The Regionalized Perinatal Care Program

In this chapter, Marguerite Holloway, a contributing editor for Scientific American and an adjunct professor of journalism at Columbia University, looks back at the efforts of the Robert Wood Johnson Foundation in the 1970s and 1980s to encourage the regionalization of perinatal services—the care delivered to mother and child shortly before and after birth. The development of high-technology care delivered in neonatal intensive care units made it possible to save the lives of low-birthweight babies who previously might have died. But not every hospital could have the sophisticated equipment and specialized staff to care for the small percentage of infants requiring intensive care. It made sense, in the eyes of many maternal and child health experts, to organize services along geographic lines in a pyramid fashion. Pregnant women at risk of delivering a low-birthweight baby would be identified early and transferred up the pyramid to a hospital capable of offering the care necessary. At the top of the pyramid would be a level III hospital—often at an academic medical center—that would treat the most needy newborns in a high-tech neonatal intensive care unit.

Building on regional arrangements to provide care for specific illnesses in the United States and reports of success with regional perinatal care networks in Canada, the Foundation funded an eight-site demonstration program—the Regionalized Perinatal Care Program—to determine whether the regionalization of perinatal services would work on a large scale and with heterogeneous populations.

As Holloway observes, the path has been rocky, and long-term successes have been elusive. While the grantees funded under the program, as well as the comparison sites, made progress toward regionalization and lowering neonatal mortality rates, these achievements often evaporated after funding ended. And from the mid-1980s on, managed care organizations seemed to be directing people to their own networks rather than to networks built along geographical lines.

What is most disturbing about the story is that while infant and neonatal mortality rates have declined over the past 30 years, severe racial, economic, and class differences in low-birthweight, preterm delivery, and infant mortality rates persist. Even though this is a retrospective review of past programs, the hope is that it will stimulate new thinking on strategies that the nation can pursue to improve perinatal care.