First trimester medication use in pregnancy in Cameroon: A multi-hospital survey

BMC Pregnancy and Childbirth, Volume 18, No. 1, Year 2018

Interpretação

Background: There is a paucity of epidemiological data on medication use in pregnancy in Cameroon. Methods: Between March and August 2015, 795 pregnant women attending 8 urban and 12 rural hospitals in Cameroon for antenatal (ANC) or other care were interviewed on first trimester medication use using structured questionnaires. Multivariate logistic regression was used to analyse the association of 18 sociodemographic factors with medication use. Results: A total of 582 (73.2%) women took at least one orthodox (Western) medication during the first trimester, 543 (68.3%) women a non-pregnancy related orthodox medication, and 336 (42.3%)women a pregnancy related orthodox medication. 44% of the women took anti-infectives including antimalarials (33.6%) and antibiotics (20.8%).The other most common medications were analgesics (48.8%) and antianaemias (38.6%). Sulfadoxine/pyrimethamine, contraindicated in the first trimester of pregnancy, was the most commonly used antimalarial(13% of women).0.2% of women reported antiretroviral use. Almost 80% of all orthodox medications consumed by women were purchased from the hospital. 12.8% of the women self-prescribed. Health unit and early gestational age at ANC booking were consistent determinants of prescribing of non-pregnancy related, pregnancy related and anti-infective medications. Illness and opinion on the safety of orthodox medications were determinants of the use of non-pregnancy related medications and anti-infectives. Age and parity were associated only with non-pregnancy related medications. Conclusion: This study has confirmed the observations of studies across Africa indicating the increasing use of medications during pregnancy. This is an indication that access to medicine is improving and more emphasis now must be placed on medication safety systems targeting pregnant women, especially during the first trimester when the risk of teratogenicity is highest. This cross sectional hospital based medication use survey was conducted during a six month period (March to August 2015) in twenty hospitals across rural and urban settings of the southwest region of Cameroon. Taking into consideration the total number of live births in South West Cameroon for 2013 (12,861 births of approximately 6,687 urban and 6,174 rural), a 6 months data collection period, and a 50% response distribution (worst case scenario), maximum sample size needed was estimated at approximately 374 for both urban and rural strata. We used a two stage cluster sampling technique: in the first step, eligible hospitals were randomly selected and in the second step, all eligible women within the selected hospitals attending during the study period were invited to participate. Both private and government hospitals were eligible to participate if they had an annual delivery rate of over one hundred and two hundred for rural and urban settings respectively. Out of forty-one eligible hospitals (twenty-two urban and nineteen rural), 20 were randomly selected. All pregnant women attending the selected hospitals on the days the researchers were in attendance (registered for antenatal clinics or not) were eligible to participate. To limit recall bias and to target the period within first trimester, only women with a gestation of three to seven months were eligible to participate in the survey. The pregnant women were recruited as they came for antenatal visits or in a small number of cases, for hospital consultation. Out of eight hundred and seventeen eligible women approached, seven hundred and ninety-five agreed to participate in the study (97.3% response rate).The observed distribution of the women into urban (55.2%) and rural (44.8%) settings of residence matched the expected distribution in the general population. Similarly, the proportion of women sampled in each health district within the data collection period was comparable to that of 2013 delivery data. Existing literature on medication use and safety were reviewed to facilitate the design of a questionnaire to be used by interviewers (Additional file 1). The questionnaire was designed to facilitate recall (e.g. the woman had to define the three months of her first trimester (exposure period of interest) prior to completing the section on medication exposure; the section on medication exposure was followed by a section on first trimester illnesses so as to validate data on exposure given (for example, if a woman reported having malaria during the first trimester, one would verify whether she reported taking an antimalarial in the previous section on medication exposure). A picture guide of orthodox and traditional medications was developed to facilitate recall. In Cameroon, patients have individual hospital books which they bring along during hospital visits. Antenatal care (ANC) files kept in the hospitals contain data only on medications prescribed during routine ANC visits. Hence medication data for other hospital visits could only be obtained from hospital books. When available, the data collectors used antenatal files and the hospital books to complement and validate data obtained from interviews. In a sub-study involving 84 participants to evaluate the relevance of using the hospital books (Table 1), we observed that 10.3% of the exposures would have been missed without the use of hospital books. Comparison of source of medication exposure (N=84 Women)a a Excluding those without a hospital book and those that did not take medications according to the hospital book In order to ensure standardized collection of data, eight nurses working in the areas of research and education were trained as data collectors and provided with a guidance note to assist them during data collection. A pilot study enabled the data collectors to feed back to adjust the questionnaire and various aspects of the data collection process. Actual data collection took place from the months of March to August 2015. Using the predesigned questionnaire, the data collectors conducted one-on-one interviews for consented women in private rooms of the hospital to obtain data on first trimester medication exposure. Following the approach of Baraka et al (2014) [10], orthodox medications were grouped as pregnancy related medications and non-pregnancy related medications. Pregnancy related medications were defined as routine medications taken not for ill-health, but to support the health of the mother and the developing fetus. These included anti-anemias, mineral supplements and vitamins. The Anatomical Therapeutic Chemical Classification System of the WHO was used to classify drugs into therapeutic classes. Drugs were also classified according to the old version of United States Food and Drug Administration (FDA) pregnancy risk classification (A, B, C, D or X; see foot note in Fig 6). The FDA classification of each drug was verified from various sources including normal Google search, the Internet Drug Index (RxList) and Drugs .com. Drugs for which no FDA class could be obtained were classified as category “U”. Epi-info 3.1 was used for data entry and cleaning while all data analyses were conducted using SPSS version 22. Prevalence of medication use was determined by dividing the number of women who took at least one medication by the total number of participating women. Differences in the prevalence of medication use within categorical variables were tested using the Pearson Chi-squared test of independence with significance level set at 0.05. Multivariatelogistic regression was used to identify the determinants of medication use. Using backward conditional logistic regression, all the variables were initially included in the model. Then, variables were removed from the model based on significance level set at 0.10, if their removal did not significantly worsen the overall prediction of the model [11]. Variables (all categorical) entered into the model were: health unit (individual primary or secondary/tertiary healthcare facility), setting of hospital (urban/rural), maternal age (13-17 years, 18-25 years, 26-35 years and 36-45 years), marital status, highest level of education attained, living conditions, level of alcohol consumption, gravidity, parity, previous pregnancy termination, gestational age at interview, gestational age at first booking, pregnancy planning, gestational age at pregnancy awareness, opinion on the safety of orthodox medication, safety advice and illness during first trimester. We investigated determinants for general orthodox medication use, pregnancy related medication use, and anti-infectives use. Results were reported as adjusted odds ratios and 95%CI. Determinants of medication use were defined as those variables retained in the final logistic regression model.

AI Digest

Study Justification:

– There is a lack of epidemiological data on medication use in pregnancy in Cameroon.
– Understanding medication use during pregnancy is important for ensuring the safety of pregnant women and their developing fetuses.
– This study aims to provide valuable insights into the prevalence and determinants of medication use during the first trimester of pregnancy in Cameroon.

Study Highlights:

– 795 pregnant women attending 8 urban and 12 rural hospitals in Cameroon were interviewed on first trimester medication use.
– 73.2% of women took at least one orthodox (Western) medication during the first trimester.
– The most common medications taken were anti-infectives, analgesics, and antianaemias.
– Sulfadoxine/pyrimethamine, contraindicated in the first trimester, was the most commonly used antimalarial.
– Almost 80% of all medications were purchased from the hospital.
– Health unit and early gestational age at ANC booking were consistent determinants of medication prescribing.
– Illness and opinion on the safety of medications were determinants of medication use.
– Age and parity were associated only with non-pregnancy related medications.

Recommendations:

– More emphasis should be placed on medication safety systems targeting pregnant women, especially during the first trimester when the risk of teratogenicity is highest.
– Healthcare providers should be educated on the appropriate prescribing of medications during pregnancy.
– Pregnant women should be provided with accurate information on the safety of medications during pregnancy.
– Further research is needed to explore the long-term effects of medication use during pregnancy.

Key Role Players:

– Healthcare providers (doctors, nurses, pharmacists) to ensure appropriate prescribing and counseling.
– Government health agencies to develop and implement medication safety systems.
– Researchers and academics to conduct further studies on medication use during pregnancy.
– Patient advocacy groups to raise awareness and provide support for pregnant women.

Cost Items for Planning Recommendations:

– Training and education programs for healthcare providers.
– Development and implementation of medication safety systems.
– Research funding for further studies.
– Awareness campaigns and educational materials for pregnant women.
– Administrative and logistical support for coordination and implementation of recommendations.

Força da prova

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is based on a cross-sectional hospital-based survey conducted in Cameroon. The study collected data from 795 pregnant women attending 20 hospitals in urban and rural settings. The study used structured questionnaires and multivariate logistic regression analysis to analyze the association of sociodemographic factors with medication use. The study found that 73.2% of women took at least one orthodox medication during the first trimester, with anti-infectives, analgesics, and antianaemias being the most common. The study also identified determinants of medication use, such as health unit and early gestational age at ANC booking. The evidence in the abstract is relatively strong as it provides specific data on medication use during pregnancy in Cameroon. However, there are some limitations to consider. The study was conducted in a specific region of Cameroon and may not be representative of medication use in other regions. The study relied on self-reporting, which may be subject to recall bias. To improve the evidence, future studies could include a larger and more diverse sample size, use objective measures of medication use, and include a wider geographic scope.

Resumo

This cross sectional hospital based medication use survey was conducted during a six month period (March to August 2015) in twenty hospitals across rural and urban settings of the southwest region of Cameroon. Taking into consideration the total number of live births in South West Cameroon for 2013 (12,861 births of approximately 6,687 urban and 6,174 rural), a 6 months data collection period, and a 50% response distribution (worst case scenario), maximum sample size needed was estimated at approximately 374 for both urban and rural strata. We used a two stage cluster sampling technique: in the first step, eligible hospitals were randomly selected and in the second step, all eligible women within the selected hospitals attending during the study period were invited to participate. Both private and government hospitals were eligible to participate if they had an annual delivery rate of over one hundred and two hundred for rural and urban settings respectively. Out of forty-one eligible hospitals (twenty-two urban and nineteen rural), 20 were randomly selected. All pregnant women attending the selected hospitals on the days the researchers were in attendance (registered for antenatal clinics or not) were eligible to participate. To limit recall bias and to target the period within first trimester, only women with a gestation of three to seven months were eligible to participate in the survey. The pregnant women were recruited as they came for antenatal visits or in a small number of cases, for hospital consultation. Out of eight hundred and seventeen eligible women approached, seven hundred and ninety-five agreed to participate in the study (97.3% response rate).The observed distribution of the women into urban (55.2%) and rural (44.8%) settings of residence matched the expected distribution in the general population. Similarly, the proportion of women sampled in each health district within the data collection period was comparable to that of 2013 delivery data. Existing literature on medication use and safety were reviewed to facilitate the design of a questionnaire to be used by interviewers (Additional file 1). The questionnaire was designed to facilitate recall (e.g. the woman had to define the three months of her first trimester (exposure period of interest) prior to completing the section on medication exposure; the section on medication exposure was followed by a section on first trimester illnesses so as to validate data on exposure given (for example, if a woman reported having malaria during the first trimester, one would verify whether she reported taking an antimalarial in the previous section on medication exposure). A picture guide of orthodox and traditional medications was developed to facilitate recall. In Cameroon, patients have individual hospital books which they bring along during hospital visits. Antenatal care (ANC) files kept in the hospitals contain data only on medications prescribed during routine ANC visits. Hence medication data for other hospital visits could only be obtained from hospital books. When available, the data collectors used antenatal files and the hospital books to complement and validate data obtained from interviews. In a sub-study involving 84 participants to evaluate the relevance of using the hospital books (Table 1), we observed that 10.3% of the exposures would have been missed without the use of hospital books. Comparison of source of medication exposure (N=84 Women)a a Excluding those without a hospital book and those that did not take medications according to the hospital book In order to ensure standardized collection of data, eight nurses working in the areas of research and education were trained as data collectors and provided with a guidance note to assist them during data collection. A pilot study enabled the data collectors to feed back to adjust the questionnaire and various aspects of the data collection process. Actual data collection took place from the months of March to August 2015. Using the predesigned questionnaire, the data collectors conducted one-on-one interviews for consented women in private rooms of the hospital to obtain data on first trimester medication exposure. Following the approach of Baraka et al (2014) [10], orthodox medications were grouped as pregnancy related medications and non-pregnancy related medications. Pregnancy related medications were defined as routine medications taken not for ill-health, but to support the health of the mother and the developing fetus. These included anti-anemias, mineral supplements and vitamins. The Anatomical Therapeutic Chemical Classification System of the WHO was used to classify drugs into therapeutic classes. Drugs were also classified according to the old version of United States Food and Drug Administration (FDA) pregnancy risk classification (A, B, C, D or X; see foot note in Fig 6). The FDA classification of each drug was verified from various sources including normal Google search, the Internet Drug Index (RxList) and Drugs .com. Drugs for which no FDA class could be obtained were classified as category “U”. Epi-info 3.1 was used for data entry and cleaning while all data analyses were conducted using SPSS version 22. Prevalence of medication use was determined by dividing the number of women who took at least one medication by the total number of participating women. Differences in the prevalence of medication use within categorical variables were tested using the Pearson Chi-squared test of independence with significance level set at 0.05. Multivariatelogistic regression was used to identify the determinants of medication use. Using backward conditional logistic regression, all the variables were initially included in the model. Then, variables were removed from the model based on significance level set at 0.10, if their removal did not significantly worsen the overall prediction of the model [11]. Variables (all categorical) entered into the model were: health unit (individual primary or secondary/tertiary healthcare facility), setting of hospital (urban/rural), maternal age (13-17 years, 18-25 years, 26-35 years and 36-45 years), marital status, highest level of education attained, living conditions, level of alcohol consumption, gravidity, parity, previous pregnancy termination, gestational age at interview, gestational age at first booking, pregnancy planning, gestational age at pregnancy awareness, opinion on the safety of orthodox medication, safety advice and illness during first trimester. We investigated determinants for general orthodox medication use, pregnancy related medication use, and anti-infectives use. Results were reported as adjusted odds ratios and 95%CI. Determinants of medication use were defined as those variables retained in the final logistic regression model.

Materiais

Inovações

Based on the provided information, here are some potential innovations that can be used to improve access to maternal health:

1. Mobile health (mHealth) applications: Develop mobile applications that provide pregnant women with information on medication safety during pregnancy. These apps can also remind women to take their medications and provide access to telemedicine consultations with healthcare providers.

2. Telemedicine services: Implement telemedicine services to allow pregnant women in rural areas to consult with healthcare providers remotely. This can help overcome geographical barriers and improve access to medication advice and prescriptions.

3. Medication safety systems: Establish medication safety systems specifically targeting pregnant women. This can include educational campaigns, guidelines for healthcare providers, and monitoring systems to ensure appropriate medication use during pregnancy.

4. Community health workers: Train and deploy community health workers to provide education and support to pregnant women in remote areas. These workers can help women understand the importance of medication safety and provide guidance on accessing healthcare services.

5. Collaboration with traditional healers: Engage traditional healers in promoting medication safety during pregnancy. This can involve training traditional healers on the potential risks of certain medications and encouraging them to refer pregnant women to healthcare facilities for appropriate care.

6. Supply chain management: Improve the availability of medications in healthcare facilities by implementing efficient supply chain management systems. This can help ensure that pregnant women have access to necessary medications when they seek care.

7. Health education campaigns: Conduct targeted health education campaigns to raise awareness about the importance of medication safety during pregnancy. These campaigns can be tailored to specific communities and delivered through various channels, such as radio, television, and community meetings.

8. Integration of maternal health services: Integrate maternal health services with other healthcare services, such as family planning and HIV/AIDS care. This can help ensure comprehensive care for pregnant women and improve access to necessary medications.

9. Empowerment of women: Promote women’s empowerment and involvement in decision-making regarding their healthcare. This can include providing information and resources to help women make informed choices about medication use during pregnancy.

10. Research and data collection: Conduct further research and data collection on medication use during pregnancy to better understand patterns and trends. This can help inform the development of targeted interventions and policies to improve access to maternal health.

AI Innovations Description

The recommendation that can be developed into an innovation to improve access to maternal health based on the provided description is to implement a medication safety system targeting pregnant women, especially during the first trimester when the risk of teratogenicity is highest. This recommendation is supported by the findings of the survey, which indicated an increasing use of medications during pregnancy in Cameroon.

To implement this recommendation, the following steps can be taken:

1. Develop guidelines and protocols: Create evidence-based guidelines and protocols for healthcare providers on safe medication use during pregnancy, particularly in the first trimester. These guidelines should include information on the safety and potential risks of different medications, as well as alternative options when necessary.

2. Training and education: Provide comprehensive training and education to healthcare providers, including doctors, nurses, and pharmacists, on the guidelines and protocols for safe medication use during pregnancy. This will ensure that healthcare providers have the knowledge and skills to make informed decisions and provide appropriate care to pregnant women.

3. Public awareness campaigns: Launch public awareness campaigns to educate pregnant women and their families about the importance of medication safety during pregnancy. These campaigns can include information on the potential risks of certain medications, the importance of consulting healthcare providers before taking any medication, and the availability of resources for medication safety during pregnancy.

4. Strengthen healthcare systems: Improve access to healthcare services, particularly antenatal care, to ensure that pregnant women have regular contact with healthcare providers who can monitor their health and provide appropriate guidance on medication use. This can be done by increasing the number of healthcare facilities, improving infrastructure and resources, and training additional healthcare providers.

5. Collaboration and partnerships: Foster collaboration and partnerships between healthcare providers, government agencies, non-governmental organizations, and other stakeholders to implement and sustain the medication safety system. This can involve sharing resources, expertise, and best practices, as well as advocating for policy changes and funding support.

By implementing these recommendations, access to maternal health can be improved by ensuring that pregnant women have access to safe and appropriate medications during pregnancy, particularly in the critical first trimester. This will help reduce the risk of teratogenicity and promote the health and well-being of both the mother and the developing fetus.

AI Innovations Methodology

Based on the provided description, here are some potential recommendations to improve access to maternal health:

1. Strengthening healthcare infrastructure: Investing in the improvement of healthcare facilities, particularly in rural areas, can help ensure that pregnant women have access to quality maternal health services.

2. Increasing healthcare workforce: Expanding the number of skilled healthcare professionals, such as doctors, nurses, and midwives, can help address the shortage of healthcare providers and improve access to maternal health services.

3. Enhancing transportation systems: Improving transportation infrastructure and services can help pregnant women in remote areas reach healthcare facilities more easily, reducing barriers to accessing maternal health services.

4. Promoting community-based care: Implementing community-based programs that provide maternal health services, such as antenatal care and postnatal care, can improve access for women who may face challenges in reaching healthcare facilities.

5. Utilizing technology: Leveraging technology, such as telemedicine and mobile health applications, can help overcome geographical barriers and provide remote access to maternal health services.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define indicators: Identify key indicators to measure access to maternal health, such as the number of pregnant women receiving antenatal care, the number of deliveries attended by skilled birth attendants, and the distance traveled to reach healthcare facilities.

2. Collect baseline data: Gather data on the current state of access to maternal health services, including the number of healthcare facilities, healthcare workforce, transportation infrastructure, and utilization rates of maternal health services.

3. Develop scenarios: Create different scenarios based on the recommended innovations, such as increasing the number of healthcare facilities, improving transportation systems, or implementing community-based care programs.

4. Simulate impact: Use modeling techniques, such as mathematical modeling or simulation software, to estimate the potential impact of each scenario on the identified indicators. This could involve projecting changes in the number of pregnant women accessing antenatal care or the reduction in travel time to reach healthcare facilities.

5. Analyze results: Evaluate the simulated impact of each scenario and compare them to the baseline data. Assess the feasibility, cost-effectiveness, and potential challenges associated with implementing each recommendation.

6. Refine recommendations: Based on the simulation results, refine the recommendations to prioritize the most effective and feasible interventions for improving access to maternal health.

7. Implement and monitor: Implement the recommended interventions and continuously monitor the progress and impact on access to maternal health services. Regularly evaluate and adjust the interventions as needed to ensure sustained improvements.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data.

Autor

Dima Health

Statistics:

Citations: 6

Identifiers:

DOI: 10.1186/s12884-018-2081-x

Research Areas:

Food Security, Health System and Policy, Infectious Diseases, Maternal Access, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants, Substance Abuse

Study Countries:

Cameroon

Study Design:

Cross Sectional Study, Grounded Theory

Study Approach:

Quantitative

Participants Gender:

Female

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