What participants understand about a maternal serum alpha-fetoprotein screening program

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.

Preconception counseling: do patients learn about genetics from their obstetrician gynecologists?

PURPOSE

The purpose of this observational survey study is to assess genetic knowledge in reproductive-aged women and to determine the role played by their obstetricians in their education.

METHODS

A 31-item survey was distributed via an internet survey service to women between the ages of 18 and 45. The survey included subject demographics, a query regarding the source of subjects' knowledge of genetics, and 6 question genetics quiz with 3 fundamental questions and 3 advanced questions. Subjects were divided into parous and nulliparous groups, and responses were compared using student's t-test for continuous variables and chi square for proportions.

RESULTS

Participants included 207 parous and 221 nulliparous women. There were no differences in demographic characteristics including age and education. Parous women scored significantly higher than nulliparous women on the fundamental genetics quiz (71 vs 61 %, p = 0.03). This difference remained but was no longer significant when the 3 advanced questions were included (48 vs 42 %). Only 39 % of parous and 8 % of nulliparous subjects listed their physician as one of their main sources of genetic information. 78 % of all subjects stated that they would prefer to receive genetic information from their physicians over other sources.

CONCLUSIONS

Recently parous women scored higher on a genetics assessment quiz than did their nulliparous counterparts, but the majority did not cite their obstetrician gynecologists as a main source of information. As genetic counseling and testing are becoming increasingly important aspects of obstetrical care, obstetricians should play a more substantial role in educating their patients.

Integrating stakeholder perspectives into the translation of cell-free fetal DNA testing for aneuploidy

BACKGROUND

The translation of novel genomic technologies from bench to bedside enjoins the comprehensive consideration of the perspectives of all stakeholders who stand to influence, or be influenced by, the translational course. Non-invasive prenatal aneuploidy testing that utilizes cell-free fetal DNA (cffDNA) circulating in maternal blood is one example of an innovative technology that promises significant benefits for its intended end users; however, it is currently uncertain whether it will achieve widespread clinical implementation. We conducted qualitative interviews with 18 diverse stakeholders in this domain, including prospective users of the technology and healthcare personnel, researchers and developers, and experts in social, legal, and regulatory aspects of genetic technology, and a pilot survey of 62 obstetric healthcare providers. Analysis of interview and survey data was combined with a review of the proceedings of a full-day, multidisciplinary conference on the topic and published scientific and ethics literature surrounding this and other relevant technologies.

DISCUSSION

We constructed potential pathways for technological implementation, identified broad stakeholder classes party to these translational processes, and performed a preliminary assessment of the viewpoints and interrelations among these diverse stakeholders. Some of the stakeholders whose priorities are critical to understand and integrate into translation include pregnant women and their families; healthcare providers; scientists, their institutions or companies, and the funding agencies that support them; regulatory and judicial bodies; third-party payers; professional societies; educational systems; disability rights communities; and other representatives from civil society. Stakeholder interviews, survey findings, and conference proceedings add complexity to these envisioned pathways and also demonstrate a paramount need to incorporate an iterative stakeholder analysis early and throughout the translational endeavor. We believe that the translational framework that we have developed will help guide crucial future stakeholder mapping and engagement activities for cffDNA aneuploidy testing and inform novel methods of technology assessment for other developments in the growing field of genomic medicine.

SUMMARY

Mapping potential pathways for implementation and exploring the attitudes and interrelations of diverse stakeholders may lead to more effective translation of a novel method of prenatal aneuploidy testing.

The role of numeracy on client knowledge in BRCA genetic counseling

OBJECTIVE

To assess the impact of numeracy and health literacy on client's ability to learn information orally communicated during a BRCA 1/2 genetic counseling session.

METHODS

Fifty-nine videotaped simulated genetic counseling sessions were shown to 246 analogue clients (AC) recruited to imagine themselves as the client in the genetic counseling session. AC numeracy, genetic literacy, state and trait anxiety, and decisional conflict were assessed. The primary outcome was AC learning about BRCA 1/2.

RESULTS

Health literacy and numeracy were moderately correlated, and each independently predicted learning. Higher numeracy was associated with higher knowledge scores only among ACs with adequate literacy. Decisional conflict was not related to literacy, numeracy, or knowledge acquisition. It was, however, inversely related to state anxiety so that the higher post-session state anxiety, the lower the AC's decisional conflict.

CONCLUSION

Numeracy and health literacy are associated with learning of orally communicated information during genetic counseling. It appears that numeracy can facilitate learning for literate subjects; it does not, however, make any difference in learning ability of clients with significant literacy deficits.

PRACTICE IMPLICATIONS

Numeracy plays an important role in client's ability to learn information communicated during medical sessions, especially among clients who are otherwise regarded as literate.

Distress associated with prenatal screening for fetal abnormality

A theoretically-based, multivariate approach was used to identify factors associated with emotional distress for pregnant women undergoing maternal serum alpha fetoprotein (MSAFP or AFP) testing, used to detect abnormalities of the fetal brain and spinal cord. Participants were those who received normal results (N = 87). Study results supported the hypothesis that different factors would predict distress before and after testing. Satisfaction with information about testing predicted lower emotional distress early in the testing process; concerns about the child having other medical conditions and low-dispositional optimism predicted distress later. Study findings indicate that even in women who receive normal test results, AFP testing is associated with a modest degree of emotional disturbance which declines, but does not completely abate, after testing.

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.

The voices and concerns about prenatal testing of Cambodian, Lao and Vietnamese women in Australia

OBJECTIVES

to examine how Cambodian, Lao and Vietnamese women experience prenatal testing and to examine their knowledge and communication with health-care providers.

SETTING

Melbourne Metropolitan Area, Victoria, Australia.

DESIGN

an ethnographic study of childbearing and childrearing among women born in South-east Asia and now living in Melbourne, Australia reporting in-depth interviews with 67 women who had given birth in Australia.

FINDINGS

nearly all the women had prenatal testing as advised by their doctors and their main concerns were about their unborn baby and the need to follow doctors' advice. The women felt 'indifferent' towards prenatal testing, perceiving it as a normal part of antenatal care in Australia. Despite agreeing to undertake prenatal testing, the women did not have adequate understanding of the tests. This may be due to lack of information per se or inadequate communication between health providers and women.

IMPLICATIONS FOR PRACTICE

inevitably, the onus rests with the health-care provider to ensure that all options available to women are understood, so that women can make a positive and informed choice regardless of their social or cultural background. This will lead to women's increased satisfaction with care during pregnancy.

Pregnancy planning guide. Evidence-based information for prospective parents

PROBLEM BEING ADDRESSED

Pregnancy planning is inadequately supported by existing information and materials.

OBJECTIVE OF PROGRAM

To design and pilot-test a new way to help women plan their pregnancies and incorporate important evidence-based information directly into their planning. To evaluate the content of the new Pregnancy Planning Guide and women's satisfaction with it.

MAIN COMPONENTS OF PROGRAM

The Pregnancy Planning Guide combines a rotating gestational wheel surrounded by information about time-specific events in pregnancy with evidence-based information about common concerns during pregnancy. The guide is designed to be used as a quick reference for women and their partners; it highlights issues to be discussed at greater length with maternity caregivers. The guide was first evaluated for content validity by 27 experienced maternity caregivers and then revised. The revised version was given to 108 women of childbearing age along with a survey to assess their satisfaction with the guide and the extent to which they thought it was useful.

CONCLUSION

The Pregnancy Planning Guide is useful for women planning pregnancy. It should promote increased use of folic acid in the periconception period and a greater understanding of when birth is likely to occur.

Attitudes to bioethical issues: a case study of a screening project

Commonly expressed in theoretical discussions about ethical problems in the context of epidemiology and screening is the need for more data. A study was carried out involving 21 explorative interviews with participant and nonparticipant mothers in a neonatal research screening project in progress in Sweden, ABIS (All Babies in Southeast Sweden). The respondents were asked, by way of open-ended questions, to give their opinions about certain ethical issues: informed consent; reasons for joining/declining; surrogate decision; the collection, analysis and storage of written and "live" material (biobanks); intervention etc. The ethical implications mentioned in the literature mostly concern the risk of creating distress and anxiety (anxiety and possible stigmatisation in respect of positive or false-positive results, worry about material collected and stored, distress caused by blood sampling procedures, etc.). Our results do not support the idea that the risks are substantial. The respondents rather indicate an attitude of benevolence--they are positive both to the current research on children, to the material they contribute (both written material and "biomaterial"), to possible results and intervention plans. On the other hand the participants expressed concern about the storage of material and the right to be informed of any screening/project results. Further studies in this field are needed and would be of help in theoretical discussion, the work of ethical committees and the designing of, for example, screening and research projects.

Education about genetic testing for breast cancer susceptibility: patient preferences for a computer program or genetic counselor

The purpose of this study was to describe and compare patient preferences for a genetic counselor or an interactive computer program for various components of genetic education and counseling for breast cancer susceptibility. As part of a randomized intervention study on genetics education and counseling for breast cancer risk, 29 women at moderate risk were educated by both a genetic counselor and an interactive computer program. After both educational interventions, participants completed Likert-style and open-ended questionnaires about what they liked most and least about each intervention, and whether they preferred the counselor or computer for a variety of tasks. Participants were largely satisfied with both the computer program and the genetic counselor. A majority preferred the genetic counselor for addressing their concerns, discussing options and alternatives, being sensitive to emotional concerns, helping to make a decision, being a good listener, assuring understanding, helping to make a good choice, helping to understand genes and breast cancer, telling them what they needed to know, being respectful, setting a relaxed tone, and putting them at ease. However, a majority of the women either preferred the computer program or were neutral about allowing patients to learn at their own pace, helping to avoid embarrassment, making good use of time, explaining genes and breast cancer, and treating the patient as an adult. Qualitative analysis of open-ended questions affirmed that patients valued the personal interactions with the counselors, and liked having their specific questions answered. They liked that the computer was self-paced, informative and private, and could be used without causing embarrassment. We concluded that a computer literate, mostly white group of women at moderate risk for inherited susceptibility to breast cancer preferred interacting with a genetic counselor for personal, individualized components of the genetic counseling process, but accepted or preferred a computer program for being self-paced, private, and informative. By incorporating such a computer program into the genetic education process, it is possible that genetic counselors would be able to spend more time performing the personal, individualized components of genetic counseling.

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

At their first hospital antenatal visit, 209 women were interviewed to explore their level of knowledge of Down syndrome and the available prenatal tests. Overall, the women had limited knowledge. Non-Caucasian women had less knowledge of Down syndrome, available prenatal tests and the association of Down syndrome with advanced maternal age than Caucasian women. Women with a history of a previous pregnancy and women over 35 years of age were not more aware of Down syndrome or the available tests than other women. These findings have significant implications for antenatal education and the implementation of screening programs for Down syndrome.

Women's experience of maternal serum screening

OBJECTIVE

To explore the ideas, opinions, feelings, and experiences of women regarding prenatal genetic screening, specifically maternal serum screening (MSS).

DESIGN

Qualitative technique of focus groups.

SETTING

Northern, rural, inner-city, urban, and suburban communities in Ontario.

PARTICIPANTS

Women who had given birth to babies from January 1994 to May 1996, but who were not currently pregnant (n = 60).

METHOD

Six focus groups composed of women living in various communities who had recently given birth to babies explored the experience of MSS.

MAIN FINDINGS

Women want informed choice about prenatal genetic screening. Three factors influenced women's decisions to undergo or decline prenatal genetic screening: their personal values, including their philosophy of life, moral, and religious values, and attitudes regarding Down syndrome and disability; social support including their partners, families, and friends; and quality of information from health care providers. Women want their providers to give them information personally; they want to receive the information as early as possible in prenatal care to allow time for reflection; and they want unbiased, accurate information in order to make a decision that is in keeping with their personal values and beliefs.

CONCLUSIONS

Knowledge of women's ideas, opinions, feelings, and experiences regarding MSS suggests specific ways health care providers can facilitate informed decision making in prenatal screening. Providing information about genetic testing needs to be individualized, with women actively participating in the decision-making process. Information needs described by these women could apply to other prenatal genetic tests that might be available in the future.

The Genetic Knowledge Index: developing a standard measure of genetic knowledge

This paper reports on the development of a unidimensional genetic knowledge index that has been tested and validated in a general population sample. The Index is intended to provide the basis for a standard measure of basic genetic knowledge that can be applied across diverse populations and research settings. The study group was composed of 330 European Americans selected randomly in the Louisville, KY, metropolitan area. The final version of the Genetic Knowledge Index (GKI) consisted of five items identified by principle components analysis, correlation coefficients, and the alpha measure of internal consistency. Construct validity of the GKI was determined by appropriate statistical correlations with educational attainment and attitudes toward genetic discrimination. The Index provides a numerical ranking of subjects' knowledge of practical genetics. Implications for research are discussed.

Who should provide genetic education prior to gene testing? Computers and other methods for improving patient understanding

As numerous new gene tests are introduced into clinical practice, patients have a growing need for accurate and comprehensive information about the risks and benefits of gene testing. However, in the changing healthcare environment, it is not clear who will provide such information because genetic counselors are scarce and their services are not widely utilized, and primary care providers lack time and expertise in genetics. Interactive computers may help fill the information gap. We review a variety of educational modalities for providing patient education and argue that interactive computers have potential advantages over other educational methods for providing information and promoting informed consent to genetic testing. Finally, some questions for further research are raised.

Informed consent to serum screening for Down syndrome: are women given adequate information?

To assess the information given to women during a maternal serum screening (MSS) programme, we prospectively applied a questionnaire to 504 pregnant women attending for amniocentesis after a screen-positive result. The survey based on 200 usable questionnaires (39.7 per cent of our study population) showed that MSS was imposed as mandatory by 41.5 per cent of providers and done without their patients' agreement by 16 per cent. After release of the test results, 6.5 per cent of women believed that they were carrying a Down syndrome-affected fetus and 21.5 per cent thought the risk was about 50-50. A total of 38.5 per cent of the pregnant women were not informed of the risk of miscarriage after amniocentesis and 67.5 per cent believed that there was no possibility of a false-negative result with MSS. Information given over the telephone was particularly poorly understood compared with information provided during an outcome visit, since women who learned of their test result during such a visit scored significantly higher (69 per cent) when questioned about the risk of carrying a Down syndrome-affected fetus, compared with women informed of their test results by telephone (38.7 per cent) or by letter (47 per cent). We therefore suggest routine consultation with an antenatal care professional before testing to enable pregnant women to give their informed consent to MSS.

Women's decision-making in prenatal screening

With serum screening (MS-AFP and hCG testing for Down's syndrome) women have to make several decisions in a limited time: whether to participate in the screening in the first place; then, if increased risk for fetal abnormality is detected, whether to have a diagnostic test, and finally, what to do if fetal abnormality is detected. The aim of this study was to examine how women themselves in an unselected population describe their decision-making in the different phases of serum screening. Women receiving a positive result from serum screening in two Finnish towns from September 1993 to March 1994 and a group of individually matched controls were invited to semistructured interviews; 45 index and 46 control women (79% of those invited) participated between their 29th and 37th weeks of gestation (mean 31 weeks). Although serum screening was most often presented as voluntary or as an option, half the women described participation as a routine or self-evident act; only one-fourth of the women described actively deciding about participation. After a positive screening result, women's reactions to diagnostic tests, and their intentions if disability would be detected, varied greatly. Most of the women actively decided about having diagnostic tests, but for 23% participation in diagnostic testing was called a self-evident act. Women's intentions regarding abortion varied from a firm decision to abort to a firm decision not to abort, and many remained ambivalent. Prenatal screening, which demands the making of several decisions in a limited time and is offered to all pregnant women as part of established maternity care, is not based on every participant's active decision-making and thus creates an ethical problem. This problem should receive special attention from those who develop, introduce and decide on new health care practices.

Eugenics and genetic testing

Pressures to lower health-care costs remain an important stimulus to eugenic approaches. Prenatal diagnosis followed by abortion of affected fetuses has replaced sterilization as the major eugenic technique. Voluntary acceptance has replaced coercion, but subtle pressures undermine personal autonomy. The failure of the old eugenics to accurately predict who will have affected offspring virtually disappears when prenatal diagnosis is used to predict Mendelian disorders. However, when prenatal diagnosis is used to detect inherited susceptibilities to adult-onset, common, complex disorders, considerable uncertainty is inherent in the prediction. Intolerance and the resurgence of genetic determinism are current pressures for a eugenic approach. The increasing use of carrier screening (to identify those at risk of having affected offspring) and of prenatal diagnosis could itself generate intolerance for those who refuse the procedures. Genetic determinism deflects society from social action that would reduce the burden of disease far more than even the maximum use of eugenics.

Informed consent for maternal serum alpha-fetoprotein screening in an inner city population: how informed is it?

OBJECTIVE

To determine if women who received information from a provider and viewed a videotape about maternal serum alpha-fetoprotein (MSAFP) screening understood enough to sign informed consent.

DESIGN

A prospective qualitative design using tape recorded interviews of women who were provided information regarding MSAFP testing from a provider and from viewing a videotape.

PARTICIPANTS

Fifty-three inner city pregnant women (58% Hispanic, 39% African-American, 3% white).

RESULTS

Two women answered all questions correctly; no one answered all questions incorrectly. Sixty-two percent correctly answered "What is MSAFP?" Sixteen percent thought "something has to be taken from my belly" for the test. Fifty-nine percent understood that children with spina bifida could have difficulty walking or urinary problems. Seventy-two percent thought their infant would be healthy in all respects if the test was negative. Only 45% could describe the follow-up to a positive test. Eighty percent planned to have the test. Many misconceptions were apparent, and for some knowledge items, as many as 80% of the women answered incorrectly.

CONCLUSIONS

Obtaining truly informed consent for a complex test is not a simple process. Participants met a few, but not all, of the criteria for informed consent. Women understood that the test was voluntary, but their comprehension of the meaning and implication of a positive test results was deficient. Despite this, they signed the informed consent document. The larger question of just how much comprehension is required to consider a woman "informed" has not been answered.

Prenatal screening for cystic fibrosis carriers: does the method of testing affect the longer-term understanding and reproductive behaviour of women?

A comparative study of women who underwent prenatal cystic fibrosis (CF) carrier screening by either the 'two-step method' or the 'couple method' was carried out 2-4 years after testing. Recall of the screening test and test result, understanding of the implications of the test result, and reproductive intentions and behaviour were compared. Women screened by the two-step method were significantly better informed on the genetic implications of the test result and the significance of being a single gene carrier than their couple screen counterparts. Regardless of the method of screening, a majority of those who had received a negative test result erroneously believed that they were definitely not a carrier. However, women who intended having further children were significantly more likely to understand correctly that a negative test result meant that they were unlikely to be a CF carrier. The method of testing had no influence on reproductive intentions or behaviour. Differences in emphasis, content and presentation of pre-screening information and counselling between the two methods of screening are identified. Reasons for variation in the long-term understanding between women screened by the two methods are discussed.

Evaluating patient's knowledge of maternal serum screening

The objective was to describe the development, characteristics, and initial use of an instrument for assessing knowledge about maternal serum screening (MSS). Items for a knowledge scale were selected based on a review of educational materials, the literature, and expert opinion. Items were pre-tested for comprehensibility and ambiguity in a convenience sample. After extensive pre-testing and pilot testing a 14-item scale, the Maternal Serum Screening Knowledge Questionnaire (MSSKQ) was developed. It was administered to 1084 women attending a maternal registration clinic. The overall knowledge score was compared across socio-demographic groups, and by sources of information about MSS. Mean MSSKQ scores increased with age, education, and family income, and among those reporting having an opportunity to discuss MSS and receiving written material. The MSSKQ is a reliable instrument with good content and construct validity. This tool should be valuable in assessing knowledge and level of informed consent in women receiving MSS and in evaluating the implementation of MSS programmes.

The effects of ethnicity, education and an informational video on pregnant women's knowledge and decisions about a prenatal diagnostic screening test

Prenatal screening for genetic disease and developmental disabilities is rapidly becoming a routine part of the management of low-risk pregnancies. Yet research on how to best inform pregnant women about these tests and their special ethical entailments remains sparse. We asked 130 low-risk pregnant women of diverse ethnic and social class backgrounds a series of questions about a prenatal test they had been offered within the previous 3 months. All had been given an informational booklet about the test at the time it was offered; about half also saw a video. We found that neither group of women retained much of the information they had received about the prenatal screening but that those who saw the video remembered more. Information-retention also varied significantly by ethnicity and level of education.

Attitudes to prenatal screening, diagnosis and research among pregnant women who accept or decline an alpha-fetoprotein test

The aim of the study was to describe the opinion of pregnant women who had accepted or declined an alpha-fetoprotein (AFP) test, not only on AFP screening in general, but also on whether every pregnant woman should be offered amniocentesis (AC)/chorionic villus sampling (CVS) and an ultrasound scan for fetal malformations. An additional aim was to describe pregnant women's attitudes concerning continued research in the prenatal field. The study was performed as a questionnaire study in two regions over a 1-year period from 1 October 1988 to 30 September 1989. Results are based on answers from 3331 women who had taken an AFP test and 336 women who had declined the offer of a test. A total of 79 per cent of the women thought that an AFP test, 70 per cent that an ultrasound scan for fetal malformations, and 26 per cent that AC or CVS should be offered to all pregnant women. Fifty-nine per cent of the women were positive towards continued research in the prenatal field. Women who had had an AFP test were generally much more positive towards screening and research than women who had declined, who were generally against. Women who had left school without a high school degree were on average more positive towards the screening issues that women who had this degree. In conclusion, the results obtained in this study strongly suggest that women's attitudes are very dependent on how the prenatal screening programme is already organized in their local area.

Perception of predictive testing for Huntington's disease by young women: preferring uncertainty to certainty?

Opinions on the implications of predictive testing for Huntington's disease were evaluated in a group of 169 women (aged 21-35 years) with interest in psychosocial issues, but with no special pre-existing knowledge or training in genetics. Predictive testing for Huntington's disease (HD) is considered to be a test case for predictive testing for other late onset diseases, monogenic as well as multifactorial disorders. In the hypothetical situation of having a 50% risk for developing HD, about half of the group expressed interest in a predictive test. As to the question of giving results of predictive tests to third parties, the group would be very reluctant to inform the employer or the insurer, but not their own family. Prenatal testing for late onset diseases was considered acceptable by half of the women; only one quarter of the total group would terminate a pregnancy of a child that might develop a late onset disease. The assessment of attitudes towards predictive testing was carried out within the context of a global evaluation of perceived advantages and disadvantages of genetic counselling. The attitudes towards predictive testing were systematically associated with perceiving 'having more certainty about the future' as an advantage of genetic counselling and with rejecting 'knowing everything in advance' as a disadvantage.

Prenatal cystic fibrosis carrier testing: designing an information leaflet to meet the specific needs of the target population

A questionnaire was given to 180 patients in an antenatal clinic, who were eligible to enter a pilot trial of cystic fibrosis (CF) carrier testing, seeking their views on the information leaflet inviting them to participate; 161 patients (89%) entered the trial and 145 patients (81%) responded to the questionnaire, including 10 who did not enter the trial. Ninety-six percent of these found the leaflet easy to understand, and 97% of those partners who read the leaflet also found it easy to understand. Fifteen percent of patients thought the leaflet should give additional information. Most (92%) had heard of CF before reading the leaflet, television being the most common source of information. Although avoiding the birth of a child with CF was the reason most patients gave for wishing to be screened, almost as many were interested to know their carrier status. The decision to accept or decline testing was taken in conjunction with their partner by 63% of women. Of those who were screened, 59% stated that taking the test made them feel reassured, while 38% felt slightly apprehensive. It was concluded that, with a number of minor amendments, the leaflet met the specific needs of the target patient population.

Prenatal screening: when and for whom?

This report discusses the role of prenatal screening in preventing congenital abnormalities or, when prevention is not possible, in avoiding the conception or the birth of those who would have untreatable abnormalities. Women who are found by screening not to be immune to rubella can be safely vaccinated prior to pregnancy; those found to be at risk of having children with genetic disorders such as Tay-Sachs disease or thalassemia have the option of avoiding the conception of affected offspring. Screening during pregnancy permits the primary prevention of Rh disease and its sequelae when it results in the prophylactic administration of Rh-immune globulin to unsensitized Rh-negative women. Maternal serum alpha-fetoprotein screening identifies pregnant women who are at increased risk of carrying fetuses with neural tube defects or Down's syndrome, giving them the option of avoiding the birth of affected fetuses through abortion. Recombinant DNA technology will permit screening for many more genetic disorders as the disease-related genes and mutations are identified. For many of these disorders, the ability to predict the risk of disease will antedate preventive and therapeutic interventions by many years. During this lag phase, issues concerning the validity of the tests, the severity of the conditions for which screening is offered, the safety of the interventions, and the autonomy of the pregnant women in deciding to be screened are important.

Factors affecting the uptake of screening for neural tube defect

A questionnaire concerning pregnant women's knowledge of, and attitudes to, serum alpha fetoprotein (AFP) screening for spina bifida was sent to all pregnant women receiving a health education leaflet on AFP screening who booked at the Birmingham Maternity Hospital in the first quarter of 1984. The majority said that they would accept the test, and subsequently did so. This suggests that low uptake of the test is not a result of patients' resistance, and the results indicated that the provision of early information about the test is likely to improve uptake and decrease anxiety. With the increasing clinical usefulness of the AFP test, routine screening of pregnant women with an 'opt-out' system is becoming clinically desirable, and the survey suggests that it would be acceptable to the patients.

Prenatal screening and pregnant women's attitudes toward the abortion of defective fetuses

We studied the attitudes of 490 pregnant women toward the abortion of defective fetuses. Three hundred of these women were participating in a prenatal screening program for neural tube defects. Although theoretical accounts of the effects of behavior on attitude would suggest that participation in a screening program would affect abortion attitudes, evidence in support of such an association was weak. The overwhelming majority of women, regardless of whether they had participated in the screening program, believed that women are justified in having an abortion in the face of fetal abnormality. There was a sharp increase in the number of screening program participants who said they would have an abortion when the probability of the fetus being affected with a neural tube defect rose from 95 per cent to 100 per cent.