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Impact of regionalisation and case-volume on neonatal and perinatal mortality: an umbrella review
Felix Walther1,2, Denise Bianca Küster1, Anja Bieber1,3
1Center for Evidence-based Healthcare, TU Dresden Faculty of Medicine Carl Gustav Carus, Dresden, Germany.
Insights
Regionalized perinatal care improves survival for very low birth weight and preterm infants. Further research is needed to address methodological quality and patient-reported outcomes in perinatal care strategies.
Area of Science:
- Neonatal Medicine
- Public Health
- Health Services Research
Background:
- Very low birth weight (VLBW) and very preterm infants face significant mortality and morbidity risks.
- Optimizing perinatal care strategies is crucial for improving outcomes in these vulnerable populations.
- Regionalization of perinatal care aims to consolidate expertise and resources for better infant outcomes.
Purpose of the Study:
- To critically appraise the evidence on the effects of regulated or high-volume perinatal care on outcomes for VLBW/very preterm infants.
- To evaluate the impact of perinatal regionalization, centralization, and case volume on infant mortality and morbidity.
- To identify gaps in the current evidence base regarding perinatal care strategies.
Main Methods:
- An umbrella review approach was employed, summarizing and critically appraising existing systematic reviews (SRs).
- A systematic search of MEDLINE and Embase was conducted, supplemented by hand searches.
- Included SRs were assessed using the A MeaSurement Tool to Assess systematic Reviews 2 (AMSTAR 2) tool.
Main Results:
- Three SRs, encompassing 40 studies, were included. Centralization was not evaluated.
- Perinatal regionalization showed a significant benefit in reducing neonatal mortality (OR 1.60).
- Evidence suggests perinatal regionalization improves various mortality and non-mortality outcomes, though methodological quality was often moderate to critically low.
Conclusions:
- Regionalized perinatal care appears to be a vital strategy for enhancing the survival of VLBW and preterm infants.
- An updated SR is recommended to address methodological limitations and include patient-reported outcomes.
- Development of an international perinatal database is suggested for evidence-based recommendations on care regionalization.
Objective:
This umbrella review summarises and critically appraises the evidence on the effects of regulated or high-volume perinatal care on outcome among very low birth weight/very preterm infants born in countries with neonatal mortality <5/1000 births.
Intervention/Exposition:
Perinatal regionalisation, centralisation, case-volume.
Primary Outcomes:
Death.
Secondary Outcomes:
Disability, discomfort, disease, dissatisfaction.
Methods:
On 29 November 2019 a systematic search in MEDLINE and Embase was performed and supplemented by hand search. Relevant systematic reviews (SRs) were critically appraised with A MeaSurement Tool to Assess systematic Reviews 2.
Results:
The literature search revealed 508 hits and three SRs were included. Effects of perinatal regionalisation were assessed in three (34 studies) and case-volume in one SR (6 studies). Centralisation has not been evaluated. The included SRs reported effects on 'death' (eg, neonatal), 'disability' (eg, mental status), 'discomfort' (eg, maternal sensitivity) and 'disease' (eg, intraventricular haemorrhages). 'Dissatisfactions' were not reported. The critical appraisal showed a heterogeneous quality ranging from moderate to critically low. A pooled effect estimate was reported once and showed a significant favour of perinatal regionalisation in terms of neonatal mortality (OR 1.60, 95% CI 1.33-1.92). The qualitative evidence synthesis of the two SRs without pooled estimate suggests superiority of perinatal regionalisation in terms of different mortality and non-mortality outcomes. In one SR, contradictory results of lower neonatal mortality rates were reported in hospitals with higher birth volumes.
Conclusions:
Regionalised perinatal care seems to be a crucial care strategy to improve the survival of very low birth weight and preterm births. To overcome the low and critically low methodological quality and to consider additional clinical and patient-reported results that were not addressed by the SRs included, we recommend an updated SR. In the long term, an international, uniformly conceived and defined perinatal database could help to provide evidence-based recommendations on optimal strategies to regionalise perinatal care.
Prospero Registration Number:
CRD42018094835.
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