Between 2014 and 2023, increases in active treatment and survival among infants born between 22 and 25 weeks' gestation were most pronounced at 22 weeks, according to a retrospective cohort study.
Among 58,918 infants, active treatment as well as survival among those with active treatment increased most for those born at 22 weeks, from 28.8% to 78.6% for an annual percentage change (APC) of 10.11% (95% CI 8.36-11.88) for active treatment and 25.7% to 41.0% (APC 4.18%, 95% CI 2.40-6.00) for survival, reported Nansi Boghossian, PhD, of the University of South Carolina in Columbia, and colleagues.
Additionally, increases in active treatment were similar across racial and ethnic groups (P>0.11), though Black infants were more likely than white infants to receive active treatment at 22 weeks, with an adjusted risk ratio (aRR) 1.18 (95% CI 1.05-1.08) and at 23 weeks (aRR 1.05, 95% CI 1.03-1.06), they stated in a JAMA research letter. The data were simultaneously presented at the Pediatric Academic Societies annual meeting in Honolulu.
"We know that the limit of viability has been shifting over time," Boghossian told MedPage Today in an email. "This study provides compelling evidence of how medical advancements and evolving clinical guidelines have contributed to that shift.
"The most striking result is the sharp increase in active treatment for 22-week infants...this indicates a growing willingness among clinicians to intervene aggressively at the earliest stages of prematurity," Boghossian added.
The authors noted in the research letter that "[m]onitoring the rate of active treatment at periviable gestations is particularly important due to increases in fertility associated with restrictive abortion policies enacted in many states since 2021."
In addition to the increase in active treatment at 22 weeks, Boghossian pointed to the "higher likelihood of Black infants receiving active treatment compared to white infants, contrary to some prior studies reporting lower treatment rates among Black infants when using birth certificate data."
"This suggests that a more comprehensive definition of active treatment, as employed in this study, may provide a clearer picture of neonatal interventions," she said.
Active treatment in the current study included face mask ventilation, nasal continuous positive airway pressure, endotracheal intubation, surfactant therapy, mechanical ventilation, chest compressions, or epinephrine, Boghossian and colleagues said.
Active treatment as well as survival among infants with active treatment also increased for those born at 23 weeks' gestation, though much less so, from 87.4% to 94.7% (APC 0.78%, 95% CI 0.39-1.16) for active treatment and 53.8% to 57.9% (APC 1.06, 95% CI 0.47-1.65) for survival.
Further findings included that, among all infants, irrespective of active treatment, survival at 22 weeks increased from 7.4% to 32.0% (APC 14.94%, 95% CI 12.41-17.52), and survival at 23 weeks increased from 46.9% to 54.7% (APC 1.92%, 95% CI 1.19-2.65).
The authors also reported a small increase in active treatment for infants born at 24 weeks, and no change for those born at 25 weeks. Survival rates for infants born at 24 weeks and 25 weeks were unchanged.
Overall, about 40% of infants included in the study were Black, about 24% were Hispanic, and about 36% were white. Nearly all were from level III and level IV NICUs.
The study included infants born between 22 and 25 weeks' gestation at 795 NICUs that are members of the Vermont Oxford Network Database Research Repository. The network enrolls an estimated 86% of U.S. births in this gestational age range, the authors noted.
Ultimately, "[t]he increasing rate of active treatment for 22-week infants suggests that neonatal teams are increasingly intervening at the threshold of viability," Boghossian said. "This underscores the importance of ongoing discussions about prognosis, parental counseling, and hospital policies that guide decision making in periviable births."
"While Black infants were more likely to receive active treatment than white infants, previous research has shown disparities in neonatal outcomes based on race and hospital-level factors," she added. "Clinicians must remain mindful of potential biases and ensure that all families receive comprehensive and unbiased counseling regarding treatment options."
Study limitations included a lack of data on outcomes beyond hospital discharge, such as neurodevelopmental outcomes.
"Clinicians must balance the increasing success in early survival with considerations for long-term quality of life when counseling families," Boghossian said.
Disclosures
Boghossian disclosed support from National Institute on Minority Health and Health Disparities.
Co-authors disclosed employment with, and/or support from, the Vermont Oxford Network.
Primary Source
JAMA
Source Reference: Boghossian NS, et al "Active treatment and survival trends for periviable births by race and ethnicity" JAMA 2025; DOI: 10.1001/jama.2025.3033.
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