Affiliations: Department of Pediatrics, University of California San
Francisco, San Francisco, CA, USA | Department of Obstetrics, Gynecology, and Reproductive
Sciences, University of California San Francisco, San Francisco, CA, USA
Note: [] Corresponding author: J. Colin Partridge, MD, MPH, Department of
Pediatrics, University of California San Francisco, San Francisco General
Hospital Mailstop 6E Pediatrics, 1001 Potrero Avenue, San Francisco, CA 94110,
USA. Tel.: +1 415 206 3088; Fax: +1 415 206 3686; E-mail:
[email protected]
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.
Keywords: Extreme prematurity, resuscitation, death and dying, counseling, decision-making
