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      Short- and Long-Term Outcomes of Extremely Preterm Infants in Japan According to Outborn/Inborn Birth Status*

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          Outborn (born outside tertiary centers) infants, especially extremely preterm infants, are at an increased risk of mortality and morbidity in comparison to inborn (born in tertiary centers) infants. Extremely preterm infants require not only skilled neonatal healthcare providers but also highly specialized equipment and environment surroundings. Maternal transport at an appropriate timing must be done to avoid the delivery of extremely preterm infants in a facility without the necessary capabilities. Cases of unexpected deliveries at birth centers or level I maternity hospitals need to be attended emergently. We compared the differences in short- and long-term outcomes between outborn and inborn infants to improve our regional perinatal system.


          Retrospective cohort study.


          Neonatal Research Network of Japan database.


          Extremely preterm infants (gestational age between 22 + 0 and 27 + 6 wk) in the Neonatal Research Network of Japan database between 2003 and 2011.



          Measurements and Main Results:

          A total of 12,164 extremely preterm infants, who were divided into outborn ( n = 785, 6.5%) and inborn ( n = 11,379, 93.5%) groups, were analyzed. Significant differences were observed in demographic and clinical factors between the two groups. Outborn infants had higher short-term odds of severe intraventricular hemorrhage (adjusted odds ratio, 1.49; 95% CI, 1.11–2.00; p < 0.01), necrotizing enterocolitis (adjusted odds ratio, 1.49; 95% CI, 1.11–2.00; p < 0.01), and focal intestinal perforation (adjusted odds ratio, 1.58; 95% CI, 1.09–2.30; p = 0.02). There were no significant differences in long-term outcomes between the two groups, except in the rate of cognitive impairment (adjusted odds ratio, 1.49; 95% CI, 1.01–2.20; p = 0.04).


          The frequency of severe intraventricular hemorrhage, necrotizing enterocolitis or focal intestinal perforation, and cognitive impairment was significantly higher in outborn infants. Thus, outborn/inborn birth status may play a role in short- and long-term outcomes of extremely preterm infants. However, more data and evaluation of improvement in the current perinatal environment are needed.

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          Most cited references 13

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          Primary, secondary, and tertiary interventions to reduce the morbidity and mortality of preterm birth.

          Interventions to reduce the morbidity and mortality of preterm birth can be primary (directed to all women), secondary (aimed at eliminating or reducing existing risk), or tertiary (intended to improve outcomes for preterm infants). Most efforts so far have been tertiary interventions, such as regionalised care, and treatment with antenatal corticosteroids, tocolytic agents, and antibiotics. These measures have reduced perinatal morbidity and mortality, but the incidence of preterm birth is increasing. Advances in primary and secondary care, following strategies used for other complex health problems, such as cervical cancer, will be needed to prevent prematurity-related illness in infants and children.
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            Level and volume of neonatal intensive care and mortality in very-low-birth-weight infants.

            There has been a large increase in both the number of neonatal intensive care units (NICUs) in community hospitals and the complexity of the cases treated in these units. We examined differences in neonatal mortality among infants with very low birth weight (below 1500 g) among NICUs with various levels of care and different volumes of very-low-birth-weight infants. We linked birth certificates, hospital discharge abstracts (including interhospital transfers), and fetal and infant death certificates to assess neonatal mortality rates among 48,237 very-low-birth-weight infants who were born in California hospitals between 1991 and 2000. Mortality rates among very-low-birth-weight infants varied according to both the volume of patients and the level of care at the delivery hospital. The effect of volume also varied according to the level of care. As compared with a high level of care and a high volume of very-low-birth-weight infants (more than 100 per year), lower levels of care and lower volumes (except for those of two small groups of hospitals) were associated with significantly higher odds ratios for death, ranging from 1.19 (95% confidence interval [CI], 1.04 to 1.37) to 2.72 (95% CI, 2.37 to 3.12). Less than one quarter of very-low-birth-weight deliveries occurred in facilities with NICUs that offered a high level of care and had a high volume, but 92% of very-low-birth-weight deliveries occurred in urban areas with more than 100 such deliveries. Mortality among very-low-birth-weight infants was lowest for deliveries that occurred in hospitals with NICUs that had both a high level of care and a high volume of such patients. Our results suggest that increased use of such facilities might reduce mortality among very-low-birth-weight infants. Copyright 2007 Massachusetts Medical Society.
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              Levels of neonatal care.

               ,  Ann R. Stark (2004)
              The concept of designations for hospital facilities that care for newborn infants according to the level of complexity of care provided was first proposed in 1976. Subsequent diversity in the definitions and application of levels of care has complicated facility-based evaluation of clinical outcomes, resource allocation and utilization, and service delivery. We review data supporting the need for uniform nationally applicable definitions and the clinical basis for a proposed classification based on complexity of care. Facilities that provide hospital care for newborn infants should be classified on the basis of functional capabilities, and these facilities should be organized within a regionalized system of perinatal care.

                Author and article information

                Pediatr Crit Care Med
                Pediatr Crit Care Med
                Pediatric Critical Care Medicine
                Lippincott Williams & Wilkins
                October 2019
                03 October 2019
                : 20
                : 10
                : 963-969
                [1 ]Department of Obstetrics and Neonatology, Funabashi Central Hospital, Funabashi, Japan.
                [2 ]Goto, Ota and Tateoka Law Firm, Nagoya, Japan.
                [3 ]Department of Gynecologic Oncology & Reproductive Medicine, The University of Texas, MD Anderson Cancer Center, Houston, TX.
                [4 ]Department of Obstetrics and Gynecology, Mie University, Tsu, Japan.
                [5 ]Department of Obstetrics and Gynecology, Asahikawa Medical University, Asahikawa, Japan.
                [6 ]Department of Neonatology, Maternal and Perinatal Center, Tokyo Women’s Medical University, Tokyo, Japan.
                [7 ]Department of Neonatology, Osaka Medical Center and Research Institute for Maternal and Child Health, Izumi, Japan.
                Author notes
                For information regarding this article, E-mail: yoshihitosasaki@
                Copyright © 2019 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies.

                This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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