Variations among US hospitals in counseling practices regarding prematurely born infants

Video Education in Early Pregnancy and Parent Knowledge of Neonatal Resuscitation Options: A Secondary Analysis of a Randomized Clinical Trial

This secondary analysis of a randomized clinical trial investigates the proportion of correct answers on neonatal resuscitation options among parents after seeing a video on these options.

Smartphone-Based Video Antenatal Preterm Birth Education: The Preemie Prep for Parents Randomized Clinical Trial

Importance

Preterm birth is a leading cause of infant mortality and child morbidity. Preterm birth is not always unexpected, yet standard prenatal care does not offer anticipatory education to parents at risk of delivering preterm, which leaves parents unprepared to make health care choices during the pregnancy that can improve survival and decrease morbidity in case of preterm birth.

Objective

To evaluate the effect of the Preemie Prep for Parents (P3) program on maternal knowledge of preterm birth, preparation for decision-making, and anxiety.

Design, Setting, and Participants

Recruitment for this randomized clinical trial conducted at a US academic medical center took place from February 3, 2020, to April 12, 2021. A total of 120 pregnant persons with a risk factor for preterm birth were enrolled between 16 and 21 weeks' gestational age and followed up through pregnancy completion.

Intervention

Starting at 18 weeks' gestational age, P3 program participants received links delivered via text message to 51 gestational age-specific short animated videos. Control participants received links to patient education webpages from the American College of Obstetricians and Gynecologists.

Main Outcomes and Measures

At 25 weeks' gestation, scores on the Parent Prematurity Knowledge Questionnaire (scored as percent correct), Preparation for Decision Making Scale (scored 0-100), and Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety computerized adaptive test. Analysis was based on an intention to treat.

Results

A total of 120 pregnant participants (mean [SD] age, 32.5 [4.9] years) were included in the study; 60 participants were randomized to each group. Participants in the P3 group scored higher than those in the control group on knowledge of long-term outcomes at 25 weeks (88.5% vs 73.2%; estimated difference, 15.3 percentage points; 95% CI, 8.3-22.5 percentage points; P < .001). Participants in the P3 group reported being significantly more prepared than did participants in the control group for neonatal resuscitation decision-making at 25 weeks (Preparation for Decision Making Scale score, 76.0 vs 52.3; difference, 23.7; 95% CI, 14.1-33.2). There was no difference between the P3 group and the control group in anxiety at 25 weeks (mean [SE] PROMIS Anxiety scores, 53.8 [1.1] vs 54.0 [1.1]; difference, -0.1; 95% CI, -3.2 to 2.9).

Conclusions and Relevance

In this randomized clinical trial, pregnant persons randomly assigned to the P3 program had more knowledge of core competencies and were more prepared to make decisions that affect maternal and infant health, without experiencing worse anxiety. Mobile antenatal preterm birth education may provide a unique benefit to parents with preterm birth risk factors.

Trial Registration

ClinicalTrials.gov Identifier: NCT04093492.

Multimedia tablet or paper handout to supplement counseling during preterm birth hospitalization

BACKGROUND

Parents of premature infants engage in shared decision-making regarding the care of their infant. The process of prenatal counseling typically involves a verbal conversation with a neonatal provider during hospitalization. Support people may not be available, and the pregnant person's memory is impaired by medications, pain, and stress. The American Academy of Pediatrics, American College of Obstetricians and Gynecologists, and the Eunice Kennedy Shriver National Institute of Child Health and Human Development have called for improvements to this process, including the development of educational aids.

OBJECTIVE

This study aimed to investigate whether a multimedia tablet would be more effective than a paper handout in supplementing verbal clinician counseling during preterm birth hospitalization.

STUDY DESIGN

This was a randomized controlled trial including English-speaking pregnant people aged ≥18 years and hospitalized at 22 to 33 weeks' gestation for preterm birth. Exclusion criteria were known fetal or chromosomal anomaly and delivery before study completion. Pregnant people received either a multimedia tablet or a paper handout before verbal clinician counseling. Preintervention assessment included demographics and State-Trait Anxiety Inventory, and postintervention assessment included the Parent Knowledge of Premature Birth Questionnaire and State-Trait Anxiety Inventory. Continuous variables were analyzed by t-test and categorical variables by Fisher exact test.

RESULTS

A total of 122 pregnant people referred for counseling were screened; 76 were randomized, and 59 completed the study. Demographics were similar between groups, except that pregnant people in the handout group were older (mean 32 vs 29 years; P=.03). The multimedia tablet group (n=32) was less likely to report reviewing all the educational material than the paper handout group (n=27) (41% vs 72%; P=.037). Both groups correctly answered a similar number of knowledge items (P=.088). Postintervention state anxiety decreased in both groups (P<.0001), with no difference between groups. Computerized tracking showed that the multimedia group spent a median of 37 minutes reviewing the tablet.

CONCLUSION

Contrary to our hypothesis, a paper handout and multimedia tablet were equally effective in the labor unit for supplementing verbal preterm birth counseling, and both decreased parental anxiety.

Prenatal counseling for extreme prematurity at the limit of viability: A scoping review

OBJECTIVES

To explore, based on the existing body of literature, main characteristics of prenatal counseling for parents at risk for extreme preterm birth.

METHODS

A scoping review was conducted searching Embase, Medline, Web of Science, Cochrane, CINAHL, and Google Scholar.

RESULTS

46 articles were included. 27 of them were published between 2017 and 2021. More than half of them were conducted in the United States of America. Many different study designs were represented. The following characteristics were identified: personalization, parent-physician relationships, shared decision-making, physician bias, emotions, anxiety, psychosocial factors, parental values, religion, spirituality, hope, quality of life, and uncertainty.

CONCLUSIONS

Parental values are mentioned in 37 of the included articles. Besides this, uncertainty, shared decision-making, and emotions are most frequently mentioned in the literature. However, reflecting on the interrelation between all characteristics leads us to conclude that personalization is the most notable trend in prenatal counseling practices. More and more, it is valued to adjust the counseling to the parent(s).

PRACTICE IMPLICATIONS

This scoping review emphasizes again the complexity of prenatal counseling at the limit of viability. It offers an exploration of how it is currently approached, and reflects on how future research can contribute to optimizing it.

The center-effect on outcomes for infants born at less than 25 weeks

Marked variation exists in the care of infants born at <25 weeks' gestation. The center or location where a fetus or infant is cared for influences outcomes at very early gestational ages. Understanding this "center-effect," including characteristics associated with centers that have high survival of births at <25 weeks' gestation, may inform future studies and guide care practices to improve outcomes. This review focuses on the impact that the location or center of birth has on survival and other important outcomes for infants born at <25 weeks' gestation. We review potential sources of variation in care practices and other factors that might explain the "center-effect."

Mobile applications for prematurity: a systematic review protocol

Background

Premature birth is a global epidemic of significant public health concern. Counselling and education of pregnant women at risk of preterm birth or mothers with premature infants are essential to improve mother and infant health. Mobile applications are an increasingly popular tool among parents to receive health information and education. This study aims to evaluate the usages and the effects of a mobile application designed for premature births in order to improve health outcomes.

Methods

This review will include all studies of different designs which evaluated the use and impact of interventions provided via mobile applications on pregnant women at risk of preterm birth or mothers with premature infants in order to address all health outcomes. A combination of keywords and MeSH(Medical Subject Headings) terms is used in the search strategy. Literature databases including Scopus, PubMed, ISI Web of Science, ProQuest, CINAHL and Cochrane Library will be searched to May 2021. Furthermore, eligible studies will be chosen from the reference list of retrieved papers. Two researchers will independently review the retrieved citations to decide whether they meet the inclusion criteria. Mixed Methods Appraisal Tool (MMAT) V.2018 will be used to assess the quality of studies. Relevant data are collected in a data extraction form and analysed. Results are reported under the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

Discussion

This systematic review will recognize and combine evidence about the usages and impact of mobile application interventions on the health improvement of pregnant women at risk of preterm birth or mothers with premature infants.

The 30-Minute Sprint: Recognizing Intrapartum Prematurity Counseling Limitations

Describe the characteristics and content of intrapartum counseling provided to women hospitalized for premature birth between 23 and 34 weeks' gestation age (GA). The study was conducted between April and December 2009 in two teaching hospitals with labor and delivery units and level 3 neonatal intensive care units. Counselors completed a postcounseling survey. From 60 sessions, 46 surveys were collected. The median counseling duration was 30 minutes; this was not associated with gestational age. The support-person was not present for most (57%) counseling sessions. There was a positive correlation (p = 0.001) between the number of maternal questions and her education. There was no difference in counseling content across the 23 to 34 weeks' GA regarding delivery room care, physical/mental disability, and vision problems. This study of characteristics and content of premature birth counseling for birth between 23 and 34 weeks' GA found that the duration of most sessions is 30 minutes; the father of the baby is not present during counseling for most premature births, and the topics discussed by counselors are fairly similar and extensive irrespective of the GA. These findings highlight the existing contrast between the recommended counseling practices and the actual practice reported by counselors.

Prenatal consults with illustrated literature (PnCIL): a RCT studying visual aids during prenatal consults

OBJECTIVE

We hypothesize that addition of illustrated handouts during prenatal consultations decreases maternal anxiety and improves maternal knowledge.

STUDY DESIGN

Inpatient gravid women at 25 0/7-34 6/7 weeks gestation were randomized to Standard or Illustrated consults, verbal consults supplemented with a visual handout. Post consult surveys were administered assessing maternal anxiety and knowledge acquisition.

RESULT

We enrolled 82 women; 54 to Standard Consult, 28 to Illustrated Consult. Consult duration was the same across arms. Anxiety and knowledge were not impacted by the intervention overall. We found higher mean knowledge by 17% for consults ≥31 min (P = 0.006; 95% CI 0.67-3.82), and 13% in primigravids (P = 0.032; 95% CI 0.15-3.21) in the intervention arm.

CONCLUSIONS

Using illustrated handouts is feasible and does not increase duration of prenatal consults. It may improve knowledge acquisition in long consults and in primigravida women, although it does not impact anxiety and knowledge overall.

Parental understanding of crucial medical jargon used in prenatal prematurity counseling

BACKGROUND

Parent-clinician shared decision making is the recommended model for the care of premature infants; thus, clinicians provide prenatal prematurity counseling to parents in the event of a mother's hospitalization for premature birth. However, parental understanding of medical jargon commonly used during prematurity counseling is unknown.

METHODS

Within an overall research agenda to develop and test an educational aid for prenatal prematurity education, we designed the Parental Knowledge of Premature Birth questionnaire. To evaluate parental comprehension of the medical jargon contained within the questionnaire, we conducted cognitive interviews, a formal method for evaluating comprehension and response to questionnaire items. Parents were recruited from a Level IV Neonatal Intensive Care Unit; purposeful recruitment ensured diversity with respect to gender, race, literacy level, and child's gestational age. Data collection and analysis followed standard qualitative methods for cognitive interviewing. We report on the insights gained from these cognitive interviews regarding parental understanding of crucial medical jargon commonly used during prenatal prematurity counseling.

RESULTS

Participants included 10 women and 6 men who ranged in age from 23 to 38 years and represented Black/African-American (38%), Asian (6%), and white (56%) backgrounds. Five participants (31%) had less than a high school education or reading level below 9th grade (Wide Range Achievement Test version 4 reading subtest). In the first round of interviews, parents of all education and literacy levels had difficulty with medical jargon commonly used in prematurity counseling. Terms that parents found difficult to understand included "gestational age", "mild or no developmental problems", and "neonatologist". Modified terms tested in a second round of interviews showed improved comprehension.

CONCLUSION

Cognitive interviews provided empirical testing of parental understanding of crucial medical jargon and highlighted that language commonly used during prenatal prematurity counseling is not understood by many parents. For parents to participate in shared decision making, plain language should be used to maximize their understanding of medical information.

Designing a tablet-based prematurity education app for parents hospitalized for preterm birth

BACKGROUND

As technology has advanced over the last decade, handheld Mobile Health (mHealth) applications have increased in popularity. Pregnancy is one area of mHealth that has rapidly expanded, however very few pregnancy apps are developed in collaboration with health professionals. This creates an environment where the pregnancy information women are accessing may be inaccurate or even dangerous. Additionally, there are relatively few medical apps devoted to prematurity or targeted to women at risk for premature birth. To address the gap in premature birth education, we assembled a multidisciplinary team, including health care professionals, and developed the Preemie Prep for Parents (P3) app.

METHODS

Our team previously conducted 5 focus group meetings to assess the information needs of our target audience. Based on this information we developed a low fidelity P3 prototype. Our software development team transferred the low fidelity prototype into a high fidelity prototype which was hosted on Test Flight (a beta testing platform). We performed heuristic evaluation as well as user testing to improve the P3 app.

RESULTS

User testing of the high fidelity P3 prototype was performed with 13 diverse participants. 6 participants were parents of currently admitted Neonatal Intensive Care Unit (NICU) babies and 7 participants were women who had been or were currently pregnant. The native language of participants included English, Spanish, and Hmong and their educational level varied between completing high school and graduate degree. Participants provided feedback on the content of the P3 app, as well as its organization and aesthetics. The feedback led to 83 iterations of the P3 app prior to its deployment. Overall, participants noted that the information was "informative" and "reliable". They also noted that the P3 app provided control over the information they could view and when they viewed it, stating "I could see info on my time". Overall, participants felt that the P3 app was a valuable tool for mothers in preterm labor and it would help them ask questions.

CONCLUSIONS

Development of a mHealth app provides unique challenges regarding content, reliability of information, organization, and aesthetics. Creation of the P3 app to address the educational needs of women at risk for premature birth required assembling a multidisciplinary team, which included target users, and implementing an iterative design process. The efficacy of this app in improving user knowledge and decreasing anxiety is currently being tested in a randomized controlled trial.

Giving Voice to Parents in the Development of the Preemie Prep for Parents (P3) Mobile App

BACKGROUND

Parents at risk for preterm birth frequently receive prematurity education when the mother is hospitalized for premature labor. Parental ability to learn and consider the information is limited because of the stress of the hospitalization. A promising approach is dissemination of information to at-risk parents before the birth hospitalization.

PURPOSE

This article describes formative research used to develop smartphone-based prematurity education app for parents at-risk for preterm birth.

METHODS

Stakeholders were parents with a prior preterm birth. Using stakeholder meeting transcripts, constant comparative analysis was used to reflect upon the parental voice.

RESULTS

The parents named the app, Preemie Prep for Parents (P3). Parent perspectives revealed desire for information in the following 5 categories. (1) Power in knowledge and control: parents want autonomy when learning information that may influence medical decision-making. (2) Content and framing of information: they desire information from a trusted resource that helps promote prenatal health and provides neonatal intensive care information. (3) Displaying content: parents want personalization, push notifications, photographs displaying fetal development, and easy-to-understand statistics. (4) Providing information without causing harm: they desire non-value-laden information, and they do not support "gamifying" the app to enhance utilization. (5) Decision making: parents want information that would benefit their decision making without assuming that parents have a certain outlook on life or particular values.

IMPLICATIONS FOR PRACTICE

These findings support the need for the P3 App to aid in decision making when parents experience preterm birth.

IMPLICATIONS FOR RESEARCH

The findings highlight the need to study the effects of smartphone-based prematurity education on medical decision-making.

Effect of written outcome information on attitude of perinatal healthcare professionals at the limit of viability: a randomized study

Background

Differences in perception and potential disagreements between parents and professionals regarding the attitude for resuscitation at the limit of viability are common. This study evaluated in healthcare professionals whether the decision to resuscitate at the limit of viability (intensive care versus comfort care) are influenced by the way information on incurred risks is given or received.

Methods

This is a prospective randomized controlled study. This study evaluated the attitude of healthcare professionals by testing the effect of information given through graphic fact sheets formulated either optimistically or pessimistically. The written educational fact sheet included three graphical presentations of survival and complication/morbidity by gestational age. The questionnaire was submitted over a period of 4 months to 5 and 6-year medical students from the Geneva University as well as physicians and nurses of the neonatal unit at the University Hospitals of Geneva. Our sample included 102 healthcare professionals.

Results

Forty-nine responders (48%) were students (response rate of 33.1%), 32 (31%) paediatricians (response rate of 91.4%) and 21 (20%) nurses in NICU (response rate of 50%). The received risk tended to be more severe in both groups compared to the graphically presented facts and current guidelines, although optimistic representation favoured the perception of “survival without disability” at 23 to 25 weeks. Therapeutic attitudes did not differ between groups, but healthcare professionals with children were more restrained and students more aggressive at very low gestational ages.

Conclusion

Written information on mortality and morbidity given to healthcare professionals in graphic form encourages them to overestimate the risk. However, perception in healthcare staff may not be directly transferable to parental perception during counselling as the later are usually naïve to the data received. This parental information are always communicated in ways that subtly shape the decisions that follow.

Development of Nationwide Recommendations to Support Prenatal Counseling in Extreme Prematurity

OBJECTIVES

To develop a nationwide, evidence-based framework to support prenatal counseling in extreme prematurity, focusing on organization, decision-making, content, and style aspects.

METHODS

A nationwide multicenter RAND-modified Delphi method study was performed between November 2016 and December 2017 in the Netherlands. Firstly, recommendations were extracted from literature and previous studies. Secondly, an expert panel (n = 21) with experienced parents, obstetricians, and neonatologists rated the recommendations on importance for inclusion in the framework. Thirdly, ratings were discussed in a consensus meeting. The final set of recommendations was approved and transformed into a framework.

RESULTS

A total of 101 recommendations on organization, decision-making, content, and style were included in the framework, including tools to support personalization. The most important recommendations regarding organization were to have both parents involved in the counseling with both the neonatologist and obstetrician. The shared decision-making model was recommended for deciding between active support and comfort care. Main recommendations regarding content of conversation were explanation of treatment options, information on survival, risk of permanent consequences, impossibility to predict an individual course, possibility for multiple future decision moments, and a discussion on parental values and standards. It was considered important to avoid jargon, check understanding, and provide a summary. The expert panel, patient organization, and national professional associations (gynecology and pediatrics) approved the framework.

CONCLUSIONS

A nationwide, evidence-based framework for prenatal counseling in extreme prematurity was developed. It contains recommendations and tools for personalization in the domains of organization, decision-making, content, and style of prenatal counseling.

Smartphone-based prenatal education for parents with preterm birth risk factors

OBJECTIVE

To develop an educational mobile application (app) for expectant parents diagnosed with risk factors for premature birth.

METHODS

Parent and medical advisory panels delineated the vision for the app. The app helps prepare for preterm birth. For pilot testing, obstetricians offered the app between 18-22 weeks gestational age to English speaking parents with risk factors for preterm birth. After 4 weeks of use, each participant completed a questionnaire. The software tracked topics accessed and duration of use.

RESULTS

For pilot testing, 31 participants were recruited and 28 completed the questionnaire. After app utilization, participants reported heightened awareness of preterm birth (93%), more discussion of pregnancy or prematurity issues with partner (86%), increased questions at clinic visits (43%), and increased anxiety (21%). Participants reported receiving more prematurity information from the app than from their healthcare providers. The 15 participants for whom tracking data was available accessed the app for an average of 8 h.

CONCLUSION

Parents with increased risk for preterm birth may benefit from this mobile app educational program.

PRACTICE IMPLICATIONS

If the pregnancy results in preterm birth hospitalization, parents would have built a foundation of knowledge to make informed medical care choices.

"I Felt Like I Was a Part of Trying to Keep My Baby Alive": Perspectives of Hispanic and Non-Hispanic Black Mothers in Providing Milk for Their Very Preterm Infants

Background: Compared with non-Hispanic white, Hispanic and non-Hispanic black mothers of very preterm infants are less likely to provide mother's milk at the point of hospital discharge; the perspectives of these mothers are poorly understood. Objectives: To examine the perceived barriers and facilitators of providing milk for very preterm infants during the hospitalization among Hispanic and non-Hispanic black mothers. Materials and Methods: We conducted 23 in-depth, semistructured interviews of English and Spanish-speaking Hispanic and non-Hispanic black mothers that initiated milk production for their very preterm infants, ≤1,750 g at birth. Following thematic saturation, results were validated through expert triangulation and member checking. Results: Twelve mothers were Hispanic, where three were English speaking and nine were Spanish speaking. Eleven mothers were non-Hispanic black and English speaking. We found themes pertaining to general experiences: (1) Breastfeeding intent impacts mothers' success in providing milk throughout the hospitalization; (2) Pumping milk for a hospitalized infant is repetitive, exhausting, and does not elicit the same emotional connection as breastfeeding; (3) Hospital providers are an important source of support, when sufficient time is spent to address ongoing issues; (4) Providing milk creates a unique sense of purpose when mothers otherwise feel a lack of control; and we found themes pertaining to the experiences of Hispanic and non-Hispanic black mothers: (1) Breastfeeding as a cultural norm influences mothers' intent to initiate and continue breastfeeding; (2) Hospital staff are viewed as more supportive when interactions and treatment are perceived as racially/ethnically unbiased and (3) when communication occurs in the primary language; and (4) Mother-infant separation creates logistical challenges that negatively impact ongoing milk production. Conclusions: While providing milk for a hospitalized very preterm infant is exhausting, and logistically challenging, Hispanic and non-Hispanic black mothers are inspired to do so because of their intent to breastfeed, support from hospital providers, and feelings of purpose.

Various experiences and preferences of Dutch parents in prenatal counseling in extreme prematurity

OBJECTIVE

To investigate experienced and preferred prenatal counseling among parents of extremely premature babies.

METHODS

A Dutch nationwide, multicenter, cross-sectional study using an online survey. Surveys were sent to all parents of extremely premature babies born between 2010 and 2013 at 24^+0/7-24^+6/7 weeks of gestation.

RESULTS

Sixty-one out of 229 surveys were returned. A minority (14%) had no counseling conversation. Conversations were done more often by neonatologists (90%) than by obstetricians (39%) and in 37% by both these experts. Supportive material was rarely used (19%). Mortality (92%) and short-term morbidity (88%) were discussed the most, and more frequently than long-term morbidity (65%), practical items (63%) and delivery mode (52%). Most decisions on active care or palliative comfort care were perceived as decisions by doctor and parents together (61%). 80% felt they were involved in decision-making. The preferred way of involvement in decision-making varied among parents.

CONCLUSION

The vast majority of parents were counseled: mostly by neonatologists, and mainly about mortality and short-term morbidity. Parents wanted to be involved in the decision-making process but differed on the preferred extent of involvement. Practice implications Understanding of shared decision-making may contribute to meet the various preferences of parents.

Ethical implications of the use of decision aids for antenatal counseling at the limits of gestational viability

Shared decision-making is a recent priority in neonatology. However, its implementation is at an early stage. Decision aids are tools designed to assist in shared decision-making. They help patients competently participate in making healthcare decisions. There are limited studies in neonatology on the formal use of decision aids as used in adult medicine. Decision aids are relatively new, even in adult medicine where they were pioneered; therefore, there is a lack of systematic oversight to their development and use. Despite evidence reporting a powerful effect on patients' decisions, decision aids are not subject to quality control, leading to potentially enormous ethical implications. These include: (i) possible introduction of developers' biases; (ii) use of outdated or incorrect information; (iii) misuse to steer a patient towards less expensive treatments; (iv) clinician liability if negative patient outcomes occur, since decision aids are currently not standard of care.

Preferred prenatal counselling at the limits of viability: a survey among Dutch perinatal professionals

Background

Since 2010, intensive care can be offered in the Netherlands at 24⁺⁰ weeks gestation (with parental consent) but the Dutch guideline lacks recommendations on organization, content and preferred decision-making of the counselling. Our aim is to explore preferred prenatal counselling at the limits of viability by Dutch perinatal professionals and compare this to current care.

Methods

Online nationwide survey as part of the PreCo study (2013) amongst obstetricians and neonatologists in all Dutch level III perinatal care centers (n = 205).The survey regarded prenatal counselling at the limits of viability and focused on the domains of organization, content and decision-making in both current and preferred practice.

Results

One hundred twenty-two surveys were returned out of 205 eligible professionals (response rate 60%). Organization-wise: more than 80% of all professionals preferred (but currently missed) having protocols for several aspects of counselling, joint counselling by both neonatologist and obstetrician, and the use of supportive materials. Most professionals preferred using national or local data (70%) on outcome statistics for the counselling content, in contrast to the international statistics currently used (74%). Current decisions on initiation care were mostly made together (in 99% parents and doctor). This shared decision model was preferred by 95% of the professionals.

Conclusions

Dutch perinatal professionals would prefer more protocolized counselling, joint counselling, supportive material and local outcome statistics. Further studies on both barriers to perform adequate counselling, as well as on Dutch outcome statistics and parents’ opinions are needed in order to develop a national framework.

Trial registration

Clinicaltrials.gov, NCT02782650, retrospectively registered May 2016.

Electronic supplementary material

The online version of this article (10.1186/s12884-017-1644-6) contains supplementary material, which is available to authorized users.

Complications of prematurity: an infographic

Infographics or information graphics are easy-to-understand visual representation of knowledge. An infographic outlining the course of an extremely preterm infant and various potential complications encountered during a neonatal intensive care unit (NICU) stay was developed. This infographic can be used to discuss outcomes of prematurity during prenatal counseling and while the infant is in the NICU.

Prenatal (non)treatment decisions in extreme prematurity: evaluation of Decisional Conflict and Regret among parents

OBJECTIVE

To evaluate Decisional Conflict and Regret among parents regarding the decision on initiating comfort or active care in extreme prematurity and to relate these to decision-making characteristics.

STUDY DESIGN

A nationwide, multicenter, cross-sectional study using an online survey in the Netherlands. Data were collected from March 2015 to March 2016 among all parents with infants born at 24^+0/7-24^+6/7 weeks gestational age in 2010-2013. The survey contained a Decisional Conflict and Decision Regret Scale (potential scores range from 0 to 100) and decision-making characteristics.

RESULTS

Sixty-one surveys were returned (response rate 27%). The median Decisional Conflict score was 28. From the subscores within Decisional Conflict, 'values clarity' revealed the highest median score of 42-revealing that parents felt unclear about personal values for benefits and risks of the decision on either comfort care or active care. The median Decision Regret score was 0. Regret scores were influenced by the actual decision made and by outcome: Decision Regret was lower in the active care group and in the survivor group.

CONCLUSION

We found little Decisional Conflict and no Decision Regret among parents regarding decision-making at 24 weeks gestation.

Population-Based Outcomes Data for Counseling at the Margin of Gestational Viability

OBJECTIVE

To survey neonatologists as to how many use population-based outcomes data to counsel families before and after the birth of 22- to 25-week preterm infants.

STUDY DESIGN

An anonymous online survey was distributed to 1022 neonatologists in the US. Questions addressed the use of population-based outcome data in prenatal and postnatal counseling.

RESULTS

Ninety-one percent of neonatologists reported using population-based outcomes data for counseling. The National Institute of Child Health and Human Development Neonatal Research Network Outcomes Data is most commonly used (65%) with institutional databases (14.5%) the second choice. Most participants (89%) reported that these data influence their counseling, but it was less clear whether specific estimates of mortality and morbidity influenced families; 36% of neonatologist felt that these data have little or no impact on families. Seventy-one percent reported that outcomes data estimates confirmed their own predictions, but among those who reported having their assumptions challenged, most had previously been overly pessimistic. Participants place a high value on gestational age and family preference in counseling; however, among neonatologists in high-volume centers, the presence of fetal complications was also reported to be an important factor. A large portion of respondents reported using prenatal population-based outcomes data in the neonatal intensive care unit.

CONCLUSION

Despite uncertainty about their value and impact, neonatologists use population-based outcomes data and provide specific estimates of survival and morbidity in consultation before and after extremely preterm birth. How best to integrate these data into comprehensive, family-centered counseling of infants at the margin of viability is an important area of further study.

Personalized Antenatal Consultations for Preterm Labor: Responding to Mothers' Expectations

OBJECTIVE

To explore prospective mothers' perspectives regarding antenatal consultations by neonatology teams for threatened preterm delivery.

STUDY DESIGN

In a prospective multicenter study, women at risk of preterm delivery between 26 and 32 weeks of gestational age were surveyed during the 72 hours following their antenatal consultation. The questionnaire used was developed and validated during a single-center study.

RESULTS

Over 18 months, 229 mothers completed the survey (73% response rate), at a median gestational age of 30 weeks. Spouses/partners were present for 49% of consultations. Most women (90%) reported a positive experience. They found it important to discuss the outcomes of prematurity (96%), but 39% of them reported receiving too much information. Women wanted their spouse/partner to be present (71%) and wished to discuss parental concerns: their roles as mother of a premature baby (82%), their integration in their baby's care (83%), and a better understanding of the neonatal intensive care unit (NICU) environment, including antenatal NICU visits (69%). The majority (56%) wanted a follow-up consultation: this was less likely if a NICU visit had been offered (P < .001), if their role as decision-maker had been discussed (P < .05), or if the consultation had lasted longer (P = .001).

CONCLUSION

Policy statements recommend a standardized approach to providing parents with child-centered information. Although clinicians follow these guidelines, mothers want personalized information focusing on their individual concerns and questions, such as what they can do for their baby, how NICUs work, and the integration of their family.

A Pilot Study of Neonatologists' Decision-Making Roles in Delivery Room Resuscitation Counseling for Periviable Births

BACKGROUND

Relatively little is known about neonatologists' roles in helping families navigate the difficult decision to attempt or withhold resuscitation for a neonate delivering at the threshold of viability. Therefore, we aimed to describe the "decision-making role" of neonatologists in simulated periviable counseling sessions.

METHODS

We conducted a qualitative content analysis of audio-recorded simulation encounters and post-encounter debriefing interviews collected as part of a single-center simulation study of neonatologists' resuscitation counseling practices in the face of ruptured membranes at 23 weeks gestation. We trained standardized patients to request a recommendation if the physician presented multiple treatment options. We coded each encounter for communication behaviors, applying an adapted, previously developed coding scheme to classify physicians into four decision-making roles (informative, facilitative, collaborative, or directive). We also coded post-simulation debriefing interviews for responses to the open-ended prompt: "During this encounter, what did you feel was your role in the management decision-making process?"

RESULTS

Fifteen neonatologists (33% of the division) participated in the study; audio-recorded debriefing interviews were available for 13. We observed 9 (60%) take an informative role, providing medical information only; 2 (13%) take a facilitative role, additionally eliciting the patient's values; 3 (20%) take a collaborative role, additionally engaging the patient in deliberation and providing a recommendation; and 1 (7%) take a directive role, making a treatment decision independent of the patient. Almost all (10/13, 77%) of the neonatologists described their intended role as informative.

CONCLUSIONS

Neonatologists did not routinely elicit preferences, engage in deliberation, or provide treatment recommendations-even in response to requests for recommendations. These findings suggest there may be a gap between policy recommendations calling for shared decision making and actual clinical practice.

Informing and educating parents about the risks and outcomes of prematurity

The current process of educating and informing parents of the concerns and outcomes of premature infants is suboptimal, mostly because of modifiable factors. Proven methods to improve the transference of information are underused. In most institutions, the task to inform and educate parents is left to individual providers. Effective parent-clinician communication depends collectively on parents, clinicians, and the health care systems. Efforts must focus on improving communication and not on decreasing information provided to parents. If done successfully, we might find new and worthy allies in the trenches of the NICU.

Comparative effectiveness and practice variation in neonatal care

Comparative effectiveness research (CER) is a relatively new term for clinical research that directly assists patients, clinicians, and policymakers in making informed decisions to improve health care. In neonatology, there are similarities and differences between CER and existing clinical research and quality improvement literature. This article uses existing examples in neonatal literature to describe CER methodology and list some future directions and challenges in neonatal CER.