[What perinatal organization in situations at risk of prematurity before 28 weeks?]

Extremely premature infants (22-26 weeks) are at high risk of neonatal death, severe morbidity, and disability. The survival of these infants is essentially linked to the obstetrical-pediatric team's willingness to provide intensive care. Numerous studies show that this increased survival rate in cases of willingness to actively manage them is not accompanied by an increased risk of morbidity and psychomotor delay in the longer term. The great variability in antenatal practices for the management of extremely premature infants reflects the confusion among medical teams who, in the absence of consensus and formalized decision-making processes, end up making management decisions that are at best based on local habits, and at worst on the individual habits of the attending clinician. This variability in practices across centers poses a problem of equity. Thus, in our country, practices and outcomes vary greatly depending on the child's place of birth. Intensive antenatal care rates for these children vary from 22 to 61% depending on the region. One consequence is a survival rate in France that is much lower than in other countries. Survival in the USA, Great Britain, Japan, Australia, and Sweden is 10 to 50% higher than in France. To improve this situation, new principles have been proposed: administration of corticosteroid therapy independently of treatment, prognostic assessment not based solely on gestational age, and collective decision-making on treatment outside of an emergency setting, and consensus on the information to be provided to parents before informing them and seeking their opinions. This approach requires consistency in care before, during, and after birth and relies on close obstetric-pediatric collaboration. This new organization is being tested in the PREMEX Cluster randomized trial involving 25 perinatal networks in France, the results of which will be available in 2026.