Parental Refusal of Vitamin K and Neonatal Preventive Services: A Need for Surveillance

Abstract

Objectives Vitamin K deficiency bleeding (VKDB) in infants is a coagulopathy preventable with a single dose of injectable vitamin K at birth. The Tennessee Department of Health (TDH) and Centers for Disease Control and Prevention (CDC) investigated vitamin K refusal among parents in 2013 after learning of four cases of VKDB associated with prophylaxis refusal. Methods Chart reviews were conducted at Nashville-area hospitals for 2011–2013 and Tennessee birthing centers for 2013 to identify parents who had refused injectable vitamin K for their infants. Contact information was obtained for parents, and they were surveyed regarding their reasons for refusing. Results At hospitals, 3.0% of infants did not receive injectable vitamin K due to parental refusal in 2013, a frequency higher than in 2011 and 2012. This percentage was much higher at birthing centers, where 31% of infants did not receive injectable vitamin K. The most common responses for refusal were a belief that the injection was unnecessary (53%) and a desire for a natural birthing process (36%). Refusal of other preventive services was common, with 66% of families refusing vitamin K, newborn eye care with erythromycin, and the neonatal dose of hepatitis B vaccine. Conclusions for Practice Refusal of injectable vitamin K was more common among families choosing to give birth at birthing centers than at hospitals, and was related to refusal of other preventive services in our study. Surveillance of vitamin K refusal rates could assist in further understanding this occurrence and tailoring effective strategies for mitigation.

Factors Associated With Refusal of Intramuscular Vitamin K in Normal Newborns

“…This refusal rate is similar to that reported in Canada (0.5%) 6 and lower than that reported in New Zealand (1.7%) 10 and in Tennessee (3%). 15 In our nested patient-control study, infants who did not receive IM vitamin K tended to also not receive both hepatitis B vaccine and ocular prophylaxis. The association of vaccine hesitancy and refusal of vitamin K has been reported previously.…”

The hepatitis B birth‐dose immunisation: Exploring parental refusal

“…Concerned parents are increasingly extrapolating uncorrected vaccine misconceptions and fears to other routine preventive perinatal care . This has been observed in studies of prophylactic intramuscular vitamin K injection uptake at birth, where refusal has been associated with rejection of the hepatitis B immunisation birth‐dose . Conflicting impressions or lack of confidence perceived by patients from different healthcare providers about early‐life public health interventions can further negatively impact uptake.…”

“…26 This has been observed in studies of prophylactic intramuscular vitamin K injection uptake at birth, where refusal has been associated with rejection of the hepatitis B immunisation birth-dose. 27,28 Conflicting impressions or lack of confidence perceived by patients from different healthcare providers about early-life public health interventions can further negatively impact uptake. Highly skewed proportions of women rejecting the intramuscular dose have been found to be receiving care from the same maternity health professional personnel, suggestive of meaningful negative influence on parental decision making.…”

Newborn Vitamin K Prophylaxis: A Historical Perspective to Understand Modern Barriers to Uptake

“…29 Researchers in recent literature have identified instances in which parental beliefs and values were incompatible with the use of vitamin K for reasons such as a strong identity with an alternative lifestyle, a belief that birth is a natural process that needs little interference, or religious or evolutionary values. These factors have all been linked to vitamin K refusal and are some of the hardest barriers to counteract, 29,41 contrasting with the above issues regarding pain or cancer, which, if adequately addressed, may lead to parental reassurance. The following factors aligned to a parental wish for a natural birth process or less medicalization have also been linked to parental refusal of IM vitamin K: having a vaginal delivery, delivery in a birth center as opposed to a hospital, greater gestational age, and having a planned home birth.…”

“…25,42 In addition to the above, declining vitamin K prophylaxis has been associated with parents who identify as anticonformist or who are questioning of mainstream medicine. 29 These beliefs are also associated with refusals of other related public health initiatives such as immunization, 25,26,41,43 newborn screening, 29 and erythromycin eye drops. 41 Again, these beliefs are extremely hard to shift, with the majority of parents in 1 study unwilling to consider alternative, scientifically accurate information and remaining steadfast in their decision to decline.…”