Neonatal intensive carehas beenoneof the success stories of thepast 30years,with steadily improving survival and slowly improving long-term outcomes for infants born early. In the 1980s, few infantsbornat25 through26weeksofgestationsurvived, but now high survival and low morbidity rates are expected throughout the developedworld. The outcome for infants born at the decreasing limit of viability has continually evoked anxiety in terms of the balance between poor survival with high rates of neuroimpairment and the burden ofproviding intensivecare formanyweeksormonths. In 1980, this limit was 25 through 26 weeks; now it is 23 weeks. This issue is frequently described as an ethical dilemma as to whether intensivecare shouldbe instituted for thesechildren.1 One of the major issues that confound attempts to provide hard management guidelines is the continual improvement inmortality,whichbringswith it changes in attitudes toward survival. Large epidemiologic studies have been performed worldwide, such as EPICure and EPICure 2 in the UnitedKingdom,2 a series of reports fromVictoria, Australia,3 the first EPIPAGE (Etude Epidemiologique sur les Petits Ages Gestationnels) study fromFrance,4 theEPIBEL (ExtremelyPreterm Infants in Belgium) study from Belgium,5 and EXPRESS (Extremely Preterm Infants in Sweden Study) from Sweden.6 This issueof JAMAPediatricscontains theheadline report from theEPIPAGE-2 iteration,coveringbirths inFrance in2011.7Such studies are expensive to perform and comprise herculean effort, involving obstetric, neonatal, and eventually developmental medicine in an effort to capture information on all births. Thesedata are then frequentlyusedas abasis for counseling parents and decision making in the perinatal and neonatal period, but equally important they shed light on a range of issues from brain development to service delivery. The results of EPIPAGE-2 reveal improvement in survival of 14% for 25 through 31 weeks of gestation since 1997 but no appreciable difference in survival at less than 25 weeks. The use of interventions known to improveoutcomes (eg, antenatal corticosteroids andsurfactants) andother interventions for which evidence is wanting (eg, induction and cesarean section) increased the number of births at 24 weeks and greater. In parallel, the proportions of infants bornwithmajor neonatalmorbidities (eg, brain injury, necrotizing enterocolitis, and bronchopulmonarydysplasia) alsodecreased.Theauthors are to be congratulated on such a comprehensive and complete study. Compared with other reports,2,3,6 their results also indicate less active intervention at less than 24 weeks and consequent low survival, in keeping with the prevailing national philosophy. Above all else, the philosophy of the health care professionals andparentswill determine survival at these low gestational ages.There is little consensusacrossEuropeon the appropriatenessof interventionat less than25weeks,8andpreviousreports6 fromSwedenindicatemuchhighersurvival rates down to 23weekswith active intervention.Despite this, there is variation within Sweden itself,9 and long-term outcomes seem as yet not to parallel improvements in survival.10 Thus, attempts to use data such as those from EPIPAGE-2 at these extremely lowgestational ages for counseling shouldbe set in context. It is difficult to use data in which we do not know whether intervention was optimized for survival. Cliniciansneed tobeable toquoteup-to-date and relevant informationtoparents facingtheprospectofextremely lowgestational age birth,11 andmuchhas beenmade about improved precision in risk. The Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Network provides data on outcomes of infants born at low gestational ages,whichvarywithbirthweight, fetal sex, and theuse of corticosteroids.12 This network provides an online calculator to refine this risk. For aparent facing adecisiononwhat action the clinical staff should take during labor and after birth, thesevariationsare somewhat irrelevant in thecontextof their child’sbirthplace.Amorecontentious issue iswhentooffer the woman choices about interventions for labor because not infrequently labor onset is rapid and progress to delivery swift. It is heartening to see thatwithinEPIPAGE-2most deaths that occurred were after redirection of care to palliation, presumably in theneonatalnurseryafter counselingofparents ina less stressful environment than during labor. Given that these large studies are expensive, timeconsuming,andchallenging toperform,are theynecessaryand doweneed tokeepperforming them?Couldwenot simplyuse local data to inform decisions? First, local data are subject to variation; when aggregate data were used during 4 years, the CIs of survival inmy institution varied from 22% to 70% at 23 weeks of gestation and 55% to88%at 24weeks (N.M., unpublished data, 2014). Outcomes vary even more because numbers are smaller. Thus, use of national or regional data improves theprecisionof theestimateandprovidesabenchmark against which individual institutions can evaluate their own performance. Second, population studies can identify trends that can help plan and develop services. For example, in the UnitedKingdom,wehave recentlyevaluatedoutcomesagainst theclinical setting inwhich thebirthoccurs, findingbetter survival for the fetus in labor and after delivery where birth ocRelated article page 230 Opinion