Resuscitation of likely nonviable infants: a cost-utility analysis after the Born-Alive Infant Protection Act.

OBJECTIVE: The purpose of this study was to compare the effects of universal vs selective resuscitation on maternal utilities, perinatal costs, and outcomes of preterm delivery and termination of pregnancy at 20-23 weeks 6 days' gestation. STUDY DESIGN: We used studies on medical practices, prematurity outcomes, costs, and maternal utilities to construct decision-analytic models for a cohort of annual US deliveries after preterm delivery or induced termination. Outcome measures were (1) the numbers of infants who survived intact or with mild, moderate, or severe sequelae; (2) maternal quality-adjusted life years (QALYs); and (3) incremental cost-effectiveness ratios. RESULTS: Universal resuscitation of spontaneously delivered infants between 20-23 weeks 6 days' gestation increases costs by $313.1 million and decreases QALYs by 329.3 QALYs; after a termination, universal resuscitation increases costs by $15.6 million and decreases QALYs by 19.2 QALYs. With universal resuscitation, 153 more infants survive: 44 infants are intact or mildly affected; 36 infants are moderately impaired, and 73 infants are severely disabled. CONCLUSION: Selective intervention constitutes the highest utility and least costly treatment for infants at the margin of viability.

Resuscitation of likely nonviable newborns: would neonatology practices in California change if the Born-Alive Infants Protection Act were enforced?

BACKGROUND: The effects of the Born-Alive Infants Protection Act of 2002, which defines the legal status of live-born infants have not been evaluated. OBJECTIVE: To study neonatologists' perceptions and the potential effects of the Born-Alive Infants Protection Act and subsequent Department of Health and Human Services enforcement guidelines on resuscitation and comfort care for infants born at 20 to 24 weeks' gestation. METHODS: From August 2005 to November 2005, we mailed surveys to all 354 neonatologists practicing in California. Surveys asked physicians to characterize their knowledge of and attitudes toward this legislation and enforcement guidelines, current resuscitation and comfort-care practices for extreme prematurity, anticipated changes in practice were the enforced, and demographic information. We hypothesized that enforcement would alter thresholds for resuscitation and care. RESULTS: We obtained 156 completed surveys (response rate: 44%); 140 fulfilled criteria for analysis. More than half of the neonatologists had not heard of this Act or the enforcement guidelines. Screening examinations at birth were infrequent (<20%) at gestational ages of <23 weeks. Although 63% of neonatologists felt that the Act clarified the definition of born-alive infants, nearly all (>90%) criticized the legislation; only 6% felt that it should be enforced. If it were enforced, physicians predicted that they would lower birth weight and gestational age thresholds for resuscitation and comfort care. CONCLUSIONS: The Born-Alive Infants Protection Act clarified the legal status of "born-alive" infants, but enforcement guidelines fail to clarify what measures are appropriate when survival is unlikely. The Act may constrain resuscitation options offered to parents, because neonatologists anticipate medicolegal threats if they pursue nonintervention. If this legislation were enforced, respondents predicted more aggressive resuscitation potentially increasing risks of disability or delayed death. Until outcomes for infants of <24 weeks' gestation improve, legislation that changes resuscitation practices for extreme prematurity seems an unjustifiable restriction of physician practice and parental rights.