Samuelson Julia L, Buehler James W, Norris Dianne, Sadek Ramses
Georgia Department of Human Resources, Division of Public Health, Atlanta, GA 30303-3186, USA.
Paediatr Perinat Epidemiol. 2002 Oct;16(4):305-13. doi: 10.1046/j.1365-3016.2002.00450.x.
To determine whether the Healthy People 2000 objective to deliver very-low-birthweight (VLBW) infants at subspecialty perinatal care centres was met, and if improvements in the regional perinatal care system could reduce neonatal mortality further for 2010, we examined place of delivery for VLBW infants, associated maternal characteristics and the potential impact on neonatal mortality. We used linked birth and death records for the 1994-96 Georgia VLBW (i.e. 500-1499 g) birth cohorts. Among 4770 VLBW infants, 77% were delivered at hospitals providing subspecialty perinatal care. The strongest predictor of birth hospital level was the mother's county of residence, defined using three levels: residence in a county with a subspecialty hospital, residence in a county adjacent to one with such a hospital or residence in a non-adjacent county. Eighty-nine per cent of infants born to women who resided in counties with subspecialty care hospitals delivered at such hospitals, compared with 53% of infants born to women who resided in a non-adjacent county. Women were also more likely to deliver outside subspecialty care if they had less than adequate prenatal care [adjusted odds ratio (AOR) 1.5, P-value = 0.0001]. The neonatal mortality rate varied by level of perinatal care at the birth hospital from 132.1/1000 to 283/1000 live births, with the highest death rate for infants born at hospitals offering the lowest level of care. Assuming that the differences in mortality were due to care level of the birth hospital, potentially 16-23% of neonatal deaths among VLBW infants could have been prevented if 90% of infants born outside subspecialty care were delivered at the recommended level. These findings suggest that a state's support of strong, collaborative, regional perinatal care networks is required to ensure that high-risk women and infants receive optimal health care. Improved access to recommended care levels should further reduce neonatal mortality until interventions are identified to prevent VLBW births.
为了确定是否实现了《健康人民2000》中关于在围产期专科护理中心分娩极低出生体重（VLBW）婴儿的目标，以及区域围产期护理系统的改善是否能够在2010年进一步降低新生儿死亡率，我们研究了VLBW婴儿的分娩地点、相关的母亲特征以及对新生儿死亡率的潜在影响。我们使用了1994 - 1996年佐治亚州VLBW（即500 - 1499克）出生队列的出生与死亡记录关联数据。在4770名VLBW婴儿中，77%在提供围产期专科护理的医院分娩。出生医院水平的最强预测因素是母亲的居住县，分为三个级别：居住在有专科护理医院的县、居住在与有此类医院的县相邻的县或居住在不相邻的县。居住在有专科护理医院的县的妇女所生婴儿中，89%在这类医院分娩，而居住在不相邻县的妇女所生婴儿中这一比例为53%。如果产前护理不足，妇女也更有可能在专科护理之外的地方分娩[调整优势比（AOR）1.5，P值 = 0.0001]。出生医院的围产期护理水平不同，新生儿死亡率也不同，从每1000例活产132.1例到283例不等，在提供护理水平最低的医院出生的婴儿死亡率最高。假设死亡率差异是由于出生医院的护理水平造成的，如果90%在专科护理之外出生的婴儿在推荐水平的医院分娩，那么VLBW婴儿中潜在的16% - 23%的新生儿死亡可能会被避免。这些发现表明，一个州需要支持强大、协作的区域围产期护理网络，以确保高危妇女和婴儿获得最佳医疗保健。在确定预防VLBW出生的干预措施之前，改善获得推荐护理水平的机会应能进一步降低新生儿死亡率。
