Doctor: Caroline Diguisto
Title: Antenatal care and neonatal consequences in extremely preterm children in France
Supervisors: François Goffinet, Laurence Foix-L’Hélias
Doctoral school: ED 393 Epidemiology and Biomedical Information Sciences, Université Paris Cité
Date of thesis defense: 01/2019
Jury: François Goffinet, Laurence Foix-L’Hélias, Laurence Meyer, Valérie Briand, Olivier Baud, Christophe Vayssière.
Survival rates of extremely preterm neonates, infants born between 22 and 26 Weeks of Gestation (WG), are lower in France than in England, Sweden, the United States or Japan. This may be related to differences in the management of extreme preterm births and in particular to differences in antenatal practices. In the case of preterm births, obstetricians are the first to meet the mothers-to-be. They decide whether or not to implement antenatal measures to improve outcomes of these unborn children: corticosteroids, caesarean sections or magnesium sulphate for neuroprotective purposes. The provision of optimal antenatal care is key to the management and survival of extremely preterm births and obstetrical teams thus play a major role. Factors associated with active antenatal care have never been studied. The first objective of our work was to identify, for extreme preterm births in France, individual or organisational determinants associated with active antenatal care. Gestational age is a well-known decision-making factor, but care could also depend on individual factors related to women or their pregnancy, practitioners or maternity units. Some extremely preterm neonates are born without having received active antenatal care. For newborns who have not received such treatment, the risk of peripartum and delivery room death is high. However some extremely preterm neonates for whom active antenatal was either voluntarily withheld or not provided because of insufficient time are resuscitated and admitted to a Neonatal Intensive Care Unit (NICU). Neonatal outcomes for these children raise medical and ethical difficulties and are poorly known. Our second objective was to study neonatal outcomes of extremely preterm neonates admitted to NICU without prior active antenatal care. Data from the EPIPAGE 2 cohort were used to answer these questions. We have shown that antenatal management for extreme preterm births varies widely between regions with regional active antenatal care rates ranging from 22% (95% CI 0.05-0.38) to 61% (95% CI 0.44-0.78). Active antenatal care was more frequent for births occurring at 25 and 26 WG than for births occurring at 24 WG. Even after adjusting for individual and organisational characteristics, active antenatal care rates varied by maternity unit of birth (p = 0.03). We also underlined that children admitted to NICU without having received active antenatal care have an increased risk of neonatal morbidity and mortality compared to children who have (crude OR of 2.60, (95% CI 1.44-4.66), adjusted OR of 1.86, (95% CI 1.09-3.20)). Differences in antenatal management between maternity units raise the issue of equality of care, especially since these practices have an impact on neonatal outcomes. These findings have led French teams to reassess the decision-making process around extreme preterm births and to the elaboration of guidelines for the management of extreme preterm births.