The choices women make about prenatal diagnosis

Parental refusal of prenatal screening for aneuploidies

OBJECTIVES

To analyze the reasons for refusal of aneuploidy screening in a multicultural Middle Eastern population.

METHODS

The study included patients delivering in a university hospital, who had refused aneuploidy screening during their pregnancy. We evaluated through a questionnaire submitted during the postpartum period the sociodemographic characteristics, beliefs, attitudes, and the main reason underpinning their choice. Religious, ethical, and financial factors, personal beliefs, medical information, perceived media information, and familial input were assessed through a Likert scale.

RESULTS

Our pilot study included 70 patients. The main reason (33 %) was the refusal to terminate pregnancy if the screening tests ultimately led to a diagnosis of aneuploidy. Lack of adequate information on the availability and benefits of this screening method (28 %), religious beliefs (17 %), in addition to other minor reasons such as financial considerations, familial recommendations, late pregnancy follow-ups, and media influence were also identified as contributing factors.

CONCLUSIONS

Aneuploidy screening is routinely offered to couples, with varying uptake rates observed worldwide. Sufficient information on prenatal screening and diagnosis should be provided to all pregnant women, presenting all available options, thus enabling them to make a free and informed choice during their pregnancy.

Risk perception in pregnancy: a concept analysis

AIM

To report an analysis of the concept of risk perception in pregnancy.

BACKGROUND

Pregnant women are increasingly exposed to the view that pregnancy and childbirth are intrinsically dangerous, requiring medical monitoring and management. Societal pressures are applied to women that dictate appropriate behaviours during pregnancy. These changes have resulted in increased perception of risk for pregnant women.

DESIGN

Walker and Avant's method was selected to guide this analysis.

DATA SOURCES

Peer-reviewed articles published in English from CINAHL, Scopus, PubMed and Psychinfo. No date limits were applied.

METHODS

Thematic analysis was conducted on 79 articles. Attributes, antecedents and consequences of the concept were identified.

RESULTS

The attributes of the concept are the possibility of harm to mother or infant and beliefs about the severity of the risk state. The physical condition of pregnancy combined with the cognitive ability to perceive a personal risk state is antecedents. Risk perception in pregnancy influences women's affective state and has an impact on decision-making about pregnancy and childbirth. There are limited empirical referents with which to measure the concept.

CONCLUSION

Women today know more about their developing infant than at any other time in history; however, this has not led to a sense of reassurance. Nurses and midwives have a critical role in assisting pregnant women, and their families make sense of the information they are exposed to. An understanding of the complexities of the concept of risk perception in pregnancy may assist in enabling nurses and midwives to reaffirm the normalcy of pregnancy.

Embodied Knowledge and Making Sense of Prenatal Diagnosis

Open-ended, qualitative interviews with women to whom amniocentesis was offered were analyzed to understand how women made sense of these tests. We found that women, whether tested or not, negotiated with biomedical information. They transformed it through identifiable processes, then wove it with their own instincts and beliefs and with their personal experiences, thereby creating "embodied" knowledge on which their decisions were based. Women who were and were not tested may have differed from each other when categorized on the basis of a final, binary choice, but they were more alike than unalike in reaching this point. The apparent importance of embodied knowledge suggests the critical role of the listening activities of the genetic counselor and of awareness of the validity and importance of women's complementary ways of knowing and doing in understanding the uses and meanings of prenatal genetic testing.

Awareness and attitude toward prenatal diagnosis of chromosomal abnormalities in patients with no access to legal termination of pregnancy

OBJECTIVE

To analyze variables affecting couples' decision making about prenatal cytogenetic diagnosis in patients with no access to legal termination of pregnancy (TOP).

METHODS

Patients undergoing invasive prenatal diagnosis were anonymously surveyed after counseling and before the procedure. The questionnaire enquired about sociodemographic features, medical history, knowledge of and attitudes toward genetic testing and TOP.

RESULTS

Two genetic units distributed 372 questionnaires. Mean maternal age was 36 +/- 4 years. Access to prenatal genetic counseling was mainly patient's own initiative, or 'self-referral'. Most self-referred patients (87%) considered that 'receiving accurate information' was the main issue. Eighty-one per cent of all couples knew that TOP because of fetal anomalies was not legal. In case of a serious anomaly, 68.2% of patients would contemplate TOP, in spite of the risk of being exposed to an unsafe abortion.

CONCLUSIONS

In many countries, prenatal genetic testing is offered, but TOP is not available. In the present study, although most of the couples who decided to undergo prenatal genetic testing were aware of this, they still chose to perform prenatal diagnosis. The main reason given was to obtain reliable information about fetal condition. Finally, if a fetal chromosomal abnormality were detected, most of them would consider TOP.

The routine and the traumatic in prenatal genetic diagnosis: does clinical information inform patient decision-making?

With the increasing technical sophistication of medicine, clinicians' task of assuring patient informed consent is increasingly elusive. Taking the example of prenatal genetic testing, we examine efforts to communicate the complexities of genetic knowledge and risk calculation to patients. In this qualitative, descriptive study, we interviewed 50 clinicians and 40 patients, and observed 101 genetic counseling sessions. We found the clinicians and patients have different goals, purposes, and values regarding testing, which affect their clinical interactions. The information the clinicians provide patients reflects their clinical interest in identifying and controlling pathophysiology, while patients, in contrast, are most concerned with protecting and nurturing their pregnancy. We argue informed patient decision-making about prenatal testing options requires information that is responsive to patient interests. We recommend developing a shared decision-making approach, to facilitate the full participation of both clinicians and patients in the decision-making process.

Residual risk for cytogenetic abnormalities after prenatal diagnosis by interphase fluorescence in situ hybridization (FISH)

Results from conventional cytogenetic studies on 21 609 amniotic fluid specimens were analyzed retrospectively to determine the residual risk for a cytogenetic abnormality if interphase FISH, capable of only detecting aneuploidy for chromosomes 13, 18, 21, X and Y, was performed and did not reveal an abnormality. Detection rates (the probability of detecting a cytogenetic abnormality when an abnormality is present) and residual risks (the likelihood of a cytogenetic abnormality, in view of normal interphase FISH results) were calculated for the four major clinical indications for prenatal diagnosis (advanced maternal age, abnormal maternal serum screen indicating increased risk for trisomy 18 or trisomy 21, abnormal maternal serum screen indicating increased risk for neural tube defects and ultrasound abnormality). Differences in detection rates were observed to depend on clinical indication and presence or absence of ultrasound abnormalities. The detection rate ranged from 18.2 to 82.6% depending on the clinical indication. The detection rates of abnormalities significant to the pregnancy being evaluated (i.e. abnormalities excluding familial balanced rearrangements and familial markers) were between 28.6 and 86.4%. The presence of ultrasound abnormalities increased the detection rate from 72.2 to 92.5% for advanced maternal age and from 78.6 to 91.3% for abnormal maternal serum screen, indicating increased risk for trisomy 18 or trisomy 21. With regard to residual risk, the risk for a clinically significant abnormality decreased from 0.9-10.1%, prior to the interphase FISH assay, to a residual risk of 0.6-1.5% following a normal interphase FISH result in the 4 groups studied. Providing patients with detection rates and residual risks, most relevant to their situation (clinical indication and presence or absence of ultrasound abnormality) during counseling, could help them better understand the advantages and limitations of interphase FISH in their prenatal diagnostic evaluation.

Anxiety among women who have undergone fertility therapy and who are considering multifetal pregnancy reduction: trends and implications

OBJECTIVE

Our primary objective was to evaluate the assumption that women carrying multiple fetuses and who have decided upon multifetal pregnancy reduction (MFPR) have a constant high level of anxiety.

METHODS

A total of 66 multigestation women considering MFPR were asked to consider how anxious they were when they first started fertility therapy. Using that level of anxiety as a reference point, and using their self-assessments as a vehicle for probing the meaning they attached to their emotional state through time, they then assessed their anxiety level at different points in their pregnancy.

RESULTS

Self-reported anxiety across time displayed considerable variation: there was a large drop in anxiety with pregnancy diagnosis. The women's anxiety rose to very high levels with the diagnosis of carrying multiples. Anxiety moderated again on average with consultation, rose sharply during the course of the procedure, and finally dropped to lower levels on average after the procedure was over.

CONCLUSIONS

We conclude that women with multigestation experience considerable fluctuations in their level of anxiety from the time that they first start fertility therapy until they learn that they are carrying multiple embryos. Their expectations for the future of becoming pregnant seem at last fulfilled (becoming pregnant), become complicated (with multiples), appear salvageable (with consultation), but with a morally complicated resolution (MFPR) that seems at last to have put the pregnancy back on a normal track (post-MFPR). Those working with MFPR patients before, during and after the operation must understand the nature and variability of the anxiety that their patients are confronting, and how they are attempting to construct a safe passage through the moral dilemma associated with the multiple-gestation situation.

Latinas, amniocentesis and the discourse of choice

Little attention has been paid to the impact of the increasingly routine use of fetal diagnosis on how U.S. minority women experience their pregnancies and decide whether to have their fetuses tested. Using narrative analysis, we offer the account of one Latina who, despite considerable turmoil, ultimately accepted an offer of amniocentesis. We describe her reasoning in choosing a course of action. Data from interviews with 147 Latinas who were faced with the same decision are used to contextualize the case study material. We seek to illuminate how a blending of Mexican and European American cultural influences helped shape the woman's experience and define the dilemma she faced when she learned her fetus might be born with a grave or incurable condition because she was ideologically opposed to abortion.

Psychosocial aspects of infertility and decisions about reproduction in young cancer survivors: a review

BACKGROUND

Several types of cancer treatment interfere with male and female fertility or can complicate pregnancy. Rates of birth defects and cancer have also been studied in the offspring of cancer survivors. Little is known, however, about the impact of a history of cancer on survivors' attitudes, anxieties, and choices about having children of their own.

PROCEDURE

We review the relevant literature on cancer survivor's concerns about infertility and childbearing and propose areas for future research.

RESULTS

We generate several hypotheses, including that cancer survivors will be more distressed than infertility patients without a major medical disorder, that survivors diagnosed in adolescence will have the most anxieties about parenthood, that women will be more distressed over infertility and more concerned about their children's health than men, that survivors who rate their overall quality of life more negatively will be less concerned about infertility and more apt to decide to forego parenthood, that survivors of inheritable cancer syndromes will have more distress about childbearing issues than other survivors, and that survivors who do have children after treatment will perceive them more positively than do parents who have not confronted cancer.

CONCLUSIONS

Research on the emotional aspects of infertility after cancer and on the factors that influence survivors' decisions about having children assumes increasing importance with the growth in number of survivors of reproductive age.

Determinants of parental decisions after the prenatal diagnosis of Down syndrome

We evaluated demographic factors and factors specific to the current pregnancy, and their relationship to the decision to continue or terminate a pregnancy after prenatal diagnosis of Down syndrome. All cases of Down syndrome (DS) managed at a tertiary care center from 1989-1997 were retrospectively analyzed with respect to maternal age, parity, gestational age, sonographic findings, insurance status, and race. Of 145 cases of trisomy 21, 19 (13.1%) of women chose continuation of pregnancy, while 126 (86.9%) chose termination. There were no differences between groups in parity, sonographic findings, insurance status, or race at the time of diagnosis. However, patients who chose termination were significantly older and earlier in gestation than those electing to continue their pregnancy. When Down syndrome is diagnosed prenatally, the choice of termination is related to maternal age and gestational age, but only gestational age is a significant independent predictor of pregnancy termination.

Healing fictions': stories of choosing in the aftermath of the detection of fetal anomalies

Between the cultural story of prenatal diagnosis emphasizing the expansion of choice and the countercultural story emphasizing the lack of choice are the individual stories of choosing told by expectant and new parents after learning of the existence of a fetal impairment. The results of a qualitative, descriptive study involving 40 interviews with 15 women and 12 of their partners suggest that they had often 'backed into', as opposed to having actively chosen or refused, prenatal testing. After learning of their babies' impairments, they constructed subtly different accounts of pregnancies continued or terminated that located the moral agency for effecting these pregnancy outcomes either in themselves or elsewhere. These emplotments of choice can be summarized as nature's choice, disowned choice, choice lost, close choice and choice found. The findings raise questions concerning which of these or other constructions of choice in the aftermath of positive fetal diagnosis are the most effective in promoting psychological recovery and optimum parent-infant interactions.