title: Perspectives on pregnancy in women with chronic kidney disease: systematic review of qualitative studies.
abstract: BACKGROUND
  Achieving parenthood in women with chronic kidney disease (CKD) is challenging due to reduced fertility and the risk of adverse outcomes. We aimed to describe women's perspectives of pregnancy in CKD.
  
  
  METHODS
  Electronic databases were searched to April 2014. Studies were synthesized thematically.
  
  
  RESULTS
  From 15 studies (n = 257) we identified seven themes. 'Pursuing motherhood' was fulfilling an innate or social desire to have a child. 'Failure to fulfill social norms' of being unable to conceive diminished their self-worth. 'Fear of birth defects' was attributed to the potential side effects of immunosuppression. 'Decisional insecurity and conflict' encompassed uncertainties of prioritizing pregnancy as sacrifices had to be made in family life and work to minimize their risk of complications. Transplant recipients were concerned about the increased likelihood of graft loss. The possibility of genetic transmission of kidney disease influenced decisions about childbearing. 'Withholding emotional investment' was a way of protecting against the devastation of inability to conceive, miscarriage or stillbirth. 'Control and determination' reflected their capacity to choose to accept the risks of pregnancy. Some felt traumatized when their physician unduly warned against pregnancy. 'Exacerbating disease' due to pregnancy was also of concern to women.
  
  
  CONCLUSIONS
  For women with CKD, pregnancy decisions can be emotionally complicated by health risks, family burden and the perceived risk of fetal malformation. Proactive counseling, shared decision-making about family planning and managing pregnancy in CKD that addresses patient preferences, and multidisciplinary care involving nephrologists, reproductive and obstetrics specialists, and psychological support may improve management of pregnancy issues in CKD.
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia.
authors.forename: Allison
authors.initials: A
authors.lastname: Tong
authors.affiliation: Central and Northern Adelaide Renal and Transplantation Service, Royal Adelaide Hospital, Adelaide, SA, Australia.
authors.forename: Shilpa
authors.initials: S
authors.lastname: Jesudason
authors.affiliation: Sydney School of Public Health, The University of Sydney, Sydney, NSW, Australia Centre for Kidney Research, The Children's Hospital at Westmead, Westmead, NSW, Australia.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Craig
authors.affiliation: Section of Nephrology, Baylor College of Medicine, Houston, TX, USA.
authors.forename: Wolfgang C
authors.initials: WC
authors.lastname: Winkelmayer
mesh_terms: D000328:Adult; D003376:Counseling; D003657:Decision Making; D005260:Female; D006801:Humans; D015201:Meta-Analysis as Topic; D009042:Motivation; D011247:Pregnancy; D011248:Pregnancy Complications / Q000523:psychology*; D036301:Qualitative Research; D051436:Renal Insufficiency, Chronic / Q000523:psychology*; D016387:Women's Health
keywords: fertility; pregnancy; qualitative research; quality of life; shared decision-making