Medication adherence among pregnant women with hypothyroidism—missed opportunities to improve reproductive health? A cross-sectional, web-based study

https://doi.org/10.1016/j.pec.2016.04.006Get rights and content

Highlights

  • This is the first study on adherence to hypothyroidism treatment in pregnancy.

  • Adherence in pregnancy is comparatively high but there is room for improvement.

  • Pregnant women might benefit from proper risk communication and information framing.

Abstract

Objective

To evaluate patterns of and factors associated with a lack of pharmacotherapy as well as low adherence to treatment of hypothyroidism in pregnancy.

Methods

This multinational, cross-sectional, internet-based study recruited pregnant woman in 18 countries. Data about women’s socio-demographic and medical characteristics, medication adherence (8-item Morisky Medication Adherence Scale), beliefs about medication (Beliefs about Medicine Questionnaire), and personality traits (Big Five Personality Trait questionnaire) were collected via an online questionnaire.

Results

229 of 5095 women had hypothyroidism during pregnancy; of these, 93% reported hypothyroidism pharmacotherapy. Adherence was low among 17% (95% CI: 12.5–22.5%) of medicated women, whilst it was moderate and high among 44% and 39%, respectively. Not using folic acid and not living in a stable relationship were associated with an increased likelihood for untreated hypothyroidism. Younger maternal age and not using folic acid in pregnancy were factors significantly associated with low adherence. Conscientiousness and the perception that the benefit of pharmacotherapy outweighed the risks were associated with higher levels of adherence.

Conclusion

There is room for improvement of adherence to hypothyroidism treatment in pregnancy.

Practice implications

Counselling of women with hypothyroidism in pregnancy should include a proper risk communication and information framing, to ameliorate maternal and foetal health.

Introduction

Hypothyroidism prevalence rates in pregnancy are described to be around 2–3% [1] with clinical hypothyroidism rates between 0.3–0.5%. However, substantially higher rates of up to 24% for increased thyrotropin (TSH) levels [2], and up to 2% for clinical hypothyroidism [3] have also been observed in some areas. Prevalence increases with age, therefore the trend towards delaying childbearing has been contributing to prevalence increase in pregnancy [4]. Since untreated hypothyroidism is known to be associated with various severe pregnancy complications such as miscarriage, preterm birth, gestational hypertension [5], placental abruption [6] and even with potential adverse foetal outcomes [7], adherence to the prescribed hypothyroidism treatment is essential for reproductive health. Clinical guidelines recommend a monthly control of TSH for pregnant women on levothyroxine in the first half of their pregnancy, because levothyroxine-dose adjustment (i.e. an up to 50% increase of the dose) is sometimes required [8].

Noteworthy, levothyroxine treatment or iodine supplementation in pregnancy are safe and health benefits can be expected for both the pregnant woman and her foetus. Despite this fact, little is known about medication use and adherence in women with hypothyroidism in pregnancy so far.

While drug intake in pregnancy is common, many women are still sceptical about drugs in pregnancy. Overestimation of teratogenic risks and avoiding any medication as soon as pregnancy is recognized are observed [9], [10], [11]. Previous studies have shown that women’s beliefs about medication and perception of medication related teratogenic risk are substantially influencing drug adherence in pregnancy [12], [13]. None of these studies, however, included the perceptions of risks related to hypothyroidism treatment.

Personality has also been related to health behaviour [14], [15]. Conscientiousness (i.e. control of impulse and self-constraint) and neuroticism (i.e. propensity to feel anxious, nervous, sad, and tense) were the most important personality traits related to drug adherence [16], [17], [18]. Whether this also applies to hypothyroidism treatment in pregnancy is unknown.

Despite its undeniable importance for maternal and foetal health, the degree of adherence to hypothyroidism treatment in pregnancy and the risk factors for low adherence still remain to be elucidated. We have utilized a data set from a multinational, web-based study on medication use in pregnancy to characterize women medicating and not medicating their hypothyroidism during pregnancy. Additionally, factors associated with low adherence by exploring pregnant women’s socio-demographic, life style and medical characteristics as well as their beliefs about medication and their personality traits have been analysed. A better understanding of these influences could improve counselling to pregnant women with hypothyroidism and help them overcome adherence obstacles.

Section snippets

Study design and data collection

This multinational, cross-sectional, web-based study was simultaneously performed in 18 countries in Western, Northern and Eastern Europe, North America and Australia. Pregnant women at any gestational week were eligible to participate. An anonymous online questionnaire (http://www.questback.com) was used to collect data; the questionnaire [19] could be accessed for a period of two months in each participating country between 1-Oct-2011 and 29-Feb-2012 and was open to the public via websites

Population characteristics

The online questionnaire was accessed by 5166 pregnant women and of these, 5095 (98.6%) accepted and completed it. We excluded women with no eligible country of residency from the analysis, as well as women not suffering from hypothyroidism, leaving 231 (4.7%) participants. Of these, use of thyroid medication during pregnancy was reported by 215 women; two out of 215 women did not fill the MMAS-8 (<75% completion) and were excluded from the analysis, leading to a final study population of 213

Discussion

This investigation is the first to extensively explore pregnant women’s adherence to their hypothyroidism treatment, providing important information for patient counselling.

On the positive side we found that adherence to pharmacotherapy for hypothyroidism during pregnancy is relatively high. About 93% of pregnant women with hypothyroidism use their thyroid medication and among them, 83% show medium to high adherence. However, 17% of women demonstrated low adherence indicating that a clinically

Funding

The study has received financial support from the Norwegian Research Council (Grant no. 216771/F11) and the Foundation for Promotion of Norwegian Pharmacies and the Norwegian Pharmaceutical Society.

Details of ethics approval

This study was carried out in compliance with the Helsinki Declaration. Informed consent was given by the participants by ticking the answer “yes” to the question “Are you willing to participate in the study?” The Regional Ethics Committee in Norway, region southeast, approved the study. Ethical approval or study notification to the relevant national Ethics Boards was achieved in specific countries as required by national legislation. All data were handled and stored anonymously.

Contribution to authorship

HJ, AL, and HN have developed the research question, drafted the article and contributed to data acquisition and interpretation, AL has analysed the data, SV and EY have contributed to data interpretation and critically revised the article for intellectual content and provided medical (SV) and psychological (EY) expertise.

Disclosure

We have no conflict of interests to report and confirm that all patient/personal identifiers have been removed or disguised so the patient/person(s) described are not identifiable and cannot be identified through the details of the story.

Acknowledgments

We thank the Steering Committee of OTIS and ENTIS for reviewing the study protocol, all website providers who contributed to the recruitment phase, Professor DE. Morisky and Professor R. Horne for the permission to use the MMAS-8 and BMQ-Specific, respectively. We are also grateful to all the participating women who took part in this study and the national study coordinators (Spigset O, Twigg MJ, Zagorodnikova K, Mårdby AC, Moretti ME, Drozd M, Panchaud A, Hameen-Anttila K, Rieutord A, Gjergja

References (53)

  • E. van den Boogaard et al.

    Significance of (sub)clinical thyroid dysfunction and thyroid autoimmunity before conception and in early pregnancy: a systematic review

    Hum. Reprod. Update

    (2011)
  • B.M. Casey et al.

    Thyroid disease in pregnancy

    Obstet. Gynecol.

    (2006)
  • J.E. Haddow et al.

    Maternal thyroid deficiency during pregnancy and subsequent neuropsychological development of the child

    N. Engl. J. Med.

    (1999)
  • Ross D.S., Hypothyroidism during pregnancy: Clinical manifestations, diagnosis, and treatment. In: Basow DS, editor....
  • A.M. van Trigt et al.

    Questions about drugs: how do pregnant women solve them

    Pharm. World Sci.

    (1994)
  • H. Nordeng et al.

    Perception of risk regarding the use of medications and other exposures during pregnancy

    Eur. J. Clin. Pharmacol.

    (2010)
  • L.S. Cohen et al.

    Relapse of major depression during pregnancy in women who maintain or discontinue antidepressant treatment

    JAMA

    (2006)
  • A. Lupattelli et al.

    Patterns and factors associated with low adherence to psychotropic medications during pregnancy-a cross-sectional, multinational web-based study

    Depress. Anxiety

    (2015)
  • A. Lupattelli et al.

    Adherence to medication for chronic disorders during pregnancy: results from a multinational study

    Int. J. Clin. Pharm.

    (2014)
  • W. Michel et al.

    Introduction to Personality: Toward An Integration

    (2004)
  • M. Axelsson et al.

    The function of medication beliefs as mediators between personality traits and adherence behavior in people with asthma

    Patient Prefer Adherence

    (2013)
  • S.E. Hampson et al.

    Handbook of personality: theory and research

  • E. Ystrom et al.

    Effects of personality on use of medications, alcohol, and cigarettes during pregnancy

    Eur. J. Clin. Pharmacol.

    (2012)
  • H.S. Friedman

    Long-term relations of personality and health: dynamisms, mechanisms, tropisms

    J. Pers.

    (2000)
  • A. Lupattelli et al.

    Medication use in pregnancy: a cross-sectional, multinational web-based study

    BMJ Open

    (2014)
  • WHO Collaborating Centre for Drugs Statistics Methodology. ATC/DDD index 2012. Available at:...
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