Levels of knowledge of Down syndrome and Down syndrome testing in Australian women

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.

Information about prenatal screening for Down syndrome: ethnic differences in knowledge

OBJECTIVE

To evaluate the provision of information about prenatal screening for Down syndrome to women of Dutch, Turkish and Surinamese origins, and to examine the effects of this provision on ethnic differences in knowledge about Down syndrome and prenatal screening.

METHODS

The study population consisted of 105 Dutch, 100 Turkish and 65 Surinamese pregnant women attending midwifery or obstetrical practices in The Netherlands. Each woman was personally interviewed for 3 weeks (mean) after booking for prenatal care.

RESULTS

Most women reported to have received oral and/or written information about prenatal screening by their midwife or obstetrician at booking for prenatal care. Turkish and Surinamese women less often read the information than Dutch women, more often reported difficulties in understanding the information, and had less knowledge about Down syndrome, prenatal screening and amniocentesis. Language skills and educational level contributed most to the explanation of these ethnic variations.

CONCLUSION

Although most Dutch, Turkish and Surinamese women reported to have received information from their midwife or obstetrician, ethnic differences in knowledge about Down syndrome and prenatal screening are substantial.

PRACTICE IMPLICATIONS

Interventions to improve the provision of information to women from ethnic minority groups should especially be aimed at overcoming language barriers, and targeting information to the women's abilities to comprehend the information about prenatal screening for Down syndrome.

Do women know that prenatal testing detects fetuses with Down syndrome?

This questionnaire-based study in Victoria, Australia, examined the responses of pregnant women, aged 37 years and over, to a question about what they expected prenatal testing (screening and/or diagnosis) for birth defects to tell them about their pregnancy. Content analysis showed that, of the 432 tested women, 61.3% mentioned Down syndrome, chromosomal abnormalities or trisomies. Women undergoing both screening and diagnosis were more likely than those having one or other test to mention Down syndrome (adjusted OR = 1.6, P = 0.06), having adjusted for age, marital status, education, residence and parity. Similarly, those from an English-speaking background were more likely to mention Down syndrome, etc. compared to women from a non-English-speaking background (adjusted OR = 3.5, P < 0.001). Down syndrome, a fundamental piece of information about prenatal tests, was not mentioned in nearly 40% of women's responses. This suggests that pregnant women need clearer information about prenatal testing, including the conditions that might be detected.

Do pregnant women in Greece make informed choices about antenatal screening for Down's syndrome? A questionnaire survey

OBJECTIVE

to investigate the knowledge and attitudes towards Down's syndrome screening among pregnant women presenting for prenatal screening in Greece, in order to explore whether Greek women are able to make informed choices.

DESIGN

survey using self-administered questionnaires.

SETTING

public hospital in Athens, Greece.

PARTICIPANTS

135 pregnant women with a gestational age of between 11 and 20 weeks, just before antenatal screening for Down's syndrome.

FINDINGS

a total of 96% of women had a positive attitude towards screening and 45% had a good level of knowledge concerning the screening process for Down's syndrome. A standard measure of informed choice was used, which was validated for use in Greek. We found that 44% of women made an informed choice and 56% of women made an uninformed choice. This was because of the low percentage of women with a good level of knowledge. It was also found that knowledge and attitudes were not associated and seemed to be independent of each other. A higher level of informed choice was associated with a higher level of educational achievement and income, time of decision-making and the satisfaction with the decision.

CONCLUSIONS

health professionals should ensure that all women receive appropriate and intelligible information about antenatal screening for Down's syndrome. This information should be suited to women's learning ability in order to increase their knowledge before undergoing screening. Health professionals should educate and increase women's knowledge, and also give women a chance to explore their attitudes and discuss the issues involved.

IMPLICATIONS FOR PRACTICE

on the basis of the current measure of informed choice, we found that knowledge is a weak determinant of uptake of screening. However, the measure focuses on knowledge regarding the screening process, rather than on the condition itself. In addition, informed choice is a far broader concept than the issues covered by the measurement tool. Therefore, it could be concluded that attempts to increase attitude-behaviour consistency (i.e. to increase uptake for women with positive attitudes towards screening and to decrease uptake for women with negative attitudes) could be more successful in increasing informed choice in screening for Down's syndrome in Greece.

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.

Informed choice in women attending private clinics to undergo first-trimester screening for Down syndrome

OBJECTIVES

Informed choice for prenatal screening has long been considered an essential aspect of service provision, and has been researched extensively in the second trimester. This study aims at examining whether women having first-trimester screening in a private clinic had made an informed choice.

METHODS

A cross-sectional survey recruited women having first-trimester screening at specialist ultrasound practices. Two questionnaires containing a validated Multidimensional Measure of Informed Choice (MMIC) were self-administered pre- and post-screening.

RESULTS

MMIC was completed by 81% (163/202) of women. Ninety-nine percent of women had a positive attitude towards screening, therefore informed choice was essentially measured on knowledge alone. Pre-screening, 68% made an informed choice, compared with 74% post-screening (chi2 = 1.6, p = 0.21 (McNemar)). Knowledge was associated with education level, information sources and perception of screening as routine or optional.

CONCLUSIONS

The Australasian Guidelines on prenatal screening state that all women having testing should be provided with written information, and it should be ensured that they have appropriate understanding of the test(s). These guidelines are not being met, even in private clinical care. Health professionals should ensure that all women are provided with suitable information about prenatal screening that is tailored to their level of education and individual needs, and should emphasise that screening is optional.

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.

Attitudes of new mothers towards genetics and newborn screening

OBJECTIVE

To evaluate new mothers' opinions of genetics and newborn screening.

SETTING

An Australian tertiary referral hospital.

POPULATION

232 women who delivered a liveborn infant and had received written and verbal information on newborn screening from midwifery staff during their antenatal care.

METHODS

Participants were interviewed within 24 hours of blood being taken from their baby by heel prick for the newborn screen. Non-English speaking women were included using medical interpreters. The questionnaire evaluated opinions about newborn screening and parental consent. The opportunity was used to also question their views on the impact on lifestyle and discrimination of a theoretical diagnosis of genetic disease or carrier status in their baby.

MAIN OUTCOME

Descriptive data on mother's attitudes.

RESULTS

200 women consented to participate in the study (86.2% response). New mothers supported newborn screening programs where outcomes could be used to prevent or reduce the severity of a disease (85-86% support), but were less supportive if screening had been used to assist with future family planning (65%). The majority of women (86%) felt that parental consent was mandatory before newborn screening tests were performed. A similar number felt that consent would be required before blood samples could be used if a National DNA library were to be created. The majority of women expressed concern that a child with a genetic illness would face discrimination and difficulty obtaining insurance or employment. A third of women felt that even a carrier of a genetic illness would face similar discrimination.

CONCLUSION

Acceptance of newborn screening programs is high but mothers consider the need for consent to be mandatory. They have concerns about discrimination children with genetic illnesses may face.

It's ‘back to school’ for genetic screening

Implementation of population genetic screening programmes requires consideration of strategies for reaching the greatest proportion of the target population in order to achieve maximum awareness. This article reviews the current strategy of school-based population genetic screening programmes. The school environment is an ideal setting for offering relevant genetic screening programmes as it provides an opportunity to engage people at a time when they are exposed to a range of educational experiences and are sufficiently mature to be involved in decision-making processes. Such programmes allow all students, not only those studying biology, an opportunity to be educated and experience genetic screening in a supportive environment, ultimately increasing understanding and empowering students. While the major form of genetic screening in schools has been for reproductive health information (eg carrier screening for TaySachs disease and cystic fibrosis), genetic screening in schools for other conditions may be a timely proposition.

Factors affecting mothers' knowledge of genetic screening

OBJECTIVE

To evaluate mothers' knowledge of terms used in genetic counselling and their participation in Down syndrome and newborn screening.

SETTING

An obstetric tertiary referral hospital in Australia.

POPULATION

A total of 232 consecutive women delivering a liveborn baby.

METHODS

Participants were interviewed within 24 h of blood being taken from their baby by the heel prick test for the newborn screen. Non-English speaking women were included using medical interpreters. The questionnaire assessed knowledge of terms used in genetic counselling for Down syndrome and newborn screening. A second researcher, blinded to subject demographics, scored questionnaires using a predefined scoring system.

MAIN OUTCOME

Demographic factors affecting knowledge and knowledge of Down syndrome and newborn screening test uptake.

RESULTS

A total of 200 women consented to participate in the present study (86.2%). New mothers had limited knowledge of genetic disease (median: 4/15, interquartile range: 2-8). In multivariate analysis, Caucasian ethnic background, English as the first language, higher level of education, and knowledge of family history were significant associations of higher knowledge scores (all P <0.006). The majority of participants who had Down syndrome testing (54%) were aware that they had done so (51.5%; kappa=90.9%). In multivariate analysis age >35 years, English as a first language and non-married status were associated with increased test uptake. In contrast, only 26.5% of participants knew that their child had undergone the newborn screen, despite it having been carried out on 98% of babies (kappa=1.5%).

CONCLUSION

Newborn screening practices may need to be reviewed.

Down syndrome screening: What do health professionals know?

OBJECTIVE

To assess the level of knowledge about Down syndrome screening among a sample of health professionals providing antenatal care.

DESIGN

A structured questionnaire-based survey.

SETTING

Health professionals allied to a tertiary level maternity hospital in metropolitan Melbourne.

METHODS

A self-administered questionnaire was given or posted to 166 health care providers to assess their knowledge of prenatal Down syndrome screening.

RESULTS

A total of 140 completed surveys were returned (83% response rate), including 70 from general practitioners, 34 from midwives, 33 from obstetricians and three from geneticists. Of these, 130 confirmed that they regularly counsel women about prenatal screening for Down syndrome. Sixteen per cent of those indicated that they only offered testing to selected 'high risk' women rather than all women. Overall, there was a high level of awareness regarding the gestations at which the commonly used screening tests are offered but a poor appreciation of the relative performances of those tests. Seventy-eight (60%) of those counselling indicated that they discussed detection and screen positive rates specific for the age of the woman. However, less than 10% were able to provide those rates.

CONCLUSION

Knowledge of Down syndrome screening was variable among those who regularly counsel women about these tests. The results of the present survey highlight the need for professional education about prenatal screening.

Women's preferences for reporting of Down syndrome screening results

OBJECTIVE

The aim of this study was to determine whether women prefer the results of screening for Down syndrome tests to be reported as the risk of Down syndrome in early pregnancy at the time of the screening test or the risk at delivery (which takes into account the number of Down syndrome pregnancies that will be spontaneously lost before birth).

DESIGN

A structured questionnaire.

SETTING

A tertiary hospital antenatal clinic.

SAMPLE

One hundred and fifteen English-speaking women who expressed an interest in having screening tests for Down syndrome performed.

METHODS

A structured questionnaire exploring women's preferences for risk reporting was self administered by women attending for their first antenatal visit.

MAIN OUTCOME MEASURES

Women's preference for reporting of screening test results as risk at time of test, risk at birth or both, and the reasons for this preference.

RESULTS

The majority (n = 82) of women preferred to have both the risk of Down syndrome at the time of screening and at the time of birth reported. The most common reason (n = 60) given for this preference was a desire to have as much information available as possible so that an informed decision regarding further investigations could be made.

CONCLUSIONS

The majority of women prefer to receive Down syndrome screening results as both the risk at the time of the test and the risk at birth.

Diagnosis of trisomy 21 in preimplantation embryos by single-cell DNA fingerprinting

Many couples presenting for preimplantation genetic diagnosis (PGD) for a single gene disorder are of advanced reproductive age (>35 years) and have a greater chance of producing embryos with chromosomal aneuploidies. The most common chromosomal aneuploidy observed in newborns is trisomy 21, or Down's syndrome. Consequently, the availability of a highly reliable system that simultaneously detects the heritable gene disorder and trisomy 21 would be beneficial to couples at specific risk. A pentaplex chromosome 21 (Ch 21) single-cell DNA fingerprinting system was developed in a multiplex fluorescence polymerase chain reaction (FL-PCR) on single cells. High reliability and accuracy rates were observed, together with low allele dropout (ADO) and preferential amplification rates on diploid buccal cells, trisomy 21 buccal cells and blastomeres derived from Ch 21 aneuploid embryos. A combined multiplex FL-PCR format was optimized with the common cystic fibrosis delta F508 mutation and validated on single buccal cells from a carrier of the cystic fibrosis delta F508 mutation. This new test is a very powerful technique, which also allows confirmation of the embryo parentage and the identification of extraneous DNA contamination that could cause a misdiagnosis in PGD cases.