Study design

This qualitative study employed a gender-based perspective [39,40]. The gender perspective is of crucial importance in this study due to the historical under-research of women’s health processes [37,41], especially during pregnancy and breastfeeding [42]. In addition, gender inequities in healthcare settings need to be addressed, as these may influence how HCP conduct their practice and their decision-making process (e.g., around the use of medicines, alternative therapies and vaccination). Approaching our research from a gender perspective could lead to more equitable health care and contribute to the promotion of social equity and justice for PBW [43,44].

The quality and rigor of this research were ensured by using Lucy Yardley’s criteria [45,46]. Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist was used to guide the research process (see S2 File).

Participants

Participants were 21 HCP in public primary healthcare centres (PHC). The inclusion criteria were: 1) working as a health professional in a primary healthcare or hospital in Catalonia; 2) providing care to PBW; 3) being able to communicate in Spanish or Catalan. Most participants identified their gender as women (N = 20) and were between 25 and 68 years old. Professionals were midwives (N = 4), gynaecologists (N = 2), family physicians (N = 6), family nurses (N = 6), paediatricians (N = 2), and a paediatric nurse (N = 1). Most worked fulltime in PHC, while four of them also worked in hospital care. Four participants worked in a rural area in the north of Catalonia, six in the city of Barcelona and eleven in an urban region in the Barcelona metropolitan area. Participants’ sociodemographic characteristics are available in Table 1.

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Table 1. Participants’ sociodemographic characteristics (N = 21).

https://doi.org/10.1371/journal.pone.0345521.t001

Sampling and recruitment

Sampling was purposive. Researchers were mindful to ensure discourse diversity by recruiting participants of different healthcare specialities (midwives, gynaecologists, family nurses, family physicians, paediatric nurses, paediatricians), areas of care (PHC; hospitals), years of healthcare experience and geographical contexts (rural area; urban area).

Participants were recruited through key contacts (midwifes, gynaecologists and research team members) in PHC, sexual and reproductive health care (ASSIR) and hospital settings in Catalonia. Snowball samples techniques were also used. These centres were located in three urban cities (holding around 46,000–1,600,000 inhabitants) and one rural town (holding around 3,600 inhabitants). The names of the participating cities and town have not been disclosed in this article to ensure confidentiality and anonymity. Some healthcare professionals were recruiters of other professionals that meet the inclusion criteria. Then they provided the contact details of potential participants to the research team, who were responsible for contacting them and giving more information on the study. All selected participants agreed to participate, but at last moment some of them could not participate because of a change in the schedule. Recruitment was especially challenging as it was done at a time when several HCP strikes were going on.

Data collection

Three discussion groups with 21 HCP were conducted in February 2024. The discussion group technique was chosen to explore narrative experiences, stimulate discussions, and account for participants’ interactions and group dynamics. The first (N = 4) was conducted in a hospital located in a rural area in the north of Catalonia. The second (N = 6) was carried out in ASSIR in an urban city, and the third (N = 11) took place in a PHC in an urban city. Data saturation was identified in the second group and reached in the third group, responses and themes were consistently repeated among participants across groups, and during second group we identified some consistency that were confirmed in the third group.

A topic guide was developed by the research team (see S1 File). The topic guide included questions on 1) experiences with medicine prescribing and vaccination during pregnancy and breastfeeding, 2) beliefs, experiences, and the role of alternative therapies during pregnancy and breastfeeding, 3) the decision-making process with users, and 4) resources used to prescribe medicines and vaccines, and recommendations on alternative therapies.

The study participants were informed about the interviewers’ work field and their motivation for doing this research. Before starting the discussion groups, participants provided both verbal and written consent and completed a sociodemographic questionnaire (see Table 1). Field notes were also taken. The discussion groups were conducted by LMP (N = 3), while BMB (N = 2) and AGE (N = 2) acted as observers, taking field notes and supporting the moderation. There was no prior relationship between the facilitators (BMB, AGE, and LMP) and most participants. BMB had a prior relationship with one participant. This relationship was approached reflexively, acknowledging its potential influence while ensuring professional boundaries throughout data collection and analysis. The session followed a predefined discussion guide, and the session was led by LMP. All analytical decisions were made collectively, which supported transparency, rigour, and the trustworthiness of the findings. This is further explained in the discussion section. The discussion groups lasted between 68 and 93 minutes and were audio recorded. A reusable water bottle was given to all participants as a token of thanks.

Regarding the research team, BMB (MPH) has worked as a research assistant in qualitative methods for over a year and AGE (MPH) has over three years of experience in qualitative and mixed-methods research. CMB is a health professional specialised in women’s health and sexual and reproductive health assistance and research. MGS, CVU, LCA, CAM, MLV, AGL have a wide experience in pharmacology and pharmacoepidemiology with expertise in primary healthcare clinical and hospital pharmacology research. LCA, CAM are consultants for teratology consultations of clinical practice. LMP (PhD) has ten years of experience conducting qualitative and mixed-methods research. The research team is committed to conduct public health research from a social determinants of health and gender-based perspective.

Data analysis

Thematic analysis was used to analyse the data [47]. This included: a) familiarisation with the data, b) coding process, c) generating initial themes, d) reviewing themes, e) defining and naming themes, f) writing the analysis. The three discussion groups were transcribed and anonymised by BMB. Then, two were coded and triangulated by AGE and BMB. The third was coded by BMB. AGE, LMP and BMB carried out two team meetings to share and consolidate the coding, to explore the potential themes and propose a preliminary thematic framework. Although LMP, AGE and BMB shared the same perspective, there were several discrepancies in the coding process that were discussed and resolved in several meetings. Then, another meeting was organised with the whole research team to discuss the findings and the preliminary thematic framework. Discrepances in data interpretation were also discussed, helped to rethink the preliminary thematic framework and enriched the analytic process. The discrepancies within the research team were attributed to the fact that the data were more exploratory than descriptive. Through these meetings, it was possible to achieve a clearer alignment with the study objectives and ultimately reach a consensus. The results were drafted to deepen the analysis and incorporate ideas that had not been previously considered. When the draft was shared with the rest of the research team, changes were made to further deepen and finalise data analysis. A further meeting between BMB, AGE, and LMP was held to generate an organisation of data, so that the results were more in line with the aim of the study and the assessments of the other research members. These changes were incorporated into the final article and reviewed by all the members of the research team. Atlas.ti software was used for coding and data triangulation.

Ethics approval and consent to participate

The study was approved by the ethics committee of the Institut de Recerca en Atenció Primària Jordi Gol i Gurina (IDIAPJGol) on 26^th Oct 2022, Ref 22/195-P. All activities included in the study were carried out according to existing guidance in ethics as indicated in the Universal Declaration on Bioethics and Human Rights adopted by UNESCO (19/10/2005); the Council of Europe Convention for the Protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine (1997) and its additional protocol on biomedical research (2005); the Helsinki Declaration (2013) and relevant EU laws (European Parliament and Council Directive 2001/20/EC); the Spanish Law on Biomedical Research (14/2007) and the LOPD (Spanish Law on Personal Data Protection) (3/2018). Participants received enough information to make an informed decision on participation. Identifiable data were deleted from the transcripts so that participants cannot be identified. All participants gave their informed consent to participate in the study.

Challenges in medicine prescription, adherence and monitoring

The participants largely concurred that the prescription of medication is a challenging aspect of their practice, especially during pregnancy but also during breastfeeding.

“Yes, in pregnancy... there is no safe medicine, right? that is, you have paracetamol, but it is not either, you have two or three for the most common and the rest, every time, you use it, you consult it” (S3, gynaecologist, GD1).

Many participants observed that PBW in general were reluctant to use prescribed medicines and it was uncommon for PBW to start any medication without first consulting.

“It is true that patients in general are almost always very reluctant, which is very good, especially almost never does anyone start taking anything without having consulted them first” (S3, gynaecologist, GD1).

S1, who was a family physician, commented that she typically preferred to wait for the “natural healing progression” before prescribing medication as it could help to prevent over-medicalisation. Family physicians often sought to build trust in their prescription decisions by discussing medication adjustments with gynaecologists or midwives.

“It’s not what we do every day, you don’t have it so immediate, but... I think that even sometimes, maybe you give something less, right?” (S10, family physician, GD2).

Additionally, family physicians observed instances in which PBW did not disclose their pregnancy status during medical appointments, which may have resulted in inappropriate medication prescriptions.

“We as family physicians see pregnant women, but many times they don’t tell you that they are pregnant. And you have this perception of making prescriptions without knowing if she is pregnant or not (…) and the same in breastfeeding, (…)” (S14, family physician, GD3).

Family physicians and nurses identified a significant challenge in the lack of knowledge about medication and the possible combinations needed when caring for pregnant patients with chronic conditions. Consequently, participants identified a need for training in obstetrics to provide more effective support and ensure greater confidence when prescribing. Other participants commented the potential value of having a clinical pharmacologist/pharmacist in PHC to address concerns towards medication use. S7, a gynaecologist, posited that family physicians are faced with a much wider array of pharmaceuticals because they treat a broader spectrum of conditions and typically manage patients who are on multiple medications. In contrast, midwives and gynaecologists reported that, in general, they had fewer doubts about the pharmacological decisions of their familiarity with pregnancy and breastfeeding. Particularly in the context of breastfeeding, several participants noted that the number of medications that can be prescribed is greater than during pregnancy because there are fewer contraindications which generates fewer concerns.

“It is not like family medicine that the list of drugs that can be prescribed is endless. Of course, the pregnant woman is usually at most, 45 years old (…). The prescription is much simpler. But because we are trained in this from the beginning, I mean, our prescription catalogue is very short and very concise” (S7, gynaecologist, GD2).

Participants reported that, in many cases, the follow-up of PBW living with a chronic or mental health condition was more manageable due to the involvement and follow-up of other HCP. Conversely, some professionals, especially family physicians, indicated that some PBW with chronic health conditions discontinued their medication without consultation, while others did not seek medical advice prior to becoming pregnant. As a result, these women either continued their previous medication during pregnancy or discontinued it without adequate follow-up. Participants explained that in a multitude of cases of PBW with chronic pathology, the cessation of medication could potentially exert a more deleterious impact on maternal health than on foetal development during gestation.

“I think chronic pathologies it’s easier, because people usually prepare. In preconception visits, which is what people should do, plan the pregnancy, (…), in any type of pregnancy. And this with chronic pathologies is much simpler, they look for the right time, in general...” (S16, midwife, GD3).

Some family physicians and nurses explained that the interdisciplinary exchanges of medical information were beneficial for them. Some participants even perceived the discussion group as a valuable space that facilitated knowledge exchange, and it was emphasised that effective coordination between HCP was essential to guarantee optimal follow-up. The role of midwives was considered significant, given their capacity to establish the most intimate and trusting relationships with users, facilitating adherence, promoting appropriate medication use and avoiding unnecessary apprehension.

Some participants, particularly those from urban areas, observed a lack of coordination between healthcare specialties. In contrast, professionals from rural areas noted effective collaboration between HCP, they found it easier to share uncertainties about prescriptions and had a deeper understanding of the users and the local context.

Here we are a very small team, we work very side by side, and the matron who has given you the talk assists you at the birth. Here’s the thing, it can’t be another matron because there is no other“ (S3, gynaecologist, GD1).

Some participants noted that some deficiencies in coordination between specialities became evident during the postpartum period, as this was frequently the point of the transition from gynaecological to family care. Also, several participants observed that the computerised medical history sometimes lacked reliable data during pregnancy in cases where postpartum follow-up was unsuccessful or ceased. Participants commented that some PBW tend to prioritise the health of the infant in the postpartum period, which can result in a tendency to neglect their own health.

“When they have given birth, I know they do check-ups, but they go all the way to primary healthcare and sometimes, they escape you. As they are with the child, they do not come to do the control analysis and tell you that they are tired, perhaps there is hyperthyroidism. I would say that perhaps a little more coordination is needed...” (S6, family nurse, GD2).

The participants indicated that they typically relied on existing protocols when formulating prescriptions. They commented that protocols help to support decision making and facilitate the unification of criteria, particularly in relation to vaccination, which has significantly reduced user uncertainty. In addition, participants also consulted other resources: clinical guides (e.g., Medimecum [48]), and the E-lactancia [9] website. Participants highlighted the potential value of developing a digital resource similar to E-lactancia but focused on pregnancy.

“We refer to the protocols, you recommend a flu vaccine and then you will see if it is effective or not. But we are linked to what they send us. In other words, we don’t have much option either to vaccinate those who are not in the protocol or to go around saying “don’t vaccinate” because there is supposed to be an advisory committee that we have to believe” (S6, family physician, GD2).

In regard to vaccination, participants did not observe a significant amount of resistance among PBW overall. While influenza and pertussis vaccination are generally accepted by PBW, instances of vaccination refusal have increased. According to the participants, the historical overview of the influenza and pertussis vaccines provides a greater degree of certainty in recommending them because have proven to be effective. However, some participants expressed concerns about the methodology employed in the SARS-CoV-2 vaccine’s development, understanding the users’ reluctancies and its potential long-term public health consequences. Other participants emphasised that the vaccine is included in the protocols, therefore, should be recommended.

“I think that the Covid-19 vaccine we can’t say anything for sure to anyone, because it’s really a different technique, it doesn’t look like any of the previous vaccines that we had used, and the manufacturing process didn’t go through the safety phases and everything, it was accelerated because it was needed, like that, right?” (S1, family physician, GD1).

The lack of scientific evidence, the role of alternative therapies and new sources of information

The participants highlighted the importance of accessing scientific evidence to make pharmacological decisions. Some participants asserted that their personal opinion should not be a factor in formulating recommendations for PBW. S17 observed that, sometimes recommendations based on scientific evidence did not effectively “reach the person”, which led to ongoing uncertainty. S7 stated that he relied on data and graphs (in accordance with the available scientific evidence) to address the typical doubts and reluctance of PBW, Despite this, participants identified significant barriers to prescribing, citing a lack of research and accessible resources. They pointed out that the available research is largely retrospective, as studying the pregnant population in a prospective manner is not feasible.

“Of course, there is no [scientific evidence] because there is selection bias and the only thing, we have is retrospective data.” (S7, gynaecologist, GD3).

Regarding alternative therapies, some participants expressed doubts about their efficacy suggesting that these therapies lacked sufficient evidence and could even be considered fraudulent. Nevertheless, other professionals acknowledged the growing interest and demand among some users. They noted that distinctions should be made between various therapies to determine which ones might be beneficial. For example, acupuncture or aromatherapy were perceived as useful techniques by S16, who highlighted that she had self-trained in aromatherapy and advocated for providing training opportunities to all professionals.

“They did ask me what infusions I can take, because I had doubts about which ones could be taken (…) But there are some that are abortifacient. Well, I did a super bibliographic search and now I have infusions to drink once, some that can never be drunk, some that nothing happens. But I had to do it myself” (S16, midwife, GD3).

S8 commented that neural therapy was a technique that was efficacious and could be offered in PHC. Both S1 and S8 emphasised the need for standardised training in alternative therapies, as they had to pursue their own in this area. Participants interested in alternative therapies noted that these practices are excluded from established protocols, although some admitted to using and recommending them. Some participants attributed their exclusion to two reasons: first, institutional resistance to these therapies within the health system due to the lack of evidence and secondly, the decision to introduce these therapies would depend on the willpower of each healthcare centre.

“The [health service] is not in favour of alternative therapies, that’s why they also eliminated neural therapy that worked very well, for mastitis, for scars, for pelvic pain and suddenly it began to disappear little by little, we could no longer talk about neural therapy, we already had to talk about injections, right?” (S8, family nurse, GD2).

A few participants suggested that identifying therapies supported by scientific evidence could help reduce medication costs and contribute to the development of a more efficient healthcare system. Particularly given the widespread perception that these therapies are harmless and the tendency of the population to use them without medical guidance, despite the potential risks involved.

Some participants highlighted the significance of social media as a conduit for health-related information, facilitating the dissemination of knowledge in a more equitable manner. S1, S14, and S16 acknowledged the importance of empowering PBW to make informed decisions regarding their own health. However, participants also explained that a considerable number of users arrived at consultations with specific demands.

“I’ve been working for many years, before people came, listened to you and did what you told them. Which is not necessary either, a middle ground. But not now, now they come to tell you what to do. It’s different...” (S14, family physician, GD3).

Some participants considered that these demands sometimes lacked coherence, yet but could not be necessarily rejected, as doing so would negatively impact on the relationship with the user. Conversely, some participants expressed concerns and frustrations when refuting PBW information obtained from “unreliable sources” (e.g., blogs, Instagram accounts run by mothers without training in gynaecology and obstetrics, doulas, journalists and psychologists).

“Sometimes (…) you have to refute unfounded arguments from Google (…) because I’m a nurse, I’ve studied it and I’ve contrasted it with reliable funds and sometimes it’s very difficult because they’ve already looked at it before and they already know what they really have to do. They only come sometimes as a tool, don’t they? I want you to put this in my prescription or I need this” (S5, family nurse, GD2).

Some participants observed that these changes are part of a paradigm shift about pregnancy, childbirth and breastfeeding. S17 explained that during the 1990s she saw a significant medicalisation of childbirth, whereas now there is a current tendency to de-medicalise it. Some participants commented that these previous practices have influenced the way women relate to the health system in the field of obstetrics, sometimes leading them to consult other specialists outside the biomedical system. S3, a gynaecologist, observed that gynaecologists are sometimes perceived as “aggressors”, especially during childbirth. Other participants expressed concern about a resurgence of traditional practices,. Moreover, S3 and S14 questioned whether “the natural childbirth movement had gone too far”, citing the resistance of PBW to certain interventions or the use of medicines, which generates difficulties in consultation.

“Because it is true that there has been a very strong current for a few years, back to what was before, I don’t really know why, because, of course, what was natural before was that the mother or the child, or both, died, then it is true that we have many here, more than at the level of medicines, at the level of manoeuvres...” (S3, gynaecologist, GD1).

The difficulties arising from double monitoring and the commodification of health

Another significant issue that emerged from participants’ narratives, all of whom worked in the public system, was the challenge of double monitoring of pregnancy in both public and private health systems.

“Of course, having double control, which I am always very against (..) there are two opinions, no one is right, and not because there are many opinions that are bad, but because of the confusion and because you create, in general, a... insecurity” (S3, gynaecologist, GD1).

S14 explained that pregnancy is a period when more health insurance options are utilised, while S16 underscored the prevalence of health insurances in the context of Catalonia. The participants emphasized that the two health systems follow different logics, such as a greater number of diagnostic tests during pregnancy and a higher rate of caesarean sections, and a significant proportion also noted the use of outdated protocols in private healthcare centres.. S16 stated that in private healthcare, “you are not a patient, but a customer”.

“And I think that the private sector plays a lot with it. All the ultrasounds so that you are as calm as possible, so that your uncertainty decreases” (S4, family physician, GD1).

For instance, S12 highlighted the different approaches to medical practice, noting a proclivity among private healthcare professionals to request a greater number of diagnostic tests and a higher tendency towards caesarean sections..

Some participants indicated that they were opposed of double follow. Participants hypothesised that the practice of double monitoring results in a greater degree of uncertainty among users. The increased number of tests and controls conducted in private healthcare, along with the ability to perform all requested ultrasound scans, has led some users to perceive that the public health system is unable to provide adequate care and has a lack of resources.

“Above all, it is to avoid the duplication of tests, because it only carries overdiagnosis, overtreatment and doubts, because each professional tells me something... Here, in the public test, since they don’t ask me for such a thing, it’s because they’re rats. Of course, I mean, there is a lot of mistrust. Then, I had to refuse some test” (S7, gynaecologist, GD2).

Other participants noted that the private healthcare system provides a more extensive range of services, including access to in vitro fertilisation for individuals in older age groups who are not eligible for public protocols. S6 observed the current situation often prevents individuals from considering parenthood at the “biologically optimal time” due to the prevailing social context, which makes it challenging to achieve pregnancy. Furthermore, S6 questioned whether the protocol that defines pregnancy between the ages of 40 and 45 as high-risk should be updated.

Regarding alternative therapies and the involvement of other non-medical professionals such as doulas, some participants expressed concerns due to conflicts during consultations, like PBW refusing a prescription or vaccine in favour of alternative therapies. Additionally, the high cost of these therapies makes them inaccessible to all PBW, limiting recommendations based on affordability. In response, some participants proposed that integrating alternative therapies into the public healthcare system could ensure more equitable access.

Some participants highlighted the existence of territorial disparities in the accessibility of healthcare resources and social networks during pregnancy and breastfeeding. They explained that in some urban contexts, there was a noticeable decline in social and community networks which can affect the way users relate to the healthcare system. Several participants linked the increased reliance on private healthcare and alternative therapies during pregnancy and breastfeeding to the insufficient responses to women’s needs from the social context and public health services. They also acknowledged the resource limitations of the public healthcare system, which result in brief primary healthcare visits, frequent rotations of HCP, and a challenging environment for fostering trusting relationships between HCP and users. Such relationships are crucial for ensuring the appropriate prescription of medication and vaccines.

“For me it is capitalism that makes the woman who has to give birth alone and work (…) and that there is no community,(…) you don’t know the neighbours. (...) if a pregnant woman doesn’t have any pathology, I don’t have to call her every week to see how she is, this is something that the society around her should do, of course here they find complementary medicine, they want someone to see her every week and tell her that everything is fine and that’s why they pay” (S6, physician, GD2).

Strengths and limitations

This study contributes to advancing knowledge on the difficulties encountered by HCP when it comes to prescribing medication, vaccination and alternative therapies during pregnancy and breastfeeding within our healthcare context. Qualitative methodology provides valuable insights to the field of pharmacological studies, particularly when a gender-based perspective is employed. One of its strengths is considering the differences among healthcare specialties, in relation to prescribing, monitoring and the lack of information. Participants perceived the discussion group as a valuable space that facilitated knowledge exchange across different specialties. Moreover, this study incorporates the experiences of professionals from a range of territorial areas within Catalonia, thereby providing insight into the nuances of big cities and smaller rural villages.

Regarding the limitations, the research team faced considerable obstacles in assembling the discussion groups due to health strikes during the recruitment process. Despite a reduction in the number of participants, the quality of the discourse enabled the achievement of findings that were consistent with the objectives. Moreover, the researchers were unable to convene a group of HCP at high obstetric risk, which would have been a valuable addition to the study’s objectives. With regard to the rural discussion group, the level of participation was relatively limited, which may have had an impact on the representativeness of this group. Conversely, there was a notable representation from family physicians and nurses, while the involvement of gynaecologists and midwives was less pronounced, suggesting that the findings may be more reflective of the experiences and needs of the former two professional groups. Additionally, there was a relatively low level of male participation, with only one male taking part, which may reflect a gender disparity in interest in participating in the study. This limited participation could also influence the results, particularly regarding aspects such as the implementation of shared decision-making and other forms of interaction with PBW, as men may approach these differently. This method may also amplify certain voices, which should be acknowledged in relation to gender and experience roles in this study.