Focus groups included twenty women (10 per group). Table 2 summarizes participant characteristics. Generally, they had high socioeconomic status (SES) as indicated by their educational status and the high rate of home ownership. Similar themes arose in each group.
Women’s general attitudes toward medication use during pregnancy
Women reported being very careful about what they consumed during pregnancy. Women described wanting to ingest only “natural” substances while pregnant and were concerned about the risks of pharmacological treatments to fetal health. They described the choice to take medication as one in which they weighed their comfort against their baby’s well-being, and the choices they made about medication use predominantly reflected what they understood as promoting the baby’s well-being. In general, women in our focus groups voiced a preference for not taking prescription medication during pregnancy, when possible.
Focus Group 1, Participant 1: With my first kid, I was so natural and everything was smooth. So I wanted to do everything I did with the first kid, so the second would come out the same…[For my severe nausea] I asked my doctor what I could do, and she prescribed me some pills. I had them in my hand but the idea that it was a prescription just freaked me out and I didn’t want to put any foreign objects in my body. I don’t know what it’s going to do to the baby. [The nausea] was really bad, but I was scared for the baby. I was just going back and forth: pills, baby. [Participant makes hand motion to demonstrate weighing two options].
Focus Group 1, Participant 2: Just like a lot of you, I don’t like to be on medication either. Actually, this was the first time I’ve ever actually taken medication being pregnant.
Pathways to prescription
While participants were selected into our focus group because they had all filled a prescription for anti-nausea medication, their pathways to getting a prescription varied. Women who participated in our study described experiencing nausea during their first trimester, during which time prenatal visits with providers occur less frequently than later in pregnancy. We learned that decision-making about taking anti-nausea medication began before being given a prescription as women made choices about scheduling early appointments to discuss nausea or ask for help in dealing with nausea. Several women visited a provider in the first trimester for nausea and vomiting and were offered a prescription. Some women requested a prescription as a result of the severity of their symptoms and/or recommendations from friends and family members. Providers often initially recommended non-prescription treatment options such as over the counter vitamin B12 (pyridoxine) with or without doxylamine and then provided a prescription for a medication if the initial treatment approach did not provide relief (in keeping with current clinical guidelines) . The prescription medication women most often talked about using was ondansetron (brand name Zofran).
Focus Group 2, Participant 8: I asked my doctor [for the medication]. Back then, I was just worried all the time how my baby was going to survive, because I lost 15 pounds in a month.
Focus Group 2, Participant 6: I didn’t even know to ask for the medicine until my friend who’s a doctor and his wife had had twins. He suggested it.
Some of the participants did not discuss their nausea and vomiting with their providers because they thought their experience was a normal part of pregnancy. These women often did not get prescribed medication until later in their first trimester or when they ended up in the emergency department with dehydration.
Focus Group 2, Participant 10: I never mentioned my nausea to my provider originally because I assumed this is what everybody goes through. I ended up getting it prescribed at Urgent Care because it got to that point.
Weighing risks of medication
Regardless of how they received their prescription, nearly all of the women gave serious consideration to the possible risks of taking medication. Women were primarily concerned about negative birth outcomes or long-term effects on their child’s health.
Focus Group 2, Participant 10: I did fill it and I took it the one time and I got anxious about the side effects. I’m always concerned about taking medicine when pregnant, so I did look it up and I heard about the heart [defects] but also cleft lip. I was [worried about] risks that would affect him long-term. I was very anxious about anything affecting my baby. So I just kind of figured I’d get over [the nausea].
Some women felt that their intense nausea interfered with their ability to function socially and professionally, and that this stress took a toll on their health and their baby’s health. For these women, nausea was disruptive and demoralizing. They described having to stop doing the things that they enjoyed as well as the things they needed to do such as care for their children. They thought that the benefit provided by the medication was worth the risk.
Focus Group 1, Participant 7: I felt tired all the time, and I couldn’t focus at work. And it’s not good for my health and not good for my baby and just weighing the risk and the benefit for taking the nausea pill, I just think maybe it’s better, yeah, to take the medication.
Focus group 1, Participant 6: You have to stand up all day, and you’re lifting [heavy items]. And I couldn’t take time to be sick. So I took the Ondansetron, which is what the doctor gave me and I just lived on it for, like, three months.
Focus Group 2, Participant 9: The lowest point was I was at work, so nauseous, and then I had to ask the office manager, “Do you have an empty room so I can sleep?” I laid on the floor with my jacket. It was so sad. It was really sad.
Focus group 2, Participant 7: Some days I had to miss school because I couldn’t get out of bed. I wasn’t eating. So I had to get on the pills to eat at school. Sometimes I had to go home from school because I couldn’t stomach watching everyone eat.
Focus Group 2, Participant 3: I was taking public transportation and I had to stop because every time I would be on the bus I would throw up.
Other women described not knowing when nausea and vomiting would occur and how this uncertainty limited their ability to move through their days. Treatment allowed them to regain their confidence and enjoy the experience of being pregnant.
Focus Group 1, Participant 6: To me, there was so much stress and misery with not knowing what -- if you were going to be able to go to work or do I have to call out or can I go to the grocery store? I just wanted my pregnancy to have a -- to be jovial. I just wanted, like, an overall good juju with the pregnancy, so I just wanted there to be a happy spirit the whole time. So that to me was really important.
What evidence matters to women
We sought to understand how women weighed and interpreted different kinds of evidence. Women got their information from a variety of sources. Many sought information by reviewing the published literature or consulting websites. Others were reassured by their doctors, by the length of time the drug has been on the market or by the experiences of their friends and family.
Focus Group 1, Participant 7: I just looked up Wikipedia, and it said it was safe. I think it’s Class A or B, so it’s relatively safe. So I just decided to try it.
Focus Group 2, Participant 4: For Zofran [ondansetron], there’s few studies, a handful, about heart defects in the baby, but I think that the percentage was from 0.8% or it could have happened anyway from 0.2%, so it wasn’t that much of a difference.
Two women were concerned about the lack of research on human fetuses or involving women like them (for instance, of the same racial or ethnic background).
Focus Group 1, Participant 7: Whatever research they do they only do it on animals, not, like, real human babies. So just in the back of my mind I would always worry,
Focus Group 1, Participant 1: There wasn’t, for me, I guess, enough research that said what it would do to my body. Are they testing on women that look like me, that are my size, my shape, my ethnicity? Is it really going to help me? And that’s what -- I’m just like -- I just can’t.
Other women found their doctor’s reassurances to be sufficient evidence of safety.
Focus Group 1, Participant 6: The doctor went to school for that. That’s their job. So if they say it’s okay, it’s okay. So I didn’t feel like if they were giving me it that there would be any huge risks associated.
Some women considered the length of time the medication had been in use by pregnant women to be evidence of safety.
Focus Group 1, Participant 4: Knowing that it had a long history of pregnant women taking it helped assure me that this is probably okay. If you’ve been having something prescribed for a couple decades [any risks] probably would have come out by then.
Other women were influenced by the experiences of family, friends and acquaintances.
Focus Group 1, Participant 11: I called my sister because she was the one who told me about it. She’s like, “I’ve used it for all of my pregnancies. They’re probably just trying to make some correlation, and there’s no [correlation].” -- So I was like, “Okay. That was reassuring enough for me.”
On the other hand, one woman whose friend had a baby with a birth defect decided not to take the medication.
Focus Group 2, Participant 1: I didn’t end up taking the Zofran. One of my close girlfriends had a son [with] a clubfoot and a cleft lip because of it because she had to take so much of [the medication]. And the doctors told her it was because of that, so I was in a lot of fear of taking that.
Though two women in our groups decided not to take the medication after filling the prescription, a majority (18/20 or 90%) took their prescribed anti-nausea medication at least once. Many women reported that the benefits of the medication were significant, allowing them to regain their appetite and function throughout their day.
Focus Group 1, Participant 2: My prescription was a saving grace. Once I actually took it and I was able to desire foods again, I was like, “Oh, I’m sold”. And I could literally get through the day.
Focus Group 1, Participant 4: I was like, “This is my little miracle thing. It makes it go away, and I feel like I can function way better.”
Some women considered the risks and either stopped taking the prescribed medication or never took it at all. They thought they could tolerate the physical discomfort, or they were concerned about negative effects on their child.
Focus Group 2, Participant 10: I stopped taking it because it made me more scared for any possible risk or whatever, so I couldn’t do it. So I just lived in the pain because I couldn’t get over that.
Finally, some women reported that their medication worked well, but they had to stop because of side effects such as severe constipation or hives.