If all of the four measures were applied (delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; hypothermia prevention; and surfactant within 2 hours of birth or early CPAP if birth before 28 weeks), there would be a 18% reduction in mortality before discharge, without any increase of severe morbidity.
Objectives Very preterm births constitute fewer than 2% of births, but up to half of infant deaths. Evidence-based (EB) practices are shown to improve preterm health outcomes in randomised trials, their use and impact in routine clinical practice remain poorly understood. We evaluated the implementation of four high-evidence practices to assess whether they constitute a lever for reducing very preterm mortality and morbidity
Population and methods A prospective multi-national population-based observational study of infants born before 32 weeks of gestational age (GA) was done in 19 regions from 11 European countries covering 850,000 annual births participating in the EPICE (Effective Perinatal Intensive Care in Europe for very preterm births) project. Infants born between 24+0 and 31+6 weeks GA without serious congenital anomalies in 2011/2012 and surviving to neonatal admission (N=7,336) were included in the analysis. The main outcome measure was the combined use of four EB practices using an All-or-None approach: delivery in a maternity unit with appropriate level of neonatal care; administration of antenatal corticosteroids; hypothermia prevention (NICU admission temperature of ≥36 °C); surfactant within 2 hours of birth or early CPAP for infants born before 28 weeks GA. Infant outcomes were in-hospital mortality, severe neonatal morbidity at discharge and a composite measure of death or severe morbidity. We modelled associations using risk ratios (RR) with propensity score weighting to account for potential confounding bias. Analyses were adjusted for clustering within delivery hospital.
Results: 58.3% of infants received all EB practices for which they were eligible. Infants with low GA, growth restriction, low Apgar scores and born on the day of maternal admission to hospital were less likely to receive EB care. After adjustment, EB care was associated with lower in-hospital mortality (RR=0.72, 95% CI=0.60-0.87) and in-hospital mortality or severe morbidity (RR=0.82, 95% CI 0.73-0.92), corresponding to an estimated 18% decrease in all deaths without an increase in severe morbidity if these EB interventions had been provided to all infants.
Conclusions: More comprehensive use of evidence-based practices in perinatal medicine could result in significant gains for very preterm infants, in terms of increased survival without severe morbidity.
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Zeitlin J, Manktelow BN, Piedvache A, Cuttini M, Boyle E, Van Heijst A, Gadzinowski J, Van Reempts P , Huusom L, Weber T, Schmidt S, Barros H, Toome L, Norman M, Blondel B, Bonet M, Draper ES, Maier RF and the EPICE Research Group. Use of evidence-based practices to improve survival without severe morbidity for very preterm infants: results from the EPICE population-based cohort. BMJ 2016 (in press)