The new Epicure 2 data show encouraging trends in outcomes in the UK and Ireland for extremely preterm babies. Survival rates have improved significantly over the whole of the British Isles, Here for example is one of the figures from the long term outcome publication.
As you can see the proportion of survivors has increased, and the proportion of severely impaired survivors has not changed, when expressed as a proportion of the survivors. When expressed as a proportion of the number of babies who can be stabilized at birth and are admitted to NICU this means that the proportion of admissions who are severely impaired has increased. So in 1995 there were 266 survivors of 666 babies admitted, 39%; of them 19% (51 infants) were severely impaired, so the percentage of the original 666 babies who were admitted for intensive care who survive with a severe impairment is 51/666 = 7.7%. In 2006 there were proportionally many more survivors; 593 survivors of 1115 babies admitted, 53%. 19% of them (113) had severe impairments, the percentage of the original 1115 babies admitted for intensive care who survive with a severe impairment is 113/1115 = 10.1%.
Now you can interpret these data according to your own prejudices, and that is indeed what has been happening. The editorial accompanying the publications in the BMJ was very negatively slanted. That editorial, written by 2 individuals from the Netherlands, includes the following quotes ‘a greater absolute number of neonates had major morbidity’, ‘the prevalence of important adverse neurological and developmental outcomes had indeed not improved’ and ‘of 100 neonates born at 24 weeks, 60 will die despite intensive care, and of the 40 survivors 12 will have serious impairments’ (this is actually a serious error! Fifteen or nineteen percent of the survivors at 24 weeks gestation had serious impairments, which means that of the 40 survivors in their scenario there would be 6 or 7 with serious impairments).
One other quote: ‘Similar outcome data are seen in the Netherlands, and neonatal intensive care is therefore not offered routinely to neonates born before 24 completed weeks’ gestation.’ This is also untrue, there are no similar outcome data from the Netherlands. As there are no survivors at 23 weeks in the Netherlands, and until recently there were no survivors at 24 weeks either, they do not have data to make that statement.
I think that anyone looking at the graph at the top of this post without any pre-existing prejudices (like me for example) would say that there have been major advances. In the context of a huge increase in the absolute number of extremely preterm infants, there are major improvements in survival with a stable proportion of impairments among the survivors. With an overall prevalence of severe disability among the survivors of 19% why do we persist in focusing on those infants? I know it is vitally important that those infants receive early evaluation and effective services and interventions. But surely we can also emphasize that 81% of these infants, who would all be dead if it wasn’t for NICU, are free of serious impairment.
The authors of the editorial appear to be of the opinion that it is OK for 81% of the potential survivors to die to avoid the survival of the 19% who have severe impairments. I beg to differ.