Adverse outcomes of (post-)term births and differences in professional organisational contexts: an integral descriptive system approach

OBJECTIVE: The development and application of an integral descriptive model for monitoring and evaluation of patient flows and adverse outcomes of childbirth related to distinct categories of professional organisational contexts. SETTING: After categorisation of the individual professional contexts in which deliveries take place, the resulting framework has been superimposed on the 2002–2010 database of the Netherlands Perinatal Registry. PARTICIPANTS: All Dutch hospitals and almost all first-line midwife practices recorded 1 469 955 (post-)term births from which only the patients with a spontaneous onset of labour (n=1 120 508) were included in a study on the quality of obstetric care outside office hours. MAIN OUTCOME MEASURES: For the performance of professional organisational contexts the difference in relative incidence of perinatal death or Apgar score <7 between the related patient groups and the reference patient groups has been used. These differences have been expressed as risk ratio (RR) with a 95% CI. RESULTS: Only the group of patients who started labour spontaneously under the supervision of the first-line midwife shows a proportional distribution over the parts of the day. In all other groups the distribution of patients is disproportional. The perinatal mortality rate declines by about 30% in the successive periods. This decline concerns mainly those patients who gave birth outside office hours. CONCLUSIONS: The complexity and the dynamics of the obstetric care system make it virtually impossible to demonstrate fixed patterns in the relationships between the separate contextual factors and the (adverse) outcomes of births. To generate useful knowledge, it is necessary to evaluate changes in the obstetric care system periodically and systematically. Thus, the longitudinal application of the model demonstrated that the differences in perinatal mortality rate between the parts of the day have disappeared in recent years.