Methods and materials
Our analysis is based on observations of PND consultations to which
women are referred when there is an increased risk of foetal anomaly.
Sixty-three observations were conducted in France between 2010 and 2012
in a PND referral centre in the Paris region, which receives a high
proportion of immigrant women, most of them from North Africa, and in a
provincial centre which treats a mixed population. Twenty-two
observations, involving a mixed population, were conducted in England in
2013, in a gynaecological and obstetric unit in a hospital that
practices foetal medicine and in a foetal medicine unit in a referral
centre. In our observations, the increased risk resulted from DS
screening (39), ultrasound imagery (24), genetic/obstetric history (12),
maternal age (8) and toxoplasma infections (2).
We must begin by pointing out a difference between the two countries in
terms of health pathways. In England, women are informed of their risk
and only sent to a referral centre if they consider that taking a sample
is an option. A midwife then goes over the information on the risks
before obtaining the woman’s consent. An ultrasound examination is then
performed; the consultant answers any questions the women may have and
the sample is taken. In France, all women “at risk” are referred to a
PND centre. Approximately one third of the consultations follow the same
format as those in England. The remainder are conducted by a midwife
alone, who provides information. No medical act is performed.
The study received ethical approval in France from a Research ethics
committee (Anonymised) and in England from the Health Research Authority
(anonymised) and the University of (Anonymised) ethics committee.
Consultations lasted between 25 and 70 minutes. 40 women attended the
consultations on their own, 42 were accompanied by their partners and
three by someone else. The authors were present during the
consultations. Field notes were made to capture the communication’s
content and delivery as well as non-verbal expressions. In England, the
consultations were also recorded and transcribed verbatim.
The analysis, conducted by both authors, draws on Grounded
Theory.26 It focuses on the nature and properties of
the (inter)actions taking place during the consultations and how these
are combined to enable a decision regarding the management of the
pregnancy to be reached. These interactions are heterogeneous and relate
to medical practices, their organisation and regulation. Yet most of
these actions are “speech acts”,27 i.e. discourses
which inform, reassure or worry, protect, advise, influence, etc.
Based on frame analysis,25 the first analytical stage
consisted of identifying the different frames mobilised by protagonists
during the consultations. The frames act as guides to action, they
convey ordinary meanings of what takes place in a situation and of the
ways people behave therein. The second analytical stage, which draws on
“combinatory pragmatics”,28 consisted of identifying
from the combination of frames and their impact on the interactions, the
different configurations of consultations and their outcome in terms of
decision-making.