Ethical issues in periviable birth

Ethical Dilemmas in Neonatal Care at the Limit of Viability

Advances in neonatal care have pushed the limit of viability to incrementally lower gestations over the last decades. However, surviving extremely premature neonates are prone to long-term neurodevelopmental handicaps. This makes ethics a crucial dimension of periviable birth management. At 22 weeks, survival ranges from 1 to 15%, and profound disabilities in survivors are common. Consequently, there is no beneficence-based obligation to offer any aggressive perinatal management. At 23 weeks, survival ranges from 8 to 54%, and survival without severe handicap ranges from 7 to 23%. If fetal indication for cesarean delivery appears, the procedure may be offered when neonatal resuscitation is planned. At a gestational age ≥24 weeks, up to 51% neonates are expected to survive the neonatal period. Survival without profound neurologic disability ranges from 12 to 38%. Beneficence-based obligation to intervene is reasonable at these gestations. Nevertheless, autonomy of parents should also be respected, and parental consent should be sought prior to any intervention. Optimal counselling of parents involves harmonized cooperation of obstetric and neonatal care providers. Every fetus/neonate and every pregnant woman are different and have the right to be considered individually when treatment decisions are being made.

Potential missed opportunities for antenatal corticosteroid exposure and outcomes among periviable births: observational cohort study

OBJECTIVE

Test the hypothesis potential missed opportunities for antenatal corticosteroids increase as gestational age decreases and are associated with adverse outcomes.

DESIGN

Observational cohort study.

SETTING

24 US centers in the Neonatal Research Network.

POPULATION

Actively treated infants 22-25 weeks' gestation and birth weight 401-1000 grams, without major birth defects, born 2006-2018.

METHODS

Potential missed opportunity was defined as no antenatal corticosteroids but did have prenatal antibiotics, and/or magnesium sulfate, and/or prolonged rupture of membranes. Poisson regression models adjusted for baseline characteristics.

MAIN OUTCOME MEASURES

Antenatal corticosteroid exposure, mortality, and severe intracranial hemorrhage or periventricular leukomalacia.

RESULTS

6966 (87.5%) were exposed to antenatal corticosteroids, 454 (5.7%) had no exposure but potential missed opportunities for antenatal corticosteroid exposure, and 537 (6.7%) had no exposure and no evidence of potential missed opportunities. Compared with infants born at 25 weeks, potential missed opportunities for antenatal corticosteroid exposure were more likely at 22 weeks (adjusted relative risk (aRR) [95% CI] 11.06 [7.52-16.27]) and 23 weeks (3.24 [2.44-4.29]) but did not differ at 24 weeks (1.08 [0.82-1.42]). Potential missed opportunities for antenatal corticosteroids decreased over time at 22-23 weeks' gestation. Antenatal corticosteroid exposed infants had lower risk of death (31.0% vs 54.8%; 0.77 [0.70-0.84]) and survivors had lower risk of severe brain injury (25.0% v 44.5%; 0.64 [0.55-0.73]) compared with infants with potential missed opportunities.

CONCLUSION

Potential missed opportunities for antenatal corticosteroid exposure increased with decreasing gestational age and were associated with higher rates of death and severe brain injury among actively treated periviable births.

Ethical implications of the shifting borderline of viability

Survival rates for babies born at 22 weeks of gestation are steadily improving at centers that offer active treatment to these babies. Still, many centers do not offer such treatment or, if they do, actively discourage it. Thus, parents will be given very different advice at different centers for babies born at the borderline of viability. Those doctors and centers that discourage treatment have concerns about the chances for survival, neurodevelopmental impairment among survivors, and cost. Yet there is strong evidence that many babies born at 22 weeks can survive, most survivors have good neurodevelopmental outcomes, and neonatal intensive care for tiny babies is cost-effective compared to many common and uncontroversial treatments. Given this growing body of evidence, policies discouraging or forbidding treatment of babies born at 22 weeks will require stronger ethical justification than has been given to date.

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

Many centres now report that more than half of babies born at 22 weeks survive and most survivors are neurocognitively intact. Still, many centres do not offer life-sustaining treatment to babies born this prematurely. Arguments for not offering active treatment reflect concerns about survival rates, rates of neurodevelopmental impairment and cost. In this essay, I examine each of these arguments and find them ethically problematic. I suggest that current data ought to lead to two changes. First, institutional culture should change at institutions that do not offer treatment to babies born at 22 weeks. Second, we need more research to understand best practices for these tiny babies.

Medications and in-hospital outcomes in infants born at 22-24 weeks of gestation

OBJECTIVE

To evaluate the most commonly used medications and in-hospital morbidities and mortality in infants born 22-24 weeks of gestation.

STUDY DESIGN

Multicenter retrospective cohort study of infants born 22-24 weeks of gestation (2006-2016), without major congenital anomalies and with available medication data obtained from neonatal intensive care units managed by the Pediatrix Medical Group.

RESULTS

This study included 7578 infants from 195 sites. Median (25th, 75th percentile): birthweight was 610 g (540, 680); the number of distinct medications used was 13 (8, 18); and different antimicrobial exposure was 4 (2, 5). The most common morbidities were BPD (41%) and grade III or IV IVH (20%), and overall survival varied from 46% (2006) to 57% (2016).

CONCLUSIONS

A large number of medications were used in periviable infants. There was a high prevalence of in-hospital morbidities, and survival of this population increased over the study period.

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.

Qualitative evaluation of a guideline supporting shared decision making for extreme preterm birth

Background and objectives: The decision to attempt resuscitation or provide palliative care at birth for extremely preterm infants between 22 and 25 weeks remains complex. The purpose of this study was to identify facilitators and barriers to implementation of a clinical practice guideline developed to support shared decision-making for these cases.Methods: A purposeful sample of healthcare providers, involved in the care of one of five cases of anticipated extremely preterm birth, was recruited for interviews. Participants shared their views on the guideline content, implementation process, and facilitators and barriers encountered. Interviews were audio-recorded and transcribed verbatim. Qualitative content analysis was used to code, categorize, and thematically describe the data. The Knowledge-Attitudes-Behaviours framework was used to organize the findings.Results: Twenty-five key informants (16 physicians, nine nurses) were interviewed. Participants described varying levels of knowledge of the guideline. Facilitators to implementation included: (1) an awareness of, familiarity with and belief in the content; (2) hard copy and electronic guideline accessibility; and, (3) institutional expertise to provide necessary care. Barriers included: (1) minimal awareness or familiarity with the content; (2) lack of agreement with the recommendations; (3) inadequate evidence and applicability to support changes in practice; and, (4) lack of resources to care for the most immature infants.Conclusions: Identified facilitators and barriers will inform the development of tailored strategies for improved local and future broader implementation. Other institutions can use the results to facilitate implementation of their guidelines on this ethically charged area.

Implicit Physician Biases in Periviability Counseling

OBJECTIVE

To assess whether neonatologists show implicit racial and/or socioeconomic biases and whether these are predictive of recommendations at extreme periviability.

STUDY DESIGN

A nationwide survey using a clinical vignette of a woman in labor at 23^2/7 weeks of gestation asked physicians how likely they were to recommend intensive vs comfort care. Participants were randomized to 1 of 4 versions of the vignette in which racial and socioeconomic stimuli were varied, followed by 2 implicit association tests (IATs).

RESULTS

IATs revealed implicit preferences favoring white (mean IAT score = 0.48, P < .001) and greater socioeconomic status (mean IAT score = 0.73, P < .001). Multivariable linear regression analysis showed that physicians with implicit bias toward greater socioeconomic status were more likely than those without bias to recommend comfort care when presented with a patient of high socioeconomic status (P = .037). No significant effect was seen for implicit racial bias.

CONCLUSIONS

Building on previous demonstrations of unconscious racial and socioeconomic biases among physicians and their predictive validity, our results suggest that unconscious socioeconomic bias influences recommendations when counseling at the limits of viability. Physicians who display a negative socioeconomic bias are less likely to recommend resuscitation when counseling women of high socioeconomic status. The influence of implicit socioeconomic bias on recommendations at periviability may influence neonatal healthcare disparities and should be explored in future studies.

Reproductive suppression, birth defects, and periviable birth

We argue that reproductive suppression has clinical implications beyond its contribution to the burden of spontaneous abortion. We theorize that the incidence of births before the 28th week of gestation, which contribute disproportionately to infant morbidity and mortality, varies over time in part due to reproductive suppression in the form of selection in utero. We further theorize that the prevalence of structural birth defects among survivors to birth from conception cohorts gauges selection in utero. We based these theories on literature positing that natural selection conserved mechanisms that spontaneously abort "risky" pregnancies including those otherwise likely to yield infants with structural birth defects or small-for-gestational age males. We test our theory using high-quality birth defect surveillance data. We identify 479,885 male infants exposed to strong selection defined as membership in conception cohorts ranked in the lowest quartile of odds of a birth defect among live-born females. We estimate the risk of periviable birth among these infants as a function of selective pressure as well as of mother's race/ethnicity and age. We find that male infants from exposed conception cohorts exhibited 10% lower odds of periviable birth than males from other conception cohorts. Our findings support the argument that selection in utero has implications beyond its contribution to the burden of spontaneous abortion.

A moving line in the sand: a review of obstetric management surrounding periviability

Periviable birth poses numerous clinical and ethical challenges for the practicing clinician. We review the data surrounding the administration of corticosteroids for fetal lung maturity, antibiotics in the case of preterm premature rupture of membranes, magnesium sulfate for cerebral palsy prophylaxis, fetal monitoring, and cesarean delivery. The ethical complexities of patient counseling are also reviewed with a recommendation toward shared decision making between patient and physician.