Discussion

In our national survey, we examined neonatologists’ attitudes towards resuscitation at the verge of viability, specifically the attitude regarding the infant’s best interest at 22, 23 and 24 weeks gestation. We asked about the resuscitation decisions during these weeks, and the basis for these decisions and assessed how they correspond with the published national guidelines. Overall, the physicians demonstrated diversity and occasional discrepancies with the national guidelines concerning resuscitation at the border of viability. Israel is a melting pot of religions and ethnicities and this variation could inform policy-makers and the health fraternity on best ways to handle a question that really has no answer.

When asked about resuscitation preferences according to parents’ wish, at 22 weeks, 14% answered that they would perform some resuscitation actions even if the parents wished to avoid it. If the parents’ wish was unknown, almost half preferred some resuscitation effort, especially if the newborn was vital. If the parents desired full treatment, over 70% would resuscitate the newborn, regardless of vitality. This variability in the approach regarding resuscitation is inconsistent with the recommendations of the National Neonatology Association that supports compassionate care only and does not correspond to the fact that over 75% thought that resuscitation is not in the best interest of the preterm newborn at this gestation.

At 23 weeks gestation, most physicians aligned with parents’ wishes and national guidelines, choosing not to resuscitate if the parents were against it or fully resuscitate if the parents wanted it. However, 25% of physicians would initiate some resuscitation, especially if the newborn was vital, even against parents’ wishes. If parents desired full treatment, all physicians tended to provide care but were often limited to intubation. Interestingly, if the parents’ wish is unknown, only 16% would provide compassionate care, despite 50% declaring previously that resuscitation is not in the newborn’s best interest at 23 weeks. Overall, our findings reveal a gap between the neonatologists’ perception as to what is or is not in the best interest of the newborn and their pragmatic view, which is mostly affected by parents’ wishes but is also related to deeper personal attitudes and beliefs that may contradict each other.

Physicians tend to provide resuscitation when attending birth at 24 weeks gestation. However, even in such cases, medical discretion is exercised. Hence, almost half and more than half will resuscitate only if the infant is vital, if the parents’ wish is unknown or against providing care, respectively. When the parents are against care, 17% will choose compassionate care only. In general, participants’ attitudes regarding resuscitation at the age of 24 weeks of pregnancy were variable, but in line with the 2020 national guidelines.

Our findings show that neonatologists’ personal beliefs as to whether providing full and intensive care immediately after a premature infant is born is in the best or not in the best interests of the infant is mostly expressed in two scenarios: when parents’ wishes are unknown, and when parents seek to withhold care. However, when parents seek full care, such personal views are less powerful in determining the course of treatment. Despite religious and cultural diversity in Israel, and similar to another study,17 which surveyed Israeli neonatologist’ views on life and death issues, our study also reveals that Israeli neonatologists’ ethnic, religious or religiosity levels have little impact on their decision of whether to resuscitate a premature child. Instead, they refer mostly to considerations such as the child’s chances of survival, caring for a handicapped child and respecting parents’ wishes.

Around the globe, neonatologists acknowledge the significance of including parents in the decision-making process, but their approach varies depending on the infant’s GA.18 19 Belgian neonatologists noted the existence of a grey zone, placed at 23–24 weeks gestation, where parents were perceived as the primary decision-makers due to the significant clinical ambiguity. Beyond this grey zone, that is, below 23 weeks and above 24 weeks gestation, physicians were considered the main decision-makers, and while parents’ desires were considered, counselling became more authoritative and the physician made the ultimate decision.19

In their study, Tan et al showed differences between clinicians and parents when deciding on resuscitation or neonatal intensive care treatment. Parents appeared to be more tolerant of a higher mortality and averse to disability risks compared with clinicians.18 However, parents do not approach these decisions from one common perspective.20 In addition, there is significant variation among neonatal professionals’ assessments of survival and severe disability rates for extremely premature infants, which can further affect the precision of informed shared decision-making.21 Accordingly, Haward et al suggested moving from doctor-driven to parent-personalised discussions when counselling at the grey zone of viability.20

The findings in this study reveal that neonatologists’ views regarding the resuscitation at 22 weeks, and in some circumstances at 23 weeks as well, do not correspond to the national guidelines. Resuscitation guidelines in the threshold of viability vary among different countries, but they generally recommend that infants born at or beyond 23 weeks gestation should be considered for active resuscitation while those born earlier will receive comfort care or should be managed according to individual circumstances. Decisions about resuscitation take into account factors such as GA, birth weight, parental preferences and the infant’s overall condition. In Canada and UK. palliative care is suggested when there is high risk for mortality or severe neurodevelopmental disability, which includes, for example, all infants born at 22 weeks GA, or birth weight <400 g irrespective of additional risk factors, and intensive care and palliative care are both usual care options for infants at 23 weeks.10 22 Based on survival rate without major impairment, in Australia and New Zealand, guidelines suggest that for infants born at 23 weeks, decisions about the baby’s best interests should be made in partnership with parents and can be flexible while those born at 22 weeks gestation will usually receive comfort care. Infants born at 24 weeks will usually receive full resuscitation and care.23 In Belgium, from 24 weeks resuscitation is mandatory. After 24 weeks, resuscitation is generally not recommended, but exceptions are considered.19 In the USA, the guidance by the American College of Obstetricians and the American Academy of Pediatrics (AAP) is to consider resuscitation at 22 and 23 weeks and recommend it at 24 and 25 weeks.24–26 As mentioned, the Israeli guidlines16 state that no intensive care should be provided at 22.0–22.6 weeks gestation, and that providing intensive care to preterm infants born at 24.0 gestation and higher is the default. At 23.0–23.6 gestation, treatment should be in accordance with the parents’ wishes and the newborn’s clinical status and response to intensive care after birth.16

Although many guidelines resemble the Israeli guidelines, in some countries, a more proactive approach is common even at 22 weeks.27 Outcomes of infants delivered at 22–24 weeks of gestation vary significantly between countries and even between centres.5 The data on survival of extremely premature infants in Israel show practically no survival at 22.0–22.6 weeks gestation, around 17% survival for preterm infants born at 23.0–23.6 weeks gestation, and 50%–60% at 24.0–24.6 weeks .28 Among other explanations for the low survival rate in Israel, which is considered a modern developed country with good medical capabilities, one can argue for a self-fulfilling prophecy explanation. Accordingly, if neonatologists in Israel believe that survival is extremely rare at 22–23 weeks gestation, they will refrain from providing intensive care to newborns born at these weeks. Adhering to this argument, it is possible, theoretically, that if neonatologists offer more intensive care at 23 and even at 22 weeks gestation, the survival rate may increase.

Similar to our research, other studies have shown that the approach of medical staff to resuscitation at the threshold of viability varies and does not always adhere to published guidelines and frameworks. One possible cause is that the prognosis of premature birth at the threshold of viability is not solely dependent on GA and is more complex.9 To better reflect the views of medical professionals, guidelines should take into consideration additional factors that affect the survival and survival without impairment of these newborns. This may result in guidelines that more accurately represent the diversity of opinions.29

Despite having more detailed guidelines that consider various factors when determining whether resuscitation should be recommended or avoided beyond GA, the medical staff still have their own attitudes and make decisions that deviate from these guidelines. In the UK, neonatal professionals’ interpretation and subsequent management decisions do not always follow the guideline framework’s recommendations.21 LoRe et al found that physicians’ views of extremely early newborns’ future quality of life correlated with self-reported resuscitation preferences and varied by specialty and level of training.30 Varying approaches used by midwives, obstetricians, neonatologists and nurses who provide perinatal counselling to parents at extremely low GAs lead to conflicting advice, particularly when opinions regarding treatment decisions diverge.31 In the USA, Boghossian et al demonstrated a significant regional disparity in perinatal interventions for the care of neonates at 22 and 23 weeks gestation. Regional and racial-ethnic differences can also influence perinatal interventions. Thus, for example, in the Northeast and West regions of the USA, neonates from minority backgrounds at 22 and 23 weeks gestation received a greater amount of postnatal life support.25

As suggested by Williams et al, plausible solution to bridge the gap between the viewpoints of healthcare providers and the guidelines would be to create guidelines based on comprehensive and extensive survey of medical professionals from various specialties who manage premature infants. This would enable the creation of guidelines that reflect a diverse range of accepted perspectives.32

Our study has limitations. We acknowledge the potential controversy surrounding the strategy of resuscitating if the baby is deemed ‘vital’ (as outlined in table 1, strategies 3 and 4). It is noted that Apgar scores and heart rates at 1 and 5 min may not reliably predict survival or intact neurological survival.31 Nevertheless, similar to the consideration of other treatment options, neonatologists contributed suggestions regarding these options during the construction of the questionnaire, and they were all chosen intermittently in the survey itself. 71 response rate, while good, may be considered moderate for such an important topic and given its descriptive nature. Non-responders’ characteristics were similar to responders (data are not shown). Additionally, this is a survey, and there might be a gap between what neonatologists say they would do and their actual practices. Further studies should compare the results of the survey to actual data regarding resuscitation and survival rates in various neonatal deliveries.