International conference «Actual approaches to the extremely preterm babies: International experience and Ukrainian realities» (Kyiv, Ukraine, March 5-6, 2013)

1. Organization of Perinatal Care in
Czech Republic
Zbynek Stranak, Petr Velebil
Institute for the Care of Mother and Child, Prague
3rd Medical Faculty, Charles University, Prague
Czech Republic

2. Perinatal mortality (per 1000 births)
10
9
8
7
Czech Republic
6 France
Germany
Ireland
5 Netherlands
Norway
4 Sweden
United Kingdom
3
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Source: WHO Euro

3. Early neonatal mortality per 1000 live births
6
5
4 Czech Republic
France
Germany
Ireland
3 Netherlands
Norway
Sweden
United Kingdom
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Source: WHO Euro

4. Infant mortality per 1000 live births
7
6
5
Czech Republic
France
4 Germany
Ireland
Netherlands
3 Norway
Sweden
United Kingdom
2
1
0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009
Source: WHO Euro

5. System of perinatal care in the Czech
Republic
 Perinatal services are provided by obstetricians and
gynaecologists and midwives together with neonatologists
 Approximately 1000 OB/GYN offices
 96 hospital facilities
 12 Regional Perinatal Centres
 Perinatal Centres of Intermediary Care
 High coverage (98 % receiving prenatal care)
 Early registration (80 % in Ist trimester)
 Extensive number of visits (96 % 6 visits and more)
 Hospital deliveries (99.8 % of all births)
 Frequency of LBW 8-8.5 %

6. Newborn Care in Institute for the Care of
Mother and Child
LEVEL
III
LEVEL
II
LEVEL
I
Level III: 20 beds
Level II: 30 beds
Level I: 70 beds

7. Data sources
 Facility-based aggregated perinatal data
 From all 96 obstetrical units in the CR
 Provided on annual basis during January for the previous
year
 Analyzed by the Czech Society of Perinatal Medicine
 Individual perinatal data
 On all births and newborns in the CR (since 1991)
 Separately on mothers and newborns with possibility to link
 Analyzed centrally by the Czech Institute for Health Statistics
and Information

8. Czech Republic - Practical measures
 prevention of preterm deliveries
 prenatal diagnosis with early detection of nonviable
malformations followed by termination of pregnancy,
if desired
 transport in utero to Perinatal Centers
 pre- and intranatal clinical management to achieve
the optimal start of extrauterine life
 improved organization and quality of neonatal care
and
 some changes of indications for cesarean section

9. Network of perinatal centers
 Before 1995 – a „natural“ network of „perinatal“
centers
 In 1995 official establishment of 12 Regional
Perinatal Centers
 In 1998 official establishement of 17 Intermediary
Perinatal Centers
 In 2002 reduction of number of intermediary centers
(only five are included in the National Perinatology
Program)

10. Goals of the Czech Society of Perinatal
Medicine
• Evaluation of health status of
• pregnant women
• mothers
• newborns
• Risk identification
• health, social, economical
• priorities
• Design of solutions – strategy
• in perinatal care (medical, organisation)
• other sectors (social, economic, legislation)

11. Perinatal data forms

12. Perinatal data forms
Perinatologická sekce

13. Age of pregnant women in the Czech Republic
60000
50000
30-34
40000
25-29
30000
20000
20-24
10000 35 +
15-19
0
89
90
91
92
93
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08

14. Proportion of multiple deliveries during 1995-2009
2 ,1
2
1 ,9
1 ,8
1 ,7
% 1 ,6
1 ,5
1 ,4
1 ,3
1 ,2
1 ,1
1
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

16. Specific ENMR of newborns in regional PCs
in the Czech Republic in 2009
Early Neonatal Mortality
500-749 750-999 1000-1499 1500-1999
Inborn 124.2 21.5 18.4 5.2
Outborn 178.6 48.8 28.6 6.9
Not centralized 526.3 97.6 36.1 1.4
Total 168.6 31.3 21.6 3.7

17. Specific ENMR of newborns in regional PCs
in the Czech Republic in 2009
Early Neonatal Mortality
500-749 750-999 1000-1499 1500-1999
Inborn 124.2 21.5 18.4 5.2
Outborn 178.6 48.8 28.6 6.9
Not centralized 526.3 97.6 36.1 1.4
Total 168.6 31.3 21.6 3.7

18. Inborns (born in a centre)
Czech Republic 2009
Live born babies
Perinatal
500-749 g 750-999 g 1000-1499 1500-1999
Centre
n % n % n % n %
Intensive 153 88.9 279 87.2 762 82.1 1155 61.4
Intermediary 5 2.9 12 3.8 80 8.6 445 23.6
Not centralized 14 8.2 29 9.0 86 9.3 282 15.0
Total 167 100.0 316 100.0 856 100.0 1907 100.0

19. Inborns (born in a centre)
Czech Republic 2009
Live born babies
Perinatal
500-749 g 750-999 g 1000-1499 1500-1999
Centre
n % n % n % n %
Intensive 153 88.9 279 87.2 762 82.1 1155 61.4
Intermediary 5 2.9 12 3.8 80 8.6 445 23.6
Not centralized 14 8.2 29 9.0 86 9.3 282 15.0
Total 167 100.0 316 100.0 856 100.0 1907 100.0

20. Proportion of multiple births
of all newborns novorozenců and their contribution to perinatal deaths
CR 2004 - 2009 (all newborns from 500 grams)
Multiples Multiples
Proportion of newborns Proportion of perinatal deaths
15 15
10 10
5 5
0 0
2004 2005 2006 2007 2008 2009 2004 2005 2006 2007 2008 2009
Proportion of newborns = 4.05 % Proportion of perinatal deaths = 8.0 %
Velebil 2010

21. Perinatal mortality among singleton and multiple births
Czech Republic 2004 - 2009 (all babies from 500 grams)
Singletons Multiples
20 20
15 15
10 10
5 5
0 0
2004 2005 2006 2007 2008 2009 2004 2005 2006 2007 2008 2009
ENMR = 0.7 ENMR ENMR = 4.2
SBR = 4.3 SBR SBR = 6.2
Velebil 2010

22. Low birthweight among singleton and multiple births
Czech Republic 2004 - 2009 (all babies from 500 grams)
Singletons Multiples
90 90
60 60
30 30
0 0
2004 2005 2006 2007 2008 2009 2004 2005 2006 2007 2008 2009
LBW = 5.7 % LBW = 61.5 %
Velebil 2010

23. Caesarean sections among singleton and multiple births
Czech Republic 2004 - 2009 (all babies from 500 grams)
Singletons Multiples
90 90
60 60
30 30
0 0
2004 2005 2006 2007 2008 2009 2004 2005 2006 2007 2008 2009
SC = 21.0 % SC = 78.0 %
Velebil 2010

24. Caesarean sections CR 2002-2008
100%
90%
80% Planned
in pregnancy
70%
% 60% Planned
in labour
50%
40% Emergency
in pregnancy
30%
20% Emergency
in labour
10%
0%
2002 2003 2004 2005 2006 2007 2008

25. Frequency of using VEX and forceps
15
10
5
0
Czech France Germany Ireland Netherlands Norway Sweden UK: England
Republic
European Perinatal Health Report, 2008

26. Perinatal Centre - Selected Characteristics
Structure
 Prenatal Outpatient Department
 4 outpatient offices
 Prenatal Diagnosis Department
 3 examining offices
 Invasive diagnostic room
 Genetists office
 High-Risk Pregnancy Department
 2 intensive care rooms + 7 (20 beds)
 Labour and Delivery Department
 Admittion
 Preparatory
 8 delivery rooms
 Emergency CS OR
 Post-partum Department
 3 wards (67 beds)
 Neonatology Department
 Complement (including ICU)

27. Perinatal Centre - Selected Characteristics
Performance
 Prenatal Outpatient Department
 21,869 outpatient prenatal care visits
(7,485 pregnant patients)
 Prenatal Diagnosis Department
 16,693 ultrasound exams
 326 AMC, 29 CVS, 3 cordocenteses,
 11 other procedures (IUT, AI, reductions)
 1,897 genetic consultations
 High-Risk Pregnancy Department
 2,223 hospitalizations
 Labour and Delivery Department
 5,071 deliveries (5,238 newborns)
 1,707 caesarean sections
 43 forceps deliveries
 1 post-partum hysterectomy
 No maternal death

28. Perinatal Mortality (‰) – CR and our PC
8
PM of all CR
6
4
PM of our PC
2
0
94
95
96
97
98
99
00
01
02
03
04
05
06
07
08
09
19
19
19
19
19
19
20
20
20
20
20
20
20
20
20
20

29. Proportion of LBW, VLBW, and ELBW
and Perinatal Mortality
PC of the Institute Czech Republic
Newborns
< 2500 grams 10.0 % 7.9 %
< 1500 grams 2.6 % 1.4 %
< 1000 grams 1.0 % 0.6 %
twins 6.3 % 4.0 %
Perinatal mortality
Singletons 3.82 ‰ 4.99 ‰
Multiples 6.17 ‰ 10.36 ‰
Total 3.97 ‰ 5.21 ‰

30. Perinatal Centre - Selected Characteristics
Current Activities
• Important role in the network od perinatal centers
• Site of analysis of perinatal data from all obstetrical units in the
Czech Republic
• Close collaboration with WHO (since 1988 repeatedly CC) and
other international institutions
• Important educational place for pre and postgraduate training

31. Newborn Care
Institute for the Care of Mother and Child
Level III: 20 beds
Level II: 30 beds
Level I: 70 beds

32. Hospital-Based Newborn Services
 Basic neonatal care (level I)
 Well-newborn nursery, evaluation and postnatal care
of healthy newborns
 Specialty neonatal care (level II)
 Special care nursery
 Specialty neonatal intensive care (level III)
 No restrictions on type or duration of mechanical
ventilation
 Major surgery performed on site (except surgical
repair of serious congenital heart anomalies that
require cardiopulmonary bypass)

33. Early Cleft Recovery Programme
1st Day 2nd Day - Surgery
6th Day -Discharge 3 Months Later

34. Neonatal Department Health Care Activity
Genetics
Perinatal Fetal
Medicine Medicine
Surgery Pediatric
Follow
up

35. Neonatal Department Educational Activity
Pregraduate Training - Medical Faculty
Postgraduate Training
Continuing Medical Education
Theoretical background Practice, Skills

36. Neonatal Department Research Activity
Basic Research: FDA, NIH
RCT: International Collaboration (CURPAP
trial, Motavizumab trial)
Grants: IGA MH CZ, EU Grant (HIP Trial)

37. Perinatal Centre - Selected Characteristics
Planned Activities
• Perinatal data related activities
• National (aggregated and individual databases)
• Europeristat (data collection and analysis)
• Participation on the EPICE project (Effective Perinatal
Intensive Care in Europe for very preterm babies)
• WHO collaboration
• Establishment of Fetal Medicine Centre
• Establishment of Simulation Training Centre for OB/GYN

38. Thank you for your attention