Prenatal Testing and Screening - Case Study Example

Prenatal testing and screening Prenatal care Pregnancy is a physiological process, but any pregnant woman can face complications. In other words, every pregnancy has got a risk of about 2 – 3 percent of ending up with a newborn with congenital anomalies (Chandra). So there are two ways to reduce these complications, either not to get pregnant or be in touch with health care provider as and when it is required or advised by the provider. From the conception to the end of the postpartum period, the longest phase is pregnancy, 40 weeks. This long period has got a potential to turn normally proceeding events in to complicated situations. As pregnancy progresses the chances of changing the normal situation to abnormal one also increases. These complications could be primarily related to mother or developing foetus and both can affect the other partner. Continuous contact between a pregnant woman and a health are provider reduces the chances of turning the situation towards real emergency situation. This care provider – client relationship not only addresses the medical issues but it becomes an excellent opportunity to discuss other related and required issues, like: nutrition, rest, event around delivery, postpartum period, care of newborn and family planning. During pregnancy, there is an opportunity for pregnant woman to get herself tested or screened as advised by her care provider. Prenatal testing and screening is a preventive measure to exclude as many pathological situations as possible so that the outcome of a pregnancy is smooth in the shape of a normal newborn. Prenatal testing During the prenatal period, pregnant women are advised some routine laboratory tests for all women. These laboratory tests require samples from blood, urine and cervix, as well as tests for sexually transmitted diseases (STIs) (Medial Library, ACOG). The purpose of this routine activity is that if some abnormality is detected then it can be treated early before complications start because of this abnormality. Moreover, treating these abnormalities is not a big task but the effects of treating these abnormalities are significantly high. Blood tests include: blood typing and antibody screening, haemoglobin and haematocrit, rubella, hepatitis B virus, syphilis, human immunodeficiency virus (HIV) and glucose. Urine is tested for the presence of sugar and proteins in the urine. High levels or sugar are of some concern otherwise sugar is excreted in urine during pregnancy but the presence of proteins suggests further work on excluding urinary tract infection (UTI), other kidney diseases or blood pressure. To look for any change in the cervix, a Pap smear is taken and assessed for any change leading to cervical cancer if it has not been taken during the last six months. At this time, a sample is also taken to check for gonorrhoea and Chlamydia. Prenatal screening Usually screening is done to assess the status of developing foetus in the womb. This process helps in detecting congenital defects and if these defects are detected at an appropriate time then preventive measures in some cases and treatment through drugs or surgery in other cases helps correcting these defects. Before the first trimester ends, it is a proper time to get screening done for these congenital defects. Firstly, some biochemical measurements are carried out on the blood samples of mother and if any derangements are found in the levels of these substances then the status is confirmed through diagnostic tests which confirm the status of any defect in the developing foetus (Medial Library, ACOG). These confirmatory tests are: 1. Amniocentesis; 2. Chorionic Villous Sampling (CVS); and 3. Ultrasound. Factors influencing the decision of women for prenatal care Education of Women There is substantial evidence from innumerable studies describing the independent effect of women’s education on the utilization of maternal health services. Maternal education is correlated with socioeconomic status but also affects attitudes. In Vietnam, the level of education of women was the most significant determinant of antenatal care (Ingrid, 1993). Results from a study conducted in the Philippines also supported the effect of women’s education associated with the use of antenatal care services (Wong, 1987). Data from a study in Nepal had a strong positive association between women education and utilization of antenatal services (Matsumura, 2001). Occupation Occupation of either husband and wife or husband alone has been studied as factor supporting the attitude of prenatal care. Results of a study in a study carried out in Jamaica results showed that women whose husbands were from higher professional groups were more likely to utilize maternal services as compared to those whose husbands were of middle or low class professional (Mcaw-Bennis, 1995). The same study also showed a similar association between women in higher professions and early utilization of services. The results from a study from rural areas of Pakistan also reflected the positive association between husband of high professional group and prenatal care of wife (Fatmi, 2002). Socioeconomic status Socioeconomic status has been shown to influence the pregnant women to decide in the direction of seeking prenatal acre. A study conducted in Kenya showed that the onset and frequency of prenatal care by women of high socioeconomic status was early and more respectively (Magadi, 2000). In Vietnam, Toan’s study found an association between increase in economic status of the household and improved utilization of maternal health services (Toan, 1996). In Nepal, economic status of the household had a positive effect on the use of prenatal care (Mesganaw, 2000). Maternal age Age of the mother at the time of pregnancy has shown varied associations with the use of maternal services. In a study of rural Northwest Ethiopia the users of prenatal care were younger than non-users (Karin, 2002). On the other hand, a study conducted in Maine, USA showed opposite results of under-utilization of prenatal services by a younger group of women (Thomas, 1998). This variation explains the influence of other factors along with age of mother, which influence use of prenatal services. Number of living children Number of living children has an inverse relation with the use of services but in reality it is the experience of the woman with her first pregnancy and delivery which leads to the behaviour of a woman as a service utilizer or not. In Turkey a study showed that the higher the level of parity, the less the likelihood of skilled attendant at delivery (Celik, 2000), this behaviour could also be a reflection of poor socioeconomic status. A similar trend of low utilization by women with high parity was reflected in a study conducted in Ethiopia (Karin, 2002). One study conducted in India showed that pregnant women with more number of children born (average) were either non-immunized or partially immunized than women with less number of children born through prenatal care (Gupta, 1998). Previous pregnancy Undesirable experience of previous pregnancy either delays, or motivates the pregnant women to over-use services during next conception; most likely the woman becomes frightened of the results of next pregnancy. A study conducted in Sweden showed that women with poor previous pregnancy history tried to delay their next conception (Karin, 2002). Women with poor previous history in Jamaica especially when a pregnancy ended in miscarriage were more likely to prenatal acre clinics regularly (Mcaw-Bennis, 1995). Desire of pregnancy Existing evidence support the negative behaviour of women with unwanted pregnancies. Women have got an attitude that either do not go for prenatal care or if go then it is very late which is usually in response to some complications. Also they seldom comply with the instructions of their care provider. These characteristics emphasize the importance of family planning services so that an unwanted pregnancy could be avoided. Husley found an association between unintended pregnancy and late or no use of antenatal care (2001). In another study conducted in Kenya, use of maternal services was highly dependent on the status of pregnancy whether it was desired or not (Magadi, 2000). Distance to health facility Greater the distance from residence to health facilities the lesser the chances of using prenatal care and other maternal health services. The increased distance results in more time and money consumption that is difficult for poor women and if they are living in far flung areas to justify and decide in the favour of accessing these prenatal services especially when they don’t have the vision to recognize the importance of health. One study in USA of African-American women showed that among other factors, distance to health facilities had a negative association with utilization of services due to transport problems and long waiting hours (Mikhail, 1999). Another study conducted in India concluded a trade off, between the quality of service provided at facilities and distance of facilities from residence, for utilization of those services. When quality of service was satisfactory, women ignored the distance and use these services otherwise they did not (Griffiths, 2001). In rural India, Gupta et al found that long distance to the vaccination site (more than 5km) was associated with non-immunization with tetanus toxoid (Gupta, 1998). Quality of care Good quality of care promotes utilization of services. A study in the Philippines showed that service utilization was dependent on quality of care provided (Wong, 1987). In Nepal, visitation of women for prenatal care was remarkably high in health facilities with good quality of care, as compared with health facilities with poor quality (Laxmi, 2000). Factors influencing the decision of women for prenatal testing Amniocentesis is a process through which a needle is inserted into the uterus to collect a small quantity of amniotic fluid present in amniotic sac around the baby. Main purpose of this activity is testing for birth defects. This procedure is not without complications like any other medical procedure. So there might be cramps, bleeding, leaking of amniotic fluid, and miscarriage. Occasionally, there could be respiratory problems of foetus, birth defects, and uterine infection (Kmom, 1996). So choice of going for this procedure is entirely up to the pregnant woman and husband. Most of the time woman is given a choice for testing and then based on the results further interventions. As far as the test results are negative there seems not to be a big issue. On the other hand, when it is presented to woman by her physician that in case of any disability she would have to choose termination of pregnancy to avoid a disabled child and this option is not a usually acceptable choice. This rather affects woman psychologically a lot (Sutton, 2003). This offer of testing is taken differently by different women. There are some who are even being at low risk opt for testing while others are so much against testing that in high risk situations they do not go for testing. Some choose amniocentesis only if they are over 35, while others choose elective amniocentesis even well before 35.  Some couples choose amniocentesis with the intention of aborting if there are any "abnormal" results, while others would choose abortion only for certain birth defects or diseases but not others (Kmom, 1996).   Some couples are willing to go for amniocentesis but with a decision that they would not go for abortion. Their choice of getting tested is an attempt to be aware of the situation if there is any abnormality is detected (Sutton, 2003). The anxiety produced by an explanation of the test performed affects a woman to a greater degree. So she knows that either everything would be fine or in case of bad test results she would loose her baby. So the pregnancy status may not be allowed to complete its term. For explaining this type of pregnancy, Rothman has discovered a term ‘tentative pregnancy’. This situation has a fairly long-term impact. A woman may not share her pregnancy status or even keep hers as if unaware of the situation. This is because if due to testing the final decision goes in favour of termination after testing then how it would be shared with others. Until she is passed through all these tests and cleared all the steps she cannot reveal her pregnancy status (Sutton, 2003). In a book review, Prenatal Testing and Disability Rights, by Fraser published in NEJM (2001) the reviewer made comparisons between critique of disability rights and critics of critique of disability rights. Disability rights companion states that, in fact, prenatal testing is against disability trait by selection. This attitude is providing hurtful messages to those who are with disability traits and the message conveys discrimination tone. While those who are critics of this disability rights say that this is not a selective termination rather it provides an opportunity to the parents to understand the situation and decide about going to have a child who would be disabled. This is rather helpful to parents to decide at appropriate time (Fraser, 2001). While woman has got an individual right to decide for testing and then further interventions especially skipping any termination or accepting. Although, this is an individual decision but it should be in the context that if a disable child is brought in then apart from family, the whole community will be accommodating that individual. So will he or she be compromising other rights are which way he or she will be moving? Rights of the community urge woman to take advantage of her individual rights and decide in a way to support and strengthen healthy community. So dualism is the situation promoted by prenatal tests. Woman tries to avoid the things to learn which mind wants to tell when, in fact, woman sees herself as detached from her body. The situation is that even though the foetus is inside woman but she deliberately refuses to accept that reality. This is because with the knowledge of having foetus inside but which she may loose due to screening tests, this thought convinces her ignore the presence of foetus (Sutton, 2003). Conclusions Prenatal testing is a routine medical activity, which helps in improving the health of mother and developing foetus. This testing is further supported by screening through confirmatory tests, which help making decision in positive direction. To avail these services the pregnant woman has to access the health facility and physicians. It is not always possible to reach to these services before this testing and screening could take place. Women are influenced by a variety of factors to reach a health facility. These factors could be part of her own physical or mental personality like, her age, education, education of husband, working status, occupation of husband, socioeconomic status, her existing family size, order of pregnancy, experience with previous pregnancies, and desire of present pregnancy. So these all factors have got their own effect in decision-making process of a pregnant woman to reach a health care provider for prenatal care. Once a woman has reached an appropriate health facility then doors to other scenarios are opened. At first provider-client (physician-pregnant woman) contact a variety of tests are advised as routine measure, some education is provided and screening is also discussed and offered to the client. This is the time when decision making from the client is required. Again this decision making is dependant and modified by a variety of factors, age of the woman, socioeconomic level of woman, family history of congenital defects, history of complications in previous pregnancy, level of awareness about the tests and screening and their outcomes. Some women may not be offered all these tests and screening because of non-availability of these services at that health facility while in other situations tests and screening services are available and offered but the economic situation of woman does not allow to go ahead. There are situations when tests are available, economy is not a problem and woman is left to decide for availing screening facility and based on result of this screening accepting any intervention required. This is the time where individual rights, clients’ emotions and understanding of the situation play an important role while making any decision. References Chandra S. Prenatal screening and diagnosis. Retrieved on Nov 19 2007 from www.obgyn.med.ualberta.ca/pdf/0405_Talks/prenatal05.pdf Fraser FC, Book Reviews, Prenatal Testing and Disability Rights, edited by Erik Parens and Adrienne Ash.2001, NEJM, vol 344, No. 18, pp.1404-05. Fatmi Z, Avan B.I. 2002. Demographic, socio-economic and environmental determinants of utilization of antenatal care in a rural setting of Sind, Pakistan. J Pak Med Assoc. Vol. 52 pp.138-42. Griffiths P, Stephensen R. 2001. Understanding users’ perspective of barriers to maternal health car use in Maharashtra, India. J Biosoc. Sci. Vol. 33 pp. 339-59. Gupta SD, Keyl PM. 1998. Effectiveness of prenatal tetanus toxoid immunization against neonatal tetanus in a rural area in India. Pediatr Infect Dis J Vol. 17 pp.316-21. Husley TM. 2001. Association between early care and mother’s intention of and desire for the pregnancy. J Obstet Gynecol Neonatal Nurs Vol. 30 275-82. Ingrid E, Nguyen M, Vu Qui N, Pham X. 1993. Factors related to the utilization of prenatal care in Vietnam. J Trop Med Hyg Vol. 96, pp.76-85. Karin G, Waldenstrom U. 2002. Does a traumatic birth experience have an impact on future reproduction? Br J Obstet Gynaecol Vol. 109, pp. 254-60. Kmom. 2004, Prenatal testing: An Amnioentesis Primer. Retrieved on Nov 19 2007 from http://www.plus-size-pregnancy.org/Prenatal%20Testing/prenataltest-amnios.htm Laxmi B, John C. 2000. Maternal and child health services in rural Nepal: Does access or quality matter more? Health Policy Plann Vol. 15, pp. 223-9. Magadi MA, Madise NJ, Rodrigues NR. 2000. Frequency and timing of antenatal care in Kenya: explaining the variations between women of different communities. Soc Sci Med Vol. 51, pp. 551-61. Matsumura M, Gubhaju B. 2001. Women’s status, household structure and the utilization of maternal health services in Nepal. Asia Pac Popul J Vol. 16, pp. 23-44. McCaw-Bennis A, Grenade JL, Deanna A. 1995. Under-users of antenatal care: a comparison of non-attenders and late attenders for antenatal care, with early attendeners. Soc Sci Med Vol. 40, pp. 1003-12. Mesganaw F, Abubeker Kedir, Assefa M, Dinsa A, Daniel M, Estifanos M. 2000. Assessment of antenatal care services in a rural training health center in Northwest Ethiopia. Ethiop J Health Dev Vol. 14, pp. 155-60. Medical library. American College of Obstetricians and Gynecologists. Retrieved on Nov 19 2007 from www.medem.com/MedLB/article,detailb_from_printer.cpu. Mikhail BI. 1999. Perceived impediments to prenatal care among low-income women. West J Nurs Res. Vol. 21, pp. 335-50. Sutton A. 2003. Prenatal diagnosis: Fears and Expectations. CBPP. (first published in ed. Antonio G Spagnolo and Gabriella Gambino, Women’s Health Issues, Societa, ditrice Universo, Rome, pp.347-354. Thomas P, Andrew F. 1998. Predictors of prenatal care utilization. Soc Sci Med Vol. 27, pp.167-72. 10 Toan N, Hoa H, Thach N, Hojer B, Persson L. 1996. Utilization of reproductive health services in a mountainous area in Vietnam. Southeast Asian J Trop Med Public health Vol. 27, pp. 325-32. Wong EL, Popkin BM, Guilkey DK, Akin JS. 1987. Accessibility, quality of care and prenatal care use in The Philippines. Soc Sci Med. Vol. 24, pp. 927-44. Read More