Mode of delivery in the context of periviable birth: informed deference and shared decision-making.

OBJECTIVE: To qualitatively evaluate women's perspectives on shared decision-making for periviable (22-25 weeks' gestational age) mode of delivery (MOD). STUDY DESIGN: Interviews were conducted at two Midwestern academic hospitals with 30 women hospitalized for threatened periviable delivery between September 2016 and January 2018. Prior to delivery (T1) and at 3-months postpartum (T2), MOD-related decision-making was explored using prompts. Interviews were coded and analyzed using NVivo 12. RESULT: The majority of women perceived the MOD options as cesarean section or vaginal delivery. Most ultimately preferred "whatever's best for baby." Understanding of MOD risks was limited, and physicians recommended each option equally. Sixteen participants perceived themselves as decision-makers at T1, while at T2, only nine participants identified themselves as such. CONCLUSION: Informed deference is introduced as a novel concept in the setting of periviable MOD decision-making, whereby the mother defers decisional authority to the provider, the baby, a higher power, or the circumstance itself.

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.

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.