Interventions to enhance medication adherence in pregnancy- a systematic review

Abstract

Background Sub-optimal medication adherence in pregnant women with chronic disease and pregnancy-related indications has the potential to adversely affect maternal and perinatal outcomes. Adherence to appropriate medications is advocated during and when planning pregnancy to reduce risk of adverse perinatal outcomes relating to chronic disease and pregnancy-related indications. We aimed to systematically identify effective interventions to promote medication adherence in women who are pregnant or planning to conceive and impact on perinatal, maternal disease-related and adherence outcomes. Methods Six bibliographic databases and two trial registries were searched from inception to 28th April 2022. We included quantitative studies evaluating medication adherence interventions in pregnant women and women planning pregnancy. Two reviewers selected studies and extracted data on study characteristics, outcomes, effectiveness, intervention description (TIDieR) and risk of bias (EPOC). Narrative synthesis was performed due to study population, intervention and outcome heterogeneity. Results Of 5614 citations, 13 were included. Five were RCTs, and eight non-randomised comparative studies. Participants had asthma (n = 2), HIV (n = 6), inflammatory bowel disease (IBD; n = 2), diabetes (n = 2) and risk of pre-eclampsia (n = 1). Interventions included education +/− counselling, financial incentives, text messaging, action plans, structured discussion and psychosocial support. One RCT found an effect of the tested intervention on self-reported antiretroviral adherence but not objective adherence. Clinical outcomes were not evaluated. Seven non-randomised comparative studies found an association between the tested intervention and at least one outcome of interest: four found an association between receiving the intervention and both improved clinical or perinatal outcomes and adherence in women with IBD, gestational diabetes mellitus (GDM), and asthma. One study in women with IBD reported an association between receiving the intervention and maternal outcomes but not for self-reported adherence. Two studies measured only adherence outcomes and reported an association between receiving the intervention and self-reported and/or objective adherence in women with HIV and risk of pre-eclampsia. All studies had high or unclear risk of bias. Intervention reporting was adequate for replication in two studies according to the TIDieR checklist. Conclusions There is a need for high-quality RCTs reporting replicable interventions to evaluate medication adherence interventions in pregnant women and those planning pregnancy. These should assess both clinical and adherence outcomes.

Impact of early preeclampsia prediction on medication adherence and behavior change: a survey of pregnant and recently-delivered individuals

“…Previously, authors have examined reasons for medication non-adherence in pregnancy and ways to improve it. Efforts to improve adherence in pregnancy have yielded mixed results, and there remains limited evidence about the potential impact of available behavioral and educational interventions [ 12 ]. Examination of the reasons behind low medication adherence have yielded insights such as the perceived medicalization of pregnancy, not realizing medication had been recommended, and not feeling that the risk applied to them, despite having stratified as high risk based on clinical factors such as race, age, and BMI [ 29 ].…”

“…This evidence-based guidance recommends interventions including remote monitoring, medications, and lifestyle and behavioral interventions to optimize the prevention of preeclampsia [ 8 ]. However, patient adherence to recommendations that require behavioral change and medication uptake has historically been challenging [ 9 – 11 ], and attempted educational interventions have shown mixed results [ 12 ]. However, evidence from other fields suggests that objective risk stratification can be a strong motivator for behavior change, as in the case of coronary artery calcium scoring and its association with significantly improved statin adherence and weight loss [ 13 – 17 ].…”

Impact of early preeclampsia prediction on medication adherence and behavior change: a survey of pregnant and recently-delivered individuals

“…Efforts to improve adherence in pregnancy have yielded mixed results, and there remains limited evidence about the potential impact of available behavioral and educational interventions. 12 Examination of the reasons behind low medication adherence have yielded insights such as the perceived medicalization of pregnancy, not realizing medication had been recommended, and not feeling that the risk applied to them, despite having strati ed as high risk based on clinical factors such as race, age, and BMI. 28 This nal insight -not feeling that the risk applied to them -ties to the current study.…”

“…8 However, patient adherence to recommendations that require behavioral change and medication uptake has historically been challenging, [9][10][11] and attempted educational interventions have shown mixed results. 12 However, evidence from other elds suggests that objective risk strati cation can be a strong motivator for behavior change, as in the case of coronary artery calcium scoring and its association with signi cantly improved statin adherence and weight loss. [13][14][15][16][17] Therefore, we wanted to understand how this could translate to an obstetrical population, and whether having a test to objectively predict the risk of preeclampsia in advance of symptoms would drive behavior change and medication adherence.…”