WEIGHING THE RISKS AND BENEFITS OF MATERNAL-FETAL SURGERY

Purpose:   In maternal-fetal surgery the potential benefits for the fetus are attainable only by risking serious morbidity for the pregnant woman and fetus alike.  Understanding provider variation in the prioritization of these risks and benefits may optimize shared decision-making and mitigate unconscious bias. 

Methods:   A cross-sectional mail-based survey conducted in 2015 of 1,200 neonatologists, pediatric surgeons, and maternal-fetal medicine specialists (MFM's) randomly selected from society member lists.  We used a discrete choice experiment with maximum difference (best-worst) scaling to enable physicians to choose the considerations they deem to be most and least important when counseling about maternal-fetal surgery.  We used latent class analysis to identify groups of physicians with similar ratings.

Results:   Of 1176 eligible physicians, 660 completed the best-worst scaling experiment (response rate = 56%).  Among 9 counseling considerations, the highest-ranked consideration was neonatal benefits (mean rating 24.8; 95% CI 24.4-25.2), followed by risk of maternal complications (mean rating 23.3; 95% CI 22.9-23.8). (Figure 1)  These were followed by the risk of fetal death (mean rating 17.2; 95% CI 16.5-17.9) and maternal autonomy (mean rating 13.6; 95% CI 12.8-14.4).  In comparison, physicians rated maternal psychological benefit (mean rating 1.5; 95% CI 1.3-1.8), maternal social support (mean rating 0.8; 95% CI 0.7-0.99), and impact on other family members (mean rating 0.6; 95% CI 0.4-0.8) as the least important considerations.  We identified 4 groups of physicians with similar patterns of prioritization, which we labeled as: risk sensitive (n=197), maternal autonomy (n=167), family impact-social support (n=64), and feto-centric (n=232).  Surgeons were more likely to be in the "risk sensitive" group, whereas neonatologists were more likely to be in the "feto-centric" group and MFMs made up the largest percentage of the "family impact -- social support" group.        

Conclusions:   Physicians prioritize a broad range of considerations when counseling women about maternal-fetal surgery.  Open dialogue about how one weighs risks and benefits may help patients interpret physician recommendations and make more informed decisions.