Lack of policy regarding periviable deliveries means families are the decision-makers
MedWire News: Family preferences strongly influence the decisions made concerning very premature deliveries, which researchers suggest may be due to a lack of formal policy on the matter.
Periviable neonates (deliveries that occur between 22 and 26 weeks) are most at risk for neonatal death and illness; half of these neonates do not survive and of those that do, half experience moderate to severe neurologic disability, write the authors of the study published in the American Journal of Obstetrics and Gynecology.
Brownsyne Tucker Edmonds and colleagues from the University of Pennsylvania, Philadelphia, USA, conducted semi-structured interviews with 21 obstetricians (six maternal-fetal medicine physicians, two maternal-fetal medicine fellows, and 13 obstetrics/gynecology generalists) from five medical centers in Philadelphia.
When asked to define periviability, all participants' definitions fell between 22 and 26 weeks, but attached was the idea that the definition is a "moving target."
When the participants were asked to comment on the patient, provider, and institutional factors that influence their decision-making, they most commonly said that they were most heavily influenced by patient-related factors. Most obstetricians were first concerned with clinical presentation that may need to be taken into account, for example, imminence of delivery, signs of infection, and malpresentation.
After all maternal and fetal clinical acuity factors had been considered, the obstetricians said their decisions were based primarily on patient preferences. Most believed that patients tend to want everything to be done to save the child: "Consistently, patients in this situation react the same… if you think there's some chance that this baby will survive, no matter how small," said one participant.
The obstetricians also said that most institutions lacked formal policies to direct universal standards for periviable care, and instead the providers tended to work according to consensus. Though they also stressed that there could be considerable variation within institutions about what made a "savable" case, for example, one participant commented that "it's very much dependent on who's on that night."
Although most participants did not feel that patient sociodemographics influenced their decision-making, some did admit to treating the babies of older patients and those undergoing in vitro fertilization (IVF) treatments more aggressively than those of younger patients because they had less chance of conceiving again. Tucker Edmonds and colleagues comment that obstetricians may not be aware of the potential bias that this attitude creates.
"Interventions and curricula to aid physicians in the communication of uncertainty, management of expectations, and assessment of patients' understanding, values, and goals are needed to equip physicians to provide more patient-centered periviable care," conclude Tucker Edmonds and team.
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