Research letter
The Survival of Extremely Premature Neonates in Perinatal Care Centers of Different Care Levels
An analysis from the German federal states of Thuringia and Saxony
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The rate of premature births in Germany is stable at the high level of 8–9%; however, this group accounts for 77% of perinatal mortality (1). Approximately 0.4% are born as extremely premature neonates before 28 weeks of gestation (WG), with 25% of these neonates dying while still hospitalized in the neonatal department (2). Since 2006, the tiered system implemented by the German Joint Federal Committee (Gemeinsamer Bundesausschuss, G-BA) has regulated the care of extremely premature neonates in level 3 perinatal centers (PNC-3), with minimum volume requirements currently set at 25 cases per year.
Critics fear that the longer travel distances could jeopardize area-wide healthcare provision. This study analyzed the association between care levels at perinatal centers and outcomes in extremely premature neonates in Thuringia and Saxony. Particular focus was placed on the neonatal mortality rate and accessibility of PNC-3.
Methods
A retrospective analysis evaluated all live births from the perinatal surveys conducted in Thuringia and Saxony between 2014 and 2018. On the assumption that births outside a PNC-3 occurred in maternity units close to home, neonatal mortality among extremely premature neonates (22 + 0 to 28 + 6 WG) was compared between births in a PNC-3 with longer travel times (≥ 40 min) versus births in a non-PNC-3 close to home. Travel time to the closest PNC-3 was determined using Google Maps (car route) based on the five-digit residential postcode. Using established covariates, the adjusted odds ratio (aOR) for neonatal mortality within the first 7 days of life was calculated with a directed acyclic graph (DAG) in Dagitty 3.1 and logistic regression (Figure 1).
Results
From a total of 241 522 births during the study period, 11 993 were premature births, of which 891 were extremely premature births. Of these, 775 survived the first 7 days. The neonatal mortality rate in 2014 was 17.7%, then ≤ 13% up to 2018. Most births (89.2%) took place at a PNC-3, with the lowest neonatal mortality rate of 10.4% (p < 0.001). In PNC-2, 34.2% of extremely premature neonates died, while in hospitals with a perinatal care focus, this figure was 40.5%. Maternity units reported only 13 cases of extremely premature births, of which two died. A total of 240 mothers of extremely premature neonates (30% of the overall cohort) had a travel time of ≥ 40 min to the closest PNC-3.
At 13.3%, the neonatal mortality rate was significantly lower for births at a regional PNC-3 (travel time ≥ 40 min) compared to 34.4% for births in local maternity units (R² = 0.1; p <0.001) (Figure 2).
After adjusting for internationally established influencing factors and their multiple interactions using a DAG, extremely premature neonates in PNC-3 still had a significantly reduced probability of death, despite a travel time of more than 40 min (aOR 0.38; 95% CI [0.2–0.7]).
Discussion
Our analysis of the healthcare system in Saxony and Thuringia shows that no correlation was found between travel time to a PNC-3 and neonatal mortality among extremely premature neonates. In contrast, the delivery of extremely premature neonates in local maternity units with lower levels of care is associated with a 2.5-fold higher neonatal mortality rate. Thus, centralizing extremely premature births in regional perinatal centers that provide maximum care appears to be a relevant factor in reducing neonatal mortality, even in Germany and irrespective of travel distance. This contrasts with the emphasis in social and political debates on local care as a key quality criterion for obstetric services.
The centralization of perinatal care has clearly been successful in other European countries: In 1989, Portugal reformed its perinatal care by closing smaller maternity units and introducing a care-level classification. As a result, the neonatal mortality rate decreased by 67% (from 8.1 to 2.7 per 1000 births) (3). Although there are 160 perinatal centers Germany providing the highest level of care over an area that is approximately 100 000 km² smaller than that of Sweden, Sweden—with only eight maximum care centers—reports a higher survival rate (81.1%) for premature neonates than Germany (77.5% <28 WG) (4). Likewise in Amsterdam, centralization resulted in a decline in perinatal mortality from 0.84% to 0.63% (p <0.001) (5).
The limitations of our analysis include, firstly, that only data from the federal states of Saxony and Thuringia— which, by 2018, already had a high level of centralization in perinatal care—were available for the evaluation; and secondly, that the proximity of non-PNC-3 centers was assumed but not measured. In addition, the data structure of the perinatal survey is limited temporally to neonatal mortality within the first 7 days of life and spatially to the postcode level.
In summary, we have shown that the neonatal mortality rate in the case of extremely premature birth at a PNC-3 is significantly lower—even taking into account the longer maternal travel time—compared to maternity units of lower care levels, irrespective of travel time to the latter. This contributes to the evidence-based discussion on the safe obstetric care of extremely premature neonates, despite longer travel distances resulting from the necessary centralization of maternity units and the increased minimum volume requirements for perinatal centers. An up-to-date analysis of German nationwide data is a high priority for health policy.
Yvonne Heimann*, Zazie Giró-Paños*, Ekkehard Schleußner, Janine Zöllkau
Conflict of interest statement
ES declares that he is a past president and current board member of the German Society of Perinatal Medicine (Deutsche Gesellschaft für Perinatale Medizin), which is actively engaged in promoting the quality of perinatal care, and that he contributed to the current AWMF guideline No. 087–001. JZ declares that she is a member of the Working Group on Obstetrics of the German Society of Gynecology and Obstetrics (Deutsche Gesellschaft für Gynäkologie und Geburtshilfe). ES and JZ are members of the Center for Early Pregnancy and Reproductive Health (CEPRE; www.uniklinikum-jena.de/cepre), which is funded by the German Federal Ministry of Education, Research, Technology, and Space (Bundesministerium für Bildung, Forschung, Technologie und Raumfahrt, BMFTR; grant No. 01GR2305A).
The remaining authors declare that no conflict of interest exists.
Manuscript submitted on 21 April 2025, revised version accepted on 21 July 2025.
Translated from the original German by Christine Rye.
Cite this as
Heimann Y, Giró-Paños Z, Schleußner E, Zöllkau J: The survival of extremely premature neonates in perinatal care centers of different care levels: An analysis from the German federal states of Thuringia and Saxony. Dtsch Arztebl Int 2025; 122: 586–7. DOI 10.3238/arztebl.m2025.0136
Datenintegrationszentrum, Universitätsklinikum Jena, Germany (Heimann)
Klinik für Geburtsmedizin, Universitätsklinikum Jena, Germany (Heimann, Giró-Paños, Schleußner, Zöllkau) ekkehard.schleussner@med.uni-jena.de
