Men's experiences of antenatal screening: A metasynthesis of the qualitative research

Abstract

Objectives

First to develop a consensus on what is known about men's experiences and involvement in antenatal screening, second to understand whether screening is an appropriate way to engage uninvolved men in pregnancy and third to identify areas requiring further research.

Design

A systematic review was conducted to extract relevant qualitative primary research studies, which were subsequently synthesised.

Data sources

International qualitative research papers, in English or with English translations, were identified using twenty-three electronic databases, such as CINAHL, MEDLINE, EMBASE, PsycInfo, ASSIA and British Nursing Index. Articles that explored men's views and opinions of antenatal screening and prenatal diagnosis were included.

Review methods

Eighteen relevant research studies that met the inclusion criteria were identified. Each one was appraised as suitable for inclusion using a published appraisal tool.

Results

Three themes were constructed, which were (1) men's emotional conflicts, (2) men's focus on information and (3) men's influence on decision-making. Men felt a responsibility towards their unborn child to be involved in screening. Despite this, their input was often limited to supporting their partners, and there was no clearly defined, additional role for them as expectant fathers. Thus screening is not likely to be sufficient as an opportunity to encourage men who are uninvolved in pregnancy to become more involved. Nonetheless, engaging men who were involved in the pregnancy and who attended screening appointments was beneficial in encouraging the responsibility they felt towards their unborn child, and in allowing them to support their partners.

Conclusions

Healthcare professionals need to engage those men who show willingness to be involved. Nevertheless trying to engage reluctant men in screening, where there is no clearly defined role for them might create further distance between them and the pregnancy. Alternative ways to engage such men in pregnancy are thus required.

Introduction

In England, Scotland and Wales, pregnant women are routinely offered antenatal screening to estimate the risk of foetal anomalies, beginning with screening for haemoglobinopathies, such as thalassaemia, and also sickle cell in high-risk populations, for example African-Caribbean or Mediterranean communities. To estimate the risk of chromosomal conditions, for instance Down syndrome, factors such as maternal age are combined with the results of a nuchal translucency ultrasound scan and maternal serum screening. Through serum screening, maternal blood is tested for hormones and proteins that would indicate foetal anomalies. A further ultrasound scan is used to check for structural anomalies. Non-invasive prenatal diagnosis via maternal blood tests can be performed to detect X-linked disorders, but is not yet offered by the National Health Service (NHS) to detect specific genetic and chromosomal conditions (Chiu et al., 2009, Lo et al., 2007, RAPID, 2012). All screening tests are optional and high risk results can be followed up with genetic counselling and/or prenatal diagnosis. Availability of tests and the number of markers screened for varies within and across Great Britain (Armstrong and Harcombe, 2008). Moreover, Rowe et al. (2008) found that in England, South Asian women were significantly less likely to be offered, and take up, Down syndrome screening than white women. Dormandy et al. (2005) also found that white women with higher socioeconomic statuses were more likely to take up screening than minority ethnic women with lower socioeconomic statuses.

There are three main reasons why it is worthwhile to investigate men's involvement in antenatal screening. Firstly, screening provides an opportunity for healthcare professionals to involve and engage men, who have otherwise been uninvolved, in pregnancy. Early paternal involvement, for example attending ultrasound scans, feeling the fetus move and attending birth classes, has been shown to elicit benefits for the child up to three years postnatally. Such benefits include increased participation in activities with the child, for example playing and reading (Bronte-Tinkew et al., 2007, Cabrera et al., 2008). For these reasons, the need to include men during pregnancy has been recognised by UK policy-makers (DCSF, 2009, Department of Health, 2009a, Department of Health, 2009b). With regard to screening specifically, a consultation of UK government policy is currently underway, which proposes that expectant fathers should be allowed statutory paternity leave for the two ultrasound screening tests, because seeing the foetal image might encourage and facilitate early commitment to the pregnancy (Department for Business, Innovation and Skills, 2011). Whether screening has such an impact requires further examination.

Secondly, non-invasive prenatal diagnosis, which requires only women's consent, allows men's genetic information to be more easily accessed and paternally inherited conditions to be more easily identified. This creates various ethical issues, and unless men are engaged by healthcare professionals in counselling and support, non-invasive diagnoses could pose a challenge to “paternal autonomy” (Wright, 2009, p. 17). Thirdly, decisions made during the process of screening could have long-term repercussions for men with regard to their status as a father, and accordingly men's opinions about screening are important to women. For example, women in Rapp (1999) and Henderson's (1999) studies suggested that the support their partners provided, as well as their partners’ attitudes towards abortion and towards the idea of fathering a child with a disability, played a large role in their own decisions of whether to continue with a pregnancy or not. These findings support research by Jaques et al. (2004), where 79.8% (387/485) of women undergoing screening or diagnosis and 73.9% (116/157) of those not undergoing tests reported that their partner strongly influenced their decisions. Studies by Green et al. (2004), Homer et al. (1999) and Lee (1998) also suggest that women want their partners included in managing antenatal information.

Engaging men is especially crucial if women are identified as haemoglobinopathy carriers, because men's carrier status will determine whether the unborn baby could inherit the condition. Despite this, a recent cluster-randomised trial showed that men's uptake of such screening is low, whether it is offered in primary or secondary care. Rates of uptake were between 0% and 2% by the recommended gestation of 77 days and only 3% and 8% overall (Dormandy et al., 2010). Prospective parents could consequently be under-informed and under-prepared for the possibility of having a child with a haemoglobinopathy. Diagnosis at a later gestation would also require a more invasive procedure for those who choose to terminate an affected pregnancy (NHS Choices, 2010). Acceptability of haemoglobinopathy screening was assessed via interviews by Dormandy et al. (2010), but no prospective fathers agreed to participate, so the reasons for men's low uptake were undetermined.

The need for midwives to engage men in antenatal care has been recognised by the Royal College of Midwives (2011) in their guide, ‘Reaching out: Involving fathers in maternity care’ (p. 4–5). Moreover, the need to provide men with information about screening and seek their opinions has been identified in the National Institute for Health and Clinical Excellence 2008 antenatal care guidelines (NICE, 2008, p. 37). In spite of this, there remains limited guidance on how midwives can engage men in screening decisions and limited empirical research about men's experiences of screening. The NICE guidelines themselves feature just one study relating to screening where men were included. This study focused on men's anxiety following ultrasound diagnoses of congenital anomalies (Kemp et al., 1998). Whether men's absence in screening research reflects that they are uninvolved in screening, or whether previous researchers have simply not recruited men (e.g. Garcia et al., 2008), remains unclear. However, one recent survey by Redshaw and Heikkila (2010) suggests that men are indeed involved in screening. Among 5333 women who gave birth within a two-week period, 88% of partners attended one or more ultrasound scans, 40% sought pregnancy information, and 56% participated in decision-making. Eighty-three percent of women thought healthcare professionals communicated with men very or quite well. Nevertheless, the reliance of women's proxy-reports about men's involvement limits the insight into men's personal experiences of antenatal screening, with regard to the exact nature of their participation, their interactions with staff and the reasons why some might be uninvolved. The limitations of proxy-reports are further illustrated by Skirton and Barr (2009). In their study, 79.3% of the 111 respondents, 100 of whom were women, stated that both parents made screening decisions. At the same time, only 31.5% reported discussing decisions with their partners, and 19.8% said they had discussed decisions a little. Therefore almost a third of those who claimed that their decision was jointly made had not actually discussed it with their partners. These results tell little about men's role in screening.

A study that did include men as participants was conducted by Hildingsson and Sjöling (2011). They found that men's experiences of overall antenatal care were contingent on the support they received. Being expected to attend antenatal appointments, but feeling uninvolved by midwives, was associated with feeling unsupported. Being unsupported was in turn associated with seeing antenatal visits as unhelpful for becoming involved with the baby. The latter finding suggests that mere attendance at appointments is not sufficient to produce a sense of engagement and involvement in the pregnancy, and hence may not elicit the postnatal benefits observed by Bronte-Tinkew et al. (2007) and Cabrera et al. (2008). The findings do not indicate the extent to which men were informed about screening, whether their partners included them in decision-making and the kind of support men may want or receive.

Further investigation into men's experiences of screening, and the reasons why men may or may not be involved in screening, is thus required. A metasynthesis of the relevant, qualitative, empirical research studies was thus constructed to (1) develop a consensus on what men's experiences are like, (2) understand whether screening is an appropriate way to engage men in pregnancy and (3) identify issues requiring further research. Within metasyntheses, findings from a range of qualitative studies are interpreted and combined to create a set of novel findings, more substantial than the findings from each individual study (Finfgeld, 2003, Downe, 2008, Jensen and Allen, 1996). The metasynthesis was performed as part of a larger study examining men's experiences of antenatal screening, and women's views of their partners’ involvement.