Collaborative Efforts to Address the Impact of Perinatal Regionalization on Infant Mortality

Collaborative Efforts to Address the Impact of Perinatal Regionalization on Infant Mortality 

By Wanda D. Barfield, MD, MPH
Director, Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention

Charlan D. Kroelinger, PhD
Acting Team Lead and Senior Scientist
Maternal and Child Health Epidemiology Program
Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion
Centers for Disease Control and Prevention

Vanessa A. White, MPH
Associate Director, Women's & Infant Health
Association of Maternal & Child Health Programs

AMCHP has been partnering with federal agencies and academic institutions to advance the definition and measurement of perinatal regionalization. The following is an overview of recent activities. 

What is perinatal regionalization and how does it impact infant health?
Perinatal regionalization is a system of designating where infants are born or are transferred based on the amount of care that they need at birth. In regionalized systems very ill or very small infants are born in hospitals that are able to provide the most appropriate care, with high-level technology and specialized health providers.  Regionalized systems define hospitals at risk-appropriate levels; Level III hospitals, for example, provide the most appropriate care for the sickest infants.  Regionalized systems are often designed, designated, and managed by state health departments, but in some states hospital networks or non-profit groups make these decisions.  Infants receiving risk-appropriate care are hypothesized to be more likely to survive when born too little or too soon.  The goal of a regionalized system is to reduce infant deaths. 

How are the current systems evaluated?
There are limited formal evaluations of these regionalized systems.  There exist multiple measures of regionalization including reporting of the percentage of very low birth weight (VLBW) infants born at facilities for high-risk neonates (National Performance Measure # 17  [NPM 17], Health Resources and Services Administration/Maternal and Child Health Bureau; HRSA/MCHB).  Additionally, information reported on the Certificate of Live Birth (BC) (2003 revised version) may be used to estimate the number of VLBW infants who receive appropriate care, specifically, in a Neonatal Intensive Care Unit (NICU).

What are leading agencies and institutions doing to help public health professionals better understand the impact of perinatal regionalization on infant health?
In 2009, AMCHP, the Centers for Disease Control’s Division of Reproductive Health (CDC/DRH) and HRSA/MCHB sponsored a meeting on the impact of perinatal regionalization and infant health.  Attendees included selected state maternal and child health (Title V) directors, perinatal health researchers, and representatives from the American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and National March of Dimes.  Specifically, the meeting focused on assessing the similarities and differences of these regionalized systems in different states across the US.  Additional topics included discussion of the national indicators used to measure risk-appropriate care, particularly NPM 17 (HRSA/MCHB).  Meeting attendees described their state’s regionalized system and provided the most recent information on VLBW infants born at risk-appropriate facilities.  Work from this meeting culminated in attendees recommending further development of guidelines for standardizing regionalized systems.   

This meeting was triggered by preliminary results of a CDC review of all current literature examining the impact of risk-appropriate care on infant survival.  Researchers from CDC/DRH, the Rollins School of Public Health, Emory University, and the University of Maryland, School of Medicine conducted a meta-analysis of published research on risk-appropriate care in the US.  The major finding from this work indicates that VLBW and very preterm infants born outside of a level III hospital are at an increased likelihood of neonatal death or death prior to discharge from the hospital.  This work was published this month, National Infant Mortality Awareness Month, in the Journal of the American Medical Association (Lasswell SM, Barfield WD, Rochat RR, Blackmon LR.  Perinatal Regionalization for Very Low-Birth-Weight and Very Preterm Infants—A Meta-analysis, JAMA 2010; 304.9: 992-1000). 

Additionally, the CDC has also conducted analyses of the percentage of VLBW infants admitted to the NICU following delivery.  This research was conducted using information obtained from the National Center for Health Statistics reported by the 19 states that have implemented the revised 2003 BC which contains information on NICU admission.  Findings from this research suggest that 77% of VLBW infants were admitted to a NICU in 2006.  This percentage is low considering the high mortality rate of these infants.  As noted by CDC/DRH Director and neonatologist, Wanda Barfield, MD, MPH “these recent scientific findings indicate that more work must be done to better understand the impact of risk-appropriate care on babies born too little or too soon.  Our regionalized systems must be systematically evaluated to determine effective care of neonates and prevent infant death”. AMCHP, CDC, HRSA/MCHB, and states will continue to partner on this important maternal and child health topic. For more information, visit here. 

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.