Women’s Satisfaction With the Current State of Prenatal Care for Pregnancies Complicated by Fetal Anomalies: A Survey of Five Academic Perinatal Units in Ontario

MRI in the diagnosis of fetal developmental brain abnormalities: the MERIDIAN diagnostic accuracy study

BACKGROUND

Ultrasonography has been the mainstay of antenatal screening programmes in the UK for many years. Technical factors and physical limitations may result in suboptimal images that can lead to incorrect diagnoses and inaccurate counselling and prognostic information being given to parents. Previous studies suggest that the addition of in utero magnetic resonance imaging (iuMRI) may improve diagnostic accuracy for fetal brain abnormalities. These studies have limitations, including a lack of an outcome reference diagnosis (ORD), which means that improvements could not be assessed accurately.

OBJECTIVES

To assess the diagnostic impact, acceptability and cost consequence of iuMRI among fetuses with a suspected fetal brain abnormality.

DESIGN

A pragmatic, prospective, multicentre, cohort study with a health economics analysis and a sociological substudy.

SETTING

Sixteen UK fetal medicine centres.

PARTICIPANTS

Pregnant women aged ≥ 16 years carrying a fetus (at least 18 weeks' gestation) with a suspected brain abnormality detected on ultrasonography.

INTERVENTIONS

Participants underwent iuMRI and the findings were reported to their referring fetal medicine clinician.

MAIN OUTCOME MEASURES

Pregnancy outcome was followed up and an ORD from postnatal imaging or postmortem autopsy/imaging collected when available. Developmental data from the Bayley Scales of Infant Development and questionnaires were collected from the surviving infants aged 2-3 years. Data on the management of the pregnancy before and after the iuMRI were collected to inform the economic evaluation. Two surveys collected data on patient acceptability of iuMRI and qualitative interviews with participants and health professionals were undertaken.

RESULTS

The primary analysis consisted of 570 fetuses. The absolute diagnostic accuracies of ultrasonography and iuMRI were 68% and 93%, respectively [a difference of 25%, 95% confidence interval (CI) 21% to 29%]. The difference between ultrasonography and iuMRI increased with gestational age. In the 18-23 weeks group, the figures were 70% for ultrasonography and 92% for iuMRI (difference of 23%, 95% CI 18% to 27%); in the ≥ 24 weeks group, the figures were 65% for ultrasonography and 94% for iuMRI (difference of 29%, 95% CI 23% to 36%). Patient acceptability was high, with at least 95% of respondents stating that they would have iuMRI again in a similar situation. Health professional interviews suggested that iuMRI was acceptable to clinicians and that iuMRI was useful as an adjunct to ultrasonography, but not as a replacement. Across a range of scenarios, iuMRI resulted in additional costs compared with ultrasonography alone. The additional cost was consistently < £600 per patient and the cost per management decision appropriately changed was always < £3000. There is potential for reporting bias from the referring clinicians on the diagnostic and prognostic outcomes. Lower than anticipated follow-up rates at 3 years of age were observed.

CONCLUSIONS

iuMRI as an adjunct to ultrasonography significantly improves the diagnostic accuracy and confidence for the detection of fetal brain abnormalities. An evaluation of the use of iuMRI for cases of isolated microcephaly and the diagnosis of fetal spine abnormalities is recommended. Longer-term follow-up studies of children diagnosed with fetal brain abnormalities are required to fully assess the functional significance of the diagnoses.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN27626961.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 49. See the NIHR Journals Library website for further project information.

Predictors of Women's Satisfaction with Prenatal Care in a Canadian Setting

OBJECTIVE

Prenatal care is a vital and important part of a healthy pregnancy, providing many maternal and health benefits. Despite Canada's publically funded health care system with universal access, inadequate rates of prenatal care continue to be observed. As a modifiable risk factor, the process variables that influence satisfaction with prenatal care in Canadian settings have received little attention. The objective of this study was to identify the predictors of satisfaction with prenatal care.

METHODS

A cross-sectional, descriptive, correlational design was used to examine the relationships between expectations, interpersonal processes of care, the quality of prenatal care, personal characteristics, and the type of provider with overall satisfaction, and with four dimensions of satisfaction. A convenience sample of 216 pregnant women was surveyed using self-administered questionnaires with women in their third trimester. Multiple linear regression analyses were used to identify predictors of satisfaction.

RESULTS

The quality of prenatal care and provider interpersonal style together explained 80% of the variance in overall satisfaction. Patient-centered decision-making was a significant predictor of satisfaction with information, while having a midwife was a predictor of satisfaction with system characteristics. Expectations were not related to satisfaction.

CONCLUSIONS FOR PRACTICE

Improving quality of care, provider interpersonal style and patient-centered decision making, and improving the structural characteristics of prenatal care may be effective in improving women's satisfaction and utilization of prenatal care.

Prenatal consultation with a neonatologist for congenital anomalies: parental perceptions

OBJECTIVES

To investigate parental expectations of a prenatal consultation with a neonatologist for a prenatally diagnosed congenital anomaly, to identify parents' values and unmet needs, and to obtain recommendations for improving physician-parent communication in a prenatal consultation.

METHODS

Parents referred to neonatology for prenatal consultation after the diagnosis of a congenital anomaly. Completed 2 qualitative interviews: the first within 1 week of the consultation and the second 1 week after delivery. Interviews were analyzed for themes by using the constant comparative method associated with the grounded theory method.

RESULTS

Thematic saturation was achieved after 42 interviews (22 women); only mothers participated. Five main themes emerged: (1) preparation; (2) knowledgeable physician; (3) caring providers; (4) allowing hope; and (5) time. Mothers believed that a consultation with a neonatologist helped them prepare for the perinatal course. They wished to know the management plan and all possible outcomes. Mothers wanted information specific to their situation and tailored to their knowledge base. Receiving conflicting information from physicians increased anxiety and eroded confidence. Seeing the NICU during the consultation was emotionally difficult but valuable. Mothers wanted realistic information, regardless of how grim, yet wanted to retain hope. All mothers would recommend a prenatal consultation with a neonatologist.

CONCLUSIONS

Mothers perceived that a consultation with a neonatologist, which included a NICU tour, prepared them for the perinatal course. Parents want realistic medical information, specific to their situation, provided in an empathetic manner and want to be allowed to hope for the best possible outcome.