Obstetric Migrant Workers and Medication Misuses
Jennifer Cardenas-Arias
CGN 5505 Pharmacotherapeutics and Technology for Advanced Practice Nurses
Dr. Tuason & Dr. Luxenburg-Horowitz
Western University of Health Sciences
March 12, 2018
Obstetric Migrant Workers and Medication Misuses
Studies have determined that anywhere from 35% to 80% of all pregnant women will consume at least one medication during their pregnancy (Peterson & Czosnowski, 2017, p. 60). Pregnancy is a unique body process that involves many more factors before beginning drug therapy for treatment of medical conditions. Teratogenicity is the ability of an exogenous agent to cause the dysgenesis of fetal organs as evidenced either structurally or functionally (Peterson & Czosnowski, 2017, p. 62). A unique and more vulnerable population within obstetrics is obstetric migrant workers who are at a higher risk for medication misuse.
Unique characteristics
Obstetric migrant workers are a vulnerable population due to a multitude of reasons. A migrant worker is defined as an individual who is required to be absent from a permanent place of residence for the purpose of seeking remunerated employment in agricultural work (Migrant Clinicians Network, 2014). The vulnerability of this population is further complicated by ethnic and/or racial minority status, language barriers, limited transportation, and cultural beliefs related to gender and health care practices. The health issues that affect this underserved population are similar to those that affect the general population but are often magnified or compounded by their migratory lifestyle (Migrant Clinicians Network, 2014). Their migrant lifestyle results in little to no continuity of care.
Vulnerability to medication misadventures
Lack of continuity of care presents itself as a possible problem because of the risk of teratogenic medications. Late entry to prenatal care is often associated with migrant workers and I have encountered patients that have stopped taking medications for pre-existing diseases because of fear of the medication affecting the fetus, many of these medications coming from their country of origin. Many migrant workers think that all prescription drugs can cause birth deformities and stop taking them when pregnant. This is a bad decision for women with pre-existing conditions such as diabetes, hypertension, seizure disorders, or psychiatric illnesses, which have to be kept under control. Discontinuing the use of medications for high risk conditions actually put the individuals at a higher risk for a life-threatening event. These medical decisions should be made in collaboration with a provider.
Nevertheless, there are drugs that should be avoided during pregnancy. The U.S. Food and Drug Administration (FDA) has categorized drugs according to fetal risks to help prevent drug-induced abnormalities in the fetus. Health care providers use these categories to determine appropriate drug therapy to effectively treat the mother with the least risks for the fetus (Peterson & Czosnowski, 2017, p. 62). For example, labetalol and nifedipine are commonly used for treatment of chronic hypertension and pre-eclampsia in obstetric patients despite the drugs being category C. According to the American College of Obstetricians and Gynecologists (ACOG) (2013), the maternal benefit and improvement in perinatal outcomes that are due to treatment must outweigh the potential risk of adverse effects on fetal and neonatal safety, including the possibility that pharmacologic reductions in maternal systemic blood pressure result in compromised utero-placental blood flow. The currently available evidence suggests potential maternal benefit of antihypertensive treatment by reducing the progression to severe hypertension, but no direct fetal benefit or significant improvement in perinatal outcomes among women with chronic hypertension (ACOG, 2013). Providers must educate their patients about the justification of antihypertensive therapy and the benefits of taking labetalol or nifedepine when compared to the risks of pre-eclampsia.
Additionally, aspirin is labeled as a category D, studies showing positive evidence of human fetal risk, but benefits from the use in pregnancy may be acceptable despite the risk (Peterson & Czosnowski, 2017, p. 63). Both ACOG and U.S. Preventive Services Task Force (USPSTF) recommend the use of low-dose aspirin (81 mg/day), initiated between 12 and 28 weeks of gestation in women with the risk factors of multiple gestation, chronic hypertension, diabetes (Type 1 or Type 2), renal disease, autoimmune disease, pre-eclampsia or in women with more than one prior pregnancy complicated by preeclampsia (ACOG, Zahn, Wax, & Porter, 2016). Providers must be actively engaged in staying up to date on evidence-based practice when caring for obstetric patients to provide the safest care for both maternal and fetal patients.
Strategies to maximize self (family)-care and client (family) decision making
Language barriers continue to be a factor when working with medications. Many of the migrant workers in California are originally from Mexico, but it is important to note other languages are spoken in Mexico as well. The Mexican state of Oaxaca speaks a language called Mixteco and this language has a variety of dialects. Many of the patients on the Central Coast of California are Oaxacan and speak limited Spanish. In my clinical setting, we have a designated staff member who sees the Mixteco speaking patients to ensure that they understand their condition and prescribed medications.
When collaborating with patients and their families, it is important to ensure that they are receiving the information in the educational level and preferred language and style of teaching to avoid any medication mishaps. Studies have shown that 40-80% of the medical information patients are told during office visits is forgotten immediately, and nearly half of the information retained is incorrect (Agency for Healthcare Research and Quality, 2015). Patients would benefit from the teach-back method to assess if they fully grasped the teaching presented to them. Medications like heparin and insulin which require daily self-administration should also be demonstrated back to providers.
Involving family members in decision making and care also helps reduce the risk of medication errors. Patient- and family-centered care is generally understood to be an approach in which patients and their families are considered integral components of the healthcare decision making and delivery processes (Hughes, 2011). The family unit should be included within provider-patient relationships because they can be important sources of care and support for patients. This may be a difficult task for migrant worker families, but it does not hurt to try.
Conclusion
Once again, the obstetric population is very vulnerable to medication mishaps partly due to physiological, emotional, and cultural factors. Fostering a strong relationship with patients is a key element when trying to minimize accidents involving drugs. Providers have an important role with these vulnerable patients and their drug treatments, keeping in mind that the mother is not the only recipient of the drug (Peterson & Czosnowski, 2017, p. 62).