Italy is a beautiful place to come into the world. The numbers say it: in our country neonatal mortality rates are very low: 2.1 compared to 2.9 in Germany, 2.6 in Denmark, 2.7 in Holland and 2.9 in England for every thousand live births (Eurostat data 2018). “Of course, there is still ample room for improvement, especially to reduce the gap between neonatal mortality rates in the North and Central Italy compared to the South and the Islands, but the network of our birth centers is among the best in Europe”. These are the words of Fabio Mosca, president of the Italian Society of Neonatology (SIN) at the opening of the XXVII National Congress, in Rome from today, October 6, until 9.
A congress during which the data emerging from the White Book of Neonatology will be presented, a very clear picture of the organization of neonatological and perinatological care (the perinatal period is the one that goes from birth to the first 7 days of life) in Italy and characteristics of the wards of Neonatology. The white paper is a tool to know how things stand, and “knowing how things stand is essential to assess their strengths and weaknesses with respect to the standards and to plan, consequently, possible improvement actions”, says Mosca . But let’s get to the method used to write the Book.
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The most important structural and organizational aspects of these departments were analyzed through a detailed questionnaire, sent to the managers of all Italian Neonatology: the number of beds, the medical and nursing staff in relation to the number of beds, the level of care complexity, parental access policies to wards, the availability of diagnostic services and technologies, the type of treatments available. Finally, the last part of the questionnaire was dedicated to the organizational characteristics of team work and to the training and motivational aspects of health professionals. 203 departments answered the questionnaire, ie 49% of the total. Of the centers that responded 96 (47%) are equipped with NICU, the neonatal intensive care, and 107 (53%) are without it.
According to the survey, which was coordinated by Luigi Oreo, director of Neonatology and neonatal intensive care at Fatebenefratelli, Isola Tiberina in Rome, there are 411 birth centers on the national territory: 172 in the North, 79 in the Center and 160 in the South and Islands. Of these 411, the facilities equipped with Neonatal Intensive Care (NICU) are 118: 44 (37%) in the North, 21 (18%) in the Center and 53 (45%) in the South and Islands. “There are not a few,” says Mosca.
There were 232,912 births in these centers, i.e. 55.4% of the 420,795 live births in Italy in 2019. The average number of births in the birth centers was equal to 1087, however, 18 centers (9%) reported less than 500 births , 80 centers (39%) between 500 and 999 deliveries, 66 centers (33%) between 1000-1999 deliveries, 18 centers (9%) from 2000-2999 deliveries and only 11 centers (5%) more than 3000 deliveries. NICU centers with less than 500 births per year are 16% in the North, 19% in the Center and 32% in the South and Islands.
The babies born with a gestational age of less than 27 weeks were 1,175, equal to 0.74% of the total. And they were 0.7, 0.6 and 0.8% of the total births in Northern, Central and Southern Italy and islands respectively. “These are the youngest children, those with the most serious problems, and with a very low birth weight – explains Mosca – for these children, only for these, mortality is higher in the south”
High-risk pregnancies: channeled to larger centers
But what are the reasons for this difference? And what to do to fill it? “To achieve better results, a center has to look after more than 25 very low birth weight infants every year, let’s talk about those under one and a half kilograms. This does not occur everywhere, especially it does not occur in the small birth centers of Southern Italy, but the fact that it does not occur could negatively influence the outcome of the patients assisted. In fact, the mortality of very young children is higher than in the South, but the difference between North and South is zero for children born later, with higher gestational age: for these children there are no differences in outcomes or mortality. It is for the category of very young children that we need to improve things in the South, ”says Mosca. How? “By reorganizing the birth path, directing high-risk pregnancies to specialized and larger centers. We in Italy can boast of our average values, but in some areas we can improve ”.
The instrumental equipment for the treatment of newborns hospitalized in the NICU and the availability of diagnostic and consultancy services were overall good and did not show significant differences between the different areas.
Much remains to be done regarding the accessibility of parents to the TIN departments and their opening 24 hours a day, especially in the Center (56% of the TIN centers with free access 24 hours a day) and in Southern Italy and the Islands (34%), less urgency c ‘is in the North, where 88% of the NICUs always allow free access to parents. “But the parents of a newborn in intensive care are not visitors, they are part of the care team, they are an integral part of the care team – says President Sin – and therefore must have 24-hour access to the wards. Direct skin-to-skin contact with the mother represents a health benefit for the newborn as well as being a prerequisite for encouraging breastfeeding. It is essential that parents enter more into the NICU, and everywhere “.
Digitization: more can be done everywhere
The diffusion of computerized medical records is lacking in the South more than in the North “but on average – adds Moscow – computerization is lacking everywhere: it can be improved all over the peninsula, but adequate investments are needed”.
“The results of these surveys – concludes President Sin – highlight the importance of data collection and analysis to evaluate the efficiency of the network of Italian birth centers, in particular those equipped with TIN. Overall, for the first time we can get to know in depth some of the most important organizational characteristics of the TIN centers in our country, which are essential to assess their strengths and weaknesses with respect to recognized standards and to plan, consequently, possible improvement actions. “.
In addition to the White Paper, Sin has just concluded the project, Organizational Standards for Perinatal Care. The aim was to review and update the organizational standards of assistance in terms of human, structural and technological resources, with an approach aimed above all at the greatest possible safety of the mother / newborn dyad. To the project, which was coordinated by Rinaldo Zanini, president of the Commission for the preparation of the organizational requirements for perinatal care Sin, the main scientific societies of the maternal and child area participated: the Italian Society of Pediatrics (SIP), the Italian Hospital Obstetricians and Gynecologists Association (SIGO), the Italian Hospital Gynecologists and Obstetricians Association (AOGOI), the Italian University Gynecologists Association (AGUI), the National Federation of Provincial Obstetric Orders (FNOPO), the National Federation of Provincial Nursing Orders (FNOPI) and the Vivere Onlus Association, representing of parents. The University of Parma (Chair of Business Economics), the Polytechnic University of Milan (Management Department) and the Bicocca University of Milan (Chair of Medical Statistics) are also involved as partners.
Together with these, then, the Italian Society of Neonatology, with the coordination of Gina Ancora, of the SIN Board of Directors and Director of Neonatal Intensive Care Department of Women’s Health, Childhood Adolescence, AUSL Romagna, Hospital Infermi Rimini and together with Vivere Onlus, he oversaw the Italian translation of the “European Standards of Care for Newborn Health”, created by the European Foundation for the Care of Newborn Infants (EFCNI), also with the collaboration of Sin, which provide new reference standards for the care of premature babies. “I am sure that, with these new reference standards, we will be able to pursue and continue our priority objective – concludes Mosca – and that is to guarantee the greatest possible safety of the mother / newborn dyad”.