High-Risk Medication Prescriptions in Primary Care for Women Without Documented Contraception

Bethany D. Panchal, MD; Rebecca Cash, MPH, NRP; Camille Moreno, DO; Emily Vrontos, PharmD; Cheryl Bourne, CNP; Sandra Palmer, DO; Amy Simpson, DO; Ashish R. Panchal, MD, PhD


J Am Board Fam Med. 2019;32(4):474-480. 

In This Article

Abstract and Introduction


Introduction: During pregnancy, women may be exposed to teratogenic medications resulting in a risk of complications and poor maternal-fetal outcomes. The objective of this study was to evaluate the prescription of teratogenic medications in women of childbearing age and the associated prescription of contraception in the primary care setting.

Methods: The use of high-risk, potentially teratogenic, medications was retrospectively evaluated in women of childbearing age (13 to 45 years old) at 2 family medicine practices. Charts were reviewed for medication use and whether patients received a form of birth control (medication, sterilization, or postmenopausal) with the teratogenic medications. A multivariable logistic regression model was used to estimate the age-adjusted association between receiving a teratogenic medication and contraception. A subgroup analysis excluding ondansetron was also performed.

Results: A total of 3,956 nonpregnant women were included with 988 (25%) prescribed at least 1 high-risk medication. The most commonly prescribed high-risk medications were ondansetron (n = 724, 73%) and lisinopril (n = 195, 20%). More than half (55%) of the women prescribed a high-risk medication were without a form of birth control. When ondansetron was excluded, 10% of the population was prescribed at least 1 high-risk medication with 62% also without a form of birth control. Women less than 25 years of age had decreased odds of receiving contraception when prescribed a teratogenic medication (adjusted odds ratio, 0.47; 95% confidence interval, 0.34–0.66).

Conclusion: In a family medicine setting, 25% of women of childbearing age were prescribed a high-risk medication with over half not having evidence of contraception management. Interestingly, younger age women had lower odds of receiving contraceptive management when prescribed high-risk medications. Prescribers should be aware of and counsel on the risks of teratogenic medications and regularly evaluate reproductive plans for patients.


Prescription medication use by pregnant women has increased over the past 30 years, with best estimates demonstrating 50% of women in 2008 using at least 1 prescription medication during pregnancy.[1–3] With the increased use, there has also been a concomitant increased exposure of pregnant women to medications that are potentially dangerous to the fetus, with approximately 6% of pregnant women in the United States being exposed to teratogenic medications.[4,5] In 1 large retrospective analysis of pregnant patients, 4.8% received a category D medication with an additional 4.6% a category X medication.[3]

One possible area of intervention to decrease the use of high-risk medications during pregnancy may be through better understanding the prescription practices of primary care providers (PCPs).[6,7] PCPs have been noted to be responsible for the largest portion of category D or X medication prescriptions due to their regular interaction with patients with a wide variety of disease processes.[7] Common medications included in this group are anxiolytics, anticonvulsants, antidepressants, antiemetics, antihypertensives, and statins and are often prescribed to women of childbearing age.[6] Basred on a large health care database, the use of high teratogenic risk medications were documented on 1 of every 13 ambulatory practice visits in women of childbearing age.[6]

Although the use of high-risk medications in women of childbearing age is sometimes necessary, the risk associated with these medications can be reduced with the provision of contraception. Unfortunately, contraception provision has been noted to be low. One study of family and internal medicine providers demonstrated low rates (20% to 48%) of contraception provision or counseling among females of reproductive age prescribed teratogens.[8] In another evaluation, when patients have specifically been prescribed category D or X medications, only 20% of visits received contraceptive counseling.[6] With these low rates of provision, it is unclear if physicians provide fertility control in patients of childbearing age who are prescribed high-risk medications. Given this knowledge gap, the objective of this study was to evaluate the use of high-risk medications in women of childbearing age and the associated use of contraception in the primary care setting at 2 clinics within an academic family medicine residency program.