sentinel event case study

• Ewen, Brenda M. MSN, RN, CPHRM
• Bucher, Gale MSN, RN, COS-C

Adverse events, including sentinel events, require comprehensive review to improve patient safety and reduce healthcare errors. Root cause analysis (RCA) provides an evidence-based structure for methodical investigation and comprehensive review of an event enabling appropriate identification of opportunities for improvement. Use of RCA is described in the home care setting.

Article Content

Every day, serious adverse events occur in healthcare systems across the country resulting in injury to tens of thousands of people annually ( Institute of Medicine, 1999 ). Home care is not immune. Lack of staff supervision, communication, coordination of care, reduced ability to engage in double checks, lack of care environment control, and a heightened reliance on patient and family cooperation are situations unique to home care that contribute to serious adverse events. Some of these events will rise to the level of a sentinel event as defined by The Joint Commission.

Sentinel Event

The Joint Commission defines a sentinel event as "an unexpected occurrence involving death or serious physical or psychological injury, or the risk thereof" (The Joint Commission, 2012, p. 1). "Risk thereof" refers to incidents for which a recurrence would involve a significant risk of serious adverse outcome. The Joint Commission (2012) further defines reviewable sentinel events as occurrences that result in "an unanticipated death or major permanent loss of function not related to the natural course of the patient's illness or underlying condition" (p. 1). Permanent loss of function may refer to sensory, motor, physiologic, or intellectual impairment requiring continued treatment or change in lifestyle not present at the start of care.

The Joint Commission's policy on sentinel events includes a subset of events that are considered reviewable regardless of death or serious injury ( The Joint Commission, 2013b ). In the past, these events have included occurrences involving patients or those receiving services. In July 2013, this list expanded to include certain "harm events" to staff, visitors, or vendors that occur on the healthcare organization's premises (The Joint Commission, 2012).

Root Cause Analysis

The Joint Commission designates events as sentinel because they require an immediate investigation and response. Accredited organizations are expected to respond to sentinel events with a "thorough and credible root cause analysis [RCA] and action plan" ( The Joint Commission, 2013a , p. 12). RCA can be defined as "a process for identifying the basic or causal factors that underlie variation in performance ( Anderson et al., 2010 , p. 8). RCA is a powerful tool used to improve systems, mitigate harm, and prevent recurrence of adverse events without directing individual blame. These goals are accomplished through in-depth examination of an organization's processes and systems with the purpose of answering three questions:

1. What happened?

2. Why did it happen?

3. What can be done to prevent it from happening again?

Identifying the RCA Team

Preparation for RCA begins immediately after the event is declared sentinel. The Joint Commission allows 45 days for completion of the analysis and development of an action plan. Delays in beginning the process could result in unnecessary stress to meet the deadline. The first step in the RCA process is the identification of team members.

A multidisciplinary team, which includes staff members with knowledge of the processes and systems, allows for an effective analysis of the event. Leadership needs be involved to bring decision-making authority to the table. Individuals able to implement change are needed. The decision to involve staff directly related to the sentinel event should be made on a case-by-case basis. Individuals emotionally traumatized by an event may be further distressed through inclusion on the team.

Teams are most effective when members are chosen for their willingness to participate and cooperate. Honed listening and communication skills are key ( Anderson et al., 2010 ). Members must be motivated with time to attend meetings and accomplish assignments. Members may attend all meetings or do so on an as needed basis.

The team needs to have a designated team leader and facilitator. Leaders with authority in the organization, knowledge of the event, and the ability to build consensus are most capable. The facilitator must be experienced with conducting RCA as well as managing groups. Small teams allow for the greatest efficiency ( Croteau, 2010 ).

Gathering Information

Gathering appropriate information is vital to the team's ability to define the problem and determine what happened. Witness information needs to be gathered quickly before memories begin to fade. Staff must be reassured that RCA is confidential and not used for discipline. Individual interviews can provide information that has not been influenced by others. Clinicians may feel more comfortable discussing the event in private. Group interviews can be used to increase the exchange of ideas and the development of problem-solving strategies. Open-ended questions are an effective means of encouraging staff to share, clarify, or elaborate information.

Pertinent medical records, photographs, notes, and phone logs should be gathered. Relevant policies, procedures, training or education records, time sheets, and schedules should be collected. A literature review, pertaining to the process in question, conducted early in the RCA helps to identify the root cause, strategies, and actions.

If a device or piece of equipment is involved, secure it for examination. Gather manufacturer guidelines, directions for use, and maintenance logs. It should be determined if the Safe Medical Devices Act requires reporting ( http://www.fda.gov/downloads/MedicalDevices/DeviceRegulationandGuidance/Guidance ).

Organizing Information

RCA often involves large amounts of information. It is critical to the success of the analysis that all information is well organized and easy to access. Team charters, agendas, and project plans can be used to outline objectives, set target dates, assign responsibility, and keep the team on track. A brief, factual summary of the event, written early in the process, will keep the team focused. Timelines and flow sheets improve understanding and identify disciplines.

Flow charts, affinity charts, or fishbone diagrams can be used to organize information in a visual format. Flow charts outline a process as it is designed as well as how it is commonly carried out. A comparison between a written process and the way it is implemented provides insight into process failures. Fishbone diagrams highlight contributing factors and causes. Affinity charts organize potential causes. The Joint Commission developed tools, including a RCA framework and action plan template, ensure comprehensive review of the event, and organize findings. Tools can be found at http://www.jointcommission.org/sentinel_event.aspx .

Contributing Factors

After information is gathered and organized, the team starts to identify factors that contributed to the event. Contributing factors are system failures that produce consequences ( Croteau, 2010 ). They are the causes of the event, although not necessarily the main cause. The key to the discovery of contributing factors is the question, "Why?"

When determining contributing factors, discussion needs to focus on outcomes and processes not on individual behavior(s). Examine processes to determine if they are inherently flawed or if a variation in the process occurred leading to the event. All possible contributing factors must be considered. Examples of possible factors include:

1. Human factors (human limitations and capabilities): Human limitations and capabilities such as fatigue, distraction, or inattentional blindness. (See Box 1 .)

2. Patient assessment: Timeliness, accuracy, link to plan of care, documentation, communication.

3. Equipment: Availability, function, condition, appropriate maintenance and calibration.

4. Environmental: Lighting, accessibility, privacy, safety.

5. Information: Accessibility, accuracy, completeness.

6. Communication: Technology, documentation, timing, handoff.

7. Training/competency: Education, scope of practice, competency assessment, qualifications, effectiveness.

8. Procedural compliance: Compliance, availability of procedures and policies, barriers.

9. Care planning: Individualized, effectiveness.

10. Organizational culture: Response to risk and safety issues, communication of priorities related to safety, and prevention of adverse outcomes.

The Joint Commission offers a "Minimum Scope of Root Cause Analysis for Specific Types of sentinel events," which can aid the team in conducting a thorough review of contributing factors (The Joint Commission, n.d.). Members need to participate in conversation analyzing contributing factors. The importance of exchanging thoughts without criticizing must be emphasized. Whiteboards and flips charts are an excellent way to group ideas and ensure that all team members can visualize information. Once the team has identified all possible contributing factors, the root cause can be identified.

Identifying the Root Cause

To identify the root cause, the team will drill down the contributing factors until the root cause, or most fundamental causal factor of the event, is determined. Success depends on the team's ability to remain focused on system issues instead of human error. When a human error is involved, the cause of the error must be identified. It is the cause of the error, not the error, which must be corrected to prevent recurrence.

There are many tools available to assist teams. "Five Whys" is easily used to isolate a root cause ( Anderson et al., 2010 ). The team starts with listing a contributing factor on a white board. They then ask, "Why?" The answer is listed on the white board and becomes the next factor requiring an answer to "Why?" This process continues until no new answer occurs.

For example, in the case of a wound infection, the team may start with the contributing factor of an unintended retention of a dressing.

There was a retained dressing. Why?

The count was not reconciled. Why?

Clinician A was unable to reconcile the dressing count. Why?

Clinician B had not documented the count. Why?

Clinician B forgot to document. Why?

Clinician B didn't have her laptop during that visit and was unable to document until later.

In this example, it takes many "Whys" before the root cause (a delay in documentation) is determined.

Identifying the root cause may be accomplished by asking three questions ( Croteau, 2010 ):

1. Is it likely that the problem would have occurred if the cause had not been present?

2. Is the problem likely to recur due to the same causal factor if the cause is corrected?

3. Is it likely that a similar condition will recur if the cause is corrected or eliminated?

If the answer to each question is "No," then the team has identified the root cause. In the above example, it is not likely that the clinician would have forgotten to document the count if she had been able to document immediately in the home. Nor is it likely a similar problem would occur if the root cause were corrected.

It is essential that the RCA team does not prematurely stop asking "why," so that the true root cause can be identified. The team may consider whether the identified cause is actionable to prevent recurrence ( Croteau, 2010 ). If it is, it may be acceptable to stop questioning. Teams must also recognize that more than one root cause is possible. Interactions between root causes cannot be overlooked and may be the actual precipitators of the event ( The Joint Commission, 2013b ). The correction of one cause does not necessarily mean the recurrence of the event will be prevented. All root causes must be corrected.

The root cause statement needs to be succinct. The Veteran's Health Administration (n.d.) suggests considering the following guidelines while developing the statement:

1. Clearly demonstrate cause and effect.

2. Avoid negative words such as "poor" or "negligent."

3. Every human error has a preceding cause.

4. Procedure violations have a preceding cause; they are not root causes.

5. Failure to act is only a root cause if there is a preexisting duty to act.

Action Plans

After determining the root cause, the team focuses on identifying strategies to reduce the risk of recurrence. Although the goal is to implement interventions to prevent a repeat of the event, the team must understand that failures and errors do occur. Design strategies to minimize the risk a process failure will reach the patient and to mitigate the effects of the failure if it does (The Joint Commission, 2010). Strategies directed at system and process issues, not individual performance or behavior, are most effective in preventing reoccurrence.

Actions that are concrete, easily understood, and clearly linked to the root cause or a contributing factor are most valuable. To avoid work-arounds, make the safest thing to do the easiest thing to do. The plan needs to clearly define who is responsible for implementing each action and a time line for completion. Action plans may include pilot testing. Determine strategies for measuring the effectiveness of each action.

Actions can vary in effectiveness. The National Center for Patient Safety (n.d.) provides a recommended Hierarchy of Actions on their Web site. Stronger actions are thought to be the most successful. Actions are divided into three categories:

* Physical changes to the work environment,

* Forcing functions,

* Simplification of the process, and

* Standardization.

Intermediate:

* Increase staffing,

* Software modifications,

* educe distractions,

* Checklists/cognitive aids,

* Read back,

* Eliminate look and sound alikes,

* Enhanced documentation or communication, and

* Redundancy.

* Double checks,

* New procedures,

* Training, and

* Warnings.

Once proposed actions are decided, cost, resources, long-term sustainability, and barriers to implementation must be considered. Buy-in from leadership and those on the front lines who will be impacted is critical. Those assigned individual actions must take ownership.

Sharing results of the RCA with leadership is necessary. Reports include a brief description of the event, analysis, the root cause, contributing factors, and the action plan. Share lessons learned with all staff. Transparency demonstrates that RCAs are not punitive, but a method to change processes and improve patient safety.

RCA is an excellent tool for identifying causes of sentinel events. The focus on systems and processes instead of performance brings with it a welcome change from past practices of placing blame on individuals. RCA can be used any time a home care agency has a serious adverse event. (See Figure 1 .) RCA can also be used proactively to examine near misses. Instead of asking "what happened," the team asks "what might have happened?" Either way, RCA can improve systems and processes and keeps patients safer.

RCA Case Study: Retained Foreign Object

A 75-year-old female patient was readmitted to the hospital with a wound infection post abdominal excision of a large seroma and delayed primary wound closure. Negative pressure wound therapy (NPWT) was initiated on January 5 and replaced with a wet to dry dressing prior to hospital discharge on January 8. The patient was admitted to home care and NPWT was reinitiated by Nurse 1. Information on packing count was not made available to the agency and there was no follow-up contact with the hospital staff.

Later that day, the patient complained that the NPWT system was not functioning. Nurse 1 determined the NPWT was defective, and packed wet to dry pending delivery of a new NPWT device. According to the electronic medical record, the wound was packed with six, 4 4 gauze pads, topped with three, 4 4 gauze pads (nine total) and four large abdominal gauzes pads secured with tape during the interim. The packing count removed, packing placed, and description for this dressing was documented in the clinical note.

On January 9, Nurse 2 removed and counted seven pieces of gauze and packed the wound with white foam, covered with black foam, and initiated the new NPWT system with no documentation of packing reconciliation. Seven pieces of gauze removed did not reconcile with the previous note, but went unnoticed. Once the NPWT was in place, the patient received home visits 3 days a week (Monday, Wednesday, and Friday) for wound assessment and dressing changes.

On January 11, Nurse 1 removed the NPWT dressing, including black and white foam as noted and one 4 4 gauze pad found in the wound bed. The nurse made a thorough exam of the wound bed using a sterile Q-tip and flashlight to visualize the deep wound bed. The patient was experiencing an increase in pain and had a temperature of 99.1[degrees]F. The nurse reported the findings immediately to the supervisor and the surgeon. The patient was accompanied by the home care nurse to the surgeon's office for further wound exploration. The patient was started on antibiotics in response to a positive wound culture.

The Joint Commission's policy on sentinel events includes retained foreign body as a reviewable event. This event warranted an immediate RCA. A timeline was created using the medical record. Inpatient records were reviewed to pinpoint when packing could have been retained. Review of inpatient and home care records indicated that it was a possibility that the gauze was retained during the inpatient stay. Because of the lack of documentation reconciliation and/or error in removing all dressings from the wound, the time of packing retention could not be pinpointed.

As one can see from the documentation, the investigation and "what-ifs" can be complex. If the reader is counting, one gauze pad is still unaccounted. The first opportunity missed was communication of packing from the hospital. The second missed opportunity occurred on January 9 when the nurse did not document that the count of packing removed was reconciled with the documentation from January 8. The gauze pads could have been retained at any point where there was no communication and/or reconciliation. A gauze pad could have been saturated in a large wound and gone unnoticed. Do staff count and reconcile cover dressings? How thoroughly are staff checking the wound bed to ensure there are no retained dressings?

The team consisted of the agency's chief nursing officer as leader, medical advisor as champion, risk manager as facilitator, wound ostomy continence nurse, supervisor, and staff nurse representatives. Members were selected to provide expert opinions and offer solutions. The chief nursing officer was essential for decision making and implementation of change. The team began the investigation by finding out what happened from interviews and documentation review. An immediate action was to send an alert to staff regarding the importance of adhering to procedures on packing reconciliation and documentation. It is imperative that staff are notified to reduce likelihood of recurrence even during investigation. The team developed an affinity chart to identify possible cause(s) and contributing factors. (See Figure 2 .)

Contributing factors were as follows:

* Process for documenting wound packing and cover dressings was not standardized.

* Lack of available Kerlix for single length packing of wounds.

* Risk of retained packing increases with use of multiple dressings.

* Variation in wound assessment; wounds are inconsistently probed and examined with high-quality lighting.

* Large wound with copious drainage made it more likely that dressings would become saturated and invisible in the wound bed.

* Reconciling counts was inconsistent among staff. This was a new process and nurses were still integrating it into practice.

The team learned that secondary cover and packed dressing materials can saturate and stick together, making it difficult to differentiate from cover and packed materials. The root cause determined by the team: Gauze used to cover wounds are not included in the count and reconciliation process; this practice increases the potential for the cover dressing to be counted as wound packing in large wounds with copious drainage resulting in a retained foreign body . This shows that the cause-and-effect relationship, if controlled or eliminated, will prevent or minimize future events. The root cause statement includes a specific description for the preceding cause, not human error or procedure violation.

Risk reduction strategies/actions were identified to eliminate or reduce the chance that the event would recur. There should be an action for each cause and contributing factor. The following actions were implemented:

* Policy : Referrals involving packed wounds must include packing count for reconciliation.

* Procedure : Revision of wound packing process included a process for counting packing and cover dressings, limiting use of multipieces used for packing and documenting dressings materials on the outside of the dressing. The nurse will immediately notify the supervisor when packing is not reconciled.

* Availability of equipment : Supply a dressing kit including single length Kerlix for use on all NPWT cases in the event that NPWT is interrupted. Upgrade quality of flashlights for wound exploration.

* Communication : Develop a log for patients and family members who change or reinforce dressings. Standardize clinical documentation and evaluate potential for customizing documentation software to include alerts. Adherence is evaluated during record review and shared with supervisors and staff.

* Training/competency : Instruct staff on the rationale for accounting for all dressing materials. Simulation training was utilized for demonstration of NPWT dressings and new documentation requirements.

The actions listed include stronger actions such as simplification (use of single length of packing material) and forcing function (software alerts). Although routine staff training is considered a weaker action, use of simulation is considered highly effective. Each action was assigned to an individual who was accountable.

Equally important was sharing lessons learned with the organization. Home healthcare agencies that are part of a healthcare system may have a structure that requires broader sharing results of the RCA. The committee may include members from other care settings and community experts. In our example, new handoff procedures from one level of care to another can result in increased patient safety.

The use and understanding of RCA is essential to healthcare risk management. Healthcare professionals who master RCAs offer valuable expertise to the organization. Experts drive direct care staff to identify best strategies for patient safety.

Anderson B., Fagerhaug T., Beltz M. (2010). Root Cause Analysis and Improvement in the Healthcare Sector . Milwaukee, WI: ASQ Quality Press. [Context Link]

Croteau R. J . (Ed.). (2010). Root Cause Analysis in Health Care: Tools and Technique . Oakbrook Terrace, IL: Joint Commission Resources. [Context Link]

Department of Veterans Affairs National Center for Patient Safety (NCPS). (n.d). Root cause analysis tools . Retrieved April 5, 2013, from http://www.patientsafety.gov/CogAIds/RCA/index.html

Gosbee J. (2010). Handoffs and communication: The underappreciated roles of situational Awareness and inattentional blindness. Clinical Obstetrics and Gynecology , 53(3), 545-558.

Green M. (2004). "Inattentional blindness" and conspicuity. Retrieved from http://www.visualexpert.com/Resources/inattentionalblindness.html

Institute of Medicine. (1999). To Err is Human: Building a Safer Health System . Retrieved April 3, 2013, from http://www.nap.edu/openbook.php?isbn=0309068371 [Context Link]

Sentinel event policy expanded beyond patients. Joint Commission Perspectives, 32 (12), 1-3.

The Joint Commission. (2013a). Comprehensive Accreditation Manual for Home Care . Oakbrook Terrace, IL: Joint Commission Resources. [Context Link]

The Joint Commission. (2013b). Responding to sentinel events conducting an effective root cause analysis. The Source, 32 (12), 12-14. [Context Link]

The Joint Commission. (n.d.). Sentinel events . Retrieved April 3, 2013, from http://www.jointcommission.org/assets/1/6/2011_CAMLTC_SE_(2).pdf

Connect with NursingCenter

Connect with us on Facebook, Twitter, Linkedin and Google+

All Content

Sentinel events.

• Joen Pritchard Kinnan

In July, a teenage mother-to-be entered a Madison, Wis., hospital to give birth. Within hours she was dead, though her baby survived.

An investigation by the Wisconsin State Department of Health revealed that the young woman had died after receiving an intravenous dose of an epidural anesthetic instead of the penicillin she was supposed to be given. Shortly after receiving the injection, the teenager had a seizure. She died less than two hours later.

In explaining what had happened, a nurse told investigators that the patient had been nervous about how she was to be anesthetized during the birth. To ease her concerns, the nurse brought out the epidural bag and told her how it worked. Unfortunately, it was one bag too many; the nurse later confused the epidural bag with the penicillin bag. The consequences were fatal.

The Human Toll

Such sentinel events are all too common. According to a just-released report, Preventing Medication Errors , prepared by the Institute of Medicine (IOM) at the behest of the Centers for Medicare and Medicaid Services, medication errors harm 1.5 million people yearly in the U.S. and kill thousands. The annual cost: at least $3.5 billion. But medication mistakes are just part of the picture.

Sentinel events—unexpected occurrences that result in death or serious physical or psychological injury, or the risk of their later occurrence—can happen anywhere along the healthcare continuum, in any setting. Statistics from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), however, show that 68% occur in general hospitals and another 11% in psychiatric hospitals. JCAHO tracked the sentinel events they reviewed from 1995 to March of 2006 and found that the most commonly reported sentinel events were patient suicide, wrong-site surgery, operative/postoperative complications, medication errors, and delay in treatment—in that order. Of the total number of cases reviewed, 73% resulted in the death of the patient and 10% in loss of function.

Hard-and-fast statistics on sentinel events are difficult to come by, however. Information from the JCAHO covers only the incidents reviewed by that organization, and experts agree that almost all types of sentinel events are under-reported. Researchers cite a number of reasons that many incidents go unreported; among them are lack of time, fear of punishment, and confusion about the severity of events that require notification. For example, do near misses count? (See “Near Misses,” The Hospitalist , May, p. 34.) Others see no benefit to themselves or their institutions from reporting.

Studies have attempted to define the true incidence of sentinel events, but a lack of consistent language and definitions makes it difficult to put the whole puzzle together, even when sentinel events do come to the surface.

Focus on Medication Errors

Share: , comment on this article cancel reply.

Your email address will not be published. Required fields are marked *

An official website of the United States government

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

• Publications
• Account settings
• My Bibliography
• Collections
• Citation manager

Save citation to file

Email citation, add to collections.

• Create a new collection
• Add to an existing collection

Add to My Bibliography

Your saved search, create a file for external citation management software, your rss feed.

• Search in PubMed
• Search in NLM Catalog
• Add to Search

Sentinel events. In memory of Ben--a case study

Affiliation.

• 1 Martin Memorial Health System, USA.
• PMID: 10177138

PubMed Disclaimer

Similar articles

• Medication errors in anaesthesia and critical care. Wheeler SJ, Wheeler DW. Wheeler SJ, et al. Anaesthesia. 2005 Mar;60(3):257-73. doi: 10.1111/j.1365-2044.2004.04062.x. Anaesthesia. 2005. PMID: 15710011 Review.
• Practical guide for improving performance. Spath PL. Spath PL. OR Manager. 2004 Mar;20(3):23-6. OR Manager. 2004. PMID: 15042724 Review. No abstract available.
• Medical errors: root cause analysis. Spath P. Spath P. OR Manager. 1998 Sep;14(9):38, 40-1. OR Manager. 1998. PMID: 10185635 No abstract available.
• Child's death leads to new medication error policies. [No authors listed] [No authors listed] Hosp Peer Rev. 1998 Aug;23(8):141-3, 146. Hosp Peer Rev. 1998. PMID: 10181311 No abstract available.
• OR med mix-up likely cause of boy's death. [No authors listed] [No authors listed] OR Manager. 1996 Dec;12(12):17-8. OR Manager. 1996. PMID: 10172862 No abstract available.
• Medication errors: pharmacovigilance centres in detection and prevention. Bencheikh RS, Benabdallah G. Bencheikh RS, et al. Br J Clin Pharmacol. 2009 Jun;67(6):687-90. doi: 10.1111/j.1365-2125.2009.03426.x. Br J Clin Pharmacol. 2009. PMID: 19594539 Free PMC article.

Publication types

• Search in MeSH

LinkOut - more resources

• MedlinePlus Health Information
• Citation Manager

NCBI Literature Resources

MeSH PMC Bookshelf Disclaimer

The PubMed wordmark and PubMed logo are registered trademarks of the U.S. Department of Health and Human Services (HHS). Unauthorized use of these marks is strictly prohibited.

• Subscribe to journal Subscribe
• Get new issue alerts Get alerts

Secondary Logo

Journal logo.

Colleague's E-mail is Invalid

Your message has been successfully sent to your colleague.

Save my selection

Clinical nurses' experiences with sentinel events

Stone, Misty MSN, RN

Misty Stone is a clinical assistant professor at the University of North Carolina at Greensboro.

The author has disclosed no financial relationships related to this article.

This study describes nurses' experiences with sentinel events in hospital settings, including intensive care, medical-surgical, long-term care, psychiatric, and Alzheimer units.

Full Text Access for Subscribers:

Individual subscribers.

Institutional Users

Not a subscriber.

You can read the full text of this article if you:

• + Favorites
• View in Gallery

Readers Of this Article Also Read

Mitigating workplace violence: an interdisciplinary approach to a behavioral..., best practices for burnout self-care.

• Open access
• Published: 12 June 2024

Risk factors for neonatal hypoxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study

• Suoma Roto 1 ,
• Irmeli Nupponen 2 ,
• Ilkka Kalliala 1 &
• Marja Kaijomaa   ORCID: orcid.org/0000-0003-2180-1483 1  

BMC Pregnancy and Childbirth volume  24 , Article number:  421 ( 2024 ) Cite this article

112 Accesses

2 Altmetric

Metrics details

Peripartum asphyxia is one of the main causes of neonatal morbidity and mortality. In moderate and severe cases of asphyxia, a condition called hypoxic-ischemic encephalopathy (HIE) and associated permanent neurological morbidities may follow. Due to the multifactorial etiology of asphyxia, it may be difficult prevent, but in term neonates, therapeutic cooling can be used to prevent or reduce permanent brain damage. The aim of this study was to assess the significance of different antenatal and delivery related risk factors for moderate and severe HIE and the need for therapeutic hypothermia.

We conducted a retrospective matched case-control study in Helsinki University area hospitals during 2013–2017. Newborn singletons with moderate or severe HIE and the need for therapeutic hypothermia were included. They were identified from the hospital database using ICD-codes P91.00, P91.01 and P91.02. For every newborn with the need for therapeutic hypothermia the consecutive term singleton newborn matched by gender, fetal presentation, delivery hospital, and the mode of delivery was selected as a control. Odds ratios (OR) between obstetric and delivery risk factors and the development of HIE were calculated.

Eighty-eight cases with matched controls met the inclusion criteria during the study period. Maternal and infant characteristics among cases and controls were similar, but smoking was more common among cases (aOR 1.46, CI 1.14–1.64, p  = 0.003). The incidence of preeclampsia, diabetes and intrauterine growth restriction in groups was equal. Induction of labour (aOR 3.08, CI 1.18–8.05, p  = 0.02) and obstetric emergencies (aOR 3.51, CI 1.28–9.60, p  = 0.015) were more common in the case group. No difference was detected in the duration of the second stage of labour or the delivery analgesia.

Conclusions

Smoking, induction of labour and any obstetric emergency, especially shoulder dystocia, increase the risk for HIE and need for therapeutic hypothermia. The decisions upon induction of labour need to be carefully weighed, since maternal smoking and obstetric emergencies can hardly be controlled by the clinician.

Peer Review reports

Peripartum asphyxia, generally referred to as birth asphyxia, is one of the main causes of neonatal mortality worldwide [ 1 ]. Approximately three to five newborns per 1000 live births in developed countries are affected by birth asphyxia [ 2 ]. This condition of hypoxia and acidemia can develop gradually during pregnancy and lead to an emergency cesarean section when detected. It can also develop abruptly when complications during labour occur [ 3 ].

The pathophysiology of birth asphyxia and its multifactorial antecedents are well studied and recognized: An increased risk is associated with maternal health problems such as diabetes mellitus, cholestasis of pregnancy, anemia, and hypertension, as well as fetal conditions like intrauterine growth restriction and infections [ 4 , 5 ]. Extensive effort is made to screen and follow-up these mothers and pregnancies with known obstetric risk factors for development of birth asphyxia.

The clinical signs associated with birth asphyxia may be transient and reversible or lead to permanent neurological impairment or death [ 6 ]. A condition called hypoxic-ischemic encephalopathy may follow and, if diagnosed, can further be divided in mild, moderate, and severe [ 7 ]. A quick recovery, normal level of consciousness, mild neurological signs and absence of seizures are typical to a mild HIE, whereas moderate and severe HIE include presence of seizures, multiorgan failure, primitive reflexes and altered level of consciousness and tone [ 7 ]. The diagnosis of severe birth asphyxia is set when the neonate presents with a five-minute Apgar score of 0 to 3 and a pH of 7.0 or less in the umbilical artery blood sample [ 4 ].

In the severe cases of birth asphyxia, HIE predisposes the resuscitated neonate to permanent neurologic morbidities such as cerebral palsy, epilepsy, and developmental delays. The medical intervention to reduce brain damage in term neonates with moderate and severe HIE is therapeutic hypothermia, i.e., cooling of the neonates to around 33 °C for three days [ 8 ].

Despite the high-quality maternal care and the recognition of antenatal risks, birth asphyxia and HIE remain a challenge in perinatal care. Due to the multifactorial nature of fetal distress [ 9 , 10 ], the adverse outcome is not always predictable in risk pregnancies. In addition, many cases of HIE occur unanticipated in low-risk pregnancies.

The aim of this study was to assess the importance of different obstetric risk factors associated with moderate and severe HIE and the need for therapeutic hypothermia in term neonates delivered at the hospitals of Helsinki University Hospital area. We particularly focused on the management protocols of pregnancy and delivery.

This was a retrospective, matched case-control study concerning pregnancies and deliveries in the Helsinki University Hospital area. The same guidelines for follow-up and treatment of pregnancy and delivery are used in all Helsinki University area hospitals. The neonatal intensive care is centralized at the Neonatal Intensive Care Unit (NICU) in Helsinki University Hospital Women’s Clinic. The study period was from January 1, 2013, to December 31, 2017. The treatment of deliveries in the Helsinki University Hospital area was re-organized after a closure of one delivery hospital in late 2017 and the patient record systems was changed in early 2020. Due to the possible bias caused by these factors, years after 2017 were excluded from the study.

The study group consisted of patients who gave birth to asphyxiated singleton neonates with aforementioned symptoms of moderate or severe HIE. Each neonate was born term (one case of 36 6/7 gestation weeks), was admitted to the NICU and offered therapeutic hypothermia for neuroprotection. The indications for hypothermia were admitted from the international guidelines and previous research [ 2 ].

After each delivery with an asphyxiated newborn, the consecutive term singleton, matched by the delivery hospital, fetal gender, presentation (occipital vs. breech), and the mode of delivery (vaginal, assisted vaginal, elective, emergency, and crash cesarean delivery), was selected as a control. An emergency cesarean was defined as a decision-to-delivery-interval of 30 min and a crash cesarean as an immediate delivery after the decision to deliver. Subgroups were formed based on the mode and onset (spontaneous vaginal delivery, induced vaginal delivery, failed induction and cesarean, cesarean) of delivery.

The data for the study was collected from the hospital database (Siemens Obstetrix). All available information concerning fetal and maternal well-being during pregnancy and delivery was collected. This included maternal age and health (pregestational body mass index (BMI), chronic illnesses, medication), gestation at delivery, parity and previous births, and information concerning hospital visits during the ongoing pregnancy. Data on the time of hospital admission and the time of birth in relation to midwife work shifts was also obtained. We considered and tested multiple previously suggested risk factors for HIE or birth asphyxia [ 11 , 12 , 13 , 14 , 15 , 16 , 17 , 18 , 19 , 20 , 21 , 22 , 23 , 24 ] and analyzed their possible interactions.

Statistics/analyses

SPSS version 25.0.0 (IBM SPSS Statistics, Armonk, New York) was used to analyze the data. Independent samples t-test and Chi-square test were used for comparing continuous and categorical variables within subgroups, and for testing the independence of variables. Interactions between variables were further assessed with a stratified analysis. ( S10 )

Crude and adjusted odds ratios (OR and aOR respectively) were calculated using logistic regression to estimate associations between different independent variables and the outcome. From the univariate logistic regression, variables with a p  < 0.1 were exported to the multivariable logistic regression analysis. A forward stepwise logistic regression analysis was used to suggest multivariable models. Statistical significance was declared at p  < 0.05 and the CIs were set to 95%. Due to the novel study design and small sample sizes, we saw fit to try out and present two different approaches to the multivariate logistic regression analysis.

We used Benjamini-Hochberg corrected p -values (q-values) in the univariate logistic regression to account for multiple testing [ 25 ]. Missing values of > 5% per category were imputed using the fully conditional specification method and with maximum iterations of 10.

During the study period, 98 355 deliveries took place in Helsinki University area hospitals, the average being 19 671 per year. One hundred and twelve term neonates (including one case of 36 + 6 gestational weeks) presented with moderate to severe HIE and were admitted to the NICU to receive therapeutic hypothermia. The study period incidence of therapeutic hypothermia for signs of moderate to severe HIE in our obstetric population was 1.0/1000.

After excluding twin pregnancies, ninety-seven singleton pregnancies with neonatal HIE and therapeutic hypothermia made up the primary study group. Due to the failure to find matched controls, nine more pregnancies were excluded, leaving us with the final study group of eighty-eight cases.

Altogether, 45.5% of the neonates (40/88) in the study group were born vaginally and 65% (26/40) of them were ventouse-assisted. Two neonates were vaginally born in breech position. Cesarean deliveries constituted 54.5% (48/88) of study group deliveries, including elective, emergency, and crash procedures with the proportion of 2.0% (1/48), 29.2% (14/48), and 68.8% (33/48) respectively. Four emergency cesarean sections were preceded by a failed instrumental delivery. Due to the matching by delivery mode, the proportions were equal in the control group (Fig.  1 : The mode of delivery among cases of HIE and therapeutic hypothermia). The mortality in the study group was 10.2% (9/88). There were no neonatal deaths in the control group.

The mode of delivery (%) among cases of hypoxic ischemic encephalopathy and therapeutic hypothermia

Approximately the same proportion of patients in the groups were nulliparous (62.5% vs. 59.1%, p  = 0.576), and no difference was observed in mean maternal age (31.99 vs. 32.96, p  = 0.239) and BMI (24.20 vs. 23.96, p  = 0.467). The mean number of daily cigarettes (1.9 vs. 0.4) was higher ( p  = 0.001) in the study group. No difference was detected in the mean gestational age at delivery (38.89 vs. 40.21 gestational weeks, p  = 0.160) and newborn weight (3458.61 vs. 3472.33 g, p  = 0.898). Post term pregnancy was more common (3.41% vs. 13.64%, p  = 0.024) in the control group (Table  1 ).

There was no difference in the incidence of the most common antenatal complications, such as hypertension or preeclampsia (10.23% vs. 12.50%, p  = 0.797), intrauterine growth restriction (5.68% vs. 7.95%, p  = 0.552), gestational (13.64% vs. 15.91, p  = 0.671) diabetes, type I diabetes (4.55% vs. 3.41%, p  = 0.701) or suspected chorionamniotis (7.95% vs. 6.82%, p  = 0.773). There were no cases of diabetes type II in the study group (0% vs. 2.27%, p  = 0.497) and cholestasis of pregnancy in the control group (3.41% vs. 0%, p  = 0.246) (Table  2 ).

We detected a higher incidence of labour induction in the study group (21.59% vs. 9.09%, p  = 0.025), but no difference was detected in the incidence of cesarean after a failed induction (4.55% vs. 11.36%, p  = 0.106) or the phase II duration of delivery (35.44 min vs. 46.38 min, p  = 0.098). The overall incidence of any obstetric emergency, i.e., shoulder dystocia, placental abruption, or uterine rupture, was higher ( p  = 0.038) in the study group (20.45% vs. 10.23%), driven by a markedly higher incidence of shoulder dystocia (6.82% vs. 0%, p  = 0.029).

There was no difference in the use of epidural (56.82% vs. 68.18%, p  = 0.121), spinal (31.82% vs. 29.55%, p  = 0.744) or oral opioid (20.45% vs. 23.86%, p  = 0.586) anesthesia of deliveries, whereas the use of oxytocin augmentation (27.27% vs. 57,95%, p  < 0.001) and nitrous oxide (38.64% vs. 53.41%, p  = 0.050) was more common in the control group.

Midwife shift change during the active phase of delivery (45.45% vs. 60.23%, p  = 0.051) was somewhat more frequent in the control group and the incidence of delivery during the night shift insignificantly more common in the study group (48.86% vs. 37.50%, p  = 0.070) (Table  2 ).

The univariate analysis showed that nine independent variables were associated ( p  < 0.1) with either the presence or absence of moderate to severe HIE: Smoking, post term pregnancy, induction of delivery, duration of phase II, any obstetric emergency, augmentation of delivery by oxytocin (all stages of labour, including induction), use of nitrous oxide, shift change of midwives during active delivery, and delivery during night shift (10 pm. to 8 am.).

In the multivariate regression model with four to eight variables in the same model, obstetric emergencies, labour induction and smoking significantly increased the odds of HIE (Table  3 , Supporting information Tables S1 - S9 ). We were able to repeat these results in most of the tried models. Induction of labour had a significant association with HIE ( p  = 0.02) in all tried models, but there was no significant association with HIE and the subgroups of induction methods (balloon catheter, vaginal misoprostol, amniotomy followed by oxytocin-infusion), when entered separately to the regression analysis. In fact, in just 33% of cases only one induction method was used.

In the stratified analysis, the association of induction of labour with HIE was even stronger when oxytocin augmentation was used, OR 9.2 (2.71–31.21). Also, the midwife shift change in induced labours resulted in higher OR for HIE (4.5, 1.73–12.20) (Supporting information, Table S10 ). When adjusted with other variables in logistic regression, the significant association of oxytocin use and HIE was still strong, while shift change, duration of the second phase of delivery, and delivery during night shift lost their statistical significance (Table  3 ).

To reveal any common features in different modes of delivery, results were further analyzed in four subgroups: spontaneous and assisted vaginal delivery, and emergency and crash cesarean (Supporting information, Table S11 ). Mothers without preceding active labour or medical intervention, were omitted from the crash cesarean subgroup.

We also made efforts to deeper analyze the cases of shoulder dystocia and induced labours.

There were six cases of shoulder dystocia in the study group, but none in the control group, which made the regression analysis inapplicable for this specific variable. However, the analyses of all obstetric emergencies (placental abruption, uterine rupture, shoulder dystocia) as a surrogate variable showed a statistically significant association with obstetric emergencies and HIE. The increase in odds of HIE with placental abruption and uterine rupture was insignificant or nonexistent. Aforementioned obstetric emergencies altogether presented an OR of 2.57 and aOR of 3.51 ( p  < 0.05) (Table  3 ). Other obstetric emergencies, such as cord prolapse and eclampsia, were not present in our data. The analysis of induced labours showed that even though newborns in the study group were heavier (3790 g vs. 3314 g, p  = 0.030), they were more often born vaginally (84.2% vs. 37.5%, p  = 0.027) (Supporting information, Table S12 ).

When analyzed by the mode of delivery, induction was more common in the study group in vaginal (OR 2.75, 95% 1.13–6.68, p  = 0.016) and assisted (ventouse) vaginal deliveries ( p  = 0.017) (Supporting information, Table S11 ). The midwife shift change was more common in the control groups of the emergency ( p  = 0.008) and crash ( p  = 0.044) caesarean sections and smoking was more common ( p  = 0.039) in the study group of the crash cesarean subgroup. Five of the six study group cases with shoulder dystocia occurred in the ventouse delivery subgroup ( p  = 0.051) (Supporting information Table S11 ).

In this study, maternal smoking, induction of labour and obstetric emergencies appeared to be independent risk factors for HIE. There was a clear dose-dependent association with maternal smoking and HIE. This finding prevailed in the multivariate analysis, although the increase in odds remained quite small. There were more induced labours in the study group and the association with labour induction was most pronounced in the subgroup that received oxytocin, accounting for the use during and after induction. Also shoulder dystocia, a poorly predictable obstetric emergency, increased the risk for HIE. Other previously stated antecedents, e.g., nulliparity, gestational age, maternal weight [ 22 ], prematurity [ 15 ] and chorionamnionitis [ 6 ] appeared mostly not to associate with HIE in this study. Furthermore, post term pregnancy, nitrous oxide, and the use of oxytocin as an independent variable had a seemingly opposite association with HIE.

Smoking is known to be a major risk factor for birth asphyxia and HIE. It is strongly associated with antecedents for asphyxia, i.e., fetal growth restriction [ 26 ] and the risk of placental abruption [ 6 , 27 , 28 ]. Smoking increases oxidative stress and reduces endogenous defenses in the fetus, which may play a role in the pathogenesis [ 29 ]. Even though the harmful effect of smoking is quite indisputable, some bias in the results has to be recognized. The proportion of missing data was substantial, and the imputed data may have skewed the results towards HIE. Also, the frequency, cessation and continuity of smoking was self-reported and susceptible to social desirability bias. It may be, however, safe to assume that the effect of smoking is at least what is presented by the unimputed data (OR 1.21, 95% CI 0.99–1.46, p  = 0.06).

The association between labour induction and HIE requires careful analysis. Significant multicollinearity between induction of labour and other supposed risk factors (obstetric emergency, oxytocin augmentation, shift change, nitrous oxide, and gestational diabetes) was noticed (Supporting information, Table S13 ). The induced labours in the study group ended more frequently in vaginal delivery than in the control group. There were no differences in the indications of labour induction. When these factors are weighed in, the independence of induction of labour as a risk factor for HIE can be considered a complex issue.

The role of induction is, however, worth serious consideration, since these pregnancies may include mothers or fetuses with multiple risk factors. In Finland the rate of induced labours has increased from 17.5% in 2007 to 33.9% in 2021 [ 30 ]. In addition, the proportion of elective inductions without a medical indication are also increasing [ 31 ]. In this study, the risk for HIE was most pronounced among patients with induction of labour together with the use of oxytocin during labour. The oxytocin associated increase in the incidence of encephalopathy was also described in the recent review and meta-analysis by Burgod et al. [ 32 ]. It is also worth noticing that even though newborns in the study group of induced labours were heavier, they were more often born vaginally and the number of ventouse deliveries was twice the proportion in the control group. Compared to zero cases in the study group, in approximately one third of control group cases, a crash cesarean followed a failed ventouse delivery. It can be speculated whether some anchoring bias in decision making is involved and the higher proportions of ventouse and vaginal deliveries in the study group and crash cesareans following ventouse trials in the control group reflect the clinicians’ decisions that are associated with the outcome of the newborn. The number of cases is however too small to draw conclusions.

Shoulder dystocia is an obstetric emergency, that results in prolongation of head-to-body delivery, traction of the brachial plexus, and possible birth trauma [ 33 , 34 ]. The shoulder dystocia incidence reported in studies is approximately 0.7% [ 35 ]. Fetal macrosomia is known to increase the risk of shoulder dystocia more than tenfold [ 35 ] and in these situations, a planned delivery at early term has been demonstrated to reduce the risk of shoulder dystocia [ 34 ]. In this study, six cases of shoulder dystocia were detected in the study group (6.8%) compared to none in the control group. This made the regression analysis inapplicable for this variable. Even though the analysis of all obstetric emergencies (placental abruption, uterine rupture, shoulder dystocia) as a surrogate variable was associated with HIE, the association of HIE with placental abruption and uterine rupture alone was less clear.

As stated, the use of oxytocin in general (irrespective of induction) and nitrous oxide was significantly more common in the control group. However, as shown in the stratified analysis (supplementary information Table S10 ), in the subgroup of induced labours, oxytocin use was more common in the study group. As the need for induction of labour itself may indicate increased risks in the pregnancy, these variables together increase the risk for adverse outcome. In contrast, spontaneous deliveries with oxytocin augmentation were more frequent in the control group. We suggest that the seemingly protective association of oxytocin augmentation in relation to HIE in the regression models could be explained by the asymmetric distribution of these different subgroups. The same can be speculated for the negative association of the administration of nitrous oxide.

The higher incidence of post-term pregnancies in the control group also needs additional attention. It can be speculated that the need for interventions in control group pregnancies was lower and post term was reached more often. It is also of note, that there was significant collinearity between post term pregnancy and oxytocin administration, midwife shift change and delivery during night shift.

In our study population, 54.5% of patients had a cesarean section and the incidences of emergency and crash cesarean were 15.9% and 37.5%. This describes the underlying existence of ante- and intrapartum complications in the study cohort, since the overall incidences of cesarean sections in the Finnish population were 16.7%, 9.2% and 0.9%, respectively [ 30 ]. For example, the rates of pre-eclampsia and pregnancy-induced hypertension in the study were 10.2% and 12.5% compared to our national and worldwide incidences of 5% and 7% [ 36 ].

The purpose of this study was to find HIE risk factors that could be anticipated and avoided in the antenatal care and treatment of delivery. For some patients in the study group, the active labour surveillance, and early obstetric interventions, were never at hand. Our efforts in prevention of HIE should be targeted to patients, that during labour are under constant care and observation.

Compared to previous studies, the selection criteria for this study group were different. Although a similar approach with therapeutic hypothermia as surrogate outcome for severe birth asphyxia (and sequential HIE) has been used before [ 19 ], most case-control studies rest on a study group of neonates diagnosed with neonatal asphyxia, or with signs of birth asphyxia (low Apgar score and/or signs of acidemia in the peripartum blood samples) [ 16 , 18 , 20 , 21 , 24 , 27 , 37 ]. In this study, we chose to use the application of therapeutic hypothermia as the study group inclusion criteria, since it is a clearly defined clinical intervention and in our clinic the indications for use are standardized. The incidence of our inclusion criteria, therapeutic hypothermia (1.1/1000), is slightly higher than the incidence of moderate and severe HIE (0.67/1000) in the study by Liljeström et al. [ 22 ]. Although moderate and severe HIE are the main indications for therapeutic hypothermia, the direct comparison of these incidences should be done with caution. Since the exact severity of HIE may still be uncertain immediately after birth (which may have occurred in another hospital) and the decision concerning this undeniably beneficial treatment has to be made within six hours, the incidence of therapeutic hypothermia treatment may be somewhat higher than the exact incidence of diagnosed moderate and severe HIE.

The study setting could be considered a strength of this study. To the best of our knowledge, this was the first case-control study pairing the groups by the mode of delivery, sex, hospital, and fetal presentation at birth. This could partially explain the differences in our results compared to previous similar studies.

The limitations of this study were its retrospective nature and small sample sizes. It is also likely that the matched case control setting together with a small number of cases failed to show the risks associated with previously described risk factors like hypertension, diabetes, and intrauterine growth restriction. These limitations, as well as coincidence, may also explain the higher incidence of post term pregnancies in the control group. The multicollinearity of some studied risk factors also set limitations when interpreting the data.

There were also some restrictions regarding obtaining data. We didn’t have access to primary health care and antenatal outpatient data, and we relied on the history information of the maternity card and database information upon mothers’ admission to the hospital. Chronic illnesses, obstetric complications and infections were not always structurally recorded. Some information such as substance abuse may be underrepresented but unlikely affects our results.

Demographic risk factors, such as social and marital status, are not collected and had to be excluded. Some previously identified risk factors (urinary tract and viral infections) [ 17 , 23 , 38 , 39 ] had to be excluded because they are treated at the primary health care level.

After controlling for multiple testing, only two of the univariate logistic regression results (maternal smoking and use of oxytocin) remained statistically significant. When studying rare outcomes in limited sample size, one must be careful not to reject the null hypothesis too readily, while minding possibly important findings that fail to reach nominal statistical significance. We considered both these pitfalls and considered clinical applicability as best we could while interpreting these results, but conclusions based on the findings should still be done with caution.

According to our results, induction of labor may be an independent risk factor for HIE, and it should only be used in situations where it evidently improves the outcome of labour. Special vigilance is required from the obstetric team when deciding upon induction and when managing these patients during labour. The increased risk of HIE associated with smoking and obstetric emergencies is unfortunately mostly out of the clinician’s reach.

Data availability

The data that support the findings of this study are available from the corresponding author upon reasonable request.

Abbreviations

• Hypoxic-ischemic encephalopathy

Neonatal Intensive Care Unit

Lawn JE, Cousens S, Zupan J. 4 Million neonatal deaths: When? Where? Why? Vol. 365, Lancet.2005;365(9462):891–900.

Jacobs SE, Berg M, Hunt R, Tarnow-Mordi WO, Inder TE, Davis PG. Cooling for newborns with hypoxic ischaemic encephalopathy. Cochrane Database Syst Rev. 2013;2013(1):CD003311.

PubMed   PubMed Central   Google Scholar  

Yli BM, Kjellmer I. Pathophysiology of foetal oxygenation and cell damage during labour. Best Pract Res Clin Obstet Gynaecol. 2016;30:9–21.

Article   PubMed   Google Scholar  

Igboanugo S, Chen A, Mielke JG. Maternal risk factors for birth asphyxia in low-resource communities. A systematic review of the literature. J Obstet Gynaecol. 2020;40(8):1039–55.

Rossi AC, Prefumo F. Antepartum and intrapartum risk factors for neonatal hypoxic-ischemic encephalopathy: a systematic review with meta-analysis. Curr Opin Obstet Gynecol. 2019;31(6):410–17.

Sarnat HB, Sarnat MS. Neonatal Encephalopathy following fetal distress: a clinical and electroencephalographic study. Arch Neurol. 1976;33(10):696–705.

Article   CAS   PubMed   Google Scholar  

Morales P, Bustamante D, Espina-Marchant P, Neira-Peña T, Gutiérrez-Hernández MA, Allende-Castro C et al. Pathophysiology of perinatal asphyxia: can we predict and improve individual outcomes? EPMA J;2(2). p. 211–30.

Shankaran S, Laptook AR, Ehrenkranz RA, Tyson JE, McDonald SA, Donovan EF, et al. Whole-body hypothermia for neonates with hypoxic-ischemic encephalopathy. N Engl J Med. 2005;353(15):1574–84.

Westgate JA, Gunn AJ, Gunn TR. Antecedents of neonatal encephalopathy with fetal acidaemia at term. Br J Obstet Gynaecol. 1999;106(8):774–82.

Seikku L, Gissler M, Andersson S, Rahkonen P, Stefanovic V, Tikkanen M, et al. Asphyxia, neurologic morbidity, and perinatal mortality in early- term and postterm birth. Pediatrics. 2016;137(6):e20153334.

Locatelli A, Incerti M, Paterlini G, Doria V, Consonni S, Provero C, et al. Antepartum and intrapartum risk factors for neonatal encephalopathy at term. Am J Perinatol. 2010;27(8):649–54.

Torres-Muñoz J, Rojas C, Mendoza-Urbano D, Marín-Cuero D, Orobio S, Echandía C. Risk factors associated with the development of perinatal asphyxia in neonates at the Hospital Universitario del Valle, Cali, Colombia, 2010–2011. Biomedica. 2017 1;37(0):51–6.

Lundgren C, Brudin L, Wanby AS, Blomberg M. Ante- and intrapartum risk factors for neonatal hypoxic ischemic encephalopathy. J Matern Fetal Neonatal Med. 2018;18(12):1595–601.

Article   Google Scholar  

Itoo BA, Al-Hawsawi ZM, Khan AH. Hypoxic ischemic encephalopathy. Incidence and risk factors in North Western Saudi Arabia. Neurosciences. 2003;8(2):113–9.

PubMed   Google Scholar  

Ayuk Widiani NN, Yuli Kurniati DP, Trisna Windiani IGA. Maternal and infant risk factors on the incidence of neonatal asphyxia in Bali: Case Control Study. Public Health Prev Med Arch. 2016;4(2):120–6.

Hall DR, Smith M, Smith J. Maternal factors contributing to asphyxia neonatorum. J Trop Pediatr. 1996;42(4):192–5.

Badawi N, Kurinczuk JJ, Keogh JM, Alessandri LM, O’Sullivan F, Burton PR, et al. Intrapartum risk factors for newborn encephalopathy: the western Australian case-control study. Br Med J. 1998;317(7172):1549–53.

Article   CAS   Google Scholar  

Blume HK, Loch CM, Li CI. Neonatal encephalopathy and socioeconomic status: Population-based case-control study. Arch Pediatr Adolesc Med. 2007;161(7):663–8.

Nelson DB, Lucke AM, Mcintire DD, Sánchez PJ, Leveno KJ, Chalak LF. Obstetric antecedents to body cooling treatment of the Newborn Infant. Am J Obs Gynecol. 2014;211(2):155–6.

Nayeri F, Shariat M, Dalili H, Bani Adam L, Zareh Mehrjerdi F, Shakeri A. Perinatal risk factors for neonatal asphyxia in Vali-e-Asr hospital, Tehran-Iran. Iran J Reprod Med. 2012;10(2):137–40.

Heinonen S, Saarikoski S. Reproductive risk factors of fetal asphyxia at delivery: a population based analysis. J Clin Epidemiol. 2001;54(4):407–10.

Liljestrom L, Wikstrom AK, Agren J, Jonsson M. Antepartum risk factors for moderate to severe neonatal hypoxic ischemic encephalopathy: a Swedish national cohort study. Acta Obstet Gynecol Scand. 2018;97(5):615–23.

Martinez-Biarge M, Madero R, Gonzlez A, Quero J, Garca-Alix A. Perinatal morbidity and risk of hypoxic-ischemic encephalopathy associated with intrapartum sentinel events. Am J Obstet Gynecol. 2012;206(2):148.e1-148.e7.

Ellis M, Manandhar N, Manandhar DS, De L, Costello AM. Risk factors for neonatal encephalopathy in Kathmandu, Nepal, a developing country: unmatched case-control study. Br Med J. 2000;320(7244):1229–36.

Benjamini Y, Hochberg Y. Controlling the false Discovery rate: a practical and powerful Approach to multiple testing. J R Stat Soc Ser B. 1995;57(1):289–300.

Abraham M, Alramadhan S, Iniguez C, Duijts L, Jaddoe VWV, Den Dekker HT, et al. A systematic review of maternal smoking during pregnancy and fetal measurements with meta-analysis. PLoS ONE Public Libr Sci. 2017;12(2):e0170946.

Tikkanen M, Surcel HM, Bloigu A, Nuutila M, Ylikorkala O, Hiilesmaa V, et al. Self-reported smoking habits and serum cotinine levels in women with placental abruption. Acta Obstet Gynecol Scand. 2010;89(12):1538–44.

Downes KL, Shenassa ED, Grantz KL. Neonatal outcomes Associated with placental abruption. Am J Epidemiol. 2017;186(12):1319–28.

Article   PubMed   PubMed Central   Google Scholar  

Gitto E, Reiter RJ, Karbownik M, Tan D-x, Gitto P, Berberi S, et al. Causes of oxidative stress in the pre- and Perinatal Period. Neonatology. 2002;81(3):146–57.

Perinataalitilasto. – synnyttäjät, synnytykset ja vastasyntyneet - THL [Internet]. [cited 2020 Aug 6]. https://thl.fi/fi/tilastot-ja-data/tilastot-aiheittain/seksuaali-ja-lisaantymisterveys/synnyttajat-synnytykset-ja-vastasyntyneet/perinataalitilasto-synnyttajat-synnytykset-ja-vastasyntyneet .

Kruit H, Nuutila M, Rahkonen L. Lääkärilehti - Synnytyksen käynnistäminen, Kun raskaus on täysiaikainen. Lääkärilehti. 2016;71(25–32/2016):1845–51.

Google Scholar  

Burgod C, Pant S, Morales MM, Montaldo P, Ivain P, Elangovan R, et al. Effect of intra-partum oxytocin on neonatal encephalopathy: a systematic review and meta-analysis. BMC Pregnancy Childbirth. 2021;21(1):1–7.

Collins KA, Popek E. Birth Injury: Birth Asphyxia and Birth Trauma. Academic Forensic Pathology. Volume 8. SAGE Publications Inc.; 2018. pp. 788–864.

Farrar D, Simmonds M, Bryant M, Sheldon TA, Tuffnel D, Golder S, et al. Treatments for gestational diabetes: a systematic review and meta-analysis. BMJ Open. 2017;7(6):e015557.

Hartiadystokia. - Duodecim Oppiportti [Internet]. [cited 2020 Aug 18]. https://www-oppiportti-fi.libproxy.helsinki.fi/op/njs15507/do?p_haku=hartiadystokia#q=hartiadystokia .

Rana S, Lemoine E, Granger J, Karumanchi SA, Preeclampsia. Pathophysiology, challenges, and perspectives. Circ Res. 2019;124(7):1094–112.

Milsom I, Ladfors L, Thiringer K, Niklasson A, Odeback A, Thornberg E. Influence of maternal, obstetric and fetal risk factors on the prevalence of birth asphyxia at term in a Swedish urban population. Acta Obstet Gynecol Scand. 2002;81(10):909–17.

Hayes BC, McGarvey C, Mulvany S, Kennedy J, Geary MP, Mattherws TG et al. A case-control study of hypoxic-ischemic encephalopathy in newborn infants at > 36 weeks gestation. Am J Obstet Gynecol. 2013;209(1):29.e1-29.e19.

Kapaya H, Williams R, Elton G, Anumba D. Can obstetric risk factors predict fetal acidaemia at Birth? A retrospective case-control study. J Pregnancy. 2018;2018:2195965.

Download references

Acknowledgements

We gratefully acknowledge the assistance of Paula Bergman, biostatistician at Biostatistics consulting, University of Helsinki, Finland, for her biostatistical advice.

Helsinki University State Research Funding.

Open Access funding provided by University of Helsinki (including Helsinki University Central Hospital).

Author information

Authors and affiliations.

Department of obstetrics and gynecology, Helsinki University Women’s Hospital, Haartmaninkatu 2, Helsinki, 00029, Finland

Suoma Roto, Ilkka Kalliala & Marja Kaijomaa

Children’s Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland

Irmeli Nupponen

You can also search for this author in PubMed   Google Scholar

Contributions

SR contributed to the literature search, figures, study design, data collection, data analysis, data interpretation and writing. IN contributed to the study design, data collection data interpretation and writing. IK contributed to the data interpretation and writing. MK contributed to the study design, data collection, data analysis, data interpretation, figures, and writing.

Corresponding author

Correspondence to Marja Kaijomaa .

Ethics declarations

Ethical approval.

The study was approved by the Helsinki University Hospital Institutional Review Board. (March 3, 2018, 1/2018).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

Additional information

Publisher’s note.

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary Material 1

Rights and permissions.

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/ . The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/ ) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Cite this article.

Roto, S., Nupponen, I., Kalliala, I. et al. Risk factors for neonatal hypoxic ischemic encephalopathy and therapeutic hypothermia: a matched case-control study. BMC Pregnancy Childbirth 24 , 421 (2024). https://doi.org/10.1186/s12884-024-06596-8

Download citation

Received : 31 May 2023

Accepted : 20 May 2024

Published : 12 June 2024

DOI : https://doi.org/10.1186/s12884-024-06596-8

Share this article

Anyone you share the following link with will be able to read this content:

Sorry, a shareable link is not currently available for this article.

Provided by the Springer Nature SharedIt content-sharing initiative

• Birth asphyxia
• Induction of labour
• Oxytocin treatment
• Shoulder dystocia
• Therapeutic hypothermia

BMC Pregnancy and Childbirth

ISSN: 1471-2393

• Submission enquiries: [email protected]
• General enquiries: [email protected]

Local News | Big growth? Boynton Beach may annex up to 4,500…

Share this:.

• Click to share on Facebook (Opens in new window)
• Click to share on X (Opens in new window)

Daily e-Edition

Evening e-Edition

• Palm Beach County News
• Broward County News
• Miami-Dade County News

SUBSCRIBER ONLY

Local news | big growth boynton beach may annex up to 4,500 acres, adding nearly 35,000 residents.

“The city is interested in annexation and wants to explore its feasibility,” Boynton Beach Planning and Development Director Amanda Radigan said. “It may be that some areas are feasible, some areas aren’t feasible. It may be that the city can grow and keep the same excellent level of service, and it may be that that’s not the case.”

The city is employing a feasibility analysis to review the city’s current level of service and if it could expand, Radigan said.

“The analysis will help us determine if we want the annex at all. And the answer won’t necessarily be the same parcel to parcel,” she said.

How annexation works

In a presentation she gave to the city commissioners on Jan. 16, Radigan provided the definition of annexation, which is, rather simply, “the process of expanding a city’s boundaries to include nearby land.”

According to state law, any municipality may annex land that is contiguous — meaning it shares a border with the municipality — compact and unincorporated area. This could be done in a few different ways, including through voluntary annexation, when a property owner or multiple property owners requests an annexation, or through a referendum, meaning people would vote either for or against the annexation. Other methods, such as enclave annexation and legislative annexation, exist too.

“We’re going to look at which (methods) would apply to which parcel,” Radigan said. “There may be none that are voluntary. There may be some that are voluntary, there may be some that end up going to referendum. All we really know at this point is the type of processes that we have, but they haven’t necessarily been applied to parcels yet.”

Weighing the options

At the January meeting, Radigan presented 11 parcels to be considered for annexation, which, if adopted, would add nearly $3 billion in taxable value to Boynton Beach. Taxable value is the value for which property owners are taxed on after exemptions are applied (it is not the same as the tax rate).

The city would have more expenses of its own, too, with an annexation, such as needing to acquire more fire and police department personnel. Part of the feasibility analysis will determine what the city would need to do and how much it would cost to support all the extra communities it would assume.

“Everything that the city does in terms of service is going to be reviewed, and we’re going to study each department individually, going to study its ability to grow and what it would take for us to grow and handle additional service,” Radigan said. “Is more staff required? Is more technology required? Are there capital improvements that need to be made?”

She added: “If the cost to maintain the level of service exceeds the actual tax benefit, then it would be at a loss to the city, and we aren’t going to annex property if we can’t maintain the level of service.”

Some of the currently un-annexed, unincorporated Palm Beach County territories being considered already receive drinking water and wastewater services from the city of Boynton Beach.

The water service agreements in place with some communities grant the city the power to employ a voluntary annexation on behalf of the customer, or the people who live in the unincorporated areas who still receive Boynton’s utility services.

Some of the communities with these agreements gave the city “a right to annex them at a future date if we want to,” Radigan said to the city commissioners during the January meeting.

Beth Rappaport has lived in Colony Preserve, a community directly west of Military Trail and outside of Boynton Beach’s boundaries, since 2007.

She said she remembers when the city tried go through with an annexation in 2016. She was against annexation then, and she is against it now.

Colony Preserve, in an unincorporated part of Palm Beach County, was appealing to her because she felt “property taxes were more reasonable,” she said.

And Rappaport preferred being served by the county’s fire rescue department and Sheriff’s Office because those agencies are “much larger than the municipal agencies.”

With annexation in the early stages of consideration, no official figures are yet available comparing the costs between being incorporated into Boynton Beach or remaining in unincorporated West Boynton.

Some residents whose neighborhoods would be annexed worry about paying more in taxes, as well as concerns about changes in emergency response times from having new agencies.

“The way that the city has gone about this is very concerning,” Rappaport said. “They did not have any community meetings to get any feedback from the impacted residents, which I find to be unusual.”

When she listened to the Jan. 16 meeting, she said the dialogue surrounding the annexation focused mainly on financial gains for the city rather than discussing the possible impact on concerned residents.

The city’s community outreach indeed would happen, Radigan said.

“Once we know if we can annex and it’s feasible to annex and we can bring the same quality of service,” Radigan said. “At that point, we will start outreach with communities to start listening to concerns and factoring in some of those other less tangible things into the feasibility analysis.”

Barbara Roth, the president of the Coalition of Boynton West Residential Associations, or COBWRA, said the organization has yet to hear from any community that desires to be part of Boynton Beach. Rather, losing the county’s services — and having to comply with the city’s tax rate — makes COBWRA members “uneasy,” Roth said.

Before 2016, the topic of annexation arose in Boynton Beach in 1998, and COBWRA commissioned consultants at the time to evaluate the implications of an annexation. The consultants determined annexed homeowners would face an increase in taxes and fees while the city would generate an annual surplus of $2 million, according to a report.

Radigan said an annexation could spur changes in taxes, but what people should also understand is that once an area is incorporated into a city, other fees could go down, such as debt services on county resident tax bills.

“It is true that they will be paying the City of Boynton Beach millage (tax rate), and they don’t pay that now,” Radigan said. “But it is also true that there are existing taxes that they are being charged currently that they will not be charged if they are incorporated.”

In terms of service, Radigan said the city will not annex anything where officials believe they cannot provide a comparable, or even better level of service, than what is provided to residents now.

Palm Beach County Commissioners Gregg Weiss and Marci Woodward, both of whom preside over districts that contain parts of the potential annexed areas, declined to comment, citing a lack of information on a topic that is still early in the process.

City officials have yet to set a date to discuss the annexation status.

On Wednesday, COBWRA issued petition to “oppose all efforts by the City of Boynton Beach to annex 33 COBWRA member communities located on or near Military Trail.”

“Our members want to continue to benefit from county services and do not want to pay higher taxes!” the group wrote in its campaign calling for people to sign the petition.

More in Local News

Politics | Trump paints dark picture of America, promises rosy future if he defeats Biden

Politics | Trump supporters gathering in West Palm Beach have a birthday wish — another term as president

Crime and Public Safety | Closing Parkland’s open wound: The dismantling of a crime scene

Florida News | Florida condo owners get more rights in bill signed Friday by Gov. Ron DeSantis

An official website of the United States government

Here’s how you know

The .gov means it’s official. Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

The site is secure. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Take action

• Report an antitrust violation
• File adjudicative documents
• Find banned debt collectors
• View competition guidance
• Competition Matters Blog

Slow the Roll-up: Help Shine a Light on Serial Acquisitions

View all Competition Matters Blog posts

We work to advance government policies that protect consumers and promote competition.

View Policy

Search or browse the Legal Library

Find legal resources and guidance to understand your business responsibilities and comply with the law.

Browse legal resources

• Find policy statements
• Submit a public comment

Vision and Priorities

Memo from Chair Lina M. Khan to commission staff and commissioners regarding the vision and priorities for the FTC.

Technology Blog

Global perspectives from the international competition network tech forum.

View all Technology Blog posts

Advice and Guidance

Learn more about your rights as a consumer and how to spot and avoid scams. Find the resources you need to understand how consumer protection law impacts your business.

• Report fraud
• Report identity theft
• Register for Do Not Call
• Sign up for consumer alerts

Get Business Blog updates

• Get your free credit report
• Find refund cases
• Order bulk publications
• Consumer Advice
• Shopping and Donating
• Credit, Loans, and Debt
• Jobs and Making Money
• Unwanted Calls, Emails, and Texts
• Identity Theft and Online Security
• Business Guidance
• Advertising and Marketing
• Credit and Finance
• Privacy and Security
• By Industry
• For Small Businesses
• Browse Business Guidance Resources
• Business Blog

Servicemembers: Your tool for financial readiness

Visit militaryconsumer.gov

Get consumer protection basics, plain and simple

Visit consumer.gov

Learn how the FTC protects free enterprise and consumers

Visit Competition Counts

Looking for competition guidance?

• Competition Guidance

News and Events

Latest news, ftc data shows major increases in cash payments to government impersonation scammers.

View News and Events

Upcoming Event

Closed commission meeting - june 20, 2024.

View more Events

Sign up for the latest news

Follow us on social media

-->   -->   -->   -->   -->  

Playing it Safe: Explore the FTC's Top Video Game Cases

Learn about the FTC's notable video game cases and what our agency is doing to keep the public safe.

Latest Data Visualization

FTC Refunds to Consumers

Explore refund statistics including where refunds were sent and the dollar amounts refunded with this visualization.

About the FTC

Our mission is protecting the public from deceptive or unfair business practices and from unfair methods of competition through law enforcement, advocacy, research, and education.

Learn more about the FTC

Meet the Chair

Lina M. Khan was sworn in as Chair of the Federal Trade Commission on June 15, 2021.

Chair Lina M. Khan

Looking for legal documents or records? Search the Legal Library instead.

• Cases and Proceedings
• Premerger Notification Program
• Merger Review
• Anticompetitive Practices
• Competition and Consumer Protection Guidance Documents
• Warning Letters
• Consumer Sentinel Network
• Criminal Liaison Unit
• FTC Refund Programs
• Notices of Penalty Offenses
• Advocacy and Research
• Advisory Opinions
• Cooperation Agreements
• Federal Register Notices
• Public Comments
• Policy Statements
• International
• Office of Technology Blog
• Military Consumer
• Consumer.gov
• Bulk Publications
• Data and Visualizations
• Stay Connected
• Commissioners and Staff
• Bureaus and Offices
• Budget and Strategy
• Office of Inspector General
• Careers at the FTC

Succor borne every minute

Earnest chats with objects are not so unusual. Mark “The Bird” Fidrych, the famed Detroit Tiger, used to stand on the pitching mound whispering to the baseball. Forky, the highly animate utensil from Toy Story 4 , once posed deep questions about friendship to a ceramic mug. And many of us have made repeated queries of the Magic 8 Ball despite its limited set of randomly generated answers.

Our talking to computers also goes way back, and that history is getting weirder. We’re seeing a wave of avatars and bots marketed to provide companionship, romance, therapy, or portals to dead loved ones, and even meet religious needs. It may be a function of AI companies making chatbots better at human mimicry in order to convince us that chatbots have social value worth paying for. Consider that some of these companies compare their products to magic (they aren’t), talk about the products having feelings (they don’t), or admit they just want people to feel that the products are magic or have feelings.

• Don’t misrepresent what these services are or can do. Your therapy bots aren’t licensed psychologists, your AI girlfriends are neither girls nor friends, your griefbots have no soul, and your AI copilots are not gods. We’ve  warned companies about making false or unsubstantiated claims about AI or algorithms. And we’ve followed up with action, including recent cases against  WealthPress ,  DK Automation ,  Automators AI , and  CRI Genetics . We’ve also  repeatedly advised companies – with reference to past cases – not to use automated tools to mislead people about what they’re seeing, hearing, or reading.
• Don’t offer these services without adequately mitigating risks of harmful output . It’s a deliberate design choice to offer bots and avatars that perform as if human. We’ve  discussed how that choice has inherent risks in terms of manipulation and inducing consumers, even if inadvertently, to make harmful choices. The risks may be greater for certain audiences, such as children. And we’ve  warned AI companies repeatedly to assess and mitigate risks of reasonably foreseeable harm before and after deploying their tools. Our recent  case against Rite Aid for its unfair use of facial recognition technology is an instructive case in point.
• Don’t insert ads into a chat interface without clarifying that it’s paid content.  More and more advertising will likely creep into the output that consumers get when interacting with various generative AI services. It will be tempting for firms offering simulated humans for companionship and the like to do the same, especially given the ability to target ads based on what these services gather or glean about their users. We’ve  explained that any generative AI output should distinguish clearly between what is organic and what is paid. The Commission has also explored the wider problem of  blurred digital advertising to children, advising marketers to steer clear of it altogether.   
• Don’t use consumer relationships with avatars and bots for commercial manipulation. A company offering an anthropomorphic service also shouldn’t  manipulate people via the attachments formed with that service, such as by inducing people to pay for more services or steering them to affiliated businesses. That notion applies equally to how such a service is designed to react if people try to cancel their subscription. Consistent with the FTC’s rulemaking proposal to make it easier for people to  “click to cancel” subscriptions, a bot shouldn’t plead, like Hal 9000 in 2001: A Space Odyssey , not to be turned off.
• Don’t violate consumer privacy rights. These avatars and bots can collect or infer a lot of intensely personal information. Indeed, some companies are marketing as a feature the ability of such AI services to know everything about us. It’s imperative that companies are honest and transparent about the collection and use of this information and that they don’t  surreptitiously change privacy policies or relevant terms of service. These principles take on even more importance when these AI services are targeted to children. As reflected by our cases involving  Alexa and Ring , the FTC will hold companies accountable for how they obtain, retain, and use consumer data. Such accountability applies fully in the context of AI and algorithms because, as you may have heard, there’s no AI exception to the laws on the books.

Is it possible that companies will ultimately develop all of these services in ways that merit no FTC attention? We posed this question to our Magic 8 Ball. Its answer: “Outlook not so good.”

The FTC has more posts in the  AI and Your Business  series:

• Keep your AI claims in check
• Chatbots, deepfakes, and voice clones: AI deception for sale
• The Luring Test: AI and the engineering of consumer trust
• Watching the detectives: Suspicious marketing claims for tools that spot AI-generated content
• Can’t lose what you never had: Claims about digital ownership and creation in the age of generative AI  
• Consumer Protection
• Bureau of Consumer Protection
• Online Advertising and Marketing
• Advertising and Marketing Basics
• Consumer Privacy
• Artificial Intelligence

Add new comment

Read our privacy act statement.

It is your choice whether to submit a comment. If you do, you must create a user name, or we will not post your comment. The Federal Trade Commission Act authorizes this information collection for purposes of managing online comments. Comments and user names are part of the Federal Trade Commission’s (FTC) public records system, and user names also are part of the FTC’s  computer user records  system. We may routinely use these records as described in the FTC’s  Privacy Act system notices . For more information on how the FTC handles information that we collect, please read our privacy policy .

Read Our Comment Policy

The purpose of this blog and its comments section is to inform readers about Federal Trade Commission activity, and share information to help them avoid, report, and recover from fraud, scams, and bad business practices. Your thoughts, ideas, and concerns are welcome, and we encourage comments. But keep in mind, this is a moderated blog. We review all comments before they are posted, and we won’t post comments that don’t comply with our commenting policy. We expect commenters to treat each other and the blog writers with respect.

• We won’t post off-topic comments, repeated identical comments, or comments that include sales pitches or promotions.
• We won’t post comments that include vulgar messages, personal attacks by name, or offensive terms that target specific people or groups.
• We won’t post threats, defamatory statements, or suggestions or encouragement of illegal activity.
• We won’t post comments that include personal information, like Social Security numbers, account numbers, home addresses, and email addresses. To file a detailed report about a scam, go to ReportFraud.ftc.gov.

We don't edit comments to remove objectionable content, so please ensure that your comment contains none of the above. The comments posted on this blog become part of the public domain. To protect your privacy and the privacy of other people, please do not include personal information. Opinions in comments that appear in this blog belong to the individuals who expressed them. They do not belong to or represent views of the Federal Trade Commission.

SUCCOR means "assistance and support in times of hardship and distress"

More from the Business Blog

How the ftc is showing its commitment to protecting renters’ rights, safeguards rule notification requirement now in effect, aqua finance’s sales, financing, and fcra practices land company in hot water, bluesnap complaint alleges unfair payment processing and credit card laundering: don’t lather, don’t rinse, and definitely don’t repeat.

• Communities
• Nation / World

Trump plans activity inside and outside the RNC in Milwaukee, campaign says

MADISON – Former President Donald Trump plans to be active both in and outside of the Republican National Convention in Milwaukee next month, his campaign said Thursday.

The campaign also disputed a report that convention planners are preparing for a scenario in which the former president does not attend in person.

"At no time has convention planning involved any other option than President Trump accepting the formal nomination as president, in person. Period," Trump campaign spokeswoman Karoline Leavitt told the Milwaukee Journal Sentinel.

The campaign is excited for voters across the country to tune into convention programming and watch the former president accept the nomination, she said.

Trump is scheduled to hold a campaign rally in Racine next week and, in a little more than a month, be officially named the GOP nominee in Milwaukee.

Leavitt's comments came in response to an NBC News report that preparations are being made both in Milwaukee and at Mar-a-Lago, Trump's Florida home, in case he chooses not to attend or is unable to do so. On the same day, Punchbowl News reported that he referred to Milwaukee as a "horrible city" in a meeting with House Republicans — which a Trump spokesman characterized as "total bullshit."

Trump is scheduled to be sentenced July 11 after a jury  convicted him last week on all 34 felony counts  in a case in which prosecutors said he had falsified business records to cover up a hush money payment to a porn star ahead of the 2016 presidential election. He is expected to appeal.

The  sentencing will come days before the Republican National Convention  kicks off at Fiserv Forum. The  convention runs July 15-18 , with a welcome party the night before it begins.

Last week, Republican National Committee Chairman Michael Whatley  told reporters in Milwaukee that GOP officials are "excited" for the former president to accept the party's nomination in person, but "if we need to make contingent plans, we will."

The trial  galvanized support in the Republican Party , Whatley told reporters, noting a  surge in fundraising  the Trump campaign and the Republican National Committee say followed the verdict.

Trump is the presumptive Republican nominee to take on President Joe Biden, a Democrat, in a rematch of the 2020 race.

In the  latest Marquette University Law School poll , Wisconsin voters are split on their November choices for president. Those surveyed by Marquette considered Trump better than Biden at handling immigration and border security, plus the economy, the Israel-Hamas war and foreign relations. Biden had the lead on health care, abortion policy and Medicare and Social Security.

Voters overall ranked the economy as their top issue, with 33% saying it would be most important in deciding who to vote for. Immigration and border security was the second, with 21% citing that issue.

Trump's Thursday comments about Milwaukee came as he discussed campaign strategies, among other GOP priorities, ahead of the 2024 election with House Republicans.

"He never said it like how it’s been falsely characterized as," Trump spokesman Steven Cheung said in a post on X. Cheung said the former president was talking about crime and election issues, though members of Wisconsin's delegation didn't agree on which topic Trump was discussing.

Republican members of Wisconsin's congressional delegation had varying accounts of the comment's context, including one at first who denied it was uttered at all.

U.S. Rep. Scott Fitzgerald said in a Thursday interview with WISN-TV that Trump was asked about election integrity by U.S. Rep. Claudia Tenney, of New York, and responded that there are 19 specific locations the campaign is concerned about — one of which is Milwaukee.

"What he was talking about was the elections in Milwaukee," Fitzgerald said.

Trump lost the state to Biden in 2020 by just about 21,000 votes. The results have been confirmed by  recounts in Dane and Milwaukee counties  that Trump paid for, court rulings,  a nonpartisan state audit  and a study by the conservative legal firm Wisconsin Institute of Law & Liberty, among other analyses.

Biden, for his part, posted on X, "I happen to love Milwaukee," with a photo of the president at the 2021 celebration of the Milwaukee Bucks' NBA championship.

The Metropolitan Milwaukee Association of Commerce released a statement praising Milwaukee as "vibrant"

"We look forward to showing the world what Milwaukee has to offer next month. We know this city will impress," the organization said.

Milwaukee County Executive David Crowley took a similar approach, saying, "The RNC still chose Milwaukee to come to, right?”

"It is my hope that not only our former president but everybody who is going to be embarking on Milwaukee sees everything that we have to offer," Crowley said.

Jessie Opoien can be reached at [email protected].