The regionalization of perinatal care in France — description of a missing policy

doi:10.1016/0301-2115(95)02107-I

European Journal of Obstetrics & Gynecology and Reproductive Biology

Volume 61, Issue 2, August 1995, Pages 99-103

https://doi.org/10.1016/0301-2115(95)02107-I Get rights and content

Abstract

This paper reviews published data on the organization and evaluation of regionalized perinatal care programs in countries where they exist and describes those elements presently lacking in France. The advantage of maternal compared to neonatal transport is described vis-85-vis its effect on perinatal deaths as well as neonatal and developmental handicaps. Most studies describe a major advantage of maternal transfers, with less perinatal deaths (including stillbirths and neonatal deaths) and lower rates of severe developmental handicaps. In contrast, French publications show that widespread regionalization of perinatal care does not exist in spite of proposals advocating this concept made more than 20 years ago. Thus, many deliveries of less than 33 weeks gestation length or/and less than 1500 g birth weight take place in maternity sites without adequate neonatal care, despite ample evidence that such infants are at much greater risk of perinatal death or severe handicaps at 2 years of age after transfer than if they had been born in a perinatal center. For these reasons, professional organizations in France should choose to implement a policy of maternal transfers as a major effort in the near future.

References (40)

LJ Butterfield
Historical perspectives of neonatal transport
Pediatr Clin North Am
(1993)
CL Anderson et al.
An analysis of maternal transport within a suburban metropolitan region
Am J Obstet Gynecol
(1981)
GB Merenstein et al.
An analysis of air transport results in the sick newborn. II Antenatal and neonatal referrals
Am J Obstet Gynecol
(1977)
TC Miller et al.
Maternal transport and the perinatal denominator
Am J Obstet Gynecol
(1983)
HD Modanlou et al.
Perinatal transport to a regional perinatal center in a metropolitan area: Maternal versus neonatal transport
Am J Obstet Gynecol
(1980)
LO Lubchenco et al.
Outcome of very-low birth weight infants: does antepartum versus neonatal referral have a better impact on mortality, morbidity, or long-term outcome?
Am J Obstet Gynecol
(1989)
V Delaney-Black et al.
Outcome of very-low birth weight infants: are populations of neonates inherently different after antenatal versus neonatal referral?
Am J Obstet Gynecol
(1989)
Improving the quality of survival for infants of birth weight < 1000 g born in non-level-III centres in Victoria
Med J Aust
(1993)
JP Shenai et al.
A successful decade of regionalized perinatal care in Tennessee: the neonatal experience
J Perinatol
(1991)
P Berle et al.
Neonatal Mortalität und Primärversorgung der sehr kleinen frühgeburten in Hessen in Jahre 1986 und 1987
Gynäkol
(1989)

AK Daltveit et al.

Risikoforhold ved transportfodsler i Norge 1967–1988

Tidsskr Nor Loegeforen

(1991)

BA Harris et al.

In utero versus neonatal transportation of high-risk perinates: a comparison

Obstet Gynecol

(1981)

LAA Kollee 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)

LAA Kollee et al.

Sterftekans na intra-uterien en neonatal transport

Ned Tijdschr Geneeskd

(1989)

LAA Kollee et al.

Five-year outcome of preterm and very low birth weight infants: a comparison between maternal and neonatal transport

Obstet Gynecol

(1992)

E Lallemand et al.

L'appel anténatal — Indications — Rôle du SAMU

Rev Fr Gynecol Obstét

(1989)

A Luttkus et al.

Sendung von Haüfigkeit und Morbidität sehr untergewichtiger Frühgeborener nach mütterlichem Transport in ein perinatales Zentrum

Geburtsh Frauenheilk

(1992)

DK Richardson et al.

Decision analysis of highrisk patient referral

Obstet Gynecol

(1984)

DM Strobino et al.

Development of an index of maternal transport

Med Decis Making

(1993)

PR Swyer

The original organisation of special care for the neonate

Ped Clin North Am

(1970)

Cited by (32)

Frequency, causes and avoidability of outborn births in a French regional perinatal network
2014, European Journal of Obstetrics and Gynecology and Reproductive Biology
Citation Excerpt :
In the meta-analysis by Lasswell [1], the risk of death was higher in the population of infants born outside a level II maternity both for VLBW (adjusted odds ratio: 1.62, 95% CI (144–183)) and VPT infants (adjusted odds ratio: 1.55 95% CI (121–198)). In France, regionalisation is a relatively recent phenomenon: perinatal networks were first set up in the 1990s and aim to achieve more than 80% of premature deliveries in maternity units of the appropriate level [3,14]. In the United States, the target of 90% VLBW infants born in a level III maternity [15] was achieved in 2008 in only 5 states, and 10 states had a rate of less than 70% [1].
To evaluate the rate and circumstances of outborn deliveries within a French perinatal network, and to determine their avoidability.
Cohort study including preterm infants <33 weeks gestation and/or weighing <1500 g born outside a level III maternity unit in Lower Normandy region, France, in 2008–2010. In 2008 and 2009, only neonates transferred to the Caen University Teaching Hospital (CHU) were included. In 2010, all outborn neonates in the region were included by means of a medical information system program. A panel of 7 experts was set up to determine the avoidability of each outborn case using a two-stage modified Delphi procedure. Inter-expert agreement was evaluated using the kappa index.
Sixty-four cases (71 neonates) were included. The outborn rate in 2010 was 16.1% (40/248, 95% CI (116–207%)). The most common reason for delivery was spontaneous onset of labour (57.8%). In 12 cases, the place of birth (level 2b maternity unit) was considered to be appropriate by the experts (term ≥32 WG), but 8 cases involved infants of low birth weight (<1500 g). For the 52 cases born in inappropriate sites, 9.6% were considered to be avoidable (kappa index = 0.42 (p < 10–3)).
Our outborn rate meets regionalisation targets. Our method of expert evaluation identified a small percentage of avoidable births in inappropriate sites. Regular reassessment of obstetric practices and good coordination between network actors are crucial to improve the management of pregnancies at risk of outborn delivery.
Perinatal health inequalities and accessibility of maternity services in a rural French region: Closing maternity units in Burgundy
2013, Health and Place
Citation Excerpt :
It has thus made geographic accessibility a major issue for ensuring equal health opportunities (Coldefy et al., 2011), especially given the large geographical disparities that already exist (Trugeon et al., 2010). The initial objectives of this restructuring of perinatal care were better management of very preterm babies (Chung et al., 2011; HCSP, 1994; Lehtonen et al., 2011; Papiernik and Combier, 1996; Papiernik and Keith, 1995; Wehby et al., 2012) and greater safety in hospital care (HCSP, 1994; Heller et al., 2002; Merlo et al., 2005; Moster et al., 1999). An economic aim was rapidly added to these, because the potential concentration of resources in a limited number of establishments was thought to make economies of scale possible (Brousselle et al., 1999; Com-Ruelle et al., 2008; Hemminki et al., 2011; Klein et al., 2002; McKee and Healy, 2000; NHS, 1996; Pouvourville (de) et al., 1997).
Maternity unit closures in France have increased travel time for pregnant women in rural areas. We assessed the impact of travel time to the closest unit on perinatal outcomes and care in Burgundy using multilevel analyses of data on deliveries from 2000 to 2009. A travel time of 30 min or more increased risks of fetal heart rate anomalies, meconium-stained amniotic fluid, out-of-hospital births, and pregnancy hospitalizations; a positive but non-significant gradient existed between travel time and perinatal mortality. The effects of long travel distances on perinatal outcomes and care should be factored into closure decisions.
Regionalisation of perinatal care in Basse-Normandie, France: Evolution over 5 years
2011, Journal de Gynecologie Obstetrique et Biologie de la Reproduction
Comparer l’évolution des transferts in utero (TIU) en Basse-Normandie entre 2004 et 2008 et en décrire les modalités en 2008.
Exploitation des données recueillies par l’observatoire des transferts : recueil prospectif, réalisé en continu depuis 2004.
Environ cinq TIU par semaine ont été réalisés. Le taux de TIU a augmenté régulièrement depuis 2004 (p = 0,003) et atteignait 16,2 pour 1000 grossesses en 2008. Les transferts hors réseau ont régulièrement diminué (p = 0,04). Pour les maternités de niveau 3, la proportion de TIU provenant d’une maternité de niveau 2 a augmenté (p < 10⁻³). Avant 32 SA, 100 % des TIU se font vers une maternité de niveau 3. Le délai médian entre TIU et accouchement et la proportion de césariennes étaient variables selon l’indication du TIU (pour les MAP, respectivement : cinq jours et 23,3 %). Le taux de retransfert vers la maternité d’origine ou de niveau adéquat était de 5,3 %.
L’observatoire des transferts a permis de recueillir des informations utiles sur l’évolution et les caractéristiques des TIU dans notre région. Cette évolution s’est faite vers une régionalisation accrue et une augmentation des TIU adaptés. Il doit, désormais, servir de base à une évaluation des pratiques.
To compare evolution and characteristics of in utero transfers (IUT) in Basse-Normandie area, France, between 2004 and 2008, and to describe characteristics of IUT in 2008.
Analysis of data from the IUT registry, collected prospectively since 2004.
An average of five IUT per week was observed. The rate of IUT regularly increased (P = 0.003) and reached 16.2 per 1000 pregnancies in 2008. Extra network IUT decreased steadily (P = 0.04). For level 3 units, the proportion of IUT from level 2 units increased (P < 10⁻³). Before 32 weeks of gestational age, all IUT were done towards a level 3 unit. Median time between IUT and delivery and caesarean section rates were variable according to IUT indication (for threats of premature delivery, respectively 5 days and 23.3%). The rate of retransfer towards initial unit of towards a birth site of relevant level was 5.3%.
The IUT registry gives useful information on evolution and characteristics of IUT in our area. An increased regionalisation and more frequent adequate IUT were observed. The registry must now serve as a basis for practices assessment.
Perinatal transfers: Survey to evaluate the satisfaction degree of obstetricians and pediatricians with the Rhône-Alpes regional hotline center
2009, Gynecologie Obstetrique et Fertilite
La circulaire du ministère de la Santé relative à l’organisation des transports périnatals des mères (DHOS n^o 2006 273) stipule « qu’ à la fin de l’année 2008 au plus tard, l’orientation des transferts de femmes et de nouveau-nés devra être traitée de manière centralisée… doit fonctionner de manière permanente ; peut revêtir plusieurs formes… dont une structure ad hoc permanente, composée de professionnels formés, de type « cellule » ou « centre » régional(e) d’orientation périnatale ». Dans ce contexte et afin d’aider les professionnels à choisir entre différents types d’organisation proposés, il nous a paru pertinent d’évaluer le degré de satisfaction des professionnels vis-à-vis de la cellule rhône-alpine.
Cette enquête postale a été adressée 15 mois après la création de la cellule aux 146 praticiens référents de la région Rhône-Alpes. Huit questions abordent les points suivants : pour les obstétriciens, l’organisation des transferts et des retransferts in utero ; pour les pédiatres, l’organisation des transferts et des retransferts néonatals. Des questions relatives à la qualité de la communication, à l’organisation globale des transports ont été posées. Enfin, les praticiens ont été sollicités pour savoir s’ils souhaitaient ou non que la cellule poursuive son activité.
Le taux de réponse est de 51 %. Soixante-douze pour cent des praticiens ont considéré que la cellule a amélioré la communication entre professionnels et 66,7 % que cette structure a amélioré l’organisation des transports. Les obstétriciens éprouvent un bénéfice dans 91,7 % des transferts in utero et dans 63,8 % des retransferts et les néonatologues dans 92,3 % des transferts de nouveau-nés et dans 53,8 % des retransferts. Enfin, 85,3 % des praticiens estiment que la cellule permet un gain de temps. Quatre-vingt-seize pour cent souhaitent que cette structure poursuive son activité.
Dans la région Rhône-Alpes, la très grande majorité des usagers de la cellule des transferts, obstétriciens et néonatologues, plébiscite une organisation de type cellule.
In 2006, the Ministry of Health issued a legal text relating to organization of maternal transports: “By the end of the year 2008, transfers of women and new-born babies will have to be treated in a centralized way”, have to provide a 24 hours service and can take several forms such as a regional transfer center, working for several perinatal network or a simple hotline within the level 3 maternity hospital of the perinatal network and would be managed by efficiently trained professionals. In order to help professionals to choose between various types of organizations, we considered to evaluate their degree of satisfaction with the Rhône-Alpes regional hotline center.
A postal survey was carried out 15 months after the creation of the regional hotline center to the 146 obstetricians and neonatologists of the perinatal network. Eight questions dealt with the following points: organization of in utero transfers and retransfers for obstetricians on the one hand, and the organization of neonatal transfers and retransfers for pediatricians on the other hand.Moreover, several questions relating to the communication quality and the global transport organization were asked to all of these professionals. Finally, practitioners were asked whether the regional hotline center should carry on its activity or not.
The response rate was 51%. Seventy-two percent of practitioners considered the regional hotline center improved the communication between professionals. 66,7% thought that it improved the organization of transport. Obstetricians get benefits in 91,7% of in utero transfers and in 63,8% of retransfers. Neonatologists get benefits in 92,3% of new born babies’ transfers and in 53,8% of retransfers. Finally, 85,3% of the doctors felt that the regional hotline center was time saving and 96% of them felt that this structure should carry on its activity.
In the French Rhône-Alpes region, most obstetricians and pediatricians are satisfied by a regional hotline center dedicated to in utero as well as neonate transfer.
Regionalization of obstetric services and anaesthetic workload in a tertiary level perinatal unit
2005, Annales Francaises d'Anesthesie et de Reanimation
Objectif. – Évaluer la charge de travail anesthésique associée à la prise en charge d’une parturiente à haut risque (c’est-à-dire toute patiente transférée dans un centre de référence périnatal).
Type d’étude. – Étude prospective de type cas-témoins.
Méthodes. – Pendant une durée de trois mois, un groupe de 63 parturientes avec transfert in utero a été suivi et comparé à un groupe témoin de 63 grossesses normales jusqu’à leur sortie.
Résultats. – À l’inclusion, le score ASA des patientes à haut risque était plus fréquemment supérieur ou égal à 2 (21 vs 0 %, p < 0,05). Le score ASA était augmenté à l’accouchement chez 8 % des patientes à risque et chez aucune patiente du groupe témoin. Les admissions en réanimation (4 vs 0), les césariennes (57 vs 11 %), les consultations préanesthésiques de nuit (41 vs 0 %) et les anesthésies générales (27 vs 0 %) étaient toutes plus fréquentes chez les patientes à haut risque (p < 0,05).
Conclusion. – La comparaison de la charge de travail occasionnée par les patientes à haut risque et celle créée par des parturientes normales confirme les besoins anesthésiques spécifiques des centres périnataux de niveau III et peut servir de base à la réflexion concernant la répartition de la main d’œuvre anesthésique au sein des réseaux périnataux.
Objective. – Evaluation of anaesthetic workload associated with care of high-risk pregnant women (i.e. patients transferred to a referral perinatal center).
Study design. – A case-control prospective study.
Methods. – During a three-month period, 63 women with in-utero transfer and their control counterparts (63 normal pregnancies) were prospectively followed until discharge.
Results. – At inclusion, high-risk patients (n=63) were more frequently scored ASA 2 or more (21 vs 0%, p <0.05). ASA score had increased at delivery in 8% of high-risk women and in none of controls. ICU admission (4 vs none), Caesarean delivery (57 vs 11%), preanaesthetic visit at night (41 vs 0%) and general anaesthesia (27 % versus none) were all more frequent in high-risk parturients (p <0.05).
Conclusion. – Comparison of the workload associated with high-risk patients and normal pregnant women confirms the need for increased anaesthetic staffing in referral perinatal centers and provides a basis for better understanding the distribution of anaesthetic requirements in each perinatal network.
Regionalization of perinatal care in Europe
2004, Seminars in Neonatology
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.

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Obstetrics and prenatal diagnosisThe regionalization of perinatal care in France — description of a missing policy

Abstract

Pediatr Clin North Am

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Am J Obstet Gynecol

Improving the quality of survival for infants of birth weight < 1000 g born in non-level-III centres in Victoria

Med J Aust

A successful decade of regionalized perinatal care in Tennessee: the neonatal experience

J Perinatol

Neonatal Mortalität und Primärversorgung der sehr kleinen frühgeburten in Hessen in Jahre 1986 und 1987

Gynäkol

Risikoforhold ved transportfodsler i Norge 1967–1988

Tidsskr Nor Loegeforen

In utero versus neonatal transportation of high-risk perinates: a comparison

Obstet Gynecol

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

Obstet Gynecol

Sterftekans na intra-uterien en neonatal transport

Ned Tijdschr Geneeskd

Five-year outcome of preterm and very low birth weight infants: a comparison between maternal and neonatal transport

Obstet Gynecol

L'appel anténatal — Indications — Rôle du SAMU

Rev Fr Gynecol Obstét

Sendung von Haüfigkeit und Morbidität sehr untergewichtiger Frühgeborener nach mütterlichem Transport in ein perinatales Zentrum

Geburtsh Frauenheilk

Decision analysis of highrisk patient referral

Obstet Gynecol

Development of an index of maternal transport

Med Decis Making

The original organisation of special care for the neonate

Ped Clin North Am

Obstetrics and prenatal diagnosis
The regionalization of perinatal care in France — description of a missing policy