Regional and Racial-Ethnic Differences in Perinatal Interventions Among Periviable Births

Abstract

Objective: To examine whether there are: 1) regional differences in three perinatal interventions that reflect active treatment among periviable gestations and 2) racial-ethnic differences in the receipt of these perinatal interventions after accounting for hospital region.

Methods: We conducted a retrospective study on neonates born at 776 U.S. centers that participated in the Vermont Oxford Network (2006-2017) with a gestational age of 22-25 weeks. The primary outcome was postnatal life support. Secondary outcomes included maternal administration of antenatal corticosteroids and cesarean delivery. We examined rates and 99% CI of the three outcomes by region. We also calculated the adjusted relative risks (aRRs) and 99% CIs for the three outcomes by race and ethnicity within each region using modified Poisson regression models with robust variance estimation.

Results: Major regional variation exists in the use of the three interventions at 22 and 23 weeks of gestation but not at 24 and 25 weeks. For example, at 22 weeks of gestation, rates of life support in the South (38.3%; 99% CI 36.3-40.2) and the Midwest (32.7%; 99% CI 30.4-35.0) were higher than in the Northeast (20.2%; 99% CI 17.6-22.8) and the West (22.2%; 99% CI 20.0-24.4). Particularly in the Northeast, black and Hispanic neonates born at 22 or 23 weeks of gestation had a higher provision of postnatal life support than white neonates (at 22 weeks: black: aRR 1.84 [99% CI 1.33-2.56], Hispanic: aRR 1.80 [1.23-2.64]; at 23 weeks: black: aRR 1.14 [99% CI 1.08-1.20], Hispanic: aRR 1.12 [1.05-1.19]). In the West, black and Hispanic neonates born at 23 weeks of gestation also had a higher provision of life support (black: aRR 1.11 [99% CI 1.03-1.19]; Hispanic: aRR 1.10 [1.04-1.16]).

Conclusion: Major regional variation exists in perinatal interventions when managing 22- and 23-week neonates. In the Northeast and the West regions, minority neonates born at 22 and 23 weeks of gestation had higher provision of postnatal life support.

Figure 1.

Regional rates of postnatal life support at 22 and 23 weeks of gestation. Pointed values represent the mean rate of postnatal life support in each hospital; vertical bars represent 99% CIs. Black solid lines represent the mean rate of postnatal life support across all hospitals in a specific region; black dotted lines represent the 99% CIs. Rates (99% CIs) by region at 22 weeks of gestation: Northeast (20.2%; 99% CI: 17.6–22.8), Midwest (32.7%; 99% CI: 30.4–35.0), West (22.2%; 99% CI: 20.0–24.4), and South (38.3%; 99% CI: 36.3–40.2). Rates (99% CIs) by region at 23 weeks of gestation: Northeast (81.3%; 99% CI: 79.5–83.1), Midwest (87.0%; 99% CI: 85.8–88.2), West (73.0%; 99% CI: 71.2–74.8), and South (88.9%; 99% CI: 88.1–89.8). Sample sizes by region at 22 weeks of gestation: Northeast (n=1,576), Midwest (n=2,736), West (n=2,341), and South (n=4,024); at 23 weeks of gestation: Northeast (n=3,237), Midwest (n=5,135), West (n=4,196), and South (n=9,057).

Figure 2.

Regional rates of antenatal corticosteroids at 22 and 23 weeks of gestation. Pointed values represent the mean rate of steroids in each hospital; vertical bars represent 99% CIs. Black solid lines represent the mean rate of steroids across all hospitals in a specific region; black dotted lines represent the 99% CIs. Rates (99% CIs) by region at 22 weeks of gestation: Northeast (10.7%; 99% CI: 8.7–12.7), Midwest (19.4%; 99% CI: 17.4–21.3), West (16.1%; 99% CI: 14.1–18.0), and South (22.4%; 99% CI: 20.7–24.1). Rates (99% CIs) by region at 23 weeks of gestation: Northeast (65.8%; 99% CI: 63.6–67.9), Midwest (70.7%; 99% CI: 69.0–72.3), West (59.1%; 99% CI: 57.1–61.0), and South (67.3%; 99% CI: 66.1–68.6). Sample sizes by region at 22 weeks of gestation: Northeast (n=1,566), Midwest (n=2,703), West (n=2,318), and South (n=3,983); at 23 weeks of gestation: Northeast (n=3,229), Midwest (n=5,114), West (n=4,168), and South (n=9,014).

Figure 3.

Regional rates of cesarean delivery at 22 and 23 weeks of gestation. Pointed values represent the mean rate of cesarean delivery in each hospital; vertical bars represent 99% CIs. Black solid lines represent the mean rate of cesarean delivery across all hospitals in a specific region; black dotted lines represent the 99% CIs. Rates (99% CIs) by region at 22 weeks of gestation: Northeast (5.1%; 99% CI: 3.7–6.5), Midwest (9.1%; 99% CI: 7.7–10.5), West (10.0%; 99% CI: 8.4–11.6), and South (12.8%; 99% CI: 11.4–14.2). Rates (99% CIs) by region at 23 weeks of gestation: Northeast (36.6%; 99% CI: 34.4–38.7), Midwest (44.6%; 99% CI: 42.8–46.4), West (39.0%; 99% CI: 37.0–40.9), and South (45.6%; 99% CI: 44.3–46.9). Sample sizes by region at 22 weeks of gestation: Northeast (n=1,577), Midwest (n=2,738), West (n=2,340), and South (n=4,026); at 23 weeks of gestation: Northeast (n=3,237), Midwest (n=5,135), West (n=4,196), and South (n=9,065).

Figure 4.

Regional rates of survival by time (days) at 22, 23, 24, and 25 weeks of gestation (see also Table 2).