A Randomized Trial of Chatbot for Prenatal Genetic Counseling

Current recommendations from the American College of Obstetricians and Gynecologists (ACOG) call for all pregnant women to be offered screening and diagnostic testing options for aneuploidy and carrier screening for cystic fibrosis and spinal muscular atrophy. As a result, the nearly 4 million pregnant women receiving prenatal care in the United States annually require access to the associated, and complex, prenatal genetic counseling. With these considerations and a commitment to patient centered-care, informed decision-making is critical, and predicated on patients having adequate knowledge of the benefits and risks of different testing options. Obstetric care providers have the challenge of addressing an ever-increasing number of topics during the first prenatal care visit, and prenatal genetic counselors face a high number of referrals. Yet there is a national shortage of genetic counselors, with an uneven geographic distribution. The resulting lack of access to standardized prenatal genetic counseling can lead to patient misinterpretation of the goals or results of prenatal genetic testing and may be contributing to differences in the uptake of prenatal genetic screening and diagnosis. Language barriers further exacerbate misunderstanding of prenatal genetic testing options. Mobile digital tools, including chatbots, provide an attractive alternative to in-person genetic counseling due to the near ubiquitous availability of mobile devices among patients and ability to ensure tailoring and standardization. Previous digital tools developed for prenatal genetic education showed promise, but most are instructional rather than interactive, computer-based rather than mobile-based, and do not include information on carrier screening currently recommended by ACOG. To address this critical need, a multidisciplinary team of perinatologists, genetic counselors, and digital health experts developed an innovative, patient-informed, mobile chatbot (iPrenatal) to simulate a text and audio-based counseling discussion about aneuploidy screening and diagnosis. Preliminary data from our randomized trial of 258 English-speaking pregnant women showed significantly higher post-intervention knowledge scores among patients who used iPrenatal compared with those who received routine provider education. We now propose to leverage this success by engaging users in formative work to create iPrenatal+ and provide all content in English and Spanish. We will evaluate iPrenatal+ in a randomized controlled trial of 1,470 pregnant women. Our specific aims are: Utilize human centered design to transform iPrenatal to an enhanced digital educational chatbot (iPrenatal+) for prenatal genetic counseling (Aim 1), Determine the effect of iPrenatal+ on patient knowledge and uptake of prenatal genetic testing, compared to in-person genetic counseling (Aim 2), and Assess the ability of iPrenatal+ to narrow the gap in knowledge and uptake of prenatal genetic screening between English-and Spanish-speaking patients, compared to in person genetic counseling (Aim 3).