Place of preterm birth and hospital transfer

#Background

Pēpi that are born in a hospital with the level of neonatal care appropriate to their gestation and needs (inborn pēpi) have better outcomes than pēpi who are born elsewhere and transferred after birth (outborn pēpi). ¹ For those born <28 weeks gestation, this includes less severe brain injury and higher survival without brain injury in comparison to those transferred into tertiary units after birth, and higher survival than those that continue to be cared for in non-tertiary units.¹ The differences in outcomes for inborn and outborn pēpi are likely due to variation in hospital care rather than the transfer itself, as evidenced by no differences in outcomes for tertiary-to-tertiary transfers,¹ and hence in utero transfer should be arranged whenever possible.

This is most pertinent for births at the limits of survival. In Aotearoa, if transfer to a tertiary unit before birth is not possible after presentation to a primary or secondary unit at <24⁺⁰ weeks gestation, pēpi have little chance of survival and therefore supported comfort/palliative care has been considered more appropriate.²

#Recommendations and Practice

Place of preterm birth

Specialised neonatal care is not available in all hospitals in Aotearoa. Neonatal intensive care resources and clinical expertise is centralised into six Level Three neonatal units throughout the country. Additional hospitals are equipped to provide Level One or Two/Two Plus care for pēpi born at later preterm gestations.

Hospital transfer

Aotearoa is geographically diverse and many wāhine/people and whānau live remotely from hospitals that can provide Level Two and Three neonatal care. When required, transfer to a hospital with the appropriate obstetric and neonatal expertise should occur, ideally prior to birth. Equitable access for all wāhine/people and their pēpi is recognised as a priority, regardless of their place of residence.

#Auditable Standards

To be developed.

#Included guidelines

The search identified 18 guidelines relevant to place of birth.^2-19 Three of these had direct relevance to place of birth and were considered high-quality in Overall Assessment (score >60%) and were recommended for use/use with modifications by the Review Panel.^2-4 Two of these high-quality guidelines provided recommendations for in utero transfer and were specific to single district health boards, both with Level Three neonatal units,^3,4 and one was a national consensus statement for care at extremely early gestations near the limit of survival.² The additional guidelines were for management of spontaneous preterm labour/prelabour preterm rupture of membranes,^5,6,11-17 or various indications for provider-initiated preterm birth^7-10,18,19 and also provided brief recommendations for place of birth. Only two of these additional guidelines met criteria for high-quality in Rigour of Development (score >60%) and Overall Assessment (score >60%) and were recommended for use,^18,19 with the remainder not meeting criteria for high-quality, but recommended by the Review Panel for use with modifications.

The two guidelines specific to single district health boards^3,4 were predominantly focused on local logistical process and not directly transferrable to a national best practice guide. The Newborn Clinical Network New Zealand Consensus Statement on the care of mother and babies at periviable gestations² provides reference to the need for transfer to a unit with Level Three neonatal intensive care facilities but the associated transfer policy document was not available for inclusion. Recommendations in this section have therefore been based on the principles included in the identified guidelines with practical guidance provided. Information regarding the levels of neonatal care provided by hospitals within Aotearoa was obtained from a 2011 nationwide service framework²⁰ and 2019 review commissioned by the Ministry of Health.²¹

#Impact on equity

Review Panel assessments identified that the recommendations in all three place of birth/hospital transfer guidelines^2-4 had potential to reduce differences by equity factors. This related to improving outcomes for those living rurally as the guidelines support access to tertiary care, and for those who receive care in provincial units as guidelines support consideration of transfer for very preterm babies. Note was made that cultural and whānau support when transfer is required is necessary to support equity in outcomes.

#Research in progress that may inform future practice recommendations

None identified.

#Statement on rationale for any differing recommendations from the high-quality guidelines

All recommendations relevant to birth at limits of survival are consistent with those included in the Newborn Clinical Network New Zealand Consensus Statement on the care of mother and babies at periviable gestations.² As noted in the evidence statement the other two included guidelines are specific to transfers and include local logistical processes and therefore not directly transferrable to this best practice guide. Practice points are consistent with both guidelines. Where possible, flowcharts and checklists have been adapted from these resources.

#References

1. Helenius K, Longford N, Lehtonen L, Modi N, Gale C. Association of early postnatal transfer and birth outside a tertiary hospital with mortality and severe brain injury in extremely preterm infants: Observational cohort study with propensity score matching. BMJ. 2019;367:1-11. DOI: 10.1136/bmj.l5678.

2. Newborn Clinical Network. New Zealand Consensus Statement on the Care of Mother and Baby(ies) at Periviable Gestations. Newborn Clinical Network; 2019. Available from: https://www.starship.org.nz/guidelines/new-zealand-consensus-statement-on-the-care-of-mother-and-baby-ies-at/.

3. Waikato District Health Board. Waikato Hospital Maternity Services - Inter Hospital Transfer and Repatriation. Hamilton: Waikato District Health Board; 2018.

4. Canterbury District Health Board. In-Utero Transfer Between Hospitals. Christchurch: Canterbury District Health Board; 2017.

5. Hutt Valley District Health Board. Preterm pre-labour rupture of membranes. Hutt Valley: Hutt Valley District Health Board; 2021.

6. Nelson Marlborough District Health Board. Pre-term, Pre-labour Rupture of Membranes (PPROM). Nelson: Nelson Marlborough District Health Board; 2020.

7. Lowe SA, Bowyer L, Lust K, McMahon LP, Morton MR, North RA, et al. Guideline for the Management of Hypertensive Disorders of Pregnancy. Society of Obstetric Medicine of Australia and New Zealand; 2014. Available from: https://www.somanz.org/content/uploads/2020/07/HTguidelineupdatedJune2015.pdf.

8. Tairāwhiti District Health Board. Management of hypertensive disorders in pregnancy. Gisborne: Tairāwhiti District Health Board; 2020.

9. Lees CC, Stampalija T, Baschat AA, da Silva Costa F, Ferrazzi E, Figueras F, et al. ISUOG Practice Guidelines: diagnosis and management of small-for-gestational-age fetus and fetal growth restriction. Ultrasound Obstet Gynecol. 2020;56(2):298-312. DOI: 10.1002/uog.22134.

10. Lausman A, Kingdom J, Gagnon R, Basso M, Bos H, Crane J, et al. Intrauterine Growth Restriction: Screening, Diagnosis, and Management. J Obstet Gynaecol Can 2013;35(8):741-8. DOI: 10.1016/S1701-2163(15)30865-3.

11. Auckland District Health Board. Preterm Labour - Management of Threatened and Active Preterm Labour. Auckland: Auckland District Health Board; 2021. Available from: https://nationalwomenshealth.adhb.govt.nz/assets/Womens-health/Documents/Policies-and-guidelines/Preterm-Labour-PTL-Management-of-Threatened-and-Active-PTL.pdf.

12. Counties Manukau District Health Board. Preterm Labour Antenatal management of women at high risk of Preterm Birth, management of threatened and acute Preterm Labour (including cervical cerclage insertion). Auckland: Counties Manukau District Health Board; 2020.

13. Lakes District Health Board. Preterm labour: Management of threatened and active preterm labour guideline. Rotorua: Lakes District Health Board; 2021.

14. MidCentral District Health Board. Management of threatened and active preterm labour. Palmerston North: MidCentral District Health Board; 2021.

15. Nelson Marlborough District Health Board. Pre-term labour guideline. Nelson: Nelson Marlborough District Health Board; 2020.

16. Northland District Health Board. Preterm labour treatment guideline. Whangarei: Northland District Health Board; 2019.

17. Tairāwhiti District Health Board. Preterm labour and birth. Gisborne: Tairāwhiti District Health Board; 2019.

18. Ministry of Health. Diagnosis and Treatment of Hypertension and Pre-eclampsia in Pregnancy in New Zealand: A clinical practice guideline. Wellington: Ministry of Health; 2018. Available from: https://www.health.govt.nz/system/files/documents/publications/diagnosis-and-treatment-of-hypertension-and-pre-eclampsia-in-pregnancy-in-new-zealand-v3.pdf.

19. World Health Organisation. WHO recommendations for prevention and treatment of pre-eclampsia and eclampsia. Geneva: World Health Organisation; 2011 (updated 2021). Available from: https://apps.who.int/iris/bitstream/handle/10665/44703/9789241548335\_eng.pdf?sequence=1.

20. Nationwide Service Framework Coordinating Group. Services for Children and Young People - Specialist Neonatal Inpatient and Home Care Services, Tier Level Two, Service Specification. 2011. Available from: https://nsfl.health.govt.nz/service-specifications/current-service-specifications/child-and-youth-health-service-specifications.

21. Malatest International. Review of neonatal care in New Zealand 2019. Available from: https://www.health.govt.nz/system/files/documents/publications/review-of-neonatal-care-in-new-zealand-aug2019.pdf.