Ethical issues in treatment of babies born at 22 weeks of gestation

Ethical considerations regarding the treatment of extremely preterm infants at the limit of viability: a comprehensive review

Advancements in perinatal care have improved survival rates of extremely preterm infants born at 22 to 23 weeks of gestation, thus introducing new ethical challenges associated with their treatment. Therefore, we reviewed the epidemiological prognosis, treatment evolution, and ethical considerations associated with the care of preterm infants at the limit of viability. We comprehensively searched PubMed to find relevant English-language articles published between January 2014 and July 2024. Survival rates of infants born at 22 to 23 weeks of gestation have improved but remain low. Proactive treatment can result in survival rates exceeding 50% for infants born at 22 weeks; however, these infants are at high risk for complications and neurodevelopmental impairment. Advancements in obstetric and neonatal care have contributed to improved outcomes. Ethical challenges include balancing survival with the disability risk, managing patients with uncertain prognoses, and considering parental wishes.Conclusion: The care of preterm infants at the limit of viability presents complex ethical dilemmas. Shared decision-making between healthcare providers and families as well as engaging in societal discourse are crucial to addressing these challenges.

Association between gestational age and severe maternal morbidity in preterm delivery: A nationwide population-based cohort study

OBJECTIVE

This study investigates whether early gestational age (GA) at delivery is associated with an increased risk for severe maternal morbidity (SMM) in women with preterm delivery.

METHODS

This retrospective national cohort study based on the Programme de Médicalisation des Systèmes d'Information database included mothers who gave birth between 22 and 37 weeks in metropolitan France in 2019 (in utero deaths and medical terminations of pregnancies were excluded). SMM was defined as a composite criterion consisting of the occurrence of at least one of the following events: death, severe preeclampsia, obstetric surgical complications, severe maternal diseases, and admission to the intensive care unit. The association between GA as a categorical variable (22-24 weeks, 24-26 weeks, 26-28 weeks, 28-32 weeks, 32-34 weeks, and >34 weeks) and SMM was assessed by performing multivariate logistic regressions. Interaction tests were performed to identify factors that might influence the association between SMM and GA.

RESULTS

Among the 42 821 women who gave birth prematurely in metropolitan France in 2019 (6.2% of all parturients), 6249 (1.6%) presented with an SMM event (mostly severe preeclampsia, at 74.3%). GA was associated with SMM (adjusted odds ratio ranging from 1.83 between 32 and 34 weeks to 2.67 between 22 and 24 weeks compared to the reference group of 34-37 weeks, P < 0.001). The evolution of the risk of SMM according to GA appeared linear.

CONCLUSION

Early GA at delivery was associated with an increased risk of SMM in women with preterm delivery. This study showed that SMM is also increased in cases of spontaneous prematurity and vaginal delivery.

Neonatologists' Resuscitation Decisions at Birth for Extremely Premature Infants. A Belgian Qualitative Study

OBJECTIVE

Deciding whether initiating or withholding resuscitation at birth for extremely preterm infants (EPIs) can be difficult due to uncertainty on outcomes. Clinical uncertainty generates ethical uncertainty. Thus, physicians' attitudes and perspectives on resuscitation of EPIs might influence resuscitation decisions. We aimed at understanding how neonatologists make clinical-ethical decisions for EPI resuscitation and how they perceive these decisions.

METHODS

We performed a qualitative study using a constructivist account of grounded theory. Face-to-face, semi-structured in-depth interviews with neonatologists comprised data collection. For data analysis, we used the Qualitative Analysis Guide of Leuven.

RESULTS

We interviewed 20 neonatologists working in 10 hospitals in Belgium. Participants' decision-making can be described as consensus-based, gestational age-based, contextualized, progressive, and shared. All participants agreed on the importance of using the consensus expressed in guidelines as a guidance for the decision-making, i.e., consensus-based. Consequently, all 20 participants use GA thresholds indicated in the guidelines, i.e., GA-based. However, they use these thresholds differently in their decisions. Few participants rigidly follow established thresholds. The vast majority reported using additional contextual factors as birthweight or parents' wishes in the decision-making, rather than only the EPIs' GA, i.e., contextualized. All participants agreed on the importance of involving the parents in the decision-making, i.e., shared, and indeed parents' wishes were among the most valued factors considered in the decision-making. However, the extent to which parents were involved in the decision-making depended on the infant's GA. Participants described a gray zone in which parents' were viewed as the main decision-makers due to the high clinical uncertainty. This mean that participants tend to follow parents' request even when they disagree with it. Outside the gray zone, physicians were viewed as the main decision-makers. This mean that, although parents' wishes were still considered, counseling was more directive and the final decision was made by the physician.

CONCLUSION

Although an EPI's GA remains the main factor guiding neonatologists' resuscitation decisions, other factors are seriously considered in the decision-making process. All neonatologist participants agreed on the importance of involving parents in the decision-making. However, they involve parents differently depending on the EPI's GA.

Neonatologists' decision-making for resuscitation and non-resuscitation of extremely preterm infants: ethical principles, challenges, and strategies-a qualitative study

Background

Deciding whether to resuscitate extremely preterm infants (EPIs) is clinically and ethically problematic. The aim of the study was to understand neonatologists’ clinical–ethical decision-making for resuscitation of EPIs.

Methods

We conducted a qualitative study in Belgium, following a constructivist account of the Grounded Theory. We conducted 20 in-depth, face-to-face, semi-structured interviews with neonatologists. Data analysis followed the qualitative analysis guide of Leuven.

Results

The main principles guiding participants’ decision-making were EPIs’ best interest and respect for parents’ autonomy. Participants agreed that justice as resource allocation should not be considered in resuscitation decision-making. The main ethical challenge for participants was dealing with the conflict between EPIs’ best interest and respect for parents’ autonomy. This conflict was most prominent when parents and clinicians disagreed about births within the gray zone (24–25 weeks). Participants’ coping strategies included setting limits on extent of EPI care provided and rigidly following established guidelines. However, these strategies were not always feasible or successful. Although rare, these situations often led to long-lasting moral distress.

Conclusions

Participants’ clinical–ethical reasoning for resuscitation of EPIs can be mainly characterized as an attempt to balance EPIs’ best interest and respect for parents’ autonomy. This approach could explain why neonatologists considered conflicts between these principles as their main ethical challenge and why lack of resolution increases the risk of moral distress. Therefore, more research is needed to better understand moral distress in EPI resuscitation decisions.

Clinical Trial Registration: The study received ethical approval from the ethics committee of UZ/KU Leuven (S62867). Confidentiality of personal information and anonymity was guaranteed in accordance with the General Data Protection Regulation of 25 May 2018.

Exploring the knowledge of community-based nurses in supporting parents of preterm babies at home: A survey-based study

Aim

This study aimed to investigate the confidence levels, knowledge base and learning needs of community‐based nurses relating to the care of preterm babies and parents, to explore what education is required and in what format.

Design

An online survey methodology was used.

Methods

A 32‐item questionnaire was distributed via social media platforms to community‐based nurses in Australia.

Results

Descriptive analysis was undertaken relating to knowledge base, confidence levels, previous training, learning and resource needs and barriers to education. It was deemed vital to expand confidence and knowledge in this area. Gaps in learning resources were identified and a need for more training in topics such as developmental outcomes, feeding, expected milestones, weight gain, growth trajectories and supporting parents. Online resources were the preferred format to teach key knowledge to community‐based health professionals, tailored to the specific features of preterm babies and support needs of parents.