Psychological impact of additional findings detected by genome-wide Non-Invasive Prenatal Testing (NIPT): TRIDENT-2 study.

In the Netherlands, genome-wide non-invasive prenatal testing (NIPT) is offered to all pregnant women as part of the nationwide TRIDENT-2 study. Findings other than trisomy 21, 18, or 13, which are called "additional findings", are reported only on request of the pregnant woman. This study examined: (1) women's pre-test perceptions and reasons to opt for additional findings and (2) women's experiences with- and the psychological impact of being informed about an additional finding. A questionnaire, consisting of the anxiety measure State-Trait Anxiety Inventory (STAI), distress measure Impact of Event Scale (IES) and questions developed specifically for this study, was retrospectively administered to 402 women who received an additional finding. A total of 227 (56.5%) women completed the questionnaire. Most (60.2%) chose to know additional findings because they wanted as much information as possible about the health of their fetus. Almost all (92%) stated that receiving the additional finding was unexpected, a shock, and/or they were in disbelief, for 85% it caused a lot of worry. Post-test, high anxiety (STAI) levels were reported in 15.5% of women, and 7.5% reported severe distress (IES). Women who gave birth to an affected child (n = 10) experienced most psychological impact (STAI and IES). Eighty-six percent of women with a fetal aberration would opt for additional findings again, compared to 49.2% of women whose result was confined to the placenta. Pre-test counseling should focus on explaining the different results NIPT can generate. Post-test counseling should focus on guiding pregnant women through this uncertain and anxious time.

(Non-)disclosure of lifetime sexual violence in maternity care: Disclosure rate, associated characteristics and reasons for non-disclosure.

BACKGROUND: In maternity care, disclosure of a past sexual violence (SV) experience can be helpful to clients to discuss specific intimate care needs. Little evidence is available about the disclosure rates of SV within maternity care and reasons for non-disclosure. AIM: The aim of this study was to examine (1) the disclosure rate of SV in maternity care, (2) characteristics associated with disclosure of SV and (3) reasons for non-disclosure. METHODS: We conducted a descriptive mixed method study in the Netherlands. Data was collected through a cross-sectional online questionnaire with both multiple choice and open-ended items. We performed binary logistic regression analysis for quantitative data and a reflexive thematic analysis for qualitative data. RESULTS: In our sample of 1,120 respondents who reported SV, 51.9% had disclosed this to a maternity care provider. Respondents were less likely to disclose when they received obstetrician-led care for high-risk pregnancy (vs midwife-led care for low-risk pregnancy) and when they had a Surinamese or Antillean ethnic background (vs ethnic Dutch background). Reasons for non-disclosure of SV were captured in three themes: 'My SV narrative has its place outside of my pregnancy', 'I will keep my SV narrative safe inside myself', and 'my caregiver needs to create the right environment for my SV narrative to be told'. CONCLUSIONS: The high level of SV disclosure is likely due to the Dutch universal screening policy. However, some respondents did not disclose because of unsafe care conditions such as the presence of a third person and concerns about confidentiality. We also found that many respondents made a positive autonomous choice for non-disclosure of SV. Disclosure should therefore not be a goal in itself, but caregivers should facilitate an inviting environment where clients feel safe to disclose an SV experience if they feel it is relevant for them.

Maternal characteristics associated with referral to obstetrician-led care in low-risk pregnant women in the Netherlands: A retrospective cohort study.

BACKGROUND: In the Netherlands, maternity care is divided into midwife-led care (for low-risk women) and obstetrician-led care (for high-risk women). Referrals from midwife-led to obstetrician-led care have increased over the past decade. The majority of women are referred during their pregnancy or labour. Referrals are based on a continuous risk assessment of the health and characteristics of mother and child, yet referral for non-medical factors and characteristics remain unclear. This study investigated which maternal characteristics are associated with women's referral from midwife-led to obstetrician-led care. MATERIALS AND METHODS: A retrospective cohort study in one midwife-led care practice in the Netherlands included 1096 low-risk women during January 2015-17. The primary outcomes were referral from midwife-led to obstetrician-led care in (1) the antepartum period and (2) the intrapartum period. In total, 11 maternal characteristics were identified. Logistic regression models of referral in each period were fitted and stratified by parity. RESULTS: In the antepartum period, referral among nulliparous women was associated with an older maternal age (aOR, 1.07; 95%CI, 1.05-1.09), being underweight (0.45; 0.31-0.64), overweight (2.29; 1.91-2.74), or obese (2.65; 2.06-3.42), a preconception period >1 year (1.34; 1.07-1.66), medium education level (0.76; 0.58-1.00), deprivation (1.87; 1.54-2.26), and sexual abuse (1.44; 1.14-1.82). Among multiparous women, a referral was associated with being underweight (0.40; 0.26-0.60), obese (1.61; 1.30-1.98), a preconception period >1 year (1.71; 1.27-2.28), employment (1.38; 1.19-1.61), deprivation (1.23; 1.03-1.46), highest education level (0.63; 0.51-0.80), psychological problems (1.24; 1.06-1.44), and one or multiple consultations with an obstetrician (0.68; 0.58-0.80 and 0.64; 0.54-0.76, respectively). In the intrapartum period, referral among nulliparous women was associated with an older maternal age (1.02; 1.00-1.05), being underweight (1.67; 1.15-2.42), a preconception period >1 year (0.42; 0.31-0.57), medium or high level of education (2.09; 1.49-2.91 or 1.56; 1.10-2.22, respectively), sexual abuse (0.46; 0.33-0.63), and multiple consultations with an obstetrician (1.49; 1.15-1.94). Among multiparous women, referral was associated with an older maternal age (1.02; 1.00-1.04), being overweight (0.65; 0.51-0.83), a preconception period >1 year (0.33; 0.17-0.65), non-Dutch ethnicity (1.98; 1.61-2.45), smoking (0.75; 0.57-0.97), sexual abuse (1.49; 1.09-2.02), and one or multiple consultations with an obstetrician (1.34; 1.06-1.70 and 2.09; 1.63-2.69, respectively). CONCLUSIONS: This exploratory study showed that several non-medical maternal characteristics of low-risk pregnant women are associated with referral from midwife-led to obstetrician-led care, and how these differ by parity and partum period.

Counselling for prenatal anomaly screening to migrant women in the Netherlands: An interview study of primary care midwives' perceived barriers with client-midwife communication.

INTRODUCTION: Large ethnic inequalities exist in the prenatal screening offer, counselling, informed decision-making, and uptake of prenatal anomaly tests. More insight into midwives' experiences with offering prenatal counselling to migrant women may provide better insight into the origins and consequences of these ethnic inequalities. METHODS: We conducted interviews with 12 midwives certified as counsellors for prenatal anomaly screening for women they identified as migrants. Interviews were analyzed using thematic analysis. RESULTS: Midwives reported most difficulties in communicating with women of 'non-western migrant background', which include first- and second-generation migrants from Africa, Latin-America, Asia, and Turkey. They experienced barriers in communication related to linguistics, health literacy, sociocultural and religious differences, with midwife stereotyping affecting all three aspects of counselling: health education, decision-making support, and the client-midwife relation. Health education was difficult because of language barriers and low health-literacy of clients, decision-making support was hampered by sociocultural and religious midwife-client differences, and client-midwife relations were under pressure due to sociocultural and religious midwife-client differences and midwife stereotyping. CONCLUSIONS: Barriers to optimal communication seem to contribute to suboptimal counselling, especially for women of 'non-western migrant background'. Client-midwife communication thus potentially adds to the ethnic disparities observed in the offer of and informed decision-making about prenatal anomaly screening in the Netherlands. The quality of prenatal counselling for women from all ethnic backgrounds might be improved by addressing linguistic, health literacy, sociocultural and religious barriers in future training and continuing education of prenatal counsellors.

Nationwide implementation of the non-invasive prenatal test: Evaluation of a blended learning program for counselors.

This study assesses the results of a mandatory blended learning-program for counselors (e.g. midwives, sonographers, obstetricians) guiding national implementation of the Non-Invasive Prenatal Test (NIPT). We assessed counselors' 1) knowledge about prenatal aneuploidy screening, 2) factors associated with their knowledge (e.g. counselors' characteristics, attitudes towards NIPT), and 3) counselors' attitudes regarding the blended learning. A cross-sectional online pretest-posttest implementation survey was sent to all 2,813 Dutch prenatal counselors. Multivariate linear regression analyses were performed to identify associations between counselors' knowledge and e.g. their professional backgrounds, work experience and attitudes towards NIPT. At T0 and T1 1,635 and 913 counselors completed the survey, respectively. Overall results show an increased mean number of correct answered knowledge questions; 23/35 (66%) items at T0 and 28/37 (76%) items at T1. Knowledge gaps on highly specific topics remained. Work experience and secondary care work-setting were positively associated with a higher level of knowledge. Most counselors (74%) showed positive attitudes towards the blended learning program. The mandatory blended learning, along with learning by experience through implementation of NIPT, has facilitated an increase in counselors' knowledge and was well received. New implementations in healthcare may benefit from requiring blended learning for healthcare providers, especially if tailored to professionals' learning goals.

Non-invasive prenatal testing (NIPT) and pregnant women's views on good motherhood: a qualitative study.

Women's views on responsible motherhood influence decision-making regarding participation in prenatal screening. Previous studies showed that the probabilistic nature of the first-trimester combined test and the potential requirement for subsequent invasive diagnostics serve as legitimate reasons for women to exclude prenatal screening from their moral responsibilities. These moral barriers might now be less relevant with the introduction of the non-invasive prenatal test (NIPT) resulting in women feeling a moral duty to use NIPT screening as part of responsible motherhood. This qualitative study explores the impact of NIPT on women's moral beliefs about the meaning of prenatal screening in relation to responsible motherhood. We performed semi-structured interviews with 29 pregnant women who were offered NIPT as a first-tier screening test within a Dutch nationwide study (TRIDENT-2). Results show that the inherent uncertainty about the fetus's health despite improved accuracy and the lack of treatment for a detected disorder, combined with the possibility to obtain information about actionable anomalies through the fetal anomaly scan, support women's perspectives that NIPT is not an obligation of responsible motherhood. Acceptance of NIPT is considered to be a free decision related to the information each woman needs to be a good mother for her child and her family. Women's views may change when NIPT has expanded to include treatable or preventable conditions.

Routinization of prenatal screening with the non-invasive prenatal test: pregnant women's perspectives.

Due to the favorable test characteristics of the non-invasive prenatal test (NIPT) in the screening of fetal aneuploidy, there has been a strong and growing demand for implementation. In the Netherlands, NIPT is offered within a governmentally supported screening program as a first-tier screening test for all pregnant women (TRIDENT-2 study). However, concerns have been raised that the test's favorable characteristics might lead to uncritical use, also referred to as routinization. This study addresses women's perspectives on prenatal screening with NIPT by evaluating three aspects related to routinization: informed choice, freedom to choose and (personal and societal) perspectives on Down syndrome. Nationwide, a questionnaire was completed by 751 pregnant women after receiving counseling for prenatal screening. Of the respondents, the majority (75.5%) made an informed choice for prenatal screening as measured by the multidimensional measure of informed choice (MMIC). Education level and religious affiliation were significant predictors of informed choice. The main reason to accept screening was "seeking reassurance" (25.5%), and the main reason to decline was "every child is welcome" (30.6%). The majority of respondents (87.7%) did not perceive societal pressure to test. Differences between test-acceptors and test-decliners in personal and societal perspectives on Down syndrome were found. Our study revealed high rates of informed decision-making and perceived freedom to choose regarding fetal aneuploidy screening, suggesting that there is little reason for concern about routinization of NIPT based on the perspectives of Dutch pregnant women. Our findings highlight the importance of responsible implementation of NIPT within a national screening program.

Clients' perspectives on the quality of counseling for prenatal anomaly screening. A comparison between 2011 and 2019.

OBJECTIVE: There have been substantial medical developments in prenatal anomaly and aneuploidy screening. However, the quality of counseling about these tests tends to lag behind. Additional quality requirements were therefore implemented in the Netherlands in 2017 to optimize this counseling. We compared clients' counseling preferences and experiences before and after implementation of these requirements. METHODS: We used the validated 57-item QUOTEprenatal questionnaire, to measure clients' counseling preferences and experiences before and after counseling in 20 obstetric organizations throughout the Netherlands. Clients' preferences and experiences were compared between pregnant women and partners, nulliparous versus multiparous clients and between results of a Dutch survey in 2011 and the current one. RESULTS: Sixty-five counselors and 649 clients (353 pregnant women and 296 partners) participated in this study. Compared to 2011, slightly more clients considered the three QUOTEprenatal components of counseling (client-counselor relationship, health education, and decision-making support) to be either important or very important, especially decision-making support. More clients than in 2011 perceived their needs as being well addressed, with the lowest percentages for decision-making support. CONCLUSION: Quality requirements seem to benefit the quality of counseling, as perceived by clients. PRACTICAL IMPLICATIONS: Counselors should consider tailoring their decision-making support more to clients' needs.

Perinatal outcomes of frequent attendance in midwifery care in the Netherlands: a retrospective cohort study.

BACKGROUND: Over the last decade, a trend towards high utilisation of primary maternity care was observed in high-income countries. There is limited research with contradictory results regarding frequent attendance (FA) and perinatal outcomes in midwifery care. Therefore, this study examined possible associations between FA in midwifery care and obstetric interventions and perinatal outcomes. METHODS: A retrospective cohort study was performed in a medium-sized midwifery-led care practice in an urban region in the Netherlands. Frequent attenders (FAs) were categorised using the Kotelchuck-Index Revised. Regression analyses were executed to examine the relationship between FAs and perinatal outcomes, stratified by antenatal referral to an obstetrician. Main outcomes of interest were Apgar score ≤ 7 and perinatal death, birth weight, mode of delivery, haemorrhage, place of birth, transfer during labour, and a requirement for pain relief. RESULTS: The study included 1015 women, 239 (24%) FAs and 776 (76%) non-FAs, 538 (53%) were not referred and 447 (47%) were referred to an obstetrician. In the non-referred group, FA was significantly associated with a requirement for pain relief (OR 1.98, 95% CI 1.24-3.17) and duration of dilatation (OR 1.20, 95% CI 1.04-1.38). In the referred group, FA was significantly associated with induction of labour (OR 1.86, 95% CI 1.17-2.95), ruptured perineum (OR 0.50, 95% CI 0.27-0.95) and episiotomy (OR 0.48, 95% CI 0.24-0.95). In the non-referred and the referred group, FA was not associated with the other obstetric and neonatal outcomes. Due to small numbers, we could not measure possible associations of FA with an Apgar score ≤ 7 and perinatal death. CONCLUSION: In our study, perinatal outcomes differed by FA and antenatal referral to an obstetrician. In the non-referred group, FA was significantly associated with medical pain relief and duration of dilatation. In the referred group, FA was significantly associated with induction of labour, ruptured perineum, and episiotomy. Further research with a larger study population is needed to look for a possible association between FA and primary adverse birth outcomes such as perinatal mortality.

Determinants and underlying causes of frequent attendance in midwife-led care: an exploratory cross-sectional study.

BACKGROUND: An adequate number of prenatal consultations is beneficial to the health of the mother and fetus. Guidelines recommend an average of 5-14 consultations. Daily practice, however, shows that some women attend the midwifery practice more frequently. This study examined factors associated with frequent attendance in midwifery-led care. METHODS: We conducted a cross-sectional study in a large midwifery practice in the Netherlands among low-risk women who started prenatal care in 2015 and 2016. Based on Andersen's behavioral model, we collected data on potential determinants from the digital midwifery's practice database. Prenatal healthcare utilization was measured by a revised version of the Kotelchuck Index, which measures a combination of care entry and numbers of visits. Logistic regression models were fitted to estimate the likelihood of frequent attendance compared to the recommended number of visits, adjusted for all relevant factors. Separate models were fitted on the non-referred and the referred group of obstetric-led care, as referral was found to be an effect modifier. RESULTS: The prevalence of frequent attendance was 23% (243/1053), mainly caused by worries and/or vague complaints (44%; 106/243). Among non-referred women, 53% (560/1053), frequent attendance was associated with consultation with an obstetrician (OR = 3.99 (2.35-6.77)) and exposure to sexual violence (OR = 2.17 (1.11-4.24)). Among the referred participants, 47% (493/1053), frequent attendance was associated with a consultation with an obstetrician (OR = 2.75 (1.66-4.57)), psychosocial problems in the past or present (OR = 1.85 (1.02-3.35) or OR = 2.99 (1.43-6.25)), overweight (OR = 1.88 (1.09-3.24)), and deprived area (OR = 0.50 (0.27-0.92)). CONCLUSION: Our exploratory study indicates that the determinants of frequent attendance in midwifery-led care differs between non-referred and referred women. Underlying causes for frequent attendance was mainly because of non-medical reasons. IMPLICATION FOR PRACTICE: A trustful midwife-client relationship is known to be needed for clients such as frequent attenders to share more detailed, personal stories in case of vague complaints or worries, which is necessary to identify their implicit needs.

Introduction of non-invasive prenatal testing as a first-tier aneuploidy screening test: A survey among Dutch midwives about their role as counsellors.

In 2014, non-invasive prenatal testing (NIPT) for trisomies 21, 18 and 13 was added to the Dutch prenatal screening program as part of the TRIDENT study. Most (85%) pregnant Dutch women are counselled for prenatal aneuploidy screening by primary care midwives. This will remain when NIPT is implemented as a first-tier screening test. We therefore investigated midwife counsellors': 1) Knowledge about NIPT; 2) Attitudes towards NIPT as first-tier screening test; and 3) Experiences with informing clients about NIPT. Between April-June 2015, an online questionnaire to assess knowledge about NIPT, attitudes towards NIPT, and experiences with NIPT was completed by 436 Dutch primary care midwives. We found that 59% midwives answered ≥7 of 8 knowledge questions correctly. Continuing professional education attendance and more positive attitudes towards prenatal screening for Down syndrome were positively associated with the total knowledge score (ß = 0.261; p = 0.007 and ß = 0.204; p = 0.015, respectively). The majority (67%) were in favor of replacing First trimester Combined Test with NIPT, although 41% preferred to maintain a nuchal translucency measurement alongside NIPT. We conclude that midwives demonstrated solid knowledge about NIPT that may still be improved in some areas. Dutch midwives overwhelmingly support the integration of NIPT as a first-tier screening test.

Health behaviour information provided to clients during midwife-led prenatal booking visits: Findings from video analyses.

OBJECTIVE: to quantify to what extent evidence-based health behaviour topics relevant for pregnancy are discussed with clients during midwife-led prenatal booking visits and to assess the association of client characteristics with the extent of information provided. DESIGN: quantitative video analyses. SETTING AND PARTICIPANTS: 173 video recordings of prenatal booking visits with primary care midwives and clients in the Netherlands taking place between August 2010 and April 2011. MEASUREMENTS: thirteen topics regarding toxic substances, nutrition, maternal weight, supplements, and health promoting activities were categorized as either 'never mentioned', 'briefly mentioned', 'basically explained' or 'extensively explained'. Rates on the extent of information provided were calculated for each topic and relationships between client characteristics and dichotomous outcomes of the extent of information provided were assessed using Generalized Linear Mixed Modelling. FINDINGS: our findings showed that women who did not take folic acid supplementation, who smoked, or had a partner who smoked, were usually provided basic and occasionally extensive explanations about these topics. The majority of clients were provided with no information on recommended weight gain (91.9%), fish promotion (90.8%), caffeine limitation (89.6%), vitamin D supplementation (87.3%), physical activity promotion (81.5%) and antenatal class attendance (75.7%) and only brief mention of alcohol (91.3%), smoking (81.5%), folic acid (58.4) and weight at the start of pregnancy (52.0%). The importance of a nutritious diet was generally either never mentioned (38.2%) or briefly mentioned (45.1%). Nulliparous women were typically given more information on most topics than multiparous women. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: although additional information was generally provided about folic acid and smoking, when relevant for their clients, the majority of women were provided with little or no information about the other health behaviours examined in this study. Midwives may be able to improve prenatal health promotion by providing more extensive health behaviour information to their clients during booking visits.

Clients' psychosocial communication and midwives' verbal and nonverbal communication during prenatal counseling for anomaly screening.

OBJECTIVES: This study focuses on facilitation of clients' psychosocial communication during prenatal counseling for fetal anomaly screening. We assessed how psychosocial communication by clients is related to midwives' psychosocial and affective communication, client-directed gaze and counseling duration. METHODS: During 184 videotaped prenatal counseling consultations with 20 Dutch midwives, verbal psychosocial and affective behavior was measured by the Roter Interaction Analysis System (RIAS). We rated the duration of client-directed gaze. We performed multilevel analyses to assess the relation between clients' psychosocial communication and midwives' psychosocial and affective communication, client-directed gaze and counseling duration. RESULTS: Clients' psychosocial communication was higher if midwives' asked more psychosocial questions and showed more affective behavior (ß=0.90; CI: 0.45-1.35; p<0.00 and ß=1.32; CI: 0.18-2.47; p=0.025, respectively). Clients "psychosocial communication was not related to midwives" client-directed gaze. Additionally, psychosocial communication by clients was directly, positively related to the counseling duration (ß=0.59; CI: 0.20-099; p=0.004). CONCLUSIONS: In contrast with our expectations, midwives' client-directed gaze was not related with psychosocial communication of clients. PRACTICE IMPLICATIONS: In addition to asking psychosocial questions, our study shows that midwives' affective behavior and counseling duration is likely to encourage client's psychosocial communication, known to be especially important for facilitating decision-making.

Midwives' perceptions of communication during videotaped counseling for prenatal anomaly tests: how do they relate to clients' perceptions and independent observations?

OBJECTIVE: This study aimed to provide insight into Dutch midwives' self-evaluation of prenatal counseling for anomaly screening in real life practice and, the degree of congruence of midwives' self-assessments with clients' perceptions and with observed performance. METHODS: Counseling sessions were videotaped. We used the QUOTE(prenatal) questionnaire to have each midwife (N = 20) and her client (N = 240) rate the prenatal counseling that they had together. We used an adapted version of the RIAS video-coding system to assess actual counseling during videotaped prenatal counseling (N = 240). RESULTS: Midwives perceived the following functions of counseling performed well: 100% of Client-Counselor relation (CCR); 80% of Health Education (HE); and 17% Decision-Making Support (DMS). Congruence on HE of midwives with observers and with clients was ≥ 75%; congruence on DMS was higher between midwives and observers (80%) compared to midwives and clients (62%). CONCLUSION: Midwives perceive that during prenatal counseling the CCR and HE functions of counseling were performed well, whereas DMS was not. Furthermore, this study shows incongruence between midwives and clients about the discussion during DMS, indicating DMS is more difficult to assess than HE. PRACTICE IMPLICATIONS: The best way to measure prenatal counseling practice might be by using assessments of different sources within one study.

Antenatal counselling for congenital anomaly tests: pregnant Muslim Moroccan women's preferences.

OBJECTIVE: to gain insight into pregnant Muslim Moroccan women's preferences regarding the content of and approach to antenatal counselling for anomaly screening. DESIGN: qualitative study using in-depth interviews. SETTING: participants were recruited from one midwifery practice in a medium-sized city near Amsterdam. PARTICIPANTS: 12 pregnant Muslim Moroccan women who live in an area with a high density of immigrants. DATA COLLECTION AND DATA ANALYSES: we conducted open interviews after the cut-off date for the 20 week fetal anomaly scan and used techniques from the thematic analysis approach described by Braun and Clarke (2006). FINDINGS: pregnant Muslim Moroccan women's preferences towards counselling could be summarised in three main findings. Firstly, pregnant Muslim Moroccan women underlined the importance of accurate and detailed information about the tests procedures and the anomalies that could be detected. Secondly, pregnant Muslim Moroccan women preferred counsellors to initiate discussions about moral topics and its relationship with the women's religious beliefs and values to facilitate an informed choice about whether or not to participate in the screening tests. Thirdly, pregnant Muslim Moroccan women preferred a counsellor who respects and treats them as an individual who has an Islamic background. The counsellor should have practical knowledge of Islamic rulings that are relevant to the anomaly tests. KEY CONCLUSIONS: pregnant Muslim Moroccan women preferred to be accurately informed about antenatal anomaly tests and to be asked about their individual views on life by a counsellor who has genuine interest in the individual client and applied knowledge of Islamic beliefs regarding the value of life. IMPLICATIONS FOR PRACTICE: counsellors should explore clients' moral values about quality of life and termination and its relationship with religious beliefs. Counsellors should know about Islamic rulings related to antenatal anomaly screening.

A qualitative study on how Muslim women of Moroccan descent approach antenatal anomaly screening.

OBJECTIVE: to extend the knowledge on Muslim women's approach of antenatal anomaly screening. DESIGN: qualitative interview study with pregnant Muslim women from Moroccan origin. SETTING: one midwifery practice in a medium-sized city near Amsterdam participated in the study. PARTICIPANTS: twelve pregnant Muslim women who live in a high density immigrant area and who attended primary midwives for antenatal care were included in the study. DATA COLLECTION AND DATA ANALYSES: we conducted open interviews with pregnant Moroccan Muslim women for the purpose of studying how they made decisions about antenatal anomaly screening. We used a thematic analysis approach. FINDINGS: women experienced the combined test as 'a test' that could identify potentially anomalous infants, and could result in being offered termination of the pregnancy; a fact that resulted in their extensive deliberations and hesitation about the test uptake. Only two women had the combined test. Conversely, women opted for the Fetal Anomaly Scan and saw it as 'only an ultrasound to see the baby'. Above all, women emphasised that whether or not to participate in antenatal anomaly tests was their own, individual decision as ultimately they were accountable for their choices. All women, including nulliparous women, viewed becoming pregnant as the point of becoming a mother - and considered antenatal screening through the lens of motherhood. KEY CONCLUSIONS: motherhood was the lens through which the decision to participate in antenatal anomaly screening was approached. Religious beliefs influenced values on termination and disability and were influential in the deliberations for antenatal testing. Combined test but not Fetal Anomaly Scan was considered to be a antenatal screening test. IMPLICATIONS FOR PRACTICE: counsellors should have knowledge of the different Islamic beliefs about - the latest possible day for - termination and an awareness that Muslim women make their own conscious choices, also beyond Islamic rulings.

Antenatal counselling for congenital anomaly tests: an exploratory video-observational study about client-midwife communication.

OBJECTIVE: antenatal counselling for congenital anomaly tests is conceptualised as having both Health Education (HE) and Decision-Making Support (DMS) functions. Building and maintaining a client-midwife relation (CMR) is seen as a necessary condition for enabling these two counselling functions. However, little is known about how these functions are fulfilled in daily practice. This study aims to describe the relative expression of the antenatal counselling functions; to describe the ratio of client versus midwife conversational contribution and to get insight into clients' characteristics, which are associated with midwives' expressions of the functions of antenatal counselling. DESIGN: exploratory video-observational study. PARTICIPANTS AND SETTING: 269 videotaped antenatal counselling sessions for congenital anomaly tests provided by 20 midwives within six Dutch practices. MEASUREMENTS: we used an adapted version of the Roter Interaction Analysis System to code the client-midwife communication. Multilevel linear regression analyses were used to analyse associations between clients' characteristics and midwives' expressions of antenatal counselling in practice. FINDINGS: most utterances made during counselling were coded as HE (41%); a quarter as DMS (23%) and 36% as CMR. Midwives contributed the most to the HE compared to clients or their partners (91% versus 9%) and less to the DMS function of counselling (61% versus 39%). Multilevel analyses showed an independent association between parity and shorter duration of antenatal counselling; (ß=-3.01; p<0.001). The amount of utterances concerning HE and DMS during counselling of multipara was less compared to nulliparous. KEY CONCLUSIONS: antenatal counselling for congenital anomaly tests by midwives is focused on giving HE compared to DMS. The relatively low contribution of clients during DMS might indicate poor DMS given by midwives. Counselling of multipara was significantly shorter than counselling of nulliparous; multiparae received less HE as well as DMS compared to nulliparous women. IMPLICATIONS FOR PRACTICE: our findings should encourage midwives to reflect on the process of antenatal counselling they offer with regards to the way they address the three antenatal counselling functions during counselling of nulliparous women compared to multiparae.

Factors affecting the uptake of prenatal screening tests for congenital anomalies; a multicentre prospective cohort study.

BACKGROUND: Two prenatal screening tests for congenital anomalies are offered to all pregnant women in the Netherlands on an opt-in basis: the Combined Test (CT) for Down syndrome at twelve weeks, and the Fetal Anomaly Scan (FAS) at around twenty weeks. The CT is free for women who are 36 or older; the FAS is free for all women. We investigated factors associated with the CT and FAS uptake. METHOD: This study is part of the DELIVER study that evaluated primary care midwifery in the Netherlands. Associations between the women's characteristics and the CT and FAS uptake were measured using multivariate and multilevel logistic regression analyses. RESULTS: Of 5216 participants, 23% had the CT and 90% had the FAS, with uptake rates ranging from 4% to 48% and 62% to 98% respectively between practices. Age (OR: 2.71), income (OR: 1.38), ethnicity (OR: 1.37), being Protestant (OR: 0.25), multiparous (OR: 0.64) and living in the east of the country (OR: 0.31) were associated with CT uptake; education (OR: 1.26), income (OR: 1.66), being Protestant (OR: 0.37) or Muslim (OR: 0.31) and being multiparous (OR: 0.74) were associated with FAS uptake. Among western women with a non-Dutch background, first generation (OR: 2.91), age (OR: 2.00), income (OR: 1.97), being Protestant (OR: 0.32) and living in the east (OR: 0.44) were associated with CT uptake; being Catholic (OR: 0.27), Protestant (OR: 0.13) were associated with FAS uptake. Among non- western women with a non-Dutch background, age (OR: 1.73), income (OR: 1.97) and lacking proficiency in Dutch (OR: 2.18) were associated with CT uptake; higher education (OR: 1.47), being Muslim (OR: 0.37) and first generation (OR: 0.27) were associated with FAS uptake. CONCLUSION: The uptake of the CT and FAS varied widely between practices. Income, parity and being Protestant were associated with uptake of both tests; ethnicity, age and living in the east were associated with CT uptake, and education and being Muslim with FAS uptake. These findings help to explain some differences between women choosing or declining early and late screening, but not the large variation in test uptake among practices, nor between the Netherlands and other countries.

Prenatal screening for congenital anomalies: exploring midwives' perceptions of counseling clients with religious backgrounds.

BACKGROUND: In the Netherlands, prenatal screening follows an opting in system and comprises two non-invasive tests: the combined test to screen for trisomy 21 at 12 weeks of gestation and the fetal anomaly scan to detect structural anomalies at 20 weeks. Midwives counsel about prenatal screening tests for congenital anomalies and they are increasingly having to counsel women from religious backgrounds beyond their experience. This study assessed midwives' perceptions and practices regarding taking client's religious backgrounds into account during counseling. As Islam is the commonest non-western religion, we were particularly interested in midwives' knowledge of whether pregnancy termination is allowed in Islam. METHODS: This exploratory study is part of the DELIVER study, which evaluated primary care midwifery in The Netherlands between September 2009 and January 2011. A questionnaire was sent to all 108 midwives of the twenty practices participating in the study. RESULTS: Of 98 respondents (response rate 92%), 68 (69%) said they took account of the client's religion. The two main reasons for not doing so were that religion was considered irrelevant in the decision-making process and that it should be up to clients to initiate such discussions. Midwives' own religious backgrounds were independent of whether they paid attention to the clients' religious backgrounds. Eighty midwives (82%) said they did not counsel Muslim women differently from other women. Although midwives with relatively many Muslim clients had more knowledge of Islamic attitudes to terminating pregnancy in general than midwives with relatively fewer Muslim clients, the specific knowledge of termination regarding trisomy 21 and other congenital anomalies was limited in both groups. CONCLUSION: While many midwives took client's religion into account, few knew much about Islamic beliefs on prenatal screening for congenital anomalies. Midwives identified a need for additional education. To meet the needs of the changing client population, counselors need more knowledge of religious opinions about the termination of pregnancy and the skills to approach religious issues with clients.

Midwives' views on appropriate antenatal counselling for congenital anomaly tests: do they match clients' preferences?

OBJECTIVE: this study aims to provide insight into: (a) midwives' views on appropriate antenatal counselling for congenital anomaly tests, and (b) whether these views match clients' preferences regarding antenatal counselling. DESIGN: a comparative (midwives versus clients) questionnaire survey. Cognitive interviews (n=8) were used to validate the internal validity of the midwifery questionnaire results. PARTICIPANTS AND SETTING: 1416 Dutch midwives (response 62%) completed a questionnaire measuring their views on appropriate antenatal counselling for congenital anomaly tests. MEASUREMENTS: we used the 58-item midwives' version of the QUOTE (prenatal), an instrument to assess clients' counselling preferences. Descriptive statistics were used to explore midwives' views on appropriate counselling and how these relate to client preferences as measured previously with the clients' version of the QUOTE (prenatal). FINDINGS: almost all midwives consider the client-midwife relation (100%) and health education (95%) to be (very) important for appropriate antenatal counselling for congenital anomaly tests. Almost half of the midwives consider decision-making support (47%) to be (very) important. These findings are practically congruent with client preferences. Still, clinically relevant differences were found regarding 13 individual items, e.g. more clients than midwives value 'medical information about congenital anomalies' and 'getting advice whether to take prenatal tests or not'. KEY CONCLUSION: like clients, most midwives value a good client-midwife relation and health education as (very) important for antenatal counselling for congenital anomaly tests. Less than half of them value decision-making support. These findings are in contrast with the literature in which decision-making support is seen as the most important part of antenatal counselling for congenital anomaly tests. IMPLICATION FOR PRACTICE: preferably, antenatal counselling for congenital anomaly tests should be consistent with the three-function model of antenatal counselling i.e. maintaining a client-midwife relation, providing health education as well as decision-making support, and tailored to clients' individual preferences. As not all midwives subscribe to these functions, reflection on their views is important. Furthermore, midwives need to bridge their views on appropriate antenatal counselling and client preferences. To do so, midwives may benefit from the Shared Decision Making approach.