Knowledge and practices of pharmacists concerning off-label and onlabel drug prescribing during pregnancy and breastfeeding: a study from the Kurdistan region, Iraq

Background: Off-label prescribing during pregnancy and breastfeeding is common due to limited approved medications, but it carries potential risks for both mother and child. Pharmacists play a key role in guiding safe drug use, yet gaps in knowledge and training may affect their ability to counsel effectively. This study was conducted to assess pharmacists’ knowledge of on-label and off-label drug use during pregnancy and breastfeeding, and to evaluate their practical recommendations for managing pregnancy-related and lactation-related conditions in Duhok Governorate of Iraq. Methods: A Cross-sectional survey using questionnaires, carried out in pharmacies across Duhok Governorate between June 2024 and September 2024. Participants from 110 pharmacies were randomly selected, 82 pharmacists agreed to participate and completed a self-administered questionnaire. Results: Among 82 pharmacists (74.5% response rate), familiarity with off-label prescribing was highest for Metformin (75.6%) and contraceptive pills (57.3%). Common on-label drugs were correctly identified as safe, including Amoxicillin (95.1%) and Methyldopa (89.0%). Pharmacists reported moderate confidence in advising pregnant and breastfeeding women on OTC medications and supplements, though knowledge gaps persisted, particularly for less commonly prescribed drugs and supplements. Many participants also perceived pharmacy college training on pregnancy and breastfeeding care as insufficient. Conclusion: Pharmacists demonstrate overall awareness and moderate confidence in maternal drug counseling and clinical decision-making; however, gaps in knowledge and limited formal training highlight the need for targeted education and professional development to improve safe medication use during pregnancy and lactation.