Very Low Birth Weight Deliveries Research Articles

Resuscitation Opportunities for Fellows of Very Low Birth Weight Infants in the Vermont Oxford Network.

Neonatal-perinatal medicine (NPM) fellowship programs must provide adequate delivery room (DR) experience to ensure that physicians can independently provide neonatal resuscitation to very low birth weight (VLBW) infants. The availability of learning opportunities is unknown. The number of VLBW (≤1500 g) and extremely low birth weight (ELBW) (<1000 g) deliveries, uses of continuous positive airway pressure, intubation, chest compressions, and epinephrine over 3 years at accredited civilian NPM fellowship program delivery hospitals were determined from the Vermont Oxford Network from 2012 to 2017. Using Poisson distributions, we estimated the expected probabilities of fellows experiencing a given number of cases over 3 years at each program. Of the 94 NPM fellowships, 86 programs with 115 delivery hospitals and 62 699 VLBW deliveries (28 703 ELBW) were included. During a 3-year fellowship, the mean number of deliveries per fellow ranged from 14 to 214 (median: 60) for VLBWs and 7 to 107 (median: 27) for ELBWs. One-half of fellows were expected to see ≤23 ELBW deliveries and 52 VLBW deliveries, 24 instances of continuous positive airway pressure, 23 intubations, 2 instances of chest compressions, and 1 treatment with epinephrine. The number of opportunities available to fellows for managing VLBW and ELBW infants in the DR is highly variable among programs. Fellows' exposure to key, high-risk DR procedures such as cardiopulmonary resuscitation is low at all programs. Fellowship programs should track fellow exposure to neonatal resuscitations in the DR and integrate supplemental learning opportunities. Given the low numbers, the number of new and existing NPM programs should be considered.

Availability of Opportunities for Delivery Room Resuscitation of Very Low and Extremely Low Birth Weight Infants in U.S. Neonatal-Perinatal Medicine Fellowship Training Programs

Background: All Neonatal-Perinatal Medicine (NPM) fellowship programs are required to provide adequate experience during training to ensure that NPM fellow physicians can independently manage very low birth weight (VLBW) and extremely low birth weight (ELBW) infants in the delivery room (DR) including opportunities to provide and/or direct continuous positive airway pressure (CPAP), endotracheal intubation, chest compressions (CC), and the administration of epinephrine. The availability of these critical learning opportunities at NPM fellowship programs is not known. Aim: To estimate the mean number of VLBW and ELBW deliveries and delivery room procedures available to …

Simulation to Support Standardization of Delivery Room Management of the Very Low Birth-Weight Infant.

The birth of a very low birth-weight (VLBW) infant occurs infrequently, especially in the community hospital setting. It is critical that the team managing care of the infant in its first minutes of life follow evidence-based resuscitation guidelines and practices to optimize outcomes for this population. To implement a simulation program in a community hospital setting that supports standardized evidence-based delivery room practices of the premature infant born less than 30 weeks' gestation. Two VLBW emergent delivery scenarios were developed utilizing the neonatal resuscitation program scenario template. Special care nursery interprofessional team members from a community hospital were invited to participate in the simulation program (n = 28). Participants were asked to complete a neonatal version of the Emergency Response Confidence Tool, then view a short presentation related to delivery room management of VLBW infants. Participants attended a simulation program and completed the confidence tool after simulation. The simulation facilitator and unit educator documented team actions during each simulation session. Fifteen opportunities for improvement within 4 simulation sessions were identified and categorized. Fourteen paired pre- and postsurveys were analyzed. Reported confidence increased in 22 of 23 resuscitation-related items. Education and simulation programs providing opportunities to experience high-risk, low-frequency VLBW delivery situations can assist in identifying areas for improvement and may improve team member confidence. Additional research is needed to assess whether results would be similar if this program were provided at all levels of neonatal care throughout the healthcare system.

Effects of a Birth Hospital’s Neonatal Intensive Care Unit Level and Annual Volume of Very-Low-Birth-Weight Infant Deliveries on Morbidity and Mortality

Annual volume of deliveries better predicts risk-adjusted mortality among preterm infant than neonatal intensive care unit (NICU) levels. However, it is unknown whether NICU level and annual volume of very-low-birth-weight (VLBW) deliveries differentially affect neonatal morbidity. In this retrospective, population-based cohort study, the authors evaluated birth records of 72,431 infants (500- to 1499-g birth weight) born between 1999 and 2009, in order to assess independent effects of VLBW deliveries and NICU level on risk of various neonatal morbidities. Primary outcomes were individual morbidity-mortality composites of death or bronchopulmonary dysplasia, necrotizing enterocolitis (NEC), retinopathy of prematurity (ROP), and severe intraventricular hemorrhage (IVH). Secondary outcomes included death (in the NICU or in-hospital), age at death, and individual morbidities without mortality. The NICU levels were I (basic well-newborn care), IIA/B (resuscitation, stabilization, and available mechanical ventilation/noninvasive positive airway pressure of preterm infants before transfer), IIIA (comprehensive care), and IIIB/C (comprehensive care for VLBW infants). Statistical analysis used multivariate logistic regression models, adjusted for covariates and other confounders. Results show that proportion of VLBW infants born at NICU level IIIB/C increased from 68.8% to 72.6% during the study period, whereas those born at NICU level I decreased from 9.5% to 7.9% (P < 0.001). Delivery at lower-level NICUs and lower-volume hospitals was associated with earlier mortality, within the first 24 hours of life, for VLBW infants (66% level I vs 48% level IIIB/C). In terms of composite morbidity-mortality, birth at hospitals with low (≤10) VLBW infant deliveries per year was associated with the highest risk-adjusted probability of death (15.3%), death/severe IVH (17.5%), and death/NEC (19.3%). Rates of complications were also higher for infants born in level I or II NICUs than those born in level IIIB/C NICUs. Risk-adjusted probability of death or ROP was highest among infants born at level IIIB/C NICU (32.6%) and lowest among infants at hospitals with level IIIA (25.5%). In contrast to all these results, when looking at individual morbidities instead of composites, risk-adjusted probability of each morbid condition, except IVH, was lowest among infants at level I NICUs or low VLBW infant deliveries per year. However, this result may be due to a “protective” effect from the high early mortality rate of 66%, meaning infants passed away before morbidities could develop. Overall, higher and earlier mortality rates among preterm infants at lower-level NICUs prevented the authors’ ability to assess full effect of birth hospital on morbidity. However, low volume of deliveries (<50 per year) was a strong risk factor for infant morbidity and death, for example, death/severe IVH and death/NEC. This risk was 15% to 36% higher after adjusting for NICU level. In addition, morbidity-mortality composite outcomes showed that VLBW infants delivered at high-level NICUs had improved outcomes compared with those delivered at low-level ones. The authors thus recommend transferring high-risk pregnancies to hospitals with high-level NICUs and a high-volume of VLBW deliveries.

Using umbilical cord blood for the initial blood tests of VLBW neonates results in higher hemoglobin and fewer RBC transfusions

We previously described a method for reducing early phlebotomy losses from very low birth weight (VLBW) neonates by obtaining the initial blood tests from otherwise discarded fetal blood from the placenta. In the present study we sought to; (1) measure the feasibility of performing this method in actual practice, (2) test the hypothesis that this method would result in higher hemoglobin concentrations and lower erythrocyte transfusion rates in the first week after birth. We conducted two studies in three Intermountain Healthcare NICUs. The first was a feasibility analysis involving 96 VLBW neonates, measuring the success of obtaining the NICU admission laboratory blood tests this way. The second study used case-control methodology to test the hypothesis that this method would result in a higher blood hemoglobin 12 to 24 h after birth, and a lower proportion receiving an erythrocyte transfusion in the first week. In 91 of 96 VLBW neonates (95%) the initial blood tests were successfully obtained with this method. The success rate was not diminished by delayed cord clamping or cord milking, as it was successful in 35 of 36 (97%) such instances. Cases and controls were well matched on demographic and level of illness comparisons. Among cases the hemoglobin generally increased between birth and 12 to 24 h later, but among controls the hemoglobin generally decreased (P<0.05). In the week following birth fewer cases received vasopressors (P<0.01) and erythrocyte transfusions (P<0.001). We judge that it is feasible to collect the initial blood tests of VLBW neonates using otherwise discarded umbilical cord/placental blood, in that this can be accomplished in about 95% of VLBW deliveries. This method, which can be used in addition to either delayed clamping of the umbilical cord or cord milking, results in higher hemoglobin concentrations, less vasopressor use and fewer transfusions in the first week.

The Effect of Neonatal Intensive Care Level and Hospital Volume on Mortality of Very Low Birth Weight Infants

To determine the adjusted effect of hospital level of care and volume on mortality of very low birth weight (VLBW) infants in the state of California, where deregionalization of perinatal care has occurred. Secondary data analysis of California maternal-infant hospital discharge data from 1997 to 2002 was performed. Logistic regression was used to evaluate the odds of mortality among VLBW infants by hospital level of neonatal intensive care and volume of VLBW deliveries, in the context of differences in antenatal and delivery factors by hospital site of delivery. Both maternal and fetal antenatal risk profiles and delivery characteristics vary by hospital site of delivery. After risk adjustment, lower-level, lower-volume units were associated with a higher odds of mortality. The highest odds of mortality occurred in level-1 units with < or =10 VLBW deliveries per year (odds ratio, 1.69; 95% confidence interval, 1.43-1.99). In isolation, hospital volume, rather than level of care, had the greater effect. Although deregionalization of perinatal services may increase access to care for high-risk mothers and newborns, its impact on hospital volume may outweigh its potential benefit.

The Economic Burden of Preterm/Very Low Birth Weight Care in Nigeria

The care of very low birth weight (VLBW) neonates may impose an enormous burden on professional resources and finances of caregivers. This study seeks to evaluate the immediate cost of care of VLBW babies in a developing economy. Twenty-four hospital case records VLBW babies who survived till discharge over a 1 year period at the University College Hospital, Ibadan, Nigeria were reviewed. Estimates of the out of pocket costs of managing these babies were calculated. The overall cost of hospital care ranged from US$211.1 to US$1573.9. The direct (median) and indirect (median) cost of care ranged from US$80 to US$1055 (US$247.3) and US$101.0 to US$1128.1 (US$257.2), respectively. These constituted 22.8% and 3966.3% (median 133.4%) of the combined family income. In conclusion, the cost of care of the VLBW deliveries in Nigeria is very high for the level of the economy and constitutes a major financial burden on the family.

Interpregnancy Primary Care and Social Support for African-American Women at Risk for Recurrent Very-low-birthweight Delivery: A Pilot Evaluation

Very-low-birthweight (VLBW) delivery accounts for the majority of neonatal mortality and the black-white disparity in infant mortality. The risk of recurrent VLBW is highest for African-Americans of lower socioeconomic status. This study explores whether the provision of primary health care and social support following a VLBW delivery improves subsequent child spacing and pregnancy outcomes for low-income, African-American women. This pilot study of mixed prospective-retrospective cohort design enrolled African-American women who qualified for indigent care and delivered a VLBW infant at a public hospital in Atlanta from November 2003 through March 2004 into the intervention cohort (n (1) = 29). The intervention consisted of coordinated primary health care and social support for 24 months following the VLBW delivery. A retrospective cohort was assembled from consecutive women meeting the same eligibility criteria who delivered a VLBW infant during July 2001 through June 2002 (n (2) = 58). The number of pregnancies conceived within 18 months of the index VLBW delivery and the number of adverse pregnancy outcomes for each cohort was compared with Poisson regression. Women in the control cohort had, on average, 2.6 (95% CI: 1.1-5.8) times as many pregnancies within 18 months of the index VLBW delivery and 3.5 (95% CI: 1.0-11.7) times as many adverse pregnancy outcomes as women in the intervention cohort. This small, pilot study suggests that primary health care and social support for low-income, African-American women following a VLBW delivery may enhance achievement of a subsequent 18-month interpregnancy interval and reduce adverse pregnancy outcomes.

Volumen- und Ausstattungsmerkmale als peri- und neonatale Qualitätsindikatoren: Eine Übersicht über Daten der letzten 4 Jahre

This article reviews recent studies on the relationship between patient volume, level of care, and peri- or neonatal outcome for term and preterm infants. A PubMed search was performed using various combinations of keywords related to neonates, patient volume and outcome published since 2000. Two studies on term infants showed that perinatal mortality in Norway and Germany was 2 - 3 times higher for term infants born in institutions with less than 500, and 40 - 80 % higher in those with < 1000 births/year compared to larger hospitals. For preterm infants, the mortality risk for those born in hospitals without a level III neonatal intensive care unit (NICU) was almost twice as high as for those born in hospitals with such an NICU. With regard to patient volume, studies from both the USA and Germany showed a significantly, up to 56 % higher mortality risk for infants admitted to units with less than 36 or 50 very low birth weight (VLBW) admissions per year compared to larger NICUs. Although patient volume or level of care are poor predictors of neonatal outcome, the above data provide arguments for a more rigorous perinatal centralisation, aiming to restrict term deliveries to hospitals with at least 1000 births per year and VLBW deliveries to perinatal centres with 24 h on-site availability of a neonatologist and at least 36 - 50 VLBW admissions per year. This may result in a significant reduction in perinatal mortality in Germany. In the interest of the families at risk of loosing their child, we must strive further to achieve this goal.

Psychiatric and substance use disorders as risk factors for low birth weight and preterm delivery

OBJECTIVE:We examined the associations between psychiatric and substance use diagnoses and low birth weight (LBW), very low birth weight (VLBW), and preterm delivery among all women delivering in California hospitals during 1995.METHODS:This population-based retrospective cohort analysis used linked hospital discharge and birth certificate data for 521,490 deliveries. Logistic regression analyses were conducted to assess the associations between maternal psychiatric and substance use hospital discharge diagnoses and LBW, VLBW, and preterm delivery while controlling for maternal demographic and medical characteristics.RESULTS:Women with psychiatric diagnoses had a significantly higher risk of LBW (adjusted odds ratio [OR] 2.0; 95% confidence interval [CI] 1.7, 2.3), VLBW (OR 2.9; 95% CI 2.1, 3.9), and preterm delivery (OR 1.6; 95% CI 1.4, 1.9) compared with women without those diagnoses. Substance use diagnoses were also associated with higher risk of LBW (OR 3.7; 95% CI 3.4, 4.0), VLBW (OR 2.8; 95% CI 2.3, 3.3), and preterm delivery (OR 2.4; 95% CI 2.3, 2.6).CONCLUSION:Maternal psychiatric and substance use diagnoses were independently associated with low birth weight and preterm delivery in the population of women delivering in California in 1995. Identifying pregnant women with current psychiatric disorders and increased monitoring for preterm and low birth weight delivery among this population may be indicated.

Managed care and perinatal regionalization in Washington State

Objective: To determine if an association exists between managed care penetration and perinatal deregionalization in Washington State. Methods: The proportions of low birth weight (LBW) and very low birth weight (VLBW) deliveries were tabulated for each hospital in Washington State for the years 1989, 1993 and 1996. Level of perinatal care, degree of health maintenance organization (HMO) penetration, and maternal demographic characteristics including age, race, smoking, and Medicaid status were derived from state and national databases. Multiple linear regression analysis was performed for each hospital level to evaluate the association between change in proportion of LBW and VLBW deliveries and change in HMO penetration per hospital between each of the 3 years. Results: From 1989 through 1993, the proportion of LBW deliveries significantly declined at level III hospitals and rose at level I and II hospitals. This trend reversed between 1993 and 1996. Very low birth weight deliveries demonstrated more limited and somewhat contrary results, significantly decreasing, then increasing in level I hospitals, and significantly increasing in level III hospitals from 1989 to 1993. After controlling for changes in maternal characteristics over time, changes in HMO penetration at the hospital level were not significantly associated with an increasing proportion of LBW or VLBW deliveries at nonlevel III hospitals. In some analyses, increasing HMO penetration actually was significantly associated with decreasing LBW and VLBW deliveries at nonlevel III hospitals. Conclusion: Despite continued growth in HMOs throughout the state, the trend toward deregionalization in Washington State noted in the early 1990s has not continued. At the hospital level, the increasing presence of HMOs is not significantly associated with perinatal deregionalization.

Very Low Birth Weight Births At Non-NICU Hospitals: The Role of Sociodemographic, Perinatal, and Geographic Factors

The purpose of this study was to assess the extent of variation in the percentage of very low birth weight (VLBW) infants born at perinatal Level 1 hospitals (no Neonatal Intensive Care Unit [NICU]) across California's nine geographic Perinatal regions. The role of sociodemographic, perinatal, and geographic factors was also assessed. Multivariate analysis of California birth certificate files between 1989 and 1993, for 24,094 live-born infants weighing between 500 and 1499 gm, was conducted to identify factors associated with delivery at a Level 1 hospital. Analyses specific for race and ethnicity were also conducted for Hispanic, African American, and white cohorts. In the 5-year study period, 1989 through 1993, 10.5% (24,094) of all live-born VLBW infants were delivered in Level 1 hospitals. Significant variation across regions was evident, ranging from a regional low of 3.1% to a high of 24.3%. After controlling for multiple factors, the odds of delivering at a Level 1 hospital were decreased for African Americans and South East Asians and increased in Hispanic women as compared with white non-Hispanic women. For all women, less then adequate prenatal care, living in a 50% to 75% urban zip code, and living greater then 25 miles from the nearest NICU significantly increased the odds of VLBW delivery at a Level 1 hospital. For Hispanics, teen pregnancy and having two or more prior infant deaths increased the odds, whereas Medi-Cal as the payer source for delivery and two or more pregnancy complications decreased the odds of a Level 1 VLBW delivery. After taking these factors into account, when compared with Los Angeles, the odds of inappropriate delivery site ranged from 0.37 to 2.75 across California's nine geographic perinatal regions. Of this variation, 78% could be accounted for by the percentage of total births that delivered at a region's Level 1 hospitals. The overall state average of 10.5% deliveries of VLBW at Level 1 hospitals, although close to the 10% national objective for the year 2000, did not indicate the wide variation seen across California's nine geographic regions. Risk-adjusted regional differences in the likelihood of inappropriate delivery site for the high-risk VLBW infants suggest that reaching the Healthy People 2000 objective will require further strengthening of California's perinatal regional networks, especially in those regions where a high percentage of total births deliver at Level 1 hospitals.

Quality assessment of perinatal regionalization by multivariate analysis: Illinois, 1991–1993

To identify (1) those elements in the infrastructure of a regionalized perinatal network that have independent effects on the variation in perinatal mortality among nontertiary units (member level I and II hospitals) and (2) shortcomings, if any, in a traditional perinatal data base that impede quality assessment of contemporary regionalized care. We analyzed perinatal surveillance data for 3 years, from 1991 to 1993, in the state of Illinois, representing more than 190,000 annual births. Fetal death and neonatal mortality rates for the 97 nontertiary hospitals studied were the dependent variables of interest. Two sets of independent variables were studied, those assessing the maternal sociobehavioral risk of populations served and those assessing the network infrastructure (defined as the facilities of member hospitals and their function within the regionalized network). We used multivariate analysis to partition the variation in hospital rates of perinatal mortality into two components, one attributable to maternal sociobehavioral risk and the other to the network infrastructure. Maternal sociobehavioral risk alone explained 73% of the variation in hospital fetal death rates and 38% of that in hospital neonatal mortality rates. When controlling for maternal sociobehavioral risk, rates of inborn very low birth weight (VLBW) deliveries (P < .001) and neonatal transport (P = .01) had independent effects on the variation in hospital fetal death rate; rates of inborn VLBW deliveries (P < .001), neonatal transport (P < .001), and proportion of VLBW infants transported out (P = .029) had independent effects on the variation in hospital neonatal mortality rate. In this mature statewide network, the rate of inborn VLBW deliveries exerted the strongest independent effect on variation in level I and II hospital rates of both fetal death and neonatal mortality. However, that there was such a large effect from maternal sociobehavioral risk alone has important public health implications. Additions and modifications to traditional perinatal surveillance are suggested better to assess the quality of regionalization in a contemporary health care environment.

Adolescence and very low birth weight infants: A disproportionate association

To examine the incidence of very low birth weight (VLBW) neonates, defined as those weighing less than 1500 g, delivered by adolescents compared with the general obstetric population. A retrospective observational study of 16,857 women delivering live-born infants from January 1, 1989, to June 30, 1993, was conducted at the University of Arizona Health Sciences Center. Adolescents were defined as those having a maternal age of 18 years or less at the time of delivery. The rate of VLBW infants delivered to adolescent mothers was compared with the general obstetric population (women at least 19 years old) using chi 2 analysis, multiple analysis of variance, and multiple linear regression. During the study period, 204 VLBW infants were delivered, yielding an overall VLBW delivery rate of 1.2%. Adolescents had a VLBW delivery rate that was considerably higher than the general obstetrical population: 35 of 1758 (2.0%) versus 169 of 15,099 (1.1%) (P = .002). Whereas adolescents accounted for 10.6% of the total deliveries during the study period, they delivered 17% of the VLBW neonates. The relative risk of an adolescent delivering a VLBW infant was 1.7 (95% confidence interval 1.2-2.2). Preterm birth is one of the major unresolved problems in modern obstetrics. Although the association between adolescence and preterm birth has been reported previously, specific attention has not been focused on the VLBW neonate. We conclude that adolescents deliver a disproportionate number of VLBW infants.