As expected, women's attitudes toward undergoing amniocentesis were predominantly positive. Our findings include the values and beliefs that contribute to these attitudes: information, desire for preparation, reassurance, and the option to terminate the pregnancy were all highly valued. Participants readily identified and elaborated on personal factors that shaped to their attitudes, describing personal values and beliefs stemming from religious upbringing, moral beliefs, and feelings of responsibility towards their unborn child. Interesting contrasts in these underlying beliefs were seen within this sample, highlighting the disparate values and lived experiences present among these women. For example, a strong sense of moral obligation for a future child's quality of life was evident in some participants' intentions to use the results of amniocentesis to plan for the birth of a child with special needs and in other participants' beliefs that a pregnancy should be terminated because a minimum standard for quality of life was unlikely to be met. These origins of our participants' attitudes are consistent with Potter and colleagues' definition of values as expressions of moral views or statements on beliefs of how life should be lived (Potter et al., 2008
). Considering undergoing amniocentesis was, for our participants, a balancing of their moral, ethical, and intellectual beliefs about pregnancy and motherhood, medical intervention, and protecting a desired, if potentially tenuous, pregnancy from harm.
Notably, all participants simultaneously described varying degrees of conflicting thoughts and feelings originating from contrasting values and beliefs. Tensions among participants' underlying values and beliefs seem to contribute to this ambivalence. Ambivalence has recently been recognized as apparent in relation to many health-related behaviors (Conner and Sparks, 2002
; Lawson et al., 2009
). Many participants were deeply ambivalent toward undergoing amniocentesis, a finding that has not been previously explored in this population. Participants viewed undergoing amniocentesis to be a responsible and empowering choice but this belief was in conflict with the desire to protect the pregnancy from harm. Documenting the nature of women's ambivalence toward undergoing amniocentesis serves as a basis for further investigation and exploration of this important dimension of women's experience when considering prenatal testing.
Participants clearly articulated the ways in which they use important referents when deciding about amniocentesis, particularly when they felt ambivalent. Other women's experiences, both of accepting and declining amniocentesis, were valued as models of different outcomes and served to inform their decision-making. Many participants mentioned their status as being of “advanced maternal age” and were aware of the specific challenges and expectations associated with being pregnant later in life. They alluded to the pressure placed on them because of this status and were aware that younger women were not offered (or were faced with) this choice, and were drawn to understanding how other women who shared their status had made a decision in the face of similar conflicting thoughts or feelings. One way women may seek to reduce their ambivalence is to expand their experiential knowledge of others' choices (Etchegary et al., 2008
Marteau and colleagues developed and validated the multi-dimensional measure of informed choice. This defines informed choice as a decision that is based upon sufficient understanding of high-quality information and consistent with the decision-maker's values (Marteau et al., 2001
). One of the goals of prenatal genetic counseling is to ensure that the components of informed choice are accessible to decision-makers. Helping women identify their attitudes toward undergoing prenatal genetic testing, the ambivalence embedded within their attitudes, and how these attitudes are informed by their personal underlying values may increase the likelihood of women making informed choices. This adds a novel approach to existing interventions such as decision aids used to facilitate such decisions (Bekker et al., 2004
). When women articulate conflicts or tensions among their values and beliefs, addressing them may help to clarify and evaluate the more overarching ones and strengthen the relationship between their attitudes toward prenatal testing and their ultimate choice.
This study is limited by selection bias inherent in the recruitment of the clinic population, as only women who had already scheduled an appointment for amniocentesis were eligible to participate in this study. Likely, those with more negative attitudes were excluded. In addition, the majority of participants were well-educated Caucasians. Although these demographic characteristics reflect those of the clientele of the recruitment site, the findings of this study may not be generalizable to underrepresented minorities nor the general population of women considering amniocentesis. Yet, the strength of this study is the demonstration of ambivalence and an examination of its presence and nuances among knowledgeable women with generally positive attitudes toward amniocentesis.