The Role of the Hospital of Birth on Survival of Extremely Low-birthweight, Extremely Preterm Infants

Abstract

After completing this article, readers should be able to: 1. Explain the differences between population-based and institutional-based outcome studies of extremely low-birthweight (ELBW)/extremely preterm (EPT) infants. 2. Define three commonly used mortality/survival outcome measures for neonatal intensive care unit admissions. 3. Explain the role of population-specific factors in the survival potential of ELBW/EPT infants. 4. Explain the role of selection bias for maternal and neonatal transport in site-of-care mortality/survival statistics for ELBW/EPT infants. 5. Explain the role of the hospital of birth in current survival statistics for United States ELBW/EPT infants. Advances in perinatal health care in the past 15 years have resulted in a marked decrease in neonatal mortality throughout the industrialized world. Prior to the late 1980s, the greater portion of improved survival among preterm infants occurred primarily in infants older than 28 weeks’ gestation at birth. Refinements in the design and operation of mechanical ventilators and intravenous nutrition support, the implementation of continuous pulse oximetry monitoring, and the introduction of medical closure of the patent ductus arteriosus with indomethacin and of surfactant replacement therapy for respiratory distress syndrome have been major contributors to the improved survival in recent years among more immature infants (<28 weeks’ gestation). In addition, use of antenatal steroid therapy for induction of lung maturity and tocolytics to delay delivery as well as aggressive management of maternal medical and obstetric complications of pregnancy have been associated with decreased severity of illness in extremely preterm infants. The organization of perinatal health services into regional networks improved the outcome of high-risk pregnancies in the 1970s. However, in the United States, during the recent time of advances in perinatal health care capabilities, regional organization was dismantled in many states due, in large part, to the economics of health care funding. There followed a proliferation of community hospital-based neonatal intensive care units (NICUs) …