Do pregnant women in Greece make informed choices about antenatal screening for Down's syndrome? A questionnaire survey

Does an educational video for aneuploidy screening improve informed choice among pregnant women? A randomised controlled trial

BACKGROUND

Poor knowledge and the lack of deliberation have been cited as reasons for women making uninformed choices about aneuploidy screening. Adequate pre-test counselling is of particular importance where non-invasive prenatal screening (NIPS) is being increasingly offered as a primary screening test.

DESIGN

Women attending the antenatal clinic with a singleton pregnancy below 14 weeks were randomised to receive routine counselling or the intervention-a 16-min educational video on aneuploidy screening before their consult. The primary outcome, rate of informed choice, was assessed using an adapted multidimensional measure of informed choice questionnaire, where informed choice was defined as good knowledge and value-consistent behaviour. Secondary outcomes included informed choice with deliberation, decisional conflict and anxiety.

RESULTS

Two hundred and eighty-six women were recruited. 69.8% of women in the intervention group made an informed choice compared with 53.6% in the control group (Risk Ratio [RR] 1.30, p = 0.014). A significantly higher number of women in the intervention group had good knowledge compared to controls (81% vs. 60.9%; RR 1.33, p = 0.001). Decisional conflict did not differ between groups, but women in the intervention group had higher anxiety scores (p < 0.001).

CONCLUSION

The study intervention was effective in helping women make informed choice. Qualitative studies to determine the reason for increased anxiety are needed.

TRIAL REGISTRATION

Trial registry: ClinicalTrials.gov; Identifier: NCT05492981.

Multisite assessment of the impact of a prenatal testing educational App on patient knowledge and preparedness for prenatal testing decision making

In this study, we wanted to assess the impact of the use of a patient educational app on patient knowledge about noninvasive prenatal testing (NIPT) and preparedness for prenatal screening decision-making. A randomized control study was carried out at three international sites between January 2019 and October 2020. Study participants completed a pre-consultation survey and post-consultation survey to assess knowledge, satisfaction, and preparedness for prenatal screening consultation. Providers completed a post-consultation survey. In the control arm, the pre-consultation survey was completed prior to consultation with their prenatal care provider. In the intervention arm, the pre-consultation survey was completed after using the app but prior to consultation with their prenatal care provider. Mean knowledge scores in the 203 participants using the app were significantly higher pre-consultation (p < 0.001) and post-consultation (p < 0.005) than those not using the app. Higher pre-consultation knowledge scores in the intervention group were observed at all sites. Most (86%) app users stated they were "Satisfied" or "Very Satisfied" with it as a tool. Providers rated the intervention group as more prepared than controls (p = 0.027); provider assessment of knowledge was not significantly different (p = 0.073). This study shows that clinical implementation of a patient educational app in a real-world setting was feasible, acceptable to pregnant people, and positively impacted patient knowledge.

Experiences of non-invasive prenatal screening: A survey study

BACKGROUND

In Australia, using non-invasive prenatal testing (NIPT) to screen for fetal abnormalities is becoming more commonplace. However, there is a lack of standardised procedures surrounding pre-test counselling. This holds the potential for variability in pregnant people's experiences when undergoing NIPT, which subsequently may impact their ability to make informed decisions surrounding NIPT results.

AIM

This study sought to characterise the experiences of Australian women undergoing NIPT, including perceptions of informed choice, counselling experiences and decision to undergo NIPT.

MATERIALS AND METHODS

Australian women who had been recently pregnant (n = 94) completed an online survey which assessed: their knowledge of and attitude toward NIPT; satisfaction with counselling; satisfaction with their decision; and decisional conflict to undergo NIPT. The survey also allowed participants to provide qualitative information about their counselling experience and reasons for undergoing NIPT.

RESULTS

Overall, participants had good knowledge of and positive attitudes toward NIPT, experienced low decisional conflict and were overall satisfied with their counselling experience and decision to undergo NIPT. However, some participants expressed dissatisfaction with the lack of information provided, and biased language, by counselling providers. The desire to be informed was the most frequent reason for undergoing NIPT.

CONCLUSION

The provision of accurate and objective information in pre-test counselling is important to reduce decisional conflict and improve satisfaction with the decision to undergo NIPT. It is recommended counselling providers present pregnant people with neutral, objective, and accurate information at the time of pre-test counselling.

Does women's place of birth affect their opportunity for an informed choice about Down syndrome screening? A population-based study in France

Background

To examine disparities by maternal place of birth in the opportunity to make an informed choice about Down syndrome screening, in France, where the national guidelines recommend that physicians offer it to all pregnant women.

Methods

We used population-based data from the nationally representative French Perinatal Surveys in 2010 and 2016 (N=24,644 women) to analyze the opportunity for an informed choice for prenatal screening, measured by a composite indicator.

Results

Among the 24 644 women in the study, 20 612 (83.6%) were born in France, 861 (3.5%) elsewhere in Europe, 1550 (6.3%) in North Africa, and 960 (3.9%) in sub-Saharan Africa. The probability of screening was lower for women born outside France. After adjustment for survey year, maternal age, parity, education level, and the maternity unit’s level of perinatal care, women born outside France had the opportunity to make an informed choice less often than women born in France. This association remained essentially the same even after excluding women without adequate prenatal care.

Conclusions

Women born outside France, including those with adequate prenatal care, had less opportunity than women born in France to make an informed choice about prenatal screening for Down syndrome.

Psychological outcomes, knowledge and preferences of pregnant women on first-trimester screening for fetal structural abnormalities: A prospective cohort study

INTRODUCTION

The primary aim of this study is to investigate the impact of a 13-week anomaly scan on the experienced levels of maternal anxiety and well-being. Secondly, to explore women's knowledge on the possibilities and limitations of the scan and the preferred timing of screening for structural abnormalities.

MATERIAL AND METHODS

In a prospective-cohort study conducted between 2013-2015, pregnant women in the North-Netherlands underwent a 13-week anomaly scan. Four online-questionnaires (Q1, Q2, Q3 and Q4) were completed before and after the 13- and the 20-week anomaly scans. In total, 1512 women consented to participate in the study and 1118 (74%) completed the questionnaires at Q1, 941 (64%) at Q2, 807 (55%) at Q3 and 535 (37%) at Q4. Psychological outcomes were measured by the state-trait inventory-scale (STAI), the patient's positive-negative affect (PANAS) and ad-hoc designed questionnaires.

RESULTS

Nine-nine percent of women wished to be informed as early as possible in pregnancy about the absence/presence of structural abnormalities. In 87% of women levels of knowledge on the goals and limitations of the 13-week anomaly scan were moderate-to-high. In women with a normal 13-week scan result, anxiety levels decreased (P < .001) and well-being increased over time (P < .001). In women with false-positive results (n = 26), anxiety levels initially increased (STAI-Q1: 39.8 vs. STAI-Q2: 48.6, P = 0.025), but later decreased around the 20-week anomaly scan (STAI-Q3: 36.4 vs. STAI-Q4: 34.2, P = 0.36).

CONCLUSIONS

The 13-week scan did not negatively impact the psychological well-being of pregnant women. The small number of women with screen-positive results temporarily experienced higher anxiety after the scan but, in false-positive cases, anxiety levels normalized again when the abnormality was not confirmed at follow-up scans. Finally, most pregnant women have moderate-to-high levels of knowledge and strongly prefer early screening for fetal structural abnormalities.

DEPIST 21: Information and knowledge of pregnant women about screening strategies including non-invasive prenatal testing for Down syndrome

OBJECTIVE

To evaluate the knowledge of pregnant women and provide information about Down syndrome (DS) screening, including non-invasive prenatal testing (NIPT).

MATERIALS AND METHODS

A prospective unicenter study of pregnant women recruited during their first trimester foetal ultrasound was carried out. Single pregnancies from 11 to 17 + 6 weeks of amenorrhoea (SA) without a history of DS were included. "Pre" and "post" questionnaire were fulfilled before and after the consultation. Patient characteristics, prior information, information provided during the consultation, and patient satisfaction were also analysed.

RESULTS

A total of 273 were included in the study, and 147 completed surveys (pre and post) were examined. In pre-consultation, 82 % of women know that integrated screening includes maternal serum markers and nuchal translucency (n = 103). Concerning NIPT for DS, 8% (n = 11) of women declare having been informed before the ultrasound. A minority of patients know modalities of reimbursement (n = 33, 26 %) and invasive sampling is mandatory for diagnosis when NIPT is positive (n = 37, 28 %). Significant improvement in right answers was obtained for three questions: "nuchal translucency is included in the combined screening test for DS" (p = 0,007); "blood serum markers is included in the combined screening for DS" (p = 0,009) and advanced maternal age increases risk for DS" (p = 0,004). Total score in the post questionnaire was significantly higher than the "pre" consultation questionnaire (14,7 ± 2.8 versus 14,1 ± 2.9; p = 0.01).

CONCLUSION

Patients show a high level of knowledge on screening strategies for DS in pre-consultation. They benefit from the consultation on global knowledge, NIPT, and ultrasound notions.

Prenatal tests for chromosomal abnormalities detection (PTCAD): pregnant women's knowledge in an Italian Population

BACKGROUND

Nowadays several Prenatal Tests for Chromosomal Abnormalities Detection (PTCAD) are available. In those cases in which there is not an Institutional protocol to advise women about the available PTCAD, the choice of which one to undergo is up to the woman and largely depends on her knowledge about them. Therefore, we decided to evaluate, as a primary outcome, knowledge about PTCAD among pregnant women attending our Term Clinic. As a secondary outcome we evaluated the relationship between the patient's knowledge and the subsequently chosen PTCAD.

METHODS

From August 2017 to August 2018 an anonymous questionnaire with multiple-choice answers was administered to all pregnant women attending our Term antenatal Clinic, a tertiary obstetric unit in Catanzaro (Italy).

RESULTS

Three hundred and twenty-five pregnant women were enrolled in the study. We observed that 28.8% of the pregnant women that chose one of the PTCAD, avoided the first trimester combined screening test; among these, 11.4% were in favour of the cell-free foetal DNA test. The latter was erroneously considered diagnostic by 34.3% of the women that had chosen it.

CONCLUSIONS

This study demonstrated that women's knowledge about PTCAD is poor and that there is a potentially dangerous confusion between the words 'screening' and 'diagnostic'. Informative campaigns about PTCAD and the application of dedicated antenatal counselling appointments should be a health-care priority to avoid unnecessary risks and costs for pregnant women and possible legal issues.

Attitude, knowledge and informed choice towards prenatal screening for Down Syndrome: a cross-sectional study

Background

Down Syndrome screening test is a bridge between knowledge and uncertainty, safety and risk, unpredictability and desire to know in order to gain control. It may be accepted either not to have a baby with Down syndrome, or to prepare to have a baby with this condition. Every woman should understand that it is an option and should be encouraged to make their own decisions based on information and personal values. The implications and possible subsequent scenarios differentiate this type of test from the common biochemical tests performed during pregnancy, of paramount importance being the right to make informed choices. The aim of this study was to investigate the knowledge and attitude towards prenatal Down syndrome screening in order to asses to what extent the Romanian women make informed choices in this area.

Methods

A cross-sectional study was carried out that included 530 postpartum women, clients of Romania’ south-east region maternities, during April–September 2016. The level of knowledge and the attitude concerning the Down syndrome screening were evaluated using a questionnaire. Data were analyzed using SPSS version 20.0.

Results

48.1% of the women have never heard about any tests for Down Syndrome and from those 51.9% who have heard, only 14.2% made an informed choice, 78.9% had a positive attitude for screening, 88% were classified as having insufficient knowledge and 68.3% made a value-consistent decision to accept or decline prenatal screening. A higher knowledge level was associated with a higher education level and the urban residence. The information satisfaction and confidence in the overall value of screening were predictive factors of positive attitude. More informed choices were made by women monitored by an obstetrician in a private practice.

Conclusions

The prenatal screening tests for Down Syndrome were mostly unknown and the women who accepted or not to perform a test were insufficiently knowledgeable that means that the ethical concept of the informed choice wasn’t followed. In our opinion the Romanian Health System needs to improve the antenatal policy by developing an adequate information strategy at the reproductive population level based on a network of trained specialists.

Electronic supplementary material

The online version of this article (10.1186/s12884-018-2077-6) contains supplementary material, which is available to authorized users.

Limits to the scope of non-invasive prenatal testing (NIPT): an analysis of the international ethical framework for prenatal screening and an interview study with Dutch professionals

Background

The introduction of non-invasive prenatal testing (NIPT) for foetal aneuploidies is currently changing the field of prenatal screening in many countries. As it is non-invasive, safe and accurate, this technique allows for a broad implementation of first-trimester prenatal screening, which raises ethical issues, related, for instance, to informed choice and adverse societal consequences. This article offers an account of a leading international ethical framework for prenatal screening, examines how this framework is used by professionals working in the field of NIPT, and presents ethical guidance for the expansion of the scope of prenatal screening in practice.

Methods

A comparative analysis of authoritative documents is combined with 15 semi-structured interviews with professionals in the field of prenatal screening in the Netherlands. Data were recorded, transcribed verbatim and analysed using thematic analysis.

Results

The current ethical framework consists of four pillars: the aim of screening, the proportionality of the test, justice, and societal aspects. Respondents recognised and supported this framework in practice, but expressed some concerns. Professionals felt that pregnant women do not always make informed choices, while this is seen as central to reproductive autonomy (the aim of screening), and that pre-test counselling practices stand in need of improvement. Respondents believed that the benefits of NIPT, and of an expansion of its scope, outweigh the harms (proportionality), which are thought to be acceptable. They felt that the out-of-pocket financial contribution currently required by pregnant women constitutes a barrier to access to NIPT, which disproportionally affects those of a lower socioeconomic status (justice). Finally, professionals recognised but did not share concerns about a rising pressure to test or discrimination of disabled persons (societal aspects).

Conclusions

Four types of limits to the scope of NIPT are proposed: NIPT should generate only test outcomes that are relevant to reproductive decision-making, informed choice should be (made) possible through adequate pre-test counselling, the rights of future children should be respected, and equal access should be guaranteed. Although the focus of the interview study is on the Dutch healthcare setting, insights and conclusions can be applied internationally and to other healthcare systems.

A qualitative study looking at informed choice in the context of non-invasive prenatal testing for aneuploidy

Objective

To explore women's attitudes towards non‐invasive prenatal testing (NIPT) and determine factors influencing their decisions around uptake of NIPT.

Method

We conducted qualitative interviews to assess knowledge, attitude and deliberation amongst women offered NIPT in a public health service. In total, 45 women took part in telephone interviews (79% participation rate).

Results

Most women could recount the key aspects of NIPT discussed during pre‐test counselling but had variable knowledge about Down syndrome. Analysis of women's attitudes towards undergoing NIPT revealed three dominant factors they considered when reflecting on the test: (1) how NIPT compared with alternative testing options, (2) reflections on coping and (3) moral or religious values. Exploring the deliberative process revealed the different paths women take when making decisions. For some, it was an extension of the decision to have Down syndrome screening; some considered it early on following the booking‐in appointment; others made step‐wise decisions about NIPT when it became relevant to them.

Conclusion

Our findings support the importance of personalised counselling, whereby women and their partners have the opportunity to reflect on the implications of the test results in the context of their own lives and values. Our data highlight the influence of personal circumstances on decision‐making. © 2016 The Authors. Prenatal Diagnosis published by John Wiley & Sons, Ltd.

What's Already Known About This Topic?

Non‐invasive prenatal testing (NIPT) for aneuploidies has entered clinical practice, although concerns exist around the potential for routinisation and erosion of informed choice.

Research into informed decision‐making for NIPT is now beginning to emerge, although these are predominantly quantitative studies.

What Does This Study Add?

Participants frequently used a combination of clinical information, personal experiences and moral values to guide action.

For many participants, decision‐making was a multistep deliberative process which occurred as and when new information became available.

Socioeconomic Differences in Informed Decisions About Down Syndrome Screening: A Systematic Review and Research Agenda

Supporting pregnant women to make informed choices about Down syndrome screening is widely endorsed. We reviewed the literature on: (a) the association between socioeconomic position and informed choices and decision-making about Down syndrome screening, and (b) the possible mediating variables (e.g., health literacy, numeracy skills, behavioral and communication variables) that might explain the relationship. EMBASE, MEDLINE, PubMed, CINAHL, and PsycINFO were searched from January 1999 to September 2014. The methodological quality of studies was determined by predefined criteria regarding the research aims, study design, study population and setting, measurement tools, and statistical analysis. A total of 33 studies met the inclusion criteria. Women from lower socioeconomic groups experience greater difficulties making informed choices about Down syndrome screening compared to women from higher socioeconomic groups. Most studies focus on individual dimensions of informed decision-making rather than assessing elements in conjunction with one another. Few studies have explored why there are socioeconomic differences in women's ability to make informed screening decisions. Future work is needed to identify mediating variables in this pathway. Systematic evidence-based intervention development to improve communication, understanding, and decision-making about Down syndrome screening is needed to ensure that women have an equal opportunity to make an informed choice about screening regardless of their socioeconomic position.

Development and validation of a measure of informed choice for women undergoing non-invasive prenatal testing for aneuploidy

Non-invasive prenatal testing (NIPT) using cell-free DNA for aneuploidy is a highly accurate screening test; however, concerns exist around the potential for routinisation of testing. The multidimensional measure of informed choice (MMIC) is a quantitative instrument developed to assess informed choice for Down syndrome screening (DSS). We have validated a modified MMIC for NIPT and measured informed choice among women offered NIPT in a public health service. The measure was distributed to women recruited across eight maternity units in the United Kingdom who had accepted DSS. Construct validity was assessed by simultaneously conducting qualitative interviews. Five hundred and eighty-five questionnaires were completed and 45 interviews conducted after blood-draw (or equivalent for those that declined NIPT). The measure demonstrated good internal consistency and internal validity. Results indicate the vast majority of women (89%) made an informed choice; 95% were judged to have good knowledge, 88% had a positive attitude and 92% had deliberated. Of the 11% judged to have made an uninformed choice, 55% had not deliberated, 41% had insufficient knowledge, and 19% had a negative attitude. Ethnicity (OR=2.78, P=0.003) and accepting NIPT (OR=16.05, P=0.021) were found to be significant predictors of informed choice. The high rate of informed choice is likely to reflect the importance placed on the provision of pre-test counselling in this study. It will be vital to ensure that this is maintained once NIPT is offered in routine clinical practice.

Informed choice about Down syndrome screening - effect of an eHealth tool: a randomized controlled trial

INTRODUCTION

The aim of this study was to evaluate the effect of an eHealth intervention (interactive website) on pregnant women's ability to make an informed choice about Down syndrome screening.

MATERIAL AND METHODS

The study was designed as a randomized controlled trial with allocation to an intervention group and a control group in a ratio of 1:1. Subsequent subgroup analysis was conducted. Participants were recruited from 5 August 2013 to 25 April 2014 at Odense University Hospital, Denmark. Inclusion criteria were: pregnant women aged ≥18 years who were invited to participate in Down syndrome screening. Exclusion criteria were: high risk of abortion, psycho-socially vulnerable women, late referral, inability to speak Danish and women declining to participate. The primary outcome was informed choice about Down syndrome screening. The Multidimensional Measure of Informed Choice was used to assess whether the choice was informed or uninformed.

RESULTS

A total of 1150 participants were included in the study, of which 910 (79%) completed the questionnaire. Only a minority (30% of the women in the intervention group) actually used the website. There was no significant difference in the groups with respect to making an informed choice. The mean knowledge scores were significantly higher for those in the intervention group who used the intervention.

CONCLUSIONS

An interactive website with information about Down syndrome screening had no direct effect on making an informed choice. However, the majority of the pregnant women who used the website were satisfied with the website and would recommend it to others.

[Assessment of patients' knowledge of first-trimester combined Down syndrome screening at the time of their first trimester ultrasonographic evaluation: Results of a prospective study about 201 women]

OBJECTIVE

Assess pregnant women's knowledge on first-trimester combined Down syndrome screening, at the time of their first trimester ultrasound scan.

MATERIALS AND METHODS

A questionnaire was submitted to the patients coming for their 12-week pregnancy ultrasonographic evaluation in a University Hospital prenatal clinic between May 2012 and May 2013. Correct and incorrect statements on Down syndrome screening were proposed to the mothers who were asked to rate them. Each patient was questioned on her prior exposition to Down syndrome screening, the category of medical of professional she previously consulted, and the information she received. Patients' knowledge was evaluated according to these criteria.

RESULTS

Two hundred and one patients were included in this study. The average correct answer rating was 4.6 (out of 8 questions). The average incorrect answer rating was 2.4 (out of 6 questions). No difference was found between the different social and demographic groups, nor according to the category of professional consulted before the first ultrasound scan. Higher correct answer ratings were observed when the patient had already been submitted to a Down syndrome screening (P=0.039), when they had previously received explanations about the screening (P=0.003); and when they stated that they had been sufficiently informed (P=0.042).

CONCLUSION

These results show that patients' knowledge on Down syndrome screening is inadequate and depends on their experience of previous screening and information. It is deemed necessary to improve information especially to young women who are pregnant for the first time.

Measuring informed choice in population-based reproductive genetic screening: a systematic review

Genetic screening and health-care guidelines recommend that programmes should facilitate informed choice. It is therefore important that accurate measures of informed choice are available to evaluate such programmes. This review synthesises and appraises measures used to evaluate informed choice in population-based genetic screening programmes for reproductive risk. Databases were searched for studies offering genetic screening for the purpose of establishing reproductive risk to an adult population sample, in which aspects of informed choice were measured. Studies were included if, at a minimum, measures of uptake of screening and knowledge were used. Searches identified 1462 citations and 76 studies were reviewed in full text; 34 studies met the inclusion criteria. Over 20 different measures of informed choice were used. Many measures lacked adequate validity and reliability data. This systematic review will inform future evaluation of informed choice in population genetic screening programmes.

Non-invasive prenatal testing: ethics and policy considerations

New technologies analyzing fetal DNA in maternal blood have led to the wide commercial availability of non-invasive prenatal testing (NIPT). We present here for clinicians the ethical and policy issues related to an emerging practice option. Although NIPT presents opportunities for pregnant women, particularly women who are at increased risk of having a baby with an abnormality or who are otherwise likely to access invasive prenatal testing, NIPT brings significant ethics and policy challenges. The ethical issues include multiple aspects of informed decision-making, such as access to counselling about the possible results of the test in advance of making a decision about participation in NIPT. Policy considerations include issues related to offering and promoting a privately available medical strategy in publicly funded institutions. Ethics and policy considerations merge in NIPT with regard to sex selection and support for persons living with disabilities.

A randomized trial of a prenatal genetic testing interactive computerized information aid

OBJECTIVE

The aim of this study was to determine whether an interactive computer program could improve patient knowledge regarding genetic screening and diagnostic concepts.

METHODS

In this randomized trial, women 6-26 weeks' gestation were assigned to standard care with provider-based counseling or to augmented counseling with an interactive computer program. The computer-based tool conveyed information about genetic testing options. Women were administered a 23-item test of content knowledge immediately and 2-4 weeks after exposure. Test scores were compared between groups at both points using T-tests.

RESULTS

A total of 150 women were randomized equally between groups. Groups were similar with regard to demographic characteristics. Women randomized to the interactive tool correctly answered a significantly greater proportion of questions than those who received standard counseling (69.4% ± 14.2% vs. 46.0% ± 15.2%, p < 0.001) on the immediate questionnaire. One hundred and twenty-three (82%) participants participated in the follow-up test. Women randomized to the tool continued to correctly answer a significantly greater proportion of questions (60.6% ± 16% vs. 49.7% ± 18.9%, p = 0.001). Education, health literacy, electronic health literacy, and other discussions with providers were not associated with a differential benefit from the educational intervention.

CONCLUSION

A patient-directed interactive computer program may help providers to convey relevant information about genetic screening and diagnostic concepts.

A qualitative and quantitative analysis of the New Zealand media portrayal of Down syndrome

BACKGROUND

There are only a small number of studies that systematically explore the tensions between the global shift to universal screening and the media representations of the people with Down syndrome. This paper contributes to the literature by analyzing the New Zealand media coverage of this topic.

OBJECTIVE

To describe the content and quality of selected New Zealand media references to Down syndrome in light of the claim by New Zealand support group Saving Downs of state supported eugenics via universal screening.

METHODS

Quantitative content analysis was conducted of 140 relevant New Zealand articles (from 2001 to 2011) and qualitative critical discourse analysis of 18 relevant articles (from 2009 to 2011) selected from television, magazine and newspaper.

RESULTS

The content analysis showed no strong directional reporting although the quality of life for people with Down syndrome was represented as slightly negative. Most articles focused on issues of society, government and care rather than genetics. The qualitative analysis identified themes around quality of life, information and bias, preparedness, eugenics, the visualness of disability and the need for public debate around genetic screening and testing.

CONCLUSION

The New Zealand print media coverage of these issues has been relatively balanced. Recent mixed media coverage of the topic is critical, complex and socially inclusive of people with Down syndrome.

Development of a fragile X syndrome (FXS) knowledge scale: towards a modified multidimensional measure of informed choice for FXS population carrier screening

BACKGROUND

Genetic carrier screening is increasingly possible for many conditions, but it is important to ensure decisions are informed. The multidimensional measure of informed choice (MMIC) is a quantitative instrument developed to evaluate informed choice in prenatal screening for Down syndrome, measuring knowledge, attitudes and uptake. To apply the MMIC in other screening settings, the knowledge scale must be modified.

OBJECTIVE

To develop and validate a modified MMIC knowledge scale for use with women undergoing carrier screening for fragile X syndrome (FXS).

SETTING AND PARTICIPANTS

Responses to MMIC items were collected through questionnaires as part of a FXS carrier screening pilot study in a preconception setting in Melbourne, Australia.

DESIGN

Ten knowledge scale items were developed using a modified Delphi technique. Cronbach's alpha and factor analysis were used to validate the new FXS knowledge scale. We summarized the knowledge, attitudes and informed choice status based on the modified MMIC.

RESULTS

Two hundred and eighty-five women were recruited, 241 eligible questionnaires were complete for analysis. The FXS knowledge scale items measured one salient construct and were internally consistent (alpha = 0.70). 71% (172/241) of participants were classified as having good knowledge, 70% (169/241) had positive attitudes and 27% (65/241) made an informed choice to accept or decline screening.

DISCUSSION AND CONCLUSIONS

We present the development of a knowledge scale as part of a MMIC to evaluate informed choice in population carrier screening for FXS. This can be used as a template by other researchers to develop knowledge scales for other conditions for use in the MMIC.

The provision of information and informed decision-making on prenatal screening for Down syndrome: a questionnaire- and register-based survey in a non-selected population

OBJECTIVE

Evaluating the information provision procedure about prenatal screening for Down syndrome, using informed decision-making as a quality-indicator.

METHODS

Questionnaire- and register-based surveys. Midwives associated with 59 midwifery practices completed process data for 6435 pregnancies. Pregnant women (n=510) completed questionnaires on informed decision-making.

RESULTS

Midwives offered information to 98.5% of women; 62.6% of them wished to receive information, of these, 81.9% actually received information. Decision-relevant knowledge was adequate in 89.0% of responding women. Knowledge about Down syndrome was less adequate than knowledge about the screening program. Participants in the screening program had higher knowledge scores on Down syndrome and on the screening program than non-participants. Of the women who intended to participate (35.8%), 3.1% had inadequate knowledge. A total of 75.5% of women made an informed decision; 94.3% of women participating in the screening program, and 64.9% of women not participating.

CONCLUSION

This quality assurance study showed high levels of informed decision-making and a relatively low participation rate in the national screening program for Down syndrome in the Netherlands. Knowledge of the Down syndrome condition needs to be improved.

PRACTICE IMPLICATIONS

This evaluation may serve as a pilot study for quality monitoring studies at a national level.

Audiovisual information affects informed choice and experience of information in antenatal Down syndrome screening--a randomized controlled trial

OBJECTIVE

To evaluate the effects of an information film on making an informed choice regarding Down syndrome screening, and women's knowledge and experiences of information.

METHODS

Randomized controlled trial including 184 women in the intervention group and 206 controls recruited from maternity units in Stockholm, Sweden. The intervention was an information film presented as a complement to written and verbal information. Data were collected via a questionnaire in gestational week 27. Three different measures were combined to measure informed choice: attitudes towards Down syndrome screening, knowledge about Down syndrome and Down syndrome screening, and uptake of CUB (combined ultrasound and biochemical screening).

RESULTS

In the intervention group 71.5% made an informed choice versus 62.4% in the control group. Women in the intervention group had significantly increased knowledge, and to a greater extent than the control group, experienced the information as being sufficient, comprehensible, and correct.

CONCLUSIONS

An information film tended to increase the number of women who made an informed choice about Down syndrome screening. Participants were more satisfied with the information received.

PRACTICE IMPLICATIONS

Access to correct, nondirective, and sufficient information is essential when making a choice about prenatal diagnostics. It is essential with equivalent information to all women.

Informing on prenatal screening for Down syndrome prior to conception. An empirical and ethical perspective

In most Western countries, information on prenatal screening for Down syndrome is provided in the first-trimester of pregnancy. The purpose of this study was to examine whether this information should additionally be provided before pregnancy to improve the informed decision-making process. In an empirical study, we obtained data from pregnant women with respect to their preferences regarding information on prenatal screening preconceptionally. Questionnaire data (n = 510) showed that 55.7% of responding women considered participating in prenatal screening for Down syndrome before pregnancy. 28.0% of women possessed information on prenatal screening preconceptionally. 84.6% preferred not to receive information preconceptionally in retrospect. In an ethical analysis, we elaborated on these preferences by weighing pros and cons. We considered two arguments against the provision of information on prenatal screening preconceptionally: women's preference to receive information in a step-by-step manner, and the risk of providing a directive message. We identified three reasons supporting its provision preconceptionally: the likelihood of making an informed decision could, firstly, be increased by "unchaining" the initial information from possible subsequent decisions, and, secondly, by providing women sufficient time to deliberate. Thirdly, the probability of equal access to prenatal screening may increase. To conclude with, we propose to incorporate an information offer on prenatal screening for Down syndrome in preconception care consultations. By offering information, instead of providing information, prospective parents are enabled to either accept or decline the information, which respects both their right to know and their right not-to-know.

Bioethical concepts in theory and practice: an exploratory study of prenatal screening in Iceland

A hallmark of good antenatal care is to respect prospective parent's choices and provide information in a way that encourages their autonomy and informed decision making. In this paper, we analyse the meaning of autonomous and informed decision making from the theoretical perspective and attempt to show how those concepts are described among prospective parents in early pregnancy and in the public media in a society where NT screening is almost a norm. We use interviews with Icelandic prospective parents in early pregnancy (N = 40) and material covering the discourse around prenatal screening in the media over 5 years period. Our analysis indicates that both prospective parents and the public media include ethical terms in their rhetoric around prenatal screening although those concepts differ in their expression. We conclude that the context in which these decisions are taken does not encourage moral reflection. Prospective parents describe that there is a lack of dialogue with professionals when decisions are made about screening. With routine offer of screening the conceptualization of bioethical concepts finds its own way through a mainstream discourse which has limited connections to the theoretical notions. This has been neglected in the implementation of screening, as limited effort has been subject to audit with reference to explore how the offer of screening and informed choice is experienced among prospective parents.

Are adolescents' decisions about prenatal screening for Down syndrome informed? A controlled, prospective study

STUDY OBJECTIVE

Maternal serum screening is routinely offered to pregnant women in public hospitals in Victoria, Australia, regardless of their age. The aim of this study was to determine whether pregnant adolescents are less likely to make informed choices about undertaking this test than adult pregnant women.

DESIGN

Controlled, prospective design.

SETTING

Public hospital antenatal clinics in Victoria, Australia.

PARTICIPANTS

Adolescents up to 20 years of age were recruited at young mothers' clinics before they were offered second trimester maternal screening. They completed self-report questionnaires prior to maternal serum screening and again after the screening result was known.

MAIN OUTCOME MEASURES

A validated measure of informed choice was used to determine whether adolescents made informed choices about undertaking second trimester maternal serum screening.

RESULTS

Complete data were available for 147 adolescents. These data were combined with data from 85 adults which had been collected in an identical way. Ten percent of the adolescents made informed decisions about having the maternal serum screening, compared with 37% of the adult participant group (P < 0.05). Adolescent women were significantly less likely to make an informed choice than adult women, when relevant demographic and reproductive history variables were controlled for (adjusted OR = 0.25; P = 0.004; 95% CI for OR: 0.10, 0.63).

CONCLUSION

Few pregnant adolescents made informed decisions about maternal serum screening. Clinicians face a challenge to improve adolescents' knowledge about maternal serum screening.

Information about prenatal screening for Down syndrome: ethnic differences in knowledge

OBJECTIVE

To evaluate the provision of information about prenatal screening for Down syndrome to women of Dutch, Turkish and Surinamese origins, and to examine the effects of this provision on ethnic differences in knowledge about Down syndrome and prenatal screening.

METHODS

The study population consisted of 105 Dutch, 100 Turkish and 65 Surinamese pregnant women attending midwifery or obstetrical practices in The Netherlands. Each woman was personally interviewed for 3 weeks (mean) after booking for prenatal care.

RESULTS

Most women reported to have received oral and/or written information about prenatal screening by their midwife or obstetrician at booking for prenatal care. Turkish and Surinamese women less often read the information than Dutch women, more often reported difficulties in understanding the information, and had less knowledge about Down syndrome, prenatal screening and amniocentesis. Language skills and educational level contributed most to the explanation of these ethnic variations.

CONCLUSION

Although most Dutch, Turkish and Surinamese women reported to have received information from their midwife or obstetrician, ethnic differences in knowledge about Down syndrome and prenatal screening are substantial.

PRACTICE IMPLICATIONS

Interventions to improve the provision of information to women from ethnic minority groups should especially be aimed at overcoming language barriers, and targeting information to the women's abilities to comprehend the information about prenatal screening for Down syndrome.

The validation and translation of Multidimensional Measure of Informed Choice in Greek

OBJECTIVE

to translate the original English version of the Multidimensional Measure of Informed Choice (MMIC) into Greek, to adapt it culturally to Greece, and to determine its psychometric properties for the assessment of informed choice in antenatal screening for Down syndrome.

DESIGN

survey using self-administrated questionnaires.

SETTING

public hospital in Athens, Greece.

PARTICIPANTS

135 pregnant women with gestational age between 11th and 20th week just prior to having antenatal screening for Down syndrome.

FINDINGS

96% of women had a positive attitude towards screening and 45% had a good level of knowledge concerning the screening process for Down syndrome. Using a standard measure of informed choice, validated for use in Greek, it was found that 44% of women made an informed choice, and thus 56% of women made an uninformed choice. The internal consistency of the scales was good; Cronbach's alpha was found to be 0.76 for the attitude scale and 0.64 for the knowledge scale, suggesting that all items were appropriate to measure. The performed factor analysis of the attitude scale indicated three factors with an eigenvalue over 1.0. Those factors were responsible for 87% of the variance.

KEY CONCLUSIONS

this study indicates that the Greek version of the MMIC appears to be a reliable and valid tool for measuring informed choice in antenatal screening for Down syndrome. Due to its short length and consumption of time, it seems to be a practical instrument for use in Greek antenatal clinics.