The emotional process from diagnosis to birth following a prenatal diagnosis of fetal anomaly: A qualitative study of messages in online discussion boards

Parental refusal of prenatal screening for aneuploidies

OBJECTIVES

To analyze the reasons for refusal of aneuploidy screening in a multicultural Middle Eastern population.

METHODS

The study included patients delivering in a university hospital, who had refused aneuploidy screening during their pregnancy. We evaluated through a questionnaire submitted during the postpartum period the sociodemographic characteristics, beliefs, attitudes, and the main reason underpinning their choice. Religious, ethical, and financial factors, personal beliefs, medical information, perceived media information, and familial input were assessed through a Likert scale.

RESULTS

Our pilot study included 70 patients. The main reason (33 %) was the refusal to terminate pregnancy if the screening tests ultimately led to a diagnosis of aneuploidy. Lack of adequate information on the availability and benefits of this screening method (28 %), religious beliefs (17 %), in addition to other minor reasons such as financial considerations, familial recommendations, late pregnancy follow-ups, and media influence were also identified as contributing factors.

CONCLUSIONS

Aneuploidy screening is routinely offered to couples, with varying uptake rates observed worldwide. Sufficient information on prenatal screening and diagnosis should be provided to all pregnant women, presenting all available options, thus enabling them to make a free and informed choice during their pregnancy.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Psychological Impact of a Prenatal Diagnosis of Congenital Heart Disease on Parents: Is It Time for Tailored Psychological Support?

The prenatal diagnosis of congenital heart disease (CHD) represents, for both parents, a particularly stressful and traumatic life event from a psychological point of view. The present review sought to summarize the findings of the most relevant literature on the psychological impact of prenatal diagnosis of CHD on parents, describing the most common mechanisms employed in order to face this unexpected finding. We also highlight the importance of counseling and the current gaps in the effects of psychological support on this population.

The use of projected autonomy in antenatal shared decision-making for periviable neonates: a qualitative study

BACKGROUND

In this study, we assessed the communication strategies used by neonatologists in antenatal consultations which may influence decision-making when determining whether to provide resuscitation or comfort measures only in the care of periviable neonates.

METHODS

This study employed a qualitative study design using inductive thematic discourse analysis of 'naturally occurring data' in the form of antenatal conversations around resuscitation decisions at the grey zone of viability. The study occurred between February 2017 and June 2018 on a labor and delivery unit within a large Midwestern tertiary care hospital. Participants included 25 mothers who were admitted to the study hospital with anticipated delivery in the grey zone of viability and practicing neonatologists or neonatology fellows who partnered in antenatal consultation. We used a two-stage inductive analytic process to focus on how neonatologists' discourses constructed SDM in antenatal consultations. First, we used a thematic discourse analysis to interpret the recurring patterns of meaning within the transcribed antenatal consultations, and second, we theorized the subsequent effects of these discourses on shaping the context of SDM in antenatal encounters.

RESULTS

In this qualitative study, that included discourse analysis of real-time audio conversations in 25 antenatal consults, neonatologists used language that creates projected autonomy through (i) descriptions of fetal physiology (ii) development of the fetus's presence, and (iii) fetal role in decision-making.

CONCLUSION

Discourse analysis of real-time audio conversations in antenatal consultations was revelatory of how various discursive patterns brought the fetus into decision-making, thus changing who is considered the key actor in SDM.

Threat and adaptation: The maternal lived experience of continuing pregnancy after receiving a prenatal diagnosis of agenesis of the corpus callosum

One stated objective of prenatal screening and diagnosis is the preparation for delivering a baby with medical needs or disability, however, psychosocial outcomes of parents who received a prenatal diagnosis suggest that this objective is not yet realised. Preparation may be complicated by diagnostic and prognostic uncertainty. A prenatal diagnosis that includes significant uncertainty due to the heterogeneous presentations, classifications, causes and outcomes is agenesis of the corpus callosum. As a neuroanatomical anomaly identified in the second or third trimesters, the diagnosis is likely to cause distress for expectant mothers, yet there is limited guidance for holistic support. To begin to address the paucity of research, this hermeneutic phenomenological study sought to explore, and provide a telling of the maternal experience of continuing pregnancy after a prenatal diagnosis of agenesis of the corpus callosum. Through interviews and a series of online, asynchronous and facilitated focus groups, lived experiences during pregnancy from the time of diagnosis to birth were explored with 26 mothers who participated in this international study. Themes were constructed through reflexive thematic analysis to describe the experience of the lived phenomenon. The first theme, Under Threat, included subthemes of The Threat to the Life of the Baby and Threatened Image of the Expected Family. The second theme, Day to Day Toward Adaptation, included subthemes of Holding it Together and Falling Apart, and More Than Information, Searching for Meaning, Hope and Control. To realise the commonly stated objective of prenatal diagnosis, to support maternal preparation, healthcare professionals require awareness of the profound, yet individual experience of prenatal diagnosis to adequately respond and support mothers through their continued pregnancies. Healthcare services should be designed to flexibly respond in a woman- and family-centred manner to reduce the threat and support maternal adaptation after a prenatal diagnosis.

'And then there was silence': shaping practice through the experience of parents' emotions

Background

Spina bifida, the most common Neural Tube Defect occurring around 28 days following conception, is often discovered in a routine ultrasound examination. Nurses offer continuous support for families who care for children with disabilities, associated with this diagnosis.

Aim

To articulate and analyse parents' recollection of the emotions they experienced when they were informed by professionals that their unborn baby may have neurological disabilities.

Method

Qualitative study, using participatory visual narrative method, engaging parents caring for young children with Spina bifida.

Results

The emotions parents described, surfacing at the point of diagnosis, and the crafted stories they shared, demonstrated the significance and the long-lasting impact of their experience. Disclosing sensitive information and the way it is shared has a significant role in shaping how families adjust to caring for disabled children.

Conclusion

Role and care transitions of parents who choose to keep their babies, despite their impending disability, is a lengthy and complex process. Nurses should be aware of and informed by the origin story, to offer appropriate support throughout this period. Policies to promote integration with services delivered by 'not for profit' organisations will benefit family-focused and person-centred care.

Exploring continuity of care for women with prenatal diagnosis of congenital anomaly: A mixed method study

AIMS

To map the pathway and service provision for pregnant women whose newborns require admission into the surgical neonatal intensive care unit at or soon after birth, and to examine the nature of continuity of care (COC) provided and the facilitators and barriers to woman- and family-centred care from the perspective of women/parents and health professionals.

BACKGROUND

Limited research exists on current service and care pathways for families whose babies are diagnosed with congenital abnormality requiring surgery.

DESIGN

A mixed method sequential design adhering to EQUATOR guidelines for Good Reporting of a Mixed Methods Study.

METHODS

Data collection methods included: (1) a workshop with health professionals (n = 15), (2) retrospective maternal record review (n = 20), prospective maternal record review (17), (3) interviews with pregnant women given a prenatal diagnosis of congenital anomaly (n = 17) and (4) interviews with key health professionals (n = 7).

RESULTS/FINDINGS

Participants perceived care delivered by state-based services as problematic prior to admission into the high-risk midwifery COC model. Once admitted to the high-risk maternity team women described care 'like a breath of fresh air' with a 'contrast in support', where they felt supported in their decisions.

CONCLUSION

This study highlights provision of COC, in particular relational continuity between health providers and women as essential to achieve optimal outcomes.

RELEVANCE TO CLINICAL PRACTICE

Provision of individualised COC offers an opportunity for perinatal services to reduce the negative consequences of pregnancy-related stress associated with diagnosis of foetal anomaly.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public was involved in the design, analysis, preparation or writing of this review.

Mapping parents' journey following prenatal diagnosis of CHD: a qualitative study

OBJECTIVE

To better understand parents' accounts of their prenatal and postnatal experience after prenatal diagnosis of CHD - particularly emotional processing and coping mechanisms - to identify strategies to improve support.

METHODS

This single-centre, longitudinal qualitative study included pregnant mothers and their support persons seen in Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May through August 2019 for probable complex CHD. Twenty-seven individuals from 17 families participated in 62 phone interviews during pregnancy and postpartum: 27 conducted after the initial prenatal cardiology consultation, 15 after a follow-up prenatal visit, and 20 after birth. Applied thematic analysis approach was used to code and analyse transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was >80%.

RESULTS

Patients included mothers (16 [59%]), fathers (8 [30%]), and other support persons (3 [11%]). Initial fetal diagnoses included a range of moderate to severe CHD. Prenatally, parents sought to maintain hope while understanding the diagnosis; planning for the future rather than focusing on day-to-day was more common if prognoses were better. Postnatally, with confirmation of prenatal diagnoses, parents' sense of control expanded, and they desired more active engagement in clinical decision making.

CONCLUSIONS

To enhance effective communication and support, understanding how parents conceptualise hope in relation to diagnosis and how that may evolve over time is critical. Expectant parents whose child has a significant risk of mortality may demonstrate hope by focusing on positivity. As prognostic uncertainty diminishes postpartum, the parental role on the team may shift, requiring clinicians to provide different support.

Information needs of parents of children with congenital anomalies across Europe: a EUROlinkCAT survey

BACKGROUND

Parents of children who have a congenital anomaly can experience significant worry about their child's health. Access to clear, helpful, and trustworthy information can provide a valuable source of support. In this study the aim was to explore the information needs of parents/carers of children with congenital anomalies across Europe.

METHOD

A cross-sectional online survey was developed in nine languages to measure parents' information needs, including: (1) the 'helpfulness'/'trustworthiness' of information received from eight relevant sources, and (2) overall satisfaction with information received. Parents/carers of children (0-10 years) with cleft lip, spina bifida, congenital heart defect [CHD] requiring surgery, and/or Down syndrome were recruited online via relevant organisations in 10 European countries from March-July 2021. Quantitative analyses using multivariable logistic regressions were performed.

RESULTS

One thousand seventy parents/carers of children with a cleft lip (n = 247), spina bifida (n = 118), CHD (n = 366), Down syndrome (n = 281), and Down syndrome with CHD (n = 58) were recruited in Poland (n = 476), the UK (n = 120), Germany (n = 97), the Netherlands/Belgium (n = 74), Croatia (n = 68), Italy (n = 59), other European countries (n = 92), and not specified/non-European countries (n = 84). Most participants were mothers (92%) and aged 31-40 years (71%). Participants were most likely to rate support groups (63%), patient organisations (60%), specialist doctors/nurses (58%), and social media (57%) as 'very helpful' information sources. 'Very trustworthy' ratings remained high for specialist doctors/nurses (61%), however, they declined for support groups (47%), patient organisations (48%), and social media (35%). Germany had the highest proportion of participants who were 'very satisfied' (44%, 95% CI = 34%-54%) with information, whereas this percentage was lowest in Croatia (11%, 95% CI = 3%-19%) and Poland (15%, 95% CI = 11%-18%). Parents of children with Down syndrome had significantly lower satisfaction ratings than parents of children with CHD; 13% (95% CI = 8%-18%) reported being 'very satisfied' compared to 28% (95% CI = 23%-33%) in the CHD group.

CONCLUSIONS

Findings suggest that informal sources of information (e.g. support groups) are of value to parents, however, they are not deemed as trustworthy as specialist medical sources. Satisfaction ratings differed across countries and by anomaly, and were particularly low in Croatia and Poland, as well as for parents of children with Down syndrome, which warrants further investigation.

Effect of Psychological Nursing Intervention on Abnormal-Induced Labor of Fetus during Puerperium: Study on the Effects of Anxiety, Depression, and Life Events

Objective. To study the effects of psychological nursing intervention on anxiety, depression, and life events in puerperal women with fetal abnormalities. Methods. From January 2020 to January 2022, eighty women with abnormal fetal induction and puerperium-treated were selected in our hospital as the subjects. The research group ( $n=40$ ) and control group ( $n=40$ ) were arbitrarily selected from 80 women with abnormal fetal induction and puerperium. The research group was given psychological nursing intervention based on routine nursing, and the control cases were given routine nursing. The scores of Generalized Anxiety Scale (GAD-7), Patient Health Questionnaire (PHQ-9), Event Impact Scale (IES-R), Life Events Scale (LES), and Newcastle Nursing Satisfaction Scale (NSNS) were studied before nursing and 4 weeks after discharge. Results. Four weeks after discharge, the score of GAD-7 in the research group was lower, and the difference was statistically significant ( $P<0.05$ ). The score of PHQ-9 in the research group was lower, and the difference was statistically significant ( $P<0.05$ ). The IES-R score of the research group was lower, and the difference was statistically significant ( $P<0.05$ ). The LES score of the research group was lower, and the difference was statistically significant ( $P<0.05$ ). And the NSNS score of the research group was higher, and the difference was statistically significant ( $P<0.05$ ). Conclusion. The value of psychological care interventions in women with abnormally induced labor is more remarkable, contributing to the reduction of anxiety and depression and increasing the satisfaction of care for women with abnormally induced labor.

Longitudinal Perinatal Palliative Care for Severe Fetal Neurologic Diagnoses

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

Praying for a Miracle Part II: Idiosyncrasies of Spirituality and Its Relations With Religious Expressions in Health

As a continuation of the previous paper, Praying for a Miracle – Negative or Positive Impacts on Health Care, published in this research topic, this second paper aims at delving deeper into the same theme, but now from a simultaneously practical and conceptual approach. With that in mind, we revisit three theoretical models based on evidence, through which we can understand the role of a miracle in hospital settings and assess its impact in health contexts. For each of the models described, we seek to illustrate the possible outcomes of belief in miracles as a modality of religious coping in situations of stress and suffering experienced by patients and caregivers in the face of gloomy diagnoses on coming across the limits of medicine to revert certain illnesses (e.g., child cancer) or biological conditions (e.g., fetal malformation). We posit that the judgment about how such a mechanism is healthy or not for each of the people involved (patient, caregiver, and/or health professional) depends on the modulation between the conception of the miracle adopted by the patient and/or caregiver and the concrete outcomes of the way of responding to the situations that accompany the gravity of the illness or condition. To better understand this process of psychological modulation that accompanies belief in miracles, we revisit the concepts of spirituality, religiosity, and religion, pointing out the connections and distinctions between them from a phenomenological perspective. We then present a conceptual model that takes these connections and distinctions into consideration to foster an understanding of miracles, their relations with the diversity of experiences of people who meet in hospital settings (patients, caregivers, and health professionals), and their respective impacts on healthcare.

Impact of prenatally diagnosed congenital heart defects on outcomes and management

Fetal echocardiogram aids in prenatal identification of neonates at high risk for congenital heart defects (CHD). Prenatal detection rates for CHD have increased with improved ultrasound technology, the use of the early fetal echocardiography, and standardization of the performance of the fetal echocardiogram. Accurate prenatal detection of CHD, particularly complex CHD, is an important contributor to improved survival rates for patients with CHD. Early detection allows for families to choose whether or not to continue with pregnancy, referral to pediatric cardiology specialists for patient education, and delivery planning. Better psychosocial supports are needed for families with CHD.

"It's a lot of pain you've got to hide": a qualitative study of the journey of fathers facing traumatic pregnancy and childbirth

BACKGROUND

This study aims to explore the emotional and behavioural responses and coping strategies of fathers or expectant fathers who faced a significant traumatic event during a partner's pregnancy, labour, or the postpartum period.

METHODS

This prospective qualitative study of 24 fathers was conducted at a public teaching hospital in Brisbane, Australia. 'Traumatic pregnancy' was defined as a pregnancy complicated by life-threatening or severe risk to the mother and the fetus, termination of pregnancy, intrauterine fetal death or stillbirth. Semi-structured interviews of participants were conducted 3-4 months after the traumatic event. An initial qualitative analysis with automatic coding was performed using Leximancer and later followed by a six-phase manual thematic analysis.

RESULTS

A pregnancy-related traumatic event had significant mental and physical impacts on fathers. Participants' reactions and coping strategies were varied and influenced by their background history, pre-existing vulnerabilities, and the gap between expectation and reality. Most fathers described a fluctuating state between their needs 'not being met' and 'being met'. These needs were conceptualised using Maslow's hierarchy and Calman's gap theory to construct a composite thematic model to depict the universal requirements of men facing a traumatic pregnancy or childbirth.

CONCLUSIONS

A greater understanding of the needs of men and gaps in their care is urgently needed. A targeted effort is required to make maternity services father-inclusive. This approach may assist in preventing long term consequences on fathers, partners, and their children.

Praying for a Miracle: Negative or Positive Impacts on Health Care?

The belief in miracle, as a modality of spiritual/religious coping (SRC) strategy in the face of stress and psychic suffering, has been discussed in psychological literature with regard to its positive or negative role on the health and well-being of patients and family members. In contemporary times, where pseudo-conflicts between religion and science should have been long overcome, there is still some tendency of interpreting belief in miracle – as the possibility of a cure granted by divine intervention, modifying the normal course of events in a bleak medical diagnosis – as having unhealthy impacts in the care and treatment of health. This position seeks to find a base in the three characteristics of hoping in a miracle, frequently pointed out by psychological literature: (a) it would imply a negation of reality instead of its confrontation; (b) it would be a coping strategy focused on emotion instead of the problem; (c) it would imply seeking to modify the supposed desire of God by extra-natural facts. In this study, we shall critically discuss this position and the dangers of its crystallization by the use of SRC scales in which the act of praying for a miracle is previously classified as a negative strategy. We revisit some tendencies in psychological literature about the subject, taking into consideration the various facets of miracle, sociocultural facts, elements of idiographic nature, and their profound outcomes in the lives of people especially in health contexts. We illustrate the dangers of a hasty generalization of the results of nomothetic studies about the role of belief in miracle with two examples of research in the Brazilian context: one carried out with pregnant women with fetal malformation and the other with family members caring for children and adolescents with cancer under chemotherapeutic treatment. In both studies, the results do not confirm the predominance of the negative aspects associated with the act of praying for a miracle, which we discuss and analyze in light of the phenomenological perspective. In this perspective, “pray for a miracle”, as experienced by patients and caregivers, can be recognized as an act of openness to life (instead of isolation in a bleak perspective), bolstering hope, and the resignification of reality in the psyche.

Digital mediation of candidacy in maternity care: Managing boundaries between physiology and pathology

This paper brings together scholarship across sociology, media and communication, and human computer interaction to explore the intersection of digital health and the maternity care system. We draw on data (including interviews, focus groups, observations, and analyses of digital media content) from 19 studies involving over 400 women to explore women's experiences of using different forms of digital support such as the Internet, mobile technologies (apps and text messaging), social media, and remote monitoring devices in their reproductive journeys. We use a best fit approach to analysis, mapping our findings to the candidacy framework and notions of trajectory work to understand how women engage in digital health practices to negotiate boundaries between physiology and pathology and to enter dialogue with maternity services during conception, pregnancy and the postnatal period. We propose an integrated revised conceptual framework which explicates intersections between digital and care practices, and micro-level negotiations between women and professionals in the maternal health context. Our revised framework retains the dimensions of candidacy, but it introduces a precursor to the identification of candidacy in the form of 'understanding normality'. It identifies distinct forms of digital work (e.g. information work, navigation work, machine work) which operate across the candidacy dimensions that women (and partners at times) engage in to negotiate legitimacy when entering into encounters with the maternity care system. Operating conditions (norms around expert motherhood; neoliberal discourses around health optimisation, risk and responsibilisation) provide a broader macro-level context, influencing the micro-level dialogic processes between women and healthcare professionals. Our synthesis highlights digital mediation as a useful filter to understand care systems, distribution of lay/professional responsibilities, relational practices and the (dis)enablement of candidacy.

Effects of an expressive writing intervention in Chinese women undergoing pregnancy termination for fetal abnormality: A randomized controlled trial

OBJECTIVE

To explore the efficacy of an expressive writing intervention on promoting psychological well-being of women who have had a diagnosis of fetal abnormality.

DESIGN AND SETTING

An open, randomized controlled trial with parallel group design was conducted at a tertiary hospital in China. 100 women were randomly assigned into either the expressive writing (EW) intervention group or the control group, and 80 women eventually took part in all the phases of the study. Psychological variables including post-traumatic growth (PTG), post-traumatic stress disorder (PTSD) and resilience were assessed at baseline, immediately after the intervention and 1-month follow-up.

PARTICIPANTS

Women who have had a diagnosis of fetal abnormalities and decided to terminate pregnancies.

INTERVENTION

Women in the intervention group were asked to write three 15 min essays in regard to their experiences with the fetal abnormalities.

FINDINGS

The intervention group had significantly higher level of PTG (p = 0.003) and lower level of PTSD symptoms (p = 0.023) immediately after the intervention, as compared with the control group. In 1-month follow-up, intervention participants demonstrated significant improvement in PTG (p = 0.014) but insignificant reduction for PTSD symptoms. No significant effects were observed in both groups in terms of changes over time in resilience.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

EW is efficacious for improving women's PTG and easing their symptoms of PTSD to some extent. Medical staff should pay more attention to this population's psychological status. In the future, EW interventions need to be conducted in larger samples with more severe symptoms of PTSD to validate its effectiveness. The efficacy of longer and more frequent writing interventions should also be investigated.

Mental health nursing and the prenatal diagnosis of a congenital anomaly; a narrative of experience

WHAT IS KNOWN ON THE SUBJECT

Many parents find out that their unborn baby has a difference in their health, development, or genetics. This news is often unexpected and can be distressing and traumatic, which can lead to anxiety. There is a gap in support for parents.

WHAT THE PAPER ADDS TO EXISTING KNOWLEDGE

This paper offers a story of the lived experience of the first-author, a mental health nurse who was told that her baby had a difference late in pregnancy. The narrative moves through the anxiety and difficulties faced when falling between gaps in the systems.

WHAT ARE THE IMPLICATIONS FOR PRACTICE

This paper identifies the need for more support for parents who receive a prenatal diagnosis. This support is within the mental health nurse scope of practice across a range of settings and services. People who have been given a psychiatric diagnosis have been excluded from other studies that explore the experience of the unexpected news of a congenital anomaly. Research in this area is indicated.

RELEVANCE TO MENTAL HEALTH NURSING

Mental health nurses are well-positioned to address the gap in psychosocial support for parents who have received a prenatal diagnosis. As clinicians who are recognized to deliver federally funded pregnancy support counselling, psychosocial support is within the mental health nurse scope of practice. Some parents will require a higher level of support, assessment and intervention when they experience reactive mental illness or pre-existing mental illness is exacerbated. Furthermore, people who have received a psychiatric diagnosis have been excluded from studies that explore the experience of receiving a prenatal diagnosis. This exclusion has resulted in a gap in knowledge.

ABSTRACT

Introduction Expectant parents who receive a prenatal diagnosis of a congenital anomaly often experience shock, distress and a heightened risk of mental illness. Aim This paper aimed to highlight the gap in psychosocial support for parents who receive a prenatal diagnosis through the personal narrative of a mental health nurse who received a third-trimester diagnosis. Method The first-author reviewed her medical records and photos to recall moments of the experience and prompt reflection. Findings The narrative moved through the shock, guilt and subsequent pathological anxiety that followed a prenatal diagnosis at 32-week gestation and the option to terminate. Discussion The gap in psychosocial supports for parents who receive a prenatal congenital anomaly diagnosis raises the risk to parental mental health and potentially confounds the risk to the baby. Mental health nurses are well-positioned as service providers to fill this gap. Implications for Practice The provision of psychosocial support after a prenatal diagnosis is within the mental health nurse scope of practice. This support may be provided through pregnancy support counselling, innovative nurse-led perinatal mental health services or as additional support to a parent with the lived experience of mental illness who receives a prenatal diagnosis of a congenital anomaly.

Peer support among parents of children with congenital heart defects: A qualitative analysis of written responses submitted via an online survey

AIM

To explore experiences of peer support among parents of children with congenital heart defects.

DESIGN

A study analysing written responses to open-ended questions about peer support, collected via an online survey distributed in Sweden.

METHODS

Respondents were recruited during 3 months in 2018 by means of convenience sampling, through ads via the Swedish foundation for families with children who have heart defects and two closed Facebook groups for peer support. An online survey containing open-ended questions was distributed and responses were analysed with systematic text condensation.

RESULTS

Peer support was grounded in a mutual understanding among parents and involved highly appreciated emotional support. Listening to the stories of peers meant an opportunity to gain useful insights about what life is like for parents of children with heart defects. Receiving and providing peer support was described as rewarding on a personal level. Negative aspects of peer support were also described, which sometimes led to psychological distress and withdrawal from peer support activities.

CONCLUSION

Peer support is emotionally relieving and appreciated among parents of children with congenital heart defects, who consider providing the support a rewarding responsibility. While peer support activities may have considerable benefits for individuals, it may also lead to psychological distress for some.

IMPACT

This study addressed peer support among parents of children with congenital heart defects. The main findings illustrate the potential impact peer support can have on individuals and calls attention to the experienced benefits related to peer support activities, while also providing some insights regarding potential negative aspects. The findings have relevance for nurses, midwives, and other health professionals working in settings providing care for these families.

Uncertainty of Prenatally Diagnosed Congenital Heart Disease: A Qualitative Study

IMPORTANCE

Parents who receive a prenatal diagnosis of congenital heart disease may experience more short- and long-term stress than those who receive a postnatal diagnosis. To identify potential interventions to ameliorate that stress, the longitudinal emotional experience of parents must first be understood.

OBJECTIVE

To better understand parents' accounts of their own prenatal experience, particularly aspects they found to be stressful or challenging, and to identify strategies to improve support.

DESIGN, SETTING, AND PARTICIPANTS

This qualitative study included analysis of transcripts of audio recorded telephone interviews with pregnant mothers and their support persons, as applicable, who were referred to and seen at the Fetal Cardiology Clinic at Vanderbilt Children's Hospital from May 2019 to August 2019 with an initial likely diagnosis of complex congenital heart disease at any gestational age. Data analysis was conducted from August 2019 to November 2019.

MAIN OUTCOMES AND MEASURES

An applied thematic analysis approach was used to code and analyze professionally transcribed interviews. Coding and codebook revisions occurred iteratively; intercoder reliability was assessed and confirmed routinely. One author coded all transcripts; a second author independently reviewed one-fifth of the transcripts at fixed intervals to ensure that interrater reliability remained greater than 80%.

RESULTS

Twenty-seven individuals from 17 families participated in 42 phone interviews during pregnancy, 27 conducted at the first time point after the initial prenatal cardiology consultation and 15 at the second time point after a follow-up prenatal cardiology visit. Most interviewees were mothers (16 interviewees [59%]; median [interquartile range] age, 30.0 [27.3-34.8] years) or fathers (8 interviewees [30%)], with a few support individuals (3 interviewees [11%]) (median [interquartile range] age of family member or support individual, 30.0 [26.0-42.0] years). Initial fetal diagnoses included a range of severe congenital heart disease. Uncertainty was identified as a pervasive central theme and was related both to concrete questions on scheduling, logistics, or next steps, and long-term unknown variables concerning the definitiveness of the diagnosis or overall prognosis. Practitioners helped families through their framing of uncertainty at various time points including before, during, and after the clinic visit.

CONCLUSIONS AND RELEVANCE

Families walk an uncertain path following a fetal diagnosis of severe congenital heart disease. The challenges faced by the cardiologists caring for them overlap in many ways with those experienced by pediatric palliative care practitioners. Potential future interventions to improve parental support were identified in the areas of expectation setting before the referral visit, communication in clinic, and identity formation after the new diagnosis.

Perinatal Palliative Care Birth Planning as Advance Care Planning

Purpose of Review: A significant number of pregnancies are complicated by a fetus with a life-limiting diagnosis. As diagnoses are made earlier in the pregnancy, families experience anticipatory grief and are faced with navigating goals of care for a baby that has yet to be born. With the support of the care team, families can begin to grieve, plan, and make meaningful memories during the duration of the pregnancy, the birth of their baby, and life of the child. Creating a palliative care birth plan, which expands beyond the traditional concept for delivery planning to include prenatal, perinatal, and neonatal care has become an important method for parents to process the diagnosis, for parents to document their wishes, and for members of the care team to communicate with the goal of supporting and enhancing the experience of the family. This articles reviews recent and relevant literature on the importance of birth planning and the role of perinatal palliative care when a life-limiting fetal diagnosis is made. Recent Findings: The process of birth planning is an important component of perinatal palliative care. Through this process, families can express their fears, values, hopes, and wishes. It also offers an opportunity for providers to communicate these wishes for the remainder of the pregnancy, the delivery, birth, and time afterwards. This has been demonstrated to decrease maternal stress and promote family centered care. Summary: Perinatal birth planning is an important component of perinatal palliative care when a fetus has a life-limiting diagnosis. The process of birth planning can be supportive and therapeutic as well as an important communication tool. With multiple practices and designs of perinatal palliative care programs, there are no standard tools even though important components have been identified. Ultimately, the strategies outlined here can be used as advance care planning tools.

Parental reactions, distress, and sense of coherence after prenatal versus postnatal diagnosis of complex congenital heart disease

INTRODUCTION

A diagnosis of congenital heart disease (CHD) in offspring triggers psychological distress in parents. Results of previous studies have been inconsistent regarding the psychological impact of a prenatal versus a postnatal diagnosis. The aim of this study was to evaluate the influence of the time of diagnosis on levels of parental distress.

METHODS

Pregnant women and their partners with a fetus diagnosed with complex CHD, parents of children with postnatally diagnosed CHD, and pregnant women and their partners with uncomplicated pregnancies were invited to participate. Data were collected during pregnancy and 2-6 months after delivery using the Hospital Anxiety and Depression Scale, sense of coherence, life satisfaction, and Dyadic Adjustment Scale.

RESULTS

During pregnancy, the prenatal group scored lower sense of coherence compared to controls (p=0.044). Postnatally the prenatal group scored lower on sense of coherence compared to the postnatal group and controls (p=0.001; p=0.001). Postnatally, the prenatal and postnatal groups had higher levels of anxiety compared to controls (p=0.025; p=0.0003). Life satisfaction was lower in the prenatal group compared to that in the postnatal group and in controls (p=0.000; p=0.0004).

CONCLUSION

Parents with a prenatal diagnosis of CHD in offspring report a low sense of coherence already during pregnancy which decreased further at follow-up. The same group reported a lower satisfaction with life compared to parents of a child with postnatal diagnosis of CHD and parents of a healthy child. This motivates further efforts to improve counselling and support during pregnancy and for parents after a prenatal diagnosis.

What's wrong with using the F word? A systematic integrative review of how the fetus is talked about in situations of fetal demise or high risk of fetal loss

BACKGROUND

Limited research exists that investigates the language parents and health professionals use when faced with a high-risk likelihood of fetal demise or an instance of fetal loss. This review examines the language used when referring to the 'fetus' in these cases to better understand the meaning different groups might ascribe to the fetus and how their word choice may reflect their strategies for managing in these situations.

METHODS

An integrative review of primary, peer-reviewed research was conducted. A systematic search of seven databases was undertaken, articles critiqued and summarised using the Preferred Reporting Items for Systemic Reviews and Meta-Analysis (PRISMA). The comprehensive process of data analysis and synthesis followed a constant comparison approach.

RESULTS

The 23 included studies represented the voices of women, their partners, obstetricians, nurses, midwives and allied health professionals. Five major themes emerged with the main finding being that the term 'Baby' is the most widely recognised word used in instances of fetal loss and high risk of fetal demise.

CONCLUSION

History, science and law all influence how the fetus is understood and discussed within society. This review contributes new insights into our understanding of the term 'fetus' emphasizing the need for further research into the way the fetus is addressed and dealt with in instances of fetal loss or high risk of fetal loss within Maternity care practices.

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.

'Hope you find your 'eureka' moment soon': a qualitative study of parents/carers' online discussions around allergy, allergy tests and eczema

OBJECTIVES

To explore understandings and concerns surrounding allergy, food intolerances and their potential impact on eczema among parents and carers of children with eczema who had posted messages in online forums.

METHODS

We conducted a scoping review for active UK-based discussion forums that did not require password/registration to view posts and identified two parenting discussion forums with high activity and frequent use. We used their internal search functions to identify and export discussion threads relating to allergy and allergy testing for eczema from 2011 to 2016. We carried out an inductive thematic analysis of the 120 exported discussion threads.

RESULTS

246 pages of text were analysed. Analysis led to three main themes: (1) confusion over the language surrounding 'allergy' and 'intolerance'; (2) diverse beliefs about allergy testing in relation to eczema and (3) parents' frustrations with perceptions of health professionals as uninterested and unhelpful about allergy testing. Forum users were concerned about immediate and delayed-type allergies but showed confusion in how terms were used, as well as different approaches to testing. Parents sought experiences of others, seeking social support as well as practical guidance.

CONCLUSIONS

The confusion around allergy-related terminology and its possible relationship with eczema means that it is essential healthcare professionals are able to signpost parents to accurate, accessible information. The lack of consistent information currently available means parents may use online discussion forums as an important source of information. This study suggests that the confused nature of discussions on these forums is inaccurate at best, and detrimental at worst.

Diagnosis of a severe congenital anomaly: A qualitative analysis of parental decision making and the implications for healthcare encounters

Objective

To explore parental decision making following diagnosis of a severe congenital anomaly, and implications for healthcare encounters.

Design

Qualitative semi‐structured interviews with 38 parents‐to‐be were collated and triangulated with data generated from consultation recordings.

Analysis

Data were analysed using a constant comparative‐based approach.

Setting

Recruitment was undertaken across four fetal medicine sites in two tertiary referral trusts.

Participants

Parents‐to‐be whose pregnancy was suspected or diagnosed as being affected by a severe congenital anomaly. This sample was purposive to include known factors affecting the decision to terminate or continue the affected pregnancy.

Findings

In trying to make a decision about how to proceed with their pregnancy, parents‐to‐be typically had to work hard to negotiate multiple uncertainties around the diagnosis and prognosis of the suspected anomaly. This was influenced by parents’ capacity to cope with uncertainty and the way in which uncertainty was managed by the clinical team. This negotiation of uncertainty was enacted within a fluid, nonlinear three‐phase process: “information seeking,” reflecting the way parents‐to‐be face the uncertainty associated with a fetal diagnosis and associated prognosis; “implications,” where consideration is given to future consequences of the decision; and “decision making,” which reflects the way in which the decision is made (head‐ or heart‐led). Spectrums of responses were apparent within each phase.

Conclusions

This study provides important insights into how parents‐to‐be make decisions following diagnosis or suspicion of a severe congenital anomaly. The impact of these on healthcare encounters is discussed, alongside recommendations for clinical practice.