A study of the referral patterns of obstetric clinics and the performance of receiving neonatal intensive care units in Taiwan

Abstract

To study the referral patterns of obstetric clinics, and the performance of receiving intensive care units measured by the survival of transported neonates, transport records were collected prospectively between July, 1991 and June, 1992. Two hundred and fifty-four transported neonates born in 51 obstetric clinics (level I units) in Tainan City and County, in southern Taiwan, were enrolled in this study. Nineteen percent of the transported neonates were very low birthweight infants (< 1500 g). Nearly equal numbers of them were transported to eight district hospitals (level II units) and to a tertiary center (level III unit), but these infants were 1.5 times more likely to die in a level II unit than a level III unit. In addition, equal numbers of infants assisted by mechanical ventilators were transported to level II and III units, but these infants were three times more likely to die in a level II unit than a level III unit (P = 0.006). Seventy-seven percent of the normal birthweight infants (> or = 2500 g) were transported to level II units, and the mortality in this group was 12.3% compared with 0% in those transported to the level III unit. Approximately 56% of these normal birthweight infants in level II units died of severe birth asphyxia. The referral patterns of level 1 units had an unfavorable effect on the survival of neonates requiring mechanical ventilation. Enhancing the skills of the staff in level I units to recognize and stabilize such infants, elevating the capability of level II units in treating some of these cases, and increasing the hospital beds for level III care are necessary to increase their chance of survival.

PIP: This study examines neonatal mortality among 254 neonates referred from level I hospitals between July 1991 and June 1992 to level II and III neonatal intensive care units (NICUs) in Taiwan. The neonates were grouped by birth weight and severity of respiratory distress. Birth weights were classified as very low birth weight (VLBW), low birth weight (LBW), and normal birth weight (NBW) (2499 g). Respiratory distress was grouped as mild, moderate, or severe. Findings indicate that 70.9% of the 254 transfers were to level II units, and 29.1% were to level III units. The mean age at transfer was 1.5 days. The mean birth weight was 2224 g, and the gestational age was 34 weeks. About 20% were VLBW, which were equally referred to level II and III units. Level II units received twice as many LBWs and over twice as many NBWs. Neonatal mortality was 35.4% in the VLBW group, 43.5% in level II units and 28.0% in level III units. Neonatal mortality was 12.3% among NBWs in level II units and 0% in level III units. Neonatal mortality was the same for LBW in either II or III units. 41% had moderate or severe respiratory distress. Level II and III units each received about half of the severe cases, but level II units received about 82.7% of moderate cases. 39.2% of severe cases died. Neonates transferred to level II units had a 37.7% higher mortality rate. 23 of the VLBWs had severe respiratory distress, and 43.5% died. Neonatal mortality was 38.1% higher in level II units for VLBWs with severe symptoms. Most level II neonatal mortality was due to asphyxia. 18.8% of VLBWs with severe symptoms could have been saved by transfer to a level III unit. Recommended improvements include stabilizing infants in level I units before transfer, mandatory transfers of severe cases to level III units, and improving the capability of level II units until level III unit facilities can be increased.