Size matters

Not every speciality in medicine can demonstrate a clear relationship between the size or throughput of a service, and the quality of the outcome. But in neonatal medicine there has been increasing evidence from around the world that larger neonatal services have better outcomes. So what about England—is there any reason to think that we might be different? Marlow and colleagues, reporting their analysis of the EPIcure2 data, now give us a definitive answer: England is not different. In fact there is a consistent gradient in favour of lower gestational age specific mortality between smaller units (with the highest), small regional centres, and large regional centres (with the lowest). Importantly, EPIcure2 examined the whole maternity pathway, so the findings relate to the outcomes of fetuses alive at the onset of labour, not just those live-born babies who made it into intensive care. Maternity networks, specialist commissioners, and neonatal networks all need to ponder the implications of these findings, which are clear: optimisation of the place of care of those mothers threatening to deliver the most immature babies, and caring for the babies themselves in …