gaps of two experienced and two beginner midwives were identified. A two-day course with mixed lectures, demonstrations and hands-on sessions was followed by a feedback session three months later consisting of an interview and check-up. The long-term effects were tested two years later. RESULTS: At the post-course test the self-assessed uncertainty was lower than at the pre-course test. The qualitative evaluation showed that the color Doppler images were difficult to interpret, but the training seems to have improved their ability to use the new technique. The ability to perform the method remained at the new level at follow-up both three months and two years later. CONCLUSIONS: Our results indicate that by implementing new imaging modalities and providing hands-on training, uncertainty can be reduced and examination time decreased, but they also show that continuous on-site training with clinical and technical back-up is important.

Maternal obesity and detection rate of fetal structural anomalies.

OBJECTIVE: To estimate the effects of maternal body mass index (BMI) on the sensitivity of detecting fetal anomalies by a routine ultrasound performed either in the first or in the second trimester. METHODS: Unselected pregnant women (n = 19,140) were divided into four BMI groups: underweight (<18.5), normal weight (18.5-24.9, reference group), overweight (25.0-29.9), and obese (≥30.0). Fetal anomaly diagnoses were grouped according to their likely clinical consequences as suggested by the Royal College of Obstetricians and Gynaecologists. Minor anomalies were excluded. The detection rate of fetal anomalies in each BMI group was calculated and compared. RESULTS: The prevalence of infants with structural anomalies in the study population was 4% and the prevalence of material obesity was 10%. The detection rates of fetal structural anomalies were 26% for normal-weight, 29% for overweight (odds ratio (OR) 1.15, 95% confidence interval (CI) 0.68-1.95), and 19% for obese women (OR 0.67, 95% CI 0.29-1.52). The detection rate of anomalies with long-term handicap was lower in the obese group (27.3%; OR 0.44, 95% CI 0.11-1.79) compared to normal-weight women (46.3%). CONCLUSION: The detection rate of fetal anomalies seems to be lower for obese women, but these findings need to be further investigated.

Comparison of first and second trimester ultrasound screening for fetal anomalies in the southeast region of Sweden.

OBJECTIVE: To assess and compare the sensitivity for detecting fetal anomalies and chromosomal aberrations by routine ultrasound examination performed in the second trimester with results from an examination performed at 11-14 weeks gestation. DESIGN: Observational study. SETTING: Five centers in the southeast region of Sweden. POPULATION: A total of 21,189 unselected pregnant women. METHODS: The scan was performed at one center in the first trimester and at the remaining four centers in the second trimester. Outcome measures resulting from first trimester scanning were compared with those from the second trimester scanning. MAIN OUTCOME MEASURES: Detection rates of fetal structural anomalies and chromosomal aberrations. Results. At the first trimester scan 13% of all anomalies were detected, and at the second trimester scan 29% were detected. Lethal anomalies were detected at a high level at both times: 88% in the first, 92% in the second. The percentage of chromosomal aberrations discovered at the early scan was 71%, in the later 42%. The percentage of heart malformations detected was surprisingly low. CONCLUSION: The results showed the advantages of the later scan in discovering anomalies of the heart, urinary tract and CNS, and of the early scan in discovering chromosomal aberrations. Lethal malformations were detected at a high level in both groups, but detection of heart malformations needs improvement.

Intersection characteristics that influence collision severity and cost.

INTRODUCTION: Traffic engineers require robust tools to assist with their day-to-day decision making, and there is no better example of this than traffic signal warrants. North American traffic signal warrant systems are lacking in how they incorporate motor-vehicle collisions from both a severity and prediction perspective. The objective of this study was to produce reliable collision costs for the development of improved traffic signal warrants that accounted for the variations in severity that practitioners should expect based on the characteristics of the intersection being studied. METHOD: The primary data used for this analysis were from the National Automotive Sampling System (NASS) Crashworthiness Data System, with adjustments from the NASS General Estimates System and Fatality Accident Reporting System. Generalized ordered logit models were used to identify the most significant intersection characteristics, which were then used to segregate the data to determine expected the collision severity profiles and average costs of both casualty and total collisions at intersections. RESULTS: The average collision at a signalized intersection was found have a lower severity than the average collision at a stop-controlled intersection. A combination of posted speed limit, urban/rural, and divided/undivided were identified as the most significant intersection characteristics in most cases and were used to delineate the data for developing collision cost estimates. CONCLUSIONS: Posted speed limit, rural/urban land use, and the presence of divided approaches are intersection characteristics that traffic engineers can readily determine and/or control for that have significant effects on intersection collision severity. Practical applications: The collision costs produced through this process give traffic engineers a reliable estimate that can provide a more substantial foundation for justifying a proposed change in intersection traffic control.

Are age-based licensing restrictions a meaningful way to enhance rural older driver safety? The need for exposure considerations in policy development.

The stated and revealed travel behavior of a sample of 60 rural drivers aged 54-92 years provided a basis to explore the potential effectiveness of two common driver's license restrictions aimed at older drivers: time of day and road class. The potential utility and impact of these restrictions have not been explored with revealed data for jurisdictions with a large population of rural older drivers where automobile dependence is high. Data were drawn from a multiday Global Positioning System-based travel diary survey of rural older drivers in New Brunswick, Canada. Revealed travel data showed that over 50 percent of the rural drivers in the sample did not drive after dark, and 40 percent drove less than 1 percent of their total surveyed kilometers on major highways, higher rates than from participant-stated responses. The proportion of participants taking night trips and traveling on major highways decreased with age. The majority of trips taken after dark by all participants had a rural destination. The average daily kilometers driven on major highways by men and women aged 75 years and older was nearly identical (1.79 km/day). These exposure considerations suggest that restricting night travel and major highway travel for the oldest rural drivers (75 years and older) may have limited utility given that the majority of participants did not drive in these situations, and for those who did, most of their trips were in rural areas where enforcement could be expected to be limited. A better approach may be to encourage increased self-regulation through training, age-friendly upgrades to transportation infrastructure to help rural older drivers stay driving safely as long as possible, and the development of appropriate rural alternatives to help a driver transition to nondriver.

Are rural older drivers subject to low-mileage bias?

Comparing exposure-based collision statistics between older drivers based on age alone erroneously assumes a linear relationship between exposure and collision frequency. Research has suggested that low-mileage drivers, of any age, tend to have higher exposure-based collision rates because the majority of their travel is typically on congested city streets with higher potential for collisions, referred to as "low-mileage bias". It is unclear whether it is appropriate to extend this perspective to rural older drivers, where it could be expected they would likely have very different travel habits than an urban older driver with equivalent annual mileage. Consequently, reliance on "low-mileage-bias" as an explanation for high collision rates among seniors would benefit from the distinction of the differences in the type of driving exposure between urban and rural drivers. This paper used the detailed driving exposure information obtained from a Global Positioning System (GPS) supported travel diary study to explore whether "low-mileage bias" exists for rural older drivers. Revealed behaviour from GPS travel diaries of a convenience sample of 60 rural drivers aged 54-92 years showed the proportion of travel on urban streets increased with self-reported mileage and decreased with age. This finding is contrary to previous results where no distinction was made between urban and rural drivers. These results, combined with previous research showing the oldest rural drivers (81 years and older) have higher collision rates than their urban counterparts, suggests "low-mileage bias" may not exist in the rural context. It is possible the collision risk for the oldest rural drivers is understated, but further research is required. Self-reported mileage groups are a useful way to organize and analyze exposure and collision information, but age group analysis should not be excluded.

Kinetic theory of coupled oscillators.

We present an approach for the description of fluctuations that are due to finite system size induced correlations in the Kuramoto model of coupled oscillators. We construct a hierarchy for the moments of the density of oscillators that is analogous to the Bogoliubov-Born-Green-Kirkwood-Yvon hierarchy in the kinetic theory of plasmas and gases. To calculate the lowest order system size effect, we truncate this hierarchy at second order and solve the resulting closed equations for the two-oscillator correlation function around the incoherent state. We use this correlation function to compute the fluctuations of the order parameter, including the effect of transients, and compare this computation with numerical simulations.