Should pregnant women be charged for non-invasive prenatal screening? Implications for reproductive autonomy and equal access

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.

Implementation challenges for an ethical introduction of noninvasive prenatal testing: a qualitative study of healthcare professionals’ views from Lebanon and Quebec

“…The comparison of our findings in Lebanon and in Quebec points out the reasons underlying a similar concern raised by the routinization of NIPT: the potential increase in pregnancy terminations, which has been as well reported in other studies [36,37]. Since prenatal testing is inevitably linked to the abortion debate -as it may lead couples and pregnant women to consider whether to continue or terminate a pregnancy, abortion policy in place is of utmost relevance.…”

Why NIPT should be publicly funded

“…Third, public funding may help to improve informed decision making and restore correct understandings of the target group of first-trimester screening programmes in countries like the Netherlands, with universal coverage healthcare systems. As we have argued, funding policies are not neutral: 1 by offering NIPT free of charge, the state may be seen to support or endorse screening, and, vice versa, by requesting a (co)payment, the state may be seen to discourage screening or deem it unimportant. The latter is of particular concern in our country.…”

“…In a recent paper in Journal of Medical Ethics , we have shown that policies requiring pregnant women to (co)pay for non-invasive prenatal testing (NIPT) raise financial barriers that will not improve informed decision making. 1 Also, they may exacerbate problems regarding equity of access to prenatal screening by disproportionally affecting women of lower socioeconomic status. 1 In a response, Dagmar Schmitz rightfully points out that the paper does not, however, provide a justification for public funding of NIPT tout court.…”

“… 1 Also, they may exacerbate problems regarding equity of access to prenatal screening by disproportionally affecting women of lower socioeconomic status. 1 In a response, Dagmar Schmitz rightfully points out that the paper does not, however, provide a justification for public funding of NIPT tout court. 2 Why should NIPT be collectively funded, Schmitz asks, in societies that seem to harbour a ‘growing unease’ with the introduction of NIPT, which is perceived to convey discriminatory messages especially about Down syndrome and is ‘obviously distressing for some’?…”

Why public funding for non-invasive prenatal testing (NIPT) might still be wrong: a response to Bunnik and colleagues

“…Bunnik and colleagues made an important contribution to a highly topical debate concerning ethical aspects of funding policies for prenatal screening 1. However, their case for public funding of non-invasive prenatal testing (NIPT) is not completely convincing.…”