Study Shows Path to Improved Outcomes for Smallest Preemies

Thursday, March 03, 2011

Transferring women in premature labor to deliver at hospitals with top-level (Level III) newborn intensive care units has significantly improved the odds these babies will survive and thrive.

That’s because transferring the mother before delivery is better for the baby than waiting until after delivery to transport the newborn preemie, according to a new Cincinnati Children’s Hospital Medical Center study, published online and in the upcoming March 7 issue of Pediatrics.

“By regionally promoting national guidelines recommending maternal transfer, the number of very low birth weight infants born at less than 32 weeks gestation at centers with Level I or II newborn units declined from 25 percent to 11.8 percent,” says Jim Greenberg, MD, associate director of the Perinatal Institute at Cincinnati Children’s and co-author of the study. “Obstetricians in the Cincinnati region deserve all the credit. They changed the way they practice so that moms are transferred before delivery, all for the benefit of their patients.”

The odds of death or major complications for these extremely premature infants are three times that of infants born at Level III centers, according to Dr. Greenberg.

Transferring a very low birth weight preemie via ambulance is problematic because it increases the risk of intracranial hemorrhage (a brain bleed) in these tiny newborns – for reasons not well understood. It is more difficult, for example, to regulate their temperature in an ambulance. And the bumps and vibrations during the ride are barriers to optimal care.

American Academy of Pediatrics guidelines for perinatal care – which is provided immediately before and after birth – recommend delivery of these low-birth weight preemies at subspecialty perinatal centers, which are ranked as Level III. The Healthy People 2010 objective is to deliver 90 percent of very low birth weight infants in subspecialty centers.

In late 2002, Cincinnati Children’s engaged in an educational campaign among maternity hospitals in the region to reduce the incidence of preterm birth. This included focusing on hospital maternity departments, where nursing leaders at each hospital were instructed on the benefits of proactive transfer of mothers in premature labor before 32 weeks gestation. If the nurse and obstetrician could not agree about the appropriateness of transfer, a Cincinnati Children’s neonatologist would provide consultation and outcomes data.

The Cincinnati Children’s researchers studied all live births at maternity hospitals in the Cincinnati region from 2003 through 2007. They compared these findings with those from a previous study they conducted of live births in the region between 1995 and 1997.

For more than 15 years, these hospitals have participated in a well-established, regional collaboration, in which neonatologists and other providers from Cincinnati Children’s provide care for high-risk infants, as well as neonatal transport, outreach education, research and quality improvement work. In all, this covers approximately 23,000 births each year.

Birth weight is considered very low if it is below 1,500 grams, or approximately three pounds, five ounces. More babies born who weigh less than 1,500 grams are born prior to 32 weeks gestation, which is more than eight weeks before the mother’s due date. The rate of severe intracranial bleeding was significantly higher in these infants. In addition, infants weighing less than 1,000 grams had significantly increased mortality when born at non-specialty centers.