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Schaa KL, Biesecker BB. Where is the "counseling" in prenatal genetic counseling? PATIENT EDUCATION AND COUNSELING 2024; 124:108278. [PMID: 38593481 DOI: 10.1016/j.pec.2024.108278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Revised: 03/16/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE Prenatal genetic testing is routinely offered to all pregnant patients in the United States and is variably offered to certain pregnant populations globally [1]. To achieve value-based, informed decision-making, we argue for a shift away from the predominant "teaching" model of genetic counseling practice that prioritizes information and counselor dominance, toward a "counseling" model of practice that prioritizes the patient's narrative, values and beliefs. DISCUSSION Since prenatal testing began, genetic counseling has aimed to facilitate informed decision-making. Many patients are not familiar with the conditions which can be screened for prenatally or the quality of life of affected children. This lack of understanding can leave expectant parents unprepared to make informed decisions about prenatal testing. As the number of prenatal genetic tests expands, genetic counselors and all healthcare providers who discuss prenatal testing face a growing amount of information that is not feasible to explain to patients in a routine appointment. Research demonstrates that the common approach to genetic counseling, including in the prenatal setting, is the provision of biomedical information. Yet, genetic counseling outcome studies suggest that attending to the relational aspects of genetic counseling are associated with more positive patient outcomes, including enhanced knowledge, informed decision-making and greater patient satisfaction [2,3]. Through case vignettes, we illustrate the application of a counseling model of practice using Accreditation Council for Genetic Counseling (ACGC) practice-based competencies in the domain of "Interpersonal, Psychosocial and Counseling Skills" [4]. Finally, we propose changes across the genetic counseling profession to move clinical practice toward a more relational model of care. PRACTICE IMPLICATIONS A counseling model of genetic counseling practice leads to more positive patient outcomes [2,3]. Genetic counselors and other prenatal healthcare providers can leverage existing counseling and communication skills to support clients in value-based, informed decision-making in prenatal genetic counseling practice.
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Affiliation(s)
- Kendra L Schaa
- University of Iowa Hospitals & Clinics, Department of Obstetrics & Gynecology, Iowa City, USA.
| | - Barbara B Biesecker
- National Human Genome Research Institute, NIH/JHU Genetic Counseling Training Program, Bethesda, USA
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Lannoo L, van der Meij KRM, Bekker MN, De Catte L, Deckers S, Devriendt K, Roggen N, Galjaard RJH, Gitsels-van der Wal J, Macville MVE, Martin L, Sistermans EA, Van Calsteren K, Van Keirsbilck J, Crombag N, Henneman L. A cross-country comparison of pregnant women's decision-making and perspectives when opting for non-invasive prenatal testing in the Netherlands and Belgium. Prenat Diagn 2023; 43:294-303. [PMID: 36740754 DOI: 10.1002/pd.6329] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Revised: 01/27/2023] [Accepted: 01/28/2023] [Indexed: 02/07/2023]
Abstract
BACKGROUND The Netherlands and Belgium have been among the first countries to offer non-invasive prenatal testing (NIPT) as a first-tier screening test. Despite similarities, differences exist in counseling modalities and test uptake. This study explored decision-making and perspectives of pregnant women who opted for NIPT in both countries. METHODS A questionnaire study was performed among pregnant women in the Netherlands (NL) (n = 587) and Belgium (BE) (n = 444) opting for NIPT, including measures on informed choice, personal and societal perspectives on trisomy 21, 18 and 13 and pregnancy termination. RESULTS Differences between Dutch and Belgian women were shown in the level of informed choice (NL: 83% vs. BE: 59%, p < 0.001), intention to terminate the pregnancy in case of confirmed trisomy 21 (NL: 51% vs. BE: 62%, p = 0.003) and trisomy 13/18 (NL: 80% vs. BE: 73%, p = 0.020). More Belgian women considered trisomy 21 a severe condition (NL: 64% vs. BE: 81%, p < 0.001). Belgian women more frequently indicated that they believed parents are judged for having a child with trisomy 21 (BE: 42% vs. NL: 16%, p < 0.001) and were less positive about quality of care and support for children with trisomy 21 (BE: 23% vs. NL: 62%, p < 0.001). CONCLUSION Differences in women's decision-making regarding NIPT and the conditions screened for may be influenced by counseling aspects and country-specific societal and cultural contexts.
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Affiliation(s)
- Lore Lannoo
- Department of Obstetrics and Gynaecology, Fetomaternal Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - Karuna R M van der Meij
- Department of Human Genetics, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynaecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Luc De Catte
- Department of Obstetrics and Gynaecology, Fetomaternal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Sarah Deckers
- Department of Obstetrics and Gynaecology, Fetomaternal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Koenraad Devriendt
- Department of Human Genetics, University Hospitals Leuven, Leuven, Belgium
| | - Nele Roggen
- Department of Obstetrics and Gynaecology, AZ Imelda, Bonheiden, Belgium
| | - Robert-Jan H Galjaard
- Department of Clinical Genetics, Erasmus MC, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Janneke Gitsels-van der Wal
- Department of Midwifery Science, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam Public Health Research Institute, Quality of Care, Amsterdam, The Netherlands
| | - Merryn V E Macville
- Department of Clinical Genetics, GROW School for Oncology and Reproduction, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Linda Martin
- Department of Midwifery Science, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Midwifery Academy Amsterdam Groningen, InHolland, Amsterdam, The Netherlands
| | - Erik A Sistermans
- Department of Human Genetics, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
| | - Kristel Van Calsteren
- Department of Obstetrics and Gynaecology, Fetomaternal Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | | | - Neeltje Crombag
- Department of Development and Regeneration, Cluster Woman and Child, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | - Lidewij Henneman
- Department of Human Genetics, Amsterdam UMC, location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Amsterdam, The Netherlands
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Perrot A, Horn R. Health professionals and scientists' views on genome-wide NIPT in the French public health system: Critical analysis of the ethical issues raised by prenatal genomics. PLoS One 2022; 17:e0277010. [PMID: 36318580 PMCID: PMC9624390 DOI: 10.1371/journal.pone.0277010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/16/2022] [Indexed: 11/06/2022] Open
Abstract
In France, since January 2020, laboratories have started to make available genome-wide Non-Invasive Prenatal Testing (GW-NIPT) beyond the three common trisomies (T21, T13 and T18) at the same cost as standard NIPT. With the possible margins for interpretation of the legal framework and in the absence of clear and updated guidelines, health professionals are left with questions about which type of screening offer may be clinically responsible, morally appropriate, and, at the same time, respectful of women’s values and ability to make autonomous choices. The aim of this study is to provide an analysis and understanding of the challenging dimensions of clinical practices in the context of evolving scientific knowledge and techniques in prenatal genomics. In this article, we develop a critical analysis of the arguments and concerns that emerge around the offer of expanded NIPT and are discussed by health professionals and scientists. To achieve this, we conducted qualitative semi-structured interviews with 17 health professionals and scientists from September 2021 to February 2022 and a comprehensive literature review (regulatory, scientific, medical, institutional sources). The results of our empirical research highlight the importance of addressing ethical issues related to the differing quality of counselling, the complexity of achieving informed consent, and the avoidance of harm to pregnant women in the feedback of findings beyond T21, T18 and T13. If there is an increase in the provision of GW-NIPT within the French public health system, it will be essential to promote medical practices that respect reproductive choices of women, support their autonomous decision and their understanding of the limitations and uncertainties associated with GW screening. Further research is required to provide an insight into women’s perceptions in order to refine our analysis from the patients’ perspective.
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Affiliation(s)
- Adeline Perrot
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- * E-mail:
| | - Ruth Horn
- Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- Ethik der Medizin, Medizinische Fakultät, Universität Augsburg, Augsburg, Germany
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7
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Schöne-Seifert B, Junker C. Making use of non-invasive prenatal testing (NIPT): rethinking issues of routinization and pressure. J Perinat Med 2021; 49:959-964. [PMID: 34469636 DOI: 10.1515/jpm-2021-0236] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 05/15/2021] [Indexed: 01/16/2023]
Abstract
First mapping the main ethical issues surrounding prenatal testing, we then analyze which concerns are specific to non-invasive methods. Presupposing the privatization premise for reproductive autonomy in fundamentally liberal societies, we go on to specify common concerns about non-invasive prenatal testing (NIPT) covered by the term 'routinization', and conceptually unravel the frequently expressed worry of increasing 'pressure' to test and/or terminate affected pregnancies. We argue that mindful decision-making should be a key educational goal (not only) of NIPT counseling which could be achieved through stepwise disclosure. In addition, we identify indirect social pressure as the most plausible threat to reproductive freedom. While continuous efforts need to be made to prevent such pressure - not least by ensuring balanced availability of options -, restricting testing options, and thus freedom of choice, cannot be the answer to this concern. Lastly, we suggest abandoning the vague term 'routinization' and instead focusing on specified concerns to enable a fruitful debate.
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Affiliation(s)
- Bettina Schöne-Seifert
- Institute for Medical Ethics, History and Philosophy of Medicine, University of Muenster, Muenster, Germany
| | - Chiara Junker
- Institute for Medical Ethics, History and Philosophy of Medicine, University of Muenster, Muenster, Germany
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van der Meij KRM, Njio A, Martin L, Gitsels-van der Wal JT, Bekker MN, van Vliet-Lachotzki EH, van der Ven AJEM, Kater-Kuipers A, Timmermans DRM, Sistermans EA, Galjaard RJH, Henneman L. Routinization of prenatal screening with the non-invasive prenatal test: pregnant women's perspectives. Eur J Hum Genet 2021; 30:661-668. [PMID: 34385671 PMCID: PMC9177612 DOI: 10.1038/s41431-021-00940-8] [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: 04/13/2021] [Revised: 06/03/2021] [Accepted: 07/13/2021] [Indexed: 11/13/2022] Open
Abstract
Due to the favorable test characteristics of the non-invasive prenatal test (NIPT) in the screening of fetal aneuploidy, there has been a strong and growing demand for implementation. In the Netherlands, NIPT is offered within a governmentally supported screening program as a first-tier screening test for all pregnant women (TRIDENT-2 study). However, concerns have been raised that the test’s favorable characteristics might lead to uncritical use, also referred to as routinization. This study addresses women’s perspectives on prenatal screening with NIPT by evaluating three aspects related to routinization: informed choice, freedom to choose and (personal and societal) perspectives on Down syndrome. Nationwide, a questionnaire was completed by 751 pregnant women after receiving counseling for prenatal screening. Of the respondents, the majority (75.5%) made an informed choice for prenatal screening as measured by the multidimensional measure of informed choice (MMIC). Education level and religious affiliation were significant predictors of informed choice. The main reason to accept screening was “seeking reassurance” (25.5%), and the main reason to decline was “every child is welcome” (30.6%). The majority of respondents (87.7%) did not perceive societal pressure to test. Differences between test-acceptors and test-decliners in personal and societal perspectives on Down syndrome were found. Our study revealed high rates of informed decision-making and perceived freedom to choose regarding fetal aneuploidy screening, suggesting that there is little reason for concern about routinization of NIPT based on the perspectives of Dutch pregnant women. Our findings highlight the importance of responsible implementation of NIPT within a national screening program.
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Affiliation(s)
- Karuna R M van der Meij
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Annabel Njio
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Linda Martin
- Department of Midwifery Science, AVAG, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Janneke T Gitsels-van der Wal
- Department of Midwifery Science, AVAG, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Mireille N Bekker
- Department of Obstetrics and Gynaecology, Utrecht University Medical Center, Utrecht, The Netherlands
| | | | | | - Adriana Kater-Kuipers
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Danielle R M Timmermans
- Department of Public and Occupational Health, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Erik A Sistermans
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Robert-Jan H Galjaard
- Department of Clinical Genetics, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Lidewij Henneman
- Department of Clinical Genetics and Amsterdam Reproduction and Development Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.
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