Bradford Heather M, Cárdenas Vicky, Camacho-Carr Katherine, Lydon-Rochelle Mona T
Department of Family and Child Nursing, School of Nursing, University of Washington, Box 357262, Seattle, WA 98195-7262, USA.
Matern Child Health J. 2007 Nov;11(6):540-8. doi: 10.1007/s10995-007-0178-3. Epub 2007 Feb 6.
Birth certificate and hospital discharge data are relied upon heavily for national surveillance and research on maternal health. Despite the great importance of these data sources, the recording accuracy in these datasets, comparing birth attendant type, has not been evaluated. The study objective was to assess the variation in chart documentation accuracy between certified nurse-midwives (CNMs) and physicians (MDs) for selected maternal variables using birth certificate and hospital discharge data.
Data was obtained on women delivering in 10 Washington State hospitals that had both CNM and MD-attended births in 2000 (n = 2699). Using the hospital medical record as the gold standard of accuracy, the true positive rate (TPR) for selected maternal medical conditions, pregnancy complications, and intrapartum and postpartum events was calculated for CNMs and MDs using birth certificate data, hospital discharge data, and both data sources combined.
The magnitude of TPRs for most recorded maternal medical conditions, pregnancy complications, and intrapatum and postpartum events was higher for CNMs than for MDs. TPRs were significantly higher in birth certificate records for pregnancy-induced hypertension, premature rupture of membranes, labor augmentation, induction of labor, and vaginal birth after cesarean (VBAC) for CNM-attended births relative to MDs. Among combined data sources, CNM TPRs were significantly higher for pregnancy-induced hypertension and premature rupture of membranes.
CNMs had consistently higher accuracy of recorded maternal medical conditions, pregnancy complications, and intrapartum and postpartum events when compared to MDs for all data sources, with several being statistically significant. Our findings highlight discrepancies between CNM and MD hospital chart documentation, and suggest that epidemiologic researchers consider the issue of measurement error and birth attendant type.
出生证明和医院出院数据在国家孕产妇健康监测和研究中被大量依赖。尽管这些数据源非常重要,但在这些数据集中,关于接生人员类型的记录准确性尚未得到评估。本研究的目的是使用出生证明和医院出院数据,评估认证护士助产士(CNM)和医生(MD)在选定孕产妇变量的图表记录准确性方面的差异。
获取了2000年在华盛顿州10家医院分娩的妇女的数据,这些医院既有CNM接生的分娩,也有MD接生的分娩(n = 2699)。以医院病历作为准确性的金标准,使用出生证明数据、医院出院数据以及两者结合的数据,计算了CNM和MD在选定孕产妇疾病、妊娠并发症以及分娩期和产后事件方面的真阳性率(TPR)。
对于大多数记录的孕产妇疾病、妊娠并发症以及分娩期和产后事件,CNM的TPR幅度高于MD。在出生证明记录中,与MD接生的分娩相比,CNM接生的分娩在妊娠高血压、胎膜早破、引产、剖宫产术后阴道分娩(VBAC)方面的TPR显著更高。在综合数据源中,CNM在妊娠高血压和胎膜早破方面的TPR显著更高。
与MD相比,在所有数据源中,CNM在记录孕产妇疾病、妊娠并发症以及分娩期和产后事件方面的准确性始终更高,其中有几项具有统计学意义。我们的研究结果突出了CNM和MD医院图表记录之间的差异,并建议流行病学研究人员考虑测量误差和接生人员类型的问题。