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Where on earth do we have the best provisions for pregnant women to have a NIPT?
A message from the editor: Prof. Joris Vermeesch, Ph.D.
The corona virus is raging across the world. Following the lock downs, normal life starts to resume in Europe and the USA. While many of us have been working from home, we start, timidly, to go out again. With summer ahead, many of us are wondering where to have our holidays. Borders are opening up, so the popular vacation destinations come into sight. International travel remains restricted, but we can assume that it will not be for long and we can move all over the globe again. If you are traveling and pregnant, where would you want to have your NIP test performed? In which country would you want to live when pregnant? And can we learn from one another?
NIPT was introduced in 2011, launched by commercial providers and took the world by storm. Within five years, the tests were available across the globe and used by millions of pregnant women. However, implementation strategy, the type of test offered and which pregnant women are tested varies widely across the globe. I will do an attempt to provide a brief overview (read also paper of the month!).
In recent years, NIPT has been implemented into public and commercial healthcare systems as either a first line test or a supplement to existing prenatal screening programs. The majority of countries/states have guidelines or policies and/or laws regulating the use of NIPT. There appears to be two main strategies for the implementation of NIPT: offering NIPT after high-risk cFTS or offering NIPT as a first line test for all. It is difficult to compare the use of NIPT in Europe with the use in Australia and the USA because of major differences in the respective healthcare systems. In the USA, the use of NIPT depends primarily on insurance company and state Medicaid policy. The American College of Obstetricians and Gynecologists suggests that NIPT is a valid alternative to invasive testing in patients identified as high risk after first trimester screening. Medicaid programs which provide health coverage, cover NIPT for high risk patients. However, NIPT is not covered in nine states. About 114 million American women have a coverage for average-risk pregnancies as well. In Europe, fourteen countries have adopted NIPT into a national policy program. Belgium and the Netherlands offer NIPT for all pregnant women whereas the others offer it for high risk women after first trimester screening. In Australia, it is mainly offered following cFTS or as a primary test. Data for the rest of the world are lacking, but based on my personal communications, in the large majority of countries the test is self-financed through private clinics. Interestingly, the type of tests offered vary widely as well. All provide testing for trisomies 13, 18 and 21, but in some countries also sex chromosomal aneuploidies and/or rare autosomal trisomies are reported. In both China and India it is forbidden and in several countries such as French advised not to return information for non-medical reasons about fetal sex to potential parents in order to dissuade sex-based abortion. NIPT can return accurate fetal sex information from 7 weeks of pregnancy, which is earlier than with existing methods of determining sex, including most ultrasounds. Hence, implementation of the test varies along with social-cultural attitudes.
As a consequence of the different reimbursements and insurance schemes, uptake of NIPT varies widely. Although less than 25% of women in most European countries currently use NIPT, uptake is between 25% and 50% in the Netherlands, Italy, Spain, Austria and most states of the USA and Australia and over 75% in Belgium. Specific national economic, social and cultural contexts affect the extent to which NIPT is offered and accepted.
I suppose few women would have their NIPT when on vacation. However, I think it is valuable to compare the different attitudes and learn from one another. Where are we moving to for prenatal care? How does the prenatal care utopic world look like? Is Belgium the route to go where over 75% of women are tested with a genome wide test? Or would it be better to apply our limited resources and restrict testing only the high risk pregnancies? Where do we want to go? Feedback from you, anonymous readers, is most welcome!