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Original article
Socioeconomic inequity in survival for deliveries at 22–24 weeks of gestation
  1. Naho Morisaki1,
  2. Tetsuya Isayama2,3,
  3. Osamu Samura4,
  4. Kazuko Wada5,
  5. Satoshi Kusuda6
  1. 1 Division of Life-Course Epidemiology, Department of Social Medicine, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
  2. 2 Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, Ontario, Canada
  3. 3 Division of Neonatology, National Center for Child Health and Development, Setagaya-ku, Tokyo, Japan
  4. 4 Department of Obstetrics and Gynecology, Jikei University School of Medicine, Minato-ku, Tokyo, Japan
  5. 5 Department of Neonatal Medicine, Osaka Medical Center and Research Institute for Maternal and Child Health, Osaka, Japan
  6. 6 Department of Neonatal Medicine, Maternal and Perinatal Center, Tokyo Women’s Medical University, Tokyo, Japan
  1. Correspondence to Dr Naho Morisaki, Department of Social Medicine, National Research Institute for Child Health and Development, 2-10-1, Okura, Setagaya-ku, Tokyo, 158-8535, Japan; morisaki-n{at}ncchd.go.jp

Abstract

Objective Guidelines recommend individual decision making on resuscitating infants of 22–24 weeks’ gestational age (GA) at birth. When the decision not to resuscitate is made, infants would likely die soon after delivery, and under some circumstances such neonatal deaths may be registered as stillbirths occurring during delivery (intrapartum stillbirth). Thus we assessed whether socioeconomic factors are associated with peridelivery deaths (during or within 1 hour of delivery) of infants delivered at 22–24 weeks’ gestation.

Methods We analysed 14 726 singletons of 22–24 weeks’ GA using the 2003–2011 Japanese vital statistics, and assessed how maternal characteristics influence risk of peridelivery death as well as intrauterine fetal death (IUFD) and death after 1 hour of age until 40 weeks postmenstrual age.

Results Living in a municipality with low-average income (lowest tertile (risk ratio 1.32, 95% CI 1.20 to 1.44), middle tertile (risk ratio 1.08, 95% CI 0.98 to 1.19)), younger maternal age (age <20 (risk ratio 1.43, 95% CI 1.17 to 1.75), age 20–34 (risk ratio 1.14, 95% CI 1.03 to 1.27)) and having previous live births (risk ratio 1.08, 95% CI 1.01 to 1.17) increased risk of peridelivery deaths, but did not increase risk of IUFD or deaths after 1 hour of age. Peridelivery death was twice as likely to occur in births to multiparous teenage mothers in a low-income municipality, compared with those of older primiparous mothers in a wealthier municipality.

Conclusions Socioeconomic factors substantially influence whether births of 22–24 weeks’ GA survive delivery and the first hour of life. Such disparities may reflect the impact of socioeconomic situations on decision making for resuscitation.

  • palliative care
  • neonatology
  • ethics
  • epidemiology

https://doi.org/10.1136/archdischild-2017-312635

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    Footnotes

    • Contributors NM designed the study, acquired data, conducted analyses, wrote the initial manuscript and approved the final manuscript as submitted. TI contributed to the design of the study, interpretation of data, revised it critically for important intellectual content and approved the final manuscript as submitted. OS, KW and SK contributed to the interpretation of data, revised the manuscript critically for important intellectual content and approved the final manuscript as submitted. NM had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

    • Funding NM was funded by the Ministry of Health, Labour and Welfare of Japan (H28-ICT-001), the Japan Society for the Promotion of Science (KAKENHI 26870889), the Japan Agency for Medical Research and Development (AMED 6013), and an Uehara Memorial Foundation Research Grant. TI was supported by the Ontario Graduate Scholarships programme. KW was funded by the Japan Agency for Medical Research and Development (AMED 6013). All funding sources had no role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

    • Competing interests None declared.

    • Ethics approval National Center for Child Health and Development.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Data sharing statement Individual data are available from the Ministry of Health, Labour and Welfare under Statistics Act Article 33. Aggregated data are available upon request from NM.

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