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A comparison of relevant statistics from National Maternity Hospital, Dublin, Ireland and University Hospital, Newark, New Jersey, USA, for the years 1983-1989, revealed that after removal of major confounding factors, such as a fourfold difference in < 2500 gram births and an about tenfold discrepancy in the frequency of lethal congenital defects, the perinatal survival rates in all weight categories were significantly higher in the American center. The findings suggest that optimum perinatal results could not be achieved in an American high risk center with the approximately 6% abdominal delivery rate favored in Dublin. The same data also suggest, however, that the 17.5% rate of abdominal deliveries in Newark was unnecessarily high. The favorable impact of the relatively liberal use of cesarean section might have been derived in this study from a marked reduction of in utero losses, in the absence of an identifiable effect upon the rate of neonatal mortality.

Based on their yearly clinical statistics for 1983-1989, the cesarean section and stillbirth rates at National Maternity Hospital (Dublin), where the patients are generally white, and University Hospital (Newark), where the patients are predominantly black, were compared. After adjusting for confounding factors, such as unregistered mothers admitted subsequent to fetal demise, differing rates of < 2500 g births and lethal congenital defects, the overall rates of intrauterine fetal demise were identical. When analyzed according to birth weights, in all weight groups, the stillbirth rates were significantly lower in Newark than in Dublin. However, for every 1000 births, more < or = 2500 g fetuses died in utero in Newark than in Dublin. This trend was reversed in the > 2500 g group, where the respective rate at National Maternity Hospital exceeded that of University Hospital more than twice. The latter result largely derived from an almost 7-fold higher rate of intrapartum deaths in the > 2500 g weight group at National Maternity Hospital as compared to University Hospital. When projected against prevailing American statistics, which reflect a stillbirth rate about twice as high among blacks than among whites, the results suggest that the management patterns favored in Newark, including a relatively liberal cesarean section rate (17.5% versus 5.8%), affected the rate of in utero losses favorably.

In the Perinatal Unit of the New Jersey Medical School, Newark the combined neonatal mortality and stillbirth rates declined from more than 51 per 1000 to less than 17 per 1000 between 1971 and 1983. This change is comparable to the reduction of perinatal mortality rates nationwide since the Second World War. Because the improvement in the fetal and neonatal survival rates occurred in a static population and against well identifiable changes in the structure, equipment, policies and management patterns of the obstetric unit, it was possible to assess the impact of various factors upon perinatal outcome. In the environment of this institution adherence to conservative concepts of obstetric management, avoidance of manipulative and extraction procedures, an increase of the rate of cesarean sections from about 7 to 15% and emphasis upon infection control appeared to be the crucially important factors. Antepartum sonography and fetal stress and non-stress testing significantly impacted upon the results. The role of intrapartum electronic monitoring was less clearly definable and seemed to be effective only in the hands of experienced physicians. The results did not seem to be adversely affected by the fact that the program de-emphasized invasive procedures, including fetal scalp pH sampling.