Subscribe to RSS
Please copy the URL and add it into your RSS Feed Reader.
https://www.thieme-connect.de/rss/thieme/en/10.1055-s-00035037.xml
Download PDF
Methods Inf Med 1997; 36(03): 191-200
DOI: 10.1055/s-0038-1636841
DOI: 10.1055/s-0038-1636841
Original Article
Methodological Considerations in the Design of an Obstetric Database Abstracted from Medical Records
The authors would like to thank all of the staff at maternity services in the South Thames Region NHS Trust where this study was conducted for their co-operation and invaluable assistance. In particular to the Deputy Manager of Medical Records for helping access the Trust’s obstetric notes and to Caroline Nickson who helped conduct the survey of current midwifery practice. Financial support was provided by the Dev R fund of the University of Greenwich.
Further Information
Publication History
Publication Date:
17 February 2018 (online)
The quality of maternal information contained within contemporary obstetric notes was investigated by abstracting data from the medical records of multiparous women who were admitted to a major city hospital in the South Thames Region. Potential sources of error were identified by comparing information recorded in different sections of each obstetric notes and within the obstetric notes of consecutive pregnancies. The format of the obstetric notes largely determined which variables were recorded and, to some extent, the accuracy of information collected. However, the quality of the data ultimately depended upon whether each variable was self-reported or directly measured. Self-reported variables were subject to selective omission and subjective bias, while measured variables were susceptible to inaccurate equipment and poor measurement practice. By interviewing a sample of midwives currently involved in antenatal care at the Trust it was possible to confirm that extensive variation in measurement and recording procedures routinely occurred.
-
REFERENCES
- 1 Moidu K, Singh AK, Boström K, Chowd-hury S, Trell E, Wigertz O, Kjessler B. Towards an essential data set: Applicability in the domain of maternal health services. Meth Inform Med 1992; 31: 182-92.
- 2 Peoples-Sheps MD, Kalsbeek WD, Siegel E, Dewes C, Rogers M, Schwartz R. Pre-natal records: A National Survey of Content. Am J Obstet Gynecol 1991; 164: 514-21.
- 3 Johnson SR, Kolberg BH, Varner MW, Railsback D. Maternal obesity in pregnancy. Surg Gynecol Obstet 1987; 164: 431-7.
- 4 Hall MH, Chng PK, MacGillivray r. Is routine antenatal care worthwhile?. Lancet 1980; 02: 78-80.
- 5 Kay S, Purves IN. Medical records and other stories: a narratological framework. Meth Inform Med 1996; 35: 72-87.
- 6 Maclntyre S. Some notes on record taking and making in an antenatal clinic. Sociologic Rev 1978; 26: 595-611.
- 7 Timmers T. Is the computer-based patient record an analog or a model of the patient?. Meth Inform Med 1993; 32: 108.
- 8 David RJ. The quality and completeness of birthweight and gestational age data in computerized birth files. AJPH 1980; 70: 964-73.
- 9 Hewson D, Bennett A. Childbirth research data: Medical records or women’s reports?. Am J Epidemiol 1987; 125: 484-91.
- 10 Aaronson LS, Burman ME. Use of health records in research: reliability and validity issues. Res Nurs HIth 1994; 17: 67-73.
- 11 Burman JF. The misinformation era: The fall of the medical record. Ann Intern Med 1989; 110: 482-4.
- 12 Musen MA. The strained quality of medical data. Meth Inform Med 1989; 123-5.
- 13 Reiser SJ. The clinical record in medicine. Part 2: Reforming content and purpose. Ann Intern Med 1991; 114: 980-5.
- 14 Van der Lei J. Use and abuse of computerstored medical records. Meth Inform Med 1991; 30: 79-80.
- 15 Quaak MJ, Frans RWesterman, van Bemmel JH. Comparisons between written and computerised patient histories. BMJ 1987; 295: 184-90.
- 16 Oppenheim AN. Questionnaire design, interviewing and attitude measurement. 2nd ed.. London: Pinter Publishers Limited; 1992
- 17 Woolf M. The reliability of fertility data obtained from pregnancy histories. Studies on medical and population subjects No. 40. London: OPCS; 1979
- 18 Harris HE, Ellison GTH, Holliday M, Lucassen E. Do the increased weight gain recommendations for pregnancy predispose parous women to obesity?. Proc Nutr Soc. (in press).
- 19 Parker JD, Abrams B. Differences in postpartum weight retention between black and white mothers. Obstet Gynecol 1993; 81: 768-74.
- 20 Williamson DF, Madans J, Pamuk E, Flegal KM, Kendrick JS, Serdula MK. A prospective study of childbearing and 10-year weight gain in US white women 25 to 45 years of age. Int J Obesity 1994; 18: 561-9.
- 21 Rona RJ, Morris RW. National Study of Health and Growth: social and family factors and overweight in English and Scottish parents. Ann Hum Biol 1982; 09: 147-56.
- 22 Greene GW, Smiciklas-Wright H, Scholl TO, Karp RJ. Postpartum weight change: how much of the weight gained in pregnancy will be lost after delivery?. Obstet Gynecol 1988; 71: 701-7.
- 23 Smith DE, Lewis CE, Caveny JL, Perkins LL, Burke GL, Bild DE. Longitudinal changes in adiposity associated with pregnancy. The CARDIA Study. JAMA 1994; 271: 1747-51.
- 24 Rookus MA, Rokebrand P, Burema J, Deurenberg P. The effect of pregnancy on the body mass index 9 months postpartum in 49 women. Int J Obesity 1987; 11: 609-18.
- 25 Schauberger CW, Rooney BL, Brimer LM. Factors that influence weight loss in the puerperium. Obstet Gynecol 1992; 79: 424-9.
- 26 Green JR, Schumacher LB, Pawson IG, Partridge JC, Kretchmer N. Influence of maternal body habitus and glucose tolerance on birth weight. Obstet Gynecol 1991; 78: 235-40.
- 27 Catalano PM, Roman NM, Tyzbir ED, Merritt AO, Driscoll P, Armini SB. Weight gain in women with gestational diabetes. Obstet Gynecol 1993; 81: 523-8.
- 28 Gleeson RP, Lobb MO. The prevalence of confidential information in antenatal records. J Obstet Gynaecol 1988; 08: 219-21.
- 29 Elbourne D, Richardson M, Chalmers I, Waterhouse I, Holt E. The Newbury Maternity Care Study: a randomized controlled trial to assess a policy of women holding their own obstetric records. Br J Obstet Gynaecol 1987; 94: 612-9.
- 30 Horwitz RI, Yu EC. Assessing the reliability of epidemiologic data obtained from medical records. J Chron Dis 1984; 37: 825-31.
- 31 Demlo LK, Campbell PM, Spaght SBrown. Reliability of information abstracted from patients’ medical records. Med Care 1978; 16: 995-1005.
- 32 Hendrickson L, Myers J. Some sources and potential consequences of errors in medical data recording. Meth Inform Med 1973; 12: 38-45.
- 33 Kokotailo PK, Adger H, Duggan AK, Repke J, Joffe A. Cigarette, alcohol and other drug use by school-age pregnant adolescents: Prevalence, detection, and associated risk factors. Pediatrics 1992; 90: 328-34.
- 34 Kroegar A. Health interview surveys in developing countries: A review of the methods and results. Int J Epidemiol 1983; 12: 465-81.
- 35 Palta M, Prineas RJ, Berman R, Hannan P. Comparison of self-reported and measured height and weight. Am J Epidemiol 1982; 115: 223-30.
- 36 Stewart AL. The reliability and validity of self-reported weight and height. J Chron Dis 1982; 35: 295-309.
- 37 Stevens-Simon C, Roghmann KJ, McAnarney ER. Relationship of self-reported prepregnant weight and weight gain during pregnancy to maternal body habitus and age. JADA 1992; 92: 85-7.
- 38 Stunkard AJ, Albaum JM. The accuracy of self-reported weights. Am J Clin Nutr 1981; 34: 1593-9.
- 39 Bean JA, Leeper JD, Wallace RB, Sherman BM, Jagger H. Variations in the reporting of menstrual histories. Am J Epidemiol 1979; 109: 181-5.
- 40 Corwin RG, Krober M, Roth HP. Patients’ accuracy in reporting their past medical history, A study of 90 patients with peptic ulcer. J Chron Dis 1971; 23: 875-9.
- 41 Wilcox AJ, Horney LF. Accuracy of spontaneous abortion recall. Am J Epidemiol 1984; 120: 727-33.
- 42 Paganini-Hill A, Ross RK. Reliability of recall of drug usage and other health-related information. Am J Epidemiol 1982; 116: 114-22.
- 43 Oberlander J, Saunders C, Knox L, Crosby L, Mullen J. Survey of weight scale variability. JPEN 1981; 04: 606.
- 44 Schlegal-Pratt K, Heizer WD. The accuracy of scales used to weigh patients. Nutr Clin Prac 1990; 05: 254-7.
- 45 Kramer MS, McLean FH, Boyd ME, Usher RH. The validity of gestational age estimation by menstrual dating in term, preterm, and postterm gestations. JAMA 1988; 260: 3306-8.
- 46 Ott WJ. Accurate gestational dating. Obstet ‘ Gynecol 1985; 66: 311-5.
- 47 Backe B, Nakling J. Term prediction in routine ultrasound practice. Acta Obst Gynecol Scand 1994; 73: 113-8.
- 48 Rowlands S, Royston P. Estimated date of delivery from last menstrual period and ultrasound scan: which is more accurate?. Br J Gen Prac 1993; 43: 322-5.
- 49 Rasmussen S, Dalaker K, Berge LN, Lundgren R, Løvslett K. One-stage ultrasound screening in pregnancy: An evaluation. Acta Obst Gynecol Scand 1990; 69: 581-8.
- 50 Hadlock FP. Sonographic estimation of fetal age and weight. Radiologic Clin N Am 1990; 28: 39-50.
- 51 Hadlock FP, Deter RL, Harrist RB, Park SK. The use of ultrasound to determine fetal age - A review. Med Ultrasound 1983; 07: 95-103.
- 52 Hadlock FP, Harrist RB, Martinez-Poyer J. How accurate is second trimester fetal dating?. J Ultrasound Med 1991; 10: 557-61.
- 53 Piantelli G, Sacchini C, Coltri A, Ludovici G, Paita Y, Gramellini D. Ultrasound dating-curve analysis in the assessment of gestational age. Clin Exp Obstet Gynecol 1994; 21: 108-18.
- 54 Persson PH, Weldner BM. Reliability of ultrasound fetometry in estimating gestational age in the second trimester. Acta Obstet Gynecol Scand 1986; 65: 481-3.
- 55 Wolfe HM, Sokol RJ, Martier SM, Zador IE. Maternal obesity: A potential source of error in sonographic prenatal diagnosis. Obstet Gynecol 1990; 76: 339-42.
- 56 Sweet BR. Baillière’s Midwives’ Dictionary. 8th ed.. London: Baillière Tindall; 1992
- 57 Registrar General’s Classification of Occupations. London: HMSO; 1970