Discussion
The political and health reforms implemented in Italy during the last decades, and the increased economic well-being allowed the reduction of mortality rate of infants <5 years of age, from 346.5‰ in 1887 to 3.6‰ in 2015 [
8]. Also mortality rates of infants <1 year and <1 week of age decreased, and in 2015 they were 3.1 and 1.4‰, respectively [
9]. Despite an overall and continuous improvement in infant/neonatal mortality rates (IMR/NMR), with lower levels than those of several European countries, notable disparities still remain disadvantaging insular and southern regions (3.4‰) than center-northern ones (2.9 and 2.5‰, respectively) and foreign citizens (4.5‰) than Italians (2.6‰) [
9].
The analysis of the main causes of mortality better defined the improvements obtained, revealing higher prevalence of congenital malformations and conditions of perinatal origin (69% in 2015), which progressively increased over time, than infectious diseases (2%), which conversely decreased [
9]. Indeed, NMR drop from 1990 to 2014 by 40% worldwide, while perinatal mortality rate (PMR) only by 15%, reaching 4.1‰ in 2013 [
10]. Variability among regions was observed also for PMR, showing higher values in Sicily (4.7‰), and lower in Lombardia (3.6‰) and Tuscany (2.7‰) [
10].
The PMR found in our study, although it reflects a sample which is not entirely representative of the whole population of pregnant women (excluding certain risk categories), seems to be lower than national and regional data. Our results, indeed, underline that the PMR gap with northern regions and the national average may be filled. However, some critical issues emerge, especially those about the management of mild prematurity/pathology. Moreover, a correlation between obstetric complications/non-physiological pregnancies and newborns transferred to II level centers was found in most cases (81%). This highlights the continuity of care between mother and newborn, and the unpredictability of birth, whose complications are not prevented in all cases excluding maternal/fetal risk factors.
The quality of emergency obstetric and newborn care, rather than its simple availability, is then essential to prevent perinatal mortality/morbidity [
11‐
14]. With the present analysis, we suggest that improvements in the observed critical areas may have a positive impact on mother and newborn health outcomes, and avoid many of maternal/fetal/neonatal deaths and diseases. Nevertheless, the measures to be taken often face challenges to scale up, many of which are context-specific [
15].
Specifically, in accordance with literature data [
16,
17], our results highlight the need to overcome obstacles as health workforce and financing [
18]. Sufficient numbers of health care providers with specific competence, including trained midwives and neonatal nurses [
19‐
21], may deliver quality care resulting in the best outcomes [
12]. In fact, their employment is associated with more efficient use of resources, reduced mortality and higher quality of care for mothers and newborns. Such improvements should be, anyway, carried on within a multidisciplinary context, which includes also obstetricians, neonatologists and community health workers [
12,
15].
High quality maternal and newborn health services should, then, require adequate financing. Conversely, the lack of investment in health is a well known issue [
12,
22]. Various strategies have been employed in different countries to improve access to and utilization of maternity services, and they showed promising results [
23‐
26]. Also in Italy, as underlined in the present report, such strategies should be applied, especially in southern regions and for complicated pregnancies and newborns with mild prematurity/pathology. Our findings specifically suggest that still HICs, mostly peripheral hospitals/rural areas, need to develop long term human resource plans for training and keeping health workers [
27], particularly midwives, neonatal nurses [
28], obstetricians and neonatologists [
29‐
31]. Specific skills are needed for those caring for newborns with prematurity/pathology, and the lack of this specialized cadre in most settings is indeed consistent with our experience [
32,
33].
Despite the critical issues detected, some encouraging results were obtained. We observed a low number (21, 2.5%) of newborns transferred on the total of live born, although among them those with mild prematurity/pathology were prevalent (18/21, 85%) (Fig.
4). Moreover, this data resulted in a milder impact than expected on “experience of care”, which is the patient’s perspective of the care received, for several presumable reasons.
First of all, the advantageous ratio between midwives and patients, which allowed human and care relationships of higher quality.
Secondly, a significant number of women (179, 22%) attended birth training courses with their partners. These took place during the study period, through regular meetings with all the figures of the staff, including clinical psychologists. They may have had not only a positive impact “per se”, but also an indirect reflection on the other mothers.
Finally, in the extra-urban and rural context like that here described, the hospital institution is deeply and intimately grafted onto the social network of the territory. The hospital and its operators, therefore, enjoy great credit and recognition at cultural and care level. The relationships between health workers and families, which have ancient roots, are unique and not dispersed and declined in the multiple health care offers, typical of the large urban centers and metropolitan areas.
The goal this study proposes, of improving the quality of care, could start by all the aspects above mentioned. The present setting, consolidating strengths and removing weaknesses, may represent a virtuous model, also in view of the strategic role played by the hospital in specific peripheral/rural contexts, such as the one here shown. The humanization and quality of care provided may, thereby, have favorable short and long-term effects on woman and child health. This is also supported by our rates of breastfeeding at discharge (55%, Fig.
5), higher than those of the whole Sicily in 2017–2018 (around 34%) [
34]. The proposals to implement the services that peripheral centers can offer could, then, include: enhancement/enlargement of birth training courses with other professionals (i.e. dietician/nutritionist, cultural mediator, social worker) to the
postpartum period, addressing obstetric and neonatal/pediatric issues (
postpartum depression/maternity blues, puerperal hygiene, vaccinations, foreign body airway obstruction, complementary feeding); courses/dedicated outpatient services of breastfeeding support, facing the territory (i.e. home interventions) and integrated with the primary pediatric care; improvement of access to
peripartum analgesia, respect for physiology, communication and sharing of health care procedures; free and active offer of prenatal screening tests to assess the risk of chromosomal abnormalities, aiming at reducing invasive diagnosis and centralizing high-risk pregnancies, also in support of the poorest population groups.
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