The far-reaching burden of Hyperemesis Gravidarum – an exploration of women’s experiences and perceptions of healthcare support

ABSTRACT

Hyperemesis Gravidarum (HG) is a rare condition of pregnancy that exerts a profound effect on a woman’s physical and psychological health, but limited research regarding women’s perceptions of healthcare for this condition exists. The aim of this study was to gain insight into the personal and healthcare experiences of women with HG. Eligible participants included women who had experienced HG in a current or recent pregnancy and were referred to the dietitian at the National Maternity Hospital, Dublin, Ireland. Suitable women were invited to participate by letter, with a follow-up phone call to confirm eligibility. Four semi-structured focus groups were conducted (n = 11). Audio recordings were transcribed and data was thematically analyzed using an inductive, data-driven approach. Participants emphasized the psychological hardship of HG, which manifested in many different ways, and unveiled the far-reaching burden of HG. Women advocated for a dedicated service for HG and the need for increased knowledge, understanding and support for HG, in order to ensure optimal HG management and woman-centered care. Women also highlighted the need for obvious clinical leadership of HG and a continuum of care throughout pregnancy and post-partum. Improvements to the day ward setting and access to HG-specific mental health support would be welcomed. At a government level, timely resolution of the financial assistance for first-line anti-emetics is needed. Overall, greater awareness and understanding of the condition is needed to improve support from family, friends and colleagues. Further research is warranted to determine whether these recommendations would result in improved pregnancy outcomes.

KEYWORDS:

• Hyperemesis Gravidarum
• patient reported outcome
• pregnancy
• women’s health

Introduction

Nausea and vomiting in pregnancy (NVP) is common with up to 70 percent of women experiencing symptoms in the first trimester (Fejzo et al. 2019). Hyperemesis Gravidarum (HG) however, is a severe and debilitating form of NVP that has a prevalence of 0.3–3 percent (Einarson, Piwko, and Gideon 2013). The recent consensus definition for HG consists of: onset of symptoms before 16 weeks’; nausea and vomiting, at least one of which is severe; inability to eat and/or drink normally; and strongly limits daily activities (Jansen et al. 2021). HG can result in greater number of hospital admissions and maternal morbidity, with women experiencing dehydration requiring IV fluids, electrolyte imbalances, >5 percent weight loss, ketonuria, malnutrition and vitamin deficiencies, including Wernicke’s encephalopathy caused by B1 vitamin deficiency. For many women, HG imposes a significant psychological burden, including feelings of guilt, lack of attachment to the fetus and self-isolation (Havnen et al. 2019; Power, Thomson, and Waterman 2010; Van Vliet et al. 2018). Furthermore, suicidal ideation, pregnancy termination, consideration of termination and implications for future childbearing decisions have been reported (Havnen et al. 2019; Nana et al. 2022; Van Vliet et al. 2018).

Research has outlined a lack of strong evidence supporting any one HG treatment or intervention (Boelig et al. 2016), thus placing increased importance on collaborative, woman-centered approaches to HG care to ensure that the woman’s preferences are incorporated into treatment. Despite this, few studies have investigated women’s perceptions of HG care. From the limited research, women convey dissatisfaction with their HG care, attributable to perceived lack of knowledge (Havnen et al. 2019; Munch 2000; Van Vliet et al. 2018) and trivialization of HG by healthcare professionals (HCPs) (Havnen et al. 2019; Poursharif et al. 2008; Van Vliet et al. 2018). The literature also highlights a perceived lack of support from HCPs, particularly in the community setting (Havnen et al. 2019; Power, Thomson, and Waterman 2010).

The first Irish Clinical Practice Guideline for HG management was published in 2015 (RCPI & HSE 2015) and is currently under review. Subsequently, advancements in HG care have been implemented in the Irish setting. In light of this and to ensure optimal management and supportive treatment for the profound sequalae of HG, an understanding of the effects of HG on women’s lives is required. The aim of this qualitative research study was to gain insight into the personal and healthcare experiences of women with HG in an Irish maternity setting.

Materials and methods

Study design

This is qualitative research using focus groups and a semi-structured interview guide. Ethical approval was received from the Research Ethics Committee at The National Maternity Hospital (NMH), Dublin in April 2019 (EC.09.2019). This research was carried out at the NMH, a large maternity hospital with over 8,000 births annually. It is located in the city center of Dublin, Ireland. Recruitment and data collection took place in June and August 2019. HG care provided at the NMH at the time of data collection was guided by the National Clinical Guidelines for Nausea and Vomiting (RCPI & HSE 2015) and a woman with HG may have experienced some or all of the services outlined in Table 1.

Table 1. Clinical services women may have experienced at the national maternity hospital.

Service	Description
Emergency department	24-hour access for acute presentation of HG staffed by midwives and obstetricians. Women may present with acute onset or worsening of HG and receive care as per national guidelines including assessment, medical management, IV fluid replacement ± IV micronutrient infusion.
Day ward unit	Typically, an elective admission for 4–8 hours, not requiring an overnight stay. The multidisciplinary team consists of midwives, dietitian and obstetrician (as required). Care provided as above.
Antenatal ward	Management for HG that requires a longer length of stay is provided in an antenatal ward. Care provided as above.
Dietetic consultation	All women diagnosed with HG are offered referral to the dietitian. Consultation takes place in the out-patient department (OPD) or by telephone. Management includes optimizing nutritional intake, hydration status, diet quality and weight gain.
Standard maternity care	Standard care is obstetric-led (public or private) or midwifery-led and predominantly hospital based.

Participants

Eligible participants included all women who had experienced HG between January – June 2019 and were referred to the dietitian at the NMH. Eligibility criteria included being pregnant or postpartum with a live born infant, having sufficient level of English to participate in a focus group and aged ≥18 years. All suitable women were invited to participate by letter, with a follow-up phone call from the research team to confirm eligibility. Those who agreed to participate were provided with an information leaflet and consent form. Sample size was determined based on other studies with similar designs, recruitment response, time, resources available and information power, rather than aiming for a definitive number of participants. As a concept, information power outlines that the more relevant information that the sample holds, the fewer the number of participants that are required (Malterud, Siersma, and Guassora 2016). Eleven women provided written consent and participated in the focus groups.

Data collection

Four semi-structured focus groups were conducted among women with experience of HG; two with pregnant women (n = 6) and two with post-partum women (n = 5). Focus groups included 2–3 participants and took place in a private meeting room at our institution. All focus groups were moderated by a female researcher (EOB) and field notes about participants’ body language and non-verbal communication were taken by another female researcher (LM), both employed as senior clinical dietitians at our institution. Neither had personal experience of HG, but both had clinical experience of assessing and treating women with HG and an existing rapport with some women, which contributed to strong interview dialogue and in-depth narratives provided by women.

The interview guide is outlined in Supplementary Table S1. Discussions were audio recorded using a SONY U×560 device. Recordings were transcribed (Rev, San Francisco, USA) and transcripts compared to recordings to ensure accuracy by two dietetics students (EB and LA) who did not have experience of HG. Transcripts were anonymized and participants were assigned pseudonyms. Demographic data were collected via a retrospective review of medical charts.

Data analyses

Preliminary analyses were conducted through discussions between researchers EOB and LM immediately after each focus groups had taken place. Following the fourth focus group, it was felt that sufficient information power had been achieved, given the significant amount of relevant information that had been obtained, with similar themes being conveyed from each of the various in-depth discussions amongst women. Thematic analyses of the data were performed by EB, LA and EOB using an inductive, data-driven approach (Braun and Clarke 2006, 2019). The first step involved familiarization with the data, whereby researchers read the transcripts repeatedly and identified preliminary trends. Subsequently, the researchers performed qualitative, open, line-by-line coding (Bradley, Curry, and Devers 2007) of the transcripts, whereby concise labels were used to broadly code the concepts expressed. Codes were then collated to identify key categories, which formed the basis of preliminary themes. Themes were discussed and consolidated amongst the research team and once agreed, appropriate theme names were determined and quotations were extracted to illustrate the sentiment of each theme.

Results

Demographic data are presented in Table 2. Women included were between the ages of 32 and 40 years, had experienced between one and 12 pregnancies and required at least one admission to either the day ward for treatment, to casualty and/or to the inpatient unit. Each focus group lasted 110–170 minutes. Overall, four overarching themes with sub-themes were identified and are outlined with supporting quotes below. Additional participant quotes to support themes are available in supplementary Table S2.

Table 2. Characteristics of interview participants.

Pseudonyms	Gravida and Parity	Age (years)	Medications (specifically for HG management, prescribed at any point in pregnancy)	Admissions to day ward for treatment	Admissions to casualty	Admissions to inpatient unit	Gestation (weeks) referred to dietetic service
Pregnancy cohort
Sarah	G2 PO	35	Pyridoxine/Doxylamine, Prochlorperazine (buccal)	/	9	/	9
Laura	G5 P2	38	Cyclizine, Ranitidine	9	/	/	13
Michelle	G3 P1	34	Pyridoxine/Doxylamine, Prochlorperazine (oral), Cyclizine, Ondansetron	5	5	2	6
Mary	G12 P1	40	Pyridoxine/Doxylamine Prochlorperazine (buccal), Ondansetron, Ranitidine	9	2	1	8
Jennifer	G3 P1	37	Pyridoxine/Doxylamine, Prochlorperazine (oral), Ranitidine	/	2	1	12
Lisa	G2 PO	34	Pyridoxine/Doxylamine, Prochlorperazine (oral), Ondansetron, Ranitidine	1	3	/	10
Postnatal cohort
Ciara	G1P1	32	Pyridoxine/Doxylamine, Prochlorperazine (buccal), Cyclizine, Ranitidine	1	2	1	12
Aoife	G3 P3	33	Pyridoxine/Doxylamine	2	1	1	11
Claire	G2 P2	35	Pyridoxine/Doxylamine, Prochlorperazine (oral), Ranitidine, Ondansetron	26	/	/	10
Karen	G2 P2	36	Pyridoxine/Doxylamine, Promethazine, Prochlorperazine (oral), Prochlorperazine (buccal), Ondansetron,	6	2	2	7
Catherine	G2 P2	38	Pyridoxine/Doxylamine	/	1	1	8

Theme 1: the emotional toll of HG

There was an overwhelming consensus that HG had a profound effect on a woman’s psychological health, well-being, and sense of self.

Sub-theme 1.1: isolation and loss of sense of self

Many women reported withdrawing from social interactions resulting in a sense of isolation from wider family and friends. While this was a coping mechanism for many, it was concurrent with feelings of low mood and depression. Habitual routines were profoundly affected by HG, as women felt incapable of sustaining the norms of day-to-day life, thus experiencing a sense of loss of self.

You can go from being a really normal person, you know, living a busy life, to suddenly being bed-bound by this for a prolonged period of time, suffering - Karen, postnatal.

Sub-theme 1.2: expectations of the ideal pregnancy vs. the HG pregnancy

The reality of HG was reported as a stark contrast to the expectations of pregnancy one might have. One postnatal woman laughed recalling her experience,

You have this great plan to do yoga, Pilates, you know all these beautiful things, sit on the mat with your bump, that was off the menu - Karen, postnatal.

Women also described how HG affected their ability to bond with their baby, both during pregnancy and post-partum, with some women feeling as though HG robbed them of the enjoyment of pregnancy.

I very much wanted this baby and we tried for it and I actually just feel like I’ve had an illness … I think everyone was a little bit worried about my lack of bonding - Laura, pregnancy.

Theme 2: the reluctant treatment of HG

There was a perception amongst women that many HCPs lacked sufficient knowledge and experience of HG, which appeared to have significant implications on HG care.

Sub-theme 2.1: perceived lack of insight and clinical experience among HCPs

Several women felt that many HCPs lacked understanding and insight into the reality of their HG experiences, which proved frustrating. They described meeting HCPs who did not fully grasp the severity of their condition. In some cases, HG was inappropriately described as “just morning sickness” (Aoife, postnatal), suggesting disbelieving attitudes; and women perceived a lack of validation from HCPs regarding symptom severity.

When they brush it off you just feel, ‘Oh, God, I’m wasting everyone’s time’. You feel like I shouldn’t be here or something - Ciara, postnatal.

Sub-theme 2.2: fear of medication

Some women described that their physician was reluctant to prescribe medications due to fear or wariness of their safety in pregnancy, which posed a significant barrier to care – “my doctor’s not supportive either because he’s too afraid to give me anything” (Mary, pregnancy). Furthermore, women’s own fears of taking necessary medications were also discussed. Mistrust and suspicion of the safety of medications were described by a number of women in the sample, despite the drugs being prescribed by their doctor - ‘the pharmacist was a bit nervous with the Cariban, which fed into my anxiety more of taking it.’

Theme 3: the HG treatment journey

Multiparous women described a more positive experience in recent pregnancies compared with previous pregnancies, indicating an improvement in the HG service over recent years. However, women outlined that some aspects of the service still needed improvement.

Sub-theme 3.1: positive treatment experiences – a lifeline

Surviving the HG journey was largely attributable to treatment received. There was unanimous agreement regarding the benefits of IV fluids for symptomatic relief.

Every week, that’s what helped me get through the whole thing. Knowing that okay, ‘I’m getting [IV] fluids on Tuesday’ and I’d actually function properly for like a day or so - Claire, postnatal.

Sub-theme 3.2: the suboptimal care environment

Most women, while appreciative of the service, agreed that the current setting was not conducive to optimal HG care. This was largely attributed to the physical environment of the day ward, where HG women were in the same clinical area as other pregnant women undergoing various assessments and treatments. Other women felt the unit lacked sufficient resources, including staff numbers, chairs and space, which presented as a major barrier to care. It was reported that casualty rooms, which were comprised of private spaces where they could lie down, were far more suitable.

I found that because of time restraints and the room, they were just trying to get them [IV fluids] into you as quickly as possible. It’s not ideal at the minute, the way they do it - Karen, postnatal.

Poor access to HG treatment in the community was also described by many and manifested in different forms. This was encapsulated in difficulty obtaining prescriptions from local GPs, limited medication stocks in community pharmacies and a lack of availability of IV fluids in the community – “Had gotten Cariban prescribed through an emergency visit. Some junior doctor had given me a prescription maybe for, two weeks. And then, honestly would you believe, from that period on, I had never had anyone who was giving me the prescription again. I always had to beg for it.” Women also reported difficulty attending the NMH for IV fluids due to physical debilitation and logistical problems – “I wouldn’t be able to even drag myself into town. I wouldn’t be able to drive into town. I wouldn’t be gettin’ on the DART to town (laughs). I wouldn’t be gettin’ on the bus to town. So even to get myself into the hospital was an effort to get the IV fluids.”

Sub-theme 3.3: clinical ownership of HG – where does it lie?

Despite encountering many HCPs throughout their pregnancy, women perceived a lack of clinical ownership of HG. Many women felt that appropriate HCPs, particularly community-based physicians, did not take lead responsibility for their HG care.

My doctor refused to talk about it, he just kept sending me to the emergency room. He still refuses to give me a repeat prescription - Lisa, pregnancy.

This seemingly resulted in certain responsibilities of HG care being inadvertently placed in the hands of other HCPs, including the dietitian. Women outlined that the dietitian played an important role in their HG care, however, the perceived role of the dietitian evidently went beyond food. One woman expressed that, “We never spoke about food with [Dietitian], we had an agreement, there was no food” (Laura, pregnancy); while another felt that the dietitian was a source of psychological and emotional support, and one woman portrayed the dietitian as an advocate – “because of [Dietitian], you felt like this is a real thing, that there is support for people” (Jennifer, pregnancy).

Sub-theme 3.4: unmet needs in the aftermath of HG

Contrary to the above findings, some women felt there was a lack of dietetic input when their HG became under clinical control – “I had no guidance on after your hyperemesis, doesn’t go, but is under control. How do you eat properly? What should you be eating to make up for all the vomiting that you did?” (Catherine, postnatal). For some, this reduction in dietetic input resulted in excess gestational weight gain. Therefore, women felt that contact with the dietitian should have been maintained, even when symptoms had resolved and in the post-natal period.

Theme 4: far-reaching burden

Although HG had profoundly devastating effects on the individual, the burden extended beyond the woman to those around her.

Sub-theme 4.1: financial burden

The management of HG imposed a financial burden on many women due to the significant cost of treatment and the impact of HG on income:

I’ve paid €330 every two weeks, for a good few months … When you’re self-employed, there’s that stress of like, there’s no sick pay, there’s no, you know? - Mary, pregnancy.

Women reported seeking Pyridoxine/Doxylamine from countries outside of Ireland, where it was more affordable, including one woman who asked friends to buy the drug in Spain. Some women perceived a lack of support in the publicly funded system and therefore felt they needed to seek obstetric care through consultant-led private healthcare, which had financial implications.

Sub-theme 4.2: the impact of HG on relationships and family dynamics

Family support played a significant role in helping these women through their HG journey, with many reporting a heavy reliance on their partners, often resulting in a change of roles – ‘He raised [daughter’s name] for all of last summer, I was nowhere in her parenting plan at all’ (Karen, postnatal). A small number of participants expressed how the burden of HG put pressure on their relationship. Furthermore, there was a lasting effect on family planning for some women. The decision to have another baby was reported as complex, as women felt they had to psychologically prepare themselves and ensure a support network was in place in advance of pregnancy.

If we were to have another baby, my mom has to be involved with this decision. We need to check her timetable, because I just wouldn’t be able to do it without the constant minding. - Ciara, postnatal.

Sub-theme 4.3: beyond nausea and vomiting

A loss of bodily control was identified due to the physically debilitating impact of HG. Women experienced urinary incontinence, uncontrollable retching, and intractable vomiting.

I’ve run in the door to get sick and the shear pressure of actually reaching the bathroom and then to wet yourself, and you’re like, ‘Oh my god, this is the new-low’ - Mary, pregnancy.

Furthermore, some women were upset at the physical consequences of HG, nutrient deficiencies and believing that the malnourishment they endured had repercussions for recovery and breastfeeding. Multiple women expressed guilt when discussing their nutritional intake during pregnancy, feeling that they couldn’t provide their baby with what they needed in utero, despite having previously described significant challenges with food.

I had no milk. How was I supposed to have any milk, when I didn’t have any, reserve? - Catherine, postnatal.

Discussion

We demonstrated the debilitating effects of HG and its profound impact on psychological well-being, and identified several aspects of the healthcare service that women with HG feel need improvement. Women emphasized the psychological hardship of HG, which manifested in many different ways, and unveiled the far-reaching burden of HG. Overall, women advocated for a dedicated HG service and the need for increased knowledge, understanding and support for HG, in order to ensure optimal HG management and woman-centered care.

The emotional toll of HG was a dominant theme. Many participants reported self-isolation as an attempt to cope with their condition and due to physical inability to perform day to day tasks. The profound impact of HG on day-to-day life resulting in an inability to perform daily tasks, self-care and household responsibilities reported by women in our study, has also been documented elsewhere (Havnen et al. 2019; Meighan and Wood 2005; Munch 2002; O’Brien and Naber 1992; O’Brien, Evans, and White-McDonald 2002). Moreover, a striking finding within our sample was women’s reduced ability to bond with their unborn baby, resulting in a sense of detachment for many participants. Furthermore, our data indicate that for some participants, lack of bonding continued post-partum. Contrastingly, it has been suggested that whilst HG is associated with a less well-developed quality of maternal-fetal attachment in early pregnancy, this adverse effect is insignificant by birth, suggesting that bonding improves as pregnancy progresses and HG symptoms resolve (McCormack, Scott-Heyes, and McCusker 2011; Mitchell-Jones et al. 2020; Molly and Wood 2005) Within our sample, many women had chronic HG throughout pregnancy, which may account for our differing results.

Women expressed a sense of perceived lack of insight and clinical experience of HG among HCPs. Lack of validation of severity of the condition, as a result of perceived dismissal of HG, has also been reported elsewhere (Havnen et al. 2019; O’Brien, Evans, and White-McDonald 2002; Poursharif et al. 2008; Power, Thomson, and Waterman 2010; Van Vliet et al. 2018). Although the safety of numerous antiemetics have been demonstrated with no increased risk of teratogenicity or other adverse gestational outcomes, our findings revealed a noticeable apprehension toward medicating during pregnancy, which has been highlighted in other studies (Havnen et al. 2019; Koren 2007). It seems like there is an essential need for women with HG to feel that their HCPs are confident in recommending medication decisions, given their own challenges in decision making because they are so unwell, combined with fetal protection concerns.

Our findings suggest that the dietitian provided substantial support to women, a finding that has been replicated elsewhere (Groleau et al. 2019). It is speculated that a strong relationship develops between the woman with HG and her dietitian as the dietitian is positioned to address many of her primary concerns, including food and nutritional issues and strategies to cope with physical suffering. Our findings suggest that the dietitian provided validation, information and reassurance, in addition to nutrition support. However, it is worth noting that while referral to the dietitian is recommended in the national guidelines for all women with severe HG, at our institution, women attending the day ward service are also reviewed regularly by the dietitian. This level of nutritional input for women with HG may not reflect the care provided nationally or internationally, as recently highlighted in a review of the role of dietitians in HG management in the UK (Maslin et al. 2021).

Women highlighted several areas of their HG care as inadequate for their needs. Primarily, women felt that the combination of women with HG and other pregnant women in the day ward was not ideal and had preference for a dedicated HG service with private rooms. Similarly, it has been shown that women with HG find it distressing to be exposed to other pregnant women and express preferences for a single hospital room (Van Vliet et al. 2018). However, we acknowledge that finite resources are a limiting factor of this. Women also emphasized a preference for community-based HG care but highlighted a lack of its availability. This finding has been reported in other settings (Havnen et al. 2019; Power, Thomson, and Waterman 2010).

While the negative effects of HG on employment, including time off work and loss of earnings, are consistent with existing literature (Havnen et al. 2019; Munch 2002; O’Brien and Naber 1992), the financial burden described by women has not been documented, and may demonstrate a unique difficulty that HG sufferers in Ireland face, specifically in relation to the antiemetic pyridoxine/doxylamine. In Ireland it is prescribed off-license in pregnancy and thus is not currently eligible for various state reimbursement schemes, despite being recommended as a first-line medication in the Irish Clinical Practice Guidelines. In October 2022 the Irish government announced that this medication will be available free of charge to women with HG, however an anticipated timeline was not released. Participants also expressed a need to seek obstetric care through consultant-led private healthcare due to perceived lack of support in the publicly funded system. This, coupled with a reduced ability to work and loss of earnings, for some, highlights the significant financial burden experienced by women with HG.

A novel finding from our study is the reported loss of bodily control secondary to the debilitating impact of HG. The physical manifestations of HG, such as urinary incontinence, were a salient finding among our FG’s. Furthermore, the importance of psychological healing post-partum and lasting psychological effects pertaining to future childbearing decisions were emphasized, which has also been highlighted by other authors (Nijsten et al. 2021). Some participants did not wish to have any more children, while others adjusted previous family plans. Perinatal mental health involvement appears essential based on our results and the significant mental health implications of HG. Emerging evidence suggests that counseling is helpful both during and following HG pregnancy, indicating a rationale for the provision of HG-aware counseling support within healthcare settings (Nicholson 2019). Whether better management and treatment of HG would improve options for future family planning was not explored in the focus groups, however, other authors have identified that informing women of the high rate of recurrence of HG may facilitate informed family planning (Nijsten et al. 2021).

This research was limited by the small sample size, however despite this, it was felt that sufficient information power had been achieved, due to the narrow and specific nature of the research aim, the rarity of HG and similar themes conveyed from each of the in-depth discussions. The potential for participant bias must be considered, as the FGs were conducted by two dietitians who worked at the NMH. To overcome this, questions were posed in an open-ended and non-judgmental manner. It is also worth noting that all women recruited in this study had been referred to a dietitian and therefore, may have experienced a level of care that other HG sufferers may not. Further, all women including in this study were over 30 years of age and therefore, our sample is not reflective of experiences of younger HG sufferers. We regrettably did not collect information about ethnicity or socioeconomic status, therefore are not in a position to comment on the generalizability of our sample. We did however only include women with sufficient level of English to take part in a focus group, therefore our results may not reflect the experiences of women with limited comprehension of English. Furthermore, the findings of this research may not be generalizable to settings outside of our institution, and replication of these results is warranted.

Conclusion

We provide an understanding of women’s perspectives of HG and an acknowledgment of the significant effect of the condition, which is crucial for ensuring optimal HG management, empathy and woman-centered care. Our findings suggest that improvements are needed to HG care. A dedicated HG service with obvious clinical leadership and a continuum of care and support throughout the duration of pregnancy and post-partum, improvements to the physical and staffing levels on the day ward, continued access to regular IV fluids and a HG-specific mental health support would improve HG care in our setting. At a government level, timely resolution of the financial assistance for first-line anti-emetics would be welcome. From a societal perspective, greater awareness and understanding of the condition could improve support from family, friends and colleagues, which is lacking at present. It is hoped that these findings, although specifically related to women attending a maternity hospital in Ireland, may be used to inform the development of HG services in other settings.

Acknowledgments

We are grateful for the time and knowledge supplied by participants.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Data available upon reasonable request to the corresponding author.

Supplemental data

Supplemental data for this article can be accessed online at https://doi.org/10.1080/03630242.2023.2219749.

Additional information

Funding

This research was supported by The National Maternity Hospital Foundation.