Pregnant women's responses to information about an increased risk of carrying a baby with Down syndrome

The childbirth experience: A systematic review of predictors and outcomes

BACKGROUND

Birth is often viewed as a pathological event, consequently, there has been an increase in literature focusing on predictors, experience and implications of traumatic childbirth and childbirth-related posttraumatic stress. However, to fully understand childbirth experiences a salutogenic perspective is required. This enables an understanding of what facilitates a positive childbirth experience besides what places women at risk of experiencing traumatic childbirth.

OBJECTIVE

To identify the psychosocial factors that could contribute to or be influenced by women's subjective accounts of childbirth.

METHOD

An in-depth literature search across four databases was undertaken. Quality appraisal based on internal and external validity was conducted and a combined numerical summary and categorical description were undertaken.

FINDINGS

Nineteen papers were included in the review and the variables grouped into three categories. The variables relate to 'Measures of labour and birth experience' (discussing the impact of events and perceptions during labour and birth). The second category discusses how 'support and relationships' can potentially shape the birth experience or be altered by it and finally, 'Psychological variables: influence and impact' is examined extensively.

DISCUSSION

The results of the review highlight significant contradictory evidence of what influences birth experiences. The findings confirm the dearth of available literature concerning positive birth experiences and most variables identified were pathogenic. This review suggests that such factors for PTSD may differ from those that influence birth experiences and should be examined separately. An enhanced understanding of the range of experiences is required to support women's rights in achieving a positive birth.

Women's decisional conflict in the pathway of prenatal screening and testing: an explorative study within Finnish public maternity care

Objectives To explore women's decisional conflict in the pathway of prenatal screening and testing (PreST) in Finland and to evaluate a counseling service. Methods Self-completion surveys were conducted at two medical settings (screening and further testing) of PreST. Decisional Conflict Scale (DCS) was the main measure. Different types of statistical tests were used to compare women's decisional conflict at different medical settings of PreST, and before-after pre-test counseling. Multivariable linear regressions analyzed the influences of the medical settings and other factors on women's decisional conflict. Results Compared to women in population-based screening, women in further testing (before pre-test counseling) were more likely to feel well informed (P < 0.001), had increased values clarity (P < 0.001), but more likely experienced uncertainty (P = 0.040). Besides medical settings, maternal age, gravidity and previous experience of fetal aneuploidy significantly influenced decisional conflict. After counseling, screen-positive women felt better informed (P < 0.001), had increased values clarity (P < 0.001), perceived more support (P < 0.001), and had better decision certainty (P < 0.001) than before counseling. Conclusions Medical settings influence women's decisional conflict during PreST. Individual counseling is effective in improving screen-positive women's decisional conflict. This research adds knowledge and experience on developing decision-making supports across the pathway of PreST.

Physicians' perception toward non-invasive prenatal testing through the eye of the Rogers' diffusion of innovation theory in China

OBJECTIVE

Physicians' attitudes and adoption behavior toward the delivery of prenatal tests take vital significance for its influence on their professional practice and patient acceptance. This study aimed to identify how physicians have perceived the diffusion of non-invasive prenatal testing (NIPT) in China.

METHODS

A cross-sectional study was conducted from July 2016 to October 2016 in Shanghai, and Fujian and Sichuan Provinces in China. Physicians working on prenatal screening completed a self-report questionnaire. Following Roger's diffusion of innovation model, multivariable logistic regressions were performed separately for the following key elements of the theory which influence diffusion: physician-perceived attributes of NIPT, communication channels, the nature of the social system, the extent of change agent (who introduces innovations into a society), promotion efforts, and physicians' benefits from adopting NIPT.

RESULTS

Most specialists had a positive attitude (53.2 percent) toward NIPT, whereas 58.9 percent of physicians had already adopted NIPT in their clinical practice. Physician adoption of NIPT was positively associated with the strength of HTA evidence (p = .03), perceived communication frequency with colleagues (p = .04), adoption by other physicians (p = .07), hospital competition (p = .06), hospital teaching status (p = .02), perceived for-profit genetic testing company's promotion (p < .001), and perceived clinical practice skill improvement (p = .02). However, the adoption behavior toward NIPT may be negatively associated with physician-perceived ethical concerns of NIPT (p = .06).

CONCLUSION

Obstetricians and gynecologists' positive perceptions facilitate the adoption of NIPT. Combined with cost-effectiveness analysis of prenatal screening methods, health policy makers can promote the adoption of appropriate, cost-effective prenatal screening in pregnant women.

Comparing prenatal screening experiences of Icelandic women who received false-positive and true-negative first-trimester combined screening results in Iceland in 2012-2016

First-trimester combined screening (FTS) has been offered to all pregnant women in Iceland since 2003. Individuals with high-risk FTS results are offered an invasive test option with a ≤1% risk of fetal loss. This study gives insight into the prenatal screening and diagnosis experiences and preferences of 101 women who underwent FTS in Iceland in the years 2012-2016, comparing the experience of those who received false-positive FTS results to those who received true-negative results. Retrospective patient-reported anxiety levels at the time of receiving FTS results were significantly higher in those who received false-positive results compared to those who received true-negative results. For a subset of these participants, the anxiety lasted through pregnancy, and for a smaller subset, it lasted even longer. Non-invasive prenatal testing (NIPT) is currently not offered in Iceland, aside from the rare exceptional case. Given the extremely low false-positive rates of NIPT, we believe NIPT is worth considering as Iceland's standard first-tier screening method for trisomy 13, 18, and 21. We believe the findings of this study are beneficial not only for Iceland but also for other countries where FTS is the first-tier prenatal screening method or the only offered test. Additionally, only 21% of participants in our study reported that they had heard of NIPT, which emphasizes the need for comprehensive NIPT pretest information to be available prior to its uptake to ensure informed and autonomous decision-making.

Women's lived experiences of a prenatal diagnosis of fetal growth restriction at the limits of viability: An interpretative phenomenological study

OBJECTIVES

The research team aimed to understand women's lived experiences during pregnancies with poor prognosis following prenatal detection of Fetal Growth Restriction at the limits of viability (FGRLV).

METHODS

Qualitative interviews with six women who had attended a specialist service following a prenatal diagnosis of FGRLV were conducted. The interview data were analysed using interpretative phenomenological analysis.

FINDINGS

Three superordinate themes alongside thirteen subthemes were identified. Theme 1 described 'a fine line between supportive and unhelpful' care experiences. A second theme of 'understanding the situation and decisions to be made' described how women faced many uncertainties. The final theme of 'parental responsibility' reflected how women imagined their futures to have been, exploring their embodied parental role and connection to their unborn or young child.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Women highlighted the importance of maternal healthcare teams providing clear information and reassurance to them. They also reported that prior experiences were important to them in influencing their perception of that pregnancy. Furthermore, women reflected on their desperation for a positive outcome. Understanding these factors can enable maternal healthcare teams to facilitate informed decision-making and provide individualised emotional support for women. Our findings will enable maternal care teams to better support women in similar clinical situations.

Value of increased nuchal translucency in the era of noninvasive prenatal testing with cell-free DNA

OBJECTIVE

To assess the value of increased nuchal translucency (NT) at first-trimester screening (FTS) despite the superiority of noninvasive prenatal testing with cell-free DNA (cfDNA) for the detection of fetal aneuploidies.

METHODS

Retrospective analysis of all FTS data from 2005 to 2015 in our department. Only cases with increased NT and euploid karyotype were considered eligible for inclusion. Abnormal findings, diagnostic work-up, and perinatal outcomes were assessed.

RESULTS

Of 18 084 FTS results, 460 (2.5%) showed increased fetal NT, of which 242 (52.6%) underwent invasive karyotyping and 179 (74.0%) had an aneuploidy. Of the remaining 63 cases, 61 (96.8%) showed an additional sonographic finding at FTS and25 (78.1%) had a major anomaly at the second trimester organ scan. The outcome was termination of pregnancy in 28 (44.4%) cases, fetal demise in 5 (7.9%), delivery of an infant with malformation in 21 (33.3%), and delivery of a healthy infant in 7 (11.1%) cases.

CONCLUSION

All cases with increased NT would have been detected by cfDNA or by a major sonographic anomaly not later than the second trimester. Routine use of cfDNA, a basic sonogram, and an organ scan could reduce unnecessary work-up and anxiety.

From Prenatal Diagnosis to Preterm Infants: A Cultural Guide to Understand Scandinavian Variation

The Scandinavian neighbors, Denmark, Sweden, and Norway, are 3 similar countries. Still, the practice and the policy on extreme premature infants are different in each of them. Why is this so? In this article, I will try to show that the differences are not primarily a result of individual disagreement among leading doctors in the 3 countries but has a cultural explanation. I compare the policies on preterm infants with a nearby one, that of prenatal diagnosis. It seems clear that the policies and practices reflect distinct features in the mentality and values of each nation. Context matters, even in situations that at first glance appear as identical. Variation in neonatal practice and policies between countries is not necessarily bad, because the cultural context is part of the moral situation in which doctors and parents decide.

Psychosocial Factors of Health Professionals' Intention to Use a Decision Aid for Down Syndrome Screening: Cross-Sectional Quantitative Study

Background

Decisions about prenatal screening for Down syndrome are difficult for women, as they entail risk, potential loss, and regret. Shared decision making increases women’s knowledge of their choices and better aligns decisions with their values. Patient decision aids foster shared decision making but are rarely used in this context.

Objective

One of the most promising strategies for implementing shared decision making is distribution of decision aids by health professionals. We aimed to identify factors influencing their intention to use a DA during prenatal visit for decisions about Down syndrome screening.

Methods

We conducted a cross-sectional quantitative study. Using a Web panel, we conducted a theory-based survey of health professionals in Quebec province (Canada). Eligibility criteria were as follows: (1) family physicians, midwives, obstetrician-gynecologists, or trainees in these professions; (2) involved in prenatal care; and (3) working in Quebec province. Participants watched a video depicting a health professional using a decision aid during a prenatal consultation with a woman and her partner, and then answered a questionnaire based on an extended version of the theory of planned behavior, including some of the constructs of the theoretical domains framework. The questionnaire assessed 8 psychosocial constructs (attitude, anticipated regret, subjective norm, self-identity, moral norm, descriptive norm, self-efficacy, and perceived control), 7 related sets of behavioral beliefs (advantages, disadvantages, emotions, sources of encouragement or discouragement, incentives, facilitators, and barriers), and sociodemographic data. We performed descriptive, bivariate, and multiple linear regression analyses to identify factors influencing health professionals’ intention to use a decision aid.

Results

Among 330 health professionals who completed the survey, 310 met the inclusion criteria: family physicians, 55.2% (171/310); obstetrician-gynecologists, 33.8% (105/310); and midwives, 11.0% (34/310). Of these, 80.9% were female (251/310). Mean age was 39.6 (SD 11.5) years. Less than half were aware of any decision aids at all. In decreasing order of importance, factors influencing their intention to use a decision aid for Down syndrome prenatal screening were as follows: self-identity (beta=.325, P<.001), attitude (beta=.297, P<.001), moral norm (beta=.288, P<.001), descriptive norm (beta=.166, P<.001), and anticipated regret (beta=.099, P=.003). Underlying behavioral beliefs significantly related to intention were that the use of a decision aid would promote decision making (beta=.117, 95% CI 0.043-0.190), would reassure health professionals (beta=.100, 95% CI 0.024-0.175), and might require more time than planned for the consultation (beta=−.077, 95% CI −0.124 to −0.031).

Conclusions

We identified psychosocial factors that could influence health professionals’ intention to use a decision aid about Down syndrome screening. Strategies should remind them of the following: (1) using a decision aid for this purpose should be a common practice, (2) it would be expected of someone in their societal role, (3) the experience of using it will be satisfying and reassuring, and (4) it is likely to be compatible with their moral values.

Experiences and expectations in the first trimester of pregnancy: a qualitative study

Background

A dominant context for pregnant women in the Western world is medical technologies such as ultrasound and screening. It has been argued that such technologies may result in tentative pregnancies, which may be particularly prominent in the first trimester. However, little is known about how women experience early pregnancy.

Objective

To explore the everyday experiences and expectations of first trimester pregnant women in a medicalized context of comprehensive and routine prenatal screening.

Design

Qualitative, semi‐structured interviews analysed using thematic analysis.

Setting

Between May 2015 and January 2016, participants were recruited from two general practices and one obstetric ultrasound unit in Aarhus, Denmark.

Participants

Twenty, first trimester pregnant women (15 primiparae, five multiparae) aged 21‐39 years.

Results

Early pregnancy is often kept secret in the first trimester due to a higher risk of miscarriage. However, the pregnancy is very real in the lives of the pregnant women who make it meaningful through practices of information seeking, listening to the body and anticipating the different milestones in pregnancy. First trimester screening represents one such milestone that is expected to mark a new and more certain phase in the pregnancy. A majority expects to terminate following a prenatal diagnosis, but this does not seem to influence their engagement with the pregnancy.

Conclusions

The pregnant women use medical technologies to mark a milestone in pregnancy but do not expect all concerns to disappear upon a normal screening result. The majority of women acknowledge that pregnancy involves simultaneous feelings of happiness and worry.

Breaking bad news in prenatal medicine: a literature review

BACKGROUND

The diagnosis of a fetal anomaly in perinatal medicine forces expectant parents and healthcare providers to face the difficult process of breaking bad news.

OBJECTIVES

This exploratory literature review was aimed at providing a medical and psychological view of the psychological experience in expectant parents and physicians in the context of prenatal diagnosis of a fetal anomaly.

METHOD

An exploratory search of PubMed and PsycINFO/PsycARTICLES databases performed by an interdisciplinary team composed of a physician and psychologists. Search terms were: prenatal diagnosis AND bad news; prenatal diagnosis AND psychological consequences; prenatal diagnosis AND psychological sequelae; prenatal diagnosis AND fetal abnormality. The processing of selected articles followed a standardised five-step procedure.

RESULTS

A total of 860 articles were screened of which 32 were retained for analysis. Four main themes emerged from the explanatory content analysis: (1) parents' subjective experience; (2) physicians' subjective experience; (3) encounters between expectant parents and professionals; and (4) ethical challenges in breaking bad news in prenatal medicine.

CONCLUSION

Expectant parents go through a complex and multidimensional experience when the diagnosis of a fetal anomaly is disclosed. Simultaneously, physicians consider breaking bad news as a very stressful event and are poorly prepared in this regard. A better knowledge of factors underlying psychological adjustment of the parental dyad and on the subjective experience of physicians delivering these diagnoses could enable better adaptation for both patients and professionals.

Coping with worry while waiting for diagnostic results: a qualitative study of the experiences of pregnant couples following a high-risk prenatal screening result

BACKGROUND

It is well documented that pregnant women experience increased worry and uncertainty following a high-risk prenatal screening result. While waiting for diagnostic results this worry continues to linger. It has been suggested that high-risk women put the pregnancy mentally 'on hold' during this period, however, not enough is known about how high-risk women and their partners cope while waiting for diagnostic results. The aim of this study was to identify the strategies employed to cope with worry and uncertainty.

METHODS

Qualitative, semi-structured interviews with 16 high-risk couples who underwent diagnostic testing. The couples were recruited at a university hospital fetal medicine unit in Denmark. Data were analysed using thematic analysis.

RESULTS

All couples reported feeling worried and sad upon receiving a high-risk screening result. While waiting for diagnostic results, the couples focused on coming to their own understanding of the situation and employed both social withdrawal and social engagement as strategies to prevent worry from escalating. Additionally, couples used gratitude, reassuring reasoning and selective memory as means to maintain hopes for a good outcome. Discussions about what to do in case of an abnormal test result were notably absent in the accounts of waiting. This bracketing of the potential abnormal result allowed the couples to hold on to a 'normal' pregnancy and to employ an 'innocent-till-proven-guilty' approach to their worries about the fetus's health. None of the interviewed couples regretted having prenatal screening and all of them expected to have prenatal screening in a future pregnancy.

CONCLUSIONS

The couples in this study did not put the pregnancy mentally 'on hold'. Worry and uncertainty must be understood as managed through a diverse range of practical and emotional strategies that change and overlap in the process of waiting. Clinicians may support appropriate ways of coping with worry and waiting through empathetic and empowering clinical communication. In addition to providing adequate information and presenting options available, clinicians may support high-risk women/couples by encouraging them to seek their own personal understandings and management strategies as a way to gain some control in an uncertain situation.

Women's Experiences and Preferences for Service Delivery of Non-Invasive Prenatal Testing for Aneuploidy in a Public Health Setting: A Mixed Methods Study

Non-invasive prenatal testing (NIPT) for aneuploidy is currently only available in the UK through the private sector outside of the research arena. As part of an implementation study in the UK National Health Service we conducted a mixed methods study to assess women’s experience of being offered NIPT using validated measures of decisional conflict, decisional regret and anxiety. Clinical service preferences were also explored. Women with a Down syndrome screening risk >1:1000 were invited to take part in the study and offered NIPT, NIPT and invasive testing (for women with a risk above 1:150) or no further testing. A cross-sectional survey and semi-structured interviews were conducted at two time points; at the time of testing and one month following receipt of results (or equivalent for NIPT decliners). In total, 845 questionnaires and 81 interviews were analysed. The main motivation to accept NIPT was for reassurance (30.8%). Decisional conflict occurred in a minimal number of cases (3.8%), however, none of the participants experienced decisional regret. Around a third (29.9%) of women had elevated anxiety at the time of testing, including intermediate risk women who traditionally would not be offered further testing (54.4% high risk; 20.1% medium risk), a finding supported through the qualitative interviews where prolonged or additional anxiety was found to occur in some medium risk cases. Women were overwhelmingly positive about the opportunity to have a test that was procedurally safe, accurate, reduced the need for invasive testing and identified cases of Down syndrome that might otherwise have been missed. Reassurance was identified as the main motivator for accepting NIPT, particularly amongst medium risk women, with high risk women inclined to accept NIPT to inform decisions around invasive testing. The current turnaround time for test result was identified as a key limitation. All the women interviewed thought NIPT should be adopted as part of NHS clinical practice, with the majority favouring NIPT offered as a first-line test. Our study highlights the potential that NIPT has to positively impact women’s experience of prenatal testing for aneuploidy.

[Termination of pregnancy: A survey about its evolution in French perinatal centres]

CONTEXT

Termination of pregnancy (TOP) is regulated by French law for decades. Indications of TOP may vary depending on progress performed in perinatal medicine and in diagnosis of fetal anomalies, and also according to the way malformations are perceived in society.

OBJECTIVES

To determine whether the frequency and indications of TOP had varied in the Lorraine Centre for Perinatal Diagnosis from 2000 to 2012.

SUBJECTS AND METHODS

Retrospective study performed on a randomized sample of medical files presented in the Lorraine Centre for Perinatal Diagnosis in years 2000, 2006 and 2012. We analyzed the number of files presented by parents-to-be, the indication motivating TOP, general characteristics of both pregnancies and mothers. We also performed a prospective enquiry among the French Centres for Perinatal Diagnosis in order to determine national rates.

RESULTS

General characteristics of mothers and pregnancies were similar from 2002 to 2012. No modification in indications of TOP was measured. In Lorraine, most TOPs were performed for chromosomal abnormality. On the national level, centres for perinatal diagnosis received more requests for TOPs in the study period. There were also more TOPs for non-lethal fetal anomalies, and parents refusing TOPs though the centres had agreed with its indication.

CONCLUSION

The national trends were not measured in Lorraine region.

Long-term outcome in apparently healthy children with increased nuchal translucency in the first trimester screening

INTRODUCTION

Increased nuchal translucency is known to be associated with chromosomal and structural defects and genetic syndromes. Little is known about the overall long-term outcome of euploid children after increased nuchal translucency. The aims of this study were to assess the additional structural defects diagnosed after discharge from the delivery hospital and the long-term overall outcome of euploid children after increased nuchal translucency and normal second trimester anomaly scan.

MATERIAL AND METHODS

All children from singleton euploid pregnancies during 2002-2007 with increased nuchal translucency in the first trimester screening, normal second trimester anomaly scan, and discharged as apparently healthy were included. Data on the structural defects and genetic disorders diagnosed until 2012 were retrieved from hospital databases and national registers. Previously published data of structural defects diagnosed after birth but before discharge and of severe neurodevelopmental impairment and genetic syndromes was added.

RESULTS

The cohort included 733 children. During the follow-up time (mean 6.5 years), major structural defects were observed in 10 (1.4%), genetic disorders in two (0.3%), and minor defects in 23 (3.1%) children. In addition, there were 42 previously published major structural defects and major neurodevelopmental impairment or genetic disorders. Adding these results together, major health problems were detected in 54 (7%) euploid children with increased fetal nuchal translucency and normal findings in second trimester anomaly scan.

CONCLUSION

Although only few additional major structural defects are diagnosed during the follow-up after increased fetal nuchal translucency, 7% of fetuses assumed to be healthy after second trimester anomaly scan have a major health impairment.

Information following a diagnosis of congenital heart defect: experiences among parents to prenatally diagnosed children

Background

Prenatal screening of pregnant women in Sweden has improved the detection of major congenital heart defects (CHD). The aim was to explore parental experiences and need for information following a prenatal diagnosis of CHD.

Methods

Semi-structured interviews conducted with six fathers and five mothers to seven prenatally diagnosed children. Data were analyzed through content analysis.

Results

Three themes and 9 categories emerged. Theme 1, Grasping the facts today while reflecting on the future, containing five categories: Difficulties sorting out information when in emotional chaos; Respectful information regarding termination of pregnancy; Early information is crucial; Understanding the facts regarding the anomaly; Preparing for the future. Theme 2, Personal contact with medical specialists who give honest and trustworthy information is valued, containing two categories: Trust in information received from medical specialists and Truth and honesty is valued. Theme 3, An overwhelming amount of information on the Internet, containing two categories: Difficulties in finding relevant information and Easy to focus on cases with a poor outcome when searching the Internet.

Conclusion

Early and honest information in line with individual preferences is crucial to support the decisional process regarding whether to continue or terminate the pregnancy. The use of illustrations is recommended, as a complement to oral information, as it increases comprehension and satisfaction with obtained information. Furthermore, the overwhelming amount of information on the Internet calls for compilation of easily accessible and reliable information sources via the Internet.

Does screening for Down's syndrome cause anxiety in pregnant women? A systematic review

BACKGROUND

Prenatal screening for Down's syndrome and other chromosomal abnormalities is included in prenatal care programs in many countries. However, the potential association between prenatal screening and maternal anxiety remains an issue of debate.

OBJECTIVE

To systematically review and summarize the current scientific evidence on whether screening for Down's syndrome might cause anxiety in pregnant women with a negative or a false-positive screening result.

METHODS

Five databases (PubMed, Embase, Cinahl, PsychInfo and Cochrane) were systematically searched for randomized controlled trials or cohort studies comparing screening and no screening, or comparing different types of screening for Down's syndrome. The search was limited to studies published between September 2001 and April 2013. In all, 316 studies were identified through search of databases and 40 were included for full-text assessment. Two observers independently screened the articles and seven studies satisfied the inclusion criteria. They were subsequently assessed for risk of bias and level of evidence.

MAIN OUTCOME MEASURES

Quantitative measurements of maternal anxiety or worry.

RESULTS

Two studies compared anxiety in pregnant women who accepted or declined screening and showed no difference between groups. All studies described a decrease in anxiety following a screen-negative result. Four studies reported that women's anxiety levels increased significantly upon receiving a screen-positive result. However, after a normal diagnostic result, anxiety levels declined to the same level as for screen-negative women.

CONCLUSION

Studies using quantitative, validated measures to estimate anxiety showed no association between screening and residual anxiety.

What women want: lead considerations for current and future applications of noninvasive prenatal testing in prenatal care

BACKGROUND

Noninvasive prenatal testing (NIPT) will change the delivery of prenatal care for all women, including those considered low risk for fetal chromosomal abnormalities. This study investigated pregnant women's attitudes, informational needs, and decision-making preferences with respect to current and future applications of NIPT.

METHODS

A survey instrument was used to identify aspects of the decision-making process for NIPT among low-risk and high-risk populations.

RESULTS

Both low-risk and high-risk women (n = 334) expressed interest in incorporating NIPT as a screening test into their prenatal care. Information specific to NIPT's detection rate (86%), indications (77%), and performance in comparison with conventional screens and diagnostic tests (63%) were identified as lead factors when considering its use. The future availability of NIPT as a diagnostic test increased women's willingness to undergo testing for fetal aneuploidy, cancer susceptibility, and childhood-onset and adult-onset diseases. Despite its noninvasive aspects, participants expressed the need for a formal informed consent process (71%) to take place before testing.

CONCLUSIONS

This study demonstrates that NIPT will introduce new challenges for pregnant women and their health care practitioners who will be charged with supporting informed decision making about its use. It is critical that obstetric professionals are prepared to facilitate a patient-centered decision-making process as its clinical application rapidly changes.

Does an information film about prenatal testing in early pregnancy affect women's anxiety and worries?

OBJECTIVE

To explore if an information film about prenatal examinations affects pregnant women's worry and anxiety.

METHODS

Randomized controlled study. The intervention was an information film about prenatal examinations. Data was collected in gestational week 26 by a questionnaire including the STAI (State-Trait Anxiety Inventory) instrument and further questions about worry. A total of 184 women in the intervention group and 206 in the control group filled in the questionnaire.

RESULTS

There were no statistically significant differences between the groups neither in state nor trait anxiety. Regarding worry about the possibility of something being wrong with the baby and worry about giving birth, there were no statistically significant differences between the groups. The women stated that to see the film increased their worry rather than decreased it.

CONCLUSION

An informational film as additional information to complement written and verbal information about prenatal testing does not appear to increase women's anxiety and worries. However, the informational film may cause worry at the time of viewing which should be taken into consideration.

Does an informational film increase women's possibility to make an informed choice about second trimester ultrasound?

OBJECTIVE

To evaluate effects of an informational film on making an informed choice regarding second trimester ultrasound.

METHOD

Randomized controlled study. The intervention was an informational film about prenatal examinations. Data were collected at gestational week 26.

RESULTS

A total of 184 women in the intervention group and 206 women in the control group participated in the study. Of those in the intervention group, 81.3% made an informed choice regarding second trimester ultrasound examination compared with 76.1% in the control group (p = 0.21). Women making an informed choice scored higher in knowledge about the examination (p < 0.001), had higher degree of education (p < 0.001), and spoke more frequently Swedish as mother tongue (89.5% vs 74.7%, p = 0.01).

CONCLUSIONS

An informational film does not increase women's knowledge or the number of women making an informed choice about the second trimester ultrasound. Women who did not make an informed choice about the second trimester ultrasound had a lower level of education and less knowledge about second trimester ultrasound screening.

Supporting patients after disclosure of abnormal first trimester screening results

PURPOSE OF REVIEW

The clinical value of first trimester aneuploidy screening is well established internationally. The implementation of a more effective testing protocol has led to an increase in 'abnormal' or worrying findings that are disclosed to women relatively early in their pregnancy. It is timely, therefore, to explore the support needs of women who are told during the first trimester that their screening result has increased their risk of fetal anomaly.

RECENT FINDINGS

A Medline search uncovered numerous papers in the review period on first trimester screening regimens, and the efficacy of particular screening markers, but very little on the psychosocial sequelae for women receiving abnormal results. Therefore, this study takes what can be gleaned from the available literature, augmented by the author's experience in an independent UK charity providing nondirective support and information to parents through prenatal screening and its consequences. [Antenatal Results and Choices (ARC) was established as a UK charity in 1988. The organization provides nondirective information and specialized support to parents throughout antenatal testing and its consequences, dealing with approximately 8000 contacts a year. ARC also provides training programmes for providers in communication skills and supporting decision-making. www.arc-uk.org.]

SUMMARY

With the shift in timing of screening programmes, there has been an emphasis in the literature on concerns about the provision of pretest information and counselling rather than what women find beneficial when dealing with results. The emotional impact of worrying news will always be significant and the ensuing decisions complex. The challenge for providers is to have a flexibility of approach that enables women and couples to be supported to understand the possible clinical implications of a screening result and what this might mean to them in the context of their individual lives.

Clinical utility of noninvasive fetal trisomy (NIFTY) test--early experience

Objective: To report the initial experience of noninvasive prenatal diagnosis of fetal Down syndrome (The NIFTY test) in a clinical setting. Methods: The NIFTY test was offered as a screening test for fetal Down syndrome to pregnant women with a singleton pregnancy at 12 weeks of gestation or beyond. A satisfaction questionnaire was sent to the first 400 patients. Results: During a 6-month period, 567 NIFTY tests were performed. Over 90% of those studied were ethnic Chinese, and the mean age of the women studied was 36 years. The test was performed at 12–13 weeks of gestation in 49.21%. The median reporting time was 9 days. The test was positive for trisomy 21 in eight cases, and for trisomy 18 in 1 case; all were confirmed by fetal karyotyping. There was no false-positive result. Of the questionnaires, 182 completed responses were received. Over 95% had complete or almost complete resolution of anxiety. Except for one, all were satisfied with the NIFTY test, and all indicated that they would recommend the test to their friends. Conclusion: The NIFTY test was a highly specific test. Unnecessary invasive tests and associated fetal losses could be avoided in almost all women who have a normal fetus.

Effectively training pediatric residents to deliver diagnoses of Down syndrome

Physicians and parents report a need for pediatricians to have additional training in delivering a diagnosis of Down syndrome (DS). This study tested a web-based tutorial to assess its effectiveness in improving physicians' perceived comfort with both ambiguous and more medically factual situations as they deliver diagnoses of DS. Based on this web tutorial that integrated prenatal and postnatal information into virtual patient scenarios, the study assessed pediatrics residents' knowledge and comfort in delivering a diagnosis of DS pre and postnatally. A separate survey, given at the same time, asked for residents' perception of their need for this training. Ninety-one volunteer residents from 10 pediatric training programs across the country participated. The tutorial yielded significant improvement in knowledge and a significant decrease in perceived level of discomfort in both ambiguous situations and more medically certain contexts related to a DS diagnosis. In addition, across all pediatric resident groups (by year, gender, and performance on the knowledge test and the comfort scale), residents strongly agreed that this type of training was beneficial for themselves, other residents, practicing physicians, and other medical professionals. This study suggests that web-based, interactive, multi-media training may be an effective tool for improving resident physician comfort with both ambiguous and more medically certain situations in delivering a diagnosis of DS to families.

'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.

Did I really want to know this? Pregnant women's reaction to detection of a soft marker during ultrasound screening

OBJECTIVE

To investigate women's expectations of routine ultrasound and experiences when soft markers were discovered: what the disclosure meant, how it affected them, how they experienced the information given and why they did or did not choose amniocentesis.

DESIGN

Semi-structured, in-depth interviews were conducted with 11 women 25-30 weeks into the pregnancy, 7-13 weeks after the discovery of a soft marker.

FINDINGS

Women lacked knowledge about the potential of the scan and detection of soft markers created strong emotional reactions that women thought could have been alleviated by prior information about potential findings. Information in connection with the scan was perceived as insufficient. Decision about amniocentesis was affected by attitudes to disability, anxiety about fetal loss due to the procedure, need for certainty by a diagnostic test, and partner's opinion.

CONCLUSIONS

Women were shocked by the unexpected and sometimes unwanted information on elevated risk for a chromosomal aberration for which they lacked any preparation. Because this event often has long-lasting effects on the pregnancy, models of information that are efficient in promoting informed decisions are imperative.

PRACTICE IMPLICATIONS

Both women and their partners need relevant information before and in connection with ultrasound scan to be able to make informed choices.

Referral for fetal echocardiography is associated with increased maternal anxiety

BACKGROUND

Referral for fetal echocardiography (fECHO) is an acute stressor that may induce significant maternal anxiety. To promote good clinical management of expectant mothers in this situation, including adequate screening for possible psychiatric interventions, data are needed regarding the psychosocial functioning of women scheduled for fECHO procedures.

OBJECTIVE

To investigate the association between fECHO and maternal anxiety.

METHODS

Pregnant women answered two questionnaires before first fECHO. The Spielberger State-Trait Anxiety Inventory (STAI) assessed how subjects feel "now" (state) versus how they "usually feel" (trait). Separate state and trait anxiety scores were calculated; scores were compared between the study cohort and a gestational age-matched historical cohort of 31 pregnant women who did not undergo fECHO. A second questionnaire developed by the investigators ascertained pregnancy specific concerns and characteristics.

RESULTS

Forty subjects were enrolled. The mean state score of the fECHO cohort (42.1 +/- 15.1) differed from the historical cohort (32.8 +/- 11.3; p = 0.006); however there was no difference between trait scores (34.7 +/- 10.8 vs. 35.4 +/- 12.8; p = 0.8). A multivariate linear regression model controlling for race and maternal age demonstrated that fECHO was a strong independent predictor of maternal state anxiety score (p = 0.004, beta = 10.4).

CONCLUSIONS

Pregnant women presenting for fECHO report high anxiety levels compared with women not presenting for fECHO. Clinician awareness and sensitivity are recommended and further investigation of modifiers of anxiety in this high risk group should be explored.

Exploring adoption with clients: the need for adoption education within the genetic counseling profession

Genetic counselors and other health professionals may encounter adoption during any counseling session. They must be skilled in using appropriate language and understand how to approach and discuss this topic with clients. A thorough knowledge of adoption as an option for clients facing a prenatal or postnatal diagnosis is necessary when presenting individuals with non-biased information needed for informed decision-making. However, three preliminary studies have demonstrated an absence of graduate education and lack of a professional knowledge base regarding this option (Mates 2008; Oksala 2007; Perry 2003). We discuss the impact of medical professionals' preconceptions on client decision-making, increasing early identification of fetal anomalies, deficiency of adoption knowledge and resources, and the resulting need for genetic counselors and other health professionals to develop their skills in discussing adoption with clients.

A critical appraisal of guidelines for antenatal care: components of care and priorities in prenatal education

There are a variety of published prenatal care (PNC) guidelines that claim a scientific basis for the information included. Four sets of PNC guidelines published between 2005 and 2009 were examined and critiqued. The recommendations for assessment procedures, laboratory testing, and education/counseling topics were analyzed within and between these guidelines. The PNC components were synthesized to provide an organized, comprehensive appendix that can guide providers of antepartum care. The appendix may be used to locate which guidelines addressed which topics to assist practitioners to identify evidence sources. The suggested timing for introducing and reinforcing specific topics is also presented in the appendix. Although education is often assumed to be a vital component of PNC, it was inconsistently included in the guidelines that were reviewed. Even when education was included, important detail was lacking. Addressing each woman's needs as the first priority was suggested historically and remains relevant in current practice to systematically provide care while maintaining the woman as the central player. More attention to gaps in current research is important for the development of comprehensive prenatal guidelines that contribute effectively to the long-term health and well-being of women, families, and their communities.

Prenatal testing for Down syndrome: comparison of screening practices in the UK and USA

Prenatal testing for Down Syndrome is a topic covered in every genetic counselor's training as it constitutes the main workload of genetic counselors in prenatal settings. Most Western countries nowadays offer some type of testing for Down Syndrome. However, practices vary according to country with regards to what tests are offered, insurance coverage and the legal situation concerning the option of terminating an affected pregnancy. In view of the growing interest in international genetic counseling issues, this article aims to compare prenatal testing practices in two English-speaking countries: the United Kingdom and the United States of America. A case will be presented to highlight some of the differences in practice. The topic underlines important implications for genetic counseling practice, such as patients' understanding of testing practices, risk perception, counseling provision and impact of prenatal testing results.

Improving residents' understanding of issues, comfort levels, and patient needs regarding screening for and diagnosing Down syndrome

OBJECTIVE

This study assessed obstetrics and gynecology and pediatrics residents' knowledge about Down syndrome (DS) and their comfort in delivering a prenatal or postnatal diagnosis of DS before and after interaction with a web-based tutorial.

STUDY DESIGN

A team of physicians, parents, and educational specialists developed an interactive tutorial that asked resident physicians to provide their own responses to "virtual patient" cases related to DS diagnoses in utero and at birth. We tested resident knowledge and comfort-level changes and their satisfaction with the web-based tool.

RESULTS

The study yielded significant improvement in knowledge and level of comfort changes with both obstetrics and gynecology and pediatric resident physicians at 16 programs nationally. There were no significant differences between the 2 specialties.

CONCLUSION

This interactive tutorial is effective in improving physicians' knowledge of and comfort level with imparting accurate, balanced information about DS pre- and postnatally.

Decisional needs assessment regarding Down syndrome prenatal testing: a systematic review of the perceptions of women, their partners and health professionals

OBJECTIVE

To identify decisional needs of women, their partners and health professionals regarding prenatal testing for Down syndrome through a systematic review.

METHODS

Articles reporting original data from real clinical situations on sources of difficulty and/or ease in making decisions regarding prenatal testing for Down syndrome were selected. Data were extracted using a taxonomy adapted from the Ottawa Decision-Support Framework and the quality of the studies was assessed using Qualsyst validated tools.

RESULTS

In all 40 publications covering 32 unique studies were included. The majority concerned women. The most often reported sources of difficulty for decision-making in women were pressure from others, emotions and lack of information; in partners, emotion; in health professionals, lack of information, length of consultation, and personal values. The most important sources of ease were, in women, personal values, understanding and confidence in the medical system; in partners, personal values, information from external sources, and income; in health professionals, peer support and scientific meetings.

CONCLUSION

Interventions regarding a decision about prenatal testing for Down syndrome should address many decisional needs, which may indeed vary among the parties involved, whether women, their partners or health professionals. Very little is known about the decisional needs of partners and health professionals.

Comparison of Prenatal Risk Calculation (PRC) with PIA Fetal Database software in first-trimester screening for fetal aneuploidy

OBJECTIVES

In February 2007 new software, Prenatal Risk Calculation (PRC), for calculating the risk of fetal aneuploidy was introduced in Germany. Our aim was to investigate its test performance and compare it with that of the PIA Fetal Database (PIA) software developed and used by The Fetal Medicine Foundation.

METHODS

Between 31 August 1999 and 30 June 2004 at the Women's Hospital of the Medical University of Hanover in Germany, 3120 singleton pregnancies underwent combined first-trimester screening at 11 + 0 to 13 + 6 weeks of gestation. Calculation of risk for fetal aneuploidy was computed prospectively using the PIA software. In a subsequent retrospective analysis, we recalculated risks for the 2653 of these datasets with known fetal outcome using the PRC software and compared the results.

RESULTS

Of the 2653 datasets analyzed, 17 were cases of aneuploidy. At a cut-off of 1 : 230, for the detection of fetal aneuploidy, the respective sensitivity, false-positive rate and positive predictive value were 70.6%, 4.1% and 9.9% for PRC and 76.5%, 2.9% and 14.6% for PIA. At a cut-off of 1 : 300, the equivalent values were 70.6%, 5.6% and 7.5% for PRC and 76.5%, 4.0% and 11.0% for PIA. The differences in test performance between the two types of software were highly significant (P < 0.0001).

DISCUSSION

The test performance of PRC was inferior to that of PIA, the sensitivity for detection of fetal aneuploidy being lower and the false-positive rate higher. Had PRC been employed prospectively in our study, 40% more women examined would have been offered unnecessarily an invasive procedure for fetal karyotyping.

Towards understanding the concept of risk for pregnant women: some nursing and midwifery implications

AIMS AND OBJECTIVES

This paper aims to explore the concept of risk in pregnancy.

BACKGROUND

Notions of risk and 'not knowing' have always surrounded pregnant women, although in the last two decades trends of increased consumer confidence and midwifery activism have together promoted a greater appreciation of pregnancy as a normal life event. At the same time, advances in pregnancy-related technologies have contributed new levels of concern related to an increasing ability to detect minor abnormalities by ultrasound. This, in turn, causes a concordant rise in the number of women referred to high-risk pregnancy care to monitor suspect findings. Overall, it seems likely that this increasing emphasis on abnormality detection and risk may have serious implications for women.

DESIGN

Concept analysis.

METHOD

In this paper, I undertake an exploration of the concept of risk as understood by health professionals and pregnant women. Then, using Deborah Lupton's understanding of a 'discourse of risk', I discuss the ways pregnant women both contribute to and are enmeshed in, this discourse. In the final section, I consider how nurses act informally to shield vulnerable women.

CONCLUSIONS

Health professionals and pregnant women understand risk differently. Women employ a subjective appraisal of risk, measuring it against their personal values and prior experience, while health professionals evaluate risk in an objective manner.

RELEVANCE TO CLINICAL PRACTICE

As increasing numbers of women are referred to 'at risk' care, it is important that health professionals understand and respond to maternal understandings of risk. Nurses and midwives particularly, have a role to play in assisting women to make sense of risk calculations. In this way, they can act to ameliorate the growing concept of risk for pregnant women.

Fitting observed and theoretical choices - women's choices about prenatal diagnosis of Down syndrome

Choices regarding prenatal diagnosis of Down syndrome - the most frequent chromosomal defect - are particularly relevant to decision analysis, since women's decisions are based on the assessment of their risk of carrying a child with Down syndrome, and involve tradeoffs (giving birth to an affected child vs procedure-related miscarriage). The aim of this study, based on face-to-face interviews with 78 women aged 25-35 with prior experience of pregnancy, was to compare the women' expressed choices towards prenatal diagnosis with those derived from theoretical models of choice (expected utility theory, rank-dependent theory, and cumulative prospect theory). The main finding obtained in this study was that the cumulative prospect model fitted the observed choices best: both subjective transformation of probabilities and loss aversion, which are basic features of the cumulative prospect model, have to be taken into account to make the observed choices consistent with the theoretical ones.

Perception of risk in relation to ultrasound screening for Down's syndrome during pregnancy

OBJECTIVE

to explore how information about being at risk of carrying a fetus with Down's syndrome was understood, and whether the actual risk and the woman's perception of risk was associated with worry or depressive symptoms during and after pregnancy.

DESIGN AND SETTING

observational study. The sample was drawn from the intervention group of a Swedish randomised controlled trial of ultrasound screening for Down's syndrome by nuchal translucency measurement.

MEASUREMENTS

data were collected by three questionnaires. Questions were asked about recall of the risk score and perception of risk. The Cambridge Worry Scale and the Edinburgh Postnatal Depression Scale measured worry and depressive symptoms, respectively, on all three occasions.

FINDINGS

of the 796 women who provided data for this study, one in five was unaware that the risk score was noted in her case record. In total, 620 women stated that they had received a risk score, but only 64% of them recalled the figure exactly or approximately. The actual risk was associated with the perceived risk, but of the 31 women who perceived the risk to be high, only 14 were actually at high risk. A high-risk score was not associated with worry or depressive symptoms in mid-pregnancy, in contrast to a woman's own perception of being at high risk. Two months postpartum, no associations were found between maternal emotional well-being and actual or perceived risk.

CONCLUSIONS

information about fetal risk is complicated and women's perception of risk does not always reflect the actual risk, at least not when presented as a numerical risk score. The possibility that the information may cause unnecessary emotional problems cannot be excluded.

IMPLICATIONS FOR PRACTICE

caregivers should ascertain that information about fetal risk is interpreted correctly by pregnant women.

[Clinical approach and epidemiological aspects of mood and anxiety disorders during pregnancy and postpartum. Review and synthesis]

The aim of this article is to review clinical and epidemiological data on pre- and postnatal anxious and depressive disorders. To this end, we systematically analysed definitions, prevalence, risk factors and obstetrical consequences of perinatal disorders, as reported in seminal as well as more recent publications. We report and discuss the most consensual results about anxious and depressive disorders of pregnancy and the postpartum, with special emphasis on maternity blues, postpartum depression and postpartum psychosis. Reviewed data confirm that the perinatal period is a time of high risk for the onset or exacerbation of several anxious or depressive disorders, which are likely to impede the normal progress of pregnancy or the child's development. The potential severity of bipolar disorders and puerperal psychosis is highlighted by the fact that they heavily contribute to maternal mortality. The specificity of perinatal disorders, their impact on public health, the extensive research and mounting knowledge in that field, provide ample justification for the recognition of perinatal psychiatry as a distinct branch of psychiatry.