Prescription Medication Use in Pregnancy in People with Disabilities: A Population-Based Cohort Study

Abstract

Background:

Individuals with disabilities may require specific medications in pregnancy. The prevalence and patterns of medication use, overall and for medications with known teratogenic risks, are largely unknown.

Methods:

This population-based cohort study in Ontario, Canada, 2004–2021, comprised all recognized pregnancies among individuals eligible for public drug plan coverage. Included were those with a physical (n = 44,136), sensory (n = 13,633), intellectual or developmental (n = 2,446) disability, or multiple disabilities (n = 5,064), compared with those without a disability (n = 299,944). Prescription medication use in pregnancy, overall and by type, was described. Modified Poisson regression generated relative risks (aRR) for the use of medications with known teratogenic risks and use of ≥2 and ≥5 medications concurrently in pregnancy, comparing those with versus without a disability, adjusting for sociodemographic and clinical factors.

Results:

Medication use in pregnancy was more common in people with intellectual or developmental (82.1%), multiple (80.4%), physical (73.9%), and sensory (71.9%) disabilities, than in those with no known disability (67.4%). Compared with those without a disability (5.7%), teratogenic medication use in pregnancy was especially higher in people with multiple disabilities (14.2%; aRR 2.03, 95% confidence interval [CI]: 1.88–2.20). Furthermore, compared with people without a disability (3.2%), the use of ≥5 medications concurrently was more common in those with multiple disabilities (13.4%; aRR 2.21, 95% CI: 2.02–2.41) and an intellectual or developmental disability (9.3%; aRR 2.13, 95% CI: 1.86–2.45).

Interpretation:

Among people with disabilities, medication use in pregnancy is prevalent, especially for potentially teratogenic medications and polypharmacy, highlighting the need for preconception counseling/monitoring to reduce medication-related harm in pregnancy.

Introduction

Nearly 70% of people use prescription medications in pregnancy.^1

–4 Although prenatal medication use is often required to maintain health, some medications are associated with perinatal complications (e.g., congenital anomalies, preterm birth).^5,6 Historically, pregnant people have been excluded from drug safety trials,⁷ and almost 40% of pregnant people take medications not studied during pregnancy.⁸ Furthermore, up to 61% of pregnancies are unintended, and people may take medications that can cause maternal or fetal harm before they know they are pregnant.^9,10 Alternatively, pregnant people may stop taking required medications from fear of fetal harm.¹¹ Thus, understanding patterns of prescription medication use in pregnancy is critical to identify groups at elevated risk of medication-related harm.

Medication use in people with disabilities is often necessary to manage symptoms (e.g., chronic pain), complications of disability (e.g., infection), and co-occurring conditions (e.g., diabetes). Consequently, compared with people without disabilities, those with disabilities have higher rates of medication use, including teratogenic medications (e.g., valproic acid), and elevated risk of polypharmacy, overprescribing, and adverse drug reactions.^12
–14 Nearly 13% of pregnancies are people with a disability.¹⁵ Yet, there are only a few studies on medication use in people with disabilities in pregnancy, primarily focused on specific disabilities (e.g., congenital physical, intellectual or developmental, inflammatory, psychiatric disabilities), and specific types of medications (e.g., opioids, psychotropic, antibacterial).^16

–19 Despite widespread medication use in people with disabilities, patterns of use of teratogenic medications and polypharmacy in pregnancy in this population are understudied. This information is critical to inform the need for accessible medication counseling for pregnant people with disabilities to reduce the risk of medication-related harm. Therefore, our objective was to examine the prevalence and patterns of prescription medication use in pregnancy more broadly among people with and without disabilities in Ontario, Canada.

Methods

Study design and setting

We conducted a cohort study in Ontario, Canada using linked population-based administrative data housed at ICES. ICES is an independent, nonprofit research institute whose legal status under Ontario’s health information privacy laws allows it to analyze health and demographic data, without consent, for health system evaluation and improvement. ICES data were used to identify recognized pregnancies and hospitalizations, emergency department visits, outpatient visits, sociodemographics, and prescription medication use. Datasets were linked using unique encoded identifiers and analyzed at ICES. Datasets are detailed in Supplementary Table S1 and described elsewhere.^20

–24 The use of data was authorized under section 45 of Ontario’s Personal Health Information Protection Act. Ethics approval was granted from the University of Toronto Ethics Board. We followed the STROBE²⁵ and RECORD²⁶ guidelines.

Cohort

We included recognized pregnancies conceived between April 1, 2004 and March 31, 2021, including people who 1) were 12–50 years of age, 2) were eligible for Ontario’s universal publicly funded health insurance program in the 2 years before conception, and 3) filled ≥1 prescriptions under the Ontario Drug Benefit (ODB) program in the year before conception or during pregnancy.²⁷ Eligibility for ODB includes unemployment, low income, disability, age <25 years and without private insurance, high prescription costs relative to income, or receipt of home care services. Recognized pregnancies comprised live births or stillbirths at ≥20 weeks’ gestation, miscarriages <20 weeks, induced abortions at any gestational week, or threatened abortion <20 weeks without a subsequently identified pregnancy outcome, the latter capturing miscarriages occurring outside a health care encounter.²⁴ Conception dates were calculated from the end of pregnancy minus gestational weeks at birth/loss. Records with missing gestational age were assigned the median value for that pregnancy outcome.²⁴

Variables

Exposure

Maternal disability status was ascertained using algorithms developed for health administrative data.^28,29 Mutually exclusive disability types included physical (e.g., cerebral palsy, spinal cord injury), sensory (e.g., hearing loss, vision loss), or intellectual or developmental disability (e.g., autism, Down syndrome), and multiple disabilities (diagnoses in ≥2 categories) based on ≥2 physician visits or ≥1 emergency department visits or hospitalizations between database inception and conception^28,29 (Supplementary Table S2). People without a disability formed the reference group.

Outcomes

Primary outcomes were teratogenic prescription medication use and ≥2 and ≥5 distinct medications dispensed concurrently in pregnancy. First, we ascertained drug dispensing data from ODB and identified any prescription medication use in pregnancy, defined as ≥1 filled prescription from the estimated date of conception to the end of pregnancy. We then used established methods to identify teratogenic drugs categorized as having positive evidence of fetal risk where the benefit may outweigh the risk or drugs contraindicated for use in pregnancy based on animal or human research, or human experience.¹⁴ We supplemented these methods with hand-selected newer teratogenic drugs,³⁰ as drug teratogenicity knowledge evolves (Supplementary Table S3). We also calculated the total number of distinct medications dispensed and created binary variables to measure polypharmacy, defined two ways: ≥2 and ≥5 distinct medications dispensed concurrently in pregnancy.³¹ In secondary analyses, we calculated study outcomes by trimester: first trimester (0–13 weeks’ gestation), second trimester (14–26 weeks), and third trimester (27–42 weeks). We also grouped medications by drug subclass using drug identification numbers and described the 10 most dispensed medications in pregnancy. Over-the-counter medications and vitamins were excluded from analyses.

Maternal characteristics

We measured age at conception, prior livebirth, neighborhood-level deprivation quintile,³² other social disadvantage,^33,34 rural residence, comorbid conditions in the 2 years preconception (i.e., stable/unstable chronic conditions³⁵ using the Johns Hopkins ACG^® System Version 10 collapsed ambulatory diagnostic groups, as well as nondisability pain conditions,^36,37 mental illness,³⁸ substance use disorder³⁸) regular primary care provider,³⁹ number of unique medications used 90 days before conception, and year of conception (Supplementary Table S1).

Statistical analyses

We used descriptive statistics and standardized differences to compare baseline characteristics between exposure groups; differences >0.10 were considered meaningful.⁴⁰ We described any medication use in pregnancy and the top 10 medication subclasses dispensed in each disability group, and examined temporal trends in study outcomes.

We compared teratogenic medication use and polypharmacy in pregnancy by disability type using modified Poisson regression to generate unadjusted and adjusted relative risks (RR) and 95% confidence intervals (CI),⁴¹ with robust variance estimators to account for clustering of pregnancies to the same mother during the study period.⁴¹ Covariates were added in two steps: first, we adjusted for age, number of previous live births, neighborhood-level deprivation quintile, social disadvantage, rural residence, and year of conception; second, we controlled for the previously mentioned confounders and preconception stable/unstable chronic conditions, pain conditions, mental illness, substance use disorders, and primary care provider.

In secondary analyses, we examined study outcomes by trimester; restricted the analysis to live births and stillbirths, wherein we had complete and accurate gestational age data; and described top medication subclasses to the most recent 10 years of the study period.

Analyses were performed in SAS Enterprise Guide, version 8.3 (SAS Institute Inc.).

Results

We identified 365,223 recognized pregnancies conceived between April 1, 2004 and March 31, 2021 with ≥1 filled prescription through ODB, of which 44,136 (12.1%) were to people with a physical disability, 13,633 (3.7%) to people with a sensory disability, 2,446 (0.7%) to people with an intellectual or developmental disability, 5,064 (1.4%) to people with multiple disabilities, and 299,944 (82.1%) to people without a documented disability (Supplementary Fig. S1; Supplementary Table S4). Compared with people without disabilities, all disability groups were more likely to have mental illness, substance use disorders, and nondisability pain conditions. People with an intellectual or developmental disability were younger, and more likely to be nulliparous and have social disadvantage. People with physical and multiple disabilities were more likely to have stable/unstable chronic conditions (Table 1).

Table 1.

Characteristics of 365,223 Recognized Pregnancies in People with and without a Disability. All Data Are Presented as a Number (%) Unless Otherwise Indicated

	Physical disability only	Sensory disability only	Intellectual or developmental disability only	Multiple disabilities	No documented disability
Characteristic	n = 44,136	n = 13,633	n = 2,446	n = 5,064	n = 299,944
Sociodemographic
Maternal age, years
Mean ± SD	27.2 ± 6.5^a	25.5 ± 6.2	24.4 ± 5.5^a	26.9 ± 6.4^a	25.7 ± 6.1
12–24	18,239 (41.3)^a	7,125 (52.3)	1,443 (59.0)^a	2,132 (42.1)^a	151,956 (50.7)
25–34	18,977 (43.0)	5,079 (37.3)	854 (34.9)	2,228 (44.0)^a	116,419 (38.8)
35–50	6,920 (15.7)^a	1,429 (10.5)	149 (6.1)^a	704 (13.9)	31,569 (10.5)
Live birth parity
Multiparous	24,111 (54.6)	6,915 (50.7)	1,141 (46.6)^a	2,535 (50.1)	159,541 (53.2)
Nulliparous	14,324 (32.5)	4,789 (35.1)	987 (40.4)^a	1,889 (37.3)^a	95,990 (32.0)
Unknown	5,701 (12.9)	1,929 (14.1)	318 (13.0)	640 (12.6)	44,413 (14.8)
Rural residence^b	5,109 (11.6)	1,451 (10.6)	269 (11.0)	539 (10.6)	28,104 (9.4)
Social disadvantage	3,421 (7.8)^a	755 (5.5)	368 (15.0)^a	540 (10.7)^a	15,457 (5.2)
Neighborhood-level material deprivation quintile
1 (low)	3,232 (7.3)	977 (7.2)	153 (6.3)	366 (7.2)	20,357 (6.8)
2	4,694 (10.6)	1,432 (10.5)	213 (8.7)	481 (9.5)	28,636 (9.5)
3	6,145 (13.9)	1,884 (13.8)	310 (12.7)	732 (14.5)	39,978 (13.3)
4	8,846 (20.0)	2,765 (20.3)	485 (19.8)	1,007 (19.9)	59,448 (19.8)
5 (high)	20,611 (46.7)	6,453 (47.3)	1,237 (50.6)	2,420 (47.8)	147,826 (49.3)
Missing	608 (1.4)	122 (0.9)	48 (2.0)	58 (1.1)	3,699 (1.2)
Era of conception
2004 to 2008	9,598 (21.7)	2,529 (18.6)^a	377 (15.4)^a	771 (15.2)^a	72,752 (24.3)
2009 to 2012	9,825 (22.3)	3,020 (22.2)	521 (21.3)	1,069 (21.1)	67,916 (22.6)
2013 to 2016	10,211 (23.1)	3,262 (23.9)	614 (25.1)^a	1,400 (27.6)^a	61,387 (20.5)
2017 to 2020	14,502 (32.9)	4,822 (35.4)	934 (38.2)^a	1,824 (36.0)	97,889 (32.6)
Preconception health
Unstable chronic medical conditions	8,183 (18.5)^a	2,021 (14.8)	364 (14.9)	1,258 (24.8)^a	36,857 (12.3)
Stable chronic medical conditions	11,558 (26.2)^a	3,206 (23.5)	494 (20.2)	1,693 (33.4)^a	61,374 (20.5)
Chronic pain conditions	20,473 (46.4)^a	5,380 (39.5)^a	1,027 (42.0)^a	2,597 (51.3)^a	99,925 (33.3)
Mood or anxiety disorder	17,192 (39.0)^a	4,694 (34.4)^a	1,361 (55.6)^a	2,355 (46.5)^a	85,213 (28.4)
Psychotic disorder	679 (1.5)	176 (1.3)	222 (9.1)^a	267 (5.3)^a	2,944 (1.0)
Substance use disorder	4,814 (10.9)^a	892 (6.5)	323 (13.2)^a	594 (11.7)^a	18,937 (6.3)
Regular primary care provider^c
Family Physician/General Practitioner (primary care enrollment model)	18,174 (41.2)	5,867 (43.0)^a	1,022 (41.8)	2,154 (42.5)^a	111,724 (37.2)
Family Physician/General Practitioner (fee for service)	24,390 (55.3)	7,276 (53.4)^a	1,308 (53.5)	2,750 (54.3)	175,900 (58.6)
No usual care provider	1,572 (3.6)	490 (3.6)	116 (4.7)	160 (3.2)	12,320 (4.1)
No. unique medications used within 90 days before conception
0	19,734 (44.7)^a	6,776 (49.7)^a	959 (39.2)^a	1,910 (37.7)^a	167,460 (55.8)
1	7,609 (17.2)	2,493 (18.3)	458 (18.7)	847 (16.7)	54,485 (18.2)
2	5,335 (12.1)	1,633 (12.0)	327 (13.4)	568 (11.2)	32,502 (10.8)
3+	11,458 (26.0)^a	2,731 (20.0)^a	702 (28.7)^a	1,739 (34.3)^a	45,497 (15.2)

Standardized differences > 0.10 comparing people with a given disability versus people without a documented disability.

Missing data for rural residence—physical, 72 (0.2%), sensory, 18 (0.1%), intellectual or developmental, 7 (0.3%), multiple, 9 (0.2%) disability, no documented disability, 425 (0.1%).

Measured in the 2 years before the index pregnancy. A primary care enrollment model includes patients registered to a particular physician or family health team, whereas fee for service includes patients not formally enrolled with a particular service provider (e.g., walk-in clinics).

Medication use in pregnancy was common in people without a disability (67.4%), but more likely in those with intellectual or developmental (82.1%), multiple (80.4%), physical (73.9%), and sensory (71.9%) disabilities (Fig. 1). Medications for nausea/vomiting (e.g., antiemetics/antinauseants), infections (e.g., penicillin), pain (e.g., opioids), respiratory diseases (e.g., selective beta-2 adrenergic agonists), and mental illness (e.g., selective serotonin reuptake inhibitors [SSRIs], benzodiazepines) were the most frequently prescribed across all groups (Supplementary Table S5). Medication use was highest in the first trimester for all groups (Supplementary Fig. S2).

FIG. 1.

Proportion of prenatal prescription medication use within recognized pregnancies, by disability type, including those without a documented disability.

People with multiple (14.2%; aRR 2.03, 95% CI: 1.88–2.20), physical (11.1%; aRR 1.73, 95% CI: 1.67–1.79), intellectual or developmental (7.8%; aRR 1.27, 95% CI: 1.09–1.48), and sensory (6.7%; aRR 1.11, 95% CI: 1.04–1.19) disabilities were all more likely to use teratogenic medications in pregnancy compared with those without a disability (5.7%) (Table 2). Antiepileptic agents and anti-infectives/antiparasitic agents were the most frequently used teratogenic medications (Supplementary Table S6).

Table 2.

The Use of a Teratogenic Medication or Multiple Medications in Pregnancy Comparing People with and Without a Documented Disability

			Relative risk (95% CI)
Outcome	Disability type	No. (%) with outcome	Unadjusted	Adjusted model 1^a	Adjusted model 2^b
Use of a teratogenic medication	None (n = 299,944)	17,099 (5.7)	1.00 (ref.)	1.00 (ref.)	1.00 (ref.)
	Physical only (n = 44,136)	4,895 (11.1)	1.95 (1.88–2.01)	1.85 (1.79–1.91)	1.73 (1.67–1.79)
	Sensory only (n = 13,633)	908 (6.7)	1.18 (1.10–1.27)	1.17 (1.09–1.25)	1.11 (1.04–1.19)
	Intellectual or developmental only (n = 2,446)	190 (7.8)	1.39 (1.19–1.62)	1.44 (1.23–1.67)	1.27 (1.09–1.48)
	Multiple (n = 5,064)	719 (14.2)	2.49 (2.30–2.70)	2.31 (2.14–2.51)	2.03 (1.88–2.20)
Use of 2+ concurrent medications	None (n = 299,944)	97,121 (32.4)	1.00 (ref.)	1.00 (ref.)	1.00 (ref.)
	Physical only (n = 44,136)	19,417 (44.0)	1.37 (1.35–1.38)	1.31 (1.29–1.33)	1.20 (1.18–1.21)
	Sensory only (n = 13,633)	5,303 (38.9)	1.21 (1.18–1.24)	1.20 (1.17–1.23)	1.15 (1.13–1.18)
	Intellectual or developmental only (n = 2,446)	1,261 (51.6)	1.62 (1.55–1.69)	1.60 (1.53–1.67)	1.39 (1.33–1.45)
	Multiple (n = 5,064)	2,724 (53.8)	1.67 (1.62–1.72)	1.58 (1.54–1.63)	1.37 (1.33–1.41)
Polypharmacy use of 5+ concurrent medications	None (n = 299,944)	9,599 (3.2)	1.00 (ref.)	1.00 (ref.)	1.00 (ref.)
	Physical only (n = 44,136)	3,733 (8.5)	2.75 (2.63-2.86)	2.22 (2.13–2.32)	1.67 (1.60–1.74)
	Sensory only (n = 13,633)	676 (5.0)	1.63 (1.49–1.77)	1.57 (1.45–1.71)	1.39 (1.28–1.51)
	Intellectual or developmental only (n = 2,446)	227 (9.3)	3.15 (2.74–3.63)	3.15 (2.73–3.63)	2.13 (1.86–2.45)
	Multiple (n = 5,064)	679 (13.4)	4.38 (4.02–4.78)	3.42 (3.13–3.74)	2.21 (2.02–2.41)

Adjusted for age, livebirth parity, neighborhood material deprivation quintile, rural residence, social disadvantage, and year of conception.

Adjusted for all covariates in Model 1 in addition to stable and unstable chronic conditions, chronic pain conditions, mental illness, substance use disorders, and type of primary care provider.

Abbreviation: CI, confidence interval.

People with multiple (53.8%; aRR 1.37, 95% CI: 1.33–1.41), intellectual or developmental (51.6%; aRR 1.39, 95% CI: 1.33–1.45), physical (44.0%; aRR 1.20, 95% CI: 1.18–1.21), and sensory (38.9%; aRR 1.15, 95% CI: 1.13–1.18) disabilities were more likely to use ≥2 medications concurrently compared with those without a disability (32.4%) (Table 2). Similarly, people with multiple (13.4%; aRR 2.21, 95% CI: 2.02–2.41), intellectual or developmental (9.3%; aRR 2.13, 95% CI: 1.86–2.45), physical (8.5%; aRR 1.67, 95% CI: 1.60–1.74), and sensory (5.0%; aRR 1.39, 95% CI: 1.28–1.51) disabilities were more likely to use ≥5 medications concurrently compared with those without a disability (3.2%) (Table 2).

The absolute risk of teratogenic mediation use decreased after the first trimester; however, RRs were even more elevated in the disability groups in the second and third trimesters, indicating greater disparities between people with versus without disability, with time. Results for polypharmacy were similar by trimester (Supplementary Table S7).

In analyses restricted to live births and stillbirths with complete information on gestational age, the results were similar, suggesting the main results were not explained by misclassification of the pregnancy-exposed period (Supplementary Table S8). The most frequently dispensed medications in the most recent 10 years were consistent with the overall study period and outcomes were relatively stable over the study period (Supplementary Fig. S3).

Interpretation

In this large, population-based cohort of public drug plan beneficiaries, medication use in pregnancy was common. All disability groups were more likely to use medications in pregnancy, including teratogenic medications and multiple medications concurrently, compared with people without disabilities. Elevated risks persisted by trimester. People with multiple and physical disabilities were most likely to use teratogenic medications in pregnancy, whereas polypharmacy was highest in people with multiple or intellectual or developmental disabilities. People with disabilities may benefit from accessible preconception medication counseling and careful monitoring in pregnancy to reduce the risk of medication-related harm.

Our findings are consistent with the few U.S. studies that examined medication use in pregnancy in people with disabilities.^17
–19 Using data from the Slone Birth Defects Study, Garcia et al. found that women with congenital physical disabilities were more likely to report using pain, psychotropic, and antibacterial medications in pregnancy compared with women without these disabilities.¹⁹ In a cross-sectional study using data from the National Survey on Drug Use and Health, odds of self-reported opioid use were elevated in pregnant women with disabilities compared with those without.¹⁸ Similar findings were reported in a retrospective cohort study of Medicaid recipients with physical, inflammatory, and psychiatric disabilities in South Carolina.¹⁷ Our findings add to the limited literature on medication use in pregnancy in people with disabilities by leveraging health administrative datasets to explore all medications, and specifically the outcomes of teratogenic medication use and polypharmacy.

Our findings are likely largely related to disability and co-occurring condition needs. Given the high rates of polypharmacy in people with disabilities overall, the patterns we see in pregnancy could be a continuation of preconception patterns. Some disabilities, especially certain physical disabilities, require medications to manage symptoms and complications and prevent progression. For example, prescription opioids were more often prescribed in people with physical and multiple disabilities, and medications for infections were commonly used across all disability groups, the latter finding possibly explained by a higher risk of genitourinary and skin infections in people with certain disabilities.^42
–44 Pregnant people with disabilities in our cohort also had high rates of co-occurring conditions, which often necessitate medication use, including mental illness. Consistent with this, SSRIs and benzodiazepines were more commonly prescribed in people with physical and multiple disabilities in our cohort compared with people without disabilities. Many of these medications are likely necessary. However, there is research to suggest that overprescribing of certain medications, particularly psychotropic medications, is a concern in people with disabilities, and may have contributed to observed prescribing patterns.^12,45 This is an important area for further exploration.

The observed prescribing patterns suggest the need to take a life course perspective to medication counseling to improve the safety of medication use in pregnancy for people with disabilities. When teratogenic medications are prescribed, it is critical for providers to engage reproductive-aged patients early in family planning discussions, including contraceptive counseling, pregnancy screening, and sexual health education to recognize the early signs of pregnancy. Preconception discussions are particularly important given that medication use was highest in the first trimester for all groups, which coincides with the critical period of organogenesis. While the safety of specific medications in pregnancy is not always known, consideration must be given to reducing teratogenic medication use in people planning a pregnancy, switching to alternative medications with a positive safety profile or nonpharmacologic interventions when possible, and clearly communicating risks and benefits of medications to promote healthy pregnancies.⁴⁶ This is particularly important for people with conditions for which medications are necessary. In our cohort, rates of teratogenic medication use decreased by trimester; however, differences between people with and without disabilities increased. We could not discern whether such patterns reflect necessity, lack of safer alternatives, lack of knowledge of medication safety, or lack of recognition of pregnancy status in people with disabilities; this is an area for exploration.

Our findings also have implications for monitoring medication use throughout pregnancy, particularly given the risks of adverse drug reactions and drug interactions associated with polypharmacy.⁴⁷ Pregnant people with disabilities often have complex health needs and multiple health care providers prescribing different medications. Qualitative studies of pregnant people with disabilities identified lack of communication and coordination between health care providers as an important barrier to care.⁴⁸ Furthermore, outside of pregnancy, people with intellectual or developmental disabilities and women with epilepsy have reported poor knowledge of their medications and associated risks.^49,50 While deprescribing and reduced dosing may not always be an option, it is critical for prenatal health care providers to conduct continual reviews of medications and improve communication with patients and other providers (e.g., disability specialists) to reduce possible drug interactions and medication-related harm.⁵¹ There is a need for research investigating whether medication reviews occur more frequently in pregnancies involving individuals with disabilities compared with those without disabilities.

Limitations

Our cohort included public drug plan beneficiaries who typically have poorer health, greater disability, and lower socioeconomic status compared with people with private drug insurance, which may limit generalizability of our findings. However, given the structure of Ontario’s health system, this is the only means of studying medication use among pregnant people in our province. We relied on diagnostic codes in hospital, emergency department, and outpatient records to identify disability, which are subject to the accuracy of diagnostic coding and may underestimate constructs not routinely recorded in health care records. This may have resulted in misclassification, and an underestimate of disability status. We assumed people took the full course of medications dispensed and we did not examine chronicity of use, which may overestimate medication use. There is no consensus definition of polypharmacy.³¹ Thus, we included two common definitions. We had no data on indication for medication use and could not assess appropriate use of medications. There may have been practice changes over the study period; however, we controlled for conception year to account for this and conducted a sensitivity analysis restricted to the most recent 10 years that showed similar results to the main findings. Finally, based on the data available, we defined disability using a medical model, which does not capture activity/functional limitations, or societal barriers faced by people with disabilities. Nevertheless, our study provides important information needed to understand patterns of medication use in pregnant people with disabilities.

Conclusion

The prevalence of medication use, and risks of teratogenic medication use and polypharmacy, were elevated in pregnant people with disabilities. Our findings show the need for accessible medication counseling for reproductive-aged women with disabilities to reduce risks of medication-related harm, as well as careful medication monitoring during pregnancy.

Footnotes

Acknowledgments

Parts of this material are based on data and/or information compiled and provided by MOH and the Canadian Institute for Health Information (CIHI). However, the analyses, conclusions, opinions, and statements expressed in the article are those of the authors, and not necessarily those of the MOH or CIHI. Geographical data are adapted from Statistics Canada, Postal Code Conversation File + 2011 (Version 6D) and 2016 (Version 7B). This does not constitute endorsement by Statistics Canada of this project. The authors thank IQVIA Solutions Canada Inc. for use of their Drug Information File.

Authors’ Contributions

Dr. A.C. undertook the conception and design of the study, analysis and interpretation of the data, and drafting of the manuscript. Drs. H.K.B., S.M.G., Y.L., and J.G.R. contributed to the conception and design of the study, interpretation of the data, and critically revised the manuscript for important intellectual content. Dr. H.L. and Ms. I.S. contributed to the design of the study, acquisition of data, and critically revised the manuscript for important intellectual content. Drs. A.G., L.T., S.V., and M.A.D.V. contributed to the interpretation of the data and critically revised the manuscript for important intellectual content. All authors approve the final version to be published and agree to be accountable for all aspects of the work.

Author Disclosure Statement

Dr. S.V. reports royalties from UpToDate Inc for authorship of materials related to depression and pregnancy. No other disclosures were reported.

Funding Information

This work was supported by ICES, which is funded by an annual grant from the Ontario Ministry of Health (MOH), and Canadian Institutes of Health Research (CIHR) Fellowship Award (AC). Hilary Brown, Mary A. De Vera, and Astrid Guttmann are funded by CIHR Canada Research Chairs.

Role of Funders

MOH and CIHR had no role in the design and conduct of the study.

Supplementary Material

Supplementary Figure S1

Supplementary Figure S2

Supplementary Figure S3

Supplementary Table S1

Supplementary Table S2

Supplementary Table S3

Supplementary Table S4

Supplementary Table S5

Supplementary Table S6

Supplementary Table S7

Supplementary Table S8

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