In the healthcare context the concept of proximity refers to the “physical availability” of different professionals and facilities that respond to the socio-healthcare needs of citizens. The recent pandemic symbolically demonstrated that proximity-based medicine is an essential resource for communities and its application requires careful planning and the ability to manage any challenges that might arise.
Perinatal care constitutes a paradigmatic example of the complexity one faces when managing proximity-based support in the healthcare context. There are multiple cultural and social aspects impacting childbirth and the delivery of support services- provided by a network of professionals that operate both in local services and in hospital facilities- has to constantly adapt to them.
Nationally, the 2010 ministerial guidelines promote the appropriateness of perinatal support services and the redefinition of the governing criteria they are based on. They indicate the optimal number of bed spaces, the minimum amount of births per birth centre and the parameters to classify healthcare facilities based on the complexity of the support they deliver [1]. Even though the report puts a strong emphasis on hospital-based care, it also proposes experimental support models- integrating hospital and local support services- that change based on the physiology of the pregnancy and any related risks.
Local government officials and citizens’ associations keep on advocating for the right to home-based childbirth but their battles risk benefitting electoral support more than proximity-based medicine.
Many regions- with various different political orientations- oppose the closure of birth centres with less than 500 births per year and the debate on the reorganisation of the network of support services has been focused on this matter for more than ten years since the State-Regions Conference approved the relevant guidelines. Local government officials and citizens’ associations keep on advocating for the right to home-based childbirth but their battles risk benefitting electoral support more than proximity-based medicine.
Safety and quality of care policies
Obstetric complications happen more frequently in facilities with low volume of activity. The closure of small birth centres is not associated to the worsening of maternal and perinatal outcomes and the professionals who provide support in a low number of deliveries per year report more complications compared to those with high levels of activity [2-4]. These scientific data should be considered alongside reflections on the ability to reconcile women/couples’ needs with low birth rates, the crisis of the different expertise in the work market and the sustainability of the system in the Country. The decreasing birth rate trend seems to be consolidated now [5]. However, the professionals available are not enough, especially in the birth centres with low volume of deliveries per year. What makes things worse is that young specialist physicians are not willing to work in facilities with modest volume of activity because it would compromise their professional education, which results in the lack of applications for those jobs. The operational, technological and safety standards outlined in the State-Regions Agreement and in the Ministerial Decree n.70 of 2015- particularly the provision of 24-hour on-call support from obstetricians, gynaecologists, anaesthesiologists and paediatricians/neonatologists- are truly testing the resilience of the network of Italian birth centres.
If the objective is to improve the provision of support services, then the closure of small birth centres should come alongside interventions that favour the physiology and demedicalization of the support, especially in high-activity facilities that deal with obstetric pathologies. In order to achieve this the National Perinatal Care Committee published some organisational directives on service provision models that give obstetricians the chance to support women with low risk pregnancy/labour independently [6]. As recommended by the World Health Organisation, it is important to ensure moms and babies are in perfect health with the lowest possible level of service provision, in line with physiological and safety requirements. Recent data from the national survey on family planning and sexual health centres [7], which was coordinated by the National Health Institute, demonstrate that these local proximity-based services are a strategic resource for the provision of perinatal care.
Organisational models should be revisited with a more wide-ranging approach in order to promote the development of professional communities that could integrate different expertise, ranging from healthcare to social support figures.
Public healthcare needs to work on a more appropriate use of its resources in order to promote quality of care while maintaining universal access to healthcare support during pregnancy. Organisational models should be revisited with a more wide-ranging approach in order to promote the development of professional communities that could integrate different expertise, ranging from healthcare to social support figures. This would enable a more synergic way to meet women and couples’ needs during pregnancy, labour and post-partum. The best response to the short-sighted request to keep small birth centres open in order to defend proximity-based medicine would be to re-launch policies around support services dedicated to the first 1,000 days of life, legislations that can integrate the concept of proximity with its most ample and noble application.
A network integrating hospital and local support services
The Perinatal Care Committee of the Emilia-Romagna region came up with an innovative pilot project for maternal/neonatal support services as an alternative to the request to keep birth centres with less than 500 births per year open [8]. The objective is to improve the network of support services and assistance dedicated to the first 1,000 days of life. The services integrating hospital and local support services are at the core of this reorganisation because they guarantee the provision of all the clinical and day-hospital services- to the population groups that will be impacted by the closure of the small birth centres- which will be decentralised in loco or prioritised by the staff mobility. This is a wide-ranging application of the concept of proximity, which contrasts the not so innovative idea of reopening small birth centres.
Furthermore the interventions outlined are not just around childbirth itself but they concern the enhancement of local support services, with a strong integration of the healthcare, social and education components. These are guarantees of proximity, support and assistance around parenting throughout the first 1,000 days of life.
There are numerous proposals specifically around this: registering and identifying the pregnant women in the districts that need to be reorganised in order to proactively offer an informative consultation by the ninth or tenth week of pregnancy; taking referrals for pregnancy related assistance based on the support profiles already used by the family planning and sexual health clinics; phone and/or home based contact, during the second and third trimester, with the obstetrician that conducted the first consultation; obstetric consultations during pregnancy and post-partum when requested by the woman; and psychological support throughout the whole birth journey.
The plan for hospital based support includes the following: the availability of wards that are specifically dedicated to risky pregnancies in the district hospitals and the integration of the relevant hospitals with the sexual health clinics; second-level prenatal diagnostics; wards dedicated to the last stage of pregnancies in order to facilitate the first access to the hospital that the woman intends to deliver her baby in; support during labour; the release of mom and baby from the hospital in combination with the support from the obstetrician, the gynaecologist, the general practitioner and the freely chosen paediatrician available in the local support services of the area; and the protected release of mom and baby from the hospital in cases of complex pregnancies with multiple issues. According to the pilot project during the post-partum period obstetricians- and, when required, other professionals in the team- would provide neonatal support at the sexual health clinic and/or at home. There would also be a 24/7 breastfeeding advice and support service, active participation in parenting projects including those dedicated to so-called “fragile” parenting and to the “Born to read” and “Born for music” projects. Additionally, the post-partum provision of antenatal courses and support groups would be increased to promote the wellbeing of mothers and children, and the cultural mediation services dedicated to struggling migrant groups would be strengthened.
The concept of proximity could finally be applied in a way that guarantees the delivery of support services while also promoting an integrated network of healthcare expertise and facilities for the benefit of the communities.
References
[1] Accordo Stato-Regioni, 16 dicembre 2010. Linee di indirizzo per la promozione e il miglioramento della qualità, della sicurezza e dell’appropriatezza degli interventi assistenziali nel percorso nascita e per la riduzione del taglio cesareo. Gazzetta Ufficiale, Serie generale n.13, 18 gennaio 2011.
[2] Kyser KL, Lu X, Santillan DA, et al. The association between hospital obstetrical volume and maternal postpartum complications. Am J Obstet Gynecol 2012;207:42.e1-17.
[3] Janakiraman V, Lazar J, Joynt KE, et al. Hospital volume, provider volume, and complications after childbirth in Usa hospitals. Obstet Gynecol 2011;118:521-7.
[4] Lasswell SM, Barfield WD, Rochat RW, Blackmon L. Perinatal regionalization for very low-birth-weight and very preterm infants: a metaanalysis. Jama 2010;304:992-1000.
[5] Istat. Natalità e fecondità della popolazione residente – anno 2019. Statistiche Report, 21 dicembre 2020.
[6] Comitato percorso nascita nazionale. Linee di indirizzo per la definizione e l’organizzazione dell’assistenza in autonomia da parte delle ostetriche alle gravidanze a basso rischio ostetrico. Ministero della salute, 23 ottobre 2017.
[7] Lauria L, Lega I, Pizzi E, et al. Consultori familiari: le sintesi regionali sui risultati dell’indagine nazionale del 2018-2019. Epicentro, dicembre 2019.
[8] Regione Emilia-Romagna. Atti amministrativi Giunta regionale delibero N. 1112 del 24.07.2017. Commissione tecnico consultiva sul percorso nascita. Proposta di riorganizzazione dell’assistenza alla nascita in Emilia-Romagna: ridefinizione della rete territoriale e ospedaliera perinatale (ostetrica e neonatologica).
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