P3.H148: Cultural and Clinical Dynamics in Neonatal Resuscitation Decision-Making: A Qualitative Study of Healthcare Providers in Ethiopia and Ghana

Background: In the United States, where respecting patient autonomy/parental authority is regarded as a central bioethical principle, clinicians must engage with parents to make decisions in situations of a poor anticipated prognosis for critically ill infants. These decisions may include whether to pursue maternal and infant interventions, whether to continue or terminate the pregnancy, what fetal monitoring is appropriate, when to deliver the infant and by what route, and which and whether resuscitative interventions should be provided to the infant at delivery. In low- and middle-income countries (LMICs), cultural norms may differ around the value of autonomy or appropriateness of engaging parents in such decisions. Limited literature exists on how healthcare workers in LMIC settings view the role of provider-patient (or in this case parent) engagement in medical decision-making, especially in the neonatal intensive care unit (NICU).

Methods: We performed an exploratory qualitative interview study to determine/ characterize clinician perspectives on provider-family communication within the neonatal intensive care unit in Ethiopia and Ghana. A purposive sample of interprofessional clinicians at three study sites with NICUs participated (n=40). Our approach followed the consolidated criteria for reporting qualitative research; we coded interviews through the constant comparative method of theme generation. Transcripts were coded by three team members with discrepancies resolved via discussion.

Results: Demographics of interviewed clinicians are in Table 1. Two major themes arose. The first major theme centered around their current practices, rationale, and disagreement with current practice (Table 2A). Clinicians in both Ghana and Ethiopia noted that parents are generally not included in resuscitation decisions, and that the default was to provide resuscitative efforts to all infants with signs of life. Their provided rationale for this approach is rooted in beneficence, cultural norms/societal expectations around paternalistic decision-making, presumed values of parents, and fears about mistrust. There were several participants who felt that parents should be more directly involved in conversations about resuscitation decision-making. The second major theme centered around exceptions to the universal resuscitation default and ways parents could influence decisions, even though their wishes were not specifically elicited in a shared-decision approach. Subthemes included non-resuscitation for known poor prognosis, pregnancy termination, abandoning the baby, leaving against medical advice, and electing not to pay for continued care.

Conclusion: Though clinicians do not routinely ask parents their preferences around provision of intensive care or comfort care, parents are able to assert their wishes not to pursue aggressive measures in some contexts through more indirect means. We speculate this may relate to the cultural acceptability of these conversations and comfort level of clinicians. More research is necessary to develop effective and culturally appropriate strategies for healthcare providers to involve parents in complex medical decision-making for their critically ill neonate in global settings.