“The medications are the decision-makers…” Making reproductive and medication use decisions among female patients with rheumatoid arthritis: a constructivist Grounded Theory

Abstract Objective To examine how female patients with RA form decisions about having children, pregnancy, and medication use. Methods We employed a constructivist grounded theory design and recruited female participants who are 18 years or older, have a rheumatologist-confirmed RA diagnosis, live in Canada, and able to communicate in English or French. We collected data through semi-structured individual and focus group interviews using telephone or video conferencing technology. Data collection and analysis were iterative, employed theoretical sampling, reflexive journaling, and peer debriefing, and culminated in a theoretical model. Results We recruited 21 participants with a mean age of 34 years and median 10 years since RA diagnosis. Overall, 33% had never been pregnant, 57% had previously been pregnant, and 10% were pregnant at the time of interview. Of those who had experienced pregnancy, 64% had at least one pregnancy while diagnosed with RA and of those, 56% used DMARD(s) during a pregnancy. We constructed a woman-centered framework depicting the dynamic relationships between 4 decision-making processes: 1) using medications, 2) having children, 3) planning pregnancy, and 4) parenting. These processes were influenced by participants’ intersecting identities and contextual factors, particularly attitudes towards health and medications, disease onset and severity, familial support system, and healthcare provider relationship. Conclusion Our framework provides insight into how patients make reproductive decisions in the context of managing RA. A patient-centered care approach is suggested to support female patients with RA in making reproductive and medication choices aligning with their individual desires, needs, and values.