Study reference

Study characteristics

Patient characteristics

Method

Outcomes

 Coping / Counselling

Comments

Áskelsdóttir (2008)

Type of study: Part narrative review, part qualitative (interviews)

Setting: rural Alberta

Country: Canada

Source of funding: not reported

Inclusion criteria: prenatal diagnosis of gastroschisis between 18 and 20 weeks of gestation

N=3

Mean age ± SD: not reported

Sex: 33% M / 66% F

Interviews were conducted after the neonates had gone through corrective surgery and were recuperating without incident in the NICU

In-depth-interviews

For all respondents the diagnosis wat unsuspected and an immense shock. Stress levels were consistently high although the parents’ experiences changed as the pregnancy progressed; the fear of the unknown became a fear of the uncontrollable.

Focusing on what is normal with the baby instead of the anomaly helped alleviate those fears. Positive comments from healthcare professionals about the baby’s progress were appreciated.

A multidisciplinary approach is needed early on to provide care by both physicians and nurses where a coordinator is appointed for each family to provide parents with a sense of continuity of care and decrease parents’ sense of confusion and lack of control. A tour of the NICU would benefit parents when fetal anomaly is diagnosed. Continuity of care is imperative for these parents. They need to be actively involved in discussions about management and care needed postnatally.

Sensitivity is needed to move toward a sense of normalcy as parents and of their child as a human being, not as anomaly

Kaasen, 2010

Type of study: prospectief, observationeel

Setting: Tertiary referral centre for fetal medicine

Country: Norway

Source of funding:

The Norwegian Women’s Public Health Association, National Centre for Women’s Health, and Oslo University Hospital.

Inclusion criteria:

Confirmed fetal structural anomalies detected by ultrasound.

All were included after 12 weeks of gestation (median 134 days of gestation, range 84–269 days of gestation).

Exclusion criteria

Not fluent in Norwegian, multiple pregnancy, <18 years old, overt psychiatric diagnosis

N=180

Pregnant women were included consecutively from May 2006 to February 2009. However, convenience sampling was undertaken during vacations and in periods with heavy clinical workload.

The comparison group included 111 pregnant women with no history of fetal anomalies or severe obstetric complications, scheduled for delivery at same hospital.

Social dysfunction and health perception were assessed by the corresponding subscales of General Health Questionnaire (GHQ-28).17 Endpoints of psychological distress were assessed by the anxiety and depressive subscalesof GHQ-28, Impact of Events Scale (IES-22),18,19 and Edinburgh Postnatal Depression Scale (EPDS).

The study group had a significantly lower educational level, a wider range of gestational age at inclusion, and longer time intervals from the suspicion of fetal anomaly to inclusion than the comparison group.

Significantly higher levels of social dysfunction, negative health perception and psychological and behavioural distress were observed in the study group than in the comparison group.

Despite lower distress scores in women with normal ultrasound findings, GHQ scores, including most of the subscales, were fairly high, which might reflect a significant period of distress before the ultrasound examination was performed.

We found that all women in our sample experienced acute distress, not only those with proven fetal malformations, genetic disorders or intrauterine fetal death, but also those with the diagnosis of a sonographic sign.

Our findings indicate that it is important for doctors and midwives to be aware of the high psychological distress levels among these women, and to individualise their care, according to predictors identified in this study.

After detection of a fetal anomaly, pregnant women experience clinically significant acute psychological distress. Health providers who counsel these women should be aware that advanced gestational age at diagnosis, the severity of the anomaly and significant prognostic ambiguity were the strongest predictors of psychological distress. These women may need extra psychological attention and support.

Lalor, 2007

Type of study:

Qualitative, symbolic interactionism

Setting: tertiary referral maternity hospital, Dublin

Country: Republic of Ireland

Source of funding:

Clinical Midwifery Research Fellowship. Health Research Board

Inclusion criteria: purposive sample,

Pregnant women with a range of fetal anomalies. 62 women were invited to participate.

N=38

Each of these women was carrying a fetus with one of the following anomalies: anencephaly (n = 3), hydrocephalus, triploidy, trisomy 18, trisomy 21, and diaphragmatic hernia

Mean age: 33 ± 5.53

Education: University (14), High school (24)

In-depth-interviews

Constant comparative method

Explores the experiences of women’s encounters with caregivers after the diagnosis of fetal anomaly on routine second trimester ultrasound examination.

The data demonstrated that women positively anticipated the ultrasound examination and were looking forward to ‘seeing’ their baby. Because the women were not selected for screening based on the presence of fetal anomaly risk criteria, all described being shocked to discover that everything was not normal.

Women who received clear information from caregivers at this initial point in the diagnostic process were more satisfied with their interaction with the caregiver than those who had inadequate responses to their questions. Women described a need for prompt information about their baby’s anomaly, and their perceived difficulty in accessing information as quickly as they would have liked added to their distress.

All women said rapid access to the fetal medicine specialist, preferably within 24 hours of the initial ultrasound scan, was desirable.

Women experienced most distress when waiting longer than this period and especially if the wait spanned a weekend, when they believed access to information was hindered. Dissatisfaction was also expressed in terms of perceived insensitivity of the specialist delivering the news, and of women not receiving sufficient detail about the prognosis or treatment available as quickly as they would have wished. Women whose babies had treatable anomalies also expressed acute distress and grief at this initial point of diagnosis.

Positive aspects of care included staff providing guidance to appropriate Internet sites, communicating clearly without the use of jargon, and enhancing understanding through the use of diagrams and other visual aids such as the ultrasound screen and percentile charts. As in other studies women valued the continuity of seeing the same health care professional(s) on repeat visits.

Because the ongoing need to access information about the pregnancy and birth was seen as fundamental to coping with the situation, women suggested the most appropriate person to provide this aspect of care would be a midwife with expertise in the area, preferable if it could be provided in their home environment and away from the tension and busyness associated with the fetal medicine clinic.

Receiving support from the departments of social work or psychiatry was associated with social stigma by women and was seen to reflect an inability to cope.

In Ireland termination of pregnancy is not allowed within state boundaries.

Lalor, 2009

Type of study: Qualititative, grounded theory

Setting: Fetal medicine unit of a major Dublin maternity hospital

Country: Republic of Ireland

Source of funding: Clinical Midwifery Research Fellowship. Health Research Board

Inclusion criteria: All low-risk Irish women booked at or referred to the study site with an ultrasound diagnosis of fetal anomaly in pregnancy were eligible to participate.

N=41

10 women terminated their pregnancy in the UK

women with diagnoses from the following prognostic range were included: (1) lethal and untreatable, (2) likely mental and/or physical deficit whereby the extent may vary but complete resolution is unachievable, (3) uncertainty as to the long-term effects and eventual quality of life, (4) treatable, but with varying degrees of risk, and (5) uncertain prognosis as improvements to or deterioration of the fetal condition was possible in utero

Repeated in-depth interviews pre- and post birth

Women who continued the pregnancy were interviewed on up to three occasions; following diagnosis (phase 1), pre-birth (phase 2) and postnatally (phase 3). Nine women who travelled to the UK were interviewed between 6 and 12 weeks after the birth as the decision to travel was usually made within 48 h of receiving the diagnosis.

Constant comparative method

Framework: Recasting hope, a theoretical framework of the process of adaptation following fetal anomaly diagnosis based on women’s experiences of carrying a baby with a fetal abnormality up to and beyond the birth.

Landmarks: (a) being informed that their baby has an abnormality, (b) concerns that emerge as the pregnancy continues and the time for birth approaches, and (c) the key issues that emerged in relation to the birth and at approximately 12 weeks postnatally (with or without a live baby).

Lack of continuity of carer led to some women being treated insensitively, as staff did not seem to be aware of the situation and interacted with the woman as if a normal outcome was expected. In spite of the difficulties, parents in this study reported that having an antenatal diagnosis helped them to be prepared for the birth.

‘Recasting Hope’, grounded in women’s experiences, represents the process of coping with and surviving this traumatic event. four theoretical codes that emerged as sub-core variables are termed: Assume Normal,’ ‘Shock,’ ‘Gaining Meaning’ and ‘Rebuilding.’

Shock, disbelief, physical symptoms, devastating, threatening to their identity as a women.

It’s not just the condition is there anything else or is it worse than they think it is. (Trina)

For some women certainty regarding the diagnosis could be achieved based on ultrasound findings alone. When other structural defects occurred, women were offered invasive testing as a means to confirm or overrule a co-existing karyotypical abnormality, and responses to this offer varied.

Many women spoke of how the responsibility to care for other children helped them to maintain some level of daily function.

However, the initial shock was soon replaced with a need to adapt to the news which frequently began with finding concrete ways to determine the causal factors involved Women consistently referred to the initial consultation with the fetal medicine specialist as the first step in finding an answer to this question, and all women had high expectations of the consultation in terms of certainty of diagnosis.

Progression to phase four ‘Rebuilding’ corresponds chronologically with moving forward after the decision to continue the pregnancy or not has been made.

For the women whose babies did not survive, creating memories was important, and individual. Some women had graves to visit, whilst others had photos or cards acknowledging the birth.

A prolonged and unsuccessful search for meaning was associated with a more complex pathway to recovery. Although a clear end-point indicating recovery was not observed for all women, planning a future pregnancy was a positive sign.

Recent decades have seen ultrasound revolutionise the management of pregnancy and its possible complications. However, somewhat less consideration has been given to the psychosocial consequences of mass screening resulting in fetal anomaly detection in low risk populations,

Leithner, 2002

Type of study: Intervention study Before-after study

Setting: Division of Prenatal Diagnosis and Therapy, Vienna University

Country: Austria

Source of funding: Jubiläeumsfond of the Austrian National Bank

Inclusion criteria:

Native German speakers

587 women who attended Division of Prenatal Diagnosis and Therapy were informed about the possibility of psychological assistance. One-hundred and forty women decided to accept the proposal and were psychologically treated by a psychologist.

Participation in the study was not a condition for the psychological treatment. 63 psychologically treated women were not included due to language problems (n = 28), acuity of somatic procedures (n = 23) or lack of consent (n = 12). The demographic comparison showed that these 63 women had a lower level of education and an unqualified job.

77 met inclusion criteria >

N=77

Mean age: 28.6 (± 5)

21% had a university degree and 75% a professional career

Intervention: The applied psychological interventions were crisis intervention, nondirective counselling and psychoanalytic short-term psychotherapy26.

Crisis intervention in this context means the earliest support, if possible, shortly after the first ultrasound investigation in the outpatient clinic

Psychological sessions took place three to five times with 44% of patients, 26% of the patients needed 6 or more sessions and the maximum number of sessions was 22 for one individual.

Spielberger State-Trait Anxiety Inventory Mood scale Freiburger Coping Behavior Scale Documentaion Instrument Follow-up instrument

A follow-up took place six months after the first contact. Complete data were available from 77% of the women (59 women). The dropout rate of the follow-up was 23% and 18 women did not respond

The mean score of the general mood scale was 44.6 at the time of the first contact, which was significantly (p <0.001) above the normative value of a non-patient population (mean 24.3)”. This reflects a severe impairment of general mood, because this score can be compared with patients suffering from major depression. After six months an improvement of general mood was evident, the mean score of 36.1 reflecting a significant change (p <0.001) within the period of comparison, yet was still significantly (p <0.001) higher than that of a non-patient population.

The extreme high score of state anxiety (mean 59.4) present at the first contact represented the emotional stress situation.

After six months the state anxiety had decreased significantly (p <0.001) (mean 39.1). while the decrease in trait anxiety was not significant, but could no longer be distinguished from the norm population. Six months after the critical life event the general mood improved and anxiety levels reduced.

The coping strategies that were most frequently applied were ’compliance behavior and confidence in medical doctors’ followed by ‘self encouragement’ and ‘problem solving’. Compared with a normal patient population (dialysis patients and breast cancer patients) the women under study showed significantly more ‘depressive coping’, ‘pessimism’ and ‘regression’

Most of the women (88%) rated medical information and explanations from doctors as being important and helpful.

The majority Of (93%) found their partners to be supportive‘ Many Of the women (71%) pronounced contact with other women who had had the same experiences as very supportive for their mourning process.

97% of the women indicated that the psychological care has been an important support for them in coping with this painful event. Overall 78% of the women have been ‘very’ and 22% ‘rather’ satisfied with the psychological treatment and 51% of the women would have wanted a long-term treatment.

No significant relationship was found between coping strategies and items such as age, children or lack of children, employment or the frequency of the psychological treatment.

We found that the use of negative coping strategies such as ‘depression’, ‘regression’, ‘pessimism’ and ‘control of emotions’ is linked with the development of somatic problems.

Medical doctors should respond to the high readiness of their patients to deal with this critical life-event -reflected in the high scores of the coping mechanism ‘compliance behaviour and confidence in medical doctors’ - by offering dialogue and psychological support

The comparison of the participants and the dropouts of follow-up did not show any significant differences in age, demographic data, history, diagnosis and outcome of pregnancy, frequency of psychological treatment, anxiety, general mood and coping behavior.

Leithner, 2004

Type of study: Survey

Setting: Division of Prenatal Diagnosis and Therapy, Vienna University

Country: Austria

Source of funding: Research grant Federal Bank of Autria

Inclusion criteria:

Subjects were referred to the Division of Prenatal Diagnosis and Therapy for detection of fetal anomalies with invasive or non-invasive prenatal screening

N=77

Mean age: 28.6 (± 5)

After ultrasound scanning or invasive procedures had been performed, 5 diagnostic groups were identified, namely: (1) fetal malformation (n = 39; 51%), (2) genetic disorder as verified by consecutive amniocentesis (n = 9; 12%), (3) sonographic sign (n =24; 31%) (i.e. oligohydramnios, restriction, nuchal translucency), (4) intrauterine fetal death (n = 4; 5%) and (5) problems during pregnancy (n = 1; 1%) (i.e. fetofetal transfusion syndrome). Forty-one (53.3%) women lost their child during pregnancy (interruption, n = 34; stillbirth, n = 7). Thirty-six women gave birth to a child (regular delivery, n = 27; preterm delivery, n = 9). Of these, 21 (58%) women gave birth to a healthy child and 15 (42%) gave birth to a child with a congenital malformation.

At baseline, immediately after the diagnostic ultrasound examination or the invasive procedure, patients underwent

an initial psychological interview and test diagnoses. Anxiety levels were measured using the Spielberger State-Trait Anxiety Inventory, a widely used self-rating instrument for the assessment of the current (state) and inherent (trait) level of anxiety. The Mood Scale.

Six months after the first contact a follow-up investigation took place. Anxiety and mood scores were reassessed using the State-Trait Anxiety Inventory and the Mood Scale. Moreover, we investigated the patients’ coping strategies following the prenatal diagnosis by means of the Freiburger Coping Behavior Scale.

Only negative coping strategies showed a significant negative effect (γ = 0.38; SE = 0.16; t = 2.34) on general mood and anxiety at follow-up.

In the present study, mood and anxiety scores of the investigated sample were found to be comparable to those of patients with a major depressive episode. This does not imply that these women actually suffered from a depressive disorder according to strict diagnostic criteria. Rather it shows that women facing a prenatal diagnosis experience considerable psychological distress, which may be underestimated by workers in prenatal care.

Moreover, we found women who lost their child to be in a worse affective state than women who gave birth to a living child (in some cases with a congenital malformation). This finding is in agreement with previous data indicating that a pregnancy loss gives rise to a marked deterioration in a woman’s mental health, particularly in the first 6 months following the loss. However, we assume that the strain of coping with a child with a congenital defect may possibly lead to a worsening of the mother’s affective state over time, but this has not been validated in the present study.

Psychological support, particularly focusing on the modification of inappropriate coping strategies, may be extremely beneficial for women presenting at a department for prenatal care, although this hypothesis has not been evaluated in the present study.

We conclude that the sole suspicion of having any prenatal problem may have a tremendous emotional impact on a pregnant woman. Special attention and follow-up services should be provided to particularly vulnerable women, namely those with a stillbirth or interruption, those with negative coping strategies, or those with a high trait anxiety level.

Subject randomly approached? See Leithner, 2002

Intervention (psychological support, Leithner, 2002) is not mentioned nor analysed.

Maijala, 2003

Type of study: Qualitative, grounded theory

Setting:

University hospital

Country:

Finland

Source of funding:

Not reported

Inclusion criteria:

The main criterion for inclusion in the study was that the mother had been informed about the foetal malformation and that she was currently receiving or had received treatment in the hospital’s outpatient or inpatient department. The mother was the principal informant and she decided whether the father was invited to participate in the study.

N=29 mothers and fathers (18 families)

Age: 10 <30 yr, 14 <40, 5 >40 or older

15 women were pregnant at time of study.

Semi-structurered interviews

Constant comparative method

The care system as an interactive environment is part of a process which results in the experiences of being helped or being left without help. The core of the interaction process comprises two dimensions: gaining strength and losing strength in relation to malformation issues.

In this study, most parents were informed about the suspected malformation in the context of ultrasound scanning. This information came as a complete surprise to most families,

All were in desperate need of additional information. They were confused and had difficulty believing what they were told. Three parents did not have a clear recollection of receiving the diagnosis, and five took a detached view of the diagnosis or were not able to take it in.

Crying,

When the malformation was diagnosed early, parents had to decide whether to continue or terminate the pregnancy. The decision involved envisioning life in the future, and fear of losing the baby later sometimes determined the course of decision-making. When pregnancy continued, uncertainty was the dominant feeling for parents. Gradual adjustment to the malformation often involved fatigue, sleeping problems and inertia. As the feeling of inertia subsided, mothers were able to accept that life must go on.

Parents often cherished the hope of the child’s recovery, although they knew that the child would die.

Families were much concerned about how other people might react to the situation, and interest shown by others was sometimes experienced as unwanted curiosity. In two families, relatives’ attitudes, for instance sharing of experiences, while well-meaning, were also perceived as negative. Protection of privacy was also important for parents, and seeing pregnant women and hearing babies cry was often painful.

Families mostly used their own coping strategies (Figure 1) alongside their expectations of caregivers.

Parents expected a physical, situation-specific approach, such as placing an arm around them. They expected caregivers to show active caring, for instance, by telephoning them. Availability and flexibility of help were sometimes more important than organized discussions. They also needed time alone, for instance, in a private room but not all wanted to share their thoughts with caregivers. Caregivers were expected to provide psychological support in the form of simple acts such as asking how the family was dealing with the situation. Six parents wanted to have a support person of their own and crisis help. Whatever the case, continuity of care was important.

Active involvement in and independent decisions about one’s own affairs were considered important.

The family’s coping was complicated if the mother found herself in an examination situation without knowing its purpose, or if a situation provoked unrealistic expectations because of conflicting information. Disregard of the family’s need for information impeded mobilizing their own resources. Disregard of fears, for instance caregivers’ non-responsiveness to the mother’s crying or verbal undermining of fears, were also experienced as negative.

Continuity of care, which the families expected, provides security, whereas fragmentary care relationships put stress on them.

Parents should have enough time and impartial support when deciding whether to continue or terminate the pregnancy.

Sharing the doctor’s waiting room with parents expecting a healthy child can also be a distressing experience.

It is important to support their own coping strategies

At the time of the first interview, nine families felt that the child’s recovery was possible, while three assessed that the child would die although the pregnancy continued. One family was preparing to give birth to a dead child and five had decided to end the pregnancy.

Maijala, 2004

Type of study: Qualitative, grounded theory

Setting: Tampere University Hospital

Country: Finland

Source of funding:

Inclusion criteria:

Semi-structurered interviews

Constant comparative method

N=22 doctors and nurses/midwifes

(18 nurses/midwifes, 4 doctors)

Reliability of the findings was enhanced on three different occasions by seeking feedback from the nurses and doctors of the research units through discussions. Some of those who participated in the discussions were research informants, some were not. The response supported the findings.

The core of the interaction process comprises two dimensions: gaining strength and losing strength in relation to malformation issues.

The data were managed as an integrated whole, without categorizing the occupational groups.

The interaction process starts when a caregiver informs the family of their child’s fetal impairment.

At the initial phase of interaction, when giving information about the details of the child’s impairment, caregivers

emphasized the importance of reliable information.

The goal of family–caregiver interaction is to help families retrieve their own resources, like the self-esteem and mutual support of the family members and their orientation towards the future.

Parents’ need for psychological support was perceived to be great. The caregivers aimed at making the parents’ voices heard and make them feel safe. Giving families time for discussion was considered important, although the temporary nature of a pregnancy often called for rapid arrangements.

“They need time, you must not be too busy, they have to feel that we are there for them, we have to spend time with them and try not to give the impression that we should be somewhere else, although this might be true”

Keeping up realistic hope required caregivers to refrain from giving empty promises while, at the same time.

Insufficient resources strained caregivers and restricted interaction. Haste led to repeat visits to the clinic, which further reduced the scarce resources. The lack of resources was shown in fragmentary care relationships, understaffing in acute situations and lack of proper facilities for discussions. Caregivers appreciated multi-professional collaboration, especially that between a doctor and a nurse/midwife

It was important that different workers provided the parents with consistent information in order to gain the family’s trust.

However, caregivers in this research criticize their own actions rather rarely, although earlier research shows that there are shortcomings in the support the families expecting a fetally impaired child are provided Hence, it can be questioned whether the caregivers participating in the research interviews have emphasized their ideal action. If so, which elements in the interviews may have prevented the interviewees from examining the shortcomings of their own actions, or, was presenting a critical self-evaluation an unfamiliar process for them?

Matthews, 1990

Type of study: Qualitative (phenomenology, interviews)

Setting: University Health Center

Country: USA

Source of funding: not reported

Inclusion criteria: Convenience sample of women pregnant of child with known major malformation

N=20

Mean age (range):

26.4 (20-32)

Education (years):

13.4 (11-16)

Income: $21,908 (2,000-60.000)

Expectancy of Loss Model (Uncertainty, Verification, Preparation, Reconfirmation, Reparation, Resilience)

Initial reactions:

Shock, fear, panic, confusion, disbelief

Guilt, blame

All informants agreed that that waiting for verification, whatever the time frame, was way too long

Closer to spouses

Seeing, holding and naming the baby, decisions about funeral and memorial services

Information received during counselling had positive impact

1) Provided information for decision making, thereby increasing their perception of being in control in un uncontrollable situation

2) Allowed for initiation of anticipatory grief reactions

3) Decreasing feelings of guilt and self-blame

4) Follow-up and genetic counselling important

Five women pregnant at time of interview, 15 women were interviewed 1 to 17 months following delivery. Of 21 children born 19 died shortly before delivery or within the first day of life

Rychik, 2013

Type of study:

Cross sectional survey (questionnaires)

Setting: Children’s hospital

Country: USA

Source of funding: Robert and Dolores Harrington Endowment at the Children’s hospital in Philadelphia

Inclusion criteria: prenatal diagnosis of fetal congenital heart disease

61 of 88 eligible pregnant women (with prenatal diagnosis of fetal congenital heart disease) participated and 59 women completed all measures

N=59

Mean age: 30 ± 7

Gestational age (17-31,5 weeks)

Comparison: normative levels of psychological stress in women spregnant of a healthy fetus.

Income: 9% <40.000$, 31 >40.000 <70.000, 17% >70.000 <100.000 and 43% >100.000

Impact of Events Scale-Revised version

State-Trait Anxiety Index

Beck Depression Index II

COPE Inventory

Dyadic Adjustment Scale

Posttraumatic stress, depression, and anxiety are common after prenatal diagnosis of CHD.

After controlling for partner satisfaction and income, multivariate analysis showed that the only coping variable significant was denial (P<0,1). Higher levels of denial were associated with increase in traumatic stress, maternal anxiety, and depression, irrespective of partner satisfaction.

Healthy partner relationships and positive coping mechanisms can act as buffers

Health care provides should look to promote the coping skills of acceptance and positive reinterpretation and growth.

Brief couples therapy focused on the implications of the diagnosis may also be of benefit.

Results should be interpreted with some limitations, study population is skewed towards affluent, educated, Caucasian women.

All women were carrying foetuses with serious CHD requiring neonatal evaluation and surgical -or catheter – base intervention within the first 6 months of life.

Counselling received during study is not evaluated.

Titapant (2015)

Type of study:

Prospective longitudinal survey (questionnaire) plus qualitative (interviews)

Setting: University hospital, Bangkok,

Country: Thailand

Source of funding: Siriraj Research Development Fund

Inclusion criteria: Pregnant women with non-lethal major and minor congenital anomalies diagnosed in during 2^nd trimester ultrasound who continue their pregnancies

60 of 89 eligible pregnant women participated and 55 women completed the study.

N=35 (STAI)

N=20 (STAI + interview)

Mean age: 27.2 (± 6.4 years)

Cultural: Buddhism: 92.7, Islam: 5.5, Christianity: 1.8

Spielberger State-Trait Anxiety Inventory

In-depth interviews

Stages: intense negative psychological reaction stage, the psychological healing stage, the intense negative reaction re-emergence state

Average anxiety score of women pregnant of child with major anomalies is higher, but difference is not statistically significant.

High level of psychological distress: shock, grief, anxiety, fear, guilt and disappointment, impairments in self-worth

Levels of stress change during pregnancy, are highest shortly after diagnosis (related to the loss of the ideal child: grief, sadness, disappointment) and before delivery (worry, fear)

Coping strategies: discrediting the bad news, recasting hope (social support, religion), stressor avoidance (don’t tell others).

It is notable that the predominant coping strategies observed are negative styles. Could potentially be explained by societal and/or cultural influences.