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Developmental Biology - Premature Births Improve
California's Premature Births Decline
A new study follows the smallest, most premature infants, born 11 to 18 weeks early or weighed 0.88 to 3.3 pounds at birth...
California's most vulnerable premature babies are now healthier when they go home from the hospital. This finding is according to a new study led by researchers at Stanford University School of Medicine and the California Perinatal Quality Care Collaborative.
Between 2008 and 2017, there was an increase from roughly 62% to 67% in the proportion of the smallest and most premature infants surviving until discharge — without major complications due to early birth. And, there were fewer births with major complications.
The study was published online June 18 in the journal: Pediatrics.
"When a family takes their baby home from the hospital, we want them to be as healthy as possible. Survival without major complications is one way we take into account that survival alone isn't our only goal."
Jeffrey Gould MD, Professor, Pediatrics; and Robert L Hess Endowed Professor, Stanford Uniersity School of Medicine; and, California Perinatal QualityCare Collborative.
About 1 in 12 California babies are born premature, arriving at least three weeks early. About 1 in 100 are born 10 or more weeks before their due date.
According to Lee, in the last 50 years, survival rates for very premature babies have greatly improved. But, some preemies continue to experience severe complications after birth: lung problems, infections, digestive disease, brain injury, brain hemorrhage and vision loss.
Although prior studies examined changes in the rates of individual complications of prematurity, none addressed whether these complications were declining among the population of preemies in California.
Hospitals working together
California hospitals have been working together since 2007 to help neonatal intensive care units improve outcomes for babies. To promote this goal, they formed the California Perinatal Quality Care Collaborative. Headquartered at Stanford, the collaborative has conducted many projects to improve preemies' health, such as studying best practices for resuscitating preemies in the delivery room and figuring out how to support breast-milk expression for mothers who deliver prematurely.
The new study focused on the smallest and most premature babies, those born 11 to 18 weeks early or who weighed 0.88 to 3.3 pounds at birth. It included 49,333 infants who were in the NICUs of 143 California hospitals between 2008 and 2017. The study did not include infants who died at birth or who had severe congenital abnormalities.
Researchers analyzed the infants' medical records to look for the presence of major complications of premature birth. Between 2008 and 2017, the percentage of very premature or very small infants in California who survived without major complications improved from 62.2% to 66.9%.
There was significant decline in mortality of these infants over the same period. Complications which decreased the most were necrotizing enterocolitis, a disease in which intestinal tissue dies, declining 45.6%; and infections, which declined 44.7%.
Fewer Complications per Infant
The number of infants in the study with four or more separate complications declined 40.2% between 2008 and 2017, the number with three complications declined 40.0% and the number with two complications declined 18.7%.
"It was really encouraging to me that we found babies were less likely to have multiple morbidities," said Lee, adding this means care is improving even for the sickest preemies. The performance of California's neonatal intensive care units became more uniform for most complications of prematurity, with less variation between hospitals. However, there is still room for improvement.
The study estimates if all hospitals matched performance seen in the top 25% of the state's NICUs — an additional 621 California preemies would go home from hospital without major complications yearly.
The California Perinatal Quality Care Collaborative is helping health care providers at all NICUs learn from each other, Lee said. "We're starting to see which hospitals have very good outcomes, or have improved significantly over the last few years. Now we can disseminate the knowledge they gained from their experience."
For families of premature babies, the new findings have a hopeful message.
"It's a hard situation when a family suddenly faces premature birth. But we can tell them that we have taken care of many babies born at this age, and we've gotten better. That would hopefully be something of a reassurance."
Henry C. Lee PhD, Perinatal Epidemiology and Health Outcomes Research Unit, Division of Neonatal and Developmental Medicine, Department of Pediatrics, School of Medicine, Stanford University, Stanford, California; and
bCalifornia Perinatal Quality Care Collaborative, Stanford, California.
Abstract Objectives
To examine trends in survival without major morbidity and its individual components among very low birth weight infants across California and assess remaining gaps that may be opportune targets for improvement efforts.
Methods
The study population included infants born between 2008 and 2017 with birth weights of 401 to 1500 g or a gestational age of 22 to 29 weeks. Risk-adjusted trends of survival without major morbidity and its individual components were analyzed. Survival without major morbidity was defined as the absence of death during birth hospitalization, chronic lung disease, severe peri-intraventricular hemorrhage, nosocomial infection, necrotizing enterocolitis, severe retinopathy of prematurity or related surgery, and cystic periventricular leukomalacia. Variations in adjusted rates and/or interquartile ranges were examined. To assess opportunities for additional improvement, all hospitals were reassigned to perform as if in the top quartile, and recalculation of predicted numbers were used to estimate potential benefit.
Results
In this cohort of 49 333 infants across 142 hospitals, survival without major morbidity consistently increased from 62.2% to 66.9% from 2008 to 2017. Network variation decreased, with interquartile ranges decreasing from 21.1% to 19.2%. The largest improvements were seen for necrotizing enterocolitis and nosocomial infection. Bronchopulmonary dysplasia rates did not change significantly. Over the final 3 years, if all hospitals performed as well as the top quartile, an additional 621 infants per year would have survived without major morbidity, accounting for an additional 6.6% annual improvement.
Conclusions
Although trends are promising, bronchopulmonary dysplasia remains a common and persistent major morbidity, remaining a target for continued quality-improvement efforts.
Authors
Biostatistician Jessica Liu, PhD; Jochen Profit, MD, associate professor of pediatrics; and Susan Hintz, MD, professor of pediatrics and the Robert L. Hess Family Professor. Lee, Profit, Hintz and Gould are members of the Stanford Maternal & Child Health Research Institute. Lee is a member of Stanford Bio-X.
Acknowledgements
The study was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (grant R01 HD087425).
The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit http://med.stanford.edu/school.html. The medical school is part of Stanford Medicine, which includes Stanford Health Care and Stanford Children's Health. For information about all three, please visit http://med.stanford.edu..
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Jun 26 2020 Fetal Timeline Maternal Timeline News
 More of the youngest and smallest California preemies are going home from the hospital without any major complications, a Stanford study has found. CREDIT Jason Mark.
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