The influence of service organisation and delivery on participation in prenatal screening for Down's syndrome: A multiple case study

INTRODUCTION: The way in which NHS screening programmes are organised and delivered
may influence public engagement. This is of particular interest in Down’s syndrome
screening where variations in uptake have not been explained by individual social
characteristics. This has led to suggestion that the influence of service organisation and
delivery may help to explain the variation.
AIM: To explore the influence of service organisation and delivery on women and partners’
participation in screening in two different health districts in England with contrasting uptake
rates.
METHOD: A multiple case study design involving document review of screening guidelines
and qualitative online interviews was adopted. Purposive sampling was employed to select
settings and invite in each group (n=18 – 24) community midwives, women and partners.
Participants responded online to vignettes with open-ended questions and prompts,
providing a range of responses. Data were analysed using content analysis.
FINDINGS: Participation was influenced by constraints such as the offer of screening as a
routine test, influence of interpreters and ambience of the environment resulting in the
routinisation of screening. Additionally, differing perceptions and the policy of
nondirectiveness created tensions in the prenatal environment, within and between
midwives, women and partners. The constraints, tensions and nuances in the
operationalisation of the screening guidelines affected midwife - woman interaction and
how screening was presented, with some midwives colluding with women to engage
passively in screening. The conceptual model developed from the findings revealed a factor
unaccounted for in previous research that the tensions, different relationships, decisionmaking
models and variation in uptake rates in screening were associated with service
organisational and delivery constraints.
CONCLUSION: The classic situation of women capable of autonomous and informed choice
and midwives capable of informing nondirectively may not exist in the prenatal context. A
shared decision-making process model to mitigate the constraints and tensions is proposed.