Don't ask, don't tell doesn't work in prenatal care

While obstetrical care providers are doing a good job working with their patients on smoking cessation, they are not doing as well on abuse of other substances that can harm a woman's unborn baby. A new study appearing in the September 2008 issue of the journal Patient Education and Counseling reports that patients don't volunteer information about substance abuse unless specifically queried.

During the course of the study, actual conversations between the doctors or midwives and their pregnant patients were audiotaped. Listening to the tapes, the researchers found that prenatal care providers were not comfortable talking with their patients about dealing with drug and alcohol abuse in spite of routinely mentioning health risks of such behavior on the unborn infant.

"The methodology of this study is important," said Richard Frankel, Ph.D, a co-author of the study. "Studies that simply rely on questionnaires for data may not get to the level of specificity needed to understand the mechanisms by which physicians and patients communicate. We were able to describe in detail the moment by moment communication behaviors involved in the prenatal conversations we studied. That's good news because previous studies have shown that one minute of a doctor's time for tobacco counseling has a measureable effect on attempts to quit smoking." Dr. Frankel is professor of medicine at the Indiana University School of Medicine, a research scientist with the Regenstrief Institute, Inc. and an investigator at the Roudebush VA Center of Excellence for Implementing Evidence Based Practice.

"We believe a similar strategy could be used to teach providers to engage pregnant women in brief but effective discussions of alcohol and drug abuse risks," he said.

The researchers call for obstetrical care providers - both physicians and midwives - to learn more about drug and alcohol cessation programs, to ask questions and to have information and counseling available when dealing with patients who use or are at risk for abusing illicit drugs or alcohol.

"Pregnant women are sensitive about being asked about substance abuse and some health-care providers may feel that talking about these issues will compromise the provider-patient relationship, however, the evidence suggests that the benefits of a frank discussion about substance abuse far outweigh the costs to the relationship," said Dr. Frankel, a medical sociologist.

"The power of the doctor or midwife in the short but intense prenatal care relationship is poorly understood. Obstetrical care providers may be more comfortable dealing with tobacco but alcohol and elicit drugs are just as, if not more, important to address. Doctors and midwives need to know what resources are available for counseling and which of these programs are most likely to work for expectant mothers. By helping the patient with alcohol and or drug abuse the provider can make a major difference in the health of the baby throughout his or her lifetime," said Dr. Frankel.

Authors of the study in addition to Dr. Frankel are first author Judy C. Chang, M.D., MPH, and Diane Dado, LSW, of the University of Pittsburgh Medical Center; Keri L Rodriguez, Ph.D., Susan Zickmund, Ph.D., and Bruce S. Ling, M.D., MPH, of the VA Pittsburgh Medical System; and Robert M. Arnold, M.D., of the University of Pittsburgh School of Medicine.