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

Providers' experiences with abortion care: A scoping review

BACKGROUND

Induced abortion is one of the most common gynecological procedures in the world, with as many as three in every ten pregnancies ending in abortion. It, however, remains controversial. The objective of this scoping review was to explore and map existing literature on the experiences of those who provide abortion care.

METHODS AND FINDINGS

This exploratory review followed the Levac et al. guidelines and was reported in accordance with the PRISMA-ScR checklist. CINAHL, Cochrane, EMBASE, PsycInfo, PubMed, and Web of Science were used to identify peer-reviewed, original research articles published on providers' experience of abortion. We identified 106 relevant studies, which include a total sample of 4,250 providers from 28 countries and six continents. Most of the studies were qualitative (n = 83), though quantitative (n = 15) and mixed methods (n = 8) studies were also included. We identified two overarching themes: (1) Providers' experiences with abortion stigma and (2) Providers' reflections on their abortion work. Our findings suggest that providers from around the world experience challenges within society and their communities and workplaces which reinforce the stigmatization and marginalization of abortion and pose questions about the morality of this work. Most, however, are proud of their work, believe abortion care to be socially important and necessary, and remain committed to the provision of care.

CONCLUSIONS

The findings of this review provide a comprehensive overview on the known experiences of providing abortion care. It is a key point of reference for international providers, researchers, and advocates to further this area of research or discussion in their own territories. The findings of this review will inform future work on how to support providers against stigmatization and will offer providers the chance to reflect on their own experiences.

Abortion care at 20 weeks and over in Victoria: a thematic analysis of healthcare providers' experiences

BACKGROUND

In many countries, abortions at 20 weeks and over for indications other than fetal or maternal medicine are difficult to access due to legal restrictions and limited availability of services. The Abortion and Contraception Service at the Royal Women's Hospital in Victoria, Australia is the only service in the state that provides this service. The views and experiences of these abortion providers can give insight into the experiences of staff and women and the abortion system accessibility. The aim of this study was to examine health providers' perceptions and experiences of providing abortion care at 20 weeks and over for indications other than fetal or maternal medicine, as well as enablers and barriers to this care and how quality of care could be improved in one hospital in Victoria, Australia.

METHODS

A qualitative study was conducted at the Abortion and Contraception Service at the Royal Women's Hospital. Participants were recruited by convenience and purposive sampling. Semi-structured interviews were conducted one-on-one with participants either online or in-person. A reflexive thematic analysis was performed.

RESULTS

In total, 17 healthcare providers from medicine, nursing, midwifery, social work and Aboriginal clinical health backgrounds participated in the study. Ultimately, three themes were identified: 'Being committed to quality care: taking a holistic approach', 'Surmounting challenges: being an abortion provider is difficult', and 'Meeting external roadblocks: deficiencies in the wider healthcare system'. Participants felt well-supported by their team to provide person-centred and holistic care, while facing the emotional and ethical challenges of their role. The limited abortion workforce capacity in the wider healthcare system was perceived to compromise equitable access to care.

CONCLUSIONS

Providers of abortion at 20 weeks and over for non-medicalised indications encounter systemic enablers and barriers to delivering care at personal, service delivery and healthcare levels. There is an urgent need for supportive policies and frameworks to strengthen and support the abortion provider workforce and expand provision of affordable, acceptable and accessible abortions at 20 weeks and over in Victoria and in Australia more broadly.

Attitudes of Chinese maternal and child health professionals toward termination of pregnancy for fetal anomaly: a cross-sectional survey

Objectives

This study explores the attitudes of Chinese maternal and child health professionals toward the termination of pregnancy for fetal anomaly (TOPFA) based on four case scenarios and further identifies the factors that influence their attitudes.

Methods

This cross-sectional study, conducted from February 14-21, 2022, aimed to explore the attitudes of maternal and child health professionals toward TOPFA in Hunan Province. We targeted health service institutions across 14 prefecture-level cities and the autonomous prefecture. A questionnaire was made available online and shared via the instant communication platform, WeChat. Participants were recruited through the same platform and completed the survey online. Descriptive statistics were used to analyze the data, and binary logistic regression was performed to determine factors affecting the health professionals' attitudes toward TOPFA, expressed as the odds ratio (OR) and 95% confidence intervals (CI).

Results

The study found that 63.5% of health professionals approved of the birth of a fetus with cleft lip and palate, while 36.5% opposed it. Similarly, 39.7% approved of the birth of a fetus with phenylketonuria, while 60.3% opposed it. The percentages of those in favor of and against the birth of a fetus with precocious heart disease were 45.5 and 54.5%, respectively, and those for and against the birth of a fetus with missing fingers were 50.8 and 49.2%, respectively. The top three factors considered by health professionals when agreeing on TOPFA were "the impact of fetal disease on fetal function and growth," "the severity of fetal disease," and "the assessment of indications for fetal disease by professionals and related professional advice." The majority of health professionals (75-78%) preferred joint decision-making by parents regarding the right to decide TOPFA.

Conclusion

Our study indicates that the attitudes of health professionals toward TOPFA can differ significantly depending on the specific birth defect under consideration. Notably, the majority of health professionals prioritized "the impact of fetal abnormalities on fetal function and development" when deciding their support for TOPFA, advocating for the decision to be a joint one between the parents. Additionally, factors such as religious beliefs, professional training, age, and job title appeared to influence these attitudes toward TOPFA. Our findings could serve as a reference point in the development of guidelines for the prevention and management of birth defects.

A meta-ethnography on the experience and psychosocial implications of providing abortion care

RATIONALE

Challenges unique to abortion care have negative implications for access to safe abortion and the psychosocial well-being of healthcare providers. A deeper understanding of the experience of providing abortion care can inform responsive interventions toward supporting abortion providers and strengthening health systems.

OBJECTIVE

A meta-ethnography was conducted to describe the experiences of providing abortion care and offer broad conceptual implications of abortion providers' experiences on their psychosocial coping and well-being.

METHODS

International grey and published research reported in English between 2000 and 2020 was identified via Web of Science Core Collection, PsycInfo, PubMed, Science Direct and Africa-Wide. Studies conducted in contexts where elective abortion is legally permitted were included. Study samples included nurses, physicians, counsellors, administrative staff and other healthcare providers involved in abortion care. Qualitative studies and qualitative data from mixed designs were included. The Critical Appraisal Skills Programme tool was used for appraisal and data was analysed using a meta-ethnographic approach.

FINDINGS

The review included 47 articles. Five themes arose from the data including the emotional challenges of providing clinical and psychological care, organisational and structural challenges, experiences characterised by stigma, pro-choice narratives, and coping with challenges. Outcomes ranged from moral and emotional alignment, resistance to abortion stigma, and job satisfaction to moral distress, emotional suppression, internalised stigma, selective participation and discontinuation of abortion care. Outcomes were dependent on the nature of interpersonal relationships, working conditions, the internalization of positive or negative messages about abortion, personal history and individual coping styles.

CONCLUSIONS

Despite facing significant challenges in their work, the presence of positive outcomes among abortion providers and the moderating role of external and individual-level factors on well-being have encouraging implications for supporting psychosocial wellness among abortion providers.

[Medical attitudes regarding the announcement of suspected foetal abnormality in ultrasound scans]

OBJECTIVES

This study's primary objective was to analyse the personal experience of different ultrasonographers during the announcement of suspected foetal abnormalities, seen either in screening or diagnostic ultrasound. The secondary objectives aimed to explore the factors influencing the announcement of the foetal abnormality, whether they complicated or facilitated the consultation. These also comprised the analysis of the knowledge, practice and attitudes of the healthcare professionals as well as the different techniques used during the consultation. Finally, this study aimed to analyse the various tools and skills used by ultrasonographers to improve the quality of their announcement of the diagnosis.

METHODS

This qualitative study was based on both the observation of consultations and the results of semi-structured interviews with ultrasonographers, in a maternity hospital in France.

RESULTS

The results highlighted feelings of great discomfort for the ultrasonographers on discovering an abnormality on the scan. The different perceptions and practices regarding the announcement of a diagnosis varied between screening ultrasonographers and specialist doctors. The uncertainty of foetal prognosis seemed to complicate the announcement for specialist doctors. Qualities that made the communication of the diagnosis easier included the ultrasonographer's availability and their attitude. Although professional experience was considered a very powerful skill, training for the communication of a diagnosis accelerates the development of good medical practice.

CONCLUSIONS

The announcement of suspected foetal abnormalities is a difficult exercice, which impacts the ultrasonographer's personal experience and his attitude. Some professional practices are to be encouraged while others are to be put under question. A trust-based relationship between the healthcare professional and the patient is partly reinforced by the quality of the announcement and its follow-up, as well as the healthcare professional's thoroughness and humanity.

Influencing factors of perinatal bereavement care confidence in nurses and midwives: A cross-sectional study

BACKGROUND

Most nurses and midwives are not prepared to provide bereavement care. The conflict between the need for high-quality care of bereaved parents and the lack of confidence in providing perinatal bereavement care among nursing staff is becoming increasingly prominent in China.

OBJECTIVE

To describe the current situation and identify influencing factors of perinatal bereavement care confidence (PBCC) among nurses and midwives in China.

METHODS

This descriptive and cross-sectional survey was conducted in 2021. A convenience sample was created by recruiting 571 nurses and midwives in 11 hospitals in Zhejiang Province. Collected the data of PBCC, secondary traumatic stress (STS) and emotional exhaustion (EE) in this study.

RESULTS

The average score of the PBCC was 67.83 ± 10.78. Average levels of STS were (23.32 ± 7.39) and EE (17.87 ± 8.62). PBCC was found to be most often associated with self-awareness, organisational support and training in perinatal bereavement care.

CONCLUSIONS

Managers should take measures to improve PBCC and optimise perinatal bereavement care practice from the perspective of enhancing self-awareness of nursing staff, strengthening organisational support and providing training in perinatal bereavement care. The mental health of nursing professionals in the context of perinatal bereavement care needs to be emphasised. Nursing managers should make clear policies and establish a communication platform for nursing staff. Professional training should be conducted in the future.

Nurse practitioners' and certified nurse midwives' experiences providing comprehensive early abortion care in New England, USA

Access to abortion is linked to better maternal health and is essential to advancing women's economic and social equality. Globally, nurses and midwives have been identified as key for increasing access to this service. In this qualitative study we describe the experiences of nurse practitioners and nurse midwives who provide comprehensive early abortion care in the New England region of the United States. In contrast to much of the existing literature from around the world on nurses who deliver abortion care, we found participants' experiences providing comprehensive early abortion was generally positive. The study has implications for theory development, research, and policy.

First and second trimester ultrasound in pregnancy: A systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers

Background

The World Health Organization (WHO) recommends one ultrasound scan before 24 weeks gestation as part of routine antenatal care (WHO 2016). We explored influences on provision and uptake through views and experiences of pregnant women, partners, and health workers.

Methods

We undertook a systematic review (PROSPERO CRD42021230926). We derived summaries of findings and overarching themes using metasynthesis methods. We searched MEDLINE, CINAHL, PsycINFO, SocIndex, LILACS, and AIM (Nov 25th 2020) for qualitative studies reporting views and experiences of routine ultrasound provision to 24 weeks gestation, with no language or date restriction. After quality assessment, data were logged and analysed in Excel. We assessed confidence in the findings using Grade-CERQual.

Findings

From 7076 hits, we included 80 papers (1994–2020, 23 countries, 16 LICs/MICs, over 1500 participants). We identified 17 review findings, (moderate or high confidence: 14/17), and four themes: sociocultural influences and expectations; the power of visual technology; joy and devastation: consequences of ultrasound findings; the significance of relationship in the ultrasound encounter. Providing or receiving ultrasound was positive for most, reportedly increasing parental-fetal engagement. However, abnormal findings were often shocking. Some reported changing future reproductive decisions after equivocal results, even when the eventual diagnosis was positive. Attitudes and behaviours of sonographers influenced service user experience. Ultrasound providers expressed concern about making mistakes, recognising their need for education, training, and adequate time with women. Ultrasound sex determination influenced female feticide in some contexts, in others, termination was not socially acceptable. Overuse was noted to reduce clinical antenatal skills as well as the use and uptake of other forms of antenatal care. These factors influenced utility and equity of ultrasound in some settings.

Conclusion

Though antenatal ultrasound was largely seen as positive, long-term adverse psychological and reproductive consequences were reported for some. Gender inequity may be reinforced by female feticide following ultrasound in some contexts. Provider attitudes and behaviours, time to engage fully with service users, social norms, access to follow up, and the potential for overuse all need to be considered.

Termination of pregnancy for foetal indication in the French context analysis of decision-making in a Multidisciplinary Centre For Prenatal Diagnosis

OBJECTIVE

In France, termination of pregnancy (TOP) for medical reasons is legal, regardless of the term, after authorisation by a Multidisciplinary Centre for Prenatal Diagnosis (MCPD). This study analyses the elements supporting the TOP decision-making process faced with a foetal pathology.

STUDY DESIGN

Medical records of one MCPD were analysed for the period 2013 and 2014 and semi-structured interviews with MCPD members were conducted.

RESULTS

Out of 265 files concerning foetal indications, all but one resulted in a decision for TOP. The main indications in number for TOP were malformations and chromosomal abnormalities. For indications such as trisomy 21, authorisations are generally given without discussion. Our results underline the importance that professionals attach to the collegiality of decisions, particularly in situations of uncertainty.

CONCLUSION

This study provides information about the activity of MCPDs within the field of prenatal diagnosis and shows the importance of these structures in supporting women and couples whilst respecting their autonomy. At present, the role of the MCPD is in the process of evolving and could become an information and advisory board for women, based on collegial expertise to guide their decision-making.

Investigating the benefits and challenges of including bereaved women in research: a multifaceted perinatal audit in a socially disadvantaged French district

OBJECTIVES

To describe experiences including interviews with bereaved women in a clinical audit.

DESIGN

The data come from an audit of all stillbirths and neonatal deaths at ≥22 weeks of gestation in Seine-Saint-Denis, a disadvantaged French district in 2014. We included bereaved women using a questionnaire that also contained open-ended questions administered in an interview format by a midwife-investigator several weeks after the death. The study included a referral protocol for bereaved women with unmet needs revealed during the interviews. A psychological support for the three midwife-investigators was set-up, in the form of a support group.

SETTING

The 11 maternity hospitals in the district.

PARTICIPANTS

218 women (227 deaths).

ANALYSES

Data come from medical records, maternal interviews, the reviews of the audit's expert panel and written narratives of their experiences provided by the midwife-investigators. Quantitative data were analysed statistically, and qualitative data thematically.

RESULTS

One-third (75) of the women agreed to an interview, but acceptance ranged from 6% to 60% by maternity unit. Characteristics of respondents and non-respondents were similar. Members of the audit's expert panel reported that 41% of the interviews contained new information relevant to their assessment. Of the women interviewed, 35% were referred to a medical professional, psychologist or social worker. Midwife-investigators' experiences illustrated the benefits of a support group with three main themes identified: improving their interactions with bereaved women as well as medical teams and protecting their psychological well-being.

CONCLUSION

These results showed that including interviews with bereaved women in audit designs was feasible and provided valuable information on women's care and social circumstances that were not available in medical records. They also highlight the importance of implementing referral protocols for the bereaved women, used in over one-third of cases, as well as providing support for study investigators.

Shall parent / patient wishes be fulfilled in any case? A series of 32 ethics consultations: from reproductive medicine to neonatology

BACKGROUND

Questions concerning the parent/ patient's autonomy are seen as one of the most important reasons for requesting Ethics Consultations (ECs). Respecting parent/ patient's autonomy also means respecting the patient's wishes. But those wishes may be controversial and sometimes even go beyond legal requirements. The objective of this case series of 32 ECs was to illustrate ethically challenging parent / patients' wishes during the first stages of life and how the principle of patient's autonomy was handled.

METHODS

The case series has a qualitative retrospective approach. A documentary sheet was designed de novo and information was gained from EC minutes and medical charts. The cases originate from the following specialties: reproductive medicine, obstetrics and neonatology as well as two interdisciplinary cases.

RESULTS

Through the structured EC minutes aspects of patient / parents' wishes could be identified explicitly. Overall the patient / parents' wishes were not supported in 61% of the cases. Central reasons for rejection of patient / parent wishes were mainly the protection of the best interest of the unborn / new-born child as well as the rejection of clinical approaches that were regarded as being substandard treatment.

CONCLUSION

The study shows that treatment decisions in reproductive medicine, obstetrics and neonatology raise substantial ethical questions leading to the request for ethics consultation. The systematic case series presented here gives insight into the ethical reflection carried out to support the clinicians in their decision-making and counselling. It shows that clinicians, after using ethics consultation, make deliberate decisions that do not "automatically" fulfil the treatment requests of the patients and parents (to-be).

MRI for Fetal Developmental Brain Abnormalities: Perspectives From the Pregnant Patient

Ultrasound is routinely used as a prenatal screening and diagnostic tool but has limitations. Some anomalies in the developing fetal brain can be difficult to detect, and in utero magnetic resonance imaging (iuMRI) is increasingly used as an adjunct to ultrasound. However, understandings of patient perspectives of iuMRI technology are still developing. Our qualitative study of 41 mothers who experienced iuMRI was embedded in a diagnostic accuracy trial and aimed to inform policy recommendations that might stem from the clinical findings. Our analysis suggests that iuMRI is seen as useful, offering valuable additional information and helping women make decisions about care options at a difficult time. However, patients' experiences demonstrated the uncertainty and anxiety associated with the prenatal diagnosis (PND) process relating to brain anomalies including the challenges of their embodied contributions. Our findings suggest more could be done to reduce the impact on pregnant women during an already difficult, anxious period.

Negotiating acceptable termination of pregnancy for non-lethal fetal anomaly: a qualitative study of professional perspectives

OBJECTIVE

This study aims to explore the perspectives of professionals around the issue of termination of pregnancy for non-lethal fetal anomaly (TOPFA).

METHODS

Semi-structured interviews were undertaken with medical professionals (14 consultants in fetal medicine, obstetrics, neonatology and paediatrics) and social care professionals (nine individuals with roles supporting people living with impairment) from the Northeast of England. Analysis adopted an inductive thematic approach facilitated by NVivo.

RESULTS

The overarching theme to emerge from the interview data was of professionals, medical and social care, wanting to present an acceptable self-image of their views on TOPFA. Professionals' values on 'fixing', pain and 'normality' influenced what aspects of moral acceptability they gave priority to in terms of their standpoint and, in turn, their conceptualisations of acceptable TOPFA. Thus, if a termination could be defended morally, including negotiation of several key issues (including 'fixing', perceptions of pain and normality), then participants conceptualised TOPFA as an acceptable pregnancy outcome.

CONCLUSION

Despite different professional experiences, these professional groups were able to negotiate their way through difficult terrain to conceptualise TOPFA as a morally acceptable principle. While professionals have different moral thresholds, no one argued for a restriction of the current legislation. The data suggest that social care professionals also look at the wider social context of a person with an impairment when discussing their views regarding TOPFA. Medical professionals focus more on the individual impairment when discussing their views on TOPFA.

Attitude toward Prenatal Testing and Termination of Pregnancy among Health Professionals and Medical Students in Saudi Arabia

This study was aimed at assessing the attitude of health care professionals in Jeddah city toward prenatal diagnosis (PND) and termination of pregnancy (TOP). A cross-sectional study was conducted, and the participants completed a self-administered questionnaire. Approximately 82% of participants showed a consistent trend of accepting PND when appropriate, and 47.5% of the respondents were in favor of TOP if the fetus had a severe disease. Compared with men (69.3%), a significantly greater number of women (88%) accepted to have PND. The most acceptable prenatal diagnostic tests in the study were invasive techniques as most of the participants thought that noninvasive tests were nonspecific.

On prenatal diagnosis and the decision to continue or terminate a pregnancy in France: a clinical ethics study of unknown moral territories

This article presents a part of the results of an empirical study conducted at a Parisian hospital between 2011 and 2014. It aimed at understanding the women and couples' motivations to terminate or not a pregnancy once a prenatal diagnosis has revealed a genetically related disease in the embryo or fetus. The article first presents the social and legal context of the study, the methodology used and the pathologies that were encountered. Then, it examines the results of the interviews conducted with 5 women alone and 23 couples explaining their reasons for deciding to terminate or not the pregnancy. Finally, it explores the patients' views about the doctor's involvement in the decision-making process. The findings reveal the reasons they formulate when they ponder whether to terminate or not the pregnancy. It highlights the process of their deliberation, their hierarchisation of arguments and concerns. They also show how patients, though often consumed in sorrow, claim to be the legitimate decision-makers, especially women, in a social and legal context in which the rejection of eugenics is viewed as an undisputable principle.

Challenges to Providing Fetal Anomaly Testing in a Cross-Cultural Environment: Experiences of Practitioners Caring for Aboriginal Women

BACKGROUND

Across Australia there are substantial disparities in uptake of antenatal testing for fetal anomalies, with very low uptake observed among Aboriginal women. The reasons behind these disparities are unclear, although poorer access to testing has been reported in some communities. We interviewed health care practitioners to explore the perceived barriers to providing fetal anomaly screening to Aboriginal women.

METHODS

In 2009 and 2010, in-depth interviews were undertaken with 59 practitioners in five urban and remote sites across the Northern Territory (NT) of Australia. Data were analyzed thematically. Maximum variation sampling, independent review of findings by multiple analysts, and participant feedback were undertaken to strengthen the validity of findings.

RESULTS

Participants included midwives (47%), Aboriginal health practitioners (AHP) (32%), general practitioners (12%), and obstetricians (9%); almost all (95%) were female. Participants consistently reported difficulties counseling women. Explaining the concept of "risk" (of abnormalities and the screening test result) was identified as particularly challenging, because of a perceived lack of an equivalent concept in Aboriginal languages. While AHPs could assist with overcoming language barriers, they are underutilized. Participants also identified impediments to organizing testing including difficulties establishing gestational age, late presentation for care, and a lack of standardized information and training.

DISCUSSION

The availability of fetal anomaly testing is challenged by communication difficulties, including a focus on culturally specific biomedical concepts, and organizational barriers to arranging testing. Developing educational activities that address the technical aspects of screening and communication skills will assist in improving access. These activities must include AHPs.

Factors Affecting Improved Prenatal Screening: A Narrative Review

Background:

Prenatal screening deals with the detection of structural and functional abnormalities in the fetus. Health care providers can minimize unintended pregnancy outcomes by providing proper counseling and performing prenatal screening. The purpose of the present review study is to investigate factors affecting improved prenatal screening.

Methods:

The present study is a narrative review searching public databases such as Google Scholar and specialized databases such as Pubmed, Magiran, Scientific Information Database, Elsevier, Ovid and Science Direct as well. Using the keywords “prenatal screening”, “fetus health” and “prenatal counseling”, 70 relevant articles published from 1994 to 2014 were selected. After reviewing the abstracts, the full data from 26 articles were ultimately used for writing the present review study.

Results:

Three general themes emerged from reviewing the studies: health care providers’ skills, clients’ characteristics and ethical considerations, which were the main factors affecting improved prenatal screening.

Conclusion:

Prenatal screening can be successful if performed by a trained and experienced expert through techniques suitable for the mother’s age. Also simultaneously providing proper counseling and giving a full description of the risks and benefits of the procedures for clients is recommended.

Prenatal diagnosis: From policy to practice. Two distinct ways of managing prognostic uncertainty and anticipating disability in Brazil and in France

Prenatal diagnosis (PND) has gradually established itself as part of the pregnancy monitoring process, with a view to reducing the number of births of children exposed to disability by combining the use of biomedical tools with laws that authorise abortion in cases of foetal pathology. This article looks at how laws which vary from one country to another modulate the way in which PND practices are organised on a daily basis, determine the discourse of practitioners and lead them to adopt specific stances during prenatal consultations with couples coping with a foetal anomaly. We present a comparative ethnographic study, which took place between 2009 and 2011 in France and Brazil, in reference units, based on observation of consultations, professional meetings, and interviews with health practitioners. The fact that access to abortion due to foetal pathology is possible in France, and criminalised in Brazil, conditions how doctors analyse the framework of their medical practice and approach the issue of disability with couples during consultations. In France, practitioners would appear to be satisfied with a professional framework that they themselves created. Faced with prognostic uncertainty, the legal obligation to inform encourages them to discuss all of the potential complications of the diagnosed anomalies and leads them to provide probabilistic information about the life of the child to be, supported by evidence-based medicine. In Brazil, in the public service, the lack of access to abortion has created a malaise among practitioners who criticise this impediment to the objective nature of their practice and to the quality of the information that they provide. Some use prognostic uncertainty to direct the thoughts of women and couples towards the dynamics proper to each individual human trajectory within a given family and a specific social environment.

Non-Invasive Testing, Non-Invasive Counseling

This article describes a new prenatal genetic test that is painless, early, and increasingly available. State legislatures have reacted by prohibiting abortion for reason of fetal sex or of fetal diagnosis and managing genetic counseling. This article explores these legislative responses and considers how physicians and genetic counselors currently communicate post-testing options. The article then examines the challenges ahead for genetic counseling, particularly in light of the troubling grip of abortion politics on conversations about prenatal diagnosis.

Would you terminate a pregnancy affected by sickle cell disease? Analysis of views of patients in Cameroon

Sickle cell disease (SCD) is a debilitating illness that affects quality of life and life expectancy for patients. In Cameroon, it is now possible to opt for termination of an affected pregnancy (TAP) where the fetus is found to be affected by SCD. Our earlier studies found that, contrary to the views of Cameroonian physicians, a majority of parents with their children suffering from SCD would choose to abort if the fetuses were found to be affected. What have not yet been investigated are the views of people suffering from/living with SCD. We used a quantitative sociological method, with administered structured questionnaires, to study the attitudes of adult patients suffering from SCD on prenatal genetic diagnosis (PND) and possible TAP. The majority of the 89 participants were urban dwellers (84.3%), women (57.3%), Christian (95.5%) and single (90.9%), with a secondary/tertiary education (79.5%). The majority (89.2%) would consider PND for SCD; almost half (48.5%) would reject TAP while 40.9% would consider it. Respondents who rejected TAP claimed mostly ethical reasons (78.1%) while those who found TAP acceptable cited fear of having an affected child (88.9%) and the poor quality of the affected child's health (81.5%). Cameroonian patients with SCD are generally supportive of PND and a remarkably high number of patients living with SCD reported that they would consider terminating a pregnancy based on their assessment of the future well-being of the child. Research is required to investigate the burden of SCD on families and their quality of life.

A call for policy action in sub-Saharan Africa to rethink diagnostics for pregnancy affected by sickle cell disease: differential views of medical doctors, parents and adult patients predict value conflicts in Cameroon

Sickle cell disease (SCD) is a debilitating illness that affects the life expectancy of patients. It is possible to test for SCD before birth, to allow for reproductive options to parents. However, under Cameroonian Law, voluntary abortion is a criminal offense and medical abortion is permitted only "…if it is done by an authorized professional and justified by the need to save the mother from grave health jeopardy." The objective of the present study was to compare the views of Cameroonian doctors, parents with at least one living SCD-affected child, and adult SCD patients, regarding prenatal genetic diagnosis and termination of SCD-affected pregnancy. We conducted a quantitative sociological survey of 110 doctors, 130 parents, and 89 adult patients. The majority accepted the prenatal genetic diagnosis for SCD (78.7%, 89.8%, and 89.2%, respectively). Parents (62.5%) were more in favor of termination of SCD-affected pregnancy, than doctors and adults patients (36.1% and 40.9% acceptance, respectively). Parents and patients who found medical abortion acceptable cited fear to have a SCD-affected child (98.1 and 88.9%) and the poor quality of the affected child's health (92.6% and 81.5%). The data underscore the urgency of policy action to place emphasis on: premarital screening, early detection and care of SCD, socio-economic measures to assist SCD-affected families, appropriateness to consider maternal distress due to fetal anomalies in medical abortion legislation. These novel findings signal potential value-based conflicts on the horizon, and can usefully inform the future policy actions in the African continent as OMICS biotechnologies are increasingly employed in global health. To the best of our knowledge, the present study is the first attempt in sub-Saharan Africa to attempt to triangulate the views of multiple stakeholders towards prenatal diagnosis of SCD and termination of an affected pregnancy.

Shaping legal abortion provision in Ghana: using policy theory to understand provider-related obstacles to policy implementation

Background

Unsafe abortion is a major public health problem in Ghana; despite its liberal abortion law, access to safe, legal abortion in public health facilities is limited. Theory is often neglected as a tool for providing evidence to inform better practice; in this study we investigated the reasons for poor implementation of the policy in Ghana using Lipsky’s theory of street-level bureaucracy to better understand how providers shape and implement policy and how provider-level barriers might be overcome.

Methods

In-depth interviews were conducted with 43 health professionals of different levels (managers, obstetricians, midwives) at three hospitals in Accra, as well as staff from smaller and private sector facilities. Relevant policy and related documents were also analysed.

Results

Findings confirm that health providers’ views shape provision of safe-abortion services. Most prominently, providers experience conflicts between their religious and moral beliefs about the sanctity of (foetal) life and their duty to provide safe-abortion care. Obstetricians were more exposed to international debates, treaties, and safe-abortion practices and had better awareness of national research on the public health implications of unsafe abortions; these factors tempered their religious views. Midwives were more driven by fundamental religious values condemning abortion as sinful. In addition to personal views and dilemmas, ‘social pressures’ (perceived views of others concerning abortion) and the actions of facility managers affected providers’ decision to (openly) provide abortion services.

In order to achieve a workable balance between these pressures and duties, providers use their ‘discretion’ in deciding if and when to provide abortion services, and develop ‘coping mechanisms’ which impede implementation of abortion policy.

Conclusions

The application of theory confirmed its utility in a lower-middle income setting and expanded its scope by showing that provider values and attitudes (not just resource constraints) modify providers’ implementation of policy; moreover their power of modification is constrained by organisational hierarchies and mid-level managers. We also revealed differing responses of ‘front line workers’ regarding the pressures they face; whilst midwives are seen globally as providers of safe-abortion services, in Ghana the midwife cadre displays more negative attitudes towards them than doctors. These findings allow the identification of recommendations for evidence-based practice.

Indications and pregnancy outcomes when multidisciplinary centers for prenatal diagnosis refuse request for termination of pregnancy: a retrospective French study

OBJECTIVES

To report indications and risk factors for effective termination of pregnancy (TOP) when multidisciplinary prenatal diagnosis centers refuse request for TOP.

METHODS

This is a retrospective study from a French national registry between 2005 and 2009. Indication groups for TOP refusal were created. Risk factors for pregnancy outcomes and effective TOP were determined by multinomial logistic regression model.

RESULTS

The overall number of TOP refusals was 573. Indications were single malformations (37%), chromosomal abnormalities (16.6%), hygroma (5.2%), potential fetopathies (11%), maternal indications (17.4%), and other indications (12.7%). Pregnancy outcomes were live infants (35.1%), effective TOP (36.3%), intra-uterine fetal death (5.4%), and lost to follow-up (23.2%). Logistic regression model showed an increased likelihood of effective TOP in groups with single malformations [odds ratio (OR) 3.4, 95% confidence interval (CI) 1.6-7.4], chromosomal abnormalities (OR 3, 95% CI 1.2-7.2), and hygromas (OR 19.6, 95% CI 2.3-16.8) compared with other groups. An increased likelihood of effective TOP was also reported when the request was made at first (OR 29.5, 95% CI 10-16.7) and second (OR 6.3, 95% CI 2.3-16.7) trimesters compared with the third trimester.

CONCLUSIONS

Effective TOP is particularly frequent when requested during the first trimester and in cases of structural anomalies of the fetus.

Faced with a dilemma: Danish midwives' experiences with and attitudes towards late termination of pregnancy

BACKGROUND

The introduction of prenatal screening for all pregnant women in Denmark in 2004 has lead to an increase in the number of late terminations of pregnancy after the 12th week of pregnancy. Midwives' experiences with late termination of pregnancy (TOP) are still poorly described in the scientific literature.

AIM

To explore Danish midwives' experiences with and attitudes towards late TOP. Focus was on how midwives perceive their own role in late TOP, and how their professional identity is influenced by working with late TOP in a time where prenatal screening is rapidly developing.

METHOD

A qualitative study consisting of ten individual interviews with Danish midwives, all of whom had taken part in late TOP.

RESULTS

Current practice of late TOP resembles the practice of normal deliveries and is influenced by a growing personalisation of the aborted foetus. The midwives strongly supported women's legal right to choose TOP and considerations about the foetus' right to live were suppressed. Midwives experienced a dilemma when faced with aborted foetuses that looked like newborns and when aborted foetuses showed signs of life after a termination. Furthermore, they were critical of how physicians counsel women/couples after prenatal diagnosis.

CONCLUSIONS

The midwives' practice in relation to late TOP was characterised by an acknowledgement of the growing ethical status of the foetus and the emotional reactions of the women/couples going through late TOP. Other professions as well as structural factors at the hospital highly influenced the midwives' ability to organize their work with late terminations. There is a need for more thorough investigation of how to secure the best possible working conditions for midwives, and how to optimise the care for women/couples going through late TOP.

Attitudes of Swedish midwives towards management of extremely preterm labour and birth

OBJECTIVE

the aim of the study was to ascertain the attitudes of Swedish midwives towards management of very preterm labour and birth and to compare the attitudes of midwives at university hospitals with those at general hospitals.

DESIGN

this cross-sectional descriptive and comparative study used an anonymous self-administrated questionnaire for data collection. Descriptive and analytic statistics were carried out for analysis.

PARTICIPANTS

the answers from midwives (n=259) were collected in a prospective SWEMID study.

SETTING

the midwives had experience of working on delivery wards in maternity units with neonatal intensive care units (NICU) in Sweden.

FINDINGS

in the management of very preterm labour and birth, midwives agreed to initiate interventions concerning steroid prophylaxis at 23 gestational weeks (GW), caesarean section for preterm labour only at 25 GW, when to give information to the neonatologist before birth at 23 GW, and when to suggest transfer to NICU at 23 GW. Midwives at university hospitals were prone to start interventions at an earlier gestational age than the midwives at general hospitals. Midwives at university hospitals seemed to be more willing to disclose information to the parents.

KEY CONCLUSIONS

midwives with experience of handling very preterm births at 21-28 GW develop a positive attitude to interventions at an earlier gestational age as compared to midwives without such experience.

IMPLICATIONS FOR PRACTICE

based on these results we suggest more communication and transfer of information about the advances in perinatal care and exchange of knowledge between the staff at general and university hospitals. Establishment of platforms for inter-professional discussions about ethically difficult situations in perinatal care, might benefit the management of very preterm labour and birth.

"Did you find that out in time?": new life trajectories of parents who choose to continue a pregnancy where a genetic disorder is diagnosed or likely

The availability of tests to detect genetic conditions prenatally has expanded considerably in recent decades. These advances allow women and couples choices; the choice of whether or not to undergo prenatal screening or diagnosis and therefore the choice whether to continue or terminate a pregnancy. Following prenatal testing many people choose to terminate an affected pregnancy, however little is known about the experiences of parents who choose to continue such a pregnancy. This exploratory qualitative study involved in-depth interviews with five mothers and four fathers who experienced a pregnancy where a genetic diagnosis was, or could have been, detected prenatally. Transcripts of the interviews were analyzed using thematic analysis. While the participants' experiences of genetic diagnoses and prenatal choices varied, findings revealed three major categories triggering new life trajectories for all of these parents: knowledge of reproductive risk and receiving a genetic diagnosis; adapting to diagnosis and new life path; and attitudes to prenatal diagnosis and disability. Parents reported that while dealing with their own attitudes and getting on with their "new world," positive and negative attitudes of others impacted on these parents' experiences. A conceptual model arising from the major themes is offered as a way of thinking about this paradigm. Parents who continue a pregnancy where a genetic condition is detected or suspected prenatally, can be supported appropriately by health professionals while adjusting to their new life path.

Confusion and ethical issues surrounding the role of Japanese midwives in childbirth and abortion: a qualitative study

This qualitative study describes midwives' experiences in providing care in both pregnancy termination and childbirth in Japan. Midwives working in the general hospital maternity unit assist in both, which is an ethical issue warranting further exploration. Eleven midwives working in a general hospital were interviewed using a semistructured interview, and responses were coded using thematic analysis. Two major themes emerged: the experience of midwives involved in childbirth and pregnancy termination (three subthemes: confusion about care of the baby and aborted fetus, inability to cater to different mothers' needs, and establishing emotional control) and professional awareness and attitude as a midwife (three subthemes: consistency with professional principles, suppression of feelings in relation to aborted fetus, and previous and current professional identities). We found that midwives are isolated in this important social moral issue and its accompanying professional confusion. Suppressing their feelings remains the most common way of dealing with the ambivalence of the roles they fulfill. Improved working conditions and enhanced training on aspects of professional ethics would assist in reducing professional confusion.

Commentary: how individual and profession-level factors influence discussion of disability in prenatal genetic counseling

Hodgson and Weil (Journal of Genetic Counseling, 2011) reports on two interactive workshops in which genetic counselors identified a broad set of counseling issues that may be impediments to promoting an adequate discussion of disability in prenatal genetic counseling. The present commentary discusses two factors that we infer underlie these counseling issues. First, countertransference concerning disability, which is normal and expected, may influence genetic counselors' decisions about raising and exploring the complex topic of disability in prenatal genetic counseling. Second, the limited involvement of the profession of genetic counseling in the complex social and ethical issues of disability provide little guidance to the individual genetic counselor with respect to discussing disability in prenatal diagnosis counseling. We suggest both factors must be acknowledged and addressed in order to adequately implement the recommendations presented in Hodgson and Weil (Journal of Genetic Counseling, 2011) as well as other efforts to increase discussion of disability in prenatal diagnosis counseling in the service of informed decision making.

Talking about disability in prenatal genetic counseling: a report of two interactive workshops

Women are commonly offered testing in pregnancy to determine the health of their baby. An important component of informed decision-making about prenatal testing is provision of relevant, accurate, meaningful information concerning the conditions that are being tested for--many of which, such as Down syndrome, are associated with a varying degree of physical and intellectual disability. A range of health professionals, including genetic counselors, may provide information and support throughout the testing process, but available data suggest that discussion of disability is frequently absent or limited. To investigate genetic counselors' perceptions of this situation and identify potential barriers to discussion we facilitated interactive workshops at the 2007 National Society of Genetic Counselors Annual Education Conference (NSGC) and the 2008 European Meeting on Psychosocial Aspects of Genetics (EMPAG). Working groups identified relevant psychosocial issues and impediments to discussion (NSGC) or used a two-part scenario to promote discussion (EMPAG) and reported findings in notes and a closing plenary discussion. Inductive content analysis revealed that participants considered informed decision making to be a major reason for presenting information about disabilities in prenatal genetic counseling and endorsed the value of including information about daily life with Down syndrome and other disabilities. However, they identified three broad types of impediments to such discussion: counseling issues concerning the most appropriate manner to discuss disability under the complex circumstances of prenatal genetic counseling, less than optimal training and experience in addressing these issues, and perceived limitations in the participants' knowledge and understanding of life with disability. Our analysis of the responses from the workshop participants and additional thoughts on these issues have led us to develop recommendations for further research, training and clinical practice.

Cell-free fetal DNA testing: a pilot study of obstetric healthcare provider attitudes toward clinical implementation

OBJECTIVE

To provide a preliminary assessment of obstetric healthcare provider opinions surrounding implementation of cell-free fetal DNA testing.

METHODS

A 37-question pilot survey was used to address questions around the translation and use of non-invasive prenatal testing using cell-free fetal DNA. The survey was distributed and collected at a Continuing Medical Education course on obstetrics and gynecology.

RESULTS

Of 62 survey respondents, 73% were female and 87% held MD/DO degrees. Respondents generally agreed that patients want prenatal diagnostic information to help make decisions about a pregnancy and that cell-free fetal DNA testing would encourage the testing of more patients for more conditions. However, there was an overall lack of knowledge or conviction about using this technology. Genetic counseling and professional society approval were deemed important to implementation, whereas the possibility of direct-to-consumer testing and government regulation produced mixed responses. Respondents indicated that they would be more likely to offer cell-free fetal DNA testing for chromosomal abnormalities and single-gene disorders, but would be cautious with respect to determination of sex and behavioral or late-onset conditions.

CONCLUSION

Preliminary assessment indicates uncertainty among obstetric providers about the details of implementing cell-free fetal DNA testing and suggests expanded research on perspectives of this stakeholder group.

Ethical decision-making for extremely preterm deliveries: results of a qualitative survey among obstetricians and midwives

OBJECTIVE

To explore the practices, attitudes and feelings of obstetricians and midwives in cases of extreme prematurity.

METHODS

A qualitative study was conducted as part of a European Concerted Action (EUROBS) in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France. Semi-structured interviews lasted an average of 60 min and were tape-recorded. They were independently analyzed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated.

RESULTS

Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the fetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as being more inclined than the obstetric team to initiate intensive care. If the child was born alive, intensive care was started, in the knowledge that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, in particular when there was no emergency situation. Compared with obstetricians, midwives tended to have a less favorable perception of the neonatologists' practices, and to report less parental involvement in decision-making.

CONCLUSIONS

Decisions about the obstetric management and resuscitation of extremely preterm infants are usually made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Decisional needs assessment regarding Down syndrome prenatal testing: a systematic review of the perceptions of women, their partners and health professionals

OBJECTIVE

To identify decisional needs of women, their partners and health professionals regarding prenatal testing for Down syndrome through a systematic review.

METHODS

Articles reporting original data from real clinical situations on sources of difficulty and/or ease in making decisions regarding prenatal testing for Down syndrome were selected. Data were extracted using a taxonomy adapted from the Ottawa Decision-Support Framework and the quality of the studies was assessed using Qualsyst validated tools.

RESULTS

In all 40 publications covering 32 unique studies were included. The majority concerned women. The most often reported sources of difficulty for decision-making in women were pressure from others, emotions and lack of information; in partners, emotion; in health professionals, lack of information, length of consultation, and personal values. The most important sources of ease were, in women, personal values, understanding and confidence in the medical system; in partners, personal values, information from external sources, and income; in health professionals, peer support and scientific meetings.

CONCLUSION

Interventions regarding a decision about prenatal testing for Down syndrome should address many decisional needs, which may indeed vary among the parties involved, whether women, their partners or health professionals. Very little is known about the decisional needs of partners and health professionals.

Inequalities in the reported offer and uptake of antenatal screening

OBJECTIVE

The objective of this study was to identify whether there is a different pattern of reported offer and uptake of antenatal screening tests across social groups.

DESIGN

Prospective cohort study.

SETTING

Two large maternity hospitals in Northern Ireland.

SAMPLE

Women booking for antenatal care were recruited consecutively over a 3-month period commencing 1 September 2003. In total, 711 women were recruited at booking: 359 at Hospital 1 and 352 at Hospital 2. Six hundred and sixty-six women completed both interviews.

METHODS

Two semi-structured interviews were arranged with consenting participants. The first interview was conducted at the booking appointment, and the second interview took place after 23 weeks of gestation after all screening, including anomaly ultrasound, would have been offered.

MAIN OUTCOME MEASURES

Reported offer and uptake of all screening tests were explored in relation to key sociodemographic indicators: level of education; mother's occupation; partner's occupation; single parent status; car ownership; religious denomination; and Townsend Deprivation Index.

RESULTS

With the exception of screening for Down's syndrome and neural tube defects, virtually all of the women were offered and underwent screening tests. Further analysis of data from Hospital 1 showed that, after controlling for other sociodemographic factors, women with a lower level of education had a lower odds of reporting Down's syndrome screening being offered Down's syndrome screening. Women having private antenatal care had a higher odds of accepting the offer of a test for Down's syndrome.

CONCLUSIONS

While the majority of antenatal screening tests are offered to all pregnant women in Northern Ireland, screening for Down's syndrome and NTD reflects a different pattern of offer and uptake. This paper provides evidence of variations in offer and uptake that exist even when it is hospital policy to offer screening to all women.

Understanding feticide: an analytic review

The medical procedure of 'feticide' has been used in clinical practice since the early 1990s in the UK. The procedure constitutes a sensitive aspect of late termination of pregnancy (TOP), an issue that is in itself contentious. The procedure has attracted attention from academic and policy commentators, but recently the medical profession has expressed some uncertainty with respect to the legal position of live birth following TOP, and professional discretion in providing feticide. To understand the meaning of these comments better, we argue that it is helpful to acknowledge the rhetoric that shapes the academic discourse on feticide. In this paper, we review how feticide has been conceptualised within academic discourse, demonstrating that the concept has multiple meanings, some of which could be considered politically charged. We then consider some examples of the comments made about the legal uncertainties of feticide, highlighting assumptions made about the problematic nature of professional discretion. Ultimately, we suggest that a better understanding of the context of feticide is needed to ensure that future research in this area of health care engages adequately with issues of professional discretion.

Problèmes éthiques posés par l'extrême prématurité: résultats d'une étude qualitative auprès des obstétriciens et des sages-femmes

OBJECTIVE

Our objective was to explore the practices, attitudes and feelings of obstetricians and midwives in case of extreme prematurity.

POPULATION AND METHODS

A qualitative study was conducted as part of a European Concerted Action (EUROBS) in 1999 and 2000 in three tertiary-care maternity units, located in three cities in the northern, southern and central areas of France respectively. Semi-structured, tape-recorded interviews were conducted and were independently analysed by two different researchers using a content analysis. All full-time obstetricians and half of the full-time midwives were eligible for the study. Overall, 17 obstetricians and 30 midwives participated.

RESULTS

Both obstetricians and midwives considered that decision-making in case of very preterm births raised ethical problems concerning the mother and the foetus. Despite some birth weight and gestational age criteria defined in advance, management around delivery appeared to be decided on a case-by-case basis. At birth, the neonatologists made the decisions. They were perceived as more inclined than the obstetrical team to initiate intensive care. If the child was born alive, intensive care was started, knowing that it could be withdrawn later, if appropriate. Parents were sometimes involved in decision-making during pregnancy, less frequently at birth or after birth.

DISCUSSION AND CONCLUSION

Compared with obstetricians, midwives tended to have a less favourable perception of the neonatologists' practices, and to deplore the lack of parental information and involvement in decision-making. Decisions about the obstetrical management and resuscitation of extremely preterm infants are essentially always made on a case-by-case basis. Parents are sometimes involved in decision-making. Midwives express serious concerns about the current practices.

Fetal conditions and fatal decisions: Ethical dilemmas in ultrasound screening in Vietnam

In the context of globalization, new technologies of pregnancy are spreading rapidly from affluent to low-income countries. Yet, to date, there is very little research on the application of prenatal diagnostic technology in developing country settings or the dilemmas that prenatal screening may give rise to in situations where health-care resources are scarce. In this article, we describe how obstetrical ultrasound scanning is used as the most important technology for prenatal diagnosis in Vietnam. We explore the social context that shapes moral sentiments and ethical deliberations within everyday medical interactions, drawing attention to the complex social processes through which ethical dilemmas are configured. The data include observations in the scanning room, and semi-structured interviews with patients and staff at a major maternity hospital in the country's capital Hanoi. We found that pregnant women received very limited information and support when a fetal anomaly was detected by ultrasound. Most women left the hospital feeling uncertain about what was wrong with the fetus and decision-making about abortion centred around the difficulties of parenting a disabled child in Vietnam. We conclude that the ethical problems surrounding prenatal screening are intensified in low-income settings such as Vietnam and point to the need for research that takes into account the wider social context that structures ethical dilemmas.

A report of two linked studies of knowledge and attitudes to prenatal screening and testing in adults of reproductive age in Japan and the UK

BACKGROUND

prenatal screening for fetal abnormality is being offered routinely in many countries. The need for informed consent demands that the nature of screening is understood by prospective parents, but the opportunities for providing information early in pregnancy before decision-making may be limited.

OBJECTIVE

to assess the knowledge about, and attitudes to, prenatal screening in adults of reproductive age in two countries.

DESIGN

two groups of adults were surveyed using a specifically designed tool to assess knowledge about fetal abnormalities and potential screening tests, attitudes to screening and termination of pregnancy, and information required by parents before making decisions.

SETTING AND PARTICIPANTS

90 participants were surveyed in Japan, 72% of whom were pregnant or had a partner who was pregnant; 93 participants were surveyed in the UK, none of whom were pregnant. All respondents were aged between 18 and 45 years.

MEASUREMENTS

demographic data were collected and analysed. Frequencies were calculated for each questionnaire response. A series of t-tests and chi(2) tests were used to assess differences between the two groups. Free-text data were analysed using content analysis.

FINDINGS

overall knowledge of prenatal tests and the conditions for which screening is offered was low in both groups. Significant differences exist between the perception of the conditions for which screening or testing can be offered and the types of conditions that can actually be detected prenatally. Most respondents in both countries would consider termination of pregnancy for fetal abnormality. The information most frequently cited by respondents as important when deciding about testing were the chances of damage to the health of fetus, mother, or both.

KEY CONCLUSIONS

women and men of reproductive age in the groups studied are not well-prepared to make decisions about screening or testing in pregnancy.

IMPLICATIONS FOR PRACTICE

improvements in preconceptual education on prenatal screening and testing may be required to ensure prospective parents can make informed decisions in early pregnancy.

French midwives' practice of termination of pregnancy for fetal abnormality. At what psychological and ethical cost?

OBJECTIVES

To study the clinical, emotional and moral difficulties that French midwives encounter in the labor ward while performing termination of pregnancy (TOP) for fetal abnormality.

SETTING

Six public maternity hospitals located in the Ile de France region, two of which were referral centers for prenatal diagnosis (PND) and TOP.

METHOD

Questionnaire survey

RESULTS

Ninety-two of 115 midwives responded. Sixty-five percent of the midwives reported that their role in the labor ward during TOP was difficult. Aspects contributing substantially to the perceived difficulties were the midwives' responsibility to provide psychological support to patients and the emotional distress of the midwives themselves. Seventy-five percent reported that they were concerned about the child being alive in cases of late TOP. Twenty-five percent of the midwives reported moral conflicts due to personal, cultural or religious background, mainly for particular indications. There was a consensus about the clinical management of TOP. Overall, midwives with professional experience, training, and those who worked in a referral center reported fewer difficulties.

CONCLUSION

It is necessary to improve institutional support available within maternity units to alleviate the difficulties midwives face in their roles. The need for training/updating midwives about psychological and ethical aspects of TOP should also be considered.

Patient Refusal of Emergency Cesarean Delivery

OBJECTIVE

To compare the attitudes of a large sample of obstetricians from eight European countries toward a competent woman's refusal to consent to an emergency cesarean delivery for acute fetal distress.

METHODS

Obstetricians' attitudes in response to a hypothetical clinical case were surveyed through an anonymous, self-administered questionnaire. The sample included 1,530 obstetricians (response rate 77%) from 105 maternity units (response rate 70%) in eight countries: France, Germany, Italy, Luxembourg, Netherlands, Spain, Sweden and the United Kingdom.

RESULTS

In every country, the majority of obstetricians would keep trying to persuade the woman, telling her that failure to perform cesarean delivery might result in the fetus surviving with disability, or even that her own life might be endangered. In Spain, France, Italy, and, to a lesser extent, Germany and Luxembourg, a consistent proportion of physicians would seek a court order to protect fetal welfare or avoid possible legal liability or both. In the United Kingdom, Sweden, and Netherlands, several respondents (59%, 41%, and 37%, respectively) would accept the woman's decision and assist vaginal delivery. Only a small minority (from 0 in the United Kingdom to 10% in France) would proceed with cesarean delivery without a court order.

CONCLUSION

Case law arising from a few countries (United States, Canada, and the United Kingdom) and professional guidelines favoring women's autonomy have not solved the underlying ethical conflict, and in Europe acceptance of a woman's right to refuse cesarean delivery, at least in emergency situations, is not uniform. Differing attitudes between obstetricians from the eight countries may reflect diverse legal and ethical environments.

LEVEL OF EVIDENCE

III.

A comparison of Australian and UK obstetricians' and midwives' preferences for screening tests for Down syndrome

OBJECTIVE

To establish and compare obstetricians' and midwives' preferences for hypothetical prenatal screening tests for Down syndrome.

METHODS

A cross-sectional questionnaire survey was completed by 296 obstetricians and midwives at two teaching hospitals: one in Melbourne, Australia (n = 175), and one in London, UK (n = 94). Conjoint analysis was undertaken using random effects probit regression.

RESULTS

No significant differences were seen in any measurements when comparing obstetricians in Australia and the UK or midwives in Australia and the UK. Obstetricians and midwives shared similar relative values regarding the importance of the detection rate of the screening tests. However, obstetricians placed higher relative values on both timing of prenatal tests and risk associated with the subsequent diagnostic test than did midwives when considering optimal tests to offer women. Marginal rates of substitution suggest that, compared with midwives, obstetricians would wait longer and accept a greater decrease in detection rate for a test if it was safer. Younger midwives placed higher value on both detection rate and safety of prenatal tests than older midwives. Female obstetricians placed higher value on the timing of a test than male obstetricians.

CONCLUSION

Obstetricians in Australia and UK placed almost identical importance on test attributes, as did the midwives in the two countries. However, different attitudes towards tests were seen between obstetricians and midwives.

Sympathetic responsibility in ethically difficult situations

BACKGROUND

Ethical issues arise in many obstetric situations and demand constant consideration by obstetricians. The aim of this study was to highlight the meaning of being in an ethically difficult situation as narrated by obstetricians.

METHODS

A descriptive design with a qualitative approach using a hermeneutic phenomenological method for analysis. Interviews were performed with 14 obstetricians working in a Swedish hospital setting.

RESULTS

The overriding theme was Sympathetic responsibility in the decisions of critical importance for the mother and her infant. Five related themes were to: (i) proceed with a moral reasoning that leads to the choice of a possible solution; (ii) balance one's own medical knowledge and moral insight with the needs and requests of the parents; (iii) be aware of one's medical and moral responsibility in relation to the decision made; (iv) experience the ability to take action and to make and carry out difficult and important decisions relating to the health of the mother and infant; and (v) reflect on a given situation in a manner leading to a rational acceptance of one's own conduct.

CONCLUSIONS

Sympathetic responsibility is the structure of the meaning of the obstetricians' lived experience, which means that the obstetricians with the help of their medical knowledge and their desire to support the mother's autonomy do what is best for the mother and her infant. Implications include that an exchange of ethical thoughts and moral reasoning should lead to a higher degree of mutual understanding between colleagues and between the different professionals. Co-operation is important to achieve the best outcome for the mother and her infant.

Chorionic villus sampling and amniocentesis: what are the risks in current practice?

PURPOSE OF REVIEW

Public demand for genetic counselling and prenatal diagnosis has increased during the past decade. As invasive diagnostic methods, such as chorionic villus sampling and amniocentesis, still have an important role to play in evaluating the fetus, one of the most important questions to address during genetic counselling is the procedure-related risk of these techniques.

RECENT FINDINGS

The possible factors modifying the specific risk of the actual fetus are discussed, together with factors that have an impact on procedure-related fetal loss and other complications. Risk factors regarding twin pregnancies, first and second-trimester chorionic villus sampling, early and mid-trimester amniocentesis are discussed separately. New developments have recently occurred in the laboratory techniques used in prenatal diagnosis. Their impact on genetic counselling and the employment of invasive techniques are also addressed.

SUMMARY

During genetic counselling, an individually tailored risk assessment needs to be established before any invasive procedure. This should take into account all the factors modifying the specific risk for aneuploidy or other disorders of the fetus, as well as the actual procedure-related risks.