Prenatal screening and diagnosis: some psychological and social issues

Update and Review: Maternal Serum Screening

Maternal serum levels of alpha fetoprotein (AFP), human chorionic gonadotropin (hCG), and unconjugated estriol (uE3) can be used to screen pregnancies for neural tube defects, Down syndrome, Trisomy 18, and pregnancy complications. This article summarizes the most recent information regarding maternal serum screening, including genetic counseling issues.

The maternal self in pregnant women undergoing maternal serum screening

BACKGROUND

Much has been written about the anxiety of pregnant women undergoing maternal serum screening, but little has focused on the maternal self.

AIMS

The purpose of this study was to explore how the maternal self was affected by abnormal results of prenatal screening. Design. A qualitative design was used, based upon a grounded theory method.

METHODS

Twenty-seven women undergoing maternal serum screening engaged in qualitative interviews about how abnormal results affected them and their family life.

RESULTS

This study identified three forms of maternal self in women who had been informed of abnormal results of maternal serum screening. The three forms of maternal self could be described as self-stigmatizing, self-conflicting and self-knowledgeable.

CONCLUSION

The self-stigmatizing and self-conflicting resulted from painful body image. The pregnant women responded to this vulnerability by reflecting on their experiences and constituting self-knowledgeable.

RELEVANCE TO CLINICAL PRACTICE

This study demonstrated that ethical issues were implicit in prenatal counselling in terms of various forms of maternal self. Understanding the self-perceptions of pregnant women coping with an increased risk of Down Syndrome could be very significant in delivering prenatal genetic counselling.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Modern maternity care: does safety have to take the meaning out of birth?

In this paper the author questions whether a medical model is sufficient for our understanding of the complexity of childbirth, and for the provision of high quality maternity care. The importance of a psychological perspective is stressed by describing the adaptive processes during pregnancy and birth, and by analysing the impact of certain medical procedures on women's experiences, such as ultrasound screening during pregnancy and obstetric analgesia in labour. The paper is modified from the "Meredith Memorial Lecture 1995' given at La Trobe University, Melbourne, and a Keynote address at the 24th Triennial Congress of the International Confederation of Midwives in Oslo, May 1996.

Psychosocial issues raised by a familial ovarian cancer register

A Familial Ovarian Cancer Register has been established which has recruited primarily through media publicity. In depth semi-structured interviews were carried out with 20 women who had volunteered in order to explore (1) knowledge about the disease, (2) motivations for contacting the Register, and (3) expectations. We found that interviewees were generally well informed about the symptoms of the disease as a result of their relatives' experiences. There was, nevertheless, a need for information which the Register was seen as potentially fulfilling, although most subjects gave altruistic reasons for volunteering. Only one interviewee said that the publicity about the Register had made her more anxious. Most said that their anxieties had not been affected either way by the Register. Subjects did not have a clear idea of what being on the Register would mean, although there was an expectation of screening for early signs of the disease. Many interviewees had models of familial disease which did not follow mendelian genetics. This has implications for the targetting of education and screening programmes. Other psychosocial issues raised by a register of this kind are discussed, many of which require continuing monitoring to ensure that the psychological costs do not outweight the benefits.

The psychological costs of screening for cancer

The benefits of cancer screening programmes accrue to those who have cancer or identifiable precancerous conditions, and in whom the disease progression is slowed or halted by earlier intervention. The costs accrue to the rest of the population for whom there is no direct benefit to health. Attention has been given to the medical risks of screening procedures and to the economic costs, but there has been very little regard paid to the psychological costs. The aim of this paper is to evaluate the psychological impact of screening. Screening participants who are found to have untreatable disease, or for whom the interventions prove ineffective, have a greater proportion of their life as a cancer patient with all the associated psychological (and perhaps physical) distress, but no increase in their life expectancy. Those who receive false positive results may experience acute psychological distress produced by the prospect of a grave diagnosis before they are found to be free from serious disease. Even the procedure of screening itself, with the disturbance of the invitation, the discomfort of the tests and the wait for the diagnosis, can have a significant impact upon some patients. This paper evaluates the psychological costs which may be involved across the whole screening procedure, from the possible alarm of receiving an invitation to participate in screening, to the trauma of a cancer diagnosis for someone who had been unaware of any symptoms.

Prenatal diagnosis and caring

Although the science of prenatal diagnosis is rapidly expanding, the art of caring for these patients is poorly understood and taught. Prenatal diagnosis programs must acknowledge the psychosocial consequences of electing to undergo prenatal testing, receiving either normal or abnormal test results, and choosing to continue or terminate a pregnancy with an identified fetal defect. There are suggestions from the literature of interventions to assist families under these circumstances (Table 3). Prospective studies of patient adaptation are needed; however, on the basis of the retrospective studies and common sense, a reasonable plan for patient support and care can be established. Prenatal diagnosis programs must demand not only excellent medical knowledge and technical expertise but also compassionate and continued care for the patient, her partner, and family.