Empowering women's choice in the new era of non-invasive prenatal testing methods: Opting for routine perinatal care information over routine screening

Abstract

Routine prenatal screening programmes are often heralded as ways to empower women's autonomous decision-making around pregnancy. The introduction of non-invasive prenatal testing (NIPT) is seen as enhancing the aim of empowering women by making screening and testing easier, more accurate, and safer. However, the possibility of a systematic (routine) offer of NIPT has been linked with risk to women's autonomous decision-making as the method's ease is feared to impair deliberate and voluntary choice. In this landscape of conflicting views, NIPT is increasingly adopted globally. Technological advancements in the field increase the likelihood of systematically offering NIPT to all pregnant women and expanding its use to include more foetal conditions alongside common aneuploidies. In this paper, I argue that autonomous decision-making amidst the challenges of new screening and testing methods requires more than providing accurate, balanced, and non-directive information. To truly empower pregnant women with choice in this era, we need to move away from entrenched ideas of routinised screening and take a new approach. My suggestion is that only by routinely offering high-quality perinatal counselling followed by an option to choose to test for genetic conditions are we likely to come anywhere near our goal of enhancing women's choice.

Keywords

Non-invasive prenatal testing (NIPT)routinised prenatal screening informed consent < human experimentation < clinical ethics prenatal screening counselling prenatal whole-genome sequencing reproductive choice

Introduction

The discovery of cell-free foetal DNA in maternal blood has opened the way for the rapid development of non-invasive methods for the detection of an increasing number of foetal conditions. DNA sequencing technologies are entering the field of prenatal screening and testing (PST) steadily but also rapidly. Prenatal exome sequencing is already a useful tool in the clinical setting of prenatal diagnostics, RNA sequencing is entering the field while the use of prenatal whole-genome sequencing (WGS), although still under investigation, is coming to be the next big thing in the field.¹ Given this development, maternal plasma has rightly been described as ‘a gold mine with [a] huge amount of information waiting for us to explore’.² On this ground, non-invasive prenatal testing (NIPT) has been implemented into publicly funded screening pathways in several countries^3,4 including the UK where NIPT has been ‘added to the existing NHS screening pathway for Down's syndrome, Edwards’ syndrome and Patau's syndrome as part of an evaluative rollout’.⁵

In the past, prenatal screening may have been at least partly motivated by eugenic thinking around disability,^6–8 or concerns about the cost incurred when those with conditions seen as disabling were born.^9,10 However, advocating for prenatal screening on these grounds is outdated and unjustified,^11,12 leaving the more palatable goal of empowering women's¹ choices as the official driver for routinised prenatal screening.^11,13–17 While routine prenatal screening may aim to empower choice, the reality is somewhat different. Studies consistently show that women are often inadequately informed about prenatal screening for their consent to be considered valid, and there is considerable evidence that women feel pressured not only to accept the screening but also, in some cases, to ‘choose’ termination of pregnancy.^18–25 These challenges for informed consent for prenatal screening will only be amplified by the likely explosion of prenatal testing that NIPT and emerging technologies like prenatal WGS promise. With initiatives such as the NHS's 100,000 Genomes Project for newborns paving the way for integrating comprehensive genomic analysis into routine care,²⁶ the prospect of prenatal WGS becoming a routine offer to all pregnant women is no longer distant. The sheer volume and complexity of information available through WGS will exacerbate existing barriers to informed, autonomous choice, making it critical to reconsider current approaches to consent and counselling before these technologies enter widespread prenatal use.

These concerns highlight the centrality of autonomy as both an ethical principle and a practical aim in prenatal care. The challenges associated with informed consent in routinised screening raise important questions about what it truly means to respect and promote women's autonomy within this context. While my purpose in this paper is not to adjudicate between competing philosophical accounts of autonomy or to propose a new conceptual model, it is important to situate the discussion within the broader ethical framework that guides it. Respect for autonomy has long been a defining tenet of modern medical ethics. Whatever theoretical account of autonomy one adopts, whether relational, procedural, or substantive, there is broad agreement that autonomy is valuable and that respecting it entails enabling people to make meaningful decisions about their lives. In the context of PST, this principle has been understood primarily through the provision of information that enables prospective parents to make meaningful, informed, and voluntary reproductive choices. This autonomy-oriented approach sees access to PST as a means of empowering women to manage their pregnancies and hence their lives in ways that align with their preferences and values.⁸ Thus, my focus in this paper is on examining how, in practice, the goal of promoting autonomy through routine prenatal screening can genuinely be fulfilled.

To ground this analysis, I work with a practical, context-sensitive understanding of autonomy: an autonomous reproductive decision requires not only access to information but also the ability to reflect on one's own values, intentions, and expectations for the future, free from undue external pressures. This conception encompasses both the internal dimension of clarity about what matters to the pregnant woman and the external dimension of an environment that does not pre-structure choices in ways that compromise voluntariness. It is this operational account, not a philosophical theory of autonomy, that underpins the analysis that follows.

Building on this operational understanding of autonomy, I argue that systematic or routinised prenatal screening is fundamentally incompatible with the goal of empowering women's choices. This incompatibility cannot be solved simply by improving the quality of information that women receive. Providing accurate, balanced, and non-directive information, I argue, may not be sufficient to ensure autonomous decision-making amidst the challenges and complexities posed by emerging PST methods. The only way to fulfil the autonomy-oriented aim of prenatal care is to move away from entrenched models of routinised screening. My suggestion is that by routinely offering high-quality perinatal counselling before introducing the option of genetic testing, we are far more likely to promote genuine reproductive choice.

This paper uses the example of the UK as the focus of this discussion. The UK approach to routine prenatal screening explicitly identifies enhancing women's choices and their reproductive autonomy as the goal of prenatal screening.^27,28 However, as many other jurisdictions similarly cite reproductive autonomy and enhanced choice as the drivers for routine prenatal screening, the UK approach serves as a good representative of many approaches to the routinisation of prenatal screening. Thus, my proposal has potentially widespread application.

Innovative prenatal screening and testing methods within screening programmes focused on systematic (routine) offer: A complex situation

NIPT is often seen as a state-of-the-art technique in the field of PST. NIPT is particularly welcomed in pregnancy care given its advantages in terms of accuracy, ease, and safety. Thus, it is reasonable to expect that access for women and couples to the medical benefits coming with innovative PST methods will be welcomed and pursued. Besides, from an ethical point of view, an extended use of these methods can be justified both in the context of the public health model and in the context of the reproductive model. Extended use of new PST methods is in line with the public health model which aims to decrease the prevalence of certain conditions in society and ‘reduce the burden of disease’¹¹ through the wide use of prenatal screening. But even considering the public health model's rival, which is the reproductive autonomy model, one can find a moral justification for the introduction and wider use of these methods. According to key arguments in support of the reproductive autonomy model, the main aim of offering prenatal testing is to enable meaningful reproductive choice,^29,30 as well ‘[p]romoting informed choice is commonly recognised as the chief purpose and benefit of prenatal screening’.³¹ Thus, relying on the reproductive autonomy rationale, the introduction and wider use of new PST methods is welcomed as a way to an invaluable source of information that those who want to embark on parenthood need in order to make meaningful reproductive choices. Extended use of new PST seems to satisfy both of the main rationales (the public health and the reproductive autonomy models respectively) on which the introduction and use of PST have been heavily relied upon. In other words, either way, it is a win–win.

However, obtaining sufficiently informed consent in prenatal screening is challenging both in public health and in the reproductive autonomy model. As I mentioned in the introduction, since the beginning of prenatal screening in the clinical setting,⁸ several healthcare systems have failed to implement suitable procedures of informed consent, particularly regarding non-invasive methods such as serum screening and ultrasound tests. For instance, it has been noted that ‘[t]he informed-consent process for ultrasound has been completely abandoned, and for serum screening, it is largely neglected’.¹¹ Regarding the recent development of NIPT, it has been argued that an expanded use of it for the detection of a larger number of conditions will further complicate the counselling process and increase the risk of information overload, limited understanding, and confusion among expectant mothers.³² Considering the example of prenatal chromosomal microarray testing, there have already been concerns about the extent to which women's maximal autonomous decision-making is achievable. This is because although the number and complexity of testing options have increased,³³ evidence suggests that the time spent discussing these options is insufficient.^32,34,35 Such difficulties will increase exponentially, as we continue to explore foetal makeup with advanced methods like WGS.

In this evolving landscape, achieving sufficiently informed consent and promoting autonomous decision-making through discussion face heightened challenges due to various factors already complicating the counselling process and the provision of information. Factors such as complex interpersonal, social, and cultural dynamics,^36,37 as well as ‘[…] individual socioeconomic and religious backgrounds and experiences with disability and genetic testing’^35,38 have been shown to influence attitudes towards prenatal options. Accordingly, it has been argued that the mere provision of additional prenatal screening options and information is insufficient to enhance reproductive autonomy, especially given the significant variation in prenatal testing scope among professionals and pregnant women.³⁷

Moreover, the expansion of NIPT to encompass more conditions is inherently tied to its broader availability to pregnant women. This expansion, driven by ongoing research,² suggests a future where NIPT could be offered as standard practice to all pregnant women, increasing the number of women whose decision-making is likely to be affected too. Despite concerns, repeated calls for widespread NIPT offering to all pregnant women suggest^25,39–41 that, sooner or later, more countries may adopt NIPT as first-tier screening. Although expanding NIPT to include more foetal conditions has been postponed for now,^31,42 technological advancements continue to drive in that direction.¹

These complexities come in addition to the ethical concerns surrounding the routine offer of prenatal screening methods, including NIPT, which has been criticised for limiting rather than expanding choice.^20–22^,24,25 The literature on the subject has extensively discussed various issues related to the routine offer of screening to women that can result in eroded autonomous choices.^17,43 These issues include concerns about undue influence and implicit pressure on women to undergo the test,^44–46 as well as women's insufficient understanding of the voluntary nature of the screening and its potential implications.³ Similarly, the ease of NIPT may inadvertently impair deliberate choice,^3,24,25 as its routine offer could be perceived as a tacit recommendation.³⁸ Some argue that including NIPT in publicly funded screening programs may increase its perceived importance, supported by research showing higher acceptance rates when NIPT is fully funded compared to when individuals have to pay for it.⁴⁷

By juxtaposing the routine offer of NIPT with its expansion to cover more conditions and its broader availability, a continuum of ethical issues emerges. These issues stem not only from routinisation but also from the challenges associated with counselling for additional conditions and decision-making for a larger population of women. Consequently, in this new era, there are tangible reasons to worry that women's reproductive autonomy will remain vulnerable. However, before drawing conclusions about the fate of reproductive autonomy in this new context, it is imperative to evaluate the effectiveness of existing strategies, particularly publicly funded ones that adopt a systematic offer of PST. Therefore, the following analysis examines a representative example of such strategies, namely the one adopted in the UK.

The interactive connection between adequate information, support for women and timing of counselling: A triadic synergy

Most countries incorporating NIPT into their screening pathways also implement strategies to safeguard and promote autonomous choices through pre-test counselling sessions with trained professionals and the provision of adequate information.²⁶ The British prenatal screening plan exemplifies this approach by prioritising the provision of adequate, accurate, balanced, and non-directive information post-offer of screening.⁴⁸

According to the Nuffield Council on Bioethics’ 2017 report on the ethics of NIPT, the NHS emphasises the importance of providing accurate, balanced information to support all screening choices equally, allowing sufficient time for discussion of concerns.²⁷ The need for accurate and balanced information is repeated several times in this report and the importance of enabling prospective parents to make autonomous, informed choices is acknowledged as a major principle which should be guiding policy-making about NIPT.²⁷ This principle is fundamental in guiding policy-making, both in the UK and elsewhere.²⁶

However, I argue that ensuring autonomous choices requires more than just providing adequate information and support after screening. The effectiveness of safeguarding reproductive autonomy depends on three essential components: accurate, balanced, and non-directive information, supportive counselling, and the timing of counselling, the significance of which in this context is often overlooked. These three elements are interconnected and form a triadic system, where the quality of each component is crucial. Therefore, evaluating and selecting the attributes of each component is essential. In this regard, below, I elaborate on this evaluation, starting with the breakdown of the first component, which is the ‘motto’ accurate, balanced, and non-directive information.

An evaluation of the ‘motto’ accurate, balanced, and non-directive information

To begin with, the idea of non-directiveness is already an ambiguous concept regarding applicability. Preservation of neutrality is the main requirement of non-directiveness to allow an individual ‘to make the best decisions for themselves and their families as judged from their own perspectives’.⁴⁹ However, the ability to achieve neutral counselling in practice has been questioned.⁴⁸ There have been concerns regarding clinicians’ ability to distinguish between choice and coercion.^23,48 Research has shown that sometimes, clinicians, even unintentionally, are directive.^48,50 Similar concerns have been raised regarding counselling professionals as well. Suter has argued that counsellors tend to provide large amounts of information aiming to support autonomous choice; however, the information provided is often one-sided as is mostly scientific.²³ Kessler has also provided an interesting perspective on non-directiveness. He has argued that in genetic counselling, directiveness and non-directiveness are two sides of the same coin as they represent ‘different strategies of influence: in the first case an attempt is being made to influence behaviour directly, whereas in the second it is the thought process that is being affected’.⁵¹ In short, it is not possible to guarantee non-directive information, whether in the current context or more complex counselling situations.

In terms of accuracy, providing truthful and correct information is relatively plausible in the current context of offering NIPT for a specific number of well-known conditions, such as trisomies 21, 18, and 13. However, informational accuracy will decrease along with the increasing number of conditions that can be detected with innovative methods such as NIPT and chromosomal microarray testing. The addition of rare conditions with unknown or unusual health implications, coupled with the unpredictable nature of incidental findings, inconclusive results, or variants of uncertain significance, renders the assurance of accurate information unattainable. Besides, this phenomenon has already been observed in cases of microdeletions and other chromosomal defects where NIPT results indicating foetal anomaly turned out to be false after diagnostic testing or after giving birth.⁵² Professionals in the field have already recognised that ‘[g]iven the expanding range of potential conditions, and their rarity, accurate pretest counseling will become increasingly challenging’.⁵³

Turning now to the balance of information, a typical view among policy-makers is that the provision of balanced information is achievable when pregnant women and couples receive information both about the benefits and limitations of NIPT,⁵⁴ the options of continuation or termination of an affected pregnancy and more importantly about the foetal condition being tested and particularly about what future parents ‘might expect from life with a child or adult with this condition’.⁵³ Such ‘balanced’ information is found in relevant informational leaflets, posters, and websites.⁵⁵ Also, professionals providing counselling learn to follow this standard.⁵⁶ However, by striving to provide balanced information, we create a tug-of-war that traps women between conflicting but equally influential sources of information. Looking into the example of Down Syndrome, in the relevant sources of information, one can find both information about a fulfilling life with Down Syndrome and health issues and challenges related to this condition. Whereas the offer of screening has been criticised for putting pressure on women to terminate an affected pregnancy^45,57 and information about the negative aspect of the condition can be used to justify such a choice and make peace with it, I argue that the provision of information about a substantially good life with the disability can equally cause ‘sensitisation’ of women and inflict an implicit influence towards pregnancy continuation. For instance, such influence could lie in the guilt of being discriminative against disability. Although there will be women already inclined to make a particular choice who will use either information to justify this choice, there will also be those who may find it difficult to choose between the two. Eventually, the choice to be made is about which of the information provided influences a woman the most depending on the woman's wider environment of influences within which this information is provided, essentially, within a maze of external influences, which are uncontrollable to an extent, such as the ones mentioned in the previous section (e.g. societal, familial, religious, and financial).

One could argue that some external influences are inevitable, which is why we aim for maximal instead of full autonomy. Indeed, we cannot eliminate these influences, but there are strategies we can use to reduce their impact, as I explain below. Yet, there is a strong need to do that because the effect of the emotional tug-of-war I mentioned earlier is likely to become more intense, involving unavoidable information overload and confusion and risking choice paralysis when more and more complex screening options are available. Although more complex testing integration has been postponed for now,²⁷ this precautionary approach does not imply that everything is under control. These new methods have not been developed to be left unused. However, when their time comes, the fundamental way of achieving maximally autonomous choices by providing adequate information that is accurate, balanced, and non-directive may not work as effectively as we would like it to. Only some further examination to deconstruct the three elements of what is considered adequate information has shown how frail these elements are.

This leads directly to my next point about the second key component, women's support. In the following section, I explain how the right quality of this component can reduce the fragility and improve the quality of the first component, the one of adequate information.

The component of support: Adding the right qualities

The conclusion from the above is that the simple provision of accurate, balanced, and non-directive information fails to consider the impact of the environment of external influences within which women are expected to make a choice. I do not intend to suggest that we should depart from aiming to offer accurate, balanced, and non-directive information about prenatal screening. However, observing this motto's deficiency reveals the necessity to improve its quality. Essentially, what is missing from the provision of accurate, balanced, and non-directive information to really tell that information is adequate is that the value of information depends on the value that the recipient attributes to this information. Such value is designated by the personal profile of the recipient and the environment of interpersonal and other influences this profile is built up in. To fill in this gap, I suggest that it is necessary to embrace this type of support where counselling does not focus on knowledge, ‘but on supporting pregnant women and their partners in making personal, value-consistent decisions about prenatal screening’.²⁷

Although this suggestion is not something new, here I highlight the importance of choosing the right kind of support which can also improve the quality of the information and subsequently, the content of PST counselling. A detailed examination of prenatal screening counselling approaches is beyond the scope of this paper; however, it is worth noting that there are several proposals about counselling approaches which can offer that kind of appropriate support as they explicitly consider this extra characteristic of the individuality of personal circumstances and view of life.

In the mid-70s, Headings proposed a process-oriented model for genetic counselling, emphasising the client's leading role, with the counsellor acting as an active listener ‘to understand the situation of the client and to clear up conflictual situations’.⁵⁸ Similarly, Hsia and Hirschhorn defined genetic counselling as an interactive learning procedure focused on providing information while considering the patient's perspective and needs.⁵⁹ Reif and Baitsch advocated for a patient-centred approach, facilitating responsible decision-making⁶⁰ through mutual information exchange ‘based on the expectations, background knowledge, and points of view of both sides’.⁵⁰ Recent shifts in the US prioritise flexible counselling approaches tailored to client and family needs and values, clinical circumstances, and desired outcomes, reflecting patient choice.⁶¹ Also, recently, McCarthy Veach et al. introduced the reciprocal-engagement model, focusing on future medical and psychosocial outcomes and supporting patient-driven decision-making in line with the patient's preferences and social situation.⁶² Another example in this long list is that of Prinds et al. who proposed a novel prenatal counselling approach, prioritising the woman's story within her societal context by flipping the traditional prenatal counselling encounter on its head by beginning as a counselling professional rather than solely as a healthcare information communicator.⁶³

My purpose in referring to existing counselling frameworks is not to recommend adherence to any particular model, but to note that an awareness of clients’ values and life contexts has long been recognised as central to effective counselling. These approaches provide useful historical and conceptual touchpoints that can be revisited and adapted to serve the autonomy-oriented aims of contemporary prenatal care.

Taken together, these models highlight a key insight: decision-making in pregnancy cannot be understood as the straightforward expression of fixed preferences. Rather, it unfolds within a complex web of expectations, relationships, and social pressures. What this scholarship offers is not a template to replicate but the conceptual lesson that autonomy is best supported when women are given space to articulate and examine what matters to them before being steered toward specific choices. This insight motivates the shift I propose toward a more reflective and dialogical form of support.

In this sense, the counselling I propose is not merely informational or confirmatory, but an active process that helps women clarify their own priorities and values and explore how these relate to possible futures, responsibilities, and relationships before being presented with specific testing options. Such support involves more than respecting stated values; it facilitates the reflective work through which those values are understood and, where necessary, refined. In this way, counselling aligns with the autonomy-oriented goal of prenatal care, not by redefining autonomy, but by creating the conditions under which it can be meaningfully exercised. This dialogical approach ensures that autonomy is realised not as passive validation but as an engaged, reflective process that deepens understanding and enables morally accountable decision-making.

The component of the timing of counselling: Working towards a feasible virtuous circle

It is worth noting that this kind of suggested appropriate support is somehow incorporated in systems such as the British system. The GMC guidance on ‘Decision making and consent’ includes a subsection that explicitly requires clinicians to find out about the patient's values, needs, and preferences.⁶⁴ According to the fourth principle of ‘The seven principles of decision making and consent’ found in the guidance, ‘Doctors must try to find out what matters to patients so that they can share relevant information about the benefits and harms of proposed options’.⁶⁵

Nevertheless, in practice, a standard offer of screening is typically made first, followed by information and support. This means that ‘the scope of testing is determined by others’,³⁷ not the women who will be offered the test, potentially overlooking their preferences. However, giving complete control to women and couples over prenatal screening is not an easy task either. Although it is a way to endorse their preferences and values, it raises two problems, giving complete control ‘will not be feasible nor desirable’³⁷ as limitless access to the genetic structure of an unborn child is not in the scope of prenatal screening and it precludes the principle of respect for the future child's autonomy.³⁷ To address this, one suggestion has been to offer women a menu of screening options to choose from.³⁷

While further analysis of this issue is beyond the scope of this article, there is an important point that I want to highlight here. Whether someone agrees with the above approach or not, the fact is that when talking about broadening the scope of PST, determining the range of conditions for which PST should be offered is already a complex and unresolved challenge for professionals.⁶⁶ When professionals themselves are navigating unchartered territory, expecting individuals to navigate this complex landscape of new methods and conditions is premature and may hinder autonomous decision-making due to the unfamiliarity of the general population with the complexities of prenatal screening.

Another important consideration is that when screening options are explicitly offered, the offer carries an implicit suggestion or recommendation to accept it. This concern is well documented in the literature^11,17,42 and supported by empirical research evidence.^38,46 An explicit offer of screening option(s) steers women's attention toward that specific option(s), narrowing rather than expanding the space for acting according to their own values and preferences. Furthermore, new methods such as NIPT can be used early on in pregnancy, which allows for an early offer of PST. This can influence and shape how a pregnant woman understands and feels about her pregnancy, the foetus, and the future child. Thomas et al. capture this well:

Before the woman has had the opportunity to make decisions about the pregnancy and its place in her life, its wantedness, what this means for her and her family based on the lived experience of pregnancy, she is offered testing on the condition of the foetus. The future child, as such, enters the woman's life via its diagnostic categorisation.⁶⁷

In other words, the very offer of screening seems able to shape and predetermine the status that the foetus acquires in the eyes of the expectant mother. In essence, it disrupts the spontaneous and authentic way in which women experience their pregnancies, think of their foetus, and make decisions about both.

Among the many properties and identities, a mother-to-be might attribute to the foetus (e.g. a cluster of cells, a budding baby, a future child), which can respectively entail a range of choices (from simply doing nothing to start making lists or collecting baby essentials), the offer adds the identity of a ‘being to be examined and diagnosed’ or a ‘potentially suffering being’. This new feature can become entangled with the choice for screening or testing and convert the choice to a desire making the choice feel inevitable rather than authentic.

Taken together, these observations illustrate a deeper point about how women's choices are shaped before any substantive decision about screening is even made. The sequencing of information and the pre-structuring of available options frame how a pregnancy is understood and what possibilities are perceived as salient. If the offer itself shapes perception and desire, then autonomy cannot be secured unless women are first given protected space to understand their pregnancy, its meaning in their lives, and the values that matter to them before any screening landscape is introduced.

This insight provides the conceptual foundation for my proposal to shift from pre-test to pre-offer counselling. To improve the quality of the dual system of information and support, and thereby maximise its ability to safeguard and promote women's reproductive autonomy,⁴⁵ there is a need to reconsider the third component identified above: the timing of counselling. Doing so enables the creation of a triadic synergy (information, support and timing) by integrating an initial, reflective stage in the prenatal care pathway before the offer is made, namely pre-offer counselling.

In detail, by pre-offer counselling, I refer to the introduction of a stage that ‘screens’ women's intentions, expectations, and concerns about pregnancy and perinatal care in general, rather than focusing on prenatal screening and testing options in particular. This stage could be incorporated into the first visits with a midwife or obstetrician and would aim at a preliminary perinatal care discussion ‘starting not so much with telling women or couples about test options and technicalities, but with first exploring their needs and concerns about the pregnancy and its possible outcome’.⁶³

It is important to clarify that pre-offer counselling is not intended merely to document pre-existing preferences or values, as if these were fixed and fully formed. Rather, its purpose is to help women articulate, explore, and, where necessary, refine their understandings of what matters to them in the context of pregnancy and future parenthood. Through guided, dialogical engagement, women can consider how their values relate to potential outcomes and decisions before facing specific screening options. In this way, pre-offer counselling supports autonomy not as the mere expression of choice but as a capacity for reflective and informed decision-making.

In contrast to offering one screening option, an approach that risks narrowing women's attention, providing information in stages empowers expectant mothers to make their own decisions and to develop a perinatal care plan grounded in their individual needs and preferences. The pre-offer stage does not limit access to PST. Instead, it enables both professionals and women to identify the latter's needs, concerns, and values, thus supporting the provision of information in a personalised and digestible manner. This approach helps mitigate the risk of information overload, especially concerning information that may not be of interest to a specific woman. Also, in every step, it is possible to re-assess the needs and understanding of women. Overall, it is more likely that more women will be making more authentic choices.

Inevitably, there may be disagreements about the feasibility of my suggestion. My proposal may be considered non-applicable due to time and money constraints. The number of couples choosing prenatal screening for ‘information only’ is likely to increase, as well as the additional support necessary for families continuing with a known affected pregnancy.⁵² Although concerns about financial and time pressures are reasonable, they are not relevant to the suggested plan. Currently, in the NHS, women are informed about prenatal testing and screening options at the first appointment.⁶⁸ Adding a pre-offer counselling stage to this appointment is not likely to aggravate financial and time pressures, but rather alleviate them.

The proposed plan is based on the idea that finding out what matters to a patient should come first; learning about patients’ priorities can better support them in making authentic decisions as, in this way, we can offer them information that relates to their priorities. A pre-offer counselling stage can work as a preparatory stage in which women will strengthen their self-awareness, confidence, and ability to make authentic choices. In this stage, women can still start receiving information; however, these will be personalised and easy to understand and digest. Thus, those women who will opt to continue in the next stage(s) will be better prepared to understand more difficult information. This educative approach can help more women make autonomous choices about various prenatal care options, including PST, more quickly. This is because only those more likely to use one or more of the available options will choose to move on to the relevant informational stages. Simultaneously, this approach does not limit access to information for those women less likely to choose the available option.

When it comes to couples requesting specific PST options, they essentially express their intentions upfront. Thus, they will be directly referred to the pre-test counselling stage. Importantly, before such a referral is determined, pre-offer counselling can help ascertain the authenticity of their choice, especially in cases where a PST request may stem from misinformation or misunderstandings. Essentially, pre-offer counselling can speed up the procedures by distinguishing the aims of individuals who explicitly request screening, clarify their understanding, and ensure the quality of the information they already have. Early resolution of misunderstandings can prevent their persistence and escalation as more information emerges in later stages, and thus, accelerate the process in subsequent stages. This approach of screening intentions and improving individuals’ understanding and decision-making not only saves time but also is likely to be cost-effective since it does not require additional personnel or logistics. Certainly, additional funding is essential for ensuring the provision of adequate information and prenatal counselling, especially with the increasing number and complexity of PST methods. However, this applies to the case of any prenatal screening plan offering more and new options.⁶³ To put it in simple terms, not investing in getting the necessary protective equipment when one upgrades from riding a scooter to riding a new high-powered motorcycle is negligent and can be dangerous.

Another concern is that the proposed plan might decrease the number of women who receive information about all available PST options, thereby limiting access to information that is often understood as necessary for making maximally autonomous choices. It is true that influential accounts in bioethics hold that information is ‘a precondition for the exercise of autonomy’,⁶⁹ because expanding the range of available options enables individuals to shape their preferred life plans.⁷⁰ In the context of prenatal screening, it has similarly been argued that screening is offered precisely so that people can avoid having a child with serious disorders or disabilities.⁶³ These views capture an important intuition: information can enhance autonomy by enabling prospective parents to anticipate and plan for possible futures. However, I argue that in the context of routinised PST, the mere expansion of information and options does not guarantee autonomy. Without guidance, personal relevance, or reflective space, information can overwhelm, distort priorities, or reinforce external pressures rather than support self-determination.

While I acknowledge arguments suggesting that more information can enhance autonomy, it is crucial to recognise that, in this context, autonomy depends not simply on the availability of information but on the conditions under which it is received and interpreted. Voluntariness, understanding, and the capacity to reflect on how information relates to one's values are essential components of autonomous decision-making. This is precisely what the proposed plan seeks to secure. By structuring information provision in stages and embedding it within an early, reflective counselling process, the plan prioritises understanding over volume and enables women to make decisions that genuinely align with their commitments and circumstances. In this way, the model safeguards not only the adequacy of information but the authenticity of the choices that follow from it.

Ultimately, I argue that the suggested plan, departing from the traditional idea of routine offer, matches better with the innovative context of screening methods and reflects the latest trends in the provision of information and counselling in PST⁷¹; it is a comprehensive framework for maintaining the required balance between securing sufficiently informed consent, clinical practicality, and screening efficacy.

Conclusion

In this paper, I endorse the view that embracing innovation in the field of PST necessitates embracing new tactics regarding women's information about this innovation too.²⁶ I advocate for a proactive approach to adapting PAT practices to the advancements in the field. While acknowledging concerns about the potential threats to women's autonomous decision-making posed by expanded screening methods, I argue for a re-evaluation of current strategies. Rather than radically altering existing approaches, I propose a refinement focused on enhancing the quality and timing of information provision and support.

Recognising the limitations of solely relying on adequate information provision, I emphasise the crucial interplay between information, support, and the timing of counselling. By prioritising the timing of counselling as a key component, I propose a departure from routine screening offers to routine perinatal care counselling, including comprehensive information about screening options. This shift, I argue, ensures a more ethical and effective approach to supporting women's reproductive autonomy. Ultimately, the synergy created by optimising these three components forms a robust framework for navigating the complexities of modern PST. By embracing this approach, we can uphold the principles of autonomy while effectively integrating new screening technologies into clinical practice.

Footnotes

Acknowledgments

Not applicable

ORCID iD

Panagiota Nakou

Ethical approval and informed consent statements

Not applicable

Funding

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Declaration of conflicting interests

The author declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data availability statement

Example text of a Data statement, as provided by the author.

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