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In Very Preterm Birth, Transfer as Good as Presenting at Level III Hospital

Babies born very preterm did no better when their mothers were initially admitted to a hospital offering high-level perinatal care versus transfer from another hospital, researchers reported from a study of nearly 5,000 early births.

Neonatal 28-day mortality did not differ significantly for infants born at 22-31 weeks gestation to mothers who transferred to a level III hospital compared to those initially admitted to such facilities (odds ratio 0.79, 95% CI 0.56-1.13), according to Kshama Shah, MD, of the Ann & Robert H. Lurie Children’s Hospital of Chicago, and colleagues.

However, infants born at non-level III hospitals — i.e., who didn’t transfer to a facility with high-level care — did fare significantly worse than those whose mothers presented to a level II hospital (OR 1.52 for 28-day neonatal mortality, 95% CI 1.14-2.02), Shah’s group reported in JAMA Pediatrics.

In an accompanying editorial, Megan Whitham, MD, and Donald Dudley, MD, both of the University of Virginia School of Medicine in Charlottesville, said that the research confirms that ensuring premature infants are delivered in risk-appropriate settings may lessen mortality risks.

“For women with pregnancies requiring very preterm deliveries, receiving care at the right hospital with the right resources can be a matter of survival or normal development for their children,” they wrote.

Whitham and Dudley also noted that women who delivered preterm babies in non-level III hospitals were more likely to be from disadvantaged groups: non-Hispanic black or Hispanic, on Medicaid, or with less than a college education. The editorialists called for further understanding about how lack of access to level III delivery facilities impacts underserved populations, pointing to the systemic racism that skews neonatal outcomes unfavorably for people of color.

“Until we acknowledge, identify and then rectify the problem of systemic institutional racism, progress in improving obstetric and pediatric outcomes will be incremental at best,” Whitham and Dudley wrote, adding that creating a uniform language to ensure all high-risk infants are transferred to the appropriate care setting is crucial to reduce mortality.

Prior research cited by Shah and colleagues has shown that babies born very preterm or with low birth weights face a lower risk of mortality before hospital discharge if their facility offers higher levels of perinatal care. Access to a level III facility — equipped to manage high-risk neonates, offering invasive and noninvasive ventilation, and providing access to pediatric subspecialties — boosts survival chances.

The current study included all infants born very preterm to Illinois residents from January 2015 to December 2016, with data from the Illinois Department of Health birth and death certificate registries.

Shah and colleagues assessed for neonatal mortality within the first 28 days, first week, and first day.

Because most level III hospitals in Illinois were located in urban counties, Shah’s group also took into account how location impacted access to delivery at a level III facility. They analyzed gestational age, presence of congenital abnormalities, whether a mother received antenatal steroids and maternal hypertension, diabetes, and sociodemographic characteristics.

The study included 4,817 infants born at 22-31 weeks gestation. Most were born at a level III hospital after maternal presentation there (68.5%). Approximately 14% were born at a level III hospital after prenatal transfer, and 17% were born at a non-level III hospital.

Infants whose mothers presented initially to level III hospitals for delivery were more likely to be born to non-Hispanic white women than to black or Hispanic mothers.

The 28-day neonatal mortality rate among all infants in the study was almost 12%. Neonatal mortality at 28 days was 10.7% among infants whose mothers presented to level III hospitals, 9.8% in the prenatal transfer group, and 17.3% for infants born in non-level III hospitals. The non-level III birth group had higher odds of mortality than the other groups on the first day and first week as well.

Limitations to the analysis include lack of data on progression of labor at the time a woman was admitted to the hospital; also, not all women presenting to non-level III facilities were necessarily appropriate for transfer. In addition, the researchers were unable to identify the hospitals from which transfers originated.

Shah and colleagues concluded that although Illinois and the U.S. continue to fall short of risk-appropriate care goals, there are many opportunities to increase prenatal transfers. A challenge of ensuring risk-appropriate neonatal care is the lack of access to level III hospitals, particularly in rural areas, they suggested. However, coordinating transfers may mitigate risks that come with decreased access to neonatal ICUs in these locations.

Shah and co-authors, as well as Whitham and Dudley, disclosed no relevant relationships with industry.


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