Lack of Provision of Social and Emotional Information about Down Syndrome Associated with Negative Prenatal Diagnosis Experiences

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Kleinert, Jian Li, Sierra Weiss, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5810442/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 May, 2025 Read the published version in Journal of Community Genetics → Version 1 posted 10 You are reading this latest preprint version Abstract Objective To determine how physician adherence to recommended practices for discussing Down syndrome impacts patient experiences, and which of these recommendations most correlate with positive prenatal patient experiences. Method Online surveys were distributed to mothers of children with DS born between 2016–2021. The descriptions of prenatal experiences were assigned sentiment analysis scores: positive, negative, or neutral. The scores were then compared against the adherence of clinicians to recommended practices for delivering prenatal screening results. Results Of the 167 patients in this study, over 50% described a negative experience. The odds of having a neutral/positive diagnosis experience were about 18 times greater for those patients whose physicians adhered to all seven social recommendations. The odds of having a positive/neutral screening experience were 11.4 times greater for those patients whose physicians adhered to both emotional recommendations ( not saying “I’m sorry” or conveying the diagnosis as bad news”). Most of the variance in the patient diagnosis experience was attributed to adherence to emotional recommendations and social recommendations. Conclusion To meet the needs of patients, obstetricians need to address their emotional, social, and informational needs by providing 1) access to balanced and accurate information about disabilities and 2) being better trained on sensitive communications. Note: “Diagnosis experiences” include both patients receiving diagnostic results and the cell-free DNA screening results. Most parents of children with Down syndrome do not proceed with diagnostic testing, and the vast majority (89%) consider screening the most important stage for receiving information about DS.( Meredith et al., 2023) Down syndrome disability obstetrician genetic counselor prenatal screening cell-free DNA screening Trisomy 21 prenatal diagnosis Figures Figure 1 INTRODUCTION For over 20 years, researchers in both the United States and Europe have repeatedly highlighted the negative experiences of parents when providers deliver the news about a prenatal diagnosis of Down syndrome (DS) (Artal et al., 2024; Hedov et al., 2002; May et al., 2020; Meredith et al., 2023; Nelson Goff et al., 2013; Skotko, 2005; Williams et al., 2002). Research by Nelson Goff et al. showed that among parents who received a prenatal diagnosis of DS, negative experiences with the provider were three times more likely than positive experiences (Nelson Goff et al., 2013). These negative experiences can lead to lasting emotional harm given that diagnosis experiences qualify as flashbulb memories that parents remember lucidly for decades (May et al., 2020). Moreover, negative diagnosis experiences can harm relationships between providers and the parents of medically vulnerable children with DS, particularly Hispanic parents of children with DS (Chung et al., 2023) . Multiple studies also point to the same causes for negative diagnosis experiences: the perception of pressure about pregnancy decisions, specifically bias toward terminating the pregnancy; the perpetuation of negative stereotypes about DS; perceived lack of sensitivity and compassion; and the lack of provision of information about DS (Artal et al., 2024; May et al., 2020; Meredith et al., 2023; Nelson Goff et al., 2013; Skotko, 2005). Parents have indicated that they want information that covers medical issues, life outcomes, local and national DS organization contact information, and supports and services that are particularly important as social determinants of health for people with disabilities at the first point on the life course (Hippman et al., 2012; Kennedy & Wood, 2020; May et al., 2020; Meredith et al., 2023; Sheets, Best, et al., 2011). Most obstetric care providers do not receive training about how to discuss DS (or other disabilities) when delivering a prenatal screening results, and bias can impact their provision of information (Driscoll et al., 2009; Meredith et al., 2023), some guidance from researchers and national obstetric and genetic organizations is available to help clinicians navigate those complex conversations (American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics et al., 2020; Bull et al., 2022; Dungan et al., 2023; Sheets, Crissman, et al., 2011; Skotko et al., 2009). Research by Skotko et al. recommends that clinicians provide accurate, balanced, and up-to-date information about the condition and contact information for parent support groups (Skotko et al., 2009). Additionally, recommendations published by the American College of Obstetricians and Gynecologists (ACOG), the National Society of Genetic Counselors (NSGC), the American Academy of Pediatrics (AAP), the American College of Medical Genetics and Genomics (ACMG), and the International Society for Prenatal Diagnosis (ISPD) add that the information about DS should cover medical care, developmental and educational information, supports and services, and psychosocial life outcomes (Bull et al., 2022; Gregg et al., 2016; Hui et al., 2023; Levis et al., 2012; Sheets, Best, et al., 2011; Sheets, Crissman, et al., 2011). However, research has yet to quantify the impact of obstetrician adherence to recommended practices on patient diagnosis experiences or the most significant types of information during those first conversations about DS. The present study investigated the extent to which adherence to the recommended practices impacts patients' self-described diagnosis experiences by assessing the data to answer these two research questions : How does physician adherence to the recommended practices impact patient diagnosis experiences? Which of the three adherence predictors examined in this study (e.g., medical, social, and emotionally oriented recommendations) is relatively more important than the others in accounting for patient diagnosis experiences? METHODS The present study is an analysis of an unpublished portion of the data set originally collected by the authors which included parents of children with DS born between 2016 and 2021 (Ijaz et al., 2024; Meredith et al., 2023). Eligible participants were 18 years or older, US residents, and either received screening results suggesting a likely DS diagnosis or received a confirmed result via diagnostic testing. Online surveys were shared with members of the national Down Syndrome Diagnosis Network (DSDN) and 12 local DS organizations reflecting a cross-section of rural, suburban, and urban areas (see Table 1 ) (Ijaz et al., 2024; Meredith et al., 2023). Table 1 Local Down Syndrome Organization Study Partners 5,18 Local DS Organizations State Type Montgomery County Down Syndrome Interest Group PA Suburban Down Syndrome Association of Central NJ NJ Suburban Green River Area Down Syndrome Association KY Rural Down Syndrome Association of Houston TX Urban and suburban Down Syndrome Association of Greater Cincinnati OH Urban and suburban Down Syndrome Association of Middle Tennessee TN Urban and suburban 21 Connect NY Urban and suburban Down Syndrome Connection of the Bay Area CA Urban and suburban Down Syndrome Connection of Northwest Arkansas AR Suburban and rural Down Syndrome Association of Brevard FL Suburban and rural Down Syndrome Connections of the Northwest ID Rural Down Syndrome Network of West Virginia WV State-wide As reported in Table 2 (demographic data) and Table 3 (CHERRIES Checklist) (Ijaz et al., 2024; Meredith et al., 2023), the survey included demographic questions, background clinical information, qualitative questions about prenatal diagnosis experiences, and 14 yes/no quantitative questions about whether obstetricians (OBs) followed recommended practices for delivering a suspected or confirmed diagnosis. (See Table 4 .) The study was approved for human subjects research by the University of Kentucky IRB (55360), and participants completed IRB-approved online consent forms. Table 2 Demographical and Clinical Background of Participants Variable Total Sample (n = 167) % Occurrence Year of Diagnosis 2016 8 4.8% 2017 19 11.4% 2018 21 12.6% 2019 32 19.1% 2020 65 38.9% 2021 20 12.0% Unspecified 2 1.2% Ethnicity* Hispanic or Latino or Spanish Origin 18 10.7% Not Hispanic or Latino or Spanish Origin 127 76.0% Unspecified 22 13.2% Race* American Indian or Alaska Native 1 0.5% Asian 1 0.5% Black or African American 4 2.1% Native Hawaiian or Other Pacific Islander 1 0.5% White 127 82.0% Unspecified 22 13.2% Clinicians Providing Treatment** Obstetrician/Gynecologist 163 97.6% Maternal Fetal Medicine Specialist 148 88.6% Genetic Counselor 104 62.3% Geneticist 30 18.0% Types of Test** Cell-free DNA test or non-invasive prenatal screening 118 71.0% Traditional maternal-serum screening (like the quad screen) 45 26.9% Ultrasound 103 61.7% Chorionic villus sampling (CVS) 10 6.0% Amniocentesis 49 29.3% Study Referrals DSDN 110 65.9% Local DS Org 53 31.7% Unspecified 4 2.4% At what stage(s) do you think it's most critical for medical professionals to give accurate, balanced information about Down syndrome or other genetic conditions? ** Prior to screening 31.1% After screening 88.0% After diagnostic testing 52.1% What types of informational resources about conditions do patients prefer?** Printed 113 67.7% Online 106 63.5% Other: Peer mentor, local organization, online support group 41 24.6% Composite Sentiment Score (n = 167) Negative 85 50.9% Neutral 31 18.6% Positive 51 30.5% OB Sentiment Score (n = 98) Negative 53 54.1% Neutral 36 36.7% Positive 9 9.2% MFM Sentiment Score (n = 54) Negative 28 51.9% Neutral 21 38.9% Positive 5 9.3% * The questions about where respondents learned about the survey, state of residence, and race were not added to the survey until 1/27/21. ** Participants could select multiple options. Table 3 Checklist for Reporting Results of Internet E-Surveys (CHERRIES) 5,18 Design Target population Parents of children with DS born between January 1, 2016 and December 31, 2021 Sample frame Parents of children with DS referred by the Down Syndrome Diagnosis Network or 12 local DS Organizations (Table 1 ). Type of sample Convenience sample. IRB IRB Approval Consent was received. Informed Consent Potential survey participants were provided information about length of time of the survey, which data were stored and how data would be used, who the investigator was, and the purpose of the study. They were then asked to confirm whether or not they wanted to participate. See Appendix B Data protection Collected data in university password-protected Qualtrics online database Development and pre-testing Development and testing The test was reviewed prior to distribution by representatives of 12 local organizations and 3 internal university staff. Usability and technical functionality also assessed with Qualtrics internal tool. Recruitment process and description of the sample having access to the questionnaire Open survey versus closed survey Limited access survey: custom link only shared with invited participants via email or private or semi-private social media parent groups. Contact Mode Shared via private and semi-private advocacy organization social media groups and emails from local advocacy organization directly to new parents. Social media and emails shared quarterly. Search engines were blocked from indexing the survey. Advertising the survey Advertising in private and semi-private advocacy organization social media groups. See Appendix B. Survey Administration Web/E-mail E-survey not posted on a website. Shared via private and semi-private advocacy organization social media groups and emails to potential participants. Context DSDN shared survey invitations on private Facebook groups divided by birth year. The local organizations sent emails to parents of children 5 and under and shared on semi-private organizational social media pages. Mandatory/Voluntary Voluntary Incentives No incentives Time/Date Local organizations: 4/29/2020-12/31/2021 DSDN: 1/27/2021-12/31/2021 Randomization of items or questionnaires No randomization used. Adaptive questioning Adaptive questions appeared depending on the types of providers seen by patients. Number of items 17 (2 of the 17 questions had 16 sub-items for a total of 47 items) Number of screens (pages) 3 Completeness check Checked for completeness after questionnaire was submitted. Completion determined by whether patient completed Question 8 or 9. Review step Questions 8–17 appear on page 3 which allows for scrolling to change answers. Response Rate Unique site visitor Each user was identified with cookies. View rate Because the survey did not have a link tracked on a website, view rates are not available. Participation rate 99.8% of participants agreed to complete the survey 423/424. 25 participants were ineligible (7 received a postnatal diagnosis, 9 were outside the US, and 9 were outside the study time frame for a prenatal diagnosis). Completion rate 61% of the eligible participants completed the survey 243/399 Preventing multiple entries from the same individual Cookies used and IP Check Cookies and duplicate IP addresses were used to prevent multiple responses. Selected Qualtrics setting to prevent respondents from taking the survey multiple times. Registration No registration required. Analysis Handling of Incomplete Questions Surveys were included as long as they completed at least through question 8 and/or 9. Table 4 Frequencies and Pearson Chi-square tests for guideline adherence indicators (N = 167) Patient Diagnosis Experience Variable Name Category Negative Neutral/Positive χ 2 df p Cramer's V N % N % Total N Medical Guideline Appointment Disagree 42 61.8% 26 38.2% 68 6.23 1 0.013 0.20 Agree 38 41.8% 53 58.2% 91 Reproductive Options Disagree 24 61.5% 15 38.5% 39 1.32 1 0.251 0.09 Agree 57 50.9% 55 49.1% 112 More Comprehensive Prenatal Care Disagree 20 74.1% 7 25.9% 27 6.94 1 0.008 0.21 Agree 63 46.3% 73 53.7% 136 Resources about Medical Issues Disagree 62 56.9% 47 43.1% 109 3.77 1 0.052 0.15 Agree 22 40.7% 32 59.3% 54 Discuss Medical Issues Disagree 40 58.0% 29 42.0% 69 1.99 1 0.159 0.11 Agree 44 46.8% 50 53.2% 94 Social Guideline Resources about Local Advocacy Orgs Disagree 73 63.5% 42 36.5% 115 24.64 1 < 0.001 0.39 Agree 10 20.8% 38 79.2% 48 Resources about National Advocacy Orgs Disagree 69 56.6% 53 43.4% 122 5.60 1 0.018 0.19 Agree 14 35.0% 26 65.0% 40 Accurate, Up-To-Date and Balanced Information Disagree 76 67.3% 37 32.7% 113 39.45 1 < 0.001 0.50 Agree 6 12.8% 41 87.2% 47 Resources about Life Outcomes Disagree 75 60.0% 50 40.0% 125 18.40 1 < 0.001 0.34 Agree 7 19.4% 29 80.6% 36 Discuss Life Outcomes Disagree 74 69.8% 32 30.2% 106 41.42 1 < 0.001 0.51 Agree 9 16.4% 46 83.6% 55 Resources about Supports and Services Disagree 73 57.5% 54 42.5% 127 10.32 1 0.001 0.25 Agree 9 26.5% 25 73.5% 34 Discuss Supports and Services Disagree 73 60.8% 47 39.2% 120 17.64 1 < 0.001 0.33 Agree 9 22.5% 31 77.5% 40 Emotional Guideline No Sorry Disagree 53 74.6% 18 25.4% 71 32.38 1 < 0.001 0.46 Agree 23 28.4% 58 71.6% 81 No Bad News Disagree 64 73.6% 23 26.4% 87 39.91 1 < 0.001 0.50 Agree 16 22.9% 54 77.1% 70 Qualitative Data Analyses When assessing the answers to the survey questions describing the patient diagnosis experiences, two reviewers (a bioethicist and a rhetorician/disability health specialist) performed a sentiment analysis (SA). (See Fig. 1 .) First, they used a scale of 1–5 to assess patient experiences with each type of medical provider mentioned in each response (Obstetrician, genetic counselor, midwife, geneticist, and maternal-fetal medicine specialist) with a defined rubric based on Pang and Lee’s standards used for software opinion mining and SA. 10 The complexity of the language nuance in the responses required the gold standard of expert human interpretation. 11 The two primary reviewers determined the coding rubric after creating a proposed scale, reading the first 20 responses, then refining the scale after discussion. After the two reviewers independently assigned sentiment scores for each type of provider mentioned in each response, they met to discuss and resolve any differences in coding. Subsequently, the reviewers assigned an overall score for each respondent determined by the general description of the experience and a composite of the scores for each provider (maternal-fetal medicine specialists, obstetricians, genetic counselors, and midwives) using the following composite scoring guide for the overall experience: The 11 (.05%) unresolved ratings were sent to a third rater, a developmental disabilities expert, for independent scoring; differences were resolved and final scores determined by consensus between all three raters. Eighteen (10.8%) respondents generally described the experience but did not mention a specific provider. Therefore, the composite score was used as the most inclusive SA score for conducting the statistical analysis. For this analysis, we only considered negative, neutral, and positive composite SA scores, since mixed scores (where patients provided both positive and negative descriptions) could not be directly correlated with the extent to which the recommended practices impacted a positive or negative experience. The study sample thus consisted of 167 out of 242 total participants who 1) indicated they had seen an MFM or OB; 2) provided answers to the 14 OB/MFM questions; and 3) answered the qualitative survey items (“Please describe your diagnosis experience”), which was classified as a positive, neutral, or negative patient diagnosis experience. Finally, we formed two contrasting groups (negative vs non-negative experiences) as we were more concerned about why some patients had negative experiences; the positive and neutral groups were combined, giving us two SA groups: negative and neutral/positive. Moreover, combining the neutral/positive SA scores isolated the definition of neutral/positive to be: no negative verbiage used to describe the experience, and isolated the definition of negative to be: only negative verbiage used to describe the experience. Quantitative Data Analyses To assess physician adherence to recommended practices, 14 total recommendations were used, among which two were reverse coded before the analysis (See Table 4 ). These adherence indicators were dichotomous variables with two categorical choices (0 = Disagree and 1 = Agree). Among these items, the research team grouped together five items about physician adherence to medical recommendations, seven about adherence to social recommendations, and two about adherence to emotional recommendations. For each of these sub-scales, the items were averaged to form a composite variable with higher scores indicating better or more adherence. Kuder-Richardson Formula 20 (KR-20), a measure appropriate for the scales based on dichotomous variables, was used to assess the internal consistency reliability for the three sub-scales (Kuder & Richardson, 1937). The reliability coefficients were .55, .88, and .72 for the medical, social and emotional sub-scales, respectively. Statistical Analyses For Research Question 1, a logistic regression analysis was conducted using the statistical package SPSS 28 to examine how the independent variables of adherence to medical, social, and emotional recommendations, evaluated by patients, are related to the dependent variable of patient diagnosis experience (IBM Corp, 2021). The dependent variable was a dichotomous variable with 0 representing negative experience and 1 representing a neutral/positive experience. Methodologically, the composite independent variables of adherence to medical, social, and emotional recommendations are continuous. However, adherence to emotional recommendations has a limited number and range of values, and caution is warranted when interpreting its coefficient to avoid the issue of extrapolation. For Research Question 2, a relative weight analysis for logistic regression (RWA) (Johnson, 2000; Tonidandel & LeBreton, 2015) was conducted to examine the relative importance of the three independent variables (i.e., adherence to medical, social, and emotional recommendations) in their explanatory power for the dependent variable (i.e., patient diagnosis experience). Confidence intervals and corresponding significance tests for the relative weight of individual independent variables were calculated and performed using bootstrapping with 5,000 replications; also, the ordinary least square R 2 statistic was adopted in the logistic relative weight analysis (Petscher et al., 2013). The RWA in this study was performed in R (R Core Team, 2024; Tonidandel & LeBreton, 2015). The alpha significance level for all the hypothesis tests in this study was set at .05. RESULTS About 49.1% of the 167 respondents from 41 different states described their composite experience as neutral/positive, and about 50.9% described their composite experience as negative. Before conducting the logistic regression for Research Question 1, descriptive statistics demonstrated how the recommendations and the composite variables were associated with patient diagnosis experiences. Table 4 displays the frequencies for the 14 recommended practices and the chi-squared test of independence. Only three of 14 adherence indicators, which were focused on medical issues, were not significantly associated with patient diagnosis experiences. The remaining 11 adherence indicators focused on social and emotional factors were significantly associated with patient diagnosis experiences (all p ’s ≤ .001). A pattern of the relationships emerged from the significant independence tests: patients who found the physicians adhered to all the diagnosis recommendations were more likely to report neutral/positive experience. The effect size of the association, as measured by Cramer’s V , for most of the significant independence tests was moderate or large by Cohen’s definition (i.e., .1 = small, .3 = moderate, and .5 = large) (Cohen, 1988). Table 5 displays the means and standard deviations of the three composite adherence variables (i.e., adherence to medical, social, and emotional recommendations) by the two patient diagnosis experience outcomes (negative vs. neutral/positive) and the independent sample t-test results. The three composite variables were all significantly related to patient diagnosis experiences. Patients reporting neutral/positive diagnosis experiences on average had higher evaluation of their physician’s adherence to the medical, social, and emotional recommendations than their counterparts reporting negative experiences (all p ’s < .001). Table 5 Descriptive statistics and independent t-tests for composite guideline adherence variables (N = 167) Patient Diagnosis Experience Variable Negative Neutral/Positive t df p N M (SD) N M (SD) Medical 84 0.54 (0.27) 80 0.68 (0.26) -3.45 162 < 0.001 Social 84 0.11 (0.21) 80 0.43 (0.37) -6.76* 123.84 < 0.001 Emotional 81 0.26 (0.37) 80 0.72 (0.40) -7.59 159 < 0.001 Note . *Welch’s t-test to address unequal variances. For Research Question 1, the logistic regression analysis is summarized in Table 6 . The Wald chi-squared test statistic provides an inferential test of each logistic regression coefficient, and the odds ratio (OR) coefficient provides information related to the change in the odds of having a neutral/positive experience that would be associated with a one-unit change in each independent variable. Adherence to medical recommendations was not significantly related to patient diagnosis experience ( Wald χ 2 = 1.32, df = 1, p = .25; OR = 2.51). Table 6 Logistic regression results for the outcome variable of patient diagnosis experience (N = 167) Variable Coef. S.E. Wald df p OR Medical 0.920 0.800 1.322 1 0.250 2.510 Social 2.874 0.803 12.824 1 < .001 17.712 Emotional 2.431 0.478 25.875 1 < .001 11.368 Constant -2.391 0.557 18.403 1 < .001 0.092 However, adherence to social recommendations was significantly related to patient diagnosis experience ( Wald χ 2 = 12.82, df = 1, p < .001; OR = 17.71); for each increase in 1 unit of adherence to social recommendations, the estimated odds of having a neutral/positive diagnosis experience would increase by a factor of 17.7 if the other two adherence variables are held constant in the model. In the context of this study, the odds of having a neutral/positive diagnosis experience were about 18 times greater for those patients who found their physicians adhered to all seven social recommendations than for those who found their physicians did not adhere to any social recommendations, if controlling for all the other variables in the model. Similarly, adherence to emotional recommendations was significantly related to patient diagnosis experience ( Wald χ 2 = 25.88, df = 1, p < .001; OR = 11.37); for each increase in 1 unit of adherence to emotional recommendations, the estimated odds of having a neutral/positive diagnosis experience would increase by a factor of 11.4 if the other two adherence variables are held constant in the model. In the context of this study, the odds of having a neutral/positive diagnosis experience were 11.4 times greater for those patients who found their physicians adhered to both emotional recommendations ( not saying “I’m sorry” and not conveying the diagnosis as bad news) than for those who found their physicians did not adhere to either emotional guideline, if controlling for all the other variables in the model. For Research Question 2, a relative weight analysis for logistic regression was conducted. The ordinary least square R 2 statistic was adopted in the logistic relative weight analysis as a proxy for the total variance in patient diagnosis experience that was accounted for by the three adherence variables (Petscher et al., 2013). Table 7 displays the raw variance (i.e., relative weight) explained by each adherence variable, the 95% confidence interval for the individual relative weights, and the rescaled relative weights that were obtained by dividing each relative weight by R 2 . The analysis results indicate that the three adherence variables explained 41% of the variance in patient diagnosis experience ( R 2 = 0.41). The relative weights of adherence to medical, social, and emotional recommendations were .04, .17, and .20, respectively. In other words, the medical, social, and emotional adherence variables accounted for 4%, 17%, and 20% of the variance in patient diagnosis experience, respectively. All the three adherence variables explained a statistically significant amount of the variance in patient diagnosis experience as the 95% CIs for the relative weights did not contain zero. The rescaled relative weights exhibit the relative importance of the three adherence variables more clearly. Most of the explained variance in patient diagnosis experiences was attributed to adherence to emotional recommendations (48% of R 2 ) and adherence to social recommendations (42% of R 2 ); the rest of the explained variance (10% of R 2 ) was attributed to adherence to medical recommendations. Table 7 Summary of logistic regression relative weight analysis Variable RW CI-L CI-U RS-RW (%) Medical 0.0401 0.0088 0.0958 9.77% Social 0.1717 0.0746 0.2674 41.77% Emotional 0.1992 0.1077 0.3084 48.46% Note. RW = Relative Weight; CI-L = Confidence Interval around Relative Weight – Lower Bound; CI-U = Confidence Interval around Relative Weight – Upper Bound; RS-RW = Rescaled-Relative Weight. COMMENT Principal Findings This study contributes to the literature by assessing whether physician adherence to professional recommendations for delivering prenatal screening/diagnosis results impact patient diagnosis experiences, and if so, which subset of these recommendations (medical, social, or emotional) most correlate with positive patient experiences. For our first research question, we found that adherence to both social and emotional recommendations was significantly related to neutral/positive patient diagnosis experiences, with an effect size of moderate to large for the majority of those 11 practices. Moreover, we found that adherence to emotional and social recommendations explained relatively more variance in patient diagnosis experiences than adherence to medical recommendations. Results Our findings are consistent with previous literature; however, this is the first study that has found the extent to which physicians follow the emotional and social recommendations can result in strikingly different patient perceptions of their diagnosis experiences as neutral/positive vs. negative (May et al., 2020; Meredith et al., 2023; Nelson Goff et al., 2013; Sheets, Best, et al., 2011). Clinical Implications Given that over half of patients described their diagnosis experiences as negative due to the absence of social and emotional information and supports, the clinical implications are that obstetricians and gynecologists need to be sure to avoid saying “I’m sorry” or assuming that a potential diagnosis of DS is bad news. In addition, clinicians need to be sure to provide accurate, balanced, and up-to-date information about the life outcomes for people with DS and talk to their patients, in depth, about the improved social and life outcomes for people with DS that have been developed and achieved in recent years. Systemically, professional medical organizations can offer more explicit guidelines about how to provide social and emotional support and training for clinicians to navigate delicate conversations such as the Brighter Tomorrows training modules (Kleinert et al., 2009). An investment in these strategies could improve the diagnosis experience for patients, improve the emotional health of pregnant patients, and strengthen relationships of trust between providers and patients, particularly for those with intersectional identities (Chung et al., 2023; Krell et al., 2023; May et al., 2020; Meredith et al., 2023). Research Implications Further research needs to determine if patients learning about other prenatal diagnoses have similar needs and if the provision of information about social determinants of health for people with disabilities at this early stage can potentially improve the health of medically vulnerable children (Kennedy & Wood, 2020). Moreover, additional research needs to examine the specific needs of patients who choose to terminate pregnancies following a diagnosis. Strengths and Limitations This study is the largest study to date of those who received a prenatal diagnosis of Down syndrome and is very recent with a statistically rigorous analysis. Several limitations should be noted within this study (Ijaz et al., 2024; Meredith et al., 2023): Like most of the previous studies on patient diagnosis experiences, our sample included an over-representation of White respondents. This limitation is especially important given disparities in health care and outcomes for individuals with DS in minority populations (Chung et al., 2023; Krell et al., 2023). When our survey participants completed the quantitative questions about what their physician did or did not do, we did not ask them to specify if they were referring to their OB or MFM specialist (for those patients who had both). To minimize this limitation, we did not include the mixed responses in our SA scores, in which multiple providers were rated differently by the same patient. Participant recall bias can be a factor; however, our respondents’ experiences were relatively recent (2016–2021) and the reception of a possible prenatal diagnosis of DS has been documented as a “flashbulb memory” (May et al., 2020). Our findings may be positively skewed since advocacy organization participants lived in regions with medical outreach programs; thus, these results might not be generalizable to expectant couples without those supports. We did not control for any background variable(s) in the analysis and therefore do not know to what extent patient diversity may have impacted our results, nor can we be certain that our results would generalize to a more international study. Conclusions Given the profound impact of emotional, social, and informational recommendations on the diagnosis experiences of patients receiving prenatal screening results, OBs can significantly improve patient experiences and support their psychological and emotional needs by providing 1) access to accurate, balanced, and up-to-date information about disabilities and 2) being better trained on disability awareness and delivery of prenatal screening results. Declarations Acknowledgements We are grateful to the participation and support of the 12 local Down syndrome organizations and the Down Syndrome Diagnosis Network who assisted with recruitment and evaluating the study. This work received funding support toward the provision of medical outreach training and patient education materials for local Down Syndrome advocacy organizations and some data analysis was funded by the US Department of Health and Human Services Administration for Community Living as part of the prenatal subcommittee for the Center for Dignity in Healthcare for People with Disabilities (90DNHC0001). Some funding for data analysis was also provided by the US Administration for Children and Families as part of the University of Kentucky, Human Development Institute, University Center for Excellence in Developmental Disabilities Core Grant. Competing Interests Dr. Harold Kleinert, Jian Li, Sierra Weiss, and Jonathan Drummond have no conflicts of interest to declare. Dr. Stephanie Meredith serves on the advisory board of the National Down Syndrome Congress in a volunteer capacity and the Trisomy Collaborative as a paid consultant and is the parent of an adult with Down syndrome. She has also received remuneration from Down syndrome non-profit organizations and non-profit medical/genetics organizations/programs (National Society of Genetic Counselors, American College of Osteopathic Obstetricians and Gynecologists, American College of Medical Genetics and Genomics, and American Society of Human Genetics) for speaking engagements and associated travel expenses. Author contributions: CRediT Dr. Stephanie Meredith: conceptualization, data curation, formal analysis (sentiment analysis), funding acquisition, investigation, methodology, project administration, resources, supervision, visualization, writing-original draft, writing-review and editing Dr. Harold Kleinert: formal analysis (sentiment analysis), methodology, project administration, writing-original draft, writing-review and editing Dr. Jian Li: formal analysis (statistics), writing-original draft, writing-review and editing, and visualization Sierra Weiss: data curation, formal analysis (sentiment analysis), methodology, writing-review and editing Jonathan Drummond: formal analysis, writing-review and editing Data Availability Statement The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions. Ethics Statement The study was approved for human subjects on 4/6/2020 research by the University of Kentucky IRB (55360). Patient Consent Statement The study only included participants who were 18 or older, and participants completed IRB-approved online consent forms. References American College of Obstetricians and Gynecologists’ Committee on Practice Bulletins—Obstetrics, Committee on Genetics, & Society for Maternal-Fetal Medicine. (2020). Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226. Obstetrics & Gynecology , 136 (4), e48–e69. https://doi.org/10.1097/AOG.0000000000004084 Artal, J. M., Randall, L., Rubeck, S., Allyse, M., Michie, M., Riggan, K. A., Meredith, S., & Skotko, B. G. (2024). Parents of children with Down syndrome reflect on their postnatal diagnoses, 2003–2022. American Journal of Medical Genetics Part A , 194 (8), e63619. https://doi.org/10.1002/ajmg.a.63619 Bull, M. J., Trotter, T., Santoro, S. L., Christensen, C., Grout, R. W., & THE COUNCIL ON GENETICS. (2022). Health Supervision for Children and Adolescents With Down Syndrome. Pediatrics , 149 (5), e2022057010. https://doi.org/10.1542/peds.2022-057010 Chung, J., Krell, K., Pless, A., Michael, C., Torres, A., Baker, S., Blake, J. M., Caughman, K., Cullen, S., Gallagher, M., Hoke‐Chandler, R., Maina, J., McLuckie, D., O’Neill, K., Peña, A., Royal, D., Slape, M., Spinazzi, N. A., Torres, C. G., & Skotko, B. G. (2023). Healthcare experiences of patients with Down syndrome from primarily Spanish‐speaking households. American Journal of Medical Genetics Part A , 191 (8), 2132–2141. https://doi.org/10.1002/ajmg.a.63250 Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed). L. Erlbaum Associates. Driscoll, D. A., Morgan, M. A., & Schulkin, J. (2009). Screening for Down syndrome: Changing practice of obstetricians. American Journal of Obstetrics and Gynecology , 200 (4), 459.e1-459.e9. https://doi.org/10.1016/j.ajog.2008.12.027 Dungan, J. S., Klugman, S., Darilek, S., Malinowski, J., Akkari, Y. M. N., Monaghan, K. G., Erwin, A., & Best, R. G. (2023). Noninvasive prenatal screening (NIPS) for fetal chromosome abnormalities in a general-risk population: An evidence-based clinical guideline of the American College of Medical Genetics and Genomics (ACMG). Genetics in Medicine , 25 (2), 100336. https://doi.org/10.1016/j.gim.2022.11.004 Gregg, A. R., Skotko, B. G., Benkendorf, J. L., Monaghan, K. G., Bajaj, K., Best, R. G., Klugman, S., & Watson, M. S. (2016). Noninvasive prenatal screening for fetal aneuploidy, 2016 update: A position statement of the American College of Medical Genetics and Genomics. Genetics in Medicine , 18 (10), 1056–1065. https://doi.org/10.1038/gim.2016.97 Hedov, G., Wikblad, K., & Annerén, G. (2002). First information and support provided to parents of children with Down syndrome in Sweden: Clinical goals and parental experiences. Acta Paediatrica , 91 (12), 1344–1349. https://doi.org/10.1111/j.1651-2227.2002.tb02832.x Hippman, C., Inglis, A., & Austin, J. (2012). What is a “Balanced” Description? Insight from Parents of Individuals with Down Syndrome. Journal of Genetic Counseling , 21 (1), 35–44. https://doi.org/10.1007/s10897-011-9417-2 Hui, L., Ellis, K., Mayen, D., Pertile, M. D., Reimers, R., Sun, L., Vermeesch, J., Vora, N. L., & Chitty, L. S. (2023). Position statement from the International Society for Prenatal Diagnosis on the use of non‐invasive prenatal testing for the detection of fetal chromosomal conditions in singleton pregnancies. Prenatal Diagnosis , 43 (7), 814–828. https://doi.org/10.1002/pd.6357 IBM Corp. (2021). IBM SPSS Statistics for Windows, Version 28.0 [Computer software]. IBM Corp. Ijaz, M. R., Trepanier, A. M., Kleinert, H. L., Weiss, S. M., & Meredith, S. H. (2024). Parent‐reported genetic counselor adherence to the NSGC practice resource for communicating a potential prenatal diagnosis: Impact on the Down syndrome diagnosis experience. Journal of Genetic Counseling , jgc4.1948. https://doi.org/10.1002/jgc4.1948 Johnson, J. W. (2000). A Heuristic Method for Estimating the Relative Weight of Predictor Variables in Multiple Regression. Multivariate Behavioral Research , 35 (1), 1–19. https://doi.org/10.1207/S15327906MBR3501_1 Kennedy, J., & Wood, E. G. (2020). DISABILITY-BASED DISPARITIES IN SOCIAL DETERMINANTS OF HEALTH AMONG WORKING-AGE ADULTS: EVIDENCE FROM THE 2018 NATIONAL HEALTH INTERVIEW SURVEYS . The Collaborative on Health Reform and Independent Living (CHRIL). https://static1.squarespace.com/static/5abe7e9b5ffd206d61d648ef/t/5f80b97ec617441793f29090/ 1602271616411/CHRIL+Disparities+Report.pdf Kleinert, H. L., Lunney, C. A., Campbell, L., & Ferguson, J. E. (2009). Improving residents’ understanding of issues, comfort levels, and patient needs regarding screening for and diagnosing Down syndrome. American Journal of Obstetrics and Gynecology , 201 (3), 328.e1-328.e6. https://doi.org/10.1016/j.ajog.2009.05.051 Krell, K., Pless, A., Michael, C., Torres, A., Chung, J., Baker, S., Blake, J. M., Caughman, K., Cullen, S., Gallagher, M., Hoke‐Chandler, R., Maina, J., McLuckie, D., O’Neill, K., Peña, A., Royal, D., Slape, M., Spinazzi, N. A., Torres, C. G., & Skotko, B. G. (2023). Healthcare experiences of patients with Down syndrome who are Black, African American, of African descent, or of mixed race. American Journal of Medical Genetics Part A , 191 (3), 742–752. https://doi.org/10.1002/ajmg.a.63069 Kuder, G. F., & Richardson, M. W. (1937). The theory of the estimation of test reliability. Psychometrika , 2 (3), 151–160. https://doi.org/10.1007/BF02288391 Levis, D. M., Harris, S., Whitehead, N., Moultrie, R., Duwe, K., & Rasmussen, S. A. (2012). Women’s knowledge, attitudes, and beliefs about Down syndrome: A qualitative research study. American Journal of Medical Genetics Part A , 158A (6), 1355–1362. https://doi.org/10.1002/ajmg.a.35340 May, C. P., Dein, A., & Ford, J. (2020). New insights into the formation and duration of flashbulb memories: Evidence from medical diagnosis memories. Applied Cognitive Psychology , 34 (5), 1154–1165. https://doi.org/10.1002/acp.3704 Meredith, S., Weiss, S., Kleinert, H. L., & Tyrrell, C. A. (2023). The impact of implicit and explicit bias about disabilities on parent experiences and information provided during prenatal screening and testing. Disability and Health Journal , 101514. https://doi.org/10.1016/j.dhjo.2023.101514 Nelson Goff, B. S., Springer, N., Foote, L. C., Frantz, C., Peak, M., Tracy, C., Veh, T., Bentley, G. E., & Cross, K. A. (2013). Receiving the Initial Down Syndrome Diagnosis: A Comparison of Prenatal and Postnatal Parent Group Experiences. Intellectual and Developmental Disabilities , 51 (6), 446–457. https://doi.org/10.1352/1934-9556-51.6.446 Petscher, Y. M., Schatschneider, C., Compton, D. L., & Petscher, Y. (Eds.). (2013). Applied quantitative analysis in education and the social sciences (1. publ). Routledge. R Core Team. (2024). R: A Language and Environment for Statistical Computing. [Computer software]. R Foundation for Statistical Computing. Sheets, K. B., Best, R. G., Brasington, C. K., & Will, M. C. (2011). Balanced information about Down syndrome: What is essential? American Journal of Medical Genetics Part A , 155 (6), 1246–1257. https://doi.org/10.1002/ajmg.a.34018 Sheets, K. B., Crissman, B. G., Feist, C. D., Sell, S. L., Johnson, L. R., Donahue, K. C., Masser‐Frye, D., Brookshire, G. S., Carre, A. M., LaGrave, D., & Brasington, C. K. (2011). Practice Guidelines for Communicating a Prenatal or Postnatal Diagnosis of Down Syndrome: Recommendations of the National Society of Genetic Counselors. Journal of Genetic Counseling , 20 (5), 432–441. https://doi.org/10.1007/s10897-011-9375-8 Skotko, B. G. (2005). Prenatally diagnosed Down syndrome: Mothers who continued their pregnancies evaluate their health care providers. American Journal of Obstetrics and Gynecology , 192 (3), 670–677. https://doi.org/10.1016/j.ajog.2004.11.001 Skotko, B. G., Kishnani, P. S., Capone, G. T., & for the Down Syndrome Diagnosis Study Group. (2009). Prenatal diagnosis of Down syndrome: How best to deliver the news. American Journal of Medical Genetics Part A , 149A (11), 2361–2367. https://doi.org/10.1002/ajmg.a.33082 Tonidandel, S., & LeBreton, J. M. (2015). RWA Web: A Free, Comprehensive, Web-Based, and User-Friendly Tool for Relative Weight Analyses. Journal of Business and Psychology , 30 (2), 207–216. https://doi.org/10.1007/s10869-014-9351-z Williams, C., Alderson, P., & Farsides, B. (2002). What constitutes ‘balanced information in the practitioners’ portrayals of Down’s syndrome? Midwifery , 18 (3), 230–237. https://doi.org/10.1054/midw.2002.0316 Additional Declarations Competing interest reported. Dr. Harold Kleinert, Jian Li, Sierra Weiss, and Jonathan Drummond have no conflicts of interest to declare. Dr. Stephanie Meredith serves on the advisory board of the National Down Syndrome Congress in a volunteer capacity and the Trisomy Collaborative as a paid consultant and is the parent of an adult with Down syndrome. She has also received remuneration from Down syndrome non-profit organizations and non-profit medical/genetics organizations/programs (National Society of Genetic Counselors, American College of Osteopathic Obstetricians and Gynecologists, American College of Medical Genetics and Genomics, and American Society of Human Genetics) for speaking engagements and associated travel expenses. Cite Share Download PDF Status: Published Journal Publication published 15 May, 2025 Read the published version in Journal of Community Genetics → Version 1 posted Editorial decision: Revision requested 19 Mar, 2025 Reviews received at journal 18 Mar, 2025 Reviewers agreed at journal 26 Feb, 2025 Reviews received at journal 07 Feb, 2025 Reviews received at journal 31 Jan, 2025 Reviewers agreed at journal 25 Jan, 2025 Reviewers invited by journal 14 Jan, 2025 Editor assigned by journal 14 Jan, 2025 Submission checks completed at journal 14 Jan, 2025 First submitted to journal 11 Jan, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-5810442","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":402170392,"identity":"808c1510-9db9-4d16-aa4c-b876cafbede8","order_by":0,"name":"Stephanie Meredith","email":"data:image/png;base64,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","orcid":"","institution":"University of Kentucky","correspondingAuthor":true,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Meredith","suffix":""},{"id":402170393,"identity":"0a240abc-7c14-4ad1-a3f0-fd21f15cc12e","order_by":1,"name":"Harold L. Kleinert","email":"","orcid":"","institution":"University of Kentucky","correspondingAuthor":false,"prefix":"","firstName":"Harold","middleName":"L.","lastName":"Kleinert","suffix":""},{"id":402170394,"identity":"df027bcf-cae1-467d-bb19-a3f131d0815a","order_by":2,"name":"Jian Li","email":"","orcid":"","institution":"Kent State University","correspondingAuthor":false,"prefix":"","firstName":"Jian","middleName":"","lastName":"Li","suffix":""},{"id":402170395,"identity":"ea632a31-ab1b-4775-8651-60fd16e7d54b","order_by":3,"name":"Sierra Weiss","email":"","orcid":"","institution":"University of Kentucky","correspondingAuthor":false,"prefix":"","firstName":"Sierra","middleName":"","lastName":"Weiss","suffix":""},{"id":402170396,"identity":"0b9d3494-c2bd-4406-b0d3-653f335434eb","order_by":4,"name":"Jonathan Drummond","email":"","orcid":"","institution":"University of Kentucky","correspondingAuthor":false,"prefix":"","firstName":"Jonathan","middleName":"","lastName":"Drummond","suffix":""}],"badges":[],"createdAt":"2025-01-11 16:38:04","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-5810442/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-5810442/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1007/s12687-025-00801-7","type":"published","date":"2025-05-15T15:58:00+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":73947346,"identity":"6315bc47-b3c5-43f6-991d-9f58107c42b7","added_by":"auto","created_at":"2025-01-16 09:02:43","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":245408,"visible":true,"origin":"","legend":"\u003cp\u003eSentiment Analysis Methodology Flowchart (Lucid)\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5810442/v1/8f428942741ae54df23a0648.png"},{"id":83068254,"identity":"f8f22d26-b61d-4163-92b4-7c52fc762ec4","added_by":"auto","created_at":"2025-05-19 16:10:16","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1877476,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5810442/v1/e5a80301-d894-4aee-9c23-8fe85ec1d446.pdf"}],"financialInterests":"Competing interest reported. Dr. Harold Kleinert, Jian Li, Sierra Weiss, and Jonathan Drummond have no conflicts of interest to declare.\nDr. Stephanie Meredith serves on the advisory board of the National Down Syndrome Congress in a volunteer capacity and the Trisomy Collaborative as a paid consultant and is the parent of an adult with Down syndrome. She has also received remuneration from Down syndrome non-profit organizations and non-profit medical/genetics organizations/programs (National Society of Genetic Counselors, American College of Osteopathic Obstetricians and Gynecologists, American College of Medical Genetics and Genomics, and American Society of Human Genetics) for speaking engagements and associated travel expenses.","formattedTitle":"Lack of Provision of Social and Emotional Information about Down Syndrome Associated with Negative Prenatal Diagnosis Experiences","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eFor over 20 years, researchers in both the United States and Europe have repeatedly highlighted the negative experiences of parents when providers deliver the news about a prenatal diagnosis of Down syndrome (DS) (Artal et al., 2024; Hedov et al., 2002; May et al., 2020; Meredith et al., 2023; Nelson Goff et al., 2013; Skotko, 2005; Williams et al., 2002). Research by Nelson Goff et al. showed that among parents who received a prenatal diagnosis of DS, negative experiences with the provider were three times more likely than positive experiences (Nelson Goff et al., 2013). These negative experiences can lead to lasting emotional harm given that diagnosis experiences qualify as flashbulb memories that parents remember lucidly for decades (May et al., 2020). Moreover, negative diagnosis experiences can harm relationships between providers and the parents of medically vulnerable children with DS, particularly Hispanic parents of children with DS (Chung et al., 2023) .\u003c/p\u003e \u003cp\u003eMultiple studies also point to the same causes for negative diagnosis experiences: the perception of pressure about pregnancy decisions, specifically bias toward terminating the pregnancy; the perpetuation of negative stereotypes about DS; perceived lack of sensitivity and compassion; and the lack of provision of information about DS (Artal et al., 2024; May et al., 2020; Meredith et al., 2023; Nelson Goff et al., 2013; Skotko, 2005). Parents have indicated that they want information that covers medical issues, life outcomes, local and national DS organization contact information, and supports and services that are particularly important as social determinants of health for people with disabilities at the first point on the life course (Hippman et al., 2012; Kennedy \u0026amp; Wood, 2020; May et al., 2020; Meredith et al., 2023; Sheets, Best, et al., 2011).\u003c/p\u003e \u003cp\u003eMost obstetric care providers do not receive training about how to discuss DS (or other disabilities) when delivering a prenatal screening results, and bias can impact their provision of information (Driscoll et al., 2009; Meredith et al., 2023), some guidance from researchers and national obstetric and genetic organizations is available to help clinicians navigate those complex conversations (American College of Obstetricians and Gynecologists\u0026rsquo; Committee on Practice Bulletins\u0026mdash;Obstetrics et al., 2020; Bull et al., 2022; Dungan et al., 2023; Sheets, Crissman, et al., 2011; Skotko et al., 2009). Research by Skotko et al. recommends that clinicians provide accurate, balanced, and up-to-date information about the condition and contact information for parent support groups (Skotko et al., 2009). Additionally, recommendations published by the American College of Obstetricians and Gynecologists (ACOG), the National Society of Genetic Counselors (NSGC), the American Academy of Pediatrics (AAP), the American College of Medical Genetics and Genomics (ACMG), and the International Society for Prenatal Diagnosis (ISPD) add that the information about DS should cover medical care, developmental and educational information, supports and services, and psychosocial life outcomes (Bull et al., 2022; Gregg et al., 2016; Hui et al., 2023; Levis et al., 2012; Sheets, Best, et al., 2011; Sheets, Crissman, et al., 2011).\u003c/p\u003e \u003cp\u003eHowever, research has yet to quantify the impact of obstetrician adherence to recommended practices on patient diagnosis experiences or the most significant types of information during those first conversations about DS. The present study investigated the extent to which adherence to the recommended practices impacts patients' self-described diagnosis experiences by assessing the data to answer these two research questions :\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eHow does physician adherence to the recommended practices impact patient diagnosis experiences?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhich of the three adherence predictors examined in this study (e.g., medical, social, and emotionally oriented recommendations) is relatively more important than the others in accounting for patient diagnosis experiences?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe present study is an analysis of an unpublished portion of the data set originally collected by the authors which included parents of children with DS born between 2016 and 2021 (Ijaz et al., 2024; Meredith et al., 2023). Eligible participants were 18 years or older, US residents, and either received screening results suggesting a likely DS diagnosis or received a confirmed result via diagnostic testing. Online surveys were shared with members of the national Down Syndrome Diagnosis Network (DSDN) and 12 local DS organizations reflecting a cross-section of rural, suburban, and urban areas (see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (Ijaz et al., 2024; Meredith et al., 2023).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLocal Down Syndrome Organization Study Partners\u003csup\u003e5,18\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal DS Organizations\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eState\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eType\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMontgomery County Down Syndrome Interest Group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Association of Central NJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNJ\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGreen River Area Down Syndrome Association\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Association of Houston\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTX\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban and suburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Association of Greater Cincinnati\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOH\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban and suburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Association of Middle Tennessee\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban and suburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e21 Connect\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNY\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban and suburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Connection of the Bay Area\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCA\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUrban and suburban\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Connection of Northwest Arkansas\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAR\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuburban and rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Association of Brevard\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFL\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuburban and rural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Connections of the Northwest\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eID\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRural\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDown Syndrome Network of West Virginia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWV\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eState-wide\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs reported in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e2\u003c/span\u003e (demographic data) and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e3\u003c/span\u003e (CHERRIES Checklist) (Ijaz et al., 2024; Meredith et al., 2023), the survey included demographic questions, background clinical information, qualitative questions about prenatal diagnosis experiences, and 14 yes/no quantitative questions about whether obstetricians (OBs) followed recommended practices for delivering a suspected or confirmed diagnosis. (See Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e.) The study was approved for human subjects research by the University of Kentucky IRB (55360), and participants completed IRB-approved online consent forms.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographical and Clinical Background of Participants\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal Sample (n\u0026thinsp;=\u0026thinsp;167)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e% Occurrence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYear of Diagnosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2016\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e4.8%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2017\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e11.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2018\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2019\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e19.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2020\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEthnicity*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHispanic or Latino or Spanish Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e10.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot Hispanic or Latino or Spanish Origin\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e76.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRace*\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmerican Indian or Alaska Native\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAsian\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBlack or African American\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNative Hawaiian or Other Pacific Islander\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhite\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e127\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e82.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e13.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eClinicians Providing Treatment**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eObstetrician/Gynecologist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e163\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e97.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaternal Fetal Medicine Specialist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e148\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGenetic Counselor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e104\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e62.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGeneticist\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTypes of Test**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCell-free DNA test or non-invasive prenatal screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e118\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e71.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTraditional maternal-serum screening (like the quad screen)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e26.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUltrasound\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e103\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e61.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eChorionic villus sampling (CVS)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e6.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAmniocentesis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e29.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudy Referrals\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDSDN\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e110\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e65.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLocal DS Org\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnspecified\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2.4%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAt what stage(s) do you think it's most critical for medical professionals to give accurate, balanced information about Down syndrome or other genetic conditions? **\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrior to screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e31.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter screening\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e88.0%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAfter diagnostic testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e52.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWhat types of informational resources about conditions do patients prefer?**\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrinted\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e113\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e67.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOnline\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e106\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e63.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther: Peer mentor, local organization, online support group\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e24.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eComposite Sentiment Score (n\u0026thinsp;=\u0026thinsp;167)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e50.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.6%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e30.5%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOB Sentiment Score (n\u0026thinsp;=\u0026thinsp;98)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e54.1%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e36.7%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.2%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMFM Sentiment Score (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNegative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e28\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e51.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNeutral\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e38.9%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePositive\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e9.3%\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e* The questions about where respondents learned about the survey, state of residence, and race were not added to the survey until 1/27/21.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e** Participants could select multiple options.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eChecklist for Reporting Results of Internet E-Surveys (CHERRIES)\u003csup\u003e5,18\u003c/sup\u003e\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDesign\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTarget population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParents of children with DS born between January 1, 2016 and December 31, 2021\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSample frame\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eParents of children with DS referred by the Down Syndrome Diagnosis Network or 12 local DS Organizations (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eType of sample\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConvenience sample.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIRB\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIRB Approval\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConsent was received.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInformed Consent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePotential survey participants were provided information about length of time of the survey, which data were stored and how data would be used, who the investigator was, and the purpose of the study. They were then asked to confirm whether or not they wanted to participate.\u003c/p\u003e \u003cp\u003eSee Appendix B\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eData protection\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCollected data in university password-protected Qualtrics online database\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDevelopment and pre-testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDevelopment and testing\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe test was reviewed prior to distribution by representatives of 12 local organizations and 3 internal university staff. Usability and technical functionality also assessed with Qualtrics internal tool.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eRecruitment process and description of the sample having access to the questionnaire\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpen survey versus closed survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited access survey: custom link only shared with invited participants via email or private or semi-private social media parent groups.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContact Mode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eShared via private and semi-private advocacy organization social media groups and emails from local advocacy organization directly to new parents. Social media and emails shared quarterly. Search engines were blocked from indexing the survey.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdvertising the survey\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdvertising in private and semi-private advocacy organization social media groups. See Appendix B.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSurvey Administration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eWeb/E-mail\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eE-survey not posted on a website. Shared via private and semi-private advocacy organization social media groups and emails to potential participants.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eContext\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDSDN shared survey invitations on private Facebook groups divided by birth year. The local organizations sent emails to parents of children 5 and under and shared on semi-private organizational social media pages.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMandatory/Voluntary\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eVoluntary\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIncentives\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo incentives\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTime/Date\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLocal organizations: 4/29/2020-12/31/2021\u003c/p\u003e \u003cp\u003eDSDN: 1/27/2021-12/31/2021\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRandomization of items or questionnaires\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo randomization used.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAdaptive questioning\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdaptive questions appeared depending on the types of providers seen by patients.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of items\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e17 (2 of the 17 questions had 16 sub-items for a total of 47 items)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNumber of screens (pages)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompleteness check\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eChecked for completeness after questionnaire was submitted. Completion determined by whether patient completed Question 8 or 9.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eReview step\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eQuestions 8\u0026ndash;17 appear on page 3 which allows for scrolling to change answers.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResponse Rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUnique site visitor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eEach user was identified with cookies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eView rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eBecause the survey did not have a link tracked on a website, view rates are not available.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eParticipation rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e99.8% of participants agreed to complete the survey 423/424. 25 participants were ineligible (7 received a postnatal diagnosis, 9 were outside the US, and 9 were outside the study time frame for a prenatal diagnosis).\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCompletion rate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e61% of the eligible participants completed the survey 243/399\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePreventing multiple entries from the same individual\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCookies used and IP Check\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCookies and duplicate IP addresses were used to prevent multiple responses. Selected Qualtrics setting to prevent respondents from taking the survey multiple times.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRegistration\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo registration required.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAnalysis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHandling of Incomplete Questions\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSurveys were included as long as they completed at least through question 8 and/or 9.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFrequencies and Pearson Chi-square tests for guideline adherence indicators (N\u0026thinsp;=\u0026thinsp;167)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c6\" namest=\"c3\"\u003e \u003cp\u003ePatient Diagnosis Experience\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable Name\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eCategory\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c4\" namest=\"c3\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNegative\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c6\" namest=\"c5\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNeutral/Positive\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003eχ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cem\u003edf\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cem\u003eCramer's V\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003e%\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eTotal N\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eMedical Guideline\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAppointment\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e42\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e61.8%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e26\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e38.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e68\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e6.23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.013\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e41.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e58.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eReproductive Options\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e61.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e38.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.09\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e50.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e49.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e112\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMore Comprehensive Prenatal Care\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e20\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e74.1%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e7\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e25.9%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e27\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e6.94\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.008\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.21\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e136\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eResources about Medical Issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e56.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e43.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e109\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e3.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.052\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e40.7%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e59.3%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscuss Medical Issues\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDisagree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e58.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e42.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e0.159\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e46.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e50\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e53.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eSocial Guideline\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResources about Local Advocacy Orgs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e73\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e63.5%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e42\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e36.5%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e115\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e24.64\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.39\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e79.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResources about National Advocacy Orgs\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e69\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e56.6%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e53\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e43.4%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e122\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e5.60\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.018\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.19\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e35.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e26\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e65.0%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAccurate, Up-To-Date and Balanced Information\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e76\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e67.3%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e37\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e32.7%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e113\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e39.45\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.8%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e87.2%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e47\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResources about Life Outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e75\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e60.0%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e40.0%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e125\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e18.40\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.34\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e29\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e80.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e36\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiscuss Life Outcomes\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e74\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e69.8%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e30.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e106\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e41.42\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.51\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e46\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e83.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eResources about Supports and Services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e73\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e57.5%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e54\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e42.5%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e127\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e10.32\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.25\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e73.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDiscuss Supports and Services\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e73\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e60.8%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e47\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e39.2%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e120\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e17.64\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.33\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.5%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"11\" nameend=\"c11\" namest=\"c1\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eEmotional Guideline\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo Sorry\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e53\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e74.6%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e18\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e25.4%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e71\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e32.38\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.46\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e28.4%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e58\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e71.6%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eNo Bad News\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cb\u003eDisagree\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003e64\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e73.6%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e23\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e26.4%\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003e87\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e39.91\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u003cb\u003e1\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e0.50\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAgree\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.9%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e77.1%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eQualitative Data Analyses\u003c/h2\u003e \u003cp\u003eWhen assessing the answers to the survey questions describing the patient diagnosis experiences, two reviewers (a bioethicist and a rhetorician/disability health specialist) performed a sentiment analysis (SA). (See Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.) First, they used a scale of 1\u0026ndash;5 to assess patient experiences with each type of medical provider mentioned in each response (Obstetrician, genetic counselor, midwife, geneticist, and maternal-fetal medicine specialist) with a defined rubric based on Pang and Lee\u0026rsquo;s standards used for software opinion mining and SA.\u003csup\u003e10\u003c/sup\u003e The complexity of the language nuance in the responses required the gold standard of expert human interpretation.\u003csup\u003e11\u003c/sup\u003e The two primary reviewers determined the coding rubric after creating a proposed scale, reading the first 20 responses, then refining the scale after discussion. After the two reviewers independently assigned sentiment scores for each type of provider mentioned in each response, they met to discuss and resolve any differences in coding.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eSubsequently, the reviewers assigned an overall score for each respondent determined by the general description of the experience and a composite of the scores for each provider (maternal-fetal medicine specialists, obstetricians, genetic counselors, and midwives) using the following composite scoring guide for the overall experience:\u003c/p\u003e\u003cp\u003e\u003cimg 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\"\u003e\u003c/p\u003e\n\u003cp\u003eThe 11 (.05%) unresolved ratings were sent to a third rater, a developmental disabilities expert, for independent scoring; differences were resolved and final scores determined by consensus between all three raters. Eighteen (10.8%) respondents generally described the experience but did not mention a specific provider. Therefore, the composite score was used as the most inclusive SA score for conducting the statistical analysis. For this analysis, we only considered negative, neutral, and positive composite SA scores, since mixed scores (where patients provided both positive and negative descriptions) could not be directly correlated with the extent to which the recommended practices impacted a positive or negative experience. The study sample thus consisted of 167 out of 242 total participants who 1) indicated they had seen an MFM or OB; 2) provided answers to the 14 OB/MFM questions; and 3) answered the qualitative survey items (\u0026ldquo;Please describe your diagnosis experience\u0026rdquo;), which was classified as a positive, neutral, or negative patient diagnosis experience. Finally, we formed two contrasting groups (negative vs non-negative experiences) as we were more concerned about why some patients had negative experiences; the positive and neutral groups were combined, giving us two SA groups: negative and neutral/positive. Moreover, combining the neutral/positive SA scores isolated the definition of neutral/positive to be: no negative verbiage used to describe the experience, and isolated the definition of negative to be: only negative verbiage used to describe the experience.\u003c/p\u003e\n\u003ch3\u003eQuantitative Data Analyses\u003c/h3\u003e\n\u003cp\u003eTo assess physician adherence to recommended practices, 14 total recommendations were used, among which two were reverse coded before the analysis (See Table \u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). These adherence indicators were dichotomous variables with two categorical choices (0\u0026thinsp;=\u0026thinsp;Disagree and 1\u0026thinsp;=\u0026thinsp;Agree). Among these items, the research team grouped together five items about physician adherence to medical recommendations, seven about adherence to social recommendations, and two about adherence to emotional recommendations. For each of these sub-scales, the items were averaged to form a composite variable with higher scores indicating better or more adherence. Kuder-Richardson Formula 20 (KR-20), a measure appropriate for the scales based on dichotomous variables, was used to assess the internal consistency reliability for the three sub-scales (Kuder \u0026amp; Richardson, 1937). The reliability coefficients were .55, .88, and .72 for the medical, social and emotional sub-scales, respectively.\u003c/p\u003e\n\u003ch3\u003eStatistical Analyses\u003c/h3\u003e\n\u003cp\u003eFor Research Question 1, a logistic regression analysis was conducted using the statistical package SPSS 28 to examine how the independent variables of adherence to medical, social, and emotional recommendations, evaluated by patients, are related to the dependent variable of patient diagnosis experience (IBM Corp, 2021). The dependent variable was a dichotomous variable with 0 representing negative experience and 1 representing a neutral/positive experience. Methodologically, the composite independent variables of adherence to medical, social, and emotional recommendations are continuous. However, adherence to emotional recommendations has a limited number and range of values, and caution is warranted when interpreting its coefficient to avoid the issue of extrapolation.\u003c/p\u003e\n\u003cp\u003eFor Research Question 2, a relative weight analysis for logistic regression (RWA) (Johnson, 2000; Tonidandel \u0026amp; LeBreton, 2015) was conducted to examine the relative importance of the three independent variables (i.e., adherence to medical, social, and emotional recommendations) in their explanatory power for the dependent variable (i.e., patient diagnosis experience). Confidence intervals and corresponding significance tests for the relative weight of individual independent variables were calculated and performed using bootstrapping with 5,000 replications; also, the ordinary least square \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e statistic was adopted in the logistic relative weight analysis (Petscher et al., 2013). The RWA in this study was performed in R (R Core Team, 2024; Tonidandel \u0026amp; LeBreton, 2015). The alpha significance level for all the hypothesis tests in this study was set at .05.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003eAbout 49.1% of the 167 respondents from 41 different states described their composite experience as neutral/positive, and about 50.9% described their composite experience as negative. Before conducting the logistic regression for Research Question 1, descriptive statistics demonstrated how the recommendations and the composite variables were associated with patient diagnosis experiences. Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e displays the frequencies for the 14 recommended practices and the chi-squared test of independence. Only three of 14 adherence indicators, which were focused on medical issues, were not significantly associated with patient diagnosis experiences. The remaining 11 adherence indicators focused on social and emotional factors were significantly associated with patient diagnosis experiences (all \u003cem\u003ep\u003c/em\u003e’s ≤ .001). A pattern of the relationships emerged from the significant independence tests: patients who found the physicians adhered to all the diagnosis recommendations were more likely to report neutral/positive experience. The effect size of the association, as measured by Cramer’s \u003cem\u003eV\u003c/em\u003e, for most of the significant independence tests was moderate or large by Cohen’s definition (i.e., .1 = small, .3 = moderate, and .5 = large) (Cohen, 1988).\u003c/p\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e displays the means and standard deviations of the three composite adherence variables (i.e., adherence to medical, social, and emotional recommendations) by the two patient diagnosis experience outcomes (negative vs. neutral/positive) and the independent sample t-test results. The three composite variables were all significantly related to patient diagnosis experiences. Patients reporting neutral/positive diagnosis experiences on average had higher evaluation of their physician’s adherence to the medical, social, and emotional recommendations than their counterparts reporting negative experiences (all \u003cem\u003ep\u003c/em\u003e’s \u0026lt; .001).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDescriptive statistics and independent t-tests for composite guideline adherence variables (N = 167)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"8\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"4\" nameend=\"c5\" namest=\"c2\"\u003e \u003cp\u003ePatient Diagnosis Experience\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c3\" namest=\"c2\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNegative\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003eNeutral/Positive\u003c/span\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003et\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003edf\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eN\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eM (SD)\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.54 (0.27)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.68 (0.26)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-3.45\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e162\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11 (0.21)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.43 (0.37)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-6.76*\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e123.84\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.26 (0.37)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e80\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.72 (0.40)\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e-7.59\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e159\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; 0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"8\"\u003e\u003cem\u003eNote\u003c/em\u003e. *Welch’s t-test to address unequal variances.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eFor Research Question 1, the logistic regression analysis is summarized in Table\u0026nbsp;\u003cspan refid=\"Tab6\" class=\"InternalRef\"\u003e6\u003c/span\u003e. The \u003cem\u003eWald\u003c/em\u003e chi-squared test statistic provides an inferential test of each logistic regression coefficient, and the odds ratio (OR) coefficient provides information related to the change in the odds of having a neutral/positive experience that would be associated with a one-unit change in each independent variable. Adherence to \u003cb\u003emedical\u003c/b\u003e recommendations was not significantly related to patient diagnosis experience (\u003cem\u003eWald χ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 1.32, \u003cem\u003edf\u003c/em\u003e = 1, \u003cem\u003ep\u003c/em\u003e = .25; OR = 2.51).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab6\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 6\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression results for the outcome variable of patient diagnosis experience (N = 167)\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"7\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eCoef.\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eS.E.\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eWald\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003edf\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003ep\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cem\u003eOR\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.920\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.800\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e1.322\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.250\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e2.510\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.874\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.803\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e12.824\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; .001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e17.712\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e2.431\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.478\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e25.875\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; .001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e11.368\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eConstant\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e-2.391\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.557\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e18.403\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt; .001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c7\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e \u003cp\u003eHowever, adherence to \u003cb\u003esocial\u003c/b\u003e recommendations was significantly related to patient diagnosis experience (\u003cem\u003eWald χ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 12.82, \u003cem\u003edf\u003c/em\u003e = 1, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001; OR = 17.71); for each increase in 1 unit of adherence to social recommendations, the estimated odds of having a neutral/positive diagnosis experience would increase by a factor of 17.7 if the other two adherence variables are held constant in the model. In the context of this study, the odds of having a neutral/positive diagnosis experience were about 18 times greater for those patients who found their physicians adhered to all seven social recommendations than for those who found their physicians did not adhere to any social recommendations, if controlling for all the other variables in the model.\u003c/p\u003e \u003cp\u003eSimilarly, adherence to \u003cb\u003eemotional\u003c/b\u003e recommendations was significantly related to patient diagnosis experience (\u003cem\u003eWald χ\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 25.88, \u003cem\u003edf\u003c/em\u003e = 1, \u003cem\u003ep\u003c/em\u003e \u0026lt; .001; OR = 11.37); for each increase in 1 unit of adherence to emotional recommendations, the estimated odds of having a neutral/positive diagnosis experience would increase by a factor of 11.4 if the other two adherence variables are held constant in the model. In the context of this study, the odds of having a neutral/positive diagnosis experience were 11.4 times greater for those patients who found their physicians adhered to both emotional recommendations (\u003cem\u003enot\u003c/em\u003e saying “I’m sorry” and \u003cem\u003enot\u003c/em\u003e conveying the diagnosis as bad news) than for those who found their physicians did not adhere to either emotional guideline, if controlling for all the other variables in the model.\u003c/p\u003e \u003cp\u003eFor Research Question 2, a relative weight analysis for logistic regression was conducted. The ordinary least square \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e statistic was adopted in the logistic relative weight analysis as a proxy for the total variance in patient diagnosis experience that was accounted for by the three adherence variables (Petscher et al., 2013). Table\u0026nbsp;\u003cspan refid=\"Tab7\" class=\"InternalRef\"\u003e7\u003c/span\u003e displays the raw variance (i.e., relative weight) explained by each adherence variable, the 95% confidence interval for the individual relative weights, and the rescaled relative weights that were obtained by dividing each relative weight by \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e. The analysis results indicate that the three adherence variables explained 41% of the variance in patient diagnosis experience (\u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e = 0.41). The relative weights of adherence to medical, social, and emotional recommendations were .04, .17, and .20, respectively. In other words, the medical, social, and emotional adherence variables accounted for 4%, 17%, and 20% of the variance in patient diagnosis experience, respectively. All the three adherence variables explained a statistically significant amount of the variance in patient diagnosis experience as the 95% CIs for the relative weights did not contain zero. The rescaled relative weights exhibit the relative importance of the three adherence variables more clearly. Most of the explained variance in patient diagnosis experiences was attributed to adherence to emotional recommendations (48% of \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e) and adherence to social recommendations (42% of \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e); the rest of the explained variance (10% of \u003cem\u003eR\u003c/em\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e) was attributed to adherence to medical recommendations.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e\u003cdiv class=\"gridtable\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003ctable float=\"Yes\" id=\"Tab7\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 7\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSummary of logistic regression relative weight analysis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003c/colgroup\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003eRW\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cem\u003eCI-L\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eCI-U\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eRS-RW (%)\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMedical\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.0401\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0088\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.0958\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e9.77%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1717\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.0746\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.2674\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e41.77%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmotional\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1992\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.1077\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.3084\u003c/p\u003e \u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e48.46%\u003c/p\u003e \u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"5\"\u003e\u003cem\u003eNote. RW = Relative Weight; CI-L = Confidence Interval around Relative Weight – Lower Bound; CI-U = Confidence Interval around Relative Weight – Upper Bound; RS-RW = Rescaled-Relative Weight.\u003c/em\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e \u003cp\u003e\u003c/p\u003e\n\n"},{"header":"COMMENT","content":"\u003ch2\u003ePrincipal Findings\u003c/h2\u003e\u003cp\u003eThis study contributes to the literature by assessing whether physician adherence to professional recommendations for delivering prenatal screening/diagnosis results impact patient diagnosis experiences, and if so, which subset of these recommendations (medical, social, or emotional) most correlate with positive patient experiences. For our first research question, we found that adherence to both social and emotional recommendations was significantly related to neutral/positive patient diagnosis experiences, with an effect size of moderate to large for the majority of those 11 practices. Moreover, we found that adherence to emotional and social recommendations explained relatively more variance in patient diagnosis experiences than adherence to medical recommendations.\u003c/p\u003e\n\u003ch3\u003eResults\u003c/h3\u003e\n\u003cp\u003eOur findings are consistent with previous literature; however, this is the first study that has found the extent to which physicians follow the emotional and social recommendations can result in strikingly different patient perceptions of their diagnosis experiences as neutral/positive vs. negative (May et al., 2020; Meredith et al., 2023; Nelson Goff et al., 2013; Sheets, Best, et al., 2011).\u003c/p\u003e\n\u003ch3\u003eClinical Implications\u003c/h3\u003e\n\u003cp\u003eGiven that over half of patients described their diagnosis experiences as negative due to the absence of social and emotional information and supports, the clinical implications are that obstetricians and gynecologists need to be sure to avoid saying \u0026ldquo;I\u0026rsquo;m sorry\u0026rdquo; or assuming that a potential diagnosis of DS is bad news. In addition, clinicians need to be sure to provide accurate, balanced, and up-to-date information about the life outcomes for people with DS and talk to their patients, in depth, about the improved social and life outcomes for people with DS that have been developed and achieved in recent years. Systemically, professional medical organizations can offer more explicit guidelines about how to provide social and emotional support and training for clinicians to navigate delicate conversations such as the Brighter Tomorrows training modules (Kleinert et al., 2009). An investment in these strategies could improve the diagnosis experience for patients, improve the emotional health of pregnant patients, and strengthen relationships of trust between providers and patients, particularly for those with intersectional identities (Chung et al., 2023; Krell et al., 2023; May et al., 2020; Meredith et al., 2023).\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eResearch Implications\u003c/h2\u003e \u003cp\u003eFurther research needs to determine if patients learning about other prenatal diagnoses have similar needs and if the provision of information about social determinants of health for people with disabilities at this early stage can potentially improve the health of medically vulnerable children (Kennedy \u0026amp; Wood, 2020). Moreover, additional research needs to examine the specific needs of patients who choose to terminate pregnancies following a diagnosis.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eStrengths and Limitations\u003c/h2\u003e \u003cp\u003eThis study is the largest study to date of those who received a prenatal diagnosis of Down syndrome and is very recent with a statistically rigorous analysis.\u003c/p\u003e \u003cp\u003eSeveral limitations should be noted within this study (Ijaz et al., 2024; Meredith et al., 2023):\u003c/p\u003e \u003cp\u003e\u003col\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eLike most of the previous studies on patient diagnosis experiences, our sample included an over-representation of White respondents. This limitation is especially important given disparities in health care and outcomes for individuals with DS in minority populations (Chung et al., 2023; Krell et al., 2023).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWhen our survey participants completed the quantitative questions about what their physician did or did not do, we did not ask them to specify if they were referring to their OB or MFM specialist (for those patients who had both). To minimize this limitation, we did not include the mixed responses in our SA scores, in which multiple providers were rated differently by the same patient.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eParticipant recall bias can be a factor; however, our respondents\u0026rsquo; experiences were relatively recent (2016\u0026ndash;2021) and the reception of a possible prenatal diagnosis of DS has been documented as a \u0026ldquo;flashbulb memory\u0026rdquo; (May et al., 2020).\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eOur findings may be positively skewed since advocacy organization participants lived in regions with medical outreach programs; thus, these results might not be generalizable to expectant couples without those supports.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003cspan\u003e\u003cli\u003e\u003cp\u003eWe did not control for any background variable(s) in the analysis and therefore do not know to what extent patient diversity may have impacted our results, nor can we be certain that our results would generalize to a more international study.\u003c/p\u003e\u003c/li\u003e\u003c/span\u003e\u003c/ol\u003e\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eGiven the profound impact of emotional, social, and informational recommendations on the diagnosis experiences of patients receiving prenatal screening results, OBs can significantly improve patient experiences and support their psychological and emotional needs by providing 1) access to accurate, balanced, and up-to-date information about disabilities and 2) being better trained on disability awareness and delivery of prenatal screening results.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgements\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe are grateful to the participation and support of the 12 local Down syndrome organizations and the Down Syndrome Diagnosis Network who assisted with recruitment and evaluating the study.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eThis work received funding support toward the provision of medical outreach training and patient education materials for local Down Syndrome advocacy organizations and some data analysis was funded by the \u003cstrong\u003eUS\u003c/strong\u003e \u003cstrong\u003eDepartment of Health and Human Services Administration for Community Living\u003c/strong\u003e as part of the prenatal subcommittee for the Center for Dignity in Healthcare for People with Disabilities (90DNHC0001). Some funding for data analysis was also provided by the \u003cstrong\u003eUS Administration for Children and Families\u0026nbsp;\u003c/strong\u003eas part of the University of Kentucky, Human Development Institute, University Center for Excellence in Developmental Disabilities Core Grant.\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting Interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Harold Kleinert, Jian Li, Sierra Weiss, and Jonathan Drummond have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003eDr. Stephanie Meredith serves on the advisory board of the National Down Syndrome Congress in a volunteer capacity and the Trisomy Collaborative as a paid consultant and is the parent of an adult with Down syndrome. She has also received remuneration from Down syndrome non-profit organizations and non-profit medical/genetics organizations/programs (National Society of Genetic Counselors, American College of Osteopathic Obstetricians and Gynecologists, American College of Medical Genetics and Genomics, and American Society of Human Genetics) for speaking engagements and associated travel expenses.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthor contributions: CRediT\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eDr. Stephanie Meredith: conceptualization, data curation, formal analysis (sentiment analysis), funding acquisition, investigation, methodology, project administration, resources, supervision, visualization, writing-original draft, writing-review and editing\u003c/p\u003e\n\u003cp\u003eDr. Harold Kleinert: formal analysis (sentiment analysis), methodology, project administration, writing-original draft, writing-review and editing\u003c/p\u003e\n\u003cp\u003eDr. Jian Li: formal analysis (statistics), writing-original draft, writing-review and editing, and visualization\u003c/p\u003e\n\u003cp\u003eSierra Weiss: data curation, formal analysis (sentiment analysis), methodology, writing-review and editing\u003c/p\u003e\n\u003cp\u003eJonathan Drummond: formal analysis, writing-review and editing\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eData Availability Statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics Statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was approved for human subjects on 4/6/2020 research by the University of Kentucky IRB (55360).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003ePatient Consent Statement\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study only included participants who were 18 or older, and participants completed IRB-approved online consent forms.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAmerican College of Obstetricians and Gynecologists\u0026rsquo; Committee on Practice Bulletins\u0026mdash;Obstetrics, Committee on Genetics, \u0026amp; Society for Maternal-Fetal Medicine. (2020). Screening for Fetal Chromosomal Abnormalities: ACOG Practice Bulletin, Number 226. \u003cem\u003eObstetrics \u0026amp; Gynecology\u003c/em\u003e, \u003cem\u003e136\u003c/em\u003e(4), e48\u0026ndash;e69. https://doi.org/10.1097/AOG.0000000000004084\u003c/li\u003e\n\u003cli\u003eArtal, J. M., Randall, L., Rubeck, S., Allyse, M., Michie, M., Riggan, K. A., Meredith, S., \u0026amp; Skotko, B. G. (2024). Parents of children with Down syndrome reflect on their postnatal diagnoses, 2003\u0026ndash;2022. \u003cem\u003eAmerican Journal of Medical Genetics Part A\u003c/em\u003e, \u003cem\u003e194\u003c/em\u003e(8), e63619. https://doi.org/10.1002/ajmg.a.63619\u003c/li\u003e\n\u003cli\u003eBull, M. J., Trotter, T., Santoro, S. L., Christensen, C., Grout, R. W., \u0026amp; THE COUNCIL ON GENETICS. (2022). Health Supervision for Children and Adolescents With Down Syndrome. \u003cem\u003ePediatrics\u003c/em\u003e, \u003cem\u003e149\u003c/em\u003e(5), e2022057010. https://doi.org/10.1542/peds.2022-057010\u003c/li\u003e\n\u003cli\u003eChung, J., Krell, K., Pless, A., Michael, C., Torres, A., Baker, S., Blake, J. M., Caughman, K., Cullen, S., Gallagher, M., Hoke‐Chandler, R., Maina, J., McLuckie, D., O\u0026rsquo;Neill, K., Pe\u0026ntilde;a, A., Royal, D., Slape, M., Spinazzi, N. A., Torres, C. G., \u0026amp; Skotko, B. G. (2023). Healthcare experiences of patients with Down syndrome from primarily Spanish‐speaking households. \u003cem\u003eAmerican Journal of Medical Genetics Part A\u003c/em\u003e, \u003cem\u003e191\u003c/em\u003e(8), 2132\u0026ndash;2141. https://doi.org/10.1002/ajmg.a.63250\u003c/li\u003e\n\u003cli\u003eCohen, J. (1988). \u003cem\u003eStatistical power analysis for the behavioral sciences\u003c/em\u003e (2nd ed). L. 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Insight from Parents of Individuals with Down Syndrome. \u003cem\u003eJournal of Genetic Counseling\u003c/em\u003e, \u003cem\u003e21\u003c/em\u003e(1), 35\u0026ndash;44. https://doi.org/10.1007/s10897-011-9417-2\u003c/li\u003e\n\u003cli\u003eHui, L., Ellis, K., Mayen, D., Pertile, M. D., Reimers, R., Sun, L., Vermeesch, J., Vora, N. L., \u0026amp; Chitty, L. S. (2023). Position statement from the International Society for Prenatal Diagnosis on the use of non‐invasive prenatal testing for the detection of fetal chromosomal conditions in singleton pregnancies. \u003cem\u003ePrenatal Diagnosis\u003c/em\u003e, \u003cem\u003e43\u003c/em\u003e(7), 814\u0026ndash;828. https://doi.org/10.1002/pd.6357\u003c/li\u003e\n\u003cli\u003eIBM Corp. (2021). \u003cem\u003eIBM SPSS Statistics for Windows, Version 28.0\u003c/em\u003e [Computer software]. IBM Corp.\u003c/li\u003e\n\u003cli\u003eIjaz, M. R., Trepanier, A. M., Kleinert, H. L., Weiss, S. M., \u0026amp; Meredith, S. H. (2024). Parent‐reported genetic counselor adherence to the NSGC practice resource for communicating a potential prenatal diagnosis: Impact on the Down syndrome diagnosis experience. \u003cem\u003eJournal of Genetic Counseling\u003c/em\u003e, jgc4.1948. https://doi.org/10.1002/jgc4.1948\u003c/li\u003e\n\u003cli\u003eJohnson, J. W. (2000). A Heuristic Method for Estimating the Relative Weight of Predictor Variables in Multiple Regression. \u003cem\u003eMultivariate Behavioral Research\u003c/em\u003e, \u003cem\u003e35\u003c/em\u003e(1), 1\u0026ndash;19. https://doi.org/10.1207/S15327906MBR3501_1\u003c/li\u003e\n\u003cli\u003eKennedy, J., \u0026amp; Wood, E. G. (2020). \u003cem\u003eDISABILITY-BASED DISPARITIES IN SOCIAL DETERMINANTS OF HEALTH AMONG WORKING-AGE ADULTS: EVIDENCE FROM THE 2018 NATIONAL HEALTH INTERVIEW SURVEYS\u003c/em\u003e. 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Healthcare experiences of patients with Down syndrome who are Black, African American, of African descent, or of mixed race. \u003cem\u003eAmerican Journal of Medical Genetics Part A\u003c/em\u003e, \u003cem\u003e191\u003c/em\u003e(3), 742\u0026ndash;752. https://doi.org/10.1002/ajmg.a.63069\u003c/li\u003e\n\u003cli\u003eKuder, G. F., \u0026amp; Richardson, M. W. (1937). The theory of the estimation of test reliability. \u003cem\u003ePsychometrika\u003c/em\u003e, \u003cem\u003e2\u003c/em\u003e(3), 151\u0026ndash;160. https://doi.org/10.1007/BF02288391\u003c/li\u003e\n\u003cli\u003eLevis, D. M., Harris, S., Whitehead, N., Moultrie, R., Duwe, K., \u0026amp; Rasmussen, S. A. (2012). Women\u0026rsquo;s knowledge, attitudes, and beliefs about Down syndrome: A qualitative research study. \u003cem\u003eAmerican Journal of Medical Genetics Part A\u003c/em\u003e, \u003cem\u003e158A\u003c/em\u003e(6), 1355\u0026ndash;1362. https://doi.org/10.1002/ajmg.a.35340\u003c/li\u003e\n\u003cli\u003eMay, C. P., Dein, A., \u0026amp; Ford, J. (2020). New insights into the formation and duration of flashbulb memories: Evidence from medical diagnosis memories. \u003cem\u003eApplied Cognitive Psychology\u003c/em\u003e, \u003cem\u003e34\u003c/em\u003e(5), 1154\u0026ndash;1165. https://doi.org/10.1002/acp.3704\u003c/li\u003e\n\u003cli\u003eMeredith, S., Weiss, S., Kleinert, H. L., \u0026amp; Tyrrell, C. A. (2023). The impact of implicit and explicit bias about disabilities on parent experiences and information provided during prenatal screening and testing. \u003cem\u003eDisability and Health Journal\u003c/em\u003e, 101514. https://doi.org/10.1016/j.dhjo.2023.101514\u003c/li\u003e\n\u003cli\u003eNelson Goff, B. S., Springer, N., Foote, L. C., Frantz, C., Peak, M., Tracy, C., Veh, T., Bentley, G. E., \u0026amp; Cross, K. A. (2013). Receiving the Initial Down Syndrome Diagnosis: A Comparison of Prenatal and Postnatal Parent Group Experiences. \u003cem\u003eIntellectual and Developmental Disabilities\u003c/em\u003e, \u003cem\u003e51\u003c/em\u003e(6), 446\u0026ndash;457. https://doi.org/10.1352/1934-9556-51.6.446\u003c/li\u003e\n\u003cli\u003ePetscher, Y. M., Schatschneider, C., Compton, D. L., \u0026amp; Petscher, Y. (Eds.). (2013). \u003cem\u003eApplied quantitative analysis in education and the social sciences\u003c/em\u003e (1. publ). Routledge.\u003c/li\u003e\n\u003cli\u003eR Core Team. (2024). \u003cem\u003eR: A Language and Environment for Statistical Computing.\u003c/em\u003e [Computer software]. R Foundation for Statistical Computing.\u003c/li\u003e\n\u003cli\u003eSheets, K. B., Best, R. G., Brasington, C. K., \u0026amp; Will, M. C. (2011). Balanced information about Down syndrome: What is essential? \u003cem\u003eAmerican Journal of Medical Genetics Part A\u003c/em\u003e, \u003cem\u003e155\u003c/em\u003e(6), 1246\u0026ndash;1257. https://doi.org/10.1002/ajmg.a.34018\u003c/li\u003e\n\u003cli\u003eSheets, K. B., Crissman, B. G., Feist, C. D., Sell, S. L., Johnson, L. R., Donahue, K. C., Masser‐Frye, D., Brookshire, G. S., Carre, A. M., LaGrave, D., \u0026amp; Brasington, C. K. (2011). Practice Guidelines for Communicating a Prenatal or Postnatal Diagnosis of Down Syndrome: Recommendations of the National Society of Genetic Counselors. \u003cem\u003eJournal of Genetic Counseling\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(5), 432\u0026ndash;441. https://doi.org/10.1007/s10897-011-9375-8\u003c/li\u003e\n\u003cli\u003eSkotko, B. G. (2005). Prenatally diagnosed Down syndrome: Mothers who continued their pregnancies evaluate their health care providers. \u003cem\u003eAmerican Journal of Obstetrics and Gynecology\u003c/em\u003e, \u003cem\u003e192\u003c/em\u003e(3), 670\u0026ndash;677. https://doi.org/10.1016/j.ajog.2004.11.001\u003c/li\u003e\n\u003cli\u003eSkotko, B. G., Kishnani, P. S., Capone, G. T., \u0026amp; for the Down Syndrome Diagnosis Study Group. (2009). Prenatal diagnosis of Down syndrome: How best to deliver the news. \u003cem\u003eAmerican Journal of Medical Genetics Part A\u003c/em\u003e, \u003cem\u003e149A\u003c/em\u003e(11), 2361\u0026ndash;2367. https://doi.org/10.1002/ajmg.a.33082\u003c/li\u003e\n\u003cli\u003eTonidandel, S., \u0026amp; LeBreton, J. M. (2015). RWA Web: A Free, Comprehensive, Web-Based, and User-Friendly Tool for Relative Weight Analyses. \u003cem\u003eJournal of Business and Psychology\u003c/em\u003e, \u003cem\u003e30\u003c/em\u003e(2), 207\u0026ndash;216. https://doi.org/10.1007/s10869-014-9351-z\u003c/li\u003e\n\u003cli\u003eWilliams, C., Alderson, P., \u0026amp; Farsides, B. (2002). What constitutes \u0026lsquo;balanced information in the practitioners\u0026rsquo; portrayals of Down\u0026rsquo;s syndrome? \u003cem\u003eMidwifery\u003c/em\u003e, \u003cem\u003e18\u003c/em\u003e(3), 230\u0026ndash;237. https://doi.org/10.1054/midw.2002.0316\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-community-genetics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocg","sideBox":"Learn more about [Journal of Community Genetics](http://link.springer.com/journal/12685)","snPcode":"12687","submissionUrl":"https://submission.nature.com/new-submission/12687/3","title":"Journal of Community Genetics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Down syndrome, disability, obstetrician, genetic counselor, prenatal screening, cell-free DNA screening, Trisomy 21, prenatal diagnosis","lastPublishedDoi":"10.21203/rs.3.rs-5810442/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5810442/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo determine how physician adherence to recommended practices for discussing Down syndrome impacts patient experiences, and which of these recommendations most correlate with positive prenatal patient experiences.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethod\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOnline surveys were distributed to mothers of children with DS born between 2016–2021. The descriptions of prenatal experiences were assigned sentiment analysis scores: positive, negative, or neutral. The scores were then compared against the adherence of clinicians to recommended practices for delivering prenatal screening results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 167 patients in this study, over 50% described a negative experience. The odds of having a neutral/positive diagnosis experience were about 18 times greater for those patients whose physicians adhered to all seven social recommendations. The odds of having a positive/neutral screening experience were 11.4 times greater for those patients whose physicians adhered to both emotional recommendations (\u003cem\u003enot\u003c/em\u003e saying “I’m sorry” or conveying the diagnosis as bad news”). Most of the variance in the patient diagnosis experience was attributed to adherence to emotional recommendations and social recommendations.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eTo meet the needs of patients, obstetricians need to address their emotional, social, and informational needs by providing 1) access to balanced and accurate information about disabilities and 2) being better trained on sensitive communications.\u003c/p\u003e\n\u003cp\u003eNote: “Diagnosis experiences” include both patients receiving diagnostic results and the cell-free DNA screening results. Most parents of children with Down syndrome do not proceed with diagnostic testing, and the vast majority (89%) consider screening the most important stage for receiving information about DS.( Meredith et al., 2023)\u003c/p\u003e","manuscriptTitle":"Lack of Provision of Social and Emotional Information about Down Syndrome Associated with Negative Prenatal Diagnosis Experiences","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-01-16 09:02:38","doi":"10.21203/rs.3.rs-5810442/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-19T12:16:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-18T23:34:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"59824242086733458453376870643286223223","date":"2025-02-26T18:40:51+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-02-07T11:42:48+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-01-31T13:58:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"277800668080802961144703311440215356500","date":"2025-01-25T08:33:28+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-01-14T18:29:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-01-14T08:47:12+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-01-14T08:44:02+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Community Genetics","date":"2025-01-11T16:22:35+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-community-genetics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jocg","sideBox":"Learn more about [Journal of Community Genetics](http://link.springer.com/journal/12685)","snPcode":"12687","submissionUrl":"https://submission.nature.com/new-submission/12687/3","title":"Journal of Community Genetics","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"1a7047e2-dc3b-497f-bdd0-fd4cc242bf9c","owner":[],"postedDate":"January 16th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-05-19T16:07:32+00:00","versionOfRecord":{"articleIdentity":"rs-5810442","link":"https://doi.org/10.1007/s12687-025-00801-7","journal":{"identity":"journal-of-community-genetics","isVorOnly":false,"title":"Journal of Community Genetics"},"publishedOn":"2025-05-15 15:58:00","publishedOnDateReadable":"May 15th, 2025"},"versionCreatedAt":"2025-01-16 09:02:38","video":"","vorDoi":"10.1007/s12687-025-00801-7","vorDoiUrl":"https://doi.org/10.1007/s12687-025-00801-7","workflowStages":[]},"version":"v1","identity":"rs-5810442","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5810442","identity":"rs-5810442","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}