Asia-Oceania J. Obstet. Gynaecol. Vol. 18, No. 2; 139-145 1992
The Israel Perinatal Census
Shlomo Mor-Yosef, Arnon Samueloff, and Joseph G. Schenker Department of Obstetrics and Gynecolom, Hadassah University Hospital, Jerusalem, Israel
Abstract A nation-wide perinatal census which included 22,815 deliveries was carried out. The cesarean section rate was 9.6% and the perinatal mortality rate was 13.5/1000. Using a logistic regression analysis the risk factors for cesarean section and for perinatal mortality were ranked. Breech presentation and one uterine scar were found to be the most important risk factors for cesarean section and breech presentation, maternal disease and multiple pregnancy for perinatal mortality. Low birth weight rate was 6.9% with nonsignificant differences between the various ethnic groups. The national cesarean section rate in breech presentation was 57.8%. It was performed mainly at the extremes of birth weight. From those with one previous cesarean section 55.1% delivered vaginally and 44.9% abdominally. The chance for vaginal delivery is higher (67.2%) providing the woman had delivered vaginally in the past. Comparison between primiparae and multiparae showed that preeclampsia, hypertension and diabetes mellitus were all significantly more frequent among older parturients and among primiparae. Key words: perinatal census, perinatal mortality, cesarean section, grandmultiparae, uterine scar
Introduction Perinatal mortality is one of the important parameters which is used to assess the quality of the health services. The perinatal mortality is the end result of the social and medical services that are given to the pregnant woman from conception until she leaves the hospital with her offspring. I n order to assess the medical care of the pregnant woman in Israel during pregnancy and delivery, a nationwide census was conducted. The results of this census have been
published in part during the last year in the medical 1iterature.l-lO) In this report we would like to present the obstetrics services in Israel and the complete results of this census which has tried to deal with the main controversial issues in perinatology.
Materials and Methods The maternity facilities in Israel serve about
4.1 million inhabitants, composed partly of immigrants coming from diverse social, cul-
Received: Aug. 6, 1991 Reprint request to: Dr. S. Mor-Yosef, Department of Obstetrics and Gynecology, Hadassah University Hospital, P.O.B. 12000, Jerusalem, Israel 91 120
139
S. MOR-YOSEF
ET AL.
tural and geographical background and partly of Israeli born, including the Arab population. The fertility rate is 3.13, a relatively high rate for a developed nation. Moslem mothers enjoy an extremely high fertility rate of 5.14, compared to only 2.84 for Jewish mothers. Medical Service in Israel Medical insurance is widely available in Israel as almost all (95%) of the population over 20 years of age, is insured in one of the nation’s sick funds.ll) Most pregnant women receive prenatal care at one of the Mother and Child Health Centers (MCHC). The MCHC were established for the purpose of providing care for babies and children, prenatal and antenatal care, etc. At present, 932 MCHC’s are in operation. Eighty-eight percent of the total pregnant women visited at least once the MCHC.ll) The estimated average number of visits of a pregnant woman to the centers from the second trimester onward is 8.411) and the average period of supervision of the pregnant woman 7.9 months.18) The rates of pregnant women going for prenatal care to MCHC does not include women receiving prenatal care either privately or by the clinic and sick fund physicians. Thus almost all women receive some degree of prenatal care. There are approximately 100,000 births per year in Israel, of which 99.7% take place in hospital.12) There are 27 hospitals which are divided into four main types, according to number of beds, types of wards and academic status, as follows: medical teaching center, general, peripheral, and community maternity hospitals. Cost of delivery is covered by the Government. The National Insurance Fund pays per delivery and not by mode of delivery. The MCHC are free of charge. A delivery bonus of $200 is given to every parturiant delivered in a hospital. The husband can remain in the delivery suite in all hospitals. “Rooming in” of mother and baby is practiced in only 20% of maternity wards. Electronic fetal monitoring is practiced in most births and all types of analgesia and anesthesia are used. There are 205 registered obstetricians, 401 registered 140
Table 1. National data for five most recent vears Population
4,100,000 ~~
No, of birth 460,857 No. of forcept birth 6,546(1.57%) 14,688 (3.54%) No. of vacuum extraction 39,971 (9%) No. of cesarean section 205 No. of registered obstetricians No. of registered midwives 401 No. of maternity beds 1,081
midwives and 1,081 maternity beds. Survey Methods1) The data were collected from a questionnaire which was sent to all the maternity departments in the country to obtain the basic information for five most recent years about number of deliveries, percentage of intervention, number of obstetricians, midwives and maternity beds and this information is presented in Table 1. During a period of 3 months the records of all births in Israel were prospectively examined. The survey covered a total of 30 obstetric wards in 27 hospitals. The questionnaires were completed by six obstetricians and senior medical students from the Hadassah Medical Center in Ein Karem, Jerusalem. The information was obtained independently from four sources: I. Delivery room chart book, 11. Maternal hospital records, III. Newborn’s hospital records, and IV. MCHC prenatal card. I n order to control for the completeness of the data, returns could be checked against the official notification of births and deaths. The scope of inquiry was wide. The questionnaire included 461 different variables, and was made up of 7 main sections: a. Demographic details of the mother b. Details of past obstetric history c. Prenatal care and abnormalities during present pregnancy d. Length and abnormalities of labor e. Details on cesarean section, when performed f. Management and outcome of the newborn g. Postpartum complications. The data was transferred from the question-
A NATION-WIDE PERINATAL CENSUS
naires to a DIG/VAX 830 computer, and processed and analyzed using the Statistical Package for the Social Sciences (SPSSX).13) Statistical evaluation carried out by means of the multivariate stepwise logistic regression analysis using the SPSSX and the BMDP statistical packages,14) the chi-square test of independence, the Mantel Haenszel procedure, the odds ratio heterogeneity test, and the Fisher’s exact test.
Results Cesarean Sectionz) There were 22,815 births in the country during that 3 month period of the census. Ninety point four percent of the deliveries were completed vaginally and 9.6% by cesarean section. Of the 20,636 vaginal deliveries, 1.7% were by forceps and 4.2% by vacuum extraction.@) Twenty percent of the cesarean sections were performed on an elective basis and 80% as an “emergency” procedure. The indications for the operation in the latter group are pesented in Table 2. The foremost indications were breech presentation fetal distress and dystocia. Using the multivariate stepwise logistic regression analysis the risk factors for cesarean section were ranked and are presented in Table 3. Breech presentation, uterine scar followed in descending order by placenta previa or abruptio placentae maternal disease, primiparity, low birth weight twins and advanced maternal age were found to be the important risk factors.
Table 2. The indications for emergency cesarean section* Indication
Emergency cesarean section (%)
Breech presentation Fetal distress No progress of labor Uterine scar x 1 Maternal disease Fetal weight Bleeding Infertility Multiple pregnancies
30.4 27.1 27.0 18.3 10.0
8.4 8.0 4.4 4.0
* In some of the women, there were two or more indications. Vaginal Delivery after Previous Cesarean Sections) The 1,080 women in the survey had one previous cesarean birth. This group was compared to 14,703 women with previous vaginal birth. Statistical evaluation was carried out by the chi-square test and the odds ratios heterogeneity test. From those with one previous cesarean section 55.1% delivered vaginally and 44.9 abdominally. The indication for a repeated cesarean section were: a previous cesarean section (28.7%) and ma1 presentation (12.8%). There were no differences in post delivery hospitalization days whether the woman had a previous cesarean section or not. Uterine rupture was followed in 1.2% (13 cases) of post cesarean women giving vaginal birth and in only 0.03% (4 cases) among those without a previous cesarean section (P
The Israel Perinatal Census
Shlomo Mor-Yosef, Arnon Samueloff, and Joseph G. Schenker Department of Obstetrics and Gynecolom, Hadassah University Hospital, Jerusalem, Israel
Abstract A nation-wide perinatal census which included 22,815 deliveries was carried out. The cesarean section rate was 9.6% and the perinatal mortality rate was 13.5/1000. Using a logistic regression analysis the risk factors for cesarean section and for perinatal mortality were ranked. Breech presentation and one uterine scar were found to be the most important risk factors for cesarean section and breech presentation, maternal disease and multiple pregnancy for perinatal mortality. Low birth weight rate was 6.9% with nonsignificant differences between the various ethnic groups. The national cesarean section rate in breech presentation was 57.8%. It was performed mainly at the extremes of birth weight. From those with one previous cesarean section 55.1% delivered vaginally and 44.9% abdominally. The chance for vaginal delivery is higher (67.2%) providing the woman had delivered vaginally in the past. Comparison between primiparae and multiparae showed that preeclampsia, hypertension and diabetes mellitus were all significantly more frequent among older parturients and among primiparae. Key words: perinatal census, perinatal mortality, cesarean section, grandmultiparae, uterine scar
Introduction Perinatal mortality is one of the important parameters which is used to assess the quality of the health services. The perinatal mortality is the end result of the social and medical services that are given to the pregnant woman from conception until she leaves the hospital with her offspring. I n order to assess the medical care of the pregnant woman in Israel during pregnancy and delivery, a nationwide census was conducted. The results of this census have been
published in part during the last year in the medical 1iterature.l-lO) In this report we would like to present the obstetrics services in Israel and the complete results of this census which has tried to deal with the main controversial issues in perinatology.
Materials and Methods The maternity facilities in Israel serve about
4.1 million inhabitants, composed partly of immigrants coming from diverse social, cul-
Received: Aug. 6, 1991 Reprint request to: Dr. S. Mor-Yosef, Department of Obstetrics and Gynecology, Hadassah University Hospital, P.O.B. 12000, Jerusalem, Israel 91 120
139
S. MOR-YOSEF
ET AL.
tural and geographical background and partly of Israeli born, including the Arab population. The fertility rate is 3.13, a relatively high rate for a developed nation. Moslem mothers enjoy an extremely high fertility rate of 5.14, compared to only 2.84 for Jewish mothers. Medical Service in Israel Medical insurance is widely available in Israel as almost all (95%) of the population over 20 years of age, is insured in one of the nation’s sick funds.ll) Most pregnant women receive prenatal care at one of the Mother and Child Health Centers (MCHC). The MCHC were established for the purpose of providing care for babies and children, prenatal and antenatal care, etc. At present, 932 MCHC’s are in operation. Eighty-eight percent of the total pregnant women visited at least once the MCHC.ll) The estimated average number of visits of a pregnant woman to the centers from the second trimester onward is 8.411) and the average period of supervision of the pregnant woman 7.9 months.18) The rates of pregnant women going for prenatal care to MCHC does not include women receiving prenatal care either privately or by the clinic and sick fund physicians. Thus almost all women receive some degree of prenatal care. There are approximately 100,000 births per year in Israel, of which 99.7% take place in hospital.12) There are 27 hospitals which are divided into four main types, according to number of beds, types of wards and academic status, as follows: medical teaching center, general, peripheral, and community maternity hospitals. Cost of delivery is covered by the Government. The National Insurance Fund pays per delivery and not by mode of delivery. The MCHC are free of charge. A delivery bonus of $200 is given to every parturiant delivered in a hospital. The husband can remain in the delivery suite in all hospitals. “Rooming in” of mother and baby is practiced in only 20% of maternity wards. Electronic fetal monitoring is practiced in most births and all types of analgesia and anesthesia are used. There are 205 registered obstetricians, 401 registered 140
Table 1. National data for five most recent vears Population
4,100,000 ~~
No, of birth 460,857 No. of forcept birth 6,546(1.57%) 14,688 (3.54%) No. of vacuum extraction 39,971 (9%) No. of cesarean section 205 No. of registered obstetricians No. of registered midwives 401 No. of maternity beds 1,081
midwives and 1,081 maternity beds. Survey Methods1) The data were collected from a questionnaire which was sent to all the maternity departments in the country to obtain the basic information for five most recent years about number of deliveries, percentage of intervention, number of obstetricians, midwives and maternity beds and this information is presented in Table 1. During a period of 3 months the records of all births in Israel were prospectively examined. The survey covered a total of 30 obstetric wards in 27 hospitals. The questionnaires were completed by six obstetricians and senior medical students from the Hadassah Medical Center in Ein Karem, Jerusalem. The information was obtained independently from four sources: I. Delivery room chart book, 11. Maternal hospital records, III. Newborn’s hospital records, and IV. MCHC prenatal card. I n order to control for the completeness of the data, returns could be checked against the official notification of births and deaths. The scope of inquiry was wide. The questionnaire included 461 different variables, and was made up of 7 main sections: a. Demographic details of the mother b. Details of past obstetric history c. Prenatal care and abnormalities during present pregnancy d. Length and abnormalities of labor e. Details on cesarean section, when performed f. Management and outcome of the newborn g. Postpartum complications. The data was transferred from the question-
A NATION-WIDE PERINATAL CENSUS
naires to a DIG/VAX 830 computer, and processed and analyzed using the Statistical Package for the Social Sciences (SPSSX).13) Statistical evaluation carried out by means of the multivariate stepwise logistic regression analysis using the SPSSX and the BMDP statistical packages,14) the chi-square test of independence, the Mantel Haenszel procedure, the odds ratio heterogeneity test, and the Fisher’s exact test.
Results Cesarean Sectionz) There were 22,815 births in the country during that 3 month period of the census. Ninety point four percent of the deliveries were completed vaginally and 9.6% by cesarean section. Of the 20,636 vaginal deliveries, 1.7% were by forceps and 4.2% by vacuum extraction.@) Twenty percent of the cesarean sections were performed on an elective basis and 80% as an “emergency” procedure. The indications for the operation in the latter group are pesented in Table 2. The foremost indications were breech presentation fetal distress and dystocia. Using the multivariate stepwise logistic regression analysis the risk factors for cesarean section were ranked and are presented in Table 3. Breech presentation, uterine scar followed in descending order by placenta previa or abruptio placentae maternal disease, primiparity, low birth weight twins and advanced maternal age were found to be the important risk factors.
Table 2. The indications for emergency cesarean section* Indication
Emergency cesarean section (%)
Breech presentation Fetal distress No progress of labor Uterine scar x 1 Maternal disease Fetal weight Bleeding Infertility Multiple pregnancies
30.4 27.1 27.0 18.3 10.0
8.4 8.0 4.4 4.0
* In some of the women, there were two or more indications. Vaginal Delivery after Previous Cesarean Sections) The 1,080 women in the survey had one previous cesarean birth. This group was compared to 14,703 women with previous vaginal birth. Statistical evaluation was carried out by the chi-square test and the odds ratios heterogeneity test. From those with one previous cesarean section 55.1% delivered vaginally and 44.9 abdominally. The indication for a repeated cesarean section were: a previous cesarean section (28.7%) and ma1 presentation (12.8%). There were no differences in post delivery hospitalization days whether the woman had a previous cesarean section or not. Uterine rupture was followed in 1.2% (13 cases) of post cesarean women giving vaginal birth and in only 0.03% (4 cases) among those without a previous cesarean section (P
