Pregnancy is a distinctive physiological state that necessitates meticulous consideration regarding medication use. The altered pharmacokinetics during pregnancy create challenges and concerns when determining the safety of medications for both the mother and the developing fetus. Nonetheless, the use of medications is often essential to treat acute medical conditions during pregnancy (1, 2). Over the past four decades, there has been a noticeable increase in medication use among pregnant women, whether prescribed or non-prescribed. This trend can be attributed to the fact that many women are now becoming pregnant at an older age, often with pre-existing chronic medical conditions that require ongoing treatment (1, 3). In one study, it was found that four out of five pregnant women were prescribed one or more medications, ranging from multivitamins and supplements to over-the-counter drugs and various prescribed medications to treat different medical conditions (4). Another study conducted among pregnant women at an ambulatory care clinic revealed that 39.3% of participants had at least one chronic medical condition necessitating drug therapy (5).

However, the use of medication during pregnancy is constrained by the lack of comprehensive safety data, complicating clinical decisions and posing health risks to both the mother and the fetus. This scarcity of data stems from the thalidomide tragedy in the early 1960s, where the drug, used as an antiemetic for pregnant women, led to a high incidence of phocomelia—congenital limb malformations occurring in 20%–30% of cases (6). The teratogenic effects of thalidomide prompted legal and regulatory decisions to exclude pregnant women from clinical trials, adversely affecting drug development and resulting in unreliable data with added safety concerns related to drug teratogenicity (7).

Teratogenic substances are defined as substances that can negatively affect embryo or fetal development if administered to pregnant women. These substances can harm the embryo or fetus in several ways, causing congenital malformations, behavioral or emotional development issues, and reduced intellectual quotient in the child. Additionally, teratogens can also lead to pregnancy complications, such as preterm labor, or abortions (8, 9). Major congenital malformations are reported in 3% of all newborns, with only 2%–4% of these anomalies attributed to drugs (9). Numerous substances, including certain medications, have been identified as teratogens (10).

Medication beliefs significantly influence medication adherence, reflecting compliance with prescriber instructions. Instruments like the Beliefs About Medicines Questionnaire (BMQ) have been developed to assess these beliefs (11). Several studies have documented the overestimation of teratogenic risks associated with medications (12, 13). A large-scale multinational survey encompassing 18 countries from Europe, North America, and Australia found that pregnant women often overestimate the risks of antidepressants and antibiotics (14). Such overestimations can lead to medication non-adherence, which is particularly critical in managing chronic diseases. Non-adherence can result in severe consequences for both the pregnant woman and the fetus, including fetal death and pregnancy termination (15).

Medication non-adherence in pregnant women is a well-documented issue, with various studies highlighting that the adherence rate among pregnant women with chronic diseases is approximately 40%. This low adherence rate leads to suboptimal management of chronic health conditions. Women generally perceive medication use during pregnancy as potentially harmful to the fetus, which makes them reluctant to use prescribed drugs during this period. Several factors contribute to this behavior, including personal beliefs and health literacy (16). One study investigating why pregnant women choose not to treat nausea and vomiting with pharmacologic medications found that concerns about potential teratogenic effects lead many to opt for non-pharmacologic alternatives, such as herbal remedies, which are perceived to carry fewer safety risks (17). In one study by Alkhaldi and Alkhammash involving pregnant women from Taif City, Saudi Arabia, the prevalence of using herbal medicines during pregnancy was 32.9%. Around 65% of these women believed that herbal medicines were unsafe for them and their unborn babies, compared to 75% for pharmacological therapies during pregnancy (18). These behaviors and attitudes toward medication use during pregnancy have garnered attention and have been studied in multiple countries.

Healthcare professionals need to understand the restrictive attitudes and practices of pregnant women regarding medication use to provide optimal and safe patient care. For instance, in developing countries, it has been reported that pregnant women frequently self-medicate without a prescription due to a lack of knowledge and awareness (19).

Given these circumstances, pregnant women often seek information from various sources with varying degrees of accuracy and reliability (20). Studies have shown that pregnant women frequently rely on online sources for information about pregnancy and medications, reflecting a growing desire to access accurate and relevant information conveniently (21, 22). One review revealed that pregnant women often view online health information as reliable and helpful for making informed decisions about their well-being (23). However, caution is necessary, as inappropriate and inconsistent information regarding the safety of medications during pregnancy is common on many websites. Encountering conflicting online information can lead to medication reluctance and increased anxiety (20). This issue is further compounded by the fact that pregnant women may not always discuss the information they find online with healthcare professionals, leading to gaps in understanding and potentially hindering effective treatment plans (22).

In conclusion, the knowledge, attitudes, and practices of pregnant women towards medications significantly influence their use. The objective of this study is to assess the knowledge, attitudes, and practices regarding medication use among pregnant women in Riyadh city, aiming to optimize healthcare for both pregnant women and their fetuses.

In our study, 562 pregnant women residing in Riyadh City, Saudi Arabia, participated in an online questionnaire aimed at assessing their knowledge, attitude, and practice regarding medication use during pregnancy. The findings revealed a commendable level of knowledge and a positive attitude and practice towards medication use. However, a conservative attitude towards medication use during pregnancy was observed, consistent with prior reports by Zaki and Albarraq in the Saudi population. Our study did not find significant associations between sociodemographic variables and participants' responses, except for three specific statements. This finding is in line with the results of Obi and Anosike's study on the Nigerian population, where no associations were identified between sociodemographic variables and responses (25).

Demographic analysis of the participants revealed that the majority fell within the 20 to 30 age range, had a high level of education, and were of Saudi nationality. The prevalence of highly educated participants might reflect the broader literacy rates among women in Saudi Arabia, as reported by UNESCO with a 96.05% adult female literacy rate as of 2020 (26). However, it's worth noting that this high level of education may be inflated due to sampling techniques. Furthermore, nearly half of the participants were primigravida, and the majority reported good health, with only 10.5% indicating the presence of at least one chronic disease requiring chronic medication.

In terms of medication use during pregnancy, 44.7% of participants in our study reported utilizing at least one medication, a figure consistent with findings reported in Taif city by Zaki and Albarraq (approximately 40%), as well as documented rates in Ireland (46.8%) and Iceland (49%) (15, 27, 28). However, this percentage is lower compared to other studies, including those conducted in Italy (59.6%), France (89.9%), India (79.6%), Ethiopia (88.4%), Malaysia (81.4%), Canada (59%), Scotland (85.2%), and Norway (69.1%) (2, 29–35). Moreover, our percentage was higher than that reported in Australia (26.5%) (5). Additionally, 44.1% of participants reported using prescribed medications, while 11.7% acknowledged using medications without prescriptions, a prevalence notably higher in Italy, with a reported rate of 43.9%, as documented by Navaro et al. (35). Interestingly, a recently published study in Riyadh City by Alyami et al. reported that 76.66% of pregnant women used medications during pregnancy, with 86.36% of these being prescribed medications. However, this study was conducted at King Saud Medical City, a tertiary care hospital that likely includes more complicated pregnancy cases, which may explain the difference in results. According to the study, 47.7% of the participants had obstetric complications, and 19.51% had comorbid conditions (36).

Regarding awareness of risks, participants demonstrated a commendable level of knowledge, with the majority being aware of critical periods during pregnancy and drugs to avoid. Furthermore, a significant majority of participants using prescribed medications demonstrated awareness of their medication indications, indicating a remarkable level of awareness.

In terms of the source of drug information, our findings indicate that a majority of participants rely on physicians for medication information, followed by the internet/social media (10%), medication leaflets (8%), and pharmacists (6%). This reliance on physicians is notable, particularly given the potential risks associated with obtaining information from non-trusted sources on the internet and social media. This finding aligns with previous research by Zaki and Albarraq, where physicians were the primary source of medication information for 71.1% of participants, with the internet accounting for only 5% (37).

However, our findings contrast with other published data that emphasize the internet as a common resource for medication information among pregnant women. For instance, a study conducted in the UK found that 76% of participants had searched the internet for information on medication safety during pregnancy (38). Similarly, in Italy, 46.9% of participants identified the internet as their primary source of information on medication use during pregnancy (35).

Moreover, participants in our study demonstrated commendable practice by regularly attending physician visits during pregnancy. It is noteworthy that in Saudi Arabia, maternity services are provided for free through the public governmental sector or health insurance, potentially positively impacting this practice. However, a concerning aspect emerged as 58.7% of participants indicated a lack of adequate information about their prescribed medication from their physician, either not at all or not consistently. Additionally, 65.7% confirmed not receiving sufficient information from pharmacists during medication dispensing, or at least not consistently. This information deficiency may adversely impact their knowledge, attitude, and practice, aligning with the findings of Zaki and Albarraq (15). Also, it is aligned with the findings of Alyami et al. who reported that 40.77% of the participants did not receive any information about medication use during pregnancy (36). The insufficient information provided by physicians and pharmacists may be related to the knowledge gap identified in previous studies conducted in Saudi Arabia by Alshebly et al. and Alrabiah et al. (38, 39). Moreover, a systematic review examining patients' knowledge and sources of information regarding medication use during pregnancy found that the majority of women had information gaps concerning prescribed medications, regardless of the country. Five studies noted that patients believed the information provided by physicians was insufficient (40). This suggests a need for improved training and continuing education programs for healthcare professionals to ensure they have the knowledge to provide comprehensive and accurate patient information. Furthermore, in our study most participants mentioned that they routinely read the medication leaflet accompanying prescribed medication during pregnancy. This cautious approach is consistent with the findings of Zaki and Albarraq in Taif, Saudi Arabia (15), reflecting a hesitancy toward using medications during pregnancy, especially in the absence of comprehensive and trusted information provided by physicians and pharmacists during the prescribing and dispensing of medications.

Regarding beliefs about medication use during pregnancy, the overall survey responses reflect a positive outlook. This segment of the study utilized a BMQ-General and Specific questionnaire developed by Horne & Weinman (11) and Nordeng et al. (24), which have been employed in various studies across different communities. Notably, Zaki and Albarraq conducted a similar study in 2013 in Taif, Saudi Arabia, focusing on assessing medication use, knowledge, and beliefs among pregnant women. A detailed comparison of responses between our sample and theirs indicates both differences and agreements, as evidenced in Tables 7, 8. Additionally, for a more comprehensive comparison, we integrated data from a distinct population (Belgium), as presented in the study by Ceulemans et al. in 2019 (41). This additional layer of analysis provides a broader perspective on medication beliefs and practices among pregnant women across various populations.

Approximately one-third of participants expressed the belief that doctors generally prescribe too many medicines, with around 20.0% specifically perceiving an excessive prescription rate for pregnant women. Notably, Saudi women exhibit a higher inclination to disagree with these statements compared to non-Saudi women. However, caution is warranted in interpreting this observation due to the limited number of non-Saudi participants. Additionally, roughly 35% of participants believe doctors would reduce medication prescriptions if they allocated more time to patients. Interestingly, 63.9% of participants believe physicians place excessive trust in medicines. These findings are consistent with Zaki and Albarraq's results, where over half of the participants expressed beliefs that doctors generally prescribe too many medicines and place excessive trust in them. Moreover, the responses to other statements were comparable (15). Interestingly, the study conducted in Belgium indicates lower agreement on the aforementioned statements, suggesting a higher level of trust and belief in the healthcare system. However, it is essential to acknowledge that both the Zaki and Albarraq, and Ceulemans et al. studies included participants from specific health facilities, potentially reflecting the influence of those facilities' practices on participants' beliefs.

Furthermore, a majority of participants in our study express positive beliefs, asserting that medications are neither addictive nor poisonous and that not all medications are harmful to the fetus. Additionally, over half of the participants believe that the benefits of medicines outweigh their risks in general. Notably, these responses align more closely with the findings of the Belgium study than the previous Saudi study, which reported a more skeptical attitude toward medications, particularly among participants with lower education levels. Significantly, our study identifies an association between responses reflecting beliefs about medication effects on the fetus and the level of education, suggesting a positive belief associated with a higher level of education. This influence of education on beliefs about medication use has been demonstrated in previous studies across different communities, including those in Saudi Arabia and Belgium (15, 41). It is noteworthy that, in terms of education level, our study population includes the highest number of participants with a high level of education compared to the other two studies.

The conservative attitude towards medication use among participants in the three distinct cohorts was comparable, with the majority expressing a higher threshold for using medicines during pregnancy compared to when not pregnant. However, the results of this study are reassuring, indicating that the majority of pregnant women do not believe that medications prescribed by physicians for medical conditions are poisonous and can lead to harm. Furthermore, most participants recognize the beneficial effects of prescribed medication for a medical condition, both for themselves and their fetus.

Regarding natural remedies, 20.1% of participants believe that pregnant women can use them, and 27.2% believe that pregnant women should use natural remedies during pregnancy. In Alyami et al, study only around 10% of the participants believed that most of the herbal medicine are safe (36). Our results align with those of the previous Saudi study, whereas the Belgian study indicates a higher preference for using natural remedies among pregnant women (15, 41). This difference may highlight the variations between the communities in general. However, the majority of participants across all discussed studies believe that pregnant women should not use natural remedies without a doctor's advice. Notably, age-dependent variations in responses were observed in our study, with the younger age group more likely to agree that pregnant women should not use natural remedies without the advice of a doctor.

Based on the study findings, implementing education and communication initiatives for healthcare professionals to enhance medication education activities, particularly in situations with limited information, will significantly impact public health. Furthermore, developing unified guidance with updated evidence-based information for healthcare professionals and pregnant women will be helpful to ensure the provision of trusted, consistent, and higher-quality evidence-based information.

In conclusion, the present study offers valuable insights into the current landscape of knowledge, attitudes, and practices concerning medication use among pregnant women in the capital city of Saudi Arabia. While the overall findings suggest a positive outlook, there are discernible variations in responses indicating a degree of hesitancy and a cautious approach toward medication during pregnancy. Healthcare professionals need to acknowledge and account for this attitude when prescribing medications for pregnant women, as understanding the beliefs held by this demographic can significantly influence safety and outcomes.

Furthermore, the study highlights a concerning inadequacy in the education provided by healthcare professionals regarding medication use during pregnancy. This shortfall in information from frontline healthcare providers underscores an area for improvement aimed at enhancing the safety and effectiveness of medication use in pregnant women. Addressing this education gap holds the potential to positively impact the care and well-being of pregnant women.