Chapter Contents
Organisation of care 53
Current provision of neonatal care in the UK 54
Classification of neonatal care in the UK 55
Staffing 56
Transfers 56
Relationship of organisational factors to outcome 57
Philosophy of care and survival 59
Service evaluation 59
The clinical governance philosophy 59
The clinical audit process 59
Benchmarking 62
Other aspects of clinical governance 62
Standards and perinatal audit tools 64
Standards 64
Definitions – mortality and morbidity 64
Neonatal data recording 66
Guidelines and evidence-based care 68
Conclusions 69
Asphyxia, prematurity, sepsis and malformations remain the major causes of mortality and morbidity identifiable at birth and result in around 4 million deaths each year worldwide. Neonatal intensive care (NIC) has made huge inroads into reducing the mortality and to some extent the morbidity associated with the first three causes, which has resulted in improving survival at increasingly low gestations. Such care, however, is increasingly under pressure as the result of budgetary and skill base constraints.
Within many health systems it is not feasible to provide such expertise and facilities in every setting in which babies are born. Most health services in the developed world have developed increasingly specialised models of neonatal services, concentrating skills and facilities for providing intensive care, ensuring high levels of basic skills close to every birth and dedicated transport facilities to ensure babies receive optimal care in the correct setting to maintain improving outcomes. Such a system is high cost and low throughput compared with many health services, including maternity care.
Concentration is not without problems and increasingly centralised care means much larger delivery units with inherent problems for the obstetric and midwifery teams and pregnant women, and is in conflict with the desire of many groups to provide birth in more ‘natural’ settings for women at low risk of neonatal complications. These tensions lead to much controversy, which is fuelled by the lack of reliable data with which to evaluate safety in various settings.
In this chapter, therefore, organisation of care will be discussed alongside systems for ensuring that care is safe and effective in different settings and monitored at service, unit and patient level.
Organisation of care
NIC services have developed differently in different health systems, to some extent dependent upon the proximity of the children’s and maternity services. In some health systems NIC is located within a children’s hospital, which has advantage for paediatric specialist care but places the postpartum mother at a disadvantage and all children have to be transferred in for specialist care. In other systems NIC has developed alongside maternity services, often in isolation from supporting paediatric services. The degree of centralisation of services has also been driven by external factors, either by market forces in privately funded systems or by population distribution. Many health systems mix these structures according to local geography. The relationship between organisational structures and outcome is highly contentious and not easily amenable to study (see below).
Pressures of health economics have driven most services to concentrate intensive care services in fewer expert centres and to review the structure and function of other neonatal services (which care for the majority of babies) in terms of their effectiveness at providing a highly expert resuscitation service or limited intensive care. One example of this is the development of highly centralised NIC in Western Australia, with a land mass 20 times the size of England and a population of 2.2 million compared with 60 million, respectively. There are relatively few large population centres; the whole state is served by two intensive care centres (one in a children’s hospital) and a highly developed antenatal and neonatal retrieval service. This contrasts with the 178 neonatal units currently providing intensive care for extremely preterm babies in the UK ( ). Many European countries have developed NIC within children’s hospitals, and thus all babies needing care are transferred in, often from very much smaller and less expert clinics. Slowly this model is being replaced by a centralised system where expertise can be concentrated in fewer and better-resourced maternity/neonatal centres.
Several classifications or categorisations of neonatal units have been used. Most use the concept that a three-tier service is most efficient: the least intensive category of unit provides only short-term stabilisation prior to transfer, the most intensive carries out a full range of intensive care activity, and the intermediate tier provides varying degrees of postnatal support depending on local resources. Evidence is evolving that care in the highest tier centres produces higher survival and less morbidity; the difficulty is how to ensure babies are delivered in an appropriate setting. Current UK definitions are shown in Table 2.1 .
| LEVEL | DESCRIPTION |
|---|---|
| Level 1 | Special care units (SCUs) provide special care for their own local population. Depending on arrangements within their neonatal network, they may also provide some high-dependency services. In addition, SCUs provide a stabilisation facility for babies who need to be transferred to a neonatal intensive care unit (NICU) for intensive or high-dependency care, and they also receive transfers from other network units for continuing special care |
| Level 2 | Local neonatal units (LNUs) provide neonatal care for their own catchment population, except for the sickest babies. They provide all categories of neonatal care, but they transfer babies who require complex or longer term intensive care to a NICU, as they are not staffed to provide longer term intensive care. The majority of babies over 27 weeks of gestation will usually receive their full care, including short periods of intensive care, within their LNU. Some networks have agreed variations on this policy, owing to local requirements. Some LNUs provide high-dependency care and short periods of intensive care for their network population. LNUs may receive transfers from other neonatal services in the network, if these fall within their agreed work pattern |
| Level 3 | Neonatal intensive care units (NICUs) are sited alongside specialist obstetric and fetomaternal medicine services, and provide the whole range of medical neonatal care for their local population, along with additional care for babies and their families referred from the neonatal network. Many NICUs in England are co-located with neonatal surgery services and other specialised services. Medical staff in a NICU should have no clinical responsibilities outside the neonatal and maternity service |
Such organisation can only function if units work together as a de facto clinical network and if the health commissioners work to ensure that each network has the capacity and resources to provide for the predicted demand. Parents of babies also need to understand the concept, and the fact that their baby will be moved, should intensive care become necessary, which is against current trends for care to be delivered in the hospital or setting of choice. Such a working pattern has major potential advantages in terms of high-throughput neonatal intensive care units (NICUs) for the maintenance of clinical skills, high occupancy for intensive care cots permitting efficient use of resources and ability to staff the high-intensity areas.
Within the UK, intensive care resources for adults and for children have been incorporated into managed clinical networks. Services are planned based on a geographic population with different ranges of facilities at each centre. The key issue in the success of these services is the central management of resources across several otherwise independent health service units (trusts). The argument for centralisation of paediatric intensive care has been well made ( ) and improved early care, triage and outcome can be anticipated through the underpinning of the network with a strong educational and training base. Despite these structures it remains important in any health system that children access the appropriate level of care ( ).
Overall the demand for NIC has risen ( Ch. 1 ). In parallel, the UK has seen increasing public demand for transparency in the delivery of healthcare, in the wake of several high-profile government reports, and there is a drive to ensure that care is provided by professionals whose expertise is appropriate to the clinical situation. Recent changes in law are leading a reduction in the traditionally overlong working hours for doctors and there is currently a paucity of nursing and specialist doctors to provide specialist neonatal care, fuelling calls for further centralisation.
Current provision of neonatal care in the UK
Women and their families expect that pregnancy, delivery and postnatal care will be delivered in one local centre as close as possible to the family home, and this perception is encouraged by healthcare managers within the National Health Service (NHS) hierarchy. Problems arise when difficulties with either the woman or the fetus develop that cannot be managed by local services. At present further management is dictated by the availability of obstetric and neonatal resources at the referral centre. Central to the planning of care is the need to forewarn parents of the likely arrangements if problems develop, so that families are not suddenly faced with the prospect of their care being transferred to another centre, often at some distance, without warning.
In the late 1990s, 246 units provided neonatal care across the UK, 76% of which provided intensive care. This dispersed model had developed as a result of market forces, there being few attempts to centralise care at the time. Since then several national initiatives have effectively centralised care for the extremely preterm baby, using the establishment of managed clinical networks for neonatal care to bring a measure of coordination of care and resources ( ). Currently, neonatal care in England is organised as 22 networks, each centred on one or more lead perinatal centres (usually a university hospital) based on 15 000–25 000 births per annum. The structure of a model neonatal network is shown in Figure 2.1 . Management of the network is organised independently of any of the contributing hospitals, in order that resources can be managed effectively and independently of local ambitions. In all networks, care for babies at 26 weeks of gestation or less is centralised, regardless of delivery site, and all have developed a measure of common guidelines and practice.
More recently the NHS has published its framework for NIC ( www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_107845 ). This comprehensive document identifies important regional organisation to support NIC and includes a set of quality standards against which neonatal practice can be audited.
With the introduction of the managed clinical network it should be possible to map out a plan for most eventualities, so that a pregnant woman understands the management plan for the anticipated normal pregnancy, what is to happen if a fetal anomaly is discovered, what will happen if very preterm delivery seems likely and what care arrangements are to be made if there is an unanticipated need for NIC. Despite the often-quoted maxim that pregnant women do not wish to travel for their care, all the evidence points to the woman willingly allowing transfer of care if it is clearly in her baby’s best interests.
Classification of neonatal care in the UK
One difficulty in determining the size of the workforce needed to staff a neonatal service is the range of activity and case mix of different services. It is thus helpful to define a range of categories of care which may allow the planning of resources.
Within any type of neonatal unit, care for an individual baby can be classified by the level of clinical dependency, which should provide a measure of the resources needed to look after that baby. The definitions of these categories of care will differ between health systems. Within the UK there are several contenders, some of which have been developed using formal studies ( ), whereas the nationally recommended categories ( ; ) have been developed by professional consensus; we presently recommend that inpatient neonatal care is divided into three categories ( Box 2.1 ).
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Special care (SC) is that provided for all other babies who could not reasonably be looked after at home by their mother. Babies receiving special care may need to have their breathing and heart rate monitored, be fed through a tube, supplied with extra oxygen or treated for jaundice; this category also includes babies who are recovering from more specialist treatment before they can be discharged. Special care which occurs alongside the mother is often called ‘transitional care‘ but takes place outside a neonatal unit, in a ward setting
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High-dependency care (HDC) takes place in a neonatal unit and involves care for babies who need continuous monitoring, for example those who weigh less than 1000 g (2 lb 3 oz), or are receiving help with their breathing via continuous positive airway pressure or intravenous feeding, but who do not fulfil any of the requirements for intensive care
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Intensive care (IC) is care provided for babies with the most complex problems who require constant supervision and monitoring and, usually, mechanical ventilation. Because of the possibility of acute deterioration, a doctor must always be available. Extremely immature infants all require intensive care and monitoring over the first weeks, but the range of intensive care work extends throughout the whole gestation period
These categories of care are of value in establishing what level of nurse staffing is necessary to provide cot-side care. Generally, minimum levels specify one nurse to one cot for intensive care, one nurse to two cots for high-dependency cots and one nurse to four cots for special-care cots, although achieving one-to-one nursing is a challenge in the current economic climate with the available workforce skills, and remains aspirational. These minimal requirements do not include managerial and other specialist roles (advanced practice, family care, practice development), which have evolved within the nursing sphere, but require extra resources.
These levels of neonatal care are more tightly defined nationally via the national Neonatal Critical Care Minimum Dataset ( http://www.isb.nhs.uk/documents/dscn/dscn2006/142006.pdf ) to ensure that there is consistency in definition across the country. The number of intensive care days needed for a particular population will vary depending primarily on the number of low-gestational-age babies cared for, as they utilise the majority of resources. This in turn is dependent upon the social and environmental mix of the population: within the regions of the south-east of the UK, which includes inner city and rural districts, the cot requirement in each region varied between 1.0 and 1.9 intensive care cots per 1000 births, estimated at the recommended 70% occupancy, using older definitions.
To these categories of care, which are dependency based, many hospitals have an intermediate category between the neonatal unit and routine postnatal ward, so-called transitional care. This is primarily aimed at nursing babies who still need ‘special care’ (for example, gavage feeding) but can be managed in an area alongside their mother and supporting the mother while she provides the majority of care ( Ch. 21 ). In different hospitals this is developed and organised differently and there are no formal definitions to facilitate comparisons. Transitional care has an important effect on neonatal unit activity in that some special care activity is transferred out to a ward staffed primarily by midwives and thus is not always counted in terms of service activity. This may free up staff to assist with the more intensive activity in the neonatal unit, changing the skill mix requirements. In addition, it becomes a local responsibility to determine staffing levels for transitional care and to ensure that adequate support for mothers is available. Despite these difficulties it is a cost-effective and desirable care strategy, encouraging maternal–infant interaction more effectively than remote management on a NICU.
Staffing
Having defined the types of neonatal services and categories of care, the staffing requirements for a neonatal service can be established.
Medical staffing is dependent upon the degree of cross-covering required to run the service and this is in turn dependent on the intensity of care that can effectively be offered:
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For special care units, it is envisaged that no intensive care will take place. Staff will be available in the hospital to attend infrequent emergencies and this cover will be provided as part of an acute paediatric service.
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For local neonatal units, continuous bedside medical support is required, either by a trainee (senior house office (SHO) or resident) or by an advanced neonatal nurse practitioner (ANNP), while middle and consultant tier cover is provided as part of the adjacent acute paediatric service.
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For NIC services, dedicated specialist staff are required with two resident tiers (SHO/ANNP and registrar/consultant), with a supervising consultant available to provide continuity.
In 1996, 25% of units providing intensive care did not have a consultant with more than 50% time dedicated to neonatal care ( ). This appears to have somewhat improved by networking. This is clearly unsatisfactory given the huge strides in neonatal care over the past 30 years. As workforce directives reduce the working hours available for all staff, the grade and competency of staff providing first-call care must be examined carefully if we are to continue to provide high-quality care. In some units this is now contributed to by advanced nurse practitioners, who form an intermediate tier of carers outside the clinical practice nursing teams, because of their expertise and wider responsibilities.
Nurse staffing relates to dependency levels and generally is calculated from an estimated establishment for a particular cot number and configuration. Daily monitoring will confirm the adequacy of this. Nurse staffing is the largest part of the unit budget and thus most vulnerable: in 1996, 79% of units had a ratio of nursing provision to that recommended of less than 1.0 (median 0.84; interquartile range 0.73–0.98), indicating significant underestablishment for the activity that was being carried out, despite taking conservative staffing levels as the norm (1 : 2 intensive care and 1 : 4 for all others) ( ). This wide variation in the adequacy of local resources to carry out neonatal care is reflected in the findings of other studies ( ) and has provided the impetus for the current changes in service structure (see below). In a repeat census taken as part of the EPICure 2 study, 73% of units now met this conservative criterion, indicating improved nurse staffing over the 22% found in 1996.
In addition to medical and nursing staff, a range of other supporting skills is required, including allied health professionals (physiotherapy, occupational therapy, speech and language therapy) and other support staff ( ). As care for the newborn infant demands different skills from those required for nursing sick older children or adults, specific competencies have been defined for these groups ( ; ).
Transfers
Any configuration of neonatal services within a region is dependent upon the availability of both cots and effective patient transport. Transfer of the pregnant woman or her infant is commonplace but within the current service the destination of any transfer cannot be determined with any certainty, as beds are often unavailable at the natural referral centre. Part of the drive to reconfigure services is to remove this lottery.
The relative merits of in utero and postnatal transfer for care require careful consideration. Studies comparing the results of each all have an inherent bias, as the need for intensive care or ventilation cannot be predicted before birth and postnatal transfer will generally be for ongoing ventilator care, although some babies may die before transfer can be effected. Thus a true study on unselected populations is almost impossible to achieve. Nonetheless, within well-centralised systems, with often independent transport services such as in the USA ( ) and Australia ( ), a more consistent service can be achieved. Even within the UK there is evidence that babies are not placed at significant risk during a well-planned transfer ( ). There are however data that suggest that mortality is increased when transfer is requested but unavailable ( ) and babies moved between tertiary centres unable to cope with peaks of demand have poorer outcomes ( ). The key to effective transfer is the establishment of adequate capacity within a clinical network, to allow planned flows of referrals that can be discussed in early pregnancy with all pregnant women.
One study has evaluated the pattern of ‘inappropriate transfers’ as a measure of the adequacy of capacity in tertiary units ( ). Inappropriate transfers were defined as those out of a perinatal centre. Over 3 months in 1999, 264 in utero transfers and 45 postnatal transfers were recorded in 37 such units. Rates of transfer in each region varied from 0.20 to 5.44 per 1000 live births. The risks and outcomes of these transfers were studied in 242 cases ( ). Of in utero transfers, only 61% delivered at the accepting hospital, 12% were moved to a third hospital following delayed delivery and 29% were returned to deliver at their referring hospital. One mother delivered during the journey and nine delivered within 1 hour of arrival. Transfer of mothers and their babies should be a planned process with defined levels of referral and, as far as possible, guaranteed capacity at the natural referral centres.
In utero transfers
It is important to distinguish the urgency with which mothers are referred for specialist care, usually because of impending prematurity, from more elective transfers for expert assessment of fetal malformation or growth restriction. There must be close liaison between both obstetric and the receiving neonatal team before any decision to move a woman is undertaken. The presence of vaginal bleeding, pre-eclampsia or labour and the obstetric history of the woman must be carefully weighed against the need for transfer. Where urgent transfer can be effected safely this must be the best mode of transfer, as both mother and baby will be cared for in the same centre, separation avoided and the baby will be exposed to minimised postnatal risk. However there is a chance of delivery during the journey and a risk of other unforeseen problems, and not infrequently women are moved before birth because of a risk of early delivery and do not deliver. Many services attempt to stratify risk by the use of fetal fibronectin ( ) or Actim Partus ( ) screening, as adjuncts to the diagnosis of preterm labour, in an attempt to avoid unnecessary transfer.
Postnatal transfers
In most areas of the UK, postnatal transfer services initially developed on an ad hoc basis. There are now formalised transport teams in most networks and competencies for staff have been identified ( Ch. 13.2 ). Quality standards for neonatal transfers have been published ( ). In the past, such transfers were deemed ‘flying squads’, where a rapid emergency response team travelled rapidly to support the local team in early-care scenarios. With improvements in care and expertise at local hospitals it should be possible to effect elective transfers at a time that is clinically appropriate for the baby, although robust arrangements need to be put in place for dealing with emergencies arising in units without on-site specialist neonatal staff. No network transport service in the UK currently provides support to standalone midwifery-led units or to home births, where midwives are reliant on calling for help via the standard emergency ambulance service using 999. A centralised service has been shown to be effective in reducing waiting times and quality markers ( ).
Relationship of organisational factors to outcome
Given the stress placed above on the structure to support neonatal care, one would anticipate that care organised according to such principles clearly leads to better outcomes. Within the UK system this is far from clear. Several attempts to investigate this relationship have been undertaken. The relationship between organisational issues and mortality is the easiest to undertake but, given the decrease in mortality over the past 10 years, death is a relatively rare event and thus small differences in mortality are more difficult to demonstrate. Furthermore large tertiary units treat a different range of babies from those managed in local services and tend to be overcrowded, with high occupancy rates, and are more likely to be understaffed. Smaller units may also transfer out sick babies soon after birth and the mortality will be attributed to the receiving unit. The complexity of these issues makes it extremely difficult to draw conclusions from comparisons.
Studies of regional outcomes for mixed hospital groups have shown inconsistent effects. In the late 1980s mortality was higher for babies cared for in smaller units in the Trent region of the UK than for babies cared for in larger units. This longitudinal study was reanalysed in the early 1990s following an NHS reorganisation and then demonstrated no difference in mortality by size of unit ( ). This was ascribed to enhancements in neonatal provision at local hospitals, but clearly the relationship is more complex than that.
Scoring systems for neonatal illness provide one way of correcting for case mix, making adjustment for the illness severity measure when comparing outcomes. The use of such measures is established in paediatric and adult critical care services. In neonatal care the two most frequently used scoring systems are SNAP ( ) (plus SNAP-II and SNAPPE-II; ) and CRIB (The ; ), although there are others. Care should be taken when using these measures, as they do not attempt to predict outcome for an individual but are scoring systems describing the clinical condition so that some adjustment between outcomes in a population can be made ( ; ). These scores require regular review and updating as techniques and interventions change. For example, a tertiary unit that uses delivery-room surfactant or early high-frequency oscillatory ventilation may appear to have low severity of illness scores (based on oxygenation) but similar mortality to other units because the gestational age of the babies cared for is lower. Hence the score itself may partly reflect the care given as much as the underlying characteristics of the baby, i.e. the score may itself be an outcome variable for perinatal care ( ).
CRIB originally included data from worst base deficit and highest and lowest inspired oxygen concentrations over the first 12 hours, making it particularly sensitive to changes in early interventions. In contrast, CRIB-II uses temperature on admission and maximal base deficit over the first hour as the clinical variables, which, together with sex, gestational age and birthweight, provide the basis for the score ( Fig. 2.2 ). Using this recently validated model with a high degree of predictive value for mortality (area under the receiver operating characteristic curve: 0.92) in an analysis of the data collected as part of the UK Neonatal Staffing Study, CRIB-II-adjusted mortality did not differ between large and small units in the UK (odds ratio (OR) 1.06; 95% confidence interval (CI) 0.70–1.60) ( ).
Nonetheless, corrections for disease severity can provide useful information concerning the relative performance of neonatal services to facilitate the identification of areas for investigation and throw up intriguing questions when applied to cross-national ( ; ) or national comparisons ( ). For example, risk-adjusted mortality appears to be significantly higher in Scotland than in England or Australia ( ). The question is raised as to whether this relates to organisation of care, being highly centralised in Australia and devolved in the UK. Caution is required when interpreting these studies as the ethnic, social and demographic profiles of any population may account for more of the variance in outcomes than the perinatal services and the obvious difference, i.e. organisation, may be confounded by population differences. This is emphasised by a further comparison of outcome for babies born at <28 weeks of gestation or <1000 g birthweight between the Trent region of the UK and Denmark ( ). Births in this group were more prevalent in Trent and, despite a higher use of antenatal steroid, babies had higher CRIB scores, received more mechanical ventilation and were more likely to die than those in the Danish population.
The UK Neonatal Staffing Study randomly selected 54 of 186 units in the UK to study the relationship between throughput, consultant and nurse staffing and outcome as mortality, cerebral damage as detected by ultrasound and nosocomial infection ( ). Data from 13 334 babies were used. High-volume NICUs, treating the sickest babies, had the highest crude mortality but this difference disappeared when risk adjustment was made. However there were important findings relating the risk of dying to the staffing levels on the shift during which a baby was admitted. Babies admitted to a unit working at full capacity were 50% more likely to die than babies admitted to a unit working at 50% capacity ( Fig. 2.3 ). The British Association of Perinatal Medicine (BAPM) has commented that this may be attributable to a number of factors, including inadequate staffing and change of case mix as workload increases. It is crucial that staffing levels and expertise are appropriate to the dependency of the babies.
In a further epidemiological study from the USA, there appeared to be an optimal relationship between neonatologist staffing and mortality ( ). The numbers of neonatologists and numbers of cots (expressed in quintiles from the distribution) were related to national statistics of neonatal deaths (in the first 28 days). On average there were 6.2 neonatologists, 33.7 intensive care cots and 17.7 high-dependency cots per 10 000 births. There was lower neonatal mortality where there were 4.8 neonatologists per 10 000 births than with 2.7/10 000 births (OR for death 0.93; 95% CI: 0.88–0.99) but increasing the number above this level did not result in further improvements. Furthermore the availability of neonatal cots was not related to mortality risk and the need for cots (as expressed by the number of babies with birthweight <1501 g) did not relate to cot availability. This must be placed in contrast to the calculated requirement of 10–19 intensive care cots per 10 000 UK births (see above).
In the current EPICure 2 study of births at 26 completed weeks of gestation or less in England during 2006, a time when the network model had become reasonably well established, it was apparent that survival for livebirths in this gestational group was higher overall in NICU services (59%) than in local neonatal units (51%) before (OR 1.51; 95% CI 1.16–1.98) and after adjustment for gestational age and birthweight (OR 1.60; 95% CI (1.17–2.19)). This advantage held when only those babies admitted were included, and this trend was also obvious among smaller and larger NICU services (OR survival livebirths 1.43; 95% CI 1.01–2.01), mainly because of higher survival at 23 and 24 weeks, respectively (EPICure 2 study group unpublished data).
The relationship between organisational factors and simple outcome measures is therefore far from clear but sides on larger services with higher staffing ratios have better outcomes in terms of survival. In the UK it is incumbent on each managed clinical network to ascertain and monitor the availability of cots and staff, and access for its residents to the service when required, and to benchmark these services against other national data.
Philosophy of care and survival
Mortality at low gestations has improved over the past 20 years such that the great majority of babies born at 26 weeks of gestation or more now survive. Attitudes to the resuscitation and continuing care of babies born at lower gestational ages will thus have a profound effect on the rates of survival and thus confound comparisons of different services. These attitudes vary widely across the world. For example, at a time when care was unusual at 24 weeks in the Netherlands, in the UK we were demonstrating about 35% survival at 23–24 weeks and both national studies from Sweden (EXPRESS) ( ; ) and Australia and New Zealand ( ) report 50% survival for babies admitted for neonatal care ( Fig. 2.4 ). However, the rates of serious neonatal and later morbidity remain very high in these survivors and cannot be ignored ( ) and wide variation in the approach to discontinuing care may distort survival further given that so many babies have elective discontinuation of care ( ).
The extent of the differences brought about by extremes of practice was explored by , who demonstrated marked differences in survival and prevalence of cerebral palsy in two studies with widely differing approaches to outcome ( Ch. 3 ). Indeed, in the UK, regional centres with a proactive approach to the care of extremely low-gestational-age babies report survival at similar levels for babies born at 23 and 24 weeks to the highly centralised Swedish national data ( ). Without a detailed study of the approach to care at these extremely low gestations the reasons for these differences cannot be explored and it would be incorrect to attribute them to quality of care.
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