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Variability in the management and outcomes of extremely preterm births across five European countries: a population-based cohort study
  1. Lucy K Smith1,
  2. Beatrice Blondel2,
  3. Patrick Van Reempts3,
  4. Elizabeth S Draper1,
  5. Bradley N Manktelow1,
  6. Henrique Barros4,
  7. Marina Cuttini5,
  8. Jennifer Zeitlin2
  9. for the EPICE Research Group
    1. 1 Department of Health Sciences, University of Leicester, Leicester, UK
    2. 2 Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Inserm UMR 1153, Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in pregnancy, Paris Descartes University, Paris, France
    3. 3 Department of Neonatology, Antwerp University Hospital, University of Antwerp, Antwerp and Study Centre for Perinatal Epidemiology Flanders, Brussels, Belgium
    4. 4 EPIUnit-Institute of Public Health, University of Porto, Porto, Portugal
    5. 5 Clinical Care and Management Innovation Research Area, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
    1. Correspondence to Dr Lucy K Smith, The Infant Mortality and Morbidity Studies (TIMMS), Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK; lks1{at}


    Objective To explore international variations in the management and survival of extremely low gestational age and birthweight births.

    Design Area-based prospective cohort of births

    Setting 12 regions across Belgium, France, Italy, Portugal and the UK

    Participants 1449 live births and fetal deaths between 22+0 and 25+6 weeks gestation born in 2011–2012.

    Main outcome measures Percentage of births; recorded live born; provided antenatal steroids or respiratory support; surviving to discharge (with/without severe morbidities).

    Results The percentage of births recorded as live born was consistently low at 22 weeks and consistently high at 25 weeks but varied internationally at 23 weeks for those weighing 500 g and over (range 33%–70%) and at 24 weeks for those under 500 g (range 5%–71%). Antenatal steroids and provision of respiratory support at 22–24 weeks gestation varied between countries, but were consistently high for babies born at 25 weeks. Survival to discharge was universally poor at 22 weeks gestation (0%) and at any gestation with birth weight <500 g, irrespective of treatment provision. In contrast, births at 23 and 24 weeks weighing 500 g and over showed significant international variation in survival (23 weeks: range: 0%–25%; 24 weeks range: 21%–50%), reflecting levels of treatment provision.

    Conclusions Wide international variation exists in the management and survival of extremely preterm births at 22–24 weeks gestation. Universally poor outcomes for babies at 22 weeks and for those weighing under 500 g suggest little impact of intervention and support the inclusion of birth weight along with gestational age in ethical decision-making guidelines.

    • viability
    • extremely premature infants
    • international perspectives
    • Neonatology
    • Intensive Care

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    • Collaborators EPICE Research Group: Belgium: Flanders (E Martens, G Martens, P Van Reempts); Denmark: Eastern Region (K Boerch, A Hasselager, L Huusom, O Pryds, T Weber); Estonia (L Toome, H Varendi); France: Burgundy, Ile-de France and Northern region (PY Ancel, B Blondel, A Burguet, PH Jarreau, P Truffert); Germany: Hesse (RF Maier, B Misselwitz, S Schmidt), Saarland (L Gortner); Italy: Emilia Romagna (D Baronciani, G Gargano), Lazio (R Agostino, D DiLallo, F Franco), Marche (V Carnielli), M Cuttini; The Netherlands: Eastern and Central (C Koopman-Esseboom, A van Heijst, J Nijman); Poland: Wielkopolska (J Gadzinowski, J Mazela); Portugal: Lisbon and Tagus Valley (LM Graça, MC Machado), Northern region (Carina Rodrigues, T Rodrigues), H Barros; Sweden: Stockholm (AK Bonamy, M Norman, E Wilson); UK: East Midlands and Yorkshire and Humber (E Boyle, ES Draper, BN Manktelow), Northern region (AC Fenton, DWA Milligan); Inserm, Paris (J Zeitlin, M Bonet, A Piedvache).

    • Contributors All authors contributed to the overall conception and design of the study. LKS wrote the first draft of this manuscript and analysed the data. All authors contributed to the interpretation of results and drafting of the manuscript. All authors read and approved the final manuscript. LKS is the guarantor. LKS affirms that the manuscript is an honest, accurate and transparent account of the study being reported; that no important aspects of the study have been omitted and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

    • Funding The research leading to these results received funding from the European Union’s Seventh Framework Programme ((FP7/2007–2013)) under grant agreement n°259882. Additional funding was received in the following region: France (French Institute of Public Health Research/Institute of Public Health and its partners the French Health Ministry, the National Institute of Health and Medical Research, the National Institute of Cancer and the National Solidarity Fund for Autonomy; grant ANR-11-EQPX-0038 from the National Research Agency through the French Equipex Program of Investments in the Future and the PremUp Foundation). UK (funding for The Neonatal Survey from Neonatal Networks for East Midlands and Yorkshire and Humber regions). The funders had no role in study design; in the collection, analysis and interpretation of data; in the writing of the report or in the decision to submit the article for publication. LKS is funded by a National Institute for Health Research Career Development Fellowship. This article presents independent research funded by the National Institute for Health Research (NIHR). The views expressed are those of the authors and not necessarily those of the National Health Service, the NIHR or the Department of Health.

    • Competing interests None declared. All authors have completed the International Committee of Medical Journal Editors uniform disclosure form at and have declared no support from any organisation for the submitted work (or describe if any); no financial relationships with any organisations that might have an interest in the submitted work in the previous 3 years (or describe if any), no other relationships or activities that could appear to have influenced the submitted work (or describe if any).

    • Ethics approval Parental consent and ethics and data protection approval was obtained in each study region as required by national legislation.

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

    • Data sharing statement No additional data are available.