Objective
The purpose of this study was to examine factors that influence obstetric decision-making and counseling for periviable deliveries and to describe counseling challenges.
Study Design
Twenty-one semistructured interviews were conducted with obstetricians who were recruited from 5 academic medical centers in Philadelphia. Two trained reviewers independently coded transcripts using grounded theory methods. Research software facilitated qualitative analysis.
Results
Circumscribed by institutional norms and clinical acuity, obstetric decision-making and counseling were influenced primarily by patient preferences. Perspectives on patient autonomy guided approaches to counseling. Thresholds for intervention varied from “attending to attending” and “institution to institution.” Sociodemographic factors were not believed to influence clinical decision-making. However, obstetricians admittedly managed in vitro fertilization pregnancies more aggressively. Communicating uncertainty, managing expectations, assessing understanding, and relaying consistent messages across specialties were frequently described counseling challenges for obstetricians.
Conclusion
The impact of institutional variation and in vitro fertilization on periviable decision-making warrants further consideration. Interventions to train and support obstetricians in communicating uncertainty, managing expectations, and assessing values and understanding are needed.
Periviable neonates bear the greatest burden of neonatal death and morbidity. As many as one-half of the neonates do not survive; among those neonates who do survive, one-half of them experience moderate to severe neurologic disability. Several studies have explored the attitudes and role of neonatologists in counseling families about resuscitation and extreme prematurity. Obstetricians, however, are usually the first providers to evaluate pregnant women when complications occur, and therefore the first to counsel women regarding maternal and fetal risks and antenatal management options. Little research has examined how obstetricians counsel patients about delivery management and resuscitation decisions. Moreover, although the approach to obstetric management has been shown to influence the outcome of extremely low birthweight infants, no research has explored the factors that influence obstetric decision-making.
To address these gaps in our knowledge, we qualitatively explored patient, physician, and institution-level factors that influence obstetric decision-making and counseling regarding risk, management options, and delivery plans for periviable deliveries among obstetricians who were recruited from academic medical centers in Philadelphia. We also explored how patient sociodemographic factors influence obstetric management and counseling practices and examined challenges that providers describe in counseling.
Materials and Methods
With approval from the University of Pennsylvania’s Institutional Review Board, we conducted 30-45 minute semistructured, in-depth interviews with general obstetrician-gynecologists and maternal-fetal medicine physicians and fellows. We excluded obstetrician-gynecologists who provide only gynecologic services. Subjects were recruited from the 6 hospitals in Philadelphia that offer labor and delivery services. We contacted the chairpersons of each Department of Obstetrics and Gynecology and requested referral to an administrative contact who could provide a departmental roster or forward a recruitment letter of invitation to departmental faculty. Follow-up email messages were sent at 2 and 6 weeks. Study recruitment concluded when we reached theoretic saturation.
The interview script had 3 main sections. First, obstetricians were asked how they define periviability . All interview responses thereafter were based on the physician’s definition of periviability. Participants were then asked to describe their typical approach to managing a periviable delivery and to include their practices regarding steroid administration, tocolysis, fetal monitoring, and cesarean delivery. Second, they were asked to describe patient factors, institutional factors, and personal factors that influence their clinical decision-making. Each physician was asked specifically how patient sociodemographics and liability played a role in their decision-making. Third, the interview focused on approaches and challenges to counseling patients. After completing the interview, participants answered brief demographic questionnaires. Physicians were interviewed at a site that was convenient for them; they received $100 for participating.
Interviews were recorded digitally and transcribed verbatim. Transcripts were coded according to a grounded theory approach. After we reviewed the first 3 transcripts, we created an initial codebook of major themes that emerged from the interviews. As subsequent transcripts were reviewed, the codebook was amended to reflect new themes or ideas. Two trained reviewers (B.T.E., S.K.) independently coded all transcripts to ensure reliability of the coding scheme. Coding discrepancies between reviewers were resolved by consensus. A final coding scheme was established and reapplied to all of the transcripts. NVivo 9 software (QSR International [Americas] Inc, Cambridge, MA)was used to facilitate analysis.
Results
Twenty-one obstetricians participated in the study: 6 maternal-fetal medicine physicians; 2 maternal-fetal medicine fellows; and 13 obstetrics/gynecology generalists. Table 1 describes their demographic characteristics. The physicians were recruited from 5 of 6 academic medical centers that were approached to participate; 3-6 obstetricians participated from each institution.
| Variable a | Percentage | n |
|---|---|---|
| Specialty | ||
| Obstetric generalist | 61.9 | 13 |
| Maternal-fetal medicine | 38.1 | 8 |
| Institution | ||
| 1 | 14.3 | 3 |
| 2 | 19.0 | 4 |
| 3 | 23.8 | 5 |
| 4 | 14.3 | 3 |
| 5 | 28.6 | 6 |
| Sex (F) | 57.1 | 12 |
| Race/ethnicity | ||
| Asian | 19.0 | 4 |
| Biracial | 9.5 | 2 |
| Black | 9.5 | 2 |
| White | 61.9 | 13 |
| Religious affiliation | ||
| Catholic or Protestant | 38.1 | 8 |
| Jewish | 23.8 | 5 |
| Hindu, Buddhist, Muslim | 14.3 | 3 |
| Other | 4.8 | 1 |
| None | 19.0 | 4 |
| Married | 76.2 | 16 |
| Parenting | 66.7 | 14 |
| Ever been sued | 71.4 | 15 |
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