Improving services
The organization of maternal and newborn services
Improvements in obstetric and neonatal services involve collaboration. In a network-based organization of perinatal services, groups of maternity and neonatal units of differing size, services, and complexity collaborate in coordinating the delivery of care.
A limited number of centres will provide facilities for the care of the high-risk obstetric patient and critical care for newborn babies (such as mechanical ventilation, therapeutic hypothermia, and surgery). Other neonatal units within a network will provide care of lesser intensity. Babies are transferred between neonatal units according to the intensity of their care needs and the distance from their homes. This structure is cost-effective and efficient, with good evidence that concentrating complex in high-volume neonatal centres results in better outcomes (6). A network structure enables the majority of babies to be looked after within a defined geographical area which in turn reduces the distance between the family home and the place of care for the newborn. This enables the family to visit more easily and the mother to more easily provide her own milk for her baby. A network structure also paves the way for forging strong clinical relationships, developing a network-wide education and governance programme, and the development of clinical practice guidelines for both obstetricians and neonatologists and in team working.Evaluating and improving practice
Improving the care of newborn infants requires a culture of openness, transparency, a willingness to learn, and robust methods for measuring healthcare processes and health outcomes. Collaboration extends from information sharing between obstetric and neonatal teams through forums such as fetal medicine, clinical governance, ‘mortality and morbidity' meetings, and multidisciplinary educational programmes.
Systematic capture of clinical information on births and admissions can provide an important opportunity to examine trends, benchmark against other centres, and assess performance against local or national standards. Reliable inferences require consistency in data recording, case definitions, and methods of analysis. The dissemination of league tables of health outcomes is unhelpful if differences in case mix (patient demographic and comorbidities) are not taken into account. Electronic patient records offer an opportunity to streamline surveillance, benchmarking, and audit but ultimately remain dependent on accurate, complete data recording by clinical teams. The United Kingdom benefits from a National Neonatal Audit Programme (82) involving all United Kingdom neonatal units, with central analysis of process and clinical outcome measures utilizing data from a National Neonatal Research Database populated through regular extractions of predefined data from the neonatal Electronic Patient Record (83).Reducing uncertainties
Testing treatments rigorously and reducing uncertainties in care are a cardinal responsibility of all clinicians. Evidence-based medicine has been embraced as the best approach for ensuring that patients receive treatments and care that are efficacious (they work) and effective (they work in real life). There are any number of examples of the harms that can ensue from the use of non-evidenced-based treatments. Notable examples in newborn care of once standard but now discarded approaches are the routine separation of mother and baby (adverse impact on breastfeeding and bonding), use of 100% oxygen in resuscitation (increased mortality compared with resuscitation in room air), and placing babies prone when sleeping (increases risk of sudden infant death). High-quality care is based on high-quality evidence from high-quality clinical research. It might therefore be considered reasonable that these would form a closely integrated partnership.
However, this is not yet the case and much needs to be done to speed the delivery of clinical research, improve the quality of clinical data, and inform professionals and the public about research methods. Not all clinical research involves randomized trials and not all randomized trials involve new treatments. Comparative effectiveness research involves evaluating treatments that are already in standard use, such as, for example, different antibiotic regimens, or different method of feeding newborn babies. Considerable effort is underway to integrate such studies more closely into clinical practice through use of data from existing registries, proportionate research ethics review, short, simple information leaflets, and explanation of the possibility of inclusion benefit through participation (84). Clinicians need to be comfortable with discussing uncertainties with patients and explaining concepts such as ‘clinical trial' and ‘randomization'. An excellent resource for practitioners and patients alike is ‘Testing Treatments', an e-book available in multiple languages (http://www.testingtreatments.org).Advocacy
Advocacy over the centuries has changed the status of the newborn baby. Child sacrifice was practised in ancient times, and infanticide, especially of female infants, remains a problem in several parts of the world to this day, even though the protection of the newborn baby is now enshrined in law. Other powerful global movements such as the Millennium Development Goals and the WHO ‘Every Newborn Action Plan' to end preventable deaths (https:// www.everynewborn.org/) have led to an increased focus upon newborn care. The science of epigenetics now provides a plausible mechanistic basis for the many epidemiological associations between early life exposures and later health and disease. Translation of this growing understanding into healthcare and societal policies that lead to incremental improvements in maternal and newborn well-being will require continued and sustained advocacy.
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