Regionalization Of Perinatal Care Research Articles

Outcome of neonatal transport in newborn with weight less than 1.5 kg and role of TOPS score as mortality predictor

Background: Neonatal period is the most vulnerable time for individual survival and newborn with weight <1.5 kg are having more morbidity then newborn with appropriate weight for age. Many of these are easy to manage and neonatal mortality can be decrease with regionalization of perinatal care and transportation in stable condition. Methods: The study was conducted at B. J. Medical College, Ahmedabad and Civil Hospital, Ahmedabad. A prospective, observational study consisting of total 140 patients, admitted in neonatal intensive care unit during the period from October 2022 to September 2023 with inclusion criteria of newborn <1.5 kg and ≤28 days of life. Study was questionnaire based, TOPS scoring was done on admission (temperature by digital thermometer, SpO2 by pulse oximeter, perfusion by CRT in midsternum, blood sugar by reagent strip). Analysis of outcome done using Chi square. Results: Out of 140 enrolled patients 134(95.8%) neonates were hospital delivered and 6 (4.3%) home delivered. Most common indication of referral was respiratory distress syndrome (27.8%). 85 (60.7%) of neonates were transferred in ambulance and 44 (31.4%) neonates were transferred in private vehicle. 58 (41.4%) were given intra-transport support in form of O2 prongs, Incubator, bag and tube ventilation and IV fluids. 72 (51.5%) and 68 (48.6%) transferred with untrained and trained personal respectively. 30.7% of the patients were expired and 69.3% of neonates were either discharged or took LAMA. Conclusions: To reduce neonatal mortality rate, neonatal facility should be upgraded, intra transport stabilization, proper referral notes and specialised neonatal ambulance will be helpful.

In France, the organization of perinatal care has a direct influence on the outcome of the mother and the newborn: Contribution from a French nationwide study.

To investigate maternal and neonatal outcomes after a delivery in France in 2019, according to hospital characteristics and the impact of distance and time of travel on mother and newborn. All parturients above 18 years of age who delivered in 2019 and were identified in the French health insurance database were included, with their newborns, in this retrospective cohort study. Main outcome measures were Severe Maternal Morbidity score and the Neonatal Adverse Outcome Indicator (NAOI). Among the 733 052 pregnancies included, 10 829 presented a severe maternal morbidity (1.48%) and 77 237 had a neonatal adverse outcome (10.4%). Factors associated with an unfavorable maternal or neonatal outcome were Obstetric Comorbidity Index, primiparity, and cesarean or instrumental delivery. Prematurity was associated with less severe maternal morbidity but more neonatal adverse outcomes. Time of travel above 30 min was associated with a higher NAOI rate. Results suggest the efficiency of regionalization of perinatal care in France, although a difference in both outcomes persists according to unit volume, suggesting the need for a further step in concentrating perinatal care. Perinatal care organization should focus on mapping the territory with high-level, high-volume maternity throughout the territory; this suggests closing down high-volume units and improving low-volume ones to maintain coherent mapping.

Оцінка ефективності перинатальної допомоги в Україні

In the context of political changes, increasing social heterogeneity of society, high income differentiation, Russia’s aggressive war against Ukraine, and the COVID-19 pandemic, women during pregnancy and childbirth and newborns are becoming the most vulnerable groups in the population. Effective maternal and newborn health can only be promoted and maintained through effective healthcare systems. Purpose - to analyze and evaluate the integrated effectiveness of perinatal care in Ukraine at the national and regional levels. Materials and methods. A comprehensive analysis of regional peculiarities and an assessment of the main indicators of perinatal care in Ukraine in 2017, 2021 according to the data of the State Institution «Centre for Medical Statistics of the Ministry of Health of Ukraine», perinatal audit according to the World Health Organization «MATRIX - BABIES» methodology were carried out. A modified outcome model was used to assess the integrated effectiveness of perinatal care. Methods of systematic approach, comparative analysis, bibliographic, statistical data processing were used. Results. The population-based comprehensive study of the integrated performance of perinatal care at the national and regional levels showed a sufficient, above-average level of achievement of results (comprehensive assessment ratio (CAR) - 0.77 in 2017 and 0.73 in 2021) with a high level of coefficient of achievement of normative values of resource components (0.82 and 0.86) and activities (0.76 and 0.77, respectively), which is likely due to the reorientation of perinatal care facilities and institutions to evidence-based medical and organizational technologies. The negative trend in the perinatal care CAR for 2017-2021 (5.19% decline rate) is due to a decrease in the ratio of achievement of the normative value of the performance component from 0.79 to 0.64 due to the rapid increase in maternal mortality from 12.5 to 42.5 per 100 thousand live births and an increase in bleeding in the sequential and postpartum periods from 7.1 to 8.9 per 1000 births, respectively, which may be due to the COVID-19 pandemic. Changes in the CAR of the integrated effectiveness of regional perinatal care systems in Ukraine in 2021 compared to 2017 were downward in the vast majority (15) of territories (the highest rate of decrease in the CAR (19.05-15.0%) was in Zhytomyr, Dnipro, Zaporizhzhia, and Poltava regions), and upward in 9 territories (the highest rate of increase in the CAR (9.37-7.58%) was in Zakarpattia, Chernivtsi, and Volyn regions), with stabilization of this indicator in Rivne region. The leaders of the integrated perinatal care efficiency (the Group 1) with a high level of results achievement ratio (CAR≥0.80), which indicates that the perinatal service in the regions is quite effective, are Kyiv, Ternopil, Ivano-Frankivsk, Lviv, and Chernivtsi regions. An another group of regions (the Group 2) with above average CAR (0.7-0.79), which requires strengthening of certain components of perinatal service facilities and institutions, includes 13 regions. The outsiders of the integral effectiveness of perinatal care (the Group 3 of regions with an average CAR of 0.6-0.69), requiring management decisions on more efficient operation of perinatal service facilities and institutions, are 7 regions (Dnipro, Donetsk, Zhytomyr, Zaporizhzhia, Kyiv, Poltava and Kherson regions). Conclusions. The integrated assessment of the effectiveness of perinatal care makes it possible to evaluate the effectiveness of management actions in ensuring the availability and quality of perinatal care, and to respond in a timely manner to changes in the macro- and microenvironment. Given that the model of integrated assessment of perinatal care effectiveness has dynamic properties, it is planned to revise them in the future as the healthcare sector transforms and the normative values of individual indicators of the integrated assessment are achieved. No conflict of interests was declared by the authors.

Influence of the maternity unit and region of delivery on episiotomy practice in France: a nationwide population-based study.

Our objective was to identify factors associated with episiotomy practice in France, in particular, characteristics of the maternity units and regions of delivery. We performed a national cross-sectional population-based study in all French maternity units in 2016 including 9284 women with vaginal delivery. Our outcome was the performance of an episiotomy. After stratification for parity, associations of episiotomy practice with individual and organizational characteristics and the region of delivery were estimated with multilevel logistic regression models. The variability in maternity unit episiotomy rates explained by the characteristics studied was estimated by the proportional change in variance. A total of 19.9% of the women had an episiotomy. The principal factors associated with episiotomy practice were maternal and obstetric and delivery in a maternity unit with <2000 annual deliveries. After adjusting for individual, obstetric and organizational characteristics, the practice of episiotomy was strongly associated with women's region of delivery. Additionally, women's individual characteristics did not explain the significant variability in episiotomy rates between maternity units (P < 0.001) but maternity unit characteristics partly did (proportion of variance explained: 7.2% for primiparas and 13.6% for multiparas) and regional differences still more (18% and 30.7%, respectively). Episiotomy practices in France in 2016 varied strongly between maternity units, largely due to regional differences. Targeted actions by the regional perinatal care networks may reduce the national episiotomy rate and standardize practices.

Strengthening Interprofessional Collaboration to Improve Transfers Between a Freestanding Birth Center and an Academic Medical Center.

The number of individuals choosing to give birth in a freestanding birth center has doubled since 2004. As many as half of all pregnant persons planning for a birth center birth ultimately develop medical complications and are unable to give birth outside of the hospital. Integrating birth centers into their regional perinatal health care system optimizes outcomes by establishing predetermined pathways for antepartum and intrapartum transfers of care and facilitates ongoing communication and cooperation among clinicians. The Vanderbilt Birth Center is a freestanding birth center that is operated by an academic medical center and partners with a hospital-based midwifery practice that cares for patients transferring from the birth center. Since the inception of the birth center in 2015, the entire perinatal team has worked to improve the process and experience of patient transfer from birth center to hospital care. This article will present strategies implemented through the ongoing collaboration between birth center and hospital health care providers. These include adopting a shared electronic health record, clinical practice guidelines that align across birth sites, preparing birth center patients prenatally for the possibility hospital transfer, the presentation of a united team across birth sites, clear and widely disseminated communication pathways for hospital admission and patient handoff, and ongoing opportunities for interteam communication, collaboration, and education. These strategies may benefit similar midwifery practice models as they seek to partner with larger health care systems and improve the transfer experience for their patients.

Role of a Fetal Ultrasound Clinic in Promoting Multidisciplinary and Inter-Facility Perinatal Care.

With the increasing rate of high-risk pregnancies, there is an increased need for early evaluation of at-risk fetuses. Fetal ultrasound imaging has become a pivotal part of this evaluation. To evaluate the role played by a fetal ultrasound clinic in promoting comprehensive perinatal care of patients with high-risk pregnancies, we retrospectively analyzed the indications and findings of fetal scans and the outcomes of the examined fetuses collected over the past 7 years (2014-2020) by our institute, which is reorganized as a perinatal medical center. During the study period, we conducted 345 fetal scans in high-risk pregnancy cases. Of these, 158 cases (46%) were referrals from other institutes. Eighty-nine neonates were admitted to our neonatal intensive care unit (NICU) after being evaluated, of which 10 neonates underwent surgery during their NICU stays. Thirty-nine pregnant women were referred to other tertiary care hospitals mainly due to fetal diagnoses with complex cardiac anomalies. Fourteen cases resulted in intrauterine fetal death or artificial abortion. Fetal ultrasound clinics have established their role in facilitating sophisticated regional perinatal care via multidisciplinary and inter-facility cooperation for high-risk pregnancy cases. In addition, providing psychological support and counseling for pregnant women whose fetuses are diagnosed with severe congenital anomalies should not be neglected.

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Noteworthy Professional News.

Hospital transfer for patients with postpartum hemorrhage in Yokohama, Japan: a single-center descriptive study.

AimTo describe the transport time and timing of transfer of patients with postpartum hemorrhage to a tertiary care institution in an urban area.MethodsWe included patients with postpartum hemorrhage transferred to our hospital from a perinatal care facility. We defined transfer time as the time between the referring physician's request for transfer and the patient's arrival at our hospital. We examined transfer time and its breakdown, the shock index before and after transfer, and the prognosis.ResultsOverall, 79 patients with postpartum hemorrhage were transported to our hospital within a median (interquartile range) of 53 min (47–63 min). In 70 cases (89%), the request for transport was made before the shock index reached 1.5, and two cases had cardiac arrest during transport.ConclusionsMost patients who were transferred to our hospital were transferred according to the criteria recommended by the guideline. However, the occurrence of cardiac arrest during transport indicates the need to shorten the time from transfer requests to emergency calls by strengthening cooperation with regional perinatal care facilities.

STATUS OF MEDICAL CARE FOR NEWBORNS IN UKRAINE

Introduction. In the context of continuing depopulation, and low birth rate, the formation and preservation of newborn generations’ health is the most important medical and social task and one of the main activities of the Ministry of Health of Ukraine and local health care institutions.&#x0D; The aim of the study was to analyze and evaluate the effectiveness of medical care for newborns in Ukraine and its impact on the main indicators of newborns’ health.&#x0D; Materials and research methods. A retrospective analysis and assessment of the dynamics of neonatal care in Ukraine was carried out according to state and industry statistics, perinatal audit according to the method of WHO “MATRIX - BABIES” for the period 2001-2019, monitoring and evaluation of the regionalization of perinatal care (for 2014-2017). Methods of a systematic approach, bibliographic, statistical data processing, and graphic representation were applied.&#x0D; Results of the study: the study showed that during the period of the research a number of newborns born in the facilities of the Ministry of Health of Ukraine decreased from 387900 in 2000 to 294100 in 2019, with a negative trend in the generalized objective criterion of the generation’s health and socio-economic well-being of the population - frequency of premature newborns with low birth weight including those with extremely low birth weight. At the same time, the frequency of newborns with congenital diseases or those who got sick after birth, decreased from 280.8 per 1000 live births in 2000 to 172.14 in 2019 with the wave-like nature of its dynamics.&#x0D; The existing state system of three-level neonatal care integrated into the perinatal service makes it possible to provide basic, qualified and highly qualified specialized medical care for newborns at all stages of its provision. During the observation period, the provision of newborns with pediatrician-neonatologists increased from 4.58 per 1000 live births to 5.34, and with hospital beds for premature and sick newborns - from 5.62 to 6.91, respectively.&#x0D; A slight increasing trend of significant criterion of newborns’ health condition was achieved (99.36% in 2001 vs 99.7% in 2019) along with the activities of the neonatological service in survival of newborns in the first 168 hours of life mainly due to a 2.6-fold increase in the survival of newborns with a birth weight of 500-999g. Sufficient efficiency of medical care for newborns was confirmed by a positive trend in early neonatal mortality from 4.71 ‰ in 2000 to 3.04 ‰ in 2019 and neonatal mortality from 6.65 ‰ to 4.57 ‰, respectively.&#x0D; At the same time, the increase of newborns’ incidence with diseases that have a direct impact on the development of chronic and disabling diseases is a cause for concern: cases of congenital pneumonia increased from 3.18 ‰ in 2000 to 5.46 ‰ in 2019, of neonatal sepsis - from 0.09 ‰ to 0.74 ‰, respectively. Also other disorders of newborns’ cerebral status increased from 18.5 ‰ in 2010 to 28.5 ‰, and neonatal jaundice - from 31.11 ‰ in 2015 to 43.65 ‰.&#x0D; An excess in 1.5 times of the standard recommended by the WHO of the proportional indicator of early neonatal mortality was revealed among infants weighing more than 1500 g. The excess of the real indicator of early neonatal mortality over the actual one was 2.2-2.3 times, which meant underestimation of the total rate of neonatal and infant mortality.&#x0D; Conclusions. Further improvement of the effectiveness of neonatal care and the decrease of early neonatal and neonatal mortality levels requires continued regionalization of perinatal care, completion of the perinatal care centers of the third level, revision and provision of patient routes, development and provision of state-guaranteed medical services/standards (such as a standard of child’s safety, safety of pregnant and postpartum woman), the reliability of determining body weight at birth, criteria for live birth and stillbirth, the introduction of follow-up monitoring of low-birth-weight newborns, the formation of a unified system for monitoring the activities of the maternal and child health services.

Translation and Psychometric Analysis of the Japanese Version of the Perceived Maternal Parenting Self-Efficacy Scale

ObjectiveTo translate the Perceived Maternal Parenting Self-Efficacy (PMP S-E) scale to Japanese and test its psychometric properties among Japanese mothers of low-birth-weight (LBW) infants. DesignDescriptive psychometric study. SettingNICUs in two regional perinatal care centers in the Kinki region of Japan. ParticipantsSeventy-nine Japanese mothers of LBW infants hospitalized in NICUs. MethodsFirst, we translated the PMP S-E scale into Japanese and assessed its face and content validity. Second, we assessed the internal consistency, test–retest reliability, and criterion-related and construct validity of the Japanese version of the PMP S-E (JPMP S-E) with data from Japanese mothers of LBW infants. ResultsThe JPMP S-E mean score was 53.0 (SD = 7.1); the total scores ranged from 38 to 68. The intraclass correlation coefficient of test–retest reliability was .75, and Cronbach’s alpha coefficient was .90. With regard to criterion-related validity, we found a significant positive correlation between the JPMP S-E and the Maternal Attachment Inventory Japanese version (r = .45, p < .001), but no correlation existed between the JPMP S-E and the General Self-Efficacy Scale (r = .21, p = .06). We evaluated construct validity using confirmatory factor analysis to assess whether the model fit the previously determined structure of the PMP S-E. The model fit was moderate in the confirmatory factor analysis (comparative fit index = .63, goodness-of-fit index = .63, root mean square error of approximation = .15). ConclusionWe found adequate estimates of reliability and moderate indicators of validity for the JPMP S-E, which support the use of the tool for clinical and research purposes.

Development of a High-Risk Maternal–Newborn Transport Team

To improve the process for safe transports of pregnant women and to develop a transport team for high-risk pregnant women and their neonates. It is the responsibility of a regional perinatal intensive care center to provide primary obstetric care to women with high-risk pregnancies and to their high-risk neonates. As the third largest birth system in the state, with more than 4,500 births last year, and the sole perinatal intensive care center in the region, the safety of pregnant women and their newborns is a priority. The health system and surrounding community needs are changing and now require a safe method to transport women with high-risk pregnancies who are in labor and women who are ready to give birth but are in a facility that does not offer inpatient labor and delivery services. The use of current resources within the established pediatric and neonatal transport team provided a solid foundation for developing the service line. A multidisciplinary group of stakeholders participated in the development, including transport team leadership, nurse and physician obstetric leadership, transfer center staff, as well as hospital administration. The addition of a perinatal nurse allows for the women in labor to receive proper care from the team as well as have the backup of a neonatal team in the event the mother gives birth. The new service also provides the ability to transport a woman who has given birth in an outlying emergency room in the same ambulance with her newborn safely. After 4 months of being in service, the team has safely transported 74 pregnant women and 7 mother–newborn pairs. Eleven of the women were from out of county, with a distance of 24 miles and greater to the regional care center. Sixty-two percent of the women were admitted for ongoing monitoring, birth, or emergent cesareans, and 36% of the women were triaged in the obstetric emergency department, monitored, and subsequently discharged. Currently, the transport team provides a high level of care for the surrounding five regional counties through a mobile intensive care unit. With the addition of a perinatal nurse, we are able to provide safe and critical services to pregnant women in our community.

Outcomes of Infants with Very Low Birth Weight Associated with Birthplace Difference: A Retrospective Cohort Study of Births in Japan and California

To determine whether outcomes among infants with very low birth weight (VLBW) vary according to the birthplace (Japan or California) controlling for maternal ethnicity. Severe intraventricular hemorrhage (IVH) and mortality were ascertained for infants with VLBW born at 24-29weeks of gestation during 2008-2017 and retrospectively analyzed by the country of birth for mothers and infants (Japan or California). Rates of severe IVH, mortality, or combined IVH/mortality were lower in the 24 095 infants born in Japan (5.1%, 5.0%, 8.8% respectively) compared with infants born in California either to 157 mothers with Japanese ethnicity (12.5%, 9.7%, 17.8%) or to a comparison group of 6173 non-Hispanic white mothers (8.4%, 8.8%, 14.6%). ORs for adverse outcomes were increased for infants born in California to mothers with Japanese ethnicity compared with infants born in Japan for severe IVH (OR, 3.31; 95% CI, 1.93-5.68), mortality (3.73; 95% CI, 2.03-6.86), and the combined outcome (3.26; 95% CI, 2.02-5.27). The odds of these outcomes also were increased for infants born in California to non-Hispanic white mothers compared with infants born in Japan. Outcomes of infants born in California did not differ by Japanese or non-Hispanic white maternal ethnicity. Low rates of severe IVH and mortality for infants with VLBW born in Japan were not seen in infants born in California to mothers with Japanese ethnicity. Differences in systems of regional perinatal care, social environment, and the quality of perinatal care may partially account for these differences in outcomes.

Weekend and off-hour effects on the incidence of cerebral palsy: contribution of consolidated perinatal care

ObjectiveThis study estimated the effects of weekend and off-hour childbirth and the size of perinatal medical care center on the incidence of cerebral palsy.MethodsThe cases were all children with severe cerebral palsy born in Japan from 2009 to 2012 whose data were stored at the Japan Obstetric Compensation System for Cerebral Palsy database, a nationally representative database. The inclusion criteria were the following: neonates born between January 2009 and December 2012 who had a birth weight of at least 2000 g and gestational age of at least 33 weeks and who had severe disability resulting from cerebral palsy independent of congenital causes or factors during the neonatal period or thereafter. Study participants were restricted to singletons and controls without report of death, scheduled cesarean section, or ambulance transportation. The controls were newborns, randomly selected by year and type of delivery (normal spontaneous delivery without cesarean section and emergency cesarean section) using a 1:10 case to control ratio sampled from the nationwide Japan Society of Obstetrics and Gynecology database.ResultsA total of 90 cerebral palsy cases and 900 controls having normal spontaneous delivery without cesarean section were selected, as were 92 cerebral palsy cases and 920 controls with emergent cesarean section. A significantly higher risk for cerebral palsy was found among cases that underwent emergent cesarean section on weekends (odds ratio [OR] 1.72, 95% confidence interval [CI] 1.06–2.81) and during the night shift (OR 2.29, 95% CI 1.30–4.02). No significant risk was found among normal spontaneous deliveries on weekends (OR 1.63, 95% CI 0.97–2.73) or during the quasi-night shift (OR 1.26, 95% CI 0.70–2.27). Regional perinatal care centers showed significantly higher risk for cerebral palsy in both emergent cesarean section (OR 2.35, 95% CI 1.47–3.77) and normal spontaneous delivery (OR 2.92, 95% CI 1.76–4.84).ConclusionLabor on weekends, during the night shift, and at regional perinatal medical care centers was associated with significantly elevated risk for cerebral palsy in emergency cesarean section.

Why so little progress in regionalization of perinatal care when transport of high-risk neonates remains a substantial risk?

Why so little progress in regionalization of perinatal care when transport of high-risk neonates remains a substantial risk?

Intermunicipal healthcare flows and perinatal births and deaths in Greater Metropolitan Rio de Janeiro, Brazil, in 2011 and 2014

The regionalization of perinatal care should consider existing healthcare structures for facilitating access. This spatial-temporal ecological study identified intermunicipal flows of perinatal births and deaths in Greater Metropolitan Rio de Janeiro, Brazil, in 2011 and 2014, defined parameters, and systematized proposals for organizing the regionalization of perinatal care. The data sources were the Brazilian Information System on Live Births, Mortality Information System, National Registry of Healthcare Establishments, and 2010 Population Census. The study identified existing relations between the mothers' municipalities of residence and the occurrence of perinatal births and deaths. Each municipality was analyzed singly and pairwise (residence/occurrence) according to the vital event, healthcare resources, and pragmatic criteria of life-threatening conditions at birth. We conducted descriptive analyses of dominant flows, exploratory principal components analysis, and cluster analysis. The existing healthcare networks were identified, and 47 variables were summarized in three factors (analytical dimensions) - availability of beds, risk of life-threatening conditions, and socioeconomic status - accounting for 60%/80%, 20%/30%, 13%/22%, respectively, of the variance pertaining to each year analyzed. The factors were used to form clusters, classified in 3 to 5 strata. Three proposals were drafted for perinatal health regions. The study's principal contribution was having presented parameters for monitoring the regionalization and systematic reevaluation of this process based on administrative records.

Pregnancy outcomes of Q fever: prospective follow-up study on Reunion island

BackgroundQ fever has been associated with perinatal complications. We conducted a prospective follow-up study to assess both the incidence of adverse pregnancy outcomes (APOs) associated with Coxiella burnetii infection and the contribution of Q fever to APOs.MethodsBetween May 1 and October 31, 2013, within the regional perinatal health care centre of Saint Pierre, Reunion island, we investigated unexplained miscarriages, stillbirths, preterm births or small-for-gestational age children. Seropositivity for C. burnetii antibodies was defined using indirect immunofluorescence for a phase 2 IgG titre ≥1:64. Acute Q fever was defined for a high phase 2 IgG titre ≥1:256 (compatible with recent or active infection) or the detection of C. burnetii genome in miscarriage products and placentas. Incidence rate ratios (IRR) for Q fever related APOs (taken as a composite outcome or individually) were assessed using Poisson regression models for dichotomous outcomes controlling major confounders.ResultsOver a 6-month period, 179 pregnant women suspected or diagnosed with an APO were investigated for Q fever, of whom 118 met the definition for an APO. Of these, 19 were seropositive and 10 presented a profile indicative of an acute infection. For three women with an acute Q fever, the chronology between the onset of infection, the APO (2 miscarriages, 1 preterm birth) and the seroconversion suggested causality in the pathogenesis. The cumulative incidence of Q fever related APOs was estimated between 2.2‰ and 5.2‰, whether causality was required or not. Both C. burnetii exposure and acute Q fever were independently associated with APOs (IRR 1.55, 95% CI 1.31–1.84; IRR 1.47, 95% CI 1.15–1.89, respectively).ConclusionsIn the endemic context of Reunion island, acute Q fever may lead to APOs. To limit the burden of Q fever on reproduction, pregnant women should be kept away from farms and avoid direct contact with ruminants.

Obstetric Care Consensus #9: Levels of Maternal Care: (Replaces Obstetric Care Consensus Number 2, February 2015)

Maternal mortality and severe maternal morbidity, particularly among women of color, have increased in the United States. The leading medical causes of maternal mortality include cardiovascular disease, infection, and common obstetric complications such as hemorrhage and vary by timing relative to the end of pregnancy. Although specific modifications in the clinical management of some of these conditions have been instituted, more can be done to improve the system of care for high-risk women at facility and population levels. The goal of levels of maternal care is to reduce maternal morbidity and mortality, including existing disparities, by encouraging the growth and maturation of systems for the provision of risk-appropriate care specific to maternal health needs. To standardize a complete and integrated system of perinatal regionalization and risk-appropriate maternal care, this classification system establishes levels of maternal care that pertain to basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The determination of the appropriate level of care to be provided by a given facility should be guided by regional and state health care entities, national accreditation and professional organization guidelines, identified regional perinatal health care service needs, and regional resources. State and regional authorities should work together with the multiple institutions within a region, and with the input from their obstetric care providers, to determine the appropriate coordinated system of care and to implement policies that promote and support a regionalized system of care. These relationships enhance the ability of women to give birth safely in their communities while providing support for circumstances when higher level resources are needed. This document is a revision of the original 2015 Levels of Maternal Care Obstetric Care Consensus, which has been revised primarily to clarify terminology and to include more recent data based on published literature and feedback from levels of maternal care implementation.

PATHOMORPHOLOGICAL PECULIARITIES OF PNEUMOPATHIES AND THEIR COMPLICATIONS IN PRETERM NEWBORNS WITH RESPIRATORY DISTRESS SYNDROME

The article presents current data on mortality rate of premature newborns due to respiratory distress syndrome in the Poltava region based on the analysis of post-mortem protocols and archival sectional materials of the Poltava regional pathology bureau for 2014-2018. Recently, the perinatal mortality rate of preterm infants has decreased significantly owing to the latest methods of resuscitation and intensive care, organization of regional perinatal care network in Ukraine, modern substitution therapy with surfactants, and effective newborn care programs. But at the same time, the share of extremely premature newborns to the total number of newborns has significantly grown. The purpose of this research was to determine the occurrence rate of the RDS syndrome among the total number of preterm infants in Poltava region for 2014-2018, to investigate the structure and pathomorphological changes in the lungs of dead premature newborns with different forms of pneumopathy, to identify the most common complications of this pathology depending on the gestational age, sex and body weight at birth. It has been found out that among children who died in the first year of life, premature infants constitute 66.3%, of whom 20.5% are infants with respiratory distress syndrome. There have been identified some features of pathological changes that involve the simultaneous formation of atelectasis and "hyaline membranes" in the alveoli (53.2% of cases), isolated massive atelectasіs in the lung tissue was detected in 46.8% of cases. 75% of pneumopathies were complicate by hemorrhagic syndrome, which manifests in the form of massive bilateral intraventricular hemorrhages and haemorrhages into internal organs. A significant percentage of premature babies (38.2%) survived only for 2 to 5 days since the birth; slightly fewer percentages of premature neonates (35.2%) survived from 20 minutes to 1 day. The study shows that health of premature newborns is a challenge for the public health care system; the significant share of all perinatal deaths is caused by respiratory distress syndrome, one of the leading causes of neonatal morbidity and mortality.

Factors affecting the provision of analgesia during childbirth, Japan.

Japan’s universal health-care system means that it is a very safe country in which to give birth. Perinatal outcomes in Japan are excellent, with low infant mortality and neonatal mortality. However, childbirth remains a challenge for many Japanese women, who are faced with a scarcity of places to give birth, limited availability of analgesia and social norms that favour natural birth. The number of birth facilities in Japan continues to decrease as fewer children are born. The numbers of qualified medical staff remain inadequate, with a continuing lack of female physicians, perpetuated by a pervasive negative gender bias. Recruitment efforts are underway, but few doctors want to specialize in obstetrics or gynaecology. Furthermore, around half of female obstetricians and gynaecologists in Japan’s male-dominated medical system stop practising when they have their own children. The difficulty of obtaining analgesia during labour is another problem. Although low uptake of labour pain relief in Japan is said to be due to cultural influences, the root of the problem is a lack of qualified anaesthesiologists and the inflexibility of a system that will not allow other staff to be trained to administer labour analgesia. Problems with labour anaesthesia have been linked to 14 maternal deaths since 2010. Japanese policy-makers need to act to renovate the nation’s obstetric facilities, reorganize regional perinatal care systems, train more obstetricians and anaesthesiologists, promote task-shifting and better integrate biomedical and traditional, non-medical care for pregnant women.

Nationwide survey of neonatal transportation practices in Italy

BackgroundDespite regionalization of perinatal care provides for the “in utero” transfer of high-risk pregnancies, there will always be a number of neonates who undergo acute inter-facility transport. The presence of a well-organized Neonatal Emergency Transport Service (NETS) can prevent and reduce risks of transportation, especially for very preterm infants, and is therefore mandatory for any program of regionalization of perinatal care. Italian National Health System is highly decentralized and Regions are autonomous to structure, plan and delivery their regional health services. Consequently, organization models and resources available vary widely and significant regional differences in access and quality of health services have been reported in the past years. A national survey was conducted in 2015 by the neonatal transport study group of the Italian Society of Neonatology with the aim to describe neonatal transfer practices and to assess the Neonatal Emergency Transport Services (NETS) status in the 20 Italian regions.MethodsA questionnaire regarding neonatal transfer practices and NETS activity for the previous year (2014) was sent to the 44 NETS operating in the 20 Italian regions. Demographic data were obtained from the Italian National Statistical Institute (ISTAT).ResultsThe overall survey response rate was 100%. In 2014, only 12 (60%) of the 20 Italian regions were fully covered by NETS, 3 (15%) regions were partially covered, while neonatal transport was not available in 5 (25%) regions. Overall, in 2014, the 44 NETS operating in Italy transported a total of 6387 infants, including 522 (8.17%) having a gestational age < 28 weeks.ConclusionsThe organization of NETS in Italy is devolved on a regional basis, resulting in a large heterogeneity of access and quality to services across the country. Where available, NETS are generally well-equipped and organized but limited volume of activities often cannot guarantee adequate levels of skills of personnel or an appropriate cost-efficiency ratio. The regions reported with lack of NETS have managed, or are trying, to fill the gap, but continuing efforts to reduce regional differences in the availability and quality of services are still needed.