Objective
To determine the impact of prenatal counseling regarding psychosocial risk factors on maternal behavior.
Study Design
We analyzed data from 198,323 women participating in the Pregnancy Risk Assessment Monitoring System (PRAMS). The χ 2 and logistic regression analyses assessed the relationship between psychosocial risk, prenatal counseling and maternal behavior.
Results
The odds of receiving risk-appropriate prenatal counseling were significantly greater for participants who used alcohol (odds ratio, 1.13; 95% confidence interval, 1.08−1.17) and tobacco (odds ratio, 2.02; 95% confidence interval, 1.91−2.13). After receiving counseling, women quit using alcohol (72.9% vs 27.1%; P < .01) and tobacco (79.9% vs 20.1%; P < .01) at a significantly greater rate and women with unintended pregnancies were more likely to use postpartum contraception (83.6% vs 16.4%; P < .01) than women who were not counseled. However, no significant differences were found in the rates of intimate partner violence during pregnancy (56.1% vs 43.9%; P = .09) between women who did and did not receive counseling.
Conclusion
Counseling regarding psychosocial risk factors during pregnancy may positively impact maternal behavior.
Pregnancies complicated by psychosocial risk factors, often manifest as drug, alcohol, and tobacco use, have been significantly associated with an increased incidence of adverse birth outcomes such as low birthweight (LBW). Evaluations of psychosocial risk factor screening and counseling have demonstrated a decrease in corresponding adverse behaviors as well as a reduction in the incidence of adverse birth outcomes. As a result, in 2006, the American College of Obstetricians and Gynecologists (ACOG) called for the incorporation of routine psychosocial screening into prenatal care practice.
Despite recommendations, many patients with psychosocial risk factors fail to receive risk-appropriate prenatal counseling. In a retrospective review of prenatal records, counseling and education regarding psychosocial risk factors such as smoking, alcohol, and drug use was only documented 50% of the time and less than 1% of women were referred to a behavior modification or treatment program. In a qualitative evaluation of prenatal providers’ approaches to alcohol, tobacco, drug, and intimate partner violence (IPV) screening, providers saw psychosocial risk prevention as “challenging” and described inconsistent practice patterns and uncertainty about success. Moreover, when compared with compliance with laboratory tests and physical examinations, evaluations of prenatal care records demonstrate significantly lower rates of compliance with psychosocial risk factor assessment and counseling. This failure to identify and address psychosocial risk during pregnancy has been attributed to an underestimation of the prevalence of psychosocial risk factors, inadequate training, time constraints, and a belief by providers that many interventions are ineffective.
Compliance with psychosocial risk assessment and counseling has not been assessed in a nationally representative sample since the publication of ACOG’s 2006 guidelines. Therefore, to evaluate the relationship between psychosocial risk, prenatal counseling and maternal behavior, we conducted a secondary analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS). Specifically, this study sought to (1) describe the prevalence of prenatal counseling targeting psychosocial risk factors, (2) determine the percentage of patients with high psychosocial risk pregnancies who receive risk-appropriate prenatal counseling, and (3) evaluate the relationship between risk-appropriate prenatal counseling regarding psychosocial risk factors and maternal behavior.
Materials and Methods
Dataset
Data regarding psychosocial risk factors and prenatal counseling was derived from the PRAMS. PRAMS is an ongoing, population-based surveillance system monitored by the Centers for Disease Control and Prevention (CDC), that collects data on a wide range of maternal behaviors and experiences before, during, and after pregnancy. For this study, we analyzed PRAMS data collected from the Phase 5 Core questionnaire, which collected data from 32 states and New York City for the years 2004-2008.
Each month, mothers who are state residents and have recently delivered a live-born infant during the preceding 2-4 months are randomly selected from a file of birth certificate records using stratified systematic sampling. The majority of states also oversample for LBW infants. Sampled mothers are mailed a letter that introduces them to the project, followed by a self-administered 14-page standardized questionnaire, which consists of about 56 core questions that are asked by all states. Datasets are created by merging states’ data from 3 different sources: the PRAMS questionnaire, the birth certificate, and survey operational data. The data are weighted to account for survey design, noncoverage, and are representative of women delivering a live infant in each respective state. Additional information about the PRAMS methodology can be found at http://www.cdc.gov/prams/methodology.htm . This study was approved by the University of Michigan Medical Institutional Review Board (IRB HUM00040396) and was reviewed by the CDC PRAMS working group.
Demographic and prenatal care variables
Demographic characteristics such as maternal age, maternal educational level, relationship status, and maternal race were derived from birth certificate variables. Method of payment for prenatal care and delivery was taken from the PRAMS questionnaire. Prenatal care use was calculated using the Kotelchuck Adequacy of Prenatal Care Utilization Index (APNCU), which combines the timing of the first prenatal visit with the ratio of observed to expected number of prenatal care visits attended based on prenatal care standards of the ACOG. Women are then categorized by the percentage of recommended prenatal care visits attended, as follows: “inadequate” (<50% of expected visits); “intermediate” (50-79%); “adequate” (80-109%); “adequate plus” (>109%).
To determine whether participants received counseling in 11 specific prenatal care content areas, we used data from the PRAMS questionnaire which asked, “During any of your prenatal care visits, did a doctor, nurse, or other health care worker talk with you about any of the things listed below?” Answering “yes” indicated the receipt of prenatal counseling in the following content areas: tobacco use, breastfeeding, alcohol use, seat belt use, postpartum contraception, safe medication use, illegal drug use, genetic screening, preterm labor, HIV testing, and IPV.
Psychosocial risk factor variables
All psychosocial risk factor variables were derived from answers to the PRAMS questionnaire. The relationship between risk status, counseling and behavior were evaluated for 4 psychosocial risk factors: (1) alcohol use, (2) tobacco use, (3) unintended pregnancy, and (4) IPV. We were not able to classify participants’ need for counseling for the remaining 7 prenatal care topics because of the lack of relevant survey data.
Tobacco and alcohol use were defined as use during the 3 months before pregnancy. Tobacco and alcohol cessation was defined as use during the 3 months before pregnancy, but the absence of use during the last 3 months of pregnancy. IPV was defined by participants who responded that they had been pushed, hit, slapped, kicked, choked or physically hurt by a current or ex-husband or partner during the 12 months prior to pregnancy. Cessation of IPV during pregnancy was defined as the proportion of participants who had a history of IPV prior to pregnancy, but reported no IPV during pregnancy. Pregnancy intendedness was derived from the question, “Thinking back to just before you got pregnant with your new baby, how did you feel about becoming pregnant?” Intendedness was categorized as intended if the participant wanted the pregnancy then or sooner and unintended if the participant wanted to be pregnant later or did not want to be pregnant then or at any time in the future. Risk-appropriate prenatal counseling regarding unintended pregnancy was defined as prenatal counseling about postpartum contraception.
Data analysis
We used weighted descriptive statistics to report demographic characteristics for the study population and to assess whether participants received counseling for 11 specific prenatal care content areas. Multivariable logistic regression analyses were conducted to determine the relationship between prenatal care counseling and psychosocial risk factors while controlling for age, education, relationship status, parity, race, insurance, and prenatal care use. Logistic regression models were evaluated for collinearity and variance inflation factor (vif) values were less than 1.5 for all independent variables. The χ 2 analyses were conducted to examine if risk-appropriate prenatal care counseling had an effect on the behavior of participants. All analyses were conducted with STATA 12 (StataCorp, College Station, TX) and PRAMS complex sampling strategy was taken into account for all analyses. Missing values were excluded from the analysis. A P value of < .05 was considered statistically significant.
Results
The sample consisted of 198,323 participants ( Table 1 ). The majority of participants were non-Hispanic White, multiparous, aged 20-29 years, married or cohabiting, and had graduated from high school. Over one third of participants had their prenatal care and delivery paid for by Medicaid. Over three-fourths of participants indicated that they had at least 1 of the 4 psychosocial risk factors evaluated in our study. Approximately 50% of women reported that they drank any alcohol before pregnancy and approximately 41% of women indicated that they had an unintended pregnancy. One fifth of women reported tobacco use before pregnancy and approximately 5% of women reported IPV before pregnancy.
| Characteristic, N = 198,323 a | Weighted % (n) |
|---|---|
| Psychosocial risk factors | |
| Alcohol use b | 50.4 (97,740) |
| Tobacco use b | 22.6 (44,049) |
| Unintended pregnancy | 41.7 (81,106) |
| Intimate partner violence c | 5.3 (10,296) |
| Race | |
| Non-Hispanic white | 60.8 (120,580) |
| African American | 15.8 (31,335) |
| Hispanic | 12.7 (24,988) |
| Other | 10.7 (2101) |
| Insurance | |
| Medicaid | 38.2 (70,754) |
| Private insurance | 38.2 (70,940) |
| Self-pay | 19.9 (36,859) |
| Other | 3.6 (6668) |
| Prenatal care use d | |
| Inadequate | 12.1 (23,167) |
| Intermediate | 13.7 (26,230) |
| Adequate | 44.4 (85,010) |
| Adequate plus | 30.0 (56,865) |
| Maternal age, y | |
| ≤19 | 9.8 (19,434) |
| 20-29 | 52.4 (103,915) |
| 30-39 | 35.2 (69,805) |
| ≥40 | 2.7 (5354) |
| Maternal education | |
| ≤12 y | 47.4 (92,661) |
| >12 y | 52.6 (102,631) |
| Relationship status | |
| Married | 62.6 (124,078) |
| Other | 37.4 (73,337) |
| Parity | |
| Multiparous | 58.0 (113,866) |
a Less than 4% missing data for all variables, except insurance status with 6.61% missing data;
d Kotelchuck Adequacy of Prenatal Care Use (APNCU) index used to calculate prenatal care utilization.
The percentage of participants reporting counseling on specific prenatal topics is shown in the Figure . A greater percentage of participants reported counseling on pregnancy specific topics such as medication use during pregnancy (89%), genetic screening (88%), labor precautions (85%), breastfeeding (83%), and HIV testing (80%) than counseling on psychosocial risk factors such as alcohol (73%), tobacco (73%), and illegal drug use (66%). Women were least frequently counseled about IPV (50%).
The relationship between psychosocial risk factors and risk-appropriate prenatal counseling is shown in Table 2 . The adjusted odds (controlling for all variables in the logistic model) of receiving risk-appropriate prenatal care counseling were significantly greater for participants who used alcohol (odds ratio [OR], 1.13; 95% confidence interval [CI], 1.08−1.17) and tobacco (OR, 2.02; 95% CI, 1.91−2.13) 3 months before pregnancy. In contrast, pregnancy intention was not significantly associated with the receipt of contraceptive counseling (OR, 1.00; 95% CI, 0.96−1.05). Finally, women who had a history of IPV in the 12 months before pregnancy were significantly less likely to receive risk-appropriate prenatal counseling regarding IPV than women who did not report a history of IPV (OR, 0.79; 95% CI, 0.74−0.85). Women, who were African American, used Medicaid to pay for their prenatal care, who were teenagers, and who had less than a high school education were significantly more likely to receive counseling for all 4 of the psychosocial risk factors considered in this study.
| Variable | OR (95% CI) | |||
|---|---|---|---|---|
| Alcohol use counseling | Tobacco use counseling | Postpartum contraceptive counseling | IPV counseling | |
| Psychosocial risk | ||||
| Alcohol use c | 1.13 (1.08−1.17) b | — | — | — |
| Tobacco use c | — | 2.02 (1.91−2.13) b | — | — |
| Unintended pregnancy | — | — | 1.00 (0.96−1.05) | — |
| IPV d | — | — | — | 0.79 (0.74−0.85) b |
| Race | ||||
| Non-Hispanic white | ref | ref | ref | ref |
| African American | 1.42 (1.34−1.50) b | 1.43 (1.35−1.52) b | 1.31 (1.23−1.40) b | 1.45 (1.38−1.52) b |
| Hispanic | 1.24 (1.16−1.32) b | 1.26 (1.18−1.35) b | 0.90 (0.84−0.96) b | 1.51 (1.43−1.59) b |
| Other | 1.21 (1.14−1.28) b | 1.21 (1.15−1.29) b | 0.87 (0.82−0.92) b | 1.39 (1.33−1.47) b |
| Insurance | ||||
| Private insurance | ref | ref | ref | ref |
| Medicaid | 1.27 (1.20−1.33) b | 1.32 (1.25−1.39) b | 1.34 (1.27−1.42) b | 1.45 (1.39−1.52) b |
| Self-pay | 0.92 (0.88−0.96) b | 0.93 (0.89−0.97) b | 1.02 (0.97−1.08) | 0.95 (0.91−0.99) a |
| Other | 1.12 (1.01−1.24) a | 1.19 (1.07−1.32) b | 1.00 (0.90−1.11) | 1.36 (1.24−1.49) b |
| Prenatal care use | ||||
| Inadequate | 1.04 (0.98−1.11) | 1.02 (0.96−1.09) | 0.83 (0.77−0.88) b | 1.02 (0.97−1.08) |
| Intermediate | 1.02 (0.96−1.07) | 1.03 (0.98−1.09) | 0.89 (0.83−0.94) b | 1.00 (0.95−1.05) |
| Adequate | ref | ref | ref | ref |
| Adequate plus | 1.07 (1.02−1.12) b | 1.07 (1.03−1.12) b | 0.99 (0.95−1.04) | 1.07 (1.03−1.11) b |
| Maternal age, y | ||||
| ≤19 | 1.19 (1.09−1.30) b | 1.22 (1.12−1.33) b | 1.32 (1.21−1.44) b | 0.94 (0.88−0.99) a |
| 20-29 | ref | ref | ref | ref |
| 30-39 | 0.89 (0.85−0.92) b | 0.88 (0.84−0.91) b | 0.79 (0.75−0.82) b | 0.86 (0.83−0.89) b |
| ≥40 | 0.76 (0.69−0.84) b | 0.73 (0.66−0.81) b | 0.60 (0.54−0.66) b | 0.74 (0.67−0.82) b |
| Maternal education | ||||
| ≤12 y | 1.43 (1.37−1.49) b | 1.47 (1.41−1.54) b | 1.14 (1.09−1.20) b | 1.46 (1.40−1.51) b |
| Relationship status | ||||
| Married | 0.69 (0.65−0.72) b | 0.69 (0.65−0.72) b | 0.89 (0.85−0.95) b | 0.74 (0.70−0.77) b |
| Parity | ||||
| Multiparous | 0.61 (0.59−0.63) b | 0.66 (0.64-0.69) b | 1.20 (1.15−1.25) b | 1.01 (0.98−1.05) |
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