Prematurity in Ireland
Presentation to Oireachtas Health Committee
November 22, 2012
Introductions
Dr John Murphy
Mandy Daly
Hilda Wall
National Clinical Lead in
Neonatology
Family Liaison, Policy &
Advocacy Manager, Irish
Premature Babies
Department Manager,
Neonatal Unit, National
Maternity Hospital
Consultant Neonatologist at the
National Maternity Hospital &
the Children’s Hospital
Board member, NIDCAP
Federation International
Senior Lecturer in Neonatology,
RCSI
Advocacy at national & EU
level
Neonatal nurse
representative, HSE
Paediatrics and Neonatology
Working Group
What informs this presentation
Clinical experience
International expertise
Parents & supporters
Visits to all 22 neonatal
units in 2011 and 2012
Neonatal Sub
Committee of the
Faculty of Paediatrics,
RCPI
European Foundation
for the Care of
Newborn Infants
March of Dimes
NIDCAP Federation
IPB support and advice
to parents
Global Alliance to
Prevent Prematurity
and Stillbirth
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75000 Births Annually
4,800 Premature births
19 Neonatal Units
300 Neonatal Cots
What is prematurity?
Definitions
Causes
Scale
A prematurity birth is
defined as less than 37
weeks’ gestation
Understanding of the
drivers of preterm birth
and the most effective
interventions to reduce
preterm birth rates is
poor
15 million babies are
born too soon every
year, with preterm birth
the largest cause of
neonatal death
worldwide (1.1 million
deaths) making it the
second leading cause of
deaths in children
younger than 5 years
Births are further
categorised by weeks of
gestation and birth
weight
The most vulnerable
are those children born
at less than 28 weeks –
more than 3 months
early – or with the
lowest birth weights
Research and discovery
is required
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What is prematurity?
 Rate is rising globally:
 Ireland 7%
 Europe 5%
 US 12%
 Pre-term distribution categories
are:
 34-36 weeks: 60%
 32-33 weeks: 20%
 28-31 weeks: 15%
 < 28 weeks: 5%
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Neonatal services in Ireland –
 11,289 neonatal admissions
 19 Neonatal Units
 11 level 1
 4 level 2
 4 level 3
 300 Neonatal Cots
 193 SCBU
 55 NICU
 52 HDU
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List and Date of Neonatal Unit Visits
Hospital
Kilkenny
Waterford
Mullingar
Portlaoise
Limerick
Cavan
Drogheda
Clonmel
Wexford
Crumlin ICU
Letterkenny
Portiuncla
Galway
Sligo
Tralee
Cork
Rotunda
Coombe
Castlebar
Holles St
South East
Temple St ICU
Date
14/9/11
26/10/11
11/11/11
2/12/11
25/1/12
15/2/12
24/2/12
14/3/12
31/3/12
5/4/12
12/4/12
19/4/12
25/4/12
6/6/12
6/6/12
15/6/12
27/6/12
28/6/12
28/6/12
1/7/12
25/7/12
Aug ‘12
Impact of current approaches
We have achieved reductions on mortality rates across most birth weights.
The smallest babies with a birth weight of less than 749 grams are a group
where current approaches have had no positive impact on mortality rates.
Perinatal Mortality Rates by birth weight (g) per 1,000 births
Change, %
-2%
-38%
-13%
-36%
-28%
-22%
-38%
-20%
-23%
-9%
+20%
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Recommendations for next steps
The 2011 European Foundation for the Care of Newborn Infants (EFCNI) report
recognised the priorities for Ireland were to:
 Develop and implement a targeted public policy
on neonatal health, with the active engagement
professionals and parents
 Increase general awareness of prematurity (its
health, social and economic implications
 Develop and implement a National Prevention and
Screening Programme for high risk pregnancies
 Take active measures to improve neonatal
workforce education and neonatal units staffing in
order to meet international standards
 Extend the current Neonatal Transport
Programme to a 24h service to ensure adequate
coverage and patient access to emergency and
quality care as needed
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Principles that inform guidelines
As Clinical Lead for Neonatology, one of my roles is to develop national
guidelines that address issues of levels of care. Principles that I consider
important include:
Equipoise: right baby, right place, right time
All Irish units support are supportive of a Neonatal Networks system
The best results are achieved where a unit treats at least 50 babies under 32
weeks; services in Ireland continue to develop around this model
It requires that units have the appropriate skills and capacity for the babies they
care for
This is a combination of “bringing expertise to baby” and “bringing baby to
expertise”
The 24/7 neonatal transport service is key to advancing this model
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Key steps in providing quality care
To provide high quality neonatal care to all 75,000 babies born in Ireland annually, we require:
Quality
Access
Cost
 Effective screening, nutrition, immunisation programme for all healthy newborns
 Provide high quality neonatal intensive care and surgical care for ill newborns
 Seamless transfer from Level 1 to Level 2 through to Level 3 Neonatal Intensive
Care
 ‘Right baby, right place right time’
 To put an efficient retro-transfer programme in place
 All babies should have equal, rapid access to neonatal intensive care and surgical
treatment irrespective of geographical location. Eradicate ‘post code’
disadvantage
 Reduction in unnecessary costs by prompt identification and timely treatment of
remedial problems
 Eradicate fragmentation and duplication of newborn specialist and intensive care
services
 Rationalisation of Neonatal Intensive Care
 Re-engage the wider paediatric community-GPs, AMOs, Public Health Nurses 11
to
reduce the ‘drift’ to hospital care with minor problems
The neonatal transport service
Neonatal Transport Service
9am to 5pm, 7 days
Sets out within 45 minutes to any hospital for a
sick infant. The team provides stabilisation
advice and intensive care at the referring
hospital, prior to, as well as during the
transport to the relevant tertiary centre. The
majority of infants are transported to Dublin
hospitals but the NNTP will also transport
neonates to regional neonatal/surgical
intensive care units nationally.
The team includes a skilled and experienced
neonatal transport nurse and a neonatal
medical registrar from one the three main
Dublin maternity hospitals.
The team travel in an ambulance which has
been designed and equipped especially for
neonatal retrievals and has a complete
transport incubator system.
Outside of these hours – 50% of the time – sub-regional and general hospitals have to depend on their
own resources and the 8 regional neonatal centres have to arrange their own transport teams.
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A 24/7 service is essential
Current
Other
transports
193 transports
Neonatal
Transport
Service
24/7 service
Impact

Neonatal
Transport
Service
Specialist transport and early
transfer can be a determining
factor in a preterm baby’s
survival, whilst also reducing
the chances of lifelong
disability and the financial
impact to the State

More than 400
transports
At 400+ transports, the
national service would be a
world-class service

It would be a service every
unit and hospital could rely on
and be proud of

Support parents of premature
babies in a time of enormous
stress and worry
Less than 100
286 transports
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The Paediatric Reference Group
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Established in 2011 for the Lead
Programme
To make children central to the
design of the Programme
To ensure that the needs of the
special needs groups are
highlighted
To link the advocacy groups with
the work of the Programme
It represents a rethink about how
Paediatric care will be developed
into the future.
It is about providing children and
their families what they require
rather what we think they need
Your questions
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