Establishing cross-discipline consensus on contraception, pregnancy and breast feeding-related educational messages and clinical practices to support women with rheumatoid arthritis: an Australian Delphi study

Sexual and reproductive health while living with rheumatoid arthritis: The impact of the disease stage on patient perspectives

BACKGROUND

Rheumatoid arthritis (RA) is one of the most prevalent rheumatic diseases that harms all aspects of patients' lives, including sexual and reproductive health (SRH), often neglected in patients' care. The study aimed to explore the sexual and reproductive experiences of Mexican outpatients with RA from a narrative perspective.

PATIENTS AND METHODS

From July 2020 to October 2021, 30 adult patients with RA from the Department of Immunology and Rheumatology outpatient clinic of a national referral center for rheumatic diseases had in-depth interviews audiotaped, transcribed, and analyzed using a thematic analysis approach. Results are presented in a descriptive and interpretative manner and integrated into a theoretical model for the topic understanding.

RESULTS

Five intertwined major themes emerged: I) RA onset: Absence of SRH contents, II) Healthcare for RA: Emerging SRH contents, III) RA's impact: Proliferation of SRH contents, IV) Coping with the process of living with RA: SRH-related strategies, and V) The impact of the COVID-19 pandemic on patients' experiences: Increased SRH burden. SRH contents emerged through these major themes (but at RA onset), mostly when inquired and mainly when narrating the RA impact and coping. Patients identified that RA affected their couple dynamics, sexual function, and reproductive project. The SRH care was considered relevant but limited and focused on reproductive contents. It worsened during the COVID-19 pandemic. We proposed a theoretical model where patients' SRH experiences are embedded across their RA biography and integrated with the RA impact and the copy with the disease process. These intertwined experiences were also evident during the COVID-19 pandemic, which challenged participants' biopsychosocial resources.

CONCLUSIONS

The sexual and reproductive experiences narrated by the RA outpatients concerning their disease-related biography showed that even when the SRH appeared as not prioritized at the disease onset, it was widely expressed during the process of living and coping with the disease and was additionally affected by the COVID-19 pandemic.

Management of chronic rheumatic diseases in women 18-45 years of age in Asia Pacific: insights from patient and clinician surveys

OBJECTIVE

Perspectives of women aged 18-45 years with chronic rheumatic diseases (CRD), and clinicians, in the Asia-Pacific (APAC) region are reported.

METHODS

Online surveys were completed by women, pregnant in the past 2-5 years, with moderate to severe rheumatoid arthritis (RA), psoriatic arthritis (PsA), axial spondyloarthritis (axSpA), and rheumatologists, obstetricians, orthopaedic surgeons who medically manage CRDs.

RESULTS

Among 210 (RA 122, PsA 48, axSpA 40) patients, 52% (n = 109/210) delayed their decision to have children, most commonly due to concerns of passing on disease to offspring. 33% (n = 70/210) discussed family planning with a healthcare professional at diagnosis. Patients most often initiated discussions. 94% (n = 193/205) stopped treatment around pregnancy due to fear of fetal harm. 66% (n = 139/210) of patients felt they did not receive all relevant information on the impact of CRDs and treatment on pregnancy. Among 335 clinicians who participated, 82% (n = 143/174) of rheumatologists, 86% (n = 72/84) of obstetricians and 43% (n = 33/77) of orthopaedic surgeons agreed good disease control during pregnancy was their primary goal. 69% (n = 120/174) of rheumatologists were 'very comfortable' with prescribing tumour necrosis factor inhibitors (TNFi) for women aged 18-45 years. Comfort levels generally decreased with the onset of family planning. More obstetricians and orthopaedic surgeons supported avoiding TNFi during pregnancy than rheumatologists (40% [n = 34/84]/38% [n = 29/77] versus 16% [n = 28/174]). Access to more TNFi safety data during pregnancy was considered paramount for increasing clinician comfort.

CONCLUSIONS

Patients and physicians need current information and multidisciplinary discussions for improved management of CRD in women in APAC.

Pregnancy planning health information and service needs of women with chronic non-communicable conditions: a systematic review and narrative synthesis

Background

Preparing for pregnancy and being in the best possible health before conception improves reproductive outcomes. For women living with a chronic non-communicable disease (NCD), pregnancy planning is essential to allow optimal disease control in preparation for pregnancy.

Aim

The aim was to review the literature relating to the pregnancy planning health information and service needs of women with NCDs.

Method

The MEDLINE (Ovid), Embase (Ovid), Emcare (Ovid), PsycINFO (Ovid), CINAHL and Scopus databases were searched. Studies were included if they were published in peer-reviewed English language journals between January 2010 and June 2020 and reported on the pregnancy planning health information and service needs of women with rheumatic diseases, asthma, cystic fibrosis, depression and/or anxiety, type 1 diabetes mellitus, epilepsy, or multiple sclerosis. Risk of bias was assessed using QualSyst. The characteristics of the studies were tabulated and summarised. Key findings of the included studies were analysed thematically using an inductive approach, where the study findings determined the themes. Findings are reported in a narrative synthesis.

Results

The database searches yielded 8291 results, of which 4304 remained after duplicates were removed. After abstract screening 104 full-text papers were reviewed. Of these 15 met inclusion criteria and were included in analysis. The narrative synthesis of the included studies revealed six themes: ‘Women with chronic conditions have unmet preconception health information needs’, ‘Women with chronic conditions want personalised preconception health information’, ‘Preferred sources of preconception health information’, ‘Learning from the experiences of other women’, ‘Improving preconception health discussions with health care professionals’, and ‘Women want holistic care’. These themes were consistent across all studies, highlighting the similarity of experiences and needs of women with different chronic conditions.

Conclusion

To improve pregnancy outcomes for women living with NCDs, health care providers need to ask women of reproductive age proactively and routinely about their pregnancy intentions and provide them with personalised advice on how to avoid unplanned pregnancy and be in optimal health when they wish to conceive.

PROSPERO registration number CRD42020176308.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-04498-1.

Rheumatology-led pregnancy clinic: patient-centred approach

Autoimmune rheumatic diseases (ARDs), which include all types of inflammatory arthritis as well as systemic Lupus, are known to have a detrimental effect on both fertility and pregnancy outcomes. Consequently, reproductive health care is considered a principle constituent of comprehensive care for all patients with rheumatic ailments seen in the standard practice. Whilst pregnancy-associated complications have been reported in lupus, rheumatoid arthritis, and Sjogren's syndrome, in some conditions such as lupus, antiphospholipid syndrome, inflammatory myopathies, and vasculitis, the pregnancy may accelerate the disease progression. Furthermore, the activity of some diseases such as lupus and antiphospholipid syndrome may be augmented by some contraceptive methods. Therapeutically, some patients are prescribed medications, such as methotrexate and mycophenolate which have potentially teratogenic effect. Therefore, to be able to help those patients, family planning should be patient-centred with decision-making tailored to the individual's disease status. For those healthcare professionals interested in reproductive health care for their patients living with autoimmune rheumatic diseases, this review summarizes the available information in the literature and offers practical suggestions of patient-centred care in a dedicated rheumatology-led pregnancy clinic. Key Points • Autoimmune disorders, particularly systemic inflammatory rheumatic diseases, affect many women, often during childbearing age. • Pregnancies in this cohort of patients with rheumatic diseases is considered to be of high risk, because of the potential for complications during periods of active disease and the possible impact of medications used on both the pregnancy outcomes as well as the baby. • There are high chances of successful and safe pregnancies particularly if pre-pregnancy planning and screening for maternal and fetal risks are undertaken, and pregnancy takes place while the disease is well controlled. Encouraging the patients, who are in their childbearing period, to initiate discussions about family planning and pregnancy, with their treating rheumatologists, would be an ideal approach to close this gap of information exchange. • Targeted patients' education is expected to improve the information quality and promote more collaborative decision-making with regard to motherhood and healthcare choices.

Rheumatology-led pregnancy clinic: men perspective

The birth of reproductive rheumatology as a subject of interest in rheumatology has led to improvement of clinical care for patients living with autoimmune rheumatic diseases and paved the way towards setting a specialized pregnancy service within the standard rheumatology practice. In contrast to women, where there has been wealth of literature regarding pregnancy, lactation, and birth outcomes, there is not as much focusing on male sexual health and outcomes among inflammatory arthritis patients. Challenges such as decrease ability to conceive, impaired fertility, erectile dysfunction, and other sexual problems have been raised by male patients living with autoimmune rheumatic diseases. This broad scope gives the reproductive health concept in men another expansion with views to include sexual health problems screening among men attending the standard outpatient rheumatology clinics. This article adds to the paucity of real-life experience and aims at discussing the sexual health from the men perspective and provides a practical approach towards screening, and assessment of men living with autoimmune diseases in standard day to day practice.

Arthritis-related work outcomes experienced by younger to middle-aged adults: a systematic review

OBJECTIVE

The aim of this review was to systematically identify, appraise and synthesise evidence on work-related outcomes experienced by younger to middle-aged adults (aged 16-50 years) with arthritis.

METHODS

Eligible studies were identified in Medline, PsycINFO, Embase and CINAHL in January 2020. Quantitative and qualitative studies containing self-reported data on work-related outcomes on younger/middle-aged adults with arthritis were included. Quality assessment was undertaken using validated quality appraisal tools from the Joanna Briggs Institute.

RESULTS

Thirty-four studies were identified for inclusion. Work outcomes were organised around five themes: (1) arthritis-related work productivity outcomes, (2) arthritis-related work participation outcomes, (3) other arthritis-related workplace outcomes, (4) barriers to work participation associated with arthritis and (5) enablers to work participation associated with arthritis. Arthritis was associated with work limitations on the Workplace Activity Limitations Scale (average scores ranging from 5.9 (indicating moderate workplace difficulty) to 9.8 (considerable workplace difficulty)), and higher work disability prevalence rates (range: 6%-80%) relative to healthy populations. Arthritis was not associated with decreased absenteeism on the Work Productivity and Activity Impairment Questionnaire (mean (SD) 7.9% (14.0%)), indicating low levels of absenteeism, similar to healthy populations. As work outcomes were commonly binary, person-centred (qualitative) perspectives on barriers and enablers augmented the quantitative findings.

CONCLUSION

Arthritis is commonly associated with poorer work outcomes for younger/middle-aged adults relative to healthy populations. Additional research focusing solely on the workplace needs of younger/middle-aged population groups is required to inform tailored interventions and workplace support initiatives to maximise productive working years.

Rheumatology-led pregnancy clinic: enhancing the care of women with rheumatic diseases during pregnancy

The autoimmune rheumatic diseases have a clear predilection for women. Consequently, issues regarding family planning and pregnancy are a vital component of the management of these patients. Not only does pregnancy by itself causes physiologic/immunologic changes that impact disease activity but also women living with inflammatory arthritic conditions face the additional challenges of reduced fecundity and worsened pregnancy outcomes. Many women struggle to find adequate information to guide them on pregnancy planning, lactation and early parenting in relation to their chronic condition. This article discusses the gaps in the care provided to women living with inflammatory arthritis in standard practice and how a rheumatology nurse-led pregnancy clinic would fill such gap, consequently enhance the care provided and ensure appropriate education is provided to these individuals who represent the majority of the patients attending the rheumatology outpatient clinics. Such specialist care is expected to cover the whole journey as it is expected to provide high-quality care before, during and after pregnancy.

"I Would be More of a Liability than an Asset": Navigating the Workplace as a Younger Person with Arthritis

Purpose Over half the population in Australia with arthritis and other musculoskeletal conditions is aged 25-64 years. This reflects the peak income-earning years for most, yet little research has examined the influence of arthritis on work issues specific to younger people. The aim of this research was to examine the work-related experiences of younger people (defined as those aged 18-50 years). Methods A qualitative exploratory design was used. Participants with inflammatory arthritis or osteoarthritis were recruited from the community, including urban and rural settings. An interview guide was based on the World Health Organization's International Classification of Functioning, Disability and Health. Deductive and inductive coding techniques were used to identify emerging work-related themes from the data. Results Semi-structured interviews were conducted with 21 younger people (90% female) with a mix of arthritis conditions, vocational backgrounds and career stages. Three themes were identified: (1) the perceived impacts of arthritis on career trajectories, (2) the impacts of arthritis on participants' workplace environment, employers, and colleagues, and (3) the personal toll of working with arthritis. The personal toll of working with arthritis relates to the arthritis-attributable impacts of physical and psychological symptoms on productivity and presenteeism in the workplace. Conclusion Younger people with arthritis experience numerous challenges at key stages of their careers, from career planning through to productive working. This can be used to inform workplace accommodations for people with arthritis and increase awareness of likely barriers to work productivity among colleagues, employers and clinicians.

"The Financial Impact Is Depressing and Anxiety Inducing": A Qualitative Exploration of the Personal Financial Toll of Arthritis

OBJECTIVE

The financial experience faced by working-age people with arthritis includes living below the poverty line for many. Financial distress among people with arthritis is known to contribute to poorer health outcomes, including high psychological distress and more severe pain. Despite the demonstrated societal cost of arthritis care and management, the personal costs borne by the individual are not well understood. The aim of this study was to explore the perceived financial impacts of living with arthritis among younger adults (defined as those ages 18-50 years).

METHODS

A qualitative descriptive study design was used. Participants with inflammatory arthritis or osteoarthritis were recruited from the community, including urban and rural settings. An interview schedule was developed, informed by existing literature, which was piloted prior to data collection. Deductive and inductive coding techniques were used to identify financial-related themes arising from the data.

RESULTS

Semistructured interviews were conducted with 21 adults (90% female) with a mix of arthritis conditions, including rheumatoid arthritis, psoriatic arthritis, and osteoarthritis. Four themes were identified: direct arthritis-attributable medical costs, indirect arthritis-attributable costs, insurance and pension costs, and broader financial impacts on the family. Nonsubsidized costs were frequently referenced by participants as burdensome and existed even within the publicly funded Australian health care system.

CONCLUSION

Adults with arthritis experience significant arthritis-attributable financial burden and related distress. Financial concerns should be actively identified and considered within shared clinical decision-making to provide more patient-centered care for these individuals.

Draft Opioid-Prescribing Guidelines for Uncomplicated Normal Spontaneous Vaginal Birth

Women who experience an uncomplicated vaginal delivery have acute intrapartum pain and variable pain in the immediate postpartum period. Although the Centers for Disease Control and Prevention (CDC) has urged clinicians to improve opioid-prescribing behavior, there are no published clinical practice guidelines for prescribing opioids during labor and delivery and at discharge for patients with uncomplicated normal spontaneous vaginal delivery. To address the knowledge gap regarding guidelines for pain management in this population, we used the national Premiere Health Care Database for deliveries of uncomplicated vaginal births from January 1, 2014, to December 31, 2016, to determine the prevalence of opioid administration. Among the 49,133 women who met inclusion criteria, 78.2% were administered opioids during hospitalization and 29.8% were administered opioids on the day of discharge. Descriptive statistics were generated to document the characteristics of the patients receiving opioids as well as the characteristics of hospitals administering opioids during inpatient labor and delivery and on discharge. Patient-level variables included age group, marital status, race, ethnicity, payer type, and length of stay. Hospital-level variables included bed size, geographic region, teaching status, and urbanicity status. These data were then presented in an electronic Delphi survey to 14 participants. The survey participants were obstetrician-gynecologists identified by the American College of Obstetricians and Gynecologists as being thought leaders in the obstetrics field and who had also demonstrated an active interest in the opioid epidemic and its effect on women's health. After the panelists viewed the opioid administration data, they were presented with an adapted version of the CDC's guidelines for opioid prescribing for chronic pain management. The eight adapted guidelines were constructed to be more relevant and appropriate for the inpatient normal spontaneous vaginal delivery population. After three rounds of the surveying process, seven of the eight adapted guidelines were endorsed by the survey participants. These seven draft consensus guidelines could now be used as a starting point to develop more broadly endorsed and studied guidelines for appropriately managing pain control for women with uncomplicated spontaneous vaginal birth.

"Nobody knows, or seems to know how rheumatology and breastfeeding works": Women's experiences of breastfeeding whilst managing a long-term limiting condition - A qualitative visual methods study

Background

Only around 1% of babies in the UK are breastfed exclusively until six months of age as recommended by the World Health Organisation. One in ten women who have recently given birth in the UK have a long-term illness and they are at increased risk of stopping breastfeeding early. We considered women with autoimmune rheumatic diseases as an exemplar group of long term illnesses, to explore the barriers and enablers to breastfeeding

Aim

To understand the experiences of infant feeding among women with autoimmune rheumatic diseases and to identify potential barriers and enablers.

Design

Qualitative visual timeline-facilitated interviews.

Participants and setting

128 women with autoimmune rheumatic diseases who were considering pregnancy, pregnant, or had young children took part in an online survey as part of the STAR Family Study. Of these, 13 women who had children were purposefully sampled to be interviewed. Interviews took place in person or on the telephone. Timeline-facilitated interviews were used to focus on lived experiences and topics important to the women, including early parenting. We conducted a focused thematic analysis of women's lived experiences of infant feeding.

Results

Three main themes were identified in relation to breastfeeding: lack of information about medication safety, lack of support in decision-making and maintaining breastfeeding, and maternal guilt.

Conclusions

Women with autoimmune rheumatic diseases found it difficult to access the information they needed about medications to make informed decisions about breastfeeding. They often also felt pressurised into breastfeeding and experienced feelings of guilt if they were unable, or did not wish to breastfeed. Tailored interventions are required that adopt a non-judgmental and person-centred approach to support decision-making in regard to infant feeding, providing women with information that can best enable them to make infant feeding choices.

Patients' perceived health information needs in inflammatory arthritis: A systematic review

OBJECTIVES

To identify the breadth of the literature regarding patients' perceived health information needs related to inflammatory arthritis care.

METHODS

A systematic scoping review of MEDLINE, EMBASE, CINAHL and PsycINFO was performed to identify relevant articles (1990 -2016) examining patients' perceived needs relating to health information in inflammatory arthritis. Data and themes were identified and categorised and risk of bias assessed.

RESULTS

Twenty nine studies (11 quantitative, 14 qualitative and 4 mixed methods) from 4121 identified articles were relevant for inclusion. Most focussed on rheumatoid arthritis. Key findings included: (1) Reasons for seeking health information often focussed on gaining ownership over their condition and facilitating self-management. (2) Demographic differences in information needs were inconsistent, but women and younger patients generally reported more needs. (3) Desired information content was broad, and included targeted and practical information covering disease treatment and psychosocial wellbeing. (4) Preferred information delivery method was consultation with a Rheumatologist; however group sessions had advantages for psychosocial issues while written information provided useful supplementation. (5) Barriers to meeting health information needs were around timely access.

CONCLUSIONS

Patients with inflammatory arthritis have high information needs, desiring practical and individualised information. When developing strategies to meet patients' information needs, aligning patient expectations with delivery methods that are accessible, cost-effective and flexible may help to optimize patient outcomes.

Identifying the unmet information and support needs of women with autoimmune rheumatic diseases during pregnancy planning, pregnancy and early parenting: mixed-methods study

Background

Autoimmune rheumatic diseases (ARDs) such as inflammatory arthritis and Lupus, and many of the treatments for these diseases, can have a detrimental impact on fertility and pregnancy outcomes. Disease activity and organ damage as a result of ARDs can affect maternal and foetal outcomes. The safety and acceptability of hormonal contraceptives can also be affected. The objective of this study was to identify the information and support needs of women with ARDs during pregnancy planning, pregnancy and early parenting.

Methods

This mixed methods study included a cross-sectional online survey and qualitative narrative interviews. The survey was completed by 128 women, aged 18–49 in the United Kingdom with an ARD who were thinking of getting pregnant in the next five years, who were pregnant, or had young children (< 5 years old). The survey assessed quality-of-life and information needs (Arthritis Impact Measurement Scale Short Form and Educational Needs Assessment Tool), support received, what women found challenging, what was helpful, and support women would have liked. From the survey participants, a maximum variation sample of 22 women were purposively recruited for qualitative interviews. Interviews used a person-centered participatory approach facilitated by visual methods, which enabled participants to reflect on their experiences. Interviews were also carried out with seven health professionals purposively sampled from primary care, secondary care, maternity, and health visiting services.

Results

Survey findings indicated an unmet need for information in this population (ENAT total mean 104.85, SD 30.18). Women at the pre-conception stage reported higher needs for information on pregnancy planning, fertility, giving birth, and breastfeeding, whereas those who had children already expressed a higher need for information on pain and mobility. The need for high quality information, and more holistic, multi-disciplinary, collaborative, and integrated care consistently emerged as themes in the survey open text responses and interviews with women and health professionals.

Conclusions

There is an urgent need to develop and evaluate interventions to better inform, support and empower women of reproductive age who have ARDs as they navigate the complex challenges that they face during pregnancy planning, pregnancy and early parenting.

Electronic supplementary material

The online version of this article (10.1186/s41927-018-0029-4) contains supplementary material, which is available to authorized users.

Reaching a consensus on research priorities for supporting women with autoimmune rheumatic diseases during pre-conception, pregnancy and early parenting: A Nominal Group Technique exercise with lay and professional stakeholders

Background:Women with autoimmune rheumatic diseases (ARDs) find it difficult to get information and support with family planning, pregnancy, and early parenting. A systematic approach to prioritising research is required to accelerate development and evaluation of interventions to meet the complex needs of this population.  Methods:A Nominal Group Technique (NGT) exercise was carried out with lay and professional stakeholders (n=29). Stakeholders were prepared for debate through presentation of available evidence. Stakeholders completed three tasks to develop, individually rank, and reach consensus on research priorities: Task 1 - mapping challenges and services using visual timelines; Task 2 - identifying research topics; Task 3 - individually ranking research topics in priority order. Results of the ranking exercise were fed back to the group for comment.   Results:The main themes emerging from Task 1 were the need for provision of information, multi-disciplinary care, and social and peer support. In Task 2, 15 research topics and 58 sub-topics were identified around addressing the challenges and gaps in care identified during Task 1.  In Task 3, a consensus was reached on the ten research topics that should be given the highest priority. These were individually ranked, resulting in the following order of priorities (from 1 - highest to 10 - lowest): 1. Shared decision-making early in the care pathway; 2. Pre-conception counseling; 3. Information about medication use during pregnancy/breastfeeding; 4. Personalised care planning; 5. Support for partners/family members; 6. Information about local support/disease specific issues; 7. Shared decision-making across the care pathway; 8. Peer-support; 9. Social inequalities in care, and; 10. Guidance on holistic/alternative therapies.    Conclusions:This systematic approach to identification of research priorities from a multi-disciplinary and lay perspective indicated that activities should focus on development and evaluation of interventions that increase patient involvement in clinical decision-making, multi-disciplinary models of care, and timely provision of information.

Hormonal contraceptives and risk of ischemic stroke in women with migraine: a consensus statement from the European Headache Federation (EHF) and the European Society of Contraception and Reproductive Health (ESC)

Several data indicate that migraine, especially migraine with aura, is associated with an increased risk of ischemic stroke and other vascular events. Of concern is whether the risk of ischemic stroke in migraineurs is magnified by the use of hormonal contraceptives. As migraine prevalence is high in women of reproductive age, it is common to face the issue of migraine and hormonal contraceptive use in clinical practice. In this document, we systematically reviewed data about the association between migraine, ischemic stroke and hormonal contraceptive use. Thereafter a consensus procedure among international experts was done to develop statements to support clinical decision making, in terms of cardiovascular safety, for prescription of hormonal contraceptives to women with migraine. Overall, quality of current evidence regarding the risk of ischemic stroke in migraineurs associated with the use of hormonal contraceptives is low. Available data suggest that combined hormonal contraceptive may further increase the risk of ischemic stroke in those who have migraine, specifically migraine with aura. Thus, our current statements privilege safety and provide several suggestions to try to avoid possible risks. As the quality of available data is poor further research is needed on this topic to increase safe use of hormonal contraceptives in women with migraine.