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Obstetricians’ Attitudes Toward the Treatment of Extremely Preterm Infants in China

Key Points Question What are the attitudes of obstetricians toward the resuscitation and treatment of extremely preterm infants (EPIs) in China? Findings In this cross-sectional study of 2817 obstetricians from 30 provinces and cities in mainland China in 2021, the proportion of obstetricians who supported resuscitation of preterm infants was 19.1% at a gestational age of 24 weeks, 24.1% at 25 weeks, 54.8% at 26 weeks, and 100.0% at 27 weeks. In addition, 27.2% of obstetricians suggested that the cutoff for providing full care to preterm infants in China should be adjusted further downward. Meaning These findings suggest that most Chinese obstetricians maintain a conservative attitude toward the treatment of EPIs, which is mainly related to their concern about the poor prognosis.


Introduction
Extremely preterm infants (EPIs) are premature infants with a gestational age of less than 28 weeks who are at high risk of mortality and disability because of their extremely immature organ development and the extreme difficulty in treating them. 1  At present, there are many ethical controversies over the lowest gestational age for the treatment of EPIs, even in developed countries and regions. 3,4 In recent years, with the development of perinatal systems and technical advancements in the treatment of premature infants, both the short-term and long-term prognosis of EPIs, especially those over 24 weeks' gestational age, have improved remarkably. 5,6 At present, most developed countries tend to adopt a positive attitude toward the treatment of EPIs. 7 A study 8 from the US showed that, from 2013 to 2018, the survival rates were 10.9% for infants born alive at 22 weeks, 49.4% for those born at 23 weeks, and 94.0% for those born at 28 weeks. In addition, the percentage of infants for whom active treatment was implemented was 36.5% for those born at 22 weeks, 88.5% for those born at 23 weeks, 97.9% for those born at 24 weeks, and more than 99.0% for those born at 25 to 28 weeks. A Chinese small sample survey 9 on the attitudes of neonatologists toward the active treatment of EPIs in 2017 showed that 21% of respondents would only resuscitate infants born at 28 weeks or later, indicating that the enthusiasm of treating EPIs in China is generally lower than that in developed countries.
Since the beginning of the 21st century, more neonatal intensive care units (NICUs) have been established throughout China, and more EPIs have been treated successfully in terms of both the survival rate and prognosis, especially in NICUs of large-scale tertiary hospitals, where the survival rate of EPIs over 24 weeks' gestational age has reached a level comparable to that in developed countries. 10,11 However, according to the guidelines for clinical diagnosis and treatment of preterm infants by the Obstetrics and Gynecology Branch of the Chinese Medical Association, 12 the current cutoff for providing full care to preterm infants in China is gestational age 28 weeks. Because of the difficulty of treatment and the high incidence of complications after survival, preterm infants born before 28 weeks are not covered. 12 Most EPIs were withdrawn from resuscitation in the delivery room, and, therefore, the proportion of them receiving active treatment in the NICU is very low. 13 The treatment of EPIs has also been a medical controversy, causing serious medical disputes and social concerns. The treatment of EPIs highly depends on well-established perinatal systems, requiring concerted cooperation between obstetrics and pediatrics, especially on the part of the obstetrician.
In China, although neonatologists are the leading force in EPI resuscitation, they are not always involved in prenatal communication with the parents. Obstetricians are important members of the resuscitation team, and they are direct communicators with the parents; therefore, their attitudes have great impact on the treatment decisions of the parents. To clarify the attitude of Chinese obstetricians toward the treatment of EPIs and their opinions about the cutoff for providing full care to preterm infants in China, we organized this national survey to provide information for improving the treatment of EPIs and optimizing pediatric health policies and services in future.

Methods
This cross-sectional study was approved by the research ethics board of the Seventh Medical Center of Chinese PLA General Hospital (Beijing, China), with a waiver of informed consent from this ethics board because of the observational design of the study. This study follows the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline.

Survey Respondents and Questionnaire Formulation
The survey respondents were obstetricians in China under the following inclusion criterion: obstetricians registered in public hospitals in mainland China. The questionnaire form was designed after repeated discussions and revisions by hospital management experts and senior neonatal and obstetric experts. The questionnaire consisted of 28 items, including characteristics of the participants, the annual delivery number of EPIs in their units, their attitudes toward the resuscitation of EPIs at different gestational ages, and their opinions about the cutoff for providing full care to preterm infants in China.

Survey Time and Methods
The survey was conducted from June to July 2021. A questionnaire form was designed and distributed via the survey platform wenjuanxing among several WeChat groups composed of national obstetric experts in China, and then was forwarded to obstetrician groups in their provinces and cities for online survey. There were standard instructions for the questionnaire survey, and appointed people were assigned to be responsible for the distribution, recovery, and quality control of the questionnaires. The questionnaires were anonymous, and all questions in the questionnaire were required to be answered.

Statistical Analysis
The results conforming to normal distribution are expressed as mean and SD, and categorical data are presented as frequencies and percentages. A multivariable logistic regression analysis was conducted to examine factors associated with obstetricians' opinions about the current lowest gestational age for providing full care to preterm infants. The variables included in the model were as follows: gender, professional title, marital status, having children or not, region, working history, hospital level, hospital category, experience of delivering EPIs, and the annual delivery number of EPIs. All P values were 2-sided, and significance was set at P < .05. The survey data were collected and statistically analyzed by use SPSS statistical software version 26.0 (IBM). Data analysis was performed from August 2021 to January 2022.

Attitudes of the Obstetricians Toward Resuscitation of EPIs at Different Gestational Ages and Birth Weights and Factors Associated With Resuscitation Decision of EPIs
The proportion of the 2817 obstetricians who supported active resuscitation for EPIs was 3.6% (102 respondents) for gestational age less than 24 weeks, 19 EPIs with a birth weight of 749 to 999 g, and 2817 (100.0%) supported resuscitation of EPIs with a birth weight of 1000 g or more (Table 2). Gestational age was considered the most important factor associated with the resuscitation decision of EPIs, followed by parents' willingness, the vitality at  (Figure). A multivariable logistic regression model was used to estimate factors associated with obstetricians' opinions about the current cutoff for providing full care to preterm infants, and the results are shown in Table 4. The higher the professional title of the obstetricians, the longer the working years, the higher the hospital level, the more annual delivery of EPIs in their departments, the higher the proportion of the obstetricians who thought of the current gestational age for providing full care as inappropriate. In addition, there were significant regional differences in the attitude toward the treatment of EPIs, and the proportion of the obstetricians who thought of the

Discussion
Whether obstetricians are active in treating EPIs is directly associated with whether EPIs can get an opportunity to enter the NICU for treatment. To our knowledge, this is the first nationwide, crosssectional, online, questionnaire-based survey on obstetricians' attitudes toward the treatment of EPIs, covering 30 provinces and cities in mainland China. We found that most obstetricians in China had a conservative attitude toward the treatment of EPIs, which was mainly associated with the concerns about their poor prognosis.
Because of the difficulty of treatment and the high incidence of complications after survival, it has always been a clinical dilemma whether to actively resuscitate EPIs, especially those in the gray area below 25 weeks. 14,15 At present, with the advancement of treatment technology, developed countries have a more positive attitude toward the treatment of EPIs, especially for EPIs with a gestational age of 24 weeks or more. A survey conducted in the UK, Sweden, and the Netherlands showed that, for an EPI who was born in a good condition, regarding the lowest gestational age at which resuscitation would be provided, 60% of UK respondents advocated resuscitation beyond 23 weeks' gestational age, 56% of Swedish respondents advocated resuscitation beyond 22 weeks' gestational age, and 58% of Dutch respondents advocated resuscitation beyond 24 weeks' gestational age. 16 A Dutch study 17 reported that 54% and 64% respondents advocated implementation of intensive care for infants at 24 and 25 weeks' gestation, respectively, and 89% and 96% of respondents advocated implementation of resuscitation for infants at 26 and 27 weeks' gestation, respectively. A Japanese study 18  another study 21 reported that physicians' years of experience did not have a significant impact on their attitude toward EPI resuscitation. A survey in a developing country 22 found that physicians aged 46 to 55 years and those older than 55 years were more likely to choose a higher birth weight as the limit of viability, and similar results were observed among physicians with 10 to 20 years of practice and those with more than 20 years of practice. The possible reason for obstetricians' positive attitude toward the treatment of EPIs in our study is that they come from large-scale tertiary hospitals, where the survival rate of EPIs is high and the incidence of sequelae is low, so they are more confident in the treatment of EPIs.
In China, economic development is not regionally balanced: the eastern region is the most economically developed, followed by the central region, and the western region is the least economically developed. The same is true of medical development. Regional distribution is also a factor affecting the attitude toward treatment of EPIs, so the enthusiasm of obstetricians in treating EPIs decreased successively in the eastern, central, and western regions. This is completely consistent with the regional difference in distribution of the neonatal treatment resources reported in our previous investigation. 23 This also indicates that the ability and level of treating EPIs directly affect the treatment attitude toward EPIs. This is consistent with the results of a Lebanese study, 22 which found that health care resource allocation was ranked second as an influencing factor of treatment of EPIs, and physicians practicing in higher level NICUs (levels Ն3) had a significant trend of choosing lower birthweight limit of viability compared with those practicing at a facility with no NICU.
Although most obstetricians investigated in China prescribed antenatal corticosteroids to EPIs and worked together with the pediatricians in birth attendance of EPIs, they on the whole held a negative attitude toward the treatment of EPIs. It was found in our study that more than half of the obstetricians felt uncertain whether EPIs should be sent to the NICU for treatment, mainly because they were not sure about the prognosis of EPIs or worried about the emergence of disputes in case a poor prognosis should occur. Because of the lack of relevant laws in this field, medical and ethical disputes arising from EPIs will surely increase in future and therefore relevant legal and ethical systems need to be augmented urgently.
This study found that the obstetricians' attitude toward the treatment of EPIs remains dilemmatic in China at present. In addition, the attitudes toward the treatment of EPIs are closely associated with the experience of the obstetricians concerned and their ability to deal with EPIs. With the further decline of the birth rate and the trend of having fewer children in the family, the treatment of EPIs is bound to arouse more attention. In our opinion, strengthening the collaboration between obstetrics and pediatrics, improving the treatment level of EPIs and the prognosis, and establishing sound legal and ethical systems should be given top priority in the future work in this field in China.

Limitations
This study has some limitations. First, it is a cross-sectional study and the participants were not selected randomly, which may limit generalizability. Second, the number of participants varies among provinces, which may result in a potential sampling bias.

Conclusions
The results of this nationwide, cross-sectional, online, questionnaire-based survey provide evidence that most Chinese obstetricians maintain a conservative attitude toward the treatment of EPIs. It is very common for EPIs to be withdrawn from treatment without entering the NICU directly after birth. Most obstetricians think that the lowest gestational age for providing full care to premature infants should be 28 weeks.