‘There is no choice apart from antibiotics…’: Qualitative analysis of views on urinary infections in pregnancy and antimicrobial resistance

Abstract Background Antimicrobial resistance (AMR) is a health risk as it can lead to life‐threatening infections. There has been a rise in resistant urinary tract infections (UTIs) which is the most common infection in pregnancy. This can be challenging in pregnancy due to the additional need to safeguard foetal development. The study's aim was to explore views about AMR in women who experienced UTIs in pregnancy. Design Fifteen semi‐structured interviews were conducted in the UK and analysed using thematic analysis. Results Results highlighted two themes: conceptualization of AMR and pregnancy as a deviation from the norm, with an overarching theme of ‘self‐efficacy’. Results show that participants were concerned about AMR but uncertain about the effect on society compared to individual's taking antibiotics and about completing antibiotic courses. Participants reported an unsparing use of antibiotics was justified in pregnancy, and behaviours like drinking adequate water were ineffective at preventing UTIs. In summary, women had low self‐efficacy regards tackling AMR and managing their health. Conclusion Misconceptions about how AMR affects society vs the individual translated into viewing it as a future problem to be tackled by the health‐care sector. Consequently, AMR requires reconceptualization as a current problem requiring collective action. This research also indicates women endorse a biomedical model of UTIs in pregnancy which attributes resolving illness to interventions such as medicines, implying an automatic reliance on antibiotics. Subsequently, there is a need for self‐efficacy by focusing on a behavioural model which emphasizes behaviours for infection prevention, thus reducing the need for antibiotics.


| INTRODUC TI ON
Antimicrobial resistance (AMR) is a global health threat and can result in serious or life-threatening infections. Although AMR is a naturally occurring phenomenon, antibiotic use is its biggest driver because the use of these drugs causes positive selection of resistant bacteria. Antibiotic use can result in carriage of resistant bacteria by individuals for a period of several months to a year after completing a course. 1 The bacteria can transfer to people in close contact and thus result in a spread of resistant infections. The transmission of resistant bacteria is particularly concerning in pregnancy as they may infect neonates during the birthing process. The choice of antibiotics in pregnancy can also be limited compared to the general population because of the risk of teratogenicity, which is the risk of harm to the developing foetus. Teratogenicity can exclude or restrict the use of antibiotics 2 to specific trimesters; for example, trimethoprim is avoided in the first trimester due to a risk of neural tube defects and the risk of haemolysis precludes the use of nitrofurantoin at term.
Due to AMR, it is essential that antibiotics are used with a careful consideration of the benefits and risks. Antibiotics are the most commonly prescribed medicines in pregnancy, 3 and urinary tract infections (UTIs) account for the majority of their use. 4 In 2013, Public Health England established the English Surveillance Programme for antimicrobial utilization and resistance (ESPAUR) that monitors and publishes national data on AMR. The ESPAUR report from 2018 to 2019 shows that AMR in UTIs is established and an increasing burden in health care. 5 The National Institute for Health and Care Excellence (NICE), who provide national care guidelines in the UK, published an update on its antimicrobial guideline for lower UTIs in October 2018 in response to this growing issue. 6 Unlike respiratory infections, UTIs are caused by bacteria, and therefore, antibiotic treatment is usually required, especially if the infection is symptomatic. However, unlike the general population, antibiotic treatment is given in pregnancy if bacteria in the urine is detected even if the patient is asymptomatic.
A systematic review of interventions to prevent UTIs in pregnancy has shown that preventative hygiene behaviours are the only evidence-based method associated with a reduced incidence of UTIs. 7 Preventing the infection in the first place is therefore preferable to treatment through avoidance of behaviours associated with increased risk of UTIs, for example wiping from back to front after urination. 8,9 Although UTIs in pregnancy have been linked with risks such as pre-term birth, 10 there are also studies that suggest no such association. 11,12 A study analysing views from an online pregnancy forum shows that women associate UTIs with a high risk of negative outcomes, which might cause them to overlook the risks of AMR. 13 A systematic review about public views of AMR has demonstrated that people might have incorrect scientific knowledge or apathy about AMR. 14 The aim of the current study is to explore views on AMR in relation to UTIs by interviewing women who have experienced a UTI in pregnancy, and the research question is 'how do women view AMR in relation to UTIs in pregnancy?'. The anticipated outcome of the study is to have an impact on the optimization of antibiotics for UTIs in pregnancy through an improved understanding of women's views about AMR.

| Design and procedure
This study used a qualitative design and consisted of 15 semi-structured telephone interviews with women who had experienced a UTI in pregnancy. The inclusion criteria were women who were over 18 years old, resident in the UK and had experienced a UTI during pregnancy. The interviews mostly took place 2 years after the pregnancy where they experienced the UTI (the mode value for this data set was 2 years). All participants except one (participant four) took antibiotics for the treatment of the UTI. Participant four employed behavioural measures, such as drinking plenty of water, to resolve the UTI. The demographic characteristics of the participants can be seen in Table 1. Purposive sampling was used to recruit participants through advertisement of the study in online pregnancy forums (www.  • How was your experience of getting a UTI during pregnancy?
• How do you think UTIs impact pregnancy?
• What do you think about using antibiotics to treat UTIs during pregnancy?
• What do you think about antimicrobial resistance?
• What do you think about using alternatives to antibiotics to treat or prevent UTIs in pregnancy?
The interviews were recorded using an audio recorder to aid transcription. Interview recordings were transcribed verbatim for analysis by the lead researcher, and an honorary research assistant with all transcriptions double-checked for accuracy. The average length of the interviews was 24.3 mins (SD ± 4.2) ranging from 18 to 29 minutes. Participants were gifted a £10 Amazon voucher at the end of the interview to thank them for their participation.

| Data analysis
Data collection and analysis occurred concurrently to recognize saturation of themes and to guide when recruitment should be stopped.
The data were organized into codes using NVivo 11 © and analysed using inductive thematic analysis. 15 Thematic analysis is a flexible qualitative method and was chosen to allow the identification, analysis and interpretation of patterns in the data. Interview transcripts were read multiple times by the lead researcher to become familiar with the data and form detailed codes. The codes were further developed into themes by careful reflection of the patterns recognized in the data.
Themes were reviewed, discussed and approved by all the authors.

| Ethical approval
Participants were asked about their illness experience, so it was anticipated that there may be a risk of emotional distress. An information sheet was provided prior to the interview to notify participants of the topics that would be covered. They were also advised at the start of the interview that they were free to not answer any question if they were uncomfortable and could withdraw at any point during the interview. Documented consent was obtained from the participants prior to the interview.

| RE SULTS
Inductive thematic analysis of the interviews with women who had experienced a UTI in pregnancy yielded two main themes: how women conceptualize AMR and how pregnancy causes a deviation from the norm in terms of antibiotic use. Transcending these themes was an overarching theme of self-efficacy. The reluctance to use antibiotics ranged from concern about side-effects to an awareness about AMR, and many women expressed an interest in alternative therapies, such as probiotics. However, they recognized that antibiotics were the only effective treatment currently available and any new treatment would still be a concern due to unknown teratogenic risks. Most women were also aware of preventative hygiene behaviours but did not consider them effective.

It's a very good idea
Um well, you know, normal hygiene that everyone knows.

Sort of wiping from front to back and general cleanliness -although I mean I suppose that doesn't make much
difference.
(P12, 3rd trimester) Thus, although participants described a preference for avoiding antibiotics, they felt they did not have a choice because of the unacceptable risks of UTIs in pregnancy. Pregnancy was interpreted as a deviation from the norm, where an unsparing use of antibiotics was required and justified. Furthermore, hygiene behaviours, such as the direction of wiping the genitals, were considered to have little impact on prevention of UTIs.

| Overarching theme: Self-efficacy
Salient across both themes was an overarching theme that highlighted women's perceptions of self-efficacy in terms of how AMR could be tackled and how they could manage their health in pregnancy. Self-efficacy, as defined by Bandura, 16 is 'the belief in one's capabilities to organize and execute the sources of action required to manage prospective solutions'.
The first theme showed that most participants described conflict regarding how AMR could be tackled because although antibiotics cause problems, they 'also save lives' (P8) which causes a dilemma around how they can be used appropriately. Women also referred to conflicting messages about which behaviours they should adopt, particularly in response to finishing a course of antibiotics.

| D ISCUSS I ON
This study qualitatively explored views on AMR in women who had experienced a UTI in pregnancy. The first theme demonstrates that participants were aware that antibiotics are overused at a population level, which can reduce their effectiveness and cause a health risk. However, misconceptions described by previous research, [17][18][19] such as the body becoming resistant at an individual level, were still prevalent. The results revealed uncertainty due to conflicting mes- The overarching theme present in the two main themes, conceptualization of AMR and pregnancy as a deviation from the norm, is self-efficacy. Bandura The study provides unique insight into perceptions of AMR by focusing on women with personal experience of UTIs in pregnancy.
Conducting an interview study had the advantage of exploring the issue in-depth by asking participants to expand or clarify their views through conversation. One of the main limitations of the study was that it focused on a small subset of the population using purposive sampling, which reduces generalizability. As the sample consisted predominantly of women who were White British, the views in this study may not be representative of women whose demographics differ significantly from the participants and need to be interpreted within this context. Future work will focus on exploring the views of health-care professionals to provide a comprehensive understanding of AMR and UTIs in pregnancy.

| CON CLUS ION
In conclusion, women recognize the risks of AMR but demonstrated low self-efficacy and perceived control of UTIs in pregnancy. There is a need to re-conceptualize AMR and provide a consistent message to avoid uncertainties. Women might require reassurance specifically in pregnancy to feel confident about their ability to manage their own health with an emphasis on behaviours that can prevent UTIs to reduce the need for antibiotics.

ACK N OWLED G EM ENTS
We would like to thank all the participants for contributing their views and the National Childbirth Trust, www.mumsn et.com and www.netmu ms.com for their support in advertising the study. Thank you to Marcus Calway, an honorary research assistant, for his assistance with transcribing the interview recordings.

CO N FLI C T O F I NTE R E S T
There are no conflicting interests.

DATA AVA I L A B I L I T Y S TAT E M E N T
The data that support the findings of this study are available from the corresponding author upon reasonable request.