Soins maternels intensifs (Maternal Intensive Care) en Belgique - KCE

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6 Maternal Intensive Care in Belgium KCE Reports 94 Koninklijk Besluit (KB) van 01/10/1996, hoofdstuk IV, afdeling 1, Art. 7. :”De Maternal Intensive Care - afdeling is een afdeling van een erkende dienst kraaminrichting (kenletter M). Deze afdeling is gericht op intensieve observatie van hoogrisico zwangerschappen. Ze staat eveneens open voor patiënten die, wegens het sterke vermoeden dat de foetus na de bevalling intensieve neonatale zorgen zal nodig hebben, bij voorkeur in een P* functie bevallen en voor patiënten die na de bevalling hooggespecialiseerde postpartum zorg vereisen.” “La section Maternal Intensive Care est une section d’un service de maternité (index M) agrée. Cette section est axée sur l’observation intensive des grossesses à haut risque. Elle peut également accueillir les patients qui en raison d’un risque présumé élevé que le fœtus nécessite, après l’accouchement, des soins néonatals intensifs, préfèrent accoucher dans une fonction P*, ainsi que les patientes qui nécessitent après l’accouchement des soins postpartum hautement spécialisés. The functions and purposes of the MIC-services are imprecisely described in the R.D. What is intensive observation? Which are the indications wherefore a baby potentially needs neonatal intensive care? How are high-risk pregnancies defined? When does a patient need highly specialised post partum care? This legal frame with regard to MIC is not sufficient to guide the daily obstetrical practise. The lack of clearly defined concepts in the R.D. required defining the peripartum continuum. The concept ‘Maternal Intensive Care’ in Belgium is understood as a level of intermediate care. The MIC-services in Belgium are not Intensive Care Units (cf. definition), specialized in peripartum complications. MIC-services provide a level of care between standard and intensive care (cf. infra). Therefore in this report we use the less confusing concept ‘Maternal Intermediate Care (MIC)’ to refer to intermediate care provided to peripartal women in Belgium. Confusions of meanings and differing interpretations are also found in the international literature. Each country has its own system of health care and use a different terminology to refer to MIC. Moreover these country-specific terminology and concepts are scarcely explained in the found studies. 1.3 HISTORY, FINANCING AND HEALTH ECONOMIC ASPECTS OF THE MIC 1.3.1 Maternal and Neonatal services in Belgium (1987) By Royal Decree, the maternal and neonatal hospital units in Belgium were reorganised as of January 1, 1988 (R.D. August 15, 1987). The main focus was on the reorganisation of the neonatal care. It was decided, for instance, that newborns who cannot stay with the mother for medical reasons, should either be cared for in a neonatal service (called n–service), located within the maternity department (called M-service) and not in the paediatric department (called E-service) or should be transferred to a neonatal intensive care facility (called N-service). The same Royal Decree divides each maternity department in three units: the delivery unit, the neonatal unit and the ward were mothers and their healthy neonates are cared for. Based on the new regulation rules, only 18 hospitals in Belgium (among which 8 university hospitals) were allowed to organise this new N-service. At the same time the hospital financing system was changed to avoid that too many newborns are separated from their mother during the post-partum period in the hospital.
KCE Reports 94 Maternal Intensive Care in Belgium 7 1.3.2 The “WENZ”-report (1993) The reorganisation caused serious commotion within associations of paediatricians, as well as paediatric nurses and some hospital managers. Following federal elections in 1988, the newly appointed Minister of Health ordered a scientific evaluation of this reorganisation. This evaluation was given the name: WENZ-study (Wetenschappelijke Evaluatie van Neonatale Ziekenhuisvoorzieningen) and was conducted from 1990 – 1991 (Promotors: L. Cannoodt, A. Pardou and E. Eggermont). Originally this study intended to evaluate only the neonatal services. The study was prolonged e.g. to also develop the concept of Maternal Intensive Care and to make further policy-recommendations in that connection. The study was published in April 1993, both in Dutch and French 2 . The most important recommendations of the researchers of this so-called WENZ-study were: A. Each hospital with a maternity department needs to meet certain minimum standards of neonatal care as well. B. Newborns don’t belong in emergency services. There is a need for a neonatal service, located in the maternity department, but under the responsibility of a paediatrician for the medical aspects and a paediatric nurse or midwife (for the nursing aspects of neonatal care) C. There is a need for an accreditation of an N*-function; separate from the accreditation of the M-service. If a hospital does not meet these accreditation rules, it looses automatically also its accreditation to run an M-service. D. All newborns who need (even for one day) intensive care should be transferred to a hospital that is accredited for this neonatal intensive care (NIC-service) with at least 15 beds. A few of the existing N-services who fit perfectly in this new concept of NICservice don’t have a M-service on the same campus. It was not recommended that they should be shut down, but it was argued that the government should follow a policy that encourages having both a Maternal Intensive Care unit and an NIC-service at the same campus. Therefore, there is a need for an accreditation of both the MIC-service and the NIC-service simultaneously. Together they form the P*-function. E. The limited number of MIC-cases does not justify the creation of separate MICservices. Rather it was recommended to accredit MIC-services with at least 8 beds as part of a larger M-service that meets certain criteria. F. The WENZ-study emphasised that it is better to transfer the mother before the delivery (called intra-uterine transfer), rather than to transfer the newborn after the delivery, when one can predict that the newborn will need neonatal intensive care. It would therefore be unwise to allow the accreditation of MIC-services in hospitals without a NIC-service. G. These MIC-services are the best place to also observe some pregnant women with high risks for serious complications at least temporary during the pregnancy. H. According to the international literature at that time, there is a need of one MIC– service for a region having an average of 10.000 births a year. As none of the Belgian maternities have more than 3.000 births a year, it is clear that each P*-function should be accessible to a larger number of patients than just those followed during pregnancy by the gynaecologists attached to that hospital. In other words, the MIC-service is a tertiary care facility, with a regional function. This means also that those responsible for a good organisation of any given M-service, the local N*-function and the regional P*function should meet regularly to strive for optimal transfer-policies to and from MICservices and NIC-services. 2 Federale diensten voor wetenschappelijke, technische en culturele aangelegenheden. (1993). Financiering van de perinatale ziekenhuiszorg in België. Brussel, auteur.
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35. Etude relative aux coûts poten
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