The burden of illness in perinatal and neonatal care: The epidemiologist's role

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Summary

Clinical research to improve outcomes of pregnancy and perinatal/neonatal care and to reduce the burden of illness is grounded in modern principles of evidence-based clinical practice. The central tool for creating convincing evidence is the randomised controlled trial (RCT). However, creating evidence is only one step to the overall goal of reducing the burden of illness. Once new evidence has been created by a RCT it must be synthesised with existing evidence, the evidence must be applied and disseminated into clinical practice, and the effect of the new evidence on the specific illness being targeted must be re-evaluated. Perinatal/neonatal epidemiologists require multiple skills to understand not only how to evaluate the burden of illness and to identify problems that might have solutions, but also how to create and synthesise evidence, apply it in practice and evaluate its clinical application, even though they need not be equally expert in all areas.

Section snippets

Identifying problems: quantifying the burden of Illness

Infants needing neonatal intensive care can have relatively high rates of adverse outcomes, including death and neurosensory, neuromotor and cognitive impairments, especially those who were very tiny1, 2 or immature at birth.3, 4, 5 However, adverse outcomes are not confined to infants requiring neonatal intensive care; many apparently healthy infants at birth have substantial long-term impairments.1 Although focus has been on survival and neurosensory results, other health outcomes are also

Creating the evidence

Although RCTs in early life date back to the 1950s, there has been a recent surge of interest in large scale RCTs in perinatal and neonatal care, some of which have recently been reported, and others are ongoing. Perinatal examples of completed trials include caesarean or vaginal delivery for breech presentation at term,17 antenatal thyrotropin to reduce respiratory distress in preterm birth,18 and magnesium sulphate for neuroprotection of the fetus in women likely to deliver before 30 weeks

Synthesising the evidence

Having created the evidence, it needs to be synthesised with the existing literature. The pivotal role of the Cochrane Database of Systematic Reviews (CDSR) in this regard is amplified in detail in several other contributions to this issue, particularly before24 and after birth.25 However, systematic reviews appear not only in the CDSR but can also be found elsewhere; some may precede appearance in the CDSR, for example prophylactic indomethacin in the first days after birth,26 and others may

Applying the evidence

Having been synthesised, application of the evidence into daily practice is facilitated by the fact that those who have generated the new knowledge are often those who are most active in clinical practice. Hence not only can they apply the evidence to their own patients but they can also affect the clinical activities of their immediate colleagues. Having positions on committees that decide health policy, being actively involved in peer-review activities, and being active teachers of others

Evaluating application of the evidence

The specific disease being targeted needs to be re-evaluated after a period of time to determine the impact of the application strategy. Rarely will the results of individual RCTs be immediately applicable to the complete group of individuals who may ultimately benefit, perhaps because there are limitations in the sample studied, or because not all outcomes are fully evaluated. Systematic reviews, because they synthesise the evidence from many RCTs, are likely to be more generalisable to the

Re-evaluating the burden of illness

By the time a specific disease has been targeted and its effects ameliorated, other illnesses may have emerged, or the pattern of existing illnesses may have altered, and hence the overall burden of illness has to be re-evaluated. This helps to determine new health problems to attack, and guides future directions for research.

Conclusions

Neonatal perinatal epidemiologists require multiple skills not only in evaluating the burden of illness, but also in creating and synthesising new evidence, disseminating and applying evidence, and in evaluating application of the evidence, even though they need not be equally expert in all areas. Given the range and changeability of the activities encompassed by the phrase “perinatal/neonatal epidemiology” it is clear that the perinatal/neonatal epidemiologist should never be unemployed.

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