To follow on somewhat from the last post, I wanted to discuss the most recent data from the Swedish EXPRESS study. If you remember, this study has examined the outcomes of less than 27 weeks babies from across Sweden, and has previously shown substantial differences in survival between regions.
One great feature of these data is the inclusion of data from mothers from the time they are admitted to hospital, so stillbirths who deliver at 22 weeks to 26+6 are included. This particular new study concentrates on the data from 844 babies who were alive when their mother was admitted to the hospital. 137 of whom were stillborn. 70% of the live born infants survived to get followed up.
Interventions were variable between regions of Sweden, for example the proportion of babies who were delivered after antenatal steroids varied between regions from 40% to 72%, and cesarean delivery between 29% and 60%. Neonatal interventions were also varied, such as giving surfactant quickly, intubation in the DR, and having a neonatologist in the DR.
The authors created a therapeutic intensity score, and then examined whether being more active improved or worsened survival and long-term outcomes.
The results showed that increasing obstetric interventions increased live birth, and among those born alive, increasing neonatal interventions improved survival. When they examined the infants at 2.5 years, they found that among the survivors, there was no increase in “NDI” with more active care, in fact, what differences there are are in the other direction, fewer babies from highly active regions had “NDI” overall, especially among the 22 to 24 week subgroup, 38% compared to 48%. (NDI was any CP affecting walking, deafness, visual impairment and Bayley 3 below -2SD on any scale, compared to the scores of a local full-term control group).
If you put the 2 outcomes together, the famous “death or NDI”, regions of Sweden that practiced higher intensity perinatal care had significantly less adverse outcomes than lower intensity regions. The Odds ratio for the group as a whole were 0.70, that is, the Odds of having a bad outcome were decreased by 30% in highly active regions, and for the most immature infants (22, 23 and 24 weeks gestation), the OR was 0.43 (0.48 after statistical adjustment) so a greater than 50% reduction in the Odds of adverse outcome, by providing more active care.
This should comfort anyone involved in care of such infants, if you work harder at getting them to survive, you end up in general with results which are at least as good among survivors than less active centers, at least in the range of actions that were examined in this study.
Here is a very striking figure from that article, showing the survival curves for infants born in high activity, versus low activity regions. The differences are striking. Its hard to imagine any other part of medicine where this survival difference would not be considered to be a major advance.
What were the extremely intensive interventions that were different between the regions? Well, very simple stuff really, its just the willingness to do them that is important
4 key obstetric indicators (delivery at level III hospitals, complete course of antenatal steroids, cesarean delivery, tocolytic treatment) and
4 key neonatal indicators (surfactant within 2 hours after birth, delivery attended by a neonatologist, intubation immediately after birth, infants admitted for intensive care [out of infants alive at 30 minutes after birth])
Of course not all these babies need to be intubated after birth, and it certainly wasn’t 100% in any region (actually varied from 35.6% to 75%), but the difference in proportions of the babies intubated was substantial, showing a greater willingness to do so in some areas than in others.