Testing HIV positive in pregnancy: A phenomenological study of women's experiences.

OBJECTIVE: globally women receive HIV testing in pregnancy; however, limited information is available on their experiences of this potentially life-changing event. This study aims to explore women's experiences of receiving a positive HIV test result following antenatal screening. DESIGN: a qualitative, phenomenological approach. SETTING: two public National Health Service (NHS) hospitals and HIV support organisations. PARTICIPANTS: a purposive sampling strategy was used. Thirteen black African women with a positive HIV result, in England, participated. METHODS: data were collected using in-depth semi-structured interviews. An interpretive phenomenological approach to data analysis was used. FINDINGS: the emergent phenomenon was transition and transformation of 'being,' as women accepted HIV as part of their lives. Paired themes support the phenomenon: shock and disbelief; anger and turmoil; stigma and confidentiality issues; acceptance and resilience. Women had extreme reactions to their positive HIV diagnosis, compounded by the cultural belief that they would die. Initial disbelief of the unexpected result developed into sadness at the loss of their old self. Turmoil was evident, as women considered termination of pregnancy, self-harm and suicide. Women felt isolated from others and relationship breakdowns often occurred. Most reported the pervasiveness of stigma, and how this was managed alongside living with HIV. Coping strategies included keeping HIV 'secret' and making their child(ren) the prime focus of life. Growing resilience was apparent with time. KEY CONCLUSIONS: this study gives midwives unique understanding of the complexities and major implications for women who tested positive for HIV. Women's experiences resonated with processes of bereavement, providing useful insight into a transitional and transformational period, during which appropriate support can be targeted. IMPLICATIONS: midwives are crucial in improving the experience of women when they test HIV positive and to do this they need to be appropriately trained. Midwives need to acknowledge the social and psychological impact of HIV and pathways should be developed to support early referral for appropriate support.

Advancing maternal age and trisomy screening: the practice challenges of facilitating choice and gaining consent.

Antenatal screening for chromosomal anomalies such as Trisomy 13, 18 and 21 (Patau's, Edward's and Down's syndrome respectively) is offered to all pregnant women in the first two trimesters.This article explores the varying considerations of consent for this type of screening, particularly in relation to women of advancing age who are at increased risk of carrying a pregnancy affected by a trisomy. The practical challenges or barriers of gaining valid, meaningful informed consent are discussed.

3. Undiagnosed breech--part of midwifery practice.

This article discusses the background to undiagnosed breech and what a midwife can do to support a woman who is giving birth to a baby in an undiagnosed breech presentation. There is no evidence to support the use of emergency caesarean section when a breech is diagnosed in labour and it is a requirement of the Nursing and Midwifery Council rules and standards that registered midwives should have been taught, pre-registration, how to assist an undiagnosed breech presenting baby to be born.

Survey of second-trimester maternal serum screening in Japan.

AIM: Second-trimester maternal serum screening (MSS) is the predominant form of prenatal screening in Japan. We hypothesize that patient education and physician knowledge of Down syndrome (DS) screening are insufficient to provide adequate information regarding prenatal screening in Japan. MATERIAL AND METHODS: In-person or telephone interviews with medical personnel were conducted at 25 medical facilities utilizing Afp(4) (Esoterix Genetic Laboratories, LLC, a wholly-owned subsidiary of Laboratory Corporation of America Holdings) second trimester screening. We explored how medical facilities provided information about the MSS process to pregnant women. RESULTS: Before prenatal testing, 60% of medical facilities spent an average of less than 5 min per patient explaining the MSS process. The option of amniocentesis for chromosomal aneuploidy was explained at nearly all facilities, but only 60% explained the risk of amniocentesis. Ultrasound examination for open neural tube defects was explained only at half the facilities. Only five of 25 (20%) medical practitioners explained the possibility of having congenital disorders fetus. CONCLUSION: This study revealed that most obstetricians in Japan do not provide their patients with sufficient information about MSS.

Drug safety in pregnancy--monitoring congenital anomalies.

AIM: This paper outlines research into the causes of congenital anomalies, and introduces a pan-European study. The potential roles of nurses and midwives in this area are illustrated by a case report. BACKGROUND: Since the thalidomide disaster, use of drugs in pregnancy has been carefully monitored to prevent anything similar happening again. However, monitoring is incomplete and questions remain unanswered. KEY ISSUES: Many medicines are essential for the health of pregnant women. However, drug use in pregnancy requires surveillance. Methods include spontaneous reporting of adverse events, cohort studies and case control studies. It is hoped that a Europe-wide study, combining data from several congenital anomaly registers, will provide a sufficiently large population to assess the impact of selected drugs on congenital anomalies. However, this work depends on the consistency of reporting by nurses and midwives. CONCLUSION: Drug safety in pregnancy remains undetermined. Collaboration across Europe has the potential to provide a framework for safety evaluation. IMPLICATIONS FOR NURSING MANAGEMENT: Prescribers should consider the possibility of pregnancy in women of child-bearing age. Careful review of maternal drug use in early pregnancy is essential. Midwives and nurses should be aware of adverse event drug reporting systems, including congenital anomaly registers.

Routinisation and constraints on informed choice in a one-stop clinic offering first trimester chromosomal antenatal screening for Down's syndrome.

OBJECTIVE: to explore routinisation and constraints on informed choice in a one-stop clinic offering first trimester antenatal chromosomal screening for Down's syndrome. DESIGN: recordings of booking appointments and pre-screening consultations in both a community and a hospital clinic setting. SETTING: one antenatal clinic site in the UK offering first trimester nuchal translucency screening in combination with maternal serum screening. PARTICIPANTS: 57 taped clinical consultations involving pregnant women and midwives and health-care assistants (HCAs). FINDINGS: midwives and HCAs expected women to make informed decisions about screening for Down's syndrome. However, midwives' attempts to maintain the normality of pregnancy and avoid discussions about potential scenarios, as well as their emphasis on the high accuracy rate of first trimester screening have routinised first trimester antenatal screening for Down's syndrome. Also, a general expectation in the clinic to take up screening and the constrained service context in which midwives and HCAs work had implications for women's informed choices. KEY CONCLUSIONS: directive information combined with lack of purposeful dialogue with pregnant women have constrained the process of information-giving about antenatal screening for Down's syndrome. IMPLICATIONS: the provision of information about antenatal screening for Down's syndrome is a challenging role for midwives. Changes in midwifery practice resulting from continuing education as well as less constraining service contexts could improve the quality of information about antenatal screening for Down's syndrome.

Educational priorities and current involvement in genetic practice: a survey of midwives in the Netherlands, UK and Sweden.

OBJECTIVE: to investigate whether practising midwives are adequately prepared to integrate genetic information into their practice. DESIGN: a cross-sectional, postal, structured questionnaire survey was sent to practising midwives. SETTING: practising midwives from the Netherlands (NL), Sweden (SE) and the United Kingdom (UK). PARTICIPANTS: 1021 replies were received, achieving a response rate of 62%. FINDINGS: 79% (799/1015) of midwives reported attending courses with some 'genetic content' during their initial training. Sixty-eight per cent (533/784) judged this to have been useful for clinical practice. Variation was seen between countries in the amount of genetic content in post-registration training (SE 87%, NL 44%, UK 17%) and most was considered useful. Questions assessing clinical activity identified a current need for genetic knowledge. Midwives described low levels of self-reported confidence both in overtly genetic procedures and in everyday tasks that were underpinned by genetic knowledge. For eight of the 12 procedures, fewer than 20% of midwives considered themselves to be confident. Differences were apparent between countries. Midwives identified psychosocial, screening and risk assessment aspects of genetic education as being important to them, rather than technical aspects or genetic science. CONCLUSIONS: given the low reported confidence with genetic issues in clinical practice, it is essential that this is addressed in terms of the amount, content and targeting of genetic education. This is especially important to ensure the success of national antenatal and baby screening programmes. The results of this study suggest that midwives would welcome further training in genetics, addressing genetic topics most relevant to their clinical practice.

A survey of midwives' views on providing aspects of antenatal care in Estonia.

OBJECTIVE: to survey the views of midwives in Estonia about who they considered should have responsibility for carrying out certain aspects of antenatal care (ANC) in Estonia. DESIGN, SETTING AND STUDY POPULATION: in collaboration with key stakeholder organisations, the authors developed eight statements on aspects of ANC and five combinations of possible professionals (including midwives obstetrician-gynaecologists and various combinations of the two) who could have responsibility for carrying out those aspects of ANC and included them in a self-administered questionnaire. The questionnaire was sent with a covering letter and stamped addressed return envelope to all 366 midwives in Estonia. Two postal reminders were sent to non-responders. RESULTS: the response rate was 73.5%. There was no consensus among respondents about whose responsibility it was to diagnose pregnancy, carry out the risk assessment of a pregnancy, or carry out fetal monitoring during pregnancy. There was consensus among respondents that either midwives or obstetrician-gynaecologists could have responsibility for referring for further tests and examinations if a pregnancy was thought to be at risk. There was also consensus that counselling, biometry and blood pressure monitoring should be the sole responsibility of midwives. KEY CONCLUSIONS: despite national policy to shift ANC towards being midwifery-led and despite provisions in a European Directive permitting most roles in ANC to be performed autonomously by trained midwives, there is no consensus among Estonian midwives that all aspects of ANC should be their responsibility at present. Thorough research is required to establish which specific ANC roles Estonian midwives are not willing to take responsibility for, and to examine why they are not willing to take on such roles.

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.