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A Retrospective Analysis Of Different Contingent Screening Models For Fetal Down Syndrome In Southwestern China. Sci Rep 2020; 10:9457. [PMID: 32528157 PMCID: PMC7289849 DOI: 10.1038/s41598-020-66320-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Accepted: 04/01/2020] [Indexed: 12/13/2022] Open
Abstract
To discuss combinations of traditional screening and noninvasive prenatal screening (NIPS) and to compare which traditional screening is the most suitable first-line screening approach to NIPS, pregnant women were recruited in this retrospective observational study. Pregnant women underwent one of four traditional screening tests. The 9 contingent models were combined by high risk cut-offs of 1:50, 1:100, 1:270 and intermediate risk cut-offs of 1:1000, 1:1500, 1:2000. We analyzed cost and performance of various screening models with contingent screening of different risk cut-offs. Compared with other screening tests, combined first-trimester screening (CFTS) had the lowest proportion of high risk (≥1:270) with the highest detection rate (DR) (78.79%) and the lowest proportion of intermediate risk (1:271~1:1000). When intermediate risk was 1:51 ~1:1500, CFTS as first-line screening had the lowest cost with DR of 93.94%. Other screening tests as the first-line screening with intermediate risk of 1:51~1:1000 had the lowest cost, there DR were 90.91%, 84.62%, 91.67%, respectively. Our study demonstrated if only one traditional screening was allowed to screen pregnant women, CFTS was recommended as the first choice. According to local health and economic conditions, adopting appropriate traditional screening with suitable cut-offs as first-line screening will contributed to a cost-effective screening model.
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Okem ZG, Orgul G, Kasnakoglu BT, Cakar M, Beksac MS. Budget impact of incorporating non-invasive prenatal testing in prenatal screening for Down syndrome in Turkey. HEALTH POLICY AND TECHNOLOGY 2019. [DOI: 10.1016/j.hlpt.2019.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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García-Pérez L, Linertová R, Álvarez-de-la-Rosa M, Bayón JC, Imaz-Iglesia I, Ferrer-Rodríguez J, Serrano-Aguilar P. Cost-effectiveness of cell-free DNA in maternal blood testing for prenatal detection of trisomy 21, 18 and 13: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2018; 19:979-991. [PMID: 29249015 DOI: 10.1007/s10198-017-0946-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Accepted: 11/29/2017] [Indexed: 06/07/2023]
Abstract
The aim of this paper was to conduct a systematic review of the cost-effectiveness of the analysis of cell-free DNA in maternal blood, often called the non-invasive prenatal test (NIPT), in the prenatal screening of trisomy in chromosomes 21, 18 and 13. MEDLINE, MEDLINE in process, EMBASE, and Cochrane Library were searched in April 2017. We selected: (1) economic evaluations that estimated the costs and detected cases of trisomy 21, 18 or 13; (2) comparisons of prenatal screening with NIPT (universal or contingent strategies) and the usual screening without NIPT, (3) in pregnant women with any risk of foetal anomalies. Studies were reviewed by two researchers. Data were extracted, the methodological quality was assessed and a narrative synthesis was prepared. In total, 12 studies were included, four of them performed in Europe. Three studies evaluated NIPT as a contingent test, three studies evaluated a universal NIPT, and six studies evaluated both. The results are heterogeneous, especially for the contingent NIPT where the results range from NIPT being dominant to a dominated strategy. Universal NIPT was found to be more effective but also costlier than the usual screening, with very high incremental cost-effectiveness ratios. One advantage of screening with NIPT is lower invasive procedure-related foetal losses than with usual screening. In conclusion, the cost-effectiveness of contingent NIPT is uncertain according to several studies, while the universal NIPT is not cost-effective currently.
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Affiliation(s)
- Lidia García-Pérez
- Servicio de Evaluación, Servicio Canario de la Salud, Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain.
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain.
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain.
- Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, La Laguna, Spain.
- Facultad de Ciencias Económicas y Empresariales, Universidad de La Laguna, Campus de Guajara, Camino de la Hornera s/n, La Laguna, 38071, Santa Cruz De Tenerife, Spain.
| | - Renata Linertová
- Servicio de Evaluación, Servicio Canario de la Salud, Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, La Laguna, Spain
| | - Margarita Álvarez-de-la-Rosa
- Obstetrics and Gynecology Department, Hospital Universitario de Canarias (HUC), Universidad de La Laguna (ULL), Carretera de Ofra s/n, La Cuesta, La Laguna, 38320, Santa Cruz De Tenerife, Spain
| | - Juan Carlos Bayón
- Department of Health, Basque Government, Basque Office for Health Technology Assessment (OSTEBA), Alameda Rekalde Nº 39, 48008, Bilbao, Spain
| | - Iñaki Imaz-Iglesia
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Instituto de Salud Carlos III, Monforte de Lemos Nº 5, 28029, Madrid, Spain
| | - Jorge Ferrer-Rodríguez
- Fundación Canaria de Investigación Sanitaria (FUNCANIS), Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain
| | - Pedro Serrano-Aguilar
- Servicio de Evaluación, Servicio Canario de la Salud, Camino Candelaria Nº 44, 1ª planta, El Rosario, 38109, Santa Cruz De Tenerife, Canary Islands, Spain
- Red de Investigación en Servicios de Salud en Enfermedades Crónicas (REDISSEC), Madrid, Spain
- Centro de Investigaciones Biomédicas de Canarias (CIBICAN), Universidad de La Laguna, La Laguna, Spain
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Harper JC, Aittomäki K, Borry P, Cornel MC, de Wert G, Dondorp W, Geraedts J, Gianaroli L, Ketterson K, Liebaers I, Lundin K, Mertes H, Morris M, Pennings G, Sermon K, Spits C, Soini S, van Montfoort APA, Veiga A, Vermeesch JR, Viville S, Macek M. Recent developments in genetics and medically assisted reproduction: from research to clinical applications. Eur J Hum Genet 2018; 26:12-33. [PMID: 29199274 PMCID: PMC5839000 DOI: 10.1038/s41431-017-0016-z] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Accepted: 09/14/2017] [Indexed: 12/15/2022] Open
Abstract
Two leading European professional societies, the European Society of Human Genetics and the European Society for Human Reproduction and Embryology, have worked together since 2004 to evaluate the impact of fast research advances at the interface of assisted reproduction and genetics, including their application into clinical practice. In September 2016, the expert panel met for the third time. The topics discussed highlighted important issues covering the impacts of expanded carrier screening, direct-to-consumer genetic testing, voiding of the presumed anonymity of gamete donors by advanced genetic testing, advances in the research of genetic causes underlying male and female infertility, utilisation of massively parallel sequencing in preimplantation genetic testing and non-invasive prenatal screening, mitochondrial replacement in human oocytes, and additionally, issues related to cross-generational epigenetic inheritance following IVF and germline genome editing. The resulting paper represents a consensus of both professional societies involved.
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Affiliation(s)
- J C Harper
- Institute for Women's Health, University College London, London, UK
| | - K Aittomäki
- Laboratory of Genetics, Helsinki University Hospital, Helsinki, Finland
| | - P Borry
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Leuven, Belgium
| | - M C Cornel
- Department of Clinical Genetics, Section Community Genetics, Amsterdam Public Health Research Institute, VU University Medical Center, Amsterdam, The Netherlands
| | - G de Wert
- Department of Health, Ethics and Society, Research Schools CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands
| | - W Dondorp
- Department of Health, Ethics and Society, Research Schools CAPHRI and GROW, Maastricht University, Maastricht, The Netherlands
| | - J Geraedts
- Department Genetics and Cell Biology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - L Gianaroli
- S.I.S.Me.R. Reproductive Medicine Unit, Bologna, Italy
| | | | - I Liebaers
- Center for Medical Genetics, UZ Brussels, Brussels, Belgium
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - K Lundin
- Reproductive Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
| | - H Mertes
- Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Ghent, Belgium
| | - M Morris
- Synlab Genetics, Lausanne, Switzerland
| | - G Pennings
- Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Ghent, Belgium
| | - K Sermon
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - C Spits
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Brussels, Belgium
| | - S Soini
- Helsinki Biobank, Helsinki University Central Hospital, Helsinki, Finland
| | - A P A van Montfoort
- IVF Laboratory, Department of Obstetrics & Gynaecology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - A Veiga
- Barcelona Stem Cell Bank, Centre of Regenerative Medicine in Barcelona, Hospital Duran i Reynals, Barcelona, Spain
- Reproductive Medicine Service of Dexeus Woman Health, Barcelona, Spain
| | - J R Vermeesch
- Department of Human Genetics, KU Leuven, Leuven, Belgium
| | - S Viville
- Institute of Parasitology and Pathology, University of Strasbourg, Strasbourg, France
- Laboratory of Genetic Diagnostics, UF3472-Genetics of Infertility, Nouvel Hôpital Civil, Strasbourg, France
| | - M Macek
- Department of Biology and Medical Genetics, Charles University-2nd Faculty of Medicine and Motol University Hospital, Prague, Czech Republic.
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5
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Harper JC, Aittomäki K, Borry P, Cornel MC, de Wert G, Dondorp W, Geraedts J, Gianaroli L, Ketterson K, Liebaers I, Lundin K, Mertes H, Morris M, Pennings G, Sermon K, Spits C, Soini S, van Montfoort APA, Veiga A, Vermeesch JR, Viville S, Macek M. Recent developments in genetics and medically-assisted reproduction: from research to clinical applications †‡. Hum Reprod Open 2017; 2017:hox015. [PMID: 31486804 PMCID: PMC6276693 DOI: 10.1093/hropen/hox015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 11/14/2017] [Indexed: 12/13/2022] Open
Abstract
Two leading European professional societies, the European Society of Human Genetics and the European Society for Human Reproduction and Embryology, have worked together since 2004 to evaluate the impact of fast research advances at the interface of assisted reproduction and genetics, including their application into clinical practice. In September 2016, the expert panel met for the third time. The topics discussed highlighted important issues covering the impacts of expanded carrier screening, direct-to-consumer genetic testing, voiding of the presumed anonymity of gamete donors by advanced genetic testing, advances in the research of genetic causes underlying male and female infertility, utilisation of massively-parallel sequencing in preimplantation genetic testing and non-invasive prenatal screening, mitochondrial replacement in human oocytes, and additionally, issues related to cross-generational epigenetic inheritance following IVF and germline genome editing. The resulting paper represents a consensus of both professional societies involved.
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Affiliation(s)
- J C Harper
- Institute for Women's Health, University College London, 86-96 Chenies Mews, London WC1E 6HX, UK
| | - K Aittomäki
- Laboratory of Genetics, Helsinki University Hospital, PO Box 720, FI-00029, Helsinki, Finland
| | - P Borry
- Department of Public Health and Primary Care, Centre for Biomedical Ethics and Law, KU Leuven, Kapucijnenvoer 35 - Box 7001. B-3000, Leuven Belgium
| | - M C Cornel
- Department of Clinical Genetics, Amsterdam Public Health Research Institute, VU University Medical Center, PO Box 7057, 1007 MB, Amsterdam, The Netherlands
| | - G de Wert
- Department of Health, Ethics and Society, Research Schools CAPHRI and GROW, Maastricht University, De Byeplein 1, 6229 HA Maastricht, The Netherlands
| | - W Dondorp
- Department of Health, Ethics and Society, Research Schools CAPHRI and GROW, Maastricht University, De Byeplein 1, 6229 HA Maastricht, The Netherlands
| | - J Geraedts
- Department Genetics and Cell Biology, GROW School for Oncology and Developmental Biology, Maastricht University Medical Center, P.O. Box 616, 6200 MD Maastricht, The Netherlands
| | - L Gianaroli
- S.I.S.Me.R. Reproductive Medicine Unit, Via Mazzini 12, 40138 Bologna, Italy
| | - K Ketterson
- Althea Science, Inc., 3 Regent St #301, Livingston, NJ 07039, USA
| | - I Liebaers
- Centre for Medical Genetics, UZ Brussel, Laarbeeklaan 101, B-1090 Brussels, Belgium
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium
| | - K Lundin
- Reproductive Medicine, Sahlgrenska University Hospital, Blå Stråket 6, 413 45, Göteborg, Sweden
| | - H Mertes
- Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Belgium
| | - M Morris
- Synlab Genetics, chemin d'Entre-Bois 21, CH-1018, Lausanne, Switzerland
| | - G Pennings
- Bioethics Institute Ghent, Department of Philosophy and Moral Science, Ghent University, Belgium
| | - K Sermon
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium
| | - C Spits
- Research Group Reproduction and Genetics, Vrije Universiteit Brussel, Laarbeeklaan 101, B-1090, Brussels, Belgium
| | - S Soini
- Helsinki Biobank, Helsinki University Central Hospital, Haartmaninkatu 3, PO Box 400, 00029 HUS, Helsinki, Finland
| | - A P A van Montfoort
- IVF laboratory, Department of Obstetrics and Gynaecology, Maastricht University Medical Center, PO Box 5800, 6202 AZ Maastricht, The Netherlands
| | - A Veiga
- Barcelona Stem Cell Bank, Centre of Regenerative Medicine in Barcelona, Hospital Duran i Reynals, Gran Via de l' Hospitalet 199, 08908, Hospitalet de Llobregat, Barcelona, Spain
- Reproductive Medicine Service of Dexeus Woman Health, Gran Via Carles III, 71-75 - 08028 Barcelona, Spain
| | - J R Vermeesch
- Department of Human Genetics, KU Leuven, O&N I Herestraat 49 - Box 602, B-3000 Leuven, Belgium
| | - S Viville
- Institute of Parasitology and Pathology, University of Strasbourg, 3 rue Koberlé, 67000 Strasbourg, France
- Laboratory of Genetic Diagnostics, UF3472-Genetics of Infertility, Nouvel Hôpital Civil, 1 place de l'Hôpital, 67091 Strasbourg cedex, France
| | - M Macek
- Department of Biology and Medical Genetics, Charles University 2nd Faculty of Medicine and Motol University Hospital, V Úvalu 84, Prague CZ-15006, Czech Republic
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Miron-Shatz T, Rapaport SR, Srebnik N, Hanoch Y, Rabinowitz J, Doniger GM, Levi L, Rolison JJ, Tsafrir A. Invasive Prenatal Diagnostic Testing Recommendations are Influenced by Maternal Age, Statistical Misconception and Perceived Liability. J Genet Couns 2017; 27:59-68. [DOI: 10.1007/s10897-017-0120-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 05/30/2017] [Indexed: 10/19/2022]
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Valdés-Miranda J, Pérez-Cabrera A, Coronel-Cruz F, Cuevas-Covarrubias S. Duo test and aneuploidy detection in women under 35 years of age with high-risk pregnancy at the Hospital General de México. REVISTA MÉDICA DEL HOSPITAL GENERAL DE MÉXICO 2017. [DOI: 10.1016/j.hgmx.2016.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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Maxwell S, O'Leary P, Dickinson JE, Suthers GK. Diagnostic performance and costs of contingent screening models for trisomy 21 incorporating non-invasive prenatal testing. Aust N Z J Obstet Gynaecol 2017; 57:432-439. [PMID: 28369759 DOI: 10.1111/ajo.12612] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2016] [Accepted: 12/31/2016] [Indexed: 01/15/2023]
Abstract
BACKGROUND Contingent screening for trisomy 21 using non-invasive prenatal testing has the potential to reduce invasive diagnostic testing and increase the detection of trisomy 21. AIM To describe the diagnostic and economic performance of prenatal screening models for trisomy 21 that use non-invasive prenatal testing as a contingent screen across a range of combined first trimester screening risk cut-offs from a public health system perspective. METHODS Using a hypothetical cohort of 300 000 pregnancies, we modelled the outcomes of 25 contingent non-invasive prenatal testing screening models and compared these to conventional screening, offering women with a high-risk (1 > 300) combined first trimester screening result an invasive test. The 25 models used a range of risk cut-offs. High-risk women were offered invasive testing. Intermediate-risk women were offered non-invasive prenatal testing. We report the cost of each model, detection rate, costs per diagnosis, invasive tests per diagnosis and the number of fetal losses per diagnosis. RESULTS The cost per prenatal diagnosis of trisomy 21 using the conventional model was $51 876 compared to the contingent models which varied from $49 309-66 686. The number of diagnoses and cost per diagnosis increased as the intermediate-risk threshold was lowered. Results were sensitive to trisomy 21 incidence, uptake of testing and cost of non-invasive prenatal testing. CONCLUSION Contingent non-invasive prenatal testing models using more sensitive combined first trimester screening risk cut-offs than conventional screening improved the detection rate of trisomy 21, reduced procedure-related fetal loss and could potentially be provided at a lower cost per diagnosis than conventional screening.
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Affiliation(s)
- Susannah Maxwell
- Health Policy and Management, School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia
| | - Peter O'Leary
- Health Policy and Management, School of Public Health, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia.,School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia.,PathWest Laboratory Medicine, Princess Margaret Hospital, Perth, Western Australia, Australia
| | - Jan E Dickinson
- Department of Maternal Fetal Medicine, School of Women's and Infants' Health, The University of Western Australia, Perth, Western Australia, Australia.,Ultrasound Department, King Edward Memorial Hospital, Perth, Western Australia, Australia
| | - Graeme K Suthers
- Department of Genetics, Sonic Healthcare, Macquarie Park, New South Wales, Australia.,School of Paediatrics & Reproductive Health, University of Adelaide SA 5006, Australia
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Chen A, Tenhunen H, Torkki P, Heinonen S, Lillrank P, Stefanovic V. Considering medical risk information and communicating values: A mixed-method study of women's choice in prenatal testing. PLoS One 2017; 12:e0173669. [PMID: 28355226 PMCID: PMC5371284 DOI: 10.1371/journal.pone.0173669] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2016] [Accepted: 02/26/2017] [Indexed: 01/25/2023] Open
Abstract
Introduction Nowadays, an important decision for pregnant women is whether to undergo prenatal testing for aneuploidies and which tests to uptake. We investigate the factors influencing women’s choices between non-invasive prenatal testing (NIPT) and invasive prenatal tests in pregnancies with elevated a priori risk of fetal aneuploidies. Methodology This is a mixed-method study. We used medical data (1st Jan 2015-31st Dec 2015) about women participating in further testing at Fetomaternal Medical Center at Helsinki University Hospital and employed Chi-square tests and ANOVA to compare the groups of women choosing different methods. Multinomial logistic regressions revealed the significant clinical factors influencing women’s choice. We explored the underlying values, beliefs, attitudes and other psychosocial factors that affect women’s choice by interviewing women with the Theory of Planned Behavior framework. The semi-structured interview data were processed by thematic analysis. Results Statistical data indicated that gestational age and counseling day were strong factors influencing women’s choice. Interview data revealed that women’s values and moral principles on pregnancy and childbirth chiefly determined the choices. Behavioral beliefs (e.g. safety and accuracy) and perceived choice control (e.g. easiness, rapidness and convenience) were also important and the major trade-offs happened between these constructs. Discussion Values are the determinants of women’s choice. Service availability and convenience are strong factors. Medical risk status in this choice context is not highly influential. Choice aids can be developed by helping women to identify their leading values in prenatal testing and by providing lists of value-matching test options and attributes.
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Affiliation(s)
- An Chen
- Aalto University, Institute of Healthcare Engineering, Management and Architecture (HEMA), Espoo, Finland
- * E-mail:
| | - Henni Tenhunen
- Aalto University, Institute of Healthcare Engineering, Management and Architecture (HEMA), Espoo, Finland
| | - Paulus Torkki
- Aalto University, Institute of Healthcare Engineering, Management and Architecture (HEMA), Espoo, Finland
| | - Seppo Heinonen
- Fetomaternal Medical Center, Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Paul Lillrank
- Aalto University, Institute of Healthcare Engineering, Management and Architecture (HEMA), Espoo, Finland
| | - Vedran Stefanovic
- Fetomaternal Medical Center, Department of Obstetrics and Gynecology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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