Trends in Active Treatment of Live-born Neonates Between 22 Weeks 0 Days and 25 Weeks 6 Days by Gestational Age and Maternal Race and Ethnicity in the US, 2014 to 2020

Abstract

Importance: Birth in the periviable period between 22 weeks 0 days and 25 weeks 6 days' gestation is a major source of neonatal morbidity and mortality, and the decision to initiate active life-saving treatment is challenging.

Objective: To assess whether the frequency of active treatment among live-born neonates in the periviable period has changed over time and whether active treatment differed by gestational age at birth and race and ethnicity.

Design, setting, and participants: Serial cross-sectional descriptive study using National Center for Health Statistics natality data from 2014 to 2020 for 61 908 singleton live births without clinical anomalies between 22 weeks 0 days and 25 weeks 6 days in the US.

Exposures: Year of delivery, gestational age at birth, and race and ethnicity of the pregnant individual, stratified as non-Hispanic Asian/Pacific Islander, non-Hispanic Black, Hispanic/Latina, and non-Hispanic White.

Main outcomes and measures: Active treatment, determined by whether there was an attempt to treat the neonate and defined as a composite of surfactant therapy, immediate assisted ventilation at birth, assisted ventilation more than 6 hours in duration, and/or antibiotic therapy. Frequencies, mean annual percent change (APC), and adjusted risk ratios (aRRs) were estimated.

Results: Of 26 986 716 live births, 61 908 (0.2%) were periviable live births included in this study: 5% were Asian/Pacific Islander, 37% Black, 24% Hispanic, and 34% White; and 14% were born at 22 weeks, 21% at 23 weeks, 30% at 24 weeks, and 34% at 25 weeks. Fifty-two percent of neonates received active treatment. From 2014 to 2020, the overall frequency (mean APC per year) of active treatment increased significantly (3.9% [95% CI, 3.0% to 4.9%]), as well as among all racial and ethnic subgroups (Asian/Pacific Islander: 3.4% [95% CI, 0.8% to 6.0%]); Black: 4.7% [95% CI, 3.4% to 5.9%]; Hispanic: 4.7% [95% CI, 3.4% to 5.9%]; and White: 3.1% [95% CI, 1.1% to 4.4%]) and among each gestational age range (22 weeks: 14.4% [95% CI, 11.1% to 17.7%] and 25 weeks: 2.9% [95% CI, 1.5% to 4.2%]). Compared with neonates born to White individuals (57.0%), neonates born to Asian/Pacific Islander (46.2%; risk difference [RD], -10.81 [95% CI, -12.75 to -8.88]; aRR, 0.82 [95% CI, [0.79-0.86]), Black (51.6%; RD, -5.42 [95% CI, -6.36 to -4.50]; aRR, 0.90 [95% CI, 0.89 to 0.92]), and Hispanic (48.0%; RD, -9.03 [95% CI, -10.07 to -7.99]; aRR, 0.83 [95% CI, 0.81 to 0.85]) individuals were significantly less likely to receive active treatment.

Conclusions and relevance: From 2014 to 2020 in the US, the frequency of active treatment among neonates born alive between 22 weeks 0 days and 25 weeks 6 days significantly increased, and there were differences in rates of active treatment by race and ethnicity.

Figure 1.. Birth Records Included of Singleton Nonanomalous Neonates Live-born in the Periviable Period Between 22 Weeks 0 Days and 25 Weeks 6 Days’ Gestation, US Natality Files, 2014-2020

^aN = 947 excluded for missing race and ethnicity data and n = 2447 excluded for race and ethnicity other than non-Hispanic White, Hispanic/Latina, non-Hispanic Black, non-Hispanic Asian/Pacific Islander (of which 488 were non-Hispanic American Indian).

Figure 2.. Frequency (per 100 Live Births) of Active Treatment of Neonates Live-born in the Periviable Period Between 22 Weeks 0 Days and 25 Weeks 6 Days’ Gestation by Maternal Race and Ethnicity and Gestational Age at Delivery

Figure 3.. Association Between Maternal Race and Ethnicity and Active Treatment of Neonates Live-born in the Periviable Period Between 22 Weeks 0 Days and 25 Weeks 6 Days’ Gestation Overall and by Gestational Age at Delivery, US Natality Files, 2014-2020

Baseline comparison is with non-Hispanic White. RR indicates relative risk. ^aModel adjusted for mother’s age, parity, prepregnancy body mass index, health insurance, education, receipt of prenatal care, chronic hypertension, gestational hypertension and/or preeclampsia, pregestational or gestational diabetes, chorioamnionitis, birthweight, sex, and year. ^bP value for the interaction of maternal race and ethnicity (referent, White individuals) with year of delivery in the adjusted model.