The size is not important

Sir The size of the labor ward: is bigger better when it comes to patient safety? This headline of an article published by Milland et al. (1) promises an answer, but the article provides neither data nor an analysis capable of answering this question because patient claims, which are the data used in this analysis, are random and a surrogate measure for patient safety. Such data are not in themselves strong enough to justify organizational changes. Based on an analysis of 1326 claims/991 375 births submitted in 1995–2009, the authors conclude that there is a significant difference between number of claims and the size of a labor ward. A significant difference between size of hospital unit and number of claims emerges as the authors divide the 29 labor wards into four groups [very large units above 4000 births (two units); large units 3000–3099 births (four units); intermediate units 1000–2999 births (19 units); small units below 1000 births (four units, one extreme unit was excluded from the analysis)]. The authors do not state the rationale behind these four categories that define unit size, nor do they not reveal if these categories were defined before the data collection or during the analysis. However, variations exist across all types of units and number of claims varies across groups from 60 to 734. Some of the small and the very large units have fewer approved claims compared with intermediate units but the statistical difference between smaller and larger wards disappears if the numbers of approved claims are related to the absolute number of deliveries [see Table 2 Milland et al (1)]. The authors claim that “standardization of care through evidence-based guidelines and algorithms can improve patient outcomes, reduce errors and thereby also decrease the number of claims,” but do not present any data to support this. We do not doubt that there may be a relation between organization and patient safety; but it is not as straightforward as suggested by Milland et al. The authors suggest training in cardiotocography (CTG) interpretation as a way to lessen obstetric errors, but no data are presented. It seems reasonable to improve CTG interpretation, but a first step would be to consider if CTG is used appropriately. CTG is a screening instrument and carries risks. It is well documented that admission CTGs do not result in decreased perinatal mortality. They do, however, increase the cesarean section rate by approximately 20% in low-risk women (2). The title of this article may wrongfully mislead readers to draw hasty conclusions. It is, however, important not to do this. Centralized and specialized care is no doubt of benefit for some types of women but on the other hand birth clinics and out-ofhospital care might also enhance safety for others. Birth centers are associated with lower rates of medical intervention and higher levels of satisfaction, without increased risk for mother and baby (3). Increasingly, better observational studies suggest that planned hospital birth is not any safer than planned homebirth assisted by an experienced midwife with collaborative medical back-up, but may lead to more interventions and more complications (4,5).