Parental Refusal of Standard-of-Care Prophylactic Newborn Practices: In One Center’s Experience, Many Refuse One but Few Refuse All

Abstract

OBJECTIVES: Several interventions to reduce neonatal morbidity and mortality are universally recommended: intramuscular (IM) vitamin K (VK), erythromycin ophthalmic prophylaxis, and hepatitis B vaccine for newborns, and maternal pertussis vaccine. Despite robust efficacy and safety evidence, parental refusal of these practices is increasing. We sought to define the current declination rate and characterize the association between declination of 1 intervention and declination of the others. METHODS: A retrospective cohort study was performed of all inborn singletons admitted to the well newborn nursery over a 12-month period (November 15, 2015 through November 15, 2016) at a large quaternary center. RESULTS: In total, 3758 infants met inclusion criteria. 25% (n = 921) did not receive at least 1 of the 4 interventions. 13.6% (n = 511) did not receive the hepatitis B vaccine, 2.3% (n = 85) did not receive IM VK, 5.9% (n = 223) did not receive erythromycin, and 7.2% (n = 271) of mothers did not receive the prenatal tetanus, diphtheria, pertussis vaccine. Odds of refusal of IM VK were 6.2 times greater for infants delivered by a certified nurse midwife versus physician (95% confidence interval 3.3–11.6). Pattern of declination was variable; of 921 mother-infant dyads who did not receive at least 1 intervention, only 2 dyads received none of the interventions. CONCLUSIONS: Our study is one of the first in which patterns of refusal of standard-of-care perinatal practices are characterized. Alarmingly, one-fourth of our cohort did not receive at least 1 core infant health intervention. Our finding of only modest overlap in declination of each intervention carries implications for the development of targeted interventions.

Refusal of Intramuscular Vitamin K by Parents of Newborns: A Review

“…We identified 7 original articles on the frequency of intramuscular vitamin K refusal by parents. [3][4][5][6][13][14][15] Rates of refusal in these studies are shown in Table 1. In the hospital setting, most parents accept intramuscular vitamin K for their newborns with reported refusal rates that ranged up to 3.2%.…”

“…In some instances, parents' refusal of intramuscular vitamin K for their infants was a result of a lack of knowledge about the risk of VKDB to their infants and the role of intramuscular vitamin K in preventing VKDB. 6,[18][19][20] Some parents would have only considered intramuscular vitamin K in the event of a potential injury to the infant or if the birth required another intervention. 8 Decisions about the refusal of intramuscular vitamin K were influenced by the opinions of other mothers or family members; statements of celebrities and health professionals, including midwives and chiropractors; as well as written information (information sheets) and Internet blogs.…”

“…15 The association between intramuscular vitamin K refusal by parents and midwife-assisted deliveries was replicated by investigators in Michigan. 6 In a cross-sectional survey of mothers in the United States, investigators found that Regimens reported in European studies included 3-dose series of oral vitamin K (given at birth, either day 4 or week 1, and week 4), 61,63 multiple-dose series (at birth and then either daily or weekly until 3 months of age), 62,65 2-dose series (at birth and day 4), 66 and 4-dose series (at birth and at weeks 2, 4, and 6 [in breastfed neonates]). 64 The incidence of VKDB after oral vitamin K prophylaxis in these studies was up to 2.8 per 100 000.…”

“…1 This response was partly due to an increase in the number of reports of parents who refuse intramuscular vitamin K for their newborns and a concomitant increase in reports of newborns with vitamin K deficiency bleeding (VKDB), a serious and potentially life-threatening condition, in recent years in the United States and other countries. [2][3][4][5][6][7][8][9][10][11][12] Newborns have low reserves of vitamin K, putting them at risk for VKDB. VKDB may present in the first week of life (classic VKDB) with bleeding from the gastrointestinal tract and/or from the umbilicus.…”

Universal Hepatitis B Antibody Screening and Vaccination in Pregnancy

“…Data demonstrate low rates of vaccination and sero-logic evidence of immunity against HBV, in concert with vaccine hesitancy, increasing maternal age, and diverse geographic provenance of reproductive-aged persons, all of which place women at risk for acquisition of HBV during their lifetime. 1,2,[55][56][57] Vaccination for HBV in pregnancy accomplishes similar seroconversion rates (greater than 90%) to those seen outside of pregnancy, with higher vaccination completion rates in pregnancy than outside of pregnancy, and without any vaccine-specific adverse outcomes reported across thousands of pregnancies. 5,8,41,58 Pregnancy is a time in which many interventions that affect long-term maternal health are recommended-for instance, cervical cytology screening and postpartum 2-hour glucose tolerance testing.…”