Décision d’interruption médicale de grossesse : le point de vue des soignants français

Pregnancy termination at a viable stage in daily clinical practice: A nationwide mortality follow-back study in Flanders, Belgium

OBJECTIVE

Congenital malformations are frequently diagnosed prenatally even at a viable stage. No adequate registration of incidence and characteristics of late termination of pregnancy (TOP) or abortion for medical reasons exists in Flanders.

METHODS

Nationwide mortality follow-back survey sent to physicians signing death certificates of all stillbirths for 22 weeks gestation onward (September 2016-December 2017) in Flanders, Belgium. Questions measured whether late TOP preceded stillbirth, and which clinical and sociodemographic characteristics were indicated. Questionnaire data were linked with sociodemographic information from death certificates.

RESULTS

Response rate was 56% (203/366). 38% of stillbirths (77/203) concerned late TOP. In 88.3% of late TOPs, physicians classified congenital anomalies of the foetus as serious or very serious (incompatibility with life outside the womb or severe neurological or physical impairment). In 26% of cases, late TOP was first suggested by the physician rather than spontaneously requested by parents (73%). 88% of late TOPs were discussed in open team meetings.

CONCLUSIONS

2/5 stillbirths were preceded by late TOP, indicating severe underreportation by existing registrations and a dire need for adequate registration methods. Although late TOP was most often explicitly requested by parents, in ¼ cases termination was suggested first by physicians. Parents are sometimes hesitant to bring up late TOP themselves, indicating that TOP should always be counselled as an equivalent option.

Healthcare professionals' attitudes towards termination of pregnancy at viable stage

INTRODUCTION

Upon prenatal diagnosis of congenital malformations, termination of pregnancy (TOP) may be an option, sometimes at a gestational age when the fetus is already viable (late TOP). We aimed to study attitudes towards late TOP of all tertiary healthcare professionals involved in late TOP practice.

MATERIAL AND METHODS

A mail survey was conducted among all physicians and paramedical professionals involved in late TOP decision-making in all eight centers with a Neonatal Intensive Care Unit in Flanders, Belgium (N = 117). The questionnaire contained general and case-based attitude items.

RESULTS

Response rate was 79%. Respondents were either physicians (51.1%) or paramedical professionals (49.9%). The composition of professionals involved in late TOP decision-making was heterogeneous between the eight centers. Late TOP was highly accepted in both lethal fetal conditions (100%) and serious (but not lethal) fetal conditions (95.6%). Where the fetus is healthy, 19.8% of respondents agreed with late TOP for maternal psychological problems and fewer respondents (13.2%) agreed with late TOP in the case of maternal socio-economic problems (P = .002). Physicians more often preferred feticide over neonatal palliative care in the case of non-lethal fetal conditions compared with paramedical professionals (68.1% vs 53.2%, P = .013). Almost nine out of ten respondents (89.1%) agreed that in the event of a serious (non-lethal) neonatal condition, administering drugs with the explicit intention to end neonatal life was acceptable. Behavioral intentions indicate that even in situations with an unclear diagnosis and unpredictable prognosis, 85.6% of professionals would still consider late TOP.

CONCLUSIONS

Healthcare professionals practicing late TOP in Flanders, Belgium have a high degree of tolerance towards late TOP, irrespective of sociodemographic factors, and are demanding legislative change regarding active life-ending in the fetal and neonatal periods. Further research should explore the correlation of attitudes to late TOP with actual medical decisions taken in daily clinical practice.

Health care professionals' attitudes about pregnancy termination for different fetal anomalies

BACKGROUND

Health care professionals (HCPs) may be involved in counselling women after an antenatal diagnosis of various fetal anomalies. Many pregnant women consider termination of pregnancy (TOP) after antenatal diagnosis of various fetal anomalies. Little is known, however, about the attitudes of HCPs regarding TOP for specific antenatal diagnoses.

OBJECTIVE

To determine the attitudes and opinions of HCPs in maternal and child health regarding TOP for fetal anomalies of varying severity.

METHODS

AN ANONYMOUS QUESTIONNAIRE WAS DISTRIBUTED TO FOUR GROUPS OF HCPS: obstetric residents; paediatric residents; delivery room nurses; and neonatal intensive care nurses. Respondents were asked about TOP if they or their spouse were to receive an antenatal diagnosis for five prenatally diagnosed conditions: trisomy 21; trisomy 18; cleft lip and palate; Turner syndrome; and hypoplastic left heart syndrome.

RESULTS

Two hundred eighty HCPs answered the questionnaire (90% response rate). Ten per cent of respondents would not consider TOP under any of the circumstances described. Among those who would consider TOP, they were most likely to do so for trisomy 18 and least likely for cleft lip and palate, and fairly evenly divided among the remaining three conditions (hypoplastic left heart syndrome [65%], trisomy 21 [56%] and Turner syndrome [37%]). Paediatric residents were less likely to choose TOP than other groups and obstetrics residents were most likely.

CONCLUSIONS

Attitudes of HCPs toward TOP vary according to prenatally identified condition and professional group. More rigorous analysis should be performed regarding the process of counselling and the impact of HCPs beliefs on parental decisions.

[Palliative care birth plan: a field of perinatal medicine to build]

Some couples may choose to continue the pregnancy unable to decide for termination of pregnancy. Such situations recently occurred in neonatology units and may lead to neonatal palliative care. Faced with all uncertainties inherent to medicine and the future of the baby, medical teams must inform parents of different possible outcome step by step. Consistency in the reflection and intentionality of the care is essential among all different stakeholders within the same health team to facilitate support of parents up to a possible fatal outcome. This issue in perinatal medicine seems to be to explore how caregivers can contribute in the construction of parenthood in a context of a palliative care birth plan.