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  • Seizing the 9-month moment

Dental Healthcare:

Seizing the "9-month moment" 

"That 9-month 'moment' is probably the only time you're going to get some of them ever in your office, and so it's a prime time to hit every single vice that they have, whether it be food and their diabetes, or smoking, or drugs, or whatever, it's a prime opportunity." [OB/Gyn resident]

We designed our study of prenatal health care providers to gain important insights into how health care providers can support women’s efforts to reduce their health-related behavioral risks during pregnancy.

The initial stages of the study involved focus groups with providers from the Bay Area. The participants in our study were obstetrician/ gynecologist physicians who provide routine prenatal care to patients in the San Francisco Bay Area. The sample comprised five focus groups, each including between six and eleven participants. A sixth focus group consisted of prenatal nurse practitioners and nurse midwives. The results confirmed that pregnancy is a time when women face crucial and difficult choices about reducing or eliminating risk behaviors in the areas of tobacco, alcohol and illicit drugs. Pregnancy is also a time when women are at increased risk for domestic violence and may be at a crossroads in their relationships.

We found remarkable consensus among prenatal health care providers that they play a role in identifying risky behaviors and helping pregnant women improve their own health and that of their babies. Providers shared specific techniques and strategies for risk assessment and counseling. Though many of their techniques differed by risk area, comparisons across provider groups found a significant amount of the assessment and intervention practices to be similar.

Four major themes emerged from the discussions:

  1. Pregnancy is an "opportune moment" for behavior change.
  2. Specific risk prevention tactics or strategies can be useful in the context of pregnancy.
  3. Related goals include reducing isolation and assessing depression.
  4. Ultimately, providers can adopt a policy of "just chipping away" at risks.

1. The "opportune moment"
Pregnancy is a time when women have more motivation to change their behavior. The repeat visits of prenatal care also create a special relationship between the patient and health care provider, facilitating open communication about risk behavior.

"[W]omen are more likely to come and see their health care provider when they're pregnant anyway. So even if I can ignore my general health my entire life, there is something about having someone in there that kind of motivates you to make sure things are okay, and so it's not just a teachable moment, for some women, it's THE teachable moment." [OB/Gyn resident]

2. Specific risk prevention tactics
The focus group participants described strategies, tactics and tips for doing risk prevention. In general, these tactics fell into five categories:

  • Normalizing Risk Prevention
    Making risk assessment appear a routine part of the prenatal visit helps the patient feel comfortable and assured.

    "I say, 'We always ask these questions for your safety, first of all, are there any concerns about domestic violence?' That's how I start out, then I ask about drinking, and drugs, because I think asking about DV really softens the [questioning] ." [OB/Gyn resident]

  • Specific Assessment Techniques
    In order to make the question less threatening and encourage truthful answers, a common technique was asking whether the patient drinks or uses specific, relatively high amounts.

    "I'll take a really high number, and I'll say, 'Would you say six drinks a day?' And they'll say, 'Oh no, I only have four drinks a day!' I think somehow that makes them feel, ‘Oh, I guess there are a lot of people who drink more than I.'" [Nurse Practitioner]

  • Counseling Strategies
    The most common strategy was to tap into patients' motivation to protect their babies' health.

    "[T]hen you talk to her about it, and if it's smoking, usually what I do is...a sonogram of the baby. It works pretty well, if you keep showing them the baby, and I keep telling them that's where the smoke is going, and it works." [OB/Gyn]

  • Harm Reduction Strategies
    Most strategies related to reducing smoking rather than abstinence, using positive reinforcement and problem-solving with patients.

    One of the most successful stories I’ve had with smoking is limiting the places the patient can smoke, counting down the numbers of cigarettes she smokes. At first I ask them if they want to stop smoking, because if you’re counseling them and they’re not motivated [it doesn’t work], but if they want to then it’s okay. So I ask them ‘Where do you smoke?’ ‘In the car or on the way home from work, or one in the morning, and one after dinner, I‘ll have one out on the back porch.’ So I’ll say ‘Okay, all you have to do this month is just not smoke in the car.’ That will count for a percentage [of their smoking], and they’ll come back, and say ‘Okay, I only smoked in the car one time,’ and the rest it’s only on the porch, and that's okay. Then I go on, ‘So now you can’t smoke on the back porch any more.’” [OB/Gyn resident]

  • Bringing Family Members into the Process
    The pregnancy may be directly affected by the behavior of a family member, or they may help the patient change her behavior.

    "[T]he other thing that I think is important is to get the whole family history, because I’ve given out tons of prescriptions for spouses. I think one of the patient’s real barriers to success is the spouse or somebody that is living with them, who’s still smoking, so I’ll give out prescriptions for the patch to the husbands." [OB/Gyn]

3. Reducing isolation and assessing depression
Health care providers believe that addressing these issues can facilitate behavioral risk discussions. They also find that isolation can exacerbate or perpetuate patients' substance abuse and DV risks. Some providers utilize patient support groups.

[W]e have a lot of immigrant patients and I have seen a disproportionate number of them being in an abusive situation, and being very, very isolated, but the idea of being taken out of their home and going to a shelter, when they don’t speak English and they don’t know anyone, it’s very unappealing to them." [OB/Gyn]

4. "Chipping away"
Addressing prenatal behavioral risk is a challenge for health care providers. Regardless of health care setting, gender or professional title, providers felt constrained by lack of time. Despite the difficulties, providers seemed optimistic about helping some women reduce their risks during pregnancy.

Pregnancy is mostly a very powerful thing for a lot of women, for most women, and even for the ones who don’t even suspect it, and the pregnancy just happened by accident. We do have people on the streets who are homeless, or are drug addicts or sex workers, and a lot of them are looking for hope for a new beginning, and, in a way, the pregnancy can be viewed as that. Some of them will make it. Many will not, but we should not stop, we need to have faith in them and try to help them in every way we can. We definitely have had some success stories.” [OB/Gyn resident]

In their brief interactions with patients, prenatal health care providers can be supportive, ask basic risk assessment questions, and give basic risk reduction messages that are tailored to the specific patient. It is especially important to "chip away" at risk behavior during each prenatal visit, both because the provider cannot predict when the patient will be ready to change, and because many of the women will lose access to a caring health care provider after their child is born.

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Page last updated October 27, 2009 2005