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Providing active antenatal care depends on the place of birth for extremely preterm births: the EPIPAGE 2 cohort study
  1. Caroline Diguisto1,2,3,
  2. François Goffinet1,4,
  3. Elsa Lorthe1,5,
  4. Gilles Kayem1,5,6,
  5. Jean-Christophe Roze7,
  6. Pascal Boileau8,
  7. Babak Khoshnood1,
  8. Valérie Benhammou1,
  9. Bruno Langer9,
  10. Loic Sentilhes10,
  11. Damien Subtil11,
  12. Elie Azria1,12,
  13. Monique Kaminski1,
  14. Pierre-Yves Ancel1,13,
  15. Laurence Foix–L’Hélias1,5,14
  1. 1Inserm UMR 1153, Obstetrical, Perinatal and Pediatric Epidemiology Research Team (Epopé), Center for Epidemiology and Statistics Sorbonne Paris Cité, DHU Risks in Pregnancy, Paris Descartes University, Paris, France
  2. 2Maternité Olympe de Gouges, Centre Hospitalier Regional Universitaire Tours, Tours, France
  3. 3Université François Rabelais, Tours, France
  4. 4DHU Risk in Pregnancy, Maternité Port Royal Paris Descartes University Cochin Broca Hotel Dieu Hospitals Assistance publique des hopitaux de Paris, Paris, France
  5. 5UPMC Univ Paris 06, Sorbonne Universités, Paris, France
  6. 6Service de Gynécologie Obstétrique, Paris, France
  7. 7Service de Néonatologie, CIC 004, INSERM, Nantes University Hospital, Nantes, France
  8. 8Service de Néonatologie, CHI Poissy St-Germain-en-Laye, University Versailles StQuentin-en-Yvelines, Versailles, France
  9. 9Pole de Gynécologie Obstétrique, Hôpital de Hautepierre, Strasbourg, France
  10. 10Department of Obstetrics and Gynecology, University Hospital Bordeaux, Bordeaux, France
  11. 11Hôpital Jeanne de Flandre, CHRU-University, Lille Nord, France
  12. 12Maternité Notre Dame de Bon Secours, Groupe Hospitalier Paris Saint Joseph, ParisDescartes University, DHU Risk in Pregnancy, Paris, France
  13. 13URC CIC P1419, DHU Risk in Pregnancy, Cochin Hotel Dieu Hopital APHP, Paris, France
  14. 14Service de Néonatologie, Hopital Armand Trousseau, APHP, Paris, France
  1. Correspondence to Dr Caroline Diguisto, Maternité Olympe de Gouges, Centre Hospitalier, Regional Universitaire Tours, 2 boulevard Tonnellé 37044, France; carolinediguisto{at}


Survival rates of infants born before 25 weeks of gestation are low in France and have not improved over the past decade. Active perinatal care increases these infants’ likelihood of survival.

Objective Our aim was to identify factors associated with active antenatal care, which is the first step of proactive perinatal care in extremely preterm births.

Methods The population included 1020 singleton births between 220/6 and 260/6 weeks of gestation enrolled in the Etude Epidémiologique sur les Petits Ages Gestationnels 2 study, a French national population-based cohort of very preterm infants born in 2011. The main outcome was ‘active antenatal care’ defined as the administration of either corticosteroids or magnesium sulfate or delivery by caesarean section for fetal rescue. A multivariable analysis was performed using a two-level multilevel model taking into account the maternity unit of delivery to estimate the adjusted ORs (aORs) of receiving active antenatal care associated with maternal, obstetric and place of birth characteristics.

Results Among the population of extremely preterm births, 42% received active antenatal care. After standardisation for gestational age, regional rates of active antenatal care varied between 22% (95% CI 5% to 38%) and 61% (95% CI 44% to 78%). Despite adjustment for individual and organisational characteristics, active antenatal care varied significantly between maternity units (p=0.03). Rates of active antenatal care increased with gestational age with an aOR of 6.46 (95% CI 3.40 to 12.27) and 10.09 (95% CI 5.26 to 19.36) for infants born at 25 and 26 weeks’ gestation compared with those born at 24 weeks. No other individual characteristic was associated with active antenatal care.

Conclusion Even after standardisation for gestational age, active antenatal care in France for extremely preterm births varies widely with place of birth. The dependence of life and death decisions on place of birth raises serious ethical questions.

  • Extreme preterm birth
  • active antenatal care

Statistics from


  • Contributors CD, FG, GK, PYA, EA and LFH conceived and designed the study. VB participated in the data collection. CD, FG, LFH and BK performed the statistical analysis. CD, FG and LFH interpreted the data helped by EL, GK, JCR, PB, MK and PYA. CD, FG, LFH, PYA and EA wrote the manuscript. EL, GK, JCR, PB, BL, LS, DS and MK reviewed the manuscript and made significant changes. All authors read and approved the final manuscript.

  • Competing interests None declared.

  • Patient consent Consent obtained from the guardian.

  • Ethics approval Consultative Committee on the Treatment of Information on Personal Health Data for ResearchPurposes (no 10.626); Committee for the Protection of People participating in Biomedical Research (no CPP SC-2873); The National Data Protection Authority(CNIL no 911009).

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

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