Saving pennies and saving premmies

According to a report in the Guardian today, premature babies in the UK
are being put at risk because of a shortage of suitably qualified
staff. It is usual in newborn intensive care units in the UK for nurses
to have to look after more than one baby at a time. There is usually
one nurse per two sick babies, whereas in adult or paediatric intensive
care there is almost always one nurse per patient. This is contrary to
the recommendations of British specialists in newborn intensive care.

The premature baby charity Bliss, who obtained the information cited in the newspaper report has argued for more funding to resolve staffing shortages. The Liberal Democrat health spokesman has responded to the report, arguing that “The same level of care should apply to all patients in intensive care units, regardless of their age."

There are several questions that might be asked here. Do the different staffing levels reflect a different priority for newborn infants in the allocation of health resources? Are there relevant differences that would justify a lower staffing level in newborn intensive care compared to adult or paediatric intensive care? Is it justifiable to give preference in terms of funding to adults or children (say) over newborn infants?

The first thing to note is that staffing shortfalls in newborn intensive care do not necessarily represent a lower priority in health care funding. One reason for this is that there are just not enough specialised nurses working in newborn intensive care to go around. There is a global shortage. There might be enough money to pay for more nurses, but this would not help if there are no extra nurses available.

Secondly, some may argue that there is not the same need for one to one nursing care for sick newborns as there is for older children or adults. In fact there is not a huge amount of evidence that 1:1 nursing improves outcomes for newborns in intensive care. There is a little bit of evidence (one paper) that paradoxically death rates may be higher for very premature babies cared for with higher nurse:infant ratios. That could be because fragile extremely premature babies do better if they are disturbed and handled less. However in addition, most premature infants in intensive care have single organ failure, whereas most critically ill adults have multi-organ failure. The level of nursing intervention required may be significantly higher for sick adults than for (at least some) sick infants.

Finally, although there may be fairness and equality grounds for the claim that newborn infants should be treated on a par with children or adults, there are some arguments that would support giving preference to older individuals. When asked to prioritise resuscitation between a number of individuals of varying ages, people consistently give priority to older children or adults over newborn infants, particular premature newborns. When the choice is made stark, between saving the life of a 6 year old or a 6 hour old infant, the vast majority of respondents choose to save the life of the 6 year old. These sorts of attitudes might be behind the lower staffing ratios for newborn intensive care. It has been claimed that they represent a form of discrimination against newborns, particularly premature newborns. However one relevant reason for preferring to save the life of an older child is that it may be much less of a harm for a newborn to die compared to an adult or a child.

However questions about funding for newborn intensive care are not simply questions about whose life to save. Lower funding for newborn intensive care could mean that some infants survive with significant impairment who might otherwise have been less impaired or not impaired at all. And it may be much more of a harm for a newborn to be impaired than for an adult (since they have potentially many years ahead of them).

If intensive care is going to be provided for newborn infants we should ensure that adequate levels of nursing and medical staff are provided to give infants the best chance of surviving without impairment. Apart from anything else, skimping on the funding of newborn intensive care now might lead to substantially higher long health care costs.

Staff shortages ‘put premature babies at risk‘ Guardian 16/10/08

Baby steps to better care – press release from BLISS 15/10/08

Callaghan LA, Cartwright DW, O’Rourke P, Davies MW.
Infant to staff ratios and risk of mortality in very low birthweight infants.
Arch Dis Child Fetal Neonatal Ed. 2003 Mar;88(2):F94-7.

Nurse staffing in relation to risk-adjusted mortality in neonatal care Arch Dis Child 2007

Nobody likes premies: the relative value of patients’ lives A. Janvier J Perinatology 2008

Is it bad for babies to die? Philsophy Etc Sept 2008

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