Perinatal intensive care

Since the end of the 1970s, neonatal intensive care (IC) has developed from a young and highly technical specialism into a broad, multidisciplinary form of treatment — known as perinatology — which frequently begins antenatally and also concerns the long-term consequences. The chances of premature or severely ill neonates surviving have increased markedly since the advent of perinatology and the majority of these children are not left with any severe handicap. However, many children have minor disabilities which have a lifelong impact and adversely affect their chances of leading an independent life. The expectation that the rapid advances in the field of medical technology and the centralization of perinatal care would also lead to a reduction in these impairments has not yet been fulfilled. A key reason for this is the fact that, precisely because of these advances, ever-increasing numbers of neonates are being considered for IC, for whom treatment would previously have been regarded as futile because they were either too premature or too sick.

The increasing percentage of neonates requiring IC is due not only to advances in medical technology, but above all to population changes: women are having children at an increasingly late stage in their lives and the proportion of non-Dutch women is growing. As problems during pregnancy occur rather more frequently in older and in non-Dutch women, the percentage of neonates requiring IC is also increasing. According to the trend witnessed in recent years, this percentage will grow from 1.45% in 1986 to 2.4% in 2005. However, due to the expected decrease in the birth rate, the number of neonates requiring IC will not increase beyond the current annual figure of 4,500 during the coming decade.

In recent years the demand for IC cots has also grown on account of longer IC stays, which, in turn, are a consequence of increased survival rates. If a child does die, this generally occurs shortly after delivery, whereas a child that survives requires prolonged care. For a child born after 25 weeks of gestation, the period spent in IC — assuming no complications arise — is six to seven weeks. Over the past five years, the increased chances of survival for children born at less than 32 weeks of gestation have led to a demand for an extra 27 IC cots. The Committee expects this trend to gradually level off, however, since only a relatively small number of children die. Only if a distinct change occurs in the limit at which a neonate is considered viable will there be a further increase in the demand for IC cots.

Outcome in babies that require neonatal IC is better when this care begins before birth as transportation of ill neonates has adverse effects. Also the expecting mother is often ill or in need of tertiary obsteric care. Tertiary obstetric care concerns care for women who deliver before 32 weeks of gestation and women with severe pregnancy hypertension, severe fetal growth retardation or expecting a baby with congenital malformations. Neonatal IC and tertiary obstetric care in the Netherlands are concentrated in ten perinatal centres.

It is often difficult to decide whether or not it is in the interest of the child to commence or continue treatment, especially when dealing with a new treatment of unproven efficacy or a child at the limit of viability. Every effort must be made to minimize this uncertainty. In order to reach a careful considered opinion on whether or not to institute intensive treatment, it is necessary to investigate both the immediate and the long-term consequences of treatment. The committee considers evaluation of immediate and long-term consequences as a prerequisite for the introduction of new treatments in perinatology. Facilities need to be created in order to continue research that has already started, even if the child has been transferred to another hospital or is back at home. Because many patients are needed in order to reach a careful decision about efficacy, the collaboration of the perinatal centres is required. The requirements for the centres should include participation in a research network and standardized follow-up research. Structural funding of overall data management, analysis and reporting of research data must then be guaranteed. It would be advisable for the professional organizations to include, in their quality control policy, a requirement for a uniform nationwide system with respect to the recording of data concerning the perinatal period and IC treatment as well as the results of follow-up research. Such follow-up research is also necessary in order to evaluate the consequences of the continually extending the limits. Equally indispensable is research into the effectiveness of programmes designed to stimulate young children and of interventions for developmental disorders. Furthermore, it is necessary to clearly define for each centre those situations in which no treatment will be offered. Parents and referring specialists must be in no doubt as to which considerations regarding medical uncertainties and which value judgements play a role in parent counselling and about the role the parents have in the decision-making process.

IC has in recent years become both increasingly effective and increasingly intensive. Invasive blood-pressure measurement, medication designed to support the circulation and improved ventilation techniques have reduced the incidence of damage caused by cerebral haemorrhage and hypoxia. Prevention of stress can avert cerebral haemorrhages and later developmental problems as well as reduce IC stays. This also applies to obstetric care that has become increasingly intensive and complex. However, this has major implications for nursing care: more personnel is needed and greater demands are made on the training level of staff in a neonatal intensive-care unit. The requisite minimum size of a perinatal centre is, to a significant extent, determined by the need to acquire and maintain medical and nursing skills. The introduction of new techniques appears at the outset to be associated with a high risk of complications. This risk diminishes as experience with the particular treatment increases. For this reason, the Committee advocates that the number of perinatal centres should not be further increased and that the minimum size of each centre should be fixed at 14 IC cots.

The personnel, equipment and infrastructural facilities required in a perinatal centre have been described in detail in two earlier Health Council advisory reports. These stipulations still apply in full. The greater intensity of the care that is provided has increased the need for medical and nursing staff, while at the same time a number of societal changes (working times, the regulation of night-duties, etc) have had the opposite effect of reducing staff availability. The present shortage of nurses and the frequently inadequate quality of medical staffing outside office hours threatens the quality of care.

The demand for neonatal IC has almost doubled since the first Planning Decree was issued in 1987, yet the growth in the allocation of cots has failed to keep pace with this demand. At present, several hundred neonates every year have no access to an IC cot and for more than 800 children there is no cot available within their own region. A total of 311 IC cots are needed in order to meet the present demand for neonatal intensive care, whereas only 157 cots have been allocated.

In addition, sufficient high care (HC) cots must be created, for neonates who require intensive nursing care, but whose vital functions are not (or are no longer) threatened. These HC units, which can be located both within the perinatal centres and in the general hospitals, must satisfy quality requirements for care that concerns the prevention of developmental disorders and to the continuation of research that has already started. This requires clear agreements regarding collaboration between these units and the perinatal centres. At present, between 211 and 235 such HC cots are needed. A sufficient number of HC cots would improve the flow of patients from IC to HC, thereby both shortening IC stays and reducing the need for IC cots. An extra number of 14 HC cots is needed to reduce IC stay by one day.

Over the next five years, perinatal units are expected to require 250 cots for tertiary obstetric care.