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Global inequities in the survival of extremely preterm infants: a systematic review and meta-analysis
Temesgen Getaneh1,2, Nusrat Homaira3,4,5, Habtamu Kasaye6,7
1College of Health Science, Midwifery Department, Debre Markos University, Debre Markos University, Debre Markos, Ethiopia. temugetaneh@gmail.com.
Insights
Global survival for extremely preterm infants is 61.4%, but significantly lower in low-income countries. Improvements were noted, yet disparities persist, highlighting the need for tailored neonatal care strategies.
Area of Science:
- Neonatal Medicine
- Global Health
- Perinatal Epidemiology
Background:
- Neonatal care advances improve survival for extremely preterm infants.
- Survival rate disparities complicate policy standardization.
- Global variations necessitate understanding of regional outcomes.
Purpose of the Study:
- Determine global survival rates of extremely preterm infants.
- Compare survival rates across income levels.
- Analyze survival trends over the past two decades.
Main Methods:
- Systematic search of major databases (PubMed, EMBASE, etc.).
- Included peer-reviewed studies on infants born before 29 weeks gestation (2000-2024).
- Compared outcomes between two epochs: 2000-2015 and 2016-2024.
Main Results:
- 61.4% of extremely preterm infants survived to discharge.
- Survival was significantly lower in low- and middle-income countries (44.3%) vs. high-income countries (69.3%).
- Low- and middle-income countries showed improvement from 38% to 44.8% survival between epochs.
Conclusions:
- Extremely preterm infant survival varies widely, with <50% survival in low- and middle-income countries.
- Improvements noted in low- and middle-income countries during the SDG period, but data limitations exist.
- Context-specific strategies and more data from low-resource settings are crucial for equitable global neonatal care policies.
Background:
Despite the associated major morbidities, advances in neonatal care units have improved the survival rates of extremely preterm infants. However, the varying survival rates make it challenging to set policy decisions around the standardization of care. Therefore, this study aimed to determine the global survival rate of extremely preterm infants and to compare it across different income levels and over time during the last two decades.
Method:
A comprehensive systematic search was conducted across major databases, including PubMed/Medline, EMBASE, CINAHL, Web of Science, Scopus, AJOL, Google Scholar and Google, to identify relevant articles. All peer-reviewed studies reported the survival rate of extremely preterm infants (born before 29 weeks' gestation) between January 1st, 2000, and June 25th, 2024, were included. Outcomes were compared between Epoch 1 (2000-2015, Millennium Developmental Goals period) and Epoch 2 (2016-2024, Sustainable Developmental Goals period). DerSimonian‒Laird random effects model was fitted to estimate the pooled weighted outcomes.
Results:
A total of 217 studies involving 917,176 infants were included. Based on published data, 61.4% (95% CI: 58.13-64.81) of extremely preterm infants survived to discharge, and 51.7% (95% CI: 44.25-59.22) of survivors were discharged without major morbidity. Survival rate was significantly lower in low- and middle-income countries (44.3%) compared to high-income countries (69.3%). Among low- and middle-income countries, survival improved from 38% during the epoch 1 to 44.8% during the epoch 2. While in high-income countries it was 69.9% during epoch 1 and 64.2% during epoch 2. These findings are based on reported literature; may not fully reflect outcomes in low-resource settings where data are limited and underreported. Variability in the inclusion and care of borderline viable infants also contributes to the heterogeneity and uncertainty of the estimates.
Conclusion:
Survival of extremely preterm infants varies widely across settings, with fewer than half surviving in low- and middle-income countries. While some improvement was observed in these regions during the Sustainable Developmental Goals period, comparisons across epochs and regions should be interpreted cautiously due to differences in data availability and population characteristics. These variations underscore the need for context-specific strategies that balance available resources, cultural values, and ethical considerations. Further population-level data, particularly from low-and middle-income countries, are essential to inform equitable global neonatal care policies.
Registration:
PROSPERO (CDR42023447612 (PROSPERO (york.ac.uk)).
Clinical Trial Number:
Not applicable.
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