Trends in Active Treatment of Live-Born Neonates Between 22 Weeks 0 Days and 25 Weeks 6 Days by Gestational Age and Maternal Race and Ethnicity in the US, 2014 to 2020
Authors: Venkatesh Kartik K. , Lynch Courtney D. , Costantine Maged M. , Backes Carl H. , Slaughter Jonathan L. , Frey Heather A. , Huang Xiaoning , Landon Mark B. , Klebanoff Mark A. , Khan Sadiya S. , Grobman William A. 
Published: March 2023

Approximately 0.4% of all US deliveries in 2015 were periviable (22 + 0 to 25 + 6 weeks' gestation), but these births accounted for 40% of all neonatal deaths. Management of periviable infants is challenging as it is not always clear whether intervention will improve the overall neonatal outcome. Although treatment decisions may vary based on gestational age at the time of delivery, they are also influenced by the clinician and by neonatal and obstetric characteristics. Current recommended guidelines advise clinicians to make family-centered decisions regarding treatment of periviable neonates, taking into account data on morbidity and mortality in the short and long term for such cases. Racial and ethnic differences in neonatal morbidity and mortality persist regardless of gestational age at birth: from 2010 to 2014, Black individuals experienced death of infants at a higher rate than similarly aged White individuals. The current analysis sought to identify patterns in active treatment for live-born neonates delivered in the periviable period in the United States from 2014 to 2020, to determine possible patterns based on gestational age and maternal ethnicity and race.

This serial cross-sectional analysis utilized data from all live births from 2014 to 2020 present in the US National Vital Statistics System (NCHS). Inclusion criteria included singleton, live-born neonates without anomalies who delivered between 22 weeks 0 days and 25 weeks 6 days of gestation. Cases of non-US residents were excluded. The analysis compared non-Hispanic Asian/Pacific Islander, non-Hispanic Black, and Hispanic/Latina with non-Hispanic White individuals overall and by neonatal gestational age at birth, as measured in completed weeks. The race and ethnicity referenced were selected as the same as the individual to whom the neonate was born.

The study's composite outcome was active treatment, which entailed any attempts to treat the neonate, including assisted ventilation at birth, surfactant therapy, assisted ventilation longer than 6 hours in duration, and/or antibiotic therapy during the neonatal intensive care unit admission. The frequency of active neonatal treatment was calculated as a percentage per year, as well as the mean annual percent change overall following each completed week of gestation, and by race and ethnicity subgroups from 2014 to 2020. Further assessment of changes in racial and ethnic differences over time was also performed, assessing difference in how active treatment by ethnicity and race changed over time.

Results of the analysis found that of 26,986,716 live births in the United States from 2014 to 2020, 66,356 (0.2%) were singleton live births in the periviable period. Following additional exclusions for missing information, the final study sample included 61,908 periviable live births. Median maternal age was 28 years, and 83% had a high school education or greater, 74% initiated first-trimester prenatal care, and 54% were Medicaid beneficiaries. The breakdown of percentages of race and ethnicity of individuals who experienced periviable live births was as follows: 5% Asian/Pacific Islander, 37% Black, 24% Hispanic, and 34% White. Individuals who were Black and Hispanic/Latina were more likely to have lower education levels, to be beneficiaries of Medicaid, to start prenatal care following the first trimester, and to be parous. In addition, Black individuals were more likely to have previously experienced a preterm birth when compared with White individuals.

Overall, 52% of neonates born in the periviable period received active treatment, with 96% receiving immediate assisted ventilation at birth, 45% receiving surfactant therapy, 47% antibiotic therapy, and 60% assisted ventilation for more than 6 hours. From 2014 to 2020, the overall frequency of active treatment increased significantly (3.9%; 95% confidence interval [CI], 3.0%–4.9%) and increased among all racial and ethnic subgroups (Asian/Pacific Islander: 3.4% [95% CI, 0.8%–6.0%]; Black: 4.7% [95% CI, 3.4%–5.9%]; Hispanic: 4.7% [95% CI, 3.4%–5.9%]; and White: 3.1% [95% CI, 1.1%–4.4%]), as well as across each gestational age range (22 weeks: 14.4% [95% CI, 11.1%–17.7%] and 25 weeks: 2.9% [95% CI, 1.5%–4.2%]). Compared with neonates born to White individuals (57.0%), neonates born to Asian/Pacific Islander (46.2%; risk difference [RD], −10.81 [95% CI, −12.75 to −8.88]; adjusted risk ratio [aRR], 0.82 [95% CI, [0.79–0.86]), Black (51.6%; RD, −5.42 [95% CI, −6.36 to −4.50]; aRR, 0.90 [95% CI, 0.89 to 0.92]), and Hispanic (48.0%; RD, −9.03 [95% CI, −10.07 to −7.99]; aRR, 0.83 [95% CI, 0.81 to 0.85]) individuals were significantly less likely to receive active treatment.

The study has some limitations, including a lack of assessment of neonatal morbidity and mortality, as no link to neonatal outcomes existed in the NCHS Natality Files. One variable with the potential to yield important variations in neonatal treatment and outcome was the hospital site, but this information was unavailable. Also, there was no plausible means to ascertain whether there were underlying variations in patient and clinician preferences that were responsible for some of the differences. There is a possibility of misclassification of exposure and outcome, although this would not account for trends over time. Finally, because this analysis began in 2014, biased data may exist because universal adoption of all states of the revised 2003 birth certificate did not take place until 2016.

The authors of the study concluded an increased frequency of active treatment among neonates born from 2014 to 2020 existed among those born alive between 22 weeks 0 days and 25 weeks 6 days. Differences in rates of active treatment by race and ethnicity were also detected.