Maternal Transport Research Articles

The impact of maternal characteristics on the moderately premature infant: an antenatal maternal transport clinical prediction rule

BackgroundModerately premature infants, defined here as those born between 30 0/7 and 34 6/7 weeks gestation, comprise 3.9% of all births in the United States and 32% of all preterm births. While long-term outcomes for these infants are better than for less mature infants, morbidity and mortality are still substantially increased in comparison to infants born at term. There is an added survival benefit resulting from birth at a tertiary neonatal care center, and although many of these infants require tertiary level care, delivery at lower level hospitals and subsequent neonatal transfer are still common.ObjectiveOur primary aim was to determine the impact of maternal characteristics and antenatal medical management on the early neonatal course of the moderately premature infant. The secondary aim was to create a clinical prediction rule to determine which infants require intubation and mechanical ventilation in the first 24 hours of life. Such a prediction rule could inform the decision to transfer maternal-fetal patients prior to delivery to a facility with a Level III Neonatal Intensive Care Unit (NICU), where optimal care could be provided without the requirement for a neonatal transfer.MethodsData for this analysis came from the cohort of infants in the Moderately Premature Infant Project (MPIP) database, a multi-center cohort study of 850 infants born at gestational age 30 0/7 to 34 6/7 weeks, who were discharged home alive. We built a logistic regression model to identify maternal characteristics associated with need for tertiary care, as measured by administration of surfactant. Using statistically significant covariates from this model, we then created a numerical decision rule to predict need for tertiary care.ResultsIn multivariate modeling, 4 factors were associated with reduction in the need for tertiary care, including, surfactant administration, including non-White race (OR=0.5, [0.3, 0.7], older gestational age, female gender (OR=0.6 [0.4, 0.8]) and use of antenatal corticosteroids (OR=0.5, [0.3, 0.8]). The clinical prediction rule to discriminate between infants who received surfactant, versus those who did not, had an area under the curve of 0.77 [0.73, 0.8].ConclusionsFour antenatal risk factors are associated with a requirement for Level III NICU care as defined by the need for surfactant administration. Future analyses will examine a broader spectrum of antenatal characteristics and revalidate the prediction rule in an independent cohort.

Fetal, maternal, and placental sources of serotonin and new implications for developmental programming of the brain

In addition to its role in neurotransmission, embryonic serotonin (5-HT) has been implicated in the regulation of neurodevelopmental processes. For example, we recently showed that a subset of 5-HT1-receptors expressed in the fetal forebrain mediate a serotonergic modulation of thalamocortical axons response to axon guidance cues, both in vitro and in vivo. This influence of 5-HT signaling on fetal brain wiring raised important questions regarding the source of the ligand during pregnancy. Until recently, it was thought that 5-HT sources impacting brain development arose from maternal transport to the fetus, or from raphe neurons in the brainstem of the fetus. Using genetic mouse models, we uncovered previously unknown differences in 5-HT accumulation between the fore- and hindbrain during early and late fetal stages, through an exogenous source of 5-HT. Using additional genetic strategies, a new technology for studying placental biology ex vivo, and direct manipulation of placental neosynthesis, we investigated the nature of this exogenous source and uncovered a placental 5-HT synthetic pathway from a maternal tryptophan precursor, in both mice and humans. These results implicate a new, direct role for placental metabolic pathways in modulating fetal brain development and suggest an important role for maternal-placental-fetal interactions and 5-HT in the fetal programming of adult mental disorders.

Transport as a system: reorganization of perinatal assistance in Northern Lombardy

The organization of perinatal care has been a pivotal mean for improvement in neonatal survivals. Despite the excellent standard of assistance in Lombardy, Obstetrics and Neonatal Units of MBBM Foundation-Monza, Manzoni Hospital-Lecco and Niguarda Hospital-Milan put forward a pilot project proposing reorganization of perinatal care in the northern part of Lombardy. The main goals of the project are implementation of maternal transport system and use of neonatal back transport as a system to increase the availability of intensive care beds. The project’s fundamental steps and critical points will be discussed.

Bioaccumulation, maternal transfer and elimination of polybrominated diphenyl ethers in wild frogs

To investigate bioaccumulation, maternal transfer and elimination of polybrominated diphenyl ethers (PBDEs) in amphibians, we collected adult frogs (Rana limnocharis) from a rice field in an e-waste recycling site in China. We found that ∑PBDEs in the whole frogs and various tissues (brain, liver, testis and egg) ranged from 17.10 to 141.11ngg−1 wet weight. Various tissues exhibited a similar PBDE congener profile, which was characterized by intermediate brominated congeners (BDE-99 and BDE-153) as the largest contributors, with less lower brominated congeners (BDE-28 and BDE-47) and higher brominated congeners (BDE-209). The maternal transfer capacity of PBDEs declined with the increase in bromine numbers of PBDE congeners. We suggest that the bromine atom number (the molecular size, to some degree) might be a determining factor for the maternal transport of a PBDE congener rather than Kow (Octanol–Water partition coefficient), which expresses a compound’s lipophilicity. ∑PBDEs concentrations in frogs decreased over time during a depuration period of 54days when these wild frogs were brought to the lab from the e-waste recycling site. The half-life of ∑PBDEs was 35days, with about 14days for BDE-47, and 36 and 81days for BDE-99 and BDE-153, respectively. The data shows that the elimination of PBDEs has no essential difference from aquatic and terrestrial species.

The Japanese experience with prenatally diagnosed congenital diaphragmatic hernia based on a multi-institutional review

To review the recent Japanese experience with prenatally diagnosed congenital diaphragmatic hernia (CDH) based on a multi-institutional survey. A multicenter, retrospective cohort study was conducted on 117 patients born between 2002 and 2007 with isolated prenatally diagnosed CDH. All patients were managed by maternal transport, planned delivery, immediate resuscitation and gentle ventilation. The primary outcome measurements were the 90-day survival and intact discharge. The examined prenatal factors included gestational age (GA) at diagnosis, lung-to-head ratio (LHR), lung-to-thorax transverse area ratio (L/T) and liver position. Physical growth and motor/speech development were evaluated at 1.5 and 3 years of age. Data were expressed as the median (range). The mean GA at diagnosis was 29 (17-40) weeks. The LHR and L/T were 1.56 (0.37-4.23) and 0.11 (0.04-0.25), respectively. There were 48 patients with liver up. The mean GA at birth was 38 (28-42) weeks. The 90-day survival rate and intact discharge rate were 79 and 63%, respectively. Twelve patients had major morbidity at discharge, and 71% of these patients had physical growth or developmental retardation at 3 years of age. This multicenter study demonstrated that the 90-day survival rate of isolated prenatally diagnosed CDH was 79%, and that subsequent morbidity remained high. A new treatment strategy is needed to reduce the mortality and morbidity of severe CDH.

Implication of alteration in blood flow on leucine transport in human placenta: search for ‘toxemia’ model

Previous research from our laboratory had shown that maternal fetal transport of some well-established reference markers were altered in preeclamptic pregnancies [1]. This observation was in agreem...

Mortality in infants with congenital diaphragmatic hernia: a study of the United States National Database

To examine the effect of regionalization of care on outcomes of neonates with congenital diaphragmatic hernia (CDH). We analyzed the National Inpatient Sample and the 'Kids' database for the years 1997 to 2004. Infants with CDH were grouped based on whether they underwent surgical repair at the hospital of birth, or at another facility. Groups were compared using chi-square, t-test and logistic regression. A total of 2140 infants were included: 41% were females, 42% were Caucasians, 48% were transported, 20% reported the use of extracorporeal membrane oxygenation (ECMO)and 33% died. Only 79% underwent operative repair, in which 85% survived after surgery. Survival among operated patients who used ECMO was 40%. Transported infants used more ECMO than non-transported ones (25 vs 15%; adjusted odds ratio (OR) 1.46; confidence interval 1.1 to 1.9, P=0.007), and had higher mortality after surgery (16 vs 13%; adjusted OR 1.46; confidence interval 1.1 to 2, P=0.02). The utilization of neonatal transport of CDH patients is associated with increased mortality and increased need for ECMO. This study supports the need for regionalization of care, and favors maternal transport before delivery of CDH newborns.

Changes in Maternal and Child Health Outcomes After Introduction of a Helicopter into Perinatal Transportation in Japan

To examine the effect of perinatal helicopter transportation on maternal and child health. Helicopter transportation for the sparsely populated southern areas of Wakayama and Mie prefectures was introduced in June 2003. Maternal and child health statistics for 2000-2002 and 2004-2006 were compared between the south and north regions of the prefectures. There were 9 maternal transports from south Wakayama, 2 from north Wakayama, and 5 from south Mie in 2004-2006; and 13 neonatal transports from south Wakayama and 7 from north Wakayama during the same period. Decreases in neonatal and perinatal mortalities in 2004-2006 compared to 2000-2002 were greater in south Wakayama than in north Wakayama (-0.31 vs. -0.28, and -0.57 vs. -0.18, respectively); and greater in south Mie than in north Mie (-0.90 vs. -0.49, and -2.49 vs. -1.48, respectively). The changes in the number of maternal deaths between 2000-2002 and 2004-2006 were 0 in south Wakayama, 1 in north Wakayama, -2 in south Mie, and -1 in north Mie, with the greatest change occurring in south Mie. Use of a helicopter for perinatal transportation can possibly improve maternal and child health in sparsely populated areas far away from urban areas.

Analysis of maternal transport in our hospital

Analysis of maternal transport in our hospital

Prospective Study of Coding Practices for Cesarean Deliveries

To assess consistency of hospital coding for patients with cesarean delivery-related admissions. Hospital coders from 11 participating institutions received a brief questionnaire and a standardized, inpatient record that was developed for nine hypothetical patients who delivered by cesarean delivery. They were asked to assign a diagnosis-related group (DRG) for each case and to submit the DRG, assigned International Classification of Diseases, 9th Revision (ICD-9) codes, and any relevant Physicians' Current Procedural Terminology Coding System codes used in their coding for each case. These responses were analyzed by mean analysis and analysis of variance tests to evaluate variation in coding practices submitted. Each participating academic hospital has a level III nursery, takes maternal transports, and has a residency and maternal-fetal medicine staff. Consensus in DRG coding was found in only two thirds of cases. Variation in use of ICD-9 codes existed, with 13.7% of ICD-9 codes assigned by all of the coding departments and 24.2% of ICD-9 codes uniquely used by a single institution. Variation in use of Physicians' Current Procedural Terminology Coding System codes also occurred, with 16.3% of the procedure codes used in the same case by all institutions and 28.6% used by a single institution. Documenting providers, coders, and institutions should exercise caution in the use of DRG codes, procedure codes, and ICD-9 codes for cesarean deliveries. The variability noted reflects the difficulty of the coding process and judgments that need to be made by the coders in assigning the codes. III.

Effects of early-and mid-pregnancy under-nutrition on maternal and foetal plasma free amino acid concentrations in Scottish Blackface and Suffolk sheep

Nutrient intake during pregnancy affects foetal development and placental function in a range of species, often with long-term effects on offspring viability. Maternal supply and placental transport of amino acids are key to delivering amino acids for foetal metabolism. Maternal under-nutrition has been shown to reduce both maternal and foetal amino acid concentrations even after a period of re-feeding (Kwon et al. 2004). Intriguingly whether sheep have been adapted to a harsh environment or not appears to influence the extent of any reduction (Jobgen et al. 2008). The present study therefore tested whether plasma amino acid concentrations differed between Scottish Blackface (B) sheep adapted to a hill environment and a lowland breed (Suffolk, S) selected for lean tissue growth when challenged by a period of under-nutrition.

Comparison of neonatal outcome for inborn and outborn very low‐birthweight preterm infants

The aim of the present study was to compare the neonatal outcome of very low-birthweight (VLBW) preterm infants with regard to inborn and outborn status in a medical center of Southern Taiwan, where short-distance neonatal transport is the rule and maternal transport was not well established. This retrospective study included outborn VLBW preterm infants admitted to the neonatal intensive care unit of Chang Gung Memorial Hospital at Kaohsiung after neonatal transport during the period from 1999 through 2003. An equal number of inborn preterm infants matched for gender and birthweight were included as controls. Infants with lethal congenital anomalies or who died in the delivery room were excluded. Data were collected from reviewing medical charts. A total of 34 inborn VLBW infants and 34 outborn VLBW infants with neonatal transport were included. Chronic lung disease (CLD) was significantly more frequent in the outborn group according to McNemar test (P = 0.0124) and logistic regression. Logistic regression also showed that outborn status (P = 0.0173) and birthweight (P = 0.0024) were the two most important risk factors for development of CLD. Well-trained short distance neonatal transport is useful and valuable for VLBW infants with gestation age of 27-34 weeks in Southern Taiwan. The respiratory outcome, however, was poor in the outborn group in terms of incidence of CLD. To improve the respiratory outcome, further modification of respiratory care during transportation or antenatal maternal transport is crucial.

Enquête de satisfaction auprès de 75 professionnels de la région Rhône-Alpes sur la mise en place d’une cellule régionale de régulation des transferts périnatals. L’avenir de cette structure est-il envisageable sur l’ensemble du territoire français ?

Objective In 2006, the Ministry of Health issued a legal text relating to organization of maternal transports: “By the end of the year 2008, transfers of women and new-born babies will have to be treated in a centralized way”, have to provide a 24 hours service and can take several forms such as a regional transfer center, working for several perinatal network or a simple hotline within the level 3 maternity hospital of the perinatal network and would be managed by efficiently trained professionals. In order to help professionals to choose between various types of organizations, we considered to evaluate their degree of satisfaction with the Rhône-Alpes regional hotline center. Patients and methods A postal survey was carried out 15 months after the creation of the regional hotline center to the 146 obstetricians and neonatologists of the perinatal network. Eight questions dealt with the following points: organization of in utero transfers and retransfers for obstetricians on the one hand, and the organization of neonatal transfers and retransfers for pediatricians on the other hand.Moreover, several questions relating to the communication quality and the global transport organization were asked to all of these professionals. Finally, practitioners were asked whether the regional hotline center should carry on its activity or not. Results The response rate was 51%. Seventy-two percent of practitioners considered the regional hotline center improved the communication between professionals. 66,7% thought that it improved the organization of transport. Obstetricians get benefits in 91,7% of in utero transfers and in 63,8% of retransfers. Neonatologists get benefits in 92,3% of new born babies’ transfers and in 53,8% of retransfers. Finally, 85,3% of the doctors felt that the regional hotline center was time saving and 96% of them felt that this structure should carry on its activity. Discussion and conclusion In the French Rhône-Alpes region, most obstetricians and pediatricians are satisfied by a regional hotline center dedicated to in utero as well as neonate transfer.

Intraventricular hemorrhage in premature infants

Dr. Stonestreet presented a case of an infant who was born 25 weeks gestation by spontaneous vaginal delivery with Apgar scores of 11 and 55. The infant was intubated because of decreased respiratory effort. He developed a pneumothorax on day 2 of life and bilateral grade 4 intraventricular hemorrhages. This case was used as a clinical example of infants that develop intraventricular hemorrhage. There is a large increase in brain maturation that occurs over the interval when infants develop intraventricular hemorrhage. From 23–32 weeks of gestation, important processes such as branching synaptagenesis, programmed cell death and reorganization of synapses are occurring in premature infants. The grading scale of LuAnn Papile has long been used to categorize grade of intraventricular hemorrhage. Fortunately, the incidence of intraventricular hemorrhage has decreased from the 1980's until 2006. In 2006, the incidence of all types of intraventricular hemorrhage were at 36 percent with severe types (Grades 3 and 4) representing 14 percent of infants <1000 gm. Many clinical prenatal and postnatal factors predispose infants to intraventricular hemorrhage. Factors that can be protective against the neonatal development of intraventricular hemorrhage include maternal transport, optimal delivery, decreased use of ventilation where possible, limitation of intravenous volume boluses, limitation of the use of Dopamine, limitation of treatment with bicarbonate, avoiding pneumothorax and gentle handling. Hemorrhagic hydrocephalus occurs 1–3 weeks after intraventricular hemorrhage. In sixty-five percent of infants that develop post-hemorrhagic, it hydrocephalus resolves within 4 weeks. Fifteen to twenty percent of these infants require a shunt for post-hemorrhagic hydrocephalus. Serial lumbar punctures do not prevent the need for a shunt or improve neurologic outcomes. However, serial lumbar punctures and ventricular taps may be necessary as a temporizing effort. Futile therapies for post-hemorrhagic hydrocephalus include early lumbar punctures, the use of diuretics and fibrinolytic therapy to prevent shunt dependence. An intraventricular shunt may be necessary for infants with post-hemorrhagic hydrocephalus. However, the timing of the shunt placement is based largely upon clinical judgment and the size of the ventricles. When the ventricular dilation is 4 ml higher than the 97th percentile for ventricular width at a given, a shunt is most likely indicated. Recent data suggests that infants that require shunting for post-hemorrhagic hydrocephalus have poorer neurodevelopmental outcomes than infants with severe hydrocephalus that do not require a shunt. Nonetheless, at age 5 the infant that was presented by Dr. Stonestreet is doing quite well and is mainstreaming in a normal school environment. Early intervention therapies can help with the neurologic development even in infants that develop post-hemorrhagic hydrocephalus. from 52nd Annual Meeting of the Society for Research into Hydrocephalus and Spina Bifida Providence, RI, USA. 11–14 June 2008

Improved perinatal and very low birth weight infant outcomes following neonatal and perinatal regionalization in a rural setting

Objective: To evaluate the changes in outcome that occurred during implementation of a comprehensive outreach program to five level I newborn care facilities, by one level III neonatal intensive care unit in rural WA State. Study design: Standardized outreach educational programs were provided. Outcome measures were assessed by collecting monthly perinatal and postnatal data on 61,551 births. Three six-year periods were defined. Period I (1988-1994) was compared with period II (1994-2000) and period III (2000-2006). Results: Comparing the averages for the three periods, there was a statistically significant increase in maternal transports from level I hospitals, and significant decreases in early-onset sepsis, meconium aspiration syndrome, low Apgar scores, major congenital malformations, neonatal and perinatal mortality rates, very low birth weight (VLBW) infant mortality, chronic lung disease and duration of hospital stay (all p< 0.001). Conclusion: A successful regionalization of perinatal service in rural areas can be accomplished by establishing extensive outreach programs. This model can be utilized to improve perinatal, neonatal and VLBW infant outcomes.

SBAR for Maternal Transports: Going the Extra Mile

SBAR for Maternal Transports: Going the Extra Mile

The concern of ART treatment on maternal transport cases in the tertiary perinatal center

OBJECTIVE: The purpose of this study was to evaluate the concern of ART treatment in the tertiary perinatal center.DESIGN: Retrospective study.MATERIALS AND METHODS: From January 2003 to December 2007, there were 1790 deliveries in our tertiary perinatal center. There were 958 referred cases including 48 ART treatments (24 conventional IVF-ET, 1 ICSI, 13 cryopreserved embryo transfer, 10 cryopreserved blastocysto transfer). In these cases, factors for referral and obstetrical outcomes (multiple pregnancies, pregnancy outcomes, congenital anomalies, growth restriction) were studied.RESULTS: Common factors on referral cases were 201 threatened premature labor including 11 ART cases, 69 maternal complications including 2 ART cases, 62 multiple pregnancies including 14 ART cases, 57 IUGR (intrauterine growth restriction) and PIH (pregnancy induced hypertention) including 8 ART cases, and 31 congenital anomalies including 3 ART cases. In referral cases, there were 193 emergency maternal transports including 7 ART treatments. The most common factor for emergency transport was threatened premature labor (123 cases including 7 ART). About referral multiple pregnancies, there were 4 triplet pregnancies including 1 ART, 38 DD (dichorionic, diamnionic) twin pregnancies including 9 ART, 18 MD (monochorionic, diamnionic) twin pregnancies including 4 ART, and 2 MM (monochorionic, monoamnionic) twin pregnancies. Those multiple pregnancies were 14 cases after ART (assisted reproduction technology), 15 after OI (ovulation induction), and 33 natural conceived. There were 7 TTTS (twin-to-twin transfusion syndrome) pregnancies including 3 ART cases. The number of spontaneous abortions and still births was 59 including 10 after ART. In cryopreserved blastocysto transfer cases, IUFD (intrauterine fetal death) and congenital anomalies were more frequent than other ART treatments.CONCLUSIONS: In emergency maternal transport, there was no concern of ART treatment. However, the increased risk of multiple pregnancies, TTTS, IUFD, and congenital anomalies was noted in ART treatment cases. OBJECTIVE: The purpose of this study was to evaluate the concern of ART treatment in the tertiary perinatal center. DESIGN: Retrospective study. MATERIALS AND METHODS: From January 2003 to December 2007, there were 1790 deliveries in our tertiary perinatal center. There were 958 referred cases including 48 ART treatments (24 conventional IVF-ET, 1 ICSI, 13 cryopreserved embryo transfer, 10 cryopreserved blastocysto transfer). In these cases, factors for referral and obstetrical outcomes (multiple pregnancies, pregnancy outcomes, congenital anomalies, growth restriction) were studied. RESULTS: Common factors on referral cases were 201 threatened premature labor including 11 ART cases, 69 maternal complications including 2 ART cases, 62 multiple pregnancies including 14 ART cases, 57 IUGR (intrauterine growth restriction) and PIH (pregnancy induced hypertention) including 8 ART cases, and 31 congenital anomalies including 3 ART cases. In referral cases, there were 193 emergency maternal transports including 7 ART treatments. The most common factor for emergency transport was threatened premature labor (123 cases including 7 ART). About referral multiple pregnancies, there were 4 triplet pregnancies including 1 ART, 38 DD (dichorionic, diamnionic) twin pregnancies including 9 ART, 18 MD (monochorionic, diamnionic) twin pregnancies including 4 ART, and 2 MM (monochorionic, monoamnionic) twin pregnancies. Those multiple pregnancies were 14 cases after ART (assisted reproduction technology), 15 after OI (ovulation induction), and 33 natural conceived. There were 7 TTTS (twin-to-twin transfusion syndrome) pregnancies including 3 ART cases. The number of spontaneous abortions and still births was 59 including 10 after ART. In cryopreserved blastocysto transfer cases, IUFD (intrauterine fetal death) and congenital anomalies were more frequent than other ART treatments. CONCLUSIONS: In emergency maternal transport, there was no concern of ART treatment. However, the increased risk of multiple pregnancies, TTTS, IUFD, and congenital anomalies was noted in ART treatment cases.

Safety and usefulness of emergency maternal transport using helicopter

Japan has a shortage of tertiary medical care facilities for maternal and fetal medicine. Establishment of efficient medical transport systems is needed for pregnant women and fetuses with severe complications. Maternal transport by helicopters is expected to shorten transportation time to advanced facilities, although its feasibility has not yet been evaluated. The aim of the present study was to investigate the status of maternal helicopter transport, and conditions of the pregnant patients and children transferred by helicopter to Kameda Medical Center (KMC). Between August 2005 and July 2006, 26 pregnant women were transported by helicopters to KMC. The median net flight time was 24 min (range 15-29 min), and the median of estimation of ground transportation time was 125 min (range 90-180 min). The causes for transfers were preterm labor in eight, preterm premature rupture of the membrane in five, cervical incompetence in five, pre-eclampsia in three and other medical reasons in five. Five of the 26 patients were discharged with restored stability of pregnancy. The remaining 21 patients underwent delivery at KMC. The median gestational age was 26 weeks (range 22-33 weeks) at the time of transfer and 31 weeks (range 22-37 weeks) at delivery. Four of 26 neonates who were born at KMC died after birth due to severe premature or congenital anomaly. Seventeen of the remaining 22 neonates, including 10 twins, received treatment in the neonatal intensive care unit. All of the 22 neonates and all the mothers were discharged in good condition. No patients developed any complications requiring treatment during flights. Helicopter transfer is feasible for pregnant patients with severe complications.

IS-013 Can prenatal diagnosis and maternal transport improve patient outcomes in neonatal surgery?(International Session IV,Better Life for Sick Children, Better Future for Pediatric Surgery,the 45th Annual Meeting of Japanese Society of Pediatric Surgeons)

IS-013 Can prenatal diagnosis and maternal transport improve patient outcomes in neonatal surgery?(International Session IV,Better Life for Sick Children, Better Future for Pediatric Surgery,the 45th Annual Meeting of Japanese Society of Pediatric Surgeons)

Absorbing and transferring risk: assessing the impact of a statewide high-risk-pregnancy telemedical program on VLBW maternal transports.

BackgroundPrior research has shown that resources have an impact on birth outcomes. In this paper we ask how combinations of telemedical and hospital-level resources impact transports of mothers expecting very low birth weight (VLBW) babies in Arkansas.MethodsUsing de-identified birth certificate data from the Arkansas Department of Health, data were gathered on transports of women carrying VLBW babies for two six-month periods: a period just before the start of ANGELS (12/02-05/03), a telemedical outreach program for high-risk pregnancies, and a period after the program had been running for six months (12/03-05/04). For each maternal transport, the following information was recorded: maternal race-ethnicity, maternal age, and the birth weight of the infant. Logistic regression was used to assess the relationship between the predictors (telemedicine, hospital level, maternal characteristics) and the probability of a transport.ResultsHaving a telemedical site available increases the probability of a mother carrying a VLBW baby being transported to a level III facility either before or during birth. Having at least a level II nursery also increases the chance of a maternal transport. Where both level II nurseries and telemedical access are available, the odds of VLBW maternal transports are only modestly increased in comparison to the case where neither is present. At the individual level, Hispanic mothers were less likely to be transported than other mothers, and teenaged mothers were more likely to be transported than those 18 and over. A mother's being Black or being over 35 did not have an impact on the odds of being transported to a level III facility.ConclusionCombinations of resources have an impact on physician decisions regarding VLBW transports and are interpretable in terms of the capacity to diagnose and absorb risk. We suggest a collegial review of transport patterns and birth outcomes from areas with different levels of resources as a vehicle for moving the entire system of care forward over time. With such an evidence-based review in place, the collegial relations among level III specialists and obstetricians from around the state can, over time, develop workable protocols for when and how level III facilities should be involved.