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Lyerly AD. Research, pregnancy, and the ethics of parental consent. THE LANCET. RHEUMATOLOGY 2024:S2665-9913(24)00155-3. [PMID: 38876125 DOI: 10.1016/s2665-9913(24)00155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2024] [Accepted: 06/03/2024] [Indexed: 06/16/2024]
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Shankar M, Hazfiarini A, Zahroh RI, Vogel JP, McDougall ARA, Condron P, Goudar SS, Pujar YV, Somannavar MS, Charantimath U, Ammerdorffer A, Rushwan S, Gülmezoglu AM, Bohren MA. Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review. PLoS Med 2024; 21:e1004405. [PMID: 38814991 PMCID: PMC11139290 DOI: 10.1371/journal.pmed.1004405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 04/19/2024] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND Poor representation of pregnant and lactating women and people in clinical trials has marginalised their health concerns and denied the maternal-fetal/infant dyad benefits of innovation in therapeutic research and development. This mixed-methods systematic review synthesised factors affecting the participation of pregnant and lactating women in clinical trials, across all levels of the research ecosystem. METHODS AND FINDINGS We searched 8 databases from inception to 14 February 2024 to identify qualitative, quantitative, and mixed-methods studies that described factors affecting participation of pregnant and lactating women in vaccine and therapeutic clinical trials in any setting. We used thematic synthesis to analyse the qualitative literature and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. We compared quantitative data against the thematic synthesis findings to assess areas of convergence or divergence. We mapped review findings to the Theoretical Domains Framework (TDF) and Capability, Opportunity, and Motivation Model of Behaviour (COM-B) to inform future development of behaviour change strategies. We included 60 papers from 27 countries. We grouped 24 review findings under 5 overarching themes: (a) interplay between perceived risks and benefits of participation in women's decision-making; (b) engagement between women and the medical and research ecosystems; (c) gender norms and decision-making autonomy; (d) factors affecting clinical trial recruitment; and (e) upstream factors in the research ecosystem. Women's willingness to participate in trials was affected by: perceived risk of the health condition weighed against an intervention's risks and benefits, therapeutic optimism, intervention acceptability, expectations of receiving higher quality care in a trial, altruistic motivations, intimate relationship dynamics, and power and trust in medicine and research. Health workers supported women's participation in trials when they perceived clinical equipoise, had hope for novel therapeutic applications, and were convinced an intervention was safe. For research staff, developing reciprocal relationships with health workers, having access to resources for trial implementation, ensuring the trial was visible to potential participants and health workers, implementing a woman-centred approach when communicating with potential participants, and emotional orientations towards the trial were factors perceived to affect recruitment. For study investigators and ethics committees, the complexities and subjectivities in risk assessments and trial design, and limited funding of such trials contributed to their reluctance in leading and approving such trials. All included studies focused on factors affecting participation of cisgender pregnant women in clinical trials; future research should consider other pregnancy-capable populations, including transgender and nonbinary people. CONCLUSIONS This systematic review highlights diverse factors across multiple levels and stakeholders affecting the participation of pregnant and lactating women in clinical trials. By linking identified factors to frameworks of behaviour change, we have developed theoretically informed strategies that can help optimise pregnant and lactating women's engagement, participation, and trust in such trials.
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Affiliation(s)
- Mridula Shankar
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Alya Hazfiarini
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Rana Islamiah Zahroh
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
| | - Joshua P. Vogel
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Annie R. A. McDougall
- Maternal, Child and Adolescent Health Program, Burnet Institute, Melbourne, Victoria, Australia
| | - Patrick Condron
- University Library, University of Melbourne, Carlton, Victoria, Australia
| | - Shivaprasad S. Goudar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Yeshita V. Pujar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Manjunath S. Somannavar
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | - Umesh Charantimath
- Women’s and Children’s Health Research Unit, KLE Academy of Higher Education and Research, Jawaharlal Nehru Medical College, Belagavi, Karnataka, India
| | | | - Sara Rushwan
- Concept Foundation, Geneva, Switzerland/Bangkok, Thailand
| | | | - Meghan A. Bohren
- Gender and Women’s Health Unit, Nossal Institute for Global Health, School of Population and Global Health, University of Melbourne, Carlton, Victoria, Australia
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Raciti CG, Marsha J, Nafiseh AA, Masese ER, Apondi E, McHenry MS. "If it benefits someone, it will be good:" perspectives on research participation from pregnant women living with HIV. AIDS Care 2023; 35:366-373. [PMID: 35341423 PMCID: PMC10775893 DOI: 10.1080/09540121.2022.2057411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 03/21/2022] [Indexed: 10/18/2022]
Abstract
Pregnant women living with HIV (PWLHIV) are becoming increasingly involved in HIV research; however, the ethical concerns regarding their decision-making related to research participation are understudied. This qualitative study aimed to understand the perspectives and lived research experiences of PWLHIV, intending to identify important considerations to inform best practices. This study used semi-structured interviews (SSIs) of PWLHIV who participated in research studies in Eldoret, Kenya. All interviews were audio-recorded, transcribed, and translated. Qualitative analyses were performed, with line-by-line coding, constant comparison, axial coding, and triangulation to identify central concepts. Twelve PWLHIV participated. Overall, participants had positive experiences with HIV research. Most participants had difficulty distinguishing the differences between the research process and enhanced clinical care. They reported a willingness to participate in future HIV research studies and indicated altruism as the primary motivator. Participants identified their preferences and experiences with recruitment, consenting, reimbursement, and enrolment of infants in HIV research. The largest barrier for participating in HIV research was identified as a concern that participation would lead to HIV disclosure. By understanding the lived experiences of PWLHIV who participate in HIV research, future researchers can design studies and consenting processes to optimize ethical research practices.
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Affiliation(s)
- Catherine G Raciti
- Richard M. Fairbanks School of Public Health, Indiana University Purdue University- Indianapolis
| | - Joy Marsha
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | | | - Eric R Masese
- Department of Sociology, Psychology and Anthropology, Moi University School of Arts and Social Sciences, Eldoret, Kenya
| | - Edith Apondi
- Department of Pediatrics, Moi Teaching and Referral Hospital, Eldoret, Kenya
| | - Megan S. McHenry
- Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
- Department of Pediatrics, Indiana University School of Medicine
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Lyerly AD. 'Experimental pregnancy' revisited. THEORETICAL MEDICINE AND BIOETHICS 2022; 43:253-266. [PMID: 35859087 PMCID: PMC9299403 DOI: 10.1007/s11017-022-09578-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
In this paper, I reflect on an important article by Bob Veatch in the inaugural issue of the Hastings Center Report, entitled "Experimental Pregnancy." It is a report and elegant analysis of the Goldzieher Study, in which nearly 400 women were randomized to receive hormonal contraception or placebo absent consent or disclosure about placebo use, resulting in several pregnancies. Noting the study's limited notoriety, I first consider the narratives that have instead dominated bioethics' approach to pregnancy and research: thalidomide and diethylstibesterol (DES). These narratives have facilitated a narrow focus on avoiding fetal risk, to the exclusion of other ethically relevant considerations. I then revisit "Experimental Pregnancy" and offer two ways in which Bob's analysis serves as an important corrective, first, by foregrounding research subjects (persons who are or may become pregnant), and second, by normalizing pregnancy and thus foregrounding foundational ethical considerations that are sometimes lost amidst pregnancy's presumed exceptionalism.
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Zappulo E, Giaccone A, Schiano Moriello N, Gentile I. Pharmacological approaches to prevent vertical transmission of HIV and HBV. Expert Rev Clin Pharmacol 2022; 15:863-876. [PMID: 35876100 DOI: 10.1080/17512433.2022.2105202] [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: 11/04/2022]
Abstract
INTRODUCTION Mother-to-child transmission (MTCT) is mainly responsible for the global pediatric HIV and HBV epidemic. Vertical transmission can be prevented and reduced through a series of interventions at the primary healthcare level, including extensive screening of pregnant women, administration of antivirals or immune-based treatments, counselling on type of delivery and breastfeeding. AREAS COVERED In this narrative review, approved therapeutic options for the treatment of pregnant women living with HIV or HBV are discussed with special focus on efficacy and safety profiles of each agent or drug class examined. The search was performed using Medline (via PubMed), Web of Science, and Google Scholar to identify studies assessing vertical transmission of both HIV and HBV. EXPERT OPINION Elimination of MTCT of both infections is firmly endorsed by major global commitments and the integration of tailored preventive interventions into maternal and newborn health services is of strategical importance to achieve this critical target. However, further research centered on antiviral-based and immunization trials among pregnant women is urgently needed to mitigate the risk of maternal and neonatal adverse outcomes, effectively prevent transmission to the offspring and finally eliminate the pediatric HIV and HBV epidemic, one of the key global health challenges of our time.
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Affiliation(s)
- Emanuela Zappulo
- Department of Clinical Medicine and Surgery, Infectious Diseases Unit, University of Naples Federico II, Naples, Italy
| | - Agnese Giaccone
- Department of Clinical Medicine and Surgery, Infectious Diseases Unit, University of Naples Federico II, Naples, Italy
| | - Nicola Schiano Moriello
- Department of Clinical Medicine and Surgery, Infectious Diseases Unit, University of Naples Federico II, Naples, Italy
| | - Ivan Gentile
- Department of Clinical Medicine and Surgery, Infectious Diseases Unit, University of Naples Federico II, Naples, Italy
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Lyerly AD, Beigi R, Bekker L, Chi BH, Cohn SE, Diallo DD, Eron J, Faden R, Jaffe E, Kashuba A, Kasule M, Krubiner C, Little M, Mfustso‐Bengo J, Mofenson L, Mwapasa V, Mworeko L, Myer L, Penazzato M, Rid A, Shapiro R, Singh JA, Sullivan K, Vicari M, Wambui J, White A, Wickremsinhe M, Wolf L. Ending the evidence gap for pregnancy, HIV and co-infections: ethics guidance from the PHASES project. J Int AIDS Soc 2021; 24:e25846. [PMID: 34910846 PMCID: PMC8673925 DOI: 10.1002/jia2.25846] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Accepted: 10/21/2021] [Indexed: 12/31/2022] Open
Abstract
INTRODUCTION While pregnant people have been an important focus for HIV research, critical evidence gaps remain regarding prevention, co-infection, and safety and efficacy of new antiretroviral therapies in pregnancy. Such gaps can result in harm: without safety data, drugs used may carry unacceptable risks to the foetus or pregnant person; without pregnancy-specific dosing data, pregnant people face risks of both toxicity and undertreatment; and delays in gathering evidence can limit access to beneficial next-generation drugs. Despite recognition of the need, numerous barriers and ethical complexities have limited progress. We describe the process, ethical foundations, recommendations and applications of guidance for advancing responsible inclusion of pregnant people in HIV/co-infections research. DISCUSSION The 26-member international and interdisciplinary Pregnancy and HIV/AIDS: Seeking Equitable Study (PHASES) Working Group was convened to develop ethics-centred guidance for advancing timely, responsible HIV/co-infections research with pregnant people. Deliberations over 3 years drew on extensive qualitative research, stakeholder engagement, expert consultation and a series of workshops. The guidance, initially issued in July 2020, highlights conceptual shifts needed in framing research with pregnant people, and articulates three ethical foundations to ground recommendations: equitable protection from drug-related risks, timely access to biomedical advances and equitable respect for pregnant people's health interests. The guidance advances 12 specific recommendations, actionable within the current regulatory environment, addressing multiple stakeholders across drug development and post-approval research, and organized around four themes: building capacity, supporting inclusion, achieving priority research and ensuring respect. The recommendations describe strategies towards ethically redressing the evidence gap for pregnant people around HIV and co-infections. The guidance has informed key efforts of leading organizations working to advance needed research, and identifies further opportunities for impact by a range of stakeholder groups. CONCLUSIONS There are clear pathways towards ethical inclusion of pregnant people in the biomedical research agenda, and strong agreement across the HIV research community about the need for - and the promise of - advancing them. Those who fund, conduct, oversee and advocate for research can use the PHASES guidance to facilitate more, better and earlier evidence to optimize the health and wellbeing of pregnant people and their children.
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Affiliation(s)
- Anne Drapkin Lyerly
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Richard Beigi
- Department of ObstetricsGynecology & Reproductive SciencesUPMC Magee‐Women's HospitalPittsburghPennsylvaniaUSA
| | - Linda‐Gail Bekker
- Desmond Tutu HIV Centre and Department of MedicineUniversity of Cape TownCape TownSouth Africa
| | - Benjamin H. Chi
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Susan E. Cohn
- Department of MedicineFeinberg School of MedicineNorthwestern UniversityChicagoIllinoisUSA
| | | | - Joseph Eron
- Department of Medicine and Center for AIDS ResearchUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Ruth Faden
- Johns Hopkins Berman Institute of BioethicsBaltimoreMarylandUSA
| | - Elana Jaffe
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Angela Kashuba
- Eshelman School of Pharmacy and Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Mary Kasule
- Botswana‐Baylor Centre for Clinical ExcellenceGabaroneBotswana
| | | | - Maggie Little
- Kennedy Institute for Ethics and Department of PhilosophyGeorgetown UniversityWashingtonDCUSA
| | - Joseph Mfustso‐Bengo
- Center of Bioethics for Eastern & Southern Africa and Department of Health Systems and PolicyCollege of MedicineUniversity of MalawiZombaMalawi
| | - Lynne Mofenson
- Elizabeth Glaser Pediatric AIDS FoundationWashingtonDCUSA
| | | | - Lillian Mworeko
- International Community of Women Living with HIV Eastern AfricaKampalaUganda
| | - Landon Myer
- Division of Epidemiology and BiostatisticsSchool of Public Health and Family MedicineUniversity of Cape TownCape TownSouth Africa
| | | | - Annette Rid
- Department of BioethicsThe Clinical CenterNational Institutes of HealthBethesdaMarylandUSA
| | - Roger Shapiro
- Department of Immunology and Infectious DiseasesHarvard T.H. Chan School of Public HealthBostonMassachusettsUSA
| | - Jerome Amir Singh
- Howard College School of LawUniversity of KwaZulu‐NatalKwaZulu‐NatalSouth Africa
- Dalla Lana School of Public Health Sciences, University of TorontoTorontoOntarioCanada
| | - Kristen Sullivan
- Department of Social Medicine and Center for BioethicsUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | | | - Jacque Wambui
- National Empowerment Network of People Living with HIV and AIDS in Kenya (NEPHAK)African Communities Advisory Board (AfroCAB)LusakaZambia
| | - Amina White
- Department of Obstetrics and GynecologyUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Marisha Wickremsinhe
- Ethox Centre and Wellcome Centre for Ethics and HumanitiesUniversity of OxfordOxfordUK
| | - Leslie Wolf
- Center for LawHealth & Society and College of Law and School of Public HealthGeorgia State UniversityAtlantaGeorgiaUSA
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Spach NC, Jaffe EF, Sullivan KA, Goldfarb IT, Anderson JR, Coleman J, Gilbert SZ, Gross MS, Rahangdale L, Faden RR, Lyerly AD. Pregnant Individuals' Views on Fetal Tissue Research in the United States. Obstet Gynecol 2021; 138:755-761. [PMID: 34619743 PMCID: PMC8542627 DOI: 10.1097/aog.0000000000004576] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Accepted: 08/05/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Fetal tissue research has driven significant medical advances but remains publicly contentious in the United States. The views of pregnant individuals in the United States regarding the donation of fetal tissue offer an important and previously unexplored perspective on this issue. METHODS We conducted a secondary analysis of data from two separate, broader qualitative studies. Pregnant and recently pregnant individuals (N=79) from clinical sites at the University of North Carolina at Chapel Hill, Johns Hopkins University, and Massachusetts General Hospital were interviewed individually using a semi-structured guide addressing a range of issues related to infectious disease research and pregnancy, including the acceptability of fetal tissue research. Interviews were transcribed, coded, and analyzed for emergent themes. RESULTS Among this sample of predominantly Black (61%), reproductive-aged pregnant and recently pregnant participants, the majority (72%) generally supported fetal tissue research. The following three themes were identified: choice, respect, and meaning. Respondents discussed the deeply personal nature of decisions surrounding fetal tissue research, emphasizing the importance of informed consent and respect for the person's emotional state when approaching for consent. The ways in which participants regarded how to respectfully handle fetal tissue also shaped views about the acceptability of donation, both for and against. For many participants, fetal tissue donation to research represented one way of ascribing meaning to pregnancy termination or loss. CONCLUSION Among this diverse sample of pregnant and recently pregnant individuals, most were supportive of fetal tissue donation for research. A better understanding of pregnant individuals' views on this topic may lead to policies and practices that are congruent with the needs and values of people facing decisions regarding the disposition of fetal remains.
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Affiliation(s)
- Natalie C Spach
- Center for Bioethics, the Department of Social Medicine, and the Department of Obstetrics and Gynecology, UNC School of Medicine, and the UNC Gillings School of Global Public Health, Chapel Hill, North Carolina; the Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston, and Harvard Medical School, Cambridge, Massachusetts; the Berman Institute of Bioethics and the Department of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Maryland; the Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, Connecticut; and the Department of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburg, Pennsylvania
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8
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Weber AZ, Harrison A, Pellowski JA. Systematic review of research focused on pregnant and postpartum women living with HIV: A relational ethics perspective. BIOETHICS 2021; 35:829-838. [PMID: 34318957 PMCID: PMC10695324 DOI: 10.1111/bioe.12917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 06/04/2020] [Accepted: 06/09/2021] [Indexed: 06/13/2023]
Abstract
Historically, maternal HIV research has focused on prevention of mother-to-child transmission and child outcomes, with little focus on the health outcomes of mothers. Over the course of the HIV epidemic, the approach to including pregnant women in research has shifted. The current landscape lends itself to reviewing the public health ethics of this research. This systematic review aims to identify ethical barriers and considerations for including pregnant and postpartum women living with HIV in treatment adherence and retention research. We completed a systematic literature review following PRISMA guidelines with analysis using a relational ethics perspective. The included studies (n = 7) identified ethical barriers related to (a) women research participants as individuals, (b) partner and family dynamics, (c) community perspectives on research design and conduct, and (d) policy and regulatory implications. These broader contextual factors will yield research responsive to, and respectful of, the needs of pregnant and postpartum women living with HIV. While current regulatory and policy environments may be slow to change, actions can be taken now to foster enabling environments for research. We suggest that a relational approach to public health ethics can best support the needs of pregnant and postpartum women living with HIV; acknowledging this population as systematically disadvantaged and inseparable from their communities will best support the health of this population.
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Affiliation(s)
- Alison Z. Weber
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
| | - Abigail Harrison
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
| | - Jennifer A. Pellowski
- Department of Behavioral and Social Sciences, Brown University School of Public Health, Providence, RI, USA
- International Health Institute, Brown University School of Public Health, Providence, RI, USA
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Manda-Taylor L, Umar E, Stewart RC, Kufankomwe M, Chorwe-Sungani G, Mwale OC, Kokota D, Nyirenda J, Kulisewa K, Pickersgill M. Developing Biopsychosocial Research on Maternal Mental Health in Malawi: Community Perspectives and Concerns. Ethics Hum Res 2021; 43:11-19. [PMID: 34196502 PMCID: PMC7613173 DOI: 10.1002/eahr.500095] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Interest in maternal mental health research is growing around the world. Maternal mental health research studies in Malawi have, for instance, sought to determine and establish the incidence and prevalence of depression and anxiety in pregnant people and the factors that contribute to experiences of these states. This article reports stakeholder perspectives on potential community concerns with biopsychosocial mental health research (which might include collecting blood samples) in Malawi. These perspectives were generated through a town hall event that featured five focus group discussions with various participants. In this article, we reflect on key themes from these discussions, demonstrating the endurance of long-standing concerns and practices around autonomy, consent, and the drawing of blood. We conclude by arguing that, while maternal mental health research conducted in Malawi could benefit Malawian women and children, consultation with community stakeholders is necessary to inform whether and how such research should be conducted.
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Affiliation(s)
- Lucinda Manda-Taylor
- Senior lecturer in the Department of Health Systems and Policy in the School of Public Health and Family Medicine in the College of Medicine at the University of Malawi
| | - Eric Umar
- Associate professor in the School of Public Health and Family Medicine in the College of Medicine at the University of Malawi
| | - Robert C Stewart
- Honorary Senior Clinical Research Fellow in the Division of Psychiatry in the College of Medicine and Veterinary Medicine at the University of Edinburgh
| | | | | | - Owen C Mwale
- Project coordinator in the College of Medicine at the University of Malawi
| | - Demoubly Kokota
- Fellow in the Department of Mental Health at the Faculty of Medicine in the College of Medicine at the University of Malawi
| | - Joyce Nyirenda
- Research assistant in the College of Medicine at the University of Malawi
| | - Kazione Kulisewa
- Lecturer in the Department of Mental Health at the Faculty of Medicine in the College of Medicine at the University of Malawi
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Ngure K, Trinidad SB, Beima-Sofie K, Kinuthia J, Matemo D, Kimemia G, Njoroge A, Achiro L, Pintye J, Mugo NR, Bukusi EA, Baeten JM, Heffron R, John-Stewart G, Kelley MC. Perceived Social Influences on Women's Decisions to use Medications not Studied in Pregnancy. A Qualitative Ethical Analysis of Preexposure Prophylaxis Implementation Research in Kenya. J Empir Res Hum Res Ethics 2021; 16:225-237. [PMID: 34133231 PMCID: PMC8261769 DOI: 10.1177/15562646211012296] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Implementation research ethics can be particularly challenging when pregnant women have been excluded from earlier clinical stages of research given greater uncertainty about safety and efficacy in pregnancy. The evaluation of human immunodeficiency virus (HIV) preexposure prophylaxis (PrEP) during pregnancy offered an opportunity to understand important ethical considerations and social influences shaping women's decisions to participate in the evaluation of PrEP and investigational drugs during pregnancy. We conducted interviews with women (n = 51), focus groups with male partners (five focus group discussions [FGDs]), interviews with health providers (n = 45), four FGDs with pregnant/postpartum adolescents and four FGDs with young women. Data were analyzed using thematic content analysis, including ethical aspects of the data. Our study reveals that women navigate a complex network of social influences, expectations, support, and gender roles, not only with male partners, but also with clinicians, family, and friends when making decisions about PrEP or other drugs that lack complete safety data during pregnancy.
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Affiliation(s)
- Kenneth Ngure
- Department of Community Health, 118985Jomo Kenyatta University of Agriculture and Technology, Nairobi, Kenya.,Department of Global Health, University of Washington, Seattle, WA, USA
| | - Susan B Trinidad
- Department of Bioethics and Humanities, University of Washington, Seattle, WA, USA
| | | | - John Kinuthia
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Research and Programs, 285569Kenyatta National Hospital, Nairobi, Kenya
| | - Daniel Matemo
- Department of Research and Programs, 285569Kenyatta National Hospital, Nairobi, Kenya
| | - Grace Kimemia
- Population Dynamic and Reproductive Health, 107883African Population and Health Research Center, Nairobi, Kenya
| | - Anne Njoroge
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Research and Programs, 285569Kenyatta National Hospital, Nairobi, Kenya
| | - Lillian Achiro
- Center for Microbiology Research, 118982Kenya Medical Research Institute Nairobi, Kenya
| | - Jillian Pintye
- Department of Global Health, University of Washington, Seattle, WA, USA
| | - Nelly R Mugo
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Clinical Research, Kenya Medical Research Institute Nairobi, Kenya
| | - Elizabeth A Bukusi
- Department of Global Health, University of Washington, Seattle, WA, USA.,Center for Microbiology Research, 118982Kenya Medical Research Institute Nairobi, Kenya.,Department of Obstetrics and Gynecology, University of Washington, Seattle, WA, USA
| | - Jared M Baeten
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA
| | - Renee Heffron
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA
| | - Grace John-Stewart
- Department of Global Health, University of Washington, Seattle, WA, USA.,Department of Epidemiology, University of Washington, Seattle, WA, USA.,Department of Medicine, University of Washington, Seattle, WA, USA.,Department of Pediatrics, University of Washington, Seattle, WA, USA
| | - Maureen C Kelley
- Wellcome Centre for Ethics & Humanities and Ethox Centre, Nuffield Department of Population Health, 6396University of Oxford, Oxford, UK
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11
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Raciti CG, Enane LA, MacDonald KR, Whipple EC, Ott MA, McHenry MS. Ethical considerations for research involving pregnant women living with HIV and their young children: a systematic review of the empiric literature and discussion. BMC Med Ethics 2021; 22:38. [PMID: 33794891 PMCID: PMC8017748 DOI: 10.1186/s12910-021-00601-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The proper and ethical inclusion of PWLHIV and their young children in research is paramount to ensure valid evidence is generated to optimize treatment and care. Little empirical data exists to inform ethical considerations deemed most critical to these populations. Our study aimed to systematically review the empiric literature regarding ethical considerations for research participation of PWLHIV and their young children. METHODS We conducted this systematic review in partnership with a medical librarian. A search strategy was designed and performed within the following electronic databases: Ovid MEDLINE, Embase and CINAHL. We screened titles and abstracts using the following inclusion criteria: (1) a study population of PWLHIV or children under 5 years of age; and (2) collection of qualitative or quantitative data regarding ethics of research participation. Excluded were reviews, commentaries, policy statements, clinical care-related ethics concerns, abstracts, case studies, or studies unrelated to HIV research. Studies were appraised for quality, data were extracted, and studies were qualitatively analyzed using a principle-based ethical framework within the Belmont Report. RESULTS Of the 7470 titles identified, 538 full-text articles were reviewed for eligibility and only three articles met full criteria for inclusion within this review. While we allowed for inclusion of studies involving young children born to mothers with HIV, only articles focused on PWLHIV were identified. Within the results of these studies, four themes emerged: (1) adequacy of informed consent; (2) consideration of paternal involvement; (3) balancing risks; and (4) access to research and treatment. A strength of this review is that it included perspectives of international research investigators, community leaders, and male partners. However, only two studies collected empiric data from PWLHIV regarding their experiences participating in research CONCLUSION: Researchers and funding agencies should be aware of these considerations and appreciate the value of and critical need for formative research to ensure clinical trials involving PWLHIV promote ethical, well-informed research participation and, ultimately, improve care outcomes. More research is needed to create a comprehensive ethical framework for researchers when conducting studies with PWLHIV.
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Affiliation(s)
- Catherine G Raciti
- Indiana University-Purdue University - Indianapolis, Indianapolis, IN, USA
| | - Leslie A Enane
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5853, Indianapolis, IN, 46202, USA
| | - Katherine R MacDonald
- Department of Adolescent and Young Adult Medicine, Children's National Hospital, Washington, DC, USA
| | - Elizabeth C Whipple
- Indiana University School of Medicine, Ruth Lilly Medical Library, Indianapolis, IN, USA
| | - Mary A Ott
- Division of Adolescent Medicine, Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Megan S McHenry
- Department of Pediatrics, The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, 705 Riley Hospital Drive, Room 5853, Indianapolis, IN, 46202, USA.
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Johansson M, Hermerén G, Sahlin NE. Paternal consent in prenatal research: ethical aspects. MEDICINE, HEALTH CARE, AND PHILOSOPHY 2020; 23:325-331. [PMID: 31399882 PMCID: PMC7260141 DOI: 10.1007/s11019-019-09919-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
The role of mothers in prenatal research has been discussed extensively. Significantly less work has been done on the father's role. In this article, focusing on ethical issues, we seek to redress this imbalance. Examining the father's position in research conducted on pregnant women, we ask whether or not paternal consent ought to be required in addition to that of the pregnant woman. Having distinguished between different concepts of father and mother, we proceed by giving an overview of the reasons for requiring consent of the woman who is carrying the child. We then examine which of these reasons apply to the biological father, and show that some of them are relevant to the father. The case, roughly speaking, revolves around privacy issues, the father's future legal responsibilities, and the likelihood that he will care about the health and wellbeing of his future child. These factors in the decision problem should all be recognized, as should the fact that they can in principle be trumped by other considerations.
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Affiliation(s)
- Mats Johansson
- Department of Clinical Sciences, Lund, Lund University, BMCI12, 221 84, Lund, Sweden.
| | - Göran Hermerén
- Department of Clinical Sciences, Lund, Lund University, BMCI12, 221 84, Lund, Sweden
| | - Nils-Eric Sahlin
- Department of Clinical Sciences, Lund, Lund University, BMCI12, 221 84, Lund, Sweden
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Sullivan K, Mtande T, Jaffe E, Rosenberg N, Zimba C, Hoffman I, Little M, Faden R, Lyerly AD. Views among Malawian women about joining HIV prevention clinical trials when pregnant. AIDS Res Ther 2020; 17:27. [PMID: 32460804 PMCID: PMC7251879 DOI: 10.1186/s12981-020-00271-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Accepted: 05/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The pressing need to expand the biomedical HIV prevention evidence base during pregnancy is now increasingly recognized. Women's views regarding participation in such trials and initiating PrEP while pregnant are critical to inform evolving policy and best practices aimed at responsibly expanding evidence-based access for this population. METHODS We conducted 35 semi-structured interviews with reproductive-aged women in Malawi in the local language, Chichewa. Participants were HIV-negative and purposively sampled to capture a range of experience with research during pregnancy. Women's perspectives on enrolling in three hypothetical HIV prevention trial vignettes while pregnant were explored, testing: (1) oral PrEP (Truvada) (2) a vaginal ring (dapivirine), and (3) a randomized trial comparing the two. The vignettes were read aloud to participants and a simple visual was provided. Interviews were audio-recorded, transcribed, translated, and coded using NVivo 11. Thematic analysis informed the analytic approach. RESULTS A majority of women accepted participation in all trials. Women's views on research participation varied largely based on their assessment of whether participation or nonparticipation would best protect their own health and that of their offspring. Women interested in participating described power dynamics with their partner as fueling their HIV exposure concerns and highlighted health benefits of participation-principally, HIV protection and access to testing/treatment and ancillary care, and perceived potential risks of the vignettes as low. Women who were uninterested in participating highlighted potential maternal and fetal health risks of the trial, challenges of justifying prevention use to their partner, and raised some modality-specific concerns. Women also described ways their social networks, sense of altruism and adherence requirements would influence participation decisions. CONCLUSIONS The majority of participants conveyed strong interest in participating in biomedical HIV prevention research during pregnancy, largely motivated by a desire to protect themselves and their offspring. Our results are consistent with other studies that found high acceptance of HIV prevention products during pregnancy, and support the current direction of HIV research policies and practices that are increasingly aimed at protecting the health of pregnant women and their offspring through responsible research, rather than defaulting to their exclusion.
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Affiliation(s)
- Kristen Sullivan
- Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia Street, Campus Box 7240, Chapel Hill, NC, 27599, USA.
| | - Tiwonge Mtande
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Elana Jaffe
- Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia Street, Campus Box 7240, Chapel Hill, NC, 27599, USA
| | - Nora Rosenberg
- Department of Health Behavior, UNC Gillings School of Global Public Health, University of North Carolina at Chapel Hill, 170 Rosenau Hall, 135 Dauer Drive, Chapel Hill, NC, 27599, USA
| | - Chifundo Zimba
- UNC Project Malawi, Tidziwe Centre, Private Bag A-104, Lilongwe, Malawi
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina at Chapel Hill, Bioinformatics Building, 130 Mason Farm Road, Chapel Hill, NC, 27599, USA
| | - Maggie Little
- The Kennedy Institute of Ethics, Georgetown University, 3700 O Street Northwest, Washington, DC, 20057, USA
| | - Ruth Faden
- Berman Institute of Bioethics, Johns Hopkins University, 1809 Ashland Avenue, Baltimore, MD, 21205, USA
| | - Anne Drapkin Lyerly
- Center for Bioethics and Department of Social Medicine, University of North Carolina at Chapel Hill, 333 S. Columbia Street, Campus Box 7240, Chapel Hill, NC, 27599, USA
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Sullivan KA, Little MO, Rosenberg NE, Zimba C, Jaffe E, Gilbert S, Coleman JS, Hoffman I, Mtande T, Anderson J, Gross MS, Rahangdale L, Faden R, Lyerly AD. Women's views about contraception requirements for biomedical research participation. PLoS One 2019; 14:e0216332. [PMID: 31067273 PMCID: PMC6505940 DOI: 10.1371/journal.pone.0216332] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Accepted: 04/18/2019] [Indexed: 11/18/2022] Open
Abstract
The scientific and ethical importance of including women of reproductive age in biomedical research is widely acknowledged. Concerns about preventing fetal exposure to research interventions have motivated requirements for contraception among reproductive aged women in biomedical studies-often irrespective of risks and benefits or a woman's actual potential for pregnancy, raising important questions about when such requirements are appropriate. The perspectives of women themselves on these issues are largely unexplored. We conducted 140 interviews, 70 in the U.S. and 70 in Malawi, with women either living with or at-risk for HIV, exploring their views about the practice of requiring contraception in clinical trials. A majority of women interviewed from both countries indicated overall support for the practice, with seven themes characterizing advantages and disadvantages raised: reproductive control, health effects, prevention of fetal harm, burden on women, deferral to authority, autonomy regarding enrollment and birth control method, and relationship concerns. While women in the US frequently raised prevention of fetal harm as a key advantage, many other positives noted by women in both countries were related to contraception use in general, not specific to a trial context. With regard to disadvantages, U.S. women tended to focus on biomedical risks such as side effects and impact on fertility, whereas Malawian women focused on the social risks of contraception requirements, including violations of trust in marital relations and suspicions of potential infidelity. Given the potential benefits and burdens highlighted, contraception in research should be sensitive to actual fetal risk assessments; directed where justified at optimizing effective pregnancy prevention; responsive to women's reproductive preferences; and made available as an ancillary benefit even where risk thresholds do not justify requirement-in order to facilitate trials that are both ethical and robustly oriented around the interests and lives of women who will participate in them.
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Affiliation(s)
- Kristen A. Sullivan
- Center for Bioethics and Department of Social Medicine, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Margaret Olivia Little
- Kennedy Institute for Ethics, Georgetown University, Washington, D.C., United States of America
| | - Nora E. Rosenberg
- Department of Health Behavior, University of North Carolina Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Elana Jaffe
- Center for Bioethics and Department of Social Medicine, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Sappho Gilbert
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Jenell S. Coleman
- Division of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Irving Hoffman
- Institute for Global Health and Infectious Diseases, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Jean Anderson
- Division of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Marielle S. Gross
- Division of Gynecology and Obstetrics, Johns Hopkins University School of Medicine, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Lisa Rahangdale
- Department of Obstetrics and Gynecology, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Ruth Faden
- Berman Institute of Bioethics, Johns Hopkins University, Baltimore, Maryland, United States of America
| | - Anne Drapkin Lyerly
- Center for Bioethics and Department of Social Medicine, University of North Carolina School of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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