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The Congress "Yes to Life," devoted to the ethical problems in perinatology, has been an important carrefour for the intercultural dialogue on these themes. This paper describes the aim of the Congress and why it was proposed.

Objective: The objective of this study is to evaluate the predictive performance of the Fetal Medicine Foundation (FMF) algorithm for prediction of preeclampsia (PE) between 11 and 14 weeks of gestation in an unselected Brazilian population., Methods: We conducted a prospective cohort study with 617 singleton pregnancies of unselected risk. Biophysical markers (mean pulsatility index, mean arterial pressure) and biochemical markers (placental growth factor (PLGF) and PAPP-A) were inserted into the FMF software and converted into multiples of the median (MoM). The subjects were divided into five groups: early-onset PE, parturition <34 weeks' gestation; preterm PE, parturition <37 weeks; PE, parturition at any gestational age; gestational hypertension (GH); and control group. Areas under the receiver operating characteristics curve (AUC) were calculated for the outcomes., Results: Among 617 patients, seven developed early-onset PE, 18 developed preterm PE (seven early PE plus 11 delivered between 34 and 36 + 6 weeks gestation), 34 developed PE (18 preterm PE plus 16 delivered after 37-week gestation), 12 pregnant women developed GH, and 517 women comprised the control group. The best predictive performance using the FMF algorithm occurred in the early-onset PE group, with AUC = 0.946 (95% CI 0.919-0.973) and the detection rate of 28.6% and 85.7% for 5% and 10% false-positive (FP), respectively., Conclusions: The FMF algorithm to predict PE was effective in a Brazilian population, mainly in the early-onset form of the disease at 10% FP.

Regional and statewide quality improvement collaboratives have been instrumental in implementing evidence-based practices and facilitating quality improvement initiatives within neonatology. Statewide collaboratives emerged from larger collaborative organizations, like the Vermont Oxford Network, and play an increasing role in collecting and interpreting data, setting priorities for improvement, disseminating evidence-based clinical practice guidelines, and creating regional networks for synergistic learning. In this review, we highlight examples of successful statewide collaborative initiatives, as well as challenges that exist in initiating and sustaining collaborative efforts., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To analyze temporal trends and management of postpartum hemorrhage (PPH) with transfusion and its related maternal near-miss (MNM) cases between 2006 and 2014 and to study risk factors., Material and Methods: This retrospective cohort study from two prospective databases included 156,047 women giving birth in all the maternity hospitals of Burgundy. We analyzed temporal trends and the distribution of PPH with transfusion, the circumstances of transfer of patients between hospitals and factors associated with PPH with transfusion. PPH with massive blood transfusion and/or non-medical treatment was defined as MNM. Statistical analysis included Chi 2 tests and logistic regression for multivariate analysis., Results: The overall rate of PPH with transfusion was 7.3‰ and globally increased during the study period whereas the MNM rate did not. MNM represented 37% of patients with PPH with transfusion and 71% of transferred patients, but surgical treatments were performed before transfer. Factors associated with PPH with transfusion were maternal age>35 years (odds ratio [OR]=1.3), prematurity (OR=5.0), cesarean section (OR=4.8), placenta previa (OR=22.0), twin pregnancy (OR=6.6), HELLP syndrome (OR=17.9) and severe small-for-gestational-age infants (OR=2.0). The first four were also associated with MNM., Conclusion: MNM cases of PPH rates were steady in Burgundy while rates of PPH with transfusion increased moderately., (Copyright © 2017 Elsevier Masson SAS. All rights reserved.)

In the Netherlands, the perinatal registry has undergone significant changes in the past decades. The purpose of this article is to describe the current health care information architecture for the national perinatal registry, including how the national data set is arranged and how electronic messages are used to submit data. We provide implications for women's health care providers based on the creation and implementation of the Dutch perinatal registry system., (Copyright © 2017 AWHONN, the Association of Women’s Health, Obstetric and Neonatal Nurses. Published by Elsevier Inc. All rights reserved.)

Management of the critically ill pregnant patient presents a clinical dilemma in which there are sparse objective data to determine the optimal setting for provision of high-quality care to these patients. This clinical scenario will continue to present a challenge for providers as the chronic illness and comorbid conditions continue to become more commonly encountered in the obstetric population. Various care models exist across a broad spectrum of facilities that are characterized by differing levels of resources; however, no studies have identified which model provides the highest level of care and patient safety while maintaining a reasonable degree of cost-effectiveness. The health care needs of the critically ill obstetric patient calls for clinicians to move beyond the traditional definition of the intensive care unit and develop a well-rounded, quickly responsive, and communicative interdisciplinary team that can provide high-quality, unique, and versatile care that best meets the needs of each particular patient. We propose a model in which a virtual intensive care unit team composed of preselected specialists from multiple disciplines (maternal-fetal medicine, neonatology, obstetric anesthesiology, cardiology, pulmonology, etc) participate in the provision of individualized, precontemplated care that is readily adapted to the specific patient's clinical needs, regardless of setting. With this team-based approach, an environment of trust and familiarity is fostered among team members and well thought-out patient care plans are developed through routine prebrief discussions regarding individual clinical care for parturients anticipated to required critical care services. Incorporating debriefings between team members following these intricate cases will allow for the continued evolution of care as the medical needs of this patient population change as well., (Copyright © 2016 Elsevier Inc. All rights reserved.)

Maternal-fetal medicine (MFM) is a multidisciplinary subspecialty dedicated to optimization of pregnancy and perinatal outcomes. MFM utilizes novel technologies for diagnostics and treatments in order to optimize obstetrical care and pregnancy outcome. Although defined as maternal and fetal medicine, originally aiming to equally address fetal and/or maternal issues, in reality the main focus of MFM has been shifted from improving maternal outcome and preventing maternal short- and long-term complications to improving fetal and neonatal outcome. In this article, we address the lack of communication between the two subspecialties and propose a resolution that will bridge the discrepancies by proposing to connect the leading hypotheses in MFM and in fetal medicine to those in maternal medicine., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The purposes of this study were to describe changes in perinatal nurse (n = 70) and physician (n = 88) perceptions of teamwork and safety climate after implementing a 6-month Crew Resource Management training program and compare responses between nurses and physicians. The Teamwork and Safety Climate Survey was administered prior to and 1 year after the intervention. There were significant improvements in nurse and physician perceptions of teamwork and safety climate; however, physicians perceived teamwork more positive than nurses.

Large clinical studies provide information and insight that are used to develop clinical guidelines. In view of the large sample sizes needed, many researchers have initiated multicenter studies. In some situations, the activities of these groups have led to networks, through which multiple trials have been executed over a longer period of time. The Global Obstetrics Network (GONet) was formed to link the different types of networks. The GONet mission is "to provide a forum for international interaction and collaboration among groups that perform clinical trials and observational studies in maternal fetal medicine and obstetrics." The purpose is to foster communication between groups to improve ongoing and future trials. This will open new avenues for cooperation in the design and conduct of large international trials, in seeking funding, and in highlighting evidence. The expectation is that this will lead to better studies and more efficient use of resources and minimize duplication. Furthermore, the group will provide insight and camaraderie, cooperate on data elements to allow future collaborations, and identify and highlight the pressing issues in maternal-fetal medicine. Here we describe the GONet mission, its objectives, structure and function, current collaborators, and plans for the future., (Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.)

Objective: To explore service users and care providers' experiences of combined fetal medicine and specialist paediatric clinics., Method: A brief survey of service users and care providers at combined fetal medicine clinics, which bring together multiple specialists and expertise for the management of pregnancies complicated by fetal cardiac, renal, neurological or surgical abnormalities., Results: Two hundred and sixty-one patients and 22 health professionals participated. More than 85% of women rated the clinic highly, 61% reported that the service had changed how they viewed the abnormality, and 53% reported that they would welcome further visits to the combined clinic. The majority of health professionals reported that combined clinics improved the accuracy of parental counselling and enhanced communication between specialties involved in the management of complicated pregnancies. The clinics are generally regarded as being useful for the training of junior staff., Conclusion: A service model that combines fetal medicine and paediatric specialists in a single clinic can efficiently modify parental perspective on fetal anomalies and enhance professional communication and training. Condition-specific information leaflets could further enhance service quality. A larger study involving a socio-demographically stratified sample of service users is needed to provide more authoritative data., (© 2012 John Wiley & Sons, Ltd.)

Objective: The aims of this study were to evaluate patients' opinions on a fetal cardiology telemedicine service compared with usual outpatient care, the effect of the telemedicine consultation on maternal anxiety and its impact on travel times and time absent from work., Methods: Prospective study over 20 months. Eligible patients attended for routine anomaly scan followed by fetal echocardiogram transmitted to the regional centre with live guidance by a fetal cardiologist, followed by parental counselling. All patients were offered a fetal cardiology appointment at the regional centre. Structured questionnaires assessing maternal satisfaction, travel times/days off and anxiety scores completed at time of both fetal echocardiograms., Results: Sixty-seven patients were recruited and 66 completed the study. Participants expressed very high satisfaction rates with fetal telecardiology, equivalent to face-to-face consultation. The telecardiology appointments were associated with significantly reduced travel times and days off work (p < 0.01). Expectant mothers expressed a clear inclination for a fetal cardiology appointment at the local hospital facilitated by telemedicine (p < 0.01)., Conclusions: Fetal telecardiology is highly acceptable to patients and is even preferred compared with travelling to a regional centre. There are additional socio-economic benefits that should encourage the development of remote fetal cardiology services., (© 2012 John Wiley & Sons, Ltd.)

In the framework of long-term scientific collaboration among the founder members coming from Holland and Italy there was a growing consensus to activate a philosophical doctorate (PhD) program, involving young Italian researchers in the field of perinatal medicine, neonatology and pediatrics. The aims were to promote excellence in research, offering to young Italian physicians the opportunity to maturate an International research experience leading to PhD degree, and to promote human and technological improvement energies in perinatal, neonatal and pediatrics research. Thus, an official collaboration among the Dutch Universities from Maastricht and Utrecht and the Italian Children's Hospital from Alessandria, has been activated on March 1st 2010, finalized to the PhD program. The experimental phase included the selection of projects and relative candidates after an interview-selection focusing on their scientific attitudes and the availability on their research projects. Candidates' selection started on May 2010 and on September 29th ten projects and candidates have been approved by the scientific commission. Research topics included: perinatal asphyxia, aging and the origin of adulthood neurodegenerative disease, neuroprotective strategies, biochemical pulmonology, intrauterine growth retardation and perinatal teratology. To date, all projects have been approved by local Ethics Committee from the University/Hospital of origin of the candidates. Five manuscripts have been published and/or submitted to international Journals regarding pneumology, perinatal asphyxia and teratology, whilst about 60-70% of data regarding clinical studies have already been collected.

The Union of European Neonatal and Perinatal Societies, worried for the lack of unanimous guidelines in the ethical domain, propose a 10-point charter about the ethical rights of the newborns. It is complementary to other charters, such as the United Nations charter of children's rights, but it adds some specific and debated points, to find a common denominator, hopefully useful to the ongoing debate.

Objectives: To test the hypothesis that the promotion of national guidelines recommending the transfer of high-risk mothers to subspecialty perinatal centers reduces mortality and morbidity through the reduction of preterm infants delivered at nontertiary maternity hospitals., Methods: After implementation of hospital-based educational and communication programs emphasizing the importance of maternal transfer to subspecialty perinatal centers, we conducted a population-based cohort study of all live births delivered at maternity hospitals in greater Cincinnati from 2003 through 2007 (n = 1825). Birth weights measured between 500 and 1499 g and gestational ages were less than 32 weeks. Risk-adjusted outcomes were measured by multivariate logistic regression in 2 stages. We compared these findings with those from a similar study conducted at our institution that included infants with birth weights less than 1500 g born between September 1, 1995, and December 31, 1997 (n = 848). The primary outcome was the percentage decrease in infants born with very low birth weights at nontertiary centers compared with our previous study., Results: The number of infants born with birth weights less than 1500 g and at less than 32 weeks' gestation delivered at hospitals without tertiary perinatal and neonatal care decreased from 25% to 11.8% between the 2 study periods. The odds of death or major morbidity for infants born with very low birth weights at nontertiary perinatal centers is 3 times that of infants born at subspecialty perinatal centers after controlling for demographic variations (odds ratio: 3.05 [95% confidence interval: 2.1-4.4])., Conclusions: Local promotion of national guidelines by neonatologists coincided with a significant reduction in the percentage of infants born with birth weights less than 1500 g and at less than 32 weeks' gestation who were not delivered at subspecialty perinatal centers, and, at 88.2%, this nearly achieves the Healthy People 2010 objective to deliver 90% of infants born with very low birth weights in subspecialty perinatal centers.

Over the past 2 decades, perinatal and neonatal health care has become less coordinated and more competitive in the United States. The impact at the state level has been the evolution of a fragmented, perinatal system with limited access and poorer outcomes. The evidence demonstrates lower mortality risk for very low-birth-weight infants born in designated tertiary centers. Regionalized systems of perinatal care are recommended to ensure that each mother and newborn achieve optimal outcomes. This article discusses the factors impacting implementation of this model at either the state or federal level as well as the incorporation of perinatal regionalization as part of the national agenda of health care reform.

The "Quality Chasm" exists in neonatal intensive care. Despite years of clinical research in neonatology, therapies continue to be underused, overused, or misused. A key concept in crossing the quality chasm is system redesign. The unpredictability of human factors and the dynamic complexity of the neonatal ICU are not amenable to rigid reductionist control and redesign. Change is best accomplished in this complex adaptive system by use of simple rules: (1) general direction pointing, (2) prohibitions, (3) resource or permission providing. These rules create conditions for purposeful self-organizing behavior, allowing widespread natural experimentation, all focused on generating the desired outcome., (Copyright 2010 Elsevier Inc. All rights reserved.)

Progress in prenatal diagnosis has led to more frequent detection of fetal abnormalities which, if left untreated, would be fatal or cause severe disabilities despite optimal postnatal care. Intrauterine surgery is possible in selected cases. Most procedures involve microendoscopy with local or regional analgesia. Fetal analgesia is indicated for procedures that are directly invasive for the fetus. Surgical treatment of twin-to-twin transfusion is so far the only example of successful fetal therapy, as demonstrated in a randomized controlled trial. The most severe forms of congenital diaphragmatic hernia may also benefit from temporary occlusion of the fetal trachea in order to allow lung growth and prevent pulmonary hypoplasia. The future of open fetal surgery will depend partly on the results of the ongoing MOM study of intrauterine coverage of myelomeningocele. These developments also raise ethical questions, including the competence of the surgical team, and the borderline between therapeutic innovation, experimental surgery, and standard of care. The possibility of therapeutic termination should not be overlooked.

The development of regional data-sharing among healthcare organizations is viewed as an important step in the development of health information technology (HIT), but little is known about this complex task. This is a case study of a regional perinatal data system that involved four hospitals, together responsible for over 10,000 births annually. Using standard qualitative methods, we chronicled project milestones, and identified 31 "critical incidents" that delayed or prevented their achievement. We then used these critical incidents to articulate six organizational capacity domains associated with the achievement of project milestones, and a seventh domain consisting of organizational incentives. Finally, we analyzed the relationship of milestone achievement to the presence of these capacities and incentives. This data center case suggests four requirements for sharing data across organizations: 1) a readiness assessment; 2) a perceived mandate; 3) a formal governance structure; and 4) a third party IT component.

Obstetric anesthesia has made significant progress over the last 50 years. It is one of the major subspecialties in anesthesia in US. Society for Obstetric Anesthesia and Perinatology (SOAP) was founded in 1968. According to its SCORE project on the practice of obstetric anesthesia, 82.4% of all parturients received some form of anesthesia for cesarean section or labor analgesia. Epidural analgesia was the most common form of labor analgesia (65%), followed by CSEA. This high percentage of anesthesia care for parturients mandates the presence of obstetric anesthesiologists at labor and delivery suites in major hospitals in US. The Japanese Society of Obstetrics and Anesthesia, formerly "Mutsu-bunben Kenkyukai", now called "Bunben to Masui Kenkyukai", was founded in Japan at about the same time as SOAP. Despite its long history, obstetric anesthesia is yet to be a major subspecialty in Japan. It is encouraging, however, that the number of attendants in obstetric anesthesia sessions in JSA seems increasing. SOAP has played an important role in the education and progress of obstetric anesthesia in US. I hope that the joint symposium of SOAP, Bunben to Masui Kenkyukai, and JSA at 39th SOAP annual meeting will facilitate the progress of obstetric anesthesia in Japan.

When a critically ill woman is pregnant, clinical interventions for the mother can have a profound effect on fetal status. It is essential that the fetus be considered as the second patient when developing the plan of care. The most practical solution for providing comprehensive care to pregnant women in the intensive care unit (ICU) is a collaborative approach involving members of the ICU and the perinatal team, each contributing their unique knowledge and skills to the care of the mother and her unborn baby. The purpose of this article is to describe a collaborative approach to caring for a pregnant woman in the ICU along with a brief overview of fetal assessment for ICU care providers so they can become familiar with terms and methods used in assessing fetal status and common interventions that promote fetal well-being.

Improvements in technology have increased the chances of survival for the micropremature infant and the very low birth-weight infant but have significantly increased the financial burden of health care organizations. This economic burden has a significant impact on third-party payers and on society in general. Of the annual US 10.2 billion dollars spent on newborn care alone, 57% is disproportionately consumed by the 10% of infants who are born preterm.

I was attending a caesarean section for a transverse lie and the baby was doing well, when the attendant brought another one! This baby also did well, and I had been attending a twin delivery without knowing it. This had happened to me once 40 years previously, when the twins had been undiagnosed. This time the problem was one of misunderstanding due to language difficulties, and visual clues such as two lots of resuscitation equipment were simply not available.

Legacy systems have proven to be long-term integration challenges for Intermountain Health Care (IHC) despite commitment and attention to share clinical information across settings and among clinicians. This study measures the extent of the disparity of data elements across three independent data systems in current use. A sample of relevant data elements was selected across systems covering prenatal, labor and delivery, and newborn intensive care units (NICU). The findings revealed only 17% of these sample data elements had compatible structure across all three systems. The implications from differences in granularity, missing data, and duplicate data entry, include diminished data quality, greater risk for medical error, increased costs of integration and inefficient use of clinician time. Retrospective guidelines for managing conceptual context and granularity are given to assist in designing an integrated longitudinal patient electronic medical record.

Background: To explore the utilisation of neonatal care resources in the region., Method: Place of birth, unit of admission, ventilator treatment, total and "unnecessary" length of stay in a tertiary unit, and to which location the children were discharged, were recorded from medical records of sick newborns from Finnmark transferred to the University Hospital of North Norway during 1992-99., Results: 255 newborns from Finnmark County were admitted to the University Hospital, of which 175 (69%) were delivered at the University Hospital. 70 (28%) were primarily admitted to an inappropriate level of care. 93% of preterms less than 32 weeks of gestational age and 85% of preterms at 32-35 weeks were transported inutero to the University Hospital. In 16% of hospital days at the University Hospital, the level of care was considered inappropriate. 50% of the children were discharged to hospitals in Finnmark County, while 41% went home directly. 58% of the preterms spent their last days in hospital in the neonatal care unit in Hammerfest., Conclusion: Improvements could be made to the allocation of patients to appropriate level of care. Preterms less than 32 weeks are adequately selected for inutero transport. A higher proportion of large preterms should be delivered and treated at the neonatal care unit in Hammerfest.

To determine whether the Healthy People 2000 objective to deliver very-low-birthweight (VLBW) infants at subspecialty perinatal care centres was met, and if improvements in the regional perinatal care system could reduce neonatal mortality further for 2010, we examined place of delivery for VLBW infants, associated maternal characteristics and the potential impact on neonatal mortality. We used linked birth and death records for the 1994-96 Georgia VLBW (i.e. 500-1499 g) birth cohorts. Among 4770 VLBW infants, 77% were delivered at hospitals providing subspecialty perinatal care. The strongest predictor of birth hospital level was the mother's county of residence, defined using three levels: residence in a county with a subspecialty hospital, residence in a county adjacent to one with such a hospital or residence in a non-adjacent county. Eighty-nine per cent of infants born to women who resided in counties with subspecialty care hospitals delivered at such hospitals, compared with 53% of infants born to women who resided in a non-adjacent county. Women were also more likely to deliver outside subspecialty care if they had less than adequate prenatal care [adjusted odds ratio (AOR) 1.5, P-value = 0.0001]. The neonatal mortality rate varied by level of perinatal care at the birth hospital from 132.1/1000 to 283/1000 live births, with the highest death rate for infants born at hospitals offering the lowest level of care. Assuming that the differences in mortality were due to care level of the birth hospital, potentially 16-23% of neonatal deaths among VLBW infants could have been prevented if 90% of infants born outside subspecialty care were delivered at the recommended level. These findings suggest that a state's support of strong, collaborative, regional perinatal care networks is required to ensure that high-risk women and infants receive optimal health care. Improved access to recommended care levels should further reduce neonatal mortality until interventions are identified to prevent VLBW births.

Knowledge translation is the process of bridging the gap between the overwhelming amount of research data/information/evidence and its critical appraisal, synthesis, dissemination, and application as knowledge by influential role models. Knowledge translation includes ongoing surveillance of the results of the implementation of new knowledge. By conducting research that is driven by relevant, well-defined questions and by using the most powerful study designs available, researchers generate valid new information that can later be translated into knowledge and applied in the clinical setting. Systematic reviews of the literature serve as good examples of knowledge management, when defined as "making proper use of the sum of what is known." Such reviews may identify that an intervention is effective without any harmful side effects, that it is noneffective, or that further research is warranted. Consumers of perinatal/neonatal health care or their ombudsmen should be encouraged to take part in setting the agenda and defining important outcomes for such research.

When three perinatal departments in three hospitals merged into a single department, the transition was complex, but cost-effective.

Today clinical information is used for a multitude of purposes beyond patient care documentation including quality review and improvement processes, allocation of resources, budgetary and long-term planning, productivity measurement, and justification to payers for services provided. Providers in perinatal medicine are faced with the challenge of finding methods to meet these information needs. Case examples of the different approaches to collecting and using obstetric and neonatal information are described. The role of computer-based patient records is outlined and solutions available to perinatal medicine are reviewed.

The current maternal/newborn care model is outdated and needs to be revised. The health care reform movement has created a window of opportunity to redefine the episode of pregnancy care and develop a more meaningful and more cost-effective model of care. The ultimate satisfaction for physicians will occur when they exert their natural control regarding the manner in which health care dollars are spent by managing the financial risk and the patient care. The optimal management of the health care dollar can only be achieved through initiation of an integrated model in which a coordinated care team supported by the appropriate risk assessment, education, prevention and wellness program, and medically necessary intensive care of the high-risk pregnancy are brought together effectively. An integrated model will give patients what they want: compassionate, convenient, comprehensive care. It will give the payers what they are looking for--appropriate care at an appropriate predicable cost and improved outcomes. Finally, it will give the providers what they want: control over the delivery medical care.

Objectives: The purpose of this study was to compare perinatal regionalization and neonatal mortality in Wales and Washington State., Methods: The 28 hospitals in Wales and the 80 hospitals in Washington State that offered maternity services and the 218,326 births that occurred in these hospitals in 1989 and 1990 were studied. Surveys were used to identify the neonatal technology and the referral policies of each hospital, and linked data from birth and death certificates were used to examine birthweight-specific neonatal mortality rates for all babies born in these hospitals., Results: Welsh district general hospitals (broadly equivalent to Level II perinatal centers in the United States) have more sophisticated neonatal technology than their Washington State counterparts and appear less likely to refer small or preterm babies to regional or subregional centers. Neonatal mortality rates were quite similar in the two settings., Conclusions: Perinatal care in Wales appears to be less regionalized than in a similar region in the United States. The relative lack of perinatal regionalization in Wales may contribute to duplication and underutilization of expensive neonatal technologies. National health care systems do not, in and of themselves, lead to optimal regionalization of services.

This article chronicles the development of the perinatal nurse practitioner (PNNP) role in providing care to high-risk obstetric patients in ambulatory and inpatient settings. Factors in the health care delivery system as well as the philosophic basis of the role are discussed. This role was modeled after neonatal nurse practitioners. Curriculum examples and role competencies are identified. Four programs are currently in existence with several more in the planning stages

Outcomes management involves goal-directed coordination of transdisciplinary teams. It focuses on achieving measurable outcomes for select populations of patients. The article presents a new advanced practice role focused on outcomes management for the perinatal population. Practice pattern reforms accomplished during 3 years of work and the associated favorable clinical, functional, service, quality, and financial outcomes are described. Supports required for the success of an outcomes management program as well as lessons learned from 2 years work are presented.

Evolving market forces are reshaping current patient, parent, provider, insurer, and hospital relationships. The traditional individualistic focus for accountability and responsibility is being supplemented by population-wide responsibilities and accountabilities. These changes, often lumped together as "managed care", are being implemented with evolving ideas on how best to manage an organize collaborative activity. In this article it is reasoned that perinatal services will improve as objective outcome measures guide the development, evolution, and operation of competing managed care networks. The article illustrates how a managed perinatal care network works with experiences drawn from the perinatal service programs of Kaiser Permanente's Southern California Region.

As flexibility and change become the only constants in health care delivery, providers are seeking improved methods for delivering quality, cost-effective services. Perinatal care is no exception. Length of stay is decreasing for obstetric patients, and the challenges of providing quality care are great. Outcomes management uses outcomes measures to improve clinical and functional results while better utilizing resources. Critical pathways and variances from that pathway are analyzed for opportunities to improve care and quality. Quality indicators are then derived from the variance data. The women's services outcomes manager, a new role, identifies and resolves quality issues.