Critical obstetric situations - obstetricians' ethical decision-making and parents' handling of threat of preterm birth

Abstract: Ethical issues arise in obstetric situations and demand the obstetrician’s moral consideration for those who are involved in the actual case (Paper I). A balance between the health of the foetus and the autonomy of the woman is necessary to do the best for both the mother and her foetus/infant. Preterm birth is one of the main causes of mortality and morbidity for the child, in short and long term (Paper II). When the mother is hospitalized, a feeling of frustration can appear due to her concern for the foetus during the pregnancy and of her ability to function as a mother, wife and working woman. Fathers are worried when their partner has a threat of preterm birth. It is important for the woman and her partner to be informed and to take part in the decision-making process. The overall aim of this thesis was to illuminate and gain deeper understanding of obstetricians’ and parents’ experiences of being in a critical obstetric situation. The thesis includes two specific aims: to highlight the meaning of being in ethically difficult obstetric situations as narrated by obstetricians (Paper I) and to gain a deeper understanding of both parents’ experiences, when the mother was hospitalized due to a threat of preterm birth (Paper II). Both studies have a qualitative approach and a hermeneutic phenomenological method was used in Paper I and Grounded Theory in Paper II. Data collection was done with tape-recorded interviews in both studies. The findings in Paper I are described thematically with one overriding theme; Sympathetic responsibility in decisions of critical importance for the mother and her infant. Five themes illuminated the decision-making process which the obstetricians went through during the situations; ‘To proceed with a moral reasoning that leads to the choice of a solution’, ‘To balance one’s own medical knowledge and moral insight with the needs and requests of the parents’, ‘To know one’s medical and moral responsibility in the relation to the decision made’, ‘To experience the ability to take action and to make and carry out difficult and important decisions for the health of the mother and her infant’ and ‘To reflect on a given situation in a manner leading to a rational acceptance of one’s own conduct’. The parents’ main concern is shown through the concepts of the parents’ experiences of threat of preterm birth (Paper II). This included the core category “Inter-adapting” followed by three categories with six related subcategories; Interacting (‘Communicating with the professional caregivers’, ‘Keeping the family together through a stressful situation’, ‘Seeking empowerment during labour and birth’), Reorganizing (‘Arranging for a new family situation’) and Caring (‘Accepting the restrictions for the sake of the health of the foetus’, ‘Reaching out to the infant and taking part in the care’). “Inter-adapting” is a new concept and was interpreted as a mutual adaptation between the actors involved in the situation. The theoretical model “Inter-adapting to Threat of Preterm Birth” was developed and named the ITPB-model. In conclusion, sympathetic responsibility is present during the obstetricians’ decision-making process and includes a moral reasoning while balancing their medical knowledge against the woman’s autonomy and the health of the foetus/infant. Emotional strain for the obstetricians could appear during the situation. Their decision-making was aimed at obtaining the best possible outcome for both mother and infant (Paper I). The concern of the foetus/infant made the parents accept the hospitalization. Reorganizing their work situation and home responsibility was important to enable the family to function. When ‘‘Inter-adapting” occurred between the parents and the actors involved, the parents were able to manage the situation (Paper II). Implications for care could be formal meetings with different professionals to discuss ethically difficult situations. This could lead to a deeper understanding and co-operation between colleagues and professions (Paper I). To strengthen and support the parents during hospitalization and decrease the feeling of separation by integrating the different wards involved, could help the family manage their situation (Paper II).