A randomised trial of three methods of giving information about prenatal testing

Ethical decision-making in prenatal diagnosis and termination of pregnancy: a qualitative survey among physicians and midwives

OBJECTIVES

This study was aimed at exploring the conflicts and ethical problems experienced by professionals involved in prenatal diagnosis and termination of pregnancy (TOP) in order to improve the understanding of decision-making processes and medical practices in the field of prenatal diagnosis.

METHODS

Qualitative study with in-depth tape-recorded interviews conducted in three tertiary care maternity units in France, between May 1999 and March 2000. All full-time obstetricians and half of the full-time midwives were contacted. Seventeen obstetricians and 30 midwives participated (three refusals, five missing). Interviews were transcribed and analysed successively by two different researchers.

RESULTS

All respondents stated that prenatal diagnosis and TOP raised important ethical dilemmas, the most frequent being request for abortion in case of minor anomalies. They pointed out the inability of our society to appropriately care for disabled children and the risk of eugenic pressures. The decisions and practices in prenatal diagnosis should be debated throughout society. All respondents reported that their unit did not have protocols for deciding when a TOP was justifiable. The transmission of information to the women appeared to be a problematic area. Moral conflicts and emotional distress were frequently expressed, especially by midwives who mentioned the need for more discussions and support groups in their department.

CONCLUSION

Health professionals involved in prenatal diagnosis face complex ethical dilemmas which raise important personal conflicts. A need for more resources for counselling women and for open debate about the consequences of the current practices clearly emerged.

Mothers' knowledge of screening for trisomy 21 in 1999: a survey in Paris maternity units

OBJECTIVE

To assess mothers' knowledge of screening tests for trisomy 21.

STUDY DESIGN

Interview of all women who had recently delivered a healthy child and were present in 15 Paris maternity units during one of the two non-consecutive days in June 1999 (N = 734).

RESULTS

Two-third said that they had access to a nuchal translucency measurement (NTM) and to maternal serum screening (MSS), and 16% to amniocentesis. Thirty-eight percent of the women who had NTMs and 69% of those who had serum screening said that they had been informed of the need for amniocentesis if the results were abnormal. Among the women who had amniocentesis, 20% did not know the risk of miscarriage and 41% had not been informed about the possibility of terminating the pregnancy if trisomy 21 was diagnosed.

CONCLUSIONS

Mothers' knowledge about the screening tests for trisomy 21 remains fragmentary. Providing comprehensive information about all these tests should be considered in early pregnancy so that women can make informed choices.

Decisions about amniocentesis by advanced maternal age patients following maternal serum screening may not always correlate clinically with screening results: need for improvement in informed consent process

We evaluated the prenatal diagnosis utilization patterns of advanced maternal age (AMA) patients who underwent serum screening to assess how screening results correlated with their decisions regarding amniocentesis. A 6-year review (1994-1999) of laboratory records identified 2,456 AMA patients who underwent multiple-marker serum screening. The relationship between screening results and patients' decisions on whether or not to undergo amniocentesis was assessed. Among the 841 AMA patients with positive screens, more than half (52%) declined amniocentesis. Of the 1,615 patients with negative serum screening results, 208 (13%) opted for amniocentesis. We concluded that decisions by AMA patients regarding amniocentesis may not always correlate clinically with maternal serum screening results. Possible explanations, including how the state of informed consent may or may not contribute to these decisions, are discussed. It is suggested that understanding the reasons for these decisions may identify opportunities for improving service delivery to all pregnant patients considering prenatal testing. Use of a questionnaire is proposed as one mechanism for gaining a clearer understanding of the possible factors contributing to AMA patient decisions.

Improving communication between health professionals and women in maternity care: a structured review

OBJECTIVE

To review trials of the effectiveness of interventions aimed at improving communication between health professionals and women in maternity care.

SEARCH STRATEGY

The electronic databases Medline, PsycLit, The Cochrane Library, BIDS Science and Social Science Indexes, Cinahl and Embase were searched. Final searches were carried out in April 2000.

INCLUSION CRITERIA

Controlled trials of interventions explicitly aimed at improving communication between health professionals and women in maternity care were included. Other trials were included where two reviewers agreed that this was at least part of the aim.

DATA EXTRACTION AND SYNTHESIS

95 potentially eligible papers were identified, read by one reviewer and checked against the inclusion criteria. The 11 included trials were read, assessed for quality and summarized in a structured tabular form.

RESULTS

The included trials evaluated interventions to improve the presentation of information about antenatal testing, to promote informed choice in maternity care, woman-held maternity records and computer-based history taking. Four trials in which women were provided with extra information about antenatal testing in a variety of formats suggested that this was valued by women and may reduce anxiety. Communication skills training for midwives and doctors improved their information giving about antenatal tests. The three trials of woman-held maternity records suggested that these increase women's involvement in and control over their care.

CONCLUSIONS

The trials identified by this review addressed limited aspects of communication and focused solely on antenatal care. Further research is required in several areas, including trials of communication skills training for health professionals in maternity care and other interventions to improve communication during labour and in the postnatal period.

Receipt of information and women's attitudes towards ultrasound scanning during pregnancy

OBJECTIVE

To audit women's receipt of information during routine antenatal ultrasound investigations; and to investigate women's perceptions of, and attitudes towards, routine screening.

DESIGN

Analysis of the records of 384 women from in and around Nottingham, UK, who maintained a diary throughout the course of their pregnancies.

RESULTS

The mean number of ultrasound scans received by each women during her pregnancy was 2.6, with more than 96% of women receiving at least one scan. Women initially scanned earlier received more scans in total. Women appeared aware of the specific reasons for each scan being undertaken, and only a minority were dissatisfied by the information they had received. The preponderance of information received during the scans related to results and arrangements for subsequent visits, with only 10% of women reporting receiving information about the procedure itself. Most women reported positive feelings towards scanning, and few gave indications that they would prefer changes in the conduct of the procedure.

CONCLUSIONS

The great majority of the women in our study were satisfied with their experiences of routine ultrasound scanning, accepting the procedure uncritically.

Prenatal diagnosis for women aged 37 years and over: to have or not to have

Forty percent of pregnant women aged 37 years and over do not have prenatal diagnosis despite being eligible for a free test. The present study aimed to determine how often, and which, untested women were making a choice about this, how many declined an offer and why. A questionnaire was given to untested women, aged 37 years and over, at no less than 24 weeks gestation. A total of 375 (81.5%) women declined, 72 (16%) were not offered a test and 13 presented too late antenatally. There was a three-fold increased likelihood (OR 3.10 95% CI 1.44, 6.65) of no offer for urban non-English speaking background women, compared with the reference group (metropolitan, English speaking). Unpartnered women were also significantly less likely to receive an offer (OR 3.18, 95% CI 1.19, 8.46). Risk to the baby was the main reason for declining. When offered non-invasive prenatal screening, most decliners of prenatal diagnosis accepted, even those who declined because they were opposed to abortion. We estimate that overall 33% of older pregnant women were being offered and declining amniocentesis and/or chorion villus sampling (CVS). Only 6% were not offered a test, but this small proportion is over-represented by minority groups who must be given equal opportunity to make this choice.

Increasing informed uptake and non-uptake of screening: evidence from a systematic review

OBJECTIVE

To report data relating to the informed uptake of screening tests.

SEARCH STRATEGY

Electronic databases, bibliographies and experts were used to identify relevant published and unpublished studies up until August 2000.

INCLUSION CRITERIA

RCTs, quasi-RCTs and controlled trials of interventions aimed at increasing the informed uptake of screening. All participants were eligible as defined by the entry criteria of individual programmes. Studies had to report actual uptake and meet three out of four criteria used to define informed uptake.

DATA EXTRACTION AND SYNTHESIS

Relevant studies were identified, data extracted and their validity assessed by two reviewers independently. Outcome data included screening uptake, knowledge, informed decision-making and attitudes to screening. A random-effects model was used to calculate individual relative risks and 95% confidence intervals.

MAIN RESULTS

Six controlled trials (five RCTs and one quasi-RCT), focusing on antenatal and prostate specific antigen screening, were included. All reported risks/benefits of screening and assessed knowledge. Two also assessed decision-making. Two reported risks/benefits to all randomized groups and evaluated different ways of presenting information. Neither found that interventions such as videos, information leaflets with decision trees, or touch screen computers conveyed any additional benefits over well-prepared leaflets.

CONCLUSIONS

There is some evidence to suggest that changing the format of informed choice interventions in screening does not alter knowledge, satisfaction or decisions about screening. It is not clear whether informed choice in screening affects uptake. More well-designed RCTs are required and further research should also be directed towards the development of a valid instrument for measuring all components of informed choice in screening.

[Maternal anxiety induced by prenatal diagnostic techniques: detection and management]

Recent improvement in the screening for chromosomal defects, in particular the widespread use of ultrasonography and maternal biochemistry, is leading to a high number of fetal invasive tests (amniocentesis or chorion villus sampling). An increased level of anxiety in the pregnant women, which may sometimes continue until the postnatal period, is believed to be due to these prenatal diagnosis procedures. Maternal anxiety originates in the doubts related to fetal integrity and pregnancy outcome after information of a positive biochemical screening or visualisation of an ultrasound marker of chromosomal abnormality. Each specialist involved in prenatal care should take special attention to this, because of at least two reasons. First, anxiety may reduce maternal well being during pregnancy. Second, because it could have deleterious effects on parent to infant relationships. Without any intention of lowering the positive aspects of prenatal diagnosis, it appears essential to consider the negative effects anxiety may have on both parents. From our own experience and the conclusion of previous reported studies, we suggest some measures to reduce the level of maternal anxiety related to prenatal diagnosis: (i) improvement in the quality and transparency of information offered to pregnant women; (ii) training and involvement in psychological and emotional care for each member in the medical team; (iii) special and systematic psychological care for the "high risk" pregnant women regarding anxious disorders.

[Knowledge of flap complications in finger pulp surgery and patient education--ethical implications]

INTRODUCTION

The two highest French courts have recently decided that not to fully inform a patient constitutes negligence, and that doctors should be able to prove that the information has been given. The medical community is now debating as to how to protect physicians without harming the doctor-patient relationship. Following this study we put forward the hypothesis that although information might not be available to surgeons nevertheless this should not prevent them taking the ethical steps necessary to redress the situation.

METHODS

We conducted a telephone interview to discover what surgeons knew about the complications of finger flaps used for the reconstruction of pulp defects. Four flaps were studied: the VY flap described by Atasoy, the island finger flap known as Ventataswami's, the reverse island flap and the thenar flap. Surgeons were asked to give the percentage of necrosis, infection, sensory disturbances, digital stiffness and exclusion, as well as the time off work, the time of healing and the sensory discrimination of the flap. The results obtained were compared to those obtained by a literature review.

RESULTS

Twenty one qualified hand surgeons answered the questionnaire. Many answers were absent or only fragmentary when sought in the literature. Where complication rates were available, there was a huge variation among series. A large variety of answers was also found in our study. The direct island flap was the best known flap. Complications of the reverse island flap and the thenar flap were overestimated in the group interviewed.

DISCUSSION

There is no true answer, either in the literature or from the study group. There is a gulf between the jurists' demand and the possibilities of knowledge by surgeons. We are still waiting for clinical studies that will answer the questions asked by patients regarding the complications of surgery. However, even if absolute knowledge is not available, it is the ethical duty of surgeons to give the patient information that is as close as possible as the "truth", and that will be helpful to them.

Use of videotapes for viewing at home to inform choice in Down syndrome screening: a randomised controlled trial

A randomised trial was carried out to assess the effect of a Down syndrome screening video on test uptake, knowledge and psychological stress. A total of 2000 women referred for antenatal care were allocated to two equal groups: one to be sent a video to their home, before their hospital booking visit, and a control group. All women also received screening information in the form of a leaflet before booking and from a midwife at booking. The video had no effect on the screening uptake rate: 638/993 (64.2%) and 652/1007 (64.7%) in the video and control groups, respectively. Women were requested to return the video for reuse in other pregnancies and 612 (62%) did so. A subset of 1200 women were selected to be posted at 17-19 weeks' gestation a self-completed questionnaire to assess the psychological endpoints. Knowledge of screening was increased in the video group with a mean score of 7.3 compared with 6.7 in the controls, a statistically significant difference (t=3.24, p=0.0005). There were no significant differences between the groups in specific worries about abnormalities in the baby, and general anxiety. We conclude that a video can increase knowledge without affecting the uptake of the test, or psychological stress.

Participation in maternal serum screening for Down syndrome, neural tube defects, and trisomy 18 following screen-positive results in a previous pregnancy

OBJECTIVE

To determine whether women who have had a positive serum screening result for Down syndrome or neural tube defect in 1 pregnancy have a lower rate of participation in screening in their next pregnancy.

SETTING

A triple-marker screening program at a university hospital.

METHODS

Pregnancy and screening information was collected from laboratory and hospital databases to compare subsequent screening participation of women who were screen-negative and screen-positive for the risk of a fetus with Down syndrome or a neural tube defect.

RESULTS

In an age-matched comparison, 108 women who had a previous screen-positive result were significantly less likely than 108 women who were screen-negative to participate in maternal serum screening in their next pregnancy. When examined according to the type of screen-positive result, the effect was significant for both those who were screen-positive for Down syndrome and those who were screen-positive for neural tube defect. The degree of risk in screen-positive women did not significantly affect their participation in screening in the next pregnancy.

CONCLUSIONS

Anxiety related to a screen-positive result probably causes decreased participation in maternal serum screening in the next pregnancy. Reducing the screen-positive rate in prenatal serum screening would alleviate maternal anxiety and would probably lead to more stable participation.

A randomized trial assessing the impact of written information on outpatients' knowledge about and attitude toward randomized clinical trials. The INFO trial group

To improve the patient education process in clinical research, three information materials describing general aspects of design and conduct of randomized clinical trials were developed. The materials varied in length, reading ability level, and reader appeal. Their influence on knowledge about and attitude toward randomized clinical trials was assessed in a randomized, parallel group, evaluator-blinded trial among 415 outpatients. The patients were randomized to the following groups: control (no intervention), leaflet, brochure, or booklet. Knowledge was assessed by a 17-item multiple-choice questionnaire and attitude was assessed by a 32-item Likert questionnaire at entry and 2 weeks after the intervention. The interventions and the questionnaires were pilot tested and power calculations were performed. At entry, the mean knowledge score was 7.9 points. At follow-up, the knowledge scores increased by 0.5 for the control, 1.0 for the leaflet, 1.6 for the brochure, and 1.4 for the booklet. The brochure and the booklet improved the knowledge score significantly compared with the control. The general attitude was positive at entry (mean 71.5 points). Only the booklet significantly increased the total attitude score (4.8 points) and the randomized clinical trials attitude subscale score (1.8 points). In conclusion, written information significantly improved outpatients' knowledge about and attitude toward randomized clinical trials. Detailed rather than brief information was more effective. Control Clin Trials 2000;21:223-240

Randomised controlled trial comparing effectiveness of touch screen system with leaflet for providing women with information on prenatal tests

OBJECTIVE

To compare the effectiveness of touch screen system with information leaflet for providing women with information on prenatal tests.

DESIGN

Randomised controlled trial; participants allocated to intervention group (given access to touch screen and leaflet information) or control group (leaflet information only).

SETTING

Antenatal clinic in university teaching hospital.

SUBJECTS

875 women booking antenatal care.

INTERVENTIONS

All participants received a leaflet providing information on prenatal tests. Women in the intervention arm also had access to touch screen information system in antenatal clinic.

MAIN OUTCOME MEASURES

Women's informed decision making on prenatal testing as measured by their uptake of and understanding of the purpose of specific tests; their satisfaction with information provided; and their levels of anxiety.

RESULTS

All women in the trial had a good baseline knowledge of prenatal tests. Women in the intervention group did not show any greater understanding of the purpose of the tests than control women. However, uptake of detailed anomaly scans was significantly higher in intervention group than the control group (94% (351/375) v 87% (310/358), P=0.0014). Levels of anxiety among nulliparous women in intervention group declined significantly over time (P<0.001).

CONCLUSIONS

The touch screen seemed to convey no benefit over well prepared leaflets in improving understanding of prenatal tests among the pregnant women. It did, however, seem to reduce levels of anxiety and may be most effective for providing information to selected women who have a relevant adverse history or abnormal results from tests in their current pregnancy.

Survey of attitudes of pregnant women towards Down syndrome screening

This study aimed to examine whether pregnant women made informed decisions based on an accurate understanding of the antenatal screening process and to explore their attitude to screening and termination of a Down syndrome fetus. Women's aspirations were the keystone that informed the development of the first strategy for antenatal screening for congenital anomalies. Semi-structured interviews were carried out with a sample of pregnant women in South Wales in 1995. A total of 34 women aged less than 35 years, who were 20 weeks pregnant, were interviewed. These women were selected because the screening policy differed between hospitals for this age group. The majority of women were not aware that screening tests were voluntary: tests were presented as routine. About half of the sample were not well informed to make decisions. Only five out of a sampling frame of 101 women refused screening; they tended to be better educated and of higher social class. All women wanted to be given the choice whether to be screened. Seven out of 34 would not terminate an affected fetus. Staff communication skills, especially in delivering risk estimate, were criticized. The survey findings supported the view that women required an information package tailored to their individual needs.

Current and potential impact of fetal diagnosis on prevalence and spectrum of serious congenital heart disease at term in the UK. British Paediatric Cardiac Association

BACKGROUND

Assessment of the effect of fetal diagnosis on the prevalence of congenital heart disease at term requires national ascertainment because referral patterns are not rigorously structured.

METHODS

Between 1993 and 1995, all 17 paediatric cardiac centres in the UK submitted to a database lists of all fetuses diagnosed, and all infants needing surgery or interventional catheterisation or dying in the first year of life because of structural heart disease; details included the postal area of residence.

FINDINGS

There were 4799 affected pregnancies, 4165 babies born alive, 1124 fetal diagnoses, and 567 terminations of pregnancy because the fetus had structural heart disease. Thus, a fetal diagnosis was made in 23.4% of affected pregnancies (11.7% of all affected livebirths) with geographical variability in diagnostic rates.

INTERPRETATION

Fetal cardiac screening has an effect on the prevalence and types of congenital heart disease seen at term because many affected pregnancies are terminated. If detection rates of affected fetuses rose nationally to those seen in the 15 postal areas where detection rates were significantly higher than the national average in 1993-95, we would expect about 218 fewer affected individuals to be born annually.

Decision aids for patients facing health treatment or screening decisions: systematic review

OBJECTIVE

To conduct a systematic review of randomised trials of patient decision aids in improving decision making and outcomes.

DESIGN

We included randomised trials of interventions providing structured, detailed, and specific information on treatment or screening options and outcomes to aid decision making. Two reviewers independently screened and extracted data on several evaluation criteria. Results were pooled by using weighted mean differences and relative risks.

RESULTS

17 studies met the inclusion criteria. Compared with the controls, decision aids produced higher knowledge scores (weighted mean difference=19/100, 95% confidence interval 14 to 25); lower decisional conflict scores (weighted mean difference=-0.3/5, -0.4 to -0.1); more active patient participation in decision making (relative risk = 2.27, 95% confidence interval 1. 3 to 4); and no differences in anxiety, satisfaction with decisions (weighted mean difference=0.6/100, -3 to 4), or satisfaction with the decision making process (2/100,-3 to 7). Decision aids had a variable effect on decisions. When complex decision aids were compared with simpler versions, they were better at reducing decisional conflict, improved knowledge marginally, but did not affect satisfaction.

CONCLUSIONS

Decision aids improve knowledge, reduce decisional conflict, and stimulate patients to be more active in decision making without increasing their anxiety. Decision aids have little effect on satisfaction and a variable effect on decisions. The effects on outcomes of decisions (persistence with choice, quality of life) remain uncertain.

Developing consumer-led maternity services: a survey of women's views in a local healthcare setting

OBJECTIVE: This paper describes a prospective study of women's views and experiences of maternity services. The aim was to examine the way women make choices and decisions about maternity care and the factors which influence decision making, with a view to developing services which best meet the needs of the population. Patient choice issues reviewed included: choice of place of birth, choice of lead professional and choices in labour management. DESIGN, SETTING AND PARTICIPANTS: A cohort of women attending maternity booking clinics, within the catchment area of Peterhead Maternity Unit (PMU) in north-east Scotland, were surveyed by means of postal questionnaires at three stages during their contact with maternity services. A subset of women also took part in in-depth interviews. RESULTS: Not all women were given information about all the available options for place of birth and many women were unclear of the differences between them. Factors influencing choice of place of birth can change, with the medical aspects of maternity care becoming more important as the pregnancy progresses. Women rated the importance of seeing the same staff at antenatal visits highly, but were less concerned with their ability to choose which professional to see. More importance was attached to being able to choose a particular midwife rather than a particular obstetrician. Women's choices with regard to labour management were largely met. Insufficient information, however, was provided about choices in pain relief. CONCLUSIONS: The survey revealed the importance of locally based research, involving all stakeholders, in developing services which best meet the needs of a population.

Prenatal screening for Down syndrome: a dilemma for the unsupported midwife?

OBJECTIVE

To explore the personal and professional concerns of midwives in relation to their experiences with women undergoing serum screening for Down syndrome.

DESIGN

Semi-structured interviews.

SETTING

A consultant-led maternity unit in the south of England.

PARTICIPANTS

Ten midwives based in areas which most commonly support women undergoing this test.

METHODS

Interviews were recorded and transcribed and a grounded theory approach involving coding was used to identify categories which were analysed.

FINDINGS

Themes identified were: education needs on introduction of the test and in relation to current research about the test; strategies for explaining the concept of 'risk'; personal and professional conflict in relation to the dilemmas raised.

KEY CONCLUSIONS

Accurate information (including psychosocial aspects) should be available to midwives prior to the introduction of potentially complex investigations. Continuing education should prepare midwives to meet the challenges related to prenatal screening for Down syndrome. Some strategies which could be considered include the use of reflection sheets, prompt cards and case studies or vignettes. Interprofessional education could provide the opportunity to increase understanding of individual roles and the conflicts experienced.

Can anxiety in pregnant women be measured using the State-Trait Anxiety Inventory

OBJECTIVE

To explore the stability of the State-Trait Anxiety Inventory (STAI), which was used to explain shifts in women's priorities for intrapartum care.

DESIGN

A comparative survey of women's priorities for intrapartum care, using a self-complete questionnaire at two intervals, 34 weeks gestation and 10 days postpartum. The questionnaire incorporated the full 40 item STAI.

SETTING

Aberdeen, Scotland.

PARTICIPANTS

217 women presenting at Aberdeen Maternity Hospital at 34 weeks gestation who were 'booked' for delivery within the hospital, and who lived within Aberdeen city. One hundred and thirty-six were expecting their first baby and 81 were expecting their second.

MEASUREMENTS

Women's priorities for intrapartum care as ascertained at 34 weeks gestation and 10 days postpartum; shifts in priorities observed during this time period; and factors, such as anxiety (measured by the STAI), which could explain these shifts.

FINDINGS

Regardless of parity, women had significantly lower A-Trait scores postnatally than antenatally, when compared over a relatively short time period. Differences between nulliparous and parous women were found where the time lapse, between completion of the scales, was more than 45 days. For nulliparous women significant differences in A-Trait scores were still evident in the 45-56 day interval, but not in the later interval of 57-91 days. Parous women appeared to follow the opposite trend, however the numbers were considerably smaller.

CONCLUSION

The findings reported in this paper are derived from a study assessing women's priorities for intrapartum care. Anxiety was not a primary outcome measure in this study, but rather a factor which was measured as a possible explanation for shifts in priorities. However, the findings suggest that the STAI may not be stable around the time of delivery. In particular, the test-retest reliability of the STAI A-Trait scale appears to be quite low.

IMPLICATIONS

The study reported here raises the need for further research in this area and cautions against the unqualified use of this tool until its performance, specifically in the context of pregnant or recently-delivered women, has been thoroughly assessed.

Antenatal screening for Down's syndrome

BACKGROUND

In 1968 the first antenatal diagnosis of Down's syndrome was made and screening on the basis of selecting women of advanced maternal age for amniocentesis was gradually introduced into medical practice. In 1983 it was shown that low maternal serum alpha fetoprotein (AFP) was associated with Down's syndrome. Later, raised maternal serum human chorionic gonadotrophin (hCG), and low unconjugated oestriol (uE3) were found to be markers of Down's syndrome. In 1988 the three biochemical markers were used together with maternal age as a method of screening, and this has been widely adopted. PRINCIPLES OF ANTENATAL SCREENING FOR DOWN'S SYNDROME: Methods of screening need to be fully evaluated before being introduced into routine clinical practice. This included choosing markers for which there is sufficient scientific evidence of efficacy, quantifying performance in terms of detection and false positive rates, and establishing methods of monitoring performance. Screening needs to be provided as an integrated service, coordinating and managing the separate aspects of the screening process. SERUM MARKERS AT 15-22 WEEKS OF PREGNANCY: A large number of serum markers have been found to be associated with Down's syndrome between 15 and 22 weeks of pregnancy. The principal markers are AFP, hCG or its individual subunits (free alpha- and free beta-hCG), uE3, and inhibin A. Screening performance varies according to the choice of markers used and whether ultrasound is used to estimate gestational age (table 1). When an ultrasound scan is used to estimate gestational age the detection rate for a 5% false positive rate is estimated to be 59% using the double test (AFP and hCG), 69% using the triple test (AFP, hCG, uE3), and 76% using the quadruple test (AFP, hCG, uE3, inhibin A), all in combination with maternal age. Other factors that can usefully be taken into account in screening are maternal weight, the presence of insulin dependent diabetes mellitus, multiple pregnancy, ethnic origin, previous Down's syndrome pregnancy, and whether the test is the first one in a pregnancy or a repeat. Factors such as parity and smoking are associated with one or more of the serum markers, but the effect is too small to justify adjusting for these factors in interpreting a screening test.

URINARY MARKERS AND FETAL CELLS IN MATERNAL BLOOD

Urinary beta-core hCG has been investigated in a number of studies and shown to be raised in pregnancies with Down's syndrome. This area is currently the subject of active research and the use of urine in future screening programmes may be a practical possibility. Other urinary markers, such as total oestriol and free beta-hCG may also be of value. Fetal cells can be identified in the maternal circulation and techniques such as fluorescent in situ hybridisation can be used to identify aneuploidies, including Down's syndrome and trisomy 18. This approach may, in the future, be of value in screening or diagnosis. Currently, the techniques available do not have the performance, simplicity, or economy needed to replace existing methods.

DEMONSTRATION PROJECTS

Demonstration projects are valuable in determining the feasibility of screening and in refining the practical application of screening. They are of less value in determining the performance of different screening methods. Several demonstration projects have been conducted using the triple and double tests. In general, the uptake of screening was about 80%. The screen positive rates were about 5-6%. About 80% of women with positive screening results had an invasive diagnostic test, and of those found to have a pregnancy with Down's syndrome, about 90% chose to have a termination of pregnancy. ULTRASOUND MARKERS AT 15-22 WEEKS OF PREGNANCY: There are a number of ultrasound markers of Down's syndrome at 15-22 weeks, including nuchal fold thickness, cardiac abnormalities, duodenal atresia, femur length, humerus length, pyelectasis, and hyperechogenic bowel. (ABSTRA

Factors affecting women's knowledge of antenatal serum screening

Antenatal screening for fetal anomaly is offered routinely in Glasgow. This study assessed pregnant women's knowledge of the test and implications of results. Questionnaires were completed by 574 women. Knowledge of the nature and uses of the test was superior to earlier studies Two-thirds knew that screening was undertaken for Down's syndrome, and 81% for spina bifida. The majority were aware of the sample used, ages invited and gestation at which it was undertaken. Knowledge of the likely results and implications was poorer. Three-quarters were unaware that 10% of results would suggest an increased risk. Half did not realise that positive results could occur without fetal abnormality, or negative results could be falsely reassuring. Socioeconomic deprivation was associated with poorer knowledge but not lower uptake. Written information was associated with superior knowledge and higher uptake. Leaflets should be provided prior to booking, at which time resultant queries can be answered.

Routine antenatal screening: not a case of informed choice

Traditional epidemiological criteria are inadequate for comprehensively evaluating screening activities to identify best practice. In 1995, a study of women in the postnatal period at a major metropolitan teaching hospital in Victoria was conducted to assess, through their perspectives, the role of other factors of significance for the evaluation of routine antenatal screening. In particular, the role of informed choice was examined. The study involved a survey of 376 women and 21 semistructured interviews. The study found that, with an 'opt-out' or routine system of screening, high rates of use were achieved at the expense of informed choice for some participants. In addition, disturbing differences in information delivery and information perception were found between public and private patients. The need for new criteria to identify what constitutes best practice in the delivery of antenatal screening programs is discussed. These criteria should incorporate consideration of broader social and ethical implications for women receiving antenatal screening.

Serum screening for Down's syndrome: how much do health professionals know?

OBJECTIVE

To assess knowledge about serum screening for Down's syndrome in health professionals involved in antenatal care.

DESIGN

Postal questionnaire survey of knowledge of performance and interpretation of serum screening.

SETTING

Portsmouth and South East Hampshire health district.

POPULATION

All health professionals likely to be involved in antenatal care.

METHODS

Questionnaires were sent to all general practitioners (n = 288), hospital midwives (n = 129), community midwives (n = 71), and obstetricians (n = 29) working in the district.

MAIN OUTCOME MEASURES

Total number of correct responses given to eight factual questions and percentage of correct responses to each individual question.

RESULTS

Responses were received from 434 health professionals (84%). Fifty-nine percent of health professionals correctly answered only a half or less of the factual questions on serum screening. Questions relating to the sensitivity, specificity, and positive predictive value were particularly poorly answered. Obstetricians scored most highly. General practitioners scored significantly less than the other groups.

CONCLUSIONS

Women need accurate information to give informed consent to serum screening. Most health professionals likely to be involved in antenatal care in this district do not fully understand the test and are thus unlikely to provide such information. Changes in the provision of maternity services following Changing Childbirth may increase the input of midwives and general practitioners. Training of professionals about serum screening should be reviewed.

Information for patients with cancer. Does personalization make a difference? Pilot study results and randomised trial in progress

Although there are a number of groups working on the provision of personalized patient information there has been little evaluation. We have developed and piloted a method of giving patients on-line access to their own medical records with associated explanations. We are comparing, in a randomised trial, personalized with general computer based information for patients undergoing radiotherapy for cancer. We present results from the pilot study and the evaluation methods to be employed.

Towards informed decisions about prenatal testing: a review

There are now several well-documented psychological problems associated with prenatal testing programmes. These include poor understanding of tests undergone or declined, anxiety following false positive results, and false reassurance in those receiving negative test results. There is, as yet, little evidence concerning how to provide services to circumvent these. The focus of this review is upon just one of these problems: how best to inform women about prenatal testing and their reproductive options following the diagnosis of a fetal abnormality. Possible methods of improving informed decision-making either about whether to undergo testing or whether to terminate an affected pregnancy are described drawing upon research from antenatal and other health care areas. Future challenges for clinical practice and research in this area concern the range of conditions and predispositions for which prenatal testing with the option of termination should be offered.