How do Clinicians View the Process of Shared Decision-Making with Parents Facing Extremely Early Deliveries? Results from an Online Survey

Objective The objective of this study was to better understand how neonatology (Neo) and maternal–fetal medicine (MFM) physicians approach the process of shared decision-making (SDM) with parents facing extremely premature (<25 weeks estimated gestational age) delivery during antenatal counseling. Study Design Attending physicians at U.S. centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. Preferences for conveying information are reported elsewhere. Here, we report clinicians' self-assessments of their ability to engage in deliberations and decision-making and perceptions of what is important to parents in the SDM process. Multivariable logistic regression analyzed respondents' views with respect to individual characteristics, such as specialty, gender, and years of clinical experience. Results In total, 74 MFMs and 167 Neos representing 94% of the 81 centers surveyed responded. Neos versus MFMs reported repeat visits with parents less often (<0.001) and agreed that parents were more likely to have made delivery room decisions before they counseled them less often (p < 0.001). Respondents reported regularly achieving most goals of SDM, with the exception of providing spiritual support. Most respondents reported that spiritual and religious views, risk to an infant's survival, and the infant's quality of life were important to parental decision-making, while a physician's own personal choice and family political views were reported as less important. While many barriers to SDM exist, respondents rated language barriers and family views that differ from those of a provider as the most difficult barriers to overcome. Conclusion This study provides insights into how consultants from different specialties and demographic groups facilitate SDM, thereby informing future efforts for improving counseling and engaging in SDM with parents facing extremely early deliveries and supporting evidence-based training for these complex communication skills. Key Points

A quality improvement intervention to improve lactation in mothers of hospitalized extreme preterm and very low birth weight infants in the first 2 weeks of life at a tertiary hospital in South India

Objectives: Early establishment of human milk (HM) feeding significantly decreases neonatal morbidity. There are barriers in establishing and maintaining lactation in mothers of hospitalized extreme preterm and very low birth weight (VLBW) infants, particularly during the first 2 weeks of life. Infant feeding policy modification was done to improve lactation as a quality initiative project and the effect of this modification was studied. Material and Methods: This study was done at SRIHER by analyzing retrospective data from the period before infant feeding policy modification (April 1, 2017–June 30, 2017) and prospective data from post-policy modification (July 1, 2017–December 31, 2017). All extreme preterm babies and VLBW babies both inborn and outborn were included in the study. The policy was approved by the institutional quality control cell. Fishbone analysis and “why” question pattern were implemented to identify pitfalls in establishing and maintaining lactation in mothers of extreme preterm and VLBW mothers. Prior antenatal counseling (for inborn deliveries), immediate postnatal assessment, constant surveillance, internal audits, and regular interprofessional team meets were done to carry out the implementation of the quality control program. Results: Daily milk output improved after intervention from baseline value in the pre-policy modification group to nearly 3 times after policy modification. The total duration of the requirement of parenteral nutrition decreased from 11 days to 7 days and time to reach birth weight decreased from 17 days to 11 days after quality improvement initiative. Conclusion: A simple quality improvement initiative was able to achieve increased lactation in mothers of extreme preterm and VLBW neonates.

Impact of postnatal counseling on care of newborn

Background: Newborn care is an integral aspect of child health care practices. Globally 2.4 million children died in the neonatal period in 2019. Currently in India around 7.47 lakh neonates die annually. Advocating and adopting proper postnatal care of newborn in aspects of breastfeeding, immunization, warmth care, cord care, eye care etc will help in reducing neonatal morbidity and mortality.Methods: This was an hospital based cross sectional study of 100 postnatal mothers of babies admitted in NICU, in a tertiary care hospital. The knowledge of the mothers on various aspects of postnatal care was assessed by a pretest, followed by counseling and reassessment with a post test.Results: The study found that postnatal mothers had better awareness regarding breastfeeding, warmth care, cord care and oil massage. Poor knowledge was seen regarding eye care, immunization, recognition of danger signs and maternal nutrition and supplementation. Health care workers focused more on breastfeeding and warmth care practices than other aspects of postnatal care during antenatal counseling which could be a reason for this. A wide gap exists between contact with health workers and antenatal counseling. Knowledge gaps of the mothers improved significantly after counseling irrespective of their parity, education and location as seen by the increase in mean scores.Conclusions: Neonatal morbidity and mortality due to avoidable causes like hypoglycemia, hypothermia, sepsis can be achieved by practicing appropriate post-natal care practices. WHO recommendations on these practices should be widely propagated through frequent antenatal and post-natal counseling by health care workers.

Composite non-clinical interventions for a safe cesarean section rate reduction: results of a pre-post interventional study

Objective To evaluate the impact on cesarean section (CS) rate with of a program of multiple non-clinical interventions targeted at health-care professional within a hospital maternity ward. Materials and methods Retrospective quasi-experimental pre-post intervention study with an historical control group conducted in a second-level teaching hospital. All women who gave birth in the period 2014 to 2018 were included. A series of multiple non-clinical interventions including a dedicated team of obstetricians for delivery room and antenatal counseling, monthly internal audits and physician education by local opinion leader were prospectively introduced from September 2016. The primary outcome of the study was the CS rate. The incidences of operative vaginal delivery, 3rd−/4th-degree perineal tears and further maternal and neonatal complications were considered as secondary outcomes. Results The CS rate dropped from 33.05 to 26.06% after starting the interventions (p < 0.01); in particular, the cumulative rate of CS performed during labor decreased significantly from 19.46 to 14.11% (p < 0.01). CS reduction was still statistically significant after multivariate correction (OR = 0.66, CI.95 = 0.57–0.76, p < 0.01). Results further showed an increased prevalence of 3rd-degree perineal tears (0.97% versus 2.24%, p < 0.01), present also after correcting for possible confounding factors (OR = 2.36, CI.95 = 1.48–3.76, p < 0.01). No differences were found in the rate of vaginal-operative births and further maternal complications, while the composite neonatal outcome was found to be improved (OR = 0.73, CI.95 = 0.57–0.93, p = 0.010). Conclusions The introduction of multiple non-clinical interventions can significantly reduce the CS rate. However, beside an improvement in neonatal composite outcome, a potential increase in high-degree perineal tears should be taken in account.

Maternal Preferences for Approach and Language Use During Antenatal Counseling at Extreme Prematurity: A Pilot Study

Introduction: Counseling families at risk for extremely preterm birth presents significant challenges to providers due to the uncertainty of infant outcomes. Aim: To determine lay-public parental preferences for approaches to prenatal counseling and preferred descriptive terminology usage by providers when discussing an anticipated extremely preterm delivery. Methods: This exploratory pilot study recruited parents through social media to participate in a survey centered around a hypothetical delivery at 23 weeks. Questions assessed participants’ understanding of medical terminology and preferences for terminology, discussion topics, and approaches to decision-making related to anticipated extremely preterm birth. Results: A total of 142 (72%) parents participated. Understanding of medical compared with nonmedical terminology was limited ( P < .01). Parents had stronger preferences for the use of certain words and terminology over others. They preferred discussions focused on the possibility of infant survival and information about intensive care, over general statistics, and outcome percentages. Most would choose attempted stabilization and neonatal intensive care unit care in this hypothetical case. Discussion/Conclusions: Parents have preferences regarding physician communication and approaches to decision-making around extremely preterm delivery, which may offer guidance to providers during counseling.

Lifestyle Habits among Pregnant Women in Denmark during the First COVID-19 Lockdown Compared with a Historical Period—A Hospital-Based Cross-Sectional Study

The first national lockdown in Denmark due to the COVID-19 pandemic was declared on 11 March 2020. From this date, national restrictions were imposed. We aimed to assess the potential influence of this first nationwide lockdown on exercise, alcohol consumption, and smoking in early pregnancy. Using a cross-sectional study based on routinely collected patient-reported data, we compared the lifestyle habits of women who were pregnant during the first phase of the pandemic (COVID-19 group) (n = 685) with those of women who were pregnant the year before (Historical group) (n = 787). We found a reduction in any exercise (PR = 0.91, 95% CI (0.84 to 0.99), in adherence to national recommendations of exercise (PR = 0.89, 95% CI (0.80 to 0.99), in cycling (15% vs. 28%, p < 0.0001), and swimming (0.3% vs. 3%, p = 0.0002) in the COVID-19 group compared with the Historical group. The prevalence of binge drinking was reduced in the COVID-19 group compared with the Historical group (PR = 0.80, 95% CI (0.68 to 0.93). In contrast, the prevalence of any weekly alcohol consumption and smoking cessation during pregnancy was similar between groups. Our findings indicate that national restrictions due to the COVID-19 pandemic influenced the lifestyle habits of pregnant women and should be addressed in antenatal counseling.

An Analysis of Causes and Avoidable Factors of Perinatal Deaths at Tertiary Care Hospital

Introduction: Perinatal deaths are potentially preventable and reflect the quality of care provided in the prenatal period, during labor, and to a newborn. The purpose of this study was to assess the causes and avoidable factors contributing to perinatal deaths in the year 2018-19 and compare these with the previous two years at Tertiary Care Hospital.Materials and Methods: This study was conducted from a retrospective analysis of all stillbirths and early neonatal deaths in the year July 2018 to July 2019. The Perinatal Mortality Rate, causes, and avoidable factors leading to perinatal deaths were analysed during this year and were compared with that of the previous two years at KIST Medical College and Teaching hospital.Results: PMR was 16.09 per 1000 births in the year 2018-19. Previous two studies at this hospital in the year 2017-18 and 2016-17 showed a Perinatal Mortality Rate of 14.61 and 16.27/1000 births respectively. The commonest primary cause of perinatal deaths was intrapartum hypoxia 6 (30%), preterm delivery 5 (31.25%), and congenital anomalies4 (19%) during the year 2018-19, 2017-18, and 2016-17 respectively. The most common avoidable factors identified were a maternal delay to seek health care, inadequate antenatal checkups, and inadequate antenatal counseling of danger signs by a service provider over the last three years.Conclusions: Maternal delay to seek health care and lack of maternal knowledge of danger signs during pregnancy were the common avoidable factors identified. More efforts should be made to raise awareness of pregnant women during antenatal care visits regarding early healthcare-seeking behavior when needed.

What Information Do Clinicians Deem Important for Counseling Parents Facing Extremely Early Deliveries?: Results from an Online Survey

Objective The study aimed to better understand how neonatology and maternal fetal medicine (MFM) physicians convey information during antenatal counseling that requires facilitating shared decision-making with parents facing options of resuscitation versus comfort care after extremely early delivery Study Design Attending physicians at US centers with both Neo and MFM fellowships were invited to answer an original online survey about antenatal counseling for extremely early newborns. The survey assessed information conveyed, processes for facilitating shared decision-making (reported separately), and clinical experiences. Neonatology and MFM responses were compared. Multivariable logistic regression analyzed topics often and seldom discussed by specialty groups with respect to respondents' clinical experience and resuscitation option preferences at different gestational weeks. Results In total, 74 MFM and 167 neonatologists representing 94% of the 81 centers surveyed responded. Grouped by specialty, respondents were similar in counseling experience and distribution of allowing choices between resuscitation and no resuscitation for delivery at specific weeks of gestational ages. MFM versus neonatology reported similar rates of discussing long-term health and developmental concerns and differed in all other categories of topics. Neonatologists were less likely than MFM to discuss caregiver impacts (odds ratio [OR]: 0.14, 95% confidence interval [CI]: 0.11–0.18, p < 0.001) and comfort care details (OR: 0.19, 95% CI: 0.15–0.25, p < 0.001). Conversely, neonatology versus MFM respondents more frequently reported “usually” discussing topics pertaining to parenting in the NICU (OR: 1.5, 95% CI: 1.2–1.8, p < 0.001) and those regarding stabilizing interventions in the delivery room (OR: 1.8, 95% CI: 1.4–2.2, p < 0.001). Compared with less-experienced respondents, those with 17 years’ or more of clinical experience had greater likelihood in both specialties to say they “usually” discussed otherwise infrequently reported topics pertaining to caregiver impacts. Conclusion Parents require information to make difficult decisions for their extremely early newborns. Our findings endorse the value of co-consultation by MFM and neonatology clinicians and of trainee education on antenatal consultation education to support these families. Key Points

Supporting Breastfeeding in 2021 and Beyond—Lessons from the Pandemic

The COVID-19 pandemic has affected maternal and infant health globally both directly from infection with the SARS-CoV-2 virus and indirectly from changes in health care resulting from social, economic, and health care policies unique to each country. The developing countries have to share the disproportionate burden on maternal and infant health. In this review, we discuss the uncertainties resulting from SARS-CoV-2 infection in pregnancy, vertical transmission of the virus, and its effects on breastfeeding of the newborn. The problems of families and communities caring for mothers with COVID-19 and its impact on breastfeeding in newborns are discussed. The challenges posed by the pandemic have forced us to think and devise innovative solutions, including telemedicine help for antenatal counseling, breastfeeding education, and lactation support. Optimal utilization of resources and technology to find creative solutions at the individual and the community level will help in facilitating maternal–infant bonding soon after birth. Appropriate health care policies to support pregnant and lactating mothers will go a long way in meeting healthy child development goals.