Perinatal outcomes for extremely preterm babies in relation to place of birth in England: the EPICure 2 study

Abstract

BackgroundExpertise and resources may be important determinants of outcome for extremely preterm babies. We evaluated the effect of place of birth and perinatal transfer on survival and neonatal morbidity within a prospective cohort of births between 22 and 26 weeks of gestation in England during 2006.MethodsWe studied the whole population of 2460 births where the fetus was alive at the admission of the mother to hospital for delivery. Outcomes to discharge were compared between level 3 (most intensive) and level 2 maternity services, with and without transfers, and by activity level of level 3 neonatal unit; ORs were adjusted for gestation at birth and birthweight for gestation (adjusted ORs (aOR)).FindingsOf this national birth cohort, 56% were born in maternity services with level 3 and 34% with level 2 neonatal units; 10% were born in a setting without ongoing intensive care facilities (level 1). When compared with level 2 settings, risk of death in level 3 services was reduced (aOR 0.73 (95% CI 0.59 to 0.90)), but the proportion surviving without neonatal morbidity was similar (aOR 1.27 (0.93 to 1.74)). Analysis by intended hospital of birth confirmed reduced mortality in level 3 services. Following antenatal transfer into a level 3 setting, there were fewer intrapartum or labour ward deaths, and overall mortality was higher for those remaining in level 2 services (aOR 1.44 (1.09 to 1.90)). Among level 3 services, those with higher activity had fewer deaths overall (aOR 0.68 (0.52 to 0.89)).InterpretationDespite national policy, only 56% of births between 22 and 26 weeks of gestation occurred in maternity services with a level 3 neonatal facility. Survival was significantly enhanced following birth in level 3 services, particularly those with high activity; this was not at the cost of increased neonatal morbidity.

The smallest of the small: short-term outcomes of profoundly growth restricted and profoundly low birth weight preterm infants

“…2 In a European study, mortality in L&D was 100% for 22 weeks gestation infants, 80% at 23 weeks gestation and 36% at 24 weeks gestation, and the majority (89%) of the deaths in L&D among these infants was due to a decision to withdraw or limit care. 10 These deaths are the lowest when mothers are transferred to a higher level of care before delivery, 11 perhaps because the transfer is a marker for an increased aggressiveness in providing vigorous prenatal and postnatal care to these infants.…”

Intensity of Perinatal Care for Extremely Preterm Infants: Outcomes at 2.5 Years

“…Others have proposed that fetuses alive at the onset of labor 41 should be the denominator, but this ignores antepartum deaths that may be related to perinatal practices, such as in utero referral and fetal monitoring. 11 In this study, outcome was considered as a continuum, including both obstetric and neonatal care and the time point "mother's admission with a live fetus" was chosen as the denominator for the primary outcome.…”

Ethical issues in NICUs: The Attitude of Greek Healthcare Professionals Towards the Value of Human Life

“…The birth of extremely/very preterm babies or babies with extremely low/very low birth weight continues to be a discouraging epidemiological reality with minimal (if any) important improvements in survival rates and rates of neurological and developmental problems incurring after hospital release [1][2][3][4][5][6]. This epidemiological reality however, raises serious bioethical questions for healthcare professionals responsible for the provision of neonatal intensive care [7,8].…”