Background Different policies and attitudes exist regarding the treatment of extreme preterms within and between countries.

Objective How do these differences influence delivery room (DR) deaths, neonatal intensive care unit (NICU) admissions and mortality at very low birth weights?

Design We reviewed charts of all newborns born alive between 450 and 800 g during 12 months in 2005/6 at four centres: Royal Victoria Hospital, Montreal (MTL, Canada), Comer Children’s Hospital, Chicago (CG, USA), Children’s Hospital of Wisconsin (WS, USA), University Medical Center Groningen (Gr, The Netherlands). We reviewed DR consultations, deaths and NICU admissions. Terminations of pregnancy were excluded.

Results See table 1 and table 2. In CG, all newborns >450 g were offered intensive care and received life-sustaining therapy. In Gr, none of the babies <25 weeks were offered intensive care and they all died in the DR. None of the DR deaths had comfort medication. In CG, admission weight was lower, and death occured later. In Gr, average birth weight was higher and mortality highest (57%) and earlier in the baby’s life. All NICU deaths received comfort medication.

Conclusions There is tremendous variation of practice in the care of extreme preterms. This variation might mirror the local perception of the value of life of premature infants. None of the DR deaths had comfort medications, whereas all NICU deaths did. This shows the need for palliative care research in the area.