Western Australian women's expectations for expanded NIPT— An online survey regarding NIPT for single gene, recessive and chromosomal conditions

Prenatal screening has evolved rapidly following the introduction of non-invasive prenatal testing (NIPT), with screening now available for an increasing number of conditions. We explored the attitudes and expectations of women within the context of using NIPT to detect multiple different single gene and chromosome conditions during pregnancy. An online survey was used to assess these issues with a sample of 219 women from Western Australia. In our study, the majority of women (96%) support of the concept of expanded NIPT for single gene and chromosome conditions provided the test involves no risk to the pregnancy and can provide the parents with relevant medical information about the fetus at any stage of pregnancy. 80% believed that expanded NIPT for single gene and chromosome conditions should be available at any stage during pregnancy and 68% of women indicated that test cost would be a factor in determining their participation in testing. Under half (43%) of the women favored an option to terminate a pregnancy at any stage if the fetus had a medical condition that would interfere with day to day functioning. The majority (78%) of women believed that testing for multiple genetic conditions would provide reassurance and lead to the delivery of a healthy child.

De novo single gene conditions are those which arise within the germ cells of the parent (sperm or egg) or occurs early in embryogenesis.Examples of genetic conditions which can occur de novo include Neurofibromatosis Type 1, with a prevalence of 1 in 3000 births and where 50% of cases are due to a de novo mutation (Friedman, 2019) and Duchenne muscular dystrophy, which occurs in 1/5000-9000 births and occurs de novo in 33% of cases (Darras et al., 2018;Ryder et al., 2017).The potential detection of de novo single gene and chromosome conditions in pregnancy is based on prenatal ultrasound findings that may indicate the need for specific genetic testing (Maxwell, Dickinson, et al., 2015).This technology may also have the potential to identify recessive conditions where the parents have not undergone reproductive carrier screening.
Diagnostic genetic testing requires a DNA sample obtained from CVS or amniocentesis, both of which carry a small risk of pregnancy loss, are resource intensive and are not appropriate for population level screening.
The current panel of single gene and chromosome conditions available commercially for the general population (i.e., not pregnancies with known fetal anomalies detected on ultrasound) through NIPT include Ehlers-Danlos syndrome, achondroplasia, Noonan syndrome, Rett syndrome and others.While these conditions are individually rare, the combined frequency of these conditions is 1 in 600 (Zhang et al., 2019), around the same incidence of trisomy 21 in our population (1-2 in 1000; Maxwell, Dickinson, et al., 2015).
Potentially, with the advent of whole exome sequencing, NIPT for hundreds of recessive or de novo single gene conditions as well as chromosomal conditions may be possible as technology advances.
Women support the use of NIPT for single gene and chromosome conditions for conditions such as sickle cell disease (Hill et al., 2014), selection of sex and physical traits and NIPT for fetal whole genome sequencing for conditions that would express at birth or early childhood (Haidar et al., 2021).With next generation screening, it is plausible that NIPT may be expanded to panels of multiple (hundreds) single gene and chromosome conditions, similar to the concept of expanded genetic carrier screening (Ong et al., 2019).
Testing for more conditions during early pregnancy provides greater reproductive choice for prospective parents, although careful pretest counseling is central to both support patient autonomy whilst avoiding routinizing this testing modality.
In 2020, Shaw et al. (2020) compared expanded NIPT for single gene and recessive conditions to NIPT for common trisomies.
A meta-analysis reported the specificity for the three common trisomies to be 99.87% and the sensitivity for trisomy 21 to be 99.7%, compared to 97.9% for trisomy 18 and 99.0% for trisomy 13 (Gil et al., 2017).The sensitivity is poor and PPVs are considerably lower than for the common trisomies, when NIPT is applied to the detection of chromosomal deletions and duplications.For 22q11.2 deletion, the PPV of NIPT ranges from 21% in low-risk pregnancies (Petersen et al., 2017) to 50%-97% in pregnancies with ultrasound anomalies (Gross et al., 2015;Helgeson et al., 2015).
This study aims to explore the thoughts and attitudes of women in Western Australia to ascertain how they approach the concept of NIPT for multiple (hundreds) of de novo or recessive single gene conditions as well as explore attitudes towards prenatal reproductive technology.

| ME THODS
In this study, we explored the attitudes and expectations of women with respect to using NIPT to detect multiple genetic conditions during pregnancy.We measured their responses to questions about the potential benefits of NIPT in reducing risk to the pregnancy and providing relevant medical information about the fetus.We sought women's views on the time when expanded NIPT should be available during pregnancy and if test cost would determine their decision to participate in testing.We also investigated women's attitudes towards termination of pregnancy for specific medical conditions.

| Survey design
An online survey was designed using questions generated by themes from a previous qualitative phase of the study.Interviews in the qualitative study process were conducted with thirty women, as previously described (Long et al., 2017), and thematically analyzed using NVivo.These themes informed the development of the current online survey which was hosted by Alchemer (formerly SurveyGizmo).
The survey had multiple choice answers as well as discrete choice experiments and scenario-based responses (see online supporting information).
Participants were recruited online from social media platforms such as Facebook and Twitter.The internet-based platform were chosen as 93% of social media users in Australia use Facebook.In Western Australia, this accounts for around 45% of the population (Sensis Pty Ltd, 2015).
Women were asked whether they agreed with several statements about testing in pregnancy.The options for answers were:

What is known about this topic
There is support by women for using non-invasive prenatal testing to screen for single gene and chromosome conditions.

What this paper adds to the topic
This paper demonstrates women support expanded NIPT for multiple (potentially hundreds) single gene and chromosome conditions, including de novo and recessive conditions, and proposes how this information can be given to women based on their own responses.

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LONG et al.

• useful at any stage of pregnancy
• useful at 10-16 weeks of pregnancy • useful at 16-20 weeks of pregnancy • only useful if there is treatment for the condition • not useful at any stage of pregnancy • unsure.
The gestation cut-offs were chosen as the time a test could be undertaken with NIPT (>10 weeks gestation), with a CVS (up to 14 weeks gestation with a result before 16 weeks' gestation), an amniocentesis (>16 weeks' gestation), and the upper gestation age for legal termination of pregnancy in Western Australia (20 weeks' gestation).The women were informed about these time lines in the introduction to the survey.There were also statements about testing in pregnancy which had 'yes,' 'no,' or 'unsure' as answer options about testing in pregnancy and 'agree,' 'disagree.'

| Statistics
The survey answers were analyzed using IBM SPSS Statics software (IBM Australia Limited).Data were then described using descriptive statistics and reported as percentages.Chi Square tests were used to assess differences with significance being defined as p < 0.05.

| RE SULTS
Of the 671 women who commenced the survey, there were 413 partial responses (61.5%) and 258 surveys were completed.Thirty-nine responses from women in other Australian states and overseas were excluded, leaving responses from 219 women (38.4%) from Western Australia for analysis.The high attrition rate was attributed to the length of the survey, which was initially designed to be under 20 min however feedback from participants was that it took around 45 min.
The length of time the survey took to complete was not mentioned by the 10 individuals who piloted the study prior to launching and predicted test time by the Alchemer program was 15 min.

| Participant characteristics
There was an overrepresentation of women from higher socioeconomic background with 58% of women living in households with combined incomes of over $AUD 91,000 annually, compared to the average Western Australian combined income of $AUD 82,940 annually (Australian Bureau of Statistics, 2016).While this sample is biased towards higher earning households, previous research shows women in higher socio-economic indexes for areas are more likely to undergo prenatal screening, as are white women and women over 35 years of age (Maxwell et al., 2011) (Table 1).
TA B L E 1 Demographics.

| Financial considerations
For 68% (149/219) women, the cost of a test to detect multiple medical conditions in the fetus would be a strong factor in deciding whether to have this test; 92% (202/219) of women would have this test if it were free and 68% (149/219) indicated that the cost of a test would influence a decision to have a test that could detect multiple medical conditions in a fetus.When asked to nominate a price they were willing to pay for expanded NIPT, the majority 73% (160/219) chose between $AUD 300 and $AUD 800 for such a test.Just 13 women (6%) in this study were prepared to pay over $AUD 1000 for expanded NIPT (Figure 1).
Income was not significantly associated with women's responses when asked how much they would pay on a sliding scale of 0 to $AUD 1000.

| Expectations and consequences of testing for multiple conditions in pregnancy
Ninety percent (197/219) of women agreed that doctors should offer testing for medical conditions in the fetus to all pregnant women, while 10% (22/219) preferred that testing should only be offered to women with a higher chance of having a baby with a genetic condition.emotional support and explanation of the conditions and options available after testing, where necessary (Figure 2).

| Individual considerations
Women were asked to choose all the issues they associated with the use of expanded NIPT.The concerns women identified are outlined in Table 3.

| DISCUSS ION
In our study, women expressed a strong interest in acquiring all the information about the fetus that was available without incurring risk to the pregnancy.These findings are in accord with those from a study performed in Quebec and Lebanon, where there was support for using NIPT with fetal whole genome sequencing to detect rare and severe conditions (Haidar et al., 2021).should not be discussed, compared with the general Australian population of which 4% disagree with abortion under any circumstances (Betts, 2004).
A minority of women (5.9%, 13/219) felt that expanded NIPT would only be useful if there was treatment for the affected fetus.
However, when a risk of miscarriage was introduced, 22.8% (50/219) of women would only take a test that could reveal medical conditions in the fetus if there were treatment options available.This shows a level of discomfort in having a test that could risk the pregnancy unless there was a therapeutic option other than abortion.While many genetic conditions have no treatment, recent advances in medicine mean there are several management options for previously lethal or severely debilitating disease.One such example is Spinal Muscular Atrophy, which in its most severe form (Type 1) is lethal by 2 years of age.With the introduction of Nusinersen as an antisense oligonucleotide therapy, Onasemnogene abeparvovec as an AAV9-based gene therapy and Risdiplam as a small molecule modifier of pre-mRNA splicing, affected children have a much better prognosis (Jablonka et al., 2022) and prenatal diagnosis may lead to early treatment and better outcomes (Messina & Sframeli, 2020).
The model of care most women preferred was to be offered expanded NIPT by a general practitioner (GP) and provided with written information about the conditions tested for.In contrast, in Belgium, which recently analyzed results from offering population based NIPT, 81% of women received the test from one of the eight 'genetic centers' (Van Den Bogaert et al., 2021).In the large TRIDENT2 trial in the Netherlands, 30-min consults were provided by health care  et al., 2019).In Australia, GPs are currently providing first trimester screening and private NIPT testing on a population level.However, whether expanded NIPT would use more GP resources due to the number of conditions tested for is unknown.In this study, approximately three quarters of women wanted to know every condition they would be tested for, which would be time consuming and overwhelming if provided verbally.There is a need for written resources to be developed to assist GPs and women in the shared decision-making process.GPs would be expected to already be familiar with the issues encountered with standard NIPT such as obtaining informed consent and informing about residual risk.
The issue of the most concern to this group of women was that expanded NIPT would raise anxiety during a pregnancy, yet 77.6% (170/219) felt the test would also be reassuring.A study of women from Australia showed NIPT for aneuploidies was associated with 'peace of mind' (Bowman-Smart et al., 2019).In practice, NIPT has been shown to raise anxiety in a small proportion of women who undergo testing, in similar numbers to those who undergo first trimester screening and more genetic counseling support has been suggested to help resolve this (Hirose et al., 2020).Interestingly, when specifically asked about whether NIPT would raise their anxiety 42.0% (92/219) disagreed, which may be due to perceiving expanded NIPT would raise other people's anxiety but not necessarily their own.
Concerns with both standard and expanded NIPT have been raised repeatedly in the literature (Horn & Parker, 2017;Kater-Kuipers et al., 2018) and by women in previous studies (Haidar et al., 2021) and were echoed here.Women were concerned about the 'pursuit of perfection' in terms of 'having a perfect child'.There was also concern about people 'not being as tolerant of people with disabilities' which was also reported by van Schendel with participants in that study concerned about there being 'little acceptance and less support of children with Down syndrome' with the use of NIPT (Van Schendel et al., 2014).The concept that people with genetic conditions naturally have a lower quality of life is an assumption people may make when they decide on any prenatal screening (Newson, 2008), leading to eugenic concerns, especially in individuals with disabilities (Newson, 2008).
The concern regarding women having more abortions because more conditions are detected with expanded NIPT has also been raised in a recent study from Belgium; following the introduction of no-cost population-based NIPT where the live birth rate of children with trisomy 21 decreased (Van Den Bogaert et al., 2021).However, other studies did not find a difference with abortion rate before and after the introduction of first trimester screening (Maxwell, Dickinson, et al., 2015) or NIPT (Hill et al., 2017).
Another concern was that some women did not want to know about certain conditions.This is challenging, as while most women did want to know every condition being tested for in a panel of multiple genetic conditions, it is not feasible to review every condition with the patient in a standard GP appointment consultation.
It may be more useful to provide a general overview of the type of conditions tested for, such as the statement from the Mackenzie's Mission project which states that the criteria used to select the genes to test and report: • Screening the gene had to be technically possible using currently available technology.
• The gene had to be known to cause a genetic condition • The condition had to affect people in childhood.
• The condition had to have a serious impact on a person's quality of life and/or be life-limiting.
• For many of the conditions, there is no treatment or the treatment is very burdensome for the child and their family.For some conditions very early diagnosis and treatment can make a difference for the child (Mackenzie's Mission, 2019).
While we did not distinguish between conditions that were of infant, childhood or adult onset conditions, the questionnaire gave a description of genetic conditions as ….medical conditions that may or may not be passed on through families.Genetic conditions are variable and can affect physical or intellectual functioning.Some conditions are very mild where as others may impact how a person manages in day to day life', leaving the interpretation of 'medical conditions' up to the participant.In the future, it would be useful to explore how women answer these questions in the context of conditions with variable ages of onset and severity.
Expanded NIPT for multiple single gene and chromosome conditions raise a number of ethical issues requiring health practitioners to address the "therapeutic gap" between the ability to conduct genetic sequencing and the ability to fully understand what the test results mean (Hashiloni-Dolev et al., 2019;Nov-Klaiman et al., 2019;Werner-Lin et al., 2016).Specifically, the ethical imperative of respect for reproductive autonomy may conflict with a perception that couples with an increased probability result should take action to avoid the birth of an affected child (Dive & Newson, 2021).The widespread adoption of prenatal screening can foster a view within a community that disability is avoidable, especially for those with conditions that may be detected by screening (Asch, 1999).Other authors have noted the potential for detection of adult onset conditions in the fetus and the chance detection of maternal malignancies which raises multiple ethical dilemmas (Bowman-Smart & Taylor-Sands, 2021; Van der Meij et al., 2019).
Implementation of genome-wide NIPT is controversial as the benefits of detecting other fetal chromosomal aberrations must be balanced against the risks of discordant positives, parental anxiety, and a potential increase in (invasive) diagnostic procedures.
In The Netherlands, nationwide NIPT uptake was 42%, based on 173,244 pregnancies at 12 weeks of gestation in 2017 ( Van der Meij et al., 2019).The majority (78%) of women chose to have additional findings of genome-wide NIPT reported, suggesting that pregnant women in general want to know more about fetal health than just the presence of the common trisomies.When genome wide NIPT for chromosomal conditions was performed in the general obstetric