How can we improve amniocentesis decision-making?

The decision to have an amniocentesis entails a trade-off between a risk of procedure associated miscarriage and the benefit of obtaining diagnostic information to identify Down syndrome or other chromosomal aneuploidy. Ideally, this trade-off is informed by first and second trimester pre-natal screening tests, such that women with low risk screening test results are not encouraged to have an amniocentesis. In a recent IJHPR article, Grinshpun-Cohen et al. surveyed 42 Israeli women without a medical indication for amniocentesis other than age. They found that one third of women who had a noninvasive serum screening test prior to amniocentesis did not even wait for the test results before electing to have the invasive procedure and 10 % of women did not have any serum screening test prior to amniocentesis. There may be multiple reasons why women of advanced maternal age are not integrating screening risk information into their decision-making about amniocentesis. However, our understanding of those reasons is limited, as we don't have information on the content of conversations between health care providers and women who are considering amniocentesis. We don't know if health care providers counseled women on how screening risk information can inform their decision about whether or not to purse a diagnostic amniocentesis. Even if women with screening tests results suggestive of a low risk of Down syndrome were counseled not to pursue an amniocentesis, some women may have a preference for diagnostic information about a fetus's Down syndrome status. Health care providers should, however, be encouraged to engage women in a process of shared decision making to ensure that women are informed and making deliberative decisions that meet their goals of care. Offering women a relatively new, cell-free fetal DNA test may provide reassurance that negates the impulse to have an amniocentesis. Public funding for amniocentesis for all women of advanced maternal age should continue as the decision to purse an amniocentesis is best determined by women who have to live with the consequences of their choice.