Invasive prenatal testing decisions in pregnancy after infertility

Decisional conflict among couples seeking specialty treatment for infertility in the USA: a longitudinal exploratory study

STUDY QUESTION

What are couples' decisional conflicts around family-building approaches before and after seeking a specialty consultation for infertility?

SUMMARY ANSWER

Decisional conflict is high among couples before an initial specialty consultation for infertility; on average, women resolved decisional conflict more quickly than men.

WHAT IS KNOWN ALREADY

Couples have multiple options for addressing infertility, and decisional conflict may arise due to lack of information, uncertainty about options and potential risks or challenges to personal values.

STUDY DESIGN, SIZE, DURATION

We conducted a total of 385 interviews and 405 surveys for this longitudinal, mixed-methods cohort study of 34 opposite-sex couples who sought a new reproductive specialty consultation (n = 68), who enrolled before the initial consultation and were followed over 12 months.

PARTICIPANTS/MATERIALS, SETTING, METHODS

The in-depth, semi-structured interviews included questions about information gathering, deliberation and decision-making, and self-administered surveys included the Decisional Conflict Scale (DCS), at six time points over 12 months. A DCS total score of 25 is associated with implementing a decision, and higher scores indicate more decisional conflict. A systematic content analysis of interview transcripts identified major themes. Paired t tests identified differences in DCS between women and men within couples. Linear mixed models predicted changes in DCS over time, adjusting for sociodemographic and fertility-related factors.

MAIN RESULTS AND THE ROLE OF CHANCE

The major qualitative themes were communication with partners, feeling supported and/or pressured in decision (s), changing decisions over time and ability to execute a desired decision. Average DCS scores were highest before the initial consultation. Within couples, men had significantly higher decisional conflict than women pre-consultation (48.9 versus 40.2, P = 0.037) and at 2 months (28.9 versus 22.1, P = 0.015), but differences at other time points were not significant. In adjusted models, predicted DCS scores declined over time, with women, on average, reaching the DCS threshold for implementing a decision at 2 months while for men it was not until 4 months.

LIMITATIONS, REASONS FOR CAUTION

This is a convenience sample from a single center, and generalizability may be limited.

WIDER IMPLICATIONS OF THE FINDINGS

Understanding how couples discuss and make decisions regarding family-building could improve the delivery of patient-centered infertility care. Our findings are the first to prospectively explore decisional conflict at multiple time points in both men and women; the observed gender differences underlie the importance of supporting both partners in clinical decision-making for infertility.

STUDY FUNDING/COMPETING INTEREST(S)

This work was supported by the National Institute of Child Health and Human Development under Grant [R21HD071332], the Research and Education Program Fund, of the Advancing a Healthier Wisconsin endowment at Medical College of Wisconsin, the National Research Service Award under Grant [T32 HP10030] and the use of REDCap for data collection from the National Center for Advancing Translational Sciences, National Institutes of Health under Grant through [8UL1TR000055]. The authors have no competing interests.

Women's decisional conflict in the pathway of prenatal screening and testing: an explorative study within Finnish public maternity care

Objectives To explore women's decisional conflict in the pathway of prenatal screening and testing (PreST) in Finland and to evaluate a counseling service. Methods Self-completion surveys were conducted at two medical settings (screening and further testing) of PreST. Decisional Conflict Scale (DCS) was the main measure. Different types of statistical tests were used to compare women's decisional conflict at different medical settings of PreST, and before-after pre-test counseling. Multivariable linear regressions analyzed the influences of the medical settings and other factors on women's decisional conflict. Results Compared to women in population-based screening, women in further testing (before pre-test counseling) were more likely to feel well informed (P < 0.001), had increased values clarity (P < 0.001), but more likely experienced uncertainty (P = 0.040). Besides medical settings, maternal age, gravidity and previous experience of fetal aneuploidy significantly influenced decisional conflict. After counseling, screen-positive women felt better informed (P < 0.001), had increased values clarity (P < 0.001), perceived more support (P < 0.001), and had better decision certainty (P < 0.001) than before counseling. Conclusions Medical settings influence women's decisional conflict during PreST. Individual counseling is effective in improving screen-positive women's decisional conflict. This research adds knowledge and experience on developing decision-making supports across the pathway of PreST.

Utah's 72-Hour Waiting Period for Abortion: Experiences Among a Clinic-Based Sample of Women

CONTEXT

In 2012, Utah became the first state to enact a 72-hour waiting period for abortion. Despite debate about the law's potential effects, research has not examined women's experiences with it.

METHODS

A cohort of 500 women recruited at four family planning facilities in Utah in 2013-2014 completed baseline surveys at the time of an abortion information visit and follow-up telephone interviews three weeks later. Logistic regression and coding of open-ended responses were used to examine which women had abortions and, for those who did not, their reasons.

RESULTS

Among the 309 women completing follow-up, 86% had had an abortion, 8% were no longer seeking abortion, 3% had miscarried or discovered they had not been pregnant, and 2% were still seeking abortion; one woman was still deciding, and the waiting period had pushed one woman beyond her facility's gestational limit for abortion. At the information visit, women reported little conflict about the abortion decision (mean score on a scale of 0-100 was 13.9 for those who eventually had an abortion and 28.5 for others). Low decisional conflict, but not socioeconomic status, was associated with having an abortion (odds ratio, 1.1). On average, eight days elapsed between the information visit and the abortion.

CONCLUSION

As most women in this cohort were not conflicted about their decision when they sought care, the 72-hour waiting requirement seems to have been unnecessary. Individualized patient counseling for the small minority who were conflicted when they presented for care may have been more appropriate.

Measuring decisional certainty among women seeking abortion

OBJECTIVE

Evaluating decisional certainty is an important component of medical care, including preabortion care. However, minimal research has examined how to measure certainty with reliability and validity among women seeking abortion. We examine whether the Decisional Conflict Scale (DCS), a measure widely used in other health specialties and considered the gold standard for measuring this construct, and the Taft-Baker Scale (TBS), a measure developed by abortion counselors, are valid and reliable for use with women seeking abortion and predict the decision to continue the pregnancy.

METHODS

Eligible women at four family planning facilities in Utah completed baseline demographic surveys and scales before their abortion information visit and follow-up interviews 3 weeks later. For each scale, we calculated mean scores and explored factors associated with high uncertainty. We evaluated internal reliability using Cronbach's alpha and assessed predictive validity by examining whether higher scale scores, indicative of decisional uncertainty or conflict, were associated with still being pregnant at follow-up.

RESULTS

Five hundred women completed baseline surveys; two-thirds (63%) completed follow-up, at which time 11% were still pregnant. Mean scores on the DCS (15.5/100) and TBS (12.4/100) indicated low uncertainty, with acceptable reliability (α=.93 and .72, respectively). Higher scores on each scale were significantly and positively associated with still being pregnant at follow-up in both unadjusted and adjusted analyses.

CONCLUSION

The DCS and TBS demonstrate acceptable reliability and validity among women seeking abortion care. Comparing scores on the DCS in this population to other studies of decision making suggests that the level of uncertainty in abortion decision making is comparable to or lower than other health decisions.

IMPLICATIONS

The high levels of decisional certainty found in this study challenge the narrative that abortion decision making is exceptional compared to other healthcare decisions and requires additional protection such as laws mandating waiting periods, counseling and ultrasound viewing.

It's complicated - Factors predicting decisional conflict in prenatal diagnostic testing

BACKGROUND

The technologies currently available to detect the presence of foetal genetic abnormalities are complex, and undergoing prenatal diagnostic testing can have wide-ranging repercussions. Before individuals can decide with certainty whether or not to take these tests, they first need to grasp the many psychosocial and clinical dimensions of prenatal genetic testing.

OBJECTIVE

To test a model integrating key psychosocial and clinical factors as predictors of decisional conflict in decisions about whether or not to undergo prenatal genetic testing.

METHOD

Adults (n = 457) read one of four hypothetical scenarios asking them to imagine expecting a child and considering the option of a prenatal test able to detect a genetic condition; age of condition onset (birth vs. adulthood) and its curability (no cure vs. curable) were manipulated. Participants completed measures of decisional conflict, perceived benefits from normal results, test response efficacy, condition coherence, child-related worry, perceived disagreement with the other parent's preference, motivation to comply with doctors' perceived preferences, and parity.

RESULTS

Prenatal testing decisional conflict was positively predicted by perceiving normal results as beneficial, doubting the test's reliability, lacking understanding of the genetic condition, worrying about the health of the foetus, perceiving differences of opinion from partner/spouse, wanting to follow doctors' preferences, and being childless.

DISCUSSION

These results, of growing relevance given the increasing availability of new technologies in pregnancy care, can inform communication strategies that facilitate couples' decision making.

CONCLUSION

This study provides insights into factors that might complicate prenatal testing decision making.

Congenital malformations and assisted reproductive technique: Where is assisted reproductive technique taking us?

Development of ART has great benefit for millions of couples all over the world and with falling fertility rate there are a growing numbers of children born with the help of ART, it is important to investigate potential risks to these children. IVF-ICSI pregnancies are associated with higher risk for multiple gestation, preterm labor and low birth weight. It is an area of great conflict and interest that whether ART is associated with increased congenital malformations or not. So, this article reviews the data and evidences linking ART to congenital malformations.