Online medication purchasing behaviour in pregnancy: a structured review of the literature

Research output: Contribution to journalArticle

Abstract

Background: When deciding to purchase medication online a pregnant woman has to negotiate a complex health system that involves concerns regarding risk, safety and responsibility for the baby along with her own needs. Research is required to determine what modifiable factors influence a pregnant women’s behaviour with regard to the purchasing of medications online. Research question: What modifiable factors influence a pregnant woman’s intention to purchase medication online? Methods: A structured review of the literature was completed using the 12-step approach described by Kable et al (2012). PRISMA guidelines were followed to ensure credibility and transparency in the review. A systematic search of the literature was carried out on eight databases including: MEDLINE (OVID), CINAHL Plus, PsycINFO, Web of Science, Scopus, Google Scholar, EtHOS and PROSPERO. Inclusion criteria were primary quantitative, qualitative, mixed method studies or literature reviews, having been published in peer review journals between January 2007 to January 2018 in English. The population was pregnant women, and the outcomes of interest were the modifiable factors that influence intention to purchase medication online. Quality appraisal of the retrieved papers was assessed using the Joanna Briggs Checklists for Analytical Cross Sectional Studies, Qualitative Studies and Diagnostic Test Accuracy. Findings: The search of the databases retrieved 4150 papers. Only four papers were eligible for inclusion in the review. Themes of medication safety, online purchasing of medication and the mother’s relationship with healthcare professionals were identified. Sub themes included attitudes towards taking medication, safety of the unborn baby, risks of online medication purchasing, advertising factors, customer reviews, changing dynamic of the doctor/patient relationship, and ability to bypass medical consultation. Conclusion: There is a definitive lack of empirical studies in this field and further qualitative and quantitative research is needed. Implications for practice: Midwives and healthcare professionals need to be aware that pregnant women are purchasing medications online.
LanguageEnglish
Pages13-20
JournalEvidence Based Midwifery
Volume16
Issue number1
Early online date4 Apr 2018
Publication statusE-pub ahead of print - 4 Apr 2018

Fingerprint

Pregnant Women
Pregnancy
Safety
Databases
Delivery of Health Care
Peer Review
Aptitude
Qualitative Research
Midwifery
Checklist
Research
Routine Diagnostic Tests
MEDLINE
Referral and Consultation
Cross-Sectional Studies
Mothers
Guidelines
Health
Population

Keywords

  • pregnancy
  • medication
  • safety
  • online purchasing
  • internet
  • evidence-based midwifery

Cite this

@article{d9ac04ee0427443f84cc429ccb876fc7,
title = "Online medication purchasing behaviour in pregnancy: a structured review of the literature",
abstract = "Background: When deciding to purchase medication online a pregnant woman has to negotiate a complex health system that involves concerns regarding risk, safety and responsibility for the baby along with her own needs. Research is required to determine what modifiable factors influence a pregnant women’s behaviour with regard to the purchasing of medications online. Research question: What modifiable factors influence a pregnant woman’s intention to purchase medication online? Methods: A structured review of the literature was completed using the 12-step approach described by Kable et al (2012). PRISMA guidelines were followed to ensure credibility and transparency in the review. A systematic search of the literature was carried out on eight databases including: MEDLINE (OVID), CINAHL Plus, PsycINFO, Web of Science, Scopus, Google Scholar, EtHOS and PROSPERO. Inclusion criteria were primary quantitative, qualitative, mixed method studies or literature reviews, having been published in peer review journals between January 2007 to January 2018 in English. The population was pregnant women, and the outcomes of interest were the modifiable factors that influence intention to purchase medication online. Quality appraisal of the retrieved papers was assessed using the Joanna Briggs Checklists for Analytical Cross Sectional Studies, Qualitative Studies and Diagnostic Test Accuracy. Findings: The search of the databases retrieved 4150 papers. Only four papers were eligible for inclusion in the review. Themes of medication safety, online purchasing of medication and the mother’s relationship with healthcare professionals were identified. Sub themes included attitudes towards taking medication, safety of the unborn baby, risks of online medication purchasing, advertising factors, customer reviews, changing dynamic of the doctor/patient relationship, and ability to bypass medical consultation. Conclusion: There is a definitive lack of empirical studies in this field and further qualitative and quantitative research is needed. Implications for practice: Midwives and healthcare professionals need to be aware that pregnant women are purchasing medications online.",
keywords = "pregnancy, medication, safety, online purchasing, internet, evidence-based midwifery",
author = "Alison Little and Sinclair, {Marlene .} and Patricia Gillen and Huiru Zheng",
note = "Reference text: Assi S, Thomas J, Haffar M, Osselton D. (2016) Exploring consumer and patient knowledge, behavior and attitude toward medicinal and lifestyle products purchased from the internet: a web-based survey. JMIR Public Health and Surveillance 2(2): e34. Berard V, Fiala C, Cameron S, Bombas T, Parachini M, Gemzell-Danielsson K. (2014) Instability of misoprostol tablets stored outside the blister: a potential serious concern for clinical outcome in medical abortion. PLoS ONE 9(12): e112401. Braun V, Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77-101. Clemow DB, Dewulf L, Michaels DL, Nolan MR, Cantrell SA, Kogelnik AM, Koren G, Mikita JS. (2014) A proposed framework to address needs of clinical data for informed medication use in pregnancy. Therapeutic Innovation and Regulatory Science 48(2): 145-54. Cox C, Kamal R, Jankiewicz A, Rousseau D. (2016) Recent trends in prescription drug costs. JAMA 315(13): 1326. EUROmediCAT. (2011) Medication safety in pregnancy. See: www. EUROmediCAT.eu/whatiseuromedicat (accessed 14 October 2016). Fittler A, B{\"o}sze G, Botz L. (2013) Evaluating aspects of online medication safety in long-term follow-up of 136 internet pharmacies: illegal rogue online pharmacies flourish and are long-lived. Journal of Medical and Internet Research 15(9): 199. Gao L, Larsson M, Luo S. (2013). Internet use by chinese women seeking pregnancy related information. Midwifery 29(7): 730-5. H{\"a}meen-Anttila K, Nordeng H, Kokki E, Jyrkk{\"a} J, Lupattelli A, Vainio K, Enlund H. (2014) Multiple information sources and consequences of conflicting information about medicine use during pregnancy: a multinational internetbased survey. Journal of Medical Internet Research 16(2): 1-11. Hansen C, Interrante JD, Ailes EC, Frey MT, Broussard, CS, Godoshian VJ, Lewis C, Polen KND, Garcia AP, Gilboa SM. (2016) Assessment of youtube videos as a source of information on medication use in pregnancy. References et al (2014) also highlighted there was little to no adherence of the Pregnancy Prevention Programme (PPP) as a condition of licensing to safeguard pregnant women and women of a childbearing age from the teratogenic effects of isotretinoin. Mothers relationship with healthcare professionals Changing dynamic of the doctor/patient relationship The accessibility of online pharmacies has altered the dynamic of the doctor/patient relationship and the consumer can directly bypass the safeguards provided by this relationship and go online to purchase prescription-only medication without a prescription (Lagan et al, 2014). Murtagh et al (2017) also recognised that purchasing medication online does not require a prescription and provides privacy and self-agency in countries where often restrictive laws, clinic closures and financial barriers inhibit a pregnant woman desiring an abortion. Ability to bypass medical consultation Murtagh et al (2017) identified that none of the 18 websites they ordered online medication from required a prescription or medical documentation, with only two requiring an online medical history questionnaire to be completed. Also, none of the questions on the questionnaire asked about gestational age or specific contraindications for mifepristone. Pregnant women have voiced concerns that by purchasing medication online and not having a consultation with a healthcare practitioner, something harmful could be missed (EUROmediCAT, 2011). Discussion A pregnant woman has to take into consideration the effect of a medication on her unborn child. This alters the decisionmaking process from that of a general purchase, often generating reservation in not only purchasing medication online but on whether to take medication in general. Twigg et al (2016) identified the safety of their baby as one of the main concerns for pregnant women when deciding not to take medication. Clemow et al (2014) found pregnant women routinely overestimated the teratogenic risks of taking medication which subsequently effected whether the woman took medication during her pregnancy. Thorpe et al (2013) also discussed the other potential reason for not taking medication as being a lack of evidence and accessible safety information. However, the majority of literature regarding the online information seeking behaviour of pregnant women would suggest that safety information was readily available and accessed regularly by the pregnant population (Sinclair et al, 2018; Sayakhot and Carolan-Olah, 2016; Ham{\"e}enAnttila et al, 2014; Gao et al, 2013; Song et al, 2013; Lagan et al, 2010). However, studies by Stephansson et al (2011) and Widnes et al (2012) suggested women with underlying co-morbidities are not compliant with taking prescribed medication during pregnancy. Sinclair et al (2018) attributed this to the possibility that a pregnant woman’s own online research regarding prescribed medications influences their informed decision making. The papers from the review highlighted the benefits of online medication purchasing for pregnant women as being cheaper, convenient, accessible, non-prescribed, and the ability to purchase across geographical boundaries contrary to regulation (Sinclair et al, 2018; Murtagh et al, 2017; Lagan et al, 2014; EUROmediCAT, 2011). These factors are not new and there is similar data from the general population by Fitter et al (2013); Assi et al (2016) and Kennedy and Wilson (2017). There is now a recognised growing trend for people accessing over the counter medication, herbal and homeopathic medication in drug stores, health food stores and supermarkets (Holtgr{\"a}fe and Zentes, 2012). All of these outlets now have online purchasing options without any meaningful engagement with healthcare professionals for guidance and can thus be a cause of concern and increase the purchasing risk for the pregnant woman. Sinclair et al (2018) identified that only 5{\%} of the pregnant population have purchased medication online during pregnancy which is a relatively small percentage. However, our recent pilot data of 44, shows that now almost 25{\%} of pregnant women are purchasing medication online (Little et al, 2018) a sharp increase from the data collected in 2013 in the UK study by Sinclair et al (2018). This is indicative of the growing number of pregnant women who have purchased medication online in the past five years. Further research is required to examine the online purchasing behaviour currently in a larger, more international sample. In the UK the majority of prescription medications are free, therefore there is not the same inclination on the purchaser to have to look for alternative more cost effective treatment. Conversely, in the US one in four people who take prescription drugs have difficulty affording them and turn to more cost effective means of procurement (Cox et al, 2016). Healthcare in the UK is rapidly changing. Press coverage has highlighted NHS England are cutting low-value medicines such as indigestion and heartburn medication from prescriptions (National Health Executive, 2017). With these trends and ever looming budget cuts, it will not be long before more pregnant women in the UK are starting to turn to the internet to obtain medication for pregnancy as a more cost effective means. The dangers associated with illegitimate online pharmacies has been recognised by the NHS Choices (2015) and the US Food and Drug Administration (2016) who have provided online advice and guidance on how to purchase medication safely online. However, Kennedy and Wilson (2017) highlighted that consumers have difficulty in recognizing the signs of an illegitimate pharmacy and that advice alone may not prevent them from accessing such sources. Sinclair et al (2014) also identified 71{\%} of women had never seen pregnancy warning symbols on online medications. Lagan et al (2014) study demonstrated that women of a child bearing age or pregnant women can potentially purchase teratogenic medication online without any risk assessment, pregnancy prevention advice or adequate warnings of the dangers associated with taking teratogenic medication on a pregnancy. This highlights a strong concern regarding the safety of purchasing medication online with the potential teratogenic risk on the fetus. As such pregnant women and women of a childbearing age need educated on the effects 20 {\circledC} 2018 The Royal College of Midwives. Evidence Based Midwifery 16(1): 13-20 Little A, Sinclair M, Zheng H, Gillen P. (2018) Online medication purchasing behaviour in pregnancy: a structured review of the literature. Evidence Based Midwifery 16(1): 13-20 Pharmacoepidemiology and Drug Safety 25: 35-44. Holtgr{\"a}fe C, Zentes J. (2012) Multifaceted determinants of online nonprescription drug information seeking and the impact on consumers’ use of purchase channels. Health Informatics Journal 18(2): 95-110. Kable AK, Pich J, Maslin-Prothero SE. (2012) A structured approach to documenting a search strategy for publication: a 12-step guideline for authors. Nurse Education Today 32(8): 878-86. Kennedy JP, Wilson JM. (2017) Clicking into harm’s way: the decision to purchase regulated goods online. American Behavioural Scientist 61(11): 1358-86. Kennedy DA, Lupattelli A, Koren G, Nordeng H. (2016) Safety classification of herbal medicines used in pregnancy in a multinational study. BMC Complementary and Alternative Medicine 16(1): 102. Kennedy DA, Lupattelli A, Koren G, Nordeng, H. (2013) Herbal medicine use in pregnancy: results of a multinational study. BMC Complementary and Alternative Medicine. 13: 355. Kenny LC, Lavender T, McNamee R, O’Neill SM, Mills T, Khashan AS. (2013) Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort. PLoS One 8(2): e56583. Klonoff-Cohen HS. (2017) Prevailing knowledge about male and female lifestyle habits and in vitro fertilization in the 21st century. Medical Research Archives 5(11). Khan KS, Kunz R, Kleijnen J, Antes G. (2003) Systematic reviews to support evidence-based medicine: how to review and apply findings of healthcare research. Royal Society of Medicine Press: London. Lagan BM, Dolk H, White B, Uges DRA, Sinclair M. (2014) Assessing the availability of the teratogenic drug isotretinoin outside the pregnancy prevention programme: a survey of e-pharmacies. Pharmcoepidemiology and Drug Safety 23: 411-8. Lagan BM, Sinclair M, Kernohan G. (2010) Internet use in pregnancy informs women’s decision making: a web-based survey. Birth 37(2): 106-15. Little A, Sinclair M, Zheng H, Gillen P. (2018) Online medication purchasing behaviour in pregnancy: pilot survey. Unpublished PhD thesis. Ulster University: Northern Ireland. McDonald H. (2017) Northern Irish woman was reported to police by GP over abortion pills. See: www.theguardian.com/world/2017/jan/31/ northern-ireland-woman-was-reported-to-police-by-gp-over-abortion-pills (accessed 14 November 2017). Medicines and Healthcare products Regulatory Agency. (2016) Medicines: packaging, labelling and patient information leaflets. See: www.gov.uk/ guidance/medicines-packaging-labelling-and-patient-information-leaflets (accessed 19 March 2018). Mehmood A, Rehman AU, Zaman M, Iqbal J. (2016) Self-medication; an emerging trend. British Journal of Pharmaceutical Research 14(1): 1-8. Meurk C, Broom A, Adams J. (2014) Relative bodies of knowledge: therapeutic dualism and maternal-foetal individuation. Social Theory and Health 12(2): 159-78. Mitchell AA, Gilboa SM, Werler MM, Kelley KE, Louik C, Hern{\'a}ndez-D{\'i}az S, The National Birth Defects Prevention Study. (2011) Medication use during pregnancy, with particular focus on prescription drugs: 19762008. American Journal of Obstetrics and Gynecology 205(1): 51. Murtagh C, Wells E, Raymond EG, Coeytaux F, Winikoff B. (2017) Exploring the feasibility of obtaining mifepristone and misoprostol from the internet. Contraception 97(4). National Health Executive. (2017) NHS England to cut low-value medicines from prescriptions. See: nationalhealthexecutive.com/Health-Care-News/ nhs-england-to-cut-low-value-medicines-from-prescriptions- (accessed 19 March 2018). NHS Choices. (2015) Dangers of buying your medicines online. See: www. nhs.uk/NHSEngland/AboutNHSservices/pharmacists/Pages/internet-drugs. aspx (accessed 19 March 2018). Sayakhot P, Carolan-Olah M. (2016) Internet use by pregnant women seeking pregnancy-related information: a systematic review. BMC Pregnancy and Childbirth 16: 65. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. British Medical Journal 349: g7647. Sinclair M, Close C, McCullough JEM, Hughes C, Liddle SD. (2014) How do women manage pregnancy-related low back and/or pelvic pain? Descriptive findings from an online survey. Evidence Based Midwifery 12(3): 76-82. Sinclair M. (2014) Over-the-counter pain medication in pregnancy. Evidence Based Midwifery 12(3): 75. Sinclair M, Lagan BM, Dolk H, McCullough N. (2018) An assessment of pregnant women’s knowledge and use of the internet for medication safety information and purchase. Journal of Advanced Nursing 74: 137-47. Song H, Cramer EM, McRoy S, May A. (2013) Information needs, seeking behaviours, and support among low-income expectant women. Women’s Health 53(8): 824-42. Stephansson O, Granath F, Svensson T, Haglund B, Ekbom A, Kieler H. (2011) Drug use during pregnancy in Sweden – assessed by the prescribed drug register and the medical birth register. Clinical Epidemiology 3: 43. The Centre for Safe Internet Pharmacies. (2016) The internet pharmacy market in 2016: trends, challenges and opportunities. See: safemedsonline. org/wp-content/uploads/2016/01/The-Internet-Pharmacy-Market-in-2016. pdf (accessed 19 March 2018). The Joanna Briggs Institute. (2016a) Checklist for analytical cross sectional studies. See: joannabriggs.org/research/critical-appraisal-tools.html (accessed 19 March 2018). The Joanna Briggs Institute. (2016b) Checklist for qualitative studies. See: joannabriggs.org/research/critical-appraisal-tools.html (accessed 19 March 2018). The Joanna Briggs Institute. (2016c) Checklist for diagnostic test accuracy studies. See: joannabriggs.org/research/critical-appraisal-tools.html (accessed 19 March 2018). Thorpe PG, Gilboa SM, Hernandez-Diaz S, Lind J, Cragan JD, Briggs G, Kweder S, Friedman JM, Mitchell AA, Honein MA. (2013) Medications in the first trimester of pregnancy: most common exposures and critical gaps in understanding fetal risk. Pharmacoepidemiology and Drug Safety 22: 1013-8. Twigg MJ, Lupattelli A, Nordeng H. (2016) Women’s beliefs about medication use during their pregnancy: a UK perspective. International Journal of Clinical Pharmacy 38: 968-76. US Food and Drug Administration. (2016). The possible dangers of buying medicines over the internet. See: fda.gov/ForConsumers/ ConsumerUpdates/ucm048396 (accessed 19 March 2018). Widnes SF, Schjott J, Granas AG. (2012) Risk perception and medicines information needs in pregnant women with epilepsy – a qualitative study. Seizure 21(8): 597-602.",
year = "2018",
month = "4",
day = "4",
language = "English",
volume = "16",
pages = "13--20",
number = "1",

}

Online medication purchasing behaviour in pregnancy: a structured review of the literature. / Little, Alison; Sinclair, Marlene .; Gillen, Patricia; Zheng, Huiru.

Vol. 16, No. 1, 04.04.2018, p. 13-20.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Online medication purchasing behaviour in pregnancy: a structured review of the literature

AU - Little, Alison

AU - Sinclair, Marlene .

AU - Gillen, Patricia

AU - Zheng, Huiru

N1 - Reference text: Assi S, Thomas J, Haffar M, Osselton D. (2016) Exploring consumer and patient knowledge, behavior and attitude toward medicinal and lifestyle products purchased from the internet: a web-based survey. JMIR Public Health and Surveillance 2(2): e34. Berard V, Fiala C, Cameron S, Bombas T, Parachini M, Gemzell-Danielsson K. (2014) Instability of misoprostol tablets stored outside the blister: a potential serious concern for clinical outcome in medical abortion. PLoS ONE 9(12): e112401. Braun V, Clarke V. (2006) Using thematic analysis in psychology. Qualitative Research in Psychology 3(2): 77-101. Clemow DB, Dewulf L, Michaels DL, Nolan MR, Cantrell SA, Kogelnik AM, Koren G, Mikita JS. (2014) A proposed framework to address needs of clinical data for informed medication use in pregnancy. Therapeutic Innovation and Regulatory Science 48(2): 145-54. Cox C, Kamal R, Jankiewicz A, Rousseau D. (2016) Recent trends in prescription drug costs. JAMA 315(13): 1326. EUROmediCAT. (2011) Medication safety in pregnancy. See: www. EUROmediCAT.eu/whatiseuromedicat (accessed 14 October 2016). Fittler A, Bösze G, Botz L. (2013) Evaluating aspects of online medication safety in long-term follow-up of 136 internet pharmacies: illegal rogue online pharmacies flourish and are long-lived. Journal of Medical and Internet Research 15(9): 199. Gao L, Larsson M, Luo S. (2013). Internet use by chinese women seeking pregnancy related information. Midwifery 29(7): 730-5. Hämeen-Anttila K, Nordeng H, Kokki E, Jyrkkä J, Lupattelli A, Vainio K, Enlund H. (2014) Multiple information sources and consequences of conflicting information about medicine use during pregnancy: a multinational internetbased survey. Journal of Medical Internet Research 16(2): 1-11. Hansen C, Interrante JD, Ailes EC, Frey MT, Broussard, CS, Godoshian VJ, Lewis C, Polen KND, Garcia AP, Gilboa SM. (2016) Assessment of youtube videos as a source of information on medication use in pregnancy. References et al (2014) also highlighted there was little to no adherence of the Pregnancy Prevention Programme (PPP) as a condition of licensing to safeguard pregnant women and women of a childbearing age from the teratogenic effects of isotretinoin. Mothers relationship with healthcare professionals Changing dynamic of the doctor/patient relationship The accessibility of online pharmacies has altered the dynamic of the doctor/patient relationship and the consumer can directly bypass the safeguards provided by this relationship and go online to purchase prescription-only medication without a prescription (Lagan et al, 2014). Murtagh et al (2017) also recognised that purchasing medication online does not require a prescription and provides privacy and self-agency in countries where often restrictive laws, clinic closures and financial barriers inhibit a pregnant woman desiring an abortion. Ability to bypass medical consultation Murtagh et al (2017) identified that none of the 18 websites they ordered online medication from required a prescription or medical documentation, with only two requiring an online medical history questionnaire to be completed. Also, none of the questions on the questionnaire asked about gestational age or specific contraindications for mifepristone. Pregnant women have voiced concerns that by purchasing medication online and not having a consultation with a healthcare practitioner, something harmful could be missed (EUROmediCAT, 2011). Discussion A pregnant woman has to take into consideration the effect of a medication on her unborn child. This alters the decisionmaking process from that of a general purchase, often generating reservation in not only purchasing medication online but on whether to take medication in general. Twigg et al (2016) identified the safety of their baby as one of the main concerns for pregnant women when deciding not to take medication. Clemow et al (2014) found pregnant women routinely overestimated the teratogenic risks of taking medication which subsequently effected whether the woman took medication during her pregnancy. Thorpe et al (2013) also discussed the other potential reason for not taking medication as being a lack of evidence and accessible safety information. However, the majority of literature regarding the online information seeking behaviour of pregnant women would suggest that safety information was readily available and accessed regularly by the pregnant population (Sinclair et al, 2018; Sayakhot and Carolan-Olah, 2016; HamëenAnttila et al, 2014; Gao et al, 2013; Song et al, 2013; Lagan et al, 2010). However, studies by Stephansson et al (2011) and Widnes et al (2012) suggested women with underlying co-morbidities are not compliant with taking prescribed medication during pregnancy. Sinclair et al (2018) attributed this to the possibility that a pregnant woman’s own online research regarding prescribed medications influences their informed decision making. The papers from the review highlighted the benefits of online medication purchasing for pregnant women as being cheaper, convenient, accessible, non-prescribed, and the ability to purchase across geographical boundaries contrary to regulation (Sinclair et al, 2018; Murtagh et al, 2017; Lagan et al, 2014; EUROmediCAT, 2011). These factors are not new and there is similar data from the general population by Fitter et al (2013); Assi et al (2016) and Kennedy and Wilson (2017). There is now a recognised growing trend for people accessing over the counter medication, herbal and homeopathic medication in drug stores, health food stores and supermarkets (Holtgräfe and Zentes, 2012). All of these outlets now have online purchasing options without any meaningful engagement with healthcare professionals for guidance and can thus be a cause of concern and increase the purchasing risk for the pregnant woman. Sinclair et al (2018) identified that only 5% of the pregnant population have purchased medication online during pregnancy which is a relatively small percentage. However, our recent pilot data of 44, shows that now almost 25% of pregnant women are purchasing medication online (Little et al, 2018) a sharp increase from the data collected in 2013 in the UK study by Sinclair et al (2018). This is indicative of the growing number of pregnant women who have purchased medication online in the past five years. Further research is required to examine the online purchasing behaviour currently in a larger, more international sample. In the UK the majority of prescription medications are free, therefore there is not the same inclination on the purchaser to have to look for alternative more cost effective treatment. Conversely, in the US one in four people who take prescription drugs have difficulty affording them and turn to more cost effective means of procurement (Cox et al, 2016). Healthcare in the UK is rapidly changing. Press coverage has highlighted NHS England are cutting low-value medicines such as indigestion and heartburn medication from prescriptions (National Health Executive, 2017). With these trends and ever looming budget cuts, it will not be long before more pregnant women in the UK are starting to turn to the internet to obtain medication for pregnancy as a more cost effective means. The dangers associated with illegitimate online pharmacies has been recognised by the NHS Choices (2015) and the US Food and Drug Administration (2016) who have provided online advice and guidance on how to purchase medication safely online. However, Kennedy and Wilson (2017) highlighted that consumers have difficulty in recognizing the signs of an illegitimate pharmacy and that advice alone may not prevent them from accessing such sources. Sinclair et al (2014) also identified 71% of women had never seen pregnancy warning symbols on online medications. Lagan et al (2014) study demonstrated that women of a child bearing age or pregnant women can potentially purchase teratogenic medication online without any risk assessment, pregnancy prevention advice or adequate warnings of the dangers associated with taking teratogenic medication on a pregnancy. This highlights a strong concern regarding the safety of purchasing medication online with the potential teratogenic risk on the fetus. As such pregnant women and women of a childbearing age need educated on the effects 20 © 2018 The Royal College of Midwives. Evidence Based Midwifery 16(1): 13-20 Little A, Sinclair M, Zheng H, Gillen P. (2018) Online medication purchasing behaviour in pregnancy: a structured review of the literature. Evidence Based Midwifery 16(1): 13-20 Pharmacoepidemiology and Drug Safety 25: 35-44. Holtgräfe C, Zentes J. (2012) Multifaceted determinants of online nonprescription drug information seeking and the impact on consumers’ use of purchase channels. Health Informatics Journal 18(2): 95-110. Kable AK, Pich J, Maslin-Prothero SE. (2012) A structured approach to documenting a search strategy for publication: a 12-step guideline for authors. Nurse Education Today 32(8): 878-86. Kennedy JP, Wilson JM. (2017) Clicking into harm’s way: the decision to purchase regulated goods online. American Behavioural Scientist 61(11): 1358-86. Kennedy DA, Lupattelli A, Koren G, Nordeng H. (2016) Safety classification of herbal medicines used in pregnancy in a multinational study. BMC Complementary and Alternative Medicine 16(1): 102. Kennedy DA, Lupattelli A, Koren G, Nordeng, H. (2013) Herbal medicine use in pregnancy: results of a multinational study. BMC Complementary and Alternative Medicine. 13: 355. Kenny LC, Lavender T, McNamee R, O’Neill SM, Mills T, Khashan AS. (2013) Advanced maternal age and adverse pregnancy outcome: evidence from a large contemporary cohort. PLoS One 8(2): e56583. Klonoff-Cohen HS. (2017) Prevailing knowledge about male and female lifestyle habits and in vitro fertilization in the 21st century. Medical Research Archives 5(11). Khan KS, Kunz R, Kleijnen J, Antes G. (2003) Systematic reviews to support evidence-based medicine: how to review and apply findings of healthcare research. Royal Society of Medicine Press: London. Lagan BM, Dolk H, White B, Uges DRA, Sinclair M. (2014) Assessing the availability of the teratogenic drug isotretinoin outside the pregnancy prevention programme: a survey of e-pharmacies. Pharmcoepidemiology and Drug Safety 23: 411-8. Lagan BM, Sinclair M, Kernohan G. (2010) Internet use in pregnancy informs women’s decision making: a web-based survey. Birth 37(2): 106-15. Little A, Sinclair M, Zheng H, Gillen P. (2018) Online medication purchasing behaviour in pregnancy: pilot survey. Unpublished PhD thesis. Ulster University: Northern Ireland. McDonald H. (2017) Northern Irish woman was reported to police by GP over abortion pills. See: www.theguardian.com/world/2017/jan/31/ northern-ireland-woman-was-reported-to-police-by-gp-over-abortion-pills (accessed 14 November 2017). Medicines and Healthcare products Regulatory Agency. (2016) Medicines: packaging, labelling and patient information leaflets. See: www.gov.uk/ guidance/medicines-packaging-labelling-and-patient-information-leaflets (accessed 19 March 2018). Mehmood A, Rehman AU, Zaman M, Iqbal J. (2016) Self-medication; an emerging trend. British Journal of Pharmaceutical Research 14(1): 1-8. Meurk C, Broom A, Adams J. (2014) Relative bodies of knowledge: therapeutic dualism and maternal-foetal individuation. Social Theory and Health 12(2): 159-78. Mitchell AA, Gilboa SM, Werler MM, Kelley KE, Louik C, Hernández-Díaz S, The National Birth Defects Prevention Study. (2011) Medication use during pregnancy, with particular focus on prescription drugs: 19762008. American Journal of Obstetrics and Gynecology 205(1): 51. Murtagh C, Wells E, Raymond EG, Coeytaux F, Winikoff B. (2017) Exploring the feasibility of obtaining mifepristone and misoprostol from the internet. Contraception 97(4). National Health Executive. (2017) NHS England to cut low-value medicines from prescriptions. See: nationalhealthexecutive.com/Health-Care-News/ nhs-england-to-cut-low-value-medicines-from-prescriptions- (accessed 19 March 2018). NHS Choices. (2015) Dangers of buying your medicines online. See: www. nhs.uk/NHSEngland/AboutNHSservices/pharmacists/Pages/internet-drugs. aspx (accessed 19 March 2018). Sayakhot P, Carolan-Olah M. (2016) Internet use by pregnant women seeking pregnancy-related information: a systematic review. BMC Pregnancy and Childbirth 16: 65. Shamseer L, Moher D, Clarke M, Ghersi D, Liberati A, Petticrew M, Shekelle P, Stewart LA. (2015) Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015: elaboration and explanation. British Medical Journal 349: g7647. Sinclair M, Close C, McCullough JEM, Hughes C, Liddle SD. (2014) How do women manage pregnancy-related low back and/or pelvic pain? Descriptive findings from an online survey. Evidence Based Midwifery 12(3): 76-82. Sinclair M. (2014) Over-the-counter pain medication in pregnancy. Evidence Based Midwifery 12(3): 75. Sinclair M, Lagan BM, Dolk H, McCullough N. (2018) An assessment of pregnant women’s knowledge and use of the internet for medication safety information and purchase. Journal of Advanced Nursing 74: 137-47. Song H, Cramer EM, McRoy S, May A. (2013) Information needs, seeking behaviours, and support among low-income expectant women. Women’s Health 53(8): 824-42. Stephansson O, Granath F, Svensson T, Haglund B, Ekbom A, Kieler H. (2011) Drug use during pregnancy in Sweden – assessed by the prescribed drug register and the medical birth register. Clinical Epidemiology 3: 43. The Centre for Safe Internet Pharmacies. (2016) The internet pharmacy market in 2016: trends, challenges and opportunities. See: safemedsonline. org/wp-content/uploads/2016/01/The-Internet-Pharmacy-Market-in-2016. pdf (accessed 19 March 2018). The Joanna Briggs Institute. (2016a) Checklist for analytical cross sectional studies. See: joannabriggs.org/research/critical-appraisal-tools.html (accessed 19 March 2018). The Joanna Briggs Institute. (2016b) Checklist for qualitative studies. See: joannabriggs.org/research/critical-appraisal-tools.html (accessed 19 March 2018). The Joanna Briggs Institute. (2016c) Checklist for diagnostic test accuracy studies. See: joannabriggs.org/research/critical-appraisal-tools.html (accessed 19 March 2018). Thorpe PG, Gilboa SM, Hernandez-Diaz S, Lind J, Cragan JD, Briggs G, Kweder S, Friedman JM, Mitchell AA, Honein MA. (2013) Medications in the first trimester of pregnancy: most common exposures and critical gaps in understanding fetal risk. Pharmacoepidemiology and Drug Safety 22: 1013-8. Twigg MJ, Lupattelli A, Nordeng H. (2016) Women’s beliefs about medication use during their pregnancy: a UK perspective. International Journal of Clinical Pharmacy 38: 968-76. US Food and Drug Administration. (2016). The possible dangers of buying medicines over the internet. See: fda.gov/ForConsumers/ ConsumerUpdates/ucm048396 (accessed 19 March 2018). Widnes SF, Schjott J, Granas AG. (2012) Risk perception and medicines information needs in pregnant women with epilepsy – a qualitative study. Seizure 21(8): 597-602.

PY - 2018/4/4

Y1 - 2018/4/4

N2 - Background: When deciding to purchase medication online a pregnant woman has to negotiate a complex health system that involves concerns regarding risk, safety and responsibility for the baby along with her own needs. Research is required to determine what modifiable factors influence a pregnant women’s behaviour with regard to the purchasing of medications online. Research question: What modifiable factors influence a pregnant woman’s intention to purchase medication online? Methods: A structured review of the literature was completed using the 12-step approach described by Kable et al (2012). PRISMA guidelines were followed to ensure credibility and transparency in the review. A systematic search of the literature was carried out on eight databases including: MEDLINE (OVID), CINAHL Plus, PsycINFO, Web of Science, Scopus, Google Scholar, EtHOS and PROSPERO. Inclusion criteria were primary quantitative, qualitative, mixed method studies or literature reviews, having been published in peer review journals between January 2007 to January 2018 in English. The population was pregnant women, and the outcomes of interest were the modifiable factors that influence intention to purchase medication online. Quality appraisal of the retrieved papers was assessed using the Joanna Briggs Checklists for Analytical Cross Sectional Studies, Qualitative Studies and Diagnostic Test Accuracy. Findings: The search of the databases retrieved 4150 papers. Only four papers were eligible for inclusion in the review. Themes of medication safety, online purchasing of medication and the mother’s relationship with healthcare professionals were identified. Sub themes included attitudes towards taking medication, safety of the unborn baby, risks of online medication purchasing, advertising factors, customer reviews, changing dynamic of the doctor/patient relationship, and ability to bypass medical consultation. Conclusion: There is a definitive lack of empirical studies in this field and further qualitative and quantitative research is needed. Implications for practice: Midwives and healthcare professionals need to be aware that pregnant women are purchasing medications online.

AB - Background: When deciding to purchase medication online a pregnant woman has to negotiate a complex health system that involves concerns regarding risk, safety and responsibility for the baby along with her own needs. Research is required to determine what modifiable factors influence a pregnant women’s behaviour with regard to the purchasing of medications online. Research question: What modifiable factors influence a pregnant woman’s intention to purchase medication online? Methods: A structured review of the literature was completed using the 12-step approach described by Kable et al (2012). PRISMA guidelines were followed to ensure credibility and transparency in the review. A systematic search of the literature was carried out on eight databases including: MEDLINE (OVID), CINAHL Plus, PsycINFO, Web of Science, Scopus, Google Scholar, EtHOS and PROSPERO. Inclusion criteria were primary quantitative, qualitative, mixed method studies or literature reviews, having been published in peer review journals between January 2007 to January 2018 in English. The population was pregnant women, and the outcomes of interest were the modifiable factors that influence intention to purchase medication online. Quality appraisal of the retrieved papers was assessed using the Joanna Briggs Checklists for Analytical Cross Sectional Studies, Qualitative Studies and Diagnostic Test Accuracy. Findings: The search of the databases retrieved 4150 papers. Only four papers were eligible for inclusion in the review. Themes of medication safety, online purchasing of medication and the mother’s relationship with healthcare professionals were identified. Sub themes included attitudes towards taking medication, safety of the unborn baby, risks of online medication purchasing, advertising factors, customer reviews, changing dynamic of the doctor/patient relationship, and ability to bypass medical consultation. Conclusion: There is a definitive lack of empirical studies in this field and further qualitative and quantitative research is needed. Implications for practice: Midwives and healthcare professionals need to be aware that pregnant women are purchasing medications online.

KW - pregnancy

KW - medication

KW - safety

KW - online purchasing

KW - internet

KW - evidence-based midwifery

M3 - Article

VL - 16

SP - 13

EP - 20

IS - 1

ER -