Neonatal ECMO in Asia: pathways to wider access

Neonatal extracorporeal membrane oxygenation, or ECMO, can provide life-sustaining cardiopulmonary support for babies born with severe respiratory or cardiac failure. Access remains uneven across Asia, where advanced neonatal centres coexist with vast rural populations and limited specialist services. The gap is driven by more than the price of equipment: safe ECMO also requires multidisciplinary teams, intensive monitoring, transport, blood products, reliable supplies and systems for selecting patients fairly.

Expanding access therefore calls for regional networks rather than isolated machines. Lessons from established programmes can guide countries building neonatal services, while Australian experience offers valuable insight into transport over long distances, collaboration between dispersed hospitals and the practical realities of maintaining highly specialised care. The history of regional scientific cooperation also provides a foundation for cross-border training, research and emergency support.

Why neonatal ECMO access varies across Asia

Asian neonatal ECMO capacity ranges from comprehensive programmes in major metropolitan hospitals to services that cannot provide continuous machine support. Japan, South Korea and Singapore have developed advanced neonatal and paediatric systems, while many hospitals across South and Southeast Asia serve large populations with fewer ECMO centres. The resulting disparity affects both survival and geography, particularly for families living far from tertiary hospitals.

A functioning ECMO programme depends on several connected resources. These include appropriate equipment, specialist neonatal and cardiac staff, perfusion support, intensive nursing, laboratory and blood-bank services, and a transport team capable of maintaining the circuit during a neonatal retrieval. A centre with a capable ventilator but no ECMO-trained nursing roster cannot safely offer the full pathway, regardless of its other neonatal facilities.

Uneven access also affects referral decisions. Hospitals without ECMO may transfer babies too late, while families may need to travel long distances at substantial cost. International and national ECMO registries can identify referral patterns and outcomes, but coverage is incomplete in many lower-resource settings. Building a reliable regional dataset is essential for judging whether new services improve survival, reduce unnecessary transfers and distribute resources equitably.

The FAOPS 2020 scientific network

FAOPS 2020 was the official website for the 21st Congress of the Federation of Asian and Oceania Perinatal Societies, planned in conjunction with PREBIC AA 2020 in Tokyo. The event was to cover the scientific programme, speakers, abstracts, registration, venue, organising committee and travel information. Its cancellation in April 2020 because of the COVID-19 pandemic and international travel difficulties interrupted plans for in-person scientific exchange.

The FAOPS 2020 congress archive nevertheless represents an important model for regional collaboration. A perinatal congress can connect clinicians, researchers and professional societies across national boundaries, helping participants compare protocols and build professional relationships. That network becomes particularly valuable when individual countries face shortages of ECMO expertise or when isolated centres struggle to maintain skills between rare cases.

The disruption also accelerated virtual collaboration. Online programmes can support case discussions, lectures, journal clubs and simulation training without requiring every participant to travel to Tokyo. For ECMO, such connectivity could support rapid consultation about circuit complications, anticoagulation and indications. Virtual exchange works best when it is paired with practical placements, shared protocols and arrangements for visiting clinical teams.

Technology, staffing, and infrastructure limits

ECMO equipment is only the visible component of a larger operational system. Neonatal programmes need reliable oxygen supply, heating and cooling systems, continuous physiological monitoring, blood pumps, oxygenators and specialised circuits. Consumables must be available before they are needed, while maintenance and infection-control processes must reduce the risk of circuit failure and hospital-acquired complications.

Staffing is an equally demanding constraint. A neonatal ECMO team commonly includes neonatologists, paediatric cardiac specialists, nurses, perfusionists, respiratory therapists, pharmacists, laboratory staff and retrieval clinicians. These professionals must coordinate around the clock. Experienced bedside nurses are especially important because subtle changes in flow, oxygenation or bleeding can require immediate interpretation and careful adjustment to the circuit.

Transport can be the decisive limitation in countries with large territories or fragmented health systems. Moving a baby on ECMO requires a specially equipped team, stable power and gas supplies, infection-control measures and enough medication and blood products for the journey. Hospitals may therefore refer early without ECMO support while arranging intensive care closer to the eventual receiving centre. Regional transport agreements and standard handover checklists can reduce delays and improve safety.

Equity, ethics, and family-centred care

Selection criteria must identify infants most likely to benefit without excluding those who could recover through other care. Gestational age, underlying diagnosis, reversible causes and the extent of organ injury all influence decisions, but prognosis remains uncertain in many cases. Multidisciplinary assessment and regular reassessment are therefore more appropriate than rigid referral rules, especially where a family faces the burden of prolonged travel.

Families also need support that extends beyond the intensive-care unit. Clear information, interpreter services where needed, mental-health care and assistance with accommodation can materially affect a family’s experience. Travelling can disrupt breastfeeding, sibling routines and employment. In Australia, partnerships with Aboriginal health services and culturally safe communication are important for families from First Nations communities, particularly when neonatal care involves relocation from a remote area.

Preventive maternal and infant health remain complementary to emergency ECMO provision. Resources examining omega-3 fatty acids contribute to wider knowledge about pregnancy and early development, although nutritional support cannot replace rapid treatment for critical neonatal illness. A comprehensive perinatal network should connect prevention, antenatal care, delivery planning, neonatal retrieval and post-discharge follow-up rather than concentrate resources solely on the ECMO circuit.

Lessons for Australia’s neonatal systems

Australia faces a distinctive version of the access problem because specialist neonatal services are concentrated in major cities such as Sydney, Melbourne, Brisbane, Adelaide and Perth. Families in regional, rural and remote areas may travel considerable distances for intensive care. For example, babies requiring ECMO support may need transfer from far northern Australia to a tertiary centre with a full multidisciplinary team, creating complex decisions about when and where to stabilise them.

Transport systems help address this geography. The Neonatal Emergency Transport Service supports retrievals in eastern Australia, while state retrieval services and the Royal Flying Doctor Service contribute to urgent transfers from remote locations. Agreements covering eligibility, handover, equipment and clinical responsibility are essential when a baby moves between jurisdictions. The Australia and New Zealand Intensive Care Registry also provides data that can support review of referrals and outcomes.

The local medical-device market presents another practical consideration. Hospitals and health services purchasing ECMO circuits and related equipment must work with sponsors, suppliers, the Therapeutic Goods Administration and Australian Border Force processes as applicable. Imported consumables need dependable customs clearance, while substitutions should be assessed by clinicians rather than accepted solely for convenience. A concentrated tertiary market can support training and inventory expertise, although shared procurement may improve resilience.

Australian centres could contribute through simulation training, tele-ECMO consultation and structured visiting support for regional hospitals. These activities would spread expertise without requiring every hospital to maintain a full ECMO programme. They should be accompanied by clear escalation pathways, transfer agreements and culturally safe care for families facing long journeys.

Models that can widen regional access

Different models suit different geographies and health-system capacities. A centralised hub offers clinical depth, while regional spokes and mobile teams bring selected expertise closer to the child. The appropriate model depends on population density, transport times, existing neonatal capacity and the number of babies likely to require ECMO.

A blended model is often the most practical. A metropolitan centre can lead training and quality review while regional hospitals provide stabilisation, early referral and follow-up. Common protocols should cover anticoagulation, emergencies, circuit changes, infection prevention and transfer preparation. Regular joint review of cases can maintain readiness even when individual centres encounter relatively few patients.

A practical path to broader neonatal ECMO access

Regional hubs in Asia can serve as training and quality-assurance anchors for nearby hospitals. They can develop simulation programmes, host short clinical placements and maintain referral networks that operate continuously rather than only during a crisis. South-to-South collaboration may be especially useful because participating institutions can share experience with comparable transport distances, staffing patterns and infrastructure constraints.

Shared procurement, local maintenance capacity and coordinated registries can reduce the cost of maintaining equipment and supply chains. Regulators and health ministries could also support regional arrangements for emergency mutual aid, credentialing and patient transfer. Research should evaluate survival, neurological outcomes, family burden and the equity of referral decisions rather than focusing only on the number of circuits used.

The immediate action for Australian clinicians, hospital leaders, funders and policymakers is to support a nationally coordinated ECMO partnership linked to international networks in Asia and the Pacific. Such a partnership should connect tertiary centres with regional hospitals through simulation, tele-ECMO, defined transfer pathways and shared quality data. A coordinated regional ECMO network, backed by trained teams and reliable transport, can turn advanced technology into consistently accessible neonatal care.