Informed consent to serum screening for Down syndrome: are women given adequate information?

Canadian Pregnant Women's Preferences Regarding NIPT for Down Syndrome: The Information They Want, How They Want to Get It, and With Whom They Want to Discuss It

OBJECTIVE

This study sought to assess Canadian pregnant women's and their partners' preferences for information about non-invasive prenatal testing (NIPT).

METHODS

Pregnant women and their partners across Canada were surveyed as part of the Personalized Genomics for prenatal Aneuploidy Screening Using maternal blood (PEGASUS) study.

RESULTS

A total of 882 pregnant women and 395 partners participated. Women preferred being informed by a physician (77.2%). They preferred getting information ahead of time, except for information about resources for families with Down syndrome, which they preferred getting with test results. More than half thought that written consent is important (63.7%) and could decide whether to do NIPT on the day they received the information (54.9%). Women preferred to be informed of results by telephone (43.7%) or in person (28%), but they preferred in person if they were considered at high risk for Down syndrome on the basis of the results (76%). The partner was the person whose input was considered most important (62.6%). Partners' preferences were similar, except that partners tended to want information later (at the time of the test or with the results) and felt that their opinion was not considered as highly by health professionals.

CONCLUSION

Canadian women want information about NIPT early, in person, by a knowledgeable physician. Partners also want to be informed and involved in the decision-making process.

Why do pregnant women accept or decline prenatal diagnosis for Down syndrome?

To investigate if actual knowledge of Down syndrome (DS), influences the decision to accept or decline prenatal diagnosis (PND). Secondary aims were to elucidate reasons for accepting or declining PND and investigate differences between the accepting and declining group in perceived information, knowing someone with DS and thoughts about decision-making. A questionnaire was completed by 76 pregnant women who underwent invasive testing and 65 women who declined tests for chromosomal aberrations in Uppsala, Sweden. Apart from one question no significant differences were found in knowledge of DS between women declining or accepting PND for DS. Both groups had varying and in several respects low levels of knowledge about DS and its consequences. Most common reasons to accept PND were 'to ease my worries' and 'to do all possible tests to make sure the baby is healthy'. Corresponding statements declining PND were 'termination of pregnancy is not an option' and 'because invasive tests increase the risk of miscarriage'. More women declining PND knew someone with DS. Knowledge of DS at these levels is not a major factor when women decide to accept or decline PND for DS. Their choice is mostly based on opinions and moral values.

Women's Experiences of Publicly Funded Non-Invasive Prenatal Testing in Ontario, Canada: Considerations for Health Technology Policy-Making

Non-invasive prenatal testing (NIPT) via fetal DNA in maternal blood has been publicly funded in Ontario, Canada, for high-risk women since 2014. We solicited women's experiences and values related to this new health technology to describe how this test is currently being used in Ontario and to provide information about patient priorities to inform future policy decisions about the use of NIPT. Guided by constructivist grounded theory methodology, we interviewed 38 women who had diverse personal experiences with NIPT. Participants' accounts of their values for decision making about NIPT heavily relied on three mutually modulating factors: timing, accuracy, and risk. The values expressed by women conflict with the way that publicly funded NIPT has typically been implemented in Ontario. We offer recommendations for how NIPT might be integrated into prenatal care pathways in a way more consistent with women's values.

To Use or Not to Use: The Prenatal Genetic Technology/Worry Conundrum

We conducted an exploratory, qualitative study investigating the factors influencing the use of genetic counseling and prenatal genetic testing for two groups: pregnant women 35 years of age and over (AMA) at the time of delivery and pregnant women with an abnormal maternal serum triple screen (MSAFP3). The convenience sample consisted of 25 semistructured interviews of women/couples and 50 observations of genetic counseling sessions. Worry turned out to be the most important variable influencing decision making about prenatal genetic testing and was greater in the MSAFP3 group than in the AMA group. The women in the AMA group appeared to assign the risk of having a child with Down syndrome to their age category rather than to themselves individually, whereas, the risk perception for women with an abnormal MSAFP3 appeared to have shifted from a general population risk for pregnant women to an individual, personal risk. There was a general lack of understanding and also more misinformation about the MSAFP3 screen compared to amniocentesis. Women in both groups were torn between fear of an invasive test and worry about the health of their fetus for the rest of their pregnancy if they did not undergo amniocentesis.

Information and knowledge about Down syndrome among women and partners after first trimester combined testing

We assessed reasons among women and partners for choosing combined ultrasound-biochemistry testing, information and knowledge about Down syndrome and decisions concerning invasive procedures and termination of pregnancy in a prospective cohort study in Uppsala County. In all 105 pregnant women and 104 partners coming for a combined ultrasound-biochemistry test answered a questionnaire. The most common reason for a combined ultrasound-biochemistry test was "to perform all tests possible to make sure the baby is healthy". Internet and midwives were the most common sources of information. Seventy-two percent had not received information on what it means to live with a child with Down syndrome. Many expectant parents perceived information as insufficient. Both women and partners had varying or low levels of knowledge about medical, cognitive and social consequences of Down syndrome. Twenty-five percent had not decided on an invasive test if indicated and only 42% would consider termination of pregnancy with a Down syndrome diagnosis.

The portrayal of Down syndrome in prenatal screening information pamphlets

OBJECTIVE

To examine the information about Down syndrome (DS) provided to pregnant women in Canada through a content analysis of prenatal screening information pamphlets.

METHODS

Prenatal screening information pamphlets were requested from Canadian prenatal testing centres. In total, 17 pamphlets were received (response rate = 65%). Statements presenting information descriptive of DS were identified from the pamphlets, and a content analysis was carried out. Specifically, each statement was analyzed with respect to both the content and the valence of the information presented on the basis of predetermined decision rules. To enhance reliability, four independent raters reviewed each statement, and any differences in coding were resolved through discussion.

RESULTS

In total, 158 statements descriptive of DS were extracted from the pamphlets. The categorical analysis revealed that 91% of the extracted statements emphasized medical or clinical information about DS, whereas only 9% of the statements relayed information pertaining to psychosocial issues. The valence analysis revealed that nearly one half of the statements portrayed a negative message pertaining to DS, while only 2.4% of the statements conveyed a positive image of DS.

CONCLUSION

The pamphlets provided to pregnant women do not appear to present a comprehensive, balanced portrayal of DS, which may serve to limit informed decision-making.

The provision of information and informed decision-making on prenatal screening for Down syndrome: a questionnaire- and register-based survey in a non-selected population

OBJECTIVE

Evaluating the information provision procedure about prenatal screening for Down syndrome, using informed decision-making as a quality-indicator.

METHODS

Questionnaire- and register-based surveys. Midwives associated with 59 midwifery practices completed process data for 6435 pregnancies. Pregnant women (n=510) completed questionnaires on informed decision-making.

RESULTS

Midwives offered information to 98.5% of women; 62.6% of them wished to receive information, of these, 81.9% actually received information. Decision-relevant knowledge was adequate in 89.0% of responding women. Knowledge about Down syndrome was less adequate than knowledge about the screening program. Participants in the screening program had higher knowledge scores on Down syndrome and on the screening program than non-participants. Of the women who intended to participate (35.8%), 3.1% had inadequate knowledge. A total of 75.5% of women made an informed decision; 94.3% of women participating in the screening program, and 64.9% of women not participating.

CONCLUSION

This quality assurance study showed high levels of informed decision-making and a relatively low participation rate in the national screening program for Down syndrome in the Netherlands. Knowledge of the Down syndrome condition needs to be improved.

PRACTICE IMPLICATIONS

This evaluation may serve as a pilot study for quality monitoring studies at a national level.

Informing on prenatal screening for Down syndrome prior to conception. An empirical and ethical perspective

In most Western countries, information on prenatal screening for Down syndrome is provided in the first-trimester of pregnancy. The purpose of this study was to examine whether this information should additionally be provided before pregnancy to improve the informed decision-making process. In an empirical study, we obtained data from pregnant women with respect to their preferences regarding information on prenatal screening preconceptionally. Questionnaire data (n = 510) showed that 55.7% of responding women considered participating in prenatal screening for Down syndrome before pregnancy. 28.0% of women possessed information on prenatal screening preconceptionally. 84.6% preferred not to receive information preconceptionally in retrospect. In an ethical analysis, we elaborated on these preferences by weighing pros and cons. We considered two arguments against the provision of information on prenatal screening preconceptionally: women's preference to receive information in a step-by-step manner, and the risk of providing a directive message. We identified three reasons supporting its provision preconceptionally: the likelihood of making an informed decision could, firstly, be increased by "unchaining" the initial information from possible subsequent decisions, and, secondly, by providing women sufficient time to deliberate. Thirdly, the probability of equal access to prenatal screening may increase. To conclude with, we propose to incorporate an information offer on prenatal screening for Down syndrome in preconception care consultations. By offering information, instead of providing information, prospective parents are enabled to either accept or decline the information, which respects both their right to know and their right not-to-know.

Patient and provider attitudes toward screening for Down syndrome in a Latin American country where abortion is illegal

OBJECTIVE

To examine patient and provider attitudes toward first trimester nuchal translucency (NT) screening for Down syndrome and to assess how patients consent to screening in a country where abortion is illegal.

METHODS

Patients presenting for first trimester ultrasound including NT screening in two obstetric units in Chile completed a questionnaire about their attitudes toward NT screening and perspectives on the consent process. A follow-up questionnaire assessed satisfaction with the test. Prenatal care providers also completed a questionnaire ascertaining their perspectives on NT screening.

RESULTS

A total of 107 patients completed the initial questionnaire and 78 completed the follow-up questionnaire. Although 98 (94%) patients desired NT screening only 38 (38%) indicated that they would undergo diagnostic testing if they received screen positive results. Only 3 patients screened positive; however, 15 (20%) participants experienced increased anxiety after the test. Almost all of the 36 providers surveyed indicated that they counsel their patients thoroughly, but 38 (39%) patients reported that they received adequate information.

CONCLUSION

NT screening is often performed without patients' full understanding of the implications of potential results and may cause anxiety. Providers should elicit patients' preferences regarding prenatal testing and engage them in shared decision making about whether to undergo screening, particularly when abortion is not an option.

Ethical considerations in choosing a model for population-based cystic fibrosis carrier screening

Cystic fibrosis (CF) carrier testing can be used to inform reproductive decision making, allowing carriers to avoid having a child with CF. A government-funded, population-based CF carrier screening program would allow greater equity of access to this test. The setting in which CF carrier screening is offered significantly affects the extent to which participants make well informed, voluntary decisions to accept or decline testing. Screening offered before pregnancy and in non-clinical environments better promotes participant autonomy than screening offered in the prenatal consultation.

Informed consent for antenatal serum screening for Down syndrome

OBJECTIVE

Respect for patients' autonomy is a principle issue in medical ethics. Patients' understanding of antenatal serum screening for Down syndrome upon informed consent has barely been assessed. Our objective was to evaluate pregnant women's perceived level of understanding of this serum screening.

MATERIALS AND METHODS

Pregnant women between the 15(th) and 21(st) gestational week were randomized into control and experimental groups, and were asked to complete a questionnaire before and after genetic counselling provided by researchers. The primary endpoints were the perceived level of understanding of serum screening for Down syndrome and the autonomy of the decision making for this serum screening. The secondary endpoints were the anxiety and depression levels of these women.

RESULTS

Participants in the experimental group (n = 96) had a significantly higher perceived level of understanding of antenatal serum screening for Down syndrome than participants in the control group (n = 97). There were significantly more respondents in the experimental group making the decision themselves to undergo serum screening than women in the control group. Anxiety and depression levels were not significantly different between the women in the two groups.

CONCLUSION

Pregnant women should be offered more information to allow them to make an informed decision before they undergo antenatal serum screening for Down syndrome. Comprehensive genetic counseling improved pregnant women's autonomy in deciding whether to participate in serum screening. Health service providers should make effort to fulfill the ethical requirements of informed consent.

Comparison of different strategies in prenatal screening for Down's syndrome: cost effectiveness analysis of computer simulation

OBJECTIVES

To assess and compare the cost effectiveness of three different strategies for prenatal screening for Down's syndrome (integrated test, sequential screening, and contingent screenings) and to determine the most useful cut-off values for risk.

DESIGN

Computer simulations to study integrated, sequential, and contingent screening strategies with various cut-offs leading to 19 potential screening algorithms.

DATA SOURCES

The computer simulation was populated with data from the Serum Urine and Ultrasound Screening Study (SURUSS), real unit costs for healthcare interventions, and a population of 110 948 pregnancies from the province of Québec for the year 2001.

MAIN OUTCOME MEASURES

Cost effectiveness ratios, incremental cost effectiveness ratios, and screening options' outcomes.

RESULTS

The contingent screening strategy dominated all other screening options: it had the best cost effectiveness ratio ($C26,833 per case of Down's syndrome) with fewer procedure related euploid miscarriages and unnecessary terminations (respectively, 6 and 16 per 100,000 pregnancies). It also outperformed serum screening at the second trimester. In terms of the incremental cost effectiveness ratio, contingent screening was still dominant: compared with screening based on maternal age alone, the savings were $C30,963 per additional birth with Down's syndrome averted. Contingent screening was the only screening strategy that offered early reassurance to the majority of women (77.81%) in first trimester and minimised costs by limiting retesting during the second trimester (21.05%). For the contingent and sequential screening strategies, the choice of cut-off value for risk in the first trimester test significantly affected the cost effectiveness ratios (respectively, from $C26,833 to $C37,260 and from $C35,215 to $C45,314 per case of Down's syndrome), the number of procedure related euploid miscarriages (from 6 to 46 and from 6 to 45 per 100,000 pregnancies), and the number of unnecessary terminations (from 16 to 26 and from 16 to 25 per 100,000 pregnancies).

CONCLUSIONS

Contingent screening, with a first trimester cut-off value for high risk of 1 in 9, is the preferred option for prenatal screening of women for pregnancies affected by Down's syndrome.

A systematic review of decision support needs of parents making child health decisions

OBJECTIVE

To identify the decision support needs of parents attempting to make an informed health decision on behalf of a child.

CONTEXT

The first step towards implementing patient decision support is to assess patients' information and decision-making needs.

SEARCH STRATEGY

A systematic search of key bibliographic databases for decision support studies was performed in 2005. Reference lists of relevant review articles and key authors were searched. Three relevant journals were hand searched.

INCLUSION CRITERIA

Non-intervention studies containing data on decision support needs of parents making child health decisions.

DATA EXTRACTION AND SYNTHESIS

Data were extracted on study characteristics, decision focus and decision support needs. Studies were quality assessed using a pre-defined set of criteria. Data synthesis used the UK Evidence for Policy and Practice Information and Co-ordinating Centre approach.

MAIN RESULTS

One-hundred and forty nine studies were included across various child health decisions, settings and study designs. Thematic analysis of decision support needs indicated three key issues: (i) information (including suggestions about the content, delivery, source, timing); (ii) talking to others (including concerns about pressure from others); and (iii) feeling a sense of control over the process that could be influenced by emotionally charged decisions, the consultation process, and structural or service barriers. These were consistent across decision type, study design and whether or not the study focused on informed decision making.

Exploring general practitioners' experience of informing women about prenatal screening tests for foetal abnormalities: a qualitative focus group study

Background

Recent developments have made screening tests for foetal abnormalities available earlier in pregnancy and women have a range of testing options accessible to them. It is now recommended that all women, regardless of their age, are provided with information on prenatal screening tests. General Practitioners (GPs) are often the first health professionals a woman consults in pregnancy. As such, GPs are well positioned to inform women of the increasing range of prenatal screening tests available. The aim of this study was to explore GPs experience of informing women of prenatal genetic screening tests for foetal abnormality.

Methods

A qualitative study consisting of four focus groups was conducted in metropolitan and rural Victoria, Australia. A discussion guide was used and the audio-taped transcripts were independently coded by two researchers using thematic analysis. Multiple coders and analysts and informant feedback were employed to reduce the potential for researcher bias and increase the validity of the findings.

Results

Six themes were identified and classified as 'intrinsic' if they occurred within the context of the consultation or 'extrinsic' if they consisted of elements that impacted on the GP beyond the scope of the consultation. The three intrinsic themes were the way GPs explained the limitations of screening, the extent to which GPs provided information selectively and the time pressures at play. The three extrinsic factors were GPs' attitudes and values towards screening, the conflict they experienced in offering screening information and the sense of powerlessness within the screening test process and the health care system generally. Extrinsic themes reveal GPs' attitudes and values to screening and to disability, as well as raising questions about the fundamental premise of testing.

Conclusion

The increasing availability and utilisation of screening tests, in particular first trimester tests, has expanded GPs' role in facilitating women's informed decision-making. Recognition of the importance of providing this complex information warrants longer consultations to respond to the time pressures that GPs experience. Understanding the intrinsic and extrinsic factors that impact on GPs may serve to shape educational resources to be more appropriate, relevant and supportive.

Ethical Considerations concerning Screening for Chromosome Aneuploidy: A Response to a 2007 American College of Obstetricians and Gynecologists Practice Bulletin

Historically, maternal age 35 years or older at the time of delivery has been the marker to identify women with a statistically greater chance for having a child with a chromosome aneuploidy. This article will examine certain aspects of the recommendations made by the American College of Obstetricians and Gynecologists (ACOG) in 2007 to expand aneuploidy screening to all women before 20 weeks gestation. The article will focus on insights within the Catholic moral tradition that help to frame a reexamination of these recommendations.

What about informed consent in first-trimester ultrasound screening for Down syndrome?

OBJECTIVES

We evaluate the level of information and informed consent given for the screening of Down syndrome (DS) before the first-trimester ultrasound scan. We evaluate the nature of the medical information given and the patient's understanding. This makes it possible to analyze the existence of the necessary elements (level of information and consent) for the patients to exercise their autonomy as to their decision making during the first-trimester ultrasound scan.

METHODS

A total of 350 patients were recruited prospectively in 2 hospitals. Patients were divided into 3 groups according to the results of maternal serum screening for DS. Group 1: Patients at high risk of having a child with DS with the second-trimester maternal serum screening (MSS) (risk >1/250). Group 2: Patients having a low risk (risk <1/250). Group 3: Patients who did not undergo maternal serum screening test. A questionnaire was completed before the medical consultation, to assess the quality of the medical consultation before the ultrasound, the level of prior knowledge and the maternal consent.

RESULTS

We excluded 45 of the 350 questionnaires from the analysis because they were incomplete (13.1%). We therefore analyzed a total of 305 questionnaires. The three groups analysed were: Group 1: 89 patients (29.2%) identified as at high risk after MSS. Group 2: 137 patients (44.9%) identified as at low risk accordingly to MSS. Group 3: 79 women (25.9%) who did not undergo maternal serum screening test for diverse reasons. The frequency of genuine informed consent was significantly (p < 0.001) higher in group 3 (56.9%) than in group 1 (52.8%) or group 2 (32.1%). Finally, the number of completely uninformed patients was significantly higher in group 2 (18%) than in the other two groups (7.8% for group 1 and 6.3% for group 3, p < 0.001). With multiple regression analysis, we found that maternal consent depended on 4 independent components: (1) Educational level (<baccalaureate, baccalaureate or at least 2 years of higher education after baccalaureate) (p < 0.03). (2) The location of consultations (hospital or private doctor's practice) (p < 0.01). (3) History of medical termination (p < 0.001). (4) The score attributed to the doctor for information about early ultrasound scans (p < 0.001). The rate of consent increased with increasing educational level and was higher for women consulting at a hospital, for women with a history medical termination and for women whose doctors had a high score. Other criteria such as belonging to group 1, 2 or 3, age of the patient, first language, number of children, history of miscarriage, sex and age group of the professionals were not found significant.

CONCLUSIONS

The response to the question 'Is the level of medical information provided to patients concerning early screening by first-trimester ultrasound scans appropriate?' is 'no'. There is no difference in our result according to social-economic level. However, educational level (66% consent for patients with 2 years of higher education after the baccalaureate), a history of medical termination (85% consent), being followed at a hospital (77% consent) and the score of the doctor (71% consent) were all significantly associated with the level of consent to prenatal screening. It is difficult for patients to exercise their autonomy as concerns first-trimester ultrasound scans. Too many patients (82%) consider such scans to be compulsory. Overall, the level of knowledge of the patients was moderate, with 227 of the 305 patients (74%) having a satisfactory knowledge score (> or =10). The negative responses to the various questions calls into question the legitimacy of consent for first-trimester ultrasound scans, particularly as concerns the measurement of nucal translucency.

Does labeling prenatal screening test results as negative or positive affect a woman's responses?

OBJECTIVE

We tested whether adding interpretive labels (eg, "negative test") to prenatal genetic screening test results changes perceived risk and preferences for amniocentesis.

STUDY DESIGN

Women (N = 1688) completed a hypothetical pregnancy scenario on the Internet. We randomly assigned participants into 2 groups: high risk of fetal chromosomal problems (12.5/1000) or low risk (2/1000). After prenatal screening, estimated risk was identical (5/1000) for all participants, but results were provided either alone or with interpretive labels.

RESULTS

When receiving test results without labels, all participants react similarly. With labels, the participants who received "positive" or "abnormal" results reported a higher perceived risk (P < .001), greater worry (P < .001), and greater interest in amniocentesis (57% vs 37%; P < .001) than did the participants who received "negative" or "normal" results.

CONCLUSION

Interpretive labels for test results can induce larger changes to a woman's risk perception and behavioral intention than can numeric results alone, which create decision momentum. This finding has broad clinical implications for patient-provider communication.

Perception of risk in relation to ultrasound screening for Down's syndrome during pregnancy

OBJECTIVE

to explore how information about being at risk of carrying a fetus with Down's syndrome was understood, and whether the actual risk and the woman's perception of risk was associated with worry or depressive symptoms during and after pregnancy.

DESIGN AND SETTING

observational study. The sample was drawn from the intervention group of a Swedish randomised controlled trial of ultrasound screening for Down's syndrome by nuchal translucency measurement.

MEASUREMENTS

data were collected by three questionnaires. Questions were asked about recall of the risk score and perception of risk. The Cambridge Worry Scale and the Edinburgh Postnatal Depression Scale measured worry and depressive symptoms, respectively, on all three occasions.

FINDINGS

of the 796 women who provided data for this study, one in five was unaware that the risk score was noted in her case record. In total, 620 women stated that they had received a risk score, but only 64% of them recalled the figure exactly or approximately. The actual risk was associated with the perceived risk, but of the 31 women who perceived the risk to be high, only 14 were actually at high risk. A high-risk score was not associated with worry or depressive symptoms in mid-pregnancy, in contrast to a woman's own perception of being at high risk. Two months postpartum, no associations were found between maternal emotional well-being and actual or perceived risk.

CONCLUSIONS

information about fetal risk is complicated and women's perception of risk does not always reflect the actual risk, at least not when presented as a numerical risk score. The possibility that the information may cause unnecessary emotional problems cannot be excluded.

IMPLICATIONS FOR PRACTICE

caregivers should ascertain that information about fetal risk is interpreted correctly by pregnant women.

How important is consent in maternal serum screening for Down syndrome in France? Information and consent evaluation in maternal serum screening for Down syndrome: a French study

OBJECTIVES

To evaluate the level of information and informed consent for maternal serum screening (MSS) for Down syndrome (DS) in the second trimester of pregnancy and analyse the exercise of autonomy towards the test by the women concerned.

METHODS

We studied the population of pregnant women attending obstetric consultations in two French hospitals over a 3-month period. The women were assigned to three groups according to MSS results for DS: women at high risk of having a child with DS (group 1), women at low risk (group 2) and women who did not undergo the test (group 3). A questionnaire was completed before the medical consultation, to assess the quality of consent before amniocentesis for the group at high risk and before the second-trimester ultrasound scan for the other two groups.

RESULTS

We analysed 305 questionnaires for 89, 137 and 79 women belonging to groups 1, 2 and 3 respectively. In total, 123 women (40.3% [IC 95%, 35-46%]) were considered to be well informed; 33 (10%, [IC 95%, 8-12%]) had a high level of knowledge, but made choices not consistent with their stated attitude, and 149 (49.7% [IC 95%, 45-56%]) were considered uninformed. Logistic regression analysis showed that maternal consent depended on three independent components: The score attributed to the doctor for information about MSS (t = 4.216, p < 0.001). Whether the patient belonged to group 1 (t = -2.631, p < 0.009). Educational level (< high-school diploma, high-school diploma or at least two years of higher education after high school) (t = 2.324, p < 0.02). The rate of consent increased with educational level and was highest for the women in group 1 and for those whose doctor had a high information score.

CONCLUSIONS

Our findings clearly show that women are provided with insufficient information concerning MSS screening for DS in the second trimester of pregnancy for real and valid consent to be obtained.

Kommunikation genetischer Risiken aus der Sicht der humangenetischen Beratung: Erfordernisse und Probleme

Genetic counselling is the single most important instrument for the individual communication of genetic risks. Beyond medical and psychosocial purposes in terms of preparing diagnostic measures and coping with results, genetic counselling also serves as a means to ensure the clients' decision autonomy through adequately informed consent. Accordingly, indispensable preconditions of the counselling process are voluntariness, individuality, non-directiveness, and respect of the right not to know. However, the requirement that any genetic diagnosis should be embedded into genet ic counselling is all too often neglected in today's reality of medicine. Consequently, there is urgent need of legislation ensuring mandatory counselling at least before prenatal and predictive genetic testing. Additionally, clear standards must be established and enforced for the quality of the counselling process as well as for the qualification of counsellors, and sufficient personal and institutional resources must be provided.

Informed choice in women attending private clinics to undergo first-trimester screening for Down syndrome

OBJECTIVES

Informed choice for prenatal screening has long been considered an essential aspect of service provision, and has been researched extensively in the second trimester. This study aims at examining whether women having first-trimester screening in a private clinic had made an informed choice.

METHODS

A cross-sectional survey recruited women having first-trimester screening at specialist ultrasound practices. Two questionnaires containing a validated Multidimensional Measure of Informed Choice (MMIC) were self-administered pre- and post-screening.

RESULTS

MMIC was completed by 81% (163/202) of women. Ninety-nine percent of women had a positive attitude towards screening, therefore informed choice was essentially measured on knowledge alone. Pre-screening, 68% made an informed choice, compared with 74% post-screening (chi2 = 1.6, p = 0.21 (McNemar)). Knowledge was associated with education level, information sources and perception of screening as routine or optional.

CONCLUSIONS

The Australasian Guidelines on prenatal screening state that all women having testing should be provided with written information, and it should be ensured that they have appropriate understanding of the test(s). These guidelines are not being met, even in private clinical care. Health professionals should ensure that all women are provided with suitable information about prenatal screening that is tailored to their level of education and individual needs, and should emphasise that screening is optional.

Psychosocial Correlates of Pregnant Women's Attitudes Toward Prenatal Maternal Serum Screening and Invasive Diagnostic Testing: Beyond Traditional Risk Status

This study examined whether psychosocial variables predict pregnant women's attitudes toward maternal serum screening and invasive diagnostic testing, beyond the influence of traditional obstetric risk status (based on advanced maternal age, history of genetic disorders, etc.). In a sample of 612 pregnant women (66.5% high risk, 33.5% low risk) we assessed responses to hypothetical scenarios of invasive testing following normal or abnormal maternal serum screening. We also assessed psychosocial variables stemming from the theory of planned behavior (e.g., knowledge, concern for fetus, attitudes toward termination, health locus of control). Overall, two thirds of the women would want serum screening. Follow-up invasive diagnostic testing would be sought by 37.2% of the women after a negative screening, and by 75.0% after a positive screening. As expected, traditional risk status predicted desire for screening and also invasive testing following either a negative or positive screen. Yet, controlling for risk status, many psychosocial variables predicted a women's interest in screening and in invasive testing: more knowledge about prenatal testing, concern about fetal health, willingness to terminate a pregnancy, and an internal or medical profession health locus of control. We conclude that psychosocial variables influence women's desire for screening or invasive testing beyond traditional risk status.

The interface between assisted reproductive technologies and genetics: technical, social, ethical and legal issues

The interface between assisted reproductive technologies (ART) and genetics comprises several sensitive and important issues that affect infertile couples, families with severe genetic diseases, potential children, professionals in ART and genetics, health care, researchers and the society in general. Genetic causes have a considerable involvement in infertility. Genetic conditions may also be transmitted to the offspring and hence create transgenerational infertility or other serious health problems. Several studies also suggest a slightly elevated risk of birth defects in children born following ART. Preimplantation genetic diagnosis (PGD) has become widely practiced throughout the world for various medical indications, but its limits are being debated. The attitudes towards ART and PGD vary substantially within Europe. The purpose of the present paper was to outline a framework for development of guidelines to be issued jointly by European Society of Human Genetics and European Society of Human Reproduction and Embryology for the interface between genetics and ART. Technical, social, ethical and legal issues of ART and genetics will be reviewed.

Les fondements du pronostic en médecine prénatale : exemple de la trisomie 21

Establishing a prognosis in prenatal medicine is often a complex and uncertain task. Predictive tools such as imagery techniques and biological markers may lack accuracy since they are used while the fetus is still pursuing its development. In France, antenatal euthanasia and fetal abandon are legal issues and socially accepted. Several non-medical factors may interfere with the final outcome such as the manner a condition is announced by the staff, the way it is experienced by the parents and the acceptance of the handicap within the society. We analysed the different medical and non medical factors intervening in the prognosis work up for Down's syndrome. Currently, the outcome of fetus with Down's syndrome is influenced by the orientation of our society that promotes screening tests and pregnancy interruptions instead of emphasizing on therapeutic research and improving their social integration.

The routine and the traumatic in prenatal genetic diagnosis: does clinical information inform patient decision-making?

With the increasing technical sophistication of medicine, clinicians' task of assuring patient informed consent is increasingly elusive. Taking the example of prenatal genetic testing, we examine efforts to communicate the complexities of genetic knowledge and risk calculation to patients. In this qualitative, descriptive study, we interviewed 50 clinicians and 40 patients, and observed 101 genetic counseling sessions. We found the clinicians and patients have different goals, purposes, and values regarding testing, which affect their clinical interactions. The information the clinicians provide patients reflects their clinical interest in identifying and controlling pathophysiology, while patients, in contrast, are most concerned with protecting and nurturing their pregnancy. We argue informed patient decision-making about prenatal testing options requires information that is responsive to patient interests. We recommend developing a shared decision-making approach, to facilitate the full participation of both clinicians and patients in the decision-making process.

Uptake of a prenatal screening test: the role of healthcare professionals' attitudes towards the test

OBJECTIVE

To investigate the association between healthcare professionals' attitudes towards prenatal Down syndrome screening and screening uptake in the women who consult them.

METHODS

The attitudes of 71 midwives and 18 obstetricians towards Down syndrome screening and screening uptake in the women who consulted them were assessed at two UK hospitals where uptake rates of Down syndrome screening differed (26 vs 61%).

RESULTS

Healthcare professionals based at the hospital with higher screening uptake had more positive attitudes towards Down syndrome screening than healthcare professionals based at the hospital with lower screening uptake (19 vs 17, p = 0.03). Pooling across hospitals, obstetricians had more positive attitudes than midwives (20 vs 17, p = 0.004). In a sub-group of women who discussed screening with one healthcare professional, there was no significant association between individual healthcare professionals' attitudes and screening uptake (Spearman correlation coefficient = 0.13, p = 0.51).

CONCLUSION

In this study powered to detect a correlation of 0.5 and over (i.e. a large effect), healthcare professionals' attitudes towards screening were unrelated to uptake of screening in the women consulting them. It remains to be determined if a smaller effect exists. The observed association between healthcare professionals' attitudes and uptake rates by hospitals raises the question of whether healthcare professionals' attitudes might influence systems of care, not just communication with pregnant women.

Survey of the knowledge, attitudes and experiences of Western Australian women in relation to prenatal screening and diagnostic procedures

OBJECTIVE

To determine the knowledge, attitudes and experiences of women in Western Australia (WA) regarding prenatal procedures.

DESIGN

A self-administered mail survey.

SAMPLE

The survey was sent to all women who gave birth during July 2001 (n = 1801). The participants were 633 women aged 15-45.

RESULTS

The mean total knowledge score was 16 out of a possible 26 (62%). The average score for all three attitude factors was four, 'agree', on a Likert scale of five. Women who reported they had private health insurance and women in the metropolitan area had significantly higher knowledge levels and had significantly more positive attitudes towards the adequacy of information. Those who did not have a screening test had less positive attitudes towards the value of the tests and had less confidence in results. Those with higher educational attainments had higher knowledge and less positive attitudes towards the value of the tests.

CONCLUSIONS

Women felt positive towards the value of the tests, were confident in their results and felt positive towards the adequacy of information; however, their understanding of this information seems to be poor. It seems that the choice to undergo testing is not well informed. It was clear women need more support, information, explanations, and more time to absorb the information.

Second trimester trisomy 21 maternal serum marker screening. Results of a countrywide study of 854,902 patients

OBJECTIVES

In France, maternal serum marker screening is governed by specific legislation. We conducted a study of the countrywide trisomy 21 screening based on second trimester maternal serum markers.

METHODS

We reviewed the medical records of 854,902 patients prospectively screened for second trimester maternal serum markers in the 60 authorized laboratories over the two-year period 1997-1998. All patients screened in France were included. The risk of trisomy 21 was calculated from the combination of maternal age and maternal serum markers. The same cut-off (1/250) was used in all laboratories.

RESULTS

In 1998, 65% of pregnant women underwent maternal serum screening. In the 837,765 patients under 38 years of age who were screened, 54,321 (6.48%; 5% CI 6.42-6.53%) had a calculated risk >1/250. Of the 884 Down syndrome cases observed, 626 were detected by maternal serum markers (70.8%; 5% CI 67.8-73.8%). These good results can be explained by a strict quality control of all steps. For the 13,891 patients over 38 years of age, the Down syndrome detection rate was 98.9% for a 34% false-positive rate.

CONCLUSIONS

Strict rules covering prenatal trisomy 21 screening are of benefit to patients, practitioners and laboratories alike, and ensure good quality control, a high trisomy 21 detection rate and a low amniocentesis rate.

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.

Descriptive information about Down syndrome: a content analysis of serum screening leaflets

It is recommended practice that prior to prenatal screening, women receive information about the condition(s) being tested for. The present study critically evaluated information about Down syndrome as contained in 80 leaflets provided to pregnant women in the UK prior to serum screening. First, a content analysis by information type was conducted to give an overall picture of the material provided. Second, the image of the condition as conveyed by the content was analysed and compared with a similar study of cystic fibrosis (CF) screening leaflets. The majority of information (89%) was of a medico-clinical nature, with 11% addressing other issues associated with Down syndrome. The median number of sentences describing the condition was one, with 33% of the leaflets containing no descriptive information. Overall, a negative image of Down syndrome was conveyed by the leaflets, which contrasted with a more neutral image of CF in the comparison study. In order to facilitate informed choices, more attention should be paid to providing women with information about Down syndrome prior to serum screening. Such information needs to be more balanced in its construction, with thought given to the needs of the reader, and to the tone and the content of the message conveyed.

Favorable attitudes toward testing for chromosomal abnormalities via analysis of fetal cells in maternal blood

PURPOSE

The NICHD Fetal Cell Isolation Study (NIFTY) was a multicentered project to isolate fetal cells from maternal blood to detect fetal chromosomal abnormalities. The project included a psychosocial component, which is the basis of this article. We examined the attitudes of high-risk pregnant women toward the availability of a maternal blood test to identify fetal chromosomal abnormalities, how women would respond to hypothetical normal and abnormal maternal blood testing results, and the factors associated with a woman's preference to have an invasive procedure in response to a normal maternal blood test.

METHODS

High-risk pregnant women (N = 854) planning to have prenatal diagnostic invasive testing (amniocentesis or chorionic villus sampling) completed a survey.

RESULTS

The women highly favored maternal blood testing. Almost all women would seek invasive testing after an abnormal blood test. Only half of the women would seek invasive testing after a normal blood test; these women were older, more willing to terminate their pregnancy, and valued the increased accuracy of invasive testing more highly than women who would not have invasive testing after a normal maternal blood test.

CONCLUSIONS

Women having invasive diagnostic testing welcome a noninvasive procedure that uses fetal cells in maternal blood, and its availability would decrease invasive testing by approximately 50%. Research needs to examine the attitudes and anticipated responses of other risk groups as well as the effects of information about maternal blood test sensitivity and specificity on attitudes and responses.

How women deal with the results of serum screening for Down syndrome in the second trimester of pregnancy

To gain insight into how pregnant women experience serum screening for Down syndrome, we sent questionnaires to two groups of relevant subjects in the north of the Netherlands. The questionnaires addressed the following issues: decision-making process, knowledge and opinions. Questionnaire A was sent to women of 36 years of age and older (n=99) (group A) who were all 20 to 36 weeks pregnant at that time. In the Netherlands prenatal diagnosis is routinely available to these women. Questionnaire B was sent to women of younger than 36 years (n=69) (group B) who had received a screen-positive result and had subsequently undergone amniocentesis. About half of these women were still pregnant at that time. For these women, serum screening is only available on the basis of opting-in. The two questionnaires were largely identical. The response rates to questionnaires A and B were 82% and 91%, respectively. Group A (women of 36 years and older) considered that second trimester serum screening made a welcome contribution to the decision-making process about whether to undergo amniocentesis. Moreover, it reduced the amniocentesis rate considerably. The vast majority said they would apply for serum screening in a following pregnancy, but favoured the idea of first trimester screening. In group B (women of younger than 36 years), reassurance was the most commonly mentioned reason for undergoing serum screening. Almost all the women experienced some degree of anxiety when they were informed about the screen-positive result and 13% continued to be anxious, even after the favourable result of the amniocentesis. The majority of the respondents would also apply for serum screening in a following pregnancy and were of the opinion that this screening should be offered to all pregnant women in the Netherlands.