Values clarification: Eliciting the values that inform and influence parents' treatment decisions for periviable birth.

BACKGROUND: Values clarification can assist families facing the threat of periviable delivery in navigating the complexity of competing values related to death, disability, and quality of life (QOL). OBJECTIVE: We piloted values clarification exercises to inform resuscitation decision making and qualitatively assess perceptions of QOL. METHODS: We conducted a mixed-method study of women with threatened periviable delivery (22 0/7-24 6/7 weeks) and their important others (IOs). Participants engaged in three values clarification activities as part of a semi-structured interview-(a) Card sorting nine conditions as an acceptable/unacceptable QOL for a child; (b) Rating/ranking seven common concerns in periviable decision making (scale 0-10, not at all to extremely important); and (c) "Agreed/disagreed" with six statements regarding end-of-life treatment, disability, and QOL. Participants were also asked to define "QOL" and describe their perceptions of a good and poor QOL for their child. Analysis was conducted using SAS version 9.4 and NVivo 12. RESULTS: All mild disabilities were an acceptable QOL, while two-thirds of participants considered long-term mechanical ventilation unacceptable. Although pregnant women rated "Impact on Your Physical/Mental Health" (average 5.6) and IOs rated "Financial Concerns" the highest (average 6.6), both groups ranked "Financial Concerns" as the most important concern (median 5.0 and 6.0, respectively). Most participants agreed that "Any amount of life is better than no life at all" (pregnant women 62.1%; IOs 75.0%) and disagreed that resuscitation would cause "Too much suffering" for their child (pregnant women 71.4%; IOs 80.0%). Half were familiar with the phrase "QOL". Although the majority described a good QOL in terms of emotional well-being (eg "loved", "happy", "supported"), a poor QOL was described in terms of functionality (eg "dependent" and "confined"). Additionally, financial stability emerged as a distinctive theme when IOs discussed poor QOL. CONCLUSION: The study offers important insights on parental perspectives in periviable decision making and potential values clarification tools for decision support.

Parents' Descriptions of Neonatal Palliation as a Treatment Option Prior to Periviable Delivery.

During periviable deliveries, parents are confronted with overwhelming and challenging decisions. This study aimed to qualitatively explore the language that pregnant women and important others utilize when discussing palliation, or "comfort care," as a treatment option in the context of periviability. We prospectively recruited women admitted for a threatened periviable delivery (22-25 weeks) at 2 hospitals between September 2016 and January 2018. Using a semistructured interview guide, we investigated participants' perceptions of neonatal treatment options, asking items such as "How was the choice of resuscitation presented to you?" and "What were the options presented?" Conventional content analysis was used and matrices were created to facilitate using a within- and across-case approach to identify and describe patterns. Thirty women and 16 important others were recruited in total. Participants' descriptions of treatment options included resuscitating at birth or not resuscitating. Participants further described the option to not resuscitate as "comfort care," "implicit" comfort care, "doing nothing," and "withdrawal of care." This study revealed that many parents facing periviable delivery may lack an understanding of comfort care as a neonatal treatment option, highlighting the need to improve counseling efforts in order to maximize parents' informed decision-making.

Using Wastewater Surveillance to Monitor Gastrointestinal Pathogen Infections in the State of Oklahoma.

During the COVID-19 pandemic, wastewater surveillance was widely used to monitor temporal and geographical infection trends. Using this as a foundation, a statewide program for routine wastewater monitoring of gastrointestinal pathogens was established in Oklahoma. The results from 18 months of surveillance showed that wastewater concentrations of Salmonella, Campylobacter, and norovirus exhibit similar seasonal patterns to those observed in reported human cases (F = 4-29, p < 0.05) and that wastewater can serve as an early warning tool for increases in cases, offering between one- and two-weeks lead time. Approximately one third of outbreak alerts in wastewater correlated in time with confirmed outbreaks of Salmonella or Campylobacter and our results further indicated that several outbreaks are likely to go undetected through the traditional surveillance approach currently in place. Better understanding of the true distribution and burden of gastrointestinal infections ultimately facilitates better disease prevention and control and reduces the overall socioeconomic and healthcare related impact of these pathogens. In this respect, wastewater represents a unique opportunity for monitoring infections in real-time, without the need for individual human testing. With increasing demands for sustainable and low-cost disease surveillance, the usefulness of wastewater as a long-term method for tracking infectious disease transmission is likely to become even more pronounced.

Improving Resident Knowledge of Ergonomics Guidelines.

OBJECTIVE: To improve resident knowledge of ergonomics guidelines for surgery, vaginal deliveries and repairs, and documentation. PROJECT SUMMARY: We consulted with a licensed occupational therapist at our institution regarding our difficulties with maintaining proper ergonomics while operating, performing deliveries, and documenting. We conducted two separate sessions: one in the obstetrics workroom regarding techniques to improve the ergonomics of our documentation and one in the operating room and labor and delivery unit to address techniques to avoid injury and promote long-term wellness. The sessions were conducted during morning report at our institution, and the obstetrics and gynecology teams attended both sessions. The sessions were available by videoconference for the entire residency program. Handouts were created to present basic ergonomics guidelines and were provided at the conclusion of the sessions. The handouts summarized the information provided during the sessions and included recommendations for adjustments that could be made in the workroom, operating room, and delivery room. The sessions were conducted during ACOG Wellness Week. OUTCOME: Adjustments were made in the obstetric and gynecology team workrooms to improve ergonomic function. Sessions improved resident knowledge of ergonomics recommendations for vaginal deliveries. Recommendations included guidelines for arm and shoulder position, tucked chins, and appropriate bed height (sitting vs standing). Adjustments were made in the workroom to position the top of the monitor just below eye level and arm's length away, and chairs were adjusted so that the keyboard and mouse height were just below elbow height. Residents were encouraged to keep arms and wrists in a relaxed, neutral position and to sit all the way back in the chair with back supported and feet firmly on the floor. Residents improved their knowledge of ergonomics guidelines and increased awareness of posture and positioning both on the labor and delivery unit and in the operating room. RELEVANCE TO WOMENS HEALTH OR PHYSICIANS IN PRACTICE: Work-related musculoskeletal disorders are prevalent among surgeons and can have a significant effect on productivity and career longevity. If we are able to implement evidence-based guidelines developed by high-quality ergonomics research, we can potentially protect obstetricians and gynecologists from injury and improve overall wellness.

Predicting COVID-19 cases in diverse population groups using SARS-CoV-2 wastewater monitoring across Oklahoma City.

SARS-CoV-2 was discovered among humans in late 2019 and rapidly spread across the world. Although the virus is transmitted by respiratory droplets, most infected persons also excrete viral particles in their feces. This fact prompted a range of studies assessing the usefulness of wastewater surveillance to determine levels of infection and transmission and produce early warnings of outbreaks in local communities, independently of human testing. In this study, we collected samples of wastewater from 13 locations across Oklahoma City, representing different population types, twice per week from November 2020 to end of March 2021. Wastewater samples were collected and analyzed for the presence and concentration of SARS-CoV-2 RNA using RT-qPCR. The concentration of SARS-CoV-2 in the wastewater showed notable peaks, preceding the number of reported COVID-19 cases by an average of one week (ranging between 4 and 10 days). The early warning lead-time for an outbreak or increase in cases was significantly higher in areas with larger Hispanic populations and lower in areas with a higher household income or higher proportion of persons aged 65 years or older. Using this relationship, we predicted the number of cases with an accuracy of 81-92% compared to reported cases. These results confirm the validity and timeliness of using wastewater surveillance for monitoring local disease transmission and highlight the importance of differences in population structures when interpreting surveillance outputs and planning preventive action.

Diverse perspectives on death, disability, and quality of life: an exploratory study of racial differences in periviable decision-making.

OBJECTIVE: To qualitatively explore perceptions of pain/suffering, disability, and coping by race among pregnant women facing the threat of a periviable delivery (22 0/7-24 6/7 weeks). STUDY DESIGN: Interviews were conducted in-hospital prior to delivery. Transcripts were coded verbatim and responses were stratified by race (white vs non-white). Conventional content analysis was conducted using NVivo 12. RESULTS: We recruited 30 women (50% white, 50% non-white). Most women expressed love and acceptance of their babies and described pain as a "means to an end." Non-white women focused almost exclusively on immediate survival and perseverance, while white women expressed concerns about quality of life beyond the NICU. The majority of non-white women were unable to recall any discussions with their doctors about their baby's comfort, pain, or suffering. CONCLUSIONS: These findings may suggest that culturally tailored approaches to counseling and decision-support may be beneficial for patients from marginalized or minoritized groups.

Examining the Impact of the Vaginal Birth After Cesarean Risk Calculator Estimation on Trial of Labor After Cesarean Counseling.

Background. Because failed trial of labor after cesarean (TOLAC) is associated with greater morbidity than planned cesarean, it is important to distinguish women with a high likelihood of successful vaginal birth after cesarean (VBAC) from those likely to fail. The VBAC Calculator may help make this distinction but little is known about how often providers use it; nor whether use improves risk estimation and/or influences TOLAC counseling. Methods. In a cross-sectional survey, a convenience sample of obstetrical providers reported their likelihood (4-point Likert-type scale) to "Recommend,""Offer," or "Agree to" TOLAC for patients presented first through five clinical vignettes; then, in different order, by corresponding VBAC calculator estimates. Results. Of the 85 (of 101, 84% response rate) participants, 88% routinely performed TOLAC, but only 21% used the Calculator. The majority (67.1% to 89.3%) overestimated the likelihood of success for all but one vignette (which had the highest estimate of success). Most providers (42% to 89%) recommended TOLAC for all five vignettes. Given calculated estimates, the majority of providers (67% to 95%) recommended TOLAC for success estimates exceeding 40%. For estimates between 20% and 40%, most providers offered (58%) or agreed (68%) to TOLAC; and even below 20%, over half still agreed to TOLAC. The vignette with the lowest estimate of success (18.7%) had the weakest intraprovider agreement (kappa = 0.116; confidence interval [CI] = 0.045-0.187), whereas the strongest agreement was found in the two vignettes with highest success estimates: 77.9% (kappa = 0.549; CI = 0.382-0.716) and 96.6% (kappa = 0.527; CI = 0.284-0.770). Limitations. Survey responses may not reflect actual practice patterns. Conclusion. Providers are overly optimistic in their clinical estimation of VBAC success. Wider use of decision support could aid in risk stratification and TOLAC counseling to reduce patient morbidity.

The impact of decision quality on mental health following periviable delivery.

PURPOSE: To assess the relationship between decision quality and mental health outcomes for women and their important others (IO) 3 months following periviable birth. METHOD: Mental health outcomes were assessed prior to delivery and at 3 months postpartum using depression (PHQ-9), anxiety (GAD-7), and post-traumatic stress disorder (PTSD) (IES-22) scales. Decision quality was measured in terms of Decisional Conflict, Control, Regret, and Satisfaction with Decision. Descriptive analyses and linear regression modeling were conducted using SAS version 9.4. RESULT: We recruited 30 eligible women and 16 IOs. Participants had mild anxiety and depression, and symptoms of PTSD were among bereaved parents. Participants with lower decision control had higher levels of depression (women: p = 0.014; IOs: p = 0.059) and anxiety (women: p = 0.053; IOs: p = 0.032). Depression was also associated with higher decisional regret (women: p = 0.073; IOs: p = 0.023). CONCLUSION: Our findings suggest that decision quality is associated with mental health outcomes for families who experience periviable delivery.

Creation of a Decision Support Tool for Expectant Parents Facing Threatened Periviable Delivery: Application of a User-Centered Design Approach.

BACKGROUND: Shared decision-making (SDM) is optimal in the context of periviable delivery, where the decision to pursue life-support measures or palliation is both preference sensitive and value laden. We sought to develop a decision support tool (DST) prototype to facilitate SDM by utilizing a user-centered design research approach. METHODS: We convened four patient and provider advisory boards with women and their partners who had experienced a surviving or non-surviving periviable delivery, pregnant women who had not experienced a prior preterm birth, and obstetric providers. Each 2-h session involved design research activities to generate ideas and facilitate sharing of values, goals, and attitudes. Participant feedback shaped the design of three prototypes (a tablet application, family story videos, and a virtual reality experience) to be tested in a final session. RESULTS: Ninety-five individuals (48 mothers/partners; 47 providers) from two hospitals participated. Most participants agreed that the prototypes should include factual, unbiased outcomes and probabilities. Mothers and support partners also desired comprehensive explanations of delivery and care options, while providers wanted a tool to ease communication, help elicit values, and share patient experiences. Participants ultimately favored the tablet application and suggested that it include family testimonial videos. CONCLUSION: Our results suggest that a DST that combines unbiased information and understandable outcomes with family testimonials would be meaningful for periviable SDM. User-centered design was found to be a useful method for creating a DST prototype that may lead to improved effectiveness, usability, uptake, and dissemination in the future, by leveraging the expertise of a wide range of stakeholders.