The results of the study are derived from a sample of 200 pregnant women between the ages of 17 and 45. The mean age of the pregnant women was 30.7 ± 5.9. The age of the pregnant women who gave birth out of a hospital was 31.0 ± 6.6, the median was 30.0 (range 17–45) and the mean age of women delivered in the hospital was 30.3 ± 4.9, median 30.0 (range 20–42). The age of pregnant women did not differ significantly according to the place of delivery, p = 0.498. The results were observed through antepartum, intrapartum, neonatal and postpartum components.
Antepartum components
Bleeding in the II and III trimesters of pregnancy was a significant feature in pregnant women who gave birth in hospital conditions (5 cases), while there were no cases in outpatient deliveries (p = 0.024). Serious antepartum complications that were not recorded during ongoing pregnancies in subject women were: gestational diabetes, mental illness and Rh sensitization. All other complications characteristic of this stage of pregnancy were represented with an optimal frequency that did not differ significantly in relation to the place of delivery, ie in outpatient or inpatient settings. (Table 1)
Table 1. Items Available for Analysis for Antepartum Section of the OI (n=100)
Antepartum items
|
OMW
|
HMW
|
p
|
Optimal
|
Not Optimal
|
Optimal
|
Not Optimal
|
%
|
%
|
%
|
%
|
|
Anemia
|
88
|
12
|
82
|
18
|
0.235
|
Gestational diabetes
|
100
|
0
|
100
|
0
|
/
|
Mental disorders
|
100
|
0
|
100
|
0
|
/
|
Placenta previa
|
100
|
0
|
99
|
1
|
1.00
|
Preeclampsia
|
100
|
0
|
99
|
1
|
1.00
|
Pyelonephritis
|
99
|
1
|
99
|
1
|
1.00
|
Rh sensitization
|
100
|
0
|
100
|
0
|
/
|
Bleeding in II or III trimesters
|
100
|
0
|
95
|
5
|
0.024*
|
Adequate antenatal care
|
50
|
50
|
49
|
51
|
0.888
|
Amniocentesis
|
97
|
3
|
100
|
0
|
0.081
|
Use of medication
|
89
|
11
|
84
|
16
|
0.301
|
NST and BFP
|
100
|
0
|
100
|
0
|
/
|
* significant p<0.05
The previous distribution of antepartum characteristics determined that the median of the total Optimality Index of this component did not differ significantly in relation to the compared groups of pregnant women who were delivered in outpatient or hospital conditions (100 vs 99, p = 0.289).
Intrapartum components
Many parameters within the intrapartum period differed significantly depending on the place of delivery (outpatient / inpatient). In hospital conditions, during phase III of childbirth, there was a significantly higher frequency of amniotomy, cesarean section, induction and stimulation of childbirth, application of painkillers and medication other than oxytocin, which are all considered suboptimal characteristics of childbirth. In addition, there were other, less optimal measures taken during childbirth, grade III or IV episiotomy or grade I or II lacerations, fetal heart rate abnormalities, postpartum hemorrhage and blood transfusions that were more appropriate for hospital conditions as suboptimal events.
In the conditions of outpatient preparation and childbirth, according to the global obstetric assessment, epidural analgesia, perineum lacerations which require sutures, and cervical lacerations were suboptimal and used with higher frequency. The presence of a support person during childbirth was a favorable feature of outpatient childbirth conditions that was quantified as a significant frequency relative to hospital births. Other intrapartum components did not differ significantly in relation to the delivery setting. Table 2.
Table 2
Items Available for Analysis for Intrapartum Section of the OI (n = 100)
Intrapartum items
|
OMW
|
HMW
|
p
|
Optimal
|
Not Optimal
|
Optimal
|
Not Optimal
|
%
|
%
|
%
|
%
|
The period between the rupture of the membrane and birth, < 24 hours
|
100
|
0
|
100
|
0
|
/
|
Amniotomy
|
86
|
14
|
49
|
51
|
< 0.001*
|
Clear amniotic fluid
|
97
|
3
|
91
|
9
|
0.074
|
Induction or stimulation of labor
|
92
|
8
|
55
|
45
|
< 0.001*
|
Use of analgesics for labor
|
88
|
12
|
55
|
45
|
< 0.001*
|
Epidural analgesia
|
90
|
10
|
97
|
3
|
0.045*
|
Fetal heart rate abnormalities
|
100
|
0
|
92
|
8
|
0.004*
|
Presence of a support person during labor
|
24
|
76
|
7
|
93
|
< 0.001*
|
Childbirth conditions
|
100
|
0
|
95
|
5
|
0.024*
|
Fetus position (cephalic)
|
96
|
4
|
95
|
5
|
0.733
|
Cesarean section
|
100
|
0
|
73
|
27
|
< 0.001*
|
Episiotomy
|
95
|
5
|
98
|
2
|
0.248
|
Perineal laceration requiring sutures and cervical lacerations
|
86
|
14
|
98
|
2
|
0.002*
|
Grade III or IV episiotomy or grade I or II lacerations
|
100
|
0
|
92
|
8
|
0.004*
|
Medication other than oxytocin during stage III of childbirth
|
97
|
3
|
71
|
29
|
< 0.001*
|
Skin to skin contact
|
98
|
2
|
72
|
28
|
< 0.001*
|
Placental retention longer than 30 minutes
|
99
|
1
|
97
|
3
|
0.312
|
Postpartum haemorrhage
|
99
|
1
|
88
|
12
|
< 0.002*
|
Blood transfusion
|
100
|
0
|
91
|
9
|
< 0.002*
|
*significant p < 0.05
aCTG, Doppler, fetoscopy, CTG finding (non – reactive)
b Unprompted pushing, Postpartum delivery, Instrumental vaginal delivery
The frequency distribution of previously analyzed intrapartum components determined the median of optimal conditions that was significantly higher in outpatient than in hospital delivery settings (97% vs 91% of cases). At the same time, the frequency of suboptimal components was significantly higher in outpatient compared to hospital delivery conditions (p = 0.01; 0.05).
Neonatal components
Individually and within neonatal components, the greatest statistical significance belongs to the role of optimal lactation at the time of hospital discharge (up to 72 hours after delivery) in outpatient maternity clinics in relation to hospital maternity wards. This is followed by a higher frequency of optimal neonatal intensive care, then the absence of bacterial infections, as well as the optimal assessment of gestational age, all of which were, in a significantly higher number of cases, appropriate for the outpatient delivery setting. Other neonatal components (infant birth weight, APGAR score at 5 min, congenital anomalies, respiratory distress syndrome), shown in Table 3, did not differ significantly with respect to the delivery setting.
Table 3
Items Available for Analysis for Neonatal Section of the OI (n = 100)
Neonatal items
|
OMW
|
HMW
|
p
|
Optimal
|
Not Optimal
|
Optimal
|
Not Optimal
|
%
|
%
|
%
|
%
|
Estimation of gestational age (37–42 weeks)
|
99
|
1
|
93
|
7
|
0.030*
|
Infant birth weight (2500–4000 gr)
|
98
|
2
|
96
|
4
|
0.407
|
APGAR 5min (7,8,9,10)
|
99
|
1
|
97
|
3
|
0.312
|
Neonatal intensive care
|
98
|
2
|
88
|
12
|
0.006*
|
Congenital anomalies
|
100
|
0
|
98
|
2
|
0.115*
|
Bacterial infections other than sepsis
|
100
|
0
|
93
|
7
|
< 0.007*
|
Respiratory distress syndrome
|
99
|
1
|
98
|
2
|
0.567
|
Other complications including sepsis
|
100
|
0
|
100
|
0
|
/
|
Lactation at the time discharge (up to 72 hours after delivery)
|
97
|
3
|
74
|
26
|
< 0.001*
|
*. significant p < 0.05 |
The median Optimality Index of neonatal components was significantly higher in outpatient compared to inpatient deliveries. At the same time, the median of suboptimal indices was higher in hospital conditions compared to outpatient ones. (p = 0.021, Graph3.).
Postpartum components
Local suture infection did not occur in any of the cases of outpatient deliveries during the postpartum period, which is a significant difference compared to six (suboptimal) events in hospital settings (p = 0.013). At this period, the frequency of prescribed medication in maternity wards was significantly higher in relation to outpatient maternity clinics (15 to 5 cases).
Other postpartum components (perinatal death between the birth and 72 hours of life, cystitis, endometritis) were not observed in outpatient settings. Yet, this is not a significant difference in relation to their prevalence (1–2 cases) in outpatient maternity clinics.
Maternal death, hematoma and mastitis did not occur in any of the cases, regardless of the delivery setting. Table 4.
Table 4. Items Available for Analysis for Postpartum Section of the OI (n=100)
Postpartum items
|
OMW
|
HMW
|
p
|
Optimal
|
Not Optimal
|
Optimal
|
Not Optimal
|
|
%
|
%
|
%
|
%
|
Perinatal death occurring between birth and 72 hours
|
100
|
0
|
99
|
1
|
1.00
|
Cystitis
|
100
|
0
|
99
|
1
|
1.00
|
Endometritis
|
100
|
0
|
98
|
2
|
0.155
|
Hematoma
|
100
|
0
|
100
|
0
|
/
|
Local suture infection
|
100
|
0
|
94
|
6
|
0.013*
|
Mastitis
|
95
|
5
|
95
|
5
|
1.00
|
Prescribed medication
|
95
|
5
|
85
|
15
|
0.018*
|
Maternal death
|
100
|
0
|
100
|
0
|
/
|
*. significant p < 0.05
The median Optimality Index for previously analyzed postpartum components, was at the border of statistically significant differences in relation to the place of delivery: outpatient or inpatient (100% vs 98.5%, p = 0.050). Graph 4.
The Total Optimality Index (OI) contained all of the synthesized, previously analyzed parameters of individual components (48 items). For the considered sample of subjects, the median total optimality index (which included antepartum, intrapartum, neonatal and postpartum components) was in the 99% range (24% -100%) for the outpatient maternity clinics as opposed to the hospital maternity wards where it was in the 96% range (3% -100 %). Statistical testing of the significance of differences shows that this difference is significant, at the adopted level of reliability, and favors the optimality of delivery conditions in outpatient settings. (p = 0.001, Graph 5).
Logistic regression analysis
All variables that stood out as statistically significant for the alpha level of 0.001 in the primary analysis were inserted into the logistic regression model where delivery settings (outpatient / inpatient conditions) represented the dependent variable.
Table 5
Independent variables
|
Multiple logistic regression
|
B
|
p
|
OR (95%CI)
|
Amniotomy
|
1.39
|
0.003*
|
4.01 (1.63–9.91)
|
Induction or stimulation of labor
|
18.88
|
0.997
|
157556047.7 (0.0-/)
|
Use of painkillers
|
-18.19
|
0.998
|
0.0 (0.0–0.0)
|
The presence of a person of support during childbirth
|
-1.53
|
0.007*
|
0.22 (0.07–0.66)
|
Cesarean section
|
35.356
|
0.997
|
2.2e 15 (0.0-/)
|
Medication other than oxytocin during stage III of childbirth
|
-0.29
|
0.779
|
0.75 (0.10–5.51)
|
Skin to skin contact
|
0.03
|
0.980
|
1.03 (0.09–11.83)
|
Lactation at the time discharge (up to 72 hours after delivery)
|
-1.24
|
0.082
|
0.29 (0.07–1.17)
|
The model contains 8 independent variables and the whole model was statistically significant (chi-square = 84.877, p<0.001), Table 5.
In the multiple logistic regression model, amniotomy was singled out as a statistically significant factor in delivery in hospital conditions (B = 1.39; p = 0.003), and pregnant women who underwent amniotomy 4 times were more likely to give birth in hospital conditions. However, the presence of a support person during childbirth is a significant factor that increases the chance of pregnant women opting for delivery in outpatient settings (B = -1.53; p = 0.003).
Another distinguishing factor is lactation at the time of hospital discharge (up to 72 hours after delivery), which is closer to the statistical significance than other variables in the model and indicates that the successful onset of lactation before discharge is another factor in favor of outpatient delivery (B = − 1.24; p = 0.082).