A COMPARISON OF NEONATAL MORBIDITY AND MORTALITY ESTIMATES PROVIDED BY OBSTETRICIANS AND NEONATOLOGISTS IN PERIVIABLE COUNSELING

Purpose: To describe the variation and range of estimates of neonatal morbidity and mortality communicated by providers in two different specialties to standardized patients (SPs) in simulated periviable counseling encounters.

Method: We conducted an exploratory single-center simulation study in which 16 obstetricians (OBs) and 15 neonatologists each counseled 2 standardized patients portraying pregnant women presenting with ruptured membranes at 23 weeks gestation. In total, 62 simulated encounters were audio and video-recorded. Two investigators identified and tabulated all instances of numerically described risk estimates (e.g. probabilities, frequencies) of neonatal mortality and long or short term morbidity, noting the number and range of unique risk estimates described across individuals and by specialty. Analyses were facilitated by NVivo 10, a qualitative research tool.

Result: Overall, 12/15 (80%) neonatologists utilized numeric estimates of survival; 6/16 (38%) OBs did. OBs frequently deferred the discussion of “exact numbers” to neonatologists. The twelve neonatologists provided 13 unique numeric estimates, ranging from 3% to 50% survival. Half of those neonatologists (6/12) provided 2-3 different estimates in a single encounter. By comparison, six OBs provided 4 unique survival estimates (“50%”, “30-40%”, “1/3-1/2”, “<10%”).  Only 2/15 (13%) neonatologists provided numeric estimates of intact survival.  Notably, none of the neonatologists used the term ‘intact’ survival, while 5 OBs did.  Three neonatologists gave numeric estimates of long-term disability and one OB did. 

Conclusion: In standardized periviable counseling encounters, neonatologists utilized numeric descriptions of risk more readily than OBs. Though OBs frequently deferred discussions of risk to the expertise of neonatologists, we found substantial variation in the point estimates provided by neonatologists and noteworthy omissions of discussions related to long-term morbidity. More tools and training are needed to improve the quality and consistency of periviable risk communication among neonatologists and obstetrical providers.