Communication following neonatal death

In circumstances where neonatal death is the outcome, family support by neonatal staff should include the antenatal team wherever possible. Continuing engagement by the obstetric staff in the postnatal care of the baby and family is especially helpful when the outcome is death or significant early morbidity. This ongoing communication between the antenatal and postnatal teams improves quality of care for the individual family and for all babies in general, as open dialogue fosters respect and support.

Managed neonatal clinical networks

Managed health service networks aim to deliver appropriate healthcare to a defined local population in the most effective and efficient manner. Specialized neonatal care is a high‐cost, low‐volume service that is increasingly delivered in managed networks. In 2009, the UK Department of Health Toolkit for High‐Quality Neonatal Services [6] set the standards of care that should be provided for preterm or sick infants. Included in these recommendations was the stipulation that neonatal care should be delivered in managed clinical networks.

Within each network, different hospitals provide a range of care as agreed by that network. The level of care provided by each hospital is based on resources, capacity, geography and the availability of appropriately skilled and trained staff. A network consists of at least one neonatal intensive care (level 3) unit providing intensive care facilities, with specialist staff and facilities. The various network hospitals collaborate to ensure that every infant has access to the most appropriate level of care. The development of coterminous maternity networks are also enhancing the organization of perinatal services.

In the UK, neonatal intensive care (level 3) units provide care for extremely preterm babies and the sickest term babies requiring all levels of advanced respiratory support and parenteral nutrition. These units have 24‐hour cover from specialized nursing staff and neonatal specialist doctors. Local neonatal (level 2) units provide respiratory support for babies of 28 weeks’ gestation or more and special care (level 1) units provide care for babies that do not require respiratory support for prolonged periods (usually 24–48 hours only).

Neonatal transport

Ensuring that babies receive the appropriate level of care ideally requires delivery in the correct place if delivery is predictable and safe antenatal transfer of mother is possible. Postnatal transfer of babies to the correct level of unit after delivery also needs to be available. Specialist neonatal transfer services are evolving that have the expertise and equipment and thus help to avoid depleting specialist staff from the either the referral unit or the specialist centre. A major role of the neonatal networks is to ensure that pregnant women are transferred to the most appropriate setting if it is predicted that their baby will need a higher level of care than that provided by the admitting hospital. In order to facilitate family involvement, it is also expected that the infant should be cared for within the network rather than being transferred great distances.

Prematurity

Prematurity is the major determinant of neonatal outcome in developed countries. The preterm birth rate (live births occurring before 37 weeks’ gestational age) is 5–9% in Europe and 12–13% in the USA and is increasing. In the USA there has been a 31% increase in prematurity since 1981 [8]. In England and Wales, there were 700 000 liveborn babies in 2013, 7% preterm and 1.0% less than 32 weeks’ gestation [9].

The infant mortality rate (deaths at less than 1 year of age) in term infants was 3.8 per 1000 live births compared with 21.1 for preterm infants. Of those born at less than 32 weeks of gestation, 15% resulted in an infant death and this accounted for over half of all infant deaths. Variation may be due to methodological differences such as case ascertainment, selection bias, and varying outcome definitions and follow‐up duration. Reports from geographically defined population‐based studies show lower survival rates than single‐centre selective studies that are subject to bias.

Variation in preterm birth rates (all births) also appears to have a major influence on reported neonatal mortality rates between populations. Compared with other European regions, the delivery rate per 1000 births between 22 and 31⁺⁶ weeks in two regions in England (Trent: 16.8, 95% CI 15.7–17.9; Northern: 17.1, 95% CI 15.6–18.6) was significantly higher compared with a group mean of 13.2 (95% CI 12.9–13.5) [10]. Live birth rates showed similar trends. When comparisons were made between regions after adjustment for prematurity rates, the variation in survival outcomes was reduced.

Perinatal management policies and differences in perinatal healthcare provision as determinants of survival are inadequately quantified. The extent to which obstetricians use antenatal steroids and actively manage delivery and whether neonatologists perform resuscitation and redirection of care during intensive care, all potentially have effects on reported survival and outcome.

At the extremes of viability, biological variation and ethical considerations are important in determining management policies. Policies based simply on gestation at birth are inadequate and prediction of outcome may be more accurate if gender, exposure to antenatal steroids, single or multiple births and birthweight are considered with gestation.

Survival

Advances in perinatal care have resulted in a significant increase in survival of preterm babies. Survival in late preterm babies (32–36 weeks) is 98–99%. There are limited data on longer‐term morbidity in this group but recent reports suggest this neglected area should be studied in greater detail. There are five times more late preterm babies born than babies born before 32 weeks’ gestation and therefore as a group require considerable healthcare resources.

Babies born before 28 weeks’ gestation have shown the greatest increase in survival since the advent of modern perinatal care. Few babies less than 28 weeks’ gestation survived until techniques were developed during the 1960s and 1970s to provide respiratory support. Over the following two decades, the use of antenatal corticosteroids, use of surfactant and improvements in respiratory support have resulted in striking improvements in reported survival.

The EPICure study of all births between 22 and 25 weeks’ gestation in the UK and the Republic of Ireland during 1995 provided important population‐based information on babies born at the borderline of viability [4,11]. During the study regionalized neonatal care was poorly developed. This study was repeated in the UK during 2006 for babies born between 22 and 26 weeks’ gestation in England [5]. Survival overall increased from 40 to 53% as well as at each week of gestation. The development of more regionalized neonatal care delivery in the UK, with increasing use of managed neonatal networks during the period between the two studies, may have contributed to the improvement.

Neonatal mortality and early morbidity

Neonatal death in preterm births is largely due to respiratory complications, periventricular haemorrhage and infection. Antenatal steroids, the use of early surfactant and continuous positive airway pressure are all associated with a reduction in death and morbidity.

Childhood morbidity

Neurodevelopmental sequelae of prematurity present during the first 5 years after birth and include cerebral palsy, poor cognitive performance and sensory impairments (visual and auditory deficits). During later years, academic underachievement and behavioural sequelae may occur. The definitions used for neurodevelopmental impairments and disability between studies are not uniform but more rigorous definitions are evolving. Disability reported in studies usually refers to one or more severe functional impairments, including non‐ambulatory cerebral palsy, developmental quotient or IQ of less than −2 or −3 standard deviations from the norm, blindness and hearing impairment not improved with aids.