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.