Variation in Women's Understanding of Prenatal Testing.

OBJECTIVE: To investigate women's understanding of prenatal testing options and of their own experience with screening, diagnostic genetic testing, or both. METHODS: This was a secondary analysis of data from a randomized controlled trial of enhanced information and values clarification regarding prenatal genetic testing in the absence of financial barriers to testing. Women in the third trimester of pregnancy were asked whether they had discussed prenatal genetic testing with their health care providers, whether they understood this testing was optional, and whether they had undergone testing during their pregnancy. Multivariable logistic regression models were fit to determine independent predictors of these outcomes. RESULTS: Data were available from 710 study participants. Discussions about screening tests were reported by 654 participants (92%); only 412 (58%) reported discussing diagnostic testing. That screening and diagnostic testing were optional was evident to approximately two thirds of women (n=470 and 455, respectively). Recall of actual tests undergone was correct for 626 (88%) for screening and for 700 (99%) for diagnostic testing. Racial, ethnic and socioeconomic variation existed in the understanding of whether screening and diagnostic tests were optional and in the correct recall of whether screening had been undertaken in the current pregnancy. In the usual care group, women receiving care in low-income settings were less likely to recall being offered diagnostic testing (adjusted odds ratio 0.23 [0.14-0.39]). CONCLUSION: Disparities exist in women's recall of prenatal genetic testing discussions and their understanding of their own experience. Interventions that explain testing options to women and help clarify their preferences may help to eliminate these differences.

Effect of enhanced information, values clarification, and removal of financial barriers on use of prenatal genetic testing: a randomized clinical trial.

IMPORTANCE: Prenatal genetic testing guidelines recommend providing patients with detailed information to allow informed, preference-based screening and diagnostic testing decisions. The effect of implementing these guidelines is not well understood. OBJECTIVE: To analyze the effect of a decision-support guide and elimination of financial barriers to testing on use of prenatal genetic testing and decision making among pregnant women of varying literacy and numeracy levels. DESIGN, SETTING, AND PARTICIPANTS: Randomized trial conducted from 2010-2013 at prenatal clinics at 3 county hospitals, 1 community clinic, 1 academic center, and 3 medical centers of an integrated health care delivery system in the San Francisco Bay area. Participants were English- or Spanish-speaking women who had not yet undergone screening or diagnostic testing and remained pregnant at 11 weeks' gestation (n = 710). INTERVENTIONS: A computerized, interactive decision-support guide and access to prenatal testing with no out-of-pocket expense (n = 357) or usual care as per current guidelines (n = 353). MAIN OUTCOMES AND MEASURES: The primary outcome was invasive diagnostic test use, obtained via medical record review. Secondary outcomes included testing strategy undergone, and knowledge about testing, risk comprehension, and decisional conflict and regret at 24 to 36 weeks' gestation. RESULTS: Women randomized to the intervention group, compared with those randomized to the control group, were less likely to have invasive diagnostic testing (5.9% vs 12.3%; odds ratio [OR], 0.45 [95% CI, 0.25-0.80]) and more likely to forgo testing altogether (25.6% vs 20.4%; OR, 3.30 [95% CI, 1.43-7.64], reference group screening followed by invasive testing). Women randomized to the intervention group also had higher knowledge scores (9.4 vs 8.6 on a 15-point scale; mean group difference, 0.82 [95% CI, 0.34-1.31]) and were more likely to correctly estimate the amniocentesis-related miscarriage risk (73.8% vs 59.0%; OR, 1.95 [95% CI, 1.39-2.75]) and their estimated age-adjusted chance of carrying a fetus with trisomy 21 (58.7% vs 46.1%; OR, 1.66 [95% CI, 1.22-2.28]). Significant differences did not emerge in decisional conflict or regret. CONCLUSIONS AND RELEVANCE: Full implementation of prenatal testing guidelines using a computerized, interactive decision-support guide in the absence of financial barriers to testing resulted in less test use and more informed choices. If validated in additional populations, this approach may result in more informed and preference-based prenatal testing decision making and fewer women undergoing testing. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00505596.

Characteristics of women who undergo second-trimester abortion in the setting of a fetal anomaly.

BACKGROUND: Most women diagnosed with a fetal anomaly terminate the pregnancy. Little is known about utilization of two procedures: dilation and evacuation (D&E) and induction termination. STUDY DESIGN: This retrospective cohort study included all women seen at the University of California, San Francisco (UCSF) Prenatal Diagnosis Center (PDC) who underwent a second-trimester abortion for an anomalous pregnancy from 2005 to 2008. We abstracted variables from the PDC database and medical charts to identify predictors associated with undergoing D&E. RESULTS: Three quarters of the 192 women underwent D&E (n=148). Higher maternal age, proximity to UCSF, earlier gestational age, singleton gestation and genetic anomaly were associated with undergoing D&E. In adjusted analysis, earlier gestational age and singleton gestation were associated with undergoing D&E. CONCLUSIONS: The D&E procedure was more commonly utilized for terminating an anomalous pregnancy at UCSF than medical induction. Further inquiry is needed to explore how provider counseling influences the choice of D&E vs. induction.

First-trimester combined screening: experience with an instant results approach.

OBJECTIVE: This study was undertaken to assess an instant results protocol for first-trimester combined screening. STUDY DESIGN: Retrospective analysis of patients having first-trimester combined screening between Nov. 1, 2003 and Oct. 31, 2005. We evaluated the feasibility of patient self-collection and mail-in of blood samples before nuchal translucency ultrasound. Primary outcome was success with providing in-office, immediate screening results after the ultrasound. Predictor variables included age, ethnicity, insurance, and provider. The chi2 analysis was performed. RESULTS: Two thousand three hundred ten women completed first-trimester combined screening, and 60.6% received instant results. When the biochemistry sample was collected at home, 80% received instant results. Age 35 years or older predicted instant results (P = .001), whereas ethnicity, insurance, and referring provider did not. Comparing the prior 24 months, clinic volume increased by 18%. Diagnostic procedure volume was unchanged, although chorionic villus sampling increased by 12% (P = .02) and amniocentesis decreased by 6% (P = .049). CONCLUSION: Patients were able to obtain instant results in 60.6% of cases, which appeared to increase the use of chorionic villus sampling.