Prenatal care: the patient's perspective. A qualitative study

Patients' choices and opinions on chorionic villous sampling and non-invasive alternatives for prenatal testing following preimplantation genetic testing for hereditary disorders: A cross-sectional questionnaire study

OBJECTIVE

The aim of this study was to investigate choices of and reasoning behind chorionic villous sampling and opinions on non-invasive prenatal testing among women and men achieving pregnancy following preimplantation genetic testing (PGT) for hereditary disorders.

METHODS

A questionnaire was electronically submitted to patients who had achieved a clinical pregnancy following PGT at the Center for Preimplantation Genetic Testing, Aalborg University Hospital, Denmark, between 2017 and 2020.

RESULTS

Chorionic villous sampling was declined by approximately half of the patients. The primary reason for declining was the perceived risk of miscarriage due to the procedure. Nine out of 10 patients responded that they would have opted for a non-invasive prenatal test if it had been offered. Some patients were not aware that the nuchal translucency scan offered to all pregnant women in the early second trimester only rarely provides information on the hereditary disorder for which PGT was performed.

CONCLUSION

Improved counseling on the array of prenatal tests and screenings available might be required to assist patients in making better informed decisions regarding prenatal testing. Non-invasive prenatal testing is welcomed by the patients and will likely increase the number of patients opting for confirmatory prenatal testing following PGT for hereditary disorders.

MRI in the diagnosis of fetal developmental brain abnormalities: the MERIDIAN diagnostic accuracy study

BACKGROUND

Ultrasonography has been the mainstay of antenatal screening programmes in the UK for many years. Technical factors and physical limitations may result in suboptimal images that can lead to incorrect diagnoses and inaccurate counselling and prognostic information being given to parents. Previous studies suggest that the addition of in utero magnetic resonance imaging (iuMRI) may improve diagnostic accuracy for fetal brain abnormalities. These studies have limitations, including a lack of an outcome reference diagnosis (ORD), which means that improvements could not be assessed accurately.

OBJECTIVES

To assess the diagnostic impact, acceptability and cost consequence of iuMRI among fetuses with a suspected fetal brain abnormality.

DESIGN

A pragmatic, prospective, multicentre, cohort study with a health economics analysis and a sociological substudy.

SETTING

Sixteen UK fetal medicine centres.

PARTICIPANTS

Pregnant women aged ≥ 16 years carrying a fetus (at least 18 weeks' gestation) with a suspected brain abnormality detected on ultrasonography.

INTERVENTIONS

Participants underwent iuMRI and the findings were reported to their referring fetal medicine clinician.

MAIN OUTCOME MEASURES

Pregnancy outcome was followed up and an ORD from postnatal imaging or postmortem autopsy/imaging collected when available. Developmental data from the Bayley Scales of Infant Development and questionnaires were collected from the surviving infants aged 2-3 years. Data on the management of the pregnancy before and after the iuMRI were collected to inform the economic evaluation. Two surveys collected data on patient acceptability of iuMRI and qualitative interviews with participants and health professionals were undertaken.

RESULTS

The primary analysis consisted of 570 fetuses. The absolute diagnostic accuracies of ultrasonography and iuMRI were 68% and 93%, respectively [a difference of 25%, 95% confidence interval (CI) 21% to 29%]. The difference between ultrasonography and iuMRI increased with gestational age. In the 18-23 weeks group, the figures were 70% for ultrasonography and 92% for iuMRI (difference of 23%, 95% CI 18% to 27%); in the ≥ 24 weeks group, the figures were 65% for ultrasonography and 94% for iuMRI (difference of 29%, 95% CI 23% to 36%). Patient acceptability was high, with at least 95% of respondents stating that they would have iuMRI again in a similar situation. Health professional interviews suggested that iuMRI was acceptable to clinicians and that iuMRI was useful as an adjunct to ultrasonography, but not as a replacement. Across a range of scenarios, iuMRI resulted in additional costs compared with ultrasonography alone. The additional cost was consistently < £600 per patient and the cost per management decision appropriately changed was always < £3000. There is potential for reporting bias from the referring clinicians on the diagnostic and prognostic outcomes. Lower than anticipated follow-up rates at 3 years of age were observed.

CONCLUSIONS

iuMRI as an adjunct to ultrasonography significantly improves the diagnostic accuracy and confidence for the detection of fetal brain abnormalities. An evaluation of the use of iuMRI for cases of isolated microcephaly and the diagnosis of fetal spine abnormalities is recommended. Longer-term follow-up studies of children diagnosed with fetal brain abnormalities are required to fully assess the functional significance of the diagnoses.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN27626961.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 49. See the NIHR Journals Library website for further project information.

Lost in explanation: Lessons learned from audio-recordings and surveys of the antenatal consultation

OBJECTIVE

Determine content of antenatal prematurity consultations and identify factors associated with satisfaction.

DESIGN

This is an observational study of consultations for possible preterm delivery. Consultations were audio-recorded and analyzed. Parents and physicians were surveyed post-consultation.

RESULTS

We analyzed 17 audio-recordings. Mean gestation was 28 weeks. Frequency of topics discussed were: antenatal steroids 82%, intubation 82%, breast milk 76%, time in NICU 65%, development 59%, and survival 53%. Parents frequently asked about length of hospitalization stay, feeding, and separation concerns. Parents' greatest fears were developmental problems, survival, separation from baby, infant health, and length of hospitalization. The parent satisfaction score was 8.9, and physician satisfaction score was 4.8 on a ten-point scale. No factors were found to be associated with satisfaction. Physicians felt 82% of consultations could be improved.

CONCLUSIONS

In consultations for possible preterm delivery, physicians discussed resuscitation details and initial neonatal care. Parental greatest fears involved more global issues. Despite content variability, parents were highly satisfied. No specific factors (such as topics discussed or length of consultation) were found to be statistically associated with parent satisfaction. Physicians were less satisfied. Providing too much/too little information was a repeated physician concern.

Health-care provider communication with expectant parents during a prenatal diagnosis: an integrative review

The pregnancy and health-care experience of expectant parents who receive a prenatal diagnosis of their unborn infant is distinctively fraught with uncertainty. Health-care providers (HCPs) that care for parents during this uncertain time have an exceptional opportunity to positively impact parental outcomes. An integrative literature review was conducted to explore HCPs' impact on parents' experiences of receiving a prenatal diagnosis. Thirty-three articles met study inclusion criteria (n=18 qualitative; 6 quantitative; 9 mixed methods). HCP communication was the major theme identified, because of its overarching impact on parents' experiences of receiving a prenatal diagnosis of their unborn infant. Parents' perception of the information communicated to them about their unborn infant's diagnosis by their HCP, and the manner in which that information is communicated to them, affects parents' ability to cope with the diagnosis. Recommendations for health-care delivery models, and for future research are discussed.

Lack of institutional pathways for referral: results of a survey among pediatric surgeons on prenatal consultation for congenital anomalies

OBJECTIVE

This paper aimed to assess pathways through which pediatric surgeons receive couples for prenatal consultation after prenatal diagnosis.

METHOD

A questionnaire was mailed to pediatric surgical centers to assess the following: (1) surgical caseload per year; (2) number of centers in which prenatal consultation is offered; (3) presence of a 'structured' prenatal consultation clinic; (4) number of consultations per year; (5) pathways for referral to the pediatric surgeon; and (6) the availability of psychological counseling.

RESULTS

Response rate was 81%, (42/52 centers). Thirty-eight centers (93%) offered prenatal consultation. Seven centers (18%) reported to have a 'structured' clinic in terms of time and location. In 13 centers (34%), 1-9 consultations were carried out, from 10 to 19 in 18 centers (47%), from 20 to over 50 in 7 centers (18%). In 34 centers, internal referrals from the obstetric departments were counseled, and in 28 centers, there were also external referrals. Eleven centers reported that couples were self-referred. Information regarding prenatal counseling was available on the institutional website in 10/38 (26%) centers. Psychological counseling was available in 36 centers.

CONCLUSION

Despite the fact that the majority of pediatric surgical centers provides prenatal consultation, caseloads are very variable as are referral modalities.

Antenatal diagnosis of congenital anomaly: a really traumatic experience?

OBJECTIVE

With increasing use of routine prenatal ultrasound, prenatal counseling after diagnosis of congenital malformations is frequently offered to prospective parents. We aimed to assess if the communication of diagnosis of a congenital anomaly in the fetus meets American Psychiatric Association (APA) criteria for trauma in parents.

STUDY DESIGN

In the period ranging from 2003 to 2009 a preliminary investigation was conducted with 165 prospective mothers and 91 prospective fathers being interviewed after communication of diagnosis. Analysis of statements was made independently by two psychologists considering the APA definition of trauma.

RESULT

A total of 145 mothers and 76 fathers experienced the communication of diagnosis in their fetus as a traumatic event. There was no correlation between type of malformation and trauma nor was there statistical difference between mother and father regarding the stressor.

CONCLUSION

Communication of diagnosis of a fetal anomaly can be a traumatic event and should be dealt with consequently. Given the therapeutic value of sharing traumatic experience such practice should be encouraged as part of the consultation process.

Authoritative knowledge, the technological imperative and women's responses to prenatal diagnostic technologies

Theories about authoritative knowledge (AK) and the technological imperative have received varying levels of interest in anthropological, feminist and science and technology studies. Although the anthropological literature abounds with empirical considerations of authoritative knowledge, few have considered both theories through an empirical, inductive lens. Data extracted from an earlier study of 30 women's responses to termination for fetal anomaly are reanalyzed to consider the women's views of, and responses to, prenatal diagnostic technologies (PNDTs). Findings indicate that a small minority embrace the societal portrayal of technology as univalently positive, while the majority have nuanced and ambivalent responses to the use of PNDTs. Further, the interface of authoritative knowledge and the technological imperative suggests that AK derives not only from medical provider status and technology use, but also from the adequacy and trustworthiness of the information. The issue of timing and uncertainty of the information also are interrogated for their impact on women's lives and what that can illuminate about the theories of AK and the technological imperative.

Prenatal consultation with a neonatologist for congenital anomalies: parental perceptions

OBJECTIVES

To investigate parental expectations of a prenatal consultation with a neonatologist for a prenatally diagnosed congenital anomaly, to identify parents' values and unmet needs, and to obtain recommendations for improving physician-parent communication in a prenatal consultation.

METHODS

Parents referred to neonatology for prenatal consultation after the diagnosis of a congenital anomaly. Completed 2 qualitative interviews: the first within 1 week of the consultation and the second 1 week after delivery. Interviews were analyzed for themes by using the constant comparative method associated with the grounded theory method.

RESULTS

Thematic saturation was achieved after 42 interviews (22 women); only mothers participated. Five main themes emerged: (1) preparation; (2) knowledgeable physician; (3) caring providers; (4) allowing hope; and (5) time. Mothers believed that a consultation with a neonatologist helped them prepare for the perinatal course. They wished to know the management plan and all possible outcomes. Mothers wanted information specific to their situation and tailored to their knowledge base. Receiving conflicting information from physicians increased anxiety and eroded confidence. Seeing the NICU during the consultation was emotionally difficult but valuable. Mothers wanted realistic information, regardless of how grim, yet wanted to retain hope. All mothers would recommend a prenatal consultation with a neonatologist.

CONCLUSIONS

Mothers perceived that a consultation with a neonatologist, which included a NICU tour, prepared them for the perinatal course. Parents want realistic medical information, specific to their situation, provided in an empathetic manner and want to be allowed to hope for the best possible outcome.

"I wasn't alone"--a study of group prenatal care in the military

The military has recognized that health and quality of life for service members are closely tied to the resources for their families, including how they are cared for during pregnancy and childbirth. However, there has been little examination of women's experience with different models of prenatal care (PNC) in military settings. The purpose of this article is to describe the results of a qualitative study of women's experiences with the CenteringPregnancy model of group PNC compared to individual PNC in two military health care settings. This clinical trial enrolled 322 women who were randomized into group or individual PNC at two military treatment facilities. Qualitative interviews were completed with 234 women during the postpartum period. Interpretative narrative and thematic analysis was used to identify three themes: 1) "I wasn't alone"-the experience with group PNC; 2) "I liked it but..."-recommendations to improve group PNC; and 3) "They really need to listen"-general concerns across the sample about PNC. Greatest concerns of women in individual PNC included lack of continuity and time with the provider. Our military families must be assured that their health care system meets their needs through personal and family-centered care. Group PNC offers the potential for continuity of provider while also offering community with other women. In the process, women gain knowledge and power as a health care consumer.

A qualitative study of women's experiences of communication in antenatal care: identifying areas for action

To identify key features of communication across antenatal (prenatal) care that are evaluated positively or negatively by service users. Focus groups and semi-structured interviews were used to explore communication experiences of thirty pregnant women from diverse social and ethnic backgrounds affiliated to a large London hospital. Data were analysed using thematic analysis. Women reported a wide diversity of experiences. From the users' perspective, constructive communication on the part of health care providers was characterised by an empathic conversational style, openness to questions, allowing sufficient time to talk through any concerns, and pro-active contact by providers (e.g. text message appointment reminders). These features created reassurance, facilitated information exchange, improved appointment attendance and fostered tolerance in stressful situations. Salient features of poor communication were a lack of information provision, especially about the overall arrangement and the purpose of antenatal care, insufficient discussion about possible problems with the pregnancy and discourteous styles of interaction. Poor communication led some women to become assertive to address their needs; others became reluctant to actively engage with providers. General Practitioners need to be better integrated into antenatal care, more information should be provided about the pattern and purpose of the care women receive during pregnancy, and new technologies should be used to facilitate interactions between women and their healthcare providers. Providers require communications training to encourage empathic interactions that promote constructive provider-user relationships and encourage women to engage effectively and access the care they need.

Psychological reactions in women undergoing fetal magnetic resonance imaging

OBJECTIVE

To investigate women's psychological reactions when undergoing fetal magnetic resonance imaging (MRI), and to estimate whether certain groups, based on clinical and sociodemographic variables, differ in their subjective experiences with fetal MRI and in their anxiety levels related to the scanning procedure.

METHODS

This study is a prospective cohort investigation of 62 women before and immediately after fetal MRI. Anxiety levels and subjective experiences were measured by questionnaires. Groups based on clinical and sociodemographic variables were compared with regard to anxiety levels and to the scores on the Prescan and Postscan Imaging Distress Questionnaire.

RESULTS

Anxiety scores before fetal MRI were 8.8 points higher than those of the female, nonclinical, norm population (P<.001). The severity of the referral diagnosis showed a linearly increasing effect on anxiety level before MRI (weighted linear term: F1,59=5.325, P=.025). Magnetic resonance imaging was experienced as unpleasant by 33.9% (95% confidence interval [CI] 21.2-46.6%) and as hardly bearable by 4.8% (95% CI 0-17.5%) of the women. Physical restraint (49.9%, 95% CI 37.4-62.4%), noise level (53.2%, 95% CI 40.7-65.7%), anxiety for the infant (53.2%, 95% CI 40.7-65.7%), and the duration of the examination (51.6%, 95% CI 39.1-64.1%) were major distressing factors.

CONCLUSION

Women who undergo fetal magnetic resonance imaging experience considerable distress, especially those with poor fetal prognoses. Ongoing technical developments, such as a reduction of noise, shortening the duration of the MRI, and a more comfortable position in open MRI machines, may have the potential to improve the subjective experiences of women during fetal MRI.

LEVEL OF EVIDENCE

III.

The health-care experiences of families given the prenatal diagnosis of trisomy 18

OBJECTIVE

The objective of this study was to examine parent-reported experiences in the health care system after receiving the prenatal diagnosis of trisomy 18 and to identify factors that contribute to satisfaction with care.

STUDY DESIGN

Nineteen families who received the diagnosis between 2002 and 2005 were given semistructured telephone interviews. Of the 19 families, 11 continued the pregnancy while the remaining 8 chose induced abortion. Classical content analysis was utilized to identify themes among subject responses.

RESULT

We identified several specific aspects of care as key in either being highly satisfied or dissatisfied: expressions of empathy from provider, continuity of care, communication, valuing the fetus and participation in medical decision-making.

CONCLUSIONS

Aspects of care that were identified as reasons for dissatisfaction are potentially modifiable by training, education or team-based approaches. Further studies are necessary to determine how we can improve the quality of services during prenatal diagnosis.

Women with high-risk pregnancies, problems, and APN interventions

PURPOSE

To (a) describe women's prenatal and postpartum problems and advanced practice nurses (APN) interventions; and (b) determine if problems and APN interventions differed by women's medical diagnosis (diabetes, hypertension, preterm labor).

DESIGN AND METHODS

Content analysis of 85 interaction logs created by APNs during a randomized clinical trial in which half of physician-provided prenatal care was substituted with APN-provided prenatal care in the women's homes. Patients' problems and APN interventions were classified with the Omaha Classification System.

FINDINGS

A total of 212,835 health problems and 212,835 APN interventions were identified. The dominant antenatal problems were physiologic (59.2%) and health-related behaviors (33.3%); postpartum were physiologic (44.0%) and psychosocial problems (31.6%). Antenatally, women with diabetes had significantly more health-related behavior problems; women with preterm labor had more physiologic problems. APN surveillance interventions predominated antenatally (65.6%) and postpartum (66.0%), followed by health teaching, guidance, and counseling both antenatally (25.4%) and postpartum (28.1%). Women with chronic hypertension required significantly more case-management interventions.

CONCLUSIONS

The categories of women's problems were largely similar across medical diagnostic groups. Interventions to address women's problems ranged from assessing maternal and fetal physiologic states to teaching interpersonal relationships and self-care management to assisting with transportation and housing. Data show the range of APN knowledge and skills needed to improve maternal and infant outcomes and ultimately reduce healthcare costs in women with high-risk pregnancies.