https://orcid.org/0000-0002-8810-5493
Dear Editor
Prenatal screening of common aneuploidies in pregnancy is based on ultrasound and blood tests. First-tier screening tests that are proposed for all pregnant women are suggested in the first trimester and second trimesters. The detection rate of these tests varies from 69% to about 96% [Citation1]. Second-tier screening test represented by the noninvasive prenatal testing (NIPT) or Cell-free DNA (cfDNA) was originally proposed for a woman at high risk of aneuploidy but is gradually being implemented in several countries such as Belgium and Netherlands as a first-tier screening test for all pregnant women [Citation2]. The cfDNA screening detects trisomy 21, 18, and 13 at a high DR with low FPR by analyzing the amount of fetal DNA circulating in maternal plasma and thus can be a reasonable alternative for women who prefer a noninvasive test. Healthcare providers should inform their patients early in the pregnancy of the benefits of these screening tests, the time when they should be performed, their detection rate for aneuploidy, their coverage by third parties, their cost and the future implications of an abnormal screening test result. This allows the couple to have sufficient time to understand the information about these different prenatal screening tests and make their own informed decision. Lebanon is considered a multicultural country with different religious and ethical beliefs among the population. This pilot study aims to determine the choice of prenatal screening tests among Lebanese patients and the factors that might affect their decision-making.
A retrospective observational study in three different hospitals included 185 consecutive Lebanese pregnant patients that were followed up by one doctor (AK) over a one-year period. Data were collected from the patients’ medical records without having to contact them. In case of refusal, the reason was noted on the file upon seeing them in consultation. Patients with first-trimester miscarriages, multiple pregnancies and first trimester ultrasound abnormalities were excluded. The study is approved and registered by our institution’s review board under the number CEHDF-1727
The sociodemographic characteristics are summarized in . The choice of prenatal screening tests differed among the 185 Lebanese couples included in this study as shown in . About 30% of the patients (n = 55) chose not to perform any prenatal diagnostic tests. Regarding other patients, 50% opted for biochemical screening methods, with 38% (n = 71) for the second-trimester serum markers screening and 12% (n = 22) for the first-trimester screening markers. 20% (n = 37) of them chose NIPT for aneuploidy prenatal screening. The main factor guiding their decision making was the cost of these screening tests knowing that they are usually not reimbursed in Lebanon and the second factor implemented in their choice of prenatal testing was their religious beliefs that play a major role in declining any type of intervention in case of an affected pregnancy. 39% of Muslim patients and 27% of Christian patients refused to perform any type of prenatal screening exams.
Table 1. Sociodemographic characteristics of the studied population.
Table 2. Distribution of screening methods among the studied population.
This study provides an insight into the views of Lebanese couples regarding prenatal screening tests. Based on our analysis, one-third of the patients (30%) declined any prenatal screening tests. This percentage is lower than that reported in the Netherlands (60–70%), close to that reported in the United Kingdom (39%), and higher than that reported in Denmark (10%) [Citation3]. Declining prenatal screening was slightly higher in Muslim couples compared to Christian couples (39 vs 27%) knowing that both religions are reluctant regarding pregnancy termination. Although being against pregnancy termination was one of the causes frequently cited in the literature for declining prenatal screening, other studies noted that refusal of abortion did not mean that patients wished to be excluded from prenatal screening [Citation4]. When it comes to NIPT, the low percentage (12%) of patients choosing it as the preferred screening test is probably due to two reasons; First, the financial challenge since NIPT costs more than the other tests and is not covered by third parties. On the other hand, there are some religious and ethical challenges with the use of NIPT, mainly when the parents seek a specific gender for the baby. All companies that offer NIPT processing report the sex chromosomes along with the risk of aneuploidies; this might eventually encourage pregnancy termination in rare cases, even though couples usually disapprove the use of NIPT for non-medical sex selection [Citation6]). The preferred screening test in our series is second-trimester serum markers. This is also concordant with a study in Romania in 2016 where only 13% of patients chose NIPT for prenatal screening while 67% of the patients chose second-trimester screening; authors suggest that it is because of the preferred recommendation by health care professionals [Citation5]. The consistency in explaining the screening modalities to the couples represent one of the strengths of this study.
This pilot study in Lebanon highlights that the couple’s preferences regarding prenatal screening tests is correlated to various financial, social, cultural and religious constraints. These findings could be useful in other countries that share a similar social and religious background.
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No potential conflict of interest was reported by the author(s).
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References
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