May 8, 2000 -- While medical advances have dramatically raised the survival rate for premature babies and lowered their risks of developing serious handicaps, many pediatricians and obstetricians may not be knowledgeable about the current statistics, a new study suggests. And researchers are concerned that this could mean they aren't treating these babies as aggressively as they should.
Premature births occur in 6% to 10% of all pregnancies, and prematurity is the most common cause of sickness and death among newborn babies. If they survive, these babies are at risk for serious handicaps such as cerebral palsy, mental retardation, and developmental delay.
A survey by researchers from the University of Alabama found that obstetricians and pediatricians underestimated premature infants' odds of survival and overestimated their chances of developing a serious handicap. For example, the researchers say, the actual survival rate for a baby delivered at 28 weeks is 84 percent, but the pediatricians who were surveyed put the rate at 68 percent, while the obstetricians estimated 58 percent.
"It?s difficult to say whether or not these misconceptions have affected care," study investigator James Haywood, MD, tells WebMD. "From our data, we can see that obstetricians tend to refer women to centers that have intensive-care nurseries, even if they have misconceptions about the baby?s outcome." Haywood is a neonatologist and associate professor of pediatrics at the University of Alabama School of Medicine in Birmingham.
Problems may occur in a hospital without a neonatologist (a pediatrician who specializes in newborn babies), he says: "A pediatrician or family doctor may be the one who will counsel a parent with a pessimistic outcome expectation." While the researchers don?t have nationwide data, says Haywood, local data from Alabama shows that when women in preterm labor or their premature babies are not referred to a medical center with appropriate facilities, the death rate is higher.
Steven Morse, MD, and colleagues from the University of Alabama at Birmingham sent out more than 1,850 questionnaires to randomly selected general practice obstetricians and pediatricians.
"Since most babies are born in centers without a neonatologist, pediatricians are going to be called upon to make decisions, whether they attend a delivery or counsel a woman in labor," Haywood says. "We wanted to survey the people who would most likely be faced with making these decisions."
It?s not surprising that many general practice obstetricians and pediatricians underestimated the survival rates, says Michael Speer, MD, who reviewed the study for WebMD. "Typically, the learning curve of the general obstetrician and general pediatrician - -as far as survival and intact survival, and degree of handicap - -will lag behind that of fetal maternal obstetricians and neonatologists," he says. "And that?s not unreasonable, because most pediatricians and obstetricians do not take care of that many small babies." Speer is a neonatologist and an associate professor of pediatrics at Baylor College of Medicine in Houston.
In the survey, obstetricians were given a hypothetical case and asked what they would do to help a women in preterm labor. Such interventions included performing a cesarean section for fetal distress, or transferring the patient to a facility capable of caring for a premature infant.
Pediatricians were asked to select which interventions they would choose for premature babies of any age. These included putting the baby on a ventilator for respiratory support, administering intravenous fluids for hydration and nutritional needs, and performing cardiopulmonary resuscitation (CPR).
The physicians were divided into "optimist" and "pessimist" groups, to further determine whether their survival rate estimates correlated with their willingness to provide therapeutic interventions.
On average, the optimists appeared more willing to perform interventions to a preterm baby at an earlier age than the pessimists. For example, an optimist may decide to do CPR on a baby born at 25 weeks, whereas the pessimist tended to wait until they were 26 weeks or older. An optimist was also more likely to have a woman in preterm labor transferred to a medical center with a newborn intensive care nursery, even if she was only 23 weeks pregnant.
Physician's opinions are often based on personal experience, Speer tells WebMD. "If physicians live in a rural area, for example, the outcome may not be that good because they don?t have neonatal facilities. ... They?re not going to be aware of what the optimal outcome is going to be."
Caregivers tend to remember the patients who had the poorest outcomes, both Haywood and Speer say. That can color their view that the general prognosis isn't good. "Doctors are influenced markedly by single patients," says Speer. "Patients who have multiple problems will loom larger in [physicians'] memory than the patient who has no problems."
The key to improving these misconceptions is education, Haywood believes. "We need to do a better job of educating our colleagues and keeping them current in neonatal outcome so they can give proper advice and take appropriate interventions."
This work was supported in part by a grant from the Alabama Chapter, March of Dimes Birth Defects Foundation; by the Agency for Health Care Policy; and by Research Department of Health and Human Services.
- Preterm births occur in 6-10% of all pregnancies and they are the most common cause of illness and death among newborns.
- Obstetricians and pediatricians have some misconceptions about preterm babies, underestimating their chances of survival and overestimating their chances of developing a handicap.
- According to one neonatal specialist, physicians need to be better educated about trends in neonatal care so that they can give appropriate advice and medical care.