Obstetricians' attitudes and practices of life support for extremely premature low birth weight infants in El Salvador

Abstract

Background: The increasing availability of costly life-support technologies in developing countries raises questions about the utility of resuscitation and intensive care for extremely premature infants.

Objective: To characterize obstetricians' attitudes and resuscitation practices for preterm infants in El Salvador.

Design/Methods: Surveys (n = 214) were mailed to Salvadoran perinatal providers in 2000, and 100 more were distributed at a Latin American obstetrics and gynecology conference in December 2000. Survey questions covered counseling practices, resuscitation thresholds for prematurity, attitudes on life support, and demographics.

Results: Of 111 Salvadoran respondents, more providers counsel parents antenatally (41% at 25 wks to 58% at 29 wks) as gestational age increased. Median thresholds for resuscitation were 26 weeks for intubation and ventilation and 27 weeks for cardiac massage or pharmacologic resuscitation, and 1000 grams for each of these interventions. Seventy-two percent of respondents would use all interventions to save life regardless of anticipated outcome, a stance correlated with religious activity (p = 0.03). Decisions to limit resuscitation were influenced by congenital anomalies (62%) more than parental wishes (28%), infant pain (21%) and moral or religious considerations (27%). Older obstetricians were more likely to withdraw support from an extremely premature infant with perinatal HIV exposure (p = 0.006), but not with severe intraventricular hemorrhage or a major congenital anomaly. Fifty-five percent felt their institution was "not aggressive enough" in caring for infants < 26 wks gestation. Less religious obstetricians were more likely to perceive their unit as "too aggressive." Over 80% believed that physicians (44%), rather than parents (15%), should make final resuscitation decisions when consensus cannot be reached.

Conclusions: In El Salvador, the obstetric management of extreme prematurity is influenced by providers' level of religious activity. The majority of obstetricians regard care in their unit as not aggressive enough, despite using higher resuscitation thresholds than in other developing countries. Local economic constraints influence resuscitation options available to obstetricians and parents of extremely premature infants.