The Edge of Perinatal Viability: Understanding the Dutch Position

Abstract

The current Dutch guideline on care at the edge of perinatal viability advises to consider initiation of active care to infants born from 24 weeks of gestational age on. This, only after extensive counseling of and shared decision-making with the parents of the yet unborn infant. Compared to most other European guidelines on this matter, the Dutch guideline may be thought to stand out for its relatively high age threshold of initiating active care, its gray zone spanning weeks 24 and 25 in which active management is determined by parental discretion, and a slight reluctance to provide active care in case of extreme prematurity. In this article, we explore the Dutch position more thoroughly. First, we briefly look at the previous and current Dutch guidelines. Second, we position them within the Dutch socio-cultural context. We focus on the Dutch prioritization of individual freedom, the abortion law and the perinatal threshold of viability, and a culturally embedded aversion of suffering. Lastly, we explore two possible adaptations of the Dutch guideline; i.e., to only lower the age threshold to consider the initiation of active care, or to change the type of guideline.

Two-year neurodevelopmental outcome in children born extremely preterm: the EPI-DAF study

“… 24 25 Also, there is a more restrictive approach towards the continuation of life-sustaining treatment for extremely preterm infants, if there are concerns on potential serious disabilities and the infant’s future quality of life. 25 Both approaches may result in differences in impairment rates. The period spanning from 24 0/7 weeks’ to 25 6/7 weeks’ gestation is considered in the Netherlands as a grey zone, in which management of infants born should be decided based on a consensus between the healthcare professionals and the parents, while other countries more often identify this grey zone as a period between 22 weeks and 24 weeks.…”

“…The period spanning from 24 0/7 weeks’ to 25 6/7 weeks’ gestation is considered in the Netherlands as a grey zone, in which management of infants born should be decided based on a consensus between the healthcare professionals and the parents, while other countries more often identify this grey zone as a period between 22 weeks and 24 weeks. 25 26 Differences between hospitals and countries in attitudes towards providing life support to the most immature infants seem to have the greatest impact on infants born in this grey zone and less on infants born at 26 weeks’ gestation. Unfortunately, our registry does not provide any information on decisions during prenatal counselling and in the delivery room.…”

“…The current Dutch approach towards treatment initiation for extremely preterm infants is more conservative than in other countries 24 25. Also, there is a more restrictive approach towards the continuation of life-sustaining treatment for extremely preterm infants, if there are concerns on potential serious disabilities and the infant’s future quality of life 25. Both approaches may result in differences in impairment rates.…”

Extremely premature birth bioethical decision-making supported by dialogics and pragmatism

“…The choice of such a line should not be permanent. The bioethical culture of healthcare should adapt when sociological, epistemological, or medical findings necessitate change [ 42 ].…”

Digital decision aid for prenatal counseling in imminent extreme premature labor: development and pilot testing

“…The use of Dutch outcome data can be regarded as cultural-sensitive, since the target population is Dutch, and Dutch health care providers wanted national data. However, others may be worried that these outcome data introduce a bias since the restrictive Dutch approach could influence outcome data [29,30]. I.e.…”