Advances in prenatal diagnosis. Social-psychological and policy issues

Fetal anomaly screening: what do women want to know?

AIM

This paper reports a study exploring women's experiences of receiving an adverse diagnosis at a routine second trimester ultrasound examination, and the factors that influenced their preparedness for an adverse finding.

BACKGROUND

Ultrasound has become a routine part of prenatal care offered to pregnant women in most developed countries and technological advances are making it increasingly possible to detect more anomalies, and at earlier gestations. When fetal anomaly detection can be an outcome of the examination, provision of effective information to ensure informed consent for screening remains a challenge.

METHOD

A grounded theory study (n = 38) was carried out in 2004 and 2005 using an in-depth interview within 4 weeks of diagnosis and constant comparative analysis.

FINDINGS

The core category of balancing information emerged, whereby women balanced the expectation of a healthy baby and the non-threatening nature of the ultrasound examination with the shock of an adverse diagnosis. Assumed fetal health was contributed to by being in good health, experiencing normal symptoms of pregnancy and having other healthy children. The majority of women believed that provision of extensive and detailed lists regarding fetal anomaly detection would only cause unnecessary anxiety and worry, and suggested that a less detailed approach is required for a routine screening programme for low-risk pregnancy.

CONCLUSION

The drive to inform all women fully of ultrasound detection rates for specific anomalies may be counter-productive as it will enhance the worry pregnant women already feel in relation to the health of their unborn baby.

Effects of maternal age and education on the pattern of prenatal testing: Implications for the use of antenatal screening as a solution to the growing number of amniocenteses

OBJECTIVE

This study was undertaken to assess age-specific effects of maternal education on patterns of prenatal testing.

STUDY DESIGN

We used data from a sample of all births in France in 1998. Statistical analysis included logistic regression and likelihood ratio tests.

RESULTS

The rate of amniocentesis of women without serum screening was 7.3% for those with 12 years or less, and 16.7% for those with more than 12 years of education. Women with lower levels of education were about 50% more likely to have an amniocentesis if they had serum screening (odds ratio [OR], 1.5; 95% CI, 1.2-1.8). In contrast, women with higher levels of education were less likely to have an amniocentesis with screening (OR, 0.7; 95% CI, 0.6-0.8); the education effect persisted across maternal age groups.

CONCLUSION

Many women eligible for reimbursed serum screening, in particular those with higher levels of education, obtain amniocentesis without serum screening. This might limit the use of antenatal screening as a solution to the growing number of amniocenteses.

Psychological response to prenatal genetic counseling and amniocentesis

The purpose of the present study was to characterize the psychological status (attitudes toward selective abortion, perceived risk, comprehension, patient satisfaction, coping, and state anxiety) of pregnant women at increased risk for fetal genetic anomalies who were referred for prenatal genetic counseling and amniocentesis; to determine which of these factors would predict amniocentesis use; and to identify patient outcomes associated with counseling and testing. Participants were 129 women aged 18 years and older who had one or more fetal genetic risk factors. All were recruited from an urban women's health clinic. The results revealed elevated perceptions of risk and moderate state anxiety despite adequate comprehension of, and patient satisfaction with, the process and content of genetic counseling. Approximately 78% agreed to testing; those who consented were more likely to hold favorable attitudes toward abortion than those who refused. Post-counseling, women experienced decrease in their perceived risk of having a baby born with a birth defect although perceived risk estimates remained higher than actual risks. Anxiety was clinically elevated and highest at the pre-counseling stage, though it dissipated to normal levels over time. Previous experience with prenatal diagnostic testing, increased perceived risk of a birth anomaly, and favorable attitudes toward abortion were independently associated with increased pre-counseling anxiety. Women who were more anxious pre-counseling remained more anxious post-counseling. Coping (high versus low monitoring) was unrelated to anxiety. These findings suggest that women who participate in prenatal counseling and testing may be subject to experience distress and unrealistic perceptions of their risk and may benefit from interventions designed to lessen these states.

Who worries that something might be wrong with the baby? A prospective study of 1072 pregnant women

BACKGROUND

Little is known about the normal range and pattern of pregnant women's worry about something being wrong with the baby, or how this relates to other factors. The objective of this study was to examine the extent to which women are worried about the possibility of something being wrong with the baby relative to other worries they may have, and to determine whether demographic, experiential, attitudinal, and personality characteristics are associated with this worry.

METHODS

Longitudinal data were collected from 1072 pregnant women who completed postal questionnaires at 16, 22, and 35 weeks of pregnancy. Multivariate statistical techniques were used to determine which variables were independently related to worry about the baby.

RESULTS

Worry that something might be wrong with the baby was one of the most prevalent worries at 16 weeks, although not as widespread a source of extreme worry as miscarriage or giving birth. Worry dropped in midpregnancy but rose again at 35 weeks. The most important factors related to this worry were perceived likelihood that something might be wrong with the baby and trait anxiety, although negative mood, previous pregnancy outcomes, and initial reactions to the current pregnancy all demonstrated significant, independent effects.

CONCLUSIONS

Women who answered "Don't know" to "Have you any reason to think that your baby might be more likely than any other to have some sort of a problem?" had consistently high anxiety throughout pregnancy. We suggest that this question be asked routinely in early pregnancy to identify these potential worries and, it is to be hoped, reassure them at an early stage.

Comparison of women who do and do not have amniocentesis or chorionic villus sampling

Even in areas where prenatal diagnostic testing is offered at no cost to women over a certain age, uptake of testing is not complete. We have studied the factors that affect uptake in Victoria, Australia. In 1988-92, 43% of 37-39-year-old women and 29% of those 40 years and over had no diagnostic testing despite their eligibility for a free test. We compared the characteristics of untested women (n = 3074) with those of tested women (2462 amniocentesis, 1575 chorionic villus sampling) by use of record-linkage between the Victorian birth register and fetal diagnosis data collection. The indication for testing was maternal age alone. Women who had had 3 or more previous births were less likely than those of lower parity to undergo testing (odds ratio 0.54 [95% CI 0.46-0.63], p < 0.001), whereas those who had had a previous termination of pregnancy were more likely to be tested than those who had not (1.52 [1.26-1.83], p < 0.001). Women born in non-English-speaking countries and women who lived in rural areas were less likely to be tested. Women who gave birth in private hospitals were more likely to be tested than those who gave birth in any public hospital or at home. These data help to distinguish between issues of choice and access to diagnostic testing. Factors that hinder testing of rural women and of those from non-English-speaking backgrounds should be addressed.

Grieving the wanted child: ramifications of abortion after prenatal diagnosis of abnormality

Prenatal diagnosis is increasingly common. Whereas amniocentesis is typically performed in the second trimester, chorionic villus sampling (CVS) is a first-trimester procedure, which makes an earlier, safer abortion possible. However, CVS carries a slightly higher risk of miscarriage and other complications. In choosing a procedure, couples (with the aid of genetic counseling) must weigh the risks of miscarriage against the odds and implications of an abnormal diagnosis. Interviews with women who decided on abortions after amniocentesis or CVS and meetings with genetic counselors indicate that both types of abortion are more traumatic than is commonly realized. Both dash dreams and hopes. Termination after amniocentesis also forces the mother to take an active part in the life and death of a nearly viable fetus. Yet, because abortions for fetal abnormality are statistically rare, there is little societal understanding and minimal support for those who experience them. This is true of health care workers as well as for the couple's primary support group.