Holland is changing

A new article from the Groningen group, plus Annie Janvier. Koper JF, et al. Dutch neonatologists have adopted a more interventionist approach to neonatal care. Acta Paediatr. 2015;104(9):888-93. It documents changes in their delivery room and NICU in end-of life practices between two periods 2001-2003 and 2008-2010.

Even with the “more interventionist approach” they only had 1 baby under 25 weeks admitted to the NICU in the later cohort (who died). So they were still, in that period, not offering intervention under 25 weeks.

I wanted to highlight however their table 2: which looks like this, the first column of numbers is the first cohort, and the proportion of the 126 deaths which occurred in each situation. The second column is the 113 babies in the second cohort. The asterisks denote statistical “significance”.

Stillbirth, dead on arrival to the hospital 44 (35%) 37 (33%)
Stillbirth, withholding surgical intervention 29 (23%) 17 (15%)
TOP, congenital malformation  22 (17%) 33 (29%)*
Induction for risk of extreme preterm birth 1(1%) 7 (6%)
Withholding resuscitation (comfort care) 25 (20%) 13 (12%) **

It is basically the table I included in my presentation at the last PAS meeting, and shows a lot more information than just the NICU admission data. The increase in termination of pregnancy (TOP) is probably related to changes in ultrasounds during pregnancy, ultrasound with screening for malformations was introduced as standard practice in Holland between the cohorts, and there was therefore an increase in antenatal diagnosis. This may also partly be the reason for the reduction in comfort care, as there would likely be fewer surprise diagnoses of serious malformations in the delivery room. The decrease in deaths due to “withholding surgical intervention” (which basically means not doing a Cesarean) is probably truly a willingness to intervene more actively for babies.

I think it is important that neonatal survival data are presented with this amount of detail. Otherwise a change in mortality among NICU admissions is difficult to interpret, and comparisons between groups of patients becomes meaningless.

About Keith Barrington

I am a neonatologist and clinical researcher at Sainte Justine University Health Center in Montréal
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