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Background: Obstetric fistula develops from obstructed labor and is a devastating condition with significant consequences across several domains of a woman's life. This study presents a narrative review of the evidence on the economic consequences of obstetric fistula., Methods: Three databases were searched, and search results were limited to English language papers published after 2003. Search results were reviewed for relevance based on title and abstract followed by full text review using specific inclusion and exclusion criteria. Bibliographies of papers were also scanned to identify relevant papers for inclusion. Data were extracted under three categories (defined a priori): the economic consequences of having the condition, the economic consequences of seeking care, and the macroeconomic impacts., Results: The search returned 517 unique papers, 49 of which were included after screening. Main findings identified from the studies include women losing their jobs, becoming dependent on others, and losing financial support when relationships are lost. Seeking care was economically costly for families or unaffordable entirely. There were no studies describing the impact of fistula on national economies., Conclusion: Economic consequences of obstetric fistula are multifaceted, pervasive, and are intertwined with the physical and psychosocial consequences of the condition. Understanding these consequences can help tailor existing fistula programs to better address the impacts of the condition. Further research to address the dearth of literature describing the macroeconomic impact of obstetric fistula will be critical to enhance the visibility of this condition on the health agendas of countries., (© 2024 The Authors. International Journal of Gynecology & Obstetrics published by John Wiley & Sons Ltd on behalf of International Federation of Gynecology and Obstetrics.)

Importance: Women and families constitute the fastest-growing segments of the homeless population. However, there is limited evidence on whether women experiencing homelessness have poorer childbirth delivery outcomes and higher costs of care compared with women not experiencing homelessness., Objective: To compare childbirth delivery outcomes and costs of care between pregnant women experiencing homelessness vs those not experiencing homelessness., Design, Setting, and Participants: This cross-sectional study included 15 029 pregnant women experiencing homelessness and 308 242 pregnant women not experiencing homelessness who had a delivery hospitalization in 2014. The study used statewide databases that included all hospital admissions in 3 states (ie, Florida, Massachusetts, and New York). Delivery outcomes and delivery-associated costs were compared between pregnant women experiencing homelessness and those not experiencing homelessness cared for at the same hospital (analyzed using the overlap propensity-score weighting method and multivariable regression models with hospital fixed effects). The Benjamini-Hochberg false discovery rate procedure was used to account for multiple comparisons. Data were analyzed from January 2020 through May 2020., Exposure: Housing status at delivery hospitalization., Main Outcomes and Measures: Outcome variables included obstetric complications (ie, antepartum hemorrhage, placental abnormalities, premature rupture of the membranes, preterm labor, and postpartum hemorrhage), neonatal complications (ie, fetal distress, fetal growth restriction, and stillbirth), delivery method (ie, cesarean delivery), and delivery-associated costs., Results: Among 15 029 pregnant women experiencing homelessness (mean [SD] age, 28.5 [5.9] years) compared with 308 242 pregnant women not experiencing homelessness (mean [SD] age, 29.4 [5.8] years) within the same hospital, those experiencing homelessness were more likely to experience preterm labor (adjusted probability, 10.5% vs 6.7%; adjusted risk difference [aRD], 3.8%; 95% CI, 1.2%-6.5%; adjusted P = .03) and had higher delivery-associated costs (adjusted costs, $6306 vs $5888; aRD, $417; 95% CI, $156-$680; adjusted P = .02) compared with women not experiencing homelessness. Those experiencing homelessness also had a higher probability of placental abnormalities (adjusted probability, 4.0% vs 2.0%; aRD, 1.9%; 95% CI, 0.4%-3.5%; adjusted P = .053), although this difference was not statistically significant., Conclusions and Relevance: This study found that women experiencing homelessness, compared with those not experiencing homelessness, who had a delivery and were admitted to the same hospital were more likely to experience preterm labor and incurred higher delivery-associated costs. These findings suggest wide disparities in delivery-associated outcomes between women experiencing homelessness and those not experiencing homelessness in the US. The findings highlight the importance for health care professionals to actively screen pregnant women for homelessness during prenatal care visits and coordinate their care with community health programs and social housing programs to make sure their health care needs are met.

Introduction: Preventing a primary cesarean birth in nulliparous women with term, singleton, vertex pregnancies (NTSV) is recognized as an important strategy to reduce maternal morbidities and risks to the newborn. Multiple professional organizations are supporting approaches to safely reduce NTSV cesarean rates, including the American College of Obstetricians and Gynecologists; the Society for Maternal-Fetal Medicine; and the Association of Women's Health, Obstetric and Neonatal Nurses. The American College of Nurse-Midwives (ACNM) is leading one such effort as part of its Healthy Birth Initiative: the Reducing Primary Cesareans (RPC) Learning Collaborative. The objective of this study is to estimate the cost savings of a decrease in NTSV cesareans at one hospital participating in the RPC Learning Collaborative., Methods: All women giving birth at Baystate Medical Center from October 1, 2016, to March 31, 2017, and their newborns were identified by Medicare Severity Diagnosis Related Group (N = 1747). Total hospital costs were calculated using a resource consumption profile for each of 6 groups: women who had vaginal birth, primary cesarean, and repeat cesarean and their linked newborns. A model was developed to estimate cost differences for the first and second births and overall cost savings., Results: For the NTSV birth, total costs for primary cesarean and newborn care were $5989 higher compared with vaginal birth and newborn care. For the subsequent birth, repeat cesareans and newborn care were $4250 higher compared with vaginal birth. In 2016, 69 primary cesareans were prevented, for an actual cost savings of $413,241. Projecting the prevention of 66 subsequent repeat cesareans would result in additional savings of $280,500, for a total savings of $693,741. Apgar score at 5 minutes and length of stay remained unchanged., Discussion: Participation in ACNM's RPC Learning Collaborative led to significant savings in hospital costs during the first year without affecting quality metrics. This cost comparison model could be replicated by other hospitals involved in cesarean reduction endeavors., (© 2019 by the American College of Nurse-Midwives.)

Maternal health still remains a major challenge in almost all developing countries. In Myanmar, the country met only 62% of its target for the maternal mortality rate (130 per 100,000 live birth) even though proportion of skilled birth attendant (SBA) and antenatal care (ANC) coverage was 80% in 2015. Despite the estimated large maternal complications, most maternal healthcare program ignored the burden of those morbidity because of limited understanding of the incidence and prevalence of morbidity conditions and cost of those morbidity burdens on society. The present study provides a general idea of the scope of obstetric complication, incidence of obstetric complication, and cost of those morbidity burdens on society. We conducted a retrospective incidence-based cost of illness study related to obstetric complication from the healthcare system perspective at 25 bedded township hospital in Yedashae during the fiscal year of 2015-2016. For the cost of obstetric complication, average treatment cost was 26.83 USD (±8.59). When looking by disease category, average treatment cost for incomplete abortion was 35.45 USD (±1.75); pelvic inflammatory disease (PID) was 16.01 USD; pregnancy-induced hypertension (PIH) was 21.02 USD (±4.68); ante-partum hemorrhage (APH) was 14.24(± 0.25); post-partum hemorrhage (PPH) was 27.04 USD (±1.56); prolonged labor was 37.55 USD (±0.42); and septicemia was 16.51 USD (±2.15). Significant predicting variables in obstetric complication cost model were incomplete abortion, prolonged labor, post-partum hemorrhage (PPH), pregnancy induced hypertension (PIH), patient age and septicemia. From this study, we can summarize the most frequently occurred obstetric complication in that township area, actual cost burden of those complications and obstetric complication cost model which can be useful for hospital financial management. This study can be considered as a starting point for cost of illness analysis in Myanmar to prioritize and target specific health problem at a country level for policy maker to set priorities for health care intervention., Competing Interests: The authors have declared that no competing interests exist.

Since 2008, Greece suffers a severe economic crisis. Adverse health outcomes have been reported, but studies on perinatal health are sparse. We aimed to examine the impact of economic crisis on perinatal parameters during early and established crisis periods. Birth records of 14 923 neonates, born in a public maternity hospital from 2005-2014, were reviewed for maternal (age, delivery mode) and neonatal (gender, birthweight, gestational age) variables. Univariable analysis tested the association of study variables with time-periods 2005-2007, 2009-2011 and 2012-2014. Multivariable logistic regression analysis identified factors independently associated with low birthweight (LBW) (<2500 g), prematurity (<37 weeks) and caesarean section (CS). During 2012-2014, compared to 2005-2007, LBW rate increased from 8.4 to 10.5% (RR 1.16; 95%CI 1.01-1.33); prematurity from 9.7 to 11.2% (RR 1.09; 95%CI 0.96-1.24), comprising mainly late-preterm neonates; CS from 43.2 to 54.8% (RR 1.21; 95%CI 1.16-1.26). Maternal age ≥30 years was risk factor for LBW, prematurity and CS; LBW was additional risk factor for CS. However, LBW and CSs increased during the study period, independently of maternal age. In conclusion, impaired perinatal parameters, manifested by increasing maternal age, LBW, prematurity and CS rate, were observed during the years of economic decline, with possible adverse consequences for later health.

Objective: Obstetric care is a high-risk area in healthcare delivery, so it is essential to have up-to-date quantitative evidence in this area to inform policy decisions regarding these services. In light of this, the objective of this study is to investigate the incidence and economic burden of third and fourth-degree lacerations in the English National Health Service (NHS) using recent national data., Methods: We used coded inpatient data from Hospital Episode Statistics (HES) for the financial years from 2010/2011 to 2013/2014 for all females that gave birth during that period in the English NHS. Using HES, we used pre-existing safety indicator algorithms to calculate the incidence of third and fourth-degree obstetric tears and employed a propensity score matching method to estimate the excess length of stay and economic burden associated with these events., Results: Observed rates per 1000 inpatient episodes in 2010/2011 and 2013/2014, respectively: Patient Safety Indicator-trauma during vaginal delivery with instrument (PSI 18)=84.16 and 91.24; trauma during vaginal delivery without instrument (PSI 19)=29.78 and 33.43; trauma during caesarean delivery (PSI 20)=3.61 and 4.56. Estimated overall (all PSIs) economic burden for 2010/2011=£10.7 million and for 2013/2014=£14.5 million, expressed in 2013/2014 prices., Conclusions: Despite many initiatives targeting the quality of maternity care in the NHS, the incidence of third and fourth-degree lacerations has increased during the observed period which signals that quality improvement efforts in obstetric care may not be reducing incidence rates. Our conservative estimates of the financial burden of these events appear low relative to total NHS expenditure for these years., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Introduction: The objective of this study was to calculate costs associated with severe fear of childbirth (FOC) during pregnancy and peripartum by comparing two groups of women expecting their first child and attending an ordinary antenatal program; one with low FOC and one with severe FOC., Material and Methods: In a prospective case-control cohort study one group with low FOC [Wijma Delivery Expectancy/Experience Questionnaire (W-DEQ) sum score ≤60, n = 107] and one with severe FOC (W-DEQ ≥85, n = 43) were followed up till 3 months postpartum and included in the analysis. Medical records were assessed and medical parameters were mapped. Mean costs for healthcare consumption and sick leave during pregnancy were calculated and compared., Results: When means were compared between the groups, the group with severe FOC had more visits for psychosocial reasons (p = 0.001) and more hours on sick leave (p = 0.03) during pregnancy, and stayed longer at the maternity ward (p = 0.04). They also more seldom had normal spontaneous deliveries (p = 0.03), and more often had an elective cesarean section on maternal request (p = 0.02). Postpartum, they more often than the group with low FOC paid visits to the maternity clinic because of complications (p = 0.001) and to the antenatal unit because of adverse childbirth experiences (p = 0.001). The costs for handling women with severe FOC was 38% higher than those for women with low FOC., Conclusion: Women with severe FOC generate considerably higher perinatal costs than women with low FOC when handled in care as usual., (© 2017 Nordic Federation of Societies of Obstetrics and Gynecology.)

Objective: To assess the cost-effectiveness of routine labour epidural analgesia (EA), from a societal perspective, as compared with labour analgesia on request., Study Design: Women delivering of a singleton in cephalic presentation beyond 36+0 weeks' gestation were randomly allocated to routine labour EA or analgesia on request in one university and one non-university teaching hospital in the Netherlands. Costs included all medical, non-medical and indirect costs from randomisation to 6 weeks postpartum. Effectiveness was defined as a non-operative, spontaneous vaginal delivery without EA-related maternal adverse effects. Incremental cost-effectiveness ratio (ICER) was defined as the ratio of the difference in costs and the difference in effectiveness between both groups. Data were analysed according to intention to treat and divided into a base case analysis and a sensitivity analysis., Results: Total delivery costs in the routine EA group (n=233) were higher than in the labour on request group (n=255) (difference -€ 322, 95% CI -€ 60 to € 355) due to more medication costs (including EA), a longer stay in the labour ward, and more operations including caesarean sections. Total postpartum hospital costs in the routine EA group were lower (difference -€ 344, 95% CI -€ 1338 to € 621) mainly due to less neonatal admissions (difference -€ 472, 95% CI -€ 1297 to € 331), whereas total postpartum home and others costs were comparable (difference -€ 20, 95% CI -€ 267 to € 248, and -€ 1, 95% CI -€ 67 to € 284, respectively). As a result, the overall mean costs per woman were comparable between the routine EA group and the analgesia on request group (€ 8.708 and € 8.710, respectively, mean difference -€ 2, 95% CI -€ 1.012 to € 916). Routine labour EA resulted in more deliveries with maternal adverse effects, nevertheless the ICER remained low (€ 8; bootstrap 95% CI -€ 6.120 to € 8.659). The cost-effectiveness acceptability curve indicated a low probability that routine EA is cost-effective., Conclusion: Routine labour EA generates comparable costs as analgesia on request, but results in more operative deliveries and more EA-related maternal adverse effects. Based on cost-effectiveness, no preference can be given to routine labour EA as compared with analgesia on request., (Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.)

Background: Though Janani Suraksha Yojana (JSY) under National Rural Health Mission (NRHM) is successful in increasing antenatal and natal care services, little is known on the cost coverage of out-of-pocket expenditure (OOPE) on maternal care services post-NRHM period., Methods: Using data from a community-based study of 424 recently delivered women in Rajasthan, this paper examined the variation in OOPE in accessing maternal health services and the extent to which JSY incentives covered the burden of cost incurred. Descriptive statistics and logistic regression analyses are used to understand the differential and determinants of OOPE., Results: The mean OOPE for antenatal care was US$26 at public health centres and US$64 at private health centres. The OOPE (antenatal and natal) per delivery was US$32 if delivery was conducted at home, US$78 at public facility and US$154 at private facility. The OOPE varied by the type of delivery, delivery with complications and place of ANC. The OOPE in public health centre was US$44 and US$145 for normal and complicated delivery, respectively. The share of JSY was 44 % of the total cost per delivery, 77 % in case of normal delivery and 23 % for complicated delivery. Results from the log linear model suggest that economic status, educational level and pregnancy complications are significant predictors of OOPE., Conclusions: Our results suggest that JSY has increased the coverage of institutional delivery and reduced financial stress to household and families but not sufficient for complicated delivery. Provisioning of providing sonography/other test and treating complicated cases in public health centres need to be strengthened.

Objective: Given that cesarean delivery is one of the most commonly performed surgical procedures in the United States and an important contributor to obstetric care costs, this analysis sought to examine maternal hospital costs associated with trial of labor after cesarean delivery (TOLAC) versus repeat cesarean delivery (RCD)., Methods: A national sample was used to identify women with singleton pregnancy who underwent either TOLAC or RCD from 2006 to 2012. Women with diagnoses that could confound cost via extended hospital length of stay prior to delivery were excluded. Other medical and obstetric covariates that could influence cost were included in an adjusted model., Results: A total of 485,247 women were identified, including 365,596 (75.3%) cesarean deliveries without labor, 41,988 (8.6%) successful and 77,663 (16.0%) unsuccessful TOLAC deliveries. The inflation-adjusted median costs in this cohort were $5512 for cesarean without labor, $4175 for successful TOLAC, $5166 for all TOLAC attempts, and $5759 for failed TOLAC. In a multivariable model, hospital region was a major predictor of median cost as were demographic variables and medical comorbidities., Conclusion: TOLAC is associated with modest reductions of cost for maternal hospitalizations. However, other medical, demographic and hospital factors appear to be more important factors.

Objective: To describe the prevalence, trends, adverse maternal-fetal morbidities and healthcare costs associated with placenta accreta (PA) in the United States (US) between 1998 and 2011., Methods: A retrospective, cross-sectional analysis of inpatient hospital discharges was conducted using the National Inpatient Sample (NIS). We used International Classification of Diseases, Ninth Edition, Clinical Modification (ICD-9-CM) codes to identify both cases of PA and of selected comorbidities. Survey logistic regression was used to assess the association between PA and various maternal-fetal outcomes. Joinpoint regression modeling was used to estimate annual percent changes (APCs) in PA prevalence during the study period., Results: The prevalence of PA from 1998 to 2011 was 3.7 per 1000 delivery-related discharges. After adjusting for known or suspected confounders, PA conferred between a 20% to over a 19-fold increased odds of experiencing an adverse outcome. This resulted in a higher mean, per-hospitalization, cost of inpatient care after adjustment for inflation ($5561 versus $4989), translating into over $115 million dollars in additional inpatient expenditures relative to non-PA affected deliveries from 2001 to 2011., Conclusions: This study updates recent trends in the prevalence of PA, which is valuable to clinicians and policymakers as they formulate targeted strategies to address factors related to PA.

In view of the growing proportion of "non-urgent" admissions to obstetric emergency rooms (OERs) and recent changes in copayment policies for OER visits in Israel, we assessed factors contributing to OER overcrowding. The changes investigated were (a) exemption from copayment for women with birth contractions, (b) allowing phone referrals to the OER and (c) exemption from copayment during primary care clinic closing hours. We analyzed data of a large tertiary hospital with 37 deliveries per day. Counts of women discharged to home from the OER were an indicator of "non-urgent" visits. The annual number of non-urgent visits increased at a higher rate (3.4%) than the natural increase in deliveries (2.1%). Exemption from copayment for visits during non-working hours of primary care clinics was associated with increases in OER admissions (IRR=1.22) and in non-urgent OER visits (IRR=1.54). Younger and first-time mothers with medically unjustified complaints were more likely to be discharged to home. We showed that the changes in the policy for OER copayment meant to attract new clients to the HMO had an independent impact on OER utilization, and hence, added to the workload of medical personnel. The change in HMO policy regulating OER availability requires rigorous assessment of possible health system implications., (Copyright © 2015 Elsevier Ireland Ltd. All rights reserved.)

Induction of labor in resource-limited settings has the potential to significantly improve health outcomes for both mothers and infants. However, there are relatively little context-specific data to guide practice, and few specific guidelines. Also, there may be considerable issues regarding the facilities and organizational capacities necessary to support safe practices in many aspects of obstetrical practice, and for induction of labor in particular. Herein we describe the various opportunities as well as challenges presented by induction of labor in these settings., (Copyright © 2015 Elsevier Inc. All rights reserved.)

Background: Obstetric fistula (OF) is a serious consequence of prolonged, obstructed labor in settings where emergency obstetric care is limited, but there are few reliable, population-based estimates of the rate of OF. Stillbirth (SB) is another serious consequence of prolonged, obstructed labor, yet the frequency of SB in women with OF is poorly described. Here, we review these data., Methods: We searched electronic databases and grey literature for articles on OF in low-resource countries published between January 1, 1995, and November 16, 2014, and selected for inclusion 19 articles with original population-based OF incidence or prevalence data and 44 with reports of frequency of SB associated with OF., Results: OF estimates came from medium- and low-HDI countries in South Asia and Africa, and varied considerably; incidence estimates ranged from 0 to 4.09 OF cases per 1000 deliveries, while prevalence estimates were judged more prone to bias and ranged from 0 to 81.0 OF cases per 1000 women. Reported frequency of SB associated with OF ranged from 32.3 % to 100 %, with estimates from the largest studies around 92 %. Study methods and quality were inconsistent., Conclusions: Reliable data on OF and associated SB in low-resource countries are lacking, underscoring the relative invisibility of these issues. Sound numbers are needed to guide policy and funding responses to these neglected conditions of poverty.

The fee exemption policy for EmONC in Mali aims to lower the financial barrier to care. The objective of the study was to evaluate the direct and indirect expenses associated with caesarean interventions performed in EmONC and the factors associated with these expenses. Data sampling followed the case control approach used in the large project (deceased and near-miss women). Our sample consisted of a total of 190 women who underwent caesarean interventions. Data were collected from the health workers and with a social approach by administering questionnaires to the persons who accompanied the woman. Household socioeconomic status was assessed using a wealth index constructed with a principal component analysis. The factors significantly associated with expenses were determined using multivariate linear regression analyses. Women in the Kayes region spent on average 77,017 FCFA (163 USD) for a caesarean episode in EmONC, of which 70 % was for treatment. Despite the caesarean fee exemption, 91 % of the women still paid for their treatment. The largest treatment-related direct expenses were for prescriptions, transfusion, antibiotics, and antihypertensive medication. Near-misses, women who presented a hemorrhage or an infection, and/or women living in rural areas spent significantly more than the others. Although abolishing fees of EmONC in Mali plays an important role in reducing maternal death by increasing access to caesarean sections, this paper shows that the fee policy did not benefit to all women. There are still barriers to EmONC access for women of the lowest socio-economic group. These included direct expenses for drugs prescription, treatment and indirect expenses for transport and food.

Background: India leads all nations in numbers of maternal deaths, with poor, rural women contributing disproportionately to the high maternal mortality ratio. In 2005, India launched the world's largest conditional cash transfer scheme, Janani Suraksha Yojana (JSY), to increase poor women's access to institutional delivery, anticipating that facility-based birthing would decrease deaths. Indian states have taken different approaches to implementing JSY. Tamil Nadu adopted JSY with a reorganization of its public health system, and Gujarat augmented JSY with the state-funded Chiranjeevi Yojana (CY) scheme, contracting with private physicians for delivery services. Given scarce evidence of the outcomes of these approaches, especially in states with more optimal health indicators, this cross-sectional study examined the role of JSY/CY and other healthcare system and social factors in predicting poor, rural women's use of maternal health services in Gujarat and Tamil Nadu., Methods: Using the District Level Household Survey (DLHS)-3, the sample included 1584 Gujarati and 601 Tamil rural women in the lowest two wealth quintiles. Multivariate logistic regression analyses examined associations between JSY/CY and other salient health system, socio-demographic, and obstetric factors with three outcomes: adequate antenatal care, institutional delivery, and Cesarean-section., Results: Tamil women reported greater use of maternal healthcare services than Gujarati women. JSY/CY participation predicted institutional delivery in Gujarat (AOR = 3.9), but JSY assistance failed to predict institutional delivery in Tamil Nadu, where mothers received some cash for home births under another scheme. JSY/CY assistance failed to predict adequate antenatal care, which was not incentivized. All-weather road access predicted institutional delivery in both Tamil Nadu (AOR = 3.4) and Gujarat (AOR = 1.4). Women's education predicted institutional delivery and Cesarean-section in Tamil Nadu, while husbands' education predicted institutional delivery in Gujarat., Conclusions: Overall, assistance from health financing schemes, good road access to health facilities, and socio-demographic and obstetric factors were associated with differential use of maternity health services by poor, rural women in the two states. Policymakers and practitioners should promote financing schemes to increase access, including consideration of incentives for antenatal care, and address health system and social factors in designing state-level interventions to promote safe motherhood.

International agencies have advocated scaling-up of midwifery resources as an important method for improving maternal health and reducing maternal mortality rates (MMR). The cost-effectiveness of midwife-led versus physician-led intrapartum care is an important consideration in the human resource planning required to reduce MMR. Studies suggest that midwife-led teams can achieve comparable effectiveness and outcomes using less medically intensive care compared with physician-led teams. In the absence of adequate medical cost data, decision makers should consider the substantially lower average costs for three main drivers: salaries, benefits and incentives (≥two-times lower); preservice training (three-times lower) and attrition (two-times lower) necessary to deliver intrapartum care at the level of midwife competencies. This suggests that scale-up of midwifery resources is a less expensive and more cost-effective way to reduce MMRs and could potentially increase access to skilled intrapartum care.

Objective: To evaluate the occurrence of severe obstetric complications associated with antepartum and intrapartum hemorrhage among women from the Brazilian Network for Surveillance of Severe Maternal Morbidity., Design: Multicenter cross-sectional study., Setting: Twenty-seven obstetric referral units in Brazil between July 2009 and June 2010., Population: A total of 9555 women categorized as having obstetric complications., Methods: The occurrence of potentially life-threatening conditions, maternal near miss and maternal deaths associated with antepartum and intrapartum hemorrhage was evaluated. Sociodemographic and obstetric characteristics and the use of criteria for management of severe bleeding were also assessed in these women., Main Outcome Measures: The prevalence ratios with their respective 95% confidence intervals adjusted for the cluster effect of the design, and multiple logistic regression analysis were performed to identify factors independently associated with the occurrence of severe maternal outcome., Results: Antepartum and intrapartum hemorrhage occurred in only 8% (767) of women experiencing any type of obstetric complication. However, it was responsible for 18.2% (140) of maternal near miss and 10% (14) of maternal death cases. On multivariate analysis, maternal age and previous cesarean section were shown to be independently associated with an increased risk of severe maternal outcome (near miss or death)., Conclusion: Severe maternal outcome due to antepartum and intrapartum hemorrhage was highly prevalent among Brazilian women. Certain risk factors, maternal age and previous cesarean delivery in particular, were associated with the occurrence of bleeding., (© 2014 Nordic Federation of Societies of Obstetrics and Gynecology.)

This study investigates the long term economic impact of severe obstetric complications for women and their children in Burkina Faso, focusing on measures of food security, expenditures and related quality of life measures. It uses a hospital based cohort, first visited in 2004/2005 and followed up four years later. This cohort of 1014 women consisted of two main groups of comparison: 677 women who had an uncomplicated delivery and 337 women who experienced a severe obstetric complication which would have almost certainly caused death had they not received hospital care (labelled a "near miss" event). To analyze the impact of such near miss events as well as the possible interaction with the pregnancy outcome, we compared household and individual level indicators between women without a near miss event and women with a near miss event who either had a live birth, a perinatal death or an early pregnancy loss. We used propensity score matching to remove initial selection bias. Although we found limited effects for the whole group of near miss women, the results indicated negative impacts: a) for near miss women with a live birth, on child development and education, on relatively expensive food consumption and on women's quality of life; b) for near miss women with perinatal death, on relatively expensive foods consumption and children's education and c) for near miss women who had an early pregnancy loss, on overall food security. Our results showed that severe obstetric complications have long lasting consequences for different groups of women and their children and highlighted the need for carefully targeted interventions.

Objective: To investigate the frequency of catastrophic expenditures for emergency obstetric care, explore its risk factors, and assess the effect of these expenditures on households in the Kayes region, Mali., Methods: Data on 484 obstetric emergencies (242 deaths and 242 near-misses) were collected in 2008-2011. Catastrophic expenditure for emergency obstetric care was assessed at different thresholds and its associated factors were explored through logistic regression. A survey was subsequently administered in a nested sample of 56 households to determine how the catastrophic expenditure had affected them., Findings: Despite the fee exemption policy for Caesareans and the maternity referral-system, designed to reduce the financial burden of emergency obstetric care, average expenses were 152 United States dollars (equivalent to 71 535 Communauté Financière Africaine francs) and 20.7 to 53.5% of households incurred catastrophic expenditures. High expenditure for emergency obstetric care forced 44.6% of the households to reduce their food consumption and 23.2% were still indebted 10 months to two and a half years later. Living in remote rural areas was associated with the risk of catastrophic spending, which shows the referral system's inability to eliminate financial obstacles for remote households. Women who underwent Caesareans continued to incur catastrophic expenses, especially when prescribed drugs not included in the government-provided Caesarean kits., Conclusion: The poor accessibility and affordability of emergency obstetric care has consequences beyond maternal deaths. Providing drugs free of charge and moving to a more sustainable, nationally-funded referral system would reduce catastrophic expenses for households during obstetric emergencies.

Cesarean delivery rates in California and the United States rose by 50% between 1998 and 2008 and vary widely among states, regions, hospitals, and health care providers. The leading driver of both the rise and the variation is first-birth cesarean deliveries performed during labor. With the large increase in primary cesarean deliveries, repeat cesarean delivery now has emerged as the largest single indication. The economic costs, health risks, and negligible benefits for most mothers and newborns of these higher rates point to the urgent need for a new approach to working with women in labor. This commentary analyzes the high rates and wide variations and presents evidence of costs and risks associated with cesarean deliveries (complete discussion provided in the California Maternal Quality Care Collaborative White Paper at www.cmqcc.org/white&#95;paper). All stakeholders need to ask whether society can afford the costs and complications of this high cesarean delivery rate and whether they can work together toward solutions. The factors involved in the rise in cesarean deliveries point to the need for a multistrategy approach, because no single strategy is likely to be effective or lead to sustained change. We outline complementary strategies for reducing the rates and offer recommendations including clinical improvement strategies with careful examination of labor management practices; payment reform to eliminate negative or perverse incentives; education to recognize the value of vaginal birth; and full transparency through public reporting and continued public engagement.

Worldwide, for an estimated 358,000 women, pregnancy and childbirth end in death and mourning, and beyond these maternal deaths, 9-10% of pregnant women or about 14 million women per year suffer from acute maternal complications. This paper documents the types and severity of maternal and foetal complications among women who gave birth in hospitals in Matlab and Chandpur, Bangladesh, during 2007-2008. The Community Health Research Workers (CHRWs) of the icddr,b service area in Matlab prospectively collected data for the study from 4,817 women on their places of delivery and pregnancy outcomes. Of them, 3,010 (62.5%) gave birth in different hospitals in Matlab and/or Chandpur and beyond. Review of hospital-records was attempted for 2,102 women who gave birth only in the Matlab Hospital of icddr,b and in other public and private hospitals in the Matlab and Chandpur area. Among those, 1,927 (91.7%) records were found and reviewed by a physician. By reviewing the hospital-records, 7.3% of the women (n=1,927) who gave birth in the local hospitals were diagnosed with a severe maternal complication, and 16.1% with a less-severe maternal complication. Abortion cases--either spontaneous or induced--were excluded from the analysis. Over 12% of all births were delivered by caesarean section (CS). For a substantial proportion (12.5%) of CS, no clear medical indication was recorded in the hospital-register. Twelve maternal deaths occurred during the study period; most (83%) of them had been in contact with a hospital before death. Recommendations include standardization of the hospital record-keeping system, proper monitoring of indications of CS, and introduction of maternal death audit for further improvement of the quality of care in public and private hospitals in rural Bangladesh.

Background: Maternal mortality is a major public health problem worldwide especially in low income countries. Most causes of maternal deaths are due to direct obstetric complications. Maternal mortality ratio remains high in Rukungiri district, western Uganda estimated at 475 per 100,000 live births. The objectives were to identify types of community involvement and examine factors influencing the level of community involvement in the management of obstetric emergencies., Methods: We conducted a descriptive study during 2nd to 28th February 2009 in rural Rukungiri district, western Uganda. A total of 448 heads of households, randomly selected from 6/11 (54.5%) of sub-counties, 21/42 (50.0%) parishes and 32/212 (15.1%) villages (clusters), were interviewed. Data were analysed using STATA version 10.0., Results: Community pre-emergency support interventions available included community awareness creation (sensitization) while interventions undertaken when emergency had occurred included transportation and referring women to health facility. Community support programmes towards health care (obstetric emergencies) included establishment of community savings and credit schemes, and insurance schemes. The factors associated with community involvement in obstetric emergency management were community members being employed (AOR = 1.91, 95% CI: 1.02 - 3.54) and rating the quality of maternal health care as good (AOR = 2.22, 95% CI: 1.19 - 4.14)., Conclusions: Types of community involvement in obstetric emergency management include practices and support programmes. Community involvement in obstetric emergency management is influenced by employment status and perceived quality of health care services. Policies to promote community networks and resource mobilization strategies for health care should be implemented. There is need for promotion of community support initiatives including health insurance schemes and self help associations; further community sensitization by empowered community based resource persons rather than health workers and improvement in quality of health care can contribute towards effective management of obstetric complications.

A difficult calving affects the welfare of the cow and has economic implications for the farm. The degree of calving difficulty can vary from no assistance needed through a slight pull required to surgery being needed. With respect to milk production, it is not clear at which degree of calving difficulty adverse effects occur or for how long they last. Studies usually only consider the milk produced by animals who completed full lactations but the saleable milk production of the whole herd, regardless of each cow having achieved a full lactation, might be a better indicator of the productivity of the cows and the underlying stresses they experience, as well as being more representative of the real losses that producers incur. The objective of this study was to investigate how various degrees of calving difficulty would alter both the cow's milk production and their production of saleable milk over different stages of their subsequent lactation. The calving difficulty scores and the subsequent milk production were retrieved from an experimental dairy farm (in the United Kingdom) for 2 herds that contained 2,430 and 1,413 lactations. To account for milk saleable by the farmer, individual cumulative saleable milk yields, referred to as saleable milk yields (SMY), were calculated at 30, 60, 90, and 300 d in milk unconditional on the animal having achieved the lactation stage of interest. Lactation SMY were obtained based on the real lactation length achieved by the animal. Mean daily milk yields were also calculated for the same lactation stages as an estimate of the cow's milk production (CMP). Calving difficulty impaired milk production of dairy cows in terms of CMP and SMY in both herds, highlighting impaired income for dairy producers as well as detrimental effects to the productivity of the cows and potentially impaired health and survival. The management of the herd affected the presence of an effect of each degree of difficulty on SMY and CMP as well as its magnitude and duration. The analysis of SMY, independently of each animal having achieved a full lactation, could be a more sensitive indicator of the subsequent long-lasting biological stresses than CMP alone., (Copyright © 2011 American Dairy Science Association. Published by Elsevier Inc. All rights reserved.)

Objective: To determine the cost-effectiveness of alternative screening and prevention strategies, including rapid intrapartum testing, for prevention of early-onset neonatal group B streptococcus (GBS) infection in the UK., Design: A decision model was developed to investigate the cost-effectiveness of screening and prevention strategies for GBS. A strategy of doing nothing was also considered. Deterministic and probabilistic sensitivity analyses were carried out., Setting: Two large UK based obstetric units., Participants: Test accuracy data were obtained from a primary study of rapid tests at the onset of labour and risk factors from 1400 women., Main Outcome Measures: Incremental health sector costs per case of early-onset GBS death avoided., Results: Compared with a strategy of do nothing, the incremental cost-effectiveness ratio was £32,000 per Early-Onset GBS Disease avoided and £427,000 per Early-Onset GBS Death avoided for the strategy of providing routine intrapartum antibiotic prophylaxis to all women without prior screening; Based on their current sensitivity, specificity and cost, screening using rapid tests was dominated by other more cost-effective strategies., Conclusions: The most cost-effective strategy was shown to be the provision of routine intrapartum antibiotic prophylaxis to all women without prior screening but, given broader concerns relating to antibiotic use, this is unlikely to be acceptable. In its absence, intrapartum antibiotic prophylaxis directed by screening with enriched culture becomes cost-effective. The current strategy of risk-factor-based screening is not cost-effective compared with screening based on culture., (© 2010 The Authors Journal compilation © RCOG 2010 BJOG An International Journal of Obstetrics and Gynaecology.)

Background: There are many avoidable deaths in hospitals because the care team is not well attuned. Training in emergency situations is generally followed on an individual basis. In practice, however, hospital patients are treated by a team composed of various disciplines. To prevent communication errors, it is important to focus the training on the team as a whole, rather than on the individual. Team training appears to be important in contributing toward preventing these errors. Obstetrics lends itself to multidisciplinary team training. It is a field in which nurses, midwives, obstetricians and paediatricians work together and where decisions must be made and actions must be carried out under extreme time pressure.It is attractive to belief that multidisciplinary team training will reduce the number of errors in obstetrics. The other side of the medal is that many hospitals are buying expensive patient simulators without proper evaluation of the training method. In the Netherlands many hospitals have 1,000 or less annual deliveries. In our small country it might therefore be more cost-effective to train obstetric teams in medical simulation centres with well trained personnel, high fidelity patient simulators, and well defined training programmes., Methods/design: The aim of the present study is to evaluate the cost-effectiveness of multidisciplinary team training in a medical simulation centre in the Netherlands to reduce the number of medical errors in obstetric emergency situations. We plan a multicentre randomised study with the centre as unit of analysis. Obstetric departments will be randomly assigned to receive multidisciplinary team training in a medical simulation centre or to a control arm without any team training.The composite measure of poor perinatal and maternal outcome in the non training group was thought to be 15%, on the basis of data obtained from the National Dutch Perinatal Registry and the guidelines of the Dutch Society of Obstetrics and Gynaecology (NVOG). We anticipated that multidisciplinary team training would reduce this risk to 5%. A sample size of 24 centres with a cluster size of each at least 200 deliveries, each 12 centres per group, was needed for 80% power and a 5% type 1 error probability (two-sided). We assumed an Intraclass Correlation Coefficient (ICC) value of maximum 0.08.The analysis will be performed according to the intention-to-treat principle and stratified for teaching or non-teaching hospitals.Primary outcome is the number of obstetric complications throughout the first year period after the intervention. If multidisciplinary team training appears to be effective a cost-effective analysis will be performed., Discussion: If multidisciplinary team training appears to be cost-effective, this training should be implemented in extra training for gynaecologists., Trial Registration: The protocol is registered in the clinical trial register number NTR1859.

Three hundred twelve mothers of infants aged 2-4 months in 11 slums of Indore, India, were interviewed to assess birth preparedness and complication readiness (BPACR) among them. The mothers were asked whether they followed the desired four steps while pregnant: identified a trained birth attendant, identified a health facility, arranged for transport, and saved money for emergency. Taking at least three steps was considered being well-prepared. Taking two or less steps was considered being less-prepared. One hundred forty-nine mothers (47.8%) were well-prepared. Factors associated with well-preparedness were assessed using adjusted multivariate models. Factors associated with well-preparedness were maternal literacy [odds ratio (OR) = 1.9, (95%) confidence interval (CI) 1.1-3.4] and availing of antenatal services (OR = 1.7, CI 1.05-2.8). Deliveries in the slum-home were high (56.4%). Among these, skilled attendance was low (7.4%); 77.3% of them were assisted by traditional birth attendants. Skilled attendance during delivery was three times higher in well-prepared mothers compared to less-prepared mothers (OR: 3.0, CI 1.6-5.4) Antenatal outreach sessions can be used for promoting BPACR. It will be important to increase the competency of slum-based traditional birth attendants, along with promoting institutional deliveries.

Background: A program to eliminate obstetric urogenital fistula (OUGF) was set up on February 19, 2004 in Niger. Though the consultations were free of charge, there was a cost involved, which constitutes the objective of this study., Method: The data were obtained from a documentary study completed by discussions with the principal management participants and interviews targeting the women suffering from OUGF attending the national hospital of Niamey during the surgery sessions of April and November 2006. Cost assessment included all resources devoted to activities involved in the program: hospital stay, hygiene education, medical and surgical treatment, social rehabilitation interventions (preparation for revenue generating activities and return to residence). Data analysis was performed with Excel and Epi2000 software. Average cost per item and patient was determined., Results: The cost of the stay at the National hospital of Niamey was 96,445 francs CFA divided between transportation (4,688), room and board (21,572), assistance bonus (3,708) and indirect costs (66,477). The hygiene education cost 194,140 francs CFA: 30,150 for human resources, 143,965 for material resources and 20,025 for operational costs. The medical and surgery treatment had a cost of 144,009 francs CFA divided between consultations (15,000), complementary explorations (44,900), surgical operation (50,000) and consumables (34,109). The preparation for revenue generating activities had a cost of 118,244 francs CFA including training for clothes dying (22,084), soap manufacture (46,160) and the financial supportive grant (50,000). The return to the community cost 295,000 francs CFA, included room and board (2,500), human resources (65,000) and material resources (227,500). Altogether, the cost of the OUGF program came up to 742,018 francs CFA for our sample (76% of women with revenue generating activity), and was assessed at a maximum of 781,362 francs CFA if none of the woman had a revenue generating activity, and a minimum of 729,594 francs CFA if all of them did., Conclusion: Without the free consultations, the high cost of the OUGF program at the national hospital of Niamey would be inaccessible to Nigerian women owing to poverty and ignorance. Because of this observation, a long-term program is warranted for the treatment of overt cases and the reduction of prevalence, to enable Nigerian women to contribute to the development activities of their country.

Objective: To demonstrate the effectiveness of a comprehensive, multispecialty, interdisciplinary team approach to prenatal and obstetric care for previously medically underserved patients., Study Design: A retrospective chart review analysis was performed on a total of 1,800 charts pertaining to 600 patients divided evenly between a publicly funded, comprehensive prenatal care program and that same institution's private faculty practice. For each of the 600 patients data were extracted from prenatal, intrapartum and postpartum records. Data were analyzed using Fisher's exact test, the chi2 test and the Mann-Whitney test. In addition, for certain parameters, the data from the publicly funded program were compared to national data., Results: In the publicly funded group, more patients initiated prenatal care at a later date (p < 0.0001), had a significantly higher rate of illegal substance use (p < 0.0007), utilized home care services more frequently (p < 0.0001) and averaged a somewhat longer hospital stay for mother and neonate (p < 0.0019, p < 0.0001, respectively). However, there was no significant difference between the 2 groups or between the publicly funded group and the national averages for most antepartum, intrapartum and postpartum complications or for maternal or fetal morbidity or mortality. The publicly funded group averaged a higher rate of breast-feeding., Conclusion: Despite belonging to a higher risk population, there were no statistically significant differences in maternal or neonatal outcomes between the publicly funded group and the private faculty practice group or between the publicly funded group and national data. This suggests that a comprehensive, multispecialty, interdisciplinary team approach to prenatal and obstetric care is an effective program to provide to patients who have previously been medically underserved.

Obstetric fistula is a devastating complication of obstructed labor that affects more than two million women in developing countries, with at least 75,000 new cases every year. Prolonged pressure of the infant's skull against the tissues of the birth canal leads to ischemia and tissue death. The woman is left with a hole between her vagina and bladder (vesicovaginal) or vagina and rectum (rectovaginal) or both, and has uncontrollable leakage of urine or feces or both. It is widely reported in scientific publications and the media that women with obstetric fistula suffer devastating social consequences, but these claims are rarely supported with evidence. Therefore, the true prevalence and nature of the social implications of obstetric fistula are unknown. An integrative review was undertaken to determine the current state of the science on social implications of obstetric fistula in sub-Saharan Africa.

Objective: The aim of the present study was to compare the consumption and cost of ephedrine in parturients with respect to two packagings: ampoules and prefilled syringes., Study Design: Prospective observational study in a French university obstetrical unit., Patients and Methods: Assessing the consumption and cost of ephedrine during two consecutive periods of 14 days: use of ampoules for period 1 (P1) versus use of prefilled syringes for period 2 (P2). Consumption was daily evaluated. The costs (ampoules and consumable supplies for P1 and prefilled syringes for P2) were calculated on the basis of the price list given by our institutional pharmacy. The number of parturients and the anaesthetic techniques which were performed were prospectively recorded., Results: One hundred and thirteen parturients were managed for the present study. The number of parturients and the anaesthetic care were similar between the two periods. In contrast, 155 ampoules were used for P1 versus 45 prefilled syringes for P2 (p<0.0001). The cost per parturient was 3.1 euro for P1 versus 2.6 euro for P2, i.e. 0.5 euro was saved for each parturient., Conclusion: The results of the present study show that the use of prefilled syringes reduces significantly the wastage of ephedrine, allowing subsequent cost minimization in obstetrical anaesthesia.

Recent years have undoubtedly been a time of dynamic changes for German midwives, which had had their source in numerous social, economic and political changes. The medical care cost growth, lack of profitability of medical centers and an increasing number of redundancies have been given lots of attention in various discussions. The above mentioned problems have started to concern the professional group of German midwives, thus giving birth to the introduction of innovatory system of obstetric care in German hospitals, known as Belegsystem. In Europe the Belegsystem has been introduced in certain Scandinavian countries, Great Britain, Austria and Switzerland. In Germany the first labour room within the Belegsystem rules has been opened on 1 June 2003 in Brema (Klinikum Bremerhaven Reinkenheide). The following two Centers have been opened in Hamburg at the beginning of 2004 (Allgemeines Krankenhaus Hamburg-Harburg i Allgemeines Krankenhaus Hamburg-Barmbek). The folllowing article presents the functioning rules and procedures of the Belegsystem labour rooms in Germany, as one of the labour care alternatives.

Obstetric fistulas occur in developing countries because of the scarcity or complete absence of obstetric services. The magnitude of the problem is unknown but thought to be sizeable. This article describes a basic approach to the care of women with fistulas in a low-resource rural hospital in northern Ghana, where the results were similar to those obtained at better-equipped centers. The facility includes an outpatient clinic for history taking and clinical examinations, and a laboratory for hemoglobin concentration assessment, sickling test, blood grouping, and cross-matching when necessary. Anesthesia consists of a spinal anesthesia given by the surgeon and monitored by a nurse while the surgeon scrubs up before repairing the fistula. Surgery is performed with the patient in exaggerated lithotomy position, and a bed sheet used as a sling prevents her from falling backwards. The patients are kept at the hospital for 14 days postoperatively for continuous bladder drainage.

Objectives: To summarize the social, economic, emotional, and psychological consequences incurred by women with obstetric fistula; present the results of a meta-analysis for 2 major consequences, divorce/separation and perinatal loss; and report on improvements in health and self-esteem and on the possibility of social reintegration following successful fistula repair., Methods: We conducted a review of the literature published between 1985 and 2005 on fistula in developing countries. We then performed a meta-analysis for 2 of the major consequences of having a fistula, divorce/separation and perinatal child loss., Results: Studies suggest that surgical treatment usually closes the fistula and improves the physical and mental health of affected women., Conclusion: With additional social support and counseling, women may be able to successfully reintegrate socially following fistula repair.

The objectives of this study were to evaluate the effect of stillbirth on survival and reproductive performance of lactating dairy cows. Data were collected from 2 different regions of the US calving-ease scores (CES) were recorded by farm personnel on a scale of 1 (no problem) to 5 (extreme difficulty). Stillbirths were recorded by farm personnel. The final analysis included 13,608 calvings of which 93.4% were live calves and 6.6% stillbirths. An increasing or decreasing trend in the incidence of stillbirth by parity and by CES was analyzed by Cochran-Armitage trend tests. A significant decreasing trend in the incidence of stillbirth by parity group was detected. The incidence of stillbirth increased as the CES increased. The incidence of stillbirths was 3.6, 11.2, 25.9, and 60.1% for CES score 1, 2, 3, and 4, respectively. Dam survival in the herd and reproductive performance were analyzed by the Cox proportional hazards model. Variables that decreased dam survival time were stillbirths, primiparity, and CES of 3 and 4. The variables that reduced reproductive performance were stillbirths, multiparity, male calves, and CES of 3 and 4. Cows that had stillbirths had significantly increased risk of culling/death throughout the lactation and increased median days open by 88 d compared with cows that had live calves. In conclusion, losses from stillbirths are far greater than just the value of the calf.

Objective: To evaluate whether the use of 17alpha-hydroxyprogesterone caproate for the prevention of recurrent preterm deliveries is cost-effective., Methods: Using decision-analysis modeling, we compared the cost-effectiveness of using 17alpha-hydroxyprogesterone caproate in four subgroups: 1) Prior preterm deliveries less than 32 weeks; 2) prior preterm deliveries 32-37 weeks; 3) prior term delivery; and 4) no prior delivery. Each subgroup was compared with a "no treatment" group. Costs included those for 17alpha-hydroxyprogesterone caproate, hospital admissions, and complications from preterm deliveries. The main outcome measures include cost per quality-adjusted life-year gained and the number of preterm deliveries prevented. Secondary outcomes include neonatal complications prevented. One-way and multiway sensitivity analyses were performed., Results: The use of 17alpha-hydroxyprogesterone caproate for the prevention of preterm deliveries result in cost-savings in women with prior preterm deliveries less than 32 weeks and 32-37 weeks. The sensitivity analyses revealed the model to be robust over a wide range of values for evaluated variables., Conclusion: Within our baseline assumptions, 17alpha-hydroxyprogesterone caproate was associated with cost-savings when used for the prevention of preterm deliveries in women with prior preterm deliveries.

The study was done throughout 2001 to find out the health care-seeking behavior & cost analysis generated from obstetric complications in rural Bangladesh. Total 350 women in postnatal period who had obstetric complications were interviewed from the study area of 150 km apart in the rural section of Bangladesh namely Dewangonj & Trishal Upazila. Majority of the respondents belonged to the age group 17-35 years & all the mothers had obstetric complications. Major obstetric complications were haemorrhage, prolonged labour, premature rupture of membrane, eclampsia, septic abortion, obstructed labour, prolonged labour etc. 74% had history of home delivery out of which 26% were reported to the hospital. Majority of them (74%) was reluctant to take the health utilization system. The major problem was financial burden, which seems to divert the major changing of health care seeking behavior.

Objectives: Most life threatening obstetric complications require hospital treatment to avert maternal mortality. Some assume that in developing countries hospital service for the poor must be in government hospitals and that a large proportion of deliveries needs to be in these hospitals to provide timely access to emergency care. This presents a major problem in countries like India, where almost all rural deliveries are at home and accessible government hospitals generally do not provide surgical treatment for obstetric emergencies. The study's objective was to determine obstetric outcomes, patterns and costs of obstetric care in a part of rural Maharashtra, India, where obstetric outcomes appear relatively good even though most deliveries are at home and government hospitals do not provide emergency obstetric care (EmOC)., Methods: 2905 pregnancies were identified and followed to term to learn the number and types of complications, where these complications were treated, how many women received EmOC and how these services affected outcome., Results: Eighty-five percent of 2861 deliveries after 24 weeks were at home. A total of 14.4% of deliveries after 24 weeks had identified complications. Of these complicated deliveries, 78.9% were in a hospital. Forty-eight percent of hospital deliveries were in a private hospital, 35% in our project hospital and 18% in a government hospital. Hospitalized patients with obstetric complications constituted 11.4% of all deliveries. The cesarean section rate for all deliveries was 2.0%. Twenty-two of the cesareans were in private hospitals, 32 in our hospital and four in a government hospital. Hospital case fatality (deaths of mothers with identified complications) was 0.3%. Overall case fatality was 0.5%. However, there were only two maternal deaths from obstetric causes (70 per 100,000 live births), making these rates less than robust. The perinatal mortality rate was 36 per thousand live and still births. These outcome and process indicators are better than those reported in most of India, but both maternal deaths could have been prevented by early referral to hospital and 64% of perinatal deaths were to infants delivered at home., Conclusions: A network of private clinics with a voluntary, low cost hospital is providing effective EmOC in a remote rural area at very low per capita cost in the absence of easily accessible government service and with only 15% of deliveries in hospitals. Charges are low but low per capita cost is primarily due to intelligent self-selection of patients who need hospital care. Even though overall cost is low, cost is still an important barrier for many poor families. Improving the purchasing power of poor families through insurance or subsidy could be a more effective way to improve EmOC than trying to improve inadequate government facilities.

Objective: To determine the most appropriate strategy to prevent neonatal streptococcal sepsis in a setting with a low incidence of the disease., Design: Decision analysis and economic evaluation., Setting: Geneva University Hospitals, Switzerland., Population: Pregnant women at 35-37 weeks of gestation and in labour., Methods: Local data and data from the literature were used in a decision analysis to compare the current policy of antibiotic administration at Geneva University Hospitals with the recommended preventive strategies., Main Outcome Measures: Number of episodes of sepsis averted; cost and number needed to treat to prevent one episode of sepsis; and proportion of women receiving antibiotics during labour., Results: Compared with the current policy, the risk factors strategy would prevent 69 streptococcal sepsis per million deliveries and the screening strategy would prevent 102 cases of sepsis per million deliveries. Cost per averted sepsis case would be 60 pounds, 700 and 473 pounds, 600, respectively. The number needed to treat to prevent one sepsis would be 1,087 with a risk factors strategy and 1,029 with a screening strategy. Preventive strategies would increase the proportion of women receiving antibiotics during labour from 6% with the current policy, to 13.5% and 16.5% respectively., Conclusions: Preventive strategies are more effective than the current policy, but imply increased hospital costs and a notable increase in the proportion of women receiving antibiotics during labour, which may be unjustified in a low incidence setting.

Objective: To determine the cost-effective method of delivery, from society's perspective, in patients who have had a previous cesarean., Methods: We completed an incremental cost-effectiveness analysis of a trial of labor relative to cesarean using a computerized model for a hypothetical 30-year old parturient. The model incorporated data from peer-reviewed studies, actual hospital costs, and utilities to quantify health-related quality of life. A threshold of $50,000 per quality-adjusted life-years was used to define cost-effective., Results: The model was most sensitive to the probability of successful vaginal delivery. If the probability of successful vaginal birth after cesarean (VBAC) was less than 0.65, elective repeat cesarean was both less costly and more effective than a trial of labor. Between 0.65 and 0.74, elective repeat cesarean was cost-effective (the cost-effectiveness ratio was less than $50,000 per quality-adjusted life-years), because, although it cost more than VBAC, it was offset by improved outcomes. Between 0.74 and 0.76, trial of labor was cost-effective. If the probability of successful vaginal delivery exceeded 0.76, trial of labor became less costly and more effective. Costs associated with a moderately morbid neonatal outcome, as well as the probabilities of infant morbidity occurring, heavily impacted our results., Conclusion: The cost-effectiveness of VBAC depends on the likelihood of successful trial of labor. Our modeling suggests that a trial of labor is cost-effective if the probability of successful vaginal delivery is greater than 0.74. Improved algorithms are needed to more precisely estimate the likelihood that a patient with a previous cesarean will have a successful vaginal delivery.

Objective: To carry out a systematic review of the literature relating to economic aspects of alternative modes of delivery., Methods: A comprehensive literature search of the years 1990-1999 was conducted of electronic and non-electronic sources using a tested search strategy. Papers considered to contain useful cost or resource use data were read in full and classified according to their relevance to the review and their methodological quality. Relevant cost and resource use data were converted to pound sterling and inflated to 1998-1999 price levels., Results: The literature search resulted in 975 papers, 49 of which met criteria for the review. Thirty-two papers were from the USA where the organisation, structure and costs of health care are significantly different from that of other industrialised countries. The aggregate costs of different modes of delivery reported in these American studies were between four and five times higher than costs reported in other studies. The majority of included studies were of poor quality. Data from the better quality studies demonstrated that caesarean section costs a health service substantially more than other modes of delivery. The range of costs of an uncomplicated vaginal delivery were 629 pound sterling - 1,298 pound sterling compared with1,238 pound sterling - 3,551 pound sterling for a caesarean section. However, papers have so far only considered short term health service costs., Conclusions: Research is required to estimate the cost and resource use attributable to alternative modes of delivery. Future research should investigate the long term health service costs and the costs that arise outside the health service which are likely to vary according to mode of delivery.

Objective: To assess risk factors and outcomes associated with nuchal cord at birth., Study Design: A population-based, case-control study was conducted using linked birth and hospitalization records. Three thousand newborns were randomly selected from all singleton births with nuchal cord as noted on the birth record (n = 5,426) in King County, Washington, 1992-1993. For comparison, 3,000 controls were randomly selected from the 46,952 unaffected singleton births., Results: An increased risk of nuchal cord was associated with induction of labor (odds ratio [OR] adjusted for maternal age and parity 2.0, 95% confidence interval [CI] 1.7-2.3), African American infant race (OR 1.3, 95% CI 1.0-1.6), primiparity (OR 1.2, 95% CI 1.0-1.5) and male sex (OR 1.2, 95% CI 1.0-1.3). After exclusion of selected obstetric complications, the risk of nuchal cord associated with induction of labor increased (OR 2.4, 95% CI 2.0-3.0). Nuchal cord was associated with increased risks of fetal distress (OR 2.7, 95% CI 2.1-3.4), meconium staining (OR 2.1, 95% CI 1.7-2.6), five-minute Apgar score < 7 (OR 1.6, 95% CI 1.1-2.4) and assisted ventilation < 30 minutes (OR 1.9, 95% CI 1.4-2.6). Although hospital charges for newborns with nuchal cord were slightly greater than for those without (P = .02), hospital lengths of stay did not differ significantly., Conclusion: Induction of labor was identified as an independent risk factor for nuchal cord. Certain adverse perinatal outcomes are increased in neonates with nuchal cord. However, neonates with nuchal cord do not have significantly longer neonatal hospital stays, and thus the adverse effects of nuchal cord may be transient.

Our aim was to analyze the financial costs of health care for women in labor transferred to primary referral maternity units in childbirth at risk. Another aim was to consider the willingness of women and their husbands to financially save and support the increasing costs of health care. For 15 consecutive days, medical students interviewed all women transferred for a risky delivery in 12 of the 17 primary referral maternity units in Burkina Faso. The median cost for transferring the women and their necessary health care was approximately 30,500 CFA. The median cost for the kit of surgical supplies was 15,000 CFA; the costs of medicine and transportation fare for the woman and her husband were 14,000 CFA and 9,800 CFA, respectively. The median cost for the health care of the newborn was 2,400 CFA. When the decision for the transfer was made, the necessary money to pay for the expenses was available for only 40 out of 79 women. Women and their husbands were willing to save for health care either through existing community institutions such as groups of villagers and popular savings developments (69 women and men); or through annuity schemes to be created (33 women and men); or through banks (4 women and men). Four women and 6 men refused to contribute because of previous experiences of poor management of collective funds. The average savings were low and insufficient to cover the expected expenses for the transfer and care of the women. The savings were reserved for payment of the transportation fare for the women and their husbands to the referral units (21 women and 20 men), prescriptions (9 women and 5 men), the medical consultation (1 woman), and to provide for both (37 women and 39 men). The costs of health care are expensive. The poverty of the couple facing an urgent problem of life or death made them discover new options for investing in their available community associations such as groups of villagers and popular savings developments and other options such as annuity schemes. A policy directed towards the involvement of these populations could facilitate the transfer and treatment of women during their pregnancy.

Objective: This article tests whether or not the factors that affect hospital choice differ for selected subgroups of the population., Data Sources: 1985 California Office of Statewide Health Planning and Development (OSHPD) discharge abstracts and hospital financial data were used., Study Design: Models for hospital choice were estimated using McFadden's conditional logit model. Separate models were estimated for high-risk and low-risk patients, and for high-risk and low-risk women covered either by private insurance or by California Medicaid. The model included independent variables to control for quality, price, ownership, and distance to the hospital., Data Extraction: Data covered all maternal deliveries in the San Francisco Bay Area in 1985 (N = 61,436). ICD-9 codes were used to classify patients as high-risk or low-risk. The expected payment code on the discharge abstract was used to identify insurance status., Principal Findings: The results strongly reject the hypothesis that high-risk and low-risk women have the same choice process. Hospital quality tended to be more important for high-risk than low-risk women. These results also reject the hypothesis that factors influencing choice of hospital are the same for women covered by private insurance as for those covered by Medicaid. Further, high-risk women covered by Medicaid were less likely than high-risk women covered by private insurance to deliver in hospitals with newborn intensive care units., Conclusions: The results show that the choice factors vary across several broadly defined subgroups of patients with a specific condition. Thus, estimates aggregating all patients may be misleading. Specifically, such estimates will understate actual patient response to quality of care indicators, since patient sensitivity to quality of care varies with the patients' risk status.

The Patient Insurance (PI) scheme in Sweden was instituted on 1 January 1975. From the PI it is possible for a patient to obtain acknowledgement of an injury sustained in connection with medical treatment or operation--and receive financial compensation therefore--without having to prove that the injury was the result of fault or neglect. Special conditions of undertaking are laid down for the guidance of PI assessors which, if fulfilled, will entitle the patient to indemnity from the respective county council (via the PI) for injury sustained in connection with medical care received from county institutions or staff. As the Swedish PI scheme was the first of its kind in the world, an evaluation of its application during the first 5 years seemed justified. The present work constitutes the obstetrical-gynaecological part of that project. The objectives of the study were: to analyse and group according to injury all claims concerning obstetrical or gynaecological intervention submitted to the PI during 1975-79; to evaluate available literature on such injuries in relation to the present findings; to make recommendations for changes in the treatment routines of frequently occurring or serious injuries; and to study the working procedures of the PI, especially regarding its assessment of patient claims. Chapter I sets out the historical background of the PI. The extent of a patient's right to indemnity from the PI is discussed, covering the conditions of undertaking that must be fulfilled on the patient's part, and the PI's obligations. The Patient Injuries Committee is presented, to which injured parties can appeal against decisions of the PI. Chapters II--X. During the period studied, altogether 275 claims concerning obstetrical and gynaecological treatment were submitted to the PI, i.e. 2.5% of all claims received by the PI during that period. Most of the injuries resulted from surgical intervention. The claims have been grouped into six gynaecological and three obstetrical chapters. The reporting frequency to the PI was low during this period and therefore no statistical information can be derived from the analysis. A review of the current literature revealed a similar pattern of severe complications as that found among claims to the PI. In one respect, however, the present study is unique, since complications resulting from certain types of intervention, though performed under so varying circumstances, have never before been compiled and evaluated. The reported injuries were fairly evenly distributed among the 26 counties and the three different sizes of hospital.(ABSTRACT TRUNCATED AT 400 WORDS)