Reasons given by pregnant women for participating in a clinical trial aimed at preventing premature delivery: a qualitative analysis

The risk tolerance and decision-making processes of Australian women regarding medication trials in pregnancy

BACKGROUND

Pregnant women have historically been excluded from participation in medication trials, in part due to the perceived risks of drug exposure to mothers and fetuses. However, little is known about pregnant women's attitudes toward risk and participation in such trials.

AIMS

To address this knowledge gap and to identify factors that influence trial participation.

MATERIALS AND METHODS

Australian women over the age of 18, currently pregnant or within six months of delivery, were recruited to participate in an online survey (n = 623) and follow-up interviews (n = 11). The survey investigated willingness to participate in five hypothetical drug trial scenarios of varying risk. Demographic and obstetric information, including COVID-19 vaccination status, was also collected. The impact of these factors on trial participation was analysed using ordinal regression. Interviews were subjected to thematic framework analysis using a priori and emergent themes.

RESULTS

Nearly half of the respondents (48%) indicated a willingness to participate in at least one of the hypothetical trials. As trial risk increased participation likelihood decreased, especially if the risk was to the fetus, regardless of benefits to the mother. COVID-19 vaccination status and medication hesitancy were predictors of an unwillingness to participate. Three broad themes emerged from the qualitative data: risk-benefit analysis, quality of evidence, and trust.

CONCLUSIONS

Overall, participants expressed a positive attitude toward research and medication trials during pregnancy, but were concerned about fetal risk. The findings of this study may help enhance trial design and the participation of pregnant women in medication trials.

A cross-sectional analysis of preterm birth incidence and survival in Al Kharj, Saudi Arabia

OBJECTIVES

To understand the prevalence and survival rates of preterm birth (PTB) is of utmost importance in informing healthcare planning, improving neonatal care, enhancing maternal and infant health, monitoring long-term outcomes, and guiding policy and advocacy efforts.

METHODS

The medical records of preterm infants admitted to the Neonatal Intensive Care Unit (NICU) with a diagnosis of prematurity at the Maternity and Children's Hospital (MCH), Al Kharj, Saudi Arabia, were reviewed between January 2018 and December 2022. Data were collected on birth weight (BW), gender, number of live births, gestational age, mortality, nationality, APGAR score, length of stay in the NICU, and maternal details.

RESULTS

A total of 9809 live births were identified between 2018 and 2022, of which 139 (3.9%) were born preterm. The overall mortality rate of the included sample was 7.19%, whereas the mortality rate according to BW was 38.4% of those born with extremely low birth weight (ELBW). The most common intrapartum complications were malpresentation (15.1%), placental complications (4.3%), and cord complications (3.6%).

CONCLUSION

This study provides valuable insights into the prevalence of PTB in the country, particularly focusing on the vulnerability of extremely preterm babies.

Factors influencing the participation of pregnant and lactating women in clinical trials: A mixed-methods systematic review

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.

Women's lived experiences of induction of labour in late- and post-term pregnancy within the Swedish post-term induction study - a phenomenological study

PURPOSE

There is a trend worldwide to induce pregnant women earlier. However, few studies have focused on women's experiences. The aim was to gain a deeper understanding of women's lived experiences of induction of labour in late- and post-term pregnancy.

METHODS

Phenomenology with a reflective lifeworld approach was chosen as the method. Twelve women participating in a larger study in which women were randomized to either induction of labour in week 41 or to expectant management until week 42, were interviewed one to three months after giving birth.

RESULTS

The essence is described as follows: labour becomes another journey than the intended one. The women adapted to this new journey by seeing the advantages and handing themselves over to the healthcare system, but at the same time something about giving birth could be lost. The result is further described by its four constituents: planning the unplannable, being a guest at the labour ward, someone else controlling the labour, and overshadowed by how it turned out.

CONCLUSION

Induced labour presents a challenge to maternity personnel to support the birthing woman's normal progress, not to rush her through labour, and to involve her in the process.

The Current Perspectives in Clinical Research: Computer-Assisted Drug Designing, Ethics, and Good Clinical Practice

In the era of emerging microbial and non-communicable diseases and re-emerging microbial infections, the medical fraternity and the public are plagued by under-preparedness. It is evident by the severity of the Coronavirus disease (COVID-19) pandemic that novel microbial diseases are a challenge and are challenging to control. This is mainly attributed to the lack of complete knowledge of the novel microbe’s biology and pathogenesis and the unavailability of therapeutic drugs and vaccines to treat and control the disease. Clinical research is the only answer utilizing which can handle most of these circumstances. In this review, we highlight the importance of computer-assisted drug designing (CADD) and the aspects of molecular docking, molecular superimposition, 3D-pharmacophore technology, ethics, and good clinical practice (GCP) for the development of therapeutic drugs, devices, and vaccines.

"Preterm birth risk, me?" Women risk perception about premature delivery - a qualitative analysis

Background

Risk perception is based on collective indicators, but it is influenced by the individual’s self-perception of his health-disease process. This study aims to investigate the risk perception of pregnant women who were identified as high-risk for premature birth and to seek strategies for better management of such cases.

Methods

This is a cross-sectional study where women who had completed their participation in P5 trial were contacted and invited to answer a structured questionnaire with open questions. Data were collected by telephone and analyzed using thematic analysis. The analysis categories were defined, and all the answers were reviewed, categorized, grouped, and a descriptive summary was prepared.

Results

Two hundred eight Brazilian women have participated. Three categories were identified: (1) Risk perception mediated by health professionals; (2) Self-perception of risk through personal experiences and relationships; (3) Perception of treatment success. After receiving an explanation from a health professional about short cervix and premature birth, women understood the risk of premature delivery, recognizing the importance of early diagnosis to prevent premature birth. Unsuccessful previous experiences in prior pregnancies influenced women’s risk perception. Patients believed in the success of the treatment performed, placing their hopes on the treatment even without research guarantees about benefits.

Conclusions

Pregnant women’s risk perception regarding prematurity is based partly on personal and family experiences but mainly on information given by health professionals. The risk perception about preterm birth may contribute to healthy pregnancy, guiding necessary interventions and preventing adverse outcomes. Prevention studies on prematurity should thus focus on neonatal outcomes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-04068-x.

Women's childbirth experiences in the Swedish Post-term Induction Study (SWEPIS): a multicentre, randomised, controlled trial

OBJECTIVE

To compare childbirth experiences in women randomly assigned to either induction of labour at 41 weeks or to expectant management until 42 weeks, in the Swedish Post-term Induction Study.

DESIGN

A register-based, multicentre, randomised, controlled, superiority trial.

SETTING

Women were recruited at 14 hospitals in Sweden, 2016-2018.

PARTICIPANTS

Women with an uncomplicated singleton pregnancy were recruited at 41 gestational weeks.

INTERVENTIONS

The women were randomly assigned to induction of labour at 41 weeks (induction group, n=1381) or expectant management until 42 weeks (expectant management group, n=1379).

OUTCOME MEASURES

As main outcome, women's childbirth experiences were measured using the Childbirth Experience Questionnaire version 2 (CEQ2), in 656 women, 3 months after the birth at three hospitals. As exploratory outcome, overall childbirth experience was measured in 1457 women using a Visual Analogue Scale (VAS 1-10) within 3 days after delivery at the remaining eleven hospitals.

RESULTS

The total response rate was 77% (2113/2760). There were no significant differences in childbirth experience measured with CEQ2 between the groups (induction group, n=354; expectant management group, n=302) in the subscales: own capacity (2.8 vs 2.7, p=0.09), perceived safety (3.3 vs 3.2, p=0.06) and professional support (3.6 vs 3.5, p=0.38) or in the total CEQ2 score (3.3 vs 3.2, p=0.07), respectively. Women in the induction group scored higher in the subscale participation (3.6 vs 3.4, p=0.02), although with a small effect size (0.19). No significant difference was observed in overall childbirth experience according to VAS (8.0 (n=735) vs 8.1 (n=735), p=0.22).

CONCLUSIONS

There were no differences in childbirth experience, according to CEQ2 or overall childbirth experience assessed with VAS, between women randomly assigned to induction of labour at 41 weeks or expectant management until 42 weeks. Overall, women rated their childbirth experiences high.

TRIAL REGISTRATION NUMBER

ISRCTN26113652.

Clinical Drug Trial Participation: Perspectives of Pregnant Women and Their Spouses

OBJECTIVE

This study aimed at investigating the factors influencing clinical drug trial participation by pregnant women and their spouses.

METHODS

This hospital-based cross-sectional study was conducted at Women's Hospital, School of Medicine, Zhejiang University, from July to September 2020. A self-administered questionnaire was distributed to pregnant women and their spouses in the maternity ward. The questionnaire consisted of two sections: The first part was aimed at collecting demographic information data while the second part consisted of 10 open-ended questions regarding clinical drug trial knowledges, financial compensation, risk awareness, psychological impact, and pregnancy outcomes.

RESULTS

A total of 206 questionnaires (115 from pregnant women and 91 from their spouses) were included in the statistical analysis. About 50% of pregnant women and their spouses had heard of clinical trials (50.43% vs 49.45%, p=0.888). Compared to their spouses, the proportion of pregnant women who thought that there is a need for the development of drugs during pregnancy was significantly higher (94.78% vs 16.48%, p=0.008). Moreover, a significant number of full-time employed pregnant women believed that clinical drug trials will increase the possibility of disease cure, relative to part-time/not employed pregnant women (98.21% vs 88.13%, p=0.030). Spouses whose education levels were below high school and those whose education level was high school or above exhibited significant differences regarding whether financial compensation will motivate their participation in clinical trials (77.78% vs 58.90%, p=0.044). Pregnant women and their spouses had no significant differences regarding various aspects: drug treatment during pregnancy, clinical trial drugs should be free, the need to increase the protection of pregnant women in clinical trials.

CONCLUSION

Due to fetus-associated concerns, most pregnant women are reluctant to be included in clinical trials. However, pregnant women and their spouses agree that medical treatment should be accessible for illnesses during pregnancy, and clinical drug trials during pregnancy should be performed. The usage of untested or sub-therapeutic drug regimens in clinical practice paradoxically increases the risk for fetuses. When recruiting pregnant volunteers for clinical drug trials, researchers should conduct in-depth consultations and comprehensively inform the pregnant women and their families on the pros and cons of their involvement.

Factors that impact on recruitment to randomised trials in health care: a qualitative evidence synthesis

BACKGROUND

Randomised trials (also referred to as 'randomised controlled trials' or 'trials') are the optimal way to minimise bias in evaluating the effects of competing treatments, therapies and innovations in health care. It is important to achieve the required sample size for a trial, otherwise trialists may not be able to draw conclusive results leading to research waste and raising ethical questions about trial participation. The reasons why potential participants may accept or decline participation are multifaceted. Yet, the evidence of effectiveness of interventions to improve recruitment to trials is not substantial and fails to recognise these individual decision-making processes. It is important to synthesise the experiences and perceptions of those invited to participate in randomised trials to better inform recruitment strategies.

OBJECTIVES

To explore potential trial participants' views and experiences of the recruitment process for participation. The specific objectives are to describe potential participants' perceptions and experiences of accepting or declining to participate in trials, to explore barriers and facilitators to trial participation, and to explore to what extent barriers and facilitators identified are addressed by strategies to improve recruitment evaluated in previous reviews of the effects of interventions including a Cochrane Methodology Review.

SEARCH METHODS

We searched the Cochrane Library, Medline, Embase, CINAHL, Epistemonikos, LILACS, PsycINFO, ORRCA, and grey literature sources. We ran the most recent set of searches for which the results were incorporated into the review in July 2017.

SELECTION CRITERIA

We included qualitative and mixed-methods studies (with an identifiable qualitative component) that explored potential trial participants' experiences and perceptions of being invited to participate in a trial. We excluded studies that focused only on recruiters' perspectives, and trials solely involving children under 18 years, or adults who were assessed as having impaired mental capacity.

DATA COLLECTION AND ANALYSIS

Five review authors independently assessed the titles, abstracts and full texts identified by the search. We used the CART (completeness, accuracy, relevance, timeliness) criteria to exclude studies that had limited focus on the phenomenon of interest. We used QSR NVivo to extract and manage the data. We assessed methodological limitations using the Critical Skills Appraisal Programme (CASP) tool. We used thematic synthesis to analyse and synthesise the evidence. This provided analytical themes and a conceptual model. We used the GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research) approach to assess our confidence in each finding. Our findings were integrated with two previous intervention effectiveness reviews by juxtaposing the quantitative and qualitative findings in a matrix.

MAIN RESULTS

We included 29 studies (published in 30 papers) in our synthesis. Twenty-two key findings were produced under three broad themes (with six subthemes) to capture the experience of being invited to participate in a trial and making the decision whether to participate. Most of these findings had moderate to high confidence. We identified factors from the trial itself that influenced participation. These included how trial information was communicated, and elements of the trial such as the time commitment that might be considered burdensome. The second theme related to personal factors such as how other people can influence the individual's decision; and how a personal understanding of potential harms and benefits could impact on the decision. Finally, the potential benefits of participation were found to be key to the decision to participate, namely personal benefits such as access to new treatments, but also the chance to make a difference and help others. The conceptual model we developed presents the decision-making process as a gauge and the factors that influence whether the person will, or will not, take part.

AUTHORS' CONCLUSIONS

This qualitative evidence synthesis has provided comprehensive insight into the complexity of factors that influence a person's decision whether to participate in a trial. We developed key questions that trialists can ask when developing their recruitment strategy. In addition, our conceptual model emphasises the need for participant-centred approaches to recruitment. We demonstrated moderate to high level confidence in our findings, which in some way can be attributed to the large volume of highly relevant studies in this field. We recommend that these insights be used to direct or influence or underpin future recruitment strategies that are developed in a participant-driven way that ultimately improves trial conduct and reduces research waste.

An exploration of women's experience of taking part in a randomized controlled trial of a diagnostic test during pregnancy: A qualitative study

OBJECTIVE

To explore pregnant women's views of participation in a clinical research trial while pregnant.

DESIGN

Prospective nested qualitative cohort study embedded within a national, multi-site randomized controlled trial of a diagnostic test for preeclampsia: Placental Growth Factor. One-to-one in-depth semi-structured interviews were undertaken with 19 women who had recently participated in the trial at a single recruiting site. The interviews were conducted in private, recorded digitally and transcribed verbatim.

SETTING

Single tertiary maternity hospital currently recruiting eligible women onto an on-going randomized controlled trial (NCT02881073).

PARTICIPANTS

Women who had participated in the PARROT Ireland randomized controlled trial during their recent pregnancy.

METHODS

Thematic analysis was utilized. Each line of the transcribed interviews was coded into a category by two researchers. The resultant categories were reviewed, and those with similarities were pooled allowing the development of themes.

MAIN OUTCOME MEASURES

Women's opinions and experience of participation in a randomized controlled trial of an interventional diagnostic test during their pregnancy.

RESULTS

Four major themes were identified as follows: (a) Understanding of preeclampsia, (b) Motivators for clinical trial participation, (c) Barriers to decision making and (d) Influence of PARROT Ireland on pregnancy experience.

CONCLUSIONS

Women are generally interested and positively inclined to participate in research during pregnancy. The potential of risk is an important consideration for eligible pregnant woman. Information and support by both researchers and clinicians are paramount in aiding women's understanding of a research trial.