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Does delivery volume of family physicians predict maternal and newborn outcome?

Michael C. Klein^*, Andrea Spence^*, Janusz Kaczorowski, Ann Kelly^* and Stefan Grzybowski

*Department of Family Practice, Children's and Women's Health Centre of British Columbia, Vancouver, BC; Department of Family Practice, University of British Columbia, Vancouver, BC; Departments of Family Medicine and of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ont.; Department of Health Care and Epidemiology, University of British Columbia, Vancouver, BC

Correspondence to: Dr. Michael C. Klein, Department of Family Practice, Children's and Women's Health Centre of British Columbia, Room F412, 4500 Oak St., Vancouver BC V6H 3N1; fax 604 875-3435; mklein@unixg.ubc.ca

Background: The number of births attended by individual family physicians who practice intrapartum care varies. We wanted to determine if the practice–volume relations that have been shown in other fields of medical practice also exist in maternity care practice by family doctors.

Methods: For the period April 1997 to August 1998, we analyzed all singleton births at a major maternity teaching hospital for which the family physician was the responsible physician. Physicians were grouped into 3 categories on the basis of the number of births they attended each year: fewer than 12, 12 to 24, and 25 or more. Physicians with a low volume of deliveries (72 physicians, 549 births), those with a medium volume of deliveries (34 physicians, 871 births) and those with a high volume of deliveries (46 physicians, 3024 births) were compared in terms of maternal and newborn outcomes. The main outcome measures were maternal morbidity, 5-minute Apgar score and admission of the baby to the neonatal intensive care unit or special care unit. Secondary outcomes were obstetric procedures and consultation patterns.

Results: There was no difference among the 3 volume cohorts in terms of rates of maternal complications of delivery, 5-minute Apgar scores of less than 7 or admissions to the neonatal intensive care unit or the special care unit, either before or after adjustment for parity, pregnancy-induced hypertension, diabetes, ethnicity, lone parent status, maternal age, gestational age, newborn birth weight and newborn head circumference at birth. High- and medium-volume family physicians consulted with obstetricians less often than low-volume family physicians (adjusted odds ratio [OR] 0.586 [95% confidence interval, CI, 0.479–0.718] and 0.739 [95% CI 0.583–0.935] respectively). High- and medium-volume family physicians transferred the delivery to an obstetrician less often than low-volume family physicians (adjusted OR 0.668 [95% CI 0.542–0.823] and 0.776 [95% CI 0.607–0.992] respectively). Inductions were performed by medium-volume family physicians more often than by low-volume family physicians (adjusted OR 1.437 [95% CI 1.036–1.992].

Interpretation: Family physicians' delivery volumes were not associated with adverse outcomes for mothers or newborns. Low-volume family physicians referred patients and transferred deliveries to obstetricians more frequently than high- or medium-volume family physicians. Further research is needed to validate these findings in smaller facilities, both urban and rural.

This article has been cited by other articles:

				J. J. Chang, D. M. Stamilio, and G. A. Macones Effect of Hospital Volume on Maternal Outcomes in Women with Prior Cesarean Delivery Undergoing Trial of Labor Am. J. Epidemiol., March 15, 2008; 167(6): 711 - 718. [Abstract] [Full Text] [PDF]

				K. Aubrey-Bassler, S. Newbery, L. Kelly, B. Weaver, and S. Wilson Maternal outcomes of cesarean sections: Do generalists' patients have different outcomes than specialists' patients? Can Fam Physician, December 1, 2007; 53(12): 2132 - 2138. [Abstract] [Full Text] [PDF]

				A. Kelly, M. C. Klein, J. Kaczorowsk, and S. Grzybowski Does experience or delivery volume of family physicians predict maternal and newborn outcomes? Can. Med. Assoc. J., February 17, 2004; 170(4): 446 - 447. [Full Text] [PDF]

				D. Dattani Delivery volume debated Can. Med. Assoc. J., October 1, 2002; 167(7): 741 - 741. [Full Text] [PDF]

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