ObjectiveEarly postnatal transfer (PNT) of extremely preterm infants is associated with adverse outcomes compared with in utero transfer (IUT). We aimed to explore recent national trends of IUT and early PNT.DesignObservational cohort study using the National Neonatal Research Database.SettingNeonatal units in England, Scotland and Wales.PatientsExtremely preterm infants 23⁺⁰–27⁺⁶ weeks’ gestation admitted for neonatal care from 2011 to 2016.Main outcomeThe incidence of IUT or PNT within 72 hours of life. Secondary outcomes included mortality, hospital transfer level between centres and temporal changes across two equal epochs, 2011–2013 (epoch 1 (Ep1)) and 2014–2016 (epoch 2 (Ep2)).Results14 719 infants were included (Ep1=7363 and Ep2=7256); 4005 (27%) underwent IUT; and 3042 (20.7%) had PNT. IUTs decreased significantly between epochs from 28.3% (Ep1=2089) to 26.0% (Ep2=1916) (OR 0.90, 95% CI 0.84 to 0.97, p<0.01). Conversely, PNTs increased from 19.8% (Ep1=1416) to 21.5% (Ep2=1581) (OR 1.11, 95% CI 1.02 to 1.20, p=0.01). PNTs between intensive care centres increased from 8.1% (Ep1=119) to 10.2% (Ep2=161, p=0.05). Mortality decreased from 21.6% (Ep1=1592) to 19.3% (Ep2=1421) (OR 0.90, 95% CI 0.83 to 0.97, p=0.01). Survival to 90 days of age was significantly lower in infants undergoing PNT compared with IUT (HR 1.31, 95% CI 1.18 to 1.46), with the greatest differences observed in infants <25 weeks’ gestational age.ConclusionIn the UK, IUT of extremely preterm infants has significantly decreased over the study period with a parallel increase in early PNT. Strategies to reverse these trends, improve IUT pathways and optimise antenatal steroid use could significantly improve survival and reduce brain injury for these high-risk infants.