According to a study published in the March issue of the American Journal of Obstetrics and Gynecology, patient preferences are a major factor in directing obstetric decision-making and counseling for periviable deliveries (early preterm birth between 22-26 weeks gestation). Obstetricians perceive that parents would rather have everything possible done in order to prolong a pregnancy or "save the baby" via interventions, such as cesarean section.
The study was conducted by researchers at University of Pennsylvania.
Nearly 50 percent of periviable babies do not survive, and half of those who do survive suffer moderate to severe neurologic disability. Neonatal outcomes can be influenced by how these cases are obstetrically managed. Findings from an earlier study revealed that neonates chances of survival increased by 3.7 times by obstetricians' willingness to perform a cesarean section at 24 weeks, although chance of survival with serious morbidity increased two fold.
In this study, 21 obstetricians at academic medical centers in Philadelphia were asked by the researchers to describe their usual approach to managing periviable delivery; personal, patient and institutional factors that influence their decision making; and their approach to counseling patients, and what challenges they encounters in doing so.
The researchers discovered that, even though obstetricians were confined by institutional norms, perspectives on patient autonomy, patient preference and clinical presentation strongly influence their decision making and counseling for periviable deliveries.
Participants of the study reported a significant amount of variation in practice. Furthermore, the researchers found that there was no formal polices to dictate practice standards for periviable care in the majority of institutions.
Thresholds for what is thought to be safe (or safeguarded) vary, even within the same institution. One study participant explained:
"It's very much dependent upon who's on that night."
Brownsyne Tucker Edmonds, M.D, M.S., M.P.H., who conducted this study during a fellowship at the University of Pennsylvania and is currently an assistant professor of Obstetrics and Gynecology at Indiana University, said:
"While most participants said their first consideration was balancing maternal and child well-being, and the need to weight the questionable benefits of cesarean delivery for neonatal survival against the known risks of maternal morbidity, many described a 'do everything default,' wherein interventions to prolong the pregnancy were universally pursued unless patients actively opted out."
Obstetricians approach to decision making and counseling was strongly influenced by how they perceived patient autonomy. Some participants believed it was their job to provide information instead of direction. Other participants made recommendations to guide care, stating that patients are often unable to make decision regarding their care due to the complexity and emotionality of the situation.
Communicating the uncertainty regarding fetal outcomes was the greatest challenge according to the participants, as well as the ability of obstetrical interventions to really enhance those outcomes.
Dr. Tucker Edmonds, explained:
"In counseling patients, the obstetricians prioritized objectivity and respect for autonomy but deemphasized hope. However, a recent study found that patients who faced these decisions prioritized hope. Such discordances contribute to the challenge of managing patients' expectations in periviable counseling."
Even though most thought that patient sociodemographic factors had no impact on clinical decisions, the authors stated that it is more difficult to counsel lower educated patients or those with poor English skills and reported a more aggressive approach towards treating older patients and those undergoing infertility treatments than to younger patients.
Dr. Tucker Edmonds, said:
"Obstetricians may be less attentive to the inherent social and economic implications of having an IVF pregnancy and therefore less aware of the potential bias that is created in appraising these pregnancies differently than others."
"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."
Written by Grace Rattue