Chronic illness, reproductive health and moral work: women's experiences of epilepsy

Investigation of illness perception and pregnancy avoidance in sexually active women with epilepsy

AIM

The aim of the study was to examine the perception of illness and avoidance of pregnancy in sexually active women with epilepsy.

METHODS

This study was completed with 82 women with epilepsy who were sexually active and who were admitted to the neurology clinic and outpatient clinic between June and September 2022. The descriptive information form, Brief Illness Perception Questionnaire (IPQ-B), and Pregnancy Avoidance Scale (PAS) were used to collect the data.

RESULTS

The mean age of the patients in the study was 32.96 ± 5.92 years and the mean disease duration was 11.19 ± 7.46 years. Among the patients, 75.6% had previous pregnancies, 70.7% did not have miscarriage or abortion, 69.5% previously gave birth, 61% used a contraceptive method (condom, intrauterine device (IUD), pills, etc.) in their last sexual intercourse, 52.4% had good communication with their spouses, 20% had two children, 51.2% had three or more seizures, and 86.6% used antiseizure medications (ASMs). The mean PAS score of the patients was 2.31 ± 1.14 and the mean IPQ-B score was 35.10 ± 13.16. The regression analysis found that the perception of illness was a significant positive predictor of avoidance of pregnancy and explained 17% of it.

CONCLUSION

Women with epilepsy avoided pregnancy and had negative illness perceptions. Moreover, negative illness perception increased pregnancy avoidance in women with epilepsy.

Non-communicable diseases and maternal health: a scoping review

Background

Non-communicable diseases [NCDs] are leading causes of ill health among women of reproductive age and an increasingly important cause of maternal morbidity and mortality worldwide. Reliable data on NCDs is necessary for accurate measurement and response. However, inconsistent definitions of NCDs make reliable data collection challenging. We aimed to map the current global literature to understand how NCDs are defined, operationalized and discussed during pregnancy, childbirth and the postnatal period. 

Methods

For this scoping review, we conducted a comprehensive global literature search for NCDs and maternal health covering the years 2000 to 2020 in eleven electronic databases, five regional WHO databases and an exhaustive grey literature search without language restrictions. We used a charting approach to synthesize and interpret the data. 

Results

Only seven of the 172 included sources defined NCDs. NCDs are often defined as chronic but with varying temporality. There is a broad spectrum of conditions that is included under NCDs including pregnancy-specific conditions and infectious diseases. The most commonly included conditions are hypertension, diabetes, epilepsy, asthma, mental health conditions and malignancy. Most publications are from academic institutions in high-income countries [HICs] and focus on the pre-conception period and pregnancy. Publications from HICs discuss NCDs in the context of pre-conception care, medications, contraception, health disparities and quality of care. In contrast, publications focused on low- and middle-income countries discuss NCDs in the context of NCD prevention. They take a life cycle approach and advocate for integration of NCD and maternal health services.

Conclusion

Standardising the definition and improving the articulation of care for NCDs in the maternal health setting would help to improve data collection and facilitate monitoring. It would inform the development of improved care for NCDs at the intersection with maternal health as well as through a woman's life course. Such an approach could lead to significant policy and programmatic changes with the potential corresponding impact on resource allocation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-022-05047-6.

Gender differences in concerns about planning to have children and child-rearing among patients with epilepsy: A prospective, multicenter study with 477 patients from Germany

OBJECTIVE

To analyze the concerns and worries about planning to have children and being a parent as a person with epilepsy and investigate gender differences in these perceptions.

METHODS

The Epi2020 study was a large multicenter study focusing on different healthcare aspects of adult patients with epilepsy in Germany. In addition to basic clinical and demographic characteristics, patients were asked to answer a questionnaire regarding their plan to have children, if they had children, and concerns about their children's health. Data were analyzed to detect differences between men and women with epilepsy according to age group.

RESULTS

In total, 477 patients with epilepsy with a mean age of 40.5 years (SD = 15.5, range: 18-83 years) participated in this study; 280 (58.7%) were female and 197 (41.3%) were male. Both women and men frequently reported concerns and worries about having children: In the age group below 45 years of age, 72.5% of women and 58.2% of men described being worried to some extent that their children may also suffer from epilepsy (p = .006). Furthermore, 67.3% of women and 54.2% of men below the age of 45 years reported being worried that their children may be disabled (p = .003). Women were more likely to have family members who are reluctant to support their desire to have children (p = .048).

CONCLUSION

Women with epilepsy of childbearing age are significantly more likely to report major concerns that their children might be disabled or also have epilepsy than men with epilepsy and, therefore, express more concerns about choosing to have a child. However, men also report frequent concerns and worries, and this should be addressed not only on request but should be included in the provision of general information on epilepsy.

Preferences and experiences of women with epilepsy regarding sexual and reproductive healthcare provision

RATIONALE

Women with epilepsy (WWE) have unique disease-specific considerations regarding their sexual and reproductive health (SRH), which impact decision-making around pregnancy and contraception. Understanding their perspectives, preferences, and experiences regarding SRH care contributes to optimizing patient-centered clinical practice.

METHODS

We conducted individual semi-structured interviews with WWE aged 18-45 years, exploring their SRH care experiences and preferences. We audio-recorded and transcribed all interviews. Two coders used both inductive and deductive strategies to perform thematic analysis and identify key themes and representative quotes.

RESULTS

Twenty WWE completed interviews (median age 23 years; range 18-43 years). Key themes included: 1) SRH counseling from neurologists often did not occur, was limited in scope, or contained misinformation, especially during adolescence and early adulthood. In particular, participants felt that they received poor counseling about contraception, fertility, folic acid, and teratogenic medications, which impacted their reproductive decision-making. 2) WWE report fragmented care between their neurologist and other SRH providers. 3) WWE prefer that their neurologists initiate routine comprehensive discussions about SRH. 4) Conversations about SRH should begin in adolescence and include private confidential discussions between neurologists and WWE. 5) Successful SRH conversations between neurologists and WWE involve detailed information, reassurance, and support for the patient's reproductive goals.

CONCLUSION

WWE desire comprehensive, coordinated counseling and care regarding SRH and epilepsy, and often experience suboptimal SRH care. Better understanding of the SRH needs, preferences, and experiences of WWE will help inform interventions to optimize patient-centered SRH counseling and care by healthcare professionals, especially during adolescence.

A Scoping Review of Breastfeeding in Women with Chronic Diseases

Background: Approximately 10-20% of mothers have a chronic disease. Studies on breastfeeding in women with chronic disease span multiple disciplines, and these have not been collated to synthesize knowledge and identify gaps. The objective of this review was to summarize published literature on breastfeeding in women with chronic disease. Methods: We conducted a scoping review of original research and systematic reviews identified in Medline, EMBASE, and CINAHL (1990-2019) and by hand searching on women with chronic diseases reporting on at least one breastfeeding-related topic. Conference abstracts, case-studies, and studies on pregnancy-induced conditions or lactation pharmacology were excluded. Content analysis and narrative synthesis were used to analyze findings. Results: We identified 128 articles that were predominantly quantitative (80.5%), conducted in Europe or North America (65.6%), analyzed sample sizes of <200 (57.0%), and published from 2010 onward (68.8%). Diabetes (42.2%), multiple sclerosis (MS; 19.5%), and epilepsy (13.3%) were the most common diseases studied. Breastfeeding was a primary focus in approximately half (53.1%) of the articles, though definitions were infrequently reported (32.8%). The most-studied topics were breastfeeding duration/exclusivity (55.7%), reasons for feeding behavior (19.1%), and knowledge and attitudes about breastfeeding (18.3%). Less studied topics (<10% of articles each) included milk expression behaviors, breastfeeding difficulties, and feeding supports. Conclusions: Existing literature focuses primarily on diabetes or MS, and breastfeeding behaviors and outcomes. Further research examining a broader range of chronic diseases, with large sample sizes, and sufficient breastfeeding measurement detail can improve our understanding of breastfeeding disparities in this population.

Well-being of mothers with epilepsy with school-aged children

PURPOSE

The purpose of the study was to examine different aspects of well-being in mothers with epilepsy with school-aged children.

METHODS

In an observational study, mothers, identified from the European Registry of Antiepileptic Drugs and Pregnancy database in the Netherlands, completed questions on epilepsy, the impact of epilepsy on daily functioning, quality of life, behavioral problems, and parenting stress. Descriptive analyses were performed to examine the prevalence of behavioral problems and the impact of epilepsy on different aspects of the mother's daily functioning and family life. We subsequently investigated which factors contributed most to the impact of maternal epilepsy using regression analyses.

RESULTS

One hundred fifty-six (46%) of the 342 invited mothers with epilepsy participated. The majority (89%) had low epilepsy severity, with well-controlled seizures. Internalizing problems within the borderline or clinical range were reported by 23% of the mothers. Behavioral problems were significantly correlated with epilepsy severity (r = 0.26, p = .002), impact of epilepsy on daily functioning (r = 0.32, p < .001), and quality of life (r = -0.52, p < 01). Quality of life was in general good (mean = 8, standard deviation [SD] = 1), with low impact of epilepsy. Epilepsy affected mostly maternal self-confidence, work, and general health. Mothers indicated to experience no to little impact of epilepsy on the relationship with their children, partner, or family. Regression analyses showed that epilepsy severity (1.0, 95% confidence interval [CI]: 0.4 to 1.6; p = .002) and quality of life (-1.3, CI: -2.3 to -0.4; p = .007) were significant contributors to the impact of epilepsy on daily functioning, while other factors (maternal education, family type, behavioral problems, and parenting stress) were nonsignificant.

DISCUSSION

The current study shows that mothers with epilepsy generally fared well. Epilepsy negatively impacted the lives of some mothers, though. As maternal well-being is of importance for mother-child interaction and child development, clinicians should be aware of the impact of epilepsy on maternal psychosocial outcomes and family life of women with epilepsy.

AntiEpileptic drug Monitoring in PREgnancy (EMPiRE): a double-blind randomised trial on effectiveness and acceptability of monitoring strategies

BACKGROUND

Pregnant women with epilepsy on antiepileptic drugs (AEDs) may experience a reduction in serum AED levels. This has the potential to worsen seizure control.

OBJECTIVE

To determine if, in pregnant women with epilepsy on AEDs, additional therapeutic drug monitoring reduces seizure deterioration compared with clinical features monitoring after a reduction in serum AED levels.

DESIGN

A double-blind, randomised trial nested within a cohort study was conducted and a qualitative study of acceptability of the two strategies was undertaken. Stratified block randomisation with a 1 : 1 allocation method was carried out.

SETTING

Fifty obstetric and epilepsy clinics in secondary and tertiary care units in the UK.

PARTICIPANTS

Pregnant women with epilepsy on one or more of the following AEDs: lamotrigine, carbamazepine, phenytoin or levetiracetam. Women with a ≥ 25% decrease in serum AED level from baseline were randomised to therapeutic drug monitoring or clinical features monitoring strategies.

INTERVENTIONS

In the therapeutic drug monitoring group, clinicians had access to clinical findings and monthly serum AED levels to guide AED dosage adjustment for seizure control. In the clinical features monitoring group, AED dosage adjustment was based only on clinical features.

MAIN OUTCOME MEASURES

Primary outcome - seizure deterioration, defined as time to first seizure and to all seizures after randomisation per woman until 6 weeks post partum. Secondary outcomes - pregnancy complications in mother and offspring, maternal quality of life, seizure rates in cohorts with stable serum AED level, AED dose exposure and adverse events related to AEDs.

ANALYSIS

Analysis of time to first and to all seizures after randomisation was performed using a Cox proportional hazards model, and multivariate failure time analysis by the Andersen-Gill model. The effects were reported as hazard ratios (HRs) with 95% confidence intervals (CIs). Secondary outcomes were reported as mean differences (MDs) or odds ratios.

RESULTS

A total of 130 women were randomised to the therapeutic drug monitoring group and 133 to the clinical features monitoring group; 294 women did not have a reduction in serum AED level. A total of 127 women in the therapeutic drug monitoring group and 130 women in the clinical features monitoring group (98% of complete data) were included in the primary analysis. There were no significant differences in the time to first seizure (HR 0.82, 95% CI 0.55 to 1.2) or timing of all seizures after randomisation (HR 1.3, 95% CI 0.7 to 2.5) between both trial groups. In comparison with the group with stable serum AED levels, there were no significant increases in seizures in the clinical features monitoring (odds ratio 0.93, 95% CI 0.56 to 1.5) or therapeutic drug monitoring group (odds ratio 0.93, 95% CI 0.56 to 1.5) associated with a reduction in serum AED levels. Maternal and neonatal outcomes were similar in both groups, except for higher cord blood levels of lamotrigine (MD 0.55 mg/l, 95% CI 0.11 to 1 mg/l) or levetiracetam (MD 7.8 mg/l, 95% CI 0.86 to 14.8 mg/l) in the therapeutic drug monitoring group than in the clinical features monitoring group. There were no differences between the groups on daily AED exposure or quality of life. An increase in exposure to lamotrigine, levetiracetam and carbamazepine significantly increased the cord blood levels of the AEDs, but not maternal or fetal complications. Women with epilepsy perceived the need for weighing up their increased vulnerability to seizures during pregnancy against the side effects of AEDs.

LIMITATIONS

Fewer women than the original target were recruited.

CONCLUSION

There is no evidence to suggest that regular monitoring of serum AED levels in pregnancy improves seizure control or affects maternal or fetal outcomes.

FUTURE WORK RECOMMENDATIONS

Further evaluation of the risks of seizure deterioration for various threshold levels of reduction in AEDs and the long-term neurodevelopment of infants born to mothers in both randomised groups is needed. An individualised prediction model will help to identify those women who need close monitoring in pregnancy.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN01253916.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 23. See the NIHR Journals Library website for further project information.

The preconception care experiences of women with epilepsy on sodium valproate

PURPOSE

To understand the preconception experiences of women with epilepsy who have been taking the teratogenic drug valproate.

METHODS

Seven women were recruited, three from a preconception clinic and four from an antenatal clinic in a region of the UK. All had taken valproate preconceptionally. Three preconception clinic encounters were observed and audio-recorded. Interviews with all women were analysed using Interpretative Phenomenological Analysis (IPA).

RESULTS

Women experienced a "trajectory of balance". Women moved from "maintaining balance" by using valproate to control seizures, to a "shattering of harmony" at the prospect of changing medication and as a result of the physical and mental effects of changing medication, to "restoring balance" which could involve "a new self" due to dramatic changes. Women balanced their health needs with those of their baby, and took responsibility for medication decision-making. They found it difficult to see "who is looking after me" in the healthcare system, either to access preconception care, or to support them through the stress of changing medication. Their journey ended with coming to terms with a variety of experiences: choosing not to have a baby due to unsuccessful change from valproate, recognising that a child from a previous pregnancy had been harmed by valproate or that the current pregnancy might be at risk, or successful medication change in preparation for pregnancy.

CONCLUSION

A clear and adequately funded preconception care pathway is needed from epilepsy diagnosis, including support for stress. Understanding what influences maternalisation may help understand uptake of preconception care.

Exploring the perception of women with epilepsy about pregnancy concerns: a qualitative study

Background and aim

Epilepsy is a common neurological disorder in pregnancy, which is associated with increased maternal and fetal adverse outcomes. This study aimed to explore the reproductive healthcare needs of women with epilepsy before, during and after childbirth.

Methods

This was a qualitative study using a content analysis method. The study population was marital women with epilepsy in reproductive age (15–45 years) referred to Imam Hossein Hospital, Tehran, Iran. Participants were 16 women chosen using purposive sampling with the consideration of maximum variation in sampling. Semi-structured interviews were held with the participants until data saturation was reached. The data were analyzed using the content analysis method. The MAXQDA software, version 2010, was used for the management of data.

Results

The data analysis led to the development of two categories. The first one is named ‘resilience against threats to safe pregnancy’ and has the following subcategories: (1) real physical complications and perceived (mental) conditions due to unwanted pregnancies, (2) the predisposing factors of anxiety related to safe pregnancy, (3) perceived consequences of pregnancy’, and (4) the approach to encounter perceived consequences of pregnancy. The second category is called ‘adverse experiences under inefficient supportive systems’ and has the following subcategories: (1) the insufficiency of reproductive healthcare services for women with epilepsy, (2) doubt about the advantages and disadvantages of breastfeeding, (3) stigma as a block to the treatment of the postpartum depression, and (4) playing the motherhood role under the shadow of self-esteem to lack of self-esteem.

Conclusion

In the prenatal, natal and postnatal duration, because of supportive system disruption and not receiving proper consultation, participants were often worried about not being able to get favorable conditions for safe pregnancy and controlling process of their pregnancy. Therefore, they often experienced unwanted pregnancy. They were also concerned about the adverse fetal outcomes. In postpartum period, they often experienced postpartum depression and were very doubtful about breastfeeding.

Misunderstood as mothers: women's stories of being hospitalized for illness in the postpartum period

AIM

This paper aims to explore women's experiences with healthcare providers to ascertain ways health care may be improved for women disrupted in their mothering.

BACKGROUND

Women can find it difficult to relinquish care even when they are acutely unwell requiring hospitalization. Despite mothering being a priority for women, many healthcare professionals do not understand the importance of continuing to mother during maternal illness.

DESIGN

This research used a qualitative methodology drawing on principles of feminism and storytelling.

METHODS

Women's stories were collected through face-to-face interviews, email and via the telephone. The twenty-seven women who participated were from either Australia or the USA, had between one and six children and identified themselves as having been disrupted in their mothering by illness. Data were collected in 2011 and were analysed thematically.

FINDINGS

The majority of participants had been hospitalized at some point in time for acute illness. A subset of participants reported feeling judged by nurses and that their efforts to continue to mother their newborn children despite their illness were misunderstood and not facilitated.

CONCLUSION

Findings from this study suggest that women are more likely to remember times that health professionals failed to understand the primacy that mothering held for them or facilitate their efforts to continue to mother despite illness. Nurses and midwives should regularly reflect on their personal values in regard to mothering, validate women's attempts to mother to the best of their ability during illness and find ways to support and empower women in their mothering.

Identifying gaps in knowledge: A map of the qualitative literature concerning life with a neurological condition

OBJECTIVES

To describe patterns in the qualitative literature regarding the everyday experience of living with a neurological condition; to identify areas of depth as well as gaps in the existing knowledge base.

METHODS

An extensive search of the literature yielded 474 articles meeting the inclusion criteria. Data extraction, based on scrutiny of both abstract and full text article included country of origin, diagnosis, stated aim, methodological framework/design, participants, and data collection method(s). Studies were categorized into 27 topics within four broad foci.

RESULTS

Four broad foci describe the field: impact and management, daily activities and occupations, impact on family, and the healthcare experience. Overall the research is unevenly distributed by diagnosis; some are well represented while others are the subject of little research. Even diagnoses well represented in quantity can be limited in breadth.

DISCUSSION

Possible explanations for the patterns of emphasis include: a focus on issues and problems, highlighted points of contact between patients and healthcare providers, and ability of participants to voice their views. The literature is also characterized by limited across diagnoses research or that comparing the experience of people with different diagnoses. There is a need for more research in particular diagnoses; more varied data collection methods and acknowledgement of ethnicity, gender, discrimination, and social inequalities.

Pregnancy-related knowledge and information needs of women with epilepsy: a systematic review

For women with epilepsy (WWE), pregnancy is complicated by considerations such as the potential teratogenicity of antiepileptic drugs (AEDs) versus the risks of having seizures during pregnancy. However, qualitative research suggests that many WWE remain uninformed about the risks associated with epilepsy and pregnancy and may, therefore, be making uninformed decisions about their families. The objectives of this review were to determine the level of patient knowledge, their informational needs, and whether these needs concerning pregnancy and childbirth issues are met among WWE. Electronic databases searched were PsycINFO, MEDLINE, Embase, CINAHL, and Web of Science. Studies were included if they used quantitative methods to survey WWE aged 16years or older about their knowledge, access to information, or informational needs specifically regarding epilepsy and pregnancy. Twelve studies were identified and assessed for research standards using the Quality Index. Overall Quality Index score was only 7.1 out of 14, indicating significant design limitations of many included studies, including highly selective sampling methods and the use of unvalidated outcome measures. There was a paucity of studies investigating specific areas of women's knowledge and information needs. Overall, WWE reported adequate awareness, but limited knowledge, of key issues regarding pregnancy and childbirth. Across studies, many women reported not receiving information about these issues. Evidence suggested that many WWE wanted to receive more information - particularly about the risks of AEDs for their offspring - well in advance of choosing an AED or planning pregnancy. Women aged under 35years wanted the most information. Preconception counseling received by many WWE appears insufficient, risking uninformed decision-making about pregnancy. Further research is needed to investigate the barriers that WWE face in accessing, receiving, and retaining appropriate information.

Creature comforts: personal communities, pets and the work of managing a long-term condition

OBJECTIVES

To explore in the context of peoples' personal social networks, the contribution that pets make to 'the work' associated with the management of long-term conditions.

METHOD

Mixed methods survey with nested parallel qualitative study; 300 participants were drawn from diabetes and chronic heart disease registers of General Practices across Greater Manchester in the North West of England. Notions of 'work' were used to describe the illness and everyday activities associated with chronic illness.

RESULTS

Nineteen percent of participants identified at least one pet within their network. Pets contributed mostly to managing emotions (emotional work), to enhancing a sense of self identity (biographical work) and to a lesser extent practical tasks (everyday work). There were indicators that pets mediated relationships for people living with a long-term condition through very weak ties with others in domestic and community settings.

CONCLUSION

The findings suggest that pets have unique qualities and are not simply substitutes for human relationships in long-term condition management. The study has potential implications for furthering a social contextual analysis of chronic illness, the understanding of relationships, and the meaning and the role of companion animals in long-term condition management.

Women living with epilepsy, experiences of pregnancy and reproductive health: a review of the literature

PURPOSE

This study aimed to investigate the experiences of pregnancy in women living with epilepsy through a review and synthesis of existing literature.

METHODS

A comprehensive search of the literature was conducted in medical and social science databases to identify qualitative research, and questionnaires that included open-ended questions, which reported on the impact of epilepsy on the lives of pregnant women from preconception to post-delivery. The search was widened to include qualitative studies on pregnancy and issues of reproduction with women living with chronic illness that had at least one woman with epilepsy in the sample. The systematic search, carried out from April to June 2012, identified 17 publications that met the inclusion criteria, and 24 publications that did not. Qualitative results from these studies were categorised into: stage of pregnancy (preconception, pregnancy, and postnatal); case studies of patients' experiences; and the reproductive health experiences of women living with chronic illness.

RESULTS

One qualitative study was identified that directly investigated women's experiences of epilepsy during pregnancy. Many of the findings from the 16 remaining publications were found to be limited in generalisability due to small sample sizes and/or the poor quality of data.

CONCLUSION

Qualitative research on women's experiences of pregnancy whilst living with epilepsy is needed to address this critical gap in knowledge. This paper calls for improved preconception, pregnancy and postnatal supports and information for women living with this condition.

The impact of epilepsy on children and adult patients' lives: development of a conceptual model from qualitative literature

AIM

This study aimed to develop a conceptual model of the impact of partial onset or generalized epilepsy on children and adults in order to guide the identification of endpoints that capture patient perspectives in new treatment trials.

METHODS

A systematic literature search was conducted in Embase and Medline to identify qualitative research reporting the impact of epilepsy on child and adult patients' lives. The search identified 20 publications describing 18 qualitative studies. Qualitative results were extracted from these publications into structured summary tables separately for impact on children and adults.

RESULTS

Results tables were reviewed by two qualitative researchers who identified 23 concepts/areas of impact. Concepts were largely universal between child and adult studies, although concept content did vary between age-groups, for example child relationship concerns were focused on developing friendships and problematic family relationships. For adults the concerns were problematic relationships with spouse or partner and fulfilling the family roles. Concepts influenced directly by epilepsy were cognitive, physical and seizure effects, other concepts such as future hopes, burden and self-esteem were influenced more indirectly by impact on other concepts. The 23 concepts were linked to form a conceptual model of the impact of epilepsy for patients guided by qualitative results reported by studies.

CONCLUSION

The conceptual model suggests potential areas of patients' lives that may be enhanced by effective treatment and allows for concepts of concern to both children and adults to be identified and explored as potential endpoints in trials of new epilepsy treatments.