Down syndrome screening: What do health professionals know?

Effect of education and attitude on health professionals' knowledge on prenatal screening

INTRODUCTION

Ongoing developments in prenatal anomaly screening necessitate continuous updating of counsellors’ knowledge. We explored the effect of a refresher counselling course on participants’ knowledge of prenatal screening.

METHODS

We investigated the association between knowledge and counsellors’ working experience. Also, the association between knowledge and counsellors’ attitude towards prenatal screening was determined. All counsellors in the North-West region of the Netherlands were invited to attend a refresher counselling course and fill in both a pre-course and a post-course questionnaire. The participants consisted of midwifes, sonographers and gynaecologists. A 55-item questionnaire assessed pre-course (T0) and post-course (T1) knowledge. At T0, counsellors’ attitude towards the prenatal screening program was assessed and its association with knowledge analysed.

RESULTS

Of 387 counsellors, 68 (18%) attended the course and completed both questionnaires. Knowledge increased significantly from 77.7% to 84.6% (p<0.01). Scores were lowest regarding congenital heart diseases. Participants with ultrasound experience scored higher on T0, but improvement was seen in participants with and without ultrasound experience. Participants with a positive attitude towards a free-of-charge first trimester combined test had higher knowledge scores than participants with a negative attitude (62% vs 46%; p=0.002).

CONCLUSIONS

A refresher course improved counsellors’ knowledge on prenatal screening. Ultrasound experience and a positive attitude towards free screening may be associated with higher knowledge levels. Participating in a mandatory refresher counselling course is useful for the continuous improvement of healthcare practitioners’ knowledge. More research on the effect of knowledge and attitude on the quality of prenatal screening is necessary.

Non-invasive prenatal testing: ethics and policy considerations

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

'Give us the full story': overcoming the challenges to achieving informed choice about fetal anomaly screening in Australian Aboriginal communities

This cross-cultural qualitative study examined the ethical, language and cultural complexities around offering fetal anomaly screening in Australian Aboriginal communities. There were five study sites across the Northern Territory (NT), including urban and remote Aboriginal communities. In-depth interviews were conducted between October 2009 and August 2010, and included 35 interviews with 59 health providers and 33 interviews with 62 Aboriginal women. The findings show that while many providers espoused the importance of achieving equity in access to fetal anomaly screening, their actions were inconsistent with this ideal. Providers reported they often modified their practice depending on the characteristics of their client, including their English skills, the perception of the woman's interest in the tests and assumptions based on their risk profile and cultural background. Health providers were unsure whether it was better to tailor information to the specific needs of their client or to provide the same level of information to all clients. Very few Aboriginal women were aware of fetal anomaly screening. The research revealed they did want to be offered screening and wanted the 'full story' about all aspects of the tests. The communication processes advocated by Aboriginal women to improve understanding about screening included community discussions led by elders and educators. These processes promote culturally defined ways of sharing information, rather than the individualised, biomedical approaches to information-giving in the clinical setting. A different and arguably more ethical approach to introducing fetal anomaly screening would be to initiate dialogue with appropriate groups of women in the community, particularly young women, build relationships and utilise Aboriginal health workers. This could accommodate individual choice and broader cultural values and allow women to discuss the moral and philosophical debates surrounding fetal anomaly screening prior to the clinical encounter and within their own cultural space.

Risk and uncertainty: shifting decision making for aneuploidy screening to the first trimester of pregnancy

PURPOSE

The clinical introduction of first trimester aneuploidy screening uniquely challenges the informed consent process for both patients and providers. This study investigated key aspects of the decision-making process for this new form of prenatal genetic screening.

METHODS

Qualitative data were collected by nine focus groups that comprised women of different reproductive histories (N = 46 participants). Discussions explored themes regarding patient decision making for first trimester aneuploidy screening. Sessions were audio recorded, transcribed, coded, and analyzed to identify themes.

RESULTS

Multiple levels of uncertainty characterize the decision-making process for first trimester aneuploidy screening. Baseline levels of uncertainty existed for participants in the context of an early pregnancy and the debate about the benefit of fetal genetic testing in general. Additional sources of uncertainty during the decision-making process were generated from weighing the advantages and disadvantages of initiating screening in the first trimester as opposed to waiting until the second. Questions of the quality and quantity of information and the perceived benefit of earlier access to fetal information were leading themes. Barriers to access prenatal care in early pregnancy presented participants with additional concerns about the ability to make informed decisions about prenatal genetic testing.

CONCLUSIONS

The option of the first trimester aneuploidy screening test in early pregnancy generates decision-making uncertainty that can interfere with the informed consent process. Mechanisms must be developed to facilitate informed decision making for this new form of prenatal genetic screening.

General practitioner management of genetic aspects of a cardiac disease: a scenario-based study to anticipate providers' practices

It is increasingly recognised that genetics will have to be integrated into all parts of primary health care. Previous research has demonstrated that involvement and confidence in genetics varies amongst primary care providers. We aimed to analyse perceptions of primary care providers regarding responsibility for genetic tasks and factors affecting those perceptions. Postal questionnaire including a hypothetical case management scenario of a cardiac condition with a genetic component was sent to random samples of medically qualified general practitioners in France, Germany, Netherlands, Sweden and UK (n = 1,168). Logistic regression analysis of factors affecting primary care practitioners' willingness to carry out genetic tasks themselves was conducted; 61% would take a family history themselves but only 38% would explain an inheritance pattern and 16% would order a genetic test. In multivariate analysis, only the country of practice was consistently predictive of willingness to carry out genetic tasks, although male gender predicted willingness to carry out the majority of tasks studied. The stage of career at which education in genetics had been provided was not predictive of willingness to carry out any of the tasks analysed. Country of practice is significantly predictive of attitudes towards genetics in primary care practice and therefore genetic education structure and content in Europe will need to be significantly tailored towards country-specific approaches.

'I want a choice, but I don't want to decide'--a qualitative study of pregnant women's experiences regarding early ultrasound risk assessment for chromosomal anomalies

OBJECTIVE

To increase our understanding of how pregnant women experience early ultrasound examination that includes a risk assessment for chromosomal anomalies and how such women perceive the test results.

DESIGN/SETTING

Qualitative study at St. Olavs Hospital in Norway. Both pre- and post-examination interviews were conducted with ten pregnant women who underwent risk assessment for chromosomal anomalies. Grounded theory was used to analyse the results.

FINDINGS

The study generated a core category (I want a choice, but I don't want to decide), which related to the conflict between choice and decision making. There were also five main categories (existential choices, search for knowledge, anxiety, feeling of guilt and counselling and care). The main categories describe the complex feelings experienced by the women regarding the risk assessment. Factors contributing to the difficulty of choice included loss of control and coping, emotional connection to the fetus and social pressure. As the women sought independent choices without any external influence, they also felt greater responsibility. The women's understanding of the actual risk varied, and they used different types of logic and methods to evaluate the risk and reach a decision.

CONCLUSIONS

The pregnant women in this study wanted prenatal diagnostic information and easy access to specialty services. Stress-related feelings and non-transparent information about the actual and perceived risks as well as personal moral judgments made the decision-making process complicated. Improved distribution of information and frequent contact with health professionals may help such women to make informed choices in accordance with their values and beliefs.

Antenatal screening and informed choice: a cross-sectional survey of parents and professionals

BACKGROUND

antenatal screening for fetal abnormalities is now offered to all pregnant women in many countries in Europe. Previous studies have shown that women and their partners may not make informed choices about screening.

OBJECTIVES

to investigate knowledge of screening in both prospective parents and professionals offering screening in England, and to identify the ways in which pregnant women and their partners could be supported to make informed decisions about antenatal screening.

DESIGN

cross-sectional survey design. Data were collected from July 2007 to January 2008 using two self-completion questionnaires.

SETTING AND PARTICIPANTS

questionnaires were completed by: (i) pregnant women (n=100) and their partners (n=11), and (ii) midwives involved in offering antenatal screening (n=78).

MEASUREMENTS

demographic data and survey responses were analysed using descriptive statistics and cross-tabulations.

FINDINGS

some midwives lack accurate knowledge about screening and the conditions for which screening is offered. Parents wish to have information about screening at an earlier stage and would like the prospective father to be included in screening discussions. There is evidence that many parents do not perceive the second trimester ultrasound scan as a method of screening. Balanced information about the lives of people with Down syndrome would be seen as helpful by many parents.

KEY CONCLUSIONS

further efforts need to be made to educate midwives more fully so that pregnant women and their partners are able to make informed choices about screening. Balanced information about the lives of people with Down syndrome should be available to prospective parents to support their decision making.

Exploring general practitioners' experience of informing women about prenatal screening tests for foetal abnormalities: a qualitative focus group study

Background

Recent developments have made screening tests for foetal abnormalities available earlier in pregnancy and women have a range of testing options accessible to them. It is now recommended that all women, regardless of their age, are provided with information on prenatal screening tests. General Practitioners (GPs) are often the first health professionals a woman consults in pregnancy. As such, GPs are well positioned to inform women of the increasing range of prenatal screening tests available. The aim of this study was to explore GPs experience of informing women of prenatal genetic screening tests for foetal abnormality.

Methods

A qualitative study consisting of four focus groups was conducted in metropolitan and rural Victoria, Australia. A discussion guide was used and the audio-taped transcripts were independently coded by two researchers using thematic analysis. Multiple coders and analysts and informant feedback were employed to reduce the potential for researcher bias and increase the validity of the findings.

Results

Six themes were identified and classified as 'intrinsic' if they occurred within the context of the consultation or 'extrinsic' if they consisted of elements that impacted on the GP beyond the scope of the consultation. The three intrinsic themes were the way GPs explained the limitations of screening, the extent to which GPs provided information selectively and the time pressures at play. The three extrinsic factors were GPs' attitudes and values towards screening, the conflict they experienced in offering screening information and the sense of powerlessness within the screening test process and the health care system generally. Extrinsic themes reveal GPs' attitudes and values to screening and to disability, as well as raising questions about the fundamental premise of testing.

Conclusion

The increasing availability and utilisation of screening tests, in particular first trimester tests, has expanded GPs' role in facilitating women's informed decision-making. Recognition of the importance of providing this complex information warrants longer consultations to respond to the time pressures that GPs experience. Understanding the intrinsic and extrinsic factors that impact on GPs may serve to shape educational resources to be more appropriate, relevant and supportive.

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.

Antenatal care implications of population‐based trends in Down syndrome birth rates by rurality and antenatal care provider, Queensland, 1990–2004

OBJECTIVE

To assess whether the rates of Down syndrome births in Queensland vary according to rurality (ie, whether the mother lives in a rural or urban area) and type of antenatal care provider, and to consider any implications for antenatal care.

DESIGN AND SETTING

Population-based study of Down syndrome births in Queensland between 1990 and 2004, stratified by rurality and type of antenatal care provider (private obstetrician, public hospital or shared care).

RESULTS

Since 2000, there has been a large fall in maternal-age-adjusted rates of Down syndrome births among mothers living in urban areas (-14.3% per year; 95% CI, -22.7%, -5.0%) and among mothers receiving their antenatal care from private obstetricians (-27.5% per year; 95% CI, -37.6%, -15.8%). Similar decreases have not occurred among mothers living in rural areas (0.0%; 95% CI, -11.7%, 13.1%) or among mothers receiving antenatal care from public hospitals (+2.9%, 95% CI, -10.3%, 17.9%).

CONCLUSION

Possible reasons for the observed trends include unequal access to antenatal screening; confusion about screening guidelines and protocols; late presentation for antenatal care; and differences in attitudes to screening and termination of pregnancy among expectant parents, such that they may choose not to have screening or not to act on a positive screening test result.

Genetic education for non-geneticist health professionals

OBJECTIVES

It was the aim of this study to assess educational needs and priorities in genetics amongst non-genetic health professionals.

METHODS

The methods used included website reviews and direct contact with individuals and organisations involved in health professional education.

RESULTS AND CONCLUSIONS

Health professional education and training differed in structure with wide variation in the content and duration of genetics education provided. Evidence from the UK, France and Germany indicates that genetics professionals are influencing the genetics content of medical curricula. In post-graduate training, some specialist regulators have adopted specific genetics education requirements, but many programmes lack any explicit genetics. We show that within each country, a sometimes confusing plethora of organisations has responsibility for setting, assessing and delivering medical and midwifery education.

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.

Evaluation of a decision aid for prenatal testing of fetal abnormalities: a cluster randomised trial [ISRCTN22532458]

BACKGROUND

By providing information on the relative merits and potential harms of the options available and a framework to clarify preferences, decision aids can improve knowledge and realistic expectations and decrease decisional conflict in individuals facing decisions between alternative forms of action. Decision-making about prenatal testing for fetal abnormalities is often confusing and difficult for women and the effectiveness of decision aids in this field has not been established. This study aims to test whether a decision aid for prenatal testing of fetal abnormalities, when compared to a pamphlet, improves women's informed decision-making and decreases decisional conflict.

METHODS/DESIGN

A cluster designed randomised controlled trial is being conducted in Victoria, Australia. Fifty General Practitioners (GPs) have been randomised to one of two arms: providing women with either a decision aid or a pamphlet. The two primary outcomes will be measured by comparing the difference in percentages of women identified as making an informed choice and the difference in mean decisional conflict scores between the two groups. Data will be collected from women using questionnaires at 14 weeks and 24 weeks gestation. The sample size of 159 women in both arms of the trial has been calculated to detect a difference of 18% (50 to 68%) in informed choice between the two groups. The required numbers have been adjusted to accommodate the cluster design, miscarriage and participant lost--to--follow up. Baseline characteristics of women will be summarised for both arms of the trial. Similarly, characteristics of GPs will be compared between arms. Differences in the primary outcomes will be analysed using 'intention-to-treat' principles. Appropriate regression techniques will adjust for the effects of clustering and include covariates to adjust for the stratifying variable and major potential confounding factors.

DISCUSSION

The findings from this trial will make a significant contribution to improving women's experience of prenatal testing and will have application to a variety of maternity care settings. The evaluation of a tailored decision aid will also have implications for pregnancy care providers by identifying whether or not such a resource will support their role in providing prenatal testing information.

Screening for Down syndrome: practice patterns and knowledge of obstetricians and gynecologists

OBJECTIVE

To assess obstetricians' practice patterns and knowledge regarding screening for Down syndrome.

METHODS

A questionnaire was mailed to 1,105 American College of Obstetricians and Gynecologists Fellows and Junior Fellows in 2004.

RESULTS

Sixty percent of questionnaires were returned. Statistical analyses were limited to the 532 practicing obstetricians. Greater than 80% felt their training and experience qualified them to counsel patients about genetic issues in pregnancy. However, 45% rated their residency training regarding prenatal diagnosis as barely adequate or nonexistent. American College of Obstetricians and Gynecologists publications were rated by 86% as an important source of information on genetic counseling. Seventy-eight percent of practitioners counsel all obstetric patients about risks for fetal aneuploidy, and 67% provide counseling for heritable genetic abnormalities. Although the majority (99%) offer second-trimester Down syndrome screening, only 55% also offer first-trimester screening for Down syndrome. Almost one half (49%) use the quad screen, and 6% offer integrated first- and second-trimester screening. The majority (88%) routinely offer amniocentesis to patients who are at elevated risk for genetic abnormalities, whereas 44% also offer chorionic villus sampling. Few (2%) perform chorionic villus sampling.

CONCLUSION

Most obstetricians manage patients at risk for fetal genetic abnormalities according to American College of Obstetricians and Gynecologists educational materials. This survey identified deficiencies related to Down syndrome screening, including a limited number of practitioners performing chorionic villus sampling and physicians' own perception that training regarding genetic counseling should be improved. Educational strategies are needed to address these deficiencies before first-trimester screening programs are widely implemented.

LEVEL OF EVIDENCE

III.

Genetic education and nongenetic health professionals: Educational providers and curricula in Europe

PURPOSE

Advances in and diffusion of genetic technology mean that nongeneticist health professionals have an increasing need to develop and maintain genetic competencies. This has been recognized by patient support groups and the European Commission. As the first phase of the GenEd (Genetic Education for Nongenetic Health Professionals) project, we investigated health professional education at undergraduate, postgraduate, and continuing levels in terms of genetic content and delivery.

METHODS

Information was collected in the five GenEd partner countries (France, Germany, Netherlands, Sweden, and the UK) by reviewing published curricula and web sites and by directly contacting educational and regulatory organizations. Information was also requested from a further six South and East European collaborators (Greece, Hungary, Italy, Lithuania, Poland, and Spain).

RESULTS

Health professional education and training differed in structure with wide variation in the content and duration of genetic education provided. France and Germany have national undergraduate medical curricula but with minimal overt genetic content, mainly confined to basic science courses. In Sweden, Netherlands, and the UK, the content is largely at the discretion of individual universities. Evidence from the UK, France, and Germany indicates that genetic professionals are influencing the genetic content of medical curricula. In postgraduate training, some specialist regulators have adopted specific genetic educational requirements, but many programs lack any explicit genetics. Within each country many organizations have responsibility for setting, assessing, and delivering medical and midwifery education.

CONCLUSIONS

Due to the multiplicity of organizations involved in the provision of genetic education, changing professional education is likely to be challenging. However, it may be that development of a multiprofessional consensus across Europe is achievable. The strategy adopted by the US National Coalition for Health Professional Education in Genetics may be helpful.

Educating general practitioners about prenatal testing: approaches and challenges

OBJECTIVES

To examine the effects of an education intervention on the knowledge and practice behaviours of general practitioners (GPs) regarding prenatal screening and diagnostic testing in Melbourne, Australia.

METHODS

A single group, pre-test, repeated post-test design was used. Information on demographics, knowledge, behaviours and skills was collected via a self-administered questionnaire prior to the educational intervention. Responses to individual questions were coded and scores calculated, as well as a percent total score. Following the education, data were again collected, immediately afterwards (Post-Q) and six-to-eight months later (Foll-Q).

RESULTS

Data for all three time points were collected from 63 GPs and showed a variable, and relatively poor knowledge regarding aspects of prenatal testing, especially before education. The percent mean total score at baseline was 51.2+/-1.59% (CI 48.02 to 54.39), which increased significantly (p<0.001) in both Post-Q (62.88+/-1.51%; CI 59.86 to 65.89) and Foll-Q (58.92+/-1.6%; CI 55.71 to 62.12).

CONCLUSION

The educational intervention significantly increased knowledge and practice behaviour of GPs, even up to eight months later, but this could be improved further, to a considerable extent. There is a need for ongoing multi-faceted approaches to educating GPs on prenatal testing to ensure that they are engaged in appropriate practice.

People who influence women's decisions and preferred sources of information about prenatal testing for birth defects

BACKGROUND

More than half of Victorian pregnant women are undergoing prenatal testing for birth defects, although little is known about the factors that are influencing their decisions.

AIMS

To examine whom women perceived as influencing their decision about prenatal testing for birth defects, with whom they would have liked to talk more, and what sources of information they preferred.

METHODS

A total of 737 pregnant women aged 37 years and over, who either had or had not undergone prenatal testing (screening and/or diagnosis) completed a questionnaire in 18 hospitals throughout Victoria.

RESULTS

Over 90% reported that they themselves had a strong influence on their decision, and 70% reported their partner as strongly influencing their decision. Approximately 30% of women who had both screening and diagnosis and more than 20% of women who had no prenatal testing, would like to have discussed prenatal testing with women who had previously had testing. Face-to-face counselling with a doctor or counsellor was the preferred source of information, followed by a pamphlet as the second choice.

CONCLUSIONS

Given that both tested and untested women felt so strongly that they were responsible for their own decisions about prenatal testing, it is unlikely that universal acceptance and uptake will occur, even in this group of women of advanced maternal age. A support network of women who have already had testing could supplement existing sources of support. However, there continues to be a need for face-to-face sessions with a doctor or counsellor in combination with printed material.