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Original research
Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review
  1. Felix Walther1,2,
  2. Denise Bianca Küster1,
  3. Anja Bieber1,3,
  4. Mario Rüdiger4,5,
  5. Jürgen Malzahn6,
  6. Jochen Schmitt1,5,
  7. Stefanie Deckert1
  1. 1Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
  2. 2Quality and Medical Risk Management, University Hospital Carl Gustav Carus, Dresden, Germany
  3. 3Institute of Health and Nursing Science, Martin Luther-Universitat Halle-Wittenberg, Halle, Germany
  4. 4Department for Neonatology and Pediatric Intensive Care, University Hospital Carl Gustav Carus, Dresden, Germany
  5. 5Saxony Center for Feto-Neonatal Health, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany
  6. 6Clinical Care, Federation of Local Health Insurance Funds, Berlin, Germany
  1. Correspondence to Stefanie Deckert; stefanie.deckert{at}


Objective This umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births.

Intervention/exposition Perinatal regionalisation, centralisation, case-volume.

Primary outcomes Death.

Secondary outcomes Disability, discomfort, disease, dissatisfaction.

Methods On 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2.

Results The literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on ‘death’ (eg, neonatal), ‘disability’ (eg, mental status), ‘discomfort’ (eg, maternal sensitivity) and ‘disease’ (eg, intraventricular haemorrhages). ‘Dissatisfactions’ were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33–1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes.

Conclusions Regionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care.

PROSPERO registration number CRD42018094835.

  • health policy
  • quality in health care
  • risk management
  • neonatal intensive & critical care
  • paediatric intensive & critical care
  • neonatology

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See:

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  • JS and SD contributed equally.

  • Contributors FW designed the concept of this umbrella review; performed the literature search, screening, data extraction and quality appraisal; and prepared and revised the first draft. DBK performed data extraction and quality appraisal, and revised the first draft. AB performed screening and revised the first draft. MR revised the first draft. JM designed the concept of this umbrella review and revised the first draft. JS designed the concept of this umbrella review and revised the first draft. SD designed the concept of this umbrella review; performed screening and quality appraisal; and performed and revised the first draft.

  • Funding This umbrella review was funded by a German statutory health insurance (AOK) [no grant number given]. Open Access Funding by the Publication Fund of the TU Dresden.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Patient consent for publication Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data availability statement All data relevant to the review are included in the article or uploaded as supplemental information.

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