Three-fold rise in extremely premature babies given respiratory life support in England and Wales after guidelines change

Professor Lucy Smith

The number of very premature babies (22 weeks) given respiratory life support (survival focused care) and/or admitted to neonatal units in England and Wales has increased 3-fold, following changes in 2019 to national guidance.

The guidance emphasises a risk-based approach to the provision of respiratory life support for babies born from as early as 22 weeks, say researchers from the University of Leicester. Their findings have now been published in the open access journal BMJ Medicine

However, while the proportion of babies born at this stage surviving to discharge has increased, there are “major implications for additional resource needs and overall survival remains low,” highlight researchers from the University of Leicester and Imperial College London.

The updated national guidance from the British Association of Perinatal Medicine sets out various pregnancy and birth factors that should inform decision making and parental discussions for premature babies born from 22 weeks onwards. But its impact on neonatal care provision hasn’t been evaluated.

The researchers therefore drew on retrospective data from two national datasets in England and Wales: MBRRACE-UK perinatal mortality data, led by the University of Leicester, and the National Neonatal Research Database (NNRD) from January 2018 to December 2021.

Between them, these datasets include all live births from 22 weeks onwards in England and Wales, as well as data on those who die before, during, and within 28 days of birth, plus care provision and outcomes up to NHS hospital discharge. 

Researchers focused on survival to admission for neonatal care; length of neonatal unit stay in days; survival to discharge home or to other healthcare settings; and survival to discharge without major health issues, such as retinopathy (eye disease) of prematurity and severe brain injury. 

Overall, 5623 premature babies were born at 22-24 weeks, 1604 of whom were stillborn. Of the 4019 babies alive when care was started in labour, 1001 (25%) were born at 22 weeks, 1380 (34%) were born at 23 weeks, and 1638 (41%) were born at 24 weeks. 

Among those alive at the start of labour at 22 weeks, the number and percentage receiving respiratory life support tripled from 59 out of 524 (11%) in 2018-19 to 183 out of 477 (38%) in 2020-21. 

Similarly, admissions to neonatal units for babies alive at the start of labour at 22 weeks rose from nearly 7.5% to just over 28% while survival to discharge from neonatal care rose from 2.5% (13 babies) to just over 8% (39).

The characteristics of those receiving respiratory life support changed between 2018-19 and 2020-21, with increases in smaller–weighing under 500g–(46% vs 64%), and more immature babies—born in the earlier part of the 22nd week—(19% vs 31%) babies.

The numbers of babies born at 22 weeks admitted to neonatal care units who died before discharge also increased from 26 to 95.

The total number of care days provided to all babies born at 22 weeks was 2535 in 2018-19 and 6840 in 2020-21.

This is an observational study, and the researchers acknowledge various limitations to their findings. For example, their definition of survival focused care was mainly limited to provision of active respiratory care because this information was uniformly available.  And they were only able to assess short term outcomes.

Lucy Smith, Professor of Perinatal Health at the University of Leicester, co-led the study alongside colleagues from Imperial College London. The authors, who included Professor Smith and Dr Sarah Seaton, perinatal and paediatric researcher in The Infant Mortality and Morbidity Studies group from the University of Leicester, said “Our analysis suggests that these rapid and substantial changes were associated with the introduction of the British Association of Perinatal Medicine guidance. 

“Although the recommendation was intended to be risk based, we speculate that, on the contrary, approaches have moved from being selective to more widespread provisions of survival focused care. This change would explain the increase in the proportion of babies at high risk who received survival focused care.” 

They added: “While survival for babies born at 22 weeks remains low, the numbers receiving survival focused care and being admitted to neonatal units has tripled. Although this finding suggests that the total number of survivors has increased, this result also means that the number of babies who died after intensive care also increased. 

“Maternity care was also affected because of likely increases in in-utero transfers (ie, moved to a specialist hospital before birth), as well as impacts on paediatric and educational services to provide for long term health and developmental needs. This change represents an important increase in workload and need for specialised health care and educational resources."