Background and aims There is concern that declines in mortality after very preterm birth are accompanied by higher morbidity as more fragile babies survive. We investigated whether rates of severe neonatal morbidity were higher in regions with low versus high mortality.

Methods The EPICE cohort included all births between 22+0 and 31+6 weeks of gestation in 19 European regions in 2011–2012 (N = 7878 live births). We divided the cohort into tertiles based on regional in-hospital mortality rates excluding deaths due to congenital anomalies: low (<12.0%), medium (12.0 to 14.9%) and high (≥15.0%). Severe neonatal morbidity was defined as intraventricular haemorrhage grades III-IV, cystic periventricular leukomalacia, surgery/peritoneal drainage for necrotizing enterocolitis or retinopathy of prematurity (grades ≥3). Bronchopulmonary dysplasia (BPD) was analysed separately. Multilevel logistic regressions were used to model regional-level effects.

Results 6770 infants were discharged home. 12.2% had at least one severe morbidity (regional range: 3.8% to 24.4%) and 15.3% had BPD (regional range: 6.7% to 34.9%). Rates of severe morbidity were 11.7%, 12.1% and 12.9% in low, medium and high mortality regions, respectively (p = 0.45). BPD was higher in low mortality regions (18.7%,16.7% and 10.2%, respectively (p < 0.001). The odds ratio for severe morbidity associated with birth in a low versus high mortality region was 0.83 (95% CI: 0.55–1.25) and for BPD was 1.81 (95% CI: 1.08–3.0).

Conclusion Rates of severe neonatal morbidity and BPD vary greatly between regions in Europe. BPD rates were higher in lower mortality regions, but this was not true for other morbidities.