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2021

ANUÁRIO DO HOSPITAL
DONA ESTEFÂNIA

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REGIONALIZATION AND MORTALITY RATES. THE PORTUGUESE CASE

Maria Teresa Neto

Faculdade de Ciências Médicas, Universidade Nova de Lisboa UCIN, Hospital de Dona Estefânia, Centro Hospitalar de Lisboa Central, EPE, Lisboa;

III Global Congress of Maternal and Infant Health 2013, 16-19/11/2013, Buenos Aires

The definition of regionalization following Scott Lorch is the development of a structured system of care to improve patient outcomes by directing patients to facilities with optimal capabilities for a given type of illness or injury.  In perinatal care means that a newborn should be born in a place with the level of care he/she needs. This authors considers that regionalization is typically driven by economic factors, such as the infeasibility of all hospitals to maintain the equipment and personnel to treat specific medical conditions.
In perinatal medicine the reason has not been economic but aiming to improve outcomes. However, this policy results in a cost-effective provision of care.
25 years ago Portugal started a regionalization of perinatal care mainly because of high mortality rates. It was done with the voluntary efforts of health care professionals-  neonatologists, obstetricians - and representatives  of health minister  with collaboration of the common people – understanding and acceptance/commitment. The results are widely credited, with reduction on maternal, perinatal, neonatal and infant mortality rates. The organization of perinatal care continues to be as described two years ago. However, birth rate continues to decrease and is the main problem nowadays. Preterm birth and low birth weight rates are steady while twins continues to increase (3,1% in 2012). In Portugal the number of neonatal intensive care beds is enough but the number of intensive care units is too high. However, compared with other European countries, Portugal is the country where the distribution of births by maternity unit volume of deliveries is better achieved. In the same way the percentage of very low birth weight infants born at the hospital where they are cared for is very high, over 90%. Because of this, the percentage of VLBW infants transported has been decreasing and the in uterus transfer has been increasing. Portugal is one of the few European countries where the biggest percentage of preterm infants are born in the highest level of care leaving only a small and still decreasing number of postnatal transfers. All mortality rates – foetal, perinatal, neonatal and infant - continue to have the lowest values all over the world positioning the country in the first three to five places in the raw. The limit of viability is somewhere between 24 and 25 weeks gestational age. The rate of prenatal steroids is over 90%. Despite these so very good results there are reasons for concern. Actually the economic crisis brought some bad realities. Beyond the low birth rate, the burden of private hospitals with maternity, and the public hospitals with private management threaten to capture preterm births; the exemplar neonatal transport system  was changed to paediatric transport; young adults are going out; families have very low incomes and unemployment is very high; doctors are going out of public service and or request early retire and, lastly, the new fashion of at home deliveries are some of the topics that have the potential to reverse the good performance of perinatal, neonatal and infant mortality rates in Portugal.
Conclusion: Defining levels of care for newborn infants results in better outcomes. High risk pregnancies should be transferred to a level III Hospital. Preterm VLBW infants and newborn with potential severe disease should be born at a level III centre. The quality of prenatal care is fundamental to improve maternal and infant health. Some threats are cause of concern
Key-words: Mortality rates, regionalization of perinatal care.