Why and How Was Regionalization of Perinatal Care Accomplished in Portugal?

(1)

Regionalisation of perinatal care in Portugal

Why and how was it accomplished

Maria Teresa Neto, MD, PhD

NICU – Hospital Dona Estefânia

Faculdade de Ciências Médicas/Universidade Nova de Lisboa

(2)

Summary

•The Portuguese National Health Care System •The Reform and organization of perinatal care – Why and How

•The Portuguese Neonatal Transport System •Results

(3)

•10 000 000 inhabitants •100 000 live births/year

(4)

Health Care System

•

•National Health Service, from 1979 National Health Service, from 1979 –– provided by the State. provided by the State. •

•Subsystems Subsystems –– offered by some companies (including State)offered by some companies (including State) •

•Private insurances Private insurances –– a growing field with multiple policies a growing field with multiple policies and levels

(5)

National Health Service

•

•Universal Universal –– everyone have access to health care even illegal everyone have access to health care even illegal immigrants, unemployed, etc

immigrants, unemployed, etc

•

•““GratisGratis”” –– Not paid when services are used. However a Not paid when services are used. However a

small amount is paid at that time to discourage abusive use.

Costs are supported by the State; the money is got from

taxes.

•

•One given person may have access to health care through One given person may have access to health care through public service always and, simultaneously, to private care

public service always and, simultaneously, to private care

through sub systems or private insurance.

(6)

Perinatal

care

in

Portugal

1980

1980 –– TheThe firstfirst NICUs, NICUs, firstfirst ““truetrue”” ventilatorsventilators 1985

1985 –– Neonatal Branch of the Portuguese Society of Neonatal Branch of the Portuguese Society of Paediatrics, nowadays the Portuguese Neonatal Society

Paediatrics, nowadays the Portuguese Neonatal Society

1987

1987 –– National neonatal transport systemNational neonatal transport system 1987

1987 –– Nomination of an Experts Committee Nomination of an Experts Committee -- Maternal and Maternal and Neonatal Health Report

Neonatal Health Report

1989

1989 –– National Committee for Women and Child HealthNational Committee for Women and Child Health 1989

1989 -- Perinatal Health Care ReformPerinatal Health Care Reform

(7)

WHY

Until the seventies of twentieth century and even

during eighties despite some NICUs, there were:

• More than 200 hospitals with deliveries

• A great part without obstetrician or paediatrician • A great percentage of pregnancies without prenatal

care

• Few neonatal intensive care units

•

• Perinatal mortality rate was one of the highest in the Perinatal mortality rate was one of the highest in the European countries

(8)

WHY

•

•In 1987 an Experts Committee was nominated by the In 1987 an Experts Committee was nominated by the Health Ministry aiming to collect and analyse data on

Health Ministry aiming to collect and analyse data on

perinatal care all over de Country and to suggest

improvements to change the picture.

•

•The Report resulting from this work is the main The Report resulting from this work is the main document on which is based the reform

document on which is based the reform

•

• As a result the Health Ministry nominated these As a result the Health Ministry nominated these Experts Committee as the Mother and Child Health

Experts Committee as the Mother and Child Health

Committee and give them power to start the reform of

perinatal care

(9)

(10)

Hospitals with deliveries were visited, all over the country, during months and months: three

neonatologists, three obstetricians, one

paediatrician, one

member of the Health Ministry…

(11)

The

Report

-

The

1989

reform

•

•Closure of hospitals with less than 1500 deliveries/yearClosure of hospitals with less than 1500 deliveries/year •

• Reclassification of hospitals: I, II and III level.Reclassification of hospitals: I, II and III level. •

• Coordinating Units between health centres and hospitals Coordinating Units between health centres and hospitals •

• Equipping neonatal intensive and intermediate care unitsEquipping neonatal intensive and intermediate care units •

• Definition of needs of obstetricians, paediatricians and Definition of needs of obstetricians, paediatricians and nurses

nurses

•

• Specialised training in neonatologySpecialised training in neonatology

(12)

HOW

•

•Defining levels of perinatal care Defining levels of perinatal care •

•Defining localization of each level of hospital according to:Defining localization of each level of hospital according to:

-- The number of deliveries in one geographic areaThe number of deliveries in one geographic area

-- Geographic difficulties and existing routes and Geographic difficulties and existing routes and connections

connections -- high ways, mountains, time spent to achieve high ways, mountains, time spent to achieve the hospital, etc

the hospital, etc

•

•Defining steps for opening and closure of different levels of Defining steps for opening and closure of different levels of hospitals

(13)

HOW

•

•Defining how many obstetricians, paediatricians and nurses Defining how many obstetricians, paediatricians and nurses and which training they should have according to the level of

and which training they should have according to the level of

care.

•

•Defining the equipment required for health centres, delivery Defining the equipment required for health centres, delivery rooms, neonatal units according to the level of care and

rooms, neonatal units according to the level of care and

predefining the type of equipment

•

• Buying the equipment directly through a Buying the equipment directly through a ““grantgrant”” of Health of Health Ministry to equip hospitals

Ministry to equip hospitals –– foetal monitors, incubators, foetal monitors, incubators, ventilators, monitors, infusion pumps, etc

(14)

HOW

•

•Taking profit of those NICUs already equipped to Taking profit of those NICUs already equipped to improve they performance giving new equipment

improve they performance giving new equipment

•

•Creating a specific training in neonatology Creating a specific training in neonatology –– a 6 a 6 months training after the title of paediatrician to be

months training after the title of paediatrician to be

obtained in a level III NICU with those former

neonatologists trained in other countries

neonatologists trained in other countries –– starting in starting in 1990

1990

•

(15)

Health Centres

Health Centres –– No deliveries. FollowNo deliveries. Follow--up of normal up of normal pregnancies. Family doctors

pregnancies. Family doctors

Level I Hospitals

Level I Hospitals –– No deliveries. No outpatient clinic for No deliveries. No outpatient clinic for pregnant women

pregnant women

Level II Hospitals

Level II Hospitals (named Perinatal Care Hospitals) (named Perinatal Care Hospitals) –– Normal Normal and low risk deliveries; at least 1500/year; obstetricians;

and low risk deliveries; at least 1500/year; obstetricians;

intermediate care unit; paediatricians with competence in

neonatology; short course ventilation.

Level III Hospitals

Level III Hospitals (named Differentiated Perinatal Care (named Differentiated Perinatal Care Hospitals). More than 3000 deliveries/year; normal, low and

Hospitals). More than 3000 deliveries/year; normal, low and

high

high--risk deliveries; obstetricians and neonatologists; NICU; risk deliveries; obstetricians and neonatologists; NICU; referral centres; teaching on obstetrics and neonatology.

referral centres; teaching on obstetrics and neonatology.

Scientific research.

Public

Perinatal

Network

Levels

(16)

Perinatal care levels

Level III Hospital

Level II Hospital Level II Hospital

Health Centres Health Centres

Coordinating Units Coordinating Units

Deliveries

(17)

(18)

Number

of

obstetrical

beds

•Delivery room – 3 to 4 beds per 1000 deliveries year if rooms are for labour and delivery; 2 to 3 beds if there is a room for labour and another one for delivery

•Obstetrical nursery – 20 beds /1000 deliveries year. Four of these beds were for pregnant women

(19)

Number

of

_of

obstetricians

_{obstetricians}

and

_and

Pediatricians

_{Pediatricians}

Number of deliveries Number of Obstetricians Number of Pediatricians >2500 10 < 2500 9 >3000 6 2000 to 3000 5 < 2000 4

(20)

Equipment

and staff for

intermediate

care

units

•5 beds, including 2 incubators/1000 LB •1 ventilator for short course ventilation •CR and apneia monitors

•FiO2 measurement • Phototherapy

•Infusion pomps

•Resuscitation equipment

•Pediatrician expert in neonatology for 24h

•Nurses with experience in neonatology – 1 for 3 to 4 newbors (1,2 to 1,5 nurses/bed)

(21)

Intensive

care

_care

units

_units

•Long term ventilation •Parenteral nutrition

•Care for VLBW neonates •Surgical conditions

(22)

Intensive

care

_care

units

_units

•Neonatologists and paediatricians with competence in neonatology 24h a day

•1.5 beds/1000 deliveries

•1 nurse for 2 intensive care beds – 2,5 nurses/intensive bed •Seated at maternities with >3000 deliveries

•A level III hospital receive normal pregnancies of their geographic area

(23)

Prenatal

referral

to a

level

III hospital

•

PrenatalPrenatal diagnosisdiagnosis of of congenitalcongenital anomaliesanomalies •

• GA < 32 GA < 32 weeksweeks •

• MultipleMultiple deliverydelivery < 34 < 34 weeksweeks GAGA •

• SevereSevere bloodblood groupgroup immunizationimmunization •

• Fetal Fetal hydropsishydropsis •

• Fetal Fetal metabolicmetabolic disordersdisorders •

(24)

Postnatal

referral

to a

level

III Hospital

•

•Birth weight <1500gBirth weight <1500g •

•Respiratory distress needing long term mechanical Respiratory distress needing long term mechanical ventilation or FiO2>40%

ventilation or FiO2>40%

•

•Conditions needing surgical intervention Conditions needing surgical intervention •

(25)

(26)

Perinatal

transport

_transport

•

• Medical Emergency National Institute (INEM) or Medical Emergency National Institute (INEM) or •

• Local hospital ambulance or Local hospital ambulance or •

• Fireman ambulanceFireman ambulance

For foetus/newborn

•

• ““In uterusIn uterus”” transport is highly recommended.transport is highly recommended. •

• Neonatal transport Neonatal transport –– National Institute for Medical National Institute for Medical Emergency (INEM).

Emergency (INEM). For pregnant women

(27)

Neonatal

transport

Neonatal INEM

(

(NationalNational InstituteInstitute for for MedicalMedical EmergencyEmergency))

•

• National organization from 1987National organization from 1987 •

• Centralized in a III level centre Centralized in a III level centre •

• North, Centre, SouthNorth, Centre, South •

• The ambulance is a NICU The ambulance is a NICU •

• Newborn cared for by a neonatologist and an neonatal nurse Newborn cared for by a neonatologist and an neonatal nurse recruited amongst NICUs staff as an extra

recruited amongst NICUs staff as an extra

•

(28)

National Neonatal Transport System North Centre South Azores Madeira

(29)

Coordination between level II and level III

hospitals are up to Neonatal Transport System

Back transport of patients to level II hospital

when intensive care is not needed is up to

(30)

The impact of regionalization

on outcomes

(31)

Imediate Results

1980 1994

Ner Hospitals 493 202

Hospitals with deliveries > 200 50

(32)

Public

hospitals

with

perinatal

care

Intensive care beds by centre 5 to 13

> 50 VLBW infants 10/21 NICU

> 35 VLBW infants 14/21NICU

Surgical centres (2) Surgeries/year: 2>70; 1>40 Cardiac centres (5) 3 South; 1 Centre; 1 North

(33)

Level III hospitals Azores Madeira 4900 deliveries 6200 deliveries 20000 LB 34100 LB 32000LB 2900LB 2700LB

(34)

Perinatal

data

–

2009

Livebirths

Livebirths –– 99 57699 576

Prematurity

Prematurity 8.88.8%%

Low

Low birthbirth weightweight 8.28.2%%

Very

Very lowlow birthbirth weightweight 0.90.9%%

Prenatal

Prenatal carecare (VLBW)(VLBW) 94.794.7%%

Prenatal

Prenatal steroids<34 steroids<34 weeksweeks 8787%%

VLBW

VLBW survivalsurvival 88%88% Mother

Mother age >35age >35 19.219.2%%

Mother

Mother age <20 age <20 4.44.4%%

(35)

9,6 6 _5,7 3,9 _3,7 3,2 3,7 13,3 7,9 4 3,1 _2,8 _2,8 2,5 2,9 0 2 4 6 8 10 12 14 1979 1989 1999 2003 2005 2007 2008 2009 Foetal (>22w) Late Foetal (>28w)

/1000LB+SB

Foetal

(36)

Late

foetal

mortality

rate

in

EU

(2005)

3 3,2 2,8 3,9 3,2 6,1 5,5 4 3,9 9,3 2 3,3 4,8 3,7 3,6 0 1 2 3 4 5 6 7 8 9 10 Deu tch Aus trich Den mar k Spa in Finl and Fran ce 0 4 Gre ece Hol and UK 04 Irlan d 04 Italy Luxe mb Por tuga l Sue den Nor way

/1000 live births plus still born =>28weeks GA

(37)

25,5 14,6 6,3 _5,1 4,3 4,3 ₄ 16,4 8,4 6,5 5,1 5 _4,6 4,5 5,5 0 5 10 15 20 25 30 1979 1989 1999 2003 2005 2007 2008 2009

Perinatal >28 weeks Perinatal >22 weeks

Perinatal

(38)

Perinatal

mortality

rate

in

EU

(2005 (2005--2007)2007) 0 1 2 3 4 5 6 7 8 9 Port ugal 07 Ger man y06 Aus tria 06 Bel gium Den mar k05 Spa in05 Finl and Fran ce01 Hol and Irla nd Italy UK Sw eden 05 Per thousand live births

(39)

Neonatal

mortality

_mortality

rate

_rate

in

_in

Portugal

_Portugal

(/1000LB)

3,6 8,1 15,7 2,7 2,1 2,1 2,1 2,4 0 2 4 6 8 10 12 14 16 18 1979 1989 1999 2003 2005 2007 2008 2009 Source: INE Reform

(40)

Neonatal

mortality

rate

in

EU

(2005 (2005--2007)2007) 0 1 2 3 4 5 6 7 8 9 10 Port ugal 07 Ger man y06 Aus tria 06 Bel gium Den mar k01 Spa in05 Finl and Fran ce05 Hol and Irla nd Italy UK Sw eden 05 Per thousand live births

(41)

VLBW mortality rates

0 100 200 300 400 500 600 700 800 900 1980 82 84 86 88 90 92 94 96 98 0

Perinatal Early NN Late NN

Source: DGS /INE

(42)

Infant

mortality

rate (/1000LB)

3,6 3,43,3 3,5 58 64,9 77,5 38,9 24,3 17,8 10,9 7,5 6 5,5 5 4,7 4,1 3,2 0 10 20 30 40 50 60 70 80 90 1 9 6 0 6 5 7 0 7 5 8 0 8 5 9 0 9 5 9 8 2 0 0 0 1 2 3 4 5 2 0 0 7 2 0 0 8 2 0 0 9 Source: INE Reform Politic revolution

(43)

Infant

mortality

rate

in

EU

(1985

–

2005)

0 2 4 6 8 10 12 14 16 18 20 Eur o 15 Ger man y Aus tria Bel gium Den mar k Spa in Finl and Fran ce Gre ece Net herla nds UK Irlan d Italy Luxe mb Por tuga l Sue den 1985 2000 2003-2005 /1000 live birhts Source: Eurostat 2008

(44)

0 100 200 300 400 500 600 2002 2003 2004 2005 2006 2007 2008 <28weeks 28-31 /1000 live births

VLBW neonatal

mortality

rates

according

to

gestational

age

groups

(45)

Survival

of VLBW

_{of VLBW}

by

_by

birth

_birth

weight

_weight

n=3561

0% 20% 40% 60% 80% 100% 2005-2008

VLBW National Network – Portuguese Neonatal Society

Survivors

(46)

In

uterus

_transfer

_{of VLBW}

_infants

(%)(%)

0 5 10 15 20 25 30 35 40 1996 97 98 99 2000 2001 2002 2003 2004 2005 2005 -200 9

In uterus transfer Neonatal transport

(47)

VLBW

infants

–

inborn

/

outborn

(%)(%)

0 10 20 30 40 50 60 70 80 90 100 1996 97 98 99 2000 2001 2002 2003 2004 2005 -200 9 Inborn Outborn

(48)

VLBW

mortality

rate

Level

Level of of birthbirth and and carecare

According to VLBW National Network 2010

1996-2000 Level II Level III p

(49)

VLBW

mortality

rate

In

In uterusuterus vsvs postnatal_postnatal transporttransport

According to VLBW National Network 2010

Mortality inborn outborn p

1996-2003 21% 46% < 0.001

(50)

Access to risk appropriate perinatal care influence mortality outcomes

(51)

CP rates/1000

live

births

in

10

10 European

European

countries

,

births

cohorts

1990

-

1998

SCPE

SCPE CollaborativeCollaborative networknetwork

0 0,5 1 1,5 2 2,5 UK _Italy Den mar k Lith uani a Sw eden _Ireland Fran ce Nor way Spa in Por tuga l

(52)

Cerebral palsy at 5 years in Portugal

(2001 - 110 156 LB)

Virella D. et al, 2010 Postneonatal infection (13/206 - 6,3%) Herpetic Encephalitis 4 Viral encephalitis 3 Meningitis 3 Encefalomielitis 1 Post malaria encephalitis 1

Sepsis 1 TORCH infection (11/206 - 5,3%) Toxoplasmosis CMV 1 10

Causes associated to great immaturity

(53)

Maternal

mortality

rates

European

European countriescountries, USA, Canada and Portugal, USA, Canada and Portugal 2001

2001--20052005 (/100 000 (/100 000 livelive birthsbirths))

0 5 10 15 20 25 30 35 Spai n USA UK Sw itze rlan d Sw eden Nor way Net herl ands Fran ce Finl and Cana da Belg ium Aust ria Port ugal According to WHO 0 5 10 15 20 25 30 35 1979 80 89 95 96 97 98 99 0 2001 2 3 4 5 6 2007

(54)

Direct

and

indirect

contributors

•

• Increasing socioeconomic conditions, higher Increasing socioeconomic conditions, higher educational level. Democratic revolution

educational level. Democratic revolution -- 1974 1974 •

• Neonatal Society Neonatal Society –– 19871987 •

• National neonatal transport system National neonatal transport system -- 19871987 •

• Perinatal health care reform Perinatal health care reform –– 19891989 •

• Post graduation in Neonatology Post graduation in Neonatology -- 19901990 •

(55)

Conclusions

•

• SocioeconomicSocioeconomic and cultural and cultural conditionsconditions of a of a population

population are are veryvery importantimportant factorsfactors for a for a highhigh pattern

pattern of of healthhealth carecare. . ThisThis influenceinfluence waswas alsoalso veryvery important

important for for NationalNational data data improvementimprovement •

• HoweverHowever thethe organizationalorganizational issueissue isis oneone of of thethe mostmost important

important factorsfactors thatthat influenceinfluence data data and and regionalization

regionalization provedproved to to bebe a a veryvery costcost effectiveeffective way

(56)

Source

of data

•National Committee for Maternal and Infant Health Report 1989

•Directorate-General of Health (DGS) - Mother and Child Hospital Referral Network, 2000

•National Institute for Statistics (INE) - Demographic Statistics •Portuguese VLBW Network – Portuguese Neonatal Society

•World Health Organization •Eurostat

(57)

(58)

Causes of

death

2009

Neonatal deaths

Congenital anomalies 12,2%

Gestation and foetal growth problems

10,6% Respiratory diseases 8%

Others 69%

Infant deaths

Congenital anomalies 14,3%

(59)

Causes of

foetal

death

2005

Before onset of labor (54.8%)

Maternal hypertention, infection, others mother related (not placenta related)

20.5%

Cord anomalies

(8.7% from total)

15.8%

Congenital anomalies 9.2%

Immaturity related causes 18.2%

Perinatal asphyxia 11.4%

(60)

How does prenatal transport work?

The best practice

• A 28 weeks pregnant woman is at home. She lives >80km far from a level III hospital. Rupture of membranes occur spontaneously.

• She goes to her level II hospital to be observed • The obstetrician says she have to go to a level

III hospital; prescribes betametasone, contacts Neonatal Transport System (INEM) who

centralises information, and ask for a bed in a level III hospital.

(61)

How does prenatal transport work?

The best practice

• INEM contacts the maternity they know to have place for the newborn.

• If NICU accept the newborn infant obstetricians from the original hospital contacts the

obstetrician of the level III hospital

• The woman in transferred. Her transport in an ambulance is up to the level II hospital

(62)

How does postnatal transport work?

The best practice

• A 28 weeks pregnant woman is at home. She lives >80km far from a level III hospital. Rupture of membranes occurs spontaneously and she starts in labour.

• She goes to her level II hospital to be observed • The obstetrician says she has full dilation and

the baby is about to born. There is no time to transfer the woman to a level III hospital.

• He calls Neonatal Transport System (INEM) telling the situation.

(63)

How does postnatal transport work?

The best practice

• INEM calls the maternity they know to have place for the neonate and ask for his/her

admission.

• Delivery occurs in the level II hospital and the newborn is transferred to the level III Unit

(64)

The Portuguese VLBW Network 1996 - 2004

Destination

on

discharge

0 100 200 300 400 500 600 700

Home Transfers Deaths ? %

1996 1997 1998 1999 2000 2001 2002 2003 2004 17% 17% 66% normal deaths problems

(65)

VLBW follow

-

up 1994 survivors

Follow

Follow--up at 3up at 3--6 years 6 years n=263

n=263

Dead Without follow-up Missing Evaluated

238 238 159 159 263 263

Lost for follow-up - 36%

Evaluated - 169

8/13 NICU

(66)

VLBW follow

-

up 1994 survivors

Follow

Follow--up at 3up at 3--6 years6 years Evaluated 169/263 Evaluated 169/263 Problems Problems 29% 29% Normal Normal 66% 66% Death Death 5 % 5 % MAJOR MAJOR 7,6% 7,6% Minor Minor

(67)

MORTE MATERNA ANOS MORTES TAXA

/100000 NV 1970 127 73,5 1975 77 42,9 1980 31 19,6 1981 29 19,1 1982 34 22,5 1983 23 15,9 1984 22 15,4 1985 14 10,7 1986 12 9,5 1987 15 12,2 1988 8 6,6 1989 12 10,1 1990 12 10,3 1991 14 12,0 1992 11 9,6 1993 7 6,1 1994 10 9,2 1995 9 8,4 1996 6 5,4 1997 6 5,3 1998 9 7,9 1999 6 5,2 Direcção-Geral da Saúde 0 10 20 30 40 50 60 70 80 1970 1975 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 /100000 NV

Maternal death

(68)

Maternal

mortality

rate

(/100 000

(/100 000 livelive birthsbirths))

0 5 10 15 20 25 30 35 1979 80 89 95 96 97 98 99 0 2001 2 3 4 5 6 2007

DGS DGS- Capture and recapture