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Physician Recommendation for Invasive Prenatal Testing: The Case of the “Precious Baby”

Srebnik, Naama; Miron-Shatz, Talya; Rolison, Jonathan J.; Hanoch, Yaniv; Tsafrir, Avi

Obstetrical & Gynecological Survey: March 2014 - Volume 69 - Issue 3 - p 131–132
doi: 10.1097/01.ogx.0000445773.67791.19
Obstetrics: Ethics, Medicolegal Issues, and Public Policy

ABSTRACT The term “precious baby” has been used for a pregnancy achieved by assisted reproductive technology (ART) or at an older maternal age. Some believe that such pregnancies are managed differently; evidence for differential management of ART pregnancies includes cesarean section rates, which are significantly higher among ART pregnancies. Women who have conceived via an ART procedure are less likely to agree to invasive procedures such as chorionic villus sampling or amniocentesis. This survey study was undertaken to explore whether clinicians manage pregnancies differently based on the conception method.

The survey was presented as one concerning clinical decision making regarding prenatal diagnosis. All Israeli citizens are entitled to fully insured prenatal care, including a serologic screening test for Down syndrome. A positive screening test is defined as a risk of 1:380 or greater. Women with a positive screening test result are offered chorionic villus sampling or amniocentesis for karyotyping. In this study, clinicians were presented with a clinical amniocentesis scenario describing a woman, aged 37 years, at 18 weeks’ gestation who had normal biochemical and sonographic screening results for Down syndrome (risk of <1:380). Clinicians were randomly assigned to receive a scenario describing either spontaneous conception (n = 85) or conception in the fourth in vitro fertilization (IVF) cycle after 3 years of infertility (n = 78). Clinicians indicated their recommendation regarding amniocentesis by selecting one of these options: (1) would recommend performing amniocentesis, (2) would recommend performing amniocentesis if the risk according to screening test results is high, (3) would recommend avoiding amniocentesis, (4) would refuse to state an opinion, and (5) none of the above reflected the clinician’s opinion. Participants also provided demographic information, rated the degree of risk associated with amniocentesis, and reported the number of amniocenteses they perform annually.

Of 163 obstetrician/gynecologists, aged 34 to 75 years, who completed the questionnaire, 55% did not perform amniocentesis at all, 16% performed less than 10 procedures annually, 16% did 10 to 50 procedures, and 14% performed more than 50 per year. Across the spontaneous and ART pregnancy scenarios, most clinicians recommended either amniocentesis without further qualification (n = 52; 31.9%) or recommended amniocentesis if the risk according to screening results was high in their opinion (n = 51; 31.3%). Twenty-one clinicians (12.9%) recommended avoiding amniocentesis, 12 (7.4%) refused to state their opinion, and 27 (16.6%) stated that no option reflected their opinion. Fewer clinicians recommended amniocentesis for an IVF pregnancy (n = 15 of 78; 19.2%) compared with a spontaneous pregnancy (n = 37 of 85; 43.5%). Clinicians were 3.2 times more likely (95% confidence interval [CI], 1.6–6.6) to recommend the test for a spontaneous than an ART pregnancy. The more they agreed that the risks of amniocentesis were negligible, the more likely they were to recommend the test (odds ratio [OR], 1.63; 95% CI, 1.23–2.15). Clinicians with more experience were more likely to recommend the test (OR, 1.07; 95% CI, 1.03–1.12). Sex (OR, 1.34; 95% CI, 0.52–3.46) or clinical setting (hospital vs both hospital and community: OR, 0.66; 95% CI, 0.26–1.71; community vs both hospital and community: OR, 1.02; 95% CI, 0.40–2.64) did not significantly predict clinicians’ recommendations for amniocentesis. Clinicians who performed amniocenteses were not significantly more likely to recommend the procedure than those who did not.

The results indicate that clinicians provided different invasive prenatal screening recommendations depending on the method of conception. The data also showed that clinicians’ subjective risk assessments influenced their recommendations. Clinicians do appear to be affected by the “precious baby” concept.

Department of Obstetrics and Gynecology, Shaare Zedek Medical Center, Hebrew University, Jerusalem (N.S., A.T.), and Center for Medical Decision Making, Ono Academic College, Kiryat Ono (T.M.-S.), Israel; and School of Psychology, Queen’s University, Belfast (J.J.R.), and School of Psychology, University of Plymouth, Plymouth (Y.H.), United Kingdom

© 2014 by Lippincott Williams & Wilkins.