Current Maternal Age Recommendations for Prenatal Diagnosis: A Reappraisal Using the Expected Utility Theory

Sicherman, Nachum; Bombard, Allan T.; Rappoport, Peter

doi:10.1159/000264226

Cited by 10 publications

(5 citation statements)

References 21 publications

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“…Although the continued reliance on the 35-year-old threshold has been questioned repeatedly over the years [7,20,31,[33][34][35] , it continues to be used. In the most recent (2001) American College of Obstetricians and Gynecologists (ACOG) 'Practice Bulletin' addressing prenatal diagnosis of fetal chromosomal abnormalities, women who will be aged 35 and older at the time of delivery are the fi rst-listed category of women who are 'at high risk' and should be offered diagnostic testing [36] .…”

Section: Current Prenatal Testing Guidelinesmentioning

confidence: 99%

Prenatal Testing Guidelines:

Kuppermann

Norton²

2005

Gynecol Obstet Invest

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Numerous advances over the past 15 years have led to a much wider array of prenatal testing options for pregnant women who are interested in obtaining information regarding the chromosomal status of their fetus. However, despite recent data calling into question the assumptions underlying current testing guidelines, including those inherent in the risk-based threshold for offering invasive testing, chorionic villus sampling and amniocentesis are still typically offered only to women whose likelihood of carrying a fetus affected by a chromosomal disorder such as Down syndrome is at least as high as that of the average 35-year-old. In this paper, we summarize the evidence suggesting that this aspect of prenatal testing guidelines should be revisited, and that women should be allowed to make informed decisions regarding the use of invasive testing that are reflective of their own values and preferences.

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Section: Current Prenatal Testing Guidelinesmentioning

confidence: 99%

Prenatal Testing Guidelines:

Kuppermann

Norton²

2005

Gynecol Obstet Invest

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“…Since Down syndrome accounts for about half of the main fetal chromosomal defects that occur, the choice of a 1:250 cut-off risk of Down syndrome as a criterion for proposing amniocentesis is commonly justified by the argument that women should be offered an amniocentesis when the probability of having a child with a major chromosomal defect exceeds the probability of having a procedure-related miscarriage (Harris et al, 2004;Grobman et al, 2002;Kuppermann et al, 2000;Seror and Costet, 1998;Sicherman et al, 1995). While the implications of this argument are that women are assumed to perceive the birth of a child with a major chromosomal disorder as a health state equivalent to that of a miscarriage, many studies (including this one) have shown that women attach significantly higher utility values to the occurrence of miscarriage than to the birth of an affected child (Harris et al, 2004;Grobman et al, 2002;Kuppermann et al, 2000).…”

Section: Discussionmentioning

confidence: 99%

Fitting observed and theoretical choices – women's choices about prenatal diagnosis of Down syndrome

Seror

2007

Health Economics

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Choices regarding prenatal diagnosis of Down syndrome - the most frequent chromosomal defect - are particularly relevant to decision analysis, since women's decisions are based on the assessment of their risk of carrying a child with Down syndrome, and involve tradeoffs (giving birth to an affected child vs procedure-related miscarriage). The aim of this study, based on face-to-face interviews with 78 women aged 25-35 with prior experience of pregnancy, was to compare the women' expressed choices towards prenatal diagnosis with those derived from theoretical models of choice (expected utility theory, rank-dependent theory, and cumulative prospect theory). The main finding obtained in this study was that the cumulative prospect model fitted the observed choices best: both subjective transformation of probabilities and loss aversion, which are basic features of the cumulative prospect model, have to be taken into account to make the observed choices consistent with the theoretical ones.

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“…These studies provide important findings, as pregnant women's trade‐offs between risks can then be compared with those leading to cut‐off risks for proposing invasive prenatal testing based on biochemical screening or NT measurement. The choice of cut‐off risks is indeed commonly based on equalization of risks of occurrence of outcomes that are supposed to be similarly valued, assuming that women should not be offered prenatal invasive testing when the probability of procedure‐related miscarriage exceeds the probability of having an affected child18–22.…”

Section: Outcomes and Decision‐makingmentioning

confidence: 99%

What understanding of decision‐making in prenatal screening could decision analysis provide?

Seror

2007

Ultrasound in Obstet & Gyne

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Prenatal screening and diagnosis aim to provide information to pregnant women regarding the risks of their pregnancy. In the case of fetal chromosomal abnormalities, this is offered as an optional component of prenatal care to give women the choice of continuing or terminating an affected pregnancy, but is often seen by the woman as reassurance that her fetus is at low risk or does not have Down syndrome. While maternal age is used as a basis for background risk calculation, the investigation of other markers, such as nuchal translucency (NT) thickness and maternal serum markers in the first or second trimester allow for individual risk to be calculated.The implementation of screening programs relies on combinations of various methods of risk assessment. Performance of screening programs has been evaluated mainly within an epidemiological or economic context, with pregnant women's decision-making summarized as uptake rates. However, both the optional and individualized components of prenatal screening place women's decision-making at the heart of the analysis of screening programs 1,2 .Understanding women's decision-making and attitudes towards screening and diagnosis is therefore a crucial issue. Most studies have focused on informed choices 3 -6 , with few addressing decision analysis frameworks as a means of providing insight into women's decision-making. It was my aim in this Editorial to explore the contribution of decision analysis in understanding individual decisionmaking in prenatal screening and invasive testing. Information and decision-makingIndividual decision analysis frameworks are based on the hypothesis that information supplied about choice options makes individuals capable of expressing a preference. Choice options are characterized by their possible outcomes, with associated likelihoods generally expressed as probabilities. Based on this representation of decision problems, choice elicitation tools such as the 'decision board' 7,8 have been designed as bedside instruments, used to decide between therapeutic alternatives 9 -11 . More specifically, decision boards are designed as trees that segregate individual choices into three components: options, chances of outcomes and outcomes, with chances of outcomes being illustrated as pie charts and outcomes being described by means of 'information cards'. Mainly used in oncology, decision boards appear to enhance patients' understanding of possible treatments as well as their awareness of individual choice and their capacity for informed decision-making 12,13 .Prenatal screening for fetal aneuploidies presents important issues concerning informed choice and published studies have mainly explored the degree of understanding resulting from information provided on test options and their results. However, decision boards have not been used in this context. Further studies should assess the practicality of using decision boards in prenatal screening and diagnosis and their impact on informed choice. Outcomes and decision-makingConsidering that choice opt...

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Current Maternal Age Recommendations for Prenatal Diagnosis: A Reappraisal Using the Expected Utility Theory

Cited by 10 publications

References 21 publications

Prenatal Testing Guidelines:

Prenatal Testing Guidelines:

Fitting observed and theoretical choices – women's choices about prenatal diagnosis of Down syndrome

What understanding of decision‐making in prenatal screening could decision analysis provide?

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