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\begin{document}

\title{Clinician bias on the low resource workfloor This is a mini commentary
on R Goldenberg et al Birth asphyxia is under-rated as a cause of
preterm neonatal mortality in low- and middle- income countries: A
prospective, observational study from PURPOSe}



\author[1]{Evelyn Verheijen}%
\affil[1]{Maasziekenhuis Pantein Boxmeer}%


\vspace{-1em}



  
  \date{May 18, 2024}


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Clinician bias on the low resource workfloor

This is a mini commentary on R Goldenberg et al.,

In this study in two LMIC settings in Asia, expert panels who looked at
cause of death of premature neonates, with significantly more
information available, found far more birth asphyxia and less
Respiratory Distress Syndrome than the discharging NICU physicians did.
Some NICU physicians attributed respiratory distress in the premature
neonate to RDS by default, especially if there was no other information
to contradict this belief. Especially in the Pakistan setting, birth
asphyxia did not seem to be on the mind of the physician.

What could be possible explanations?

The maternal population, illiteracy rates, low rates of NICU admission
and high death rates in the Pakistan setting suggest an impoverished
background population and very restrained resources.

In such setting one could easily imagine diagnostic means and treatment
options are limited. If there is also lack of staff, reduced
availability of beds, and work overload (ref: authors correspondence),
priorities have to be made who to admit and who to treat. Life
expectancy and quality of life may play a role in triaging.

Physicians who work in labourward settings without CTGs may recognize
the viewpoint that obstetric management only be guided by the maternal
condition. On several SubSaharan African labourwards I experienced that
decisions were not (solely) to be based on the supposed fetal condition.
To perform `an unnecessary caesarean section', or on the other hand to
try and salvage the life of a baby who then turns out to be brain
damaged after a poor start, was not seen as good obstetric care. A
premature baby with apparent severe birth asphyxia might consequently
not be transferred to the NICU. A baby who is admitted may not carry the
diagnosis birth asphyxia since, as the authors point out this may imply
mismanagement. It could even go further: if potential fetal compromise
is not relevant in the obstetric management, it may also not be picked
up. The obstetric physician could in such situation easily develop a
blind spot for birth asphyxia.

Another cause of clinician bias in such low resource settings could be
underestimation of the gestation, making RDS a more likely diagnosis. If
gestational scans are not available, and last menstrual periods are
unreliable (associated with illiteracy) gestational age is more often
estimated by fundal height at presentation in labourward, or by the
birthweight of the baby. Underestimation could be the case in Pakistan
where 65\% of babies were thought to be less than 32 weeks, only 12,5 \%
of the neonates were thought to be growth restricted which is associated
with birth asphyxia, but nearly 63 \% suffered with birth asphyxia
according to the panel.

These are several hypotheses how physicians in a low resource setting
could form biases in their clinical thinking, which, when not corrected
by other information, could lead to incorrect diagnoses and
mismanagement. This correcting information could come from diagnostic
tools, such as PCR tests Xchest, etc,. However, sufficient time and
systems in place for proper handovers, e.g. between the obstetrician and
pediatrician, an open mind and awareness of pitfalls, audit and
reflection on one's management, and training to stay up to date are just
as important. Hopefully expert panel studies such as these, could
stimulate awareness and be a motor to improved Obstetric and Pediatric
Care in LMIC settings.

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