Primary care and haemoglobin disorders: A study of families and professionals

Responsible implementation of expanded carrier screening

This document of the European Society of Human Genetics contains recommendations regarding responsible implementation of expanded carrier screening. Carrier screening is defined here as the detection of carrier status of recessive diseases in couples or persons who do not have an a priori increased risk of being a carrier based on their or their partners' personal or family history. Expanded carrier screening offers carrier screening for multiple autosomal and X-linked recessive disorders, facilitated by new genetic testing technologies, and allows testing of individuals regardless of ancestry or geographic origin. Carrier screening aims to identify couples who have an increased risk of having an affected child in order to facilitate informed reproductive decision making. In previous decades, carrier screening was typically performed for one or few relatively common recessive disorders associated with significant morbidity, reduced life-expectancy and often because of a considerable higher carrier frequency in a specific population for certain diseases. New genetic testing technologies enable the expansion of screening to multiple conditions, genes or sequence variants. Expanded carrier screening panels that have been introduced to date have been advertised and offered to health care professionals and the public on a commercial basis. This document discusses the challenges that expanded carrier screening might pose in the context of the lessons learnt from decades of population-based carrier screening and in the context of existing screening criteria. It aims to contribute to the public and professional discussion and to arrive at better clinical and laboratory practice guidelines.

Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of women's experiences and expectations of participation

OBJECTIVE

To describe the acceptability to women of being offered antenatal Sickle cell and Thalassaemia (SC&T) screening in primary and secondary care at the visit to confirm pregnancy; and to explore the implications of their views for participating in decisions about their health care.

METHODS

Qualitative semi-structured interviews were conducted with twenty-one ethnically diverse women registered at twenty-five general practices in two English inner-city Primary Care Trusts. The material was analysed thematically, using the method of constant comparison.

RESULTS

Women generally welcomed the opportunity of early diagnosis, although they expected screening to confirm they were carrying a healthy child. Women felt general practitioners did not present antenatal screening as a choice, but they did not necessarily see this as a problem. Doctors were believed to be acting out of concern for the women's well being.

CONCLUSIONS

Women were generally positive about being offered screening in primary care at the first visit to confirm pregnancy. To this extent it was acceptable to them, although this was largely informed by assumptions associated with being a 'good mother' rather than a straightforward enactment of informed choice, assumed by health-care policy. This represents the context in which women participate in decisions about their health care.

Offering antenatal sickle cell and thalassaemia screening to pregnant women in primary care: a qualitative study of GPs' experiences

BACKGROUND

Timely antenatal sickle cell and thalassaemia (SC&T) screening for all women in primary care facilitates informed decision making, but little is known about its implementation.

AIM

To assess the feasibility of offering antenatal SC&T screening in primary care at the time of pregnancy confirmation.

DESIGN OF STUDY

Cross-sectional investigation of GPs' beliefs and perceived practices.

METHOD

Informal face-to-face interviews with 34 GPs.

SETTING

Seventeen inner-city general practices that offered antenatal SC&T screening as part of a trial.

RESULTS

GPs identified both barriers and facilitators. Organisational barriers included inflexible appointment systems and lack of interpreters for women whose first language was not English. Professional barriers included concerns about raising possible adverse outcomes in the first antenatal visit. Perceived patient barriers included women's lack of awareness of SC&T. Hence, GPs presented the test to women as routine, rather than as a choice. Organisational facilitators included simple and flexible systems for offering screening in primary care, practice cohesion, and training. Professional facilitators included positive attitudes to screening for SC&T. Perceived patient facilitators included women's desire for healthy children.

CONCLUSION

GPs reported barriers, as well as facilitators, to successful implementation but the extent to which screening could be regarded as offering 'informed choice' remained fundamental when making sense of these barriers and facilitators.

Delay between pregnancy confirmation and sickle cell and [corrected] thalassaemia screening: a population-based cohort study

BACKGROUND

Antenatal sickle cell and thalassaemia screening sometimes occurs too late to allow couples a choice regarding termination of affected fetuses. The target gestational age for offering the test in the UK is 10 weeks.

AIM

To describe the proportion of women screened before 70 days' (10 weeks') gestation and the delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening.

DESIGN OF STUDY

Cohort study of reported pregnancies.

SETTING

Twenty-five general practices in two UK inner-city primary care trusts offering universal screening.

METHOD

Anonymised data on all pregnancies reported to participating general practices was collected for a minimum of 6 months.

RESULTS

There were 1441 eligible women intending to proceed with their pregnancies, whose carrier status was not known. The median (interquartile range [IQR]) gestational age at pregnancy confirmation was 7.6 weeks (6.0-10.7 weeks) and 74% presented before 10 weeks. The median gestational age at screening was 15.3 weeks (IQR = 12.6-18.0 weeks), with only 4.4% being screened before 10 weeks. The median delay between pregnancy confirmation and screening was 6.9 weeks (4.7-9.3 weeks) After allowing for practice level variation, there was no association between delay times and maternal age, parity, and ethnic group.

CONCLUSION

About 74% of women consulted for pregnancy before 10 weeks' gestation but fewer than 5% of women were screened before the target time of 10 weeks. Reducing the considerable delay between pregnancy confirmation in primary care and antenatal sickle cell and thalassaemia screening requires methods of organising and delivering antenatal care that facilitate earlier screening to be developed and evaluated.