The Dreaming Spires of Oxford

The Victorian poet Matthew Arnold called Oxford ‘the city of dreaming spires’ inspired by the stunning architecture of Oxford’s famous university buildings. In September 2017, I was invited as a plenary speaker at the second Edition Neonatal Transport Conference, held in the Examinations School at Oxford University, a building rich in history since completion in 1882. I was also invited to give the Grand Round at the John Radcliffe Hospital the following week.

As a neonatal nurse researcher with a 20-year career with the Newborn Emergency Transport Service, Victoria (now the Paediatric Infant Perinatal Emergency Retrieval Service), the opportunity to present my research to an international audience, who all share my passion for improving outcomes in babies needing retrieval and intensive care after birth was a dream in itself: being invited to do so in the beautiful city of Oxford was a career highlight.

My research focuses on identifying risk factors associated with perinatal (around the time of birth) and infant (up to one year after birth) mortality and morbidity in babies born very preterm. The plenary session at the Neonatal Transport Conference was titled: In-utero transfers- how successful are we?” The Grand Round at the John Radcliffe was titled “Outcomes of infants born at 22-27 weeks gestation- how do Victoria and England compare?” Both were based on my research investigating outcomes of a population-based cohort of every birth less than 32 weeks’ gestation in Victoria over two decades (1990-2009)1 and a more recent cohort born extremely preterm (less than 28 weeks’ gestation) in 2010-2011.2

Victoria and England have many similarities- geographically we are similar in size, both have a three- tiered system of pregnancy care (tertiary being the highest level) and both have clinical practice guidelines stating births less than 28 weeks’ gestation should occur in a tertiary centre. However, unlike England, all tertiary centres in Victoria are in the Melbourne metropolitan area, at Parkville (Royal Women’s), Clayton (Monash Children’s) and Heidelberg (Mercy Hospital for Women). Women with threatened preterm labour or high-risk pregnancies who are booked in any of the 70 public and private hospitals throughout the state must be transferred in-utero to one of the three centres in Melbourne to receive tertiary care. All babies requiring neonatal intensive care must also be admitted to one of these three centres, or the Royal Children’s Hospital. It was interesting to compare non-tertiary preterm birth rates in Victoria with that of England, where geographical proximity to a tertiary centre is much closer, even in rural areas of England.

In Victoria, 15-19 per cent of very preterm babies less than 32 weeks’ gestation were born in non-tertiary hospital– swell above the World Health Organisation target of less than 10 per cent. One-in every-six babies were born in inappropriate hospitals in Victoria. Of greater concern, one in every five of the most vulnerable babies, born before 28 weeks’ gestation were born in non-tertiary hospitals– a trend seen even as recently as 2010-2014.

The comparative cohort of English babies3 were born in 2006 and at 22-26 weeks’ gestation. Of these 42 per cent were non-tertiary births- significantly higher than the rate in Victoria which was 16 per cent in 2010-2011. The consequence of being born very preterm in a non-tertiary hospital is the significantly increased risk of death in the first 28 days or first year of life. Babies born in non-tertiary hospitals in Victoria were three times more likely to die compared with babies born in one of the three tertiary perinatal centres.

Of greater concern, the risk of death had not improved for these babies. In 2010-2011, 58 per cent of babies born non-tertiary hospitals less than 28 weeks’ gestation died before one year of age, compared with 31 per cent of tertiary born peers. A key reason for the difference was babies born in non-tertiary hospitals in Victoria were less likely to be admitted to a tertiary neonatal intensive care unit (NICU) compared with those babies born in a tertiary centre (58 per cent versus 87 per cent respectively). All babies not admitted to NICU died within hours of birth. Reasons for this are currently being explored in a new cohort of preterm births in 2012-2016 as part of my post-doctoral research.

We do know that in some instances, very preterm birth in an inappropriate hospital is not avoidable. Some women labour quickly and give birth before there is time transfer the woman to a tertiary centre with baby in-utero. There may not be sufficient time to administer drugs to the mother to improve outcome for the baby, including corticosteroids to mature the fetal lungs and magnesium sulphate to protect the fetal brain. Non-tertiary hospitals are encouraged to request a PIPER team at extremely preterm births so neonatal intensive care can be provided from birth- but distance and time to travel to some regional areas of Victoria means this is only achieved in one in three cases.2

Overall, 60 per cent of all babies born at 22-26 weeks’ gestation in Victoria in 2010-2011 survived to at least one year of age. In comparison, 51 per cent of babies born in England in 2006 survived. Of course, longer term consequences of being born extremely preterm need to be evaluated, as these babies are at significantly increased risks of neurodevelopmental impairment. Both groups of babies are being followed-up in their county of birth. It will be interesting to compare their progress in early school years and beyond.

By Rosemarie Boland

References

1. Boland RA, Dawson JA, Davis PG, et al. Why birthplace still matters for infants born before 32 weeks: Infant mortality associated with birth at 22–31 weeks’ gestation in non-tertiary hospitals in Victoria over two dec-ades. Australian and New Zealand Journal of Obstetrics and Gynaecology 2015;55(2):163-69. doi: 10.1111/ ajo.12313

2. Boland RA, Davis PG, Dawson JA, et al. Outcomes of infants born at 22–27 weeks' gestation in Victoria ac-cording to outborn/inborn birth status. Archives of Disease in Childhood - Fetal and Neonatal Edition 2017;102 (2):F153-F61. doi: 10.1136/archdischild-2015-310313

3. Costeloe KL, Hennessy EM, Haider S, et al. Short term outcomes after extreme preterm birth in England: comparison of two birth cohorts in 1995 and 2006 (the EPICure studies). BMJ: British Medical Journal 2012;345:e7976. doi: 10.1136/e.7976