2nd March 2023
Research published today in the BMJ Open journal has found that a reluctance among healthcare professionals to prescribe and dispense medications to women who are pregnant is placing their health and lives at risk.
The study conducted by researchers at the Centre for Reproductive Research & Communication at BPAS, Cardiff University, Pregnancy Sickness Support, and UCL, involved analysis of survey responses from 7090 women and interviews with 34 women who were pregnant or had been pregnant in the last 5 years.
Refusal to prescribe and dispense for serious conditions
There are few medications that should ideally not be used by pregnant women due to their teratogenicity, for example, thalidomide, sodium valproate and isotretinoin. Most other medications are safe and widely used during pregnancy, and there are several national prescribing guidelines for treatment during pregnancy.
While prescribers need to balance maternal benefit with potential fetal harm when prescribing in pregnancy, women’s individual circumstances were not always considered, and they were not fully engaged in decision making. Possibly reflecting the tendency of health professionals to overestimate the teratogenic potential of drugs, researchers found many examples where health professionals used fear of fetal harm to justify a refusal to prescribe or dispense otherwise recommended medications. This had a significant impact not only on women’s health, but on their emotional well- being.
One participant described the distress that resulted when a pharmacist would not fulfil a prescription for anti-depressants prescribed by her GP.
“They just wouldn’t give me my prescription, and people were behind me in the queue and could hear what I was on, that I was pregnant. I wasn’t 12 weeks yet, so I hadn’t told anybody. I had to just sit there waiting for them to decide whether I could have it or not and then they said, ‘No, you can’t have it.’ I left without any medication, and I was just crying in the car.”
Even when medication was provided, women were warned repeatedly by healthcare professionals that taking the medication could result in serious harm to their babies, resulting in a reluctance to use the prescribed medication and / or feelings of shame and guilt.
“She saw I was on antidepressants and she made me feel like I was the world’s worst mother… She made me feel like, ‘You’re hurting your baby’. Then when I went to the pharmacy to pick up my meds, they made me feel like it on the same day as well. I think that was the point where I started to really decline in my mental health. It just seemed to trigger something off that I was going to be a terrible mother.”
“All the doctors I saw had completely different advice”
In the UK, prescribing for pregnant women is undertaken by different health professionals, including GPs, midwives, and obstetricians. This multidisciplinary approach to antenatal prescribing was found often to be fragmented, with women hearing conflicting opinions even from different members of the same professional group. One woman received conflicting opinions from two GPs working in the same practice:
“So, I was prescribed by one doctor the ondansetron and because I was running out, they said I had to speak to another doctor… to get the repeat prescription. Then when this doctor phoned me, she said, ‘You shouldn’t be taking this. This is for cancer patients. There’s no reason why you should be taking it. You’re putting your baby’s life at risk’. … She just wasn’t having any of it. I even told her that I’d just had a scan like 45 minutes before the phone call, and she said, ‘Oh well, that can change at your 20 week scan. Don’t come crying to me when they tell you that your baby has got heart defects’.”
“I ended up being hospitalised during pregnancy because of my seizures”
The belief that all medication use during pregnancy carries risk is commonly held among women, with paracetamol, antibiotics and antidepressants considered to be on a continuum of increasing risk.
Similar to the lack of preconceptual and antenatal care for women with epilepsy highlighted in reviews of maternal deaths, where information on medications used for chronic conditions was not shared, some women discontinued treatments without medical consultation resulting in hospitalisation or exacerbation of symptoms. One participant experienced temporary blindness following the discontinuation of medication for cranial hypertension.
“I am epileptic and though my seizures increased during pregnancy I was too scared to tell my midwife as I was afraid of my medication being increased and the risks to my unborn baby. I ended up being hospitalised during pregnancy because of my seizures and my daughter had to be delivered early by caesarean section.”
“I stopped taking my inhaler, just because I just didn’t want to harm the baby. I took a bad cold, and I was coughing up blood, and then they sent me to hospital.”
“Because there isn’t a lot of research into [cranial hypertension] in pregnancy, I decided, personally, to stop taking the medication… I did struggle with a few migraines throughout the pregnancy, one which was quite severe, which resulted in a loss of vision in my left eye, but luckily, it came back.”��
Commenting, Clare Murphy, Chief Executive of the British Pregnancy Advisory Service, BPAS, and co-author of the study, said:
“The vast majority of pregnant women in the UK will need to use medication for a short-term or chronic condition, and safe and effective prescribing is an essential component of antenatal care. Yet it is clear from our research that women’s health and wellbeing is being harmed by an overly precautionary approach. We need to challenge the prevailing cultural climate in which pregnant women’s own needs are often seen as secondary to those of her fetus because, as our research shows, this can have serious consequences for women.”
Julia Sanders, Professor of Clinical Midwifery at Cardiff University and first author of the study, said:
“During the study we heard from many pregnant women who could not access the medications they needed. This particularly related to medicines for severe sickness, pregnancy pain and mental health conditions. Some women were blocked from getting recommended medicines because doctors would not prescribe them or pharmacists refused to dispense them. Other women were prescribed medicines, but a lack of information meant they did not have the confidence to take them. This study shows all professional groups need to work harder to ensure women are able to access safe effective medicines throughout pregnancy.”
Professor Marian Knight, Professor of Maternal and Child Population Health at the University of Oxford, who was not involved in the research, said:
“This work shows very starkly the challenges pregnant women face trying to access medications in pregnancy. Women face conflicting advice and their healthcare professionals often do not recognise the importance of taking medication in pregnancy for pregnancy-specific conditions or pre-existing illnesses. This may sometimes have tragic consequences for either women or their babies. It is important that staff caring for pregnant women recognise the benefits of taking medication in pregnancy as well as how to access high quality information on medicine safety.”
For further information, please contact Katherine O’Brien, BPAS Associate Director of Campaigns and Communications, on katherine.o’firstname.lastname@example.org or 07881 265276.
Notes to Editors
The citation and DOI for the paper is: Sanders J, et al. BMJ Open 2023;13:e067987. doi:10.1136/bmjopen-2022-067987
The full paper, attached, will be published by the BMJ Open here at 00:01 Thursday 2nd March 2023.
The British Pregnancy Advisory Service, BPAS, is a charity that sees over 100,000 women a year for reproductive healthcare services including pregnancy counselling, abortion care, miscarriage management and contraception at clinics across Great Britain.
BPAS exists to further women’s reproductive choices. We believe all women should have the right to make their own decisions in and around pregnancy, from the contraception they use to avoid pregnancy right the way through to how they decide to feed their newborn baby, with access to evidence-based information to underpin their choices and high-quality services and support to exercise them.
BPAS also runs the Centre for Reproductive Research and Communication, CRRC. Through rigorous multidisciplinary research and impactful communication, the CRRC aims to inform policy, practice, and public discourse. You can find out more here.