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Strengthen the Evidence for Maternal and Child Health Programs

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Association of State and Territorial Health Officials. Fact sheet: Perinatal regionalization. http://www.astho.org/Programs/ASTHO-Perinatal-Regionalization-Fact-Sheet/. Access Abstract

Freeman VA. Very low birth weight babies delivered at facilities for high-risk neonates: A review of Title V National Performance Measure 17. 2010. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Screening Tool Implementation Training, Educational Material
Intervention Description: This study was designed to examine the trends for NPM #17 for each State and for all States combined and to explore reasons that States report for change in this marker. In the first part of this report, nine years of NPM #17 data are examined to look at trends in the rate of VLBW deliveries in the appropriate hospital on a State-by-State basis and for all States, calculating the change in rate over the nine-year period. Part II describes in some detail on information obtained from both a review of State Title V Application/Annual Reports and from follow-up conversations with MCH staff in a sample of states. States with rates that have improved, worsened or remained the same are included.
Primary Outcomes: N/A
Conclusion: Monitoring the NPM #17 rate and addressing barriers to high-risk care is a small part of the perinatal health picture, but, nonetheless, an important one. The rate for all States combined, as well as the rate for most individual States, has not reached the Healthy People 2010 goal of 90% and some rates have changed little since 2000. True improvement is hard to assess, though, when there are many challenges to accurate measurement. States are making efforts to improve their data and are using data to drill down and better target interventions. They are exploring where VLBW births occur and why some do not occur in facilities for high-risk deliveries. Further, they are looking more broadly at fetal and infant mortality through FIMRs. These comprehensive review processes are important because they involve community leaders and explore all contributors to mortality to identify the most appropriate interventions. In the case of VLBW infants, understanding if health care system factors have played a role in a poor outcome and which factors can be modified can be an important contribution to improving this indicator. Surveillance of VLBW births is necessary for the quality improvement initiatives that were frequently mentioned by States as processes by which they hoped to improve neonatal health and health care. Many activities to promote perinatal health and positive birth outcomes are evident in a review of State Title V Annual Reports and also reported by State officials. All States promote and most of them provide early and comprehensive prenatal care that includes screening for risk for premature delivery. Education for consumers, obstetricians, family physicians, nurse midwives, maternity care nurses and others is provided by Title V agencies and by their partners in academic centers and in work groups, task forces, and other organizations devoted to perinatal health. Formal and informal regionalized perinatal care has ensured the availability of facilities for care of high-risk mothers and infants, consultative services to assess the need and co-manage care, agreements for transfer of care and transport services to ensure a smooth transition of care. The value of this National Performance Measure to States ranges from a perception of NPM #17 as a valuable marker of performance and useful tool for program evaluation to a less valuable but necessary monitoring requirement.
Study Design: Systematic Review
Significant Findings: Yes
Setting: Data from all 50 states and PR
Data Source: NPM 17 data and State Title V Application/Annual Reports and from follow-up conversations with MCH staff in a sample of states
Sample Size: Data from all 50 states and PR
Age Range: N/A

Healthy People. Maternal, Infant, and Child Health. https://www.healthypeople.gov/2020/data-search/Search-the-Data#objid=4892. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Description: N/A
Primary Outcomes: N/A
Conclusion: N/A
Study Design: N/A
Significant Findings: N/A
Setting: N/A
Data Source: N/A
Sample Size: N/A
Age Range: N/A

Nowakowski L, Barfield WD, Kroelinger CD, et al. Assessment of State Measure of Risk-Appropriate Care for Very Low Birth Weight Infants and Recommendations for Enhancing Regionalized State Systems. Matern Child Health J. 2012:16:217-227. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Policy/Guideline (National)
Intervention Description: The authors reviewed state perinatal regionalization models and levels of care to compare varying definitions between states and assess mechanisms of measurement and areas for improvement.
Primary Outcomes: N/A
Conclusion: State models of regionalized risk-appropriate care vary. Due to these discrepancies, national attempts to compare access to risk-appropriate perinatal care, and establish the evidence base for effectiveness, have been difficult to achieve. This impacts efforts to optimize VLBW infant access to appropriate facilities, a worthwhile endeavor as this population comprises a majority of neonatal deaths [7, 8]. State legislatures, regulatory institutions, public health officials, and hospitals themselves must recognize and commit to the need for national standards and definitions, determine what these standards will be, and disseminate this information to healthcare providers, clinicians, and patients.
Study Design: N/A
Significant Findings: N/A
Setting: 7 states
Data Source: Information was gathered from meeting presentations, presenters, state representatives, and state websites.
Sample Size: 7 state models
Age Range: N/A

Committee on Perinatal Health. Toward Improving the Outcome of Pregnancy III: Enhancing Perinatal Health Through Quality, Safety and Performance Initiatives (TIOP III). March of Dimes Birth Defects Foundation. 2010. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Access, Educational Material, Policy/Guideline (State)
Intervention Description: The report investigates and reports out on Enhancing perinatal health through quality, safety and performance initiatives
Primary Outcomes: N/A
Conclusion: Ultimately, reaching a more efficient, more accountable system of perinatal care will require a level of collaboration, services integration and communication that lead to successful perinatal quality improvement initiatives, many of which are described throughout this book. In addition to the consistent collection of data and measurement and the application of evidence-based interventions, successful collaborations, like all perinatal quality improvement, depend on the engagement, support and commitment of everyone reading this book: health care professionals and hospital leadership, public health professionals and community-based service providers, research scientists, policymakers and payers, as well as patients and families. TIOP III is the call to action and the tool that can inspire and guide their efforts toward improving the outcome of pregnancy.
Study Design: N/A
Significant Findings: N/A
Setting: N/A
Data Source: N/A
Sample Size: N/A
Age Range: N/A

American Academy of Pediatrics. Levels of Neonatal Care. J Pediatr. 2012;130(3):587-597. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Quality Improvement/Practice-Wide Intervention, Organizational Changes
Intervention Description: This revised policy statement reviews the current status of the designation of levels of newborn care definitions in the United States, which were delineated in a 2004 policy statement by the American Academy of Pediatrics (AAP).1 Since publication of the 2004 policy statement, new data, both nationally and internationally, have reinforced the importance of well-defined regionalized systems of perinatal care, population-based assessment of outcomes, and appropriate epidemiologic methods to adjust for risk. This revised statement updates the designations to provide (1) a basis for comparison of health outcomes, resource use, and health care costs, (2) standardized nomenclature for public health, (3) uniform definitions for pediatricians and other health care professionals providing neonatal care, and (4) a foundation for consistent standards of service by institutions; state health departments; and state, regional, and national organizations focused on the improvement of perinatal care.
Primary Outcomes: N/A
Conclusion: Current evidence indicates that family and cultural considerations are important for care of sick neonates.62,–65 These considerations include family- and patient-centered care, culturally effective care, family-based education, and opportunities for back-transport to level II facilities or transfer to the family’s local community facility when medically and socially indicated.
Study Design: Systematic Review
Significant Findings: N/A
Setting: N/A
Data Source: N/A
Sample Size: N/A
Age Range: N/A

American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine, Menard MK, et al. Levels of maternal care. Am J Obstet Gynecol. 2015;212(3):259-271. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Organizational Changes
Intervention Description: To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States. To develop standardized definitions and nomenclature for facilities that provide each level of maternal care. To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion. To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services.
Primary Outcomes: N/A
Conclusion: Many barriers to the implementation of levels of maternal care may need to be overcome. The development of the classification system is the first step; the next step, is the implementation of this concept in all facilities that provide maternal care. The questions of whether to have state-level or national-level accrediting bodies establish and set these proposed levels of maternal care, as well as how to provide the financing needed to run them, are unanswered. Follow-up interdisciplinary work groups are needed to further explore the implementation needs to adopt the proposed classification system for levels of maternal care in all facilities that provide maternal care. The determination of the appropriate level of care to be provided by a given facility should be guided by local and state health care regulations, national accreditation and professional organization guidelines, and identified regional perinatal health care service needs.6 State and regional authorities should work together with the multiple institutions within a region to determine the appropriate coordinated system of care.
Study Design: N/A
Significant Findings: N/A
Setting: N/A
Data Source: N/A
Sample Size: N/A
Age Range: N/A

Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth- weight and very preterm infants: a meta-analysis. JAMA. 2010;304(9):992-1000. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Description: N/A
Primary Outcomes: N/A
Conclusion: For VLBW and VPT infants, birth outside of a level III hospital is significantly associated with increased likelihood of neonatal or predischarge death.
Study Design: Systematic Review
Significant Findings: Yes
Setting: N/A
Data Source: Systematic search of published literature (1976-May 2010) in MEDLINE, CINAHL, EMBASE, and PubMed databases and manual searches of reference lists.
Sample Size: 41 studies
Age Range: N/A

The Robert Wood Johnson What Works for Health Project. http://www.countyhealthrankings.org/roadmaps/what-works-for-health. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Description: N/A
Primary Outcomes: N/A
Conclusion: N/A
Study Design: N/A
Significant Findings: N/A
Setting: N/A
Data Source: N/A
Sample Size: N/A
Age Range: N/A

Bronstein JM, Ounpraseuth S, Jonkman J, et al. Improving perinatal regionalization for preterm deliveries in a Medicaid covered population: initial impact of the Arkansas ANGELS intervention. Health Serv Res. 2011;46(4):1082-1103. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Access to Provider through Hotline, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, STATE, Policy/Guideline (State), Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital)
Intervention Description: To examine the factors associated with delivery of preterm infants at neonatal intensive care unit (NICU) hospitals in Arkansas during the period 2001–2006, with a focus on the impact of a Medicaid supported intervention, Antenatal and Neonatal Guidelines, Education, and Learning System (ANGELS), that expanded the consulting capacity of the academic medical center's maternal fetal medicine practice.
Conclusion: Perinatal regionalization is the consequence of a complex set of provider and patient decisions, and it is difficult to alter with a voluntary program.
Study Design: Time trend analysis
Significant Findings: Yes
Setting: All Arkansas hospitals Five level III hospitals from 2001- 2005, six in 2006
Target Audience: Infants born at <35 weeks GA
Data Source: Data from Medicaid claims for pregnancy linked to birth certificates for women covered by Medicaid in Arkansas
Sample Size: Total (n= 5,150) 2001 (n= 812) 2002 (n= 1,105) 2003 (n= 824) 2004 (n= 824) 2005 (n= 887) 2006 (n= 698) Infants born at <35 weeks GA
Age Range: Not specified

Cowett RM, Coustan DR, Oh W. Effects of maternal transport on admission patterns at a tertiary care center. Am J Obstet Gynecol. 1986;154(5):1098-1100. Access Abstract

NPM: 3: Perinatal Regionalization
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.
Conclusion: Patterns of modern perinatal care are materially changing the delivery of health care at tertiary care facilities.
Study Design: Time trend analysis
Significant Findings: Yes
Setting: Rhode Island and southeastern Massachusetts One tertiary center and 13 other obstetric facilities
Target Audience: 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

Hall RW, Hall-Barrow J, Garcia-Rill E. Neonatal regionalization through telemedicine using a community-based research and education core facility. Ethn Dis. 2010;20(1 0 1):S1-136-140. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Access to Provider through Hotline, HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Consultation Systems (Inter-Hospital Systems), Consultation Systems (Hospital), Telemedicine Systems (Inter-Hospital Systems), Telemedicine Systems (Hospital), STATE, Policy/Guideline (State)
Intervention Description: Telemedicine has been used successfully for medical care and education but it has never been utilized to modify patterns of delivery in an established state network.
Conclusion: Telemedicine is an effective way to translate evidence based medicine into clinical care when combined with a general educational conference. Patterns of deliveries appear to be changing so that those newborns at highest risk are being referred to the regional perinatal centers.
Study Design: Time trend analysis
Significant Findings: Yes
Setting: All Arkansas hospitals
Target Audience: Infants born weighing 500-2499 gm. Data not given for other study years.
Data Source: Data from Arkansas Vital Statistics Data System linked with corresponding hospitalization records from Arkansas Hospital Discharge Data System.
Sample Size: Total (n= 12,258) 2001 (n= 2,965) 2004 (n= 3,154)
Age Range: Not specified

Nugent RR. Perinatal regionalization in North Carolina, 1967-1979: services, programs, referral patterns, and perinatal mortality rate declines for very low birthweight infants. N C Med J. 1982;43(7):513-515. Access Abstract

NPM: 3: Perinatal Regionalization
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, STATE, Policy/Guideline (State), Funding Support, Perinatal Committees/Councils, Increased Reimbursement
Study Design: Time trend analysis
Significant Findings: Yes
Setting: Non-federal North Carolina hospitals
Target Audience: Infants born weighing ≤1500 gm
Data Source: Data source not provided.
Sample Size: Percentages given without numerator or denominator.
Age Range: Not specified

Powers WF, McGill L. Perinatal market penetration rate. A tool to evaluate regional perinatal programs. Am J Perinatol. 1987;4(1):24-28. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, STATE, Policy/Guideline (State)
Intervention Description: Viewing the 1001-1500 gm regional cohort of fetuses as a potential "market" for center delivery, and measuring a center's penetration into this market, quantitates how well a center draws to itself these small, high-risk fetuses for delivery.
Conclusion: The penetration rate into a defined market measures how well a center fulfills this obligation.
Study Design: Time trend analysis
Significant Findings: Yes
Setting: Illinois North Central Perinatal Region: 31 hospitals including one tertiary center
Target Audience: Infants born weighing 1001 to 1500 gm
Data Source: Data from 1973-1982 obtained from the Illinois Department of Public Health live birth files. Data from 1983 from an Illinois Department of Public Health administered monthly hospital reporting system.
Sample Size: 1973 (n= 100) 1974 (n= 104) 1975 (n= 102) 1976 (n= 88) 1977 (n= 102) 1978 (n= 97) 1979 (n= 101) 1980 (n= 85) 1981 (n= 100) 1982 (n= 83) 1983 (n= 81)
Age Range: Not specified

Tomich PG, Anderson CL. Analysis of a maternal transport service within a perinatal region. Am J Perinatol. 1990;7(1):13-17. Access Abstract

NPM: 3: Perinatal Regionalization
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.
Conclusion: The perinatal mortality rate for the region has decreased from 1981 to 1986.
Study Design: Time trend analysis
Significant Findings: Yes
Setting: Metropolitan Chicago: Cook County and Suburban Dupage County Two level I, 11 level II, and one level III hospitals
Target Audience: 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

Vendittelli F, Riviere O, Crenn-Hebert C, Giraud-Roufast A. Do perinatal guidelines have an impact on obstetric practices? Rev Epidemiol Sante Publique. 2012;60(5):355-362. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Policy/Guideline (National), NATIONAL, POPULATION-BASED SYSTEMS
Intervention Description: The goal of this study was to assess the impact of eight French perinatal guidelines on actual obstetric practices.
Conclusion: Globally, the impact on actual practices of clinical practice guidelines, except the guideline concerning the active management of the third stage of labour, was low. Most of the changes observed in practices began before the pertinent guideline was published.
Study Design: Time trend analysis
Significant Findings: Yes
Setting: French hospitals
Target Audience: Subsample of all infants born weighing <1500 gm Data from 1994 to 1998 only included singleton pregnancies
Data Source: Data from the voluntary Audipog database in which participating hospitals send data on all deliveries covering a given period of at least a full month (chosen by hospital) each year. Authors extracted a subsample from the data.
Sample Size: Percentages given without numerator or denominator.
Age Range: Not specified

Bowes WA, Jr. A review of perinatal mortality in Colorado, 1971 to 1978, and its relationship to the regionalization of perinatal services. Am J Obstet Gynecol. 1981;141(8):1045-1052. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, STATE, Policy/Guideline (State), Funding Support, Perinatal Committees/Councils
Intervention Description: Vital records data (1971 to 1978) were used to assess the change in neonatal and fetal mortality in Colorado in relationship to the regionalization of perinatal health care within the state.
Conclusion: These date suggest that outreach education in perinatal medicine should now emphasize current knowledge and methods for reducing antepartum deaths.
Study Design: QE: pretest-posttest
Significant Findings: Yes
Setting: All Colorado hospitals Three level III, seven level II, remaining level I
Target Audience: Infants born weighing greater than one lb.
Data Source: Data from the Bureau of Vital Records, Colorado State Health Department.
Sample Size: Pretest: 1.8% (n=2,818) Posttest: 1.8% (n=2,967) Infants born weighing one to four lbs.
Age Range: Not specified

Campbell MK, Chance GW, Natale R, Dodman N, Halinda E, Turner L. Is perinatal care in southwestern Ontario regionalized? CMAJ. 1991;144(3):305-312. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers, POPULATION-BASED SYSTEMS, INTER-HOSPITAL SYSTEMS, Maternal/In-Utero Transport Systems, Follow-Up Given On Transferred Patients, STATE, Perinatal Committees/Councils, NICU Bed Registry/Electronic Bulletin Board
Intervention Description: To determine whether perinatal care in southwestern Ontario is regionalized, to identify trends over time in referral patterns, to quantify trends in perinatal death rates and to identify trends in perinatal death rates that give evidence of regionalization.
Conclusion: Perinatal care in southwestern Ontario is regionalized and not centralized; regionalization in southwestern Ontario increased between 1982 and 1985.
Study Design: QE: pretest-posttest
Significant Findings: Yes
Setting: Southwestern Ontario One level III, one modified level III and 30 level II or I
Target Audience: Births greater than 500 gm
Data Source: Data obtained from hospital delivery room books and for 31 of the 32 hospitals, from hospital charts of women and neonates.
Sample Size: Pretest: 1.17% (n= 194) Posttest: 1.31% (n= 211) Infants born weighing 500-1499 gm
Age Range: Not specified

Gale C, Santhakumaran S, Nagarajan S, Statnikov Y, Modi N. Impact of managed clinical networks on NHS specialist neonatal services in England: population based study. BMJ. 2012;344:e2105. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): Reorganization of Neonatal Services, NATIONAL, POPULATION-BASED SYSTEMS
Intervention Description: To assess the impact of reorganisation of neonatal specialist care services in England after a UK Department of Health report in 2003.
Conclusion: There is evidence of some improvement in the delivery of neonatal specialist care after reorganisation.
Study Design: QE: pretest-posttest
Significant Findings: Yes
Setting: Pretest: 294 maternity centers and neonatal units in England, Wales and Northern Ireland Posttest: 146 neonatal units (23 managed clinical networks) in England
Target Audience: Infants born at 27+0 to 28+6 (weeks+ days) GA In pretest, live births In posttest, admitted to a neonatal unit (no details on babies who died in labor ward)
Data Source: Pretest: Data from a published report of the Confidential Enquiry into Stillbirths and Deaths in Infancy Project 27/28 which identified 28 day outcomes of all live births at 27-28 weeks GA in England, Wales, and Northern Ireland. Posttest: Data from National Neonatal Research Database held by the Neonatal Data Analysis Unit.
Sample Size: Pretest (n=3,522) Posttest (n=2,919)
Age Range: Not specified

Victorian Infant Collaborative Study Group (VICSG). Improvement of outcome for infants of birth weight under 1000 g. Arch Dis Child. 1991;66:765-769. Access Abstract

NPM: 3: Perinatal Regionalization
Intervention Components (click on component to see a list of all articles that use that intervention): HOSPITAL, Continuing Education of Hospital Providers
Intervention Description: The two year outcome of extremely low birth-weight (ELBW) infants (birth weight 500 to 999 g), born in the state of Victoria over two distinct eras, 1979-80 and 1985-7, were compared.
Conclusion: There has been a concomitant improvement in both survival and reduction in neurological morbidity.
Study Design: QE: pretest-posttest
Significant Findings: No
Setting: All hospitals in Victoria, Australia
Target Audience: Infants born weighing 500-999 gm
Data Source: Data from the Victorian Perinatal Data Collection Unit (with linkages to death certificates) and crosschecked with data from each level III hospital in the state and the Newborn Emergency Transport Service.
Sample Size: Pretest (n= 351) Posttest (n= 560)
Age Range: Not specified

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This project is supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U02MC31613, MCH Advanced Education Policy, $3.5 M. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.