Geographic Variation in Active Perinatal Management and Outcomes for Extremely Preterm Infants in New South Wales: A Population‐Based Cohort Study

BACKGROUND: Perinatal management of infants born at 22-25 weeks' gestation varies internationally and may influence survival and long-term outcomes. In New South Wales (NSW), no contemporary statewide guideline exists. AIMS: To evaluate rates of active delivery room management and associated survival and neurodevelopmental outcomes among infants born at 22-25 weeks' gestation in NSW. MATERIALS AND METHODS: Population-based cohort study of all live births at 22 + 0-25 + 6 weeks in NSW (2011-2019) using linked administrative and clinical datasets. Active management was defined as provision of respiratory support or higher in the delivery room. Primary outcomes were survival to 1 year and moderate or severe neurodevelopmental impairment (NDI) at 2-3 years. RESULTS: Among 1285 live-born infants, 69.0% received active management, increasing from 61.7% in 2011 to 74.5% in 2019 (p < 0.001). Rates varied across local health districts (54.9%-83.5%). One-year survival was 44.9% overall (64.4% among actively managed infants) and increased with gestational age. Of 577 children eligible for follow-up, 440 (76.3%) underwent assessment at 2-3 years, of whom 18.4% had moderate or severe NDI. Maternal transfer to a tertiary centre was associated with a lower adjusted hazard of death (HR 0.79, 95% CI 0.63-0.98) but not with NDI. CONCLUSIONS: Active management and survival increased over time; however, marked regional variation persists. Development of a statewide clinical practice guideline could support equitable, evidence-based care for extremely preterm births.