Regionalization Of Perinatal Care Research Articles

Turkish Neonatal Society guideline on the safe transport of newborn.

The rational presentation form of perinatal care in developed countries is evaluated within the regionalization program. Neonatal transport is the main step for the regionalization of perinatal care. It is a very important factor for reducing neonatal mortality and morbidity, especially in developing countries. Neonatal transport is a system integrity that includes more than one essential matter. Neonatal transport requires special hardware and serious organization because it can be a caused of mortality and morbidity in its own right. This guideline deals with the transport of newborn infants (definitions, personnel, technical equipment, stabilization conditions, special medical conditions, communication), and the current situation in our country and standard approaches. It should not be forgotten that changes in public space will also change the approach and that every baby should be evaluated within himself or special conditions.

833: Severe maternal morbidity associated with hypertensive disorders of pregnancy after regionalization of perinatal care in New York City

Severe maternal morbidity as defined by the CDC (CDC-SMM) is increasing. In 2003, the New York State Department of Health developed a Regional Perinatal Center (RPC) model, which categorized all hospitals for each designated level of perinatal care and promoted regional perinatal partnerships to improve birth outcomes. While it is known that hypertensive disorders of pregnancy (HDP) are associated with CDC-SMM, the relationship with levels of maternal care is unclear. This study evaluated the impact of RPC on CDC-SMM during delivery hospitalization among women with HDP. In this retrospective cohort study of women, 15-55 years old with a singleton gestation between 2008-12 in New York City (NYC), we examined the risk of CDC-SMM in women with HDP compared to normotensive controls. CDC-SMM rates were stratified by delivery hospital’s level of care. CDC-SMM was identified by linked birth certificate and hospital discharge data. Levels of care were designated per ACOG/SMFM Obstetric Care Consensus. With multivariable logistic regression, we assessed the odds of CDC-SMM in hypertensive versus normotensive women during the delivery hospitalization for each level of perinatal care. Models were adjusted for relevant sociodemographic and pregnancy-specific variables and chronic medical conditions. 574,565 women met inclusion criteria, with 41,713 (7.26%) having HDP. When compared to normotensive controls, women with HDP who delivered at a level 2 hospital had the highest odds of CDC-SMM during the delivery hospitalization, adjusted odds ratio (aOR) 4.21 (95% CI, 3.63-4.89). Women with HDP who delivered at a RPC had the lowest odds of CDC-SMM, aOR 1.86 (95% CI 1.74-1.99). When assessing the risk for CDC-SMM excluding transfusions, the adjusted odds ratio trend was conserved. (Table 1). Compared to controls and stratified for level of care, women with HDP have the highest increased odds of CDC-SMM when cared for at facilities with lower level of care designations. Further analysis can inform clinical guidelines to determine which patients require timely transfer to an RPC and also aid in development of coordinated treatment protocols for HDP at lower levels of care. Utilization of the NYC RPC model for levels of perinatal care may significantly decrease severe maternal morbidity across the nation.

Analyse des parcours de soins en périnatalité. Les naissances avant 31 SA en maternité de type 2B sont-elles évitables ?

Regionalization of perinatal care has been developed to improve the survival of preterm babies. The mortality rate is higher among very premature infants born outside level-3 maternity units. The objective of this study was to evaluate the preventability of these very premature births occurring outside recommendations within level-2B maternity units. The secondary objective was to describe the care of premature infants between 23 and 24 weeks. This is a single-center retrospective qualitative study of the care delivery pathways. Thirty-one deliveries in which the fetus was alive between 23 and 30 weeks+6 days occurred in a level-2B maternity unit in Thionville, France, between 1 January 2013 and 31 December 2015. After oral presentation of the cases, a level 2-3 multidisciplinary committee of experts in Lorraine evaluated the preventability criteria and reasons, and divided the deliveries into three groups: (i) birth in level-2B institutions avoidable, (ii) inevitable with factors related to the mother or the organization of care, (iii) with no inevitable factors. Out of the 31 deliveries included, the committee classified six deliveries as preventable, 14 as inevitable with factors, and 11 as inevitable with no factors. The criteria for preventability of birth in a level-2B unit were underestimation of maternal and fetal risk, an erroneous initial estimate of term or preterm labor, and two births in the upper limits of the French recommendations for in utero transfer. Nineteen of the 35 premature infants before 31 weeks' gestation died, 16 children were transferred to a level-3 maternity ward, and 16 children were allowed to go home. Analysis of the obstetrical-pediatric care course by an expert committee determined the preventability of the average birth and prematurity in level-2B maternity units in Lorraine for a small but significant number of cases. The local regionalization of neonatal care could be improved by the application of this method of analysis to other maternity wards in the Lorraine network.

Behavioral Patterns in Adolescents Born at 23 to 25 Weeks of Gestation.

This study examined mental health outcomes in extremely preterm children (EPT) born at 23 to 25 weeks of gestation between 1992 and 1998 at 2 Swedish tertiary care centers that offered regional and active perinatal care to all live-born EPT infants. We assessed 132 (98%) of the 134 EPT survivors at 10 to 15 years of age alongside term-born controls. Behavioral and emotional problems were evaluated by using Achenbach's Child Behavior Checklist and Teacher Report Form and Conners' Parent and Teacher scales for attention-deficit/hyperactivity disorder. Parents and teachers reported significantly more problems with internalizing behaviors as well as attention, social, and thought problems in EPT children than in controls, even when those with major neurodevelopmental disabilities (NDDs) were excluded. Multivariate analysis of covariance of the behavioral problems reported by parents and teachers revealed no interactions, but significant main effects emerged for group status (EPT versus control) and sex, with all effect sizes being medium to large and accounting for 8% to 14% of the variance. Compared with the controls, EPT children without NDDs had significantly increased rates of ≥90th percentile for total Conners' attention-deficit/hyperactivity disorder problem scores (parents: 40% vs 15%, odds ratio: 3.7, P < .001) (teachers: 24% vs 9%, odds ratio: 3.3, P = .005). The corresponding rates were higher in the total population. EPT children with or without NDDs had behavioral problems characterized by a higher risk for anxiety and attention, social, and thought problems. These findings further strengthen the proposition that a preterm behavioral phenotype is recognizable in adolescents born EPT.

АНАЛІЗ РЕЗУЛЬТАТИВНОСТІ РЕГІОНАЛІЗАЦІЇ ПЕРИНАТАЛЬНОЇ ДОПОМОГИ ЖІНКАМ В УКРАЇНІ

Мета: вивчити та проаналізувати результативність регіоналізації перинатальної допомоги жінкам в Україні.Матеріали та методи. Дослідження результативності регіоналізації перинатальної допомоги проведено із застосуванням даних державної і галузевої статистики, перинатального аудиту за BABIES-МATRICA за 2011–2015 рр., моніторингу та оцінки РПД за даними 2014–2015 рр., SWOT-аналізу. Застосовано методи: статистичний, графічного зображення.Результати. Регіоналізація перинатальної допомоги має позитивні результати щодо стану здоров’я жінок. Так, рівень абортів скоротився з 17,0 до 9,8 на 1000 жінок фертильного віку при співвідношенні абортів та живонароджених дітей 1:3,9. При цьому відмічається тенденція до збільшення частки абортів, які проводяться безпечними методами. Збільшилася частка жінок із вадами серця (61,0%–66,9%) та еклампсією і прееклампсією (78,0%–83,0%), які народжували в закладах третього рівня. Тенденцію до скорочення мають такі ускладнення, як маткові кровотечі (з 18,59% до 18,1%).Висновки. Отримані дані підтвердили позитивний вплив регіоналізації перинатальної допомоги на показники здоров’я матерів в Україні.

Chronic Conditions and Health Care Needs of Adolescents Born at 23 to 25 Weeks' Gestation.

We examined chronic conditions, functional limitations, and special health care needs in extremely preterm children (EPT; 23-25 weeks' gestation) born between 1992 and 1998 at 2 Swedish tertiary care centers that offered regional and active perinatal care to all live-born EPT infants. Of 134 surviving EPT children, 132 (98%) were assessed at 10 to 15 years of age alongside 103 term-born controls. Identification of children with functional limitations and special health care needs was based on a questionnaire administered to parents. Categorization of medical diagnoses and developmental disabilities was based on child examinations, medical record reviews, and parent questionnaires. In logistic regression analyses adjusting for social risk factors and sex, the EPT children had significantly more chronic conditions than the term-born controls, including functional limitations (64% vs 6%; odds ratio [OR], 15; 95% confidence interval [CI], 6.1-37.2; P < .001), compensatory dependency needs (60% vs 29%; OR, 3.8; 95% CI, 2.2-6.6; P < .001), and services above those routinely required by children (64% vs 25%; OR, 5.4; 95% CI, 3.0-9.6; P < .001). Specific diagnoses and disabilities for the EPT group versus controls included cerebral palsy (9.1% vs 0%; P < .001), asthma (21.2% vs 6.8%; P = 001), IQ < -2 SD (31.1% vs 4.9%; P < .001), poor motor skills without neurosensory impairment (21.9% vs 1.9%; P < .001), and psychiatric conditions (15.2% vs 1.9%; P < .001). Adolescents born EPT have considerable long-term health and educational needs. Few had severe impairments that curtailed major activities of daily life.

新生児外科の頻度と新生児・周産期医療体制からみた問題点 : 静岡県の現状と今後の課題( 小児外科regionalizationへの提言)

新生児外科の頻度と新生児・周産期医療体制からみた問題点 : 静岡県の現状と今後の課題( 小児外科regionalizationへの提言)

Outborns or Inborns: Where Are the Differences? A Comparison Study of Very Preterm Neonatal Intensive Care Unit Infants Cared for in Australia and New Zealand and in Canada

Background: Very preterm infants born outside tertiary centers are at higher risks of adverse outcomes than inborn infants. Regionalization of perinatal care has been introduced worldwide to improve outcomes. Objective: To compare the risk-adjusted outcomes of both inborn and outborn infants cared for in tertiary neonatal intensive care units in Australia and New Zealand and in Canada. Methods: Deidentified data of infants <32 weeks' gestational age from the 29 Australian and New Zealand Neonatal Network units (ANZNN; n = 9,893) and 26 Canadian Neonatal Network units (CNN; n = 7,133) between 2005 and 2007 were analyzed for predischarge adverse outcomes. Results: ANZNN had lower rates of outborns compared to CNN (13 vs. 19%), particularly of late admissions (>2 days of age; 5.8 vs. 22.2% of outborns) who had high morbidity rates. After adjusting for confounding variables including gestation, ANZNN inborn infants had lower odds of chronic lung disease [CLD; 17.0 vs. 23.3%; adjusted odds ratio (AOR) = 0.70, 95% CI: 0.64-0.77], severe neurological injuries on ultrasound (SNI; 4.1 vs. 6.7%; AOR = 0.62, 95% CI: 0.53-0.73), severe retinopathy (5.6 vs. 7%; AOR = 0.71, 95% CI: 0.59-0.84) and necrotizing enterocolitis (3.5 vs. 5.4%; AOR = 0.67, 95% CI: 0.56-0.79), but no difference in mortality odds. After excluding the late outborn admissions, ANZNN outborns had lower odds of SNI (AOR = 0.43, 95% CI: 0.32-0.58) and CLD (AOR = 0.63, 95% CI: 0.49-0.81) than CNN. Conclusions: ANZNN inborn and early admitted outborn infants had lower odds of neonatal morbidities than their CNN counterparts. However, compared to ANZNN, the higher CNN rates of outborns and their late admissions are likely related to the differences in regionalization and referral practices, and may explain differences in outcomes.

Стан регіоналізації перинатальної допомоги в Україні

Стан регіоналізації перинатальної допомоги в Україні

Transport of the high-risk neonate

Neonatal transport is continuously evolving and has developed to a cornerstone of modern perinatal medicine. Although the regionalization of perinatal care and delivery of high-risk neonates in appropriately designed centres improves neonatal outcome, neonatal transport represents an invaluable resource in order to guarantee tertiary level care throughout the region. A highly trained, adequately skilled and well-equipped transport team is key in order to provide a good quality of care for a wide variety of clinical disorders and their potential complications. A safe and efficient neonatal transport begins in the referring hospital. An optimal communication between the referring team and the transport team is paramount. Besides collecting information the transport team may advise the referring team about specific steps to undertake until arrival [1]. Adequate resuscitation and effective stabilization improve survival and reduce the chances of deterioration during transport, especially in critically ill neonates with limited physiological reserves [2]. High risk conditions like pneumothorax, congenital diaphragmatic hernia, oesophageal atresia, cardiac malformations, abdominal wall and neural tube defects and hypoxic ischemic encephalopathy (HIE) are still life threatening and require highly specialized care and monitoring [3]. The equipment routinely used for monitoring in the neonatal intensive care unit (NICU) is not specifically designed for transport and may not function properly under transport conditions. However, standard monitoring including temperature, ECG, pulse oximetry and CO2-monitoring should be routinely provided [4]. Delivering adequate ventilatory support including the administration and measurement of iNO may be challenging. A ventilator with an integrated flow sensor is helpful to assess respiratory function. The recommended ventilatory strategies in the NICU like volume-targeted ventilation can minimize lung damage and maintain more stable paCO2 values. There is a strong physiological rationale supporting the use of pre-heated and humidified air in ventilated infants, since it reduces trauma to the respiratory epithelium and is helpful to stabilize the body temperature [5,6]. Pharmacologic management including catecholamines, prostaglandins and analgosedation via multiline infusions may be necessary, thus rendering difficult situations still more complex. Active or passive body cooling in case of HIE is often demanding. Adequate protocols and an optimal temperature control to avoid accidental hyper- or hypothermia are essential [7]. In literature, data on high-risk transports are lacking, likely because of the difficulty to perform randomized studies in this field. Advanced training in resuscitation and stabilization of the neonate, as well as a specific transport and simulation based team training are mandatory for all personnel.

THE REGIONALIZATION OF PERINATAL CARE IN UKRAINE – MODERN ST ATE OF PROBLEM

The creation of perinatal center system is worldwide recognized way of the decreasing of perinatal loss, frequency of chronic morbidity formation and disability. Modern aspects of regionalization of perinatal care reviewed and the definition and functions of system's components, main problems and ways of their solution in Ukraine presented in the article.

Training program for the management of two obstetric emergencies within a French perinatal care network

ObjectivesTo evaluate the effectiveness of an interdisciplinary team training program based on simulated scenarios and focusing on two obstetrical emergency situations: shoulder dystocia and complicated breech vaginal delivery (CBVD). These situations are rare, so there are few opportunities for real-life training, yet their competent and efficient management is crucial to minimizing the risks to mother and child. Study designThe target population for training comprised the 450 professionals working in the French regional perinatal care network ELENA. An expert committee defined the topics for the training program, selected the simulated scenarios and developed the evaluation grids. The training sessions were conducted by two qualified and experienced professionals in each maternity unit. They comprised a theoretical introduction followed by practical exercises in management of simulated emergency situations by the participant teams, with the aid of a mannequin. Each team completed the exercises twice, their performances being filmed, reviewed and evaluated in each case. ResultsThe training sessions took place over 9 months between September 2012 and June 2013. A total of 298 professionals (obstetricians, residents in obstetrics, midwives and nursery nurses) were trained, representing 75% of the staff working in the ELENA perinatal care network. The results showed substantial and significant increases in the overall scores for management of the two emergency situations (from 74.5% to 91.4% for shoulder dystocia [p<0.0001], and from 67.2% to 88.4% [p<0.0001] for CBVD) as well as in the scores for all the specific areas of expertise assessed: safety, know-how, technique, team communication and communication with the patient. ConclusionThis study demonstrated the value of multidisciplinary team training for obstetric emergencies, encouraging the ELENA perinatal care network to implement an annual training program for its staff. Over and above our experience, the future establishment of a national education program to optimize the management of obstetric emergencies seems to be essential.

Obstetric Care Consensus No. 2: Levels of maternal care.

In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. Since the publication of the Toward Improving the Outcome of Pregnancy report, more than three decades ago, the conceptual framework of regionalization of care of the woman and the newborn has been gradually separated with recent focus almost entirely on the newborn. In this current document, maternal care refers to all aspects of antepartum, intrapartum, and postpartum care of the pregnant woman. The proposed classification system for levels of maternal care pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The goal of regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reducing maternal morbidity and mortality in the United States.

Levels of maternal care

In the 1970s, studies demonstrated that timely access to risk-appropriate neonatal and obstetric care could reduce perinatal mortality. Since the publication of the Toward Improving the Outcome of Pregnancy report, more than 3 decades ago, the conceptual framework of regionalization of care of the woman and the newborn has been gradually separated with recent focus almost entirely on the newborn. In this current document, maternal care refers to all aspects of antepartum, intrapartum, and postpartum care of the pregnant woman. The proposed classification system for levels of maternal care pertains to birth centers, basic care (level I), specialty care (level II), subspecialty care (level III), and regional perinatal health care centers (level IV). The goal of regionalized maternal care is for pregnant women at high risk to receive care in facilities that are prepared to provide the required level of specialized care, thereby reducing maternal morbidity and mortality in the United States.

Maternal Mortality, Near Misses, and Severe Morbidity

An increase in the prevalence of obesity, hypertension, diabetes, and abnormal placentation, among others, has fueled the recent rise in maternal mortality, "near misses" and severe morbidity. In 1976, the March of Dimes published a report, "Toward Improving the Outcome of Pregnancy," which included recommendations for levels of perinatal care. Although the original intent was to address the needs of both mother and neonate, implementation in the ensuing years focused mostly on the latter. Currently, there are no well-defined nationally accepted levels of maternal care similar to those adopted by the American Academy of Pediatrics for neonatal intensive care units. When discussing regionalization of perinatal care, the needs of the mother are frequently overlooked. We propose that it is time to address this deficiency and develop levels of care that are specific to the mother. We expect that improving maternal care will also improve neonatal outcome. We call on various organizations and agencies to establish national standards and levels of maternity care much as our colleagues in neonatology have already successfully done. We canvassed the available publications by states and other countries and found a number of noteworthy examples. We propose that the goal would be an integrated maternal-fetal-neonatal care network, a model similar to what is done in stroke or emergency care. In addition to accepting transfers, the central facility functioning at the highest level would also be responsible for education, evidence-based best practices, policy development, and quality review and improvement within the network.

Does facility-based newborn care improve neonatal outcomes? A review of evidence

Facility based newborn care is gaining importance as an intervention aiming at reduction of neonatal mortality. To assess different factors that affect effectiveness of facility based newborn care on neonatal outcomes. Electronic search using key search engines along with search of grey literature manually. Observational and interventional studies published between 1966-Aug 2010 in English having a change in neonatal mortality as an outcome measure were considered. A total of 40 articles were fully reviewed for generating synthesized evidence. All were observational studies. The exposure variables that affected neonatal outcomes were grouped into three categories- regionalization of perinatal care (17 articles), strengthening of lower level neonatal facilities (12), and other miscellaneous factors (11). Regionalization played a key role in advancing newborn care practices. It increased in-utero transfer of high risk newborns and improved survival outcomes especially for very low birth weight neonates at level III facilities. It led to reduction in neonatal mortality owing primarily to enhanced survival of low birth weight infants. Strengthening of lower level units contributed significantly in reducing neonatal mortality. High patient volume (>2,000 deliveries/year), inborn status, availability of referral system and inter-facility transfers, and adequate nursing care staff in neonatal units also demonstrated protective effect in averting neonatal deaths. Countries investing in facility based newborn care should give impetus to establishing regionalized systems of perinatal care. Strengthening of lower level units with high case loads, can yield optimal reduction in NMR.

1230 Changing Pattern of Neonatal Mortality of VLBW Infants in Croatia in 1998-99 and Ten Years Later - Population Survey

Aim: Analysis of VLBW newborns' mortality and comparison over ten-year period.Methods: Data were collected from nurseries and NICUs, embracing all VLBW newborns in Croatia.Results: Total of 663 VLBW newborns born in 1998- 99, and 345 who were born in 2008, are analyzed. Early neonatal mortality (ENM) and mortality to discharge from hospital (MDH) are shown in the table. Table Table Full size table Conclusions: ENM and MDH are reduced over the time.Efforts of neonatal services to reduce neonatal mortality could be realized as excess of “later mortality”, neonatal services in BW groups of 500- 599 g, 700-899 g reduced ENM substantially more than MDH.Apart of increased knowledge and experience in intensive care of newborns, as well as better equipment in maternities and NICUs, important increase in proportion of VLBW newborns who were born in maternities with NICU occurred, from 61% in 1998-99 to 81% in 2008. Extent of contribution of increased regionalization of perinatal care to reduction of neonatal mortality is unknown.

From knowledge to planning considerations: a matrix to assess health needs for the perinatal network in eastern Paris

Regionalization of perinatal care is required throughout networks to reduce perinatal morbidity and mortality and to organize access to health services for high-risk new borns, such as in the eastern Paris in 2007. Our study sought to design a matrix to build a perinatal knowledge base for assessing health needs and facilitating public health planning process for the perinatal network in eastern Paris. Our matrix listed as its columns 'perinatal stages' from conception through the age of 6 years, whereas the rows covered components related to public health planning (i.e. target population, perinatal risk factors and health services). For each situation, the matrix lists require information and potential data sources to measure health status and health services. Our matrix structures the cyclical process for building knowledge for action. The eastern Paris has a population of 670,000. Its nine maternity units are distributed into three levels of care, a level-3 unit opened up in June 2007. A total of 16,400 deliveries occur every year in the nine units; 2500 women living in the eastern area deliver outside the area. Our matrix is useful for building a comprehensive perinatal knowledge base depending upon perinatal stages and health-care dimensions. It should imply stakeholders in collecting, synthesizing and analysing massive amounts of data. It can be adapted to any health network or local health policy.

Le réseau périnatal de l’Est parisien (2008–2010). Définition de la population concernée pour évaluer les besoins à couvrir par le réseau

Background Since the 1990s, governmental plans in France have imposed the regionalization of perinatal care to improve both safety and quality of care. The Eastern Paris Perinatal Network is under construction in health area 75-2, which includes the 11th, 12th, 13th and 20th arrondissements of Paris. A major issue is ensuring that the network can meet the needs of its target population. The objective is to define the network's target population of mothers and newborns. Methods We designed a matrix to help assess these needs and identify the data required to define the network's population. Four principal data sources were analyzed: the National Statistics and Economic Studies Institute (Insee) data, annual health facility activity data, national medical informatics program data, and 8th-day health certificates. Results The network's target population varies according to the precise perinatal period and the planning stage. For the conception period, it includes the general population and specifically all women of childbearing age (15–49 years). The health area included 672,000 inhabitants in 2006, 29% of them are women of childbearing age. The proportion of people born outside France and who are of foreign nationality ranges, according to arrondissement, from 13.2 to 20.0%; the mean for the Paris metropolitan area is 14.7%. Approximately 16,500 women gave birth in 2007, at nine obstetric facility sites in the health area (five level I, three level II, and one type III); only 41.46% of them resided in the health area. Approximately 2500 women living in the health area gave birth at a facility outside the area. The population likely to be covered by the network is thus estimated at approximately 19,000 women. Conclusion A network must simultaneously take into account the local resident population and the population using its health care system. In an urban area such as Paris, where the health care supply is dense, it is essential for policy planning process to define the contours of the target population of a health network.

Access to level III perinatal care for pregnancies of very short duration (&lt;32 weeks)

To evaluate to which extent pregnancies of very short duration (<32 weeks' gestation) are concentrated in level III centers. Area-based study in the 57 maternity units of the Lazio Region (Italy), years 2003-2004, including: 1012 live births (gestational age 22-31 weeks), 261 fetal losses (22-31 weeks) and 209 induced abortions (22-25 weeks). Variables associated with access to a level III unit were evaluated through multivariable logistic regression models. 83.7% of all pregnancies <32 weeks (88.8% of live births, 71.6% of fetal losses and 75.1% of induced abortions) were admitted to a level III perinatal center; 23.4% of live newborns, delivered in a level III hospital, were subsequently transferred to a same level facility. The probability that a fetal loss was not treated in a level III perinatal unit was higher for women without pregnancy complication, with lower education level, and living outside the metropolitan area. Regionalization of perinatal care in Lazio is not satisfactory. Concentration of high-risk deliveries in level III centers is good, but in utero transfer is insufficient. This study can help to define the effectiveness of different organizational systems on access to locally available perinatal facilities and to optimize general organizational patterns of perinatal care.