The Medical Process in Pregnancy Terminations for Fetal Anomaly: An Analysis of Counselling and Bereavement

Pregnancy termination for fetal anomaly (TOPFA) is a possible outcome of a pregnancy complicated by a fetal anomaly detected during routine prenatal care. Limited research is available on the quality of the counselling offered to women, in terms of enabling them to make an informed decision. The goal of this descriptive cohort study was to examine the medical process offered to a cohort of 151 women who underwent TOPFA in 2018 in a single tertiary mother and child hospital to identify areas for potential quality improvement (QI). Statistical analysis comprised basic statistical tests, Pearson's χ² test, and logistic regression. Counselling was evaluated by two fetal health specialists who found that the counselling process was minimal in 42% of cases. Counselling referrals to pediatric specialists were made in 26% of cases, with many potential explanations for this finding. Complicated bereavement was present in 39% of cases. Risk factors for complicated bereavement were explored and were found to be insufficient social support (odds ratio [OR] 6.5; 95% CI 2.0-21.0, P < 0.001), history of a mood disorder (OR 3.4; 95% CI 1.3-8.8, P < 0.01), and history of another TOPFA (OR 6.2; 95% CI 1.2-31.0, P = 0.01). Viewing the fetus after termination was not correlated with a significant reduction in complicated bereavement. The evaluation of the counselling as minimal in 42% of cases and the high prevalence of complicated bereavement call for quality improvement (QI) in the process for women who undergo TOPFA. Clinicians should be able to screen women most at risk for complicated bereavement to best orient preventive care.

The Psychological Challenges of Replacing Conventional Karyotyping with Genomic SNP Array Analysis in Prenatal Testing

Pregnant couples tend to prefer a maximum of information about the health of their fetus. Therefore, we implemented whole genome microarray instead of conventional karyotyping (CK) for all indications for prenatal diagnosis (PND). The array detects more clinically relevant anomalies, including early onset disorders, not related to the indication and more genetic anomalies of yet unquantifiable risk, so-called susceptibility loci (SL) for mainly neurodevelopmental disorders. This manuscript highlights the psychological challenges in prenatal genetic counselling when using the array and provides counselling suggestions. First, we suggest that pre-test decision counselling should emphasize deliberation about what pregnant couples wish to learn about the future health of their fetus more than information about possible outcomes. Second, pregnant couples need support in dealing with SL. Therefore, in order to consider the SL in a proportionate perspective, the presence of phenotypes associated with SL in the family, the incidence of a particular SL in control populations and in postnatally ascertained patients needs highlighting during post-test genetic counselling. Finally, the decision that couples need to make about the course of their pregnancy is more complicated when the expected phenotype is variable and not quantifiable. Therefore, during post-test psychological counseling, couples should concretize the options of continuing and ending their pregnancy; all underlying feelings and thoughts should be made explicit, as well as the couple’s resources, in order to attain adequate decision-making. As such, pre- and post-test counselling aids pregnant couples in handling the uncertainties that may accompany offering a broader scope of genetic PND using the array.

Is there a role for psychiatry in late termination of pregnancy?

The aim of the present review was to explore the role of the psychiatrist in late terminations of pregnancy. A literature review was conducted using MEDLINE and psycINFO databases, focussing on articles that explored (i) existing decision-making processes in late terminations; (ii) psychological sequelae of both early and late termination of pregnancy; (iii) the role of psychiatry in both early and late termination of pregnancy; and (iv) the involvement of psychiatry in complex medical decisions. The decision to perform a late termination of pregnancy is complex. Contributing to its complexity is an array of political, legal, societal, and ethical factors. The literature regarding psychological sequelae is frequently confusing and weakened by methodological problems. Methods of assisting in this decision-making process include the involvement of committees and psychiatrists. There are precedents for the involvement of psychiatrists in such a setting. Historically, psychiatrists played a role in screening women who requested an early termination. Psychiatrists are often involved in ethically challenging and complex clinical decisions in the general hospital setting. The involvement of psychiatry in this complex decision-making process has potential advantages and disadvantages. It is timely for psychiatrists to consider their position on their discipline's involvement.

Caregivers' experiences of interaction with families expecting a fetally impaired child

BACKGROUND

On the basis of earlier research, caregivers' actions when interacting with clients should be developed. However, nursing research has focused little attention on the interaction between caregivers and families expecting a fetally impaired child.

AIM

The study aimed at generating a practical family nursing theory of caregivers' interaction with families expecting a malformed child.

METHODS

A grounded theory study was undertaken at Tampere University Hospital in Finland in 1999-2000. Data consisted of semi-structured interviews with 22 (n=22) nurses and doctors. The data were analysed using the constant comparative method.

RESULTS

The interaction process starts when a caregiver informs the parents of the fetal impairment. The process is influenced by caregivers' attitude towards issues related to the family's life situation. Caregivers' views of their job, and of human coping and cultural attitudes towards these issues are also of importance. These factors account for their goals in the interaction, which, in turn, underlie their actions. When the caregiver's interpretation is that the family accepted the help provided, the outcome of the interaction is satisfaction with having been able to help. Correspondingly, in the case of an opposite interpretation, the caregiver experiences strain caused by inadequacy of the help he/she is providing. The core of interaction consists of two dimensions: gaining strength and losing strength in relation to impairment issues.

CONCLUSIONS

Caregivers' views of helpful interaction were consistent with earlier research on the subject, but the findings of this study showed that more attention should be focused on the family as a whole. Furthermore, caregivers rarely criticized their own actions, thus their interaction skills should be upgraded by focusing on systematic self-assessment through training. Nursing research deepening our understanding of why interaction fails is warranted.

RELEVANCE TO CLINICAL PRACTICE

The study results can be used in the family nursing practice as tools in reinforcing the caregivers' ability to helpful interaction with families expecting a fetally impaired child. The results may enhance caregivers' systematic self-evaluation and conscious use of the self.

Interaction between caregivers and families expecting a malformed child

BACKGROUND

Earlier research has shown that the care of families expecting a malformed child should be intensified and that the topic is understudied.

AIM

This study aimed at generating a practical nursing theory of interaction between caregivers and families expecting a malformed child, as experienced by families.

METHODS

A grounded theory study was undertaken at a university hospital, Finland. Data consisted of semi-structured interviews with 29 mothers and fathers, analysed using the constant comparative method.

FINDINGS

The interaction process starts with the confirmation of the diagnosis. It usually comes as a shock to the parents, and gives rise to questions about the nature of the malformation, family members' relationship with themselves, family relationships and relationships with people outside the family. These questions are crucial to the family's coping and form the core of interaction. Families' own coping strategies are either reinforced or undermined by caregivers' actions and are reflected in parents' expectations about caregivers, which in part account for their actions and experiences of interaction. The care system as an interactive environment is part of a process which results in the experiences of being helped or being left without help. The core of the interaction process comprises two dimensions: gaining strength and losing strength in relation to malformation issues.

CONCLUSIONS

The findings of the study are consistent with earlier research and complement it by providing a detailed delineation of the interaction from the perspective of the family. They can be used to formulate recommendations for improving caregivers' interactive skills and awareness of the topic through training. The care system should be developed to ensure that families receive psychological support and that the family as a whole receives proper care. Consideration of the viewpoint of siblings is a challenge for further research.

The quality of the caregiving environment and child developmental outcomes associated with maternal history of abortion using the NLSY data

BACKGROUND

Studies suggest that experiencing a perinatal loss may leave women vulnerable to mental health problems and may compromise parenting. Unfortunately, compared to miscarriages and stillbirths, very little research has examined the potential for grief and feelings of loss associated with elective abortion. Therefore, the aim of this study was to compare the quality of the childcare environment and children's development among children of mothers with a history of abortion prior to childbirth (n = 672) and children of non post-abortive women (n= 4,172).

METHOD

Data were derived from the National Longitudinal Survey of Youth (NLSY), with comparisons based on two assessments of the caregiving environment and scores on four child outcome variables. The sample was divided into three child age categories: 1-4 years (n = 1,502), 5-9 years (n = 2,121), and 10-13 years (n = 1,524).

RESULTS

After controlling for numerous potentially confounding socio-demographic variables, lower scores were observed for the post-abortion group relative to the level of emotional support in the home among first-born children in the youngest age category. Further, among 5-9-year-olds, more behavior problems were revealed for the children of women with a history of abortion. Finally, no main effects were detected between the abortion history groups relative to the level of cognitive stimulation in the home.

CONCLUSION

Although it is widely recognized that at least 10% of post-abortive women experience negative psychological consequences, the potential effects of negative subjective experiences on parenting need more systematic attention.