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RAND Review
Baby Steps
Comparison of Neonatal Services Points to National Health Care Lessons
By Michael Hallsworth and Evi Hatziandreu
Michael Hallsworth is an analyst at RAND Europe. Evi Hatziandreu is director of health and health care studies at RAND Europe.
An international comparison of neonatal services in Scotland, Wales, Northern Ireland, England, the United States, Canada, Australia, and Sweden shows a downward trend in mortality rates in all areas over the past decade. The study also points to several lessons that government health agencies can learn from one another.
Three mortality rates are of concern: perinatal mortality (death within 7 days of birth), neonatal mortality (death within 28 days of birth), and infant mortality (death within one year of birth). England, Scotland, Wales, Northern Ireland, Canada, and Australia all have similar perinatal, neonatal, and infant mortality rates. All three rates are consistently higher in the United States and consistently lower in Sweden.
Effective neonatal intensive care increases survival rates among premature newborns and those of low birthweight. Effective care also lowers morbidity rates, improving the long-term health prospects and quality of life for premature or low-birthweight babies while reducing the long-term burden on state health care and social welfare systems.
The rates of premature births and low-birthweight births are much lower in Sweden than in all other countries studied. |
A pervasive problem in Scotland, Wales, and Northern Ireland is a shortage of neonatal staff, including nurses, consultants, and dedicated neonatal transportation teams. Across the United Kingdom, 78 percent of neonatal units had to turn away babies because of insufficient capacity in 2006, up from 70 percent in 2005. There is also some evidence of nursing shortages in the United States and, to a lesser extent, in Canada.
As might be expected from their large geographical areas, the United States, Canada, and Australia have highly regionalized services, provided at the state or substate level. Within these countries, sophisticated neonatal networks have been developed in four regions: California, British Columbia, Victoria, and New South Wales.
The highlighting of these four regional networks does not mean that others are poor. Some networks that serve smaller or more dispersed populations and that contain a limited number of institutions may rely on more informal networking practices, simply because the economies of scale do not justify the cost of formalizing the practices.
Figure 1 —Neonatal Mortality Rates Declined over the Past Decade Throughout the United Kingdom |
SOURCE: The Provision of Neonatal Services, 2008. |
Figure 2 —Neonatal Mortality Rates Were Exceptionally High in the United States and Exceptionally Low in Sweden |
SOURCES: The Provision of Neonatal Services, 2008; “Perinatal Statistics in the Nordic Countries, Statistical Summary 22/2007,” STAKES National Research and Development Centre for Welfare and Health, 2007. |
Figure 3 —Across the United Kingdom, Falling Infant Mortality Rates Generally Followed Neonatal Mortality Rates |
SOURCE: The Provision of Neonatal Services, 2008. |
Figure 4 —Among the Countries Studied, the United States Had the Highest Infant Mortality Rates, and Sweden Had the Lowest |
SOURCE: The Provision of Neonatal Services, 2008. |
Of the countries studied, only Sweden is moving toward a more centralized system of neonatal care. The Swedish health care system is mainly region based, but neonatal intensive care is increasingly centralized, because relatively few Swedish children require it. The rates of premature births and low-birthweight births are both much lower in Sweden than in all other countries studied.
Progress and Patterns
In the past 20 years, significant advances in perinatal and neonatal medicine have resulted in substantial declines in infant mortality rates. A major factor contributing to the reduced mortality and improved long-term outcomes for premature and ill newborns has been the development of neonatal intensive care units.
For newborns, the main health risks are low gestational age and low birthweight. In 1975, almost half the babies born prematurely with very low birthweight in the United Kingdom died within 28 days of birth. By 1995, this ratio had fallen to one in six. By 2005, premature babies of even just 27–28 weeks’ gestation had an 88 percent survival rate. The increased effectiveness parallels an increased demand for neonatal services. Today, 10–12 percent of all babies born in the United Kingdom require some form of special care at birth, and 1–3 percent require the services of neonatal intensive care units.
As shown in Figure 1, neonatal mortality rates declined over the past decade throughout the United Kingdom. From 1995 to 2004, the largest decline came in Northern Ireland, where the rate fell from 5.5 to 3.7 deaths per 1,000 live births. England and Wales saw steadily declining rates. Scotland’s rate fluctuated until 2000 and declined thereafter.
Neonatal mortality rates, which incorporate perinatal mortality rates, generally fell throughout the other countries as well. As shown in Figure 2, the U.S. rates were markedly higher than those of Canada, Australia, and England (shown as a representative British region), while Sweden’s rates were much lower than those in all the other countries. In 2005, Sweden’s rate fell even further, to just 1 death per 1,000 live births.
Infant mortality trends across the United Kingdom were mostly similar to the neonatal mortality trends. One distinction is that Northern Ireland’s infant mortality rate rose during the last two years considered by the study (see Figure 3).
In the other four countries, infant mortality patterns also mirrored those of neonatal mortality. The United States had the highest infant mortality rates, and Sweden had the lowest, with Canada and Australia bunched in the middle (see Figure 4). In fact, this pattern held true across all five categories: premature births, low-weight births, perinatal mortality, neonatal mortality, and infant mortality. In each case, the United States had the highest rates, Sweden had the lowest, and the other countries ranked in between.
The British National Audit Office commissioned RAND Europe to conduct this international comparison of neonatal networks to supplement a study of those in England. Scotland, Wales, and Northern Ireland use different methods of organizing neonatal services than does England, while still operating within Britain’s National Health Service.
The other countries were selected because they share a similar level of economic development, have contrasting health systems, and often adopt a structure whereby different regions coordinate neonatal services within a single country, which is roughly analogous to the situation in the United Kingdom. Sweden serves as an example of how another European country organizes neonatal services within a centralized health system.
Networks and Standards
Scotland, Wales, and Northern Ireland provide state-sponsored health care as part of Britain’s National Health Service, but the executive government of each region manages its own health budget and administration. This arrangement results in different organizational structures and funding streams. None of the regions operates a managed clinical network of neonatal services, although this is a stated aim across the regions. Northern Ireland appears to be closest to reaching the goal; Wales is perhaps the furthest away from it.
Scotland has the only networked neonatal transportation system in the United Kingdom. The network uses standardized training and equipment, ensuring maximum reach and efficiency; employs dedicated transfer teams, whose members are used solely to accompany neonatal transfers and do not form part of any nursing or medical staff; and coordinates transfers centrally, allowing clinicians to focus on medical care, not on time-consuming telephone calls to find appropriate beds and transportation modes. The network offers air transfer and has developed specialized incubators suitable for both rotary- and fixed-wing aircraft.
A neonatal transportation network can thus be the seed of a neonatal treatment network. As in Scotland, transportation services can themselves contribute to creating an informal clinical network and improving the efficiency and effectiveness of care.
The absence of a centralized transportation network with dedicated transportation teams also exacerbates the nursing shortage. Everywhere in the United Kingdom except Scotland, each neonatal transfer currently occupies the clinical staff at the hospital ward of origin for the duration of the transfer, further reducing the number of available ward staff.
In the United States, Canada, and Australia, the main organizing units for neonatal care are the states or provinces. Among the outstanding neonatal networks in these countries, the elements that constitute quality and sophistication include the communications and administrative systems, transportation techniques, centralized decisionmaking and oversight bodies, data-sharing infrastructures, best practice guidelines, reporting mechanisms, use of consultative committees, internal cohesion, family involvement, quality improvement, and evaluation exercises.
The United States has more neonatal intensive care resources per capita than do Canada and Australia, but the United States has lower survival rates for infants of low birthweight. This situation underscores that the organization and distribution of funds, not just the total value of funds, are paramount.
The organization of neonatal care in California is relatively sophisticated. Since 1976, the state has operated perinatal transportation systems and collected their data for analysis and planning. Northern and Southern California both operate perinatal transportation dispatch centers. The state sets detailed specifications for designated levels of neonatal intensive care. There is a sophisticated system for accrediting the level of care provided by neonatal intensive care units, all of which must provide monitoring data. California has also set up two major quality improvement efforts: one to collect information on neonatal outcomes and resource utilization, the other to eliminate blood infections at neonatal care units.
Nevertheless, there is evidence that the organization of perinatal and neonatal services in the United States as a whole has been hampered by competition and professional jealousies. It has been argued that a combination of factors — the desire of physicians and hospitals to compete for families with health insurance, the cost-cutting incentives brought about by managed care, and the widespread availability of advanced technology and highly trained perinatal specialists — has led to a reduction in high-risk births at U.S. regional centers and an increase in community-based neonatal intensive care units that provide neonatologists on site but may lack the outreach and the ability to coordinate services regionally, thereby intensifying the competitive situation. The issue is controversial, but a 2001 survey of state perinatal health policies found substantial variation in the definition of neonatal intensive care levels, while disagreements among physicians and hospitals made it more difficult to enforce uniform definitions. In 2004, the American Academy of Pediatrics declared that “no national definition” of neonatal care levels existed.
Canada’s perinatal, neonatal, and infant mortality rates compare well with those of the United States and Australia. Canadians generally have good access to highly organized perinatal care. Unlike in the United States, universal health care is guaranteed. Standards of health care and health insurance must conform to federal criteria to be eligible for federal reimbursement. Nevertheless, the variations in quality of neonatal intensive care across the Canadian provinces can be as wide as the variations seen in the United States.
The organization and distribution of funds, not just the total value of funds, are paramount. |
British Columbia exhibits superior management of neonatal care systems. In this province, five regional health authorities deliver local health services, including neonatal services, while a province-wide authority oversees a specialized perinatal program. Thanks partly to a centralized system of patient referral and transfer, the province enjoys a very efficient utilization of neonatal intensive care beds, compared with the rest of Canada. Throughout the country, centralized neonatal transportation systems are coordinated either by neonatal intensive care institutions or by provincial services.
Australia has successfully managed its neonatal transportation services despite the vast distances between some rural communities and the nearest perinatal centers. The states of Victoria and New South Wales offer highly organized neonatal transportation systems. Victoria operates custom road ambulances, fixed-wing aircraft, and helicopters, all supported by a centralized information infrastructure that classifies referrals into three categories according to the urgency of response required. New South Wales provides clinical transportation guidelines, modified transportation equipment, and specially built vehicles. There is evidence that the system has contributed to a significant improvement in the outcomes of extremely premature infants in New South Wales.
Victoria also maintains a perinatal information center database, collects standardized performance indicators, and includes quality improvement in its neonatal care guidelines. Meanwhile, the New South Wales neonatal network enhances its internal cohesion by operating a statewide database of available beds and a perinatal advice line.
In Sweden, the implementation of neonatal care varies from region to region but exists within a national framework of universal health care. Sweden has a compulsory, predominantly tax-based health care system that covers the entire population.
On the regional level, Swedish county councils oversee and finance health care services. To facilitate cooperation on specialized care, including neonatal intensive care, the 21 Swedish counties are grouped into six medical care regions. Clinical teams, fully equipped for neonatal care, were introduced in Sweden during the 1960s and gradually spread. Mobile transportation teams are also managed on a regional basis. All ambulance services are organized closely with local health care centers. The four northern counties of Sweden share two fixed-wing aircraft ambulances equipped for intensive care.
In recent decades, neonatal intensive care has become increasingly centralized in Sweden because of the relatively small number of children who require treatment. Indeed, Sweden has one of the lowest infant mortality rates in the world: At 3.1 deaths per 1,000 live births within a full year of birth, the rate is by far the lowest of the countries studied. These facts suggest that a centralized system for neonatal services may be appropriate for some countries because of the size, distribution, and health needs of the population. 
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