Presenting a routine screening test in antenatal care: practice observed

The anxiety caused by abnormal results of Down syndrome screening tests

The objective of our survey was to evaluate the anxiety experienced by women receiving abnormal results of prenatal Down syndrome screening by an electronic anonymous survey. Anxiety level was evaluated by a six-item Spielberger State-Trait Anxiety Inventory. Of 559 respondents, high anxiety scores were reported in the majority (86.0%). Higher anxiety scores were noted in women informed of the abnormal result by the caregiver vs. written answer. 59.1% of the respondents preferred the risk reported as percentage, while only 4.4% gave precedence to the current form (e.g. 1 in 100). The participants noted several factors which could relieve their anxiety, including an explanatory booklet (72.4%) or a website (77.9%). In conclusion, women receiving abnormal results of Down syndrome screening experience significant anxiety. Efforts should be made to relieve this distress, including changing the historical ratio risk format to percentage, adding a non-directive verbal annotation, an explanatory website and improving health professionals' understanding of the exact statistical meaning of the risk.Impact statementWhat is already known on this subject? Abnormal results of prenatal screening for Down syndrome might cause the women significant anxiety. Several simple methods are able to relieve this distress; however, they are frequently not implemented in the routine practice.What the results of this study add? We show that abnormal results of the screening tests are associated with high anxiety scores in the majority of women (86.0%). The majority of the respondents preferred the risk reported as percentage (vs. historical representation as a ratio). The participants noted several factors which could relieve their anxiety, including an explanatory booklet or a website.What the implications are of these findings for clinical practice and/or further research? Based on the results, we discuss the numerous ways able to available alleviate the distress.

Is routine prenatal screening and testing fundamentally incompatible with a commitment to reproductive choice? Learning from the historical context

An enduring ethical dispute accompanies prenatal screening and testing (PST) technologies. This ethical debate focuses on notions of reproductive choice. On one side of the dispute are those who have supported PST as a way to empower women's reproductive choice, while on the other side are those who argue that PST, particularly when made a routine part of prenatal care, limits deliberate choice. Empirical research does not resolve this ethical debate with evidence both of women for whom PST enhances their choices but also persistent evidence of recurrent problems between PST and women's autonomous decision-making. While there have been attempts to remove challenges to reproductive choice, it has been argued that these challenges cannot be removed entirely. In this paper I provide a historical review of PST technologies' development and in doing so provide a detailed insight into the root causes of this tension between the opposing sides of this debate. This historical account provides evidence that those who championed the early use of these technologies did so in order to achieve a number of wholly different goals other than women's choice and empowerment. These different aims focus on scientific discovery and eugenic goals and, I argue, are irreconcilable with women's choice and empowerment. It thus may not be surprising that the resulting practice of PST continues to resist compatibility with women's choice and empowerment. Ultimately, by understanding the historical foundations of PST we can more effectively assess how to reconcile women's reproductive autonomy with routine prenatal screening.

Safe discharge parameters for patients with isolated antenatal hydronephrosis

INTRODUCTION

Antenatal hydronephrosis is a steady source of urology referrals since the era of routine fetal ultrasonography. Although most resolve, there are no guidelines for follow-up.

OBJECTIVE

Our goal is to define safe parameters with which patients can be discharged early and avoid unnecessary follow-up.

METHODS

We retrospectively reviewed all patients referred to a single children's referral hospital center for isolated antenetal hydronephrosis between 2010 and 2012. We looked at patients and renal units separately and divided the cohort into two groups for comparison. Our analysis endpoint is progression. That is, if the initial postnatal anterior-posterior diameter (APD) is less than 10 mm, progression occurs if the APD increases to 10 mm or above upon follow-up. Conversely, if the initial APD is 10 mm or more in at least one renal unit, progression occurs if the APD remains at 10 mm or above upon follow-up.

RESULTS

There majority of the 186 patients and 308 renal units included in the analysis, were classified in the APD less than 10 mm group. Most renal units in the APD of less than 10 mm group were of SFU grades 0-2 (92.1%) and most of the renal units in the APD of 10 mm or greater group were of SFU grades 3-4 (60%) (Table). Only 19 renal units (6.2%) underwent pyeloplasty, and they were all from the APD of 10 mm or greater group and classified as SFU grade 3-4. No renal unit with an APD of less than 10 mm, nor any with an APD of 10 mm or greater and a SFU grade 0-2 underwent pyeloplasty. More than half of the renal units' hydronephrosis resolved in the APD of 10 mm or greater group, in comparison with 96.1% of the APD of less than 10 mm group. On multivariate analysis, patients with an APD of 10 mm or greater were 7.76 times more likely to show progression (p = 0.0006).

CONCLUSION

An initial postnatal APD of 10 mm or greater, with a SFU grade 3-4, merits follow-up. However, all patients with an APD of less than 10 mm, especially when with a SFU grade 1-2, can be safely discharged as they are unlikely to experience complications.

Key Ethical Issues in Prenatal Genetics: An Overview

The clinical integration of prenatal genetic technologies raises a series of important medical and ethical considerations for patients, families, health care providers, health care systems, and society. It is critical to recognize, understand, and address these issues in conjunction with the continued development of new prenatal genetic screens and tests. This article discusses some of the lead ethical issues as a starting point to further understanding their ramifications on patients, families, communities, and health care providers.

Down syndrome screening information in midwifery practices in the Netherlands: Strategies to integrate biomedical information

The aim of this qualitative study was to analyse counselling with regard to prenatal screening in midwifery consultations in the Netherlands where a national prenatal screening programme has only existed since 2007, after years of social and political debates. The methodology is based on in situ observations of 25 counselling consultations in four midwifery practices in two main cities in the Netherlands. The results of this study show that, since midwives are obliged to offer information on Down syndrome screening to all pregnant women (2007), they have to deal with the communication of medical screening information using biostatistical concepts to explain risks, calculations, probabilities and chromosomal anomalies. In order to avoid the risk of medicalization of their consultation, midwives develop strategies that allow them to integrate this new biomedical discourse while maintaining their low medicalized approach of midwife-led care. One of their main strategies is to switch from 'alarming' biomedical messages to 'reassuring words' in order to manage the anxiety induced by the information and to keep the control over their low medicalized consultation. They also tend to distance themselves from the obligation to talk about screening. The way midwives handle these counselling consultations allows them to respect their obligation to propose information, and to remain faithful to their struggle to protect the natural process of pregnancy as well as their professional autonomy.

Talking about disability in prenatal genetic counseling: a report of two interactive workshops

Women are commonly offered testing in pregnancy to determine the health of their baby. An important component of informed decision-making about prenatal testing is provision of relevant, accurate, meaningful information concerning the conditions that are being tested for--many of which, such as Down syndrome, are associated with a varying degree of physical and intellectual disability. A range of health professionals, including genetic counselors, may provide information and support throughout the testing process, but available data suggest that discussion of disability is frequently absent or limited. To investigate genetic counselors' perceptions of this situation and identify potential barriers to discussion we facilitated interactive workshops at the 2007 National Society of Genetic Counselors Annual Education Conference (NSGC) and the 2008 European Meeting on Psychosocial Aspects of Genetics (EMPAG). Working groups identified relevant psychosocial issues and impediments to discussion (NSGC) or used a two-part scenario to promote discussion (EMPAG) and reported findings in notes and a closing plenary discussion. Inductive content analysis revealed that participants considered informed decision making to be a major reason for presenting information about disabilities in prenatal genetic counseling and endorsed the value of including information about daily life with Down syndrome and other disabilities. However, they identified three broad types of impediments to such discussion: counseling issues concerning the most appropriate manner to discuss disability under the complex circumstances of prenatal genetic counseling, less than optimal training and experience in addressing these issues, and perceived limitations in the participants' knowledge and understanding of life with disability. Our analysis of the responses from the workshop participants and additional thoughts on these issues have led us to develop recommendations for further research, training and clinical practice.

Antenatal screening by history taking-a missed opportunity

In order to determine how effectively obstetricians and midwives identify and manage women at increased risk of fetal abnormality a case note review was undertaken. Two district general hospitals in each of two health regions and their tertiary referral centres making seven hospitals in all were studied. Women booked for antenatal care over a one-year period were included (19 895) which was estimated to be 75% of the total. Significant numbers of women at high risk because of age, past obstetric, medical or family history were not offered appropriate tests such as detailed scanning, carrier status testing, amniocentesis or chorion villus sampling. Asian women were less likely to be offered screening compared with Caucasians. Women at low risk were subjected to inappropriate tests such as amniocentesis. Ultrasound departments were rarely informed that a woman had had a previous baby with a structural abnormality. In conclusion the quality of booking histories was poor allowing important information about past medical, family or obstetric history to be overlooked. Maternity units should use carefully structured forms taking when booking histories and all staff must have regular training on risk factors.

The outcome of five years' implementation of maternal serum screening for Down's syndrome comparing actual age risks and mode of delivery

In this paper 13 613 triple test results from the period 1992- 1997 were analysed. The probability of receiving a high risk result for Down's syndrome from a serum screen, related to the patient's age, was calculated. The modes of delivery of the patients receiving a high risk result were also compared with the rest of the population. The probability of receiving a high risk result increased from 1.2% at 25 years of age to 43.9% at 40 years of age. There was a decrease in the likelihood of having operative intervention at delivery amongst the high risk group but this did not reach statistical significance. This highlights the need for accurate information in risk and probability when counselling a patient undergoing serum screening. Patient's anxiety relating to mode of delivery may also be alleviated by knowing they have no greater risk of operative delivery.

Assessment of the content and process of genetic counseling: a critical review of empirical studies

This article reviews studies that assessed the process and content of genetic counseling communication. A systematic search of the literature was undertaken of studies that audio- or videotaped genetic counseling sessions conducted by genetics health care providers and subjected them to communication analyses. A total of 18 studies (published in 34 articles) were identified that met the eligibility criteria. Studies show that providers speak more than clients, that a large proportion of communication is biomedical rather than psychosocial and that the teaching model of genetic counseling is widely implemented. Higher levels of counselor facilitation of understanding and empathic responses, lower levels of verbal dominance (ratio of counselor to client talk) and the provision of a summary letter of the consultation are associated with more positive client outcomes. Findings from these studies should be used as an evidence base for teaching and continuing education of genetic counseling providers.

'It's something for you both to think about': choice and decision making in nuchal translucency screening for Down's syndrome

Policies and practices around antenatal screening services have long been the subject of debate in a sociological context. However, existing research has largely overlooked the way in which the policies and practices that underpin antenatal screening services are enacted through talk between pregnant women and their health professionals. This paper focuses on one such policy, that of informed choice. It uses data from 14 tape-recorded pre-screening consultations with community midwives, forming part of a newly introduced nuchal translucency screening programme, to examine how the issue of choice is topicalised and discussed. It concludes that, whilst there is clear evidence that midwives are at pains to explicitly invoke the issue of decision making, there are other more subtle factors in the interactional presentation of screening tests that serve to undermine whether and how a recognition of choice is received by pregnant women.

Educational priorities and current involvement in genetic practice: a survey of midwives in the Netherlands, UK and Sweden

OBJECTIVE

to investigate whether practising midwives are adequately prepared to integrate genetic information into their practice.

DESIGN

a cross-sectional, postal, structured questionnaire survey was sent to practising midwives.

SETTING

practising midwives from the Netherlands (NL), Sweden (SE) and the United Kingdom (UK).

PARTICIPANTS

1021 replies were received, achieving a response rate of 62%.

FINDINGS

79% (799/1015) of midwives reported attending courses with some 'genetic content' during their initial training. Sixty-eight per cent (533/784) judged this to have been useful for clinical practice. Variation was seen between countries in the amount of genetic content in post-registration training (SE 87%, NL 44%, UK 17%) and most was considered useful. Questions assessing clinical activity identified a current need for genetic knowledge. Midwives described low levels of self-reported confidence both in overtly genetic procedures and in everyday tasks that were underpinned by genetic knowledge. For eight of the 12 procedures, fewer than 20% of midwives considered themselves to be confident. Differences were apparent between countries. Midwives identified psychosocial, screening and risk assessment aspects of genetic education as being important to them, rather than technical aspects or genetic science.

CONCLUSIONS

given the low reported confidence with genetic issues in clinical practice, it is essential that this is addressed in terms of the amount, content and targeting of genetic education. This is especially important to ensure the success of national antenatal and baby screening programmes. The results of this study suggest that midwives would welcome further training in genetics, addressing genetic topics most relevant to their clinical practice.

Does labeling prenatal screening test results as negative or positive affect a woman's responses?

OBJECTIVE

We tested whether adding interpretive labels (eg, "negative test") to prenatal genetic screening test results changes perceived risk and preferences for amniocentesis.

STUDY DESIGN

Women (N = 1688) completed a hypothetical pregnancy scenario on the Internet. We randomly assigned participants into 2 groups: high risk of fetal chromosomal problems (12.5/1000) or low risk (2/1000). After prenatal screening, estimated risk was identical (5/1000) for all participants, but results were provided either alone or with interpretive labels.

RESULTS

When receiving test results without labels, all participants react similarly. With labels, the participants who received "positive" or "abnormal" results reported a higher perceived risk (P < .001), greater worry (P < .001), and greater interest in amniocentesis (57% vs 37%; P < .001) than did the participants who received "negative" or "normal" results.

CONCLUSION

Interpretive labels for test results can induce larger changes to a woman's risk perception and behavioral intention than can numeric results alone, which create decision momentum. This finding has broad clinical implications for patient-provider communication.

Different perceptions and attitudes regarding prenatal testing among service providers and consumers in Israel

INTRODUCTION

The increasing number of prenatal tests for fetal abnormalities calls for a prenatal care policy which will reflect not only medical values, but also the needs and attitudes of the services' consumers.

OBJECTIVES

To compare attitudes of prenatal service consumers and providers regarding extent of prenatal testing and to evaluate these attitudes in relation to sociodemographic and professional characteristics.

METHODS

Women were interviewed by phone 5-8 weeks postpartum (n = 596) using a structured questionnaire. Health professionals (n = 351) completed a parallel questionnaire.

RESULTS

Health professionals were significantly more supportive of comprehensive prenatal testing than women (61.1 vs. 34.1%, respectively). In a multivariable analysis, age over 35, Ashkenazi origin and being better informed regarding tests, predicted a preference for comprehensive testing among women. Among health professionals, predictors of that attitude were secularism and a paramedical profession.

CONCLUSIONS

Providers and consumers of prenatal services differ in their perceptions and opinions. Policy makers should have mechanisms in place to properly represent this diversity.

Prenatal screening and diagnosis of congenital toxoplasmosis: a review of safety issues and psychological consequences for women who undergo screening

As part of the EUROTOXO initiative, this review focuses on the potential risks associated with prenatal testing for congenital toxoplasmosis. We first review the evidence on the risks of adverse events associated with amniocentesis, which is required for definitive diagnosis of toxoplasmosis infection in the fetus, and for which the most important risk is fetal loss. To date, there has been only one randomized trial to document risks associated with amniocentesis. This trial, which was conducted in 1986, reported a procedure-related rate of fetal loss of 1.0% (95% CI, 0.3-1.5). However, evidence from available controlled studies suggests that the pregnancy loss associated with mid-trimester amniocentesis may be lower. Potential psychological consequences of prenatal testing for congenital toxoplasmosis include parental anxiety due to false positive results and uncertainties related to prognosis of children with a prenatal diagnosis of congenital toxoplasmosis. Parental anxiety may be particularly important in screening strategies that include more frequent screenings, which may in turn entail substantial, and at times unnecessary, anxiety or other negative consequences for women and their families. These negative psychological outcomes should be balanced against the benefits of testing, which can allow women to make an informed choice regarding the pregnancy.

Are pregnant Australian women well informed about prenatal genetic screening? A systematic investigation using the Multidimensional Measure of Informed Choice

BACKGROUND

Ethical practice requires that decisions to participate in medical care be well informed. Investigations into prenatal genetic screening for Down syndrome have assessed women's knowledge but have not examined whether being well informed about the potential consequences of screening, such as subsequent diagnostic testing, diagnosis and termination, is associated with psychological distress for women.

AIMS

To assess informed choice to participate in second trimester maternal serum screening (2MSS) in pregnant women using a validated measure and to compare anxiety levels in women who were well informed versus poorly informed.

METHODS

A prospective cohort study where pregnant women completed the Multidimensional Measure of Informed Choice and the Hospital Anxiety and Depression Scale immediately prior to the offer of 2MSS. Follow-up questionnaires assessing psychological symptomatology were completed at 20 and 30 weeks gestation.

RESULTS

Only 37% of decisions were informed; those who participated in screening were more likely to have made an informed decision than those who did not (P = 0.01); 31% did not know that miscarriage was a possible consequence of diagnostic testing subsequent to an increased risk screening result and only 62% correctly identified that termination of pregnancy would be offered if Down syndrome were to be diagnosed. Short-term anxiety levels in those who were well informed were not significantly different from those who were poorly informed (P = 0.14).

CONCLUSIONS

Health promotion strategies, which are readily applicable in clinical settings and address diverse learning needs and attitudes of pregnant women, are needed. The impact of antenatal screening on other dimensions of pregnancy psychology remains to be investigated.

From a genetic innovation to mass health programmes: the diffusion of Down's Syndrome prenatal screening and diagnostic techniques in France

Down's Syndrome prenatal diagnostic and screening techniques have spread widely in France over the last 30 years and are now part of the routine clinical practice of prenatal care. These techniques, which originated in the field of genetics, ultrasonography and biochemistry, were the first to provide the possibility of choosing the features of the foetus, or at least to reject some of its characteristics. They lead to new norms of healthy foetuses and a progressive acceptance of medical abortions. The aim of this paper is to understand how the use of these tests has been generalised in France despite scientific controversies about their risks and ethical questioning about a potential renewal of eugenics. It analyses the representations of public needs that have been articulated by key players in the scientific and medical fields. This research explores political and administrative decision making processes to understand how progressively widening public access to prenatal testing has been organised and funded. The results highlight the scientific and political role of biomedical researchers, the forms of involvement of health authorities and politicians, and the passive participation of the vast majority of the users. The paper also examines the characteristics of the French health system that facilitated the generalised use of the technology.

Genetics education in the nursing profession: literature review

AIM

This paper reports a literature review exploring genetics education for nursing professionals. The aim was to contribute to the debate about the future direction of such education.

BACKGROUND

Advances in genetics science and technology have profound implications for health care and the growing importance and relevance of genetics for everyday nursing practice is increasingly recognized.

METHOD

A search was conducted in February 2005 using the CINAHL and Google Scholar databases and the keywords nurse, midwife, health visitor, education and genetics. Papers were included if they were published in English between 1994 and 2005 and included empirical data about genetics education in nursing. In addition, attempts were made to access the grey literature, with requests for information on research, for example, to members of the Association of Genetic Nurses and Counsellors and searches of relevant websites.

FINDINGS

Agreement on the relevance of genetics for nursing practice is extensive. Empirical evidence of the learning needs of practitioners highlights widespread deficits in knowledge and skills, and low confidence levels. Provision of nursing education in genetics is patchy and insubstantial across a number of countries, further hampered by lack of strategic development. Significant progress has been made in the identification of learning outcomes for nurses. Research on the delivery of genetics education is limited, but the role of skills-based training, use of clinical scenarios, and importance of assessment have all been identified as factors that can promote learning.

CONCLUSION

Whilst areas of good performance were revealed, many studies identified gaps in professional competence and/or education. New initiatives are underway to support genetics education and its integration into professional practice, but further research is needed on the most effective forms of educational delivery, and an international collaborative approach to this should be considered.

Distress associated with prenatal screening for fetal abnormality

A theoretically-based, multivariate approach was used to identify factors associated with emotional distress for pregnant women undergoing maternal serum alpha fetoprotein (MSAFP or AFP) testing, used to detect abnormalities of the fetal brain and spinal cord. Participants were those who received normal results (N = 87). Study results supported the hypothesis that different factors would predict distress before and after testing. Satisfaction with information about testing predicted lower emotional distress early in the testing process; concerns about the child having other medical conditions and low-dispositional optimism predicted distress later. Study findings indicate that even in women who receive normal test results, AFP testing is associated with a modest degree of emotional disturbance which declines, but does not completely abate, after testing.

How prenatal diagnosis became acceptable in France

Since the 1960s, prenatal diagnosis techniques have been developed in industrialized countries. There is no therapeutic treatment for most of the diagnosed foetuses and the only solution medicine can offer is abortion; therefore, the techniques might seem controversial. Here, I aim to explore why some prenatal diagnosis and screening techniques are widely used when pregnant women are often ambivalent about them. This article draws on previous sociological work, accounts of health practitioners and a case study of the diffusion of Down's Syndrome prenatal diagnosis in France. It argues that numerous factors, other than the demand of the users, can contribute to speed up the diffusion of a technique.

Termination of pregnancy: attitudes and behavior of women in a traditional society

OBJECTIVES

The Bedouin Arabs, a Muslim traditional ethnic minority in Israel, are faced with difficult choices when offered prenatal diagnosis as part of the universally provided prenatal care in Israel. This paper is to examine attitudes towards and practice of pregnancy termination, following an unfavorable prenatal diagnosis.

METHODS

Semistructured interviews with 83 women were conducted to study attitudes. Data from the Soroka Medical Center, where all births in the area take place, were used to assess the rate of terminations of pregnancies following a diagnosis of a chromosomal anomaly.

RESULTS

While divided on the question of termination, many women believed that a second medical opinion is needed, preferably from an Arab physician. The reasons for termination are both child- and mother-related. Opposing termination is based on both the suspicion that the diagnosis might be wrong and on religious reasons. Between 1995 and 1999, 686 Bedouin women had undergone amniocentesis (2.4% of all pregnancies). Six of 11 pregnancies with the diagnosis of a trisomy were terminated (54.5%). All cases in which a trisomy was terminated were trisomy 21.

CONCLUSIONS

Culturally acceptable prenatal diagnostic services for Muslim populations should be based on early testing, and should involve Muslim physicians and religious authorities.

Differences in Individual Approaches: Communication in the Familial Breast Cancer Consultation and the Effect on Patient Outcomes

This multicenter study aimed to assess (i) whether individual clinical geneticists and genetic counselors vary in their communication skills and (ii) whether this variation in communication impacts on patient outcomes, such as anxiety, depression, genetics knowledge, and satisfaction. One hundred and fifty women from high-risk breast cancer families attending their first genetic counseling consultation completed pre and post-consultation self-report questionnaires. The consultations were audiotaped and transcribed verbatim. Univariate analyses showed highly significant differences between individual clinical geneticists and genetic counselors in: facilitating understanding (p < or = 0.001); facilitating active involvement (p < or = 0.001); facilitating partnership building (p = 0.003); addressing emotional concerns (p < or = 0.001); and discussing prophylactic mastectomy (p = 0.017). Multivariate linear regressions showed that this variation in communication resulted in a greater change in patient's depression 4 weeks after the counseling session (p = 0.017). These findings suggest clinical geneticists and genetic counselors have achieved some standardization in communicating information, but showed diversity in their facilitation skills. Communication skills may be a useful area to explore further in this field.

Presenting and discussing nuchal translucency screening for fetal abnormality in the UK

OBJECTIVE

to investigate the relationship between information giving by midwives and decision-making by women offered nuchal translucency (NT) screening. To establish how risk figures are discussed in practice, with the intention of relating this to the existing, and often critical, literature on women's accounts of antenatal screening.

DESIGN

a qualitative study following women through the process of being offered and deciding to undergo NT screening. Tape recording of consultations, analysed in their entirety, was combined with post-screening interviews.

SETTING

a large teaching hospital in the UK.

PARTICIPANTS

fourteen pregnant women eligible for NT screening at the time of recruitment.

DATA COLLECTION

(i) tape recordings of consultations between community midwives and pregnant women where nuchal translucency screening was offered; (ii) tape recordings of consultations between hospital midwives and pregnant women immediately post-screening; (iii) individual face-to-face interviews with pregnant women between two and six weeks after the screening, carried out by the first author.

FINDINGS

NT screening was in general well received, particularly by those women who had undergone serum screening with previous pregnancies. However, communicating the nature of a risk figure is an interactionally complex process. A large amount of interactional work is required by midwives both before and after screening to ensure that women comprehend this information. Despite the emphasis placed in these consultations on understanding the purpose of NT screening and the status of the results, women often framed their decision to undergo NT screening in terms of it being a formality, or of presuming that all was well. This sometimes created practical and personal difficulties in terms of decision-making.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

previous sociological and psychological research has tended to be critical of midwives in terms of ensuring informed choice in screening, but this research is often based on post hoc accounts. Examining actual consultations with these accounts helps to illustrate the other factors that affect women's perceptions of testing, and the way in which risk, choice and decision-making are introduced and discussed in practice. Encouraging women to consider what action they might take on the basis of a personally unfavourable NT result in advance of undergoing the scan may help them to decide whether the information gained will be useful to them. Recognising the complex interactional work required in making sure that women understand the nature of the results that will be obtained is an important issue for the education and training of midwives.

Ethnicity and the politics of the new genetics: principles and engagement

Identifying the genetic basis of disease is not a straightforward medical procedure but implicates the broader social, cultural and political context. Ethnicity represents an important part of this context, particularly given the confused and poorly informed debate about genetic differences among supposedly different 'racial' populations. Debates about the 'new genetics', however, have not engaged fully with the issue of ethnicity and racism. This paper, by reviewing a mix of empirical and theoretical debates, explores the discursive practices that inform current thinking on genetics, ethnicity and race. The account begins by exploring some of the philosophical tensions inherent in providing genetic testing. In doing so, the paper argues that current debates about genetics are not neutral but evoke a specific set of received ideas and codes of intervention, embodying social and power relationships. The paper then broadens the discussion by exploring the general meaning of screening and counselling for the 'lay' population, before focusing on the process of providing information and identifying people as carriers. The paper concludes by suggesting that the social space in which the 'new genetics' is enacted, understood and given meaning raises generic concerns, irrespective of ethnicity. These include the potential tension between prevention and informed decision making, whereby ideas about empowering individuals to exercise choice exist alongside a more general societal concern with minimising impairment and illness. In more practical terms, individual choice is compromised by poor-quality care, inadequate information, insensitivity to an individual's worries and concerns and a more general failure to meet his or her needs. At the same time, however, the often racialised perspectives articulated through the activities of service professionals can further complicate the choices and decisions available to minority ethnic populations. The failure to recognise and respond to diversity; blaming minority ethnic populations for their health problems; and the pervasiveness of racist myths and stereotypes in service provision, serve to disadvantage minority ethnic populations. This explains why themes such as equity and access, political engagement as well as more general notions of deservingness based on the construction of citizenship and identity emerge as fundamental in making sense of the relationship between ethnicity and the politics of the 'new genetics'.

Ethics and practice: two worlds? The example of genetic counselling

The aim of this paper is to work out the relationship between ethics and practice with reference to genetic counselling. First, the most important principles with respect to genetic counselling and to counsellor-client-interaction, are explained briefly. Then, we discuss what these principles might mean, when applied to the practice of counselling. To do so, we also look at some empirical data. Finally, we draw some conclusions.

Women's decision-making about their health care: views over the life cycle

This paper describes a compilation and further analysis of three qualitative studies, conducted independently, on women's health care decisions. Key areas regarding women's health, which span the life cycle, were examined including prenatal genetic screening, hormone replacement therapy and the use of complementary/alternative medicine in the treatment of breast cancer. Common themes were evident across all the focus groups in each of the three studies including: women's information seeking behavior; reliance on trusted information sources; the desire for information sharing; active involvement in the decision-making process; and accepting the consequences of the final decision. The findings have important implications for health care professionals as they engage women in the decision-making process about health concerns.

The voices and concerns about prenatal testing of Cambodian, Lao and Vietnamese women in Australia

OBJECTIVES

to examine how Cambodian, Lao and Vietnamese women experience prenatal testing and to examine their knowledge and communication with health-care providers.

SETTING

Melbourne Metropolitan Area, Victoria, Australia.

DESIGN

an ethnographic study of childbearing and childrearing among women born in South-east Asia and now living in Melbourne, Australia reporting in-depth interviews with 67 women who had given birth in Australia.

FINDINGS

nearly all the women had prenatal testing as advised by their doctors and their main concerns were about their unborn baby and the need to follow doctors' advice. The women felt 'indifferent' towards prenatal testing, perceiving it as a normal part of antenatal care in Australia. Despite agreeing to undertake prenatal testing, the women did not have adequate understanding of the tests. This may be due to lack of information per se or inadequate communication between health providers and women.

IMPLICATIONS FOR PRACTICE

inevitably, the onus rests with the health-care provider to ensure that all options available to women are understood, so that women can make a positive and informed choice regardless of their social or cultural background. This will lead to women's increased satisfaction with care during pregnancy.

Interpreting information: what is said, what is heard--a questionnaire study of health professionals and members of the public

OBJECTIVE

To investigate how people perceive some of the words and phrases commonly used in prenatal diagnosis counselling.

METHODS

A questionnaire containing 25 questions with forced choice answers was administered in the form of a lecture. Respondents were asked to report how worrying they would find different ways of being told about hypothetical anomalies or risks of anomalies in their baby. 581 questionnaires were completed by 372 health professionals and 209 members of the public. The sample was obtained opportunistically. The exact number of non-responders is not known but is estimated to be less than 5%.

RESULTS

Respondents reported being particularly worried by the use of genetic jargon and use of the following words: rare, abnormal, syndrome, disorder, anomaly and high risk. They found risk expressed as 1 in X more worrying than when it was expressed as a percentage, and they consistently reacted as if they estimated the chance of an undesired outcome occurring to be greater than that of a desired outcome occurring when both events were equally likely.

CONCLUSIONS

The choice of words used to describe a condition or to inform someone about the level of risk of an adverse event occurring may significantly affect how the person perceives that condition or risk.

Ethical decision-making in prenatal diagnosis and termination of pregnancy: a qualitative survey among physicians and midwives

OBJECTIVES

This study was aimed at exploring the conflicts and ethical problems experienced by professionals involved in prenatal diagnosis and termination of pregnancy (TOP) in order to improve the understanding of decision-making processes and medical practices in the field of prenatal diagnosis.

METHODS

Qualitative study with in-depth tape-recorded interviews conducted in three tertiary care maternity units in France, between May 1999 and March 2000. All full-time obstetricians and half of the full-time midwives were contacted. Seventeen obstetricians and 30 midwives participated (three refusals, five missing). Interviews were transcribed and analysed successively by two different researchers.

RESULTS

All respondents stated that prenatal diagnosis and TOP raised important ethical dilemmas, the most frequent being request for abortion in case of minor anomalies. They pointed out the inability of our society to appropriately care for disabled children and the risk of eugenic pressures. The decisions and practices in prenatal diagnosis should be debated throughout society. All respondents reported that their unit did not have protocols for deciding when a TOP was justifiable. The transmission of information to the women appeared to be a problematic area. Moral conflicts and emotional distress were frequently expressed, especially by midwives who mentioned the need for more discussions and support groups in their department.

CONCLUSION

Health professionals involved in prenatal diagnosis face complex ethical dilemmas which raise important personal conflicts. A need for more resources for counselling women and for open debate about the consequences of the current practices clearly emerged.

Women's knowledge of prenatal ultrasound and informed choice

This study evaluated women's understanding of prenatal ultrasound in terms of meeting the requirements for informed choice. A cross-sectional survey was conducted to evaluate (1) how information is provided, (2) women's perceived value of the information received and, (3) their understanding of ultrasound in relation to the principles of informed choice. Women (n=113) completed a questionnaire prior to their 18-week ultrasound. Fifty-five percent stated they received no information from their care provider. Only 31.9% considered health care providers as a "very helpful" source of information. Yet, 69.0% stated their care provider gave them information that facilitated their understanding. Gaps were identified in women's understanding of ultrasound. Specifically, 46.0% did not view ultrasound as a screen for anomalies; some were uncertain about their safety (18.6%), diagnostic capabilities (26.5%), and limitations of testing (37.2%). These results suggest that women's understanding of ultrasound does not meet the requirements of informed choice.

Facilitating informed choice in prenatal testing: how well are we doing?

There is a consensus that prenatal testing services need to provide the information and support necessary for women to make informed choices about prenatal testing. Informed choices are those based on relevant information that reflect the decision-maker's values. To date, most research has focused on the information provided to women deciding whether to undergo tests. This has highlighted the poor quality of information provided to many women. There is agreement on the need to provide information on three key aspects of any test: the condition for which testing is being offered, characteristics of the test, and the implications of testing. Very little research has been conducted on decisions after the diagnosis of a fetal abnormality and how information and emotional and decisional support are and should be provided. Research is now needed in four key areas: first, on the optimal ways of organizing services to facilitate choices that are not only based on relevant information, but also reflect the decision-maker's values; second, on the most effective ways of framing information needed for the different decisions involved in prenatal testing; third, on the most effective media in which to deliver information; and, fourth, to identify aspects of counseling that facilitate informed choices following diagnoses of fetal abnormality. If we value women's ability to make informed choices about prenatal tests as highly as we value reliable laboratory tests, evidence-based quality standards need to be developed for the information and support women are given at all stages of the process of prenatal testing.

Decisions about amniocentesis by advanced maternal age patients following maternal serum screening may not always correlate clinically with screening results: need for improvement in informed consent process

We evaluated the prenatal diagnosis utilization patterns of advanced maternal age (AMA) patients who underwent serum screening to assess how screening results correlated with their decisions regarding amniocentesis. A 6-year review (1994-1999) of laboratory records identified 2,456 AMA patients who underwent multiple-marker serum screening. The relationship between screening results and patients' decisions on whether or not to undergo amniocentesis was assessed. Among the 841 AMA patients with positive screens, more than half (52%) declined amniocentesis. Of the 1,615 patients with negative serum screening results, 208 (13%) opted for amniocentesis. We concluded that decisions by AMA patients regarding amniocentesis may not always correlate clinically with maternal serum screening results. Possible explanations, including how the state of informed consent may or may not contribute to these decisions, are discussed. It is suggested that understanding the reasons for these decisions may identify opportunities for improving service delivery to all pregnant patients considering prenatal testing. Use of a questionnaire is proposed as one mechanism for gaining a clearer understanding of the possible factors contributing to AMA patient decisions.

[Maternal anxiety induced by prenatal diagnostic techniques: detection and management]

Recent improvement in the screening for chromosomal defects, in particular the widespread use of ultrasonography and maternal biochemistry, is leading to a high number of fetal invasive tests (amniocentesis or chorion villus sampling). An increased level of anxiety in the pregnant women, which may sometimes continue until the postnatal period, is believed to be due to these prenatal diagnosis procedures. Maternal anxiety originates in the doubts related to fetal integrity and pregnancy outcome after information of a positive biochemical screening or visualisation of an ultrasound marker of chromosomal abnormality. Each specialist involved in prenatal care should take special attention to this, because of at least two reasons. First, anxiety may reduce maternal well being during pregnancy. Second, because it could have deleterious effects on parent to infant relationships. Without any intention of lowering the positive aspects of prenatal diagnosis, it appears essential to consider the negative effects anxiety may have on both parents. From our own experience and the conclusion of previous reported studies, we suggest some measures to reduce the level of maternal anxiety related to prenatal diagnosis: (i) improvement in the quality and transparency of information offered to pregnant women; (ii) training and involvement in psychological and emotional care for each member in the medical team; (iii) special and systematic psychological care for the "high risk" pregnant women regarding anxious disorders.

Participation in maternal serum screening for Down syndrome, neural tube defects, and trisomy 18 following screen-positive results in a previous pregnancy

OBJECTIVE

To determine whether women who have had a positive serum screening result for Down syndrome or neural tube defect in 1 pregnancy have a lower rate of participation in screening in their next pregnancy.

SETTING

A triple-marker screening program at a university hospital.

METHODS

Pregnancy and screening information was collected from laboratory and hospital databases to compare subsequent screening participation of women who were screen-negative and screen-positive for the risk of a fetus with Down syndrome or a neural tube defect.

RESULTS

In an age-matched comparison, 108 women who had a previous screen-positive result were significantly less likely than 108 women who were screen-negative to participate in maternal serum screening in their next pregnancy. When examined according to the type of screen-positive result, the effect was significant for both those who were screen-positive for Down syndrome and those who were screen-positive for neural tube defect. The degree of risk in screen-positive women did not significantly affect their participation in screening in the next pregnancy.

CONCLUSIONS

Anxiety related to a screen-positive result probably causes decreased participation in maternal serum screening in the next pregnancy. Reducing the screen-positive rate in prenatal serum screening would alleviate maternal anxiety and would probably lead to more stable participation.

Randomised controlled trial comparing effectiveness of touch screen system with leaflet for providing women with information on prenatal tests

OBJECTIVE

To compare the effectiveness of touch screen system with information leaflet for providing women with information on prenatal tests.

DESIGN

Randomised controlled trial; participants allocated to intervention group (given access to touch screen and leaflet information) or control group (leaflet information only).

SETTING

Antenatal clinic in university teaching hospital.

SUBJECTS

875 women booking antenatal care.

INTERVENTIONS

All participants received a leaflet providing information on prenatal tests. Women in the intervention arm also had access to touch screen information system in antenatal clinic.

MAIN OUTCOME MEASURES

Women's informed decision making on prenatal testing as measured by their uptake of and understanding of the purpose of specific tests; their satisfaction with information provided; and their levels of anxiety.

RESULTS

All women in the trial had a good baseline knowledge of prenatal tests. Women in the intervention group did not show any greater understanding of the purpose of the tests than control women. However, uptake of detailed anomaly scans was significantly higher in intervention group than the control group (94% (351/375) v 87% (310/358), P=0.0014). Levels of anxiety among nulliparous women in intervention group declined significantly over time (P<0.001).

CONCLUSIONS

The touch screen seemed to convey no benefit over well prepared leaflets in improving understanding of prenatal tests among the pregnant women. It did, however, seem to reduce levels of anxiety and may be most effective for providing information to selected women who have a relevant adverse history or abnormal results from tests in their current pregnancy.

Antenatal minimal hydronephrosis: is its follow-up an unnecessary cause of concern?

The aim of this study was to determine if follow-up of antenatally diagnosed minimal hydronephrosis (anteroposterior renal pelvis diameter <10 mm) is justified or if it is an unnecessary cause of concern for the parents involved. A case-control study, with subjects and controls selected from the Wessex Antenatally Detected Anomalies Register was performed. Information regarding antenatal and postnatal follow-up, renal tract morbidity and degree of concern was obtained from a parental questionnaire. 70 of the 115 subjects contacted (60.9 per cent) and 52 of the 81 controls (64.2 per cent) returned the questionnaire. 65 of the 70 subjects (92.9 per cent) were rescanned postnatally when 28 cases (43.1 per cent) had resolved. Coexisting ureteric and/or calyceal dilatation was evident postnatally in 12 cases and this group was significantly more likely to have underlying pathology than the group with isolated renal pelvis dilatation. Subjects were significantly more likely than controls to have a UTI. The degree of concern was significantly greater in the subject group and subject parents thought about the result significantly more often than controls. From our results we concluded that the follow-up of minimal hydronephrosis can be modified. There is no need for repeated antenatal scanning, a change that could reduce the level of parental anxiety. Postnatal follow-up is required in all patients to exclude an underlying uropathy but again this can be modified, with the majority of patients requiring only an ultrasound scan. This reduced intensity of investigation accompanied with careful explanation to the parents should help to minimize their concerns.

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

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

Prenatal screening for Down syndrome: a dilemma for the unsupported midwife?

OBJECTIVE

To explore the personal and professional concerns of midwives in relation to their experiences with women undergoing serum screening for Down syndrome.

DESIGN

Semi-structured interviews.

SETTING

A consultant-led maternity unit in the south of England.

PARTICIPANTS

Ten midwives based in areas which most commonly support women undergoing this test.

METHODS

Interviews were recorded and transcribed and a grounded theory approach involving coding was used to identify categories which were analysed.

FINDINGS

Themes identified were: education needs on introduction of the test and in relation to current research about the test; strategies for explaining the concept of 'risk'; personal and professional conflict in relation to the dilemmas raised.

KEY CONCLUSIONS

Accurate information (including psychosocial aspects) should be available to midwives prior to the introduction of potentially complex investigations. Continuing education should prepare midwives to meet the challenges related to prenatal screening for Down syndrome. Some strategies which could be considered include the use of reflection sheets, prompt cards and case studies or vignettes. Interprofessional education could provide the opportunity to increase understanding of individual roles and the conflicts experienced.

Screening and counselling for sickle cell disorders and thalassaemia: the experience of parents and health professionals

Shortfalls in haemoglobinopathy provision result in patients and their carers receiving inadequate support. This paper, by drawing on material from a project evaluating service provision to families caring for a child with a sickle cell disorder or thalassaemia, discusses screening and counselling services. It explores the perspectives of parents, front-line practitioners, managers and health commissioners. Poor quality care, inadequate information and professionals' insensitivity were salient themes in parental accounts. The parents' experience also confirms the problems faced by minority ethnic people in having their welfare needs recognised, more generally. Although our focus in on genetic conditions affecting minority communities in the UK, the issues we address are at the heart of the 'new genetics'.

Women's decision-making in prenatal screening

With serum screening (MS-AFP and hCG testing for Down's syndrome) women have to make several decisions in a limited time: whether to participate in the screening in the first place; then, if increased risk for fetal abnormality is detected, whether to have a diagnostic test, and finally, what to do if fetal abnormality is detected. The aim of this study was to examine how women themselves in an unselected population describe their decision-making in the different phases of serum screening. Women receiving a positive result from serum screening in two Finnish towns from September 1993 to March 1994 and a group of individually matched controls were invited to semistructured interviews; 45 index and 46 control women (79% of those invited) participated between their 29th and 37th weeks of gestation (mean 31 weeks). Although serum screening was most often presented as voluntary or as an option, half the women described participation as a routine or self-evident act; only one-fourth of the women described actively deciding about participation. After a positive screening result, women's reactions to diagnostic tests, and their intentions if disability would be detected, varied greatly. Most of the women actively decided about having diagnostic tests, but for 23% participation in diagnostic testing was called a self-evident act. Women's intentions regarding abortion varied from a firm decision to abort to a firm decision not to abort, and many remained ambivalent. Prenatal screening, which demands the making of several decisions in a limited time and is offered to all pregnant women as part of established maternity care, is not based on every participant's active decision-making and thus creates an ethical problem. This problem should receive special attention from those who develop, introduce and decide on new health care practices.

Antenatal screening for Down's syndrome

BACKGROUND

In 1968 the first antenatal diagnosis of Down's syndrome was made and screening on the basis of selecting women of advanced maternal age for amniocentesis was gradually introduced into medical practice. In 1983 it was shown that low maternal serum alpha fetoprotein (AFP) was associated with Down's syndrome. Later, raised maternal serum human chorionic gonadotrophin (hCG), and low unconjugated oestriol (uE3) were found to be markers of Down's syndrome. In 1988 the three biochemical markers were used together with maternal age as a method of screening, and this has been widely adopted. PRINCIPLES OF ANTENATAL SCREENING FOR DOWN'S SYNDROME: Methods of screening need to be fully evaluated before being introduced into routine clinical practice. This included choosing markers for which there is sufficient scientific evidence of efficacy, quantifying performance in terms of detection and false positive rates, and establishing methods of monitoring performance. Screening needs to be provided as an integrated service, coordinating and managing the separate aspects of the screening process. SERUM MARKERS AT 15-22 WEEKS OF PREGNANCY: A large number of serum markers have been found to be associated with Down's syndrome between 15 and 22 weeks of pregnancy. The principal markers are AFP, hCG or its individual subunits (free alpha- and free beta-hCG), uE3, and inhibin A. Screening performance varies according to the choice of markers used and whether ultrasound is used to estimate gestational age (table 1). When an ultrasound scan is used to estimate gestational age the detection rate for a 5% false positive rate is estimated to be 59% using the double test (AFP and hCG), 69% using the triple test (AFP, hCG, uE3), and 76% using the quadruple test (AFP, hCG, uE3, inhibin A), all in combination with maternal age. Other factors that can usefully be taken into account in screening are maternal weight, the presence of insulin dependent diabetes mellitus, multiple pregnancy, ethnic origin, previous Down's syndrome pregnancy, and whether the test is the first one in a pregnancy or a repeat. Factors such as parity and smoking are associated with one or more of the serum markers, but the effect is too small to justify adjusting for these factors in interpreting a screening test.

URINARY MARKERS AND FETAL CELLS IN MATERNAL BLOOD

Urinary beta-core hCG has been investigated in a number of studies and shown to be raised in pregnancies with Down's syndrome. This area is currently the subject of active research and the use of urine in future screening programmes may be a practical possibility. Other urinary markers, such as total oestriol and free beta-hCG may also be of value. Fetal cells can be identified in the maternal circulation and techniques such as fluorescent in situ hybridisation can be used to identify aneuploidies, including Down's syndrome and trisomy 18. This approach may, in the future, be of value in screening or diagnosis. Currently, the techniques available do not have the performance, simplicity, or economy needed to replace existing methods.

DEMONSTRATION PROJECTS

Demonstration projects are valuable in determining the feasibility of screening and in refining the practical application of screening. They are of less value in determining the performance of different screening methods. Several demonstration projects have been conducted using the triple and double tests. In general, the uptake of screening was about 80%. The screen positive rates were about 5-6%. About 80% of women with positive screening results had an invasive diagnostic test, and of those found to have a pregnancy with Down's syndrome, about 90% chose to have a termination of pregnancy. ULTRASOUND MARKERS AT 15-22 WEEKS OF PREGNANCY: There are a number of ultrasound markers of Down's syndrome at 15-22 weeks, including nuchal fold thickness, cardiac abnormalities, duodenal atresia, femur length, humerus length, pyelectasis, and hyperechogenic bowel. (ABSTRA