What is the Video Doctor all about?
HIV and Healthcare: The Positive Choice Project
Prenatal Care: Health in Pregnancy and Keep Fit Projects
- Seizing the 9-month moment
Primary Healthcare: The PRE-VIEW Project
Domestic Violence Tutorial for Dentists
HRSA-Funded Project for AEGD Residents
"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
- Pregnancy is an "opportune moment" for behavior change.
- Specific risk prevention tactics or strategies
can be useful in the context of pregnancy.
- Related goals include reducing isolation
and assessing depression.
- 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
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.'"
- 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."
- Harm Reduction Strategies
Most strategies related to reducing smoking rather than
abstinence, using positive reinforcement and problem-solving
“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
- 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
"[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
3. Reducing isolation and assessing
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
“[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
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.”
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.