By Tim Bonfield
The Cincinnati Enquirer

When a pregnant woman goes into very early labor, seeking out a specialty hospital to deliver the baby can be the difference between life and death, according to a study from Cincinnati Children's Hospital Medical Center.

"Very low birth weight babies" - who weigh 1.1 to 3.3 pounds and are less than 32 weeks gestation - are twice as likely to die or suffer major medical problems if they are delivered at a hospital that lacks "Level III" intensive care services and expertise.

These findings were published Monday in the January edition of Pediatrics.

The study is based on data from babies born in Cincinnati from 1995 through 1997. But long before the study was published, the data prompted widespread changes in how high-risk babies are delivered in Greater Cincinnati.

Those changes make Cincinnati a model for cities nationwide for how to handle extreme cases, doctors say.

"I think we have become an example for other areas of the country," said Dr. Barbara Warner, a neonatologist at Children's and the TriHealth hospitals, who was lead author of the study.

"In the mid-1990s, with all the advances in neonatal care, some people were saying that regionalized care didn't matter anymore. There was pressure in Cincinnati and all around the country to do more deliveries in community hospitals, even the very low birth weight ones," she said. "But we found that it still does matter."

The findings do not apply to babies born at full-term. For babies born after 32 weeks, most area hospitals are more than adequate to handle most problems, Warner said.

But for the tiniest babies, the study found that the best care existed at University and Good Samaritan hospitals. They are the only ones of 19 hospitals in Greater Cincinnati that deliver babies that have "Level III" neonatal intensive care.

Level III centers have neonatal specialists available around the clock and extensive experience at stopping premature labor, reviving non-breathing newborns and providing long-term ventilation care.

Children's also runs a Level III intensive care service for sick babies of all sizes. But the hospital does not deliver infants.

The study found that six to eight years ago, about 25 percent of small preemies were being delivered at the 17 non-Level III hospitals. Some were later transferred to Children's.

Outcomes of care varied sharply, researchers noted even though babies were being treated by doctors who worked at multiple hospitals.

For example, nearly 27 percent of babies born weighing 750 to 999 grams were dying at lower-level hospitals, compared to 11 percent at the most sophisticated hospitals.

Meanwhile, non-fatal, but often debilitating brain hemorrhages were striking 15 percent of small babies in most hospitals, compared to 8 percent of the babies at the most advanced hospitals.

It took several years for researchers to pin down enough details for publication in a national medical journal.

But the preliminary data - which were shared with doctors and hospitals as far back as 1998 - was enough to change policies city-wide.

"There's clearly a class of patients that just do better at specialized centers," said Dr. William Polzin, director of maternal/fetal medicine at Good Samaritan Hospital, the city's largest maternity service.

"I think we are very much a model for how to regionalize obstetric care. Cincinnati has managed the problem, but other cities may not have these arrangements in place," said Dr. Eric Silver, director of obstetrics and gynecology at Mercy Hospital Fairfield, one of the area's newest suburban maternity services.

While many groups of doctors deliver babies, Cincinnati is unusual among large cities because a single group of neonatologists provides post-birth intensive care services at every Tristate maternity unit. In recent years, those doctors have helped lead a standardization of care.

In some emergencies, there isn't enough time to transfer patients around. But in most cases, doctors and hospital administrators now agree that it is better to transfer a pregnant woman with a high-risk case to a Level III hospital - even during labor - than to try to move a tiny baby after it is born.

Moving an extremely premature infant requires disconnecting and reconnecting ventilation equipment, handling the baby, and risking the bumps of the road during an ambulance ride.

Disturbing such children can make them fight their ventilator, which can lead to brain hemorrhages and other complications, Warner said.

At the time of birth, doctors also agree it is better to have specialists immediately at hand - which is required at a Level III facility. At a Level II service, the standard is to have specialists on-call, ready to be at the hospital within 20 minutes.

Experience that comes from sheer volume of cases also matters.

"For example, everyone (in neonatal care) has to be certified in neonatal resuscitation. But being certified is different than having actual experience doing it," Warner said.

While having the highest technology and expertise is crucial to the tiniest babies, it is not necessary to have every maternity unit in town equipped and staffed to provide Level III care, doctors say.

The existing services, even with some reorganization, have been enough to meet the demand, Warner said.

The study's findings

 Of more than 66,635 total births between Sept. 1, 1995 and Dec. 31, 1997, 848 involved babies weighing less than 1,500 grams (3.3 pounds). Such small babies are typically born at less than 32 weeks gestation.

 Of those small babies, 193 died before leaving the hospital.

 Of 19 hospitals in Greater Cincinnati that deliver babies, two have the highest, Level III, capabilities - University and Good Samaritan.

 About 25 percent of very low birth weight babies (213 infants) were delivered at non-Level III hospitals, including 48 cases where women took more than 12 hours to deliver and 17 cases that involved five to 12 hours of labor.

 For small babies, the odds of dying or suffering severe, lifelong health problems were 2.6 times higher at the region's 17 non-Level III hospitals.

 Since 1998, when preliminary data were shared among doctor groups and hospitals in Greater Cincinnati, many more deliveries of extremely premature babies have been routed to University and Good Samaritan hospitals. But the study does not provide a specific figure.

Source: Cincinnati Children's Hospital Medical Center

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E-mail tbonfield@enquirer.com