Neonatal Mortality of VLBW in EuropeThe Portuguese Experience

Portuguese VLBW Infants Network

Hercília Guimarãesherciliaguimaraes@gmail.com

Brussels, December 2009

10 millions inhabitants

100000 births / year

Universal National Healthcare

Perinatal Care System

VLBWRegister

Perinatal

Early neonatal

Late Fetal

Perinatal, late fetal and early neonatal mortality rate, Portugal 1980-2005

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

InfantMortality(‰)

7.4 6.9 6.4 6.0 5.6 5.5 5.0 5.0 4.1 3.8 3.5 3.3 3.4 3.3

PerinatalMortality(‰)

9.0 8.4 7.2 6.8 6.4 6.2 5.6 6.0 5.1 4.4 4.3 4.6 4.3 4.0

Neonatal mortality(‰)

4.7 4.2 4.1 3.7 3.6 3.4 2.9 3.4 2.7 2.6 2.2 2.8 2.0 2.1

Foetal morality(‰)

5.5 5.4 4.4 4.0 3.7 3.7 3.4 3.4 3.1 2.7 2.8 3.1 3.6 3.2

Perinatal, neonatal and infant mortality evolution

Portuguese Perinatal Healthcare Policy National Committee for mother and child healthcare (1989)

Maternities with < 1500 deliveries/year were closed

Hospitals were classified as Level II and Level III

Functional Coordinating Units connect the Hospitals to the Primary Healthcare Centers

The post graduation of Paediatricians in Neonatology originated the creation of the Special Studies on Neonatology Cycle.

Transport in utero was recognized as the best

Neonatal transport – INEM, was created as an alternative.

Local Health Center

Local Health Center

Local Health Center

Local Health Center

Level II HospitalIntermediate

Neonatal Care

Level II HospitalIntermediate

Neonatal Care

Level III Hospital

Neonatal Intensive

Care Unit

Intensive care beds by center 5-13

>50 VLBW infants 10/21

Surgical centers Surgeries/year:2>70;1>40

Cardiac centers 2 south;1 center;1 north

Public hospitals with perinatal care

Level II-27 Level III-21 (including islands)

North

Center

South

National Neonatal Transport

3 centers placed in level 3 hospitals

Centralized information system

Ambulance equipped with a NICU, and nurse and doctor with expertise in neonatal transport

Neonatal MortalityPortugal 2007/ VLBW Network

0

50

100

150

200

250

23-27 28-31 32-36 Total

VLBW Death Neonatal death

< 32weeks49% of neonatal mortality

VLBW Network 1994-2009Neonatal Society

Portuguese VLBW Infants Network - 1994

To consolidate a Network of multicenter prospective neonatal studies

To integrate clinical research in activities of assistence

To determine the prevalence of VLBW in Portugal and the contribution in the mortality and morbidity

To analyse the efficiency of neonatal regionalization

To monitor clinical practices in order to have a national standard for the self-assessement

Main Goals

Methods

VLBW infants 500-1499gr (1994-98); 401-1499gr (>1998)

Central Coordination – Coimbra Data Base on line: htpp//downloads.lusoneonatologia.net

National Meetings (objectives and methods)

Integration in clinical practice – Registration Form Collective and voluntary participation

Portuguese VLBW Network

0

10

20

30

40

50Level III Level II

Level II 0 14 16 15 14 13 13 13 14 17

Level III 13 18 18 20 22 23 23 23 23 23

1994 1996 1997 1998 1999 2000 2001 2002 2003 >2004

VLBW infants - Portuguese NetworkParticipating NICU´s

VLBW National NetworkCover rate

1994 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

VLBW 660 830 828 897 979 1041 977 1029 1001 1016 1006 880 860 832

NIS 830 892 913 974 1183 1138 990 1067 964 1021 1012 916 934 900

0

200

400

600

800

1000

1200

1400

Reg

iste

rs

100%

0

200

400

600

800

1000

1200

0

0,2

0,4

0,6

0,8

1

1,2

VLBW (n) 660 830 897 1041 977 1029 1001 1016 1030 911 1024

Prevelence 0,66 0,81 0,86 0,94 0,88 0,92 0,88 0,92 0,94 0,83 0,99

1994 1996 1998 2000 2001 2002 2003 2004 2005 2006 2007

n %

Portuguese VLBW database 1994 - 2004

The Portuguese VLBW Network VLBW Prevalence (%)

European Perinatal Health Report,2008

Portuguese VLBW Infants NetworkRegionalization

0 25 50 75 100

In uterus transport

Level 3

Neonatal transport

Return transport

30

90

5,6

30

17

2005-2008

Nº = 3561

REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009

Secção de Neonatologia - SPP

Place of delivery – 10 years evolution

1996 2005

In uterus transport

176 (21%) 374 (37%) P<0.001

Birth in level III 678 (82%) 920 (92%) P<0.001

Neonatal transport

124 (15%) 79 (8%) P<0.001

In born 706( 85%) 921 (92%) P<0.001

Portuguese VLBW Network

706 719 776 886 950 910 923922 884

0%10%20%30%40%50%60%70%80%90%

100%

1996 1997 1998 1999 2000 2001 2002 2003 2004

OUT

IN

15%

9%

Effectiveness of regionalization.

It worthes to avoid neonatal transport.

Europeristat 2008

The Portuguese VLBW Network

VLBW 2000-2004

n=5034VLBW 2004

n=1016

n Deaths %

IN 4523 780 17.2

OUT 514 136 26.5

P<0.001

n Deaths %

IN 923 133 14.4

OUT 93 25 26.9

P<0.001

It worthes to be born in the right place.

Portuguese VLBW Network Evolution of mortality per BW

0

10

20

30

40

50

60

Mortality <1000g 54 47 43 39 40 34 41 38 29 27 26

Mortality > 1000g 12 12 10 10 8 7,3 8 7 7 4 4,4

1996 1997 1998 1999 2000 2001 2002 2003 2004 2006 2007

Improving the efficiency in ELBW

Portuguese VLBW Infants NetworkPerinatal data

0 25 50 75 100

Prenatal care

Prenatal steroids

CST

ETT in delivery room

92,4

86

72

56,3

23

Nº = 3561

REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009

Secção de Neonatologia - SPP

85 %

85 %

6.521%

8,58%

4.9%

EuroNeoNet 2007

Threshold of Viability Birth Weight

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Live birth

Dead

25

2005-2008

Nº = 3561

REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009

Secção de Neonatologia - SPP

2005-2008n = 3561

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

22 23 24 25 26 27 28 29 30 31 32 33 34 35 36

Live Birth

Dead

26

2005-2008 Nº = 3561

REGISTO NACIONAL DO GRANDE PREMATURO 1994-2009

Secção de Neonatologia - SPP

Threshold of Viability (GA)

2005-2008n = 3561

Portuguese VLBW Network

Threshold of viability >50% alive 1996 – 27 w1997 – 26 w

>2004 – 25 w

Threshold of survival without major sequelae

1996 – 29 w1997 – 28 w

>2004 – 27 w

22 w GA: no survivors23 w GA: rare24 w: survival rate - 38 %

Portuguese VLBW NetworkMorbidity

Morbidity (%) 1996 2000 2006 2007

RDS 57 60 73 73

PDA 23 19 20 19

BPD (O2 36 w) 23 22 8.8 8.3

ROP 21 19 19.3 15

IVH (III,IV) 6.2 6.2 7.4 7.1

PVL 6.6 4.4 6 3.4

NEC (II,III) 5.3 4.3 6.3 3.6

Nos.Sepsis 32 31 26.5 29.6

EuroNeoNet 2007

53,8%9%

65%42%19%

2.41.71.12.736%

92%8,7%

4,2%

4,1%20,8%

5,6 %

61,5%24,7%3,7%

Portuguese VLBW Network

The aims of regionalisation were achieved.

The perinatal care reform in Portugal is an example of how a good diagnosis and adequate proposals combined with a strong political will is important for changing .

Conclusions

Portuguese VLBW Infants Network

To keep the benefits of organizational measures

To improve Follow-up of VLBW infants at 36 m and 5 years

To promote self-evaluation of NICU´s (Quality)

To improve Network of Neonatal Research

The next years objectives