OPTI-PREM

What was studied? : The study explored best place of birth for babies born very preterm between 27⁺⁰ and  31⁺⁶ weeks (27-31 weeks) gestation in England.

Why: Very preterm babies are at risk of death and serious long-term problems. For those preterm babies born at <26 weeks, outcomes are better with birth and care in tertiary maternity and neonatal units (Neonatal intensive care units; NICU). But it is not known whether this is true for the next most vulnerable group, born between 27-31 weeks gestation. In England, these babies are born and cared for in either NICU or in local neonatal units (LNU; non-tertiary). Both types of units are currently able to care for these babies but are skilled to different degrees.

The study: The OPTI-PREM study was a mixed methods study. It explored whether core neonatal outcomes (death, serious brain injury, chronic lung disease/bronchopulmonary dysplasia, retinopathy of prematurity, necrotising enterocolitis, and receipt of breast milk feeds on discharge from neonatal care) for babies born between 27-31 weeks differed based on where they were born and initially cared for. It studied national neonatal data on 18,847 very preterm babies, costs of care, staff and parents’ perspectives, quality of care and outcomes. It utilised national data from the National Neonatal Research Database (NNRD) with linkage to NHS Digital. Parents from the national charity for babies born premature or ill, BLISS were actively engaged in all stages of the project and in the Study Steering Committee. The parent panel was chaired by Kelvin Dawson.

What did the team find: Risk of deaths: There was no difference in risk of death up to 1 year of life based on place of birth (LNU/non-tertiary vs NICU/tertiary) and early care for very preterm babies born between 27⁺⁰ and 31⁺⁶ in England.

Risk of serious brain injury: For births at 27 weeks of gestation, there was a higher risk of severe brain injury (SBI) when

• born into maternity services co-located with LNU compared with NICU, and when
• born into maternity services co-located with low-volume (providing <1614 intensive care days/year) compared with high-volume neonatal units (providing >1614 intensive care days/year).

This risk of SBI existed in those transferred out in the first 72 hours after birth.

Costs of care There was no difference in NHS neonatal costs for babies born at 27 weeks (~£76 000) between NICU and LNU. £0.26 billion per year was spent on NHS neonatal care for babies born between 27-31 weeks in England.

Parent and staff perspectives: Staff managed decision-making, to ensure space for babies. Parents valued their baby’s development, homecoming, continuity of care, being included, and having their emotional and physical wellbeing supported.

Overall conclusion: OPTI-PREM findings suggest babies between 28⁺⁰ and 31⁺⁶ weeks can safely be born and cared for in either LNU or NICU. However, to minimise risk of brain injury, births at 27 weeks should preferentially be in maternity units co-located with NICU. If born at 27 weeks gestation in a maternity service co-located with a LNU, transfers should be risk assessed especially in the first 72 hours after birth.

Published References for OPTI-PREM

1.  Pillay T, Rivero-Arias O, Armstrong N, Seaton SE, Yang M, Banda VL, et al. Optimising neonatal services for very preterm births between 27+0 and 31+6 weeks gestation in England: the OPTI-PREM mixed-methods study. Health Soc Care Deliv Res 2025;13(12). https://doi.org/10.3310/JYWC6538
   https://www.journalslibrary.nihr.ac.uk/hsdr/JYWC6538
2. Pillay T, Seaton SE, Yang M, et al Improving outcomes for very preterm babies in England: does place of birth matter? Findings from OPTI-PREM, a national cohort study. Archives of Disease in Childhood - Fetal and Neonatal Edition Published Online First: 27 December 2024. doi: 10.1136/archdischild-2024-327474
3. Rivero-Arias O; Pillay T; Ratushnyak S; Boyle E; Modi N; Campbell H. Cost-Effectiveness of Intensive and Local Neonatal Care Units in England: A Real-World Evidence Analysis of a National Birth Cohort. Value in Health 2024; 27 (12) S79-S80
4. Cupit C, Paton A, Boyle E, Pillay T, Anderson J, Armstrong N; OPTI‐PREM team. Parenting through place-of-care disruptions: A qualitative study of parents' experiences of neonatal care. Health Expect. 2024 Feb;27(1):e13933. doi: 10.1111/hex.13933. PMID: 39102689; PMCID: PMC10726285.
5. Yang M, Campbell H, Pillay T, Boyle EM, Modi N, Rivero-Arias O. Neonatal health care costs of very preterm babies in England: a retrospective analysis of a national birth cohort. BMJ Paediatr Open. 2023 May;7(1):e001818. doi: 10.1136/bmjpo-2022-001818. PMID: 37130654; PMCID: PMC10163543.
6.  Ismail AQT, Boyle EM, Pillay T. Clinical outcomes for babies born between 27 – 31 weeks of gestation: Should they be regarded as a single cohort? J Neo Nurs 2023; 29 (1): 27-32
7. Paton A, Cupit C, Armstrong N. Organising work in neonatal transfer: Optimising place of care for babies born moderately preterm Sociology of Health and Illness. 2023; 45 (8): 1634-1651https://doi.org/10.1111/1467-9566.13656
8. Cupit C, Paton A, Boyle E, Pillay T, Armstrong N; OPTI-PREM Study Team. Managerial thinking in neonatal care: a qualitative study of place of care decision-making for preterm babies born at 27-31 weeks gestation in England. BMJ Open. 2022 Jun 27;12(6):e059428. doi: 10.1136/bmjopen-2021-059428. PMID: 35760541; PMCID: PMC9237905. 
9. Ismail AQT, Boyle EM, Oddie S, Pillay T. Exploring variation in quality of care and clinical outcomes between neonatal units: a novel use for the UK National Neonatal Audit Programme (NNAP): BMJ Open Quality 2022;11:e002017.
10. Ismail AQT, Boyle EM, Pillay T; OptiPrem Study Group. The impact of level of neonatal care provision on outcomes for preterm babies born between 27 and 31 weeks of gestation, or with a birth weight between 1000 and 1500 g: a review of the literature. BMJ Paediatr Open. 2020 Mar 17;4(1):e000583. doi: 10.1136/bmjpo-2019-000583. PMID: 32232179; PMCID: PMC7101044.
11. Pillay T, Modi N, Rivero-Arias O, Manktelow B, Seaton SE, Armstrong N, Draper ES, Dawson K, Paton A, Ismail AQT, Yang M, Boyle EM. Optimising neonatal service provision for preterm babies born between 27 and 31 weeks gestation in England (OPTI-PREM), using national data, qualitative research and economic analysis: a study protocol. BMJ Open. 2019 Aug 22;9(8):e029421. doi: 10.1136/bmjopen-2019-029421. PMID: 31444186; PMCID: PMC6707683.
     

Study details: This was a NIHR Health and Social care Delivery Research Project [grant number 15/70/104]. The project was undertaken in collaboration with a team of experts from the University of Oxford, University of Leicester, Imperial college, NDAU and BLISS and led by Prof T Pillay, University of Wolverhampton and Head of Neonatal Services for University Hospitals NHS Trust. At Imperial College and NDAU  this project was supported by Prof Neena Modi as co-applicant, Dr Victor Banda as senior data analyst, and the in-house NDAU team of analysts.

Findings from OPTI-PREM are now published. (https://doi.org/10.3310/JYWC6538)