NICU by the Numbers

40% Care Gap in Outborn Infants for Receipt of Antenatal Steroids


Administration of corticosteroids to mothers prior to preterm delivery accelerates fetal lung development and decreases risks of mortality, respiratory distress syndrome, intraventricular hemorrhage, and necrotizing enterocolitis (1). The American Congress of Obstetricians and Gynecologists (ACOG) recommends corticosteroids for pregnant women between 24 weeks 0 days and 33 weeks 6 days of gestation who are at risk of preterm delivery within 7 days (2). The goal of this analysis was to characterize rates of exposure to antenatal steroids among very low birth weight infants.


We examined 211,501 infants 24 weeks 0 days to 29 weeks 6 days gestational age without major congenital anomalies at 782 North American hospitals from 2009 to 2016. Exposure was defined as betamethasone, dexamethasone, or hydrocortisone administered to the mother at any time prior to delivery. Overall rates of antenatal steroids exposure increased from 80.2% to 87.1%. However, the location of delivery (inborn vs. outborn) was strongly associated with the rate of corticosteroid administration. Only 56% of mothers of infants born outside of VON centers received corticosteroids, compared to 89% of mothers who delivered at VON centers

Rates of antenatal steroid administration to mothers of eligible infants by location of delivery, 2009 to 2016


Danielle Ehret, MD, MPH, University of Vermont Medical Center, Burlington, VT

By 2016, VON centers closed the quality of care gap to less than 10% of mothers delivering inborn at 24 to 29 weeks’ gestation lacking receipt of antenatal steroids. However, outborn infants experienced a quality of care gap of approximately 40%.

Outborn infants may represent precipitous or emergent deliveries in unintended locations. Still, the belief that a full course of antenatal steroids will not be completed does not justify omission of therapy. Building upon the evidence synthesized in the Cochrane Systematic Review (1), Norman et al. recently examined the antenatal steroids administration-to-birth interval and survival and morbidity among infants with gestational ages 24 to 31 weeks. They found an immediate and rapid decline in mortality with antenatal steroids less than 12 hours before birth (3), supporting a more pragmatic approach to antenatal steroids administration.

Increasing the evidenced-based practice of antenatal steroids administration is a prime target for quality improvement methodology. Our work to date has been too specific in focusing on processes of care for inborn infants. As leaders in neonatal-perinatal medicine, VON centers have the opportunity to drive multi-disciplinary and systematic improvement throughout the referring perinatal networks that care for our infants and families.

Explore Further

Dr. Danielle Ehret’s presentation from the 2017 Annual Quality Congress, “Vermont Oxford Network Data at the Edges of Viability” provides a deeper analysis on the effectiveness of antenatal steroids for infants at 22-25 weeks gestation inborn in the U.S.

View the presentation by logging on to the VON Learning Management System (subscription required).


  1. Roberts D, Brown J, Medley N, Dalziel SR. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Database Syst Rev 2017;3:CD004454.
  2. ACOG Committee Opinion No. 475: antenatal corticosteroid therapy for fetal maturation. Obstet Gynecol 2011;117(2 Pt 1):422-424.
  3. Norman M, Piedvache A, Borch K, et al. Association of short antenatal corticosteroid administration-to-birth intervals with survival and morbidity among very preterm infants: Results from the EPICE Cohort. JAMA Pediatr 2017;171:678-86.

Your VON Data in Action

This report is made possible by Vermont Oxford Network members who voluntarily contribute data in a global effort to improve the care of high-risk newborns. VON members can view center-specific data by logging on to Nightingale and benchmark against this NICU by the Numbers report.

Editors: Erika Edwards, PhD, MPH; Roger Soll, MD

Analyst: Lucy Greenberg, MS