Is neonatal intensive care justified in all preterm infants?

A proactive policy of resuscitation at birth and prompt initiation of intensive care have been shown to be associated with an improvement in the survival of very preterm infants in both institution-based and population-based studies. As a greater percentage of live births were offered intensive care, the survival rate rose progressively in all birth weight and gestation subgroups among extremely low birth weight infants, including those who were born at borderline viability between 23 weeks and 25 weeks of gestational age. Their quality-adjusted survival rate also rose progressively, since the large gains in survival over time had not been offset by significant increases in survival with disability. Cost-effectiveness and cost-utility ratios remained stable overall, with efficiency gains in the smaller infants over time, as more such infants were being born in Level III perinatal centers with the regionalization of perinatal-neonatal healthcare programs. National and international surveys of obstetricians and neonatologists on their perception of viability and their management decisions in extremely preterm infants have shown significant variations on the application use of intensive care in those born extremely preterm. If doctors believe that such infants have little prospect for intact survival, their management would be suboptimal or delayed, thus creating a self-fulfilling prophecy. Both developed and developing countries need to develop appropriate policies for initiating and withdrawing intensive care, taking into consideration their own cultural, social, and economic factors.