Extreme prematurity: How low can we go? Survival and long-term outcome.

Abstract

A proactive policy of resuscitation at birth and prompt initiation of intensive care have been shown to be associated with an improvement in the survival of very preterm infants in regional population-based studies within the State of Victoria in Australia. As a greater percentage of livebirths were offered intensive care in this study which spanned over 20 years, the survival rate rose progressively in all birthweight and gestation subgroups among extremely low birthweight infants, including those who were bom at borderline viability down to 23 weeks gestational age. Their quality-adjusted survival rate also rose progressively, since the large gains in survival over time had not been offset by significant increases in survival with disability. Cost-effectiveness and cost-utility ratios remained stable overall, with efficiency gains in the smaller infants over time, as more such infants were being transfeffed-in-utero and were born in Level III perinatal centers with the regionalization of perinatal-neonatal health care programs. Multicentered collaboration to conduct long-term studies of geographically-defined cohorts provides unique information not available from institution-based studies. Such data are vital for answering questions such as "How low should we go?" Quality outcomes depend more on the comprehensive organization of an effective system of networking perinatal-neonatal services within a geographically determined region, than on the introduction of expensive high-technology therapies within individual neonatal intensive care units.