One of the things that is striking in neonatology are the variations in outcomes of the most immature babies. In some centers, and in some countries, when a mother presents with threatened delivery at what the doctors think is 23 or at 24 weeks gestation (which we don’t actually know very precisely) the babies are not offered active care. Other places discourage active intervention, while others are more open, or actively encourage institution of life support.
Not surprisingly if you don’t offer intensive care the babies die. Then you can honestly go to the parents and say ‘we don’t offer intensive care because all these babies die’. On the other hand if you are active at 24 weeks gestation, then overall survival can be over 2/3. Then you can go to the parents and say ‘we routinely start intensive care because the majority of the babies survive’. So the attitudes of the caregivers are the greatest single factor influencing survival rates.
As John Lantos has asked ‘why is this tolerated? If the same was true for breast cancer survival there would be a national/international outcry.’
Four recent publications all address this issue.
Mehrotra A, Lagatta J, Simpson P, Olivia Kim U, Nugent M, Basir MA: Variations among us hospitals in counseling practices regarding prematurely born infants. J Perinatol 2013, 33(7):509-513. In this questionnaire study the authors asked at numerous hospitals a series of questions about the antenatal counseling service. Who does it, when do they get asked to see the patient etc. They showed that antenatal counseling is universally available in tertiary hospitals for mothers who a threatening very preterm delivery. Apart from the lack of standard approaches and the rather surprising and worrying fact that obstetricians and Ob residents do a fair amount of the counseling sessions, their was a lot of variation in the earliest gestational age at which a consultation will be requested. More than half do not ask for a consult at 22 weeks.
This is of course related to the next study, Arzuaga BH, Meadow W: National variability in neonatal resuscitation practices at the limit of viability. American journal of perinatology 2013. Individual neonatologists were asked whether they would intervene in a number of different situations, at different gestational ages and birth weights and so on. There were substantial variations in practice that varied according to where in the USA they practiced. Practices were not much affected by religion, and there was quite a lot of variability.
Alleman BW, Bell EF, Li L, Dagle JM, Smith PB, Ambalavanan N, Laughon MM, Stoll BJ, Goldberg RN, Carlo WA et al: Individual and center-level factors affecting mortality among extremely low birth weight infants. Pediatrics 2013. I already discussed this paper in a previous post, but the point today is that there is a great deal of variation between centers, even those that you might expect to be a bit more homogeneous, US teaching hospitals in the NICHD neonatal network. Much of the variation in survival in infants less than 25 weeks gestation seemed to be associated with variations in the use of certain interventions, and the variations in survival were enormous, for all babies less than 25 weeks, survival ranged from 10% to 72%!
Serenius F, Sjörs G, Blennow M, Fellman V, Holmström G, Maršál K, Lindberg E, Olhager E, Stigson L, Westgren M et al: Express study shows significant regional differences in one-year outcome of extremely preterm infants in sweden. Acta Paediatrica 2013. And to show this is not just a US phenomenon, this regional study from Sweden showed variations in Obstetric interventions between regions of Sweden, and variation in neonatal interventions, and in infant survival. Most of the differences in survival were very early after birth, so they mostly probably were a result of decisions to intervene or not. So the proportion of babies at 22 to 24 weeks gestation who died before 12 hours varied from 11% to 46%.
I wonder what would happen if I went to a doctor with my skin cancer, and he told me, ‘on the other side of the river they treat this actively and you would have a 50% chance of survival, over here we don’t think that 50% is good enough, so we don’t offer treatment. But we can make your death painless, we have become really good at palliative care’. Not only would I be out of there like a shot (and I bet that doctors who discourage active care at 24 weeks would also be out of there fast) but I would make sure that there was some sort of investigation of why patients were being allowed to die just because of the doctors beliefs.