Original articleWomen's Perspectives on Screening for Alcohol and Drug Use in Prenatal Care
Introduction
Universal screening for alcohol and drug use in prenatal care is promoted as a public health approach to alcohol and drug use during pregnancy (American College of Obstetricians and Gynecologists (ACOG), 2008, Chasnoff,, Kennedy et al., 2004, Littaua et al., 2006, Washington State Department of Health (WSDOH), 2008). Women's perspectives on screening have not been considered but are important because women who drink seven or more drinks per week and who use drugs are overrepresented among women who deliver with late, limited, and no prenatal care (Hankin et al., 2000, Kelly et al., 1999, Maupin et al., 2004, Melnikow et al., 1991, Pagnini and Reichman, 2000) and little is known about barriers to care for this population.
Research about barriers to prenatal care for women who use alcohol and drugs has been primarily conducted with low-income women and suggests that pregnant women who use drugs face difficulties with health insurance and transportation, fear being reported to Child Protective Services (CPS) and, at times, prioritize drug use over prenatal care (Klein and Zahnd, 1997, Milligan et al., 2002, Murphy and Rosenbaum, 1999). Although screening could influence decisions about prenatal care attendance, these two literatures—universal screening and barriers to prenatal care—have developed separately. At the nexus of the two is the question of screening acceptability: How does the possibility of being identified as a pregnant alcohol and/or drug user through screening in prenatal care influence prenatal care attendance and engagement?
Research has been conducted in related areas, such as acceptability of screening for alcohol misuse in dental offices and emergency departments (Miller et al., 2006, Schermer et al., 2003), screening for domestic violence (Ramsay et al., 2002, Renker and Tonkin, 2006), and mandatory testing for HIV among pregnant women (Fielder & Altice, 2005). This research indicates that screening is acceptable to some, but not others, and in certain settings, not others. People not wanting to be identified have responded by avoiding care if they think they will be subject to mandatory testing (Fielder & Altice, 2005) and/or concealing problems if screening relies only on verbal disclosure (Renker & Tonkin, 2006). Importantly, the possibility of being identified as drug users by providers is a reason some people who use drugs avoid health care (Fitzgerald et al., 2004, Murphy and Rosenbaum, 1999). These findings raise questions about the acceptability of alcohol/drug screening in prenatal care and the implications of excluding women's perspectives. No research has been published about women's perspectives on alcohol/drug screening in prenatal care or how the possibility of being identified as a pregnant alcohol or drug user through screening influences prenatal care attendance and engagement.
Section snippets
Methods
This paper is based on analysis of data collected as part of a larger qualitative study on barriers to prenatal care among pregnant women who use alcohol/drugs (Roberts & Pies, in press) in which concern about being identified as a drug user by prenatal providers emerged as a key finding. Human Subjects approval was obtained from the University of California, Berkeley, and written informed consent was obtained from all study participants.
This study took place in a California county where all
The process of being identified
Women worried that if they attended prenatal care, providers would identify their drug use. Some expected that providers would “find out” or somehow just “know” they were using. Women described the strategies providers used to identify them such as asking questions about drug use and testing their urine samples for drugs. When providers asked questions about drug use, women not wanting to be identified tended to deny use. Even when women chose to not disclose use, most feared and many
Discussion
Three main findings emerged. First, many women were averse to having drug use identified by prenatal providers, especially through urine tests and especially when not informed of testing in advance. Second, women's concerns with having drug use identified centered around expectations that identification would lead to adverse psychological, social, and legal consequences. Overall, women did not trust providers to help or protect them from these consequences, especially CPS involvement. Women's
Acknowledgments
The author is independent of any funder or sponsor and had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Cheri Pies provided helpful comments on this paper. An earlier version of this paper was presented at the 71st Annual Conference on Problems of Drug Dependence (Reno, NV June 2009).
Amani Nuru-Jeter, PhD, MPH, is an Assistant Professor in Community Health and Human Development and Epidemiology at the University of California, Berkeley, School of Public Health. Her research focuses on the intersection of social and psychosocial determinants of racial inequalities in health.
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Amani Nuru-Jeter, PhD, MPH, is an Assistant Professor in Community Health and Human Development and Epidemiology at the University of California, Berkeley, School of Public Health. Her research focuses on the intersection of social and psychosocial determinants of racial inequalities in health.
Sarah C. M. Roberts, DrPH, is a postdoctoral fellow at the Alcohol Research Group and University of California, Berkeley. Her research focuses on policies relating to alcohol and drug use during pregnancy and on gender equality and health.
Supported by a March of Dimes Community Award and NIAAA Graduate Training on Alcohol Problems, T32 AA07240.