Pre-pregnancy care and contraception – the two-sided coin of reproductive health and safe prescribing

Almost half of all pregnancies in England are unplanned. ¹ This is the stark backdrop against which policymakers, healthcare professionals and women themselves need to consider the latest stream of government guidance advising against conception whilst taking drugs that are potentially teratogenic, ² anti-epilepsy medication ³ and specifically valproate. ⁴

However, at this same time, UK funding for and provision of contraceptive services have been dramatically cut and many women are unable to access reliable options. ⁵ Experiences in many other countries are similar. This is despite both the World Health Organization and United Nations identifying universal access to family planning as a Sustainable Development Goal. ⁶

A drug safety update from the UK's Medicines and Healthcare products Regulatory Agency (MHRA) advises highly effective contraception for women taking medicines of teratogenic potential, ³ with recommendations from the Faculty of Sexual and Reproductive Healthcare (FSRH) to support individualised contraceptive choice, ⁷ and includes safety measures prior to each repeat prescription. Implementation of these recommendations however is not straightforward – if not carefully thought through, they could result in women being denied repeat prescriptions of important treatments, an even greater patient safety issue.

The other side of this coin must also be considered. Those with chronic medical disorders must also know what to do before and during a planned pregnancy so that their own health and that of their baby can be optimised. All these recent guidance documents consider only how to stop women from conceiving and none consider the care for those who wish to be pregnant.

Public Health England recommends an integrated approach to reproductive health – ‘making reproductive health and pregnancy planning everyday business’ by creating opportunities to optimise health prior to pregnancy and ensuring that pregnancies are planned and timed accordingly. ¹

MBRRACE-UK have also identified pre-pregnancy planning and contraception as essential facets of delivering safe and high-quality care for women of childbearing age with chronic health conditions, in whom unplanned pregnancies are associated with increased complications. ⁸ Reliable contraception is, therefore, key to delivering better pregnancy outcomes for mother and baby.

But how in practice can we make this happen? In obstetric medicine, antenatal clinics and elsewhere, we often see women with unplanned pregnancy, suboptimal disease control and inappropriate medications. This is not new. Problems remain of ownership and responsibility, trust and information sharing, and education – for women and healthcare providers. This recent unbalanced guidance does not facilitate a holistic approach to reproductive health and safe prescribing.

Challenges of implementing these recommendations include:

In all decisions regarding medication choices and changes, the potential for deterioration in the mother's wellbeing through side effects or reduced disease control (and therefore the baby) and the exposure of the fetus to both agents when switches are made must be balanced against possible fetal gains. Understanding the potential impact of reduced control of the medical disorder on a pregnancy is key.

Responsibility for prescribing medications for chronic conditions often transfers from specialist centres to the primary care teams – mechanisms to implement this welcome guidance to avoid unplanned pregnancy in women taking drugs of teratogenic potential must ensure that all healthcare professionals receive education in this often nuanced decision-making process. Women with chronic health conditions, therefore, should not suffer interruptions in treatment during transfer of care, and planning for safe pregnancy can also be proactively managed.

‘Teratogenic potential’ is a poorly defined term that is rarely binary and needs clarification for each agent. The UK Teratology Information Service (UKTIS, http://www.uktis.org/) is a valuable source of available information but it is likely that each woman will need nuanced discussion, as long-term exclusion of pregnant women from research trials means that data are often limited. To maximise the positive impact of this integrated approach on reproductive health, clarification of the medications to which the MHRA recommendations apply would be welcome by those tasked with and possibly struggling with implementation.

It is so important that women taking medication with teratogenic potential for chronic medical disorders receive both contraception and pre-pregnancy care – often both sides of this important coin can be delivered together. Recent publications miss an important opportunity to do just that, although it is a very welcome step forward that the topic is being addressed.