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Heterogeneity in Blood Product Acceptance Among Antenatal Patients of the Jehovah's Witness Faith

Hubbard, Richard MD; Waters, Jonathan H. MD; Yazer, Mark H. MD

doi: 10.1097/AOG.0000000000001065
Contents: Original Research
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OBJECTIVE: To understand the antepartum attitudes toward blood product transfusion among members of the Jehovah's Witness faith.

METHODS: We performed a retrospective study using antenatal consultation notes of Jehovah's Witness patients from the bloodless medicine program at a regional tertiary care maternity hospital over a 4-year period to determine their blood transfusion preferences.

RESULTS: Eighty-seven consultations were performed. The median age of women undergoing consultation was 27 years (range 14–39 years), and most were either African American (48/87 [55.2%]; 95% confidence interval [CI] 44.8–65.7) or Caucasian (35/87 [40.2%]; 95% CI 29.9–50.5). The mean±standard deviation antenatal hemoglobin concentration was 11.9±1.4 g/dL (n=57). Although all 87 women stated that they would not accept conventional blood products such as red blood cells, plasma, or platelets, 55 of 87 (63.2%; 95% CI 53.1–73.3) stated that they would accept all of the recombinant or fractionated blood products including cryoprecipitate. Stated acceptance of fractionated or recombinant products did not vary by parity, race, or age. A further 23 of 87 (26.4%; 95% CI 17.1–35.7) women stated they would accept some but not all of the fractionated or recombinant blood products, whereas 9 of 87 (10.3%; 95% CI 3.9–16.7) stated they would not accept any of these products.

CONCLUSION: In the antenatal period, Jehovah's Witness women have variable attitudes toward receipt of blood products. A discussion with each patient is essential to understand whether and which blood products may be used when indicated.

In the antepartum period, Jehovah's Witness patients state they would decline conventional blood products but many would accept certain kinds of fractionated or recombinant products.

Departments of Anesthesiology, Bioengineering, and Pathology, University of Pittsburgh, the McGowan Institute for Regenerative Medicine, and the Institute for Transfusion Medicine, Pittsburgh, Pennsylvania.

Corresponding author: Mark H. Yazer, MD, The Institute for Transfusion Medicine, 3636 Boulevard of the Allies, Pittsburgh, PA 15213; e-mail: yazermh@upmc.edu.

Financial Disclosure The authors did not report any potential conflicts of interest.

The authors thank Mary Kay Wisniewski for critical review of the manuscript.

The Jehovah's Witnesses are a Christian denomination with a global population of approximately 8.2 million, representing 0.8% of the U.S. population. There exists a perception that they will decline all blood products. Although some blood products are generally forbidden according to the tenets of the faith such as red blood cells (RBCs), granulocytes, plasma, and platelets, the choice to accept or decline others, including fractioned blood products and salvaged shed blood, is generally left to the individual's conscience. Several studies have investigated the viewpoints of people of the Jehovah's Witness faith concerning the receipt of blood products with many respondents reporting divergent views on the receipt of specific blood products.1–31–31–3 These studies indicate that apart from declining all of the conventional blood products, significant heterogeneity exists in their attitudes toward the receipt of other blood products.

The peripartum setting is a particularly challenging environment for the care of Jehovah's Witnesses given the risk of hemorrhage and the resulting potential for morbidity and mortality in both mother and fetus. However, little research has been conducted on the actual views and decisions taken by pregnant Jehovah's Witnesses with regard to blood transfusion. A previous study reported that nearly 10% would accept allogeneic RBCs, and nearly 40% would accept other kinds of blood products.3 This study was designed to investigate the nature of the blood products that antenatal Jehovah's Witness patients would and would not accept in the event of a postpartum hemorrhage.

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MATERIALS AND METHODS

This retrospective study was conducted at a 300-bed regional tertiary care women's hospital that performs approximately 11,000 deliveries per year. The health care system to which this hospital belongs offers a bloodless medicine program for patients who, for religious or for other reasons, do not wish to be transfused with blood products. During the initial nursing assessment on admission for any chief complaint, even for patients seen in the emergency department who will not be admitted to the hospital, all patients are asked about their preference for the receipt of blood transfusion; a consultation to the bloodless medicine program is automatically generated for those who state that they would decline transfusion. A consultation to this program could also be generated at any time by a physician who sees a Jehovah's Witness patient or one who states she would decline blood transfusions. This program is staffed by members of the Jehovah's Witness faith who have been specially trained in the composition and preparation of whole blood components (RBCs, platelets, plasma) as well as fractionation (albumin, intravenous immunoglobulin, Rh immune globulin, prothrombin complex concentrates), recombinant products (recombinant activated factor VII, erythropoietin, certain clotting factor VIII concentrations), and salvaged shed blood. The consultation involves reviewing a checklist of the blood products that are on the hospital's formulary with the patient, explaining the church's teachings vis-à-vis these products and allowing the patient to decide which products, if any, she wishes to receive. A standardized note detailing this conversation is then placed in the patient's medical record.

This study was a retrospective analysis of the blood transfusion preferences of antenatal women who are members of the Jehovah's Witness faith and were seen at least once during their pregnancy at this hospital. All of the bloodless medicine consultation notes from the inception of the program on January 1, 2011, through the end of the 2014 calendar year were reviewed, and the information for this study was derived from these notes. Bloodless medicine program consults on patients who were not of the Jehovah's Witness faith were excluded.

Patient demographics along with their blood product preferences were collected and analyzed to determine whether any patterns of transfusion preferences among patients of the Jehovah's Witness faith could be identified. The data collection process for this study was approved by the University of Pittsburgh Medical Center Quality Improvement Board, a division of the institutional review board. Continuous variables were analyzed using descriptive statistics or a two-tailed Mann-Whitney test as appropriate, and dichotomous variables were analyzed by a two-tailed Fisher's exact test (GraphPad Prism 6). P<.05 was considered significant.

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RESULTS

During the first 4 years of the bloodless medicine program at this hospital, 87 consultations on antenatal women of the Jehovah's Witness faith were performed (Table 1).

Table 1

Table 1

All 87 women stated that they would decline whole blood, RBC concentrates, platelets, and granulocyte transfusions (collectively referred to as “conventional blood products”). However, among these women, there were differences in the stated acceptance rates of the other plasma derived and recombinant products, including cryoprecipitate (collectively referred to as “other blood products”; Table 2). Among all of the women in this study, the other blood product that they most commonly stated would be accepted was cell salvage, which included both intra- and postoperative salvage techniques. A majority of these women stated that they would accept cryoprecipitate.

Table 2

Table 2

Stated acceptance of fractionated or recombinant products did not vary by parity, race, or age (Table 3).

Table 3

Table 3

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DISCUSSION

This retrospective study demonstrated that antenatal Jehovah's Witness patients are not homogenous in terms of the blood products that they state that they would accept. Although all of the patients in this study stated that they would decline conventional blood products, many were amenable to receiving recombinant or fractionated products. Thus, it is essential to have a detailed discussion with each Jehovah's Witness patient to determine her specific wishes for transfusion.

The use of cell salvage was stated to be acceptable to nearly 90% of the women in this study and the use of cryoprecipitate in more than half. This is similar to the results of two studies in the United Kingdom. In the first study of obstetricians and gynecologists, 77% reported having access to this technology for use in Jehovah's Witness patients, and nearly 85% of those with access to it reported using it most of the time or sometimes.13 The second study found that approximately 70% of the Jehovah's Witness patients would accept cell salvage.14 However, only 21% of respondents reported having around-the-clock access to the equipment, whereas 20% of the respondents would try to transfer high-risk patients to a tertiary care center. Thus, although potentially effective in returning shed blood to the patient, only certain postpartum bleeding patients receive a reinfusion equivalent to at least one unit of blood,15 its use can be restricted by limited access to the equipment, and there is a cost to its use.16

Cryoprecipitate is not a substitute for plasma; it contains mainly fibrinogen and does not contain a significant quantity of most of the other pro- and anticoagulants that are found in plasma. It has been suggested that the patient's fibrinogen concentration should be maintained at a high level during postpartum hemorrhage so having the ability to use cryoprecipitate,17 or a pharmaceutical fibrinogen concentrate, could potentially be beneficial.18 However, cryoprecipitate does not have the same hemostatic properties as plasma and cannot be used interchangeably with it. Many of the patients in this study stated that they would accept plasma-derived or recombinant coagulation factor concentrates, which at the moment are the only other blood products available to improve hemostasis. The results of the WOMAN Trial (the World Maternal Antifibrinolytic Trial) will be useful in informing the use of tranexamic acid in the postpartum hemorrhage setting.19

Some limitations of our study warrant discussion. Although a significant number of patients in our single-center study stated that they were amenable to the receipt of some blood products, these individual decisions based on matters of conscience might not be generalizable to the larger Jehovah's Witness population or even to other pregnant Jehovah's Witness patients. This study was a review of patients' expressed preferences toward transfusion during an interview in the antenatal period and not any actual choices they made. Moreover, women who did not undergo a bloodless medicine consult were not included in our study and the preferences of such women may differ from those on whom a consult was performed. These limitations aside, we think that our study underscores the importance of an individualized approach to transfusion in Jehovah's witnesses.

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