Neonatal Care



Neonatal Care

Summary

Neonatal intensive care for extremely-low-birth-weight (ELBW, 500-999 g) infants must be evaluated to determine that it is effective, efficient, and available to those who need it. From the late 1970s until the late 1990s in the state of Victoria, Australia, neonatal intensive care has been increasingly effective, with large increases in the long-term survival rate from 25% in 1979-1980 to 73% in 1997, and in the quality-adjusted survival rate from 19% to 59% over the same time. Its efficiency has been relatively high and stable over time, comparing favourably with many other health-care programmes. It is increasingly available, with fewer than 10% of ELBW infants born outside level III perinatal centres in the latest era, and proportionally more ELBW infants being offered intensive care over time. Neonatal intensive care should be re-evaluated at intervals in the future to ensure that its effectiveness, efficiency and availability are maintained.

Introduction

Neonatal intensive care is expensive, especially in developed countries. The cost is measured not only in financial terms, but also by the burden of illness caused by the inability to fund alternative health-care programmes that have to be foregone to finance neonatal intensive care. For those responsible within the health-care system, including those who treat the babies directly, it is obviously vital to evaluate neonatal intensive care thoroughly.

Sinclair et al. in their landmark paper on the evaluation of neonatal intensive care programmes, wrote in 1981 '…the overall effectiveness of these programs has not been tested experimentally', and 'We conclude that neonatal intensive care programs require further evaluation with rigorous scientific methods'. In the 25 years since their comments, the need for evaluation of neonatal intensive care programmes has not diminished but instead has increased, especially since intensive care has been offered to more very tiny or preterm infants, at considerable cost to health-care systems.

Sinclair et al.1 described the four steps required to evaluate neonatal intensive care programmes: efficacy, effectiveness, efficiency and availability. Efficacy asks if a programme works under ideal conditions, in contrast with effectiveness, which investigates whether a programme works under normal or 'field' conditions. Efficiency assesses whether the programme is worth implementing, and availability examines whether the programme is reaching those who need it. Effectiveness, efficiency and availability ideally should all be evaluated within the geographically defined regions that are served by the programmes.

Although there have been reports on individual components necessary for a full evaluation within a geographical region, there is only one group that has evaluated and re-evaluated neonatal intensive care within the same geographical region over several decades. The extremely-low-birth-weight (ELBW, 500-999 g) infants in these studies comprised consecutive ELBW live births born in the state of Victoria during four distinct eras, 1979-1980, 1985-1987, 1991-1992 and 1997. The state of Victoria comprises approximately one-quarter of the population of Australia and has had approximately 60,000 births annually over this time.

Efficacy of neonatal intensive care

Sinclair et al. outlined some components of neonatal intensive care that had proven efficacy up to 1981. Since then there have been major advances in the ...