Recognizing the broad range of psychosocial issues that pregnant women face is an important step toward improving women's health and birth outcomes. The Committee on Health Care for Underserved Women of the American College of Obstetricians and Gynecologists (ACOG) has developed an educational bulletin on perinatal screening and intervention for psychosocial risk factors. Educational Bulletin no. 255 appears in the November 1999 issue of Obstetrics and Gynecology.
According to the ACOG committee, screening for psychosocial risk factors may predict a woman's attentiveness to personal health matters, her use of prenatal services and the health status of her children. Some physicians may not be prepared to manage the psychosocial issues that women encounter. Growing evidence shows that patients appreciate attention to these issues. Clinicians should be prepared to screen for psychosocial risk factors and to provide or refer patients for services to manage psychosocial problems.
One screening system—the Healthy Start Program—has been used successfully by the Florida Department of Health since 1992 (see Table). The ACOG bulletin discusses each topic identified in the tool. Some questions may appear to be relevant only for low-income populations, but screening of all patients presenting for pregnancy evaluation or prenatal care is an important step. Asking these questions will highlight areas of concern and the physician can refer the patient for additional evaluation or intervention.
Because of the sensitive nature of the screening, ACOG recommends that physicians make every effort to screen patients in private, especially when asking about domestic violence. Even then, women may not be comfortable discussing problems with a physician until a trusting relationship has been established.
The following information is a summary of the areas of discussion in the ACOG bulletin:
Barriers to Care
Some women may encounter barriers to care, such as inadequate health insurance coverage, inability to pay for services and not knowing where to go for care. Adolescents are most likely to be faced with such barriers. Other problems include lack of transportation and day care and language difficulties. Referral to a social service agency may be helpful in these cases.
The second question on the screening tool asks about frequent moves. A variety of problems may force a woman to move frequently. She may have financial difficulties and be unable to afford adequate housing. Again, social service agencies can provide information about resources. Frequent moves may also reflect violence in the home or indicate problems with the law that can cause stress.
Safety concerns can relate to safety in the home or safety in the neighborhood. If the patient is in immediate danger, alternative housing should be discussed. If children are involved, a referral to the state child protection agency may be required. If the danger is the result of domestic violence, a referral to a battered women's shelter should be made. Hospital beds may be available on an emergency basis in some cases.
If the concern relates to the home, such as structural defects, insect infestation or sanitary issues, further inquiry can determine the necessary intervention.
Nutritional problems range from an inability to acquire and prepare food to eating disorders. Problems can be found in women from all walks of life. All low-income women should receive information about food stamps and the Special Supplemental Food Program for Women, Infants and Children. Social service agencies may be contacted about additional benefits.
Adolescents and young women should be asked about eating habits such as fasting or meal skipping. If it is found that the patient has an eating disorder such as anorexia or bulimia, referral to a psychiatrist and nutritionist should be made. Poor weight gain may also reflect substance abuse, domestic violence or depression.
Smoking is associated with a higher rate of perinatal mortality, bleeding complications of pregnancy and a higher risk of having babies who are small for their gestational age. Evidence also links maternal smoking with the child's development of attention-deficit/hyperactivity disorder and behavioral or learning problems. Patients who smoke should be given information on smoking cessation. Even brief interventions have been shown to make a difference in cessation rates.
Women who abuse substances are at increased risk of preterm delivery, fetal growth restriction, fetal alcohol syndrome, fetal death and long-term neurobehavioral problems in the child. These women are also at increased risk for sexually transmitted diseases. Women who abuse substances are likely to not seek prenatal care until late in pregnancy and may frequently miss appointments and achieve poor weight gain. In addition, substance abuse by a woman or her partner is a risk factor for domestic violence, so questions about substance use by a patient's partner can be helpful.
Many studies report that domestic violence often begins during pregnancy; if already present, it may escalate. Up to 20 percent of all pregnant women may be subject to abuse. In addition, violence may increase during the postpartum period. Therefore, women should be asked about violence at least once in each trimester, during the postpartum period and whenever bruising, injury or depression is noted.
Maternal stress is measurable and affects neonatal activity and irritability. Women who are anxious during pregnancy tend to have smaller infants and women with high levels of stress hormones are more likely to deliver preterm. The stress associated with pregnancy itself, concerns about labor and delivery and fears about parenting can be reduced by providing education. Other patients may need referral to mental health professionals to help identify and resolve distress in their lives.
Almost one half of pregnancies are unintended at the time of conception. The number is even higher among adolescents. Having an unintended pregnancy is a predictor of insufficient prenatal care. Furthermore, these women are more likely to smoke and drink and are more likely to deliver a low-birth-weight infant. Unintended pregnancies are more common among battered women, and abuse is more common during an unplanned pregnancy.
Women who did not intend to become pregnant often come to terms with their condition and accept their pregnancies. However, if the pregnancy remains unwanted, women should be counseled about the full range of reproductive options, including abortion and adoption. Women must be allowed to make independent decisions about their pregnancies.
Addressing psychosocial issues is an essential step to improving women's health and birth outcomes, according to ACOG. An effective system of referrals will increase the likelihood of successful intervention. Screening should be performed regularly and the patient's prenatal record should be documented.