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Perinatal regionalization for very low-birth-weight and very preterm infants: a meta-analysis
Sarah Marie Lasswell1, Wanda Denise Barfield, Roger William Rochat
1Division of Reproductive Health, National Center for Chronic Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, 4770 Buford Hwy NE, Atlanta, GA 30341, USA.
Insights
Birth at a lower-level hospital significantly increases mortality risk for very low-birth-weight (VLBW) and very preterm (VPT) infants. Specialized level III hospital delivery is crucial for improving survival rates in these vulnerable newborns.
Area of Science:
- Neonatal care
- Perinatal health
- Public health policy
Background:
- Guidelines recommend specialized hospital births for very low-birth-weight (VLBW) infants.
- Despite recommendations, many VLBW infants are born in lower-level facilities.
Purpose of the Study:
- To assess the association between hospital level at birth and mortality for VLBW and very preterm (VPT) infants.
- To evaluate existing literature on this critical perinatal care issue.
Main Methods:
- Systematic literature search of multiple databases (1976-2010).
- Inclusion of 41 studies (RCTs, cohort, case-control) on neonatal/predischarge mortality.
- Data extraction and quality assessment by independent reviewers; meta-analysis using random-effects models.
Main Results:
- Higher mortality odds for VLBW infants born outside level III hospitals (OR 1.62).
- Increased mortality odds for VPT infants born outside level III facilities (OR 1.55).
- Consistent findings across higher-quality studies and infants <1000g.
Conclusions:
- Birth outside a level III hospital is linked to higher neonatal/predischarge death risk for VLBW and VPT infants.
- This highlights the importance of perinatal regionalization for vulnerable newborns.
Context:
For more than 30 years, guidelines for perinatal regionalization have recommended that very low-birth-weight (VLBW) infants be born at highly specialized hospitals, most commonly designated as level III hospitals. Despite these recommendations, some regions continue to have large percentages of VLBW infants born in lower-level hospitals.
Objective:
To evaluate published data on associations between hospital level at birth and neonatal or predischarge mortality for VLBW and very preterm (VPT) infants.
Data Sources:
Systematic search of published literature (1976-May 2010) in MEDLINE, CINAHL, EMBASE, and PubMed databases and manual searches of reference lists.
Study Selection And Data Extraction:
Forty-one publications met a priori inclusion criteria (randomized controlled trial, cohort, and case-control studies measuring neonatal or predischarge mortality among live-born infants < or = 1500 g or < or = 32 weeks' gestation delivered at a level III vs lower-level facility). Paired reviewers independently assessed publications for inclusion and extracted data using standardized forms. Discrepancies were decided by a third reviewer. Publications were reviewed for quality by 3 authors based on 2 content areas: adjustment for confounding and description of hospital levels. We calculated weighted, combined odds ratios (ORs) using a random-effects model and comparative unadjusted pooled mortality rates.
Data Synthesis:
We observed increased odds of death for VLBW infants (38% vs 23%; adjusted OR, 1.62; 95% confidence interval [CI], 1.44-1.83) and VPT infants (15% vs 17%; adjusted OR, 1.55; 95% CI, 1.21-1.98) born outside of level III hospitals. Consistent results were obtained when restricted to higher-quality evidence (mortality in VLBW infants, 36% vs 21%; adjusted OR, 1.60; 95% CI, 1.33-1.92 and in VPT infants, 7% vs 12%; adjusted OR, 1.42; 95% CI, 1.06-1.88) and infants weighing less than 1000 g (59% vs 32%; adjusted OR, 1.80; 95% CI, 1.31-2.46). No significant differences were found through subgroup analysis of study characteristics. Meta-regression by year of publication did not reveal a change over time (slope, 0.00; P = .87).
Conclusion:
For VLBW and VPT infants, birth outside of a level III hospital is significantly associated with increased likelihood of neonatal or predischarge death.
