Doctors and Moms Need to Chat

Doctors take cues from pregnant women and their families

(RxWiki News) Giving birth between 22 and 26 weeks can involve painful decisions, given the various risks to the baby, which has about a 50 percent chance of survival.

But a recent study of obstetricians' attitudes toward these tough situations reveals that the decisions they make regarding a woman's care and how the early delivery occurs are strongly influenced by their patients' preferences and what their patients communicate to them.

"Be open and direct with your OB about your wishes regarding a difficult pregnancy."

Babies born between 22 and 26 weeks are called "periviable" because they are just barely on the cusp of being able to survive on their own outside the womb. But nearly half of them don't make it, and those who do usually experience serious illness and long-term health problems and are likely to have some form of neurological disability.

Brownsyne Tucker Edmonds, M.D., M.S., M.P.H., an assistant professor of Obstetrics and Gynecology at Indiana University, led a study investigating how obstetricians make decisions in these cases since the doctor's care management plays a big part in the babies' outcomes.

One past study shows that a baby's likelihood of surviving nearly quadruples if the woman gives birth by cesarean section at 24 weeks - but then the likelihood that the child has serious long-term neurological disability doubled.

In detailed, structured interviews, 21 OBs at academic medical centers throughout Philadelphia described how they manage these cases and what patient, institutional and personal factors influence their decisions. They also answered questions about how they counseled patients in these situations.

The three biggest factors figuring into OBs decisions are the patient's preference, the specific medical details of the particular pregnancy involved and how each the doctor thought about patient autonomy.

"While most participants said their first consideration was balancing maternal and child well-being, and the need to weigh the questionable benefits of cesarean delivery for neonatal survival against the known risks of maternal morbidity, many described a 'do everything default,' wherein interventions to prolong the pregnancy were universally pursued unless patients actively opted out," Dr. Tucker Edmonds said.

According to Dr. Tucker Edmonds' study, significant variation existed among the doctors in terms of their perspectives on patient autonomy, but these views tended to be crucial in how each doctor cared for his or her patient.

Some laid out the facts and likelihoods and allowed the patient and her family to make the decision on their own while others made more specific recommendations because they tended to believe that the situations were too complex and emotional for the patients to be able to make good decisions.

Explaining the uncertainties and risks of the babies' outcomes was cited as the biggest challenge for doctors, who found it hard to communicate the extent to which modern medicine could improve the significant health risks for babies born so early.

"In counseling patients, the obstetricians prioritized objectivity and respect for autonomy but deemphasized hope," Tucker Edmonds said. Yet she said another recent study found patients in these situations prioritized hope.

"Such discordances contribute to the challenge of managing patients' expectations in periviable counseling," she said.

The doctors also cited the difficulties of counseling patients with limited English-speaking skills or lower education levels. She concluded that doctors need better tools within the field to handle these cases, including managing patients' expectations, assessing patients' values and understanding of the risks, and conveying the uncertainties of these situations.

The study appears in the March issue of the American Journal of Obstetrics and Gynecology.

Review Date: 
March 2, 2012