Patel Archana B, Prakash Amber Abhijeet, Raynes-Greenow Camille, Pusdekar Yamini V, Hibberd Patricia L
Lata Medical Research Foundation, Nagpur, India.
Sydney School of Public Health, Sydney Medical School, The University of Sydney, Camperdown, New South Wales, Australia.
BMC Health Serv Res. 2017 May 19;17(1):360. doi: 10.1186/s12913-017-2302-4.
In 2008, the Indian government introduced financial assistance to encourage health facility deliveries. Facility births have increased, but maternal and neonatal morbidity and mortality have not decreased raising questions about the quality of care provided in facilities and access to a quality referral system. We evaluated the potential role of inter-institutional transfers of women admitted for labor and delivery on adverse maternal and neonatal outcomes in an ongoing prospective, population-based Maternal and Newborn Health Registry in Central India.
Pregnant women from 20 rural Primary Health Centers near Nagpur, Maharashtra were followed throughout pregnancy and to day 42 post-partum. Inter- institutional referral was defined as transfer of a woman from a first or second level facility where she was admitted for labor and delivery to facility providing higher level of care, after admission to the day of delivery. Maternal mortality, stillbirth, early and late neonatal mortality were compared in mothers who were and were not referred. Factors associated with inter-institutional referral were analyzed using multivariable models with generalized estimating equations, adjusted for clustering at the level of the Primary Health Center.
Between June 2009 and June 2013, 3236 (9.4%) of 34,319 women had inter-institutional referral. Factors associated with referrals were maternal age (adjusted Relative Risk or aRR 1.1; 1.0-1.2); moderate or severe anemia (aRR 1.2; 1.2-1.4), gestational age <37 weeks (aRR 1.16; 1.05-1.27), multiple gestation (aRR 1.6; 1.2-2.1), absent fetal heart rate (aRR 1.7; 1.3-2.2), primigravida (aRR 1.4; 1.3, 1.6), primigravida with any pregnancy related maternal condition such as obstructed or prolonged labor; major antepartum or post-partum hemorrhage, hypertension or preeclampsia and breech, transverse or oblique lie (aRR 4.7; 3.8, 5.8), multigravida with any pregnancy related conditions (aRR 4.2; 3.4-5.2). Stillbirths, early neonatal,late neonatal and early infant deaths occurred in 7.3% referred mothers vs. 3.7% of not referred.
Almost 10% of the women had an inter-institutional referral and still birth or neonatal deaths were doubled in referred women. Conditions associated with referral were often known before onset of labor and delivery. Improvements in maternal and neonatal outcomes will likely require pregnant women with conditions associated with referral to be directly admitted at facilities equipped to care for complicated pregnancies and at risk neonates, as well as prompt detection and transfer those who develop "at risk" conditions during labor and delivery.
ClinicalTrials.gov NCT01073475 .
2008年，印度政府推出财政援助以鼓励在医疗机构分娩。医疗机构分娩的比例有所增加，但孕产妇和新生儿的发病率及死亡率并未下降，这引发了对医疗机构提供的护理质量以及是否有优质转诊系统的质疑。我们在印度中部一项正在进行的基于人群的前瞻性孕产妇和新生儿健康登记研究中，评估了因分娩入院的妇女机构间转诊对不良孕产妇和新生儿结局的潜在作用。
对来自马哈拉施特拉邦那格浦尔附近20个农村初级卫生中心的孕妇进行全程孕期跟踪，直至产后42天。机构间转诊定义为妇女在分娩入院后，从一级或二级医疗机构转至提供更高水平护理的机构直至分娩。比较了转诊和未转诊母亲的孕产妇死亡率、死产率、早期和晚期新生儿死亡率。使用广义估计方程的多变量模型分析与机构间转诊相关的因素，并对初级卫生中心层面的聚类进行了调整。
2009年6月至2013年6月期间，34319名妇女中有3236名（9.4%）进行了机构间转诊。与转诊相关的因素包括产妇年龄（调整后相对风险或aRR为1.1；1.0 - 1.2）；中度或重度贫血（aRR为1.2；1.2 - 1.4），孕周<37周（aRR为1.16；1.05 - 1.27），多胎妊娠（aRR为1.6；1.2 - 2.1），无胎心（aRR为1.7；1.3 - 2.2），初产妇（aRR为1.4；1.3，1.6），患有任何与妊娠相关的孕产妇疾病如产程梗阻或延长、产前或产后大出血、高血压或先兆子痫以及臀位、横位或斜位的初产妇（aRR为4.7；3.8，5.8），患有任何与妊娠相关疾病的经产妇（aRR为4.2；3.4 - 5.2）。转诊母亲的死产、早期新生儿、晚期新生儿和早期婴儿死亡发生率为7.3%，未转诊母亲为3.7%。
近10%的妇女进行了机构间转诊，转诊妇女的死产或新生儿死亡增加了一倍。与转诊相关的情况在分娩开始前往往是已知的。要改善孕产妇和新生儿结局，可能需要将患有与转诊相关疾病的孕妇直接收治到有能力护理复杂妊娠和高危新生儿的机构，并在分娩期间及时发现并转诊那些出现“高危”情况的孕妇。
ClinicalTrials.gov NCT01073475 。
