Application of Prospect Theory in Obstetrics by Evaluating Mode of Delivery and Outcomes in Neonates Born Small or Appropriate for Gestational Age

Abstract

IMPORTANCEAntenatal diagnosis of fetal weight is challenging, and the detection rate of fetal growth restriction (FGR) is low. Neonates with FGR are known to have an increased rate of obstetric intervention during labor, but the association of antenatal fetal weight estimation with mode of delivery and neonatal outcomes among neonates who are small and appropriate for gestational age (SGA and AGA) has not been reported. OBJECTIVE To evaluate the association of antenatal fetal weight estimation with mode of delivery and neonatal outcomes among neonates who are SGA and AGA, applying psychological concepts of cognitive bias and prospect theory to a model of clinical behavior. DESIGN, SETTING, AND PARTICIPANTS This cohort study was conducted between 2019 and 2020 using data from 2006 to 2018 at a tertiary care center in Jerusalem, Israel. Participants were 100 198 term singleton neonates without anomalies who were categorized into 4 groups according to the presence of an antenatal suspicion of FGR and final birth weight. Neonates with false positives (FPs;ie, group 1-FP: those with suspected FGR who were AGA) and neonates with true positives (TPs; ie, group 2-TP: those with suspected FGR who were SGA) were compared with neonates with AGA antenatal fetal weight estimation, including neonates with false negatives (FNs; ie, group 3-FN: those not suspected to have FGR who were SGA) and neonates with true negatives (TNs; ie, group 4-TN:those not suspected to have FGR who were AGA). Data were analyzed from July 2019 to July 2020. EXPOSURES Fetal weight estimation was performed according to sonographic and clinical evaluation at admission to labor, with FGR defined as a birth weight less than the 10th percentile for gestational age. Sonographic fetal weight estimation was performed according to Hadlock formula.Clinical weight estimation was performed by trained obstetricians. MAIN OUTCOMES AND MEASURESThe primary outcomes were obstetric intervention and mode of delivery; the secondary outcomes were neonatal Apgar score (with low Apgar score defined as <7) and neonatal intensive care unit (NICU) admission rates. RESULTS Among 100 198 neonates eligible for the study (50941 [50.8%] male neonates), there were 5671 neonates in group 1-FP, 3040 neonates in group 2-TP, 8508 neonates in group 3-FN, and 82 979 neonates in group 4-TN. Mean (SD) maternal age was 28.6 (5.7) years. Among 8711 neonates with suspected FGR, 34.9% were below the 10th percentile at birth, while 65.1% were AGA.Neonates with suspected FGR had a significantly increased rate of induction of labor (group 1-FP: 649 neonates [11.4%] and group 2-TP: 969 neonates [31.9%]) compared with neonates in group 3-FN (1055 neonates [12.4%]) and group 4-TN (7136 neonates [8.6%]) (P < .001) and a significantly increased rate of cesarean delivery (group 1-FP: 915 neonates [16.1%] and group 2-TP: 556 neonates [18.3%] vs group 3-FN: 1106 neonates [13.0%] and group 4-TN: 6588 neonates [7.9%]; P < .001).Increased NICU admission was found for neonates who were SGA compared with neona...

Serial plotting of symphysis–fundal height and estimated fetal weight to improve the antenatal detection of infants small for gestational age: A cluster randomised trial

“…Another difference between our study and the two observational studies investigating serial plotting policies is that FGR was detected for 37% of SGA births in the control arm of our trial. This was higher than previous estimates of FGR detection in France and in other developed countries, where reports range from one‐fifth to one‐third of SGA births 13–19,57 . It was also higher than the detection rates in the recent GAP trial in the UK (25.9% and 27.7% in the intervention and usual care arms, respectively).…”

Diagnosing Fast and Slow

“…They argue that, ".confirmation bias may lead the obstetrician to advise for a prompt intervention via an instrumental or cesarean delivery." 6 From the Departments of Obstetrics and Gynecology, Staten Island University Hospital, Northwell, Staten Island, Maimonides Medical Center, Brooklyn, and SUNY Downstate School of Public Health, Brooklyn, New York.…”

A Lesson From Behavioral Economics for Reducing Obstetric Interventions—Placing More Weight on Perceived Gains vs Perceived Losses

“…In their retrospective cohort study, Michaeli et al 1 aimed to apply psychological concepts of cognitive bias and prospect theory to evaluate the association of antenatal fetal weight estimation with mode of delivery and outcomes of neonates being small for gestational age (SGA) and appropriate for gestational age (AGA). A total of 100 198 singleton, term neonates without anomalies were categorized into 4 groups according to the presence of an antenatal suspicion of fetal growth restriction (FGR) and final birth weight: neonates with false positives (FPs; ie, group 1-FP: those with suspected FGR who were AGA), neonates with true positives (TPs; ie, group 2-TP: those with suspected FGR who were SGA), neonates with false negatives (FNs; ie, group 3-FN: those not suspected to have FGR who were SGA), and neonates with true negatives (TNs; ie, group 4-TN: those not suspected to have FGR who were AGA).…”

“…Second, people attribute excessive weight to events with low probabilities and insufficient weight to events with high probabilities. The findings from Michaeli et al suggest that applying prospect theory in obstetrics could be a useful tool to improve quality of care in one of the most difficult conditions involving mothers, babies, and health care systems.…”

“…The findings by Michaeli et al suggest that our future goals in FGR research should be to follow 3 trajectories at least. First, we should aim for a better antenatal identification of incidences of FGR by improving its definition.…”