Kim Shin Y, Bailey Marie A, Richardson Jaylan, McFarland Cheryl A S, Sappenfield William M, Luke Sabrina, Sharma Andrea J
National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy, NE MS K-23, Atlanta, GA, 30341, USA.
Florida Department of Health, Tallahassee, FL, USA.
Matern Child Health J. 2019 Feb;23(2):148-154. doi: 10.1007/s10995-018-2604-0.
Objective Examine agreement with the medical record (MR) when gestational weight loss (GWL) on the Florida birth certificate (BC) is ≥ 0 pounds (lbs). Methods In 2012, 3923 Florida-resident women had a live, singleton birth where BC indicated GWL ≥ 0 lbs. Of these, we selected a stratified random sample of 2141 and abstracted from the MR prepregnancy and delivery weight data used to compute four estimates of GWL (delivery minus prepregnancy weight) from different sources found within the MR (first prenatal visit record, nursing admission record, labor/delivery records, BC worksheet). We assessed agreement between the BC and MR estimates for GWL categorized as 0, 1-10, 11-19, and ≥ 20 lbs. Results Prepregnancy or delivery weight was missing or source not in the MR for 23-81% of records. Overall agreement on GWL between the BC and the four MR estimates ranged from 39.1 to 57.2%. Agreement by GWL category ranged from 10.6 to 38.0% for 0 lbs, 47.6 to 64.3% for 1-10 lbs, 49.5 to 60.0% for 11-19 lbs, and 47.8 to 67.7% for ≥ 20 lbs. Conclusions Prepregnancy and delivery weight were frequently missing from the MR or inconsistently documented across the different sources. When the BC indicated GWL ≥ 0 lbs, agreement with different sources of the MR was moderate to poor revealing the need to reduce missing data and better understand the quality of weight data in the MR.
当佛罗里达州出生证明（BC）上的孕期体重减轻（GWL）≥0磅（lbs）时，检查其与病历（MR）的一致性。方法：2012年，3923名佛罗里达州常住妇女进行了单胎活产，出生证明显示GWL≥0 lbs。其中，我们选取了2141名妇女的分层随机样本，并从病历中提取了孕前和分娩体重数据，用于计算病历中不同来源（首次产前检查记录、护理入院记录、分娩记录、出生证明工作表）的GWL的四个估计值（分娩体重减去孕前体重）。我们评估了出生证明和病历中GWL估计值在0、1 - 10、11 - 19和≥20 lbs分类下的一致性。结果：23% - 81%的记录中孕前或分娩体重缺失或病历中无相关来源。出生证明与病历的四个GWL估计值的总体一致性在39.1%至57.2%之间。按GWL分类的一致性在0 lbs时为10.6%至38.0%，1 - 10 lbs时为47.6%至64.3%，11 - 19 lbs时为49.5%至60.0%，≥20 lbs时为47.8%至67.7%。结论：病历中经常缺少孕前和分娩体重数据，或者不同来源的记录不一致。当出生证明显示GWL≥0 lbs时，与病历不同来源的一致性为中等至较差，这表明需要减少缺失数据，并更好地了解病历中体重数据的质量。
