Negativity about the outcomes of extreme prematurity a persistent problem - a survey of health care professionals across the North Queensland region

"It feels like you have to choose one or the other": a qualitative analysis of obstetrician focus groups on periviability counseling

OBJECTIVES

The objective of this study was to gain knowledge and ascertain challenges about periviability counseling among obstetricians to inform curricular development.

METHODS

Focus groups were utilized. A series of open-ended questions was posed to each group of obstetricians; responses were audio recorded and transcribed. Transcriptions were analyzed by two coders using thematic analysis.

RESULTS

Four focus groups were convened. Prominent themes included: (1) Obstetrician knowledge about neonatal outcomes is limited, (2) Periviability counseling is both time intensive and time-challenged, (3) Patient processing of information relies on the content, delivery and patient readiness, and (4) Obstetrician bias is toward advocating for maternal safety, which may run counter to parental instinct to "do everything." The last theme was specifically focused on the role of cesarean delivery.

CONCLUSIONS

Curricula focused on improving obstetrician periviability counseling should focus on neonatal outcomes, the role of cesarean delivery, and utilization of shared decision-making.

Ethics Roundtable: How Much is Too Much?

How should the medical team approach care for a very preterm infant with a significant painful and life-limiting condition when the parents wish to pursue all life-sustaining therapies? Here, we discuss a case of an infant born at 28 weeks' gestation with a diagnosis of Carmi syndrome (junctional epidermolysis bullosa and pyloric atresia). While the medical team felt that a do-not-resuscitate order and redirection to comfort care were appropriate, the family held on to hope for recovery and wished to continue with full intensive care measures.

Outcomes in extremely low birth weight (≤500 g) preterm infants: A Western Australian experience

BACKGROUND AND AIM

Extremely preterm (EP) infant survival has significantly improved with advanced neonatal care; however outcomes of infants born with birth weight (BW) ≤500 g remain poor. We aimed to review outcomes of this cohort in our institution.

METHODS

Retrospective study of all inborn preterm infants born at ≥22 weeks gestational age (GA) and weighing ≤500 g between January 2001-December 2017. Outcomes included short-term morbidity, mortality, neurodevelopmental impairment and growth up to five years of age.

RESULTS

Of a total 438 eligible infants, 92 livebirths were admitted to intensive care [median (range) GA: 24 (22-30) weeks; median (IQR) BW: 427.5 (380-499) grams]. Majority [78/92 (84.7%)] were small for gestational age (SGA). In 50% of non-survivors, median (IQR) age of death was 3.5 (1-17.5) days with no late deaths. Medical morbidities were common. Follow-up, including standardised cognitive assessments, was available for 41/46 (89%) infants. At a median age of 5.06 years, 17/41 (41.5%) had moderate-severe disability; non-statistically higher in SGA compared to appropriate for gestational age/AGA (48.6% vs. 33.3%) group. Cerebral palsy (4/41; 10%), deafness needing amplification (1/41; 2.4%) were noted. Weight (32/41, 78%) and height (27/41, 66%) of most children remained at >2 SD below normal.

CONCLUSIONS

In a cohort of preterm infants weighing ≤500 g at birth, 50% survived after admission to intensive care. Medical morbidities were common and 54% were free from moderate to severe disability at five years. SGA infants had higher rates (48.6%) of moderate to severe disability. Ongoing suboptimal growth in childhood is common.

Survey of clinical staff knowledge on the long-term outcomes of very preterm infants delivered in a tertiary referral hospital

AIM

To assess knowledge of our neonatal intensive care unit clinical staff regarding preterm neurodevelopmental outcomes using the 33-item Preterm Birth Knowledge Scale (PB-KS).

METHODS

An anonymous convenience sampling survey of clinical staff in the Neonatal Directorate was conducted between July and December 2019. PB-KS, demographic information and prior staff education on long-term outcomes in very preterm infants were collected.

RESULTS

There were 56 responses (five neonatologists, eight paediatric trainees, 41 neonatal nurses and two allied health staff). Responses were scored as correct or incorrect. The mean score on the PB-KS was 19.5 (range: 4-29 out of 40) with 50% correct answers. Accuracy was highest (96%) for rates of cerebral palsy and lowest (11%) for estimation of quality of life among preterm survivors. Staff reported training in long-term outcomes of preterm infants through attending a conference/seminar (20%) or a combination of formal training and seminars (41.1%). Over half of our clinical staff reported a lack of formal training. Formally trained clinical staff scored significantly better in this survey. Didactic seminars were indicated as preferred choice for staff education.

CONCLUSIONS

Results of our survey will assist in developing a customised educational programme to address identified gaps in the knowledge of clinical staff as our survey also showed significantly better scores among staff who were formally trained about long-term outcomes in very preterm infants. Staff responses indicated that knowledge on long-term outcomes was variable but more accurate with regard to more severe disabilities and shorter-term developmental outcomes.

Exploring implicit bias in the perceived consequences of prematurity amongst health care providers in North Queensland - a constructivist grounded theory study

Background

A study was done to explore the attitudes of relevant health care professionals (HCP) towards the provision of intensive care for periviable and extremely premature babies.

Methods/design

Applying a constructivist grounded theory methodology, HCP were interviewed about their attitudes towards the provision of resuscitation and intensive care for extremely premature babies. These babies are at increased risk of death and neurodisability when compared to babies of older gestations. Participants included HCP of varying disciplines at a large tertiary centre, a regional centre and a remote centre. Staff with a wide range of experience were interviewed.

Results

Six categories of i) who decides, ii) culture and context of families, iii) the life ahead, iv) to treat a bit or not at all, v) following guidelines and vi) information sharing, emerged. Role specific implicit bias was found as a theoretical construct, which depended on the period for which care was provided relative to the delivery of the baby. This implicit bias is an underlying cause for the negativity seen towards extreme prematurity and is presented in this paper. HCP caring for women prior to delivery have a bias towards healthy term babies that involves overestimation of the risks of extreme prematurity, while neonatal staff were biased towards suffering in the neonatal period and paediatricians recognise positivity of outcomes regardless of neurological status of the child. The implicit bias found may explain negativity towards intensive care of periviable neonates.

Conclusion

Understanding the presence and origins of role specific implicit bias may enable HCP to work together to improve care for parents preparing for the delivery of extremely premature babies.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03539-5.