The Definition of Life: A Survey of Obstetricians and Neonatologists in New York City Hospitals Regarding Extremely Premature Births

Abstract

Among obstetricians and neonatologists in administrative roles in New York City hospitals, a survey was initiated to compare the physicians' definitions of live birth and fetal death, the gestational age at which they consider infants viable, and the resuscitation practices of the neonatologists. The target survey population was 34 neonatologists, and 39 obstetricians representing 41 of the City's 43 maternity hospitals. A telephone survey was used to gather qualitative data from the physicians regarding their definitions of live birth, fetal death, and viability, and their practices regarding extremely premature births. Surveys were completed for 58 physicians, a response rate of 79% (94% for neonatologists and 67% for obstetricians). Physicians' definitions of live birth and fetal death varied, with almost a third (29%) of physicians including gestational age as part of their live birth criteria. Most of the physicians (90%) consider infants born at ≥23 weeks gestation viable. Most neonatologists (97%) said they always resuscitate infants born at ≥23 weeks gestation, and most (94%) said they would never resuscitate infants born at <20 weeks gestation. For infants born at 20-22 weeks gestation, there were differences in resuscitation practices. There is a gap between clinical practices and reporting requirements for live birth and fetal death. Whereas reporting requirements are based on definitions of live birth and fetal death, physicians make resuscitation and other clinical decisions regarding extremely premature infants based on definitions of viability.

Comparing regional infant death rates: the influence of preterm births <24 weeks of gestation

“…In order to make direct comparisons in mortality, be it international, regional or unit level, it is essential there is detailed validation and standardisation to ensure we are comparing ‘like with like’,3 distinguishing ‘real’ variation from ‘artefacts’ that arise from reporting and registration differences 13. In the US, despite the implementation of national reporting requirements, clinical decision making based on definitions of viability do not match clinical decision making14 and variation exists in state registration practices15 similar to that shown here. A standardised approach to the collection, calculation and presentation of death rates is required to reduce artefactual differences 16.…”

“…However, there are practical difficulties in interpreting true signs of life and subjective differences in judgements about the best outcome for parents. In the US, where the WHO definition is accepted, research shows nearly a third of physicians to include gestational age in their personal criteria for defining a live birth14 with definitions ‘open to subjective interpretation’ 9…”

The Definition of Life: The Impact of Physicians’ Reporting Practices on Neonatal Mortality Rate in New York City

“…Data on hospital's reporting practices were extracted from a survey conducted in 2008 [18]. The survey data was collected using a 15-minute telephone interview of hospital administrators.…”

Interpretation of early life mortality rates

“…Within the UK such ecological differences have been shown to represent a doubling of risk for very preterm birth between women from the least and most deprived populations 12. While data demonstrate that in the short term, for an individual child, their socioeconomic deprivation does not appear to impact on their initial disease severity, the higher rates of babies born preterm in more deprived areas means there is an increased burden of babies ‘more likely to die’9 and hence even if hospital care is of a high standard more deaths will be recorded than from those hospitals serving a less deprived catchment area. Perceptions of viability Even within the UK, Europe and USA, where there are clear definitions of stillbirth and little variation in access to neonatal care, there is evidence of variation in the perceptions of viability 2 13. This is likely to arise from practical difficulties in interpreting true signs of life, inconsistent approaches by hospitals to such babies and subjective differences in judgements about the best outcome for parents.…”

“…Even within the UK, Europe and USA, where there are clear definitions of stillbirth and little variation in access to neonatal care, there is evidence of variation in the perceptions of viability 2 13. This is likely to arise from practical difficulties in interpreting true signs of life, inconsistent approaches by hospitals to such babies and subjective differences in judgements about the best outcome for parents.…”