Pediatricians, Obstetricians Clash Over Prenatal Counseling

Yael Waknine

November 19, 2012

Obstetricians may be resisting pediatricians' input when managing certain maternal conditions that can affect a baby's health, according to the results of a survey published online November 5 in Pediatrics.

"Pediatric specialists at the forefront of prenatal diagnosis and therapy have long claimed that medical innovations in prenatal diagnosis and therapy will ultimately blur the boundaries between obstetrics and pediatrics, insofar as the well-being of the fetus and future child are concerned," write Stephen D. Brown, MD, from Boston Children's Hospital in Massachusetts, and colleagues.

For the study, investigators mailed confidential, self-administered, 106-item questionnaires to 454 maternal-fetal medicine specialists (MFMs) and 416 fetal care pediatric specialists (FCPs).

Analysis of data from 434 respondents showed that FCPs would like to counsel mothers before continuing or interrupting pregnancies complicated by alcohol abuse, cocaine abuse, antiseizure medication, or diabetes, but MFMs do not see the need.

MFMs were more than twice as likely to deny a need for FCP involvement before continuing or interrupting pregnancies complicated by alcohol abuse (63.1% vs 35.9%; odds ratio [OR], 3.5; 95% confidence interval [CI], 2.2 - 5.4) or cocaine abuse (59.7% vs 31.9%; OR, 3.5; 95% CI, 2.3 - 5.4).

MFMs were also less likely to see a need for FCP inclusion in cases involving antiseizure medications (62.1% vs 32.8%; OR, 3.3; 95% CI, 2.2 - 5.0) or diabetes (56.5% vs 27.4%; OR, 3.5; 95% CI, 2.3 - 5.4; P < .001 for all).

FCPs were also more likely to favor seeking court interventions for maternal refusal to enter cocaine detox (72.2% vs 32.9%; OR, 5.8; 95% CI, 3.7 - 9.0), refusal of azidothymidine therapy to prevent perinatal HIV transmission (79.9% vs 41.3%; OR, 6.6; 95% CI, 4.1 - 10.7), and refusal of percutaneous transfusion for fetal anemia (62.2% vs 28.0%; OR, 4.4; 95% CI, 2.9 - 6.8; P < .001 for all).

"[O]ur demonstrated differences between FCPs and MFMs regarding pediatric consultation for maternal conditions may not only reflect different understandings about the conditions per se, but also, the likelihood of postnatal consequences," the authors suggest.

Need for Teamwork

"As fetal care evolves, pediatric and obstetric practitioners (and their respective institutions and professional organizations) should recognize gaps in knowledge, understanding, and values, and work toward consensus reflecting best medical evidence and legal precedent," the authors write, noting the importance of supporting patients' abilities to make well-informed decisions according to their own values and free from coercion.

On the surface, MFMs and FCPs agree that collaboration between their fields is in the best interest of mother and baby.

"As an MFM doctor involved in prenatal diagnosis and fetal therapy, working at an academic center, I personally cannot imagine providing the kind of care we do without the input of our pediatric colleagues. They participate actively in our consultations regarding fetal birth defects, periviable care, and pending prematurity," Nancy Chescheir, MD, clinical professor of maternal-fetal medicine in the Department of Obstetrics & Gynecology at the University of North Carolina at Chapel Hill School of Medicine, told Medscape Medical News in an interview.

An FCP expressed similar sentiments to Medscape Medical News: "I like to say that everything I know about obstetrics, I learned in medical school 30 years ago. Obviously things have evolved for all of us, and I can't expect my MFM colleagues to be up to date on pediatric surgery, just like I need them to update me on obstetric care," said Francois I. Luks, MD, PhD.

Dr. Luks is a professor of surgery, pediatrics, obstetrics, and gynecology at the Alpert Medical School of Brown University and pediatric surgeon at the Fetal Treatment Program of New England in Providence, Rhode Island.

However, beneficence-based motivations to improve fetal and neonatal outcomes may not suffice in the context of new interventions. Some of these interventions raise ethical issues regarding maternal autonomy and decision-making, and in some cases, an institution's organizational requirements encourage turf wars between FCPs and MFMs.

Dr. Chescheir, for example, does not typically engage pediatricians in consultations regarding maternal illness or behaviors that do not involve fetal birth defects, periviable care, and pending prematurity, finding the concept "a bit foreign."

"As a maternal-fetal medicine physician, I do not feel the need to have pediatricians counsel patients about diabetes, substance abuse, or possible teratogen exposure. If an obstetrician were uncomfortable doing such counseling and the patient were considering termination for fetal indication, then consultation with an MFM if available is adequate consultation in my opinion to discuss the fetal/neonatal risks," Dr. Chescheir told Medscape Medical News.

Dr. Luks, however, favors a multidisciplinary approach to counseling that may benefit MFMs as well as the mother and baby.

"It's not that we need to override the MFM's counseling — the MFM specialists themselves are grateful to have a multidisciplinary team to help them counsel the patients," Dr. Luks explained, noting that a collaborative approach also guarantees that the decision to continue or terminate the pregnancy, although a personal and private one, is based on up-to-date medical evidence, rather than on old knowledge and misconceptions.

Collaboration can be of particular importance for issues such as diabetes, which can be addressed in different ways depending on the individual patient.

"Gestational diabetes is a condition that is usually within the realm of [the] MFM specialty, and its effects are probably more acute during pregnancy and childbirth than later in the child's life," Dr. Luks said. "On the other hand, complicated or poorly controlled maternal diabetes is often associated with specific fetal conditions such as caudal regression, and in those cases, FCPs are very often consulted early."

At Dr. Luks' institution, MFM specialists identify fetal conditions that may benefit from prenatal counseling, and sometimes intervention, by pediatric subspecialists. A fetal treatment program nurse coordinator arranges these consultations and often arranges for case discussion at Multidisciplinary Antenatal Diagnosis and Management meetings, which have been held for 16 years.

"We make sure that MFM and FCP specialists work together to offer consistent counseling," Dr. Luks emphasized, noting the potential for improved patient care provided by teamwork.

"Joint counseling is something that can be organized. If it is done for some conditions, it can also be done for a vaster group of patients, as discussed in this paper. Our neonatologists are very often asked to counsel pregnant women with conditions or behaviors that could affect the newborn, such as diabetes and alcohol abuse. Neonatologists are much better able to explain the findings and management of fetal alcohol syndrome as it affects the baby, not the mother," Dr. Luks stated.

Counseling Trumps Legal Action

"Nondirectiveness in counseling is based on respect for autonomous decision making by the patient, [and] autonomy is one of the core ethical principals underlying healthcare. I do not support court interventions to force patients to comply with care," Dr. Chescheir asserted in an interview with Medscape Medical News, calling the higher rate of willingness to seek legal injunctions reported by FCPs in the survey "somewhat alarming."

"There are certainly individuals who believe that the fetal rights trump the maternal rights. I am not one of them. It is my goal to work with pregnant women to make informed and autonomous decisions that usually will benefit, or at least not harm, the fetus," Dr. Chescheir added.

"Experience has shown that threatening pregnant women with incarceration for substance abuse has the result of driving women away from prenatal care altogether," she noted.

Dr. Luks agrees, emphasizing that cooperation between specialities can be of benefit in this arena as well.

"When it comes to less direct endangerment, such as cessation of smoking, MFM and FCPs should work in concert to convince the patient and to direct her to people who can help her. Both specialists are complementary and can help point out the danger to the mother, to the pregnancy, and to the future child," Dr. Luks told Medscape Medical News.

"But using a court order has the direct effect of violating the patient–doctor relationship, and in the absence of clear legal obligations, I believe that we, as physicians, have to uphold that patient–doctor bond as much as possible; therefore, counseling, referral and persuasion are more important and helpful than involvement of the court system," Dr. Luks added.

Funding was provided by grants from the Greenwall Foundation, the Kornfeld Program in Bioethics and Patient Care, and the Harvard University Milton Fund. Dr. Brown received salary support from the American Roentgen Ray Society Leonard Berlin Scholarship in Medical Professionalism and a Faculty Career Development Award, Office of Faculty Development, Boston Children's Hospital. The other authors and Dr. Luks and Dr. Chescheir have disclosed no relevant financial relationships.

Pediatrics. Published online November 5, 2012. Abstract