Perinatal Care Program Research Articles

The regionalization of perinatal care in France — description of a missing policy

This paper reviews published data on the organization and evaluation of regionalized perinatal care programs in countries where they exist and describes those elements presently lacking in France. The advantage of maternal compared to neonatal transport is described vis-85-vis its effect on perinatal deaths as well as neonatal and developmental handicaps. Most studies describe a major advantage of maternal transfers, with less perinatal deaths (including stillbirths and neonatal deaths) and lower rates of severe developmental handicaps. In contrast, French publications show that widespread regionalization of perinatal care does not exist in spite of proposals advocating this concept made more than 20 years ago. Thus, many deliveries of less than 33 weeks gestation length or/and less than 1500 g birth weight take place in maternity sites without adequate neonatal care, despite ample evidence that such infants are at much greater risk of perinatal death or severe handicaps at 2 years of age after transfer than if they had been born in a perinatal center. For these reasons, professional organizations in France should choose to implement a policy of maternal transfers as a major effort in the near future.

A subsidized perinatal care program in a rural Colorado county.

A large number of medically indigent women in rural areas currently receive little or no prenatal care, raising major concerns regarding perinatal health. In Colorado, subsidized prenatal and labor/delivery programs have been instituted to address this problem. This article describes the implementation of two programs in one rural county. In these rural programs, private physicians, health department personnel, and social work staff at the local hospital collaborate to provide financial assistance, comprehensive health education, and quality medical care for eligible pregnant women. The identified benefits and barriers unique to the provision of quality perinatal care in rural settings are discussed.

Temporal Patterns of Cocaine Use in Pregnancy

Seventy-five cocaine-using women enrolled in a comprehensive perinatal care program were divided into two groups: those who used cocaine in only the first trimester of pregnancy (group 1 [N = 23]) and those who used cocaine throughout pregnancy (group 2 [N = 52]). Perinatal outcomes of these pregnancies were compared with perinatal outcomes of a matched group of obstetric patients with no history or evidence of substance abuse (group 3 [N = 40]). Group 2 women had an increased rate of preterm delivery and low-birth-weight infants as well as an increased rate of intrauterine growth retardation. Group 1 women had rates of these complications similar to the drug-free group. Mean birth weight, length, and head circumference for term infants were reduced in only the group 2 infants. However, both groups of cocaine-exposed infants demonstrated significant impairment of orientation, motor, and state regulation behaviors on the Neonatal Behavioral Assessment Scale.

Prospective Pricing System for Tertiary Neonatal Intensive Care

This study assessed the potential impact of the federal neonatal diagnosis-related group (DRG) pricing system upon reimbursement to a state neonatal intensive care program. Data for length of intensive care unit stay, procedures, hospital charges, and audited cost reports from the state of Florida's ten regional neonatal intensive care centers were analyzed for 8,492 neonates whose charges totaled $118 million. Mean lengths of stay in these tertiary care centers were substantially longer than those reported for the federal DRGs, which were based on community hospital data. If federal DRG-based reimbursement to hospitals were implemented in Florida's perinatal intensive care program, compensation would range from 9% to 56% of actual hospital care charges. Federal DRG price rates were not predictive of hospital charges. Only 16% of the total variation in hospital charges was explained by differences among federal DRG rates (R2 = .16). Analysis of data by major determinants of resource consumption provided groups more homogeneous with respect to hospital charges and, hence, cost. Therefore, we developed a prospective pricing system that used modifications of federal newborn DRG system. These modifications resulted in a threefold increase in R2 (.52). Our proposed system permits prediction of cost and reimbursement for infants by three criteria: birth weight, need for mechanical ventilation and/or major surgery, and survival status and length of survival for those who die.

Controlled Evaluation of Rural Regional Perinatal Care: Developmental and Neurologic Outcomes at 1 Year

The effectiveness of a rural regionalized perinatal care (RPC) program was evaluated by a controlled, population-based design. The RPC program, begun in a carefully selected study region in July 1975, evolved into a system of care which included the following major components: identification of high-risk pregnancies and high-risk newborn infants; obstetric and newborn consultation and referral services between Level I, II, and III centers; professional education for physicians, nurses, and other health professionals; and nutrition and social work consultation. Substantial resources were made available from 1975 to 1980 to implement this "total package" of RPC. A matched, control region was identified which, except for the RPC program, was as comparable as possible to the study region. It was hypothesized that the RPC intervention would have the following effects when the study region was compared with the control region: reduction in fetal and neonatal mortality, no increase in postneonatal mortality, and reduction in obstetric and newborn morbidity. These findings were reported previously. This paper presents results of hypothesized reductions in adverse developmental, neurologic, maternal-infant attachment, and selected physical health outcomes. A sample of 447 infants was assessed by an extensive battery of instruments at 1 year, adjusted for gestational age. The most notable findings were mothers' reports of receptive language development and observations of maternal attachment behaviors that significantly favored the study region. No significant differences between study and control regions were observed for Bayley Mental and Motor Scores, abnormal neurologic signs, and the physical health measures.(ABSTRACT TRUNCATED AT 250 WORDS)

The effect of ten years of regionalized perinatal health care in Iowa, U.S.A.

In 1973, Iowa, a rural, midwestern state in the U.S.A., established a Statewide Perinatal Care Program. A major objective was to develop and maintain a regionalized system of care. Such a system has been developed but differed from traditional systems by using regional level II centers. Iowa's low population density necessitated this modification. The development and maintenance of Iowa's system is described. Evaluation is provided by analysis of commonly available birth and mortality data. Improved birth-weight-specific neonatal and fetal mortality rates suggest an overall improvement in care. A more favorable birth weight distribution and evidence of screening and selective referral of high-risk patients provide evidence of improvements in prenatal care. Data are presented to show that a stratified system of care is evident in the state. Level I hospitals currently manage low-risk patients and report very low mortality rates. Level II facilities receive high-risk referrals, but selective referral occurs since the tertiary center accounts for a disproportionate number of fetal and neonatal deaths, and births weighing less than 1500 g. Other regions may benefit from similar approaches to development of regionalized systems of care and evaluation of the same.

A controlled evaluation of rural regional perinatal care: impact on mortality and morbidity.

The impact of a rural regional perinatal care (RPC) program was assessed by a quasi-experimental, controlled, population-based design. Outcome measures included changes in five-year average fetal and neonatal mortality rates as well as short-term obstetric and newborn morbidity. Declines in fetal and neonatal as well as birthweight specific mortality rates were observed for both pilot and control regions, for both races, and especially for 1501-2500 g infants. However, comparisons of preprogram (1966-74) and postprogram (1975-80) average yearly changes showed no statistically significant differences between regions. While the incidence of prenatal morbidity was the same for both regions, intrapartum and newborn morbidity significantly favored the pilot region. These results were difficult to interpret. Program relevant implications of the findings in relation to rural RPC in North Carolina are discussed. Specific benefits appeared to be associated with the development of two high-risk maternity clinics and a Level II center capability in the pilot region. The importance of community support and public/private sector cooperation in relation to RPC is noted.

The impact of publicly funded perinatal care programs on neonatal outcome, Georgia, 1976–1978

The State of Georgia administers three publicly funded perinatal care programs for medically high risk and/or low-income women: the High Risk Pregnancy Program, the Medicaid Program, and the Maternal and Infant Care Projects. To assess the impact of these programs on infant health, we compared the birth weight distribution and neonatal mortality rates of infants born to women in each program with those of infants of a nonfunded group of women with <12 years' education. Infants of women in publicly iunded groups were more likely to weigh ≤2,500gm at birth than those of women in the nonfunded group. Neonatal mortality rates for publicly funded groups were similar to those of the nonfunded group. The neonatal mortality rates for infants of birth weight ≤2,500 gm of publicly-funded women were significantly lower than those of the nonfunded women. There were no significant differences between groups for neonatal mortality rates for infants of birth weight >2,500 gm. These findings suggest that publicly funded perinatal care programs may improve neonatal survival of infants of birth weight ≤2,500 gm of low-income mothers.

Analysis of interrupted time series mortality trends: an example to evaluate regionalized perinatal care.

Interrupted time series designs are frequently employed to evaluate program impact. Analysis strategies to determine if shifts have occurred are not well known. The case where statistical fluctuations (errors) may be assumed independent is considered, and a segmented regression methodology presented. The method discussed ia applied to the assessment of changes in local and state perinatal postneonatal mortality to identify historical trends and will be used to evaluate the impact of the North Carolina Regionalized Perinatal Care Program when seven years of post-program mortality data become available. The perinatal program region is contrasted with a control region to provide a basis for interpretation of differences noted. Relevant segmented regression models provided good fits to the data and highlighted mortality trends over the last 30 years. Considerable racial differences in these trends were identified, particularly for postneonatal mortality. Segmented regression is considered relevant for the analysis of interrupted time series designs in other applications when errors can be taken to be independent. Thus, the methodology may be regarded as a general statistical tool for evaluation purposes.

1010 A TEN YEARS EXPERIENCE WITH REGIONALIZED NEONATAL CARE

The Wisc. Perinatal Care Program including 6 regional centers has been functioning for over 10 years. Regionalization has offered educational enhancement to community health providers and allowed high risk mothers and infants more uniform exposure to intensive care and therapeutic advances. To assess the program's efficacy, we evaluated state mortality rates and compared these to national statistics. While the Wisc. birth rate of LBW infants has remained constant (6-7%), the death rate for these neonates decreased 32.7% over the survey period. Reflecting increased center utilization, 57% of neonatal deaths occurred in tertiary centers in ′74, as opposed to only 20% in ′68. Over the 10 yrs, the death rate during the first 24 hrs has decreased by 43% and during the first week by 36.1%. The decremental trend for Wisc. general and disease specific meonatal death rates has consistently surpassed national norms. Deaths/1000 live births due to HMD/RDS have continued to fall despite persistent high national trends. Further, Wisc. was unique among states with > 50,000 births/yr in showing decreasing HMD/RDS death rates between ′68-′73. Maintenance of low, declining neonatal mortality rates and consistent reduction in deaths from major causalities with a marked shift in timing and place of death, establishes the positive influence of regionalized care.

The evaluation of Regionalized Perinatal Health Care Programs

A survey, conducted in the summer of 1974, to determine the extent of regionalized perinatal care in the United States revealed 28 states to have programs in operation. Evaluation was a common concern of these programs. A model for the evaluation of Regionalized Perinatal Care Programs is presented here with the North Carolina program used as an example. Evaluation was mandated as an integral component of the program in North Carolina, and this model has been developed in response to that mandate.