C. H. Browner

Why women say yes to prenatal diagnosis

Despite considerable concern of bioethicists, disabilities rights activists, feminists and others about the spread of prenatal diagnostic technologies, their routine acceptance in many parts of the world continues at a rapid pace. Yet, there is wide variation by country and region in rates of acceptance of prenatal diagnosis. We draw on John McKinlays model of how a medical innovation becomes routinized to explore the circumstances that led to the widespread use of one prenatal diagnostic screen-the maternal serum alpha fetoprotein (MSAFP) test for the detection of neural tube defects and other developmental disabilities. As predicted by McKinlays model, analysis of published data suggests that strong institutional or provider support is the best predictor of womens level of MSAFP test acceptance. Data collected at a health maintenance organization in California illuminate the processes through which medico-legal and institutional forces affect the use of MSAFP screening. By examining the language women use to talk about MSAFP screening, we show how providers also shape womens understandings of the meaning and purpose of MSAFP screening. These data ultimately shed light on how the very ethical issues which concern critics of prenatal diagnosis become obscured in the processes by which this screening test becomes accepted as routine.

Genetic counseling gone awry: miscommunication between prenatal genetic service providers and Mexican-origin clients.

Amniocentesis, and other prenatal genetic tests, have become a well-established feature of modern prenatal care. But these tests place a considerable decision-making burden on the expectant mothers to whom they are offered: the genetic issues involved are complex and the appropriate course of action sometimes ambiguous. Genetic counseling aims to help pregnant clients make an informed decision about prenatal genetic tests. But the clientele of prenatal genetic counseling has changed significantly in the years since the practice was established. Clients were once a self-selected group of women well-informed about the genetic services being offered. In contrast, clients now include an increasing number of women, particularly ethnic minority women, who had no prior knowledge of genetic testing, but were found to be at risk of birth defects after routine screening. Little is known about how well genetic counseling serves the needs of this new clientele. This paper investigates the possibility that miscommunication between genetic counselors and their Mexican-origin clients contributed to the higher rates of amniocentesis refusal. We interviewed 156 pregnant Mexican-origin women who screened positive on a blood test routinely offered in California to detect birth defects. We also observed the genetics consultations of a sub-sample of the women. We identified five common sources of miscommunication: (1) Medical jargon; (2) The non-directive nature of counseling; (3) The inhibitions of counselors stemming from misplaced cultural sensitivity; (4) Problems of translation; (5) Problems of trust. We found that many Mexican-origin women are skeptical of genetic testing and do not easily surrender their own lay theories about the causes of their condition. In order to dislodge the misunderstandings of their clients, counselors must give clients the opportunity to air their own views, however contrary to those of genetics professionals these may be.

Characteristics of women who refuse an offer of prenatal diagnosis: Data from the California maternal serum alpha fetoprotein blood test experience

This paper presents data from the California maternal serum alpha fetoprotein (MSAFP) program in order to explore the effect and interaction of various factors, especially ethnicity, abortion history and attitudes, religion, and religiosity on MSAFP test decision. The intent is to describe which women are more likely to reject MSAFP screening and also to understand the reasons for refusal and the meanings associated with it. We obtained data on sociodemographics and reproductive history from 595 obstetrical patient charts; we conducted semistructured interviews with an additional 158 pregnant women who were European-American, English-speaking Latina, or Spanish-speaking Latina. All of the women had been offered screening within the context of Californias MSAFP Program. We found that women who had never terminated a pregnancy, Spanish-speaking Latinas, and women who scored high on a religiosity scale were significantly more likely to refuse testing. However, we found that all of those factors were strongly mediated by the effects of ethnicity and acculturation, producing different patterns of association in different groups of women.

Plants used for reproductive health in Oaxaca, Mexico.

The use of herbal remedies for the treatment of reproductive health problems and the management of reproduction is still nearly universal in many indigenous communities throughout modern Mexico. This paper describes the medicinal plants and related substances used for childbirth, fertility regulation, and the treatment of reproductive disorders in a bilingual Chinantec-Spanish speaking township in highland Oaxaca. The discussion focuses on how the group’s ideas about reproduction and reproductive physiology influence their selection of these plant species.

Access to women's health care: A qualitative study of barriers perceived by homeless women

ABSTRACT Homelessness is an escalating national problem and women are disproportionately affected. Nevertheless, few studies have focused on the special circumstances associated with being a homeless woman. For instance, while both genders experience serious barriers to obtaining health care, homeless women face an additional burden by virtue of their sexual and reproductive health needs. The current study was conducted as the first stage of a qualitative/quantitative investigation of homeless womens access and barriers to family planning and womens health care. We interviewed 47 homeless women of diverse ages and ethnic backgrounds. A qualitative approach was initially taken to explore the factors homeless women themselves perceive as barriers to their use of birth control and womens health services, and factors they believe would facilitate their use. Key findings are that health is not a priority for homeless women, that transportation and scheduling can be particularly burdensome for homeless women, and that being homeless leads some to feel stigmatized by health care providers. Despite being homeless, having children was extremely important to the women in our study. At the same time, those interested in contraception confronted significant barriers in their efforts to prevent pregnancies. We conclude with suggested interventions that would make general, gynecological, and reproductive health care more accessible to homeless women.

Ethnicity, bioethics, and prenatal diagnosis: the amniocentesis decisions of Mexican-origin women and their partners.

Bioethical standards and counseling techniques that regulate prenatal diagnosis in the United States were developed at a time when the principal constituency for fetal testing was a self-selected group of White, well-informed, middle-class women. The routine use of alpha-fetoprotein (AFP) testing, which has become widespread since the mid-1980s, introduced new constituencies to prenatal diagnosis. These new constituencies include ethnic minority women, who, with the exception of women from certain Asian groups, refuse amniocentesis at significantly higher rates than others. This study examines the considerations taken into account by a group of Mexican-origin women who had screened positive for AFP and were deciding whether to undergo amniocentesis. We reviewed 379 charts and interviewed 147 women and 120 partners to test a number of factors that might explain why some women accept amniocentesis and some refuse. A womans attitudes toward doctors, medicine, and prenatal care and her assessment of the risk and uncertainty associated with the procedure were found to be most significant. Case summaries demonstrate the indeterminacy of the decision-making process. We concluded that established bioethical principles and counseling techniques need to be more sensitive to the way ethnic minority clients make their amniocentesis choices.

WOMEN, HOUSEHOLD AND HEALTH IN LATIN AMERICA

Although recent studies have identified some of the links in Latin America between uneven capitalist economic development and health, the impact of development on either the health of women or on household health is still largely unknown. This account identifies several areas of needed research. It focuses on how changing womens roles and patterns of domestic production affect womens reproductive behavior, and the consequences of these changes for the health of women and other members of their households.

Relationship power decision making and sexual relations: an exploratory study with couples of Mexican origin.

This study explored how couples of Mexican origin define power in intimate relationships, what makes men and women feel powerful in relationships, and the role of each partner in decision making about sexual and reproductive matters. Interviews were conducted with each partner of 39 sexually active couples and data were analyzed using content analysis. Results indicate that power is perceived as control over ones partner and the ability to make decisions. Women say they feel more powerful in relationships when they make unilateral decisions and have economic independence. Men feel powerful when they have control over their partner and bring home money. Respondents agreed that women make decisions about household matters and children, while men make decisions related to money. Findings indicate that whereas couples share decision making about sexual activities and contraceptive use, men are seen as initiators of sexual activity and women are more likely to suggest condom use.

The effects of ethnicity, education and an informational video on pregnant women's knowledge and decisions about a prenatal diagnostic screening test

Prenatal screening for genetic disease and developmental disabilities is rapidly becoming a routine part of the management of low-risk pregnancies. Yet research on how to best inform pregnant women about these tests and their special ethical entailments remains sparse. We asked 130 low-risk pregnant women of diverse ethnic and social class backgrounds a series of questions about a prenatal test they had been offered within the previous 3 months. All had been given an informational booklet about the test at the time it was offered; about half also saw a video. We found that neither group of women retained much of the information they had received about the prenatal screening but that those who saw the video remembered more. Information-retention also varied significantly by ethnicity and level of education.

The Politics of Reproduction in a Mexican Village

The following account analyzes the relationship between the population practices in one indigenous community in Mexico and the Mexican governments recent effort to reduce population growth. It shows that the governments fertility-reducing policy was superimposed on a longstanding local conflict between this communitys women who wished to limit the size of their own families and the community as a whole which wanted all of its female members to reproduce abundantly. The data concern a sample of 180 women and 126 men from San Francisco a township in Oaxaca state and were collected in 1980-1981. The results show that women generally refused the contraceptive services available and continued to have high fertility. The reasons why women did not try to achieve the low levels of fertility desired are explored with a focus on the cultural barriers to the acceptance of fertility control. (EXCERPT)