Objectives Control of infectious diseases in developing countries often requires using drugs that are contraindicated during pregnancy. Avoiding inadvertent exposure to drugs involves women (a) recognising pregnancy early, (b) disclosing the pregnancy to health workers and (c) using medicines in an informed manner. We explored these factors to inform and improve the process by which health workers provide care and treatment to pregnant women.Design Qualitative study.Setting The Gambia.Population Rural women and men.Methods We conducted 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants (TBAs).Main outcome measure Pregnancy disclosure.Results Most women recognised early signs and symptoms of pregnancy and believed other people could easily do so. To avoid gossip, women hid their pregnancies and delayed antenatal care, even though husbands and TBAs insisted on attendance. Women acutely ill in early pregnancy hoped health workers would recognise pregnancy without explicit disclosure. Women said that they knew, and sought to avoid, some contraindicated drugs, but their knowledge was rudimentary. Health workers stressed the benefits, not the risks of prescribed drugs.Conclusions Despite public health and clinical benefits of preventing and treating pregnancy infections, women were ill informed and pressurised into taking drugs. These ethical issues should be more widely addressed.Keywords Antenatal care, drugs, Gambia, informed decisionmaking, pregnancy.Please cite this paper as: Stokes E, Dumbaya I, Owens S, Brabin L. The right to remain silent: a qualitative study of the medical and social ramifications of pregnancy disclosure for Gambian women.

BackgroundThe use of most anti-malarial medications is restricted during pregnancy, but two doses of sulphadoxine-pyrimethamine are recommended after the first trimester as intermittent preventive treatment in pregnancy (IPTp). In The Gambia, only 32% of women receive two doses and very little research has been conducted on women's awareness of drug safety during pregnancy. The objective of this paper was to assess whether rural Gambian women were aware of the importance of the timing of the two-dose IPT dose schedule and its relevance to drug safety.MethodsThis was a qualitative study in which 41 interviews and 16 focus group discussions with women, adolescents, men and traditional birth attendants were conducted. A generic qualitative approach was used to generate a theory as to why women might not participate in IPTp as recommended.ResultsAlthough most women used calendar months to count their stage of pregnancy, these months did not correlate with their concept of foetal development. Foetal growth was described following Islamic tradition as water, clot, piece of meat and human being, although there was little consensus about the order or timing in which these stages occurred. Common signs and conditions of malaria were known. Women were anxious about miscarriage and recognized that some medicines should not be taken in the first trimester, but were urged by men and traditional birth attendants to attend for antenatal care in the first trimester to "start treatment." General knowledge about the purpose of pregnancy medications and when they should be taken was poor among both men and women. One important result was that women relied entirely on health workers to provide safe drugs, at the correct time.ConclusionWomen did not have relevant information to judge the safety and appropriate timing of pregnancy drugs, which made them over-reliant on health workers. They should be encouraged to date their own pregnancies in culturally relevant terms and to anticipate when and which medications they should receive.