Perinatal Regionalization

The Maternal and Child Health Bureau (MCHB) Title V Maternal and Child Health Services Block Grants to States Program has established 15 National Performance Measures for the 2015-2017 grant cycle. Performance Measure 3 is the percent of very low birth weight (VLBW) infants born in the hospital with a Level III+ Neonatal Intensive Care Unit (NICU). This evidence brief points to a selection of resources for state MCH programs on risk-appropriate care for VLBW infants, with an emphasis on evidence based information.

Significance

The Title V Maternal and Child Health Services Block Grant to States Program guidance¹ defines the significance of this goal as follows:
Very low birth weight infants (‹1,500 grams or 3.25 pounds) are the most fragile newborns. Although they represented less than 2% of all births in 2010, VLBW infants accounted for 53% of all infant deaths, with a risk of death over 100 times higher than that of normal birth weight infants (>=2,500 grams or 5.5 pounds). VLBW infants are significantly more likely to survive and thrive when born in a facility with a level-III Neonatal Intensive Care Unit (NICU), a subspecialty facility equipped to handle high-risk neonates. In 2012, the AAP provided updated guidelines on the definitions of neonatal levels of care to include Level I (basic care), Level II (specialty care), and Levels III and IV (subspecialty intensive care) based on the availability of 62 appropriate personnel, physical space, equipment, and organization. Given overwhelming evidence of improved outcomes, the AAP recommends that VLBW and/or very preterm infants (‹32 weeks' gestation) be born in only level III or IV facilities. This measure is endorsed by the National Quality Forum (#0477).

Data and Statistics

Centers for Disease Control and Prevention. 2010. Neonatal Intensive Care Unit admission of infants with very low birthweight - 19 states, 2006 Morbidity and Mortality Weekly Report (MMWR) 59(44):1444-1447. Provides a lay of the landscape, editorial discussion, and data on very low birth weight and NICU admission in 19 reporting states.
Healthy People 2020: Maternal, Infant, and Child Health. One objective addresses very low birth weight infants born at Level III hospitals:
Objective MICH-33: Increase the proportion of very low birth weight (VLBW) infants born at Level III hospitals or subspecialty perinatal centers.
Health Resources and Services Administration, Maternal and Child Health Bureau: Title V Information System (TVIS). State data is searchable by national performance and outcome measures. (NPM 3 is related to NPM 17, percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates.)
American Academy of Pediatrics, Section on Perinatal Pediatrics. 2012. United States neonatal-perinatal training program centers: ONTPD directory. The most recent directory is available to AAP members. Elk Grove Village, IL: American Academy of Pediatrics. Data on levels of care provided at neonatal intensive care units.

Key Websites

American Academy of Pediatrics, Section of Perinatal Pediatrics. Guidelines, resource spotlights, current articles of interest, family and professional education, and a directory of U.S. neonatal intensive care units.
American College of Obstetricians and Gynecologists (ACOG). Patient education and professional resources, including guidelines for perinatal care that address maternal transport and definitions of levels of neonatal care.
Centers for Disease Control and Prevention.

Division of Reproductive Health. Links to reproductive health topics and programs to improve birth outcomes.

Perinatal Quality Collaboratives (PQC). Success stories, webinars, and state PQC initiatives to improve perinatal outcomes by improving the quality of perinatal care in PQC network states.

Policy Recommendations

Johnson K. From Evidence to Improved Policy and Program Practices: Perinatal Regionalization. 2014. National Center for Education in Maternal and Child Health. Georgetown University: Washington, DC.
American Academy of Pediatrics, Committee on Fetus and Newborn. 2012 revised. Levels of neonatal care: Policy statement. Pediatrics 113(3):587-97.
Association of State and Territorial Health Officials. 2012. Improving birth outcomes position statement. Arlington, VA: Association of State and Territorial Health Officials.

Interventions

Association of Maternal and Child Health Programs (AMCHP). AAP guidelines: Levels of neonatal care. (2012). This AMCHP webinar examines the data and presents perinatal regionalization strategies.

Forging a comprehensive initiative to improve birth outcomes and reduce infant mortality: Policy and program options for state planning (Compendium). (2012). Includes examples of state programs that improve patient access to risk-appropriate care
Collaborative Improvement and Innovation Network to Reduce Infant Mortality(COIIN). Priorities to reduce infant mortality include improving perinatal regionalization -- a geographically-targeted approach to assure risk-appropriate care for mothers and infants. Audio recordings of meeting sessions that address successes and opportunities and examples from the field are available.
Freeman, VA. 2010. Very low birth weight babies delivered at facilities for high-risk neonates: A review of Title V National Performance Measure 17. Rockville, MD: Health Resources and Services Administration, Maternal and Child Health Bureau. Study of current NPM 17 (the percent of very low birth weight infants delivered at facilities for high-risk deliveries and neonates), which is related to NPM 3. Provides information on what states are doing to improve their performance on this measure.