Key Feature 5a: In pregnant patients: Identify those at high risk (ex: teens, domestic violence victims, single parents, drug abusers, impoverished women).
Skill: Clinical Reasoning, Selectivity
Phase: Hypothesis generation, History
Key Feature 5b: In pregnant patients: Refer these high-risk patients to appropriate resources throughout the antepartum and postpartum periods.
Skill: Clinical Reasoning
Phase: Treatment, Referral
As a medical student, I gradually learned the importance of taking a good history, and how this is often the most important part of a clinical assessment. As a family medicine resident, I am now learning the importance of taking a good social history, and how this tends to be the best predictor of whether or not any clinical decision is even relevant. When it comes to patients who are pregnant, this is as true as ever. If a patient cannot afford a medication, no matter how important it is that they take it, they just won’t take it, because they can’t. And if a patient is addicted to smoking cigarettes, simply quitting cold turkey because it’s harmful for her infant may not be realistic. Notice the examples of the high-risk patients listed in this key feature are not those who have serious medical disease with medical ramifications, but rather it highlights those who are at high risk according to social risk factors. While pregnant patients with serious medical illness may indeed be at increased risk of morbidity and mortality, most women bearing children in the world do not have medically complex histories, typically because they are still young, and their risk of harm will likely be more influenced by their ability to eat a nutritious diet, abstain from using drugs, and avoiding the harm inflicted on them by an abusive partner.
Social risk factors are typically not easily fixable, but that’s not to say they aren’t modifiable either. Interventions will depend on the specific factors complicating the patient’s life, and on the clinician’s ability to build rapport and identify those factors in the first place (for example, many patients may not readily divulge a pattern of domestic abuse, or they may feel too embarrassed to say they cannot afford a prenatal vitamin). After taking a good social history, interventions that may be considered to address identified risk, applied in a patient-centered way, include: programs that subsidise cost of medications (ex: provincial drug plans for patients with low income) or that help provide income assistance, group prenatal classes, mental health supports for addictions/psychiatric illness, support groups for pregnant teenagers or programs that assist them prepare for becoming a mom while continuing to work toward obtaining their high school diploma, visits by a public health nurse to the patient’s home (who may also be a source of significant information and perspective on ways in which a patient could benefit from supports in the community), etc. The possible interventions will vary depending on the community and what is accessible online. Check out the website posted in this previous blog post for community resources that may be significant help for a woman who is pregnant in the province of British Columbia.