1. Neonatal Mortality of VLBW in Europe The Portuguese Experience Portuguese VLBW Infants Network Hercília Guimarães Brussels, December 2009

2. 10 millions inhabitants
births / year
Universal National Healthcare

3. Perinatal, late fetal and early neonatal mortality rate,
Perinatal Care
System
VLBW
Register
Perinatal
Early neonatal
Late Fetal
Perinatal, late fetal and early neonatal mortality rate,
Portugal 3

5. Perinatal, neonatal and infant mortality evolution
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
Infant
Mortality
(‰)
7.4
6.9
6.4
6.0
5.6
5.5
5.0
4.1
3.8
3.5
3.3
3.4
Perinatal
9.0
8.4
7.2
6.8
6.2
5.1
4.4
4.3
4.6
4.0
Neonatal mortality
4.7
4.2
3.7
3.6
2.9
2.7
2.6
2.2
2.8
2.0
2.1
Foetal morality
5.4
3.1
3.2 5

6. Portuguese Perinatal Healthcare Policy National Committee for mother and child healthcare (1989)
Maternities with < 1500 deliveries/year were closed
Hospitals were classified as Level II and Level III
Functional Coordinating Units connect the Hospitals to the Primary Healthcare Centers
The post graduation of Paediatricians in Neonatology originated the creation of the Special Studies on Neonatology Cycle.
Transport in utero was recognized as the best
Neonatal transport – INEM, was created as an alternative.

7. Intermediate Neonatal Care
Local Health
Center
Level II Hospital
Intermediate Neonatal Care
Local Health
Center
Level III Hospital
Neonatal Intensive Care Unit
Local Health
Center
Level II Hospital
Intermediate Neonatal Care
Local Health
Center 7

8. Level II-27 Level III-21 (including islands)
Public hospitals with perinatal care
Level II-27 Level III-21 (including islands)
Intensive care beds by center
5-13
>50 VLBW infants
10/21
Surgical centers
Surgeries/year:2>70;1>40
Cardiac centers
2 south;1 center;1 north 8

9. National Neonatal Transport
3 centers placed in level 3 hospitals
Centralized information system
Ambulance equipped with a NICU, and nurse and doctor with expertise in neonatal transport
North
Center
South

10. Neonatal Mortality Portugal 2007/ VLBW Network
< 32weeks
49% of neonatal mortality
VLBW Network
Neonatal Society 10

11. Portuguese VLBW Infants Network - 1994
Main Goals
To consolidate a Network of multicenter prospective neonatal studies
To integrate clinical research in activities of assistence
To determine the prevalence of VLBW in Portugal and the contribution in the mortality and morbidity
To analyse the efficiency of neonatal regionalization
To monitor clinical practices in order to have a national standard for the self-assessement

12. Portuguese VLBW Network
Methods
VLBW infants gr ( ); gr (>1998)
Central Coordination – Coimbra
Data Base on line: htpp//downloads.lusoneonatologia.net
National Meetings (objectives and methods)
Integration in clinical practice – Registration Form
Collective and voluntary participation

13. VLBW infants - Portuguese Network Participating NICU´s
A incidência em 1994 foi 0,66%. Dois anos depois passou para 0,81, atingindo o 1% em Os reflexos na mortalidade fetal foram notórios. A reanimação de fetos no limite da viabilidade aumentou verificando-se uma estagnação nos últimos anos.

14. VLBW National Network Cover rate
100% 14

15. The Portuguese VLBW Network VLBW Prevalence (%)
Portuguese VLBW database 15

16. European Perinatal Health Report,200816

17. Portuguese VLBW Infants Network Regionalization 17
REGISTO NACIONAL DO GRANDE PREMATURO
Secção de Neonatologia - SPP

18. Place of delivery – 10 years evolution
1996
2005
In uterus transport
176 (21%)
374 (37%)
P<0.001
Birth in level III
678 (82%)
920 (92%)
Neonatal transport
124 (15%)
79 (8%)
In born
706( 85%)
921 (92%) 18

19. Portuguese VLBW Network
It worthes to avoid neonatal transport.
15% 9%
Effectiveness of regionalization. 19

20. Europeristat 2008

21. The Portuguese VLBW Network
It worthes to be born in the right place.
VLBW
n=5034
VLBW 2004
n=1016 n
Deaths % IN
4523
780
17.2
OUT
514
136
26.5 n
Deaths % IN
923
133
14.4
OUT 93 25
26.9
P<0.001
P<0.001 21

22. Portuguese VLBW Network Evolution of mortality per BW
Improving the efficiency in ELBW 22

23. Portuguese VLBW Infants Network Perinatal data23
REGISTO NACIONAL DO GRANDE PREMATURO
Secção de Neonatologia - SPP

24. 85 %
85 %
6.5
21%
8,5 8%
4.9%
EuroNeoNet 2007

25. Threshold of Viability Birth Weight
Nº = 3561
n = 3561 25
REGISTO NACIONAL DO GRANDE PREMATURO
Secção de Neonatologia - SPP 25

26. Threshold of Viability (GA)
Nº = 3561
n = 3561 26
REGISTO NACIONAL DO GRANDE PREMATURO
Secção de Neonatologia - SPP 26

27. Portuguese VLBW Network
22 w GA: no survivors
23 w GA: rare
24 w: survival rate - 38 %
Threshold of viability
>50% alive
1996 – 27 w
1997 – 26 w
>2004 – 25 w
Threshold of survival
without major sequelae
1996 – 29 w
1997 – 28 w
>2004 – 27 w 27

28. Portuguese VLBW Network Morbidity
1996
2000
2006
2007
RDS 57 60 73
PDA 23 19 20
BPD (O2 36 w) 22
8.8
8.3
ROP 21
19.3 15
IVH (III,IV)
6.2
7.4
7.1
PVL
6.6
4.4 6
3.4
NEC (II,III)
5.3
4.3
6.3
3.6
Nos.Sepsis 32 31
26.5
29.6 28

29. 53,8% 9%
65%
42%
19%
2.4
1.7
1.1
2.7
36%
92%
8,7%
4,2%
4,1%
20,8%
5,6 %
61,5%
24,7%
3,7%
EuroNeoNet 2007

30. Portuguese VLBW Network
Conclusions
The aims of regionalisation were achieved.
The perinatal care reform in Portugal is an example of how a good diagnosis and adequate proposals combined with a strong political will is important for changing .

31. Portuguese VLBW Infants Network
The next years objectives
To keep the benefits of organizational measures
To improve Follow-up of VLBW infants at 36 m and 5 years
To promote self-evaluation of NICU´s (Quality)
To improve Network of Neonatal Research