Prenatal Genetic Testing: Content of Discussions Between Obstetric Providers and Pregnant Women BARBARA A. BERNHARDT, MS, GAIL GELLER, ScD, TERESA DOKSUM, MPH, SUSAN M. LARSON, MS, DEBRA ROTER, DrPH, AND NEIL A. HOLTZMAN, MD, MPH Objective: To document the content and accuracy of discus- sions about prenatal genetic testing between obstetric pro- viders and pregnant women. Methods: The first prenatal visits of 169 pregnant women with 21 obstetricians and 19 certified nurse-midwives were audiotaped and analyzed for whether a discussion of family history or genetic testing took place and if so, its length, content, and accuracy. Results: Family history was discussed in 60% of visits, maternal serum marker screening in 60%, second-trimester ultrasonography for fetal anomalies in 34%, and for women at least35 yearsold, amniocentesis orchorionicvillus sampling (CVS) in 98%. The length of discussions of genetic testing averaged 2.5 minutes for women younger than 35 yearsof age and 6.9 minutes for olderwomen.Topics discussed most often were the practical details of testing, the purpose of testing, and the facthattesting is voluntary. Discussionsseldom werecomprehensive. Obstetricians were more likely to make a recommendation about testing than were nurse-midwives and were less likely to indicate that testing is voluntary. Most women were satisfied with the amount of information, and the majority of women of advanced maternal age had made a decision about amnio- centesis or CVS by the end of the visit. Conclusion: The information about genetic testing pro- vided in the first prenatal visit is inadequate for ensuring informed autonomous decision-making. Guidelinesad- dressing the content of these discussions should be devel- oped with input from obstetricians, nurse-midwives, genetic counselors, and pregnant women. (Obstet Gynecol 1998;91: 648 –55.© 1998 by The American College of Obstetricians and Gynecologists.) Guidelines for the content of prenatal care developed by the Public Health Service Expert Panelemphasize the importance of risk assessment and education early in pregnancy, 1 specifying thatthe firstprenatalvisit should include a detailed medical and obstetric history, as well as health promotion activities including educa- tion aboutprenatalcare.However,little guidance is provided about patient education about genetic testing, an aspect of prenatal care that is becoming increasingly importantas the number ofdisorders diagnosable in utero continues to increase. 2,3 The advent of noninva- sive screening, such as maternal serum marker screen- ing,followed by a confirmatory invasive procedure, is making prenatal genetic testing available to more wom- en. 3 ACOG has produced some guidelineson how geneticrisk should be established and the circum- stancesunder which genetic testing should be of- fered. 4 –10 However, these documentsprovide little guidance relating specifically to the content and process of discussions in which genetics or genetic testing is raised. The practice ofprenatalcare providers,including obstetricians and certified nurse-midwives, generally adheres closely to ACOG guidelines for components of care that have been recommended for many years, such as physical examination and certain laboratory studies. Guidelines are followed less often for components that have been added recently, such as the offer of maternal serum alpha-fetoprotein screening, 11 and for compo- nents thathave been recommended about counseling and education in health behaviors such as smoking, drinking,and drug use. 12 Studies 11–13 of the content of early prenatal care have From the Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland, and the Department of Health Policy and Man- agement, Johns Hopkins School of Hygiene and Public Health, Baltimore, Maryland. We are grateful to Courtland Robinson, MD, and Lisa Summers, CNM, for assistance with the recruitment of providers and the develop- mentof study instruments, and to Gary Chase, PhD, for statistical advice. Thiswork wassupported by grant R01 HG00908 from the National Center for Human Genome Research, National Institutes of Health. 648 0029-7844/98/$19.00 Obstetrics & Gynecology PII S0029-7844(98)00011-8