Purpose

This study evaluates the effectiveness of a novel, live continuing pharmacy education program regarding gained knowledge and comfort in providing interventions to promote healthy pregnancies, as well as pharmacist motivation to incorporate these interventions in their practice.

Methods

Pharmacists and student pharmacists completed assessments before and after a continuing pharmacy education program about pharmacologic interventions for healthy pregnancies. The assessments evaluated knowledge, comfort level, and practices on healthy birth spacing, preeclampsia, and preterm birth in a total of 186 participants. Data were analyzed by comparing responses from the pre- and post-assessments using paired t-tests.

Results

Following the program, participants’ average knowledge score increased from 40% to 86% on the pre- and post-assessment, respectively (p<0.001). Participants’ comfort level increased in identifying and counseling patients in need of low-dose aspirin for preeclampsia prevention, progesterone injection for preterm birth prevention, and postpartum contraception use for healthy birth spacing (p<0.001). Participants also showed interest in prescribing self-administered hormonal contraception under statewide protocol. Most pharmacists identified logistical hurdles as challenges to incorporating the new knowledge into practice.

Conclusion

Pharmacists and student pharmacists significantly increased their knowledge about healthy birth spacing, preeclampsia prevention, and preterm birth prevention after attending a novel continuing pharmacy education program. Participants also reported greater comfort with identifying and counseling patients in need of selected pharmacologic interventions. With motivation to implement relevant interventions in their practice and sufficient training, pharmacists can serve as highly accessible and valuable resources for the provision of reproductive health services to patients in the community.

In the United States, short interpregnancy intervals (IPIs), preterm birth, and preeclampsia are associated with poorer maternal and infant outcomes. Approximately 29% of pregnancies nationwide occur at an IPI less than the recommended 18-month interval, and 1 in 10 infants is born preterm.(1,2) Furthermore, preeclampsia affects nearly 5% of delivery hospitalizations.(3) Compared to white women, Black, Indigenous, and women of color (BIWOC) are more likely to have preterm deliveries and die from pregnancy-related complications.(4) To reduce their incidence, appropriate pharmacologic interventions should be promoted and provided to those at risk of preeclampsia or preterm delivery.

Preterm birth, defined as delivery before 37 weeks of gestation, is the leading cause of neonatal morbidity in the U.S.(5) Preterm birth is associated with vision, hearing, and respiratory problems, cerebral palsy, and learning disabilities.(6) In addition, preeclampsia, or new-onset hypertension in the mother occurring after 20 weeks of gestation with proteinuria or multisystem organ damage, may increase the risk of low birth weight and stillbirth.(7)

A short IPI and preeclampsia can both increase the risk of preterm birth. To decrease this risk, contraception can be used to achieve healthy birth spacing.(8) Additionally, the U.S. Preventive Services Task Force recommends initiation of low-dose aspirin (81 mg) after 12 weeks of gestation in pregnant women at high risk of preeclampsia, including those with chronic diseases (e.g., diabetes, hypertension, renal disease, etc.).(9) To prevent preterm birth, administration of weekly intramuscular injections of 17-hydroxyprogesterone (17-OHP) starting at 16 to 24 weeks through 34 weeks of gestation is recommended for women with a history of spontaneous preterm birth.(5)

As highly accessible healthcare providers, pharmacists are well positioned to provide care to pregnant and postpartum patients and those of reproductive age. Community pharmacies are very convenient for these patients for consultations and other health services. Recent expansions in scope of practice have allowed pharmacists in selected states, including California, to provide certain reproductive health services, such as administration of injectable medications (e.g.,17-OHP) and prescribing of emergency contraception.(10) Additionally, in California and other selected states, trained pharmacists are able to prescribe hormonal contraception.(11)

There were no continuing pharmacy education (CPE) programs available for pharmacists interested in becoming more involved in care to promote healthy pregnancies. Therefore, a CPE curriculum about pharmacologic interventions for healthy birth spacing, preeclampsia prevention and treatment, and preterm birth prevention was developed for pharmacists and delivered across California.

The goal of this study was to evaluate the effectiveness of a novel, live CPE program regarding gained knowledge and comfort in providing interventions to promote healthy pregnancies, as well as pharmacist motivation to incorporate these interventions in their practice.

The CPE program was offered through live in-person events from October 2018 to March 2019 in seven California counties with high volumes of preterm births – San Diego, Los Angeles, San Bernardino, Kern, Fresno, Santa Clara, and Sacramento.(12) Three topics were covered during the three-hour programs: preterm birth prevention with progesterone, preeclampsia prevention with low-dose aspirin and treatment, and healthy birth spacing with contraception.

The Accreditation Council for Pharmacy Education-accredited CPE program was developed and delivered by pharmacist and physician experts after being peer-reviewed. A community grant from the March of Dimes – with support from the Anthem Blue Cross Foundation – provided funding for the CPE programs offered by Birth Control Pharmacist. In addition, local universities and local chapters of state pharmacist associations helped disseminate the program announcements.

Participants completed a pre- and post-test immediately before and after the program, which assessed knowledge about healthy pregnancies and measured the changes in attitudes about providing pharmacologic interventions. Knowledge-based questions were related to IPI, preeclampsia, and preterm birth (Table 1). In addition, participants’ comfort level in making recommendations about postpartum contraceptive use, identifying and counseling patients about low-dose aspirin use during pregnancy, and administering and facilitating access to progesterone was assessed. Finally, interest was asked about prescribing self-administered hormonal contraception under statewide protocol.

Table 1.

Five knowledge-based questions on pre- and post-test

Five knowledge-based questions on pre- and post-test
Five knowledge-based questions on pre- and post-test

Data were analyzed using Microsoft Office Excel 2013 (Redmond, WA) for descriptive statistics and IBM SPSS 25 (Armonk, NY) for analytic tests. Paired t-tests were used to compare pre- and post-test results, with alpha set a-priori at 0.05. The study did not qualify as human subjects research and was therefore deemed exempt by the University of California San Diego institutional review board.

Pre-test responses were received from 202 participants and post-test from 186 participants. Only the responses from those who returned both pre- and post-tests were matched. Most participants were staff pharmacists (n=75), followed by student pharmacists (n=58). Participants primarily practiced in community chain pharmacies (n=45) and settings other than community pharmacies (n=54) (Table 2).

Table 2.

Demographic data of participants from live programs (N = 202)

Demographic data of participants from live programs (N = 202)
Demographic data of participants from live programs (N = 202)

The average pretest score for knowledge-based questions was 40%, which increased significantly to 86% after the program (p<0.001). Compared to the pretest, a significantly higher number of participants answered the following questions correctly on the post-test: gestational age for initiation of 17-OHP injection (p<0.001), frequency of 17-OHP injections for preterm birth prevention (p<0.001), recommended minimum IPI (p<0.001), and postpartum contraceptive considerations (p<0.001).

Overall, participants felt more comfortable with providing pharmacologic interventions for healthy pregnancies after the program. There was significant increase in comfort with administering progesterone injections (p<0.001), facilitating patient access to commercial 17-OHP (p<0.001), counseling patients about the safety of aspirin use during pregnancy (p<0.001), identifying candidates for aspirin use during pregnancy (p<0.001), discussing postpartum contraception plans with pregnant patients (p<0.001), and determining safe contraception methods during postpartum and breastfeeding (p<0.001).

Participants’ interest in prescribing self-administered hormonal contraception under statewide protocol increased from 61% at baseline to 66% on the post-test (p=0.158). Behavioral change was also assessed upon program completion (Table 3). Most participants planned to discuss the information with colleagues (n=121), counsel pregnant patients about aspirin (n=113), make referrals for appropriate patients (n=104), and screen pregnant patients for eligibility of aspirin use (n=84).

Table 3.

Participant behavior changes after program completion (N=186)

Participant behavior changes after program completion (N=186)
Participant behavior changes after program completion (N=186)

Most participants anticipated logistical hurdles to be the biggest challenges to incorporating the new knowledge into their practice (Table 4). Management/company implementation (40%, n=74) and time/staffing resource limitations (39%, n=72) were the top two barriers to implementing services.

Table 4.

Top two barriers or challenges to incorporating new knowledge into practice (n=186)

Top two barriers or challenges to incorporating new knowledge into practice (n=186)
Top two barriers or challenges to incorporating new knowledge into practice (n=186)

Participants were also asked to evaluate the program in accordance with CPE program accreditation standards. More than 60% of the participants strongly agreed the program met standards of content relevance, learning objective achievements, presentation quality, and participant satisfaction.

This study provides the first insights of knowledge, comfort, and motivation among pharmacists regarding the provision of pharmacologic interventions for healthy pregnancies. After attending a novel CPE program about healthy pregnancies, participant knowledge and comfort in providing presented pharmacologic interventions significantly increased. Though participant interest in prescribing self-administered hormonal contraception was mostly unaffected, this result was reasonable and expected since participants who volunteered to attend the programs likely had high interest in reproductive health at baseline.

Most participants were motivated to implement pharmacologic interventions for healthy pregnancies, suggesting a willingness to expand services and counseling in their practice to encompass such care. In addition to providing pharmacologic interventions to promote healthy pregnancies, this opportunity can help close the gap for other needed reproductive health services, such as interventions involving alcohol use, nicotine use, teratogenic medication use, contraception use, weight management, immunizations, and management of high-risk medical conditions.(13) Pharmacists can identify eligible patients by screening for medications related to pregnancy or postpartum management, as well as addressing medication safety concerns during pregnancy or breastfeeding. Pharmacists can also provide chronic disease state management to reduce risk of preeclampsia in current or future pregnancies. Pharmacists trained to identify racism in the healthcare system and address cultural competency can be powerful advocates for all patients to reduce care disparities and other factors related to structural racism, which plays a role in the disproportionate impact of pregnancy-related complications in BIWOC and their children.(4,14)

The results of this CPE program indicate potential to expand sessions to other geographic locations in California and other states with a high incidence of preterm birth. The program is also available on the Birth Control Pharmacist website as an online two-hour home study CPE program.(15) Such information and training should also be incorporated into Doctor of Pharmacy curricula to better prepare students to promote healthy pregnancies in their future practice. Further studies on pharmacists’ behavioral changes in their practice after attending the program will be beneficial to evaluate the impact of the program on patient outcomes.

A limitation of the study included possible self-selection bias. As individuals attended the program voluntarily, they likely had an interest in this area, possibly impacting their plans to incorporate gained knowledge into their practices. Furthermore, not all participants returned both pre- and post-tests, limiting the number of participants who could be evaluated. Strengths of this program included the large number of participants. Additionally, the pre- and post-tests provide insights on possible improvements to future iterations of this program.

Pharmacists and pharmacy students demonstrated a significant increase in knowledge of healthy birth spacing and preterm birth prevention after attending a novel, live CPE program. They showed interest in prescribing self-administered hormonal contraception under statewide protocol and felt more comfortable with providing pharmacologic interventions for healthy pregnancies to eligible patients after attending the program. Pharmacists also intended to incorporate knowledge gained from the program into their practice to improve reproductive health outcomes. With adequate training and accessible tools, pharmacists can include reproductive health services in their practice to positively impact maternal and infant health outcomes.

The authors would like to thank Doug Humber, PharmD at the UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences for supporting this project as the faculty administrator for UC San Diego’s continuing pharmacy education program.

1.
Thoma
ME,
Copen
CE,
Kirmeyer
SE.
Short Interpregnancy Intervals in 2014: Differences by Maternal Demographic Characteristics
.
NCHS Data Brief
.
2016
Apr
; (
240
):
1
8
.
2.
Centers for Disease Control and Prevention [Internet]
.
Atlanta
:
Centers for Disease Control and Prevention
.
Preterm birth [cited 2020 Sep 8]. Available from: https://www.cdc.gov/reproductivehealth/maternalinfanthealth/pretermbirth.htm.
3.
Fingar
KR,
Mabry-Hernandez
I,
Ngo-Metzger
Q,
Wolff
T,
Steiner
CA,
Elixhauser
A.
Delivery Hospitalizations Involving Preeclampsia and Eclampsia, 2005–2014: Statistical Brief #222. 2017 Apr [cited 2020 Sep 8]
. In:
Healthcare Cost and Utilization Project (HCUP) Statistical Briefs [Internet]
.
Rockville (MD)
:
Agency for Healthcare Research and Quality (US)
2006
Feb
4.
March of Dimes [Internet]
.
Arlington, VA
March of Dimes
.
A health crisis impacting women and babies of color; 2020 [cited 2020 Sep 17]. Available from: https://www.marchofdimes.org/mission/health-disparities.aspx
5.
Rundell
K,
Panchal
B.
Preterm Labor: Prevention and Management
.
Am Fam Physician
.
2017
Mar
15
;
95
(
6
):
366
372
6.
Galson
SK.
Preterm birth as a public health initiative
.
Public Health Rep
.
2008
Sep–Oct;
123
(
5
):
548
50
. doi: .
7.
Bokslag
A,
van Weissenbruch
M,
Mol
BW,
de Groot
CJ.
Preeclampsia; short and long-term consequences for mother and neonate
.
Early Hum Dev
.
2016
Nov
;
102
:
47
50
. doi: .
8.
Prepregnancy Counseling
.
Committee Opinion No. 762. American College of Obstetricians and Gynecologists
.
Obstet Gynecol.
2019
;
133
:
e78
89
.
9.
US Preventive Services Task Force
,
Bibbins-Domingo
K,
Grossman
DC,
Curry
SJ,
Barry
MJ,
Davidson
KW,
Doubeni
CA,
Epling
JW
Jr,
Kemper
AR,
Krist
AH,
Kurth
AE,
Landefeld
CS,
Mangione
CM,
Phillips
WR,
Phipps
MG,
Silverstein
M,
Simon
MA,
Tseng
CW.
Screening for Preeclampsia: US Preventive Services Task Force Recommendation Statement
.
JAMA
.
2017
Apr
25
;
317
(
16
):
1661
1667
. doi: .
10.
Rafie
S,
Landau
S.
Opening new doors to birth control: state efforts to expand access to contraception in community pharmacies
.
Birth Control Pharmacist [Internet]
.
2020
11.
Birth Control Pharmacist [Internet]
.
Pharmacist Prescribing of Hormonal Contraception [cited 2021 Apr 8]
.
12.
March of Dimes [Internet]
.
Arlington, VA
:
March of Dimes
.
2018 Premature Birth Report Card United States. 2018 [cited 2019 Sep 26]. Available from: https://www.marchofdimes.org/materials/PrematureBirthReportCard-United%20States-2018.pdf.
13.
Luli
AJ,
Tran
N,
Ataya
A,
Rafie
S.
Patient Screenings for Preconception Health Interventions at a Community Pharmacy
.
Pharmacy (Basel)
.
2020
Oct
5
;
8
(
4
):
181
. doi: .
14.
Beck
AF,
Edwards
EM,
Horbar
JD,
Howell
EA,
McCormick
MC,
Pursley
DM.
The color of health: how racism, segregation, and inequality affect the health and well-being of preterm infants and their families
.
Pediatr Res
.
2020
Jan
;
87
(
2
):
227
234
. doi: .
15.
Birth Control Pharmacist [Internet]
.
Pharmacologic Interventions for Healthy Pregnancies [cited 2021 Feb 28]
. Available from:

About the Authors

Karen Cheung, PharmD, is a graduate of University of California San Diego (UC San Diego) Skaggs School of Pharmacy and Pharmaceutical Sciences and participated in the project while in school. Dr. Cheung has no conflicts of interest to report.

Email:sycheung@health.ucsd.edu

Agnes Suh, PharmD is a graduate of UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences and participated in the project while in school. Dr. Suh has no conflicts of interest to report.

Email:a4suh@health.ucsd.edu

Cydnee Ng, PharmD, is a drug information pharmacist at GoodRx, Inc. and a graduate of UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. Dr. Ng has no conflicts of interest to report.

Email:cng@goodrx.com

Natalie DiPietro Mager, PharmD, PhD, MPH, is a professor of pharmacy practice at Ohio Northern University Raabe College of Pharmacy. She is active in the American Public Health Association Pharmacy Section, the American Association of Colleges of Pharmacy Public Health Special Interest Group, and the Ohio Public Health Association. Dr. DiPietro Mager has no conflicts of interest to report.

Email:n-dipietro@onu.edu

Sally Rafie, PharmD, is a pharmacist specialist at UC San Diego Health and an assistant clinical professor at UC San Diego Skaggs School of Pharmacy and Pharmaceutical Sciences. She is also the founder of Birth Control Pharmacist. Dr. Rafie is a former President of the San Diego County Pharmacists Association and an active member of the American College of Clinical Pharmacy Women’s Health PRN. She is a member of the clinical advisory board for Afaxys, Inc and speaker for TherapeuticsMD.

Email:sally@birthcontrolpharmacist.com