If women with inadequately controlled disease due to inadequate adherence with drug therapy are identified, they may be targeted for evidence-based counselling to correct their misperceptions, allay their fears, and hopefully improve medication-taking behaviour [43
]. In addition, it may be possible to avoid medication nonadherence before it happens by proactively addressing the pregnant woman's concerns about the safety of medications. Ideally, with chronic drug therapy this counselling may occur as part of prepregnancy planning. Survey studies have shown that pregnant women feel they need information about the use of drugs during pregnancy [14
]. Media and other sources may provide misleading information provoking anxiety amongst pregnant women [43
]. Given the overestimation of risk, the discussion should include, if available, evidence-based information on the effects of the medication's use during pregnancy allowing the pregnant women to make an informed decision as to whether to continue their prescribed therapy. Education should focus on the important role of good medication adherence for the health of both the mother and fetus.
Counselling by teratogen information services may play a role in influencing medication-taking behaviour [43
]. After counselling by Motherisk, a Canadian teratogen information service, 61.1% (22/36) of pregnant women who had discontinued their antidepressant or benzodiazepine medication restarted their medication within a few days [44
]. Health care workers, such as obstetricians and family physicians, are uniquely positioned to not only monitor adherence but to encourage consultation with drug information services to dispel misconceptions about the risks of medications to the fetus.
A meta-analysis of studies of directly observed therapy of highly active antiretroviral therapy (DOT-HAART) found that DOT-HAART recipients were more likely to achieve undetectable viral load and HAART adherence of greater than or equal to 95% [45
]. A similar approach has been suggested for pregnant women. The third trimester of pregnancy may present an opportunity for the use of directly observed HAART to achieve virologic suppression for prevention of mother-to-child transmission of HIV [46
]. Using a simulation model, use of DOT in women receiving HAART in 3rd trimester was associated with a relative risk of mother-to-child HIV transmission of 0.39 relative to conventional HAART. It was projected to be highly cost-effective, averting the downstream medical costs associated with pediatric HIV infection [46
]. All but one of 17 Latina pregnant and postpartum women positively evaluated a proposed hypothetical modified DOT program [29
] suggesting that at least some women would be accepting of this approach.