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Malhamé I, Hardy E, Cheng MP, Tong SYC, Bowen AC. Walking the walk to include pregnant participants in non-obstetric clinical trials: Insights from the SNAP Trial. Obstet Med 2023; 16:3-4. [PMID: 37139509 PMCID: PMC10150304 DOI: 10.1177/1753495x231163351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023] Open
Affiliation(s)
- Isabelle Malhamé
- Department of Medicine, McGill University Health Centre, Canada
- Research Institute of the McGill University Health
Centre, Canada
| | - Erica Hardy
- Department of Medicine, Women and Infants Hospital, Warren Alpert
School of Medicine of Brown University, USA
| | - Matthew P Cheng
- Department of Medicine, McGill University Health Centre, Canada
- Research Institute of the McGill University Health Centre, Canada
| | - Steven YC Tong
- Victorian Infectious Diseases Service, The Royal Melbourne Hospital, at the Peter Doherty Institute for Infection and Immunity,
Australia
- Department of Infectious Diseases, The University of
Melbourne at the Peter Doherty Institute for Infection and Immunity, Australia
| | - Asha C Bowen
- Department of Infectious Diseases, Perth Children's Hospital, Australia
- Wesfarmers Centre for Vaccines and Infectious Diseases,
Telethon Kids Institute, University of Western Australia, Australia
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2
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Manca TA, Sadarangani M, Halperin SA, Langley JM, McClymont E, MacDonald SE, Top KA. Vaccine regulation should require and enforce the inclusion of pregnant and breastfeeding women in prelicensure clinical trials. Hum Vaccin Immunother 2022; 18:2104019. [PMID: 35880903 DOI: 10.1080/21645515.2022.2104019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Exclusion of pregnant and breastfeeding women from the pivotal randomized controlled trials for COVID-19 vaccines that led to emergency regulatory approval created gaps in data needed for vaccine policy, healthcare provider recommendations, and women's decisions about vaccination. We argue that such knowledge gaps increase potential for vaccine hesitancy and misinformation relating to the health of women and infants, and that these gaps in evidence are avoidable. Over several decades, ethical and scientific guidance, scholarship, and advocacy in favor of pregnant and breastfeeding women's participation in clinical development of vaccines has accumulated. Guidance on how to include pregnant and breastfeeding women in vaccine trials ethically and safely predates the COVID-19 pandemic but has yet to be routinely incorporated in vaccine development. We highlight the important role regulatory authorities could play in requiring that pregnant and breastfeeding women be eligible as volunteer participants in prelicensure vaccine trials for products that are expected to be used in this population. Inclusion of pregnant and breastfeeding populations in clinical trials leading to market approval or emergency use authorization should be undertaken early or concurrently at the time of trials in the general population.
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Affiliation(s)
- Terra A Manca
- Canadian Center for Vaccinology, IWK Health, Nova Scotia Health and Dalhousie University, Halifax, Canada.,Department of Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, Vancouver, Canada.,Department of Pediatrics, University of British Columbia, Vancouver, Canada
| | - Scott A Halperin
- Canadian Center for Vaccinology, IWK Health, Nova Scotia Health and Dalhousie University, Halifax, Canada.,Department of Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Joanne M Langley
- Canadian Center for Vaccinology, IWK Health, Nova Scotia Health and Dalhousie University, Halifax, Canada
| | - Elisabeth McClymont
- Department of Pediatrics, University of British Columbia, Vancouver, Canada.,Department of Obstetrics and Gynecology, University of British Columbia, Vancouver, Canada
| | - Shannon E MacDonald
- Faculty of Nursing, University of Alberta, Edmonton, Canada.,School of Public health, University of Alberta, Edmonton, Canada
| | - Karina A Top
- Canadian Center for Vaccinology, IWK Health, Nova Scotia Health and Dalhousie University, Halifax, Canada.,Department of Pediatrics, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Manca TA, Top KA, Weagle K, Graham JE. Deferring Risk: Limitations to the Evidence in Product Labels for Vaccine Use in Pregnancy. J Womens Health (Larchmt) 2022; 31:1103-1112. [PMID: 35730988 DOI: 10.1089/jwh.2021.0609] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The gaps in clinical trial evidence about vaccination in pregnancy have serious implications for health care worker and public misunderstandings. Contradictions between National Immunization Technical Advisory Group (NITAG) recommendations and regulatory product labeling information contribute to misinformation about vaccine safety and effectiveness. Methods: A mixed methods approach that included a stakeholder consensus decision-making workshop and a national survey of Canadian health care providers (HCPs). Results: We identified knowledge gaps and serious limitations concerning the information in vaccine product labels. Stakeholders were troubled that some HCPs rely on regulatory product labels to inform their decisions without knowing their limitations in content. Our survey showed that HCPs were uncertain about the purpose of product labels and the evidence contained in them. Over a third of respondents incorrectly thought that product labels and NITAG recommendations are based on the same evidence and that the information they contain is regularly updated. Conclusions: Applying social risk theories, we show how such gaps in information defer responsibility for decisions about disease risk and vaccine safety from regulatory agencies and vaccine manufacturers onto HCPs and their clients. This may be especially relevant for COVID-19 and other emerging vaccines that are initially authorized for conditional or emergency use, and especially in understudied populations such as pregnant people. More frequent updating and alignment of robust, unbiased, and independently reviewed clinical trial and postmarket safety and effectiveness evidence with NITAG recommendations would allay HCP and public misunderstandings.
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Affiliation(s)
- Terra Anne Manca
- Department of Pediatrics (Infectious Diseases), Dalhousie University, Halifax, Canada.,Canadian Center for Vaccinology, IWK Health Centre, Halifax, Canada.,Technoscience & Regulation Research Unit, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Karina A Top
- Department of Pediatrics (Infectious Diseases), Dalhousie University, Halifax, Canada.,Canadian Center for Vaccinology, IWK Health Centre, Halifax, Canada
| | - Kirsten Weagle
- Department of Pediatrics (Infectious Diseases), Dalhousie University, Halifax, Canada
| | - Janice E Graham
- Department of Pediatrics (Infectious Diseases), Dalhousie University, Halifax, Canada.,Canadian Center for Vaccinology, IWK Health Centre, Halifax, Canada.,Technoscience & Regulation Research Unit, Faculty of Medicine, Dalhousie University, Halifax, Canada
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Trahan MJ, Cumyn A, Cheng MP, McDonald EG, Lapinsky SE, Daneman N, Abenhaim HA, Malhamé I. Physician Perspectives on Including Pregnant Women in Covid-19 Clinical Trials: Time for a Paradigm Change. Ethics Hum Res 2021; 43:19-27. [PMID: 34699138 PMCID: PMC8652879 DOI: 10.1002/eahr.500107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Excluding pregnant people from Covid-19 clinical trials may lead to unintended harmful consequences. For this study, an online questionnaire was sent to physicians belonging to Canadian professional medical associations in order to evaluate their perspectives on the participation of pregnant women in Covid-19 clinical trials. The majority of respondents expressed support for including pregnant women in Covid-19 trials (119/165; 72%), especially those investigating therapies with a prior safety record in pregnancy (139/164; 85%). The main perceived barriers to inclusion identified were unwillingness of pregnant patients to participate and of treating teams to offer participation, the burden of regulatory approval, and a general "culture of exclusion" of pregnant women from trials. We describe why some physicians may be reluctant to include pregnant individuals in trials, and we identify barriers to the appropriate participation of pregnant people in clinical research.
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Affiliation(s)
| | - Annabelle Cumyn
- Professor of medicine and an obstetric medicine specialist in the Department of Medicine in the Centre Hospitalier Universitaire de Sherbrooke
| | - Matthew P Cheng
- Assistant professor of medicine and an infectious diseases and medical microbiology specialist in the Department of Medicine at McGill University Health Centre and the Research Institute of the McGill University Health Centre
| | - Emily G McDonald
- Associate professor of medicine and an internist in the Department of Medicine at McGill University Health Centre and the Research Institute of the McGill University Health Centre
| | - Stephen E Lapinsky
- Professor of medicine and critical care specialist in the Department of Medicine at Mount Sinai Hospital, Toronto
| | - Nick Daneman
- Clinician scientist and infectious disease specialist in the Department of Medicine at Sunnybrook Health Sciences Centre, Toronto
| | - Haim A Abenhaim
- Associate professor and maternal-fetal medicine specialist in the Department of Obstetrics and Gynecology at McGill University and in the Department of Obstetrics and Gynecology and Lady David Research Institute at Jewish General Hospital in Montreal
| | - Isabelle Malhamé
- Assistant professor of medicine and an obstetric medicine specialist in the Department of Medicine at McGill University Health Centre and the Research Institute of the McGill University Health Centre
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Mastroianni AC, Franceschini R, Wicks SL, Henry LM. The Pathway Forward: Insights on Factors that Facilitate Research with Pregnant Women. Ethics Hum Res 2021; 42:2-16. [PMID: 32672419 DOI: 10.1002/eahr.500058] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The near-routine exclusion of pregnant women from clinical research has resulted in evidence gaps that endanger the health of pregnant women and their future offspring. Although existing literature documents numerous obstacles along the clinical trial pathway that can stymie research involving pregnant women, there is little guidance on how to facilitate such research. This qualitative study aims to fill that void by examining the experiences of individuals involved in conducting, approving, or overseeing research involving pregnant women at one academic institution. The study identifies factors throughout the clinical pathway-from protocol development, to IRB review, and ultimately trial execution-that likely contribute to the successful conduct of research with pregnant women. Attention to those factors, coupled with agreement among stakeholders that research with pregnant women should and can be done ethically and legally, is critical to shifting the narrative from "why we cannot" do such research to "how we can."
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Affiliation(s)
- Anna C Mastroianni
- Professor at the School of Law at the University of Washington and an associate director at the Institute for Public Health Genetics at the University of Washington
| | | | | | - Leslie Meltzer Henry
- Professor of law at the University of Maryland Carey School of Law and a member of the core faculty at the Johns Hopkins Berman Institute of Bioethics
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Kaye DK. The moral imperative to approve pregnant women's participation in randomized clinical trials for pregnancy and newborn complications. Philos Ethics Humanit Med 2019; 14:11. [PMID: 31492178 PMCID: PMC6731584 DOI: 10.1186/s13010-019-0081-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Accepted: 09/04/2019] [Indexed: 05/14/2023] Open
Abstract
BACKGROUND There is longstanding consensus on the need to include pregnant women in research. The goal of clinical research is to find highly regulated, carefully controlled, morally responsible ways to generate evidence about how to effectively and safely prevent illness or treat sick people. This manuscripts present a conceptual analysis of the ethicality of clinical trials in 3 scenarios: where the pregnant is involved in clinical trials as a participant during pregnancy for data that addresses pregnancy complications, where the pregnant woman consents to clinical trial participation for an unborn baby that has complications, to generate data on complications at this stage of life, and where the mother may consent for participation of their newborn child in clinical trials. METHODS Conceptual analysis. FINDINGS Investigators often choose to exclude pregnant women and newborns from research, even where there is possibility for them to benefit from the study intervention. Objections include vulnerability of pregnant women, altered pharmacokinetics and risk of adverse effects, with a need to balance potential maternal and fetal risks and benefits of research participation. While the objections may be valid, not performing research magnifies what should be a carefully controlled risk during research, pushing this risk into the clinical setting, and subsequently posing a challenge to clinicians who are faced with making treatment decisions for pregnant patients with limited evidence of efficacy and safety. The potential benefits of fair inclusion in clinical trials outweigh the potential risks. CONCLUSION Research involving pregnant women is necessary to provide women with effective treatment during pregnancy, to promote fetal safety (such as by avoiding the clinical use of drugs that may be harmful to the developing fetus), and to reduce avoidable harm from suboptimal care (such as from underdosing) and to provide pregnant women, their fetuses and newborns (with access to potential benefits of research participation).
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Affiliation(s)
- Dan Kabonge Kaye
- College of Health Sciences, Department of Obstetrics and Gynecology, Makerere University, P.O. Box 7072, Kampala, Uganda.
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, 21205, USA.
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van der Zande ISE, van der Graaf R, Hooft L, van Delden JJM. Facilitators and barriers to pregnant women's participation in research: A systematic review. Women Birth 2018; 31:350-361. [PMID: 29373261 DOI: 10.1016/j.wombi.2017.12.009] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2017] [Revised: 12/01/2017] [Accepted: 12/22/2017] [Indexed: 11/18/2022]
Abstract
BACKGROUND Although there is consensus among many that exclusion of pregnant women from clinical research should be justified, there is uncertainty as to whether and why pregnant women themselves would be willing to participate even if they were found to be eligible. The objective was to identify the reasons why pregnant women participate in clinical research and thereby to distinguish between facilitators and barriers. METHODS We conducted a systematic review of articles regarding pregnant women's reasons for participation in clinical research. We used the PubMed/MEDLINE, EMBASE, PsycINFO and CINAHL databases and retrieved additional articles through manually searching the reference lists. We included all articles that reported on pregnant women's reasons for participation in clinical research. We accumulated all reasons that were mentioned in the total of articles and collated them to themes, classifying these themes as a facilitator or a barrier. RESULTS The search identified thirty articles that met the inclusion criteria. Themes classified as facilitators: aspirational benefits, collateral benefits, direct benefits, third party influence and lack of inconvenience. Themes classified as barriers: inconveniences, risks, randomisation, lack of trust in research enterprise, medical reasons and third party influence. CONCLUSIONS Pregnant women report mostly altruistic and personal reasons for their willingness to participate in clinical research, while barriers primarily relate to inconveniences. It appears that pregnant women's described reasoning is similar to the described reasoning of non-pregnant research subjects. Enhancing the facilitators and overcoming the barriers is the next step to increase the evidence-base underlying maternal and foetal health.
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Affiliation(s)
- Indira S E van der Zande
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, Utrecht, The Netherlands.
| | - Rieke van der Graaf
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, Utrecht, The Netherlands.
| | - Lotty Hooft
- Cochrane Netherlands, University Medical Center Utrecht, Utrecht, The Netherlands; University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Department of Epidemiology, Utrecht, The Netherlands.
| | - Johannes J M van Delden
- University Medical Center Utrecht, Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, Utrecht, The Netherlands.
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Roes KCB, van der Zande ISE, van Smeden M, van der Graaf R. Towards an appropriate framework to facilitate responsible inclusion of pregnant women in drug development programs. Trials 2018; 19:123. [PMID: 29458400 PMCID: PMC5819166 DOI: 10.1186/s13063-018-2495-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2017] [Accepted: 01/23/2018] [Indexed: 11/19/2022] Open
Abstract
Evidence-based treatment for pregnant women will ultimately require research conducted in the population of pregnant women. Currently, few scholars have addressed the issue of responsible inclusion of pregnant women in drug research. Because of additional risks associated with including pregnant women in drug research and the altered ways in which drugs are processed by the pregnant body, pregnant women cannot be treated as an ordinary subgroup in the various phases of drug development. Instead, responsible inclusion of pregnant women requires careful design and planning of research for pregnant women specifically. Knowledge about these aspects is virtually nonexistent. In this article, we present a practical framework for the responsible inclusion of pregnant women in drug development. We suggest that the framework consists of using a question-based approach with five key questions in combination with three prerequisites which should be addressed when considering inclusion of pregnant women in drug research. The five questions are:Can we consider the drug safe (enough) for first exposure in pregnant women and fetuses? In which dose range (potentially depending on gestational age) can the drug be considered to remain safe in pregnant women? At what dose (regimen, within the range considered safe) can we expect efficacy in pregnant women? Can efficacy be confirmed at the target dose, either similar to the initial population or different? Can clinical safety be confirmed at a sufficiently acceptable level at the target dose for pregnant women and fetuses, so as to conclude a positive benefit–risk ratio?
Combining questions and prerequisites leads to a scheme for appropriate timing of responsible inclusion of pregnant women in drug research. Accordingly, we explore several research design options for including pregnant women in drug trials that are feasible within the framework. Ultimately, the framework may lead to (i) earlier inclusion of pregnant women in drug development, (ii) ensuring that key prerequisites, such as proper dosing, are addressed before more substantial numbers of pregnant women are included in trials, and (iii) optimal use of safety and efficacy data from the initial (nonpregnant) population throughout the drug development process.
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Affiliation(s)
- Kit C B Roes
- Department of Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, University of Utrecht, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Indira S E van der Zande
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University of Utrecht, University Medical Center Utrecht, P.O. box 85500, 3508, GA, Utrecht, the Netherlands.
| | - Maarten van Smeden
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University of Utrecht, University Medical Center Utrecht, P.O. box 85500, 3508, GA, Utrecht, the Netherlands
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9
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van der Graaf R, van der Zande ISE, den Ruijter HM, Oudijk MA, van Delden JJM, Oude Rengerink K, Groenwold RHH. Fair inclusion of pregnant women in clinical trials: an integrated scientific and ethical approach. Trials 2018; 19:78. [PMID: 29378652 PMCID: PMC5789693 DOI: 10.1186/s13063-017-2402-9] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2017] [Accepted: 12/11/2017] [Indexed: 11/26/2022] Open
Abstract
Background Since pregnant women are severely underrepresented in clinical research, many take the position that the exclusion of pregnant women from research must be justified unless there are compelling “scientific reasons” for their exclusion. However, it is questionable whether this approach renders research with pregnant women fair. This paper analyzes and evaluates when research with pregnant women can be considered as fair and what constitutes scientific reasons for exclusion. Methods Conceptual ethical and methodological analysis and evaluation of fair inclusion. Results Fair inclusion of pregnant women means (1) that pregnant women who are eligible are not excluded solely for being pregnant and (2) that the research interests of pregnant women are prioritized, meaning that they ought to receive substantially more attention. Fairness does not imply that pregnant women should be included in virtually every research project, as including only a few pregnant women in a population consisting only of women will not help to determine the effectiveness and safety of a treatment in pregnant women. Separate trials in pregnant women may be preferable once we assume, or know, that effects of interventions in pregnant women differ from the effects in other subpopulations, or when we assume, or know, that there are no differences. In the latter case, it may be preferable to conduct post-marketing studies or establish registries. If there is no conclusive evidence indicating either differences or equivalence of effects between pregnant and non-pregnant women, yet it seems unlikely that major differences or exact equivalence exist, the inclusion of pregnant women should be sufficient. Depending on the research question, this boils down to representativeness in terms of the proportion of pregnant and non-pregnant women, or to oversampling pregnant women. Conclusions Fair inclusion of pregnant women in research implies that separate trials in pregnant women should be promoted. Inclusion of pregnant women has to be realized at the earliest phases of the research process. In addition to researchers and research ethics committees, scientific advisory councils, funders, drug regulatory agencies, pharmaceutical companies, journal editors and others have a joint responsibility to further develop the evidence base for drug use in pregnant women.
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Affiliation(s)
- Rieke van der Graaf
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Indira S E van der Zande
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands.
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Martijn A Oudijk
- Department of Obstetrics and Gynaecology, Academic Medical Center, Amsterdam, The Netherlands
| | - Johannes J M van Delden
- Department of Medical Humanities, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, PO Box 85500, 3508 GA, Utrecht, The Netherlands
| | - Katrien Oude Rengerink
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Rolf H H Groenwold
- Department of Epidemiology, Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
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Saenz C, Cheah PY, van der Graaf R, Henry LM, Mastroianni AC. Ethics, regulation, and beyond: the landscape of research with pregnant women. Reprod Health 2017; 14:173. [PMID: 29297343 PMCID: PMC5751636 DOI: 10.1186/s12978-017-0421-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Scarce research with pregnant women has led to a dearth of evidence to guide medical decisions about safe and effective treatment and preventive interventions for pregnant women and their potential offspring. In this paper, we highlight three aspects of the landscape in which pregnant women are included or, more frequently, excluded from research: international ethics guidance, regional and national regulatory frameworks, and prevailing practices. Our paper suggests that, in some cases, regulatory frameworks can be more restrictive than international ethics guidance, and that even when regulations permit research with pregnant women, practical challenges-as well as the prevailing practices of stakeholders, such as ethics review committees and investigators-may lead to the generalized exclusion of pregnant women from research.
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Affiliation(s)
- Carla Saenz
- Knowledge Management, Bioethics and Research, Pan American Health Organization, Washington, D.C, USA
| | - Phaik Yeong Cheah
- Mahidol Oxford Tropical Medicine Research Unit, Mahidol University, Bangkok, Thailand
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | | | - Leslie Meltzer Henry
- University of Maryland Carey School of Law, Baltimore, MD USA
- Johns Hopkins Berman Institute of Bioethics, Baltimore, MD USA
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van der Zande ISE, van der Graaf R, Oudijk MA, van Delden JJM. A qualitative study on acceptable levels of risk for pregnant women in clinical research. BMC Med Ethics 2017; 18:35. [PMID: 28506267 PMCID: PMC5432995 DOI: 10.1186/s12910-017-0194-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 04/27/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND There is ambiguity with regard to what counts as an acceptable level of risk in clinical research in pregnant women and there is no input from stakeholders relative to such research risks. The aim of our paper was to explore what stakeholders who are actively involved in the conduct of clinical research in pregnant women deem an acceptable level of risk for pregnant women in clinical research. Accordingly, we used the APOSTEL VI study, a low-risk obstetrical randomised controlled trial, as a case-study. METHODS We conducted a prospective qualitative study using 35 in-depth semi-structured interviews and one focus group. We interviewed healthcare professionals, Research Ethics Committee members (RECs) and regulators who are actively involved in the conduct of clinical research in pregnant women, in addition to pregnant women recruited for the APOSTEL VI case-study in the Netherlands. RESULTS Three themes characterise the way stakeholders view risks in clinical research in pregnant women in general. Additionally, one theme characterises the way healthcare professionals and pregnant women view risks with respect to the case-study specifically. First, ideas on what constitutes an acceptable level of risk in general ranged from a preference for zero risk for the foetus up to minimal risk. Second, the desirability of clinical research in pregnant women in general was questioned altogether. Third, stakeholders proposed to establish an upper limit of risk in potentially beneficial clinical research in pregnant women in order to protect the foetus and the pregnant woman from harm. Fourth and finally, the case-study illustrates that healthcare professionals' individual perception of risk may influence recruitment. CONCLUSIONS Healthcare professionals, RECs, regulators and pregnant women are all risk adverse in practice, possibly explaining the continuing underrepresentation of pregnant women in clinical research. Determining the acceptable levels of risk on a universal level alone is insufficient, because the individual perception of risk also influences behaviour towards pregnant women in clinical research. Therefore, bioethicists and researchers might be interested in changing the perception of risk, which could be achieved by education and awareness about the actual benefits and harms of inclusion and exclusion of pregnant women.
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Affiliation(s)
- Indira S. E. van der Zande
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, P.O. box 85500, 3508 GA The Netherlands
| | - Rieke van der Graaf
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, P.O. box 85500, 3508 GA The Netherlands
| | - Martijn A. Oudijk
- Academic Medical Center, Department of Obstetrics and Gynaecology, Amsterdam, The Netherlands
| | - Johannes J. M. van Delden
- Julius Center for Health Sciences and Primary Care, Department of Medical Humanities, University Medical Center Utrecht, Utrecht, P.O. box 85500, 3508 GA The Netherlands
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