Physicians' knowledge of alcohol, tobacco and folic acid in pregnancy.

OBJECTIVE: To assess: (1) physicians' knowledge and clinical confidence regarding problematic substance use in pregnancy compared to folic acid, and (2) physicians' desire for education in this area and their preferred learning modalitiestools. DESIGN: Self-administered survey. SETTING: Family Medicine Forum 2004 in Toronto, Canada. PARTICIPANTS: Physicians attending Family Medicine Forum 2004 in Toronto who provide antenatal care. MAIN OUTCOME MEASURES: Knowledge of folic acid, smoking and alcohol in pregnancy. Clinical confidence and interest in resources regarding problematic substance use in pregnancy. RESULTS: Sixty-six surveys completed. Physicians answered 92.3% of folic acid questions correctly, compared to 82.0% for nicotine and 57.1% for alcohol. Scores were higher on questions about effects of nicotine and alcohol use in pregnancy than on questions about treatment options. A perceived inability to influence clinical outcomes and a lack of professional resources regarding substance use in pregnancy were also identified. Physicians were interested in learning more about problematic substance use in pregnancy, particularly from continuing medical education events, websites and pocket cards. CONCLUSION: Participants' level of knowledge regarding substance use in pregnancy was significantly lower than their knowledge of folic acid, as was their clinical confidence. This lack of knowledge was not attributable to disinterest and clearly more educational resources are needed to address this topic.

Using the ALPHA form in practice to assess antenatal psychosocial health. Antenatal Psychosocial Health Assessment.

BACKGROUND: The assessment of the psychosocial health of pregnant women and their families, although recommended, is not carried out by most practitioners. One reason is the lack of a practical and evidence-based tool. In response, a multidisciplinary group created the Antenatal Psychosocial Health Assessment (ALPHA) form. This article describes the development of this tool and experience with it in an initial field trial. METHODS: A systematic literature review revealed 15 antenatal psychosocial risk factors associated with poor postpartum family outcomes of woman abuse, child abuse, postpartum depression, marital/couple dysfunction and increased physical illness. The ALPHA form, incorporating these risk factors, was developed and refined through several focus groups. It was then used by 5 obstetricians, 10 family physicians, 7 midwives and 4 antenatal clinic nurses in various urban, rural and culturally diverse locations across Ontario. After 3 months, these health care providers met in focus groups to discuss their experiences. A sample of pregnant women assessed using the ALPHA form were interviewed about their experience as well. Results were analysed according to qualitative methods. RESULTS: The final version of the ALPHA form grouped the 15 risk factors into 4 categories--family factors, maternal factors, substance abuse and family violence--with suggested questions for each area of enquiry. The health care providers uniformly reported that the form helped them to uncover new and often surprising information, even when the women were well known to them. Incorporating the form into practice was usually accomplished after a period of familiarization. Most of the providers said the form was useful and would continue to use it if it became part of standard care. The pregnant women in the sample said they valued the enquiry and felt comfortable with the process, unless there were large cultural barriers. INTERPRETATION: The ALPHA form appears to be an important tool in assessing psychosocial health in pregnancy and to be readily integrated into practice. More study is required to quantify the number of risks identified and resources used, to determine the form's reliability and validity and, ultimately, to assess the effect of its use on postpartum outcomes.

Antenatal psychosocial risk factors associated with adverse postpartum family outcomes.

OBJECTIVE: To determine the strength of the association between antenatal psychosocial risk factors and adverse postpartum outcomes in the family, such as assault of women by their partner, child abuse, postpartum depression, marital dysfunction and physical illness. DATA SOURCES: MEDLINE, Cinahl, Famli, Psych Abstracts and the Oxford Database of Perinatal Trials were searched from relevant articles published from Jan. 1, 1980, to Dec. 31, 1993, with the use of MeSH terms "depression, involutional," "child abuse," "child neglect," "domestic violence," "family," "marital adjustment," "family health," "newborn health," "child health," "physical illness," "social support," "psychosocial risk," "prediction," "risk factors," "obstetrics" and "prenatal care." Further articles were identified from bibliographies. STUDY SELECTION: Of the 370 articles identified through the search, 118 were included for review. Studies were included if they examined the association between psychosocial risk factors and the outcomes of interest. Articles were excluded if they were reviews of poor quality or they had one or more of the following features: insufficient description of the sample, a high attrition rate, a lack of standardized outcome measures, outcomes other than the ones of interest or results that had already been reported in a previous study. DATA EXTRACTION: The strength of evidence of each study was evaluated. On the basis of the evidence, each risk factor was assigned a rating of the strength of its association with each of the postpartum outcomes. The ratings were class A (good evidence of association), class B (fair evidence) and class C (no clear evidence). Of the 129 antenatal psychosocial risk factors studied, 15 were found to have a class A association with at least one of the postpartum outcomes. DATA SYNTHESIS: Child abuse and abuse of the mother by her partner were most strongly correlated (class A evidence) with a history of lack of social support, recent life stressors, psychiatric disturbance in the mother and an unwanted pregnancy. Child abuse was also strongly associated with a history of childhood violence in the mother or her partner, previous child abuse by the mother's partner, a poor relationship between the mother and her parents, low self-esteem in the mother and lack of attendance at prenatal classes. Postpartum abuse of the mother was also associated with a history of abuse of the mother, prenatal care not started until the third trimester and alcohol or drug abuse by the mother or her partner (class A evidence). Child abuse had a fair (class B) association with poor marital adjustment or satisfaction, current or past abuse of the mother and alcohol or drug abuse by the mother or her partner. There was class B evidence supporting an association between abuse of the mother and poor marital adjustment, traditional sex-role expectations, a history of childhood violence in the mother or her partner and low self-esteem in the mother. Postpartum depression was most strongly associated with poor marital adjustment, recent life stressors, antepartum depression (class A evidence), but was also associated with lack of social support, abuse of the mother and a history of psychiatric disorder in the mother (class B evidence). Marital dysfunction was associated with poor marital adjustment before the birth and traditional sex-role expectations (class A evidence), and physical illness was correlated with recent life stressors (class B evidence). CONCLUSIONS: Psychosocial risk factors during the antenatal period may herald postpartum morbidity. Research is required to determine whether detection of these risk factors may lead to interventions that improve postpartum family outcomes.

A randomized, controlled trial of the influence of prenatal parenting education on postpartum anxiety and marital adjustment.

OBJECTIVE: The aim of this study was to measure the impact of two middle-trimester parenting communication classes on postpartum anxiety, marital adjustment, and postpartum adjustment. METHODS: Seventy primiparous, low-risk couples enrolled in prenatal classes in a large urban hospital were randomized to experimental and control groups. An educational intervention consisting of two second-trimester classes was facilitated by two social workers. The classes were based on a previous assessment of the educational needs of postpartum couples and contained didactic sessions, role-playing sessions, and values clarification exercises. The Spielberger State-Trait Anxiety Inventory and the Dyadic Adjustment Scale were administered to both groups prenatally in the second trimester and at 6 weeks and 6 months postpartum. A modified version of the O'Hara Postpartum Adjustment Questionnaire was administered at 6 weeks and 6 months postpartum. RESULTS: Both groups scored comparably in the prenatal period. The experimental group scored significantly lower on anxiety and higher on dyadic adjustment at both postpartum time periods than the control group. The experimental group also indicated a higher degree of postpartum adjustment. CONCLUSION: Prenatal parenting communication classes had a significant impact on postpartum anxiety, postpartum marital satisfaction, and postpartum adjustment.

Psychosocial risk factors during pregnancy. What do family physicians ask about?

OBJECTIVE: To determine whether physician characteristics affect attitudes or practices regarding assessment of psychosocial risk factors during pregnancy, and to evaluate whether an antenatal psychosocial risk factor assessment form would help family physicians. DESIGN AND SETTING: A questionnaire asking physicians to rate the importance of information on a scale of one to five was mailed to all active members of the University of Toronto Department of Family and Community Medicine's Survey Network of Attitudes and Practice (SNAP). PARTICIPANTS: A volunteer sample of physicians doing prenatal and intrapartum obstetrics who are active members of SNAP. The network is made up of full-time faculty in the University of Toronto's family practice units and teaching practice physicians (rural, suburban, and urban) who are interested in participating in research projects. MAIN OUTCOME MEASURES: Response rate was 78%. Responses of the 45 SNAP members who did not practise obstetrics were excluded; 125 of 218 questionnaires mailed were analyzed. RESULTS: Women family physicians rated the form potentially helpful more frequently than their male colleagues. Urban and suburban physicians' concerns differed from those of rural physicians. Alcohol and drug abuse, abuse in the relationship, and acceptance of the pregnancy were rated highly important by physicians. Of the physicians surveyed, 77% thought that an antenatal psychosocial risk assessment form would be of some benefit or very helpful. Only 15% indicated it would be useless or not helpful. CONCLUSION: The importance respondents accorded to risk factors showed little correspondence to the frequency of inquiry about them. The survey confirmed our plan to design an antenatal psychosocial risk factor assessment form.

Does family-centered maternity care empower women? The development of the woman-centered childbirth model.

Family-centered maternity care (FCMC) developed as a consumer reaction to the depersonalization of birth that had been the management standard for childbirth during the first half of the century. The philosophy and focus shifted from technologization to personalization, from birth as a biomedical event to birth as a normal developmental task. Proponents of FCMC focused on the emotional and psychosocial needs of the childbearing family but often defined the family as the traditional nuclear family. Because of this restrictive view of the family, care within FCMC defies simple definition and seems to hinge on the values, philosophy, and sex of the care givers. The issue of power is a predominant theme throughout FCMC and relates to the question of where power is vested--in the woman or in the system. Empowerment of women during childbirth is possible but may need to be conceptualized differently from the current FCMC model. Proposed here is a woman-centered childbirth model that shifts the emphasis back onto the mother as key principal in childbirth and grants her the mandate to personalize her birth to suit both her needs and the needs of her family, however defined.

Early Postpartum Discharge: Implications for Canadian program development.

Early postpartum discharge (EPD) programs could soon become normative for low-risk women in Canada. To meet new mothers' health care, educational, and psychosocial needs, EPD programs must reflect a deeper understanding of the immediate postpartum period. Structured teaching in hospital must be replaced by a fluid, individualistic approach to mother-infant care. Family physicians can play a vital role.

Pain perception in the neonate.

Pain expression in both pre-term and term infants is a little understood phenomenon. Recent research has generated data documenting that the newborn can feel pain, can act to avoid the pain, and may form memory traces of the experience. "Nociceptive activity" or "noxious stimuli" are better terms to use when addressing aversive stimulation of the neonate because they encourage scrutiny of the behavioural and physiologic responses of the newborn without placing emphasis on the emotional and subjective associations of the word "pain". Many invasive procedures are performed on infants with little or no provision for adequate pain management. The general and specific responses of the neonate to pain must be recognized. Analgesia and anesthesia should be made available to all infants, pre-term or term, sick or well, on the same basis on which they are made available to older children and adults.

Assessing postpartum family functioning.

The birth of a child requires adaptation and reorganization within the family system in order to accommodate the new family member and to allow the family to continue in its psychosocial development. Knowledge of the normative and transitional changes required at this stage of family life will enhance family practitioners' understanding of some of the common concerns and complaints related to them by various family members during the postpartum period. The Family FIRO model represents a helpful conceptual framework to increase the family physician's understanding of the issues of inclusion, control, and intimacy that are highlighted during the transition to parenthood. The authors briefly present this model and discuss its application to postpartum adjustment and its implications for health-care professionals.