The incidence of fatal fetal anomalies associated with perinatal mortality in Ireland

Non-invasive prenatal testing: Assessing the availability and accessibility of information available to the pregnant population within the Republic of Ireland

OBJECTIVE

While non-invasive prenatal testing (NIPT) has been widely adopted throughout Europe, Australia, and the USA, population level access to NIPT varies considerably. Ireland has no national screening programme for fetal anomalies, although NIPT is available from out-of-country providers. We aimed to describe the availability of NIPT in Ireland and the quality of information available online from NIPT providers.

METHODS

Information available online from NIPT providers in the Republic of Ireland was analysed by examining all healthcare facilities websites and reviewing private health insurance directories. Data on information provided by NIPT providers was collected by two independent researchers from April to May 2023.

RESULTS

Four of the 19 maternity hospitals/units in Ireland had information on NIPT on their websites, with three including an explanation of NIPT, testing accuracy, and associated fees (€380-480). Twenty private clinics led by obstetric consultants advertised NIPT online, of which seventeen clinics included an explanation of NIPT, testing accuracy, and associated fees (€380-€650). Twenty-nine other providers, which included ultrasound clinics, direct-to-consumer laboratory testing, and General Practitioners, advertised NIPT with 18 of these providers including an explanation of NIPT, testing accuracy, and associated fees (€179-€630).

CONCLUSION

While there is apparent demand for NIPT and it is available in Ireland, there is disparity between providers on the type and quality of information available. Difficulty obtaining accessible information, the associated financial costs and location of providers advertising NIPT are likely to be barriers to accessing NIPT. A national screening programme for aneuploidy should be considered to ensure both equitable access to and reliable information about prenatal screening.

Fetal anomaly diagnosis and termination of pregnancy in Ireland: a service evaluation following implementation of abortion services in 2019

BACKGROUND

Approximately 3% of pregnancies are diagnosed with a fetal anomaly, of which a proportion is fatal or life-limiting. The introduction of legislation for termination of pregnancy in Ireland in 2019 for conditions "likely to lead to the death of the fetus" made termination of pregnancy for "fatal fetal anomaly" an option for pregnant women in Ireland.

OBJECTIVE

This study examined all cases of termination of pregnancy performed for major fetal anomaly over the first 3 years of service implementation, including cases that did not meet the legal criteria, resulting in women traveling outside Ireland for abortion care.

STUDY DESIGN

A retrospective service evaluation of tertiary fetal medicine clinics in 2 tertiary maternity hospitals between 2019 and 2021 was undertaken. We compared pregnancies of patients diagnosed with fatal fetal anomaly who underwent termination of pregnancy in Ireland with those of patients who did not meet the legal criteria and hence traveled outside Ireland for termination of pregnancy.

RESULTS

Overall, 139 pregnancies met the inclusion criteria; 83 (59.7%) patients had termination of pregnancy in the tertiary maternity hospital (local), and 56 (40.3%) traveled abroad, mainly to the United Kingdom. Demographic characteristics were similar between the 2 groups, as was gestation at diagnosis and delivery. All cases where termination of pregnancy was local were discussed at fetal medicine multidisciplinary meetings, as opposed to 34% of cases of patients who ultimately traveled outside Ireland for termination of pregnancy. The most common indication (25/83; 30.1%) for local termination of pregnancy was trisomy 18, followed by anencephaly. Traveling to obtain abortion care was mainly due to diagnosis of trisomy 21 (30/56; 53.6%), followed by other multiple structural anomalies/syndromes deemed locally as not meeting the legal criteria.

CONCLUSION

Legislation for termination of pregnancy for fetal anomaly, restricted to fatal diagnoses, is difficult to implement, requires significant multidisciplinary input, and can lead to limited services for pregnancies diagnosed with major fetal anomalies. Our findings emphasize the impact of legislative barriers to abortion care for fetal anomaly and the need for policies and services that support women's access to termination of pregnancy for fetal anomaly.

Fatal fetal anomaly: Experiences of women and their partners

OBJECTIVE

This study explored the care experiences of parents whose pregnancy was diagnosed with a fatal fetal anomaly following the legalisation of termination of pregnancy in 2019 in Ireland.

METHODS

A qualitative study using in-depth semi-structured interviews and interpretative phenomenological analysis was undertaken. Purposeful sampling was used to recruit 10 parents, six women and four of their male partners. Parents recruited included those who terminated and continued the pregnancy.

RESULTS

Three superordinate themes were identified: 'Attachment and coping', 'There's no place for you in the pregnancy world' and 'Consistency of quality care'. Parents shared the different approaches and level of attachment to their baby that supported their coping. Regardless of the level of attachment, many parents benefited from the acts of remembrance. Parents expressed how they no longer felt they belonged in the 'pregnancy world' and described a need for healthcare professionals to recognise their loss and create a safe and supportive environment in which they could share their grief. Despite this, parents' accounts highlighted variations and inconsistencies in care and service provision.

CONCLUSION

Our study highlighted parents' need for consistent, well communicated, and comprehensive care, which encourages an individualised perinatal palliative care approach to meet parental needs.

"This pregnancy makes sense": Experiences of women who have decided to continue pregnancy after lethal fetal diagnosis

Lethal fetal diagnosis defines severe developmental disorders that lead to the death of a fetus or newborn. Using semi-structured interviews, we explored the experiences of women in Poland who actively decided to continue with the pregnancy after diagnosis. We thematically analyzed data collected from 10 women. We identified four themes: pregnancy as an experience of prenatal motherhood; the child as person; birth as encounter and farewell; and the mother experience in retrospect. This study was conducted while the termination of pregnancy due to the irreversible fetal abnormality was legal in Poland. Since October 2021, it is no longer legal.

Fetal medicine specialist experiences of providing a new service of termination of pregnancy for fatal fetal anomaly: a qualitative study

OBJECTIVE

To explore fetal medicine specialists' experiences of caring for parents following a diagnosis of fatal fetal anomaly (FFA) during the implementation of termination of pregnancy (TOP) for FFA for the first time.

DESIGN

Qualitative study.

SETTING

Fetal medicine units in the Republic of Ireland.

POPULATION

Ten fetal medicine specialists from five of the six fetal medicine units.

METHODS

nvivo 12 assisted in the thematic analysis of semi-structured in-depth face-to-face interviews.

MAIN OUTCOME MEASURES

Fetal medicine specialists' experiences of prenatal diagnosis and holistic management of pregnancies complicated by FFA.

RESULTS

Four themes were identified: 'not fatal enough', 'interactions with colleagues', 'supporting pregnant women' and 'internal conflict and emotional challenges'. Fetal medicine specialists feared getting an FFA diagnosis incorrect because of media scrutiny and criminal liability associated with the TOP for FFA legislation. Challenges with the ambiguous and 'restrictive' legislation were identified that 'ostracised' severe anomalies. Teamwork was essential to facilitate opportunities for learning and peer support; however, conflict with colleagues was experienced regarding the diagnosis of FFA, the provision of feticide and palliative care to infants born alive following TOP for FFA. Participants reported challenges implementing TOP for FFA, including the absence of institutional support and 'stretched' resources. Fetal medicine specialists experienced internal conflict and a psychological burden providing TOP for FFA, but did so to 'provide full care for women'.

CONCLUSIONS

Our study identified challenges regarding the suitability of the Irish legislation for TOP for FFA and its rapid introduction into clinical practice. It illustrates the importance of institutional and peer support, as well as the need for supportive management, in the provision of a new service.

TWEETABLE ABSTRACT

The implementation of termination services for fatal fetal anomaly is complex and requires institutional support.