“It feels like you have to choose one or the other”: periviability counseling focus groups

Abstract

Periviability counseling is both a difficult skill to master and an ideal application of shared decision-making, as it involves high stakes decisions that hinge upon individual patient values. Previous research shows that counseling varies between providers, and that obstetric (OB) providers often fail to integrate shared decision-making principles into counseling. The objective of this study was to understand baseline knowledge about periviability counseling among OB providers, and to ascertain challenges to counseling to inform curricular development. This qualitative study included four focus groups of OB providers encompassing upper-level OB residents, maternal fetal medicine (MFM) fellows, general obstetrician/gynecologists, and MFM specialists. The same series of open-ended questions was posed to each group; responses were audio recorded and transcribed. Transcriptions were analyzed independently by two coders using thematic analysis. Themes were finalized and inconsistencies resolved through discussion. Sixteen providers were included in the focus groups. Four main themes were identified (Table): (1) Periviability counseling is both time intensive and time-challenged, (2) Patient processing of information relies on the content, delivery and patient readiness, (3) Decisions regarding periviable cesarean highlight the conflict between the obstetrician’s concern for maternal risks, the neonatologists focus on neonatal risks, and the parental desire to “do everything” and (4) OB provider knowledge about neonatal outcomes is limited and plagued by uncertainty. We identified at least four specific challenges faced by OB providers when performing periviability counseling. Some, like the knowledge gap regarding neonatal outcomes, can be modified through education while others, such as time intensivity, cannot be. Practicing shared decision-making through advanced communication training may help address the issues related to optimal means of information delivery and balancing one’s own biases with patient values.