Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Development/Improvement of Services, Continuing Education of Hospital Providers, HOSPITAL, HEALTH_CARE_PROVIDER_PRACTICE

Intervention Description: Creation of a small baby program requires special resources and multidisciplinary engagement.

Intervention Results: While it took pre-planning to time routine exams with cares, this approach resulted in a significant decrease in apnea, bradycardia, and desaturation events than previously observed.

Conclusion: We have described benefits, challenges, and practical approaches to creating and maintaining a small baby program that could be a model for the development of special programs for other sub-populations within in the NICU.

Intervention Components (click on component to see a list of all articles that use that intervention): Other Education, Provider Training/Education, Development/Improvement of Services, Patient Reminder/Invitation

Intervention Description: This intervention presents a toolkit developed by the March of Dimes, California Maternal Quality Care Collaborative, and the California Department of Public Health, aimed at eliminating non-medically indicated (elective) deliveries before 39 weeks of gestation. The toolkit provides guidance and strategies for healthcare providers, hospitals, and policymakers to reduce early elective deliveries (EEDs), which are associated with neonatal morbidities and increased healthcare costs. It identifies common barriers to reducing EEDs, such as lack of effective policies, provider resistance, lack of patient awareness, and data collection challenges. The toolkit offers recommendations to overcome these barriers through policy changes, hard-stop policies, provider and patient education, data collection guidance, and measurement strategies using The Joint Commission's PC-01 measure for EEDs.

Intervention Results: The toolkit highlights several successful quality improvement (QI) interventions implemented by healthcare organizations to reduce early elective deliveries. Intermountain Healthcare, through a multidisciplinary team approach, data-driven interventions, and strict enforcement of policies, reduced elective deliveries before 39 weeks from 28% to less than 3% within six years. Additionally, they observed a decrease in stillbirth rates and no significant increase in maternal morbidity. Magee Women's Hospital achieved a significant reduction in elective inductions before 39 weeks and lower cesarean section rates among nulliparous women after implementing induction guidelines, involving key physician and nursing leaders, and establishing a chain of support for enforcement. The Ohio Perinatal Quality Collaborative reported a decrease in elective deliveries from 25% to less than 5% within 14 months among participating hospitals, along with a decline in stillbirth rates and fewer NICU admissions for infants born between 36 and 38 weeks.

Conclusion: Despite efforts to curb early elective deliveries, the toolkit acknowledges that some areas still face difficulties in achieving desired results. It emphasizes the need for a coordinated effort from various stakeholders, including healthcare providers, hospitals, professional organizations, patient advocates, and policymakers. The toolkit serves as a comprehensive resource, offering evidence-based strategies, educational tools, and case studies to support the elimination of non-medically indicated deliveries before 39 weeks. By addressing barriers, promoting policy changes, enhancing data collection and measurement, and increasing awareness among providers and patients, the toolkit aims to facilitate sustainable improvements in maternal and neonatal health outcomes.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services, Needs Assessment, Consultation Systems (Hospital), HOSPITAL, Reorganization of Neonatal Services, NATIONAL

Intervention Description: The natural extension of inpatient-focused neonatal neurocritical care (NNCC) programs is the evaluation of long-term neurodevelopmental outcomes in the same patient population.

Intervention Results: To achieve this goal, we devised a two-clinic follow-up model at Children's Wisconsin: HOPE (Healthy Outcomes Post-ICU Engagement) and DREAM: Developmentally Ready: Engagement for Achievement of Milestones) clinics. Those infants with significant neurologic diagnoses attend DREAM clinic, while all other high-risk neonatal intensive care unit (NICU) infants are seen in the HOPE clinic.

Conclusion: These clinic models allow for a targeted approach to post-NICU care, which has improved family engagement and perceptions of value.

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services, HOSPITAL

Intervention Description: Effects of maternal transport on admission patterns at a tertiary care center.

Intervention Results: The number of maternal transports to the level III hospital increased from 65 before intervention to 280 after intervention. This was accompanied by a corresponding increase in number of infants admitted to the NICU who were born to transferred women from 43 before intervention to 201 after intervention, suggesting some of the increase in maternal transfer was due to anticipated neonatal care needs. The authors do not comment on statistical significance of this result.

Conclusion: Patterns of modern perinatal care are materially changing the delivery of health care at tertiary care facilities.

Study Design: Time trend analysis

Setting: Rhode Island and southeastern Massachusetts One tertiary center and 13 other obstetric facilities

Population of Focus: Total live births >500 gm in tertiary center

Data Source: Data from annual hospital statistics. Maternal transport data only available for 1978 and later.

Sample Size: 1973 (n=5,300) 1984 (n=7,317) Total live births >500 gm in tertiary center

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): NATIONAL, Policy/Guideline (National), HOSPITAL, Development/Improvement of Services

Intervention Description: We performed a cross-sectional study and linked 2014 American Hospital Association survey and State Inpatient Database data from seven representative states. We used American Hospital Association–reported hospital characteristics and State Inpatient Database procedure codes to assign a level of maternal care to each hospital. We then assigned each patient to a minimum required level of maternal care (I–IV) based on maternal comorbidities captured in the State Inpatient Database. Our outcome was delivery at a hospital with an inappropriately low level of maternal care. Comorbidities associated with delivery at an inappropriate hospital were assessed using descriptive statistics.

Intervention Results: The analysis included 845,545 deliveries occurring at 556 hospitals. The majority of women had risk factors appropriate for delivery at level I or II hospitals (85.1% and 12.6%, respectively). A small fraction (2.4%) of women at high risk for maternal morbidity warranted delivery in level III or IV hospitals. The majority (97.6%) of women delivered at a hospital with an appropriate level of maternal care, with only 2.4% of women delivering at a hospital with an inappropriate level of maternal care. However, 43.4% of the 19,988 high-risk patients warranting delivery at level III or IV hospitals delivered at level I or II hospitals. Women with comorbidities likely to benefit from specialized care (eg, maternal cardiac disease, placenta previa with prior uterine surgery) had high rates of delivery at hospitals with an inappropriate level of maternal care (68.2% and 37.7%, respectively).

Conclusion: Though only 2.41% of deliveries occurred at hospitals with an inappropriate level of maternal care, a substantial fraction of women at risk for maternal morbidity delivered at hospitals potentially unequipped with resources to manage their needs. Promoting triage of high-risk patients to hospitals optimized to provide risk-appropriate care may improve maternal outcomes with minimal effect on most deliveries.

Setting: Seven states (Florida, Massachusetts, New Jersey, New York, North Carolina, Oregon, and Washington)

Population of Focus: Women with high-risk maternal medical conditions

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, Development/Improvement of Services

Intervention Description: In the Thames Valley region of the UK in 2012-2014, covering 27 000 births per annum, about 50% of extremely premature babies were born in a specialist centre. Audit showed a number of potential areas for improvement. We used regional place of birth data and compared the place of birth of extremely premature babies for 2 years before our intervention and for 4 years (2014-2018) after we started. We aimed to improve the proportion of neonates born in a specialist centre with three interventions: increasing awareness and education across the region, by improving and simplifying the referral pathway to the local specialised centre, and by developing region-wide guidelines on the principal precursors to preterm birth: preterm labour and expedited delivery for fetal growth restriction.

Intervention Results: There were 147 eligible neonates born within the network in the 2 years before the intervention and 80 (54.4%) were inborn in a specialised centre. In the 4 years of and following the intervention, there were 334 neonates of whom 255 were inborn (76.3%) (relative risk of non-transfer 0.50 (95% CI 0.39 to 0.65), p<0.001). Rates showed a sustained improvement.

Conclusion: The proportion of extremely premature babies born in specialist centres can be significantly improved by a region-wide quality improvement programme. The interventions and lessons could be used for other areas and specialties.

Setting: Network of hospitals in the Thames Valley region of UK

Population of Focus: Extremely premature babies born within network

Intervention Components (click on component to see a list of all articles that use that intervention): Prenatal Care Access, Policy/Guideline (State), Development/Improvement of Services,

Intervention Description: improving housing stability, access to healthcare, and support services could be beneficial for this vulnerable group

Intervention Results: The majority (81%) of the women identified as African American. Over 95% of the women were single, and 74 women reported a prior pregnancy. Almost half of the women reported being behind on rent at least one time in the last 6 months, and 43% indicated that they had lived in more than three places in the last year.

Conclusion: indicate a significant financial and maternity risk for pregnant women experiencing homelessness. The study emphasizes that addressing the needs of homeless pregnant women requires more than just standard case management and healthcare coordination. It recommends additional financial resources to address utility arrears, long-term rent support, higher security deposits, and intensive prenatal care that integrates prior preterm birth history and other health issues. The study underscores the importance of tailored interventions to support the maternal and child health of homeless pregnant women

Study Design: cross-sectional

Setting: Columbus, OH

Population of Focus: women who report pregnancy/unhoused.

Sample Size: n=100

Age Range: 25.5 years, with a standard deviation of 4.6 years

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services

Intervention Description: We used birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000. We identified areas likely to have been affected by the opening of a new nearby midlevel unit, analyzed changes over time in the share of births that took place in midlevel NICU hospitals, and compared patterns in areas that were and were not likely affected by the opening of a new midlevel unit. We also tracked the corresponding changes in the share of births in high-level hospitals and in those without NICU facilities (low-level).

Intervention Results: The probability of a 500- to 1499-g infant being born in a midlevel unit increased by 17 percentage points after the opening of a new nearby unit. More than three quarters of this increase was accounted for by reductions in the probability of birth in a hospital with a high-level unit (−15 points), and the other portion was resulting from reductions in the share of newborns delivered in hospitals with low-level centers (−2 points). Similar patterns were observed in 1500- to 2499-g newborns.

Conclusion: The introduction of new midlevel units was associated with significant shifts of births from both high-level and low-level hospitals to midlevel hospitals. In areas in which new midlevel units opened, the majority of the increase in midlevel deliveries was attributable to shifts from high-level unit births. Continued proliferation of midlevel units should be carefully assessed.

Study Design: N/A

Setting: Data on newborns from California

Data Source: birth certificate, death certificate, and hospital discharge data for essentially all low birth weight, singleton California newborns born between 1993 and 2000.

Sample Size: N/A

Age Range: newborn babies

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, Needs Assessment, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Agreement for Level III Hospital to Accept All Patients, STATE, Funding Support, Perinatal Committees/Councils

Intervention Description: A major objective was to develop and maintain a regionalized system of care. Such a system has been developed but differed from traditional systems by using regional level II centers. Iowa's low population density necessitated this modification.

Intervention Results: Level I hospitals currently manage low-risk patients and report very low mortality rates. Level II facilities receive high-risk referrals, but selective referral occurs since the tertiary center accounts for a disproportionate number of fetal and neonatal deaths, and births weighting less than 1500 g.

Conclusion: Other regions may benefit from similar approaches to development of regionalized systems of care and evaluation of the same.

Study Design: QE: pretest-posttest

Setting: All Iowa hospitals Pretest: 129 level I, 11 level II, and one level III hospital Posttest: 118 level I, 11 level II, and one level III hospital

Population of Focus: All infants born at ≥20 weeks GA and ≤1500 gm

Data Source: Data from Iowa State Health Department matched birth and infant death certificates.

Sample Size: Pretest (n= 432) Posttest (n= 343)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, Needs Assessment, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Agreement for Level III Hospital to Accept All Patients, Perinatal Committees/Councils, STATE

Intervention Description: A voluntary system of regionalized perinatal health care was developed in Iowa to provide accessible services for a rural population.

Intervention Results: The intervention in Iowa focused on increasing both level III and level II VLBW births due to population density concerns in Iowa. Among all VLBW infants, there were changes in the birth location distribution. Of these infants, there was a statistically significant increase in percentage born in level III hospitals from 6.7% to 22.6% (p<0.05)1 and an increase in births in level II hospitals from 26.9% to 35.6%. The percentage born in level I centers decreased from 68.2% to 41.8%.

Conclusion: The concept of a mortality risk ratio (neonatal deaths/<1,500 gm live births) is suggested as a method of reviewing mortality data from the perspective of risks inherent in the population served.

Study Design: QE: pretest-posttest

Setting: All Iowa hospitals Pretest: 130 level I, 10 level II, and one level III hospital Posttest: 122 level I, 10 level II, and one level III hospital

Population of Focus: All live births <1500 gm

Data Source: Data from Iowa State Health Department matched birth and infant death certificates.

Sample Size: Pretest (n= 440) Posttest (n= 402)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services,

Intervention Description: The Perinatal and Postpartum Contraceptive Services Project for Migrant Women (PPCSP) provided free contraceptive counseling and methods in the maternity setting prior to postpartum discharge, as well as additional support and services during the first postpartum year. Specifically, the intervention involved offering contraceptive methods to women according to their choice prior to discharge, followed by counseling and further support at 6 weeks and at 3, 6, 9, and 12 months postpartum via scheduled telephone calls and/or clinic visits.

Intervention Results: Just after postpartum counseling, 47 women (32.9%) decided to use the intrauterine device (IUD), 23 (16.1%) condoms, 16 (11.2%) progestin injections, 7 (4.9%) oral contraceptives, and 7 (4.9%) coitus interruptus for contraception. Thirty-six women (25.2%) did not decide on any method of use. At the time of the telephone interview the actual method used was learned. Fifty-one women (35.7%) were using coitus interruptus, 45 women (31.5%) condoms, and 14 (9.8%) the IUD. Sixteen women (11.2%) were reported as not using any methods.

Conclusion: The study reported that among all participants, the median time to contraceptive initiation and sexual resumption was 2 months postpartum, respectively. The overall contraceptive prevalence at 12 months was 97.1%, with more than half of the women using long-acting contraception. The incidence rate of unintended pregnancy during the first year postpartum was 2.2 per 100 women-years. These results indicated that the intervention led to earlier initiation of postpartum contraception, a higher percentage of contraceptive use throughout the first year postpartum, and a lower incidence of unintended pregnancies compared to non-intervention cohorts.

Study Design: Prospective cohort study

Setting: 4 participating hospitals in Shanghai, China

Population of Focus: Urban to rural women migrant women 18-44 years

Sample Size: 840 women

Age Range: 18-44 years

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), STATE, Policy/Guideline (State), Funding Support

Intervention Description: This report summarizes the evaluation of a national demonstration program of such regionalization that was funded by the Robert Wood Johnson Foundation (RWJF) in 1975.

Intervention Results: In both funded regions and comparison areas, the neonatal mortality rates decreased sharply over the decade of the 1970s. This decline was linked to shifts in the hospital of delivery that indicated antepartum risk identification and transfer of management of high-risk pregnancies to tertiary centers for delivery, a change in service pattern consistent with some aspects of regionalization. The centralization of high-risk deliveries appeared so widespread that the special effect of the RWJF program could not be detected.

Conclusion: Surveys of surviving 1-year-old infants showed that the decrease in neonatal mortality was accompanied by a decrease in selected morbidity.

Study Design: QE: pretest-posttest nonequivalent control group

Setting: Eight regions and eight comparison regions

Population of Focus: Infants born weighing ≤1500

Data Source: Data from reproduced computer tapes of births and matched infant death and birth certificates obtained from state and local health offices in several states.

Sample Size: Intervention group: Pretest (n≈ 4080) Intervention (n≈ 3416) Posttest: (n≈ 4033) Comparison: Pretest: (n≈ 5221) Intervention: (n≈ 4297) Posttest: (n≈ 4596)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, Needs Assessment

Intervention Description: This was a prospective population-based cohort study of perinatal outcomes before and after 1 full year of implementation of the preterm birth prevention program.

Intervention Results: In the state overall, the rate of singleton preterm birth was reduced by 7.6% and was lower than in any of the preceding 6 years. This reduction amounted to 196 cases relative to the year before the introduction of the initiative and the effect extended from the 28-31 week gestational age group onward. Within the tertiary level center, the rate of preterm birth in 2015 was also significantly lower than in the preceding years.

Conclusion: A comprehensive and multifaceted preterm birth prevention program aimed at both health care practitioners and the general public, operating within the environment of a government-funded universal health care system can significantly lower the rate of early birth. Further research is now required to increase the effect and to determine the relative contributions of each of the interventions.

Setting: Hospitals in Western Australia

Population of Focus: Pregnant women in Western Australia

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services, Policy/Guideline (Hospital)

Intervention Description: The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges.

Intervention Results: The existing system worked remarkably well for clinical care, training, referrals, and provider and patient satisfaction. There was a high level of inter-hospital collaboration and regional leadership in obstetrics and pediatrics, but strong and growing competition between their hospitals. Hospital administrators enumerated the competitive threats that obligated them to compete and the financial disincentives to support the regional structures. Business leaders and insurance executives emphasized the need to control costs. Analysis of discharge data showed marginal adequacy of NICU beds but maldistribution between NICUs, particularly between level III and level II units. The consultants recommended no new beds based on population projections, declining lengths of stay nationally, and substantial gains available from aggressive back-transport of convalescing infants. The consultants emphasized the need for all stakeholders to support the regional infrastructure (referral, transport, education, evaluation, quality assurance) and to modify competition when it impaired effective regionalization.

Conclusion: Regionalization permits better care at lower cost, yet competition may disrupt this effective system. Active cooperation by stakeholders is vital. Substantial new research is required to define optimal regional organization.

Study Design: N/A

Setting: N/A

Data Source: The consultant team interviewed stake-holders in area hospitals, health maintenance organizations, insurance companies, businesses, state agencies, and community groups, and analyzed quantitative data on newborn discharges.

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Development/Improvement of Services,  , HOSPITAL

Intervention Description: With the increasing rate of high-risk pregnancies, there is an increased need for early evaluation of at-risk fetuses. Fetal ultrasound imaging has become a pivotal part of this evaluation.

Intervention Results: During the study period, we conducted 345 fetal scans in high-risk pregnancy cases. Of these, 158 cases (46%) were referrals from other institutes. Eighty-nine neonates were admitted to our neonatal intensive care unit (NICU) after being evaluated, of which 10 neonates underwent surgery during their NICU stays. Thirty-nine pregnant women were referred to other tertiary care hospitals mainly due to fetal diagnoses with complex cardiac anomalies. Fourteen cases resulted in intrauterine fetal death or artificial abortion.

Conclusion: Fetal ultrasound clinics have established their role in facilitating sophisticated regional perinatal care via multidisciplinary and inter-facility cooperation for high-risk pregnancy cases. In addition, providing psychological support and counseling for pregnant women whose fetuses are diagnosed with severe congenital anomalies should not be neglected.

Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Development/Improvement of Services, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems

Intervention Description: Analysis of a maternal transport service within a perinatal region.

Intervention Results: Analysis of perinatal statistics from the Loyola University Perinatal Center from 1979 to 1986 supports: (1) increasing numbers of maternal and neonatal transports, with the number of maternal transports exceeding the number of neonatal transports since 1982; (2) increasing proportion of low birthweight and very low birthweight infants delivered at the perinatal center; (3) a decrease in the number of infants less than 1500 gm sent as neonatal transports; and (4) increasing proportion of neonatal transports with a birthweight greater than 2500 gm.

Conclusion: The perinatal mortality rate for the region has decreased from 1981 to 1986.

Study Design: Time trend analysis

Setting: Metropolitan Chicago: Cook County and Suburban Dupage County Two level I, 11 level II, and one level III hospitals

Population of Focus: Infants born weighing >500 gm. Data for entire region only given from 1981-1986.

Data Source: Data obtained from the Illinois Department of Public Health and Loyola University annual statistics reports.

Sample Size: 1981 (n= 18,365) 1982 (n= 19,460) 1983 (n= 19,162) 1984 (n= 19,379) 1985 (n= 20,132) 1986 (n= 19,751)

Age Range: Not specified