title: Association between day of delivery and obstetric outcomes: observational study.
abstract: OBJECTIVE
  What is the association between day of delivery and measures of quality and safety of maternity services, particularly comparing weekend with weekday performance?
  
  
  METHODS
  This observational study examined outcomes for maternal and neonatal records (1,332,835 deliveries and 1,349,599 births between 1 April 2010 and 31 March 2012) within the nationwide administrative dataset for English National Health Service hospitals by day of the week. Groups were defined by day of admission (for maternal indicators) or delivery (for neonatal indicators) rather than by day of complication. Logistic regression was used to adjust for case mix factors including gestational age, birth weight, and maternal age. Staffing factors were also investigated using multilevel models to evaluate the association between outcomes and level of consultant presence. The primary outcomes were perinatal mortality and-for both neonate and mother-infections, emergency readmissions, and injuries.
  
  
  CONCLUSIONS
  Performance across four of the seven measures was significantly worse for women admitted, and babies born, at weekends. In particular, the perinatal mortality rate was 7.3 per 1000 babies delivered at weekends, 0.9 per 1000 higher than for weekdays (adjusted odds ratio 1.07, 95% confidence interval 1.02 to 1.13). No consistent association between outcomes and staffing was identified, although trusts that complied with recommended levels of consultant presence had a perineal tear rate of 3.0% compared with 3.3% for non-compliant services (adjusted odds ratio 1.21, 1.00 to 1.45). Limitations of the analysis include the method of categorising performance temporally, which was mitigated by using a midweek reference day (Tuesday). Further research is needed to investigate possible bias from unmeasured confounders and explore the nature of the causal relationship.
  
  
  CONCLUSIONS
  This study provides an evaluation of the "weekend effect" in obstetric care, covering a range of outcomes. The results would suggest approximately 770 perinatal deaths and 470 maternal infections per year above what might be expected if performance was consistent across women admitted, and babies born, on different days of the week.
  
  
  BACKGROUND
  The research was partially funded by Dr Foster Intelligence and the National Institute for Health Research (NIHR) Imperial Patient Safety Translational Research Centre in partnership with the Health Protection Research Unit (HPRU) in Healthcare Associated Infection and Antimicrobial Resistance at Imperial College London. WLP was supported by the National Audit Office.
authors.affiliation: Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London SW7 2AZ, UK National Audit Office, London, UK w.palmer07@imperial.ac.uk.
authors.forename: William L
authors.initials: WL
authors.lastname: Palmer
authors.affiliation: Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London SW7 2AZ, UK.
authors.forename: A
authors.initials: A
authors.lastname: Bottle
authors.affiliation: Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London SW7 2AZ, UK.
authors.forename: P
authors.initials: P
authors.lastname: Aylin
mesh_terms: D000328:Adult; D001724:Birth Weight; D036861:Delivery, Obstetric / Q000379:methods / Q000706:statistics & numerical data; D004739:England / Q000453:epidemiology; D005260:Female; D005865:Gestational Age; D006297:Health Services Accessibility / Q000706:statistics & numerical data*; D006801:Humans; D007231:Infant, Newborn; D008423:Maternal Age; D008427:Maternal Health Services / Q000592:standards; D007744:Obstetric Labor Complications / Q000453:epidemiology / Q000209:etiology; D010043:Outcome and Process Assessment, Health Care; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010343:Patient Admission / Q000706:statistics & numerical data*; D054238:Perinatal Mortality; D010561:Personnel Staffing and Scheduling / Q000706:statistics & numerical data; D011247:Pregnancy; D011256:Pregnancy Outcome / Q000453:epidemiology; D013997:Time Factors