OBJECTIVE: Prenatal counseling at the threshold of viability is a challenging yet critically important activity, and care guidelines differ across cultures. Studying how this task is performed in the actual clinical environment is extremely difficult. In this pilot study, we used simulation as a methodology with 2 aims as follows: first, to explore the use of simulation incorporating a standardized pregnant patient as an investigative methodology and, second, to determine similarities and differences in content and style of prenatal counseling between American and Dutch neonatologists. METHODS: We compared counseling practice between 11 American and 11 Dutch neonatologists, using a simulation-based investigative methodology. All subjects performed prenatal counseling with a simulated pregnant patient carrying a fetus at the limits of viability. The following elements of scenario design were standardized across all scenarios: layout of the physical environment, details of the maternal and fetal histories, questions and responses of the standardized pregnant patient, and the time allowed for consultation. RESULTS: American subjects typically presented several treatment options without bias, whereas Dutch subjects were more likely to explicitly advise a specific course of treatment (emphasis on partial life support). American subjects offered comfort care more frequently than the Dutch subjects and also discussed options for maximal life support more often than their Dutch colleagues. CONCLUSIONS: Simulation is a useful research methodology for studying activities difficult to assess in the actual clinical environment such as prenatal counseling at the limits of viability. Dutch subjects were more directive in their approach than their American counterparts, offering fewer options for care and advocating for less invasive interventions. American subjects were more likely to offer a wider range of therapeutic options without providing a recommendation for any specific option.