Nephrologist Perspectives on Navigating Pregnancy Planning and Care in Women With Kidney Disease: A Qualitative Study.

Rationale & Objective: As more women with chronic kidney disease (CKD) consider pregnancy, the demand for informed and supportive reproductive counseling grows. Despite this, the preparedness of nephrologists to provide such care is uncertain. We aimed to describe the perspectives of nephrologists on addressing and managing conception and pregnancy in women with CKD. Study Design: Individual semi-structured interviews. Setting & Participants: Australian nephrologists (August 2021 to June 2023). Analytic Approach: Transcripts were coded and analyzed thematically. Results: Twenty nephrologists were interviewed (55% men) from 6 Australian states, with a mean 15.7 ± 9.8 years in practice. We identified 5 themes with subthemes: knowledge, training, and confidence gaps (inadequate and ad hoc training, absence of formal education, low exposure impairing confidence); lack of reliable resources to guide care (absence of guidelines, personal networks as a substitute for formal support); deprioritized and difficult to discuss (not seen as core nephrology work, oversight amid competing demands, gendered assumptions, and clinical discomfort); risk aversion driven by fear of catastrophic outcomes (avoiding disastrous consequences, pregnancy discouraged until post-transplant); and navigating patient autonomy and shared decision making (preference for patients to initiate discussions, need for patient education and support resources, shared decision making as a care principle). Across interviews, transplantation functioned as a clinical threshold and clinicians commonly deferred pregnancy discussions until after a transplant, viewing it as a prerequisite for acceptable maternal and fetal risk. Limitations: Findings from the Australian health care setting may not be fully transferable to other health systems. Conclusions: Nephrologists in Australia face considerable barriers in delivering reproductive care. Despite expressing support for patient autonomy, many clinicians defer or avoid reproductive discussions, especially in women with advanced CKD, limiting informed decision making. Addressing these barriers through structured training, clear guidelines, and systematic integration of reproductive care into routine nephrology practice is essential to ensuring that women receive timely, equitable, and patient-centered reproductive care.