Prenatal diagnosis: From policy to practice. Two distinct ways of managing prognostic uncertainty and anticipating disability in Brazil and in France

Prognosis of severe congenital heart diseases: Do we overestimate the impact of prenatal diagnosis?

BACKGROUND

Prenatal diagnosis of congenital heart disease (CHD) is controversial because of unclear benefits in terms of morbidity and mortality, and issues with healthcare costs and organization.

AIM

To compare, in children with severe CHD, 1-year morbidity and mortality between prenatal and postnatal diagnosis groups.

METHODS

All pregnancies and children aged<1 year with a diagnosis of severe CHD were collected over a 5-year period from our database. Severe CHDs were defined as lethal cases, cases leading to medical termination of pregnancy, or children requiring surgery and/or interventional catheterization and/or hospitalization during their first year of life. The primary endpoint was 1-year mortality rate among live births.

RESULTS

Overall, 322 cases of severe CHD were identified; 200 had a prenatal diagnosis and there were 97 terminations of pregnancy. Of the 225 live births, 34 died before the age of 1 year. The 1-year mortality rate was not significantly different between prenatal and postnatal groups (16.7% vs. 13.9%; p=0.13). In the prenatal group, prostaglandin use was more important and precocious, duration of hospitalization stay was longer, extracardiac complications were less common and cardiac surgery was performed more frequently and later. An association with chromosomal or syndromic anomalies was a risk factor for 1-year mortality.

CONCLUSIONS

Prenatal diagnosis of severe CHD had an impact on the decision regarding termination of pregnancy, but not on the 1-year prognosis among live births. We should now use large multicentre CHD registries to determine the impact of prenatal diagnosis on postnatal management, neurological prognosis and quality of life.

Coming to terms with the imperfectly normal child: attitudes of Israeli parents of screen-positive infants regarding subsequent prenatal diagnosis

This study examines the interface between newborn screening and prenatal diagnosis from the point-of-view of parents of screen-positive children. Many conditions covered by newborn screening represent classic (autosomal recessive) Mendelian disorders. Parents of screen-positive infants therefore often come to learn that they are carriers of the disease, and face a decision whether to test for it in future pregnancies. Semi-structured interviews were conducted in 2015-2017 with 34 Israeli parents whose child was screen positive. Three major themes emanated from the parents' attitudes toward prenatal testing for the disease in prospective hypothetical pregnancies: rejection of prenatal testing for the disease associated with the screen positive, and relying instead on newborn screening to reveal if a future baby is also sick (18/34, 53%); support of prenatal testing to get more information (7/34, 21%) and support of prenatal testing in order to abort in case of a test positive (9/34, 26%). We discuss the importance of newborn screening for reproductive decision-making, highlighting the arguments associated with positive and negative parental views of the possibility of having another child with the same condition associated with the screen-positive of the child that had already been born. The conclusions challenge the common assertion that parents pursue the dream of the "perfect child" through prenatal diagnosis that "naturally" leads to selective abortion. The diversity of views expressed by Israeli parents of screen-positive children highlights the diversity of normative scripts of "genetic responsibility" in the context of parenthood.

“Simply providing information”: Negotiating the ethical dilemmas of obstetric ultrasound, prenatal testing and selective termination of pregnancy

Obstetric ultrasound is key to opposing ways of valuing foetuses, that is, both to the ascription of foetal personhood and to foetal selection and termination of pregnancy. Whilst ultrasound images are increasingly common within the public sphere there has been relatively little public discussion of its role in identifying actual or potential foetal anomaly and the consequences of this. This paper examines how professionals working with obstetric ultrasound encounter, navigate and make sense of the different uses of this technology. Professionals commonly delineate their work (as providing information) from women’s autonomous choices. Emphasising “women’s choice” can obscure consideration of different collective ways of valuing foetuses with anomalies. It can also deflect consideration of the fundamentally ambiguous information that ultrasound can produce. Distinguishing information from choice is underpinned by a questionable fact–value distinction. We describe alternate professional practices which involve questioning these binaries and foregrounding clinicians’ responsibilities for women’s current and future experience. Public discussion of ultrasound’s different roles in valuing foetuses would be enriched if the discourses and practices shaping professionals’ attempts to facilitate ethical decision-making were included for collective consideration.