Matern Child Health J (2007) 11:241–247DOI 10.1007/s10995-006-0169-9

ORIGINAL PAPER

Prenatal Screening for Substance Use and Violence: Findingsfrom Physician Focus GroupsPolly Taylor · Jeanette Zaichkin · Diane Pilkey ·Judith Leconte · Bryan K. Johnson · Anne C. Peterson

Published online: 5 December 2006C© Springer Science+Business Media, LLC 2006

Abstract Objective: To guide quality improvement activi-ties, the study sought to identify effective strategies for in-fluencing and improving physician screening and referralof pregnant women for violence and substance abuse (al-cohol, drugs and tobacco). Methods: This qualitative studyconducted in Washington State consisted of interviews witheight physicians and focus groups with twenty-eight physi-cians who practice obstetric care. Physicians, selected usingsystematic sampling, were asked about perceptions on theimportance of screening and barriers to effective screening,awareness of information and resources from the state De-partment of Health, and the effectiveness of various providertraining strategies for improving prenatal screening. Results:Physicians were most interested in practical, concise infor-mation for themselves and office staff. Referral informationand patient handouts were identified as important tools toincrease the efficacy of screening and intervention. Physi-cians supported in-person programs in offices or in hospitalsbut rejected use of audio conferences and direct mailings.Conclusions: This study provided insight about the way wedeliver best practice information to physicians. Collectingqualitative data from physicians is important prior to devel-

P. Taylor (�) · J. Zaichkin · D. PilkeyWashington State Department of Health,Maternal and Child Health,PO Box 47880, Olympia, WA 98504-7880, USAe-mail: Polly.Taylor@doh.wa.gov

J. LeconteTBA Consulting Group,PO Box 15505, Seattle, WA 98115, USA

B. K. Johnson · A. C. PetersonInsight Policy Research Incorporated,1655 North Fort Myer Ave, Arlington,VA 22209, USA

oping statewide quality improvement activities aimed at thisgroup.

Keywords Physician focus groups . Prenatal care .

Alcohol tobacco and drugs . Domestic violence . Bestpractice

Introduction

Identifying substance use and domestic violence during preg-nancy is critical in assuring the health of mothers and babiesand is a priority of the Washington State Department ofHealth (DOH). The Washington State DOH conducted astudy to increase understanding of strategies that may be ef-fective in promoting universal screening for substance useand domestic violence during pregnancy. Findings from thestudy will inform decisions about the best strategies to con-tinue prenatal care quality improvement activities.

Background

The use of alcohol, tobacco, and illegal substances duringpregnancy is a major risk factor for low birth weight, prema-ture delivery, mental retardation, developmental disabilities(such as cerebral palsy, autism, mental retardation, visionand hearing impairments), physical abnormalities and fetaldeath [1]. Research supports the strong association betweentobacco use during pregnancy and adverse perinatal out-comes [2]. In addition to substance use, domestic violence isemerging as one of the most serious public health problemsaffecting women’s health in this country [3, 4]. Those expe-riencing domestic violence just prior to or during pregnancyare more likely to have caesarean birth, kidney infection,abruptio placentae, premature labor/birth, low birth weight

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and trauma directly resulting from the abuse [5]. Substanceuse and domestic violence often occur in tandem, althoughneither specifically causes the other [6–9].

Doctors with appropriate training are more likely to screenfor alcohol use than those who have not had training [10].According to an American College of Obstetricians and Gy-necologists (ACOG) survey, most physicians asked aboutsmoking but wanted to learn more about how to intervene[11]. Educating physicians and providing them with a pro-cess for implementing successful screening practices, docu-menting high risk patients, and ensuring that the interventionis started early and maintained during pregnancy is criticalin reducing health risks to the unborn child.

Why screen?

Routine screening during pregnancy takes advantage of thefrequent contact between clients and health care providersto identify problems and engage women in treatment. Iden-tification and referral are particularly important for domesticviolence victims and substance users, who are dispropor-tionately isolated from the health care system due to fear,stigma, or shame associated with their situations. In addi-tion, treatment for substance use during pregnancy can bemore effective than at other times in a woman’s life becausethe woman is often more motivated to change her behaviorfor the sake of her child [12]. Current research on prenatalsmoking cessation shows that a brief intervention by a trainedprovider will increase smoking cessation rates [13, 14].

According to ACOG, obstetrician-gynecologists have anethical obligation to use a protocol for universal screeningquestions, brief intervention and referral to treatment in orderto provide patients and their families with comprehensiveand effective medical care [15]. To promote screening foralcohol, drug, and tobacco use, ACOG has published severaldocuments to encourage providers to learn establishedtechniques for screening and intervention, to create a teamapproach to deal with barriers and to use external resources.ACOG also encourages obstetric providers to screen forpsychosocial risk factors, such as violence and substanceuse and refer for essential services to address these concerns[9]. In September 2000 and again in October 2005, ACOGpublished guidance on smoking cessation during pregnancy,recommending that all providers identify pregnant smokersand integrate the brief intervention into their office practices[16, 17].

Washington State’s effort to promote screening

Washington State recognizes the importance of universalscreening for substance use and domestic violence duringprenatal visits. Based on data from the 2003 Pregnancy Risk

Assessment Monitoring System (PRAMS) survey, an esti-mated 91% of women in Washington State reported beingasked by their provider about smoking during prenatal care,83% reported being asked about alcohol use, 73% reportedbeing asked about illegal drug use, and 61% reported beingasked about domestic violence. The DOH has tried severalinitiatives to improve identification and screening rates forsubstance use and domestic violence.

In 1998, DOH initiated the Perinatal Partnership AgainstDomestic Violence (PPADV), a training curriculum for pre-natal care providers on screening for domestic violence. Aperinatal outreach nurse was paired with a domestic vio-lence advocate in her community and together, they attendeda training session on how to train health care providers toscreen pregnant women for domestic violence. This collabo-ration resulted in an opportunity for hospital-based nurse ed-ucators and community advocates to share networking strate-gies and experiences from their workplaces. The PPADV,while not completely successful in its goal to train largenumbers of physicians, did reach and train numerous healthcare professionals, including nurses, midwives, social work-ers, community health workers, and outreach workers.

In 1999, the Washington State Legislature provided fund-ing to educate health care providers in the use of substanceuse assessment tools and interventions for pregnant women.Shortly after, the DOH Office of Maternal and Child Healthestablished the Maternal Substance Abuse Screening Initia-tive for Providers. Resources for prenatal care providers in-cluded three best practice booklets, fact sheets, safety cards,clinician pocket reference cards, and a professional website.Changes were made to the uniform prenatal medical record(used by over 90% of prenatal care providers in the state) toimprove the assessment and documentation of screening forsubstance use and violence. From January 2000 through June2004, training was conducted in the four regional perina-tal programs across the state through individualized practicetraining, presentations and exhibits at professional meetings.

This project required regional program trainers to developstrategies for engaging physicians and office staff in the out-patient setting instead of in hospitals and at conferences andhad limited success. Providers were reluctant to attend thistraining and office staff had difficulty scheduling time on aclinic day. Many health care providers stated that they werealready informed and adequately screening, and did not con-sider this topic a priority. Perceived lack of treatment optionsand difficulty with intervention steps following identificationalso affected provider motivation to learn about and changescreening practice.

To address the need to increase smoking cessation ef-forts within maternity care, the DOH developed a best prac-tice booklet that provides guidelines and tools for doing abrief intervention with pregnant women who smoke. In ad-dition, Washington Medicaid has added a smoking cessation

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counseling benefit for pregnant women in its fee-for-servicecoverage. The benefit covers pregnant women up to twomonths postpartum and when appropriate, payment forBupropion SR (Zyban). DOH developed a provider referencecard with information on the benefit and guidelines for pre-scribing Bupropion SR (Zyban). All of these materials weremailed to obstetrical providers statewide and distributed atstate medical meetings and conferences and through regionalperinatal programs.

Despite improvement in screening rates and numerousavailable referral resources, Washington has not achieveduniversal screening for substance use and domestic violence.Therefore in 2003, DOH conducted a study to learn whatphysicians thought might be more effective strategies forpromoting universal screening for substance use and do-mestic violence during pregnancy. The purpose of the studywas to identity physician perceptions on the importance ofscreening, barriers to effective prenatal screening, aware-ness of resources from the Washington State Department ofHealth, and the effectiveness of various provider trainingstrategies.

Methods

This qualitative study consisted of both telephone interviewsand focus groups with Washington State physician providersof obstetric care. Participant recruitment, interviews and thefocus groups were conducted by a professional research orga-nization. Their summary report identified common themes,patterns, and trends. This work was screened by the Washing-ton State Institutional Review Board (IRB) and was classifiedas public health practice and not research. Therefore, reviewand approval by the Washington State IRB was not required.

Obstetric providers were selected using systematic sam-pling of the Washington State Integrated Provider NetworkDatabase, a comprehensive list of providers maintainedby the Washington Department of Social and Health Ser-vices (DSHS). Medicaid, the Basic Health Plan and all in-surance carriers who participate in the state’s Public Em-ployees Benefits Board contribute to this database, whichwas originally intended as a means for the general publicto find medical providers. Before sampling, the list wassorted geographically by perinatal region, zip code, cityand street name. A systematic sample of physicians wasselected to provide geographic diversity across the stateand ensure that no two providers were selected from thesame practice. A separate sample was selected for the semi-structured interviews and for each of the four focus groups.Eligibility was limited to physicians who provide obstetriccare.

Semi-structured interviews

Individual semi-structured telephone interviews were con-ducted with 8 physicians, recruited from a systematicsample of 30 physicians who practice obstetric care inWashington. The interviews lasted 60–90 min and physi-cians were compensated $150. Common themes wereidentified and guided development of the focus groupprotocol.

Focus groups

Efforts were made to ensure diverse participation by physi-cians. While all participants were physicians who providedobstetric care, half were also family practitioners. Partici-pants included male and female physicians from large ur-ban practices as well as solo practitioners in rural areaswith fewer annual deliveries. Almost all practices serveda proportion of high-risk patients and many estimated thatapproximately 50% of the women they served were Med-icaid eligible. Three participants worked in clinics for lowincome, high-risk patients only, while one belonged to agroup practice serving affluent women. Prior to each focusgroup, respondents were asked to complete a short writtenquestionnaire that asked for general background about theirscreening activities and the size and nature of their medicalpractices.

Two in-person focus groups were held in both easternand western Washington and two were held by telephone tofacilitate inclusion of physicians serving rural communities.Phone participants received $200 while in person partic-ipants received a $250 honorarium. The groups consistedof 28 out of 38 randomly selected physicians who practiceobstetric care.

The focus groups lasted 60 to 90 minutes and were mod-erated by a senior researcher with extensive experience inthis activity. Topics covered during the interviews and fo-cus groups included patient demographics and characteris-tics of the physician’s practice as well as specifics on theiroffice procedures for screening for substance use and do-mestic violence during pregnancy and postpartum (Table 1).The moderator used a semi-structured guide that focusedon the three major areas of interest: physician opinions andattitudes about substance use and domestic violence screen-ing and intervention for pregnant women; physician aware-ness of existing DOH materials about screening; and barriersand effective strategies for communication and education ofphysicians on screening. After each session, audio or video-tapes and extensive field notes were analyzed to identifydominant themes and key points.

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Table 1 Topic areas for interviews and focus groups

Demographics Patient demographicsCharacteristics of physician’s practice

Behaviors/motivations Screening practicesScreening frequencyMotivations and barriers to screeningScreening tools used

Attitude Importance of screeningEffectiveness of screening for identifying patients needing referralEffectiveness of screening in getting patient referred or problem addressed

Awareness/knowledge Knowledge of specific screening tools and publicationsAvailability of materials such as pamphlets, articles, flyers, handouts, and other items

used to train physicians about screening and intervention for substance use anddomestic violence

Opinions on specific DOH best practice materials and publications on this topicEffective strategies for

communication and educationEffective communication and education strategies for DOH to use with physicians to

promote universal screening

Results

Provider attitudes toward screening practices were consistent(Table 2). Providers felt that screening for drug use, alcoholuse, and domestic violence during pregnancy is good prac-tice; however, most screen only once. Physicians reportedthey were more likely to screen for tobacco and alcohol usethan for drug use and domestic violence. Physicians men-tioned that establishing a bond with the patient and conduct-

ing the screening interview after that bond had been formedwas the best means for identifying patients with these is-sues. Cultural and language barriers make it more difficultto screen effectively.

While respondents appreciated efforts to help educatethem about screening, they saw the provision of reliableand updated referral information as even more important.Many physicians said that if there was one foreseeable bar-rier to their ongoing screening efforts it was the fact that they

Table 2 Key findings/current screening behaviors

Physician attitudes Physicians felt that screening for drug, alcohol, tobacco use or domestic violenceIs their responsibilityIs “part of being a good doctor”“Prevents poor outcomes and averts complications”Is “worth it even if you only help one patient”Does not compromise the doctor-client relationshipDoes not put the provider in a position of policeman instead of doctor

Screening practice Most physicians screened their patients only once unless the patient had a history of substance use or violenceUse of other office staff Physicians voiced that

Screening is more effective if both physicians and office staff ask the questions. Office staff play a largerole in the screening process

The patient is sometimes more likely to talk to the nurse about these issuesBarriers to effective screening Physicians found it relatively easy to screen for alcohol and cigarettes. Physicians found it more difficult to

screen for drugs and domestic violence, because these patients are reportedly more difficult to identify, toinfluence behavioral change, and to refer

Physicians perceived the presence of family members during prenatal visits and patients’ fear of reprisal fromChild Protective Services and or family members as barriers to effective screening

Physicians were often unsure of where to refer patientsPatient privacy issues limit the physician’s ability to check up on whether patients have acted on a referral

Use of screening tools Most physicians do not use a formal screening tool (such as the T-ACE, TWEAK, CAGE, AUDITS, and4-Ps), but relied on the Prenatal History Questionnaire (part of the Washington uniform prenatal medicalrecord), internal screening forms, and the ACOG questions (for domestic violence)

CAGE was the only formal screening tool used by respondents, with three of the eight in-depth intervieweesusing CAGE for screening

Medicaid reimbursement Physicians were not aware of our state’s Medicaid reimbursement for tobacco cessation counseling but didnot see this payment as a motivator

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Table 3 What physicians want in education materials and training

General suggestions Information and materials for physician education shouldSave timeProvide access to intervention and resourcesHelp providers avoid legal riskEncourage and support provider efforts to educate patients about the issuesBe created by people who “think like doctors”Include “state-of-the-art” information that is specific, rather than generalBe short (one page) and scientific looking. Put all key points on one page. Include “tables and flow charts that

appeal to people with scientific training”Formats Desirable formats for information and physician training materials

Website of reliable and updated information on intervention and referral resources, downloadable into a PDA“Screening and intervention kit” that includes relevant screening and referral information for physicians and

education materials to stimulate interest and reinforce medical advice for patientsWebsite for physicians dedicated to screening issues

Training suggestions Include all office staff in training programsEnsure practical training that takes into account the realities of day-to-day medical practiceProvide well-prepared, dynamic trainers who understand how screening fits into medical practiceUtilize existing regional perinatal system to provide physician educationDevelop DOH alliances with pharmaceutical companies to promote and co-sponsor educational sessions in

physician officesEnlist hospital education departments as hosts for DOH training as a way to reach a maximum number of

physicians at hospital-based trainingsProvide lunchtime education programs

Ineffective strategies Email alertsLegislative mandateDirect mailings/ flyersTelephone conferences

Strategies with mixed reviews A DOH perinatal newsletterDirect mailMedicaid reimbursement (though appreciated, would not increase screening)

often felt discouraged after identifying a potential problemthen being unsure of where to refer the patient for continuedassistance.

Physicians identified four themes necessary to encouragetheir participation in screening education (Table 3):

� Access to current intervention and referral resources� Time-saving tools for screening and intervention� Emphasis on avoidance of legal risk through good screen-

ing� Patient education materials that encourage and support

provider efforts.

Physicians also suggested information about access toreferral, short and scientific-looking training materials, andon-site trainings for all office staff. Ineffective training strate-gies cited included e-mail alerts, legislative mandates, directmailings/flyers, and telephone conferences.

Discussion

Overall, physicians in this study felt that screening preg-nant women for substance use and domestic violence is an

integral and worthwhile part of prenatal care. These physi-cians saw all screening topics as equally important, but statedthey had the most difficulty screening for drugs and domes-tic violence. Domestic violence was discussed as especiallychallenging in part because of the difficulty in affecting pa-tient behavioral change or getting the patient to use a re-ferral. Frequency and methods for screening varied accord-ing to physician attitude, experience and preference. DOHbest practice materials, while appreciated by physicians,were not considered the best strategy to encourage universalscreening.

A variety of factors may explain the varying practicelevels of patient screening by obstetric providers. Studieshave shown that while providers generally support prena-tal screening, they struggle with barriers to implementingscreening which include time limitations, lack of train-ing, and lack of resources [11, 14, 18]. Overall the physi-cians participating in our focus groups felt that screeningshould occur for substance use and domestic violence dur-ing prenatal visits. The following is a discussion of factorsthat influenced or presented barriers to quality screeningpractices.

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Physicians may be influenced by the potential legal impli-cations of screening pregnant women for alcohol, drug use,and domestic violence. Mandated reporting requirements,if present, may inhibit patient-provider communication andlead to significant ethical issues. These issues impact whatthe woman is willing to tell her provider and likewise, mayinfluence the types of questions the provider is willing toask. In South Carolina, for example, one hospital’s policywas to turn positive drug testing results over to law enforce-ment. Though this policy was struck down by the SupremeCourt in Ferguson vs. City of Charleston, it demonstrates thepotential legal implications of substance use screening [19].Washington State does not have a mandatory reporting lawfor health care providers for domestic violence involvingpregnant women, nor is there a mandate to report substanceuse during pregnancy. Children’s Protective Services encour-ages reporting positive maternal or newborn drug tests. How-ever, the provider must decide if the woman’s situation po-tentially endangers her children because mandatory reportinglaws do exist for the abuse of children and vulnerable adults.

Physician attitudes and expectations impact screeningpractices. Because domestic violence interventions are of-ten perceived to be less successful than interventions fortobacco, alcohol, or drug use, providers may feel that domes-tic violence screening is futile [20, 21]. Physician expecta-tions for screening sometimes differ from domestic violenceadvocates’ and substance abuse providers’ expectations ofscreening. The medical model expects that when a positivescreening occurs the physician will intervene with servicesthat are effective and the patient is “cured.” Professionalsin substance use and domestic violence consider screeningthe first intervention in a process or series of interventionsover time that leads to a positive outcome for the patient, soexpectations from a medical model perspective differ sub-stantially from the domestic violence and substance abuse“process” perspective. Physicians may feel a sense of failurewhen they cannot “cure” the domestic violence survivor orthe addicted victim with one quick and effective intervention.This difference requires long term attitudinal change.

Lack of time and timing of screening plays a role. Mostscreening for substance use and domestic violence duringpregnancy occurs at the first visit with their provider [10]. Forthose patients who use their primary care practitioner as theirobstetric provider, the first visit may pre-date prenatal carevisits, and the screening questions may not be asked againduring pregnancy. In addition, many pregnant women withsubstance use and violence issues will not disclose at the firstvisit. This makes the development of a trusting relationshipand multiple screening points important in order to identifywomen who are ready to make behavioral changes and acceptreferrals [22].

Last, many physicians believe that they have inadequateresources to intervene; therefore, they may screen less often

or screen only for those behaviors for which resources andreferrals, (such as drug and alcohol treatment programs andwomen’s shelters) are readily available and effective [10,20]. In one study on physician beliefs about domestic vi-olence, the majority of physicians surveyed (70%) do notbelieve that they have the resources available to them to as-sist victims of domestic violence [21]. Another study foundthat 95% of obstetrician-gynecologists surveyed were unsureabout what patient education materials on smoking cessationwere appropriate for pregnant women [11]. Increasing link-ages between providers and the interventionists for each areamay increase provider confidence and referrals to availableresources.

Generally, continuing medical education programs are de-veloped by planning committees who decide what medicalproviders need to know. While this method may ensure thatcritical information is provided, it may fall short of successin terms of engaging providers and in effecting provider be-havioral change. Focus groups of physicians can be a usefulmeans of identifying the issues for structuring professionaleducation programs [23, 24]. Getting input from the tar-get audience enables the education sponsor to understandthe current care standards and how best to improve practice.Target audience input about preferred education methods andbest practice tools may improve quality of care and outcomes[24].

Physicians look to their professional association for prac-tice guidance; however, lack of awareness or disagreementabout a clinical guideline have been identified as barriers toprovider adherence. Other reasons providers don’t adopt abest practice include lack of self efficacy, lack of outcomeexpectancy, and the inertia of previous practice patterns [18].Perhaps more focus on ways to overcome all barriers wouldhelp to increase provider implementation of proven screen-ing methods.

Limitations of this study must be acknowledged, andinclude those that are inherent with focus groups, self-reporting, and small sample size. Limitations of focus groupsinclude facilitator bias and the risk of dominant members tak-ing over and sidetracking discussions. We attempted to avoidthese limitations by using professional contractors with ex-perience in facilitating groups of physicians. The primarylimitation for this study is that the results cannot be gener-alized to the whole provider population. However, the focusgroups provided us with access to our target audience andallowed us to solicit recommendations and suggestions forfuture consideration.

Findings from this study will help guide efforts to edu-cate obstetric providers about the importance of screeningduring pregnancy. Providers made it clear that they are moremotivated to screen if they have good support, materials andinterventions that help their patients. These come in partfrom professional groups (for example, ACOG), but this

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does not ensure that all providers are compliant. Standard-ized tools might prove helpful if administered by physicianson a voluntary basis. Legislative mandates and small mon-etary incentives were clearly denounced as a motivator forscreening.

Although this study was small, it could be easily repli-cated on a larger scale to gain a broader perspective. Repli-cation of this qualitative study with a larger sample sizemight provide important data to validate the findings fromthese focus groups. This would help to determine if dif-ferences exist in screening practices and attitudes betweenfamily practitioners and obstetricians, between urban andrural providers, between providers serving Medicaid or non-Medicaid clients, between providers under age 40 and overage 40, and between physician providers and office staff. Ex-pansion of the study might include information on methodsto train providers during internships and residency.

Findings from this study provided rich data to furtherexplore strategies for improving universal screening of preg-nant women for substance use and domestic violence. Sug-gestions to improve physician education in this area did notpoint to any one strategy that would be effective for all physi-cians. However, results are valuable because physicians’ at-titudes about screening, barriers to universal screening, andrecommendations to improve education and outreach willstimulate discussion with stakeholders and other state agen-cies. These qualitative data are an important component forfuture planning of communication and education strategieswith obstetric providers.

Acknowledgements This study was funded by State General Fundsprovided to the Washington State Department of Health. Insight PolicyResearch, Inc of Maryland contributed substantially to this manuscript.The authors wish to acknowledge Riley Peters, Sherilynn Casey, KathyChapman, and Sara Bausch for their contributions.

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