Original Title: Resultados de la asistencia neonatal de los muy prematuros en la red sanitaria del País Vasco

Authors' objectives: • Study the determining and protective factors relating to prematurity, as well as the variability in the clinical practice performed in perinatal and neonatal units in the Autonomous Community, with regard to the results of care of f Very Low Birthweight Babies (VLBW) babies. • Examine the factors that determine good results in the short and medium term from the care of very immature newborn children. • Analyse the factors that lead to premature births. • Establish the incidence of VLBWBs and children born after less than 32 weeks of pregnancy in our environment. • Describe the varying modes of clinical presentation of the premature birth and its relationship with the burden of disease in the different hospital centres that attend to births in the Autonomous Community of the Basque Country (ACBC). • Study the variability of care results in VLBW babies treated in hospitals of the Basque Health Service, Osakidetza, in accordance with perinatal risk factors and neonatal interventions. • Compare the quality of perinatal care given to VLBWBs in the Basque health service with that provided in Spanish units as a whole and those of other European countries. • Assess the results of monitoring the neurosensory development of VLBW babies at 2 years of age.

Authors' results and conclusions: Premature birth occurs for a variety of different reasons. The summary of the scientific evidence concerning the causes of prematurity included in this document indicates that some of the most common causes are as follows: multiple pregnancies, infections, anomalies of the placenta, vaginal bleeding, the consumption of substances and chronic illnesses. However, the causal association of premature birth with some of these characteristics may be the result of confounding factors and consequently in most cases it is not possible to establish a precise mechanism. A review carried out of a number of premature birth prevention programmes indicates a significant gap in the knowledge of interventions intended to delay birth and lower the incidence of prematurity. Studies carried out of programmes designed to encourage patients to stop smoking, the use of progestational agents and the cervical cerclage suggested a number of benefits in the prevention of premature births with a moderate-high quality of evidence. The remaining interventions did not provide any solid evidence. The analysis of the situation with regard to the perinatal characteristics of VLBWBs showed that 99 % of pregnant women received prenatal care and 89 % were given prenatal steroids. In both cases, there was a significant increase during the period studied. Forty-three percent of pregnancies were multiple and 62 % of cases involved Caesarean births. Bronchopulmonary dysplasia (DPB) showed a statistically significant decrease from 15.5 % to 11 %. The incidence of level 3 or 4 intraventricular haemorrhages was 7.8 % and the incidence of periventricular leukomalacia was 3.1 %. Vertical infection was diagnosed in 4 % of children and sepsis or late meningitis in 25 %, Necrotizing Enterocolitis in 3.9 % and persistence of ductus arteriosus in 15.5 % of children. Treatment with indometacin or ibuprofen fell significantly during the study. The gross rate of total late and early neonatal mortality remained constant during this period. Immediate neonatal mortality showed a downward trend and a significant difference according to sex, this being greater in boys. The comparative analysis of our data showed significant differences between different Neonatal Intensive Care Units. An analysis of the monitoring data shows that after two years, the dropout rate was 7 %. Infant Cerebral Palsy was diagnosed in 5.3 % of cases, 6.5 % exhibited language disorders of varying levels of severity and hearing deficit was detected in five patients (0.8 %). At four years of age, visual acuity deficit was observed in 4 % of patients who had been given ophthalmological checkups (40 %), ametropia was detected in 44 % and strabismus in 12 %. According to the Bayley scale, the average score obtained by 88 % of the children in the population we assessed places them in the normal category, compared to 8 % with a mental development index or psychomotor development index of between 70 and 84 or 0.8 % of children with a value of less than 70. CONCLUSIONS • A better understanding of the causes and mechanisms that lead to premature birth will improve the development of efficient preventive strategies. • More research is required into the potential markers for the detection of the population of pregnancies with a higher risk of premature birth. • There is a significant lack of studies that show efficient interventions designed to delay birth and to reduce the incidence of prematurity. • In the last 10 years, studies of preventive and therapeutic interventions in symptomatic women that suggest some benefit are of a moderate-high quality. These studies relate to programmes to encourage patients to stop smoking, the use of progestational agents and the cervical cerclage or pessary. • Our population base data provides us with very valuable information on the morbidity and mortality of VLBWBs admitted to hospital centres, especially to examine differences in daily clinical practice between the different neonatal units. • Prenatal care reaches virtually all pregnant women. • The morbidity-mortality rates of very low birthweight babies cared for in the centres of the Basque Country and Navarre improved during the study period and DBP dropped significantly. • Although the targets proposed by the Basque-Navarre Neonatal Studies Group some years ago to collect data on VLBWBs with common definitions (these give us an idea of the real situation of this population group) have been met, the following step is to propose interventions that bring about a drop in morbility and mortality in the newborn such as the prevention of nosocomial sepsis and to implement measures to improve the quality of care in our region or in others. • It is necessary to encourage, extend and improve the monitoring of newborn children at risk in order to identify the restrictive and incapacitating conditions that range from health problems to the specific problems of learning and behavioural disorders.

Authors' methods: The following tasks have been performed: • Review of the literature in order to determine, on the one hand, the causes of prematurity and, on the other, to assess the effectiveness of the different premature births prevention programmes. • A descriptive, observational study was carried out of a cohort of 1917 VLBWBs who received care between 2001 and 2008 in five hospitals in the Basque Country and Navarre. A total of 37 variables were collected. These refer to perinatal risk and protective factors, demographic characteristics, days in hospital, interventions, morbidity and mortality rates. • A retrospective, descriptive study was carried out of a cohort of 719 newborn babies with a birthweight of less than 1,500 g. These babies were admitted to the Neonatal Unit of the University Hospital of Cruces between January 1994 and December 2005 and were controlled in outpatient clinics until 2 or 4 years of life.

Project Status: Completed

Year Published: 2013

URL for published report: https://www.euskadi.eus/contenidos/informacion/2013_osteba_publicacion/es_def/adjuntos/Informe%20D-13-11%20Asistencia%20neonatal.pdf

English language abstract: An English language summary is available

Publication Type: Other

Country: Spain

Organisation Name: Basque Office for Health Technology Assessment

Contact Address: C/ Donostia – San Sebastián, 1 (Edificio Lakua II, 4ª planta) 01010 Vitoria - Gasteiz

Contact Name: Lorea Galnares-Cordero

Contact Email: lgalnares@bioef.eus

Copyright: <p>Osteba (Basque Office for Health Technology Assessment) Health Department of the Basque Government</p>