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Decision-making at the limits of viability: recognising the influence of parental factors
  1. Lucy K Smith,
  2. Ruth J Matthews,
  3. David J Field
  1. The Infant Mortality and Morbidity Studies, Department of Health Sciences, Centre for Medicine, University of Leicester, Leicester, UK
  1. Correspondence to Dr Lucy K Smith, The Infant Mortality and Morbidity Studies, Department of Health Sciences, University of Leicester, Centre for Medicine, Leicester LE1 7RH, UK; lucy.smith{at}

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Advances in antenatal and neonatal care of very preterm births have significantly improved the survival of babies who were once seen as non-viable,1–3 highlighting the need for reconsideration of the limits of viability.4 Recently, the American Academy of Pediatrics Neonatal Resuscitation Programme amended their recommendation to withhold resuscitation from babies born below 22 weeks of gestation rather than 23 weeks.5 6

Despite these trends, the well-established high rates of severe morbidity associated with survival at 22–24 weeks of gestation raise difficult ethical and policy questions when determining management policy, counselling parents and deciding whether to initiate intensive care. Care at these gestations is often referred to as individualised with many doctors only initiating active care if the parents are in clear agreement that they should do so. Inevitably, this can lead to significant variation in practice.7 A recent systematic review of 34 guidelines among 23 different countries highlighted that 68% supported the use of just comfort care at 22 weeks of gestation, but there was a lack of consensus regarding care provision at 23 and 24 weeks.8 In contrast from 25 weeks of gestation onwards, 65% supported active treatment and resuscitation.8

Morisaki and colleagues explored variations in the management of babies born at 22–24 weeks of gestation in Japan. They considered the influence of socioeconomic factors on death during delivery and up to 1 hour of life, which they labelled the peridelivery period. Death during …

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