Couple screening would be easier for many centres

BMJ 1996; 312 doi: https://doi.org/10.1136/bmj.312.7035.909 (Published 06 April 1996) Cite this as: BMJ 1996;312:909
  1. Richard A Doherty,
  2. Linda A Bradley,
  3. James E Haddow
  1. Director, genetics division Director, cystic fibrosis screening laboratory Medical director Foundation for Blood Research, Scarborough, ME 04070-0190, USA

    EDITOR,—H S Cuckle and colleagues provide further economic evidence supporting antenatal screening for cystic fibrosis.1 The couple model is estimated to cost more than the sequential model, largely because of retesting in subsequent pregnancies if the woman's partner has changed. However, the estimate takes into account neither the cost nor the complexity of counselling and other contact with the patients in the sequential model. The cost of counselling would be modest, but locating each woman who was a carrier, explaining the need for and obtaining a sample from her partner, and subsequently explaining the results of the test would add complexity in decentralised health care settings. Furthermore, counselling 3% of couples, only one member of whom is a carrier, can raise anxiety with no prospect of definitive resolution by prenatal diagnosis. Some investigators report anxiety to be a continuing problem in the sequential model.

    Besides avoiding these problems, the couple model requires that both the pregnant woman and the father agree to screening and submit samples at the outset. This simplifies the overall process, minimises further contact, and adds assurance that the decision to be screened is neither casual nor due to coercion. Genetic counselling is required for only the 0.1% of all couples (carrier woman with carrier partner) to whom definitive prenatal diagnosis can be offered.

    Between June 1994 and December 1995 our group carried out a pilot study to evaluate antenatal screening for cystic fibrosis.2 Enrolled couples lived in a sparsely populated region (Maine) and received antenatal care from 68 physicians at 38 health care sites. Before initiating the pilot study we determined that these sites could, without difficulty, provide initial printed information and material for collecting samples, obtain informed consent, and answer general questions. The staff could not, however, offer the more sophisticated counselling necessary for people found to be carriers. The sequential model would require that the physician's office recontact each carrier woman, obtain her partner's sample for analysis, explain the need for counselling, and arrange it. This was viewed as burdensome. Particularly in the case of couples in which the woman was a carrier but her partner was not, geographic barriers and work schedules could restrict access to timely genetic counselling. These considerations led us to select the couple model for the pilot study.

    The staff at the sites where antenatal care was given and a random subset of patients were surveyed at the end of the study to identify problems. Both patients and staff reported a high level of satisfaction. The couple model could thus more realistically be implemented in our setting.


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