Introduction
Non-invasive prenatal testing (NIPT) using cell-free placental DNA is increasingly being used to test for fetal aneuploidy. By using a maternal blood sample, NIPT can test for Down syndrome with a sensitivity of more than 99 % and a false-positive rate of less than 0.1 % (Gil et al.
2015). For women with an elevated risk based on the first-trimester combined test (FCT), NIPT is a safe alternative to invasive testing, although invasive testing will be required to confirm a positive NIPT result. Due to its high accuracy, NIPT can also be used as a first-tier screening test for all pregnant women, thereby replacing the FCT (Benn et al.
2015), although the positive predictive value is significantly lower in lower-risk women as compared to high-risk women (Norton et al.
2015). The introduction of this innovative test is having great impact on the prenatal landscape. Furthermore, it has been proven possible to scan the whole fetal genome with NIPT (Lo et al.
2010), so future use is likely to expand to testing for a wider range of genetic disorders.
Several studies have investigated the attitudes towards NIPT of important stakeholders such as health professionals and pregnant women. Overall, these studies show that both pregnant women (Farrell et al.
2014; Lewis et al.
2013; van Schendel et al.
2014) and health professionals (Musci et al.
2013; Tamminga et al.
2015) have great interest in NIPT due to its ability to test early in pregnancy with high accuracy and no miscarriage risk. However, concerns were expressed about potential “routinized” or uncritical use of NIPT, women feeling pressure to test, and the possible impact of NIPT on acceptance of people with a disability (Lewis et al.
2013; van Schendel et al.
2014). Alongside these concerns, the introduction of NIPT in routine prenatal care has been criticized (Kaposy
2013), on the basis of the disability rights critique (Kaposy
2013; Parens and Asch
2003). It has been argued that prenatal screening for Down syndrome sends out a message that emphasizes the negative aspects of living with Down syndrome, and implementing NIPT runs counter to the hope of improving attitudes towards Down syndrome (Kaposy
2013).
Very little is known about what parents of children with Down syndrome think about prenatal screening and, in particular, about NIPT. Using an online survey, Kellogg et al. (
2014) studied the attitudes of 73 US mothers of children with Down syndrome towards NIPT. They showed that the majority of mothers agreed that NIPT should be available to all pregnant women, and that NIPT was a good thing because it allows people to prepare themselves for a child with Down syndrome. However, most of the mothers also expected NIPT to cause an increase in pressure to test and in social stigma for having a child with Down syndrome (Kellogg et al.
2014). When looking at the attitudes of parents of children with Down syndrome towards prenatal testing in general, it seems that most believe prospective parents should have autonomy and reproductive freedom (Inglis et al.
2012; Scott et al.
2013). However, studies have shown cultural and religious differences in attitudes towards prenatal testing and termination of pregnancy amongst parents of children with Down syndrome (Ahmed et al.
2013; Bryant et al.
2011). A study of 78 women who had a sibling with Down syndrome showed that they overall had a positive experience of having a brother or sister with this condition, but around one-third would still consider prenatal testing and termination of pregnancy since they experienced a negative impact on themselves and their family (Bryant et al.
2005).
Decisions in a national screening system need political support, thus taking account of many perspectives. Since the introduction of NIPT could have an impact on the way society perceives Down syndrome and the lives of people living with this condition, it is important to further investigate what parents of children with Down syndrome think about introducing NIPT into a national prenatal screening system and which consequences they think this will have. This information can be used to establish a responsible implementation of NIPT, taking account of all stakeholder perspectives. This study therefore addresses the following research questions: 1) What do parents of children of Down syndrome think are the advantages and disadvantages of using NIPT for prenatal screening?; 2) What are important requirements for a responsible NIPT offer according to them?; and 3) What do they think about widening the scope of prenatal testing with NIPT?
This study was performed in the Netherlands, where the uptake of prenatal screening for Down syndrome (and trisomy 18 and 13) is relatively low (~27 %) (Schielen
2010) compared to nearby countries like Denmark (90 %) (Ekelund et al.
2011) or England (74 %) (National Health Service
2012). The low uptake of screening might be partially explained by the way screening is offered to women, with a clear emphasis on the “right not to know,” women having to pay for FCT (Crombag et al.
2014), and the rather positive attitudes towards Down syndrome in the Netherlands (Bakker et al.
2012; Crombag et al.
2016).
Methods
A qualitative research design was used. Focus groups were formed to explore multiple perspectives and to stimulate discussion. Additional individual, semi-structured interviews were held to allow for a more private environment to explore the attitudes and (often emotional) experiences of parents of children with Down syndrome. Ethical approval for this study was obtained from the Medical Ethical Committee of the VU University Medical Center Amsterdam (VUMC). Informed consent was obtained from all individual participants included in the study.
Participants
Participants were recruited with help of the Dutch Genetic Alliance (VSOP). An invitation for participation was placed on the website of the Dutch Down Syndrome Foundation (SDS, parent organization). As this produced no responses, another invitation was placed on a closed Facebook group consisting of about 900 members sharing experiences of having a child with Down syndrome. In total, 58 parents responded to the invitation, and two parents were recruited through the researchers’ network. A total of 27 people took part in the study; 16 participated in the three focus groups (each consisting of 5 to 6 participants) and 11 in an individual interview. The parents who participated in the focus groups were not related. Two of the focus group participants were not parents but relatives of a child with Down syndrome (sister and aunt). Participant characteristics are summarized in Table
1. After three focus groups and 11 interviews no new information was obtained, and therefore data saturation was reached.
Table 1
Characteristics of participants in the three focus groups and individual interviews
Sex |
Female | 14 | 9 |
Male | 2 | 2 |
Mean age, years (range) | 39.7 (29–50) | 41.1 (31–48) |
Level of educationa
|
Low | 0 | 0 |
Medium | 1 | 4 |
High | 15 | 7 |
Religion | | |
None | 12 | 9 |
Christian | 4 | 2 |
Mean number of children (range) | 2 (0–3) | 2 (1–4) |
Number of children with DS |
0 | 2b
| 0 |
1 | 13 | 10 |
2 | 1 | 1 |
Mean age of child with DS, years (range) | 6 (1–17) | 6 (1–16) |
Prenatal screening during pregnancy of child with DS |
Yes:
| | |
Low-risk FCT result | 2 | 2 |
Low-risk FCT result, invasive test after ultrasound abnormality | 1 | 0 |
High-risk FCT result, no invasive test | 2 | 0 |
High-risk FCT result, invasive test | 0 | 1 |
FCT (result unknown) | 1 | 0 |
No:
| | |
Not interested | 5 | 7 |
Not offered | 3 | 0 |
Declined screening because of the costs | 0 | 1 |
Not applicable:
| 2b
| 0 |
Instrumentation and Procedures
In April 2014 NIPT became available in the Netherlands in public healthcare as a second-tier screening test. The first two focus groups were conducted prior to this period, in September 2013, in a community center in the middle of the Netherlands (Utrecht). The last focus group was in April 2015 at the VUMC in Amsterdam. The individual interviews were conducted by A.K.K. between March and April 2015, and took place at participants’ home, workplace or by telephone.
The focus group sessions were conducted using a semi-structured interview guide based on the one used in our previous study of pregnant women and their partners (van Schendel et al.
2014). The guide included the following topics: participants’ perceptions of the current Down syndrome screening using the FCT and invasive tests; perceptions of the advantages and disadvantages of NIPT, especially when NIPT would become available as a first-tier screening test; and opinions about testing for a wider range of disorders using NIPT. Via a PowerPoint presentation, participants were given a brief explanation of the characteristics of the current screening program and characteristics of NIPT, including testing for more genetic disorders. The focus groups were managed by an experienced moderator, together with an assistant taking notes and observing group interactions. For the individual interviews, the same semi-structured interview protocol, with some minor changes, was used. During the individual interviews, information about the current screening program and NIPT was provided verbally, supported by illustrations.
Data Analysis
Focus groups and interviews were audiotaped and transcribed verbatim. After transcription, a thematic content analysis was performed using the qualitative software program ATLAS.ti 5.2. Responses in the text were coded independently by R.v.S. and A.K.K., and ranked and clustered into main topics and subtopics in order to identify important themes. Themes and codes were discussed with a third researcher (L.H.), and discrepancies were discussed until consensus was reached. Representative quotes from the focus groups (FG) and interviews (I) were translated from Dutch and are presented to illustrate the themes.
Discussion
Parents of children with Down syndrome considered the accuracy, safety and possibility to test earlier as advantages of using NIPT in prenatal screening. However, they thought that prenatal screening in general, and the use of NIPT in particular, put too much focus on Down syndrome, making it seem like Down syndrome is the worst thing that can happen to one’s child. They expected that NIPT would lower the barrier for participation in screening, which has both advantages and disadvantages. Participants argued that NIPT gives people a more accurate option to test for Down syndrome without having to risk a miscarriage; but because of that, testing for Down syndrome and terminating the pregnancy could also become more normal. They feared the latter could erode the acceptance, facilities and research for Down syndrome, which in turn leaves women with little room to decline testing (self-reinforcing process illustrated in Fig.
1). Participants stated that, when implementing NIPT, the counseling should be improved by giving more balanced, accurate information, including more information about living with Down syndrome. Although participants assumed that testing for more disorders with NIPT diverts the focus away from Down syndrome and allows for early medical intervention, they worried about where to draw the line. They also feared a loss of diversity in society.
This study describes the views of a sample of parents and relatives of children with Down syndrome in the Netherlands, a country with relatively low uptake of prenatal screening. When compared with the attitudes of pregnant women in the Netherlands as well as pregnant women in other countries (Farrell et al.
2014; Lewis et al.
2013; van Schendel et al.
2014), it seems that parents of children with Down syndrome often perceive similar advantages and disadvantages of NIPT. Like pregnant women, they believe NIPT lessens the barrier for participation in screening because it is a simple and safe test that can be done early in pregnancy. Similar to the study by Kellogg et al. (
2014) of mothers of children with Down, participants agreed the lower barrier is beneficial because it allows people to test without risk and decide, after confirmation, whether or not to continue the pregnancy based on that information.
The notion that it could also lead to an increase in termination of pregnancies also corresponds to findings of Kellogg et al. (
2014), where the majority believed NIPT would lead to the termination of more pregnancies. A study by Natoli et al. (
2012) on termination rates after a Down syndrome diagnosis showed that higher termination rates were associated with earlier gestational age. This finding supports the assumption that NIPT’s ability to test earlier could lead to more termination of pregnancies, although others have suggested that with NIPT the percentage of women who opt for termination of pregnancy in the case of an affected pregnancy may decrease (Verweij et al.
2013).
The fear expressed by participants that fewer children with Down syndrome being born could lead to stigmatization and fewer facilities, is a concern that was also observed in several other studies (Allyse et al.
2015; Haider et al.
2016; Lewis et al.
2013; van Schendel et al.
2014). Due to the lower barrier for NIPT, participants indicated that good quality counseling and informed decision-making are of great importance. This awareness also exists amongst health professionals, for example, genetic counselors from the UK, who stated that because NIPT has the potential to become routinized, it is the professional’s role to make sure that women understand what they are consenting to (Alexander et al.
2014).
To help healthcare professionals facilitate meaningful discussions between themselves and prospective parents, Sachs et al. (
2015) have developed a framework for pre-test counseling about NIPT, especially focusing on its capabilities and limitations. Participants in our study, however, felt that already in current screening practice, information and counseling were not up to standard. They were especially critical of the quality of the information about Down syndrome given at different stages of the screening trajectory. Studies in other countries suggest that knowledge of Down syndrome among healthcare professionals could be improved (Ternby et al.
2015a), and that some parents perceive the information about what it may mean to live with this condition, both for the individual and for the parents, as insufficient (Carroll et al.
2012; Ternby et al.
2015b) or overly negative (Kellogg et al.
2014). It was also noted that the information leaflets for those considering screening for Down syndrome should provide more accurate information about this (Saiklang and Skirton
2015). Participants in our study thought that parents of children with Down syndrome could play a valuable role in this respect as well.
Similar to pregnant women (van Schendel et al.
2014), parents of children with Down syndrome think that testing for more disorders with NIPT can have some advantages. Interestingly, one of the advantages mentioned was that it would shift the focus away from Down syndrome, thus avoiding the impression of Down syndrome as a disorder for which screening would somehow be more justified than for other (including more serious) conditions, something that many of these parents find unjust and hurtful. Participants, however, feared testing for more disorders would confront prospective parents with even more difficult decisions. This fear was also expressed in our previous questionnaire study of Dutch pregnant women, who stated that “testing for a broad range of disorders may complicate the decision-making process beyond what most couples are able to comprehend” (van Schendel et al.
2015). Although it was not explicitly mentioned in this study, widening the scope of testing will also make it increasingly difficult to meaningfully discuss prior to testing what it is like to have a child with any of the conditions screened for. Participants in our study also feared a loss of diversity in society, which is in line with findings from a previous study in the UK that highlighted public fears of fueling a problematic quest for perfection if NIPT were to be used to screen for an ever wider range of disorders (Kelly and Farrimond
2012).
Study Limitations and Research Recommendations
A strength of this study is the qualitative approach, which allows for exploring in-depth views about NIPT. Using both focus groups and individual interviews allowed us to explore opinions in both a group context and more private environments, which strengthened the credibility of the results. As far as we know, this is the first qualitative study of the attitudes of parents of Down syndrome children towards NIPT. A limitation of the study is that almost all participants were recruited from one source, a Facebook group which consisted of people with relatively young children. Moreover, participants were Caucasian and highly educated. This might have led to biased responses. Additionally, previous discussions on this Facebook page might have influenced participants’ opinions. Moreover, attitudes of parents might have been influenced by the strongly articulated opinions in the Dutch media. In the focus group and individual interviews held in 2015, participants seemed more negative about NIPT than in the focus groups in 2013. However, the sample size is too small to draw conclusions on this point. The study was conducted in the Netherlands, where prenatal testing is offered in a nationally organized prenatal screening system, the uptake of which is relatively low. Attitudes of participants in this study may thus vary from those living in countries where NIPT is offered by individual (commercial) healthcare providers, or in countries with other cultures and religions. Finally, qualitative data are not intended to be generalized to the population of interest. Future studies might include larger samples of males and females. Moreover, should NIPT be introduced as a first-tier screening test, it would be interesting to see whether and how it affects parents’ opinions.
Conclusion and Practice Implications
The findings from this study provide insight into the expectations and concerns that parents of children with Down syndrome have about introducing NIPT into a national prenatal screening system. It can be concluded that parents of children with Down syndrome may have ambivalent attitudes towards NIPT. While they do not necessarily all agree with prenatal screening, they do acknowledge that NIPT offers a better option than the combined test to know whether the fetus has Down syndrome. However, they also expressed concerns for the future of children with Down syndrome and emphasized the need for good counseling and information provision, including more information about living with Down syndrome.