Healing fictions': stories of choosing in the aftermath of the detection of fetal anomalies

Culpable Ignorance, Professional Counselling, and Selective Abortion of Intellectual Disability

In this paper I argue that selective abortion for disability often involves inadequate counselling on the part of reproductive medicine professionals who advise prospective parents. I claim that prenatal disability clinicians often fail in intellectual duty-they are culpably ignorant about intellectual disability (or do not disclose known facts to parents). First, I explain why a standard motivation for selective abortion is flawed. Second, I summarize recent research on parent experience with prenatal professionals. Third, I outline the notions of epistemic excellence and deficiency. Fourth, I defend culpable ignorance as the best explanation of inadequate disability counselling. Fifth, I rebut alternative explanations. My focus is pregnancies diagnosed with mild or moderate intellectual disability.

Integrative Review of Nursing Practices in Fetal Therapy

OBJECTIVE

To synthesize nursing practices related to fetal therapy (intervention to correct or treat a fetal anomaly).

DATA SOURCES

We searched electronic databases, including PubMed, Embase, OvidSP, and CINAHL, for all relevant published work. We identified additional resources through discussion with experts in the field, hand searches of relevant resources, and examination of the reference lists of articles in our search results.

STUDY SELECTION

Any published literature about fetal therapy in which nursing practices were discussed by nurses.

DATA EXTRACTION

We used Whittemore and Knafl's methodology to guide this integrative review (2005). We completed data extraction using an analytic review template organized to compare results to Kim's (2015) theoretical framework for nursing practice.

DATA SYNTHESIS

We used qualitative techniques described by Miles, Huberman, and Saldaña (2014) to code and thematically interpret the data. Nurses described their contributions to the establishment of fetal therapy programs through the development of entirely new technical and caring skills and their work in relation to care quality, clinician education, ethics, research, and health policy. Data were synthesized under three philosophies of nursing practice: therapy, care, and professional work.

CONCLUSION

Nurses have made important contributions to the evolving practice of fetal therapy, a nuanced practice that is critical to the development and provision of comprehensive patient- and family-centered care. Clinical implications of this review include practical recommendations for enhanced support of nursing practice in fetal therapy, which includes the provision of reliable forums to learn and share feedback about nursing practice in this field. Future work should focus on increasing understanding and visibility of nursing in fetal therapy through interdisciplinary evidence-based practice development.

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.

Perinatal Palliative Care: A qualitative study evaluating the perspectives of pregnancy counselors

BACKGROUND

A prenatal diagnosis of a life-limiting disease raises complex ethical, emotional, and medical issues. Studies suggest that 40%-85% of parents decide to continue the pregnancy if given the option of Perinatal Palliative Care. However, structured Perinatal Palliative Care programs are missing in many European countries. In Germany, parents have the right to free psychosocial support from pregnancy counseling services after the prenatal diagnosis of a life-limiting disease.

AIM

We aimed to investigate whether German professional pregnancy counselors perceive the need for structured Perinatal Palliative Care and if so, how it should be conceived.

DESIGN

This is a qualitative interview study with purposeful sampling. The interviews were analyzed with the coding method of Saldaña.

SETTING/PARTICIPANTS

A total of 10 professionals from three different pregnancy counseling services participated in the study.

RESULTS

The main topics raised by the professionals were as follows: (1) counseling and parental support during the decision-making process; (2) fragmented or missing support infrastructure for parents; and (3) challenges, hesitations, and barriers, particularly from the different stakeholders, regarding a Perinatal Palliative Care framework. They highlighted the importance of the integration of Perinatal Palliative Care in existing structures, a multi-professional approach, continuous coordination of care and education for all healthcare providers involved.

CONCLUSION

A structured Perinatal Palliative Care program is considered as necessary by the pregnancy counselors. Future research should focus on (1) needs reported by concerned parents; (2) attitude and role of all healthcare providers involved; (3) strategies to include stakeholders in the development of Perinatal Palliative Care networks; and (4) outcome parameters for evaluation of Perinatal Palliative Care frameworks.

Reproductive choices: a qualitative study of Dutch Moroccan and Turkish consanguineously married women's perspectives on preconception carrier screening

BACKGROUND

Cousin marriages, in the Netherlands most frequently between Turkish or Moroccan couples, are at higher risk of having offspring with recessive disorders. Often, these couples not perceive or accept this risk, and it is hardly considered a reason to refrain from family marriages. Preconception carrier screening (PCS) is offered to Jewish groups, and more recently in the Netherlands, to genetically isolated communities. In this study, Dutch Moroccan and Turkish women's perspectives on preconception carrier screening (PCS) and reproductive choices were explored.

METHODS

Individual interviews were held with Dutch Turkish and Moroccan consanguineously married women (n = 10) and seven group discussions with Turkish and Moroccan women (n = 86). Transcripts and notes were analyzed thematically.

RESULTS

All women welcomed PCS particularly for premarital genetic screening; regardless of possible reproductive choices, they prefer information about their future child's health. Their perspectives on reproductive choices on the basis of screening results are diverse: refraining from having children is not an option, in vitro fertilization (IVF) combined with pre-implantation genetic diagnosis (PGD) was welcomed, while prenatal genetic diagnosis (PND), termination of pregnancy (TOP), in vitro fertilization with a donor egg cell, artificial insemination with donor sperm (AID), and adoption, were generally found to be unacceptable. Besides, not taking any special measures and preparing for the possibility of having a disabled child are also becoming optional now rather than being the default option.

CONCLUSIONS

The women's preference for PCS for premarital screening as well as their outspokenness about not marrying or even divorcing when both partners appear to be carriers is striking. Raising awareness (of consanguinity, PCS and the choice for reproductive options), and providing information, screening and counseling sensitive to this target group and their preferences are essential in the provision of effective health care.

Evaluating a novel intervention to reduce trauma symptoms and sexual risk taking: qualitative exit interviews with sexual minority men with childhood sexual abuse

Childhood sexual abuse (CSA) continues to affect sexual minority men (SMM) at disproportionate levels and contributes to multiple negative health outcomes, including sexual-risk taking and HIV acquisition. This paper presents qualitative evaluative feedback from SMM (N = 9) who participated in a 10-session Cognitive Behavioral Therapy-Trauma and Sexual Health (CBT-TSH) intervention to reduce CSA-related posttraumatic stress reaction and distress. The treatment was designed to increase accurate sexual risk appraisals and to improve self-care health behaviors related to HIV/STI acquisition. The researchers identified four emerging themes: (1) motivation to participate, (2) response to cognitive therapy, (3) process of change, and (4) considerations for intervention improvement. These qualitative findings provide useful feedback on the acceptability of an innovative program that integrates CBT for trauma related to CSA with sexual risk-reduction counseling.

Expanding Use of cfDNA Screening in Pregnancy: Current and Emerging Ethical, Legal, and Social Issues

Purpose of Review

In 2011, screening platforms became available in the US that detect and analyze fragments of cell-free placental DNA (cfDNA) in maternal blood serum. Marketed as noninvasive prenatal tests (NIPT), cfDNA screening is more accurate than previously available serum screening tests for certain aneuploidies. The combination of a noninvasive procedure, high specificity and sensitivity, and lower false positive rates for some aneuploidies (most notably Down's syndrome) has led to broad clinician and patient adoption. New ethical, legal, and social issues arise from the increased use and expanded implementation of cfDNA in pregnancy.

Recent Findings

Recently, several professional associations have amended their guidelines on cfDNA, removing language recommending its use in only "high-risk" pregnancies in favor of making cfDNA screening an available option for women with "low-risk" pregnancies as well. At the same time, commercial cfDNA screening laboratories continue to expand the range of available test panels. As a result, the future of prenatal screening will likely include a broader range of genetic tests in a wider range of patients.

Summary

This article addresses the ethical, legal, and social issues related to the shift in guidance and expanded use of cfDNA in pregnant women, including concerns regarding routinized testing, an unmet and increasing demand for genetic counseling services, social and economic disparities in access, impact on groups living with disabling conditions, and provider liability.

Couple's Narratives of Communion and Isolation Following Abnormal Prenatal Microarray Testing Results

In 2% to 3% of cases, prenatal microarray testing detects deletions and duplications in a fetus' genome that are undetected by conventional cytogenetics. Many of these changes are associated with variable or uncertain symptomatology. Little is known about how couples experience uncertain results. This study analyzed 24 interviews with members of 12 heterosexual U.S. couples who received pathogenic or uncertain microarray prenatal testing results. Researchers used narrative analysis to examine couples' understanding and incorporation of findings into decision making regarding pregnancy termination. Couples felt unprepared for these findings and frustrated because scant information was available to aid interpretation. Women sought information and made decisions, and men marginalized their distress to support their wives. A shift in voice from first to second person indicated attempts to normalize emotional responses by making the process "common" to all couples. Families pursuing highly sensitive prenatal testing may need expert guidance to support decision making.

Acknowledged Dependence and the Virtues of Perinatal Hospice

Prenatal screening can lead to the detection and diagnosis of significantly life-limiting conditions affecting the unborn child. Recognizing the difficulties facing parents who decide to continue the pregnancy, some have proposed perinatal hospice as a new modality of care. Although the medical literature has begun to devote significant attention to these practices, systematic philosophical reflection on perinatal hospice has been relatively limited. Drawing on Alasdair MacIntyre's account of the virtues of acknowledged dependence, I contend that perinatal hospice manifests and facilitates virtues essential to living well with human dependency and vulnerability. For this reason, perinatal hospice deserves broad support within society.

Embodied Knowledge and Making Sense of Prenatal Diagnosis

Open-ended, qualitative interviews with women to whom amniocentesis was offered were analyzed to understand how women made sense of these tests. We found that women, whether tested or not, negotiated with biomedical information. They transformed it through identifiable processes, then wove it with their own instincts and beliefs and with their personal experiences, thereby creating "embodied" knowledge on which their decisions were based. Women who were and were not tested may have differed from each other when categorized on the basis of a final, binary choice, but they were more alike than unalike in reaching this point. The apparent importance of embodied knowledge suggests the critical role of the listening activities of the genetic counselor and of awareness of the validity and importance of women's complementary ways of knowing and doing in understanding the uses and meanings of prenatal genetic testing.

Selective Reproductive Technologies

From a historical perspective, selective reproduction is nothing new. Infanticide, abandonment, and selective neglect of children have a long history, and the widespread deployment of sterilization and forced abortion in the twentieth century has been well documented. Yet in recent decades selective reproduction has been placed under the aegis of science and expertise in novel ways. New laboratory and clinical techniques allow for the selective fertilization of gametes, implantation of embryos, or abortion of fetuses. Although they will often overlap with assisted reproductive technologies (ARTs), what we term selective reproductive technologies (SRTs) are of a more specific nature: Rather than aiming to overcome infertility, they are used to prevent or allow the birth of certain kinds of children. This review highlights anthropological research into SRTs in different parts of the world, discussing how selective reproduction engages with issues of long-standing theoretical concern in anthropology, such as politics, kinship, gender, religion, globalization, and inequality.

Who seeks abortions at or after 20 weeks?

CONTEXT

Recent years have seen the introduction of state bills seeking to ban abortions after 20 weeks, but little empirical data exist on who is affected when such bans become law.

METHODS

As part of a larger study, 272 women who received an abortion at or after 20 weeks' gestation and 169 who received first-trimester abortions at 16 facilities across the country in 2008-2010 were interviewed one week after the procedure. Mixed effect logistic regression analyses were used to determine the characteristics associated with later abortion (i.e., at 20 weeks or later). Causes of delay in obtaining abortion were assessed in open- and closed-ended questions; profiles of women who received later abortions were identified through factor analysis.

RESULTS

Women aged 20-24 were more likely than those aged 25-34 to have a later abortion (odds ratio, 2.7), and women who discovered their pregnancy before eight weeks' gestation were less likely than others to do so (0.1). Later abortion recipients experienced logistical delays (e.g., difficulty finding a provider and raising funds for the procedure and travel costs), which compounded other delays in receiving care. Most women seeking later abortion fit at least one of five profiles: They were raising children alone, were depressed or using illicit substances, were in conflict with a male partner or experiencing domestic violence, had trouble deciding and then had access problems, or were young and nulliparous.

CONCLUSION

Bans on abortion after 20 weeks will disproportionately affect young women and women with limited financial resources.

Receiving the initial Down syndrome diagnosis: a comparison of prenatal and postnatal parent group experiences

This study explored the preliminary experiences of parents upon learning of their child's diagnosis of Down syndrome. Qualitative data from a web-based, national survey were analyzed based on two groups: prenatal (n  =  46) or postnatal (n  =  115) diagnosis. Three primary categories emerged from the data analysis: prenatal screening/testing decisions by parents, the adjustment process for parents, and postdiagnosis resources and support for parents. Participants' rationale behind pursuing testing ranged from wanting to be better prepared to not pursuing testing because it was not a factor in continuing the pregnancy. Participant reactions to the diagnosis involved a range of intense preliminary emotions; participants described their extreme grief and loss experience at the initial news of the diagnosis, which also was ambiguous in nature and required differing timelines of adjustment. Finally, participants described experiences with medical professionals, information/education, and faith/religion as resources and areas of support, although not all were described as positive in nature. Participants in both groups identified having negative experiences with medical professionals during the diagnosis process. The results indicated the importance of these early experiences for parents of children with Down syndrome and emphasize providing effective education, resources, and practical information from reliable sources.

Women's experiences receiving abnormal prenatal chromosomal microarray testing results

PURPOSE

Genomic microarrays can detect copy-number variants not detectable by conventional cytogenetics. This technology is diffusing rapidly into prenatal settings even though the clinical implications of many copy-number variants are currently unknown. We conducted a qualitative pilot study to explore the experiences of women receiving abnormal results from prenatal microarray testing performed in a research setting.

METHODS

Participants were a subset of women participating in a multicenter prospective study "Prenatal Cytogenetic Diagnosis by Array-based Copy Number Analysis." Telephone interviews were conducted with 23 women receiving abnormal prenatal microarray results.

RESULTS

We found that five key elements dominated the experiences of women who had received abnormal prenatal microarray results: an offer too good to pass up, blindsided by the results, uncertainty and unquantifiable risks, need for support, and toxic knowledge.

CONCLUSION

As prenatal microarray testing is increasingly used, uncertain findings will be common, resulting in greater need for careful pre- and posttest counseling, and more education of and resources for providers so they can adequately support the women who are undergoing testing.

The model of Palliative Care in the perinatal setting: a review of the literature

BACKGROUND

The notion of Palliative Care (PC) in neonatal and perinatal medicine has largely developed in recent decades. Our aim was to systematically review the literature on this topic, summarise the evolution of care and, based on the available data, suggest a current standard for this type of care.

METHODS

Data sources included Medline, the Cochrane Library, CINAHL, and the bibliographies of the papers retrieved. Articles focusing on neonatal/perinatal hospices or PC were included. A qualitative analysis of the content was performed, and data on the lead author, country, year, type of article or design, and direct and indirect subjects were obtained.

RESULTS

Among the 1558 articles retrieved, we did not find a single quantitative empirical study. To study the evolution of the model of care, we ultimately included 101 studies, most of which were from the USA. Fifty of these were comments/reflections, and only 30 were classifiable as clinical studies (half of these were case reports). The analysis revealed a gradual conceptual evolution of the model, which includes the notions of family-centered care, comprehensive care (including bereavement) and early and integrative care (also including the antenatal period). A subset of 27 articles that made special mention of antenatal aspects showed a similar distribution. In this subset, the results of the four descriptive clinical studies showed that, in the context of specific programmes, a significant number of couples (between 37 and 87%) opted for PC and to continue with the pregnancy when the foetus has been diagnosed with a lethal illness.

CONCLUSIONS

Despite the interest that PC has aroused in perinatal medicine, there are no evidence-based empirical studies to indicate the best model of care for this clinical setting. The very notion of PC has evolved to encompass perinatal PC, which includes, among other things, the idea of comprehensive care, and early and integrative care initiated antenatally.

"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.

Affirming motherhood: validation and invalidation in women's perinatal hospice narratives

BACKGROUND

Perinatal hospice is an option for women who learn during pregnancy that their fetuses are affected by terminal conditions and choose to continue their affected pregnancies. These women face emotional pain and the impending loss of their fetuses or infants. The aims of this study were to explore the experiences of perinatal hospice mothers, to gather knowledge useful to health professionals, and to guide future research.

METHODS

  Narrative analysis was performed using the personal stories of 15 women who continued pregnancies affected by lethal fetal anomalies.

RESULTS

The participants identified themselves as mothers and their fetuses or newborns as babies. Mothers valued caring for and interacting with their babies. Health professionals who affirmed their status as mothers, the value of their babies, and the significance of their losses were perceived as supportive. Invalidating attitudes and behavior caused significant distress among mothers.

CONCLUSIONS

Optimal care of perinatal hospice mothers supports the development of maternal identity and contact between mothers and newborns when desired. Professionals who care for perinatal hospice mothers can affirm their motherhood through their behavior and attitudes.

Continuity and change in mothers' narratives of perinatal hospice

OBJECTIVES

(1) To broadly explore the experiences of women who chose to continue pregnancies affected by lethal fetal diagnoses and (2) to develop knowledge useful to nurses and other healthcare professionals who provide perinatal hospice (PH) care.

DESIGN

Qualitative descriptive study using narrative analysis.

PARTICIPANTS

Fifteen women who learned during their pregnancies of a lethal fetal diagnosis and chose to continue the affected pregnancies.

METHOD

Participants' stories of their PH experiences were recorded in face-to-face interviews. A qualitative approach using narrative analysis was used to identify themes and develop suggestions for care.

RESULTS

The element of time was prevalent in mothers' stories. Some aspects of mothers' experiences continued, particularly feelings of love and connection to their babies. Mothers also reported evolving changes in their thoughts and feelings. Personal changes such as increased compassion, faith, and strength were frequently mentioned. Mothers described transient phases of highs and lows. Drawing personal meanings or life lessons was the main way mothers connected their experiences to their present lives.

CONCLUSIONS

Mothers' descriptions of their experiences can enhance nurses' understanding of perinatal loss. Established care practices, such as birth planning and creating mementoes, were supported. Nurses can help mothers experiencing loss by elucidating and reflecting their personal meanings.

Truth telling and severe fetal diagnosis: a virtue ethics perspective

PURPOSE

Increased use of prenatal technologies has increased the numbers of women and partners whose fetus is diagnosed with a severe impairment. Virtue ethics provides a useful perspective to consider truth telling in this context, specifically how couples and providers interpret the diagnosis and prognosis to create truth. Virtue ethics is person-centered rather than act-centered, with moral actions guided by how a virtuous person would act in the same circumstance. Phronesis (practical wisdom) guides these actions.

SUBJECTS AND METHODS

Fifteen women and 10 male partners with a severe fetal diagnosis participated in this longitudinal ethnography examining their experiences across 3 available care options: termination, routine obstetric care, and perinatal end-of-life care. Data from 39 interviews were analyzed to determine how they created meaning and truth in context of the diagnosis.

RESULTS AND CONCLUSIONS

Providers' interactions were usually, but not always, characterized by the practice of phronesis. Couples were in a more complex moral situation than were providers. Those who terminated created a socially acceptable truth within a negative social environment related to abortion. Those seeking routine care had uncertain fetal prognoses and struggled with the meanings of "odds" of survival. One couple with end-of-life care experienced a close alignment of the facts and the truth they made public.

Exploring adoption with clients: the need for adoption education within the genetic counseling profession

Genetic counselors and other health professionals may encounter adoption during any counseling session. They must be skilled in using appropriate language and understand how to approach and discuss this topic with clients. A thorough knowledge of adoption as an option for clients facing a prenatal or postnatal diagnosis is necessary when presenting individuals with non-biased information needed for informed decision-making. However, three preliminary studies have demonstrated an absence of graduate education and lack of a professional knowledge base regarding this option (Mates 2008; Oksala 2007; Perry 2003). We discuss the impact of medical professionals' preconceptions on client decision-making, increasing early identification of fetal anomalies, deficiency of adoption knowledge and resources, and the resulting need for genetic counselors and other health professionals to develop their skills in discussing adoption with clients.

Choosing not to choose: reproductive responses of parents of children with genetic conditions or impairments

Parents of children with genetic conditions or impairments stand in a unique position with regard to choices and dilemmas posed by prenatal screening and testing options offered to at-risk parents as a means to a 'healthy' baby. This article reports the results of a qualitative study of parents whose children are clients of a state-wide rural genetic outreach programme in the US. The analysis seeks to connect the lived experience of parents of children with genetic conditions or impairments to choices with which women are confronted as prenatal testing technologies continue to proliferate. It reports the finding that a majority of parents in the study chose not to choose: avoiding future pregnancies, declining prenatal testing for subsequent pregnancies, or limiting testing to 'for information only'. These decisions do not reflect simple rejection of medical intervention, opposition to abortion, and/or affirmation of a positive parenting experience with an affected child. Rather, choosing to avoid the condition of choice appears to be a strategy of responsible parenting that emerges from ambivalence towards the options presented by reproductive technologies.

A literature update on maternal-fetal attachment

OBJECTIVE

To critically review and synthesize original research published since 2000 designed to measure factors that influence maternal-fetal attachment.

DATA SOURCES

EBSCOhost Research Databases that included PubMed, CINAHL Plus, PsycINFO, and SCOPUS were searched for journal articles published in the past 7 years (2000-2007) that examined variables thought to increase, decrease, or cause no change in level of maternal-fetal attachment. Keyword searches included maternal-fetal attachment, parental attachment, and prenatal attachment.

STUDY SELECTION

Twenty-two studies were selected that met the inclusion criteria of original research, clear delineation of the measurement of maternal-fetal attachment, measurement of maternal-fetal attachment during pregnancy, and inclusion of women or couples, or both.

DATA EXTRACTION

Studies measuring maternal-fetal attachment included a broad range of variables as potential risk or protective factors, or both. Factors associated with higher levels of maternal-fetal attachment included family support, greater psychological well-being, and having an ultrasound performed. Factors such as depression, substance abuse, and higher anxiety levels were associated with lower levels of maternal-fetal attachment.

DATA SYNTHESIS

The large majority of studies reviewed were limited by small, homogenous samples deemed insufficient to detect significant differences, inconsistent measurement of maternal-fetal attachment during gestational periods, and cross-sectional designs.

CONCLUSIONS

Further research is essential to identify factors influencing maternal-fetal attachment. Specifically, research needs to be conducted on larger sample sizes of greater racial and ethnic diversity.

Women's stories of birth: a suitable form of research evidence?

In the past one to two decades, midwifery care has taken a new direction, which encompasses a valuing of women's birth experiences. This move has been contingent upon, and congruent with the adoption of 'woman centred' care and a renewed emphasis on normal birth. In line with these developments, women's stories and anecdotes of birth and midwives stories of experience increasingly form the basis of presentations at midwifery conferences and forums. Overall, this philosophical realignment, which commenced in Australia in the early 1990s, has been applauded by many midwives in terms of a greater valuing of the wishes and experiences of childbearing women and as being consistent with a greater promotion of normal birth. Nonetheless, it also gives rise to several questions, regarding the suitability of this form of research evidence. In a bid to answer some of those questions, this paper aims to evaluate the use of stories and anecdotal evidence within midwifery. First, an overview is presented of the way in which stories of pregnancy and birth appear in the literature. Secondly, the value of stories as evidence is critiqued and, finally, the ratio of story based publications, compared to traditional research methodologies, is reviewed. This review aims to address an area poorly attended in the literature and asks specifically: Are women's birth stories a suitable form of research evidence in midwifery?

Family-centered care in the context of fetal abnormality

Women confronted with prenatal diagnosis of fetal abnormality face emotionally challenging choice options and considerable uncertainty regarding impact of choice on their families. Prenatal diagnosis of fetal abnormality presents childbearing women with difficult choices, such as continuation of pregnancy with no intervention, abortion, and, in selected cases, experimental fetal therapy. Regardless of their decision, it is a time of transition marked by grief and loss. The experience women and families have with the option chosen has an impact on their short- and long-term well-being. Healthcare providers are paramount in facilitating this transitional time in supporting family needs.

Experiences of prenatal diagnosis of spina bifida or hydrocephalus in parents who decide to continue with their pregnancy

The current study aimed to gain an understanding of the perspectives of those parents provided with a prenatal diagnosis of spina bifida or hydrocephalus and who decided to continue with their pregnancy. Qualitative interviews were conducted with 15 parents who learned of their unborn child's spina bifida and/or hydrocephalus in the prenatal period. The interviewer asked parents about their experiences of receiving a prenatal diagnosis and their experience of coping throughout the remainder of the antenatal period. Parents' reactions and experiences fell into five domains: response to diagnosis, experience of medical systems, information gathering, decision-making regarding continuation of the pregnancy following diagnosis and responses of significant others. Each of these domains is explicated. The findings derived from the current study have implications for professionals who provide support to parents during the prenatal period. Future research needs to further explore the common and unique issues for parents living in both urban and rural areas.

The Lived Experience of Pregnancy While Carrying a Child With a Known, Nonlethal Congenital Abnormality

OBJECTIVE

To gain an understanding of the experience of pregnancy while carrying a child with a known, nonlethal congenital abnormality.

DESIGN

Phenomenological study.

SETTING

The participants were interviewed in their own homes, a quiet clinic room, or another location comfortable for them.

PARTICIPANTS

Fifteen pregnant women carrying a child with a nonlethal, congenital abnormality participated.

RESULTS

The pregnancy experience was of a paradoxical nature. Knowledge of the fetal diagnosis resulted in both positive and negative consequences. Three major themes were common to the experience for women: Time is good, but it is also the enemy; you grieve, but you do not grieve; my baby's not perfect, but (s)he's still mine.

CONCLUSION

Because of the paradoxical feelings experienced, women need as much information as they request regarding the abnormality, its treatment, and prognosis. An appointment during pregnancy with pediatric specialists to discuss the plan for care of the infant after delivery is beneficial. Health care providers should support women's prenatal attachment during this unique pregnancy.

Parental Decision-Making after Ultrasound Diagnosis of a Serious Foetal Abnormality

OBJECTIVE

The purpose of this article is to provide clinicians who are involved in the field of foetal medicine with a comprehensive overview of theories that are relevant for the parental decision-making process after ultrasound diagnosis of a serious foetal abnormality.

METHODS

Since little data are available of parental decision-making after ultrasound diagnosis of foetal abnormality, we reviewed the literature on parental decision-making in genetic counselling of couples at increased genetic risk together with the literature on general decision-making theories. The findings were linked to the specific situation of parental decision-making after an ultrasound diagnosis of foetal abnormality.

RESULTS

Based on genetic counselling studies, several cognitive mechanisms play a role in parental decision-making regarding future pregnancies. Parents often have a binary perception of risk. Probabilistic information is translated into two options: the child will or will not be affected. The graduality of chance seems to be of little importance in this process. Instead, the focus shifts to the possible consequences for future family life. General decision-making theories often focus on rationality and coherence of the decision-making process. However, studies of both the influence of framing and the influence of stress indicate that emotional mechanisms can have an important and beneficial function in the decision-making process.

CONCLUSION

Cognitive mechanisms that are elicited by emotions and that are not necessarily rational can have an important and beneficial function in parental decision-making after ultrasound diagnosis of a foetal abnormality. Consequently, the process of parental decision-making should not solely be assessed on the basis of its rationality, but also on the basis of the parental emotional outcome.

The Travesty of Choosing After Positive Prenatal Diagnosis

OBJECTIVE

To integrate the findings of qualitative studies of expectant parents receiving positive prenatal diagnosis.

DATA SOURCES

Seventeen published and unpublished reports appearing between 1984 and 2001 and retrieved between December of 2002 and March of 2003. The electronic databases searched include Academic Search Elite, AIDS Information Online (AIDSLINE), Anthropological Index Online, Anthropological Literature, Black Studies, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Digital Dissertations, Dissertation Abstracts Index (DAI), Educational Resource Information Center (ERIC), MEDLINE, PsycInfo, Public Affairs Information Service (PAIS), PubMed, Social Science Abstracts (SocSci Abstracts), Social Science Citation Index, Social Work Abstracts, Sociological Abstracts (Sociofile), Women's Resources International, and Women's Studies.

STUDY SELECTION

Qualitative studies involving expectant parents living in the United States of any race, ethnicity, nationality, or class who learned during any time in pregnancy of any fetal impairment by any means of diagnosis were eligible for inclusion.

DATA EXTRACTION

Metasummary techniques, including the calculation of frequency effect sizes, were used to aggregate the findings. Metasynthesis techniques, including constant comparison analysis and the reciprocal translation of concepts, were used to interpret the findings.

DATA SYNTHESIS

The topical emphasis in the findings is on the termination of pregnancy following positive diagnosis. The thematic emphasis is on the dilemmas of choice and decision making. Positive prenatal diagnosis was for couples an experience of chosen losses and lost choices. Couples managed information to minimize stigmatization and cognitive dissonance.

CONCLUSIONS

Existing guidelines for caring for couples after perinatal losses must accommodate the chosen loss experientially defining positive prenatal diagnosis.

Providing letters and audiotapes to supplement a prenatal diagnostic consultation: effects on later distress and recall

OBJECTIVES

Information provided at a mid-trimester fetal scan aims to improve patients' knowledge and minimize anxiety. This randomized controlled trial conducted at the Fetal Medicine Centre at Birmingham Women's Hospital aimed to assess the relative value of providing 1.standard information: a consultation and computer-generated ultrasound report (n = 29); 2.standard information plus a post scan written non-technical letter (n = 29); 3.standard information plus audiotapes of the consultation (n = 29); 4.standard information plus both non-technical letters and audiotapes (n = 30). It also aimed at exploring whether severity of diagnosis (none; mild; moderate-severe) interacted with the type of information provided to affect subsequent anxiety, depression and recall of information.

PARTICIPANTS

Women (n = 550) referred with suspected fetal anomalies (without a previous history of anomaly or known psychiatric illness) were sent information regarding this study. One hundred and seventeen women consented and were randomly assigned to one of four information groups. The groups were similar with regard to age, education and marital status.

MAIN OUTCOME MEASURES

State anxiety and depression were evaluated with the self-report State-Trait Anxiety Inventory (STAI) and Beck Depression Inventory (BDI) prior to consultation and two weeks post-scan. A structured telephone interview assessed recall of information approximately two weeks later.

RESULTS

Two weeks after the initial consultation, women who received an audiotaped recording of the consultation reported significantly less anxiety than the control group (mean STAI 41.44 [95% CI 35.63-47.26] versus 44.92 [39.32-50.52]; difference = 10.70 [3.56-17.83], p < 0.01). Women who received a non-technical letter also reported less anxiety than the control group, an effect that approached significance (mean STAI 39.08 [95% CI 32.85-45.30]; difference = 6.48 [0.21-13.16], p = 0.058). There were no differences between the information groups on depression scores or recall of information. Women with a more severe abnormality reported higher anxiety and depression two weeks post-consultation, and had greater free recall but less cued recall of information.

CONCLUSIONS

Provision of additional material (particularly an audiotape) following a prenatal scan appears to minimise anxiety compared with standard practice. Provision of audiotapes and non-technical letters do not appear to affect patient recall.

The decision to continue: the experiences and needs of parents who receive a prenatal diagnosis of holoprosencephaly

Holoprosencephaly (HPE) is a condition characterized by a defect in the development of the midline embryonic forebrain. When detected prenatally, the diagnosis of HPE offers parents a poor but often uncertain prognosis. Since the majority of parents receiving a prenatal diagnosis of an abnormality terminate their pregnancies, few studies have examined parents' experiences and needs surrounding the decision to continue a pregnancy. We present a descriptive study of in-depth interviews with 24 parents who chose to continue their pregnancy after receiving a prenatal diagnosis of HPE. Parents were asked about their decision-making process to continue the pregnancy. Qualitative analysis was used to identify common themes that emerged from these parents' experiences. The results suggest that most parents did not make an active decision about continuing the pregnancy. Rather, they described a more subtle decision-making process that evolved over time and consisted of several factors. These factors included the parents' religious and personal beliefs, past experiences, and the uncertainty involved in the diagnosis of HPE. Throughout the decision-making process, they described informational, emotional, and supportive needs from family, friends, and health professionals. All of these factors contributed to the evolution of the parents' decision to continue the pregnancy and the acceptance of their decision. Results of this exploratory study suggest health care professionals need to work with parents as they make their decision to continue an affected pregnancy. The results also provide the groundwork for prospective investigation into parents' decision-making process as they receive and adjust to prenatal diagnoses of an abnormality.

Real qualitative researchers do not count: the use of numbers in qualitative research

Two myths about qualitative research are that real qualitative researchers do not count and cannot count. These antinumber myths have led to the underutilization of numbers in qualitative research and to the simplistic view of qualitative research as non- or antinumber. Yet numbers are integral to qualitative research, as meaning depends, in part, on number. As in quantitative research, numbers are used in qualitative research to establish the significance of a research project, to document what is known about a problem, and to describe a sample. But they are also useful for showcasing the labor and complexity of qualitative work and to generate meaning from qualitative data; to document, verify, and test researcher interpretations or conclusions; and to re-present target events and experiences. Although numbers are important in the treatment of qualitative data, qualitative researchers should avoid the counting pitfalls of verbal counting, overcounting, misleading counting, and acontextual counting.

Towards a "good" death: end-of-life narratives constructed in an intensive care unit

End-of-life decisions regarding the withdrawal and withholding of life supporting technology have become commonplace within intensive care units (ICUs). In this paper, we examine the dialogue between ICU team members and families regarding limitation of treatment as a therapeutic narrative--that is, as a story which frames therapeutic events as well as the critically ill patient's experience in a meaningful and psychologically comforting way for families and health care providers alike. The key themes of these end-of-life narratives are discussed, as well as the qualities that the stories share with other narratives of the same genre.

Midwife or doctor: a study of pregnant women making delivery decisions

Eighty-eight women from diverse educational backgrounds were interviewed as they made several important and related life decisions during their pregnancies. In this article, the focus is on the choice of birth attendant. There were few differences between those women who did and did not consider a midwife. Women who selected a midwife reported feeling more knowledgeable about birth attendants, more in control over the birth attendant decision, more satisfied about their delivery decisions, more in control of and satisfied with pain medication decisions, more autonomous in their pregnancy decision making, and more in agreement with "alternative birth" philosophies. and less in agreement with "conventional birth" philosophies. The participants also reported receiving more approval from spouse/significant other and friends, were more likely to use "gut instinct" and previous experience or habit to make pregnancy decisions, and were more ready to make these decisions than were women who had not selected a midwife as their primary birth attendant.

Between fear and relief: how rural pregnant women experience foetal ultrasound in a Botswana district hospital

Ultrasound technology has achieved almost universal coverage in industrialised countries with particular importance in antenatal surveillance. Its routine use has, however, been viewed critically from medical as well as from sociological perspectives. Studies on women's perception of ultrasound underline the crucial role of client provider communication supporting the technical procedure. Ultrasound is now increasingly available in developing countries. Little is known about how clients in these settings perceive the technology. This study was concerned with women's experience of ultrasound scanning in an African district hospital setting and how their experience concurs with the health professionals' views about the new technology. The study was qualitative and used semi-structured in-depth interviews with 41 clients and structured non-participant observation of the examination process, as well as semistructured interviews with health staff. Most women viewed ultrasound as being beneficial. Some expressed considerable fear. The quality of client-provider interaction played a decisive role in how the procedure was perceived. Many statements, however, reflect women's overestimation of the diagnostic power of ultrasound and prenatal therapeutic possibilities. Technology and its often expatriate providers tend to be mystified and at the same time non-technological procedures provided by local staff in the context of normal history taking and antenatal care undervalued. Health staff expressed very positive views of ultrasound. They admitted, however, that since the availability of ultrasound they were tempted to take histories and physical examinations less thoroughly than before. Irrational expectations from the clients' side and unindicated overuse of ultrasound by health professionals may in the long run interact in a way that possibly undermines the quality and rational utilisation of antenatal care and respective referral guidelines. Indications for the use of ultrasound must be clearly specified within specific societal contexts and mechanism of ensuring adherence to these criteria be established. Communication with patients and appropriate information about the benefits and limitations of ultrasound are essential to alleviate fear, and to discourage irrational expectations and demand.

Decisions about prenatal testing for chromosomal disorders: perceptions of a diverse group of pregnant women

We conducted a study to elucidate factors influencing women's decisions regarding prenatal genetic screening for and diagnosis of chromosomal disorders and to learn about their experiences with these tests and with the medical system. Using focus group interviews and questionnaire assessments, we obtained detailed impressions of a diverse group of 75 pregnant women. Participants varied with respect to race/ethnicity, religious background, and reproductive history, as well as in their decisions about use of prenatal screening and diagnostic testing. Substantial variation surfaced in attitudes toward testing. Factors influencing women's views included available resources, feelings about having a child with Down syndrome, moral beliefs, family and social influences, perceptions of one's own health, the difficulty of becoming pregnant, and willingness to put the fetus at elevated miscarriage risk. Such findings indicate that age-based policies regarding access to prenatal diagnoses that, among other reasons, are based on the balance of risks between bearing a child with a chromosomal abnormality versus procedure-related loss are incompatible with the range of concerns that women bring to this decision and the weight individual women may assign to the outcomes.

The World War II plutonium experiments: contested stories and their lessons for medical research and informed consent

During the Second World War medical researchers around the USA injected 18 hospital patients with radioactive plutonium in order to learn its effects on the body. Two documents, a newspaper account and a university committee report, tell divergent stories of the scientists and patients involved in that experiment. This article uses those documents-plutonium narratives-as a catalyst for exploring the problematic representation of past human experimentation, assumptions of moral progress in medical research, and the nature of informed consent today. Informed consent is shown to be an evolving process and discursive practice that cannot be understood apart from its historical and cultural embeddedness.