Informed decision-making about prenatal cfDNA screening: An assessment of written materials

Do non-invasive prenatal tests promote discrimination against people with Down syndrome? What should be done?

By implementation of non-invasive prenatal testing (NIPT) for the diagnosis of Down syndrome (DS) in maternity care, an ethical debate is newly inflamed how to deal with this information. Fears of the consequences of an increased use of NIPT are justified with the same arguments when amniocentesis and preimplantation genetic diagnosis (PGD) were introduced decades ago. It can be expected that the prevalence of people with DS would significantly increase in Western societies as a result of the increasing age of pregnant women and the improved medical care for people with DS. The net effect as to whether an increasing uptake of NIPT will result in more abortions of fetuses with trisomy 21 cannot be reliably estimated. This holds true since more and more couples will use results of NIPT for information only, but will not opt for termination of pregnancy. Although parents love their children with DS, in a society where reproductive autonomy is seen as an achievement, access to NIPT cannot be limited. On this background, comprehensive and qualified pretest counseling is vital, also to avoid possible stigmatization of people with DS and as the resulting consequence to avoid feared deterioration in their living conditions, for which, however, there is no evidence to date. The personal view of a mother of a child with DS illustrates the complexity in dealing with NIPT, which does not allow simple answers and must be understood as a challenge for society as a whole.

Counselling and education for prenatal screening and diagnostic tests for pregnant women: Randomized controlled trial

AIM

The aim of this study is to evaluate the effect of education and counselling on prenatal screening and diagnostic tests on pregnant women's decisional conflict, anxiety levels and attitudes towards the tests.

BACKGROUND

Clinical practice guidelines recommend prenatal genetic counselling for pregnant women before participation in the tests.

METHODS

A total of 210 pregnant women participated in the study by completing the State-Trait Anxiety Inventory-I, Decisional Conflict Scale, SURE Scale, Knowledge Assessment Forms, Decision Satisfaction Form and Attitudes Scale between June 2017 and March 2018. In the first stage, pregnant women were evaluated who had only prenatal genetic screening tests and in the second stage, pregnant women who had been recommended to receive diagnostic tests. The intervention group received face-to-face individual education and counselling about prenatal genetic tests. Independent samples t test, t tests and Pearson correlation tests were used.

RESULTS

Education and counselling for prenatal screening tests and diagnostic tests from the first weeks of pregnancy were effective in decreasing anxiety, decisional conflict, increasing attitudes towards tests and had positive effects on pregnant women's knowledge level and decision satisfaction (P < 0.005).

CONCLUSION

Prenatal genetic counselling and education are more effective if provided from the first weeks of pregnancy. Decreasing anxiety, decisional conflict and increasing knowledge levels of pregnant women are important to make informed decisions.

The Emergence and Global Spread of Noninvasive Prenatal Testing

Since its introduction in 2011, noninvasive prenatal testing (NIPT) has spread rapidly around the world. It carries numerous benefits but also raises challenges, often related to sociocultural, legal, and economic contexts. This article describes the implementation of NIPT in nine countries, each with its own unique characteristics: Australia, Canada, China and Hong Kong, India, Israel, Lebanon, the Netherlands, the United Kingdom, and the United States. Themes covered for each country include the structure of the healthcare system, how NIPT is offered, counseling needs and resources, and cultural and legal context regarding disability and pregnancytermination. Some common issues emerge, including cost as a barrier to equitable access, the complexity of decision-making about public funding, and a shortage of appropriate resources that promote informed choice. Conversely, sociocultural values that underlie the use of NIPT vary greatly among countries. The issues described will become even more challenging as NIPT evolves from a second-tier to a first-tier screening test with expanded use.

Prenatal Genetic Screening and Potential Complicity in Abortion: Considerations for Catholic Health Care

Prenatal genetic screening (PGS) is commonplace in the United States and in some parts of the world. The commonly held rationale for screening is to respect patient autonomy and to either allow the mother the opportunity to prepare herself to parent a child with a genetic disorder or to abort. As a result, PGS combined with prenatal diagnostic testing followed by abortion has significantly reduced the number of babies born with Down syndrome, for example, and, furthermore, has raised concerns about discrimination against persons with disabilities and eugenics. Although Catholic teaching clearly prohibits PGS and testing when undertaken with the intention of abortion, screening routinely is performed in Catholic health care, sometimes without regard to intent. This essay explores the issue of PGS in Catholic health care and suggests the development of a policy designed to support morally legitimate use of screening through an educational and informed consent process and attestation as to intent so as to prevent abortion or at least avoid complicity in it. Although the issue applies to prenatal testing as well as screening and for a variety of disorders as well as gender, this essay limits itself to a discussion of first trimester screening and a focus on Down syndrome. Objections to such a policy are discussed.

Imaginaries as infrastructures? The emergence of non-invasive prenatal testing in Austria

Non-invasive prenatal testing (NIPT) is a new technology used in prenatal testing (PT) that capitalizes on genomic platforms to transform DNA fragments in the blood of pregnant women into information about the genome of a foetus. Since its market introduction in 2011, it has travelled around the globe with remarkable speed. This article engages with the emergence of NIPT in and around Vienna, the capital city of Austria, to explore why and how this technology could travel so quickly in practice. Based on a qualitative analysis of interviews, documents, and field notes, it argues, first, that NIPT could travel so quickly because it travelled as ‘adaptable boxes’ that added on to different ‘local worlds of prenatal testing (PT)’, without disrupting them. Second, in so doing, NIPT could travel on a moral and material ground, or an ‘imaginary of PT’, built in the past. Third, the article argues that elements of this imaginary were also mobilized by commercial pioneers of NIPT, who ‘infrastructurized’ extant values, practices, and networks among biomedical professionals. Thus, various actors converged in mobilizing moral and material elements of an imaginary, transforming them into an infrastructure that facilitated the travels of NIPT, while also shaping its use.

Trends in the use of prenatal testing services for fetal aneuploidy in Ontario: a descriptive study

BACKGROUND

In 2014, Ontario augmented its publicly funded multiple-marker screening program for prenatal aneuploidy by incorporating cell-free fetal DNA (cffDNA) analysis for high-risk pregnancies. We assessed trends in the use of multiple-marker screening, cffDNA screening and prenatal diagnostic testing before and after implementation of public funding.

METHODS

We conducted a descriptive study based on data from the Better Outcomes Registry & Network (BORN) Ontario. The study population included all pregnant women in Ontario with a singleton pregnancy and an expected date of delivery between July 1, 2012, and Mar. 31, 2016, with pregnancy data captured in BORN. Pregnancy losses and terminations before 20 weeks' gestation not captured in BORN were excluded. We generated descriptive statistics to show trends and regional variations in use.

RESULTS

The study sample included 534 210 singleton pregnancies. After cffDNA screening was funded for specific indications, uptake of multiple-marker screening increased slightly, from 66.5% to 68.1% (p < 0.001). Uptake of cffDNA screening among women with a positive multiple-marker screening result increased substantially, from 3.2% to 48.8% (p < 0.001). In contrast, the rate of prenatal diagnostic testing in this group decreased from 54.8% to 30.8% (p < 0.001). Although women aged 40 years or older are eligible for primary cffDNA screening, only a small decrease in the use of multiple-marker screening was observed in this group. The greatest use of cffDNA screening and greatest decline in prenatal diagnostic testing were seen in women with a level of risk for trisomy 21 of 1:101-1:200 based on multiple-marker screening.

INTERPRETATION

After public funding of cffDNA screening was implemented in Ontario, there was a significant increase in cffDNA screening and a significant decrease in prenatal diagnostic testing among women with a positive multiple-marker screening result. These changing patterns show the significant impact of public policy and funding decisions on women's choices regarding prenatal testing.

What education, background, and credentials are required to provide genetic counseling?

Technological advances in genetics have resulted in an increase in the number and complexity of screening and diagnostic tests in the prenatal clinical arena. It is critical that patients are provided with appropriate counseling to enable them to make educated decisions. During this workshop session participants discussed the education, background and credentials required to provide counseling regarding prenatal genetic testing options. The participants agreed that prenatal care providers may have limited time and training to adequately address prenatal genetic testing. Telemedicine and online education may help to address this challenge. Workshop participants agreed that educational and certifying organizations should work together to develop standards for the certification and maintenance of certification processes.

Expanding Use of cfDNA Screening in Pregnancy: Current and Emerging Ethical, Legal, and Social Issues

Purpose of Review

In 2011, screening platforms became available in the US that detect and analyze fragments of cell-free placental DNA (cfDNA) in maternal blood serum. Marketed as noninvasive prenatal tests (NIPT), cfDNA screening is more accurate than previously available serum screening tests for certain aneuploidies. The combination of a noninvasive procedure, high specificity and sensitivity, and lower false positive rates for some aneuploidies (most notably Down's syndrome) has led to broad clinician and patient adoption. New ethical, legal, and social issues arise from the increased use and expanded implementation of cfDNA in pregnancy.

Recent Findings

Recently, several professional associations have amended their guidelines on cfDNA, removing language recommending its use in only "high-risk" pregnancies in favor of making cfDNA screening an available option for women with "low-risk" pregnancies as well. At the same time, commercial cfDNA screening laboratories continue to expand the range of available test panels. As a result, the future of prenatal screening will likely include a broader range of genetic tests in a wider range of patients.

Summary

This article addresses the ethical, legal, and social issues related to the shift in guidance and expanded use of cfDNA in pregnant women, including concerns regarding routinized testing, an unmet and increasing demand for genetic counseling services, social and economic disparities in access, impact on groups living with disabling conditions, and provider liability.

Attitudes towards non-invasive prenatal diagnosis among obstetricians in Pakistan, a developing, Islamic country

OBJECTIVES

Stakeholders' views are essential for informing implementation strategies for non-invasive prenatal testing (NIPT). Little is known about such views in developing countries. We explored attitudes towards NIPT among obstetricians in Pakistan, a developing, Islamic country.

METHODS

A 35-item questionnaire was distributed and collected at eight events (a national conference and seven workshops in five cities) for obstetric professionals on advances in fetal medicine.

RESULTS

Responses from 113 obstetrician show positive attitudes towards implementation of NIPT: 95% agreed prevention of genetic conditions was a necessity, and 97% agreed public hospitals should provide prenatal screening tests. However, participants also agreed the availability of NIPT would increase social pressure on women to have prenatal screening tests and to terminate an affected pregnancy (53% and 63%, respectively). Most participants would not offer NIPT for sex determination (55%), although 31% would. The most valued aspects of NIPT were its safety, followed by its utility and then accuracy.

CONCLUSION

Participants generally supported the implementation of NIPT but raised concerns about social implications. Therefore, national policy is needed to regulate the implementation of NIPT, and pretest information and post-test genetic counselling are needed to mitigate social pressure and support parents to make informed decisions. © 2017 John Wiley & Sons, Ltd.

Impact of the increased adoption of prenatal cfDNA screening on non-profit patient advocacy organizations in the United States

The 'Stakeholder Perspectives on Noninvasive Prenatal Genetic Screening' Symposium was held in conjunction with the 2015 annual meeting of the International Society for Prenatal Diagnosis. During the day-long meeting, a panel of patient advocacy group (PAG) representatives discussed concerns and challenges raised by prenatal cell-free DNA (cfDNA) screening, which has resulted in larger demands upon PAGs from concerned patients receiving prenatal cfDNA screening results. Prominent concerns included confusion about the accuracy of cfDNA screening and a lack of patient education resources about genetic conditions included in cfDNA screens. Some of the challenges faced by PAGs included funding limitations, lack of consistently implemented standards of care and oversight, diverse perspectives among PAGs and questions about neutrality, and lack of access to training and genetic counselors. PAG representatives also put forward suggestions for addressing these challenges, including improving educational and PAG funding and increasing collaboration between PAGs and the medical community. © 2016 John Wiley & Sons, Ltd.