Abstract
There is no international consensus on content and process regarding antenatal counseling in extreme prematurity. The need for adequate training is increasingly recognized. This descriptive study evaluates current practice in antenatal counseling amongst European trainees using an online survey. Focusing on the process, the majority of respondents did not have a medical consensus guideline. Seven percent of the trainees received some formal training. Focusing on the content, about half of the subjects did not mention any statistics about mortality.
Conclusion: We observed wide variation in actual content and organization in antenatal counseling in Europe amongst European trainees in neonatology.
Introduction
The impending delivery of an extremely premature infant confronts prospective parents and professionals with medical, ethical and emotional issues. Parents should be provided accurate and essential information in a comprehensive and understandable way to be able to understand their situation and to participate in the decision-making process. Surveys on practices in antenatal counseling in different regions (e.g. Northern America [Citation1], Asia and Oceania [Citation1] and England [Citation2]) showed heterogeneity in structure and content. A pilot study in a simulated setting exploring antenatal counseling in a Dutch and American cohort, confirmed this variation [Citation3]. Recommendations on antenatal counseling have been made and the need for adequate training to learn this complex task is increasingly recognized [Citation4,Citation5]. It is unsure to what extent formal training for antenatal counseling is already applied in Europe. The practice and perception on prenatal counseling of trainees in neonatology is important; they are our future neonatologists and it is, for example, known that the site of residency influences their ethos regarding resuscitation and decision-making in extreme prematurity [Citation6]. As part of the participation in the Leonardo da Vinci NOTE (Neonatal Online Training in Europe) project (MH, EM, SB) we used their existing network to explore current practices by trainees in European countries, both in process and content of antenatal counseling in very preterm birth.
Materials and methods
This custom-made online survey focused on both content (mortality, morbidity and practical aspects) and process (organizational aspects and supportive conditions) of antenatal counseling. The questions were about counseling practices prior to any anticipated extreme preterm birth (WHO) and aimed to look at actual practice as experienced by trainees. Information was obtained using an online survey (24 multiple-choice questions), set out in October 2010. Subjects were participants (n = 190) from the Leonardo da Vinci NOTE project and were all neonatologists in training. This NOTE project aimed to offer trainees a cross-cultural training program on several neonatal subjects (http://www.neonataltraining.eu/). Potential trainees were emailed through national organizations and participation was voluntarily. One reminder was sent in November 2010. Descriptive statistics were used (shown as a percentage, including only responders per question). We analyzed results on an individual level.
Results
Demographics
The response rate was 27% (n = 47). Of those 47 surveys, 43 were completed. Respondents were from 14 countries (Sweden (n = 10), United Kingdom (n = 10), Denmark (n = 5), Estonia (n = 4), Spain (n = 3), Slovenia (n = 2), Germany (n = 2), Latvia (n = 2), Netherlands (n = 2), Norway (n = 2), Turkey (n = 2), Ireland (n = 1), Poland (n = 1) and Slovakia (n = 1)) and from 38 different hospitals. As background information we refer to Gallagher et al., for a summary of national guidelines on resuscitation at the limits of viability [Citation7].
Table 1. Process and content of antenatal counseling.
Process of antenatal counseling
The majority of respondents (64%) did not have a written (local hospital) medical consensus guideline about procedure and/or content of antenatal counseling. Forty percent of respondents indicated that counseling conversations were not documented and only verbally communicated to colleagues, whereas 32% was reported in the maternal medical record or in a separate document in maternal (13%) or neonatal (9%) files. Seven percent of all respondents had some formal training in antenatal counseling and the other 93% acquired this knowledge and skill by observing colleagues and doing it themselves. Almost half of the respondents (47%) provided written information to parents; the remaining (53%) did not.
Content of antenatal counseling
Almost all respondents discussed mortality (98%), of whom 55% provided data on mortality based on gestational age and 43% did not discuss numbers or percentages with parents. Fifty percent mentioned long-term morbidity data if explicitly requested to do so by the parents and when long-term morbidity data were given in the counseling conversations a variety of sources was used.
Regarding the question “do you elaborate on potential events during delivery?” 81% discussed details of any resuscitation with the parents and also, 66% of the participants discussed that resuscitation may not be successful. There was some uniformity in the discussion of short-term physical problems and therapies related to preterm birth, for example 95% of respondents included the potential need for mechanical ventilation and surfactant 86% covered the need for care in an incubator; 82% the need for umbilical lines and 77% the need for intensive monitoring.
Discussion
European neonatal trainees reported variation in their antenatal counseling practices. Focusing on the process of antenatal counseling we discovered that the majority of respondents did not have a written medical consensus guideline about counselling and the majority did not receive formal training. Also, the counseling conversation was not documented in 40% of the cases and only verbally communicated, a similar percentage as previously found by Janvier et al. studying medical records on antenatal counselling conversations [Citation8]. In our opinion, such an important conversion should be noted - especially when resuscitation decisions are made, and it is important to facilitate fast and easy record keeping.
With regard to the content of antenatal counseling these data suggests that a significant number of respondents (45%) would not mention any statistics relating to mortality. It is questionable whether statistics should be used. Kipnis questions the value of statistics [Citation9] and Boss [Citation10] found that physicians’ predictions of morbidity and death are not central to parental decision-making regarding delivery room resuscitation. However, Partridge found parents suggesting “more data on outcomes” as an improvement for counseling [Citation1]. Maybe it is best to individually assess whether parents want to hear statistics.
The strongest aspect of this study is being the first study amongst trainees in neonatology in Europe, an interesting equivalent group (assumingly little experience in prenatal counseling and a relatively young age). An important limitation of our study is the representativeness since the response rate was low and the convenience sample of subjects makes it impossible to guarantee applicability of our data to all European trainees. Furthermore countries with large differences in population size can have the same number of correspondents. However, we think there is value of this study since it gives insight in current practice and training in different countries from participants of NOTE project. Also it is unknown how counseling is incorporated in the training in different countries. It is unsure whether trainees in neonatology are able to adequately assess all aspects of counseling. Performing adequate antenatal counseling in extreme prematurity is one of the objectives of neonatal trainees; their perception on counseling practices is certainly important.
Variety in reported practice may be due to cross-cultural differences, local policies on care, personal or hospital habits etc., but variation may also be due to insufficient training in antenatal counseling or due the lack of guidance. We believe that variation in antenatal counseling is in the best interest of the patient when the variation is based on individual characteristics for example: different norms and values of parents, different fetal (weight, age, etc.) and maternal characteristics. However, when variation is due to unclear data on morbidity or decision-models, insufficient training, or due to arbitrariness e.g. ‘who’s on call’, then we do not believe that is in the best interest of parents and their expected child. A supported consensus-guideline on antenatal counseling can provide guidance for the professionals who need to perform this complex task: for both senior staff members as well as for trainees. We believe that by providing frames for antenatal counseling, quality will be improved and even more scope for individualization will be created. Besides, it is important to guide trainees in the complex task of performing antenatal counseling. A minority in this survey did receive formal training (7%). This is similar to other findings: only 33% of Canadian fellow programs provide structured training for antenatal counseling at the threshold of viability [Citation5] and 41% of US fellows had no formal training focused on neonatal communication skills [Citation11]. A framework suggested by Moussa et al. might be of help in providing the most appropriate antenatal consultation for parents. Incorporating these kinds of frameworks in an educational curriculum might be a good idea and these trainee curricula may also benefit by the use of simulation [Citation3,Citation4].
Conclusion
We observed wide variation in the actual content and organization in antenatal counseling in European trainees in neonatology.
Declaration of interest
There was no funding. All authors declare that there is no conflict of interest. Informed consent was obtained from all individual participants included in the study.
Compliance with ethical standards
All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.
Acknowledgements
We would like to thank the participants and organization of the Leonardo da Vinci NOTE (Neonatal Online Training in Europe) project for their cooperation.
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