Over 1 million women of child-bearing age live in the Republic of Ireland and at any point could be planning to conceive, be pregnant or in the postnatal period. While pregnancy and childbirth are normal physiological events, some women do require extra care to optimise their pregnancy outcomes. During a woman’s reproductive years, there are increased opportunities to engage and educate women on their healthcare priorities, as well as those of their families. It is thus imperative that all healthcare providers use any of these interactions for health promotion and protection.
Dr Claire McCarthy is a Consultant Obstetrician/Gynaecologist with a special interest in managing medical conditions in pregnancy. Dr McCarthy is also involved with the Irish Medicines in Pregnancy Service (IMPS), a multidisciplinary service based at the Rotunda Hospital, which provides information and expertise to support safe and effective use of medicines before, during and after pregnancy and in lactation.
At the heart of the community, a pharmacy and its’ staff are in the valuable position of being able to provide care to women and their families for both minor ailments and illnesses, but also provide advice, support and dispensing of medication to service users. Therefore, there can be innumerable opportunities to provide advice and support for those pregnant or considering pregnancy. Some of these elements are outlined in the Health Service Executive document “Healthy Ireland, the Framework for Improved Health and Wellbeing 2013-2025”, which underlines that early intervention before birth is as critical as ongoing early years support.
The National Maternity Strategy was formally launched in 2016 as a ten-year plan, with the aim to support the implementation of National Standards of Care. The National Maternity Strategy, along with the National Standards represent the essential building blocks to provide a consistently safe and high-quality maternity service. This is both hospital and community based, with input from the multidisciplinary team. The National Women and Infants Health Programme provides oversight and governance of maternity services nationally, with the aim to further improve the quality and standard of care that is received.
From a pre-conceptual perspective, it is advised that women have a healthy balanced diet, minimise alcohol consumption and take folic acid (0.4mg once daily) for at least three months pre-conceptually. Some women (e.g. those with Diabetes Mellitus, family or personal history of a neural tube defect, taking anti-seizure medication or those with a Body Mass Index over 30kg/m 2 ) should be prescribed higher dose folic acid (5mg) supplementation. Vitamin D supplementation is also recommended for women who are deficient, or at risk of being deficient. Women who are entering pregnancy with a medical condition can sometimes benefit from pre-conceptual counselling. This can provide an opportunity to optimise medication, achieve disease control and allow counselling on potential pregnancy complications or outcomes that may arise owing to their condition, or indeed medications that they are taking. It is essential that women who are taking prescribed medication do not suddenly cease or discontinue taking medication on finding out they are pregnant, as in some cases this can lead to a deterioration in their health, putting themselves and their pregnancy at a greater risk. It is essential that these women undertake a risk-benefit discussion with their prescriber and evaluate whether continuing to take the medication is of a greater benefit than the actual or theoretical risks that taking the medication might pose.
Smoking during pregnancy additionally is noted to be detrimental to the health of both the mother and the fetus. The national tobacco control policy document “Tobacco Free Ireland” provides specific recommendations for smoking cessation both in pregnancy, but also pre-pregnancy. It notes that frontline healthcare professionals should have formalised and documented training in smoking cessation. Women may attend their community pharmacy for support in accessing nicotine replacement therapy if non-pharmacological methods have failed, which required a detailed discussion on the risks, benefits and alternatives.
MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquires across the UK) is a report published annually which examines maternal deaths and morbidities over a rolling three-year period, critically analysing and evaluating care given to women and their families. It provides healthcare providers with essential information to allow us to continually strive for improved care in our maternity services. Closer to home, the NPEC (National Perinatal Epidemiology Centre) based in University College Cork also publishes reports documenting Ireland’s maternal morbidity and mortality findings. It has been noted in many of these reports that there is a rising cultural bias to medication use in pregnancy, particularly in the context of older mothers, and those with increasingly complex medical conditions. Recommendations from these reports can be seen to take a pattern over the years. Specifically, with respect to medication, the 2018 MBRRACE report noted that the “decision on continuing, stopping or changing medication in pregnancy should be made only after careful review of the benefits and risks of doing so, to both mother and infant”.
Antenatally, the National Maternity Strategy aims is to create three dedicated pathways for women to access care. The Supported Care pathway is intended for normal-risk mothers and babies with midwives leading and delivering care within the multi-disciplinary framework. The Assisted Care pathway is intended for mothers/babies considered to be at medium risk, and for those who chose obstetricled care. This care is provided by obstetricians and midwives, as part of a multi-disciplinary team. For those women who are high-risk, the Specialised Care pathway provides obstetricled care, with input from other medical specialities, again delivered in partnership with midwifery services. These women may require a multi-disciplinary, multi-speciality approach to care and care planning.
Currently, from an obstetric perspective, families can opt for consultant-led care, or combined care. This is facilitated through the Maternity and Infant Care Scheme, available to every woman who is pregnant and ordinarily resident in Ireland, sharing care between the family doctor and hospital service. A number of maternity units also provide a suite of midwifery-led care, as well as midwifery-led units, a DOMINO (Domiciliary In and Out) service, Early Transfer Home and homebirth services. The HSE also facilitates a homebirth service through a number of registered selffree employed community midwives. Community pharmacists are an important resource during the antenatal period. Women may need support and resources in the management of both pregnancy-related and pre-existing complications. It is essential that pharmacists are empowered and supported in providing this, but also referring to the patients’ primary care or maternity care provider where necessary.
Postnatally, women are eligible for postnatal care both in hospital, but also in the community. Ideally, this should be a seamless transfer, either through hospital follow-up (i.e. community midwifery, early transfer home schemes), or through public health nurses and community care, in liaison with a primary care service. In this period, women may access the pharmacy for postnatal medications, or medical equipment/devices to support their recovery and rehabilitation.
Vaccination is also a key public health innovation to afford protection from severe forms of a condition but also to prevent disease. Some pharmacies offer vaccination against a variety of diseases to their communities, and thus knowledge on vaccination during pregnancy is important. The Irish Immunisation Guidelines for Pregnant Women recommend that all rubella seronegative women of childbearing age should be offered a dose of the MMR postnatally. All pregnant women should be offered the influenza vaccine throughout the influenza season. The pertussis vaccine should be offered between 16 and 36 weeks gestation in order to allow passage of antibodies to the fetus. More recently, vaccination against COVID has predominated healthcare advice. It is essential that pharmacists and their staff are proactive in supporting and recommending vaccination. There are helpful Decision Aids and Infographics available through the Royal College of Physicians of Ireland website to support and assist women in their decisionmaking surrounding COVID vaccination.
Breastfeeding is important for the health of both mothers and infants. From the maternal perspective, it reduces risk of cardiovascular disease, breast and ovarian cancer, as well as more short term conditions such as postpartum depression. For infants, breastmilk provides improved protection from acute infections and respiratory illnesses, as well as reduced childhood obesity. Despite this, breastfeeding rates in Ireland are amongst the lowest in the OECD. Public consultations have noted that some of the factors in these low rates are lack of breastfeeding supports in the hospital, community and home setting, as well as inconsistent and contradictory poor quality information on breastfeeding. In that context, support from all healthcare professionals, including pharmacists, is essential to improve our breastfeeding rates and support mothers who wish to successfully breastfeed. This can include on medication use in lactation, but also the provision of correct knowledge and support surrounding challenges women may experience and attend for advice (such as thrush, painful feeding, low supply) for both medical reasons, but assistance with medical supplies such as nipple shields and breast pump supports.
It would be remiss not to mention contraception when discussing women’s health and maternity services. In July 2022, the Minister for Health announced the introduction of a contraception scheme for women aged 17-25 years of age. From 2023, this will be extended to 16 to 30 year olds. The community pharmacy will be at the crux of the provision and dispensing of medications, along with the primary care teams. Going forward, it may be possible for women to access some hormonal contraceptive options in the community pharmacy, which will continue the precedence set by the successful provision of emergency contraception in the pharmacy setting. While this is a significant undertaking by the community pharmacy sector, it has revolutionised contraception provision, underpinning the centrality of the role of the community pharmacist and their team in the community.
Finally, it is known that one in six couples may experience difficulties in conceiving and may attend for advice both prior to attending for assessment, as well as during treatment. The community pharmacy can again play a key role in the support of couples through their subfertility journey, as well as the supply of medications that may be prescribed during this period of time. The Assisted Reproductive Technology journey can be fraught with emotional challenges, and can pose financial difficulties to couples which is important to acknowledge and help support as much as possible.
The community pharmacy as a location at the hub of a community has the unique ability and position to influence and promote positive healthcare changes in their clientele. Their knowledge of both their patients, but the wider factors surrounding prenatal, antenatal and postnatal care will be crucial going forward in the success of the National Maternity Strategy but also the healthcare of the population at large. Through continued engagement with education and increased provision of funding to the sector, the community pharmacy will continue to remain an essential part of the multidisciplinary healthcare team caring for generations of pregnant women.
References
Health Service Executive. Healthy Ireland, the Framework for Improved Health and Wellbeing 2013-2025.
Department of Health/Health Service Executive. National Maternity Strategy: Creating a Better Future Together 2016-2026
Health Information and Quality Authority. National Standards for Safer Better Maternity Services. 2016.
Department of Health. Tobacco Free Ireland: Report of the Tobacco Policy Review Group. Oct 2013.
Knight M, Bunch K, Tuffnell D, Jayakody H, Shakespeare J, Kotnis R, Kenyon S, Kurinczuk JJ (Eds.) on behalf of MBRRACE-UK. Saving Lives, Improving Mothers’ Care – Lessons learned to inform maternity care from the UK and Ireland Confidential Enquiries into Maternal Deaths and Morbidity 2014-16. Oxford: National Perinatal Epidemiology Unit, University of Oxford 2018
https://www.hse.ie/eng/health/immunisation/ pubinfo/pregvaccs/
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