Birth "Out-of-Hours": An Evaluation of Obstetric Practice and Outcome According to the Presence of Senior Obstetricians on the Labour Ward.
BACKGROUND
Concerns have been raised that a lack of senior obstetricians ("consultants") on the labour ward outside normal hours may lead to worse outcomes among babies born during periods of reduced cover.


RESULTS
We carried out a multicentre cohort study using data from 19 obstetric units in the United Kingdom between 1 April 2012 and 31 March 2013 to examine whether rates of obstetric intervention and outcome change "out-of-hours," i.e., when consultants are not providing dedicated, on-site labour ward cover. At the 19 hospitals, obstetric rotas ranged from 51 to 106 h of on-site labour ward cover per week. There were 87,501 singleton live births during the year, and 55.8% occurred out-of-hours. Women who delivered out-of-hours had slightly lower rates of intrapartum caesarean section (CS) (12.7% versus 13.4%, adjusted odds ratio [OR] 0.94; 95% confidence interval [CI] 0.90 to 0.98) and instrumental delivery (15.6% versus 17.0%, adj. OR 0.92; 95% CI 0.89 to 0.96) than women who delivered at times of on-site labour ward cover. There was some evidence that the severe perineal tear rate was reduced in out-of-hours vaginal deliveries (3.3% versus 3.6%, adj. OR 0.92; 95% CI 0.85 to 1.00). There was no evidence of a statistically significant difference between out-of-hours and "in-hours" deliveries in the rate of babies with a low Apgar score at 5 min (1.33% versus 1.25%, adjusted OR 1.07; 95% CI 0.95 to 1.21) or low cord pH (0.94% versus 0.82%; adjusted OR 1.12; 95% CI 0.96 to 1.31). Key study limitations include the potential for bias by indication, the reliance upon an organisational measure of consultant presence, and a non-random sample of maternity units.


CONCLUSIONS
There was no difference in the rate of maternal and neonatal morbidity according to the presence of consultants on the labour ward, with the possible exception of a reduced rate of severe perineal tears in out-of-hours vaginal deliveries. Fewer women had operative deliveries out-of-hours. Taken together, the available evidence provides some reassurance that the current organisation of maternity care in the UK allows for good planning and risk management. However there is a need for more robust evidence on the quality of care afforded by different models of labour ward staffing.
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.|Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
Hannah E
HE
Knight
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Jan H
JH
van der Meulen
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Ipek
I
Gurol-Urganci
Department of Obstetrics and Gynaecology, University of Cambridge, Cambridge, United Kingdom.
Gordon C
GC
Smith
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
Amit
A
Kiran
Department of Obstetrics and Gynaecology, University of Exeter Medical School, Exeter, United Kingdom.
Steve
S
Thornton
Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
David
http://orcid.org/0000-0001-6844-1329
D
Richmond
Lindsay Stewart Centre for Audit and Clinical Informatics, Royal College of Obstetricians and Gynaecologists, London, United Kingdom.
Alan
A
Cameron
Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom.
David A
DA
Cromwell
D000328:Adult; D039602:After-Hours Care / Q000458:organization & administration*; D001034:Apgar Score; D002585:Cesarean Section; D016009:Chi-Square Distribution; D002983:Clinical Competence; D003253:Consultants; D003695:Delivery of Health Care / Q000458:organization & administration*; D036861:Delivery, Obstetric / Q000009:adverse effects / Q000401:mortality; D005113:Extraction, Obstetrical; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007743:Labor, Obstetric; D050498:Live Birth; D016015:Logistic Models; D015999:Multivariate Analysis; D007744:Obstetric Labor Complications / Q000209:etiology; D016017:Odds Ratio; D010561:Personnel Staffing and Scheduling / Q000458:organization & administration*; D011247:Pregnancy; D017064:Process Assessment, Health Care; D012307:Risk Factors; D013997:Time Factors; D006113:United Kingdom