Parent views on a two-step consent process used in emergency neonatal research in the delivery room in Eastern Uganda.

backgroundObtaining ethically valid consent for delivery room research from parents facing the imminent birth of a sick or preterm infant is particularly challenging. While deferred consent has been used successfully in some delivery room studies - especially in low-risk observational research - its application is more complex in settings with high neonatal mortality and in the context of interventional trials. In such contexts, alternative approaches such as two-step consent - where initial verbal consent is obtained at enrolment, followed by full written informed consent after maternal and neonatal stabilisation - have been proposed. This study explores the acceptability of this approach.

methodsThis qualitative study from March 2023 and February 2024, was nested within a pilot randomised controlled trial of immediate continuous positive airways pressure (CPAP) in the delivery room for very low birthweight infants (< 1500 g) at a government hospital in Uganda. Focus group discussions were held with 6-12 purposively selected mothers, fathers, and other caregivers of infants enrolled in the trial, with a total of three FGDs conducted. Groups were mixed by caregiver type. Data were analysed inductively using a thematic approach, allowing codes and themes to emerge directly from the data. Transcripts were coded using NVivo 12 to facilitate analysis and explore shared and divergent perspectives across participants.

resultsMothers generally viewed the two-step consent process positively. Verbal consent was seen as sufficient for an initial decision despite limited understanding, while written consent was considered more appropriate once the mother and infant were stabilised. Mothers valued the autonomy that the initial verbal consent gave them. Digital recording was acceptable to all, and the use of a script supported consistency. Fathers wished to be informed, but mothers emphasised their capacity to decide independently, while many preferred fathers to be present.

conclusionDelivery room trials in low-resource settings involve complex ethical and practical challenges related to obtaining informed consent in time-sensitive situations. In this study, the two-step consent process was found to be acceptable to parents and caregivers, supported by collaboration with the community advisory board. Further research should continue to refine consent approaches to ensure they remain ethically robust, practically feasible in emergency settings, and acceptable to parents across diverse cultural and clinical contexts.

trial registrationStudy is registered on Pan African Clinical Trials Registry (PACTR) PACTR202208462613789. Registered 08 August 2022. https://pactr.samrc.ac.za/TrialDisplay.aspx?TrialID=23888 .