Abstract
This review examines the factors that affect the decision-making process of parental couples evaluating prenatal screening and diagnostic tests. A systematic search was performed using PubMed and PsycInfo databases. The 46 included studies had to: investigate the decision-making process about prenatal testing; focus on tests detecting trisomy 21, 18, 13, and abnormalities of sex chromosomes; be published in English peer-reviewed journals. The decision-making process seems composed of different levels: an individual level with demographic, clinical, and psychological aspects; a contextual level related to the technical features of the test and the information received; a relational level involving family and society.
Introduction
Pregnancy is characterized by many uncertainties for parents, and usually the primary one is the fetus’ health (Öhman et al., 2003). Many countries offer prenatal testing programs: prenatal screening is an option for all pregnant women who intend to assess the likelihood of having a fetus with a chromosomal abnormality, while prenatal diagnosis is indicated for women who are positive at the screening stage or have other risk factors, such as advanced maternal age (35 and older), family history of a genetic disorder, or abnormal ultrasound finding (Leiva Portocarrero et al., 2015). Screening tests offer an estimated risk calculation of fetal aneuploidy, diagnostic tests detect the actual presence of a genetic aneuploidy with a theoretical 100% accuracy (Sapp et al., 2010). Prenatal testing (both screening and diagnostic test) has the function of identifying fetuses with a high risk of developing genetic pathologies, including Trisomy 21 (Down syndrome), Trisomy 13 (Patau syndrome), Trisomy 18 (Edwards syndrome), triploidy, and Turner syndrome.
Several procedures are available to obtain prenatal genetic information: the non-invasive combined first-trimester screen (cFTS) takes into account the mother’s age and weight, the fetal crown-rump length and nuchal translucency thickness measured by the ultrasound, and maternal serum biomarkers; the invasive diagnostic procedures include the chorionic villus sampling (CVS) and the amniocentesis, both of which carry a risk of miscarriage reported to be approximately 1:200 (Akolekar et al., 2015).
Since 2011, a new non-invasive prenatal screening test that uses fetal cell-free DNA (NIPT) obtained from circulating maternal blood is available (Lo et al., 1997). It can be performed starting from the 9th week of pregnancy, as it involves a single blood draw with a result turnaround time of about 2 weeks (Scott et al., 2018). NIPT holds no risk of miscarriage and offers clinical benefits over existing prenatal screening tests by detecting the presence of Trisomy 21 with high sensitivity (99.9%) and specificity (98%) (Birko et al., 2019; Metcalfe, 2018). Moreover, it carries a false positive rate of 0.09–0.12% (Yu et al., 2017), which is lower than other prenatal screening tests rates. However, NIPT is not covered by the publicly funded healthcare system and is not considered accurate enough to be sufficient for a diagnosis. Therefore, this test entails both benefits and concerns (Vanstone et al., 2018). Specifically, the advent of NIPT definitely enriched prenatal testing available to parental couples, but its higher costs and the impossibility of a diagnosis further entangle the complex decision-making process.
The uptake of prenatal screening and diagnosis has differed between societies despite the apparent similarity in set-up of the screening program. This might reflect differences in society’s attitude toward screening (i.e. if the screening is private or public, if it is self-paid or insurance-dependent), and in the individual’s attitude (Crombag et al., 2014).
When evaluating prenatal testing, women face a double burden, which includes the worries and the responsibilities for their own health and for their unborn baby. For these reasons, the choice is often complicated and emotionally distressing (Lobel et al., 2005). Reassurance about the health of the fetus, attitude toward abortion and test characteristics are examples of the key factors that play a role in the decision (Green et al., 2004; van den Berg et al., 2006). However, the relatively recent introduction of the NIPT as an alternative to other screening tests, could significantly impact on this decision-making process, making past review on the topic obsolete.
Therefore, the present systematic review aims at updating previous reviews (Crombag et al., 2013; Godino et al., 2013) not considering literature on the NIPT, for providing an in-depth examination of the factors that affect the decision-making process of parental couples when evaluating prenatal testing, including non-invasive (cFTS, NIPT) and invasive (CVS, amniocentesis) tests. Specifically, the purpose of this review is answering to the following questions: a) What are the decision-making factors associated with undergoing prenatal testing? b) Are different decision-making factors associated with different kinds of tests?
Methods
Study design and search strategy
Potentially eligible articles were systematically searched on PsycInfo and PubMed databases on 11th June 2020 using the following combinations of terms: “prenatal diagnosis,” “prenatal screening,” “prenatal genetic testing,” “invasive prenatal testing,” “non-invasive prenatal testing,” “amniocentesis,” “cell-free fetal DNA,” “chorion villus,” and “decision-making” (the full search strategy is available in Appendix 1). We limited the search to papers published since January 2011 (i.e. the introduction of NIPT) to ensure findings related to the current practice regarding prenatal testing.
We developed the following set of inclusion criteria for papers to be included in our review:
Studies had to report on primary research;
Studies had to be published in a peer-reviewed journal;
Studies had to be written in English;
Studies had to be quantitative or mixed-methods;
Studies had to address the decision-making process about prenatal testing of pregnant women or when available both parents;
Studies had to address prenatal testing that detect trisomy 21, 18, 13, and abnormalities of sex chromosomes.
Exclusion criteria were as follows:
Qualitative studies;
Studies that took into account only test uptake without analysis of the reasons for accepting or declining tests;
Studies implemented with decision support tools;
Studies focusing on healthcare professionals’ attitudes toward prenatal testing;
Retrospective studies;
Reviews of the literature.
We removed duplicates through Zotero software version 5.0. In the first stage, three independent researchers (FF, GP, VT) screened titles and abstracts of the papers found. In the second stage, the same researchers screened the full texts of all remaining studies to assess their eligibility and reference lists of these articles were screened. When discrepancies were identified between the researchers, they discussed the article in question to come to a consensus opinion.
Studies were not required to meet a quality threshold to be included in the review; however, the NIH Checklist for Study Quality Assessment (National Institutes of Health, 2014) was used to evaluate the methodological quality of the included studies, classifying them into good (8–10), fair (4–7) and poor (0–3) methodological rigor. In all studies, four items of the checklist were not applicable and were therefore excluded.
Data extraction
FF, GP, and VT participated in data extraction and analysis. The data consisted of the findings from both the results and discussion sections of the relevant studies.
The authors extracted data about: publication year, country of study, participant information, risk level of the pregnancy, variables addressed, test uptake, significant factors of decision-making, and methodological quality of the included studies.
To synthesize the data, we performed a qualitative synthesis of findings. We identified a variety of themes involved in the decision-making process about prenatal testing, such as sociodemographic and clinical characteristics, test characteristics, psychological aspects, attitude toward termination of pregnancy, relational factors, knowledge of prenatal testing, and information provision.
Results
Studies selection and characteristics
Databases searching identified 768 articles; afterwards duplicates removal pinpointed 651 potentially eligible studies. After reading titles and abstracts, 566 articles were excluded; of the remaining 85, 46 met our inclusion criteria (see Figure 1 for studies selection and Table 1 for a summary of the selected studies).
Study selection.
Characteristics of included studies.
NIPT: Non-Invasive Prenatal Test; IPT: Invasive Prenatal Test; cFTS: combined First Trimester Screening; CVS: Chorionic Villus Sampling; DS: Down Syndrome; OSCAR: One Stop Clinic for Assessment of Risk test; NHS screening: National Health Service screening; NT: nuchal translucency; STS: serum triple screening test.
NHS screening: measures two blood markers and provide a detection rate of approximately 60%.
OSCAR test: measures two blood markers and incorporates ultrasound techniques with a detection rate of approximately 90%.
Among the selected studies, two examined pregnant women with a low-risk of carrying a fetus with abnormalities, 14 examined women with a high-risk pregnancy and 30 considered pregnant women at all risk levels.
The studies were conducted in the United States (n = 5), Canada (n = 3), United Kingdom (n = 5), The Netherlands (n = 7), Denmark (n = 6), Sweden (n = 3), Finland (n = 2), Czech Republic (n = 1), France (n = 1), Italy (n = 1), Portugal (n = 1), China (n = 6), Japan (n = 1), Israel (n = 2), Turkey (n = 1), and Vietnam (n = 1).
Eight studies were related to prenatal screening, six studies focused on invasive testing, eight studies investigated NIPT, and 24 studies analyzed different kinds of tests.
Seven studies had poor methodological rigor, 35 studies had fair methodological quality, and four studies had good quality.
Sociodemographic and clinical characteristics
The present review identifies advanced maternal age as the principal reason for undergoing prenatal testing (Gil et al., 2015; Schoonen et al., 2012; Ternby et al., 2015), concerning both NIPT (Watanabe et al., 2017) and invasive testing (Grinshpun-Cohen et al., 2015a, 2015b).
Higher educational attainment is associated with a greater use of both invasive and non-invasive prenatal testing (Bangsgaard and Tabor, 2013; Beulen et al., 2015; Canh Chuong et al., 2018; Dicke et al., 2014; Farrell et al., 2014; Gil et al., 2015). In addition, the studies by Chan et al. (2014) and by Cheng et al. (2018) indicate that a low level of education is associated with the choice of invasive prenatal diagnosis rather than NIPT. Only the study by Crombag et al. (2016) reports that Dutch women with a high level of education are more likely to decline cFTS.
As far as the relationship status is concerned, having other children and long-term marital relationship seems to favor prenatal testing uptake independently from invasive or non-invasive test (Lewis et al., 2014; Seven et al., 2017). In contrast, Gil et al. (2015) show that being parous predicts a reduced likelihood of prenatal testing.
Data regarding the association between ethnicity and the use of prenatal testing are scarce and heterogeneous. In particular, some studies report that non-Caucasian women seem to underestimate the importance of a false positive result in their choice (Farrell et al., 2011) and they use NIPT more frequently (Lewis et al., 2014); others show that being non-Caucasian is associated with a negative attitude toward both invasive and non-invasive prenatal tests (Dicke et al., 2014; Gil et al., 2015).
Regarding clinical characteristics, the presence of previous abortion is associated with prenatal screening uptake, with a preference for non-invasive tests such as cFTS and NIPT (Chan et al., 2014; Seven et al., 2017; Skutilova, 2015). Moreover, couples at high risk for cFTS and who have undergone fertility treatment seem to prefer an invasive test that provides certain genetic information and they are willing to face the risk of miscarriage compared to low-risk couples with spontaneous pregnancy (Lund et al., 2018). Similarly, women with a high risk of carrying a baby with chromosomal abnormalities are more likely to undergo prenatal testing and to prioritize information about the chance of a false positive result (Farrell et al., 2014).
Test characteristics
In the decision-making process, women confer a great importance to the technical features of the test, in particular accuracy, safety, timing and easiness (Beulen et al., 2015; Carroll et al., 2013; Chen et al., 2017, 2018; Farrell et al., 2014, Lewis et al., 2014, 2016; Lund et al., 2018; Seror et al., 2019; Skutilova, 2015; van Schendel et al., 2016).
Some studies show that the most important factors for choosing NIPT are its high detection rate and the absence of physical risks for the fetus, along with the easiness of the procedure, especially for high-risk women (Chen et al., 2017; Lewis et al., 2016).
However, some couples do not choose this test or cFTS because they do not provide certainties and generate ambiguity (Crombag et al., 2016; Seror et al., 2019), differently from invasive tests.
Furthermore, some studies highlight costs as a factor affecting NIPT choice, which is quite expensive in many countries (Birko et al., 2019; Carroll et al., 2013).
Finally, the gestational age at which the test can be performed is another relevant factor (Chen et al., 2017, 2018).
Psychological factors
Women choose to undergo prenatal testing in order to seek a good life for themselves and their children, in spite of possible detrimental effects on pregnancy (Cheng et al., 2018, 2019; Grinshpun-Cohen et al., 2015a, 2015c; Lewis et al., 2016; Miltoft et al., 2018; Ternby et al., 2015, 2016; Verweij et al., 2013). In particular, Cheng et al. (2018) report that anxiety is a predictor of invasive prenatal tests uptake. On the contrary, avoiding the anxiety caused by waiting for the result could be a reason to refuse invasive investigations following the screening test (Gil et al., 2015). Fumagalli et al. (2018) investigate women’s decision to undergo prenatal testing depending on the perception of the probability of having a baby with Down Syndrome and the acceptability of this risk and the procedure-related miscarriage. They report that the acceptability of the risk, rather than the numerical likelihood, affects the interpretation of the result.
Moreover, personality seems to play a role in decision-making, as women with alexithymic traits show less decisional conflict when choosing NIPT (Schlaikjær-Hartwing et al., 2019).
Attitude toward termination of pregnancy
In general, women undergoing prenatal testing seem more inclined to terminate pregnancy in the event of an abnormal outcome compared to women who decline prenatal testing (Birko et al., 2019; Crombag et al., 2016; Farrell et al., 2011; Gil et al., 2015; Miltoft et al., 2018). Even more clearly, women who consider terminating pregnancy in the event of a positive outcome choose more frequently invasive tests, consequently accepting the risk of a possible miscarriage related to the procedure (Grinshpun-Cohen et al., 2015a, 2015c; Ternby et al., 2016; van Schendel et al., 2016).
Women undergoing prenatal screening to prepare themselves for the birth of a child with Down Syndrome take more time to decide about going through NIPT (Laberge et al., 2019; van Schendel et al., 2015).
Relational factors
Prenatal testing does not involve only the pregnant woman, but also her partner, family and society.
In particular, some studies report that decision-making about screening for Down Syndrome is a couple joint decision, with little involvement from other people (Laberge et al., 2019; Nazaré et al., 2011), even though pregnant women want to retain control over the screening outcome. In fact, partners may perceive a more passive role in decision-making (Nazaré et al., 2011; Watanabe et al., 2017).
Other studies highlight that pregnant women experience social influence from maternity care units and from their partners (Chen et al., 2018), and they seem to consult with family and friends for the NIPT choice more often than their partners do (Watanabe et al., 2017).
Furthermore, women feel a sort of social pressure in so far as they consider the risk assessment compulsory and they perceive the responsibility of doing the right thing (Ngan et al., 2020; Salema et al., 2018).
Finally, religion may influence decision-making, as Islam seems to be associated with very low prenatal testing uptake (Seven et al., 2017).
Knowledge
Knowledge of the characteristics of the different prenatal test options and knowledge of the genetic conditions tested are essential for informed decision-making. Most studies investigating the level of prenatal screening knowledge show that women participating in this program have a better knowledge of Down Syndrome and of the screening program itself, compared to women who decline such possibility (Dahl et al., 2011a, 2011b; Lo et al., 2019; Schoonen et al., 2012). Farrell et al. (2011) report a similar finding concerning CVS. In particular, it seems that a higher level of knowledge is associated with less decisional conflict and decisional regret, higher levels of wellbeing and lower levels of anxiety (Dahl et al., 2011b; Lo et al., 2019).
However, studies from different countries affirm that, in general, women do not have enough knowledge to be able to make an informed decision concerning prenatal screening and diagnosis (Grinshpun-Cohen et al., 2015a; McCoyd, 2013; Seven et al., 2017).
Information provision
Some studies underline the importance for women of receiving information about prenatal testing options in person rather than through information brochures and as early as possible during pregnancy (Laberge et al., 2019; Sahlin et al., 2016). Regarding the type of information provided, pregnant women are more interested in the potential risks involved in the test regardless of test type (Lewis et al., 2014). Only two studies consider the role of the informant, identifying the physician as women's preferred information provider (Laberge et al., 2019), especially the gynecologist (Skutilova, 2015).
Pre-test counseling characterized by clinicians’ patient-centeredness communication and non-directiveness, has been found to influence the test uptake (van der Steen et al., 2019). For example, talking about the risk of miscarriage for an invasive procedure using words like “negligible” or “extremely small” encourages taking this test.
Silcock et al. (2015) show that women prefer to take the test on the same day as counseling, in particular NIPT (Silcock et al., 2015). In contrast, Schlaikjær-Hartwig et al. (2019) report an increase in decisional conflict the day of genetic counseling. According to Lewis et al. (2014), the decision about the invasive test takes several days to be elaborated.
Discussion
The aim of this review was to explore the significant factors involved in prenatal testing decision-making and, in particular, whether there were differences according to the type of test chosen.
The decision-making process in the field of prenatal testing appears to be complex and composed of different levels. First, variables relevant to the decision include individual aspects, such as demographic and clinical characteristics, along with the needs and emotions of the woman or the couple (e.g. anxiety). In addition, contextual factors related to the type, quantity and modality of information received may contribute to a clear understanding of the technical features of the test, allowing for a better informed choice. Moreover, relational factors seem to play a significant role in decision-making, in fact marital intimacy is related to sharing decisions and most women share the choice of prenatal testing with their partner. Couples make a decision by balancing multiple dimensions, which are strictly interrelated. The studies examined show that non-invasive prenatal screening is the most chosen procedure when the sample includes women with low risk pregnancy or both low and high-risk pregnancy (Bangsgaard and Tabor, 2013; Chan et al., 2014; Chen et al., 2018; Dahl et al., 2011a, 2011b; Farrell et al., 2014; Fumagalli et al., 2018; Gil et al., 2015; Lo et al., 2019; Lund et al., 2018; Miltoft et al., 2018; Sahlin et al., 2016; Seven et al., 2017; van Schendel et al., 2015; Verweij et al., 2013). In studies with samples composed only of high-risk women, this trend is confirmed in favor of NIPT compared to invasive diagnosis (Cheng et al., 2018, 2019; Lo et al., 2017; Schlaikjær-Hartwing et al., 2019; Seror et al., 2019; van der Steen et al., 2019; van Schendel et al., 2016; Watanabe et al., 2017). The couples’ preference for the use of the NIPT as a first-tier screen therefore clearly emerges. In addition, women who rejected the available prenatal screening procedures would elect to have NIPT if it were available (Birko et al., 2019; Verweij et al., 2013). This data is in line with existing literature which stresses the importance of introducing NIPT and its relevance in reducing invasive procedures (Scott et al., 2018).
From a socio-demographic and clinical-obstetric point of view, studies with different quality levels unanimously indicate that advanced maternal age (Beulen et al., 2015; Gil et al., 2015; Grinshpun-Cohen et al., 2015a, 2015b; Schoonen et al., 2012; Ternby et al., 2015; Watanabe et al., 2017), having a risk for genetic anomalies and previous abortions induce women to undergo prenatal testing, without distinction between invasive or non-invasive test (Chan et al., 2014; Seven et al., 2017; Skutilova, 2015). Similarly, no differences emerge in the use of both invasive and non-invasive prenatal testing in relation to educational level, in particular a higher educational attainment is associated with a greater use of prenatal test in general (Bangsgaard and Tabor, 2013; Beulen et al., 2015; Canh Chuong et al., 2018; Dicke et al., 2014; Farrell et al., 2014; Gil et al., 2015). Only a study with poor methodological quality (Crombag et al., 2016) reports that women with a high level of education are more likely to decline cFTS.
In a homogeneous and univocal way, the studies show that women confer a great importance to the technical features of the test, in particular accuracy, safety, timing and easiness, often favoring the recent NIPT (Beulen et al., 2015; Carroll et al., 2013; Chen et al., 2017, 2018; Farrell et al., 2014; Lewis et al., 2014, 2016; Lund et al., 2018; Seror et al., 2019; Skutilova, 2015; van Schendel et al., 2016).
Another parameter on which NIPT is positively considered is the gestational age at which it can be performed (Chen et al., 2017, 2018). In fact, the NIPT can be carried out from the 9th gestational week, leaving women who get a positive result several weeks to make a decision concerning possible pregnancy termination within the terms of the law (Scott et al., 2018). In contrast, the amniocentesis is performed starting from the 15th week, leading to a more complicated procedure for pregnancy termination, which is associated with more adverse psychological and physical implications (Alfirevic et al., 2017). Notably, these patterns clearly emerge, irrespectively from the quality of the studies.
The psychological factors that influence decision-making in prenatal testing area involve a need to have as much information as possible about the fetus and intolerance to uncertainty. Both aspects are related to the desire of gaining control over pregnancy and lower anxiety levels. In line with the existing literature (Ahmed et al., 2006a, 2006b), our review shows that most women consider to undergo prenatal testing in order to know whether the fetus is healthy and to be reassured (Cheng et al., 2018, 2019; Grinshpun-Cohen et al., 2015a, 2015c; Lewis et al., 2016; Miltoft et al., 2018; Ternby et al., 2015, 2016; Verweij et al., 2013). It is conceivable that such knowledge is associated with the desire to eliminate uncertainty about the health status of the fetus.
The attitude toward abortion in case of genetic abnormalities of the fetus plays a crucial role in the choice of whether or not undergoing prenatal testing. In particular, the results show that women who are more more likely to have abortion are also more likely to undergo prenatal testing (Birko et al., 2019; Crombag et al., 2016; Farrell et al., 2011; Gil et al., 2015; Miltoft et al., 2018) and they also accept the risk of miscarriage foreseen by invasive procedures (Grinshpun-Cohen et al., 2015a, 2015c; Ternby et al., 2016; van Schendel et al., 2016). However, the percentage of couples who undergo prenatal testing to prepare themselves to welcome a disabled child should not be overlooked.
Unfortunately, the papers included in our review do not report data on the influence of cultural factors and it would be interesting to learn more since the existing literature (van den Heuvel and Marteau, 2008; van den Heuvel et al., 2009) shows that in Northern Europe greater value is placed on the importance of parental choice in prenatal testing than in Southern Europe or Asia, where the point of view of significant others and healthcare professionals is deemed more important in the test decision. Responsibility for the care of children with disabilities seems to put a heavy burden on Asian families and communities. This burden can be reflected in cultural differences in attitudes toward disability, which tend to be more negative in Asian countries where many consider the birth of a disabled child irresponsible toward both family and society (van den Heuvel et al., 2009). In addition, having a faith that strongly condemns abortion, such as Islam, as well as living in countries where abortion is illegal, strongly influence women’s choice not to undergo prenatal testing of any kind (Seven et al., 2017). Religion also seems to be associated with the level of knowledge; in fact, those who describe themselves as religious also report a low level of knowledge and consequently undergo less likely prenatal testing (Beulen et al., 2015; Schoonen et al., 2012; Seven et al., 2017). On the contrary, good knowledge correlates with a greater uptake of prenatal testing (Dahl et al., 2011a, 2011b; Farrell et al., 2011; Schoonen et al., 2012).
Pregnancy is an important event not only in the life of women, but also in the life of their partner. As several studies have shown, the choice of prenatal testing involves the couple and rarely external elements (Laberge et al., 2019; Nazaré et al., 2011). However, the social pressure felt by women, who often interpret prenatal testing as part of pregnancy routine without a real conscious choice, should not be underestimated (Ngan et al., 2020; Salema et al., 2018).
Regarding prenatal test counseling, the results indicate a preference for oral and specific information on the risks of each type of test, provided by the physician (Laberge et al., 2019; Lewis et al., 2014; Sahlin et al., 2016; Skutilova, 2015).
In general, we suggest caution in reading the data of low-quality studies. In turn, a greater emphasis should be placed on studies conducted with good methodological rigor, which show that women with higher education make more informed choices (Bangsgaard and Tabor, 2013) and that women value receiving as much information as possible (Miltoft et al., 2018). Moreover, decisional conflict increases when women receive genetic counselling the same day as NIPT, but it can be reduced if women are satisfied with the genetic counselling or if they present certain personality traits (Schlaikjær-Hartwig et al., 2018). Another important factor for pregnant women is the safety of the test, especially for those who are less likely to terminate an affected pregnancy (Miltoft et al., 2018). Finally, high-quality studies suggest that advanced maternal age is the most common reason for seeking NIPT (Watanabe et al., 2017).
Conclusion
This is the first review that examines the decision-making process involved in the choice of prenatal testing, including the NIPT as a possible choice. Although our review provides some insights, some limitations should be noted. First, the inclusion of studies run in countries with different health policies and health-related values leads to a complex pattern of results, highlighting the interaction of these elements with individual factors. In light of these considerations, future studies could specifically investigate the weight of individual factors in different cultural contexts. Another limitation is the over-representation of North-European countries, with few studies conducted in Southern Europe. Indeed, the sole inclusion of studies published in English may have narrowed the results, future reviews should thus include studies published in other languages to cover national peer-reviewed literature.
Other considerations emerge from this review. Currently, only one longitudinal study is available. Longitudinal studies are important to understand the trajectory of emotional difficulties in this population and to investigate the psychological consequences of the choice made.
Most of the studies examined use non-validated tools, created ad hoc for the study, for the evaluation of the decision-making process, which do not allow a precise review of the results, limiting the possibility of drawing strong conclusions. In fact, the qualitative evaluation of the studies shows that only four of them have a good methodological rigor, as the tools or methods used for measuring outcomes are not accurate and reliable. This aspect is important because it influences confidence in the validity of study results. Interestingly, three out of four high-quality studies are Danish, which could bias the results. However, despite different quality levels, the majority of the studies included in the present review point toward the same direction. Nonetheless, given that overall the quality of studies is not particularly high, we must underline how this branch of medicine and health psychology would benefit from studies conducted with greater methodological rigor.
The interaction between the characteristics of women and healthcare professionals has not been deeply explored in this review. Moreover, more research is needed on the influence of healthcare providers and also of the healthcare system characteristics.
The present review shows the importance of an individualized, oral counseling to couples, taking into account individual factors (i.e. the woman’s age and her clinical history), and clearly explaining the technical features of the test. It would also be recommended to check with targeted questions if the woman/couple understood the main features of the test. For example, the model proposed by Gammon et al. (2018) seems to increase the knowledge about available prenatal tests, the test uptake, and facilitate decision-making. In this model, patients receive information on testing options in a group session and a one-to-one interview for individual questions and risk assessment is subsequently carried out (Gammon et al., 2018). In conclusion, the present review could help healthcare systems to pinpoint which information is relevant to women evaluating prenatal testing and how this information should be provided. Moreover, our findings could help gynecologists to identify which women would benefit psychological counseling.
Footnotes
Appendix 1
Declaration of conflicting interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
