title: Effect of hospital size and on-call arrangements on intrapartum and early neonatal mortality among low-risk newborns in Finland.
abstract: OBJECTIVE
  To evaluate the influence of delivery unit size and on-call staffing in the performance of low-risk deliveries in Finland.
  
  
  METHODS
  A population-based study of hospital size and level based on Medical Birth Register data. Population was all hospital births in Finland in 2005-2009. Inclusion criteria were singleton births (birth weight 2500g or more) without major congenital anomalies or birth defects. Additionally, only intrapartum stillbirths were included. Birthweights and maternal background characteristics were adjusted for by logistic regression. Main outcome measures were intrapartum or early neonatal mortality, neonatal asphyxia and newborns' need for intensive care or transfer to other hospital and longer duration of care. On-call arrangements were asked from each of the hospitals.
  
  
  RESULTS
  Intrapartum mortality was higher in units where physicians were at home when on-call (OR 1.25; 95% CI 1.02-1.52). A tendency to a higher mortality was also recorded in non-university hospitals (OR 1.18; 95% CI 0.99-1.40). Early neonatal mortality was twofold in units with less than 1000 births annually (OR 2.11; 95% CI 0.97-4.56) and in units where physicians were at home when on-call (OR 1.85; 95% CI 0.91-3.76). These results did not reach statistical significance. No differences between the units were found regarding Apgar scores or umbilical cord pH.
  
  
  CONCLUSIONS
  The differences in mortality rates between different level hospitals suggest that adverse outcomes during delivery should be studied in detail in relation to hospital characteristics, such as size or level, and more international studies determining obstetric patient safety indicators are required.
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Obstetrics and Gynecology, Helsinki, Finland.
authors.forename: Elina
authors.initials: E
authors.lastname: Karalis
authors.affiliation: THL, National Institute for Health and Welfare, Helsinki, Finland; NHV, Nordic School of Public Health, Gothenburg, Sweden.
authors.forename: Mika
authors.initials: M
authors.lastname: Gissler
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Obstetrics and Gynecology, Helsinki, Finland; University of Helsinki, Hyvinkaa Hospital Area, Helsinki and Uusimaa Hospital District, Finland.
authors.forename: Anna-Maija
authors.initials: AM
authors.lastname: Tapper
authors.affiliation: University of Helsinki, Helsinki University Hospital, Department of Obstetrics and Gynecology, Helsinki, Finland. Electronic address: Veli-Matti.Ulander@hus.fi.
authors.forename: Veli-Matti
authors.initials: VM
authors.lastname: Ulander
mesh_terms: D000328:Adult; D005260:Female; D005313:Fetal Death; D005387:Finland / Q000453:epidemiology; D006276:Health Facility Size; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D016015:Logistic Models; D008875:Middle Aged; D011247:Pregnancy
keywords: Early neonatal mortality; Intrapartum mortality; Maternity hospitals; Neonatal asphyxia; Perinatal mortality