The role of networks in improving perinatal and neonatal care

Many studies have shown that highly specialised perinatal centres with large caseloads may provide better quality of care, leading to lower mortality and morbidity 1. However, centre-specific policies to provide treatment for extremely low birthweight (ELBW) infants at the threshold of viability 2 and centre-specific obstetrical factors 3 have been shown to be important confounding factors for outcome. Healthcare systems for perinatal care should be designed to aim for the highest quality of care possible for all citizens, even for patients living in remote areas of the country. However, tertiary care cannot be provided within short distance from home to the whole population for logistic and economical reasons. Adequate training of healthcare providers requires a certain number of cases to keep up the level of experience. To consider these factors, neonatal networks were established in many countries in the 1980s to 1990s to improve outcomes for pregnant women and for neonates 4, 5. Maternal transport before birth, instead of transferring newborn infants after birth, has been shown to be feasible and associated with better outcomes. In this issue of Acta Paediatrica, Bellini et al. report back on their analysis of their database for VLBW infants admitted from 2010 to 2016 to their regional centre, which is the only level III-IV centre in a region with approximately 11 000 births per year in Liguria, Italy 6. From 2010 to 2012, their NICU had to manage a large caseload of VLBW infants, including both inborn and many outborn infants, which they could only handle with frequent early transfers – in 33–41% of cases – to remote level two NICUs. The authors state that this was a common problem in Italy, where the capacity in level-three centres seemed to be too low to provide appropriate care, but small delivery services handling <500 births a year still remained active. Experiences from established networks suggest that almost all high-risk pregnancies can be identified in time to allow for prenatal transfer to regional centres. This allows for these neonates to be born and be treated in centres where highly experienced obstetricians, neonatologists, midwifes and neonatal nurses with sufficient training and expertise, and all subspecialties, such as paediatric cardiology, paediatric surgery, are available. More than 20 years ago, Pollack et al. published an effective model for the reorganisation of perinatal services in California, where level-two hospitals providing postnatal care for babies worked in close collaboration with level-three facilities to provide shared responsibilities for patient care 5. Neonates with an estimated gestational age of <32 weeks, who needed surgical interventions or to be evaluated for suspected cardiac disease, were preferentially delivered in level-three facilities, which resulted in less postnatal transports from level two- to level-three centres. However, more infants were transported from level-three centres back to level-two centres for further care after they had survived the most critical period of early life. The authors showed that the reorganisation in their region resulted in a decrease in mortality in 1988–1989. In a recently published study of more than 58 000 VLBW infants from neonatal networks in Australia and New Zealand, Canada, Israel, Japan, Spain, Sweden, Switzerland and the United Kingdom, marked differences in mortality and morbidity were reported, such as severe intraventricular haemorrhage, treated retinopathy of prematurity or bronchopulmonary dysplasia 7. The networks from Australia and New Zealand and Japan, Switzerland and Sweden had better outcomes than the other networks. The authors speculated that these differences may have been related to differences in recording data, the populations studied, care processes or the organisation of perinatal healthcare delivery. It is worth noting that Japan and Sweden have had very well-organised regionalised perinatal healthcare systems for many years. The results of the EPICure studies were among the driving forces for changes in the perinatal healthcare system in the United Kingdom, which limit now the care of the most immature preterm infants to regional centres and use level-two centres to transfer infants back to hospitals closer to their homes. The results of the EPICure 2 study suggested that being born in a level-three centre rather than a level two centre, and being born in a level-three centre with a high case load as compared to a level-three centre with a lower case load, were associated with lower mortality, with adjusted odds ratios and 95% confidence intervals of 0.73 (0.59–0.90) and 0.68(0.52–0.89), respectively 8. The most dramatic change in perinatal healthcare policy in recent years was probably implemented in Portugal in 1989, when all delivery services with <1500 deliveries per year were closed by the government. From 1989 to 2003, this intervention was associated with a decrease in the maternal death rate from 9.2 to 5.3 per 100 000 deliveries, a decrease in the neonatal mortality rate from 8.1 to 2.7 per 1000 live births and a decrease in the infant mortality rate from 12.2 to 4.0 per 1000 live births 9. Data from the national Portuguese network of VLBW infants indicated that this change in policy was associated with an improvement in survival 10. The authors concluded that the reform in perinatal care in Portugal was an example of how a good diagnosis and adequate proposals, combined with a strong political will, was crucial for changing the system. Furthermore, regionalisation of perinatal healthcare also makes sense from a socioeconomical perspective. In many countries, there is a shortage of experienced neonatal nurses and maintaining specialist services, such as paediatric cardiology for congenital heart disease or paediatric surgery on a 24/7 basis to be able to treat malformations or gastrointestinal complications, is extremely expensive. The available resources should be used in the most efficient way as healthcare costs are rising continuously in most western countries. Redirecting healthcare funds to support a structured regionalised perinatal healthcare system with fewer level-three centres cooperating with a larger number of level two centres, in close collaboration in regional networks, may be cost-effective and result in better outcomes and more parental satisfaction.

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