Association of Active Postnatal Care With Infant Survival Among Periviable Infants in the US

Neonatal Survival and Outcomes following Periviable Rupture of Membranes

To clarify survival for infants affected by periviable prolonged preterm premature rupture of membranes (PPROM) in the military health system (MHS). To add to current literature on outcomes following expectant management, including long-term neurodevelopment outcomes.Retrospective matched cohort review of six level 3 military neonatal intensive care units (NICUs; 2010-2020). Cases were matched 1:1 with control infants, matched by location, gender, gestational age (within 1 week), birth weight (within 300 g), and rupture of membranes (ROM) within 24 hours of delivery. Follow-up data were obtained for each infant through 48 months' corrected age or age of last documented health visit in a military treatment facility.Forty-nine infants met inclusion criteria. Mean ROM for cohort infants was 20.7 weeks, with mean latency period of 34.6 days and mean gestational age at delivery of 25.7 weeks. Cohort infants had a mean birth weight of 919 g. Cohort survival to NICU discharge was 75.5 versus 77.6% of controls (p = 0.81). Statistically significant short-term outcomes: oligohydramnios or anhydramnios at delivery (p < 0.0001), pulmonary hypertension (p = 0.0003), and high-frequency ventilation (p = 0.004) were higher in cohort infants. No differences were found regarding rates of early sepsis, intraventricular hemorrhage, surgical necrotizing enterocolitis, oxygen at 36 weeks or at discharge. No statistical difference in long-term outcomes at 18 to 48 months of age or incidence of autism, cerebral palsy, attention deficit hyperactivity disorder, or asthma.Cohort survival to discharge in the MHS was 75.5%, higher than previously reported and not different from matched controls. Infants born after periviable PPROM should deliver at centers with access to high-frequency ventilation and ability to manage pulmonary hypertension. There was no difference in long-term neurodevelopment between the groups. · Survival to NICU discharge is similar between infants exposed to periviable PPROM and controls.. · Cohort survival to discharge was 75.5%, higher than previously reported in recent literature.. · Infant with periviable PPROM should delivery at centers capable of managing pulmonary complications..

What Is Culture Made of? An Exploratory Study of Ethical Cultures and Provider Perspectives on the Care of Periviable Neonates

OBJECTIVE

 Studies examining intercenter variation in neonatal intensive care unit practices at the limits of fetal viability have hypothesized that institutional "culture" can be one of many factors that impact patient care. This study aimed to describe institutional culture at a single, large academic center with regard to the antenatal consultation, resuscitation, and postnatal management of periviable neonates.

STUDY DESIGN

 Members of six clinical groups-attending and fellow maternal-fetal medicine physicians, attending and fellow neonatal-perinatal medicine physicians, neonatal nurses, advanced practiced neonatal nurses, pediatric hospitalist physicians, and neonatal respiratory therapists-were invited to complete qualitative, semi-structured interviews. All audio recordings were transcribed. Dedoose software was used to complete team-based coding and thematic analysis.

RESULTS

 Twenty-two interviews were completed. Thematic analysis revealed three central themes described by participants as contributory to institutional culture: Perception, referring to factors based on individual attitudes and insights, Statements of Information, referring to factors anchored in more objective concepts such as outcomes data and institutional policy, and Dynamic Factors, referring to the relatively fluid factors of institutional culture that interact with both Perception and Statements of Information. Participants were more likely to mention factors in the Perception category (n = 430) compared with factors in the Information category (n = 225), and although the latter were described as critical components of antenatal counseling and perinatal management, the philosophy of our unit appeared to be more heavily rooted in institutional memory and individual belief systems.

CONCLUSION

 Our data demonstrate a personal undertone to institutional culture at the limits of viability, with an emphasis on individual attitudes and subjective interpretations of fact rather than empirical data. As the landscape of neonatology continues to change, understanding those factors that contribute to culture remains a necessary step toward deconstructing institutional belief systems and optimizing clinical care.

KEY POINTS

· Institutional culture is the collective norms and attitudes that help guide organizational behavior.. · Institutional culture may be one of many factors that impact the care of periviable neonates.. · Deconstructing culture helps us better understand our clinical environment and optimize patient care..

Neurological outcomes and associated perinatal factors in infants born between 22 and 25 weeks with active care

OBJECTIVES

To elucidate the outcomes of periviable infants receiving active care (AC) and explore perinatal factors associated with neurodevelopmental outcomes.

METHODS

This is a single-center retrospective study on infants born at 22-25 weeks of gestation, all of whom received AC. A developmental quotient (DQ) ≥ 85 at corrected 18 months was judged as normal.

RESULTS

Fifty-seven infants were included in the study. The survival rates at discharge were 83%, 86%, 93%, and 93% at 22, 23, 24, and 25 gestational weeks, respectively. The overall percentage of normal DQ was 26/47 (55%). Acidemia in the arterial blood gas measured within 6 h after birth was identified as a factor significantly associated with subnormal DQ.

CONCLUSIONS

Not only high survival rates, but also favorable neurodevelopmental outcomes may be achieved by AC in periviable infants. Moreover, impaired neurodevelopmental outcomes may be associated with early postnatal acidemia following initial resuscitation.

Need for national guidance regarding proactive care of infants born at 22-23 weeks' gestation

With recent rapid improvements in neonatal intensive care, the limit of viability has shifted downward to 22-23 weeks' gestation. The younger the gestational age of preterm infants, the higher the risk of survival despite severe neurodevelopmental impairments. For infants born at 22-23 weeks' gestation, the limit of viability, neurodevelopmental outcomes, and survival rates may be determined by the quality of proactive care. Owing to the high risk of severe neurodevelopmental impairment in 22-23 weeks' gestation, proactive care is sometimes withheld according to ethical or legal considerations, and there are significant differences in the provision of proactive care and survival rates across countries or institutions. Additionally, there are differing or even lacking guidelines regarding the care of these infants across countries and institutions. Japan and Sweden are countries with well-established national guidance and proactive care for infants born at 22-23 weeks' gestation, resulting in higher survival rates among them. In Korea, where there is an extreme shortage of neonatologists, maternal transfer before delivery at 22-23 weeks' gestation to high-activity regions with appropriate neonatal intensive care unit resources, such as adequate personnel and facilities similar to the centralized care model seen in Sweden, is crucial for improving the survival rates of infants born at 22-23 weeks' gestation. The survival of these infants largely depends on the quality of proactive care provided. This rate is not static and can be improved through proactive care based on national guidance and the implementation of enhanced neonatal intensive care practices, including centralization of care.

Survival outcomes among periviable infants: a systematic review and meta-analysis comparing different income countries and time periods

Background

Periviable infants are a highly vulnerable neonatal group, and their survival rates are considerably affected by patient-, caregiver-, and institution-level factors, exhibiting wide variability across different income countries and time periods. This study aims to systematically review the literature on the survival rates of periviable infants and compare rates among countries with varied income levels and across different time periods.

Methods

Comprehensive searches were conducted across MEDLINE, Embase, CENTRAL, and Web of Science. Cohort studies reporting survival outcomes by gestational age (GA) for periviable infants born between 22 + 0 and 25 + 6 weeks of gestation were considered. Paired reviewers independently extracted data and assessed the risk of bias and quality of evidence. Data pooling was achieved using random-effects meta-analyses.

Results

Sixty-nine studies from 25 countries were included, covering 56,526 live births and 59,104 neonatal intensive care unit (NICU) admissions. Survival rates for infants born between 22 and 25 weeks of GA ranged from 7% (95% CI 5-10; 22 studies, n = 5,658; low certainty) to 68% (95% CI 63-72; 35 studies, n = 21,897; low certainty) when calculated using live births as the denominator, and from 30% (95% CI 25-36; 31 studies, n = 3,991; very low certainty) to 74% (95% CI 70-77; 48 studies, n = 17,664, very low certainty) for those admitted to NICUs. The survival rates improved over the two decades studied; however, stark contrasts were evident across countries with varying income levels.

Conclusion

Although the survival rates for periviable infants have improved over the past two decades, substantial disparities persist across different economic settings, highlighting global inequalities in perinatal health. Continued research and collaborative efforts are imperative to further improve the global survival and long-term outcomes of periviable infants, especially those in Low- and Middle-Income Countries.

Systematic review registration

PROSPERO, CRD42022376367, available from: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022376367.

Viability of Extremely Premature neonates: clinical approaches and outcomes

Viability refers to an infant's ability to survive outside the womb, which is influenced by both developmental maturity and the quality of medical care received. The concept of periviability, which has evolved alongside medical advancements, describes the stage between viability and nonviability, typically spanning from 200/7 to 25 6/7 weeks of gestation. While the chances of survival are extremely low at the earlier end of this range, the possibility of surviving without significant long-term complications improves towards the later end. The effectiveness of various antenatal and postnatal care practices, particularly those considered to be part of an active approach, plays a crucial role in influencing survival rates and mitigating morbidities. However, the decision to provide such active care is heavily influenced by national guidelines as well as international standards. The variability in guideline recommendations from one country to another, coupled with differences based on gestational age or accompanying risk factors, prevents the establishment of a standardized global approach. This variability results in differing practices depending on the country or institution where the birth occurs. Consequently, healthcare providers must navigate these discrepancies, which often leads to complex ethical dilemmas regarding the balance between potential survival and the associated risks. This review article explores the evolution of the definition of viability, the vulnerabilities faced by periviable infants, and the advancements in medical care that have improved survival rates. Additionally, it examines the viability and periviability definitions, the care and outcomes of periviable infants and recommendations in guidelines.

Survival of Infants Born at 22 to 25 Weeks' Gestation Receiving Care in the NICU: 2020-2022

OBJECTIVE

To provide contemporary data on infants inborn at 22 to 25 weeks' gestation and receiving care at level 3 and 4 neonatal intensive care units in the United States.

METHODS

Vermont Oxford Network members submitted data on infants born at 22 to 25 weeks' gestation at a hospital with a level 3 or 4 NICU from 2020 to 2022. The primary outcome was survival to hospital discharge. Secondary outcomes included survival without severe complications, length of stay, and technology dependence.

RESULTS

Overall, 22 953 infants at 636 US hospitals were included. Postnatal life support increased from 68.0% at 22 weeks to 99.8% at 25 weeks. The proportion of infants born at 22 weeks receiving postnatal life support increased from 61.6% in 2020 to 73.7% in 2022. For all infants, survival ranged from 24.9% at 22 weeks to 82.0% at 25 weeks. Among infants receiving postnatal life support, survival ranged from 35.4% at 22 weeks to 82.0% at 25 weeks. Survival without severe complications ranged from 6.3% at 22 weeks to 43.2% at 25 weeks. Median length of stay ranged from 160 days at 22 weeks to 110 days at 25 weeks. Among survivors, infants born at 22 weeks had higher rates of technology dependence at discharge home than infants born at later gestational ages.

CONCLUSIONS

Survival ranged from 24.9% at 22 weeks to 82.1% at 25 weeks, with low proportions of infants surviving without complications, prolonged lengths of hospital stay, and frequent technology dependence at all gestational ages.

Variability of Care Practices for Extremely Early Deliveries

OBJECTIVES

Assess temporal changes, intercenter variability, and birthing person (BP) factors relating to interventions for extremely early deliveries.

METHODS

Retrospective study of BPs and newborns delivered from 22-24 completed weeks at 13 US centers from 2011-2020. Rates of neonatology consultation, antenatal corticosteroids, cesarean delivery, live birth, attempted resuscitation (AR), and survival were assessed by epoch, center, and gestational age.

RESULTS

2028 BPs delivering 2327 newborns were included. Rates increased in epoch 2-at 22 weeks: neonatology consultation (37.6 vs 64.3%, P < .001), corticosteroids (11.4 vs 29.5%, P < .001), live birth (66.2 vs 78.6%, P < .001), AR (20.1 vs 36.9%, P < .001), overall survival (3.0 vs 8.9%, P = .005); and at 23 weeks: neonatology consultation (73.0 vs 80.5%, P = .02), corticosteroids (63.7 vs 83.7%, P < .001), cesarean delivery (28.0 vs 44.7%, P < .001), live birth (88.1 vs 95.1%, P < .001), AR (67.7 vs 85.2%, P < .001), survival (28.8 vs 41.6%, P < .001). Over time, intercenter variability increased at 22 weeks for corticosteroids (interquartile range 18.0 vs 42.0, P = .014) and decreased at 23 for neonatology consultation (interquartile range 23.0 vs 5.2, P = .045). In BP-level multivariate analysis, AR was associated with increasing gestational age and birth weight, Black BP race, previous premature delivery, and delivery center.

CONCLUSIONS

Intervention rates for extremely early newborns increased and intercenter variability changed over time. In BP-level analysis, factors significantly associated with AR included Black BP race, previous premature delivery, and center.

Withdrawal and withholding of life sustaining treatment (WWLST): an under recognised factor in the morbidity or mortality of periviable infants?-a narrative review

Background and Objective

The morbidity and mortality of infants born extremely preterm varies substantially across networks, within countries and throughout the globe. Most of the literature tends to focus on the management at birth and choices around active resuscitation of extremely preterm infants. Withdrawal and withholding of life sustaining treatment (WWLST) is an important and central process in the neonatal intensive care unit (NICU) and practices vary substantially. As such, our objective in this review was to explore whether end of life decisions also contribute to variations in the morbidity and mortality of periviable infants.

Methods

This narrative literature review is based on studies from the last 15 years found using several searches of medical databases (OVID Medline, Scopus and Cochrane Systematic Reviews) performed between March 2021 and December 2023.

Key Content and Findings

Just as outcomes in periviable infants vary, the rates of and processes behind WWLST differ in the periviable population. Variation increases as gestational age decreases. Parental involvement is crucial to share decision making but the circumstances and rates of parental involvement differ. Strict guidelines in end-of-life care may not be appropriate, however there is a need for more targeted guidance for periviable infants as a specific population. The current literature available relating to periviable infants or WWLST is minimal, with many datasets rapidly becoming outdated.

Conclusions

Further research is needed to establish the role of WWLST in variation of periviable infants' outcomes. The unification of data, acquisition of more recent datasets and inclusion of variables relating to end-of-life decisions in data collection will aid in this process.

The artificial placenta and EXTEND technologies: one of these things is not like the other

The so called "Artificial Placenta" and "Artificial Womb" (EXTEND) technologies share a common goal of improving outcomes for extreme premature infants. Beyond that goal, they are very dissimilar and, in our view, differ sufficiently in their technology, intervention strategy, demonstrated physiology, and risk profiles that bundling them together for consideration of the ethical challenges in designing first in human trials is misguided. In this response to the commentary by Kukora and colleagues, we will provide our perspective on these differences, and how they impact ethical clinical study design for first-in-human trials of safety/feasibility, and subsequently efficacy of the two technologies.

Key factors associated with quality of postnatal care: a pooled analysis of 23 countries

Background

Progress in reducing maternal and neonatal mortality, particularly in low-income and middle-income countries (LMICs) and regions, is insufficient to achieve the Sustainable Developmental Goals by 2030. High-quality postnatal care (PNC) for mothers and neonates is crucial for mothers and babies, yet it remains the most neglected intervention on the continuum of maternal and child care. We aimed to estimate the associations between observable factors and high-quality maternal and neonatal PNC in pooled and country-specific analyses.

Methods

In this cross-sectional study, we used the most recent (2015-2022) Demographic and Health Surveys from 23 countries across Africa (n = 14), Southeast Asia (n = 3), Eastern Mediterranean (n = 2), Europe (n = 2), Americas (n = 1), and Western Pacific (n = 1). Women who, within the last 5 years, were aged 15-49 years at their last live birth that had delivered a singleton child were included. We identified eleven PNC behaviours recommended by the World Health Organization (WHO) to measure PNC quality, and applied thresholds to create binary outcomes for quality maternal and neonatal PNC. 15 factors were included in our analysis to assess their association with high-quality PNC for mothers and neonates in a series of single-adjusted and mutually adjusted logistic regression models, both in pooled and country-specific analysis. We also conducted two sets of subgroup analyses for place of residence and maternal age at last birth, and two sets of supplementary analyses to test the robustness of the results.

Findings

Among 172,526 women and their most recent child, 41.42% (40.93-41.91) received quality maternal PNC while 42.34% (41.86-42.83) received quality neonatal PNC. In the pooled analysis, we found that the factors showing the strongest associations with quality maternal PNC were delivery by skilled birth attendants (SBAs) (OR: 4.92; 95% CI: 4.32-5.59), four or more antenatal care (ANC) visits (OR: 1.69, 1.58-1.81), and institutional delivery (OR: 1.61; 1.46-1.78). Consistent results were found for all factors of quality newborn care (e.g., delivery by SBA: OR, 4.25; 3.75-4.81; four or more ANC visits: OR, 1.83; 1.70-1.96) except institutional delivery. The association between these leading factors and PNC quality were broadly consistent across countries. Subgroup analyses and sensitivity analyses showed generally consistent results.

Interpretation

Our study demonstrated that institutional delivery and frequent ANC visits had the strongest positive associations with quality PNC for both mothers and neonates. Our findings highlight that improvements to the quality of maternal and neonatal PNC in the LMICs we assessed are urgently needed to achieve ambitious maternal, newborn, and child health goals.

Funding

China National Natural Science Foundation.