Deliverables
Several European initiatives have proposed common norms for the definition of levels of perinatal care. The EURO-PERISTAT project, a project financed within the EU Public Health Programme to develop indicators for monitoring perinatal health in the European union has recommended as one of its indicators the % of babies <32 weeks of gestational age born in a maternity with on-site intensive care. The feasibility study undertaken by this project showed that without further work on harmonising the definitions of perinatal units, this indicator could not be operationalised. The MOSAIC study provides the empirical basis for completing this work. These data will also make it possible to formulate common policy initiative in Europe with respect to this group of high risk babies by standardising definitions of structures of care.
END USERS OF THIS RESULT: Health policy makers seeking to evaluate care in their countries, European level bodies seeking to assess quality of perinatal health care among members states, regional governments modifying policy, professional societies seeking to elaborate guidelines, clinicians interested in contrasting their own results with those in other organisational contexts.
DISSEMINATION STRATEGY: working with the EURO-PERISTAT project, publishing MOSAIC findings in the scientific literature both internationally and in national medical journals within the MOSAIC regions.
The MOSAIC project provides high quality data on the health and care of very preterm babies in 2003. These data provide a benchmark for comparisons over time and over geographic zones for the MOSAIC regions and for the countries of Europe. Currently, comparative population data on these babies are not available. MOSAIC results document large differences in rates, mortality and morbidity of these babies in regions in Europe. Practices also differ greatly, with respect to caesarean rates and care at birth as well as care after birth (ventilation practices, surgery etc..). The study makes it possible to explore the reasons for these differences and to assess the efficacy of these different practices.
Furthermore, this research also underscored the large diversity in European countries with respect to ethical decision-making for these high risk babies. While these differences have been highlighted in previous EU funded work (the EURO-OBS and EURONIC projects), the MOSAIC project provides data on actual practices. Our data show that these values are associated with the survival of high risk babies, as well as other measures of outcome (for example, by limiting neonatal complications associated with risk of longer-term impairments). The recognition of these differences is essential in comparative assessments of outcome, since normative judgements, and thus corresponding objectives with respect to mortality and morbidity, vary by context.
END USERS OF THIS RESULT: Perinatal epidemiologists and other health researchers, clinicians working with very preterm babies
DISSEMINATION STRATEGY: presenting MOSAIC findings in regional, national and international scientific conferences and publishing MOSAIC findings in the scientific literature both internationally and within national medical journals in the MOSAIC regions.
This result is 2 validated questionnaires that measure key indicators of organization for obstetrical and neonatal wards. To develop the questionnaires, a review of existing questionnaires available in European countries was first undertaken. Questionnaires were identified which included questions about the organization of neonatal and maternity units from the UK, France, Poland and from European studies (EURONIC and EUROOBS on ethical decision making). A review of the literature also identified key indications used for the study of the organization of maternity and neonatal care. Working groups on maternity and neonatal units were set up and met to discuss questions that were proposed by the research coordinator based on a review of the literature and previous studies.
These working groups identified questions that were not comparable across countries and specified the wording of other questions so that they would be as comparable as possible. These working groups contained representatives from each MOSAIC regions. It was also decided to add a section on ethical practices to questionnaires for both maternity neonatal units. Neonatologists and obstetricians, external to the MOSAIC consortium, but not included in the studies, were asked to complete the questionnaires in their final forms in order to ensure that the questions were clear.
These instruments are postal questionnaires that are filled out by the head of the neonatal and maternity wards (or someone designated by the head). The analysis of the data from these questionnaires made it possible to validate the items. An article is in preparation on these instruments to highlight indicators which can be reliably measured and to discuss indicators which are more difficult to compare across health systems.
END USERS OF THIS RESULT: Researchers interested in the organization of neonatal and obstetrical care. People implementing studies.
DISSEMINATION STRATEGY: Publication of an article on indicators of organization and collaboration with other research projects. A research project in Italy (the ACTION project) is already using the MOSAIC questionnaires. Another study in Belgium also used some of the questions from these questionnaires.
The MOSAIC project provides empirical high quality data on the current state of care for very preterm babies in Europe. Very preterm babies have better survival and lower mortality when they are born in a maternity with neonatal intensive care units and many countries have designated specialised perinatal units (often labeled level III unit) where these babies should be delivered. However, assessment of the care of these babies in most Europe countries is not possible because of the absence of comparable data. Furthermore, while there is widespread agreement about the negative impact of birth in a maternity unit with no neonatal intensive care on-site, there is no clear consensus about the key structural characteristics of a perinatal center. In particular, some studies have found that care in units with a lower volume of patients is associated with poor outcomes.
With respect to these important public health issues, the MOSAIC project provides information on:
- The place of birth of very preterm births in relation to the structural characteristics of the maternity and neonatal units; this provides a benchmark for assessing regionalisation of care in Europe in health systems with a large variability in organizational structure.
- The health outcomes of babies with respect to the different models of organization. In this project several models were able to obtain similar health outcomes for this high risk population. At the same time, the project identified organisational weaknesses, which exist in several different models of care, that are related to poor outcome.
These results are important for recognising that (1) European countries can attain common goals using different models of care and that (2) research on the organisation of care in these diverse models makes it possible to identify the characteristics of care that lead to poor outcome. This approach can be applied more generally to the organisation of health services in other health disciplines.
The project also described marked differences in the use of human and capital resources and in travel distances for users in the various systems; these data can be used to improve the efficiency of health care delivery.
END USERS OF THIS RESULT: Health policy makers seeking to improve the organisation of health care in their countries, European level bodies seeking to assess quality of perinatal health care among member states, regional governments modifying policy, professional societies seeking to elaborate guidelines, clinicians interested in contrasting their own results with those in other organisational contexts.
DISSEMINATION STRATEGY: Through presentations in scientific congresses and publications in the scientific press. Within the MOSAIC regions, advocacy work by the regional teams with respect to these results.
One of the problems facing European countries wishing to compare care and outcomes for very preterm babies is the differences in the way that data are collected for these babies, such as inclusion criteria and the definition of data items. The MOSAIC project brought together health professionals managing routine databases on these babies who collaborated in defining a common protocol for data collection and identifying data items from routine databases which were comparable in Europe.
These choices were then tested in the data analyses. For instance, one of the important findings from the MOSAIC project is the importance of using as the population of comparison for mortality statistics all babies alive at onset of labour. Because of large differences between countries in the proportion of babies dying intrapartum and immediately after delivery in the maternity ward, this population is considered to be the most comparable. Our results identify several robust well defined data items which can be used to compare health outcome and practices across regions with very different practices and health systems.
END USERS OF THE RESULT: People constructing or managing databases on very preterm babies. Health professionals using data from these databases.
DISSEMINATION STRATEGY: This information will be presented in scientific congresses and published in the scientific press. The MOSAIC consortium will make its protocols and instruments available to interested researchers in Europe. Furthermore, collaborations with other regions that have similar data on very preterm babies is envisaged as part of the follow-up work on the MOSAIC project.
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