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Yang C, Hu L, Jiang S, Liang F, Zhang S. Analysis of the impact of noninvasive prenatal testing for trisomies 21 and 18 in twin pregnancies undergoing artificial reproductive technology. Medicine (Baltimore) 2022; 101:e29985. [PMID: 35984138 PMCID: PMC9387948 DOI: 10.1097/md.0000000000029985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 06/12/2022] [Accepted: 06/22/2022] [Indexed: 01/05/2023] Open
Abstract
PURPOSE The purpose of this study was to evaluate the performance and impact of noninvasive prenatal screening (NIPS) on twin pregnancies. PATIENTS AND METHODS Twin pregnancies after artificial reproductive technology(ART) were tested by NIPS for screening trisomy 21, 18, and 13 in a single medical center in Hangzhou. Positive NIPS results were confirmed by karyotyping, while negative results were interviewed after delivery. RESULTS From January 2019 to December 2020, 474 twin pregnancies were tested by NIPS for screening trisomy 21, 18, and 13 in a single medical center in Hangzhou. The performance of NIPS had been evaluated compared to the invasive diagnostic results. The positive predictive value (PPV) of NIPS for chromosome 21 and 18 aneuploidies is 80% (95CI, 36.09-96.59) and 100%, respectively. The incidence of trisomy 21, and 18 chromosome aneuploidies among the twin pregnancies undergoing ART was 0.84% and 0.21%, respectively. CONCLUSION The performance of NIPS was substantially accurate among the twin pregnancies after ART in this study, and NIPS potentially avoided a considerable part of aneuploidies liveborn in twin pregnancies in Hangzhou.
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Affiliation(s)
- Cuiyu Yang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, China
| | - Linhua Hu
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, China
| | - Shudan Jiang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, China
| | - Fengbing Liang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, China
| | - Songying Zhang
- Assisted Reproduction Unit, Department of Obstetrics and Gynecology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Key Laboratory of Reproductive Dysfunction Management of Zhejiang Province, China
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Weiner CP, Weiss ML, Zhou H, Syngelaki A, Nicolaides KH, Dong Y. Detection of Embryonic Trisomy 21 in the First Trimester Using Maternal Plasma Cell-Free RNA. Diagnostics (Basel) 2022; 12:1410. [PMID: 35741220 PMCID: PMC9221829 DOI: 10.3390/diagnostics12061410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/03/2022] [Accepted: 06/04/2022] [Indexed: 11/16/2022] Open
Abstract
Prenatal trisomy 21 (T21) screening commonly involves testing a maternal blood sample for fetal DNA aneuploidy. It is reliable but poses a cost barrier to universal screening. We hypothesized maternal plasma RNA screening might provide similar reliability but at a lower cost. Discovery experiments used plasma cell-free RNA from 20 women 11−13 weeks tested by RNA and miRNA microarrays followed by qRT-PCR. Thirty-six mRNAs and 18 small RNAs of the discovery cDNA were identified by qPCR as potential markers of embryonic T21. The second objective was validation of the RNA predictors in 998 independent pregnancies at 11−13 weeks including 50 T21. Initial analyses identified 9−15 differentially expressed RNA with modest predictive power (AUC < 0.70). The 54 RNAs were then subjected to machine learning. Eleven algorithms were trained on one partition and tested on an independent partition. The three best algorithms were identified by Kappa score and the effects of training/testing partition size and dataset class imbalance on prediction were evaluated. Six to ten RNAs predicted T21 with AUCs up to 1.00. The findings suggest that maternal plasma collected at 11−13 weeks, tested by qRT-PCR, and classified by machine learning, may accurately predict T21 for a lower cost than plasma DNA, thus opening the door to universal screening.
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Affiliation(s)
- Carl P. Weiner
- Departments of Obstetrics and Gynecology and Molecular and Integrative Physiology, University of Kansas School of Medicine, Kansas City, KS 66160, USA;
- Rosetta Signaling Laboratory, Phoenix, AZ 85018, USA;
| | - Mark L. Weiss
- Departments of Anatomy and Physiology & Midwest Institute of Comparative Stem Cell Biology, Kansas State University, Manhattan, KS 66506, USA;
| | - Helen Zhou
- Departments of Obstetrics and Gynecology and Molecular and Integrative Physiology, University of Kansas School of Medicine, Kansas City, KS 66160, USA;
| | - Argyro Syngelaki
- Fetal Medicine Research Institute, King’s College Hospital, London SE5 9RS, UK; (A.S.); (K.H.N.)
| | - Kypros H. Nicolaides
- Fetal Medicine Research Institute, King’s College Hospital, London SE5 9RS, UK; (A.S.); (K.H.N.)
| | - Yafeng Dong
- Rosetta Signaling Laboratory, Phoenix, AZ 85018, USA;
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de Groot-van der Mooren M, de Graaf G, Weijerman ME, Hoffer MJV, Knijnenburg J, van der Kevie-Kersemaekers AMMF, Kooper AJA, Voorhoeve E, Sikkema-Raddatz B, van Zutven LJCM, Srebniak MI, Huijsdens-van Amsterdam K, Engelen JJM, Smeets D, van Kaam AH, Cornel MC. Does non-invasive prenatal testing affect the livebirth prevalence of Down syndrome in the Netherlands? A population-based register study. Prenat Diagn 2021; 41:1351-1359. [PMID: 34176145 PMCID: PMC8519113 DOI: 10.1002/pd.6003] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Revised: 06/06/2021] [Accepted: 06/17/2021] [Indexed: 11/25/2022]
Abstract
Objective To evaluate if non‐invasive prenatal testing (NIPT) affects livebirth (LB) prevalence of Down syndrome (DS) in the Netherlands. Method Data from clinical genetics laboratories and the Working Party on Prenatal Diagnosis and Therapy (2014–2018) and previous published data (1991–2013) were used to assess trends for DS LB prevalence and reduction percentage (the net decrease in DS LBs resulting from selective termination of pregnancies). Statistics Netherlands provided general population data. Results DS LB prevalence increased from 11.6/10,000 in 1991 to 15.9/10,000 in 2002 (regression coefficient 0.246 [95% CI: 0.105–0.388; p = 0.003]). After 2002, LB prevalence decreased to 11.3/10,000 in 2014 and further to 9.9/10,000 in 2018 (regression coefficient 0.234 (95% CI: −0.338 to −0.131; p < 0.001). The reduction percentage increased from 26% in 1991 to 55.2% in 2018 (regression coefficient 0.012 (95% CI: 0.010–0.013; p < 0.001)). There were no trend changes after introducing NIPT as second‐tier (2014) and first‐tier test (2017). Conclusions Introducing NIPT did not change the decreasing trend in DS LB prevalence and increasing trend in reduction percentage. These trends may be caused by a broader development of more prenatal testing that had already started before introducing NIPT.
What's already known about this topic?
The introduction of NIPT changed the landscape in prenatal screening worldwide. No long‐term population‐based study on the impact of NIPT on DS LB prevalence has been published.
What does this study add?
This study shows how to calculate DS LB prevalence in the absence of a national registration program. Introducing NIPT caused no trend changes in DS LB prevalence and reduction percentage in the Netherlands.
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Affiliation(s)
- Maurike de Groot-van der Mooren
- Department of Neonatology, Amsterdam Public Health and Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centres, location VUmc, Amsterdam, The Netherlands
| | - Gert de Graaf
- Dutch Down Syndrome Foundation, Meppel, The Netherlands
| | | | - Mariette J V Hoffer
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | - Jeroen Knijnenburg
- Department of Clinical Genetics, Leiden University Medical Centre, Leiden, The Netherlands
| | | | - Angelique J A Kooper
- Department of Clinical Genetics, Amsterdam University Medical Centres, location AMC, Amsterdam, The Netherlands
| | - Els Voorhoeve
- Department of Clinical Genetics, Amsterdam University Medical Centres, location VUmc, Amsterdam, The Netherlands
| | | | | | | | | | - John J M Engelen
- Department of Clinical Genetics, Research Institute Growth and Development (GROW), Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Dominique Smeets
- Department of Human Genetics, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Anton H van Kaam
- Department of Neonatology and Amsterdam Reproduction & Development Research Institute, Amsterdam University Medical Centres, location VUmc, Amsterdam, The Netherlands
| | - Martina C Cornel
- Department of Clinical Genetics and Amsterdam Public Health Research Institute, Amsterdam University Medical Centres, Vrije Universiteit Amsterdam, location VUmc, Amsterdam, The Netherlands
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MacDonagh L, Farrell L, O'Reilly R, McNally P, Javadpour S, Cox DW. Efficacy and adherence of noninvasive ventilation treatment in children with Down syndrome. Pediatr Pulmonol 2021; 56:1704-1715. [PMID: 33730448 DOI: 10.1002/ppul.25308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Revised: 01/01/2021] [Accepted: 01/20/2021] [Indexed: 01/30/2023]
Abstract
OBJECTIVE Children with Down syndrome (DS) have an increased prevalence of obstructive sleep apnea (OSA). Noninvasive ventilation (NIV) is a common modality of OSA treatment in this cohort. This study aimed to measure adherence and efficiency of NIV delivery in children with DS. STUDY DESIGN This was a retrospective cohort study involving 106 children with confirmed OSA and home NIV with downloadable data capacity. Children were divided into DS (n = 44) and non-DS cohorts (n = 62). Adherence, clinical outcomes apnea-hypopnoea index (AHI), positive airway pressure delivery, and leakage were recorded and compared between DS and non-DS cohorts and within the DS cohort based on past surgical history. RESULTS Significantly greater NIV usage was observed in the DS cohort, they showed more consistent use with an increased percentage of days used relative to their non-DS counterparts (78.95 ± 2.26 vs. 72.11 ± 2.14, p = .031). However, despite greater usage, poorer clinical outcomes in the form of increased AHI (p = .0493) was observed in the DS cohort, where significantly greater leakage was also shown 41.00 ± 1.61 L/min versus 36.52 ± 1.18 L/min (p = .022). Twenty children with DS had prior cardiac surgery; compliance across all parameters was significantly reduced relative to those without. CONCLUSION These data confirm that satisfactory NIV adherence is achievable in children with DS. However, we have identified excessive system leak at the machine-patient interface as a factor, which could undermine NIV efficacy in children with DS.
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Affiliation(s)
- Lauren MacDonagh
- School of Medicine, Department of Health Sciences, University College Dublin, Belfield, Dublin, Ireland
| | - Lisa Farrell
- Department of Respiratory, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Ruth O'Reilly
- Department of Respiratory, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Paul McNally
- Department of Respiratory, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Sheila Javadpour
- Department of Respiratory, Children's Health Ireland, Crumlin, Dublin, Ireland
| | - Des W Cox
- School of Medicine, Department of Health Sciences, University College Dublin, Belfield, Dublin, Ireland.,Department of Respiratory, Children's Health Ireland, Crumlin, Dublin, Ireland
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Ravitsky V, Roy MC, Haidar H, Henneman L, Marshall J, Newson AJ, Ngan OMY, Nov-Klaiman T. The Emergence and Global Spread of Noninvasive Prenatal Testing. Annu Rev Genomics Hum Genet 2021; 22:309-338. [PMID: 33848430 DOI: 10.1146/annurev-genom-083118-015053] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
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.
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Affiliation(s)
- Vardit Ravitsky
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Quebec H3C 3J7, Canada;
| | - Marie-Christine Roy
- Department of Social and Preventive Medicine, School of Public Health, University of Montreal, Quebec H3C 3J7, Canada;
| | - Hazar Haidar
- Institute for Health and Social Policy, McGill University, Montreal, Quebec H3A 1A3, Canada;
| | - Lidewij Henneman
- Department of Clinical Genetics, Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, 1081 BT Amsterdam, The Netherlands;
| | - John Marshall
- United Kingdom National Screening Committee, London SE1 8UG, United Kingdom;
| | - Ainsley J Newson
- Sydney Health Ethics, Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales 2006, Australia;
| | - Olivia M Y Ngan
- Centre for Bioethics, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China;
| | - Tamar Nov-Klaiman
- Department of Sociology and Anthropology, Ben-Gurion University of the Negev, Beer-Sheva 8410501, Israel;
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Bunnik EM, Kater-Kuipers A, Galjaard RJH, de Beaufort I. Why NIPT should be publicly funded. JOURNAL OF MEDICAL ETHICS 2020; 46:783-784. [PMID: 32277019 PMCID: PMC7656139 DOI: 10.1136/medethics-2020-106218] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Accepted: 03/26/2020] [Indexed: 05/16/2023]
Abstract
Asking pregnant women to (co)pay for non-invasive prenatal testing (NIPT) out of pocket leads to unequal access across socioeconomic strata. To avoid these social justice issues, first-trimester prenatal screening should be publicly funded in countries such as the Netherlands, with universal coverage healthcare systems that offer all other antenatal care services and screening programmes free of charge. In this reply, we offer three additional reasons for public funding of NIPT. First, NIPT may not primarily have medical utility for women and children, but rather offers relevant information and reproductive options, and thus serves important autonomy interests of women. Second, public funding of NIPT can be justified because it results in a reduction of collectively borne costs associated with care and support for children with chromosomal abnormalities. It is important to note that this is not an argument for individual women to take part in screening or to terminate an affected pregnancy. However, it is a legitimate argument in policy making regarding funding arrangements for screening programmes. Finally, public funding would help to amend current misunderstandings among pregnant women (eg, that they are not at risk), and thus to support informed consent for first-trimester prenatal screening.
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Affiliation(s)
- Eline Maria Bunnik
- Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Adriana Kater-Kuipers
- Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Clinical Genetics, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Inez de Beaufort
- Medical Ethics, Philosophy and History of Medicine, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
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He Y, Wang Y, Li Z, Chen H, Deng J, Huang H, He X, Zeng W, Liu M, Huang B, Chen P. Clinical performance of non-invasive prenatal testing for trisomies 21, 18 and 13 in twin pregnancies: A cohort study and a systematic meta-analysis. Acta Obstet Gynecol Scand 2020; 99:731-743. [PMID: 32166736 DOI: 10.1111/aogs.13842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2019] [Revised: 02/25/2020] [Accepted: 03/10/2020] [Indexed: 12/14/2022]
Abstract
INTRODUCTION The objective of this study was to report on the clinical performance of non-invasive prenatal testing (NIPT) for trisomies 21, 18 and 13 in twin pregnancies and to define the performance of NIPT by combining our cohort study results with published studies in a systematic meta-analysis. MATERIAL AND METHODS A cohort study was carried out in the First Affiliated Hospital of Sun Yat-sen University and Kanghua Hospital. Meanwhile, searches of PubMed, EMBASE, The Cochrane Library and Web of Science for all relevant peer-reviewed articles were performed with a restriction to English language publication before 15 June 2019. Quality assessments were conducted with the Quality Assessment Tool for Diagnostic Accuracy Studies-2 checklist. Data analysis, heterogeneity, subgroup analysis and publication bias were carried out using META-DISC 1.4 and STATA 12.0. RESULTS In all, 141 twin pregnancies included in our cohort study; confirmation revealed one true-positive case for trisomy 21 and 140 true-negative cases. The sensitivity and specificity for trisomy 21 by NIPT were both 100%. Twenty-two eligible studies were enrolled in this meta-analysis together with our study. There were 199 cases of trisomy 21, 58 cases of trisomy 18, 14 cases of trisomy 13 and 6347 cases of euploids in total. For trisomy 21, NIPT showed the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 0.99, 1.00, 145.81, 0.06 and 1714.09, respectively. For trisomy 18, the pooled sensitivity, specificity, positive likelihood ratio, negative likelihood ratio and diagnostic odds ratio were 0.88, 1.00, 200.98, 0.19 and 483.68, respectively. CONCLUSIONS The performance of NIPT for trisomy 21 in twin pregnancy was excellent and it was similar to that reported in singleton pregnancy. However, due to publication bias (trisomy 18) and small number of cases (trisomy 13), accurate assessment of the predictive performance of NIPT for trisomies 18 and 13 could not be achieved.
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Affiliation(s)
- Yuting He
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Yichong Wang
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Zhuyu Li
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Haitian Chen
- Department of Obstetrics and Gynecology, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Jiankai Deng
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Hao Huang
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Xiaohong He
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Wentao Zeng
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Min Liu
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Bin Huang
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
| | - Peisong Chen
- Department of Clinical Laboratory, The First Affiliated Hospital, Sun Yat-sen University, Guangzhou, China
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Bunnik EM, Kater-Kuipers A, Galjaard RJH, de Beaufort ID. Should pregnant women be charged for non-invasive prenatal screening? Implications for reproductive autonomy and equal access. JOURNAL OF MEDICAL ETHICS 2020; 46:194-198. [PMID: 31527142 PMCID: PMC7042959 DOI: 10.1136/medethics-2019-105675] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 09/02/2019] [Accepted: 09/09/2019] [Indexed: 05/28/2023]
Abstract
The introduction of non-invasive prenatal testing (NIPT) in healthcare systems around the world offers an opportunity to reconsider funding policies for prenatal screening. In some countries with universal access healthcare systems, pregnant women and their partners are asked to (co)pay for NIPT. In this paper, we discuss two important rationales for charging women for NIPT: (1) to prevent increased uptake of NIPT and (2) to promote informed choice. First, given the aim of prenatal screening (reproductive autonomy), high or low uptake rates are not intrinsically desirable or undesirable. Using funding policies to negatively affect uptake, however, is at odds with the aim of screening. Furthermore, copayment disproportionally affects those of lower socioeconomic status, which conflicts with justice requirements and impedes equal access to prenatal screening. Second, we argue that although payment models may influence pregnant women's choice behaviours and perceptions of the relevance of NIPT, the copayment requirement does not necessarily lead to better-informed choices. On the contrary, external (ie, financial) influences on women's personal choices for or against prenatal screening should ideally be avoided. To improve informed decision-making, healthcare systems should instead invest in adequate non-directive, value-focused pretest counselling. This paper concludes that requiring (substantial) copayments for NIPT in universal access healthcare systems fails to promote reproductive autonomy and is unfair.
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Affiliation(s)
- Eline M Bunnik
- Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Adriana Kater-Kuipers
- Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Inez D de Beaufort
- Medical Ethics and Philosophy of Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
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