Preventive counseling during prenatal care

Abstract

Background: Prenatal care provides an opportunity for counseling about behaviors and experiences that increase the likelihood of adverse maternal and fetal outcomes.

Objectives: To document (1) prevalence of preventive health counseling during prenatal care, (2) prevalence of women in higher need of counseling about specific health concerns, and (3) whether women in higher need for counseling were more likely than women in lower need to have received counseling.

Methods: Analysis of the Pregnancy Risk Assessment Monitoring System (PRAMS), a state-specific, population-based, random sample of postpartum women, was performed by using data from 14 states for births during 1997 or 1998, for a total of 24,620 participants. Outcome measures included report of preventive health counseling during prenatal visits by specific topic as well as behaviors and experiences about cigarette use, alcohol use, breast-feeding, partner violence, and preterm labor.

Results: The percentage of women that report preventive counseling during prenatal care is relatively high (≥75%) for 9 of 13 topics. However, the percentage of women that report counseling is relatively low (<75%) for partner violence, seat belt use, illegal drug use, and human immunodeficiency virus (HIV) risk. Except for counseling about cigarette and alcohol use, women in higher need, compared with women in lower need, for three other health topics were not significantly more likely to receive counseling.

Conclusions: Preventive health counseling for partner violence, seat-belt use, illegal drug use, and risk of HIV could be increased across prenatal settings. Counseling should involve assessment of risks, with focused counseling related to those risks.

Introduction

O ne of the main premises behind preventive health care is to identify behaviors that may put an individual at risk for a specific morbidity or mortality and to affect change in that individual’s risk-taking behavior. This is a two-step process that involves assessing a patient’s risk-taking or health-promoting behaviors and then providing counseling about risks and benefits in a supportive, clear, and unbiased manner.1

In an effort to advance the mission of preventive health practice, the U.S. Preventive Services Task Force compiled the landmark Guide to Clinical Preventive Services.1 The collection of expert review and testimony led to recommendations for the types of preventive interventions that should be performed during clinical visits. These interventions are grouped into three categories, including screening, counseling, and chemoprophylaxis. In an effort to promote preventive health practice in clinical settings, the Task Force recommended that preventive health practices “must specifically address patients’ personal health practices” and healthcare providers “must take every opportunity to deliver preventive services.”1

Despite the literature and protocols that support the practice of preventive health care in medicine, there are important differences between recommended practices and actual provider performances in preventive health counseling.1, 2, 3 The prevalence of preventive health counseling has been examined from different perspectives, including that of the provider2, 3 and of the patient.4 The current literature that evaluates the prevalence of preventive health counseling involves a variety of practice settings and is often limited to a specific topic such as cardiovascular health5 or smoking cessation.6 In general, this literature demonstrates that the prevalence of preventive healthcare counseling is low, and even women at highest behavioral risk for particular health problems, such as women who smoke6 or women with cardiovascular risk factors,5 are not often given focused counseling about their specific risks.

The Task Force’s recommendations, in some cases, are pertinent to specific groups of patients. One of the patient-specific groups included is pregnant women. Preventive healthcare counseling during prenatal care is particularly important, as it promotes health for both the mother and the developing fetus.1 Many adverse outcomes of pregnancy can be linked to a limited number of high-risk behaviors, such as substance use7 and poor diet,8 which could be modified by behavioral changes. For example, behaviors both before and during pregnancy, such as cigarette smoking,9 illegal drug use,10 and alcohol use,11 may negatively influence pregnancy outcomes and newborn health status. Given this outcome, the Task Force recommends that pregnant women be counseled on a variety of prevention health topics, including tobacco cessation, alcohol and other drug use, benefits of breast-feeding, and use of seat belts during pregnancy.1 Some recommendations, including counseling about tobacco cessation, alcohol, and breast-feeding, are associated with strong evidence in support of the intervention improving specific outcomes (“A” recommendations). Other topics, such as use of seat belts during pregnancy and other drug use, have weaker evidence that counseling on these issues improves outcomes. However, as the Task Force noted, “this lack of evidence does not constitute evidence of ineffectiveness.”1 Hopefully, preventive health counseling during prenatal care can identify behaviors and experiences that increase the likelihood of adverse health outcomes and provide information and counseling that would lead to health promotion.

Prenatal care is an optimal time to provide preventive health counseling because of the large number of women who obtain such care. It is estimated that approximately 98% of the 4 million women who delivered a live birth in 1997 received some prenatal care.12 In addition, pregnant women may have a variety of behaviors or experiences that may increase the likelihood of adverse maternal and fetal outcomes, including smoking during pregnancy, experiences of partner violence during pregnancy, or lack of intention to breast-feed.13 These behaviors and experiences may be amenable to change with focused preventive health counseling.

Despite the high prevalence of behaviors and experiences that increase the likelihood of adverse health outcomes, we do not know the extent to which pregnant women are asked about preventive health topics. We also do not know the extent to which pregnant women who exhibit behaviors or who have had experiences that increase the likelihood for a specific health problem are counseled about that specific topic. To improve preventive health counseling practice during prenatal care, we need a better understanding of patients’ current preventive counseling experiences, and how this counseling may be related to patients’ behaviors and experiences. This study extends research in this area by examining Pregnancy Risk Assessment Monitoring System (PRAMS) data in 14 states to document three areas. The first area is the prevalence of preventive health counseling during prenatal care for 13 specific topics, including cigarette smoking, alcohol use, nutrition, breast-feeding, partner violence, preterm labor, seat belt use, family planning after delivery, use of medicines during pregnancy, illegal drug use, fetal development, and human immunodeficiency virus (HIV) risk and HIV testing. The second area is the prevalence of women’s behaviors and experiences that increase the likelihood for adverse health outcomes related to cigarette smoking, alcohol use, lack of breast-feeding, risk of domestic violence, and risk of preterm labor. The third area is whether the women with behaviors and experiences that increase the likelihood for these five health concerns were more or less likely than women in lower need of counseling to have received counseling for these issues during prenatal care.