Obstetric anesthesia services in Israel snapshot (OASIS) study: A 72 hour cross-sectional observational study of workforce supply and demand

BACKGROUND: We planned an observational study to assess obstetric anesthesia services nationwide. We aimed to assess the effect of the anesthesia workload/workforce ratio on quality and safety outcomes of obstetric anesthesia care. METHODS: Observers prospectively collected data from labor units over 72 h (Wednesday, Thursday and Friday). Independent variables were workload (WL) and workforce (WF). WL was assessed by the Obstetric Anesthesia Activity Index (OAAI), which is the estimated time in a 24-h period spent on epidurals and all cesarean deliveries. Workforce (WF) was assessed by the number of anesthesiologists dedicated to the labor ward per week. Dependent variables were the time until anesthesiologist arrival for epidural (quality measure) and the occurrence of general anesthesia for urgent Cesarean section, CS, (safety measure). This census included vaginal deliveries and unscheduled (but not elective) CS. RESULTS: Data on 575 deliveries are from 12 maternity units only, primarily because a major hospital chain chose not to participate; eight other hospitals lacked institutional review board approval. The epidural response rate was 94.4%; 321 of 340 parturients who requested epidural analgesia (EA) received it. Of the 19 women who requested EA but gave birth without it, 14 (77%) were due to late arrival of the anesthesiologist. Median waiting times for anesthesiologist arrival ranged from 5 to 28 min. The OAAI varied from 4.6 to 25.1 and WF ranged from 0 to 2 per shift. Request rates for EA in hospitals serving predominantly orthodox Jewish communities and in peripheral hospitals were similar to those of the entire sample. More than a fifth (13/62; 21%) of the unscheduled CS received general anesthesia, and of these almost a quarter (3/13; 23%) were attributed to delayed anesthesiologist arrival. CONCLUSIONS: Inadequate WF allocations may impair quality and safety outcomes in obstetric anesthesia services. OAAI is a better predictor of WL than delivery numbers alone, especially concerning WF shortage. To assess the quality and safety of anesthetic services to labor units nationally, observational data on workforce, workload, and clinical outcomes should be collected prospectively in all labor units in Israel

Urinary organophosphate metabolite levels in Palestinian pregnant women: results of the Middle East Regional Cooperation Project

The purpose of the study was to measure urinary organophosphate (OP) metabolites in Palestinian pregnant women, and to compare levels with those in pregnant women in Jerusalem and women from the general population in Israel. We measured six dialkyl phosphates in urine samples collected from 148 pregnant women from the West Bank area. Median total dimethyl phosphate (DMtotal) levels were significantly lower in Palestinian women compared to Jerusalem pregnant women and women in Israel (p = 0.041). In Palestinian women reporting that their place of residence was near an agricultural field, DMtotal levels were significantly higher (p = 0.037). Lower urinary excretion of dimethyl phosphate pesticide metabolites in Palestinian women compared to Israeli women may result from lower consumption of fruits and vegetables in the Palestinian population. Our findings highlight differences in OP pesticide exposure in populations with close geographical proximity but with differences in culture, diet, lifestyle, and regulatory oversight of pesticides.This work was supported by the United States Agency for International Development [grant number M27-028] and by the Environment and Health Fund in Jerusalem, Israel [grant number RGA 1101]

Socioeconomic disparities in breast cancer incidence and survival among parous women: findings from a population-based cohort, 1964–2008

Background Socioeconomic position (SEP) has been associated with breast cancer incidence and survival. We examined the associations between two socioeconomic indicators and long-term breast cancer incidence and survival in a population-based cohort of parous women. Methods Residents of Jerusalem who gave birth between 1964–1976 (n = 40,586) were linked to the Israel Cancer Registry and Israel Population Registry to determine breast cancer incidence and vital status through mid-2008. SEP was assessed by husband’s occupation and the woman’s education. We used log ranks tests to compare incidence and survival curves by SEP, and Cox proportional hazard models to adjust for demographic, reproductive and diagnostic factors and assess effect modification by ethnic origin. Results In multivariable models, women of high SEP had a greater risk of breast cancer compared to women of low SEP (Occupation: HR 1.18, 95 % CI 1.03-1.35; Education: HR 1.39, 95 % CI 1.21-1.60) and women of low SEP had a greater risk of mortality after a breast cancer diagnosis (Occupation: HR 1.33, 95 % CI 1.04-1.70; Education: HR 1.37, 95 % CI 1.06-1.76). The association between education and survival was modified by ethnic origin, with a gradient effect observed only among women of European origin. Women of Asian, North African and Israeli origin showed no such trend. Conclusions SEP was associated with long-term breast cancer incidence and survival among Israeli Jews. Education had a stronger effect on breast cancer outcomes than occupation, suggesting that a behavioral mechanism may underlie disparities. More research is needed to explain the difference in the effect of education on survival among European women compared to women of other ethnicities

Socioeconomic status and polycystic ovary syndrome

BACKGROUND: Polycystic ovary syndrome (PCOS) is a common metabolic-endocrine disorder in women and is associated with a number of metabolic morbidities. We examined the association of PCOS and its components with socioeconomic status (SES) over the life course to explore the role of the environment on the development of PCOS. METHODS: Participants included 1163 women, aged 34-39, from the Coronary Artery Risk Development in Young Adults (CARDIA) Women\u27s Study, examined at year 16 of the CARDIA study (2001). PCOS was defined according to the 1990 National Institutes of Health (NIH) criteria. RESULTS: Logistic regression models, adjusted for age, body mass index (BMI), waist circumference, and oral contraceptive (OC) use, demonstrated a statistically significant association between those women with low parental education/high personal education and PCOS (odds ratio [OR] 2.5, 95% confidence interval [CI] 1.4-4.4). CONCLUSIONS: Our results indicate that women who experienced low childhood SES are at increased risk of PCOS, but this risk is limited to those who have personally attained a high level of education. More research is needed to determine the childhood socioeconomic factors that might influence this risk and whether conditions associated with upward life mobility play a role or if this group of at-risk women is simply more likely to recall the symptoms that define PCOS

Adherence to diabetes quality indicators in primary care and all-cause mortality: A nationwide population-based historical cohort study.

BackgroundIn the last three decades, much effort has been invested in measuring and improving the quality of diabetes care. We assessed the association between adherence to diabetes quality indicators and all-cause mortality in the primary care setting.MethodsA nationwide, population-based, historical cohort study of all people aged 45-80 with pharmacologically-treated diabetes in 2005 (n = 222,235). Data on annual performance of quality indicators (including indicators for metabolic risk factor management and glycemic control) and vital status were retrieved from electronic medical records of the four Israeli health maintenance organizations. Cox proportional hazards and time-dependent models were used to estimate hazard ratios (HRs) for mortality by degree of adherence to quality indicators.ResultsDuring 2,000,052 person-years of follow-up, 35.8% of participants died. An inverse dose-response association between the degree of adherence and mortality was shown for most of the quality indicators. Participants who were not tested for proteinuria or did not visit an ophthalmologist during the first-5-years of follow-up had HRs of 2.60 (95%CI:2.49-2.69) and 2.09 (95%CI:2.01-2.16), respectively, compared with those who were fully adherent. In time-dependent analyses, not measuring LDL-cholesterol, blood pressure, HbA1c, or HbA1c>9% were similarly associated with mortality (HRs ≈1.5). The association of uncontrolled blood pressure with mortality was modified by age, with increased mortality shown for those with controlled blood pressure at older ages (≥65 years).ConclusionsLongitudinal adherence to diabetes quality indicators is associated with reduced all-cause mortality. Primary care professionals need to be supported by health care systems to perform quality indicators

Disparities in the use of antenatal care service in Ethiopia over a period of fifteen years

BACKGROUND: Little is known about factors contributing to inequities in antenatal care use in Ethiopia. We aimed to assess inequities in the use of antenatal care on the basis of area of residence, administrative region, economic status and education. METHODS: This study was based on data from repeated cross-sectional surveys carried out by Measure Demographic and Health Survey and Central Statistical Authority of Ethiopia. The surveys were conducted in February-June 2000, April-August 2005, and December 2010-June 2011. The surveys employed a cluster sampling design to select a nationally representative sample of 15–49 year-old women. The main outcome variable was at least one antenatal care visit for the last live birth in the 5 years preceding the surveys. Statistical analysis was completed by applying the sampling weights in order to consider the complex sampling design. RESULTS: A total of 7978, 7307 and 7908 weighted number of women participated in the three surveys, respectively. The rate of antenatal care coverage in Ethiopia has increased from 26.8% in 2000 to 42.7% in 2011. The odds of antenatal care use were 2.4 (95% CI: 1.7-3.2, p < 0.0001), 1.6 (95% CI: 1.2-2.2, p = 0.003) and 1.8 (95% CI: 1.3-2.6, p = 0.001) times higher among women from urban areas than those from rural areas at the three time points, respectively. The odds ratio of antenatal care use among women with secondary or higher education compared with women of no education increased from 2.6 (95% CI: 2.0-3.4, p < 0.0001) in 2000 to 5.1 (95% CI: 2.8-9.4, p < 0.0001) in 2011. Moreover, the odds of use among women from the richest households at the three time points were 2.7 (95% CI: 2.1-3.6, p < 0.0001), 4.4 (95% CI: 3.3-6.0, p < 0.0001), and 3.9 (95% CI: 2.8-5.5, p < 0.0001) times higher compared with their counterparts from the poorest households. Furthermore, we have observed a wide regional variation in the use of ANC in Ethiopia. CONCLUSIONS: The wide inequities between urban and rural areas, across economic and educational strata in the use of antenatal care highlight the need to put more resources to poor households, rural areas, and disadvantage regions. We suggest further study to understand additional factors for the deep unmet need in rural areas and some regions of Ethiopia