| Summary: | INTRODUCTION: The way in which NHS screening programmes are organised and delivered may influence public engagement. This is of particular interest in Down’s syndrome screening where variations in uptake have not been explained by individual social characteristics. This has led to suggestion that the influence of service organisation and delivery may help to explain the variation. AIM: To explore the influence of service organisation and delivery on women and partners’ participation in screening in two different health districts in England with contrasting uptake rates. METHOD: A multiple case study design involving document review of screening guidelines and qualitative online interviews was adopted. Purposive sampling was employed to select settings and invite in each group (n=18 – 24) community midwives, women and partners. Participants responded online to vignettes with open-ended questions and prompts, providing a range of responses. Data were analysed using content analysis. FINDINGS: Participation was influenced by constraints such as the offer of screening as a routine test, influence of interpreters and ambience of the environment resulting in the routinisation of screening. Additionally, differing perceptions and the policy of nondirectiveness created tensions in the prenatal environment, within and between midwives, women and partners. The constraints, tensions and nuances in the operationalisation of the screening guidelines affected midwife - woman interaction and how screening was presented, with some midwives colluding with women to engage passively in screening. The conceptual model developed from the findings revealed a factor unaccounted for in previous research that the tensions, different relationships, decisionmaking models and variation in uptake rates in screening were associated with service organisational and delivery constraints. CONCLUSION: The classic situation of women capable of autonomous and informed choice and midwives capable of informing nondirectively may not exist in the prenatal context. A shared decision-making process model to mitigate the constraints and tensions is proposed.
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