Abstract
BackgroundIn high income countries, guidelines exist recommending gestational age thresholds for offering and obligating neonatal resuscitation for extremely preterm infants. In low- and middle- income countries, this approach may be impractical due to limited/inconsistent resource availability and challenges in gestational dating. Scant literature exists on how clinicians in these settings conceptualize viability or make resuscitation decisions for premature infants.MethodsQualitative interviews of interprofessional neonatal clinicians were conducted in Kumasi, Ghana, at Komfo Anokye Teaching Hospital and Suntreso Government Hospital, and in Addis Ababa, Ethiopia, at St. Paul’s Hospital Millennium Medical College. Transcribed interviews were coded through the constant comparative method.ResultsThree discrete major themes were identified. The principal theme was a respect for all life, regardless of the likelihood for survival. This sense of duty arose from a duty to God, a duty to the patient, and a duty intrinsic to one’s role as a medical provider. The duty to resuscitate was balanced by the second major theme, an acceptance of futility for many premature infants. Lack of resources, inappropriate staffing, and historically high local neonatal mortality rates were often described. The third theme was a desire to meet global standards of newborn care, including having resources to adopt the 22–25-week thresholds used in high income countries and being able to consistently provide life-saving measures to premature infants.ConclusionsNeonatal clinicians in Ghana and Ethiopia described respect for all life and desire to meet global standards of newborn care, balanced with an awareness of futility based on local resource limitations. In both countries, clinicians highlighted how wide variations in regional survival outcomes limited their ability to rely on structured resuscitation guidelines based on gestational age and/or birthweight.
Highlights
Preterm delivery remains a worldwide problem, with 10.6% of infants each year born prior to 37 weeks gestation and 4.1% of these preterm births occurring prior to 28 weeks [1]
Rent et al BMC Pediatrics (2022) 22:97 is a significant gap in survival noted between high income countries (HICs) and low- and middle-income countries (LMICs), with over 90% of babies born before 28 weeks gestation surviving in HICs but only 10% of babies in this same gestational age range surviving in LMICs – a phenomenon known as the “90:10 survival gap” [2]
Concurrent but more tempered progress has been seen in the risk of long-term morbidity and neurodevelopmental impairment among survivors [3, 7]. At this “margin of viability,” or the gestational age at which survival outside the womb is possible but unlikely, questions arise regarding for which infants intensive care is beneficial and for which it is not
Summary
Preterm delivery remains a worldwide problem, with 10.6% of infants each year born prior to 37 weeks gestation and 4.1% of these preterm births occurring prior to 28 weeks [1] Concurrent but more tempered progress has been seen in the risk of long-term morbidity and neurodevelopmental impairment among survivors [3, 7] At this “margin of viability,” or the gestational age at which survival outside the womb is possible but unlikely, questions arise regarding for which infants intensive care is beneficial and for which it is not. Guidelines exist recommending gestational age thresholds for offering and obligating neonatal resuscitation for extremely preterm infants. Scant litera‐ ture exists on how clinicians in these settings conceptualize viability or make resuscitation decisions for premature infants
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