Pregnancy interrupted: loss of a desired pregnancy after diagnosis of fetal anomaly

Prenatal twin-less twins: The congenital loss experience of individuals who lost a twin sibling in utero

Congenital loss involves the loss of an immediate family member, specifically a parent or sibling, either during or prior to birth, and bears unique bereavement-related challenges. The current study investigated the unique congenital loss experiences of those who lost a twin sibling in utero. Through analysis of interviews with 18 Jewish Israeli participants who encountered this type of twin loss, a more comprehensive understanding of their experiences was attempted. The research employed a hybrid methodology, combining two qualitative thematic analysis methods: deductive and data-driven inductive approaches. The analysis revealed four themes: incoherency and uncertainty, ownership over a limited story, continuing an unborn bond, and the identity of a "twin-less" twin. The findings underscore the unique nature of twin loss in utero.

Fetal anomaly diagnosis and termination of pregnancy in Ireland: a service evaluation following implementation of abortion services in 2019

BACKGROUND

Approximately 3% of pregnancies are diagnosed with a fetal anomaly, of which a proportion is fatal or life-limiting. The introduction of legislation for termination of pregnancy in Ireland in 2019 for conditions "likely to lead to the death of the fetus" made termination of pregnancy for "fatal fetal anomaly" an option for pregnant women in Ireland.

OBJECTIVE

This study examined all cases of termination of pregnancy performed for major fetal anomaly over the first 3 years of service implementation, including cases that did not meet the legal criteria, resulting in women traveling outside Ireland for abortion care.

STUDY DESIGN

A retrospective service evaluation of tertiary fetal medicine clinics in 2 tertiary maternity hospitals between 2019 and 2021 was undertaken. We compared pregnancies of patients diagnosed with fatal fetal anomaly who underwent termination of pregnancy in Ireland with those of patients who did not meet the legal criteria and hence traveled outside Ireland for termination of pregnancy.

RESULTS

Overall, 139 pregnancies met the inclusion criteria; 83 (59.7%) patients had termination of pregnancy in the tertiary maternity hospital (local), and 56 (40.3%) traveled abroad, mainly to the United Kingdom. Demographic characteristics were similar between the 2 groups, as was gestation at diagnosis and delivery. All cases where termination of pregnancy was local were discussed at fetal medicine multidisciplinary meetings, as opposed to 34% of cases of patients who ultimately traveled outside Ireland for termination of pregnancy. The most common indication (25/83; 30.1%) for local termination of pregnancy was trisomy 18, followed by anencephaly. Traveling to obtain abortion care was mainly due to diagnosis of trisomy 21 (30/56; 53.6%), followed by other multiple structural anomalies/syndromes deemed locally as not meeting the legal criteria.

CONCLUSION

Legislation for termination of pregnancy for fetal anomaly, restricted to fatal diagnoses, is difficult to implement, requires significant multidisciplinary input, and can lead to limited services for pregnancies diagnosed with major fetal anomalies. Our findings emphasize the impact of legislative barriers to abortion care for fetal anomaly and the need for policies and services that support women's access to termination of pregnancy for fetal anomaly.

Needs for supporting women undergoing termination of pregnancy for fetal anomaly: A phenomenological study based on the cognitive-emotional-behavioral framework

OBJECTIVE

To determine and describe the needs of women undergoing termination of pregnancy for fetal anomaly (TOPFA) in China.

STUDY DESIGN

Qualitative study with semi-structured interviews. Consolidated Criteria for Reporting Qualitative Studies checklist was used for reporting.

SETTING

Three general hospitals and one special hospital in Changsha, Hunan, China.

PARTICIPANTS

12 women who had undergone TOPFA and 12 healthcare providers who had experienced in caring for these women.

METHODS

This study was based on the cognitive-emotional-behavioral framework (CEBF) of women who had to undergo TOPFA. Twenty-four participants (12 women and 12 healthcare providers) were recruited from two hospitals in China. Semi-structured face-to-face interviews were conducted based on interview guides. ATLAS.ti software was used to encode and analyze data. Qualitative content analysis was also applied.

FINDINGS

Four themes emerged: information, emotional, professional psychological, and social supports. Each theme was subdivided into four phases for a detailed description of the temporal order (denial, confirmation, decision-making, and recovery phases) within the framework.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Our study analyzes the four needs of women who underwent TOPFA and the specifics of each need at different phases based on the CEBF. The importance of offering professional psychological support, detailed information, timely emotional support, and comprehensive social support for these women is illustrated. This study contributes to the understanding of women's needs, hence providing a theoretical basis for the construction of supportive programs.

Counseling pregnant people after previous termination of pregnancy for fetal anomaly (TOPFA): the double RAINBOW approach

BACKGROUND AND OBJECTIVES

Pregnancy loss is exceptionally common, yet there exist few interventions for clinical providers to assist parents who are expecting again. Perhaps even less prevalent are practice models for parents who have terminated a pregnancy due to fetal anomaly (TOPFA). In this article, we present the "Double Rainbow" acronym, which provides evidence-supported guidance for counseling people experiencing a subsequent pregnancy after TOPFA.

DESIGN AND METHODS

Using prompts of: Remember; Rehearse & Anticipate; Attach & Internalize; Interrogate decision; Neutralize; Normalize; Bond; Breathe & Observe; Optimize health; Weave and Whole story, we tie intervention techniques to evidence-based treatments and clinical practice examples.

RESULTS

Filling a gap for guidance for effective intervention with people during subsequent pregnancies after termination of pregnancy due to fetal anomaly, we aim to improve such treatment while also encouraging evaluation of the approach, encouraging evaluation of its use with broader populations.

CONCLUSIONS

The double RAINBOW approach weaves together evidence-based therapies while also attending to the work of distinguishing past losses and promoting parental attachment and caregiving systems in clients who have terminated a pregnancy due to fetal anomaly.

Termination of pregnancy for fetal malformation: A traumatic event? A qualitative analysis of women's perception

Objective: To investigate women's experience of termination of pregnancy (TOP) for severe fetal malformation.We focus on women's individual perception of psychological counselling on decision making, experiencing the birth process, seeing and holding the baby as well as emotional processing. Methods: An explorative study was conducted with 42 women (the age range was between 21 and 45 years [mean 36.17; SD±6.66]) on average twelve months after TOP using semi-structured qualitative interviews. All women received psychological counselling before, during and after the time of TOP (mean 5.2; range 2-11), at the initial counselling session all partners were present. Data were analysed by means of qualitative content analysis by Mayring; the main research question focused on women's perception of psychological counselling on experiencing TOP and coping with this incisive life event. Results: After receiving psychological counselling most of the women felt sufficiently prepared to make a decision, to experience the birth process and to bid farewell to their child. Seeing and holding the baby were perceived as helpful for emotional processing. At the time of the interview, despite the emotional distress,most women reported having positivememories and felt they had coped with the loss. Conclusions: Long-term psychological care from the time of diagnosis through TOP and follow up impacts positively on experiencing TOP, saying farewell to the child and integrating the loss into life. Further studies to detect women at risk for prolonged mourning-reactions are needed.

Fatal fetal anomaly: Experiences of women and their partners

OBJECTIVE

This study explored the care experiences of parents whose pregnancy was diagnosed with a fatal fetal anomaly following the legalisation of termination of pregnancy in 2019 in Ireland.

METHODS

A qualitative study using in-depth semi-structured interviews and interpretative phenomenological analysis was undertaken. Purposeful sampling was used to recruit 10 parents, six women and four of their male partners. Parents recruited included those who terminated and continued the pregnancy.

RESULTS

Three superordinate themes were identified: 'Attachment and coping', 'There's no place for you in the pregnancy world' and 'Consistency of quality care'. Parents shared the different approaches and level of attachment to their baby that supported their coping. Regardless of the level of attachment, many parents benefited from the acts of remembrance. Parents expressed how they no longer felt they belonged in the 'pregnancy world' and described a need for healthcare professionals to recognise their loss and create a safe and supportive environment in which they could share their grief. Despite this, parents' accounts highlighted variations and inconsistencies in care and service provision.

CONCLUSION

Our study highlighted parents' need for consistent, well communicated, and comprehensive care, which encourages an individualised perinatal palliative care approach to meet parental needs.

Shouldering Death: Moral Tensions, Ambiguity, and the Unintended Ramifications of State-sanctioned Second-trimester Selective Abortion in Denmark

This article is based on an ethnographic study of pregnant couples' embodied, emotional, and moral experiences of second-trimester selective abortion in Denmark. Drawing on 16 selective abortion stories, I unpack the intense, often highly accelerated, days that follow from the moment a fetal aberration is detected to the moment of fetal disposal or burial. I show that although prenatal screening and diagnostics have come to occupy a routinized part of pregnancy in Denmark, when women and their partners opt for termination, they are faced with a series of bodily events and actions they are entirely unprepared for while at the same time feeling essentially alone in grappling with the moral confusion that ensues. I argue that despite widespread medico-legal sanctioning and social endorsement of selective abortion, the specificities of how such terminations are done in Denmark in ambiguous, and conflicted, ways situate women and their partners in a series of moral tensions around how to relate to the abortion, the dead fetus, their grief, and their entitlement to such mourning. By chronicling the core struggles that the process of termination catalyzes, I point to the social and moral ramifications of the embodied practices and medico-legal choreographing of selective abortion in Denmark. [selective abortion, moral tensions, embodied practices, responsibility, death].

Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 1, experiences and recommendations for service design

Prospective parents whose fetus is diagnosed with a neurological anomaly go through a complex range of emotions. They describe their discussions of antenatal counselling from health care professionals as focusing too much on the nature of the anomaly involving unintelligible medical terminology, when what they really want is a picture of the best- and worst-case scenarios. Whilst information on the level of risk for their fetus is important, it is not the parents' primary concern. When statistics for risk are given, they may not be as well understood as the health care professionals think. This review discusses the published evidence on antenatal counselling and recommendations for explaining risk to parents of fetuses with neurological anomalies. From this data we make recommendations for the organization of antenatal counselling services.

"I had to think: This is not a child." A qualitative exploration of how women/couples articulate their relation to the fetus/child following termination of a wanted pregnancy due to Down syndrome

OBJECTIVE

Termination of a wanted pregnancy due to fetal anomaly may generate complex feelings of grief and loss. The aim of this study was to explore the different ways that women/couples articulated their relation to the fetus/child following a termination of pregnancy due to a prenatal diagnosis of Down syndrome.

METHOD

Qualitative interview study with 21 women/couples who had recently terminated a wanted pregnancy. Data were analyzed using thematic analysis.

RESULTS

The analysis identified how some women detached themselves from the fetus/child following the diagnosis by mentally separating from the fetus/child, by acting as if they were not pregnant (e.g., by drinking wine), or by deliberately using the term 'fetus' to designate the fetus/child as a biological entity. The analysis also identified accounts of attachment such as singing a lullaby to the fetus/child or using the term 'our child' or 'my baby'. However, accounts of detachment and attachment often intermingled and changed over time. Following the termination, many women/couples felt ambiguous about the sonogram as a symbol of the potential child. Overall, the analysis showed that the relation to and the meaning of the fetus/child was ambiguous and open to reinterpretation.

CONCLUSION

The main contribution of this study is the identification of how articulations of attachment and detachment are not mutually exclusive but coexist and may change over time. Furthermore, we argue that detachment does not equal indifference. Thus, healthcare professionals must support the couple in finding a terminology and a narrative that are meaningful for them.

Perinatal Palliative Care Birth Planning as Advance Care Planning

Purpose of Review: A significant number of pregnancies are complicated by a fetus with a life-limiting diagnosis. As diagnoses are made earlier in the pregnancy, families experience anticipatory grief and are faced with navigating goals of care for a baby that has yet to be born. With the support of the care team, families can begin to grieve, plan, and make meaningful memories during the duration of the pregnancy, the birth of their baby, and life of the child. Creating a palliative care birth plan, which expands beyond the traditional concept for delivery planning to include prenatal, perinatal, and neonatal care has become an important method for parents to process the diagnosis, for parents to document their wishes, and for members of the care team to communicate with the goal of supporting and enhancing the experience of the family. This articles reviews recent and relevant literature on the importance of birth planning and the role of perinatal palliative care when a life-limiting fetal diagnosis is made. Recent Findings: The process of birth planning is an important component of perinatal palliative care. Through this process, families can express their fears, values, hopes, and wishes. It also offers an opportunity for providers to communicate these wishes for the remainder of the pregnancy, the delivery, birth, and time afterwards. This has been demonstrated to decrease maternal stress and promote family centered care. Summary: Perinatal birth planning is an important component of perinatal palliative care when a fetus has a life-limiting diagnosis. The process of birth planning can be supportive and therapeutic as well as an important communication tool. With multiple practices and designs of perinatal palliative care programs, there are no standard tools even though important components have been identified. Ultimately, the strategies outlined here can be used as advance care planning tools.

Assessment of depression, anxiety, and social support in the context of therapeutic abortion

PURPOSE

The purpose of this study is to determine the levels of anxiety, depression, social support, and nursing care needed by women undergoing therapeutic abortion.

DESIGNS AND METHODS

Sixty women were administered a sociodemographic form, the Hospital Anxiety Depression Scale and the Multidimensional Perceived Social Support Scale.

RESULTS

More than half of the women experienced anxiety (61.7%). Anxiety scores were high (10.8 ± 3.7), and most of the women had depression (85.0%). Social support from family and friends of the women decreased the women's anxiety and depression levels significantly; social support from their partners also decreased the women's anxiety levels (P < 0.05).

PRACTICE IMPLICATIONS

Support from family and friends after therapeutic abortion is a fundamental affective variable on anxiety scores.

Supportive needs of women who have experienced pregnancy termination due to fetal abnormalities: a qualitative study from the perspective of women, men and healthcare providers in Iran

Background

Extensive application of screening tests for early diagnosis of fetal abnormalities would justify support for women who are facing pregnancy termination due to fetal abnormalities. Considering the lack of available information regarding supportive sources for these people, the present study was conducted to determine the supportive needs of women who have experienced pregnancy termination due to fetal abnormalities.

Methods

The present research was a qualitative study. The participants were selected using a purposeful sampling method with maximum variation. Data were collected through in-depth personal interviews and taking of field notes and were analyzed simultaneously using conventional content analysis.

Results

The main categories that appeared in the present study included “support from the husband” with sub-categories of “mental support and necessary accompaniments”, “participating in planning for future pregnancy” and “financial support to pay the costs of diagnosis and follow-up”, “support from the family and friends” with sub-categories of “helping in taking care of other children”, “help in performing daily activities” and “empathy, companionship and necessary support to maintain mental peace” and finally “support from peers” with sub-categories of “communicating with the peers and receiving information from them” and “creating a sense of confidence and hopefulness”.

Conclusions

Results of the present study, by determining and highlighting the supportive needs of women who have experienced pregnancy termination due to fetal abnormalities, could be an appropriate basis for providing effective strategies to improve constant participation of the husbands, family members and the peers along with other professional care.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-6851-9) contains supplementary material, which is available to authorized users.

The Effect of Watson’s Care Model on Anxiety, Depression, and Stress in Turkish Women

This study was designed to determine the effect of the care, given according to Watson’s model, on depression, stress, and anxiety levels of women who underwent medical abortion. This study was conducted between 2016 and 2017 as a real test model with a pretest-posttest control group. The data were collected by the researcher in women’s homes. Watson’s model decreased DAS levels of the women in the experimental group after the medical abortion.

The Experience of Genetic Counselors Working with Patients Facing the Decision of Pregnancy Termination after 24 Weeks Gestation

Prenatal genetic counselors are health care professionals who counsel women making reproductive decisions which include decisions such as terminating pregnancies due to fetal anomalies. Little is known about the experiences and practices of prenatal genetic counselors working with women who have the option of termination after 24 weeks gestation. In this national survey of 168 genetic counselors who have practiced prenatal genetic counseling, we asked about their general practice patterns, including indications for which termination is offered and types of abortion care services that are coordinated by genetic counselors. We report respondents' self-assessments of level of understanding of federal abortion law and abortion procedures. Seventy-six percent of respondents have offered and counseled on termination after 24 weeks and 93% of respondents believe it is the responsibility of the counselor to discuss this option with patients. However, one-third report that they have some or no understanding of the procedures and three-quarters report that they have some or no understanding of federal abortion law. The results of this study provide insight into knowledge and experiences of genetic counselors working with these patients, allowing for improved genetic counselor training and continuing education to provide better guidance and develop more effective means of assisting patients.

Mothers' Continuing Bond With the Baby: The Case of Feticide

The nature of the ongoing bond maintained by the bereaved with the deceased has attracted considerable attention, but studies have generally ignored postdeath relationships when loss occurs in utero. The goal of this research was to reach an interpretive understanding of the continuing bond experience among Israeli mothers who underwent feticide, examining the strategies they use in maintaining a postdeath relationship with a child they did not know, whose death they chose and witnessed, within a social context that ignores their loss and forces them to silence their grief. The results highlight two themes: (a) strategies for relinquishing connection with the baby and (b) strategies for maintaining a postdeath relationship. These processes partially correspond with two theoretical views that shed light on interpretation of the results: the dual process of coping with bereavement and relational dialectic theory. Implications of the results to the practice of health providers are outlined.

Women's experiences of labour and birth when having a termination of pregnancy for fetal abnormality in the second trimester of pregnancy: A qualitative meta-synthesis

OBJECTIVE

to explore women's experiences of labour and birth in the context of a termination of pregnancy for fetal abnormality in the second trimester of pregnancy.

DESIGN

meta-synthesis of 10 qualitative studies which included the experiences of 581 women. Data analysis was informed by van Manen's four lifeworld existentials (lived body, lived space, lived time and lived human relationships) and focused only on women's experiences of their labour and birth when terminating a pregnancy in the second trimester for fetal abnormality.

KEY FINDINGS

eight themes were generated by the analysis. In my head: a storm of emotion reflected the lived or felt space. In this space women make meaning of the experience. Too late to turn back time and Living and escaping the moment considered lived time; it is lived time that enables a woman to reinterpret who they once were and who they are becoming. The existential concept of lived body represented the women's physical or bodily presence and was reflected in the themes; The language of labour: un-describable torture, The meaning of pain; punishment and protection and Being a mother in the space where birth meets death. Relational or the lived human relationship is reflected in See me… talk to me…hear me… be with me and Sorry baby. These themes describe the women's lived sense of others in the interpersonal space that they share with them.

KEY CONCLUSIONS

the findings of this meta-synthesis provide insight into how emotionally and physically traumatic a woman's labour and birth experiences can be in this context. Women wanted to spend time with their baby constructing lasting memories that they could hold onto and share. They needed acknowledgment that their baby existed and their loss was tangible and real. What happened within the space of the relationship women shared with care providers was seen as vital, especially when respectful and dignified interaction was experienced. The women's need for human contact and support through their experience was also seen as critical.

IMPLICATIONS FOR PRACTICE

the need for greater understanding and acknowledgement of the woman's experience by all caregivers is required. Woman-centred and situation sensitive care provision should be prioritised. Further research that acknowledges and prioritises the feminine voice and the lived experience of women is required.

Coping strategies of pregnant women following unexpected ultrasound results, Alexandria, Egypt

BACKGROUND

Receiving a diagnosis of a potential fetal anomaly causes severe stress to a pregnant woman. Little is known about the coping strategies used by these women, especially in Egypt.

OBJECTIVE

This study explored the coping strategies used by women following unexpected findings in routine antenatal ultrasound scan in Alexandria, Egypt.

PATIENTS AND METHODS

A mixed method (convergent parallel) quantitative and qualitative approach was used to target pregnant women at 20-32 weeks of gestation. The quantitative study included 93 women, whereas the qualitative one included a purposively chosen subsample of 30 women representing diverse diagnoses. A 10-item questionnaire was used in the quantitative part to assess active, avoidant, and negative coping strategies. In the qualitative part, coping was assessed by analyzing the transcripts of women's experiences.

RESULTS

Although women used equal numbers of avoidant and active strategies (3.34±0.56 vs. 3.30±0.73, Z=0.273, P=0.78), the reported effectiveness of active strategies ranked higher than that of the avoidant ones (χ=54.64, P<0.001). Women with an education level up to high school or higher perceived high effectiveness of active and/or avoidant strategies compared with women with less education (χ=4.087, P<0.05).

CONCLUSION AND RECOMMENDATIONS

Women concurrently used more than one coping strategy. The effectiveness of active strategies was higher than that of the avoidant ones. The educational level was the only factor associated with perceived high effectiveness of active and/or avoidant strategies. Helping future mothers acquire active coping skills through counseling sessions and support groups are recommended.

The decision: Relations to oneself, authority and vulnerability in the field of selective abortion

This article is about selective abortion. It concentrates on the existential, moral and social conditions that arise when pregnant women, using prenatal diagnosis (PND), are told that there is something seriously wrong with the foetuses that they are carrying. This is characterised as a micro state of emergency, where both normal cognitive categories and normative orders are dissolved. The analyses are anchored in the womens' own presentations and understandings of the processes and dilemmas related to the abortion decisions, and our most important empirical materials are interviews with women who have experienced them. Our main ambition is to show the relation between some important dimensions of the situation in which the abortion decision has to be made, and the special kind of authority on behalf of the women that presents itself. Of equal importance is the vulnerability of the pregnant women, resulting in a co-production of the women as both Sovereigns and Homo Sacer in the decision situation. We also analyse some of the experienced relations between the women and the foetuses, and how the women constitute themselves as moral subjects, with a particular emphasis on the motifs of sacrifice and self-sacrifice. It is a central argument in the article that we have to understand the specificity of the decision situation, without reducing it either to other phases (before or after) of the total processes of PND and selective abortion, or to general discourses of disability or normality. The specificity of the situation in which the abortion decision is made is a pivotal point in society's regulation (in a broad sense) of the field and in the constitution of the regime of selective abortion.

Grief after second-trimester termination for fetal anomaly: a qualitative study

OBJECTIVES

We aimed to qualitatively evaluate factors that contribute to and alleviate grief associated with termination of a pregnancy for a fetal anomaly and how that grief changes over time.

STUDY DESIGN

We conducted a longitudinal qualitative study of decision satisfaction, grief and coping among women undergoing termination (dilation and evacuation or induction termination) for fetal anomalies and other complications. We conducted three post-procedure interviews at 1-3 weeks, 3 months and 1 year. We used a generative thematic approach to analyze themes related to grief using NVivo software program.

RESULTS

Of the 19 women in the overall study, 13 women's interviews were eligible for analysis of the grief experience. Eleven women completed all three interviews, and two completed only the first interview. Themes that contributed to grief include self-blame for the diagnosis, guilt around the termination decision, social isolation related to discomfort with abortion and grief triggered by reminders of pregnancy. Social support and time are mechanisms that serve to alleviate grief.

CONCLUSIONS

Pregnancy termination in this context is experienced as a significant loss similar to other types of pregnancy loss and is also associated with real and perceived stigma. Women choosing termination for fetal anomalies may benefit from tailored counseling that includes dispelling misconceptions about cause of the anomaly. In addition, efforts to decrease abortion stigma and increase social support may improve women's experiences and lessen their grief response.

IMPLICATIONS

The nature and course of grief after second-trimester termination for fetal anomaly are, as of yet, poorly understood. With improved understanding of how women grieve over time, clinicians can better recognize the significance of their patients' suffering and offer tools to direct their grief toward positive coping.

The experience of pregnant women with a diagnosis of fetal lower urinary tract obstruction (LUTO)

OBJECTIVE

to gain insight into the experiences and perspectives of pregnant women diagnosed antenatally with fetal lower urinary tract obstruction (LUTO) participating in an interventional fetal medicine randomised controlled trial (RCT).

DESIGN

a qualitative study using semi-structured interviews. Interviews were analysed using Riessman's narrative analysis.

SETTING

fetal medicine clinics within the United Kingdom National Health Service (NHS).

PARTICIPANTS

five pregnant women who were recruited as part of an RCT and two additional women who were recruited after the trial was terminated before completion.

FINDINGS

three themes were identified and form the basis of this article: the use of technology in pregnancy, the loss of a normal pregnancy, and decision making in uncertainty.

IMPLICATIONS AND CONCLUSIONS

undertaking qualitative research within an RCT can illuminate the experience of the condition being studied. Women's experience of a pregnancy where LUTO was diagnosed in the fetus entailed an emotional journey following the visualisation of the abnormality through the use of routine ultrasound screening. Women tried to make sense of the diagnosis in order to make the best, albeit less than ideal, decisions for themselves, their baby, and their family. Midwives are in a good position to support women through the emotional distress of diagnosis and to help them negotiate the uncertain terrain in which they make decisions.

Women's experiences of coping with pregnancy termination for fetal abnormality

Pregnancy termination for fetal abnormality (TFA) can have significant psychological consequences. Most previous research has been focused on measuring the psychological outcomes of TFA, and little is known about the coping strategies involved. In this article, we report on women's coping strategies used during and after the procedure. Our account is based on experiences of 27 women who completed an online survey. We analyzed the data using interpretative phenomenological analysis. Coping comprised four structures, consistent across time points: support, acceptance, avoidance, and meaning attribution. Women mostly used adaptive coping strategies but reported inadequacies in aftercare, which challenged their resources. The study's findings indicate the need to provide sensitive, nondirective care rooted in the acknowledgment of the unique nature of TFA. Enabling women to reciprocate for emotional support, promoting adaptive coping strategies, highlighting the potential value of spending time with the baby, and providing long-term support (including during subsequent pregnancies) might promote psychological adjustment to TFA.

"If it helps..." the use of microarray technology in prenatal testing: patient and partners reflections

The objective was to gain insight into the experiences of women and their partners diagnosed with a fetal abnormality on prenatal ultrasound examination and receiving genetic testing including microarray. Twenty-five semi-structured interviews were performed with women +/- their partners after receiving the results of prenatal genetic testing. Framework analysis was performed to elicit themes and subthemes. Five main themes were recognized; diagnosis, genetic testing, family and support, reflections of the treatment received and emotions. Our results showed that women recall being told about QFPCR for trisomy 13, 18, and 21 but often no further testing. Women expected the conventional karyotype and microarray result would be normal following a normal QFPCR result. There were frequent misconceptions by couples regarding aspects of counseling/testing. Communication of variants of unknown (clinical) significance (VOUS) presents a particularly difficult challenge. Good clear communication by health care professionals is paramount. When counseling women and their partners for fetal chromosomal testing it should be reinforced that although the most common, trisomy 13, 18, and 21 only account for some of the chromosomal changes resulting in abnormal scan findings. Couples should have literature to take home summarizing scan anomalies and reinforcing information about genetic testing.

State of the science on perinatal palliative care

OBJECTIVE

To report the state of the science since 1995 on the concept of palliative care for parents who opt to continue a pregnancy after receiving a life-limiting fetal diagnosis.

DATA SOURCES

PubMed, Ovid, PsycInfo, CINAHL, and Medline were searched from 1995 to July 2012 using the terms perinatal palliative care and perinatal hospice.

STUDY SELECTION

Inclusion criteria included empirical studies written in English that focused on experiences of parents who opted to continue a pregnancy in which the fetus had a life-limiting condition or on perinatal palliative care. Twenty studies met inclusion criteria.

DATA EXTRACTION

Results from empirical studies contributing to the knowledge base of perinatal palliative care are presented.

DATA SYNTHESIS

Women are confronted with powerful emotions, challenging decisions, and considerable uncertainty following the news of a life-limiting fetal anomaly. Women choose to continue their pregnancies for a variety of reasons and when doing so embark on a search for meaning. The science suggests that perinatal palliative care is welcomed by parents and is a medically safe and viable option. Women voiced positive feedback about their decisions to continue their pregnancies, and parents cited personal growth in the aftermath. Perinatal palliative care programs provide services that incorporate early and integrative care beginning in the antenatal period. A multidisciplinary coordinated approach provides parents with comprehensive, holistic support.

CONCLUSION

More research is needed to elucidate the factors that will benefit parents who continue their pregnancies. Investigating the needs and perceptions of clinicians and their willingness to participate in this new model of care is necessary as is examining barriers that may undermine care. Nurses can lead research on these topics and implement evidence-based practice grounded on study findings.

Preparation for prenatal decision-making: a baseline of knowledge and reflection in women participating in prenatal screening

OBJECTIVE

This prospective study gathered baseline information about knowledge and intentions regarding prenatal testing from women attending their nuchal translucency (NT) ultrasound and first sequential blood screen.

METHOD

Surveys including questions about pregnancy history and hypotheticals about fetal diagnoses were distributed to all willing participants at an urban hospital and a suburban medical building during the waiting time for the NT (N = 659).

RESULTS

The majority "never thought anything could be wrong" with their fetus and had not talked with the father or the health providers about that possibility. Presented with varied fetal diagnoses, the larger group nearly always "had the baby", except in the case of a fatal condition where 28% said they would have the baby in contrast to 26% who would end the pregnancy (remainder undecided). Hypotheticals about varied fetal conditions were generally "undecided" by a quarter to nearly half of the respondents.

CONCLUSION

Women's baseline knowledge and reflection about the nature of prenatal screening and diagnosis are minimal in contrast to the large impact positive results could have on their lives. Providers need to weigh the benefit of priming decision-making by exposing women to the possibility of fetal diagnosis, against the cost of raised anxiety.

What parents say about disclosing the end of their pregnancy due to fetal abnormality

OBJECTIVE

to describe men's and women's experiences of deciding whether to tell people in their social network, including their children, about their pregnancy loss following a termination for fetal abnormality.

DESIGN

secondary analysis of qualitative narrative interview data informed by a critical realist approach.

SETTING

respondents were recruited throughout the United Kingdom and interviewed at home between 2004 and 2005.

PARTICIPANTS

twenty-eight women and nine men who had ended a pregnancy diagnosed with a fetal abnormality and who talked about disclosing or not disclosing the termination to others.

FINDINGS

few respondents reported having any advice or information about whether or how to disclose their termination. None said they completely concealed their decision from adults in their social network; most said they disclosed selectively, telling close friends and family they had terminated and acquaintances they had miscarried. Most respondents reported telling their young children that the baby had died but did not reveal that they had chosen to end the pregnancy. A minority had not told their existing offspring about the pregnancy loss. Common reasons given for (partially) concealing a termination were: guilt over the decision; to avoid being judged; and to protect other people's feelings. Common reasons for disclosure were: others knew of the pregnancy; needing time off work; needing practical help and/or emotional support during diagnosis and termination; and wanting recognition of their loss. Positive consequences of disclosure were said to be getting more support and less criticism than expected; negative consequences included not getting the anticipated support and empathy; and encountering disapproval. Some respondents felt that concealing their pregnancy loss from their children had resulted in their confusion over the cause of their parents' distress. Some men said they found it hard to access emotional support from their social networks because of expectations about how men 'should' deal with emotions.

KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

midwives have to make difficult judgements about what, how and when to provide information when trying to support and advise parents who have ended a pregnancy due to fetal abnormality. Further education and training in this area could be of benefit. Midwives could signpost parents to existing sources of advice around disclosure, taking into account parents' individual preferences, help parents to consider the potential implications of disclosure and concealment and different ways of disclosing. They could also recommend alternative sources of emotional support, bearing in mind that men in particular may find it harder to access support from their social networks.

"Did you find that out in time?": new life trajectories of parents who choose to continue a pregnancy where a genetic disorder is diagnosed or likely

The availability of tests to detect genetic conditions prenatally has expanded considerably in recent decades. These advances allow women and couples choices; the choice of whether or not to undergo prenatal screening or diagnosis and therefore the choice whether to continue or terminate a pregnancy. Following prenatal testing many people choose to terminate an affected pregnancy, however little is known about the experiences of parents who choose to continue such a pregnancy. This exploratory qualitative study involved in-depth interviews with five mothers and four fathers who experienced a pregnancy where a genetic diagnosis was, or could have been, detected prenatally. Transcripts of the interviews were analyzed using thematic analysis. While the participants' experiences of genetic diagnoses and prenatal choices varied, findings revealed three major categories triggering new life trajectories for all of these parents: knowledge of reproductive risk and receiving a genetic diagnosis; adapting to diagnosis and new life path; and attitudes to prenatal diagnosis and disability. Parents reported that while dealing with their own attitudes and getting on with their "new world," positive and negative attitudes of others impacted on these parents' experiences. A conceptual model arising from the major themes is offered as a way of thinking about this paradigm. Parents who continue a pregnancy where a genetic condition is detected or suspected prenatally, can be supported appropriately by health professionals while adjusting to their new life path.

Affirming motherhood: validation and invalidation in women's perinatal hospice narratives

BACKGROUND

Perinatal hospice is an option for women who learn during pregnancy that their fetuses are affected by terminal conditions and choose to continue their affected pregnancies. These women face emotional pain and the impending loss of their fetuses or infants. The aims of this study were to explore the experiences of perinatal hospice mothers, to gather knowledge useful to health professionals, and to guide future research.

METHODS

  Narrative analysis was performed using the personal stories of 15 women who continued pregnancies affected by lethal fetal anomalies.

RESULTS

The participants identified themselves as mothers and their fetuses or newborns as babies. Mothers valued caring for and interacting with their babies. Health professionals who affirmed their status as mothers, the value of their babies, and the significance of their losses were perceived as supportive. Invalidating attitudes and behavior caused significant distress among mothers.

CONCLUSIONS

Optimal care of perinatal hospice mothers supports the development of maternal identity and contact between mothers and newborns when desired. Professionals who care for perinatal hospice mothers can affirm their motherhood through their behavior and attitudes.

Systematic review of the literature: parental outcomes after diagnosis of fetal anomaly

Advancing technology has made detecting fetal abnormalities in the first and second trimesters a reality. Few families are prepared for the difficult decisions that must be made if their unborn children are diagnosed with a life-limiting condition. Expectant parents are compelled to make decisions on the basis of limited options. A systematic review of the literature is presented with an aim to inform clinicians of parental experiences and outcomes after diagnosis of a fetal anomaly. The review focused on patients given a diagnosis for fetal anomalies for the 40-year period from 1970 to 2010 by using the key words such as fetal anomaly, congenital malformations, pregnancy termination, perinatal palliative care, and perinatal hospice. Regardless of the option taken, women often experienced intense grief reactions. Both giving birth to a child with a life-limiting condition and termination of pregnancy for fetal anomaly can be emotionally traumatic life events, both associated with psychological morbidity. Nonaggressive obstetric management, allowing natural birth without life-sustaining therapeutics, is an option for families. Couples presented with a coordinated perinatal palliative care model may opt to continue their pregnancy. Families who experienced perinatal hospice/palliative care report positive feedback, but more research is needed to explore the psychological outcomes of this choice.

Spiritual needs of couples facing pregnancy termination because of fetal anomalies

The spiritual needs of couples (9 mothers and 5 fathers) who were planning to terminate wanted second trimester pregnancies because of serious fetal anomalies were surveyed. Their greatest needs were for a "guidance from a higher power" and for "someone to pray for them." Unlike other reported groups of patients, they did not want or expect their healthcare team to discuss their faith, or to pray with them. Most would prefer support from their own pastors, but their religious community was involved to only a small extent. They would welcome support from hospital chaplains, who could play a substantive and unique pastoral role in this clinical context.

Authoritative knowledge, the technological imperative and women's responses to prenatal diagnostic technologies

Theories about authoritative knowledge (AK) and the technological imperative have received varying levels of interest in anthropological, feminist and science and technology studies. Although the anthropological literature abounds with empirical considerations of authoritative knowledge, few have considered both theories through an empirical, inductive lens. Data extracted from an earlier study of 30 women's responses to termination for fetal anomaly are reanalyzed to consider the women's views of, and responses to, prenatal diagnostic technologies (PNDTs). Findings indicate that a small minority embrace the societal portrayal of technology as univalently positive, while the majority have nuanced and ambivalent responses to the use of PNDTs. Further, the interface of authoritative knowledge and the technological imperative suggests that AK derives not only from medical provider status and technology use, but also from the adequacy and trustworthiness of the information. The issue of timing and uncertainty of the information also are interrogated for their impact on women's lives and what that can illuminate about the theories of AK and the technological imperative.