PRENATAL DIAGNOSISPrenat Diagn 2004; 24: 864–868.Published online in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/pd.1028

Uptake of a prenatal screening test: the role of healthcareprofessionals’ attitudes towards the test

Elizabeth Dormandy and Theresa M. Marteau*1Department of Psychology (at Guy’s), Health Psychology Section, Institute of Psychiatry, King’s College London

Objective To investigate the association between healthcare professionals’ attitudes towards prenatal Downsyndrome screening and screening uptake in the women who consult them.

Methods The attitudes of 71 midwives and 18 obstetricians towards Down syndrome screening and screeninguptake in the women who consulted them were assessed at two UK hospitals where uptake rates of Downsyndrome screening differed (26 vs 61%).

Results Healthcare professionals based at the hospital with higher screening uptake had more positiveattitudes towards Down syndrome screening than healthcare professionals based at the hospital with lowerscreening uptake (19 vs 17, p = 0.03). Pooling across hospitals, obstetricians had more positive attitudes thanmidwives (20 vs 17, p = 0.004). In a sub-group of women who discussed screening with one healthcareprofessional, there was no significant association between individual healthcare professionals’ attitudes andscreening uptake (Spearman correlation coefficient = 0.13, p = 0.51).

Conclusion In this study powered to detect a correlation of 0.5 and over (i.e. a large effect), healthcareprofessionals’ attitudes towards screening were unrelated to uptake of screening in the women consultingthem. It remains to be determined if a smaller effect exists. The observed association between healthcareprofessionals’ attitudes and uptake rates by hospitals raises the question of whether healthcare professionals’attitudes might influence systems of care, not just communication with pregnant women. Copyright 2004John Wiley & Sons, Ltd.

KEY WORDS: Down syndrome screening; healthcare professionals’ attitudes; screening uptake

BACKGROUND

Procedure rates vary between healthcare providers andbetween healthcare professionals. For example, rates ofjoint replacement vary tenfold between American states(Vitale et al., 1999), rates of cervical cancer screeningvary fivefold between GP practices in one Londonhealth authority (Majeed et al., 1994), rates of breastcancer screening vary twofold between GP practices(Gatrell et al., 1998) and rates of uptake of prenatalHIV testing vary threefold between midwives (Simpsonet al., 1998). Such variations have been described asunwarranted because they cannot be explained byvariations in either illness severity or by the attitudesand preferences of patients (Wennberg, 2002). Prenatalscreening for Down syndrome provides another exampleof variation in procedure rates. Uptake varied almostfourfold (between 25 and 93%) between 29 hospitalsin one UK health region (Dormandy et al., 2002a).This variation questions the extent to which a centralaim of the UK prenatal screening programme, namely,facilitating informed choice, is being achieved (NationalScreening Committee, 2000). Sources of unwarrantedvariation in prenatal screening uptake include the way

*Correspondence to: Theresa M. Marteau, Department of Psychol-ogy (at Guy’s), Health Psychology Section, Institute of Psychiatry,King’s College London, 5th Floor, Thomas Guy House, Guy’sCampus, London SE1 9RT, UK.E-mail: theresa.marteau@kcl.ac.uk

testing is conducted and the way tests are presentedby healthcare professionals, perhaps reflecting theirattitudes towards the test (Boyd et al., 1999; Dormandyet al., 2002a; Gekas et al., 1999; Marteau et al., 1993;Simpson et al., 1999; Weinans et al., 2000).

Healthcare professionals generally report positive atti-tudes towards prenatal screening for Down syndrome,with obstetricians reporting more positive attitudes thanmidwives (Hemminki et al., 2000; Jallinoja et al., 1999;Khalid et al., 1994). Such differences between obstetri-cians and midwives may reflect the different groups ofpregnant women seen by these healthcare profession-als. Midwives traditionally offer care to women withlow-risk pregnancies and regard pregnancy as more of anormal physiological state than do obstetricians (Johan-son et al., 2002; Schuman and Marteau, 1993). Therehave, however, been few studies exploring the relation-ship between healthcare professionals’ attitudes towardsDown syndrome screening and uptake of screening bythe women who consult them.

The effect of healthcare professionals’ attitudes couldbe mediated either through the organisation of a screen-ing programme within hospitals or through individualconsultations with pregnant woman. Examples of medi-ation through organisation include healthcare profes-sionals with positive attitudes towards Down syndromescreening, conducting screening tests at the same timeas other investigations to facilitate uptake of testing.Conversely, those with negative attitudes may organ-ise for screening to be conducted separately from other

Copyright 2004 John Wiley & Sons, Ltd. Received: 12 February 2004Accepted: 26 July 2004

HEALTHCARE PROFESSIONALS’ ATTITUDES TOWARDS SCREENING 865

investigations to facilitate the decline of testing. Media-tion through individual consultations could occur whenhealthcare professionals with negative attitudes towardsDown syndrome screening emphasise negative aspectsof the screening test to the women who consult them,such as the risk of miscarriage following a diagnostictest. Conversely, those with positive attitudes towardsscreening may emphasise the benefits of screening bydiscussing the difficulties of bringing up a child withDown syndrome. Healthcare professionals, explicitly orimplicitly, can steer women towards a particular courseof action (Levy, 1999).

The present study used two approaches to investigatethe association between healthcare professionals’ atti-tudes towards prenatal Down syndrome screening anduptake of the screening test in the women who con-sulted them. The first approach involved a comparisonof midwives’ and obstetricians’ attitudes towards pre-natal Down syndrome screening at two hospitals whereuptake of Down syndrome screening differs. The secondinvolved assessing the association between attitudes ofindividual healthcare professionals towards Down syn-drome screening and screening uptake in the womenwho consulted them.

METHOD

Design

A prospective, descriptive study of midwives and obste-tricians who discussed prenatal Down syndrome screen-ing with women at two hospitals.

Setting

Two UK NHS Trusts that offered the ‘Double test’ basedon maternal age, alpha-fetoprotein and human chorionicgonadotrophin. Midwives at both hospitals discussed thescreening test with pregnant women at the first prenatalvisit and gave the same written information about thescreening test. Thereafter, the patterns of care differed.

Hospital A

Routine prenatal blood tests were taken at the bookingvisit at around 10 weeks’ gestation. Women attendedthe hospital for their ultrasound-dating scan at about12 weeks’ gestation. About one-third of the women(those under consultant-led care) also saw a consultantobstetrician at this visit. The remaining two thirds,receiving midwifery-led care, did not see a midwifeor obstetrician when attending for their dating scans.All the women who wanted Down syndrome screeningwere asked to make an appointment with their midwivesfor a blood test at about 16 weeks’ gestation. Screeninguptake was 26% (Huttly and Cromby, 2001).

Hospital B

All women attended the hospital at about 16 weeks’gestation when ultrasound screening, routine prenatal

blood tests, and a consultation with an obstetrician ormidwife took place. If women wanted Down syndromescreening, blood was taken at this visit, along withroutine prenatal blood tests. Screening uptake was 61%(Huttly and Cromby, 2001).

Participants

The participants were 89 healthcare professionals, 71midwives and 18 obstetricians, 47 from Hospital A (41midwives and 6 obstetricians) and 42 from the HospitalB (30 midwives and 12 obstetricians) who routinelydiscussed screening with pregnant women.

Measures

Healthcare professionals’ attitudes towards Downsyndrome screening

These were measured using a scale based on onedeveloped to assess midwives’ attitudes towards prenatalHIV testing (Simpson et al., 1999). Respondents wereasked how much they agreed or disagreed with thefollowing items, responding on a five-point Likert scale:

On balance, I am in favour of the screening testfor Down syndrome.On balance, it is a good idea for women to havethe screening test for Down syndrome.On balance, it is a bad idea for women to have thescreening test for Down syndrome.Prenatal care is improved by offering the screeningtest for Down syndrome.Prenatal care is hampered by offering the screeningtest for Down syndrome.

The scale was scored to give a scale range of 5 to 25,with higher scores denoting more positive attitudes. Theα coefficient of reliability was 0.78.

Concurrent validity of the scale was assessed by com-paring responses to a published measure of healthcareprofessionals’ attitudes towards Down syndrome screen-ing (Green, 1994). The two scales were significantly cor-related (r = 0.73, p < 0.001). The data were assessedfor normality using the Kolmogorov–Smirnov test;responses were not normally distributed (KS statistic0.12, p = 0.012), indicating the need for non-parametricdata analysis.

Uptake of Down syndrome screening by healthcareprofessional

Screening uptake was assessed from laboratory records.Uptake rates were calculated for two groups of health-care professionals:(i) Healthcare professionals who had seen ten or more

women, comprising 70 healthcare professionals and1756 women. This group was chosen to reduce theunreliability associated with uptake rates based onsmall samples (Simpson et al., 1998). Women in this

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866 E. DORMANDY AND T. M. MARTEAU

group had seen one or two healthcare professionalsprior to the opportunity for testing.

(ii) Healthcare professionals who were the sole profes-sionals to discuss screening with a pregnant woman,and who had been consulted by ten or more women.This group comprised 29 midwives who were theonly healthcare professional to discuss screeningwith 519 women. This group was chosen to min-imise the potential confounding effect of two health-care professionals’ attitudes on women’s choices.Post hoc power calculations showed that this sam-ple provided 90% power to detect a large effect.The number of healthcare professionals seen bya woman was inferred from knowing the type ofcare a woman received. All women who receivedconsultant-led care saw more than one healthcareprofessional before the opportunity for testing. Thenumber of healthcare professionals seen by womenwho received midwife-led care was determined bya researcher hand-searching the women’s hand-heldmaternity notes when the woman attended for adating scan. The number of women seen by indi-vidual healthcare professionals was identified bydetermining which healthcare professional informeda woman about screening, as described above. Fromthese data, the number of women seen by eachhealthcare professional was calculated.

Procedure

The Local Research Ethics Committees at both hos-pitals approved the study protocol (LREC2/1/00 andJan 00/4f). Questionnaires were sent to midwives andobstetricians with a letter from the Head of Midwiferyand Clinical Director of Obstetrics at each hospital ask-ing them to complete and return questionnaires to theresearcher (ED). Up to four postal reminders were sent.

Data analysis

Non-parametric tests of difference (Mann–Whitney U)were used to assess differences in attitudes betweenhealthcare professional groups. Non-parametric tests ofcorrelation (Spearman’s correlation coefficient) wereused to assess the association between individual health-care professionals’ attitudes and uptake in the womenconsulting them.

Response rate

One hundred and five healthcare professionals wereeligible for the study. Eighty-nine (85%) completedand returned named questionnaires. The response ratewas 81% at Hospital A and 89% at Hospital B.Similar response rates were seen from midwives andobstetricians (85% in both groups).

RESULTS

Overall, all groups of healthcare professionals had pos-itive attitudes towards screening as evident from thescores that were above the midpoint of the measure ofattitudes towards the screening test. Healthcare profes-sionals from Hospital B (higher uptake hospital) hadmore positive attitudes towards Down syndrome screen-ing than those from Hospital A (lower uptake hospital)(median score 19 vs 17, MWU = 727p = 0.03). Pool-ing data across hospitals, obstetricians had more posi-tive attitudes towards Down syndrome screening thandid midwives (median score 20 vs 17, MWU = 361,p = 0.004), (Table 1).

Uptake varied between 15 and 89% across the 70healthcare professionals who offered screening to tenor more women. There was no significant correlationbetween healthcare professionals’ attitudes and screen-ing uptake in women who discussed screening withone healthcare professional only (Spearman correlationcoefficient = 0.13, p = 0.51).

DISCUSSION

Healthcare professionals expressed more positive thannegative attitudes towards Down syndrome screening,and in line with published data, obstetricians expressedmore positive attitudes than did midwives.

In this article, the relationship between healthcare pro-fessionals’ attitudes and screening uptake was examinedin two ways. The first approach compared the attitudesof healthcare professionals at two hospitals with differ-ing uptakes rates. Healthcare professionals working atthe hospital with higher screening uptake were found tohave more positive attitudes towards Down syndromescreening than those working at the hospital with loweruptake. The descriptive nature of the study precludesany conclusions being drawn about the causal nature

Table 1—Attitudes towards prenatal screening for Down syndrome of midwives and obstetricians working at one of two hospitals

Professionalgroup

Hospital A (lower uptake)(median, inter-quartile range)

Hospital B (higher uptake)(median, inter-quartile range)

Both hospitals (median,inter-quartile range)

Midwives 17.0 14.0–19.0 18.0 15.0–20.0 17.0 15.0–20.0(n) (41) (30) (71)Obstetricians 18.5 14.75–22.0 20.0 18.0–21.0 20.0 18.0–21.25(n) (6) (12) (18)Midwives and obstetricians 17.0 14.0–20.0 19.0 15.0–20.25 18.0 15.0–20.0(n) (47) (42) (89)

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of this association. That is, the more positive attitudesof healthcare professionals at the higher uptake hospitalmay have resulted in them organising screening in such away as to facilitate higher uptake. Equally, the healthcareprofessionals at this hospital may express more posi-tive attitudes towards screening to facilitate the cognitiveconsistency that follows from working in a system thatreflects one’s own values. Alternatively, uptake and atti-tudes may be correlated with a third factor that accountsfor the observed association.

The second approach to examining the relationshipbetween healthcare professionals’ attitudes and women’suptake of screening described the correlation betweenthe attitudes of individual healthcare professionals anduptake of screening by women who consulted them,where women were informed by only one healthcareprofessional about the screening test. No association wasfound. While the lack of an association between the atti-tudes of individual healthcare professionals and uptakewas not predicted from evidence gained in other areasof health care such as uptake of prenatal HIV testing(Simpson et al., 1998), other evidence suggests that theresults of the current study may be valid. Women’s atti-tudes towards undergoing the test, their age, parity andethnicity are associated with uptake (Dormandy et al.,2002b), these latter variables perhaps having a largerassociation with screening uptake than the attitudes ofhealthcare professionals’ whom women consult duringpregnancy. The apparent difference between prenatalHIV testing and Down syndrome screening may reflectthe lack of familiarity women had with HIV screen-ing, which was only recently introduced at the time ofthe Simpson study, in contrast with the current studywhere Down syndrome screening had been available forseven years at both study hospitals. The relative lackof familiarity with HIV testing is likely to result inhealthcare professionals’ views having a larger impacton women’s decisions about HIV uptake than women’sdecisions about Down syndrome screening, a test thatwomen are more familiar with.

The current study had sufficient power to detect a cor-relation of 0.5 or greater between individual healthcareprofessionals’ attitudes and Down syndrome screeninguptake in women they informed about the screening test.It remains a possibility that a correlation of less than 0.5occurred, which the study was underpowered to detect.The current results show only that healthcare profes-sionals’ attitudes do not have a large effect on women’sscreening behaviour. Studies powered to detect smallereffects are now needed to examine this relationshipfurther.

Although no association was found between theattitudes of individual healthcare professionals andwomen’s uptake, healthcare professionals based at thehospital with the highest screening uptake had more pos-itive attitudes towards screening than those based at thehospitals with lower screening uptake. In the light of thedifferent results from the two approaches used to exam-ine the association between healthcare professionals’attitudes and uptake, how are these results to be inter-preted? One hypothesis to emerge is that healthcare pro-fessionals’ attitudes influence the choices women make

through the influence of their attitudes upon the methodof conducting screening that is available in a hospital.Alternatively, this association may reflect a process ofcognitive consistency, whereby attitudes come to reflectthe circumstances of individual lives. Thus, working in ahospital with high uptake could result in healthcare pro-fessionals reporting positive attitudes to the status quo.More studies are needed to consider whether and howhealthcare professionals’ attitudes influence systems ofcare.

The strength of the current study is that it investigatesin a quantitative manner, the association between health-care professionals’ attitudes towards prenatal Downsyndrome screening and uptake of the test. Thereare three main limitations. First, there is difficultyin assessing healthcare professionals’ attitudes usingnon-anonymised (identifiable) questionnaires when greatemphasis has been placed on facilitating informedchoices. For example, healthcare professionals mayrespond to questionnaires in which their identities areknown with what they perceive to be appropriateresponses, rather than reporting their true views. In keep-ing with this, one study reported that individual inter-views failed to elicit the difficulties healthcare profes-sionals faced when providing information about Downsyndrome screening in a non-directive way, whereasgroup sessions did (Williams et al., 2002). There is,however, some evidence to support the validity of themeasure used in the present study. First, the measureshows evidence of concurrent validity with a publishedmeasure, and, second, there is evidence of predictivevalidity because the measure distinguished between pro-fessional groups in a predicted manner. The secondlimitation of the current study is that it was poweredto detect only a large effect and the possibility of amedium or small effect (i.e. a correlation of less than 0.5between healthcare professionals’ attitudes and screen-ing uptake in women who consult them) cannot beexcluded. Third, information on the health professionalseen by women was taken from the women’s hand-heldmaternity notes, in which the healthcare professionalwho discussed screening with a pregnant woman signedand dated the notes. Within the healthcare system inoperation at the time of the study, it was possible to val-idate which women had seen midwives and obstetricians,but there was no method of independently validating thenumber of midwives seen. It is difficult to estimate theeffect of this potential error on our results. Uptake ratesby healthcare professional seen on the basis of the largenumber of women included in this sample are, however,less likely to be influenced by errors in record keepingthan studies based on smaller samples.

CONCLUSION

In this study powered to detect a correlation of 0.5and over (i.e. a large effect), healthcare professionals’attitudes towards screening were unrelated to uptake ofscreening in the women consulting them. It remains tobe determined if a smaller effect exists. The observed

Copyright 2004 John Wiley & Sons, Ltd. Prenat Diagn 2004; 24: 864–868.

868 E. DORMANDY AND T. M. MARTEAU

association between healthcare professionals’ attitudesand the uptake of screening in their hospitals raises thequestion of whether healthcare professionals’ attitudesmight influence women’s behaviour via the systems ofcare adopted, not just communications between individ-ual healthcare professionals and pregnant women.

ACKNOWLEDGEMENTS

We are grateful to the staff at Luton and DunstableNHS Trust and Bedford NHS Trust who participated inthe study, in particular, Mrs Tricia Jones, Ms NaomiGallagher, Mr Malcolm Griffiths and Mr Ed Neale.This study was funded as part of a programme grant(No 037006) from The Wellcome Trust (TMM is Prin-cipal Investigator). ED is funded by NHS R and D(RDC02020).

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