Validity of a Delphi consensus definition of growth restriction in the newborn for identifying neonatal morbidity.

BACKGROUND: Small for gestational age is defined as a birthweight below a birthweight percentile threshold, usually the 10th percentile, with the third or fifth percentile used to identify severe small for gestational age. Small for gestational age is used as a proxy for growth restriction in the newborn, but small-for-gestational-age newborns can be physiologically small and healthy. In addition, this definition excludes growth-restricted newborns who have weights more than the 10th percentile. To address these limits, a Delphi study developed a new consensus definition of growth restriction in newborns on the basis of neonatal anthropometric and clinical parameters, but it has not been evaluated. OBJECTIVE: To assess the prevalence of growth restriction in the newborn according to the Delphi consensus definition and to investigate associated morbidity risks compared with definitions of Small for gestational age using birthweight percentile thresholds. STUDY DESIGN: Data come from the 2016 and 2021 French National Perinatal Surveys, which include all births ≥22 weeks and/or with birthweights ≥500 g in all maternity units in France over 1 week. Data are collected from medical records and interviews with mothers after the delivery. The study population included 23,897 liveborn singleton births. The Delphi consensus definition of growth restriction was birthweight less than third percentile or at least 3 of the following criteria: birthweight, head circumference or length <10th percentile, antenatal diagnosis of growth restriction, or maternal hypertension. A composite of neonatal morbidity at birth, defined as 5-minute Apgar score <7, cord arterial pH <7.10, resuscitation and/or neonatal admission, was compared using the Delphi definition and usual birthweight percentile thresholds for defining small for gestational age using the following birthweight percentile groups: less than a third, third to fourth, and fifth to ninth percentiles. Relative risks were adjusted for maternal characteristics (age, parity, body mass index, smoking, educational level, preexisting hypertension and diabetes, and study year) and then for the consensus definition and birthweight percentile groups. Multiple imputation by chained equations was used to impute missing data. Analyses were carried out in the overall sample and among term and preterm newborns separately. RESULTS: We identified that 4.9% (95% confidence intervals, 4.6-5.2) of newborns had growth restriction. Of these infants, 29.7% experienced morbidity, yielding an adjusted relative risk of 2.5 (95% confidence intervals, 2.2-2.7) compared with newborns without growth restriction. Compared with birthweight ≥10th percentile, morbidity risks were higher for low birthweight percentiles (less than third percentile: adjusted relative risk, 3.3 [95% confidence intervals, 3.0-3.7]; third to fourth percentile: relative risk, 1.4 [95% confidence intervals, 1.1-1.7]; fifth to ninth percentile: relative risk, 1.4 [95% confidence intervals, 1.2-1.6]). In adjusted models including the definition of growth restriction and birthweight percentile groups and excluding birthweights less than third percentile, which are included in both definitions, morbidity risks remained higher for birthweights at the third to fourth percentile (adjusted relative risk, 1.4 [95% confidence intervals, 1.1-1.7]) and fifth to ninth percentile (adjusted relative risk, 1.4 [95% confidence intervals, 1.2-1.6]), but not for the Delphi definition of growth restriction (adjusted relative risk, 0.9 [95% confidence intervals, 0.7-1.2]). Similar patterns were found for term and preterm newborns. CONCLUSION: The Delphi consensus definition of growth restriction did not identify more newborns with morbidity than definitions of small for gestational age on the basis of birthweight percentiles. These findings illustrate the importance of evaluating the results of Delphi consensus studies before their adoption in clinical practice.

Long-term health in individuals born preterm or with low birth weight: A cohort study.

BACKGROUND: To measure the association of prematurity and non-preterm low birth weight (LBW) with several long-term health outcomes. METHODS: We selected adult participants from the Constances cohort. Associations between preterm birth (<37 weeks versus ≥37 weeks) and outcomes were measured using modified Poisson regression with adjustment for participant age and parental history. We used the same modeling methods to measure the association between LBW (i.e.,

Recommendations for data collection in cohort studies of preterm born individuals - The RECAP Preterm Core Dataset.

BACKGROUND: Preterm birth (before 37 completed weeks of gestation) is associated with an increased risk of adverse health and developmental outcomes relative to birth at term. Existing guidelines for data collection in cohort studies of individuals born preterm are either limited in scope, have not been developed using formal consensus methodology, or did not involve a range of stakeholders in their development. Recommendations meeting these criteria would facilitate data pooling and harmonisation across studies. OBJECTIVES: To develop a Core Dataset for use in longitudinal cohort studies of individuals born preterm. METHODS: This work was carried out as part of the RECAP Preterm project. A systematic review of variables included in existing core outcome sets was combined with a scoping exercise conducted with experts on preterm birth. The results were used to generate a draft core dataset. A modified Delphi process was implemented using two stages with three rounds each. Three stakeholder groups participated: RECAP Preterm project partners; external experts in the field; people with lived experience of preterm birth. The Delphi used a 9-point Likert scale. Higher values indicated greater importance for inclusion. Participants also suggested additional variables they considered important for inclusion which were voted on in later rounds. RESULTS: An initial list of 140 data items was generated. Ninety-six participants across 22 countries participated in the Delphi, of which 29% were individuals with lived experience of preterm birth. Consensus was reached on 160 data items covering Antenatal and Birth Information, Neonatal Care, Mortality, Administrative Information, Organisational Level Information, Socio-economic and Demographic information, Physical Health, Education and Learning, Neurodevelopmental Outcomes, Social, Lifestyle and Leisure, Healthcare Utilisation and Quality of Life. CONCLUSIONS: This core dataset includes 160 data items covering antenatal care through outcomes in adulthood. Its use will guide data collection in new studies and facilitate pooling and harmonisation of existing data internationally.

Growth charts for use at birth and in the neonatal period: Recommendations of the French Neonatal Society.

INTRODUCTION: The use of different growth charts can lead to confusion in discussions between professionals. There are obstetric charts (of fetal growth) and neonatal charts (of measurements at birth and of postnatal growth). These charts can be descriptive (derived from an unselected population) or prescriptive (derived from of a population at low risk and with optimal conditions for growth). OBJECTIVES: (1) To describe available charts for infants at birth and in the neonatal period and compare them, and (2) to recommend one or more charts for use in neonatology in France. METHODS: Bibliographic research was conducted on MEDLINE and completed by the guidelines of professional societies. RESULTS: Antenatal information about fetal growth restriction or fetuses identified as small-for-gestational-age using Intrauterine charts must be integrated into the identification of newborns at risk, but the use of Intrauterine charts to evaluate birthweight is not recommended to allow consistency with postnatal charts used in neonatal practice. Z-score variations using the updated Fenton postnatal charts are the most appropriate for the assessment of birthweight and postnatal growth for infants born preterm. These charts are sex-specific, include the three measurements (length, weight, and head circumference) and enable longitudinal follow-up of growth up to 50 weeks of corrected age and are linked to the World Health Organization charts at term. The French Audipog charts, although are individualized, accessible online and can be used in maternity units to evaluate birthweight for term infants, but do not allow the follow-up of postnatal growth, while Fenton charts may be used to evaluate birthweight and postnatal growth in the first month for hospitalized term infants. CONCLUSION: The updated Fenton charts are the neonatal charts that best suit the objectives of pediatricians in France for monitoring the growth of preterm newborns. The use of the Audipog charts at term remains an alternative in maternity wards, while Fenton charts can be used for hospitalized term newborns.

Socioeconomic disparities in changes to preterm birth and stillbirth rates during the first year of the COVID-19 pandemic: a study of 21 European countries.

BACKGROUND: Despite concerns about worsening pregnancy outcomes resulting from healthcare restrictions, economic difficulties and increased stress during the COVID-19 pandemic, preterm birth (PTB) rates declined in some countries in 2020, while stillbirth rates appeared stable. Like other shocks, the pandemic may have exacerbated existing socioeconomic disparities in pregnancy, but this remains to be established. Our objective was to investigate changes in PTB and stillbirth by socioeconomic status (SES) in European countries. METHODS: The Euro-Peristat network implemented this study within the Population Health Information Research Infrastructure (PHIRI) project. A common data model was developed to collect aggregated tables from routine birth data for 2015-2020. SES was based on mother's educational level or area-level deprivation/maternal occupation if education was unavailable and harmonized into low, medium and high SES. Country-specific relative risks (RRs) of PTB and stillbirth for March to December 2020, adjusted for linear trends from 2015 to 2019, by SES group were pooled using random effects meta-analysis. RESULTS: Twenty-one countries provided data on perinatal outcomes by SES. PTB declined by an average 4% in 2020 {pooled RR: 0.96 [95% confidence intervals (CIs): 0.94-0.97]} with similar estimates across all SES groups. Stillbirths rose by 5% [RR: 1.05 (95% CI: 0.99-1.10)], with increases of between 3 and 6% across the three SES groups, with overlapping confidence limits. CONCLUSIONS: PTB decreases were similar regardless of SES group, while stillbirth rates rose without marked differences between groups.

The early educational environment at five years of age in a European cohort of children born very preterm: challenges and opportunities for research.

BACKGROUND: Early childhood education offers opportunities for stimulation in multiple developmental domains and its positive impact on long-term outcomes and wellbeing for children is well documented. Few studies have explored early education in children born very preterm (VPT; <32 weeks of gestation) who are at higher risk of neurodevelopmental disorders and poor educational outcomes than their term-born peers. The purpose of the study is to describe and compare the educational environment of children born VPT in European countries at 5 years of age according to the degree of perinatal risk. METHODS: Data originated from the population-based Screening to Improve Health In very Preterm infants (SHIPS) cohort of children born VPT in 2011/2012 in 19 regions from 11 European countries. Perinatal data were collected from medical records and the 5-year follow-up was conducted using parental questionnaires. Outcomes at 5 years were participation in early education (any, type, intensity of participation) and receipt of special educational support, which were harmonized across countries. RESULTS: Out of 6,759 eligible children, 3,687 (54.6%) were followed up at 5 years (mean gestational age 29.3 weeks). At 5 years, almost all children (98.6%) were in an educational program, but type (preschool/primary), attendance (full-time/part-time) and use and type of school support/services differed by country. In some countries, children with high perinatal risk were more likely to be in full-time education than those with low risk (e.g. Estonia: 97.9% vs. 87.1%), while the inverse pattern was observed elsewhere (e.g. Poland: 78.5% vs. 92.8%). Overall, 22.8% of children received special educational support (country range: 12.4-34.4%) with more support received by children with higher perinatal risk. Large variations between countries remained after adjustment for socio-demographic characteristics. CONCLUSIONS: There are marked variations in approaches to early education for children born VPT in Europe, raising opportunities to explore its impact on their neurodevelopment and well-being.

The aetiology of preterm birth and risks of cerebral palsy and cognitive impairment: A systematic review and meta-analysis.

AIM: The associations between the aetiology of preterm birth and later neurodevelopmental outcomes are unclear. A systematic review and meta-analysis examined the existing evidence. METHODS: The PubMed and Embase databases were searched for papers published in English from inception to 16 December 2020. We included original papers on the causes of preterm birth and the risks of cerebral palsy (CP) and suboptimal cognitive development. Two reviewers independently evaluated the studies and extracted the data. RESULTS: The literature search yielded 5472 papers and 13 were selected. The aetiology of preterm birth was classified under spontaneous or medically indicated delivery. A meta-analysis was performed, comprising 104 902 preterm infants from 11 papers on CP. Preterm infants born after a medically indicated delivery had a lower CP risk than infants born after spontaneous delivery, with a pooled odds ratio of 0.59 (95% confidence interval 0.40-0.86). This result was robust in the subgroup and sensitivity analyses. Cognitive development was reported in three papers, which suggested that worse outcomes were associated with medically indicated deliveries. CONCLUSION: The aetiology of preterm delivery may contribute to the risk of CP and cognitive delay. Further research is needed, using individual-level meta-analyses to adjust for possible confounders, notably gestational age.

Treating very preterm European infants with inhaled nitric oxide increased in-hospital mortality but did not affect neurodevelopment at 5 years of age.

AIM: We examined the outcomes of using inhaled nitric oxide (iNO) to treat very preterm born (VPT) infants across Europe. METHODS: This was a sub-study of the Screening to Improve Health in Very Preterm Infants in Europe research. It focused on all infants born between 22 + 0 and 31 + 6 weeks/days of gestation from 2011 to 2012, in 19 regions in 11 European countries. We studied 7268 infants admitted to neonatal care and 5 years later, we followed up the outcomes of 103 who had received iNO treatment. They were compared with 3502 propensity score-matched controls of the same age who did not receive treatment. RESULTS: All countries used iNO and 292/7268 (4.0%) infants received this treatment, ranging from 1.2% in the UK to 10.5% in France. There were also large regional variations within some countries. Infants treated with iNO faced higher in-hospital mortality than matched controls (odds ratio 2.03, 95% confidence interval 1.33-3.09). The 5-year follow-up analysis of 103 survivors showed no increased risk of neurodevelopmental impairment after iNO treatment. CONCLUSION: iNO was used for VPT patients in all 11 countries. In-hospital mortality was increased in infants treated with iNO, but long-term neurodevelopmental outcomes were not affected in 103 5-year-old survivors.

Preterm births among male and female conception cohorts in France during initial COVID-19 societal restrictions.

PURPOSE: A recent meta-analysis finds reduced risk of preterm birth (PTB; <37 weeks gestational age) during the initial stage of COVID-19 in which infection rates remained relatively low but many societies imposed restrictions on movement. None of this work, however, examines sex-specific responses despite much literature on other ambient "shocks" which would predict male sensitivity. We use a conception cohort approach to explore potential sex-specific PTB responses in France, a country which imposed a lockdown in Spring 2020. METHODS: We applied interrupted time series methods using national data in France for 207 weeks among 1403,284 males and 1341,359 females conceived from 19 Jan 2016 to 6 Jan 2020. RESULTS: For males in utero, the 1st COVID-19 societal lockdown corresponds with a - 0.60 per 100 conception reduction in PTB cases per week, for 12 consecutive weeks (95% confidence interval [CI]: -.36, -.84). For females in utero, the PTB reduction is smaller (-0.40 reduction per 100 conceptions, for 10 consecutive weeks, 95% CI: -.15, -.61). A formal test of sex differences in the PTB response indicates a stronger reduction in male (vs. female) PTB during the lockdown (p = .001). CONCLUSIONS: Explanations for the counterintuitive reduction in PTB during COVID-19 among cohorts in utero during Spring 2020 should consider mechanisms that disproportionately affect males.

Association between risk of infant death and birth-weight z scores according to gestational age: A nationwide study using the Finnish Medical Birth Register.

OBJECTIVE: To investigate the association between infant mortality and birth weight using estimated fetal weight (EFW) versus birth-weight charts, by gestational age (GA). METHODS: This nationwide population-based study used data from the Finnish Medical Birth Register from 2006 to 2016 on non-malformed singleton live births at 24-41+6 weeks of gestation (N = 563 630). The outcome was death in the first year of life. Mortality risks by birth-weight z score, defined as a continuous variable using Marsál's EFW and Sankilampi's birth-weight charts, were assessed using generalized additive models by GA (24-27+6, 28-31+6, 32-36+6, 37-38+6, 39-41+6 weeks). We calculated z score thresholds associated with a two- and three-fold increased risk of infant death compared with newborns with a birth weight between 0 and 0.675 standard deviations. RESULTS: The z score thresholds (with corresponding centiles in parentheses) associated with a two-fold increase in infant mortality were: -3.43 (<0.1) at 24-27+6 weeks, -3.46 (<0.1) at 28-31+6 weeks, -1.29 (9.9) at 32-36+6 weeks, -1.18 (11.9) at 37-38+6 weeks, and - 1.34 (9.0) at 39-41+6 weeks according to the EFW chart. These values were - 2.43 (0.8), -2.62 (0.4), -1.34 (9.0), -1.37 (8.5), and - 1.43 (7.6) according to the birth-weight chart. CONCLUSION: The association between birth weight and infant mortality varies by GA whichever chart is used, suggesting that different thresholds for the screening of growth anomalies could be used across GA to identify high-risk newborns.

Maternal Characteristics and Rates of Unexpected Complications in Term Newborns by Hospital.

Importance: The Joint Commission Unexpected Complications in Term Newborns measure characterizes newborn morbidity potentially associated with quality of labor and delivery care. Infant exclusions isolate relatively low-risk births, but unexpected newborn complications (UNCs) are not adjusted for maternal factors that may be associated with outcomes independently of hospital quality. Objective: To investigate the association between maternal characteristics and hospital UNC rates. Design, Setting, and Participants: This cohort study was conducted using linked 2016 to 2018 New York City birth and hospital discharge datasets among 254 259 neonates at low risk (singleton, ≥37 weeks, birthweight ≥2500 g, and without preexisting fetal conditions) at 39 hospitals. Logistic regression was used to calculate unadjusted hospital-specific UNC rates and replicated analyses adjusting for maternal covariates. Hospitals were categorized into UNC quintiles; changes in quintile ranking with maternal adjustment were examined. Data analyses were performed from December 2022 to July 2023. Main Outcomes and Measures: UNCs were classified according to Joint Commission International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) criteria. Maternal preadmission comorbidities, obstetric factors, social characteristics, and hospital characteristics were ascertained. Results: Among 254 259 singleton births at 37 weeks or later who were at low risk (125 245 female [49.3%] and 129 014 male [50.7%]; 71 768 births [28.2%] to Hispanic, 47 226 births [18.7%] to non-Hispanic Asian, 42 682 births [16.8%] to non-Hispanic Black, and 89 845 births [35.3%] to non-Hispanic White mothers and 2738 births [1.0%] to mothers with another race or ethnicity), 148 393 births (58.4%) were covered by Medicaid and 101 633 births (40.0%) were covered by commercial insurance. The 2016 to 2018 cumulative UNC incidence in New York City hospitals was 37.1 UNCs per 1000 births. Infants of mothers with preadmission risk factors had increased UNC risk; for example, among mothers with vs without preeclampsia, there were 104.4 and 35.8 UNCs per 1000 births, respectively. Among hospitals, unadjusted UNC rates ranged from 15.6 to 215.5 UNCs per 1000 births and adjusted UNC rates ranged from 15.6 to 194.0 UNCs per 1000 births (median [IQR] change from adjustment, 1.4 [-4.7 to 1.0] UNCs/1000 births). The median (IQR) change per 1000 births for adjusted vs unadjusted rates showed that hospitals with low (<601 deliveries/year; -2.8 [-7.0 to -1.6] UNCs) to medium (601 to <954 deliveries/year; -3.9 [-7.1 to -1.9] UNCs) delivery volume, public ownership (-3.6 [-6.2 to -2.3] UNCs), or high proportions of Medicaid-insured (eg, ≥90.72%; -3.7 [-5.3 to -1.9] UNCs), Black (eg, ≥32.83%; -5.3 [-9.1 to -2.2] UNCs), or Hispanic (eg, ≥6.25%; -3.7 [-5.3 to -1.9] UNCs) patients had significantly decreased UNC rates after adjustment, while rates increased or did not change in hospitals with the highest delivery volume, private ownership, or births to predominantly White or privately insured individuals. Among all 39 hospitals, 7 hospitals (17.9%) shifted 1 quintile comparing risk-adjusted with unadjusted quintile rankings. Conclusions and Relevance: In this study, adjustment for maternal case mix was associated with small overall changes in hospital UNC rates. These changes were associated with performance assessment for some hospitals, and these results suggest that profiling on this measure should consider the implications of small changes in rates for hospitals with higher-risk obstetric populations.

Which fetal growth charts should be used in France? Position of the French College of Obstetricians and Gynecologists (CNGOF).

OBJECTIVE: To assess which fetal growth charts best describe intrauterine growth in France defined as the ability to classify 10% of fetuses below the 10th percentile (small for gestational age [SGA]) and above the 90th percentile (large for gestational age [LGA]) in the second and third trimesters. METHODS: We analyzed five studies on fetal ultrasound measurements using three French data sources. Two studies used second and third trimester ultrasound data from a nationwide birth cohort in 2011 (the ELFE study, N = 13 197 and N = 7747); one study used third trimester ultrasound data from on a nationwide cross-sectional study (the 2016 French National Perinatal Survey, N = 9940); and the last two studies were from the "Flash study" 2014 which prospectively collected ultrasound data from routine visits in the second and third trimesters (N = 4858 and N = 3522). For each study, we reported the percentage of measurements below the 10th percentile or above the 90th percentile, using French, Hadlock's, WHO and Intergrowth (IG) charts. RESULTS: WHO classified 4.7% and 16.3% of fetuses as having an estimated fetal weight (EFW) <10th and >90th percentiles in the second trimester compared to 3.3% and 34.7% with IG. The percentage of fetuses in the third trimester with an EFW <10th and >90th percentiles, ranged from 9.1% to 9.4% and from 8.0% to 11.1%, respectively, for WHO, and from 3.9% to 4.1% and from 17.3% to 21.6%, respectively, for IG. The WHO and IG charts for head circumference were very similar and performed well. Compared to the WHO charts, the French and Hadlock's charts deviated more frequently from the target percentiles values for EFW and biometric measures. CONCLUSION: It is recommended to use the WHO charts for the assessment of EFW and ultrasound biometric measurements in France (strong recommendation; low quality of evidence).

Variations in neonatal mortality of preterm infants with intraparenchymal haemorrhage in Europe: the EPICE cohort.

OBJECTIVE: The aim of this study was to investigate variations in mortality before neonatal intensive care unit (NICU) discharge of infants born preterm with intraparenchymal haemorrhage (IPH) in Europe with a special interest for withdrawing life-sustaining therapy (WLST). DESIGN: Secondary analysis of the Effective Perinatal Intensive Care in Europe (EPICE) cohort, 2011-2012. SETTING: Nineteen regions in 11 European countries. PATIENTS: All infants born between 24+0 and 31+6 weeks' gestational age (GA) with a diagnosis of IPH. MAIN OUTCOME MEASURES: Mortality rate with multivariable analysis after adjustment for GA, antenatal steroids and gender. WLST policies were described among NICUs and within countries. RESULTS: Among 6828 infants born alive between 24+0 and 31+6 weeks' GA and without congenital anomalies admitted to NICUs, IPH was diagnosed in 234 infants (3.4%, 95% CI 3.3% to 3.9%) and 138 of them (59%) died. The median age at death was 6 days (3-13). Mortality rates varied significantly between countries (extremes: 30%-81%; p<0.004) and most infants (69%) died after WLST. After adjustment and with reference to the UK, mortality rates were significantly higher for France, Denmark and the Netherlands, with ORs of 8.8 (95% CI 3.3 to 23.6), 5.9 (95% CI 1.6 to 21.4) and 4.8 (95% CI 1.1 to 8.9). There were variations in WLST between European regions and countries. CONCLUSION: In infants with IPH, rates of death before discharge and death after WLST varied between European countries. These variations in mortality impede studying reliable outcomes in infants with IPH across European countries and encourage reflection of clinical practices of WLST across European units.

Neonatal Mortality Disparities by Gestational Age in European Countries.

Importance: There are wide disparities in neonatal mortality rates (NMRs, deaths <28 days of life after live birth per 1000 live births) between countries in Europe, indicating potential for improvement. Comparing country-specific patterns of births and deaths with countries with low mortality rates can facilitate the development of effective intervention strategies. Objective: To investigate how these disparities are associated with the distribution of gestational age (GA) and GA-specific mortality rates. Design, Setting, and Participants: This was a cross-sectional study of all live births in 14 participating European countries using routine data compiled by the Euro-Peristat Network. Live births with a GA of 22 weeks or higher from 2015 to 2020 were included. Data were analyzed from May to October 2023. Exposures: GA at birth. Main Outcomes and Measures: The study investigated excess neonatal mortality, defined as a rate difference relative to the pooled rate in the 3 countries with the lowest NMRs (Norway, Sweden, and Finland; hereafter termed the top 3). The Kitagawa method was used to divide this excess into the proportion explained by the GA distribution of births and by GA-specific mortality rates. A sensitivity analysis was conducted among births 24 weeks' GA or greater. Results: There were 35 094 neonatal deaths among 15 123 428 live births for an overall NMR of 2.32 per 1000. The pooled NMR in the top 3 was 1.44 per 1000 (1937 of 1 342 528). Excess neonatal mortality compared with the top 3 ranged from 0.17 per 1000 in the Czech Republic to 1.82 per 1000 in Romania. Excess deaths were predominantly concentrated among births less than 28 weeks' GA (57.6% overall). Full-term births represented 22.7% of the excess deaths in Belgium, 17.8% in France, 40.6% in Romania and 17.3% in the United Kingdom. Heterogeneous patterns were observed when partitioning excess mortality into the proportion associated with the GA distribution vs GA-specific mortality. For example, these proportions were 9.2% and 90.8% in France, 58.4% and 41.6% in the United Kingdom, and 92.9% and 7.1% in Austria, respectively. These associations remained stable after removing births under 24 weeks' GA in most, but not all, countries. Conclusions and Relevance: This cohort study of 14 European countries found wide NMR disparities with varying patterns by GA. This knowledge is important for developing effective strategies to reduce neonatal mortality.

Characteristics of High Versus Low-Performing Hospitals for Very Preterm Infant Morbidity and Mortality.

Objective: To ascertain organizational attributes, policies, and practices that differentiate hospitals with high versus low risk-adjusted rates of very preterm neonatal morbidity and mortality (NMM). Methods: Using a positive deviance research framework, we conducted qualitative interviews of hospital leadership and frontline clinicians from September-October 2018 in 4 high-performing and 4 low-performing hospitals in New York City, based on NMM measured in previous research. Key interview topics included NICU physician and nurse staffing, professional development, standardization of care, quality measurement and improvement, and efforts to measure and report on racial/ethnic disparities in care and outcomes for very preterm infants. Interviews were audiotaped, professionally transcribed, and coded using NVivo software. In qualitative content analysis, researchers blinded to hospital performance identified emergent themes, highlighted illustrative quotes, and drew qualitative comparisons between hospital clusters. Results: The following features distinguished high-performing facilities: 1) stronger commitment from hospital leadership to diversity, quality, and equity; 2) better access to specialist physicians and experienced nursing staff; 3) inclusion of nurses in developing clinical policies and protocols, and 4) acknowledgement of the influence of racism and bias in healthcare on racial-ethnic disparities. In both clusters, areas for improvement included comprehensive family engagement strategies, care standardization, and reporting of quality data by patient sociodemographic characteristics. Conclusions and relevance: Our findings suggest specific organizational and cultural characteristics, from hospital leadership and clinician perspectives, that may yield better patient outcomes, and demonstrate the utility of a positive deviance framework to center equity in quality initiatives for high-risk infant care.

Maternal Wellbeing Five Years after a Very Preterm Delivery: Prevalence and Influencing Factors in a European Cohort.

(1) Background: Mothers of very preterm (VPT) infants may experience psychological symptoms compromising long-term emotional wellbeing. This study describes the emotional wellbeing of mothers of five-year-old children born VPT. We assess the association between sociodemographic, perinatal and neonatal characteristics, and the child's health and development at five years old and maternal emotional wellbeing. (2) Methods: Data are from the prospective European "Effective Perinatal Intensive Care in Europe" (EPICE) and subsequent "Screening for Health In very Preterm infantS in Europe" (SHIPS) projects including births <32 weeks' gestational age in 11 countries in 2011/12. Data were abstracted from obstetric and neonatal records. At five years old, 2605 mothers answered a parental questionnaire including the Mental Health Inventory-5 (MHI-5). Associations between sociodemographic and health characteristics and the mother's MHI-5 score were investigated using multilevel multivariate linear regression analysis with the country modelled as a random effect and inverse probability weighting to correct for attrition bias. (3) Results: The mean MHI-5 score was 71.3 (SD 16.7) out of 100 (highest emotional wellbeing) with a variation among countries from 63.5 (SD 16.8; Poland) to 82.3 (SD 15.8; the Netherlands). MHI-5 scores were significantly lower for mothers whose child had a severe health problem, developmental, or speech delay, for multiparous and single mothers, and when at least one of the parents was unemployed. (4) Conclusions: The emotional wellbeing of mothers of VPT infants differs between European countries. Identifying sociodemographic characteristics and child's health and developmental conditions that affect maternal emotional wellbeing may help to identify groups of mothers who need special assistance to cope with consequences of the delivery of a VPT child.