Are current trends in perinatal practice associated with an increase or a decrease in handicapping conditions?

Influence of obstetric management on outcome of extremely preterm growth retarded infants

AIM

To describe the long term outcome of extremely preterm growth retarded infants in relation to obstetric management and various perinatal events.

METHODS

A cohort study was undertaken in two tertiary care centres with different obstetric management. All infants with fetal growth retardation due to placental insufficiency and resulting in fetal distress at 26 to 32 weeks of gestation, were included for the years 1984-89. Main outcome measures were impairment, disability, or handicap at 2 years corrected age and at school age (4 1/2 to 10 1/2 years).

RESULTS

One hundred and twenty five (98%) were followed up until 2 years corrected age in the outpatient department; 114 (90%) were assessed at school age. Impairments were found in 37% and disabilities or handicaps in 9% of the assessed infants, with no difference between centres. All disabled or handicapped children had already been identified by 2 years corrected age.

CONCLUSIONS

Disability or handicap were related to neonatal complications (intracerebral haemorrhage or bronchopulmonary dysplasia) and not to obstetric variables, thus making antenatal prediction impossible. The incidence of disability or handicap in these growth retarded infants was comparable with that of other preterm infants.

The Scottish low birthweight study: I. Survival, growth, neuromotor and sensory impairment

Of all 908 livebirths weighing less than 1750 g at birth who were born in Scotland in 1984, 896 (99%) were enrolled in a prospective study to document survival and determine the prevalence of neuromotor and sensory impairments and disability. At the age of 4.5 years, 636 (71%) had survived and 611 (96%) were assessed. Overall 16% were disabled; 47 had cerebral palsy (52.5/1000 livebirths), seven were blind (7.8/1000 livebirths), and 11 were deaf and using aids (12.3/1000 livebirths). Among those not overtly disabled, the prevalence of poor neuromotor competence was high and related to birth weight. All growth measures had mean values below the standard population mean indicating a downward shift in the distribution which was related to birth weight. In addition the height distribution was negatively skewed.

The work of the National Perinatal Epidemiology Unit. One example of technology assessment in perinatal care

This article describes one approach to assessing the effects of perinatal care--that adopted by the National Perinatal Epidemiology Unit in Oxford, England. The unit's research has been based primarily on a combination of simple, descriptive analyses of observational data and statistically robust analyses of evidence derived from randomized controlled trials.

International perspectives on treatment choice in neonatal intensive care units

Over the past 25 years, neonatal intensive care units (NICUs) have been established throughout the industrialized world and in some Third World nations to provide sophisticated medical interventions for critically ill newborns. This paper discusses the four major factors affecting treatment choices for newborns with disabilities or at risk for disabilities: the availability of resources, societal attitudes toward medical interventions and life with disabilities, the roles of physicians, parents and other decision-makers, and the role of the law. Much has been written on the bioethical issues surrounding such treatment as it is practiced in the United States, including analysis by social scientists; however, little has been written on how those issues are perceived and dealt with in most other nations, and very little comparative research has been conducted. The author provides an international perspective on the bioethical issues involved by comparing U.S. practice, which has received much attention, with a generalized commentary on practices in other parts of the world, which have received less examination. The nations surveyed include Australia, Brazil, Britain, Canada, China, France, India, Israel, Japan, the Netherlands, Poland, Sweden, and West Germany. The value of further comparative research is discussed in order to encourage others to do such research.

Decreased disability rate among 3-year-old survivors weighing 501 to 1000 grams at birth and born to residents of a geographically defined region from 1981 to 1984 compared with 1977 to 1980

In this article we report the survival and morbidity rates for all live-born infants weighing 501 to 1000 gram at birth and born to residents of a defined geographic region from 1977 to 1980 (n = 255) compared with 1981 to 1984 (n = 266). During these periods, there were no changes in the proportion of infants delivered at the tertiary care center or community hospitals (171/84 vs 194/72); use of the tertiary care center increased only slightly, from 84% to 91%; and changes in neonatal management were mainly in improvements in diagnostic and monitoring techniques. When infants were grouped according to birth weights in 100 gm increments, survival improved significantly only for infants weighing between 501 and 600 gm at birth (2% vs 20% p less than 0.001). There were no differences in the overall survival rates to hospital discharge (46% vs 48%). The prevalence of neurosensory impairments was 24% in period 1 and 17% in period 2. There was a significant improvement in the proportion of infants considered to have disabilities by a functional classification assigned at 3 years corrected age (50% vs 27%, p less than 0.001), but only for infants weighing more than 800 gm at birth (49% vs 22%, p less than 0.001). Infants delivered at the community hospitals had a higher prevalence of neurosensory impairments compared with infants delivered at the tertiary care center (period 1, 35% vs 21%, not significant; period 2, 37% vs 14%, p less than 0.05). These data are encouraging; further efforts should be directed toward assessing which, if any, components of perinatal care are contributing to the improvement in morbidity rates.

Changed prognosis of breech-presenting low birthweight infants

We have compared the mortality and morbidity of low birthweight breech-presenting singleton infants born in the Coventry Maternity Hospital during the years 1973 and 1974 with those born during 1979 and 1980. During this period changes in management have included an increase in the caesarean section rate and the continuing development of methods of intensive care for the newborn infants. The neonatal mortality rate has fallen but the increased survival rate is accounted for largely by the survival of handicapped infants. The value of routine caesarean section in the absence of other obstetric pathology for low birthweight breeches is unproven and may be deleterious to mother and baby.

Cerebral palsy and severe educational subnormality in low-birthweight children: a comparison of births in 1951-53 and 1970-73

The prevalence at school age of cerebral palsy and severe education subnormality in children of low birthweight (less than or equal to 4 lb=1814 g) born to residents in the region served by the South East Thames Regional Health Authority in the early 1970s was compared with that in children of the same birthweight born in 1950-53. The prevalence of one or both of these defects was lower in the 1970s cohort; this was due to both a fall in the incidence of extreme gestational immaturity among children of low birthweight and a reduction in risk of defects to the gestationally immature births that occurred. The decreased risk of these defects in children of low birthweight was approximately counter-balanced by the increased likelihood of their survival; among children of all birthweights the prevalence of these defects attributable to children of very low birthweight changed little.