Parental response to severe or lethal prenatal diagnosis: a systematic review of qualitative studies

A time/space bubble: Expectant parents' experience of birth after termination of pregnancy due to fetal anomaly in a midwifery-led, obstetric unit for prenatal loss

Termination of pregnancy due to a fetal anomaly is a challenging and mentally stressful experience, associated with trauma-related stress, depression and symptoms of complicated grief. It differs from other types of pregnancy loss because of the role of active decision-making. Expectant parents depend on caring and experienced staff to guide them during a time full of ambiguity and contrasting emotions. This study examines how expectant parents experience the process of birth with termination of pregnancy due to fetal anomaly at a specialised unit for prenatal loss. Data was generated from semi-structured interviews with 11 women and 9 male partners, one to five months after termination of pregnancy. Three themes were identified 1) Suspended time/space bubble; the unit for prenatal loss was described as a time-space bubble, that promoted a sense of meaning, a feeling of togetherness and an awareness of parallel worlds, 2) The midwife matters; participants emphasised midwives' 'invisible', chronological and individualised practice, making it possible to be present and in the process, and 3) Meeting and spending time with the fetus/baby; participants' responses and relation to the fetus were very different, with most of them embracing the fetus as a baby, grateful for the opportunity to have time together. The findings from this study suggest a need for specialised midwives dedicated to prenatal loss, in units designed as private and protected spaces to accommodate the requirements of parents undergoing termination of pregnancy due to fetal anomaly.

The Role of Midwives in US Perinatal Palliative Care: A Scoping Review

INTRODUCTION

Perinatal palliative care (PPC) is a rapidly growing and essential reproductive health care option for pregnant persons with a diagnosed life-limiting fetal condition who continue their pregnancy. The provision of PPC is within the scope of basic midwifery competencies, and midwives are well-positioned to make unique and valuable contributions to interprofessional PPC teams. However, little is known about midwives' past or current involvement in PPC in the United States.

METHODS

This scoping review of the literature investigated what is known about the role of midwives in PPC in the United States. Multiple databases of published literature were used for this review: PubMed, CINAHL, Embase, Web of Science, ProQuest, Google Scholar, and relevant citations from identified studies. All types of English language publications addressing midwives' involvement in PPC in the United States were included, without any limitations on publication date.

RESULTS

The role and contributions of midwives in PPC is not well represented in existing literature. Of the 259 results identified, 7 publications met criteria for inclusion. These included 5 case reports, one quantitative research article, and one conference abstract. Midwives are involved in PPC through the provision of direct clinical care (including antepartum, intrapartum, postpartum, neonatal, bereavement, postmortem, and follow-up care) and care planning and coordination as part of an interprofessional team.

DISCUSSION

Despite midwives being uniquely positioned to provide holistic, family-centered, and person-centered care in situations of pregnancy with life-limiting fetal conditions, there is limited literature about their involvement in PPC in the United States. PPC should be incorporated into midwifery education and training programs. Midwives should play a central role in shaping future research and policies to ensure the accessibility and quality of PPC.

Parents' experiences of receiving their child's diagnosis of congenital heart disease: A systematic review and meta-synthesis of the qualitative literature

PURPOSE

This systematic review aimed to synthesize qualitative research on parents' psychological experiences following their child's diagnosis of congenital heart disease (CHD).

METHODS

A systematic search of six electronic databases (CINAHL, Embase, MEDLINE, PsycINFO, PubMed and Web of Science) was completed, inclusive of all years up to May 2022. Any included articles were synthesized using thematic synthesis and appraised using the Critical Appraisal Skills Programme Qualitative Checklist.

RESULTS

Twenty-six articles were included. Four main themes, and 11 subthemes, emerged from the synthesis. Theme 1 (unpreparedness for the diagnosis) concerned parents' shock, guilt and anger regarding the diagnosis. Theme 2 (the overwhelming reality of CHD) described parental fear about decision-making and the child's prognosis, and the influence of professionals on parents' well-being. Theme 3 (mourning multiple losses) detailed parents' sadness at losing their envisioned pregnancy, birth and parenthood experiences. Theme 4 (redefining hopes to reach an acceptance of CHD) described parents' adjustment to the diagnosis.

CONCLUSIONS

Receiving a child's CHD diagnosis was a uniquely challenging situation for parents. The findings provided insight into the emotions parents experienced and how they adjusted to the diagnosis psychologically. As parents' experiences were significantly influenced by their interactions with professionals, clinicians should offer compassion, validation and clear information throughout the diagnosis process.

Fetal Anomaly: Family Experiences and Preferences for Care: An Integrative Review

BACKGROUND

The prenatal diagnosis of a fetal anomaly is unexpected, creating a family crisis. Expectant parents are at an increased risk for perinatal depression and traumatic stress. Prior reviews examined parents' experiences when terminating but not continuing the pregnancy. This review synthesized qualitative research to describe the experiences, emotional responses, and needs of families continuing their pregnancy.

METHODS

An integrative review was performed using the Whitemore and Knafl methodology and PRISMA guidelines. A systematic review of peer-reviewed articles published between 2000 and 2200 on the experiences of fetal anomaly was performed using 5 databases. Eligible articles included qualitative studies describing families' experiences with a fetal anomaly diagnosis who elected to continue their pregnancy. Methodological quality was evaluated using the Critical Skills Appraisal Program checklist.

RESULTS

Of the 678 article results, 16 met inclusion criteria. There were 298 participants from 5 countries. The major overarching theme of Response to the Diagnosis of Fetal Anomaly was identified. The major categories were emotional response, coping strategies, influences, health care experiences, and family needs. Uncertainty and grief were the most common emotions.

DISCUSSION

Parents choosing to continue pregnancy benefit from compassionate, sensitive care, and accurate, concise information, provided in tailored instruction using multiple styles.

Strategies to communicate pregnancy complications: a systematic review and practical points for healthcare professionals

PURPOSE/METHODS

This systematic review aims to provide an overview of strategies available for healthcare professionals (HCPs) to effectively communicate unexpected news in pregnancy, specifically for the most common pregnancy complications. Three medical databases and grey literature were searched until March 2023 using subject headings and keywords. Snowball techniques were also used. The articles were reviewed at each stage of screening independently by two separate authors. Qualitative, quantitative and mixed methods studies were included.

RECENT FINDINGS

Forty-three studies were included and grouped according to the gestational age of the pregnancy complication - miscarriage, increased risk screening, foetal conditions, stillbirth. The main key points for communication were outlined at each specific complication and eventually the six common themes that emerged from all the categories were included in the acronym PRICES (Preparation - Referral - Individualized care - Clarity - Empowerment - Sensitivity).

SUMMARY

Given the negative impact of failed communications both in pregnancy outcomes and patients' experience, we advocate that communication training for HCP providing pregnancy care should be mandatory, and skills should be updated at regular intervals. Tools like our acronym PRICES can be used during teaching HCPs how to communicate more effectively.

Patient-reported outcomes for congenital diaphragmatic hernia: A qualitative study

OBJECTIVE

To identify Patient-reported outcomes (PROs) for parents with a lived experience of a prenatal diagnosis of isolated congenital diaphragmatic hernia (CDH).

METHOD

Thematic analysis of in-depth interview transcripts.

RESULTS

Interviews (n = 26) identified 11 PROs for given time points throughout the CDH trajectory. At the time of diagnosis, acceptable quality of life was selected as relevant PRO to decide whether to continue or terminate the pregnancy. During pregnancy, (neonatal) survival chances and the eligibility for foetal therapy were prominent outcomes with foetal and maternal complications adding distress. After birth, postnatal management options became the next milestone. When survival was deemed likely, post-hospital discharge complications and future care for infant and child became important. In retrospect, impact on family, bonding, parental mental health, and parental satisfaction with care were reported as relevant outcomes.

CONCLUSION

PROs are relevant in addition to hard medical outcomes, as they help parents to make decisions suiting their unique needs and personal situation. Given the knowledge inherently related to the parent's perspective, our findings provide relevant directions for clinicians to support parents and their family in facing challenging decisions in healthcare. The outcomes impacting parents are essential to prepare parents for the steep journey ahead.

Parental information about the option to apply for pregnancy termination after the detection of a congenital abnormality and factors influencing parental decision-making: a cohort study

BACKGROUND

The detection of an abnormality during prenatal screening implies that the parents are informed about possible treatment and management of the pregnancy, birth, and postnatal course. This information should enable the parents to make decisions regarding the pregnancy, especially in cases where termination of pregnancy may be an option. The objectives of this study were to investigate how often doctors informed parents about pregnancy termination when the fetus had an anomaly and which demographic factors were related to parental decision-making.

METHODS

This was a retrospective cohort study with prospectively collected data of fetuses diagnosed with an abnormality during prenatal screening between 2014 and 2016 in Denmark. We categorized the abnormalities into five long-term prognosis groups and analyzed their association with the doctor provided information about termination. We tested the association between demographic variables and parental decisions using univariate and multivariate statistical analyses.

RESULTS

Three hundred and twenty fetuses were diagnosed with an abnormality. In 67% of these cases, the parents were informed about termination. All parents whose fetus had a lethal prognosis were informed about termination. By comparison, the parents of 98% of fetuses with genetic disorders, 96% of fetuses with poor prognosis, 69% of fetuses with uncertain prognosis, and 12% of fetuses with good prognosis were informed about termination. Of these parents, 92% chose to terminate. A lethal long-term prognosis was the only factor related to parental decision to terminate a pregnancy.

CONCLUSIONS

Doctors mainly informed parents about the option of pregnancy termination for conditions with a poor or lethal long-term prognosis or for genetic disorders. Only conditions with a lethal prognosis were significantly related to the parental decision to terminate the pregnancy.

Longitudinal Perinatal Palliative Care for Severe Fetal Neurologic Diagnoses

Perinatal palliative care (PnPC) focuses on enhancing family and newborn quality-of-life in the setting of a life-limiting fetal condition while simultaneously ensuring medical care delivery that is soundly in line with the family's goals and values. The inclusion of PnPC in the multidisciplinary care of a family facing severe fetal neurologic diagnoses allows for skilled exploration of the values and experience that ultimately drive creation of goals of care. The parental experience of receiving a life-limiting fetal diagnosis pushes parents into an emotional journey, which typically follows a recognizable progression of stages. PnPC providers appreciate the significance of this experiential journey and the importance of parental movement toward readiness to simultaneously welcome and mourn their child. Through longitudinal supportive care, beginning early in the fetal diagnostic progress and continuing throughout pregnancy and into the newborn period, PnPC providers explore the uncharted parental experience alongside the family and support them in creating value-driven care plans for their child. They contribute greatly to the multidisciplinary fetal and neonatal care teams as the advocate for and promote insightful communication and assist in delivery and coordination of value-driven care.

Maternal Distress in Disclosing a Nonlethal Fetal Anomaly Diagnosis to Family and Friends

PURPOSE

To describe experiences of women disclosing a nonlethal fetal anomaly diagnosis to family and friends from initial prenatal diagnosis through postpartum.

STUDY DESIGN AND METHODS

A descriptive, qualitative approach was used to explore women's perceptions of nonlethal fetal anomaly diagnosis in a high-risk obstetric clinic. In-depth interviews were conducted with 10 pregnant women, followed by postpartum interviews with 8 women. Data were analyzed using thematic analysis.

RESULTS

Analysis of semistructured interviews revealed an overarching theme, Pregnancy Forever Changed, which captured the experience when expectant women first heard the news about their fetus. Prenatal themes were News of a Diagnosis, No Going Back; A Mother's Response: Managing Information; and Words from Others Matter. Women's struggles continued into postpartum, The Journey Continues: Echoing Past Concerns; and Not the Journey We Planned.

CLINICAL IMPLICATIONS

Women with a nonlethal fetal anomaly diagnosis experienced distress and stigma about disclosure of the diagnosis to others. Distress with disclosure continued throughout the pregnancy and extended into postpartum. Women described negative responses from others and ongoing management of information as stressful and painful. Clinicians are aware disclosing a lethal diagnosis is distressing for women but may not understand the experience of women with a nonlethal diagnosis. An appreciation of women's distress on disclosure of nonlethal fetal anomaly diagnoses can guide practice for maternity, neonatal, and pediatric nurses providing interventions that include information and anticipatory guidance.

The importance of information and support following a suspected second-trimester anomaly that is later discarded: A qualitative study of women's experiences

INTRODUCTION

A second-trimester anatomy scan may identify a suspected minor fetal anomaly and/or "soft marker," such as choroid plexus cysts or femoral shortening. Such findings can raise a medical concern, as they could indicate severe fetal disease; however, they are also often transient or a "false alarm." The aim of this study was to explore the experiences of pregnant women, where a medical concern was raised at the second-trimester ultrasound scan and later discarded after follow-up examinations and diagnostic testing.

MATERIAL AND METHODS

This study consists of qualitative, in-depth interviews with nine women, where a minor anomaly/soft marker was identified at the second-trimester scan and a severe anomaly was later ruled out. Data were analyzed using thematic analysis.

RESULTS

The main source of worry was uncertainty about the possible implications for the pregnancy and the baby, particularly concerns about potential termination of pregnancy for a severe fetal condition. The women described four strategies to manage worry and uncertainty during the diagnostic process: (a) seeking additional information to feel more in control, and (b) using social networks to share their concerns. Some women tried to (c) mentally distance themselves from the pregnancy during the diagnostic period, while (d) extra scans could relieve worry and support attachment. The women appreciated when the fetal medicine specialist pointed to normal features in the pregnancy and the baby, as this provided some counterbalance to the sense of uncertainty. In general, the women expressed satisfaction with the information received during the diagnostic process. However, all of them were worried during the diagnostic process, and where this process was prolonged, such worry lingered even after the minor anomaly/soft marker had been discarded.

CONCLUSIONS

Diagnostic uncertainty cannot be avoided in obstetric ultrasound and the women concerned appreciated being informed about the suspected findings even if it caused increased worry. Expedient diagnostic processes may alleviate worry, but are not always possible. Women in a prolonged diagnostic process may benefit from psychological and social support in parallel with, and even beyond, the obstetric investigation. However, further research is warranted.

Narrative Inquiry Into Nursing Care of Pregnant Women and Families in Specialized Fetal Diagnosis and Treatment Settings

OBJECTIVE

To examine how nurses describe caring for women and families in specialized fetal diagnosis and treatment settings.

DESIGN

We used narrative inquiry.

SETTING

A secure online survey platform.

PARTICIPANTS

We recruited 26 nurses from the Fetal Therapy Nurse Network as a subsample from a prior Delphi study on the essential structures, processes, outcomes, and challenges of nursing practice in the emerging field of fetal diagnosis and treatment.

METHODS

We used narrative inquiry and Clandinin's three-dimensional space narrative analysis to interpret the stories provided by participants to illustrate their practice and the relationship between their practice and care quality and health outcomes.

RESULTS

Participants described three primary types of fetal diagnoses and management scenarios: prenatal intervention (maternal-fetal surgery to treat a fetal anomaly), postnatal intervention (neonatal surgery), and perinatal palliative care (continuation of a pregnancy after a life-limiting fetal diagnosis). We identified three overarching themes related to nursing processes: A Sounding Board: Counseling the Pregnant Woman and Family, A Care Coordinator: Orchestrating a Complex Journey, and A Constant Presence: Being With the Pregnant Woman and Family. We also identified specific outcomes related to nursing care.

CONCLUSION

We used narrative inquiry to expand on prior research and advance the conceptualization of a model of nursing practice in fetal diagnosis and treatment settings. Our results provide a basis to begin to test theories that connect nursing practice to care quality and outcomes in clinical practice settings. To comprehensively evaluate and enhance care as it evolves and expands, the immediate and long-term effects of nursing practice must be identified.

Bereaved Parents: Insights for the Antenatal Consultation

OBJECTIVE

 The study aimed to explore experiences of extremely preterm infant loss in the delivery room and perspectives about antenatal consultation.

STUDY DESIGN

 Bereaved participants were interviewed, following a semi-structured protocol. Personal narratives were analyzed with a mixed-methods approach.

RESULTS

 In total, 13 participants, reflecting on 17 pregnancies, shared positive, healing and negative, harmful interactions with clinicians and institutions: feeling cared for or abandoned, doubted or believed, being treated rigidly or flexibly, and feeling that infant's life was valued or not. Participants stressed their need for personalized information, individualized approaches, and affective support. Their decision processes varied; some wanted different things for themselves than what they recommended for others. These interactions shaped their immediate experiences, long-term well-being, healing, and regrets. All had successful subsequent pregnancies; few returned to institutions where they felt poorly treated.

CONCLUSION

 Antenatal consultations can be strengthened by personalizing them, within a strong caregiver relationship and supportive institutional practices.

KEY POINTS

· Personalized antenatal consultations should strive to balance cognitive and affective needs.. · Including perspectives from bereaved parents can strengthen antenatal consultations.. · Trusting provider-parent partnerships are pivotal for risk communication..

Perinatal loss and parental loneliness: Narratives of late termination of pregnancy

Advances in perinatal medicine, present increasing numbers of women with difficult decisions about their pregnancy. We explored the views of 5 parents and 5 perinatal healthcare professionals regarding late termination of pregnancy following the principles of qualitative content analysis. Parents deciding on whether to (dis)continue pregnancy needed more time and decisional support. Decentralized care and lacking continuity between caregivers led to negative experiences. No standardized bereavement services were offered after leaving the hospital. Integrating principles of perinatal palliative care to care might help to offer further decisional support and to overcome the fragmentation of care.

What should we tell parents? Congenital diaphragmatic hernia

Congenital diaphragmatic hernia (CDH) is characterized by a defect in the muscle dividing the thoracic and abdominal cavities. This leads to herniation of the abdominal organs into the thorax and a disturbance of lung development. Two-thirds of cases are identified by prenatal ultrasound in the second trimester, which should prompt referral to a tertiary center for prognosis assessment and counseling by a multidisciplinary team familiar with this condition. In this review, we summarize evidence on prenatal diagnosis and postnatal management of CDH. There is a focus on information that should be provided to expecting parents during prenatal counseling.

Implementation of exome sequencing in fetal diagnostics-Data and experiences from a tertiary center in Denmark

INTRODUCTION

Applying whole-exome sequencing (WES) for the diagnosis of diseases in children has shown significant diagnostic strength compared with chromosomal microarray. WES may also have the potential of adding clinically relevant prenatal information in cases where a fetus is found to have structural anomalies. We present results from the first fetal exomes performed in a tertiary center in Denmark.

MATERIAL AND METHODS

Couples/expectant parents were included in Central Denmark Region from July 2016 to March 2019. Inclusion was not systematic, but where one or more fetal malformations or severe fetal hydrops were detected, and a specific diagnosis had not been obtained by chromosomal microarray. WES was performed in ongoing pregnancies (N = 11), after intrauterine demise (N = 5), or after termination of pregnancy based on ultrasound findings (N = 19). In most cases, a trio format was applied comprising fetal and parental DNA.

RESULTS

WES was performed in 35 highly selected fetal cases. Pathogenic variants, or variants likely to explain the phenotype, were detected in 9/35 (26%). Variants of uncertain significance were detected in 7/35 (20%) and there was one secondary finding (3%). Out of the 11 ongoing pregnancies, four reached a genetic diagnosis (36%). Detection rate was highest in cases of multisystem anomalies (7/13, 54%). WES was completed in all three trimesters and both autosomal dominant, autosomal recessive and X-linked inheritance were revealed.

CONCLUSIONS

We present data from 35 cases of exome sequencing applied in a setting of fetal malformations. Importantly, though, we wish to share our personal experiences with implementing WES into a prenatal setting. As a medical society, we must continue to share what we do not understand, what went wrong, what is difficult, and what we do not agree upon. A common understanding and language are warranted. We also advocate that more research is needed concerning the clinical value, as well as costs and patient perspectives, of using WES in pregnancy. We believe that WES will lead to improved prenatal and perinatal care.

"It was God's will": Continuing pregnancy after perinatal infection by Zika virus

OBJECTIVE

to understand the influence of the religious beliefs on the decision of a group of women residing in the Huila Department to continue their pregnancies despite perinatal infection by the Zika virus.

METHOD

a focused ethnography. The participants were 21 women who had presented a perinatal infection by the Zika virus and whose babies were born with congenital microcephaly. 2 discussion groups and 6 semi-structured interviews were conducted, and thematic analysis was used for data treatment.

RESULTS

three themes emerged, namely: "God, why me?" is the initial questioning of the women to God for the prenatal diagnosis of microcephaly in their babies, "Clinging to a divine miracle" describes how the women did not lose their faith and begged for a divine miracle for their babies to be born healthy, and "It was God's will" means acceptance, resignation, and respect for God's will, as well as the denial to abort despite the medical recommendations.

CONCLUSION

religiosity and religious beliefs were determinant factors in the women's decision to continue their pregnancies. It becomes necessary to continue investigating this theme to understand their experiences and to generate follow-up and support actions from nursing care.

Decisions Parents Make When Faced With Potentially Life-Limiting Fetal Diagnoses and the Importance of Perinatal Palliative Care

When parents face a potentially life-limiting fetal diagnosis in pregnancy, they then have a series of decisions to make. These include confirmatory testing, termination, and additional choices if they choose to continue the pregnancy. A perinatal palliative team provides a safe, compassionate, and caring space for parents to process their emotions and discuss their values. In a shared decision-making model, the team explores how a family's faith, experiences, values, and perspectives shape the goals for care. For some families, terminating a pregnancy for any reason conflicts with their faith or values and pursuing life prolonging treatments in order to give their baby the best chances for survival is the most important. For others, having a postnatal confirmatory diagnosis of a life limiting or serious medical condition gives them the assurance they need to allow their child a natural death. Others want care to be comfort-focused in order to maximize the time they have to be together as a family. Through this journey, a perinatal palliative team can provide the support and encouragement for families to express their goals and wishes, as well as find meaning and hope.

Parental decision-making following a prenatal diagnosis that is lethal, life-limiting, or has long term implications for the future child and family: a meta-synthesis of qualitative literature

BACKGROUND

Information on the factors influencing parents' decision-making process following a lethal, life-limiting or severely debilitating prenatal diagnosis remains deficient. A comprehensive systematic review and meta-synthesis was conducted to explore the influencing factors for parents considering termination or continuation of pregnancy following identification of lethal, life-limiting or severely debilitating fetal abnormalities.

METHODS

Electronic searches of 13 databases were conducted. These searches were supplemented by hand-searching Google Scholar and bibliographies and citation tracing. Thomas and Harden's (2008) thematic synthesis method was used to synthesise data from identified studies.

RESULTS

Twenty-four papers were identified and reviewed, but two papers were removed following quality assessment. Three main themes were identified through systematic synthesis. Theme 1, entitled 'all life is precious', described parents' perception of the importance of the fetus' life, a fatalistic view of their situation alongside moral implications as well as the implications decisions would have on their own life, in consideration of previous life experiences. Theme 2 ('hope for a positive outcome') contained two sub-themes which considered the parent's own imagined future and the influence of other people's experiences. Finally, Theme 3 ('a life worth living') presented three sub-themes which may influence their parental decision-making: These described parental consideration of the quality of life for their unborn child, the possibility of waiting to try for another pregnancy, and their own responsibilities and commitments.

CONCLUSION

The first review to fully explore parental decision-making process following lethal, life-limiting, or severely debilitating prenatal diagnosis provided novel findings and insight into which factors influenced parents' decision-making process. This comprehensive and systematic review provides greater understanding of the factors influential on decision-making, such as hope, morality and potential implications on their own and other's quality of life, will enable professionals to facilitate supported decision-making, including greater knowledge of the variables likely to influence parental choices.

Clinical practice guidelines for perinatal bereavement care - An overview

BACKGROUND

High quality perinatal bereavement care is critical for women and families following stillbirth or newborn death. It is a challenging area of practice and a difficult area for guideline development due to a sparse and disparate evidence base.

AIM

We present an overview of the newly updated Perinatal Society of Australia and New Zealand/Stillbirth Centre of Research Excellence guideline for perinatal bereavement care. The guideline aims to provide clear guidance for maternity health care providers and their services to support the provision of care that meets the needs of bereaved parents.

DISCUSSION

The Guideline for Respectful and Supportive Perinatal Bereavement Care is underpinned by a review of current research combined with extensive stakeholder consultation that included parents and their organisations and clinicians from a variety of disciplines. The Guideline contains 49 recommendations that reflect five fundamental goals of care: good communication; shared decision-making; recognition of parenthood; effective support; and organisational response.

CONCLUSION

Best available research, parents' lived experiences and maternity care providers' insights have contributed to a set of implementable recommendations that address the needs of bereaved parents.

Receiving a prenatal diagnosis of Down syndrome by phone: a qualitative study of the experiences of pregnant couples

OBJECTIVES

To examine how pregnant couples experience receiving a prenatal diagnosis of Down syndrome (DS) by phone-a practice that has been routine care in the Central Denmark Region for years.

DESIGN

Qualitative interview study.

SETTING

Participants were recruited from hospitals in Central Denmark Region, Denmark.

PARTICIPANTS

Couples who had received a prenatal diagnosis of DS by phone and decided to terminate the pregnancy. They were recruited from the obstetric department where the termination was undertaken. During the study period (February 2016 to July 2017), 21 semistructured, audio-recorded interviews were conducted by an experienced anthropologist. Interviews were conducted 4-22 weeks after the diagnosis and analysed using thematic analysis.

RESULTS

A prearranged phone call was considered an acceptable practice. However, the first theme 'Expected but unexpected' shows how the call often came earlier than expected. Consequently, most women were not with their partner and were thus initially alone with their grief and furthermore responsible for informing their partner, which some considered difficult. The second theme 'Now what?' shows how during the phone calls, physicians were quick to enquire about the couples' agendas. As the majority had already decided to seek termination of pregnancy, the dialogue focused on related questions and arrangements. Only half of the couples received additional counselling.

CONCLUSION

A prearranged phone call was considered an acceptable and appropriate practice. However, some aspects of this practice (particularly related to the context of the call) showed to be less than optimal for the couples. To make sure that a diagnostic result is delivered in accordance with the couples' needs and requests, the context of the call could be addressed and agreed on in advance by physicians and couples.

National screening guidelines and developments in prenatal diagnoses and live births of Down syndrome in 1973-2016 in Denmark

INTRODUCTION

Denmark was the first country in the world to implement a national, free-for-all offer of prenatal screening for Down syndrome to all pregnant women. It has a high uptake (>90%) compared to other countries. Thus, Denmark offers an interesting case for investigating the consequences of implementing comprehensive, national prenatal screening guidelines. The aim of this study was to describe the historical developments in invasive procedures, pre-/postnatal diagnoses of Down syndrome and Down syndrome live births in the period 1973-2016 in Denmark.

MATERIAL AND METHODS

Data on invasive procedures, pre- and postnatal Down syndrome diagnoses were retrieved from the Danish Cytogenetic Central Registry.

RESULTS

From 1973 to 1993, screening based on maternal age and high-risk indications resulted in a constant increase in invasive procedures. After the introduction of the triple test in 1994, invasive procedures decreased for the first time in 20 years. Following the introduction of an offer of combined screening to all pregnant women in 2004, the number of invasive procedures decreased markedly, while there was a concurrent increase in prenatal diagnoses of Down syndrome. Additionally, the number of Down syndrome live births decreased suddenly and significantly, but subsequently stabilized at 23-35 annual live births. Of these, the majority were diagnosed postnatally.

CONCLUSION

Though prenatal screening technologies constantly improve, it was the introduction of and adherence to national guidelines that resulted in marked shifts in screening procedures and outcome in Denmark.