Having a disease shouldn’t mean you can’t have a child. And being pregnant shouldn’t prevent you from getting treatment. However, there is still a big knowledge gap on pregnancy and medicine.
Attitudes to taking medication during pregnancy may have changed in recent years, but conflicting advice and a lack of clinical evidence means many expectant mothers are unsure what is the best thing to do for themselves and their baby.
The Safe Motherhood Week report that we published earlier this year surveyed women across seven different European countries on their attitude towards medication and pregnancy. The survey found that roughly one-third of women had taken one or more medication during their pregnancy; this may be indicative of a growing acceptance of taking medication during pregnancy or else an increase in the number of women with co-morbid medication conditions that require treatment during pregnancy.
Significantly, 10 per cent of those surveyed reported suffering from a chronic illness such as asthma, diabetes, and pain, among others.
The survey also found that older women were more likely to take medication, and were more likely to have a chronic condition.
The international picture
The survey results reflect international data; a 2014 multinational study of almost 10,000 pregnant women found that 67% of women used an over the counter (OTC) medication while pregnant, whereas 68.4% and 17% of women reported that they used at least one medication for the treatment of acute/short-term illnesses and chronic/long-term disorders, respectively.
There is significant variation between countries; the extent of self-reported medicated illnesses and types of medication used by indication varied across regions, especially in relation to urinary tract infections, depression or OTC nasal sprays.
Echoing the Safe Motherhood Week report findings, it was observed that women with higher age or lower educational level, housewives or women with an unplanned pregnancy were those most often reporting use of medication for chronic/long-term disorders.
Some studies report even higher rates; for example, a 2011 study using U.S. data from 1976-2008 reported that the vast majority of women (90%) will take at least one medication during pregnancy and 70% will take at least one prescription medication.
The data, from the Center for Disease Control in the US, also suggests that first trimester use of prescription medications has increased more than 60%, while first trimester use of four or more medications nearly tripled and use of four or more medications anytime during pregnancy more than doubled during this time.
Yet there is a significant cohort of women who refuse to use medicines, even when it is medically appropriate and necessary. Many pregnant women are “overestimating the risks” of taking over the counter and prescribed medication, according to recent research carried out by pharmacists in the UK.
The research found that women are choosing not to treat common pregnancy symptoms such as nausea, heartburn and aches and pains with medications. It was also seen that mothers-to-be are choosing not to take medication for urinary tract infections (UTIs).
Lead researcher Dr Michael Twigg, from University of East Anglia’s School of Pharmacy said that many women were avoiding safe medications, while others were not treating conditions that could have an impact on the developing fetus.
“We also found that a large number of women thought that taking paracetamol during pregnancy was risky and would avoid it. It is, however, perfectly safe. One of the most worrying things we discovered was that many women who experienced a UTI did not take medication for it. If left untreated, UTIs can cause significant complications and harm the fetus.”
In general, women who did not take medication perceived the risk to be greater than those who chose to take medication. According to Dr Twigg, the results illustrate a knowledge gap and a wide range of misperceptions about medication use in pregnancy.
“What this all shows us is that women need more information about the safety of medications during pregnancy to encourage them to treat conditions effectively. Understanding women’s concerns is also essential to promote adherence to prescribed medications during pregnancy,” he said.
Speaking to Safe Motherhood Week, Professor Twigg said that women are right to be cautious, but must see advice from experts if they are uncertain as to whether they should take a particular medicine, whether it is OTC or prescription.
“I would say that that medicines use in pregnancy has traditionally been associated with caution and this is not a bad thing. We advocate that pregnant women feel empowered to discuss their particular circumstances with a health care professional.”
If attitudes have changed this dramatically, then why has the grey area of taking medication during pregnancy not become any clearer in recent years? A big factor is that ethical reasons preclude many pregnant women from taking part in clinical trials of drugs, and thus conclusive evidence is limited.
Many researchers are continuing to look closely at the issues surrounding medication use in pregnancy, however, and one of those is Professor Megan Clowse, Associate Professor of Medicine, and Director of the Duke Autoimmunity in Pregnancy Registry, at the Duke University Medical Centre in North Carolina, US.
Professor Clowse is involved in a number of research projects exploring medication use for chronic autoimmune conditions, such as psoriasis, arthritis, and inflammatory bowel disease. She tells Safe Motherhood Week that for many women it can be more detrimental to discontinue their medications for their condition.
“We now have data that suggests allowing the disease to flare leads to higher rates of pregnancy complications – more preterm deliveries and smaller babies. But there are medications that are now considered safe in pregnancy,” she explains.
Until recently there was not a clear consensus on whether the stronger biologic medications were safe for the expectant mother and her unborn baby. As the number of women on these medications who become pregnant grows, the literature on the topic has also swelled and most people and datasets now agree that these medications are safe in pregnancy, says Clowse.
Some women, however, dislike the idea of taking medication during pregnancy, and this can lead to significant problems. In addition, there is a misconception that autoimmune conditions tend to improve during pregnancy – this can certainly happen, but not in the vast majority of cases. Dr Clowse says that women who cease their normal medication may suffer greatly by doing so – and at greater risk to the baby.
“Almost all women that I’ve cared for who have decided to stop their arthritis medication have a significant flare of their disease and end up with a lot of pain, inflammation, and having to take strong steroids – the pregnancy would likely be more successful if they had stayed on the medication to control their arthritis.”
The evidence may be there to support the use of certain medications during pregnancy, but the issue of taking medication while pregnant is a very personal one, and not all expectant mothers are privy to the most up-to-date information. Is the decision-making process for a woman with an autoimmune condition difficult?
According to Clowse, it is, particularly when obstetricians and rheumatologists or gastroenterologists may have differing views.
“Many women can’t find clear answers and get conflicting guidance from their rheumatologists and obstetricians. This isn’t surprising given the limited available data and the infrequency that these physicians are faced with a pregnant patient. Many women feel most comfortable stopping all drugs in pregnancy, but for women with chronic diseases, that might not be the best approach to having a healthy baby.”
Attitudes are changing, and the body of evidence is growing, but it is clear that there remains a significant knowledge gap when it comes to medication use during pregnancy. Access to timely and appropriate care and information during pregnancy is vital for a safe and positive motherhood experience.