Active Treatment for Extremely Preterm Babies on the Rise

Babies born extremely preterm were more likely to receive active treatment in recent years, but there were gaps in treatment among different racial and ethnic groups, according to a cross-sectional study.

From 2014 to 2020, the proportion of extremely preterm infants who received active treatment rose nearly 4% each year (45.7% to 58.8%), increasing in all racial and ethnic groups, reported Kartik K. Venkatesh, MD, PhD, of the Ohio State University College of Medicine in Columbus, and colleagues.

The frequency of active treatment increased in all gestational age groups, and most rapidly among babies born in week 22 of pregnancy, at an average increase of 14.4% per year in the study time period (from 14.0% to 29.7%), they stated in JAMA.

However, babies born to white individuals were more likely to undergo treatment compared to those born to Asian or Pacific Islander, Black, or Hispanic people. The authors stated that in “2019, 66% of periviable neonates were born to a mother who identified as either non-Hispanic Black or Hispanic,” and said “one possible explanation for variations in active treatment in the periviable period by race and ethnicity may be differing decisions of clinicians and families when faced with the high likelihood of morbidity and mortality and predictive uncertainty.”

In an accompanying editorial, Henry Lee, MD, and Deirdre Lyell, MD, both of the Stanford University School of Medicine in California, noted that more data are needed about treatment efficacy and prognosis. They added a lack of data describing an infant’s individual morbidity and mortality risk after active treatment creates barriers to effective counseling, as the definition of active treatment is unclear and dependent on the region where a patient receives care, the level of care at a hospital, and the individual family.

“Unlike other interventions that may be considered appropriate or optimal for a broad population, it is challenging to characterize active treatment and its components for the extremely premature population as always the ‘right’ treatment, given the uncertainties in the likelihood of survival and survival without morbidity,” they stated. “Quality care in this context should be viewed not as a simple matter of pursuing active treatment but rather as the optimal alignment of treatment, prognosis, and the values of the mother and family.”

The serial cross-sectional study, obtaining data on live births between 2014 and 2020 with data from the U.S. National Vital Statistics System Natality Files. Venkatesh’s group collected data from all live births, defining periviable births as infants born between 22 weeks’ and 25 weeks and 6 days’ gestation. The researchers excluded infants who were not U.S. residents and those with clinical anomalies.

They analyzed the proportion of neonates who received active treatment, which included interventions such as surfactant therapy, immediate assisted ventilation at birth, assisted ventilation for more than 6 hours, and antibiotic therapy during neonatal ICU admission. They adjusted for covariates including maternal education, insurance status, year of delivery, age, parity, prepregnancy BMI, preterm birth, gestational diabetes, infant birthweight and sex, among others.

Of nearly 27 million live births in the U.S., approximately 62,000 extremely preterm neonates were included in the final analysis. The median maternal age was 28 and 54% of births were covered by Medicaid.

Around 5% of the infants in the study were Asian or Pacific Islander, 37% were Black, 24% were Hispanic, and 34% were white.

Of all periviable births, just over half received active treatment. Approximately 45% who received active treatment underwent surfactant therapy, 96% immediate assisted ventilation at birth, 60% assisted ventilation for more than 6 hours, and 47% antibiotic therapy.

Compared to infants born to white individuals, those born to Asian or Pacific Islander (adjusted risk ratio [aRR] 0.82, 95% CI 0.79-0.86), Black (aRR 0.90, 95% CI 0.89-0.92), or Hispanic (aRR 0.83, 95% CI 0.81-0.85) individuals were less likely to receive active treatment. Infants born to people of color who were also delivered at 23, 24, and 25 weeks’ gestation were all significantly less likely to receive active treatment.

Study limitations included the lack of assessment of neonatal morbidity and mortality. Also, the researchers did not include stillbirths in the analysis, which raises the possibility for selection bias regarding the coding of deliveries as live births or stillbirths. And previous studies have had varying definitions of active treatment, the authors pointed out.