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

Abstract

The antenatal diagnosis of fetal weight is a challenge that relies on sonographic estimations and the clinical assessment of fetal and maternal status. Meanwhile, the rate of detection of fetal growth restriction (FGR) is <40%. Because neonates who are small for gestational age (SGA) are more likely to experience perinatal and long-term complications, the timely detection of FGR is important to prevent intrauterine death or long-term disability. In addition, approximately 30% of fetuses with FGR are born via cesarean delivery (CD). Yet, for fetuses with FGR, the benefit of CD and, alternatively, the optimal mode of delivery remain unclear. Given that fetal weight is unknown until after delivery, clinical decisions on the mode of delivery may be made based on the prospect theory or making decisions under stress with uncertain outcomes while subject to cognitive biases such as confirmation bias. The aim of this study was to examine biases associated with estimating fetal weight by evaluating the mode of delivery and outcomes for SGA and appropriate for gestational age (AGA) neonates.This study was conducted at a tertiary center in Jerusalem, Israel, from January 1, 2006, to December 31, 2018, using retrospective, deidentified data from electronic medical records. Included were neonates born to women with singleton, term pregnancies with no anomalies. They were categorized into 4 groups according to suspected FGR and actual birth weight. Neonates with suspected FGR were divided into 2 groups: those born AGA (false positive [1-FP]) and those born SGA [true positive [2-TP]). They were compared with neonates not suspected of FGR: those born SGA (false negative [3-FN]) and those born AGA (true negative [4-TN]). The primary outcomes were obstetric intervention and mode of delivery. Secondary outcomes were neonatal Apgar score <7 minutes and admission to the neonatal intensive care unit (NICU).A total of 100,198 neonates were included in the analysis, with 5671 in the 1-FP group, 3040 in the 2-TP group, 8505 in the 3-FN group, and 82,979 in the 4-TN group. Neonates with suspected FGR (1-FP and 2-TP groups) compared with those without suspected FGR (3-FN and 4-TN groups) were more likely to have been induced (11.4% and 31.9% vs 12.4% and 8.6%; P < 0.001), delivered by elective CD (12% and 9.5% vs 5.9% and 4.6%; P < 0.001), and delivered by CD overall (16.1% and 18.3% vs 13% and 7.9%; P < 0.001). Small for gestational age neonates (2-TP and 3-FN groups) compared with AGA neonates (1-FP and 4-TN groups) had significantly higher rates of instrumental delivery (7.9% and 8.6% vs 4.4% and 5.5%; P < 0.001), third-stage placental complications (3.4% and 3.5% vs 2.6% and 2.8%; P < 0.001), maternal hemoglobin drop >3 g/dL (6.2% and 7.0% vs 5.4% and 5.9%; P < 0.001), and maternal blood transfusions (1.2% and 1.1% vs 0.9% and 0.8%; P < 0.001). In multivariate analysis, suspicion of FGR was independently associated with an increase in the rate of CD >70% (odds ratio, 1.72; 95% confidence interval, 1.56-1.88; P < 0.001).Of the 8711 neon...