Termination of pregnancy following a Down Syndrome diagnosis: decision-making process and influential factors in a Muslim but secular country, Turkey.

OBJECTIVES: This study aims to present the termination of pregnancy (TOP) rates and elucidate the decision-making process following a prenatal diagnosis of Trisomy 21 in Turkey. METHODS: This retrospective single-center study was conducted with 146 pregnant women between January 2016 and December 2019 in a tertiary hospital. Data on maternal characteristics, sonographic findings, indications for chromosome analysis, and educational, religious, and economic factors that can influence the parental decision process were collected. RESULTS: The TOP rate of Down syndrome (DS) in our center was 78.8%. We concluded that maternal age, earlier diagnosis, indication for chromosome analysis, and previous pregnancies had no effect on the TOP decision. On the other hand, not having a minor or a major sonographic sign, employed mothers, middle- and high-income families, and families having a secondary or higher education tended to terminate the pregnancy affected by DS at statistically higher rates. CONCLUSIONS: There are many studies worldwide investigating the TOP preferences for DS. However, there is limited data about TOP rates and influential factors affecting the decision-making process in Muslim countries. This study contributes by clarifying the factors in the decision-making process and elucidating perspectives about TOP in a Muslim country with a unique status: Turkey.

Mindfetalness to increase women's awareness of fetal movements and pregnancy outcomes: a cluster-randomised controlled trial including 39 865 women.

OBJECTIVE: To examine whether a method for raising women's awareness of fetal movements, Mindfetalness, can affect pregnancy outcomes. DESIGN: Cluster-randomised controlled trial. SETTING: Sixty-seven maternity clinics in Stockholm, Sweden. POPULATION: Women with singleton pregnancy with birth from 32 weeks' gestation. METHODS: Women registered at a clinic randomised to Mindfetalness were assigned to receive a leaflet about Mindfetalness (n = 19 639) in comparison with routine care (n = 20 226). Data were collected from a population-based register. MAIN OUTCOME MEASURES: Apgar score <7 at 5 minutes after birth, visit to healthcare due to decrease in fetal movements. Other outcomes: Apgar score <4 at 5 minutes after birth, small-for-gestational-age and mode of delivery. RESULTS: No difference (1.1 versus 1.1%, relative risk [RR] 1.0; 95% CI 0.8-1.2) was found between the Mindfetalness group and the Routine care group for a 5-minute Apgar score <7. Women in the Mindfetalness group contacted healthcare more often due to decreased fetal movements (6.6 versus 3.8%, RR 1.72; 95% CI 1.57-1.87). Mindfetalness was associated with a reduction of babies born small-for-gestational-age (RR 0.95, 95% CI 0.90-1.00), babies born after gestational week 41+6 (RR 0.91, 95% CI 0.83-0.98) and caesarean sections (19.0 versus 20.0%, RR 0.95; 95% CI 0.91-0.99). CONCLUSIONS: Mindfetalness did not reduce the number of babies born with an Apgar score <7. However, Mindfetalness was associated with the health benefits of decreased incidence of caesarean section and fewer children born small-for-gestational-age. TWEETABLE ABSTRACT: Introducing Mindfetalness in maternity care decreased caesarean sections but had no effect on the occurrence of Apgar scores <7.

Perinatal grief following neonatal comfort care for lethal fetal condition.

BACKGROUND: The objective of the study was to assess perinatal grief experienced after continuing pregnancy and comfort care in women diagnosed with lethal fetal condition compared with termination of pregnancy for fetal anomaly (TOPFA). METHODS: This was a retrospective observational study which included women who chose to continue their pregnancy after the diagnosis of lethal fetal condition with comfort care support at birth at the Prenatal Diagnosis Center of Rennes Hospital from January 2007 to January 2017. Women were matched with controls who underwent TOPFA for the same type of fetal anomaly, gestational age at diagnosis and year. Women were evaluated by a questionnaire including the Perinatal Grief Scale. RESULTS: There were 28 patients in the continuing pregnancy group matched with 56 patients in the TOPFA group. Interval between fetal loss and completion of questionnaire was 6±3 years. Perinatal grief score was similar at 61±22 vs 58±18 (p = 0.729) in the continuing pregnancy and TOPFA groups, respectively. Women in the TOPFA group expressed more guilt. The cesarean-section rate in the continuing pregnancy group was 25%. CONCLUSION: Perinatal grief experienced by women opting for continuing pregnancy and comfort care after diagnosis of a potentially lethal fetal anomaly is not more severe than for those choosing TOPFA.

Written narratives from immigrants following a prenatal diagnosis: qualitative exploratory study.

BACKGROUND: Expectant parents often have optimistic expectations of the obstetric ultrasound examination and are unprepared for a diagnosis of foetal anomaly. Research that gives voice to the experiences of immigrants faced with a prenatal diagnosis is scarce, and there is a need for more exploratory research that provides insights into the experiences of these persons. The aim of this study was to explore narratives of experiences of immigrants with Arabic or Sorani interpreter needs when presented with a prenatal diagnosis of foetal anomaly. METHODS: A web-based tool with open-ended questions was distributed via Arabic and Kurdish non-profit associations and general women's associations in Sweden. Responses were received from six women and analysed with qualitative content analysis. RESULTS: The analysis resulted in three themes: (1) an unexpected hurricane of emotions, (2) trying to understand the situation though information in an unfamiliar language, and (3) being cared for in a country with accessible obstetric care and where induced abortion is legal. CONCLUSIONS: Immigrant women described an unexpected personal tragedy when faced with a prenatal diagnosis of foetal anomaly, and emphasised the importance of respectful and empathic psychological support. Their experiences of insufficient and incomprehensible information call attention to the importance of tailored approaches and the use of adequate medical interpreting services. There is a need for more descriptive studies that investigate decision-making and preparedness for induced abortion among immigrants faced with a prenatal diagnosis.

"I Would Do It All Over Again": Cherishing Time and the Absence of Regret in Continuing a Pregnancy after a Life-Limiting Diagnosis.

Parents, after learning of a life-limiting fetal condition (LLFC), experience emotional distress and must consider options that impact the remainder of the pregnancy, their future lives, and family members. For those who continue, little is known about their long-term presence or absence of regret about their choice, the reasons for this feeling, or its impact on their life. The aim of this research was to examine the concept of decision regret in parents who opted to continue a pregnancy affected by an LLFC. The contextual factors, conditions, and consequences surrounding the presence or absence of regret were analyzed. Data were retrieved from a cross-sectional study using the Quality of Perinatal Palliative Care and Parental Satisfaction Instrument. Participants were parents (N = 405) who experienced a life-limiting prenatal diagnosis and opted to continue their pregnancy. Secondary data analysis examined qualitative responses (121/402) to an item addressing regret. Dimensional analysis was used to examine data, identifying context, conditions, and consequences associated with the presence or absence of regret. Absence of regret was articulated in 97.5 percent of participants. Parents valued the baby as a part of their family and had opportunities to love, hold, meet, and cherish their child. Participants treasured the time together before and after the birth. Although emotionally difficult, parents articulated an empowering, transformative experience that lingers over time.

A survey of health professionals' views on acceptable gestational age and termination of pregnancy for fetal anomaly.

Termination of pregnancy for fetal anomaly is legal in the UK with no upper limit, if two doctors, in good faith, agree "there is a substantial risk that if the child were born it would suffer from such physical or mental abnormalities as to be seriously handicapped". This is Clause E of the Human Fertlisation and Embryology Act. The most commonly sighted Clause is C, which states "the pregnancy has not exceeded its twenty-fourth week and that the continuance of the pregnancy would involve risk, greater than if the pregnancy were terminated, of injury to the physical or mental health of the pregnant woman". This study aimed to investigate health professionals' views on gestational age and acceptable termination of pregnancy for fetal anomaly (TOPFA). We undertook a questionnaire survey of UK health professionals working in fetal medicine, obstetrics and gynaecology and neonatology. A study pack consisting of a self-completion questionnaire, an invitation letter, participant information sheet, and a stamped addressed return envelope, were sent to health professionals. We used four fetal anomalies as case study examples in the questionnaire: isolated cleft lip, hypoplastic left heart, spina bifida and trisomy 21. These anomalies were chosen as they differed in terms of the type of anomaly, the type of impairment, and the perceived severity. Forty-one study packs were returned. For anomalies deemed less serious, later gestational ages were an important consideration when deciding acceptable TOPFA. The prognosis of an anomaly was considered an important factor in deciding whether a TOPFA was acceptable alongside gestational age. Clause C of the current UK legislation, which allows a legal termination prior to 24 weeks gestational age if continuing with the pregnancy would impact the mental health of the mother, was deemed a reasonable option for termination when parents are requesting a TOPFA. For each case study example, health professionals responded that TOPFA at '25 weeks and over' was acceptable (cleft lip n = 1; hypoplastic left heart n = 19; spina bifida n = 13 and Trisomy 21 n = 10). Professionals also distinguished between their personal and professional views. These findings offer new insight into how gestational age considerations influence professionals' conceptualisation of acceptable TOPFA.

Decision-making on terminating pregnancy for Muslim Arab women pregnant with fetuses with congenital anomalies: maternal affect and doctor-patient communication.

BACKGROUND: This study focused on decision-making on terminating pregnancy for Arab Muslim women in Israel who were pregnant with fetuses diagnosed with congenital anomalies. It examined the impact of the doctor-patient interaction on the women's decision, especially in light of social and religious pressures not to terminate under any circumstances. Our goal was to identify perceptions and attitudes of Muslim Arab women who choose to continue their pregnancy following the detection of congenital anomalies in prenatal tests. Specific objectives included (1) To examine the Muslim Arab women's perceptions on genetic testing, and ascertain the reasons for their decision to continue the pregnancy following the detection of a congenital anomaly in the fetus; and (2) To examine risk communication of gynecologists regarding genetic testing and abortions, and regarding the decision of continuing or terminating a pregnancy following detection of a congenital anomaly. METHODS: The research framework used the constructivist classical qualitative method to understand the experience of women at high risk for congenital anomalies and their experience of how doctors communicate the risk. RESULTS: It showed that the emotional element is no less dominant than religious and social elements. The findings emphasized the disparities between doctors and women regarding emotional involvement (non-directive counselling). The women interviewees (N = 24) felt that this expressed insensitivity. As far as we know, the emotional component has not been raised in previous studies of Muslim women at high risk for congenital defects in their fetus, and therefore comprises a significant contribution of the present study. CONCLUSIONS: To mitigate gaps, doctors should take affect into consideration in their communication with patients. It is important for doctors to understand the emotional element in risk communication, both in how they respect women's emotions and in creating an emotional interaction between themselves and the women.

Maternal risks of fetal therapy.

PURPOSE OF REVIEW: Although most fetal disorders can be treated after birth, a few conditions that predictably lead to fetal or neonatal death, or that progress significantly before birth, are ideally treated prenatally. The number of centers offering fetal therapeutic procedures is gradually increasing worldwide. Patients and caregivers should be aware of the potential maternal risks of these interventions. RECENT FINDINGS: For transplacental medical therapy (corticosteroids, antiarrhythmics and immunoglobulins), severe maternal adverse events are rare, when done in expert centers. Minimally invasive procedures carry a risk of maternal complications of about 5%, with 1% being severe complications (pulmonary edema or placental abruption). Open fetal surgery carries important risks to the mother, both in the index pregnancy (pulmonary edema, placental abruption, chorioamnionitis and scar dehiscence) and in subsequent pregnancies (uterine rupture), yet some of these risks are decreasing with surgical refinement and increasing experience of the surgical team. SUMMARY: The information in this manuscript provides a base to counsel expectant mothers on risk of fetal therapy.

Parent reported outcomes of quality care and satisfaction in the context of a life-limiting fetal diagnosis.

OBJECTIVE: To identify which quality indicators (QI) predict patient satisfaction. METHODS: A cross-sectional design using a validated tool was administered using a Web-based platform. Parents (n = 405) who experienced a life-limiting fetal diagnosis and opted to continue their pregnancy provided feedback on 37 QI and satisfaction with prenatal care. Descriptive analyses and logistic regression identified relationships among variables. RESULTS: Parental satisfaction with care was 75.6%. Statistically significant differences in mean scores were reported with satisfied patients reporting higher agreement with quality indicators. Parents who were satisfied with their care had 1.9 times the odds of reporting that consistent care was provided (CI: 1.4-2.4, p < 0.01), 1.8 times the odds of reporting compassionate care (CI: 1.4-2.5, p < 0.01) and 1.8 times the odds that they received help to cope with their emotions (CI: 1.4-2.3, p < 0.01). The model correctly predicted parent satisfaction 92% of the time. CONCLUSION: Provision of consistent prenatal care is an important quality indicator for this population of parents. The odds of securing satisfied parents increase when families are treated with compassion and given resources to help them cope with the emotionally devastating experiences associated with a life-limiting fetal diagnosis.

Communication of support and critique in Swedish virtual community threads about prenatal diagnoses of fetal anomalies.

BACKGROUND: A prenatal diagnosis of a fetal anomaly involves acute grief and psychological distress. The Internet has the potential to provide virtual support following the diagnosis. The overall aim was to explore communication of support and critique in Swedish virtual community threads about prenatal diagnoses of fetal anomalies. METHODS: Systematic searches in Google resulted in 117 eligible threads. Fifteen of these were purposefully selected and subjected to deductive content analysis. RESULTS: The virtual support involved mainly emotional support (meaning units n = 1,992/3,688, 54 %) and was described as comforting and empowering. Posters with experience of a prenatal diagnosis appreciated the virtual support, including the opportunity to gain insight into other cases and to write about one's own experience. Critique of the decision to continue or terminate the pregnancy occurred, primarily against termination of pregnancy. However, it was met with defense. CONCLUSIONS: Peer support, mainly emotional, is provided and highly appreciated in threads about prenatal diagnoses of a fetal anomaly. Critique of the decision to terminate the pregnancy occurs in virtual community threads about prenatal diagnoses, but the norm is to not question the decision. Future studies need to investigate if virtual peer support promotes psychosocial function following a prenatal diagnosis and what medium would be most suitable for these types of supportive structures.

Ethical challenges in the new world of maternal-fetal surgery.

This article explores some of the complex ethical challenges that exist in the field of fetal diagnosis and treatment, especially surrounding maternal-fetal surgery. The rise of these new treatments force us to reconsider who or what is the fetus, what are our obligations to the fetus, and what are the limits to those obligations. In addition, we will consider provider and professional biases, disability issues, and how maternal-fetal surgery has, for a select group of women, changed the very experience of motherhood.

Vulnerability, therapeutic misconception and informed consent: is there a need for special treatment of pregnant women in fetus-regarding clinical trials?

Historically, pregnant women have generally been excluded from clinical trials. One of the reasons for this exclusion has been the belief that pregnant women are vulnerable as research participants. Although this view has now largely fallen into disfavour, this article argues that in the situation where the pregnant woman is newly diagnosed with a fetal condition for which the only option, other than watchful waiting, is enrolment in a clinical trial, she should be considered a cognitively and medically vulnerable research participant. This is because she is in a highly stressed emotional state and so less able to decide completely freely whether or not to participate in the clinical trial. In other words, she is under a higher risk of therapeutic misconception and of not understanding what she is consenting to. This article suggests that in order for the consent of these women to be given freely and without emotional pressure, it has to be ensured that strategies are developed to ensure they are fully informed and actually understand the information. This surpasses the requirements of the English law of informed consent and also of General Medical Council (GMC) guidance on consent to research but such an approach would help safeguard that, despite these women's poor bargaining position, their trial participation is really free, voluntary and informed.

Maternal-fetal attachment and prenatal diagnosis of heart disease.

OBJECTIVE: To test the hypothesis that there are differences in the level of maternal-fetal attachment before and after fetal echocardiography in the presence or absence of cardiac abnormalities. STUDY DESIGN: Cohort study in which the mothers responded to a validated Maternal-Fetal Attachment Scale. The study compared a group of pregnant women with diagnosis of fetal heart disease (FHD) with a group without this diagnosis ("no fetal heart disease" - NFHD). RESULTS: 197 pregnant women were included, 96 FHD and 101 NFHD. Maternal-fetal attachment at the initial and final periods showed no significant baseline differences between groups (p=0.081). At the final period, migration from medium to high level of attachment was significantly higher in FHD (p=0.017). Transition from medium to high levels comparing the initial and final periods was more pronounced in FHD (p=0.009). CONCLUSION: Diagnosis of fetal heart disease increases the level of maternal-fetal attachment.

Epigenetic programing of depression during gestation.

Gestational factors play a role in the development of several neuropsychiatric disorders including schizophrenia and autism. In utero conditions influence future mental health through epigenetic mechanisms, which alter gene expression without affecting DNA coding sequence. Environmental factors account for at least 60% of the risk for developing major depression, and earlier onset of depressive illness has been observed over the past decades. I speculate that gestational factors may play a greater role in programing depression than previously recognized. Here, I examine recent evidence for a role for gestational factors in programing mood disorders, and how epigenetic mechanisms mediate this effect.

Effectiveness of psychological intervention for treating symptoms of anxiety and depression among pregnant women diagnosed with fetal malformation.

OBJECTIVE: To determine the effectiveness of a psychological intervention targeting pregnant women with fetal malformation. METHODS: A clinical study was conducted that enrolled 65 pregnant women attending Clinics Hospital at Ribeirão Preto, University of São Paulo, Brazil, between February 2004 and May 2008. Participants were allocated to 1 of 4 groups: normal pregnancy (NP), fetal malformation (FM), fetal or neonatal death (FD), and control (CG). Psychological intervention-including support, empathy, education, and desensitization-was provided to the NP, FM, and FD groups. Women in CG did not receive the intervention and were assessed in the postnatal period only. Anxiety was measured using the Hospital Anxiety and Depression (HAD) scale. Depression was measured by HAD and the Edinburgh Postnatal Depression Scale. RESULTS: Significant reductions from baseline were observed in anxiety and depression scores after psychological intervention in the NP and FM groups. Symptom scores in the postnatal period were also significantly reduced among these groups (P<0.001). CONCLUSION: Psychological intervention was effective in relieving symptoms of anxiety and depression experienced by pregnant women with fetal malformation.

Pregnancy as public property: the experience of couples following diagnosis of a foetal anomaly.

BACKGROUND: Pregnant women find themselves subject to comments and questions from people in public areas. Normally, becoming 'public property' is considered friendly and is relatively easy for pregnant women to deal with. However, following diagnosis of a foetal anomaly, the experience of being public property can exacerbate the emotional turmoil experienced by couples. Original research question: What is the experience of couples who continue pregnancy following the diagnosis of a foetal anomaly? METHOD: The study used an interpretive design informed by Merleau-Ponty and this paper reports on a subset of findings. Thirty-one interviews with pregnant women and their partners were undertaken following the diagnosis of a serious or lethal foetal anomaly. Women were between 25 and 38 weeks gestation at the time of their first interview. The non-directive interviews were audio-taped, transcribed verbatim and the transcripts were thematically analysed. FINDINGS: A prominent theme that emerged during data analysis was that pregnancy is embodied therefore physically evident and 'public'. Women found it difficult to deal with being public property when the foetus had a serious or lethal anomaly. Some women avoided social situations; others did not disclose the foetal condition but gave minimal or avoidant answers to minimise distress to themselves and others. The male participants were not visibly pregnant and they could continue life in public without being subject to the public's gaze, but they were very aware and concerned about its impact on their partner. CONCLUSION: The public tend to assume that pregnancy is normal and will produce a healthy baby. This becomes problematic for women who have a foetus with an anomaly. Women use strategies to help them cope with becoming public property during pregnancy. Midwives can play an important role in reducing the negative consequences of a woman becoming public property following the diagnosis of a foetal anomaly.

What parents say about disclosing the end of their pregnancy due to fetal abnormality.

OBJECTIVE: to describe men's and women's experiences of deciding whether to tell people in their social network, including their children, about their pregnancy loss following a termination for fetal abnormality. DESIGN: secondary analysis of qualitative narrative interview data informed by a critical realist approach. SETTING: respondents were recruited throughout the United Kingdom and interviewed at home between 2004 and 2005. PARTICIPANTS: twenty-eight women and nine men who had ended a pregnancy diagnosed with a fetal abnormality and who talked about disclosing or not disclosing the termination to others. FINDINGS: few respondents reported having any advice or information about whether or how to disclose their termination. None said they completely concealed their decision from adults in their social network; most said they disclosed selectively, telling close friends and family they had terminated and acquaintances they had miscarried. Most respondents reported telling their young children that the baby had died but did not reveal that they had chosen to end the pregnancy. A minority had not told their existing offspring about the pregnancy loss. Common reasons given for (partially) concealing a termination were: guilt over the decision; to avoid being judged; and to protect other people's feelings. Common reasons for disclosure were: others knew of the pregnancy; needing time off work; needing practical help and/or emotional support during diagnosis and termination; and wanting recognition of their loss. Positive consequences of disclosure were said to be getting more support and less criticism than expected; negative consequences included not getting the anticipated support and empathy; and encountering disapproval. Some respondents felt that concealing their pregnancy loss from their children had resulted in their confusion over the cause of their parents' distress. Some men said they found it hard to access emotional support from their social networks because of expectations about how men 'should' deal with emotions. KEY CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: midwives have to make difficult judgements about what, how and when to provide information when trying to support and advise parents who have ended a pregnancy due to fetal abnormality. Further education and training in this area could be of benefit. Midwives could signpost parents to existing sources of advice around disclosure, taking into account parents' individual preferences, help parents to consider the potential implications of disclosure and concealment and different ways of disclosing. They could also recommend alternative sources of emotional support, bearing in mind that men in particular may find it harder to access support from their social networks.

Differing attitudes toward fetal care by pediatric and maternal-fetal medicine specialists.

OBJECTIVES: The expansion of pediatric-based fetal care raises questions regarding pediatric specialists' involvement in pregnancies when maternal conditions may affect pediatric outcomes. For several such conditions, we compared pediatric and obstetric specialists' attitudes regarding whether and when pediatrics consultation should be offered and their views about seeking court authorization to override maternal refusal of physician recommendations. METHODS: We used a mail survey of 434 maternal-fetal medicine specialists (MFMs) and fetal care pediatric specialists (FCPs) (response rate: MFM, 60.9%; FCP, 54.2%). RESULTS: FCPs were more likely than MFMs to indicate that pediatric counseling should occur before decisions regarding continuing or interrupting pregnancies complicated by maternal alcohol abuse (FCP versus MFM: 63% vs 36%), cocaine abuse (FCP versus MFM: 60% vs 32%), use of seizure medications (FCP versus MFM: 62% vs 33%), and diabetes (FCP versus MFM: 56% vs 27%) (all P < .001). For all conditions, MFMs were more than twice as likely as FCPs to think that no pediatric specialist consultation was ever necessary. FCPs were more likely to agree that seeking court interventions was appropriate for maternal refusal to enter a program to discontinue cocaine use (FCP versus MFM: 72% vs 33%), refusal of azidothymidine to prevent perinatal HIV transmission (80% vs 41%), and refusal of percutaneous transfusion for fetal anemia (62% vs 28%) (all P < .001). CONCLUSIONS: Pediatric and obstetric specialists differ considerably regarding pediatric specialists' role in prenatal care for maternal conditions, and regarding whether to seek judicial intervention for maternal refusal of recommended treatment.

Attentional bias for smoking-related information in pregnant women: relationships with smoking experience, smoking attitudes and perceived harm to foetus.

According to recent models of drug dependence, attentional bias for drug cues provides an index of vulnerability to drug-taking and relapse. The present study examined attentional bias for smoking-related information in pregnant women and its relationship with smoking experience and attitudes. Participants were 71 pregnant women (35 without smoking experience; 36 with experience of smoking, of whom 16 reported currently smoking). Attentional bias was assessed from the interference index of smoking-related words on a modified Stroop task. The attentional bias for smoking cues was positively associated with smoking experience, and with more favourable general attitudes to smoking (i.e. incentive-related bias). The bias was also greater in women who perceived greater harm of passive smoking to their foetus (i.e. threat-related bias), which was independent of smoking experience. Results indicate that attentional bias for smoking-related cues is independently associated with both incentive-related (reward) and threat-related (aversive) evaluations of cigarette smoking in pregnant women. This work highlights the need for longitudinal research to investigate whether the attentional bias provides a cognitive index of vulnerability for persistent smoking behaviour both during and after pregnancy.

Fatal fetal paternalism.

Heuser and colleagues' survey of obstetricians provides a valuable insight into the current management of severe fetal anomalies in the United States. Their survey reveals two striking features - that counselling for these anomalies is far from neutral, and that there is significant variability between clinicians in their approach to management. In this commentary I outline the reasons to be concerned about both of these. Directiveness in counselling arguably represents a form of paternalism, and the evident variability in practice is likely the result of physician personal values. However, Heuser's survey may, by shining a light on practice, provide an important step towards a more consistent approach.