Perspectives on Resuscitation Decisions at the Margin of Viability among Specialist Newborn Care Providers in Ghana and Ethiopia: A Qualitative Analysis

Abstract

Background In 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. Methods Qualitative 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. Results Three 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. Conclusions Neonatal 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.

Resuscitation in the “Periviable” Period—Commentary of Opposing Views

“…To put things in perspective, overall, at 28 weeks of gestational age in a HIC, a newborn has 90% survival chance compared to only 10% in a newborn born in an LMIC. 21 The take-home message is that we must stop viewing the outcomes of preterm births in developed countries, to formulate recommendations and guidelines in LMICs. 3.…”

“…To put things in perspective, overall, at 28 weeks of gestational age in a HIC, a newborn has 90% survival chance compared to only 10% in a newborn born in an LMIC. 21 The take-home message is that we must stop viewing the outcomes of preterm births in developed countries, to formulate recommendations and guidelines in LMICs. Outcomes: In the developing world, it is estimated that 250 million children (43% of the population of children) are at increased risk of not achieving their full cognitive development potential in the first five years of life. 22 India is one of the main contributors.…”

“…The limited data suggest certain common themes, such as a higher threshold for actively treating preterm babies (28-32 weeks of gestation age), acceptance of futility for many premature babies, lack of resources, inadequate staff, and sometimes even cultural issues. 21, 26 To make matters worse, there are no data to guide caregivers, there is a critical deficiency of healthcare personnel in the country, and they are inadequately trained in ethics and communication. Health care costs: Studies have pointed out that NICU care is cost-effective overall. However, there are 4 important considerations.…”

“…The limited data suggest certain common themes, such as a higher threshold for actively treating preterm babies (28-32 weeks of gestation age), acceptance of futility for many premature babies, lack of resources, inadequate staff, and sometimes even cultural issues. 21, 26…”

Perinatal loss in Tanzania: Perspectives of maternal-child healthcare providers

“…The influence of gestational age on perinatal loss classification has also posed a challenge for researchers and clinicians. Notably, the WHO’s threshold of 28-weeks’ gestation for international reporting of stillbirth and neonatal mortality [ 15 ] has falsely been extrapolated as representing a practice guideline offered by the WHO [ 16 ]. This extension of a research threshold into clinical practice can impact which infants receive resuscitation and how deaths are classified.…”