What makes hospitals safe for mothers and babies?
Hospitals with low rates of maternal death don’t necessarily have equally low rates of neonatal death, according to results of a new study from investigators from Yale and Stanford. The findings, the authors say, point to a need for more research to identify factors that contribute to hospital performance and contribute to increased rates of overall maternal and neonatal morbidity.
Published in Birth, the conclusions are from an analysis of hospital performance that accounted jointly for maternal and newborn morbidity rates and looked at variation in the combined maternal-newborn outcome across hospitals. Supported by the Agency for Healthcare Research and Quality, the study was based on data from birth certificate and hospital discharged records reflecting more than 1.3 million term births at 248 hospitals from 2010 to 2012.
After adjusting for patient clinical risk factors, the authors calculated a risk-standardized rate of severe maternal morbidities and a risk-standardized rate of severe newborn morbidities for each hospital. Then they ranked the hospitals based on combined information on those rates. The composite measure, developed by the Centers for Disease Control and Prevention, took into consideration in-hospital maternal death, maternal transfer for acute inpatient care, and diagnosis of 16 major morbidities. For neonatal outcome, severe unexpected newborn morbidities were measured.
Of the hospitals, 28.6% were urban teaching hospitals, 7.7% were in rural areas, and 65.7% were private nonprofit hospitals. Across these institutions, the authors found that risk-standardized severe maternal and severe newborn morbidity rates varied substantially (10thto 90thpercentile range = 67.5 to 148.2 and 141.8 to 508.0 per 10,000 term births, respectively) but there was no significant association between the two (P= 0.15). Government (non-federal) hospitals were more likely than other hospitals to be in worse rank quartiles (Pvalue for trend = 0.004) whereas large volume was associated with better rank among hospitals in the first three quartiles (P= 0.004).
“Contrary to conventional beliefs,” the authors said, “we found no significant correlation between the two rates [maternal and severe newborn morbidity], suggesting that hospitals which excel in maternal outcomes may not perform well in newborn outcomes.” They theorize that there may be a number of reasons for the lack of concordance: disproportionate focus on one side of the outcomes by a hospital, differing perceptions about quality of care on the part of obstetric and pediatric providers, and differences in level of capacity of care between obstetric and pediatric services at an institution.
The findings, the researchers said, point to a need to consider maternal and newborn outcomes jointly to fully understand how a hospital performs with perinatal care. For mothers, the most prevalent morbidities that differed progressively across hospital rank quartiles were severe hemorrhage, disseminated intravascular coagulation, and heart failure during procedure/surgery. For neonates, they were severe infection, respiratory complication, and shock/resuscitation. These are the complications, the authors said, that may warrant particular attention in future research.