Relationship of Informed Choice about Fetal Anomaly Screening with Worry and Anxiety in Pregnant Women

Introduction

Prenatal screening as part of the routine prenatal care is recommended to pregnant women in many countries (1). According to some prestigious scientific institutions, all pregnant women should be offered to undergo such screening tests as Down syndrome, Edward syndrome, and open neural tube defects regardless of age factor (2). These institutions include the American Congress of Obstetricians and Gynecologists, Society of Obstetricians and Gynecologists of Canada, Canadian College of Medical Genetics, the UK National Institute for Health and Clinical Excellence, and the screening protocol administered in Iran.

Nevertheless, many of the health professionals are opposed to recommend screening tests to the pregnant women since they believe that suggesting these tests may increase the anxiety in this population because they think that their fetuses may have anomaly (3). Suggesting these test by the doctor or midwife exposes the pregnant mother and her family to a difficult condition for decision-making. Since the screening tests can lead to decisions about diagnostic tests and also abortion, the health professionals have emphasized to fall this decision on the families (4).

The purpose of the prenatal screening programs is enabling the people to make an informed choice and reducing the uncertainty and ambiguity in decision-making regarding performing the test (5). However, in a study conducted by Green et al. (2004), they found that an informed choice related to the screening tests led to higher anxiety level and less satisfaction with the decision (6); therefore, the effect of informed choice is ambiguous. The informed choice is acceptable only when the females receive adequate information and are not under any pressure (7). Researchers have shown that increased knowledge and information affect a person's ability to identify key and important issues and lead to increased understanding and positive attitudes (8, 9).

On the other hand, the lack of knowledge results in anxiety, which has adverse effects on the decisions in this regard (10). Given the importance of mental health during pregnancy, the pregnant women should be able to decide with higher capacity about undergoing the prenatal screening and diagnostic tests, which leads to have the lowest levels of anxiety and costs (11).

Since the knowledge and awareness of the pregnant women are considered as the main elements of the informed choice about screening tests (12), equipping them with sufficient information can be associated with better mental management (13).

In a study carried out by Van den Berg et al. (2005), no significant relationship was found between the informed choice and anxiety in the pregnant women (5). Similarly, in a study conducted by Rowe et al. (2006), there was no statistically significant difference between the pregnant women who had informed choices about performing prenatal genetic screening and those who had non-informed choices in terms of their level of anxiety and depression (14). Likewise, Michie et al. (2002) concluded that the level of anxiety was not significantly different between the pregnant women who performed the screening tests informed and those taking the tests non-informed (15).

However, in a study carried out by Green et al. (2004), the informed choices of pregnant women about undergoing the screening tests were associated with higher anxiety levels (6). Regarding these contradictory research findings and lack of any study investigating this issue in Iran, the present study was performed to investigate the relationship of the informed choice about performing the prenatal chromosomal screening tests with anxiety and worry in the pregnant women.

Materials and Methods

This cross-sectional study was conducted on 160 pregnant women at Mashhad, Iran in 2014. The present study was approved by the Research Ethics Committee of the Mashhad University of Medical Sciences. The study began after obtaining an introduction letter from the School of Nursing and Midwifery and submitting it to the authorities of healthcare centers. In line with the ethical codes, the researchers explained the objectives of the study to the pregnant women and obtained their written consents; subsequently, the sampling was carried out.

The sample size was calculated as 160 subjects based on a pilot study on 10 pregnant women and using the correlation coefficient formula with test power of 80% and confidence level of 95%. For the purpose of data collection, one of the health centers in Mashhad was randomly selected. Subsequently, the participants were selected from the pregnant women referring to this healthcare center using convenience sampling method.

The data were collected using several research instruments including the individual-pregnancy information and informed choice questionnaires, the Cambridge Worry Scale, as well as the Spielberger’s Anxiety Inventory. The participants filled out these tools at 20-22 weeks of pregnancy, and if necessary, they were given some explanations about the questions by the researcher. The informed choice was measured qualitatively and the anxiety and worry were measured quantitatively.

The informed choice questionnaire was employed from a study conducted by Marteau et al. (2001) in England (16). This questionnaire consists of three subsections including knowledge, attitude, and behavior of the pregnant women about performing fetal abnormality screening tests during pregnancy. The section related to knowledge entails 16 items, which are prepared based on valid books and articles about the fetal anomaly screening and diagnosis. Giving the correct response to more than 8 items represents good awareness, and obtaining 8 or less scores indicates poor awareness.

The attitude section, including 4 items, is scored from 1-7 with the minimum and maximum scores of 4 and 28, respectively. The median score in this section is 16, which indicates a neutral attitude, i.e., the scores higher and lower than the median score represent the positive and negative attitudes, respectively. The behavior section includes two Yes-No questions enquiring whether the subject choose to perform the screening tests or not based on the results recorded in the laboratory.

The criteria of the informed choice for the pregnant mother were defined as follows: 1) good knowledge, positive attitude, and performing the screening tests and 2) good knowledge, negative attitude, and not performing the screening tests. The criteria of the non-informed choice were defined as follows: 1) good knowledge, negative attitude, performing the screening tests, 2) good knowledge, positive attitude, not performing the screening tests, 3) poor knowledge, positive attitude, performing the screening tests, 4) poor knowledge, negative attitude, performing the screening tests, 5) poor knowledge, positive attitude, not performing the screening tests, and 6) poor knowledge, negative attitude, and performing the screening tests.

The Cambridge Worry Scale was obtained from a study conducted by Green et al. (2004) (6). This scale contains 16 items assessing the rate of worry in relation to various issues of pregnancy. This tool is rated on 6-point Likert scale (i.e., 0: not worried to 5: severely worried). The minimum and maximum scores in this scale were zero and 80, respectively. The Spielberger’s State-Trait Anxiety Inventory contains 40 items measuring the state (20 items) and trait anxiety (20 items). This inventory is rated on a 4-point Likert scale (i.e., very low to very much).

The validity of all the research instruments was determined using content validity. These tools were prepared by studying the latest books and research papers in this field, and then given to some experts and professors for evaluation. The reliability of the informed choice questionnaire, Cambridge Worry Scale, and Spielberger Anxiety Inventory was estimated using Cronbach's alpha coefficient, which were 0.78, 0.90, 0.82, respectively.

The inclusion criteria entailed: 1) Iranian nationality, 2) having at least the basic education, 3) no history of undergoing fetal chromosomal abnormality screening or diagnostic tests, 4) performing first trimester screening tests, and 5) not being a health care worker. On the other hand, the exclusion criteria included the history of mental diseases over the past one year (mental diseases diagnosed by a psychiatrist) and the occurrence of major stressful or traumatic events during pregnancy (e.g., death of first-degree relatives, ​​intense family disputes, financial problems, and major changes in life status).

The data were analyzed using the descriptive statistics (i.e., mean, standard deviation, frequency distribution, etc.), Chi-square test, Spearman correlation coefficient, and logistic regression through SPSS version 16. The P-value less than 0.05 was considered statistically significant.

Results

According to the results of the study, the mean age of the participants was 27.57±5.2 years. Furthermore, 150 pregnant women (93.8%) lived in the urban areas, 85 subjects (53.1%) had high school and diploma, and 108 (67.5%) participants were housewives. In addition, the husbands of 111 (69.4%) participants were self-employed, 130 (54.2%) subjects did not have any family relationship with their husbands, and 141 (88.1%) cases had wanted pregnancy. The mean and standard deviation of the participants’ worry, state anxiety, and trait anxiety are illustrated in Table 1.

Out of the 160 pregnant women participating in this study, 85.6% (n=137) and 14.4% (n=23) of them had informed and non-informed choices about the prenatal screening tests.

Also, for one unit increase in the score of worry in pregnant women, the ratio of informed choice is 1.017 times more than the non-informed choice, and for one unit increase in the score of state anxiety, the ratio of informed choice is 1.042 times than non-informed choice, and for one unit increase in the score of trait anxiety, the ratio of informed choice is 1.004 times than non-informed choice that is shown in Table 2.