Perceptions of teratogenic risk
To help patients get the most from their treatment, it is important that their experience of medication use be explored and understood. In recent years, there has been an increasing interest in research on the perception of teratogenic risk [16]. This is corroborated by results of the current review, which shows that all papers included were published only in the last two decades. Additionally, the relatively small number of studies included in the review (seven studies) indicates that the study of perceptions of teratogenic risk is an important area for further research.
Two methods were used to measure the perception of teratogenic risk of participants, and those were either a numeric scale [15, 24, 79, 80, 82] or a visual analogue scale [16, 81]. One major issue regarding the use of a numeric scale to estimate the risk is its dependence on numeracy skills of participants [82, 94]. Evidence from the literature shows that correct estimation and understanding of health related risk information is significantly correlated with an ability to understand numbers and mathematical concepts [94, 95]. The second method to measure the perception of teratogenic risk was the use of a visual analogue scale. There is an ongoing debate on the utility of visual analogue scales in measuring risk perception. Some argue that responses of participants to questions including a visual analogue scale tend to cluster around the middle point of the scale and might over-estimate the risk when it is low [16, 96], while others suggest that a visual analogue scale can provide a wide range of responses that can be chosen by research participants [97]. Pons et al. investigated the level of agreement between a visual analogue scale and a numeric scale in estimating the teratogenic risk. In their research, they concluded that there was no agreement between the two methods in estimating teratogenic risk. [96]. Furthermore, it is recommended that future research exploring perceptions of teratogenic risk needs to utilise qualitative methods in addition to quantitative research. This is one way to overcome the ongoing controversy regarding how to reliably measure perception of teratogenic risk and will provide a deeper understanding of how risk is perceived [92].
It is clear from the results of the review that teratogenic risk of medications tends to be over-estimated [16, 24, 79-81], while proper estimation [15, 82] or under-estimation [15] occurs less frequently. Yet while there is agreement in the literature about the difficulty of understanding the teratogenic risk of medications due to scientific uncertainty [98, 99], a realistic perception of teratogenic risk is needed by women in child bearing age to adhere to their therapy [100].
Over-estimating the teratogenic risk of medications might be due to several factors. For women, pregnancy is viewed as a sensitive phase of their lives which can be easily adversely affected by exposure to a number of teratogens (such as alcohol) and including medications. In addition, pregnancy entails a significant responsibility to the mother to keep her foetus as safe as possible. These attitudes are further emphasized by social norms and cultural beliefs and can affect women’s ideas about medications [13, 98, 101]. On the other hand, for health care professionals and particularly for physicians, exaggerating the teratogenic risk of medications can be a result of inadequate knowledge, which in turn might be the result of insufficient training and education provided for physicians [81], or the lack of relevant resources being utilized when needed [102]. Furthermore, physicians’ fear of legal liability or possible accusation of malpractice if anything goes wrong while prescribing a potential teratogen might underpin this over estimation of the teratogenic risk of medications [102]. Subsequently, future research needs to focus on understanding how teratogenic risk is conceptualised and the reasons behind the tendency to exaggerate it.
The strength of this review relies in being the first attempt to shed light on the current status of implementing risk management measures when teratogenic medications are prescribed to women of child bearing age. It utilises the principles of medicines optimisation, a paradigm that aims to help patients get the best outcomes from using medicines. However, this systematic review has some limitations. First, title and abstract screening were only carried out by one researcher which means that there is a possibility of missing publications. Second, for the section on perceptions of teratogenic risk, the number of included articles was relatively small, which is justified by the limited publications in this area.