Offering induction of labor for 22-week premature rupture of membranes: a survey of obstetricians

Objective: To describe obstetricians’ induction counseling practices for 22-week preterm premature rupture of membranes (PPROM) and identify provider characteristics associated with offering induction. Methods: Surveyed 295 obstetricians on their likelihood (0–10) of offering induction for periviable PPROM across 10 vignettes. Twenty-two-week vignettes were analyzed, stratified by parental resuscitation preference. Bivariate analyses identified physician characteristics associated with reported likelihood ratings. Results: Obstetricians (N=205) were not likely to offer induction. Median ratings by preference were as follows: resuscitation 1.0, uncertain 1.0 and comfort care 3.0. Only 41% of obstetricians were likely to offer induction to patients desiring comfort care. In addition, several provider-level factors, including practice region, parenting status and years in practice, were significantly associated with offering induction. Conclusions: Obstetricians do not readily offer induction when counseling patients with 22-week ruptured membranes, even when patients prefer palliation. This may place women at risk for infectious complications without accruing a neonatal benefit from prolonged latency.This publication was made possible in part by Grant Number KL2 TR000163 (A. Shekhar, PI) from the National Institutes of Health, National Center for Advancing Translational Sciences, Clinical and Translational Sciences Award and the Robert Wood Johnson Foundation’s Harold Amos Medical Faculty Development Program

Maternal-Fetal Medicine physicians’ practice patterns for 22-week delivery management

Objective: To describe Maternal-Fetal Medicine (MFM) physicians’ practice patterns for 22-week delivery management. Mehods: Surveyed 750 randomly-sampled members of the Society of Maternal-Fetal Medicine, querying MFMs’ practices and policies guiding 22-week delivery management. Results: Three hundred and twenty-five (43%) MFMs responded. Nearly all (87%) would offer induction. Twenty-eight percent would order steroids, and 12% would perform cesarean for a patient desiring resuscitation. Offering induction differed significantly based on the provider’s practice setting, region, religious service attendance and political affiliation. In multivariable analyses, political affiliation remained a significant predictor of offering induction (p = 0.03). Conclusions: Most MFMs offer induction for PPROM at 22 weeks. A noteworthy proportion is willing to order steroids and perform cesarean. Personal beliefs and practice characteristics may contribute to these decisions. While little is known about the efficacy of these interventions at 22 weeks, some MFMs will offer obstetrical intervention if resuscitation is intended

Cost Minimization Analysis of Same-Day Long-Acting Reversible Contraception for Adolescents

Importance: Long-acting reversible contraception (LARC) is considered first-line contraception for adolescents but often requires multiple clinic visits to obtain. Objective: To analyze Indiana Medicaid's cost savings associated with providing adolescents with same-day access to LARC. Design, Setting, and Participants: An economic evaluation of cost minimization from the payer's (Medicaid) perspective was performed from August 2017 through August 2018. The cost model examined the anticipated outcome of providing LARC at the first visit compared with requiring a second visit for placement. The costs and probabilities of clinic visits, devices, device insertions and removals, unintended pregnancy, and births, according to previously published sources, were incorporated into the model. The participants were payers (Medicaid). Main Outcomes and Measures: The outcomes were the cost of same-day LARC placement vs LARC placement at a subsequent visit in US dollars, and rates of unintended pregnancy and abortion. One-way sensitivity analysis was done. Results: Same-day LARC placement was associated with lower overall costs ($2016 per patient over 1 year) compared with LARC placement at a subsequent visit ($4133 per patient over 1 year). Compared with the return-visit strategy, same-day LARC was associated with an unintended pregnancy rate of 14% vs 48% and an abortion rate of 4% vs 14%. Conclusions and Relevance: Providing same-day LARC could save costs for Medicaid, largely by preventing unintended pregnancy. Expected cost savings could be used to implement policies that make this strategy feasible in all clinical settings

Health Equity Starts with Us: Recommendations from the IN-CTSI Racial Justice and Health Equity Task Force

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Comparing neonatal morbidity and mortality estimates across specialty in periviable counseling

Objective To describe and compare estimates of neonatal morbidity and mortality communicated by neonatologists and obstetricians in simulated periviable counseling encounters. Methods A simulation-based study of 16 obstetricians (OBs) and 15 neonatologists counseling standardized patients portraying pregnant women with ruptured membranes at 23 weeks gestation. Two investigators tabulated all instances of numerically-described risk estimates across individuals and by specialty. Results 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 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 survival without impairment. 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 We found substantial variation in estimates and noteworthy omissions of discussions related to long-term morbidity. Across specialties, we noted inconsistencies in the use and meaning of terms like ‘intact survival.’ More tools and training are needed to improve the quality and consistency of periviable risk-communication

Doctor, What Would You Do?: An ANSWER for patients requesting advice about value-laden decisions

This article presents a previously published framework, summarized in the mnemonic ANSWER (A, Active listening; N, Needs assessment; S, Self-awareness/reflection; W, Whose perspective?; E, Elicit values; R, Respond) for how to respond to the question, “Doctor, what would you do?” when considering medical decisions that are preference-sensitive, meaning there is limited or debatable evidence to guide clinical recommendations, or are value-laden, such that the “right” decision may differ based on the context or values of a given individual. Using the mnemonic and practical examples, we attempt to make the framework for an ethically appropriate approach to these conversations more accessible for clinicians. Rather than a decision rule, this mnemonic represents a set of points to consider when physicians are considering an ethically acceptable response that fosters trust and rapport. We apply this approach to a case of periviable counseling, among the more emotionally challenging and value-laden antenatal decisions faced by providers and patients

Patient knowledge and attitudes toward cervical cancer screening after the 2012 screening guidelines

Objective To assess women’s attitudes and preferences related to recent changes in cervical cancer screening guidelines. Methods We distributed 380 surveys in three University based and Community clinics. Study participants anonymously completed surveys, which included questions related to demographics, cervical cancer, screening practices, risk perception and attitudes towards changing practices. Results 315 women agreed to participate (83%). 60% (185/310) of participants had some college education or higher and 12% (36/305) worked in the medical field. On average, participants answered 4.1 (SD = 1.3) of the 8 knowledge questions correctly. Knowledge scores significantly increased with education level (Kruskal-Wallis test p-value < 0.001). The majority (72%, n = 228) reported that they should be screened annually, and that screening should be initiated with the onset of sexual activity (63%, n = 197). Participants that were more knowledgeable of current screening practices were more comfortable extending screening intervals (Kruskal-Wallis test p < 0.001). Conclusion Even among a relatively highly educated population of women, participants had limited knowledge of cervical cancer and current screening guidelines. Many participants reported discomfort with less frequent screening intervals. Practice implications This study supports the need for improvement in cervical cancer prevention education especially with regards to the new screening guidelines

Morbidity and mortality associated with mode of delivery for breech periviable deliveries

OBJECTIVE: The purpose of this study was to estimate the odds of morbidity and death that are associated with cesarean delivery, compared with vaginal delivery, for breech fetuses who are delivered from 23-24 6/7 weeks' gestational age. STUDY DESIGN: We conducted a retrospective cohort study of state-level maternal and infant hospital discharge data that were linked to vital statistics for breech deliveries that occurred from 23-24 6/7 weeks' gestation in California, Missouri, and Pennsylvania from 2000-2009 (N = 1854). Analyses were stratified by gestational age (23-23 6/7 vs 24-24 6/7 weeks' gestation). RESULTS: Cesarean delivery was performed for 46% (335 fetuses) and 77% (856 fetuses) of 23- and 24-week breech fetuses. In multivariable analyses, overall survival was greater for cesarean-born neonates (adjusted odds ratio [AOR], 3.98; 95% confidence interval [CI], 2.24-7.06; AOR, 2.91; 95% CI, 1.76-4.81, respectively). When delivered for nonemergent indications, cesarean-born survivors were more than twice as likely to experience major morbidity (intraventricular hemorrhage, bronchopulmonary dysplasia, necrotizing enterocolitis, asphyxia composite; AOR, 2.83; 95% CI, 1.37-5.84; AOR, 2.07; 95% CI, 1.11-3.86 at 23 and 24 weeks' gestation, respectively). Among intubated neonates, despite a short-term survival advantage, there was no difference in survival to >6-month corrected age (AOR, 1.77; 95% CI, 0.83-3.74; AOR, 1.50; 95% CI, 0.81-2.76, respectively). There was no difference in survival for intubated 23-week neonates who were delivered by cesarean for nonemergent indications or cesarean-born neonates who weighed <500 g. CONCLUSION: Cesarean delivery increased overall survival and major morbidity for breech periviable neonates. However, among intubated neonates, despite a short-term survival advantage, there was no difference in 6-month survival. Also, cesarean delivery did not increase survival for neonates who weighed <500 g. Patients and providers should discuss explicitly the trade-offs related to neonatal death and morbidity, maternal morbidity, and implications for future pregnancies

Creation of a Decision Support Tool for Expectant Parents Facing Threatened Periviable Delivery: Application of a User-Centered Design Approach

Background Shared decision-making (SDM) is optimal in the context of periviable delivery, where the decision to pursue life-support measures or palliation is both preference sensitive and value laden. We sought to develop a decision support tool (DST) prototype to facilitate SDM by utilizing a user-centered design research approach. Methods We convened four patient and provider advisory boards with women and their partners who had experienced a surviving or non-surviving periviable delivery, pregnant women who had not experienced a prior preterm birth, and obstetric providers. Each 2-h session involved design research activities to generate ideas and facilitate sharing of values, goals, and attitudes. Participant feedback shaped the design of three prototypes (a tablet application, family story videos, and a virtual reality experience) to be tested in a final session. Results Ninety-five individuals (48 mothers/partners; 47 providers) from two hospitals participated. Most participants agreed that the prototypes should include factual, unbiased outcomes and probabilities. Mothers and support partners also desired comprehensive explanations of delivery and care options, while providers wanted a tool to ease communication, help elicit values, and share patient experiences. Participants ultimately favored the tablet application and suggested that it include family testimonial videos. Conclusion Our results suggest that a DST that combines unbiased information and understandable outcomes with family testimonials would be meaningful for periviable SDM. User-centered design was found to be a useful method for creating a DST prototype that may lead to improved effectiveness, usability, uptake, and dissemination in the future, by leveraging the expertise of a wide range of stakeholders

The influence of resuscitation preferences on obstetrical management of periviable deliveries

Objective Determine the relative influence of patient's resuscitation preferences on periviable delivery management. Methods Surveyed 295 obstetrician-gynecologists about managing periviable preterm premature rupture of membranes. Across 10 vignettes, we systematically varied gestational age; occupation; method of conception; and resuscitation preference. Physicians rated their likelihood (0-10) of proceeding with induction, steroids, and cesarean. Data were analyzed via conjoint analysis. Results 205 physician responses were included. Median ratings for management decisions were: induction 1.89; steroids 5.00; cesarean for labor 3.89; cesarean for distress 4.11. Gestational age had the greatest influence on physician ratings across all decisions (importance values ranging from 72.6-86.6), followed by patient's resuscitation preference (range= 9.3-21.4). Conclusion Gestational age is weighted more heavily than patients’ resuscitation preferences in obstetricians’ decision-making for periviable delivery management. Misalignment of antenatal management with parental resuscitation preferences may adversely affect periviable outcomes. Interventions are needed to facilitate more patient-centered decision-making in periviable care