Attitudes of Obstetric and Pediatric Health Care Providers Toward Resuscitation of Infants Who Are Born at the Margins of Viability
OBJECTIVES. The objective of this study was to determine the attitudes of a variety of health care providers toward the recommendations that should be made to parents regarding the resuscitation of infants who are born at the margins of viability.
METHODS. A written questionnaire was distributed to the medical and nursing staff at 4 tertiary perinatal centers. For each of 5 weekly gestational age intervals from 22 weeks to 26 weeks, 6 days, the health care providers were asked to describe on a scale from 1 to 5 whether they would strongly discourage through strongly encourage resuscitation. They also were queried regarding their comfort with counseling regarding these issues. The attitudes of various groups of providers were compared across weekly intervals.
RESULTS. A total of 204 physicians and 539 nurses completed the survey. The majority would strongly discourage, either discourage or strongly discourage, be neutral or recommend, recommend or strongly recommend, and strongly recommend resuscitation during the 23rd, 24th, 25th, 26th, and 27th weeks of gestation, respectively. Obstetric caregivers were slightly less likely than pediatric caregivers to strongly discourage resuscitation from 22 weeks to 22 weeks, 6 days and 23 weeks to 23 weeks, 6 days. There were no significant differences in the recommendations of obstetricians and pediatricians. Pediatric nurses were more likely to strongly recommend resuscitation from 26 weeks to 26 weeks, 6 days and more likely either to discourage or to strongly discourage resuscitation from 23 weeks to 23 weeks, 6 days and to strongly discourage resuscitation from the 22 weeks to 22 weeks, 6 days than their obstetric counterparts. Obstetric nurses were slightly less likely than obstetricians to strongly recommend resuscitation at 26 weeks to 26 weeks, 6 days and less likely to strongly discourage resuscitation from 22 weeks to 22 weeks, 6 days.
CONCLUSIONS. The caregivers' recommendations seem to be based logically on the current literature regarding survival and morbidity that is experienced by infants who are born at the threshold of viability. Although there are minor differences, there was a relatively consistent approach among professional groups.
The waning years of the 20th century and the early years of the 21st century have witnessed dramatic improvements in neonatal survival at gestational ages of 22 to 26 weeks.1–5 Unfortunately, many of the surviving infants have been afflicted by serious developmental and/or long-term health problems.2–10 The issue of survival versus quality of survival has engendered ethical debate.11–13 It has prompted professional societies to express interest and make recommendations to health care providers regarding appropriate care of mothers and infants at this threshold of viability.14,15
For several years, the Vermont Oxford Network has conducted multiinstitutional collaborative quality improvement projects, called the Neonatal Intensive Care Quality Improvement Collaboratives, that focused primarily on improving outcomes by improving neonatal care practices. In 1 such project to improve perinatal outcomes, the Neonatal Intensive Care Quality Improvement Collaborative, the Vermont Oxford Network expanded its efforts beyond exclusive neonatal quality improvement to perinatal–neonatal quality improvement by recruiting pilot sites that volunteered to focus on obstetric and perinatal issues in addition to neonatal ones.
The 3 tertiary perinatal centers that initially formed this exploratory group subsequently were joined by 2 others. The 5 participating centers were (1) Akron General Medical Center, Children's Hospital Medical Center, and Summa Health System, (2) Dartmouth-Hitchcock Medical Center, (3) Providence St Vincent Medical Center, (4) Rockford Memorial Hospital, and (5) Children's Hospitals and Clinics. Thus formed, the group decided to explore and to attempt to improve the collaboration between the obstetric and neonatal caregivers within their centers.
As a first step in this process, 4 centers (Akron, Dartmouth, Portland, and Rockford) decided to assess the opinions of various groups of caregivers regarding the resuscitation of infants at the threshold of viability. In its initial discussions, the exploratory group recognized that several subgroups of obstetric and neonatal caregivers other than physicians, although not providing formal or specific counseling, interacted with and exerted considerable influence on these patients. Therefore, the exploration was extended beyond pediatricians, neonatologists, obstetricians, and maternal–fetal medicine specialists to include neonatal and obstetric nurses, neonatal nurse practitioners, and certified nurse midwives. Herein, we report the multicenter findings.
For ascertainment of the opinions of a wide variety of perinatal health care providers, a written questionnaire was distributed to the entire medical and nursing staffs of 4 tertiary perinatal centers. For each of the 5 gestational weeks, 22 through 26, the health care providers were asked to consider the following question: “A mother is about to deliver an extremely premature fetus at the listed gestational age. The pregnancy to this point has been uncomplicated, and the fetus has been healthy and is of an average size for gestational age. How would you counsel the family for each gestational age?”
The potential answers were coded numerically (1, strongly discourage resuscitation; 2, recommend against resuscitation but would be comfortable with parent's request to resuscitate; 3, neutral; 4, recommend resuscitation but would be comfortable with parent's request to provide comfort care only; and 5, strongly encourage resuscitation). The questionnaires were collected, and the responses were entered into Excel spreadsheets (Microsoft Corp, Redmond, WA). At 3 of the 4 centers, the participants also were asked to rate their comfort level with counseling parents regarding these issues. The potential responses also were coded numerically (1, not comfortable; 2, somewhat uncomfortable; 3, neutral; 4, somewhat comfortable; and 5, very comfortable).
The data from the centers were compared. The responses of the obstetric and pediatric health care providers, obstetricians and pediatricians, obstetric nurses and neonatal nurses, physicians and nurses, obstetric physicians and nurses, pediatric physicians, and neonatal nurses were compared. Statistical analysis was performed in weekly categories by using the χ2 test. P < .05 was considered to be statistically significant.
A total of 743 caregivers returned completed questionnaires. Unfortunately, some of the centers did not keep track of how many surveys were sent as planned. Therefore, there is no way to calculate the overall response rate. This limited the analysis to what is presented here. A total of 204 respondents were physicians, and 539 were nurses. As illustrated in Table 1, in the 22nd week, the majority (69.2%) would strongly discourage and an additional 19.3% would discourage resuscitation. In the 23rd week, the majority (70.0%) would either discourage (40.9%) or strongly discourage (29.1%) resuscitation. In the 24th week, the majority (63.3%) were either neutral (28.7%) or would recommend (34.6%) resuscitation. In the 25th week, the majority (85.3%) would either recommend (36.8%) or strongly recommend (48.5%) resuscitation. By the 26th gestational week, the majority (94.5%) would strongly recommend (78.8%) and an additional 15.7% would recommend resuscitation. When the various centers were compared, the only significant difference occurred during the 23rd week, when caregivers at Lebanon and Portland were somewhat more likely than their counterparts in Akron and Rockford to recommend strongly against resuscitation (P < .0001).
The responses of obstetric physicians and nurses were compared as a group with pediatric physicians and neonatal nurses as a group (Table 2). Pediatric caregivers were more likely than their obstetric colleagues to strongly discourage resuscitation of neonates who were born in the 22nd and 23rd weeks (P = .0003 and .0008, respectively). No other statistically significant differences were noted between obstetric and pediatric caregivers.
The responses of the 2 groups of physicians were compared (Table 3). There were no statistically significant differences in resuscitation recommendations regarding or counseling comfort between the 2 physician groups in any gestational age subcategory. The next step was the comparison of the responses of the 2 groups of nurses, obstetric and neonatal (Table 4). Neonatal nurses were more likely to strongly recommend resuscitation in the 26th week (P = .0162). They also were more likely to either discourage or strongly discourage resuscitation in the 23rd week and to strongly discourage resuscitation in the 22nd week than their obstetric counterparts (P = .0042 and P < .0001, respectively). When counseling comfort was compared, obstetric nurses were less comfortable than neonatal nurses (P < .0001).
Comparisons were made between physicians and nurses as groups (Table 5), between obstetricians and obstetric nurses as groups (Table 6), and between pediatricians and neonatal nurses as groups (Table 7). As a total group (Table 5), nurses were slightly less likely than physicians to strongly discourage resuscitation in the 22nd week (P = .0235). They also were substantially less comfortable than physicians with counseling parents regarding these issues (P < .0001).
The discomfort with counseling was true for both obstetric nurses in contrast to obstetricians (Table 6) and neonatal nurses in comparison with pediatricians (P < .0001 for both groups; Table 7). Obstetric nurses were slightly less likely than obstetricians to strongly recommend resuscitation in the 26th week and less likely to strongly discourage resuscitation in the 22nd week (P = .0035 and .0016, respectively). There were no statistically significant differences between the recommendations of neonatal nurses and pediatricians in any of the gestational age subcategories.
Opinion surveys regarding resuscitation recommendations of neonates who are at the margins of viability (22–26 weeks' gestation) and involving neonatologists,16–18 obstetricians,19–21 maternal–fetal medicine specialists,22 and neonatal nurses18 have been conducted and published. However, this is the first attempt to describe the contemporaneous attitudes of all of these disciplines from multiple centers regarding newborn resuscitation at the threshold of viability. A previous publication reported an opinion survey of a smaller group of nurses from a single NICU,18 and another detailed the efforts of multiple disciplines to develop consensus recommendations regarding the resuscitation of periviable infants within a single tertiary center.23 This study expanded on those previous publications by surveying opinions of a larger group of various obstetric and neonatal health care providers from multiple institutions. It should be emphasized that at this point in our efforts, we were simply to determine current opinions as opposed to attempt to influence those opinions.
The survey results indicated that there was no difference between obstetricians and pediatricians in resuscitation recommendations for neonates who are at the margins of viability. This may be attributable to both disciplines' having access to simultaneously published information about this issue by both the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists.14,15
The data in the current study regarding nursing attitudes merit consideration. A previous publication reported that Canadian NICU nurses were less optimistic than neonatologists regarding the probability of survival and freedom from serious morbidity among extremely preterm infants.18 In this study, neonatal nurses and pediatricians had very similar attitudes as judged by their infant resuscitation recommendations. This may be the result of intervening time and more widespread dissemination of knowledge regarding the outcomes of extremely preterm infants.
The overall differences between neonatal and obstetric providers were related mainly to differences in the opinions of the nurses. Obstetric nurses seemed to be considerably less comfortable than their neonatal counterparts with making strong recommendations for or against resuscitation at the upper and lower extremes of gestational age encompassed in the current investigation. Although we did not specifically query the providers regarding the rationale for their opinions, one could speculate that these differences may be related to less familiarity with outcomes on the part of obstetric nurses given less direct experience with neonatal care and its outcomes.
Both groups of nurses seem to be substantially less comfortable than their physician colleagues regarding counseling about these issues. This is demonstrated by the 7.8% decrease in nurses' completing the questionnaire at 22 versus 26 weeks in comparison with only a 0.5% decrease among physicians at corresponding ages and the markedly higher percentage of nurses who reported that they were either very or somewhat uncomfortable with counseling patients regarding these issues. Although nurses frequently speak with patients and sometimes discuss previous experiences or even offer advice, they may not perceive these discussions as counseling and therefore may be uncomfortable with that term or role.
Given recent data that suggest that attitudes toward survival and willingness to intervene aggressively at the threshold of viability may significantly influence neonatal survival5,22,24 and that parental grief may be substantially affected by the attitudes of their and their infant's health care providers,21 the opinions of and advice given by perinatal health care providers regarding resuscitation at these very early gestational ages have significant implications. Recent guidance from professional societies has emphasized the need for opinions and advice to be based on large national as well as local gestational age data and to involve collaboration between obstetric and pediatric health care disciplines.14,15
This study was the effort of 5 hospitals' working without any research funding for this specific project. Consequently, the time that was available for complex statistical analysis was limited. Ideally, the data could have been analyzed using multinomial logistic regression with resulting odds ratios. That approach would allow for cluster observations by centers and would prevent possible spurious tests of significance that can occur with χ2 analysis. The ideal analysis would be evaluation of response bias between staff who completed the survey and those who did not complete it. The response bias analysis would allow more generalization of the results. In addition, more analysis could have been done on the respondents to determine the rationale that led to their recommendations. Despite these limitations, our data provide valuable insight into the attitudes of health care providers who care for pregnant women and infants who are at marginally viable gestations.
The data in the current investigation, which were generated from widely geographically distributed US tertiary perinatal centers with numerically disparate patient populations, suggest that, in contrast to previous reports, such advice is relatively uniform and consistent to a significant degree. Although there are minor differences, for the most part, there seems to be substantial agreement among this variety of health care disciplines. In addition, these opinions seem to be in substantial agreement with guidelines published by professional societies14,15 and reasonable in light of outcome data from large studies.1,2 Finally, although the authors believe that formal counseling regarding resuscitation should be provided by the most highly qualified individuals, such as neonatologist and maternal–fetal medicine specialists, given the disruptive effect that atypical advice that is based on anecdotal experience can have on care planning, parent confidence, and emotional well-being, it will be important for other centers to monitor attitudes among their caregivers. We do not wish to suggest that consensus or agreement necessarily implies that the recommendations are correct; neither do we wish to suggest that individual circumstances or patient desires should not lead to differing recommendations, although we do believe that health care providers whose opinions regarding resuscitation vary substantially from local and national recommendations should be challenged to justify their divergent views in an evidenced-based manner.
This work was undertaken as a multisite project by the Divisions of Maternal–Fetal Medicine and Neonatology at Akron General Medical Center, Summa Health System, and Children's Hospital Medical Center; Dartmouth Hitchcock Medical Center; Providence St Vincent Medical Center; Rockford Memorial Hospital; and Children's Hospitals and Clinics. It represents the application of quality improvement methods and resources that were adopted as a result of participation in the Vermont Oxford Network NIC/Q 2002 Evidence-Based Quality Improvement Collaborative for Neonatology.
- Accepted July 18, 2006.
- Address correspondence to Justin P. Lavin, Jr., MD, Department of Maternal Fetal Medicine, Children's Hospital Medical Center of Akron, 1 Perkins Square, Akron, OH 44308. E-mail:
The conclusions and opinions expressed are those of the authors and not necessarily those of the participants in the NIC/Q 2002 of the Vermont Oxford Network.
The authors have indicated they have no financial relationships relevant to this article to disclose.
- ↵Lemons JA, Bauer CR, Oh W, et al. Very low birth weight outcomes of the National Institute of Child Health and Human Development Neonatal Research Network, January 1995 through December 1996. NICHD Neonatal Research Network. Pediatrics.2001;107(1) . Available at: www.pediatrics.org/cgi/content/full/107/1/e1
- Bottoms SF, Paul RH, Iams JD, Mercer BM, Thom EA, Roberts JM. Obstetric determinants of neonatal survival: influence of willingness to perform cesarean delivery on survival of extremely low-birth-weight infants. National Institute of Child Health and Human Development Network of Maternal-Fetal Medicine Units. Am J Obstet Gynecol.1997;176 :960– 966
- Vohr BR, Wright LL, Dusick AM, et al. Neurodevelopmental and functional outcomes of extremely low birth weight infants in the National Institute of Child Health and Human Development Neonatal Research Network, 1993–1994. Pediatrics.2000;105 :1216– 1226
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- ↵MacDonald H, American Academy of Pediatrics, Committee on the Fetus and Newborn. Perinatal care at the threshold of viability. Pediatrics.2002;110 :1024– 1027
- ↵American College of Obstetricians and Gynecologists. Perinatal Care at the Threshold of Viability. Washington, DC: ACOG; 2002. ACOG practice bulletin 38
- ↵Streiner DL, Saigal S, Burrows E, Stoskopf B, Rosenbaum P. Attitudes of parents and health care professionals toward active treatment of extremely premature infants. Pediatrics.2001;108 :152– 157
- ↵Kaempf JW, Tomlinson M, Arduza C, et al. Medical staff guidelines for periviability pregnancy counseling and medical treatment of extremely premature infants. Pediatrics.2006;117 :22– 29
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