International Journal of Clinical Pharmacy

, Volume 36, Issue 1, pp 145–153 | Cite as

Adherence to medication for chronic disorders during pregnancy: results from a multinational study

  • Angela LupattelliEmail author
  • Olav Spigset
  • Hedvig Nordeng
Research Article


Background For a variety of chronic disorders, low medication adherence during pregnancy may jeopardize maternal as well as foetal health. Little is known about how closely pregnant women follow their chronic pharmacotherapy regimens. Objective To explore the level of adherence to medication for a variety of chronic disorders, namely cardiovascular, rheumatic and bowel disorders, diabetes and epilepsy, during pregnancy and to identify determinants of low adherence during pregnancy. Setting This multinational, cross-sectional, internet-based study was undertaken in 18 countries in Europe, North America and Australia. Data originating from some South American countries were also collected. Methods The study period lasted from 1-October-2011 to 29-February-2012. By using an anonymous on-line questionnaire we collected information about maternal demographics, chronic disorders and related medication use during pregnancy, and women’s pregnancy-specific beliefs about medication. Main outcome measure Adherence to medication during pregnancy via the 8-item Morisky Medication Adherence Scale (MMAS-8). Results A total of 210 pregnant women reported chronic medication use during pregnancy and filled in the MMAS-8. Overall, 36.2 % had low medication adherence. On the basis of the MMAS-8, the rates of low adherence were 55.6 % for medication for rheumatic disorders, 40.0 % for epilepsy, 36.1 % for bowel disorders, 32.9 % for cardiovascular disorders, and 17.1 % for diabetes. A lack of folic acid use, having previous children, and individual pregnancy-specific beliefs about medication were significant determinants of low medication adherence during pregnancy. Conclusion Many pregnant women had low adherence to their chronic pharmacotherapy regimens during pregnancy. Women’s beliefs about medication were a central factor determining low adherence.


Adherence International study Medication Pregnancy 



We thank the Scientific Board of OTIS and ENTIS, the website providers who contributed to the recruitment phase, the national coordinators of the study (Twigg MJ, Zagorodnikova K, Mårdby AC, Moretti ME, Drozd M, Panchaud A, Hameen-Anttila K, Rieutord A, Gjergja Juraski R, Odalovic M, Kennedy D, Rudolf G, Juch H, Passier JLM and Björnsdóttir I) and all participating women. We also thank Professor Donald E. Morisky for letting us use the MMAS-8.


The study has received financial support from the Norwegian Research Council (Grant no. 216771/F11) and the Foundation for Promotion of Norwegian Pharmacies and the Norwegian Pharmaceutical Society.

Conflicts of interest

The authors declare no conflicts of interest.

Supplementary material

11096_2013_9864_MOESM1_ESM.docx (63 kb)
Supplementary material 1 (DOCX 63 kb)


  1. 1.
    Sawicki E, Stewart K, Wong S, Leung L, Paul E, George J. Medication use for chronic health conditions by pregnant women attending an Australian maternity hospital. Aust N Z J Obstet Gynaecol. 2011;51(4):333–8.PubMedCrossRefGoogle Scholar
  2. 2.
    Ross DS. Hypothyroidism during pregnancy: clinical manifestations, diagnosis, and treatment. In: Basow DS, editor. Up to date. Waltham, MA: Up To Date; 2013.Google Scholar
  3. 3.
    Jovanovic L, Knopp RH, Kim H, Cefalu WT, Zhu XD, Lee YJ, et al. Elevated pregnancy losses at high and low extremes of maternal glucose in early normal and diabetic pregnancy: evidence for a protective adaptation in diabetes. Diabetes Care. 2005;28(5):1113–7.PubMedCrossRefGoogle Scholar
  4. 4.
    Correa A, Gilboa SM, Besser LM, Botto LD, Moore CA, Hobbs CA, et al. Diabetes mellitus and birth defects. Am J Obstet Gynecol. 2008;199(3):237 e1–9.CrossRefGoogle Scholar
  5. 5.
    ACOG practice bulletin. Chronic hypertension in pregnancy. ACOG Committee on practice bulletins. Obstet Gynecol. 2001;98(1):suppl 177–185.Google Scholar
  6. 6.
    Sabaté E. Adherence to long-term therapies: evidence for action: World Health Organization; 2003.Google Scholar
  7. 7.
    Matsui D. Adherence with drug therapy in pregnancy. Obstet Gynecol Int. 2012; 2012:Article ID 796590, 5 pages.Google Scholar
  8. 8.
    Nordeng H, Ystrøm E, Einarson A. Perception of risk regarding the use of medications and other exposures during pregnancy. Eur J Clin Pharmacol. 2010;66(2):207–14.PubMedCrossRefGoogle Scholar
  9. 9.
    Julsgaard M, Norgaard M, Hvas CL, Buck D, Christensen LA. Self-reported adherence to medical treatment prior to and during pregnancy among women with ulcerative colitis. Inflamm Bowel Dis. 2011;17(7):1573–80.PubMedCrossRefGoogle Scholar
  10. 10.
    Nielsen MJ, Norgaard M, Holland-Fisher P, Christensen LA. Self-reported antenatal adherence to medical treatment among pregnant women with crohn’s disease. Aliment Pharmacol Ther. 2010;32(1):49–58.PubMedGoogle Scholar
  11. 11.
    WHO Collaborating Centre for Drugs Statistics Methodology. ATC/ddd index 2012. [cited 2012 17 March]; Available from:
  12. 12.
    Briggs GG, Freeman RK, Yaffe SJ. Drugs in pregnancy and lactation. [S.l.]: Lippincott Williams & Wilkins; 2011.Google Scholar
  13. 13.
    Morisky DE, Ang A, Krousel-Wood M, Ward HJ. Predictive validity of a medication adherence measure in an outpatient setting. J Clin Hypertens (Greenwich). 2008;10(5):348–54.PubMedCentralCrossRefGoogle Scholar
  14. 14.
    Donald Morisky’s website. Morisky medication adherence scale. 2011 [cited 2013 23 May]; Available from:
  15. 15.
    Dempster AP, Laird NM, Rubin DB. Maximum likelihood from incomplete data via the em algorithm. J R Stat Soc Series B Stat Methodol. 1977;39(1):1–38.Google Scholar
  16. 16.
    Hosmer DW, Lemeshow S. Applied logistic regression. 2nd ed. New York: Wiley-Interscience; 2000.CrossRefGoogle Scholar
  17. 17.
    Cronbach LJ. Coefficient alpha and the internal structure of tests. Psychometrika. 1951;16(3):297–334.CrossRefGoogle Scholar
  18. 18.
    Ostensen M, Villiger PM, Forger F. Interaction of pregnancy and autoimmune rheumatic disease. Autoimmun Rev. 2012;11(6–7):A437–46.PubMedCrossRefGoogle Scholar
  19. 19.
    de Man YA, Hazes JM, van der Heide H, Willemsen SP, de Groot CJ, Steegers EA, et al. Association of higher rheumatoid arthritis disease activity during pregnancy with lower birth weight: results of a national prospective study. Arthr Rheum. 2009;60(11):3196–206.CrossRefGoogle Scholar
  20. 20.
    Agret F, Cosnes J, Hassani Z, Gornet JM, Gendre JP, Lemann M, et al. Impact of pregnancy on the clinical activity of crohn’s disease. Aliment Pharmacol Ther. 2005;21(5):509–13.PubMedCrossRefGoogle Scholar
  21. 21.
    Fairgrieve SD, Jackson M, Jonas P, Walshaw D, White K, Montgomery TL, et al. Population based, prospective study of the care of women with epilepsy in pregnancy. BMJ. 2000;321(7262):674–5.PubMedCrossRefGoogle Scholar
  22. 22.
    Williams J, Myson V, Steward S, Jones G, Wilson JF, Kerr MP, et al. Self-discontinuation of antiepileptic medication in pregnancy: detection by hair analysis. Epilepsia. 2002;43(8):824–31.PubMedCrossRefGoogle Scholar
  23. 23.
    Schachter SC. Management of epilepsy and pregnancy. In: Basow DS, editor. Up to date. Waltham, MA: Up To Date; 2013.Google Scholar
  24. 24.
    Kitzmiller JL, Block JM, Brown FM, Catalano PM, Conway DL, Coustan DR, et al. Managing preexisting diabetes for pregnancy: summary of evidence and consensus recommendations for care. Diabetes Care. 2008;31(5):1060–79.PubMedCentralPubMedCrossRefGoogle Scholar
  25. 25.
    Mardby AC, Akerlind I, Jorgensen T. Beliefs about medicines and self-reported adherence among pharmacy clients. Patient Educ Couns. 2007;69(1–3):158–64.PubMedCrossRefGoogle Scholar
  26. 26.
    Horne R, Weinman J. Patients’ beliefs about prescribed medicines and their role in adherence to treatment in chronic physical illness. J Psychosom Res. 1999;47(6):555–67.PubMedCrossRefGoogle Scholar
  27. 27.
    Jasper JD, Goel R, Einarson A, Gallo M, Koren G. Effects of framing on teratogenic risk perception in pregnant women. Lancet. 2001;358(9289):1237–8.PubMedCrossRefGoogle Scholar
  28. 28.
    Einarson A, Selby P, Koren G. Abrupt discontinuation of psychotropic drugs during pregnancy: fear of teratogenic risk and impact of counselling. J Psychiatry Neurosci. 2001;26(1):44–8.PubMedCentralPubMedGoogle Scholar
  29. 29.
    Ekman A, Dickman P, Klint Å, Weiderpass E, Litton J-E. Feasibility of using web-based questionnaires in large population-based epidemiological studies. Eur J Epidemiol. 2006;21(2):103–11.PubMedCrossRefGoogle Scholar
  30. 30.
    van Gelder MM, Bretveld RW, Roeleveld N. Web-based questionnaires: the future in epidemiology? Am J Epidemiol. 2010;172(11):1292–8.PubMedCrossRefGoogle Scholar
  31. 31.
    Seybert H. Internet use in households and by individuals in 2011. Eurostat statistics in focus 2011.Google Scholar
  32. 32.
    Internet World Stats. Usage and population statistics. 2012 [cited 2012 13 November]; Available from:
  33. 33.
    Australian Bureau of Statistics. Household use of information technology, Australia, 2010-11 [cited 2012 13 November]; Available from:
  34. 34.
    Statistics Canada. Individual internet use and e-commerce. 2010 [cited 2012 13 November]; Available from:
  35. 35.
    United States Census Bureau. The 2012 statistical abstract. Information & communications: Internet publishing and broadcasting and internet usage. 2010 [cited 2012 13 November]; Available from:

Copyright information

© Koninklijke Nederlandse Maatschappij ter bevordering der Pharmacie 2013

Authors and Affiliations

  • Angela Lupattelli
    • 1
    Email author
  • Olav Spigset
    • 2
    • 3
  • Hedvig Nordeng
    • 1
    • 4
  1. 1.Department of Pharmacy, School of PharmacyUniversity of OsloOsloNorway
  2. 2.Department of Clinical PharmacologySt Olav’s University HospitalTrondheimNorway
  3. 3.Department of Laboratory Medicine, Children’s and Women’s HealthNorwegian University of Science and TechnologyTrondheimNorway
  4. 4.Division of Mental HealthNorwegian Institute of Public HealthOsloNorway

Personalised recommendations