Premature Delivery – Obstetrician’s Clinical Decision Making Heavily Influenced By Parents
A study conducted by researchers at University of Pennsylvania focused on parent’s influence on obstetricians regarding deliveries between the 22 and 26 weeks of gestation (periviable deliveries). Parents usually want to prolong pregnancy or pursue any intervention possible to save the baby’s life. The results were published in the March issue of the American Journal of Obstetrics and Gynecology.
Neonates born at the gestational age of 22 to 26 weeks are prone to neonatal death (about 50% of the newborns) or severe illness mainly neurologic disabilities. A previous study concluded that performing cesarean at 24 weeks translates into a higher chance of survival but also doubles morbidity.
The current study was based on data collected from 21 obstetricians from academic medical centers in Philadelphia. Obstetricians were interviewed regarding personal factors that concur to their clinical decision making, their typical patient approach and how they usually manage periviable delivery. Challenges they face while counseling the patient were also put into question. The results were very surprising: primary influence in obstetric decision making was the patient’s preference and perspectives on patient autonomy. Formal policies regarding practice standards for this kind of delivery varies from institution to institution, and even in the same institution different obstetricians have different opinions whether a particular neonate could be saved or not. One participant said: “It’s very much dependent upon who’s on that night.”
Patient autonomy is regarded differently by obstetricians and this influenced their approach to decision making and counseling: from just offering information to considering that the emotions and the complexity of the case interfere too much with the parents’ judgement and thus they are incapable of making a correct decision. The hardest part is being uncertain about the fetal outcome or about the benefit of certain obstetrical interventions and trying to explain this uncertainty to parents. Dr. Tucker Edmonds, assistant professor of Obstetrics and Gynecology at Indiana University said: “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.”
Patients with poor education or patients not fluent in English are harder to counsel according to most study participants, although they also declared they are not influenced by social factors.