Review article
Regionalization of perinatal care in Europe

https://doi.org/10.1016/j.siny.2003.08.004Get rights and content

Abstract

This review describes European health policies related to the place of birth of very preterm babies, and the organizational context in which these policies were enacted using data from two European studies. It also compiles available information on the place of birth of very preterm babies from the published literature. In Europe, there is significant diversity in approaches to the provision of intensive care services for the small proportion of pregnant women and babies that need it, both in terms of health policies and the supply and characteristics of maternity and neonatal units. These diverse models in countries with similar levels of development and medical technology could offer an opportunity to understand how different organizational characteristics affect access to care, health outcomes and resource use.

Introduction

Public health programmes in the USA introduced and defined the concept of regionalization of perinatal care in the 1970s.1These programmes were designed to organize health services for high-risk babies to ensure that they were born in hospitals equipped with the expertise and technology needed for their optimal care. Maternity units were classified into three levels of care in relation to the services they could provide for high-risk mothers and babies, transport systems were organized to these centres, and links were organized between health structures to maintain expertise in lower-level centres that were encouraged to transfer out their high-risk cases.2These programmes encouraged in utero transfer, which was considered the safest way to transfer a very preterm baby. In 1974, regionalization programmes operated in 28 states, and evaluations of these programmes were planned in 26 of them.1Some Canadian provinces also implemented and evaluated regionalization programmes at this time.3These evaluations provide the empirical basis for much of the scientific knowledge on the effects of place of delivery on the survival of high-risk babies.4, 5They also established routine indicators for monitoring regionalization, and thus led to its continued evaluation in North America,6, 7even as it has come under attack by managed care systems.8

Ensuring access to intensive care for high-risk babies is also a priority in Europe. Survival has improved greatly in recent decades, as shown in Fig. 1, a graph of neonatal mortality in Europe and the USA. These reductions are due in part to the development of neonatal intensive care services. Evaluations of the care and outcome of very preterm babies have been conducted in many European countries,9, 10, 11, 12, 13, 14but because these studies do not share the health policy context of the American and Canadian experiences, it is difficult to extract a picture of regionalization in Europe from them.

European countries embrace similar values about the responsibility of the state for the provision of health care to its citizens. They differ in their methods for achieving these aims, however, for Europe is composed of heterogeneous countries with varied health systems. The scale of the countries themselves differs substantially, from Germany, with a population of 82 million and 785 thousand annual births, to Luxembourg, population 430 000 and 5400 births/year. Recognition of the demographic, political and cultural diversity of Europe is a necessary backdrop to any discussion of the ‘European’ experience.

This review describes European approaches to the care of very preterm babies. It uses results from a European project called the European Network for Perinatal Transport (EUROPET), that aimed to describe perinatal transfer policies and practices. EUROPET was intended to fill gaps in knowledge and also to provide information for European countries that had no regionalization programmes.15We also review published data on the place of birth of very preterm babies in Europe, and use the preliminary work of a newer European project (MOSAIC) on the models of organizing care for very preterm births. We begin by describing health policies and the organizational context in which these policies were enacted, and then present data on place of delivery. The discussion addresses the implications of European approaches for the care and health of very preterm babies.

Section snippets

Methods

The EUROPET project was established in 1996 with financing from the European Commission to study policies and practices of perinatal transport, and to develop good practice guidelines for Europe.16The project brought together a group of perinatal health experts from 22 countries; they met on eight different occasions to share information about the policies in their countries.

The EUROPET project also carried out two studies in 1997. The first surveyed policies on maternal transfers in high-risk

Policy

The policy approach to the care of very preterm births varies widely in Europe, as shown in Table 1, which reports results of the EUROPET study on policies in place in 1998. Note that some policies may have been modified since this review.

Government policies do not exist in every country, and when they exist, they do not have the same content. In some countries or regions within countries, official health policy defines levels of care based on the capacity of maternity units to care for

Discussion

The European experience shows that there are many ways to ensure access to health services before, after and during delivery for the small proportion of pregnant women and babies that need them (about 1.5%, for very preterm babies). Technological developments have been adopted rapidly throughout Europe, but this review shows that no organizational approach has received similar general acceptance or widespread dissemination. The variety of approaches in countries with similar levels of

Acknowledgements

We thank members of the MOSAIC Research Consortium for providing data on the organization of care in the regions participating in the study.

The EUROPET study was funded by the European Commission (BMH4-CT96-1583) as is the MOSAIC study (QLG4-CT-2001-01907).

References (50)

  • K Cambell

    Assessment of regionalized perinatal programs

    J Dev Physiol

    (1991)
  • R.J Ozminkowski et al.

    Inborn/outborn status and neonatal survival: a meta-analysis of non randomised studies

    Stat Med

    (1988)
  • N Paneth et al.

    Newborn intensive care and neonatal mortality in low-birth-weight infants: a population study

    N Engl J Med

    (1982)
  • D Gagnon et al.

    Perinatal care: the threat of deregionalization

    Pediatr Ann

    (1988)
  • K Viisainen et al.

    Birth outcomes by level of obstetric care in Finland: a catchment area based analysis

    J Epidemiol Commun Health

    (1994)
  • L.A Kollée et al.

    Maternal and neonatal transport: results of a national collaborative survey of preterm and very low birth weight infants in The Netherlands

    Obstet Gynecol

    (1988)
  • M Obladen et al.

    Differences in morbidity and mortality according to type of referral of very low birthweight infants

    J Perinat Med

    (1994)
  • O Finnstrom et al.

    The Swedish national prospective study on extremely low birthweight (ELBW) infants. Incidence, mortality, morbidity and survival in relation to level of care

    Acta Paediatr

    (1997)
  • D Field et al.

    Survival and place of delivery following preterm birth 1994–1996

    Arch Dis Child Fetal Neonatal Ed

    (1999)
  • E Papiernik et al.

    Introduction to the European Network for Perinatal Transport (EUROPET) Project

    Prenat Neonat Med

    (1999)
  • C Debauche et al.

    Maternal and neonatal transfer policies in Europe

    Prenat Neonat Med

    (1999)
  • L Kollée et al.

    Perinatal transport practices: a survey of inborn versus outborn very preterm infants admitted to European neonatal intensive care units

    Prenat Neonat Med

    (1999)
  • Ministère des affaires sociales de la santé publique et de l'environnement

    Moniteur Belge

    (1996)
  • Planningsbluit Neonatale Intensive Care

    Staatscourant

    (1993)
  • Ministère de l'emploi et de la solidarité

    Journal officiel de la république française

    (1998)
  • Cited by (0)

    1

    See Appendix 1for members of the EUROPET group.

    View full text