Provider’s Guide
Antenatal Psychosocial Health Assessment
Deana Midmer, BScN, EdD, FACCE
Faculty of Medicine
Department of Family and Community Medicine
University of Toronto
Antenatal Psychosocial Health Assessment
Provider’s Guide
3rd Edition
Deana Midmer, BScN, EdD, FACCE
Faculty of Medicine
Department of Family and Community Medicine
University of Toronto
3rd Edition
September, 2005
Copyright © 2005 by The ALPHA Group
Department of Family & Community Medicine
Faculty of Medicine
University of Toronto
For information on this reference guide,
the development of the ALPHA Form,
and the companion provider-training video
The ALPHA Form: Assessing Antenatal Psychosocial Health
Direct inquiries to:
The ALPHA Group
Department of Family & Community Medicine
263 McCaul Street, 5th Floor
Toronto, M5T 1W7, ON, Canada
416-946-3223
416-978-3912 Fax
deana.midmer@utoronto.ca
http://dfcm19.med.utoronto.ca/research/alpha/default.htm
Bibliography Reference:
Midmer D, Biringer A, Carroll JC, Reid AJ, Stewart DE. (2005). A Reference Guide for Providers:
The ALPHA Form-Antenatal Psychosocial Health Assessment Form. 3rd Edition. Toronto:
University of Toronto, Faculty of Medicine, Department of Family & Community Medicine.
CONTENTS
THE ALPHA FORMS
Purpose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
THE REFERENCE GUIDE FOR PROVIDERS
Using the Guide . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
RISK FACTORS
1. Family Factors
Social Support . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Recent Stressful Life Events . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Couple’s Relationship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Socioeconomic Status . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
22
24
26
28
2. Maternal Factors
Late Onset Prenatal Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Prenatal Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Feelings About Pregnancy After 20 Weeks . . . . . . . . . . . . . . . . . . . . . . .
Relationship With Parents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Self-Esteem Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Emotional/Psychiatric History. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Depression in This Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32
34
36
38
40
42
44
3. Substance Abuse
Smoking During Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Alcohol Use in Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
4. Family Violence
Childhood Experience of Family Violence . . . . . . . . . . . . . . . . . . . . . . . .
Current or Past Woman Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Previous Child Abuse by Woman or Partner . . . . . . . . . . . . . . . . . . . . . .
Child Discipline. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
54
56
58
60
RESOURCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
62
ALPHA GROUP MEMBERS . . . . . . . . . . . . . . . . . . . . . . . . . . .
63
ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
64
5
THE ALPHA FORMS
Overview
National guidelines in Canada and the U.S. have stressed the importance
of assessing the psychosocial health of the pregnant woman as a part
of comprehensive obstetrical care. The ALPHA (Antenatal Psychosocial
Health Assessment) Forms were developed as tools to facilitate the
collection of psychosocial data during pregnancy in a structured, logical,
and time-efficient manner. The ALPHA Form is available in a providercompleted or self-report version.
Purpose of the ALPHA Forms
The forms contain questions that focus on antenatal factors that have
been found to be associated with poor or adverse postpartum outcomes.
These outcomes include: child abuse (CA); woman abuse (WA), or intimate
partner violence; postpartum depression (PD); and couple dysfunction (CD).
Development Process
An interdisciplinary group of obstetrical care providers1 began to meet
in 1989 to explore the area of psychosocial assessment in pregnancy.
We first surveyed family physicians to determine their current antenatal
assessment strategy, the importance they ascribed to the adverse
outcomes during the postpartum period, and their views on using a
specially designed assessment tool to help them interview around these
issues. Results indicated that they assessed sporadically, attributed
high importance to adverse postpartum outcomes, and displayed a keen
interest in using a comprehensive tool.2 Subsequently, we conducted
a comprehensive and critical literature review to identify the antenatal
6
THE ALPHA FORMS
factors associated with the adverse postpartum outcomes,3 which could be
included in an assessment tool.
Development of the Forms
The initial version of the ALPHA Form was developed as a providercompleted tool. We tested the form in focus groups of providers from
different disciplines (medicine, midwifery, and nursing) and used their
feedback to modify the form further.4 We also developed the Provider’s
Guide and a training video.5 We received feedback from pregnant women
and nurses in our pilot study, that a self-report version would be helpful
for those women without fluency in English. Some physicians also
indicated a need for a self-report in order to minimize assessment time.
Consequently we developed a self-report version of the form and tested
it against the provider version on P.E.I.6 This study indicated that both
versions of the form performed well, with equal utility, yield and provider
and consumer satisfaction.
A randomized controlled trial was conducted in Ontario with family
physicians, obstetricians and midwives. The intervention group used the
provider version of the ALPHA form while the control group provided usual
care to pregnant women. Results indicated that ALPHA group providers
were more likely than control providers to identify psychosocial concerns
(odds ratio [OR] 1.8, 95% confidence interval [CI] 1.1-3.0; p=0.02) and
to rate the level of concern as “high” (OR 4.8, 95% CI1.1-20.2; p=0.03).
ALPHA group providers were also more likely to detect concerns related
to family violence (OR 4.8, 95% CI 1.9-12.3; p=0.001). Using the ALPHA
form helped health care providers detect more psychosocial risk factors
for poor postpartum outcomes, especially those related to family violence.
7
THE ALPHA FORMS
It is a useful prenatal tool, identifying women who would benefit from
additional support and interventions.7
Concurrent with the ALPHA development process, the Ontario Medical
Association (OMA) was revamping the Ontario Antenatal Record (OAR).
The ALPHA group presented to the OMA committee on the OAR, and
discussed the need for psychosocial assessment as part of the OAR.
Changes to the OAR were made and the most recent iteration has several
check-off boxes for psychosocial issues, with headings that reflect the
headings on the provider ALPHA Form. Using the ALPHA Form facilitates
the completion of this section on the OAR and provides the practitioner
with a rich history of the woman’s life situation. [A full history of the ALPHA
development process has been reported elsewhere.8]
The Different ALPHA Versions
On both ALPHA versions, the antenatal factors have been grouped
intuitively by topic into four categories for ease of questioning during a
clinical encounter, with suggested questions: Family Factors, Maternal
Factors, Substance Use and Family Violence.
Provider-completed ALPHA
The provider-completed ALPHA Form has 35 questions relating to 15
antenatal factors. The questions are only suggestions, and providers are
encouraged to modify the questions to suit the pregnant women in their
practice and their practice style. On the provider version the adverse
outcomes are abbreviated after each antenatal factor. Bold italics indicate
a good association; regular print indicates a fair association. There is a
8
THE ALPHA FORMS
column with check off boxes to indicate the concern over any antenatal
factor. Space on the right of the form is available for notes. There is a list
of resources at the end of the form to facilitate follow-up planning.
Self-Report ALPHA
The self-report has been expanded to 43 questions that have been
formatted either with a ranking scale from 1-5 or with a yes/no response
with room for comments. The associations with the adverse postpartum
outcomes are not included on the form itself. The associations are printed
on the provider recap or summary sheet that can be used with the selfreport version. The summary form also has a list of resources similar to
the provider version.
Both versions are included at the end of the chapter. They are also
available at http://dfcm19.med.utoronto.ca/research/alpha
9
USING THE GUIDE
1. Interviewing Process
The provider version can be completed in one session of about 20 minutes
or over several prenatal visits. The woman should be advised in advance
that her next appointment would be longer because of the assessment
process. Providers can bill for counseling/psychotherapy when appropriate.
The self-report version can be given to the woman to complete at the end
of a visit or when she is waiting before a visit. It is not advisable for the
woman to take the form home or to complete it if she is waiting with her
partner. Some of the questions are very confidential in nature or relate to
sensitive couple issues.
It is recommended that either version of the form be completed after
20 weeks gestation. It is helpful to normalize the interview process
by indicating that current practice is to ask all pregnant women about
the psychosocial issues in their lives. Feedback from women in the
pilot study and the study on P.E.I. revealed that the women enjoyed
the interview process and found that it enhanced the provider’s
understanding of their life situation.
2. Problem Identification
The forms serve as means to identify antenatal factors associated with
adverse postpartum outcomes. Early problem identification can lead to
greater understanding and tailoring of care. Providers can collaborate with
pregnant women around decision-making and the identification of the best
intervention strategies.
10
USING THE GUIDE
3. Grouping of Factors
The antenatal factors have been intuitively grouped into categories.
These are: Family Factors, Maternal Factors, Substance Abuse, and Family
Violence. The factors are arranged in order from less-to-more sensitive
areas of inquiry. This layout facilitates the provider’s development of an
interviewing rhythm with the pregnant woman.
4. Issues of Confidentiality
Information elicited may be very confidential in nature. Except in the
case of child abuse, which must be reported to children’s protective
services, careful consideration and permission-seeking should occur
before information is shared with others. It would be appropriate to share
information with the other members of the health care team, including
the family physician, obstetrician, midwife, pediatrician, community health
nurse and perinatal nursing staff.
5. Causality is NOT Implied
The antenatal factors are only associated with problematic postpartum
outcomes. If an antenatal factor is identified, the woman will not necessarily
experience an adverse outcome. Identifying the factor in the pregnancy
allows the provider to engage in watchful-waiting to see if a postpartum
problem begins to develop.
11
USING THE GUIDE
6. Identification of Resources
It is incumbent on providers to identify resources that are appropriate and
available. Smaller communities may not have extensive resources, or may
have resources with long waiting lists or some distance away, making it
difficult or impossible for some women to attend.
7. Cultural Competence
Each culture has a rich social fabric. In some cultures, disclosure of
psychosocial issues is rare and discouraged, and the use of outside
resources is frowned upon. In other communities, elders are often arbiters
and mediators. If an antenatal factor is disclosed, it would be appropriate
to ask the woman, “In your culture, how is this issue managed/handled?”
“Who would you tell about this problem?”
8. Interpreters
Care must be taken when using interpreters. Because of the personal
nature of the questions, it is advisable to use trained women interpreters.
However, in some instances, because of the close inter-connectivity of
some cultural groups, a woman may be reluctant to disclose sensitive
issues to an interpreter she may meet in social situations. Using an
interpreter who speaks the woman’s language but does not share her
culture may be most appropriate.
If interpreters are not available, it is wise to use non-family members
and avoid using the woman’s spouse or children. Before beginning the
ALPHA assessment, it is appropriate if the interpreter introduces herself,
12
USING THE GUIDE
normalizes her presence at the interview, and assures the woman that the
discussion will be kept private and confidential, in all areas, except in the
area of child abuse.
9. Design of Guide
The guide was developed for use as a quick reference tool. For this reason,
many of the sections outlining suggestions for interventions are repeated
in entirety, i.e., information on woman abuse. This repetition is not to be
construed as an over-emphasis on any one psychosocial issue.
1 ALPHA Group: Family Physicians: Anne Biringer, June Carroll, Richard Glazier, Anthony Reid,
Lynn Wilson; Psychiatrist, Donna Stewart; Anthropologist, Beverly Chalmers; Midwives, Maryn Tate,
Freda Seddon; Nurse Educator/Researcher, Deana Midmer
2 Carroll JC, Reid A, Biringer A, Wilson L, Midmer D. Psychosocial Risk Factors During Pregnancy:
What do Family Physicians ask about? Canadian Family Physician, 1994; 40:1280-1290.
3 Wilson L, Reid A, Midmer D, Biringer A, Carroll JC, Stewart DE. Antenatal psychosocial risk factors
associated with adverse postpartum family outcomes. CMAJ, 1996; 15:785-791.
4 Reid A, Biringer A, Carroll JC, Midmer D, Wilson L, Chalmers B, Stewart DE. Using the ALPHA
Form in practice to assess antenatal psychosocial health. CMAJ, 1998; 159(6): 677-684.
5 Assessing Psychosocial Health in Pregnancy: Using The ALPHA Form, 2003. Executive Producer.
The Department of Family and Community Medicine, University of Toronto.
6 Midmer D, Bryanton J, Brown R. Assessing Antenatal Psychosocial Health Using Two Versions of
the ALPHA Form. Canadian Family Physician: 2004;50:80-87.
7 Carroll JC, Reid AJ, Biringer A, Midmer D, Wilson L, Permaul JA, Pugh P, Chalmers B,
Seddon F, Stewart DE. Effectiveness of the Antenatal Psychosocial Health Assessment (ALPHA)
form in detecting psychosocial concerns: a randomized controlled trial. CMAJ 2005;173(3):253-9.
8 Midmer D, Carroll JC, Bryanton J, Stewart DE. From research to application: The development of
an antenatal psychosocial health assessment tool. CJPH 2002; 93(4):291-6.
13
Please visit website for letter size forms at
http://dfcm19.med.utoronto.ca/research/alpha
Antenatal Psychosocial
Health Assessment (ALPHA)
Addressograph
Antenatal psychosocial problems may be associated with
unfavorable postpartum outcomes. The questions on this form
are suggested ways of inquiring about psychosocial health.
Issues of high concern to the woman, her family or the caregiver
usually indicate a need for additional supports or services.
When some concerns are identified, follow-up and/or referral
should be considered. Additional information can be obtained
from the ALPHA Guide. *Please consider the sensitivity of this
information before sharing it with other caregivers.
ANTENATAL FACTORS
CONCERN
FAMILY FACTORS
Social support (CA, WA, PD)
How does your partner/family feel about your pregnancy?
Who will be helping you when you go home with your baby?
£ Low
£ Some
£ High
Recent stressful life events (CA, WA, PD, PI)
What life changes have you experienced this year?
What changes are you planning during this pregnancy?
£ Low
£ Some
£ High
Couple’s relationship (CD, PD, WA, CA)
How would you describe your relationship with your partner?
What do you think your relationship will be like after the birth?
£ Low
£ Some
£ High
MATERNAL FACTORS
Prenatal care (late onset) (WA)
First prenatal visit in third trimester? (check records)
£ Low
£ Some
£ High
Prenatal education (refusal or quit) (CA)
What are your plans for prenatal classes?
£ Low
£ Some
£ High
Feelings toward pregnancy after 20 weeks (CA, WA)
How did you feel when you just found out you were pregnant?
How do you feel about it now?
£ Low
£ Some
£ High
Relationship with parents in childhood (CA)
How did you get along with your parents?
Did you feel loved by your parents?
£ Low
£ Some
£ High
Self-esteem (CA, WA)
What concerns do you have about becoming/being a mother?
£ Low
£ Some
£ High
History of psychiatric/emotional problems (CA, WA, PD)
Have you ever had emotional problems?
Have you ever seen a psychiatrist or therapist?
£ Low
£ Some
£ High
Depression in this pregnancy (PD)
How has your mood been during this pregnancy?
£ Low
£ Some
£ High
ASSOCIATED POSTPARTUM OUTCOMES
The antenatal factors in the left column have been shown to be associated with
the postpartum outcomes listed below. Bold, Italics indicates good evidence of association.
Regular text indicates fair evidence of association.
CA – Child Abuse CD – Couple Dysfunction PI – Physical Illness
PD – Postpartum Depression WA – Woman Abuse
COMMENTS/PLAN
ANTENATAL FACTORS
CONCERN
COMMENTS/PLAN
SUBSTANCE USE
Alcohol/drug abuse (WA, CA) (1drink=11/2 oz liquor, 12 oz beer, 5 oz wine)
How many drinks of alcohol do you have per week?
Are there times when you drink more than that?
Do you or your partner use recreational drugs?
Do you or your partner have a problem with alcohol or drugs?
Consider CAGE (Cut down, Annoyed, Guilty, Eye opener)
£ Low
£ Some
£ High
FAMILY VIOLENCE
Woman or partner experienced or witnessed abuse
(physical, emotional, sexual) (CA, WA)
What was your parents’ relationship like?
Did your father ever scare or hurt your mother?
Did your parents ever scare or hurt you?
Were you ever sexually abused as a child?
£ Low
£ Some
£ High
Current or past woman abuse (WA, CA, PD)
How do you and your partner solve arguments?
Do you ever feel frightened by what your partner says or does?
Have you ever been hit/pushed/slapped by a partner?
Has your partner ever humiliated you or psychologically abused
you in other ways?
Have you ever been forced to have sex against your will?
£ Low
£ Some
£ High
Previous child abuse by woman or partner (CA)
Do you/your partner have children not living with you?
If so, why?
Have you ever had involvement with a child protection agency
(i.e. Children’s Aid Society)?
£ Low
£ Some
£ High
Child discipline (CA)
How were you disciplined as a child?
How do you think you will discipline your child?
How do you deal with your kids at home when they misbehave?
£ Low
£ Some
£ High
FOLLOW UP PLAN
q Supportive counselling by provider
q Additional prenatal appointments
q Additional postpartum appointments
q Additional well baby visits
q Public Health referral
q Prenatal education services
q Nutritionist
q Community resources /
mothers’ group
q Homecare
q Parenting classes / parents’ support group
q Addiction treatment programs
q Smoking cessation resources
q Social Worker
q Psychologist / Psychiatrist
q Psychotherapist / marital / family therapist
q Assaulted women’s helpline /
shelter / counseling
COMMENTS:
Date Completed
Signature
© ALPHA Group, April, 2005; Department of Family & Community Medicine, University of Toronto
http://dfcm19.med.utoronto.ca/research/alpha
q Legal advice
q Children’s Aid Society
q Other:
q Other:
q Other:
q Other:
THE ALPHA SELF-REPORT QUESTIONNAIRE FOR WOMEN
Name
Date
Months Pregnant
Having a baby usually means changes in your family life. You may wish to discuss some of these topics with your healthcare
provider. She/he may help you with these changes. Please answer the questions the best way you can. Your answers are
confidential and will be kept private.
Please answer the questions by circling a number on the scale, writing an answer in the space,
or marking “yes” or “no”. If some of the questions do not apply to you, please circle N/A (not applicable).
YOUR FAMILY LIFE
Please answer the following questions about your family life.
Family Factors
1. About this pregnancy, my partner feels
very happy
1
2. About this pregnancy, my family feels
very happy
1
3. I feel supported in this pregnancy
very much
1
4. My partner will be involved with the baby
a great deal
1
5. When I am home with the baby I will have help from (state relationship)
Comments:
2
2
2
2
3
3
3
3
4
4
4
4
5
5
5
5
very unhappy
very unhappy
not at all
not at all
Recent Life Stresses (moving, job change or loss, family illness or death, money troubles, and so on)
6. Over the past year, my life has been
very relaxed
1
2
3
4
5 very stressful
7. I am making life changes during this pregnancy
q No q Yes If yes, describe
Comments:
Relationship With Partner (if this applies)
8. My relationship with my partner is usually
9. After the baby, I expect my partner and I will get along
Comments:
YOUR OWN LIFE
very happy
very well
1
1
2
2
3
3
4
4
5
5
very unhappy
not at all
Please answer the following questions about your own life and feelings.
10. In this pregnancy, I first came for care when I was
(indicate number) child.
11. I am planning to take prenatal classes
Comments:
months pregnant. This is my
q Yes q No
1st
2nd
3rd
Reasons, if no,
Feelings About Being Pregnant
12. My feelings about this pregnancy at first
13. My feelings about this pregnancy now
Comments:
very happy
very happy
1
1
2
2
3
3
4
4
5
5
very unhappy
very unhappy
Relationship With Parents
14. When I was a child, I got along with my parent(s)
15. As a young child I felt loved by my mother
16. As a young child I felt loved by my father
Comments:
very much
very much
very much
1
1
1
2
2
2
3
3
3
4
4
4
5
5
5
not at all
not at all
not at all
Feelings About Becoming/Being a Mother
17. I have concerns about becoming/being a mother
Comments:
none at all
1
2
3
4
5
very many
q No q Yes
q No q Yes
happy/up
1
2
3
4
5
sad/down
Emotional Health
18. I have had some emotional problems
19. I have seen a psychiatrist/therapist
20. In this pregnancy, my mood has been usually
Comments:
N/A
N/A
CONCERNS IN YOUR LIFE Please answer the following questions about stress in your life.
Alcohol and Drug Use During Pregnancy
21. Each week I drink
drinks. (1 drink = 1 1/2 oz liquor, 12 oz beer, 5 oz wine)
22. There are times when I drink more during the week
q No q Yes If yes, describe
23. Sometimes I’ve felt:
A need to cut-down my drinking q No q Yes
Annoyed by people criticizing my drinking q No q Yes
Guilty about my drinking q No q Yes
A need for a drink first thing in the morning q No q Yes
24. I use recreational drugs, e.g., marihuana
25. I have some drug problems
26. My partner uses recreational drugs, e.g., marihuana
27. My partner has some drug problems
never
1
2
3
4
q No q Yes If yes, describe
never
1
2
3
4
q No q Yes If yes, describe
5
very often
5
very often
Comments:
Parent’s Relationship (when you were a young child)
28. My parents usually got along
very well
1
29. My father sometimes scared or hurt my mother
never
1
30. My parents sometimes scared or hurt me
never
1
31. As a child I was sexually abused
q No q Yes
2
2
2
3
3
3
4
4
4
5
5
5
not at all
very often
very often
N/A
N/A
N/A
2
2
3
3
4
4
5
5
a lot of tension
great difficulty
N/A
N/A
2
2
3
3
4
4
5
5
very often
very often
N/A
2
3
4
5
very often
N/A
Comments:
Relationship With Partner (if this applies)
32. My relationship with my partner usually has no tension
1
33. We work out arguments with
no difficulty 1
34. I’ve sometimes felt scared by what
my partner says or does
never
1
35. I’ve been hit/pushed/slapped by a partner
never
1
36. I’ve sometimes been put down or humiliated
by my partner
never
1
37. I’ve been forced to have sex against my will
q No q Yes
Comments:
Raising Children
38. I have children not living with me
q No q Yes
39. My partner has children not living with him
q No q Yes
40. As a child, I was involved with Children’s Protective Services (Children’s Aid)
41. Children in my care have been involved with Children’s Protective Services
q No q Yes
q No q Yes
Comments:
42. As a child, I was harshly disciplined by parents/family
43. I think spanking is necessary
never
never
1
1
2
2
3
3
4
4
Comments:
44. Overall, how concerned are you about your emotional and family life?
not at all concerned
1
2
3
4
5
6
7
extremely concerned
45. What issues in your life are most concerning to you?
46. What help, if any, would you like?
© ALPHA Group, April, 2005; Department of Family & Community Medicine, University of Toronto
http://dfcm19.med.utoronto.ca/research/alpha
5
5
very often
very often
THE ALPHA SELF-REPORT
QUESTIONNAIRE FOR WOMEN
Addressograph
Antenatal Psychosocial Health Assessment
Provider Summary
Antenatal psychosocial problems may be associated with unfavorable
postpartum outcomes. Once the woman has completed the selfreport ALPHA, this form can be used to note her responses.
Issues of high concern to the woman, her family or the caregiver
usually indicate a need for additional supports or services. When
issues of some concern are identified, follow-up and/or referral
should be considered. Additional information can be obtained
from the ALPHA Guide. Please refer to the other side of this
page for information on antenatal psychosocial factors that are
associated with problematic postpartum outcomes. Please consider
the sensitivity of this information before sharing it with other caregivers.
For specific information on how to deal with psychosocial issues refer to the Reference Guide for Providers or
go to http://dfcm19.med.utoronto.ca/research/alpha
FOLLOW UP PLAN
q Supportive counselling by provider
q Additional prenatal appointments
q Additional postpartum appointments
q Additional well baby visits
q Public Health referral
q Prenatal education services
q Nutritionist
q Community resources /
mothers’ group
q Homecare
q Parenting classes / parents’ support group
q Addiction treatment programs
q Smoking cessation resources
q Social Worker
q Psychologist / Psychiatrist
q Psychotherapist / marital / family therapist
q Assaulted women’s helpline /
shelter / counseling
DATE (YY/MM/DD)
SUMMARY/REFERRAL
Date (YY/MM/DD)
Signature
q Legal advice
q Children’s Aid Society
q Other:
q Other:
q Other:
q Other:
FOLLOW-UP
PROVIDER GUIDE FOR THE ALPHA SELF-REPORT QUESTIONNAIRE FOR WOMEN
Problems in questions below have been shown to be associated with problematic postpartum outcomes.
CA
CD
Child Abuse
Couple Dysfunction
PI
PD
Physical Illness
Postpartum Depression
WA
Woman Abuse
If a woman’s responses on the Self-Report ALPHA indicate psychosocial concerns, the following postpartum associations may
apply. Bold italics indicates good association, regular type indicates fair association with adverse postpartum outcomes.
FAMILY FACTORS
1. About this pregnancy, my partner feels
2. About this pregnancy, my family feels
3. I feel supported in this pregnancy
4. My partner will be involved with the baby
5. When I am home with the baby I will have help from
6. Over the past year, my life has been
7. I am making life changes during this pregnancy
8. My relationship with my partner is usually
9. After the baby, my partner and I will get along
Lack of social support
Lack of social support
Lack of social support
Lack of social support
Lack of social support
Recent stressful life events
Recent stressful life events
Couple dysfunction
Couple dysfunction
C A,
C A,
C A,
CD,
C A,
C A,
C A,
CD,
CD,
WA, PD
WA, PD
WA, PD
PD, WA, CA
WA, PD
WA, PD, PI
WA, PD, PI
PD, WA, CA
PD, WA, CA
Late onset prenatal care
Refusal to attend/quitting
Unwanted pregnancy after 20 weeks
Unwanted pregnancy after 20 weeks
Poor relationship with parents
Poor relationship with parents
Poor relationship with parents
Low self-esteem
Emotional/psychiatric history
Emotional/psychiatric history
Depression: prenatal & postpartum
WA
CA
C A,
C A,
CA
CA
CA
C A,
C A,
C A,
PD
Problematic substance use
Problematic substance use
Problematic substance use
Problematic substance use
Problematic substance use
Problematic substance use
Problematic substance use
WA,
WA,
WA,
WA,
WA,
WA,
WA,
Experience/witness abuse
Experience/witness abuse
Experience/witness abuse
Experience/witness abuse
Past/current intimate partner violence
Past/current intimate partner violence
Past/current intimate partner violence
Past/current intimate partner violence
Past/current intimate partner violence
Past/current intimate partner violence
Previous child abuse
Previous child abuse
Previous child abuse
Previous child abuse
Use of harsh discipline
Use of harsh discipline
C A, WA
C A, WA
C A, WA
C A, WA
WA, CA, PD
WA, CA, PD
WA, CA, PD
WA, CA, PD
WA, CA, PD
WA, CA, PD
CA
CA
CA
CA
CA
CA
MATERNAL FACTORS
10. I came for prenatal care when I was in
11. I am planning to take prenatal classes
12. My feelings about the pregnancy at first
13. My feelings about the pregnancy now
14. When I was a child, I got along with my parent(s)
15. As a child, I felt loved by my mother
16. As a child, I felt loved by my father
17. I have concerns about becoming/being a mother
18. I have had some emotional problems
19. I have seen a therapist/psychiatrist
20. In this pregnancy, my mood has been usually
WA
WA
WA
WA, PD
WA, PD
SUBSTANCE ABUSE
21. Each week I drink
22. There are times when I drink more during the week
23. Sometimes I’ve felt (CAGE questions)
24. I use recreational drugs
25. I have some drug problems
26. My partner uses recreational drugs
27. My partner has some drug problems
CA
CA
CA
CA
CA
CA
CA
FAMILY VIOLENCE
28. My parents usually got along
29. My father sometimes scared or hurt my mother
30. My parent(s) sometimes scared or hurt me
31. As a child I was sexually abused
32. My relationship with my partner usually has
33. We work out arguments with
34. I’ve felt scared by what my partner says or does
35. I’ve been hit/pushed/slapped by a partner
36. I’ve been put down or humiliated by my partner
37. I have been forced to have sex against my will
38. I have children not living with me
39. My partner has children not living with him
40. As a child I was involved with CAS
41. Children in my care have been involved with CAS
42. As a child I was harshly disciplined
43. I think spanking is necessary
NOTE: Although low SES/financial concerns were not found to be associated with the poor postpartum outcomes,
they were associated with Low Birth Weight.
© ALPHA Group, April, 2005; Department of Family & Community Medicine, University of Toronto
http://dfcm19.med.utoronto.ca/research/alpha
FAMILY FACTORS
Social Support
Recent Stressful Life Events
Couple’s Relationship
Socioeconomic Status
Family Factors
SOCIAL SUPPORT
Definition of
Social Support
FAST FACTS
In its broadest sense, while
Lack of social support has shown
being modified and reshaped
Good evidence of association with
ˆ child abuse (CA)
ˆ woman abuse (WA)
by culture, ethnicity, and
family of origin, social support
reflects an individual’s sense
of belonging and safety with
respect to a caring partner,
Fair evidence of association with
ˆ postpartum depression (PD)
family or community. Some
individuals have large support networks, and others have fewer people
upon which to call for support. People get support in myriad ways, from
interactions with family and friends to chat rooms on the internet.
Lack of Social Support
Insufficient social support during pregnancy is characterized by isolation; a
lack of help when dealing with daily tasks, stressful events, or crises; and
a lack of social, instrumental, and/or emotional support from a spouse,
close friend or family member. The lack of support can range from
severe-to-mild and is best articulated by the woman. Sometimes a scaling
question is effective: On a scale of 1-to-10, with 1 being “very little” and
10 being “a lot”, how much support would you say you have in your life?
Social Support and Culture
Women who have recently relocated or immigrated to a new community
may experience a lack of social support. This is particularly true for refugee
women, who may experience a severe lack of support. The separation from
22
Family Factors
SOCIAL SUPPORT
their country of origin or from their cultural community may deeply compound
feelings of isolation. A lack of literacy in English or French may further
increase their sense of disconnection.
How to Ask
• How do your partner and/or family feel about your pregnancy?
• What support do you get from your family, friends, and partner?
• Who will be helping you when you go home with the baby?
• What family and/or friends do you have in town?
• Who do you turn to when you have a problem or when you’ve had a
bad day?
For immigrant and refugee women: If you were still in your country, what
support would you get? How can you get support here in Canada?
What to Do
Options to consider if you determine that the woman is lacking social support:
• Help her to understand the importance of and need for support after the baby is born.
• Ask the woman to identify how she might increase the support in her life.
• Consider additional visits during the pregnancy and postpartum periods.
• Consider meeting with her partner and/or family.
• Provide information about community groups for new mothers; encourage
her joining.
• Identify local resources that will provide culturally appropriate support.
• Consider a referral to social work, PHN, or to homecare for postpartum support
and follow-up.
23
Family Factors
RECENT STRESSFUL LIFE EVENTS
Definition of
Stressful Events
FAST FACTS
Stressful events are those
Stress and serious life problems
have shown
life experiences that require
some degree of adaptation,
with a resultant depletion of
emotional reserves. Stressful
events may be negative,
e.g., financial problems, job
loss, illness/death of a loved
one, legal problems, and/or
Good evidence of association with
ˆ child abuse (CA)
ˆ woman abuse (WA)
ˆ postpartum depression (PD)
Fair evidence of association with
ˆ physical illness (PI)
household or work moves.
Joyful events, such as marriages in the family or promotions and/or other
opportunities at work, can also be stressful and require adaptation by the
young family.
Responses to Stress
If over-stressed, individuals may resort to the stress-reduction behaviours
modeled in their family-of-origin. These may include social withdrawal,
abuse of alcohol or other substances, somatization, and/or inappropriate or
violent venting of anger and frustration. These negative stress management
strategies were often role-modeled by a parent, and the movement into
parenting roles may evoke these problematic behaviours in the new parents.
24
Family Factors
RECENT STRESSFUL LIFE EVENTS
How to Ask
• What major negative life changes have you experienced this year?
For example, job loss, financial problems, illness/death of a loved one?
• Have you had other stresses that are happy yet demanding of
your energy?
• Are you planning other changes during this pregnancy?
• How do you usually cope with stress in your life? How does your
partner cope?
• How did your parents cope with stress when you were a child at home?
• Tell me about a time when you managed stress well.
What to Do
Options to consider if you determine that the woman and/or her partner
have experienced recent stress:
• If appropriate, encourage the woman to discuss life stresses with her partner.
• Advise against taking on additional, elective changes, if possible.
• Consider meeting with her partner and/or family.
• Identify what positive stress reduction strategies have been effective in
the past, e.g., discussions with others, exercise, yoga, deep breathing,
visualization, and relaxation exercises.
• Identify what stress reduction strategies are being used that may be potentially
harmful, e.g., use of alcohol or other substances, withdrawal, eating disorders.
• Inquire at each visit about progress in this area and encourage small changes.
• Provide information about community resources to learn about stress reduction.
• Identify local resources that will provide culturally appropriate support.
• Consider referral to a social worker or relaxation therapist.
• Schedule extra visits for postpartum and well-baby care.
25
Family Factors
COUPLE’S RELATIONSHIP
Postpartum Couple
Relationship
FAST FACTS
The strongest predictor of a
Antenatal couple dysfunction and
rigid traditional roles have shown
good postnatal relationship is
the quality of the relationship
in the antenatal period. How
couples rate their relationship
antenatally is strongly
correlated with the way they
rate their relationship in the
first postnatal months. Another
Good evidence of association with
ˆ couple dysfunction (CD)
ˆ postpartum depression (PD)
Fair evidence of association with
ˆ woman abuse (WA)
ˆ child abuse (CA)
predictor is the quality of the
marriage in their family of origin. If their parents were happy, they are also
more likely to experience good couple functioning.
The Traditional Postpartum Relationship
Most marriages or partnerships become more traditional in the
postpartum period by virtue of the woman’s increased emotional
and financial dependence on her partner. Because of this shift in the
spousal structure, women who hold less traditional role expectations
may experience more marital dissatisfaction in the postpartum period,
especially if there is rigid sex-role stereotyping of household tasks.
26
Family Factors
COUPLE’S RELATIONSHIP
How to Ask
• How will your partner be involved in looking after the baby?
• How do you share tasks at home? How do you feel about this?
• Has your relationship changed since pregnancy? What will it be like
after the baby?
• Do you have any concerns about your relationship with your partner?
• Are you traditional by nature? Is your partner?
• In your culture, what usually happens in a couple relationship once
the baby is born?
What to Do
Options to consider if you determine the woman is experiencing couple
relationship difficulties:
• Discuss the woman’s feelings about the relationship. What changes does
she want?
• Rule out woman abuse as an issue if there is any couple dysfunction.
• Elicit what is a culturally appropriate intervention for the woman and
her partner.
• Encourage the couple to problem solve and seek solutions together.
• Offer to see the couple together and provide office counseling, if appropriate.
• Refer to a social worker, marital therapist, G.P. psychotherapist, or psychologist.
27
Family Factors
SOCIOECONOMIC STATUS
Low SES and
Psychosocial
Outcomes
Low socioeconomic status
(SES) by itself was not found
to be an antenatal predictor
for adverse postpartum family
FAST FACTS
Low socioeconomic status (SES)
is not strongly associated with
adverse birth outcomes or low birth
weight (LBW)
ˆ
outcomes. However, adequate
housing, appropriate nutrition,
and enough money to survive
Low SES may be a marker for
other factors associated with LBW,
such as smoking and povertyrelated low maternal weight
are social determinants of
health. The inability to meet basic survival needs and the experience of
poverty may limit the capacity of individuals to feel safe and secure in their
day-to-day lives.
The constant and unrelenting stress and anxiety that can accompany
jeopardized survival may be mitigating factors in the adverse postpartum
outcomes of child abuse, woman abuse, couple dysfunction, and
physical illness.
How to Ask
• Are you and/or your partner presently receiving pay for work?
• What is your employment/occupational history?
• How are you managing financially?
• Do you have financial concerns/worries?
• How do you think you will manage after the baby is born?
28
Family Factors
SOCIOECONOMIC STATUS
What to Do
Options to consider if you determine the woman and family are
financially stressed:
• Ask the woman what financial strategies have worked in the past.
• Determine how the financial stresses are impacting on the woman,
e.g., poor nutrition.
• Refer to a nutritionist, if appropriate.
• Begin nutritional supplementation, if appropriate.
• Identify community resources, including local food banks.
• Identify problems the woman may have in relating to resources,
e.g., language barrier.
• Refer to a social worker, if appropriate.
• Discuss different approaches to the problem, e.g., courses on budgeting,
time management, money management, credit counseling.
29
MATERNAL FACTORS
Late Onset Prenatal Care
Prenatal Education (refusal or quit)
Feelings About Pregnancy After 20 Weeks
Relationship With Parents
Self-Esteem Issues
Emotional/Psychiatric History
Depression in This Pregnancy
Maternal Factors
LATE ONSET PRENATAL CARE
Seeking
Prenatal Care
FAST FACTS
If a primiparous woman
Late onset of prenatal care has shown
does not start prenatal care
Good evidence of association with
ˆ woman abuse/intimate partner
violence (WA)
until the third trimester, this
is a “red flag” for concern
because of the association
with intimate partner violence.
It is important to inquire why there was a delay in seeking prenatal care. If
a woman indicates that she has just moved into the area as the reason for
seeking care late in pregnancy, it is wise to delve into this a little further.
In some cases of intimate partner violence, constant location changes are
part of the abuse pattern. It is also important to identify any cultural factors
that impact on the woman’s decision to attend for care. In some instances,
delayed care may be due to a denial of the pregnancy, mental illness or a
scarcity of physicians.
A woman may experience the following types of abuse:
• emotional: being controlled by her partner; threatened with harm;
denigrated, criticized and humiliated
• physical: being hit, slapped, choked, pushed, burnt, whipped; objects
thrown at her
• sexual: sexual assault or rape; pressure to perform sexual acts unwillingly
• financial: total financial dependence on partner; having to account for
money spent
• social: isolation in the community; denial of access to friends or family
• spiritual: denied access to a church, temple or synagogue
32
Maternal Factors
LATE ONSET PRENATAL CARE
How to Ask
• When did you first start prenatal care?
• What is the reason you did not start prenatal care sooner?
• In your culture, when do women usually seek care when pregnant?
From whom?
What to Do
Options to consider if you determine/suspect the woman is being
abused/assaulted:
• Interview her alone; if necessary use an interpreter (non-family).
• Explore the issue with care and sensitivity to cultural differences.
• Reassure her about confidentiality and your concern for her health and welfare.
• If IPV is disclosed, explain that it is not her fault and that no one has a right to
hit another person.
• Allow her to make decisions and take charge and control of her life.
• Help her to explore her options: family, friends, hostel/shelter, and counseling.
• Make her aware that violence can increase during pregnancy or after birth.
• Determine whether the woman is safe in her home and help her develop a
safety plan.
• Indicate that you will support her whether she decides to stay with or leave
her partner.
• Make her aware of community resources: numbers of shelters, legal aid,
support groups.
• Make her aware that assault is a crime punishable by law, and keep
detailed notes.
• If danger is severe, request permission to consult with local police for advice.
• Determine if other children in the family are at risk or are being abused.
33
Maternal Factors
PRENATAL EDUCATION
Attendance at
Prenatal Classes
If a primiparous woman
refuses to attend prenatal
classes or quits prenatal
classes, this is associated
FAST FACTS
Refusal to attend or quitting
prenatal classes has shown
Good evidence of association with
ˆ child abuse (CA)
with an increased likelihood
of child abuse. However, as
with all maternal factors, it is important to look at the context of a woman’s
life situation before drawing conclusions about her risk for postpartum
difficulties.
A woman may not attend classes because she and/or her partner do not
speak the language in which they are given in her community. She may
not choose to attend because she is single and classes are only offered
to couples, because she is in a same-sex relationship and classes are
heterosexual in orientation, because her partner refuses to attend, or
because she can not afford the class fees. However, she may also not attend
because she does not want the pregnancy. It is important to explore her
reasons for non-attendance. This is particularly important if she comes from
a demographic group where attending prenatal classes is a normal part of
the pregnancy experience. If this is her second or other pregnancy, or if she
is scheduled for an elective Caesarian, she may have no need of classes.
How to Ask
• Are you planning to take prenatal classes? If not, why not?
• What were your reasons for quitting your prenatal classes?
• In your culture, how do new mothers learn about giving birth?
34
Maternal Factors
PRENATAL EDUCATION
What to Do
Options to consider if you determine the woman refuses or has quit
prenatal classes:
• Explore her feelings about the pregnancy and coming child.
• Discuss any concerns she may have about the birth.
• Determine whether the decision to not attend or quit classes is hers or
her partner’s.
• Offer alternative educational opportunities: readings, birth videos, private
classes, and sessions with the office nurse.
• Schedule extra well-baby visits and follow the family closely after birth.
• Consider whether a visit by the PHN in the postpartum period is warranted.
• Refer to a social worker, psychologist or counselor if appropriate.
• If you have serious concerns, contact the CAS for general advice on
how to intervene.
• Consider whether this risk factor, in conjunction with other information about the
family, indicates that CAS should be involved in the postpartum period.
35
Maternal Factors
FEELINGS ABOUT PREGNANCY
AFTER 20 WEEKS
Feelings Towards
Pregnancy
Most women experience
some ambivalence about
being pregnant in the early
weeks. It is helpful to discuss
any ambivalence with the
FAST FACTS
Unwanted pregnancy after 20 weeks
has shown
Good evidence of association with
ˆ child abuse (CA)
ˆ woman abuse (WA)
woman early in her pregnancy
and offer her support. It is
also important to determine a woman’s feelings later in the pregnancy,
since an increased risk for child abuse is associated with an unwanted
and unaccepted pregnancy after 20 weeks. This may also be an indication
of distress in her relationship with her partner. Exploring the issue around
intimate partner violence is also warranted.
The woman may express unhappy feelings or demonstrate little interest in
the pregnancy. In particular, it is important to determine a woman’s feelings
about the pregnancy when she has initially decided to put the baby up for
adoption and then changes her mind later in the pregnancy.
How to Ask
• How did you feel when you found out you were pregnant?
How do you feel about it now?
• How does your partner feel about the pregnancy? Your family?
• In your culture, how do women describe their feelings about
being pregnant?
36
Maternal Factors
FEELINGS ABOUT PREGNANCY
AFTER 20 WEEKS
What to Do
Options to consider if you determine the woman does not want or accept
the pregnancy at 20 weeks:
• Discuss the woman’s feelings further and help her explore her options.
• Consider meeting with the woman and her partner together.
• Schedule extra antenatal visits to provide a forum for discussion
and/or counseling.
• Refer to PHN or social worker, if appropriate.
• Refer to a therapist, psychologist, or psychiatrist, if appropriate.
• Schedule extra well-baby visits and monitor very closely.
• Contact the CAS for general advice on how to intervene if rejection is severe
and chronic.
• Consider whether this risk factor, in conjunction with other information about
the family, indicates that CAS or PHN should be involved in the
postpartum period.
Options to consider if you determine/suspect the woman is being
abused/assaulted:
• Interview her alone; if necessary use an interpreter (non-family).
• Reassure her about confidentiality and explain that it is not her fault.
• Help her to explore her options: family, friends, hostel/shelter, and counseling.
• Determine whether the woman is safe in her home and help her develop a
safety plan.
• Indicate that you will support her whether she decides to stay with or leave
her partner.
• Make her aware of community resources: numbers of shelters, legal aid,
support groups.
• Make her aware that assault is a crime punishable by law, and keep
detailed notes.
• If danger is severe, suggest that she consult with local police for advice.
37
Maternal Factors
RELATIONSHIP WITH PARENTS
Quality of
Relationship
With Parents
If a pregnant woman
describes herself as having
had a poor relationship with
FAST FACTS
A poor childhood relationship with
parents has shown
Good evidence of association with
ˆ child abuse (CA)
her parents when growing up,
there is an association with
child abuse in the future. For example, a woman may describe herself as
having had conflict and a lack of closeness with her mother, or she may
have had feelings that her parents were displeased with her as a child.
She may also have felt unaccepted by her family of origin, or describe the
parenting she received as cold and rejecting.
However further exploration is necessary. Many women who were reared
by cold or non-engaged parents make a conscious decision to mother in a
different manner, with love and warmth. Also, if opportunities arise, it would
also be important to pursue the following lines of questioning with the
woman’s partner as well.
How to Ask
• As a child, did you feel loved by your parents?
• How do you get along with your parents now? How did you get along
as a child?
• In what ways will you parent like your parents did? What would you
do differently?
• In your culture, what is the usual way of parenting? Of disciplining?
Of showing affection?
38
Maternal Factors
RELATIONSHIP WITH PARENTS
What to Do
Options to consider if you determine the woman had a poor childhood
relationship with her parents:
• Discuss how this may affect her mothering.
• Ask the woman to identify how she can develop a strong bond with her infant.
• Refer for infant-parent attachment therapy, if appropriate and/or available in
your area.
• Refer to mothering/parenting classes through prenatal education/community
resources.
• Refer to a new parent support group, if appropriate.
• Monitor closely and schedule extra visits postpartum, if necessary.
• Refer to PHN, social worker, psychologist or counselor, if appropriate.
• Consider whether this risk factor, in conjunction with other information about
the family, indicates that CAS should be involved in the postpartum period.
39
Maternal Factors
SELF-ESTEEM ISSUES
Definition of
Self-Esteem
FAST FACTS
Self-esteem can be defined
Low maternal self-esteem has shown
as self-respect or having a
Good evidence of association with
ˆ child abuse (CA)
favorable opinion of oneself.
A woman with healthy selfesteem would feel good
about herself and see herself
Fair evidence of association with
ˆ woman abuse (WA)
as generally successful in life.
Many primiparous women have some anxiety around infant care, yet they
also have secure and positive feelings about their mothering skills.
Lack of Maternal Self-Esteem
Women who view themselves as unsuccessful in life often regard
themselves negatively and have insecure feelings about their future
mothering skills. These feelings of insecurity may be related to how they
viewed their mother’s feelings of competence and her ability as a parent.
There is a good correlation between low maternal self-esteem and child
abuse and a fair correlation with woman abuse.
How to Ask
• What concerns do you have about becoming/being a mother?
• What sort of mother do you think you’ll be?
• How do you picture yourself as a mother?
• What was your mother like?
40
Maternal Factors
SELF-ESTEEM ISSUES
• In your culture, what are mothers expected to be like?
• In your culture, how are mothers supposed to act or behave?
What to Do
Options to consider if you determine that the woman has poor self-esteem
or negative expectations of mothering:
• Discuss during visits and provide on-going support and follow-up.
• Meet with woman and her partner, if appropriate.
• Schedule extra well-baby visits and monitor closely postpartum.
• Identify situations when the woman has had higher self-esteem and encourage
her to seek out more of these situations.
• Refer to prenatal education or community for mothering groups or new
parent groups.
• Refer to a social worker, psychologist or counselor, if appropriate.
• Refer for infant-parent attachment therapy, if available in your area.
41
Maternal Factors
EMOTIONAL/PSYCHIATRIC HISTORY
Past History
of Emotional
or Psychiatric
Problems
During the course of
prenatal care, it is important
to determine whether the
woman has experienced a
psychiatric disorder in the
past or present because of
FAST FACTS
A history of psychiatric or emotional
problems has shown
Good evidence of association with
ˆ child abuse (CA)
ˆ woman abuse (WA)
Fair evidence of association with
ˆ postpartum depression (PD)
the strong association with
postpartum mental illness, child abuse and woman abuse.
Specifically, the conditions that have been found to be important include
depression, anxiety, bipolar affective disorders, schizophrenia, chronic
psychiatric problems, or a history of past or present psychiatric treatment.
If a woman presents with an untreated major mental illness during
pregnancy, immediate referral to a psychiatrist is essential.
How to Ask
• Have you ever had emotional problems? How serious were they?
Were you taking any medication?
• Have you ever seen, or are you seeing, a psychiatrist or therapist?
• How would you describe your current emotional/mental health?
• In your culture, what does a woman do if she has serious emotional/
psychiatric problems?
42
Maternal Factors
EMOTIONAL/PSYCHIATRIC HISTORY
What to Do
Options to consider if you determine the woman has/had serious emotional
or psychiatric problems:
• Assess the woman’s current state of emotional/mental health.
• Identify extra social support resources that might be available for the woman in
the postpartum period.
• Schedule extra antenatal visits for monitoring and follow-up.
• Monitor carefully for postpartum depression disorders or flare-ups of other
psychiatric disorders.
• Refer to a PHN, social worker, a psychologist, or homecare, if appropriate.
• Refer to a therapist for counseling, if the disorder is mild.
• Refer to a psychiatrist for assessment and treatment if the disorder is moderate
or severe.
43
Maternal Factors
DEPRESSION IN THIS PREGNANCY
Depression in
Pregnancy
In general, 10-15% of
new mothers experience
a postpartum depression
and approximately the
FAST FACTS
A history of depression or anxiety
in this pregnancy has shown
Good evidence of association with
ˆ postpartum depression (PD)
same number experience
depression during pregnancy.
Numerous studies have shown that if a woman is clinically anxious or
depressed during her pregnancy, she is at higher risk for a postpartum
mood or anxiety disorder.
Other factors that increase her risk of experiencing postpartum depression
include previous depression, recent serious life stress, a lack of social
support, couple relationship problems, a family history of depression,
previous other emotional and/or psychiatric problems, a previous
postpartum depression, and a difficult infant.
A woman may develop a postpartum mood or anxiety disorder immediately
after birth or at any time in the first postpartum year.
How to Ask
• How has your mood been during this pregnancy?
• Have you felt low, very tense, or depressed at times during this
pregnancy? If yes, for how long?
• Were you anxious or depressed during or after previous pregnancies?
• Did you take medication to manage a previous depression or anxiety?
44
Maternal Factors
DEPRESSION IN THIS PREGNANCY
What to Do
Options to consider if you determine the woman is at risk for a postpartum
mood or anxiety disorder:
• Provide close follow-up before and after delivery.
• Schedule a visit with the woman and her partner to discuss postpartum mood
and anxiety disorders.
• Schedule extra visits early after birth and monitor the woman’s mental
health closely.
• Identify extra social support resources that might be available for the
woman postpartum.
• Refer to community support and self-help groups.
• Refer to a PHN, homecare, social worker, therapist, and/or psychiatrist,
if appropriate.
• Consider the use of antidepressants in pregnancy and during the postpartum
period, if needed.
45
SUBSTANCE ABUSE
Smoking During Pregnancy
Alcohol Use in Pregnancy
Substance Abuse
SMOKING DURING PREGNANCY
Smoking During
Pregnancy
Numerous studies have
shown a strong correlation
between smoking during
pregnancy and low birth
FAST FACTS
Smoking during pregnancy
has shown
Good evidence of association with
ˆ low birth weight (LBW)
weight. It is important to
determine whether the woman
is a smoker, her degree of addiction to nicotine, and whether she is planning
to quit. It is also important to determine if she is smoking substances other
than tobacco, and whether her partner or other household members smoke.
How to Ask
• Do you currently smoke or are you an ex-smoker?
• If you currently smoke, how many cigarettes do you smoke each day?
• Would you like help in trying to quit smoking? Have you ever quit before?
• Does your partner or someone else in the home smoke?
• Do you smoke other substances besides tobacco?
What to Do
Options to consider if you determine that a woman or her partner
smoke tobacco:
• Identify why she is smoking: stress reduction, social habit,
weight management, etc.
• Identify previous quitting strategies the woman has employed.
48
Substance Abuse
SMOKING DURING PREGNANCY
• Discuss the problems and risks of smoking for the health of the fetus.
• Discuss the impact of smoking and second hand smoke on the infant,
especially with respect to SIDS.
• Suggest she quit or cut down, and provide strategies for doing so.
• Consider enlisting her partner’s and family’s support, if appropriate.
• Encourage her partner to quit or cut down (if appropriate), or to smoke
out of the home.
• Refer her to a smoking cessation program, if desired.
• Refer her to a program to help her quit using other substances.
Resources
Provincial Smoker’s Helplines:
• BC
1-877-455-2233
• SK
1-877-513-5333
• PEI
1-888-8186300
• AB
1-866-332-2322
• NS
1-877-513-5333
• NFLD 1-800-363-5864
• NB
1-877-513-5333
• NNV 1-866-877-3845
• QC
1-888-853-6666
• YK
• ON
1-877-513-5333
• NWT No line
• MB
1-877-513-5333
1-800-661-0408 (x8393)
www.pregnets.com
www.addictionmedicine.ca
49
Substance Abuse
ALCOHOL USE IN PREGNANCY
Consequences
of Alcohol or
Substance Use
in Pregnancy
Abuse of alcohol or other
substances by the woman or
her partner is an important
antenatal risk factor, both
FAST FACTS
The use of alcohol during
pregnancy has shown
Good evidence of association with
ˆ woman abuse (WA)
Fair evidence of association with
ˆ child abuse (CA)
medically and psychosocially.
Alcohol use in pregnancy may result in a Fetal Alcohol Spectrum Disorder
(e.g., Fetal Alcohol Effects or Fetal Alcohol Syndrome).
Associated psychosocial risk factors include child abuse and woman
abuse. Heavy use of alcohol may be determined from self-report, a history
of black-outs, need for an “eye-opener”, loss of control, dependency on
alcohol, and hallucinations or delirium tremens in the abstinence phase.
The use of illicit drugs can be determined by urine assay or self-report.
Abuse of sedative, hypnotic or prescription narcotics can be associated
with significant postpartum difficulties.
How to Ask
• How many standard drinks do you have per week? (1½ oz. liquor,
12 oz. beer, 5 oz. wine)
• Are there times when you drink more? If yes, how much?
• Do you use alcohol to help manage stress in your life?
• Do you feel that you or your partner has a problem with alcohol or drugs?
• Does your partner pressure you to use alcohol or other drugs?
50
Substance Abuse
ALCOHOL USE IN PREGNANCY
Cage Screen:
C
Have you felt you ought to cut down your drinking
A
Have people annoyed you by criticizing your drinking?
G
Have you felt bad or guilty about your drinking?
E
Have you ever needed an eye-opener in the morning
to get going?
(2 or more positive answers of “sometimes” or “quite often”
warrant in-depth assessment)
What to Do
Options to consider if you determine a woman or her partner abuse alcohol
or other substances:
• Identify “triggers” for alcohol and/or substance use.
• Identify pros/cons of current alcohol or substance use.
• Discuss times when the woman uses less alcohol and/or substances,
and encourage her to employ these strategies more often.
• Help woman develop an action plan for dealing with triggers.
• Inform woman of the risks and problems for the health of the woman and fetus.
• Assess woman’s willingness to cut down or stop.
• Refer to a treatment program, if appropriate.
• Offer to assess partner’s alcohol or drug use.
Resource
Specialized Programs
www.addictionmedicine.ca
Montreal : Herzl Family Practice Clinic,
514-340-8253
www.pregnancyaddiction.ca
Toronto: Toronto Centre for Substance Use
in Pregnancy, 416-530-6036
Vancouver: Sheway Maternity Clinic,
604-216-1699
51
FAMILY VIOLENCE
Childhood Experience of Family Violence
Current or Past Woman Abuse
Previous Child Abuse by Woman or Partner
Child Discipline
Family Violence
CHILDHOOD EXPERIENCE OF
FAMILY VIOLENCE
Experienced or
Witnessed Violence
If a pregnant woman or her
partner either experienced
violence or witnessed
violence during childhood,
they are at higher risk of
violence in their own family.
Violent childhood experiences
FAST FACTS
Experience/witness of abuse by
woman/partner has shown
Good evidence of association with
ˆ child abuse (CA)
Fair evidence of association with
ˆ woman abuse (WA)
can include physical,
emotional, and/or sexual abuse. There is a good correlation between the
childhood experience or witnessing of abuse and child abuse, and a fair
correlation with postpartum intimate partner violence.
How to Ask
• What was your parents’ relationship like? How did they get along?
• Did you ever see your father (or your mother’s partner) scaring/hurting
your mother?
• Have you ever been hit or scared by (either of) your parents or
other family caregivers? How often?
• In your culture, what happens when there is violence in the family?
54
Family Violence
CHILDHOOD EXPERIENCE OF
FAMILY VIOLENCE
What to Do
Options to consider if you determine or suspect that child abuse
may be a problem:
• Discuss parenting problems in current situation.
• Schedule extra well-baby visits to monitor closely and provide follow-up.
• Refer to parenting classes and/or new parents support groups.
• Refer to a social worker, PHN, psychologist or for counseling, if appropriate.
• Refer to CAS, if appropriate.
If you determine that woman abuse may be a problem:
• Interview her alone; if necessary use an interpreter (non-family).
• Explore the issue with care and sensitivity to cultural differences.
• Reassure her about confidentiality and your concern for her health and welfare.
• Explain that it is not her fault and that no one has a right to hit another person.
• Allow her to make decisions and take charge and control of her life.
• Help her to explore her options: family, friends, hostel/shelter, and counseling.
• Make her aware that violence can increase during pregnancy.
• Determine whether the woman is safe in her home and help her develop a
safety plan.
• Indicate that you will support her whether she decides to stay with or leave
her partner.
• Make her aware of community resources: numbers of shelters, legal aid,
support groups.
• Make her aware that assault is a crime punishable by law, and keep
detailed notes.
• If danger is severe, suggest she consult with local police for advice.
• Determine if children in the family are at risk or are being abused.
55
Family Violence
CURRENT OR PAST WOMAN ABUSE
Woman Abuse
FAST FACTS
Woman abuse (intimate
partner violence) and child
abuse are under-reported by
patients and under-diagnosed
by health care providers.
Studies have shown that
pregnancy is a high-risk time
for woman abuse.
Current or past woman abuse, or
intimate partner violence, has shown
Good evidence of association with
ˆ postpartum woman abuse (WA)
Fair evidence of association with
ˆ child abuse (CA)
ˆ postpartum depression (PD)
If a pregnant woman has
experienced or is currently
experiencing intimate partner violence (IPV) by her partner, she is at high
risk of abuse during the rest of the pregnancy and during the postpartum
period. There is also fair evidence that current or past IPV is associated
with child abuse and postpartum depression. Woman abuse can be
emotional, physical, sexual, financial, social and spiritual.
How to Ask
• How do you and your partner solve arguments?
• Have you ever been hit/pushed/shoved by your partner?
• Do you ever feel frightened by what your partner says or does?
• Does your partner ever humiliate you or psychologically abuse you
in other ways?
• Have you ever been forced to have sex against your will?
• In your culture, what does a woman do if she is experiencing intimate
partner violence?
56
Family Violence
CURRENT OR PAST WOMAN ABUSE
What to Do
Options to consider if you determine or suspect that the woman is
being abused:
• Interview her alone; if necessary use an interpreter (non-family).
• Explore the issue with care and sensitivity to cultural differences.
• Reassure her about confidentiality and your concern for her health and welfare.
• Explain that it is not her fault and that no one has a right to be violent.
• Allow her to make decisions and take charge and control of her life.
• Determine whether the woman is safe in her home and help her develop
a safety plan.
• Indicate that you will support her whether she decides to stay with or
leave her partner.
• Make her aware of community resources: numbers of shelters, legal aid,
support groups.
• Make her aware that assault is a crime punishable by law, and keep
detained notes.
• If danger is severe, request permission to consult with local police for advice.
If you have determined that child abuse may be a problem:
• Discuss parenting problems in current situation.
• Schedule extra well-baby visits to monitor closely and provide follow-up.
• Refer to parenting classes and/or new parents support groups.
• Refer to a social worker, PHN, psychologist, or psychiatrist, if appropriate.
If a woman discloses IPV, consult with Child Protective Services if there
are other children in the home, even if the woman says they are not being
abused or do not witness the violence.
57
Family Violence
PREVIOUS CHILD ABUSE BY
WOMAN OR PARTNER
Definition of
Child Abuse
FAST FACTS
Child abuse, or child
Previous child abuse by the
woman or partner has shown
endangerment, is the
deliberate act of physically,
sexually, or emotionally
Good evidence of association with
ˆ child abuse (CA)
assaulting and/or violating
a child’s rights or person. If
either the pregnant woman or her partner has ever been officially reported
to have committed any form of child abuse or if a child of theirs has ever
been placed in foster care, there is a significant risk of abuse to the child
the woman is carrying.
Notification of Children’s Aid Society
All health care providers and adults connected with the child and family,
e.g., teachers, are bound by law to notify the appropriate child protective
services (CPS) in their area if they have suspicion that a child is being
abused. Contacting CPS services should not be delegated. Health care
professionals are considered to have a greater burden of expectation
regarding assessing for abuse, and have greater liability if they
do not report.
If there is no child living in the home, but the provider is concerned about
risk to the newborn, the women should be encouraged to contact her local
CPS agency to request aftercare support. Women who contact the local
CPS voluntarily feel more control and tend to view the agency as helpful
rather than punitive.
58
Family Violence
PREVIOUS CHILD ABUSE BY
WOMAN OR PARTNER
How to Ask
For multiparous women or women whose partner’s have children:
• Do you have any children who are not living with you? If so, why not?
• Does your partner have children? Are they living with you?
If no, where are they living?
• Was CAS involved with your family when you were a child?
If there are children in foster care:
• Why aren’t they living with you?
What to Do
Options to consider if you determine that there has been previous
child abuse:
• Discuss parenting issues and/or problems in current situation.
• Schedule extra well-baby visits to monitor closely and provide follow-up.
• Refer to parenting classes and/or new parents support groups.
• Refer to a social worker, PHN, psychologist or counselor, if appropriate.
• Suggest the woman contact the child protection services agency herself in order
to elicit help.
• Contacts CAS if concerns or suspicions exist and speak to a worker to determine
status of case, i.e., whether it is open.
59
Family Violence
CHILD DISCIPLINE
Child Discipline
FAST FACTS
The use of corporal
punishment, such as frequent
and hard spanking, or the
use of physical punishment
of a baby prior to crawling;
A history of harsh discipline
has shown
Good evidence of association with
ˆ child abuse (CA)
excessive cursing at a child;
withholding food, shelter,
and basic requirements for healthy living; as well as deliberate emotional
rejection are examples of harsh discipline and may be considered
child abuse.
There are strong cultural components to child rearing and much behaviour
observed at face value may be culturally appropriate to the family.
Culture is not limited to ethnicity. Families have individual cultures, as
do demographic groups, e.g., teens. It is important to ask parents not
only about their parenting beliefs but also about the parenting beliefs of
members of their extended families who may be involved in child rearing.
How to Ask
• How do you think you will discipline your child? How will your
partner discipline?
• If family members will be caring for the baby, how will they discipline?
• How do you deal with your children at home when they misbehave?
• How did your parents discipline you? Were you ever spanked?
• In your culture, what is the usual way children are disciplined in
the family?
60
Family Violence
CHILD DISCIPLINE
What to Do
Options to consider if you determine the woman/partner may use
harsh discipline:
• Discuss with the woman, and her partner if appropriate.
• Determine cultural influences, if any, on parenting practices.
• Inform parents that you have a legal obligation to report suspicions of child
neglect or abuse to the CAS.
• Monitor closely during infancy and continue to follow up during childhood.
• Refer parents to parenting classes and support groups.
• Refer to a social worker, PHN, psychologist, or for counseling, if appropriate.
• Consider whether this risk factor, in conjunction with other information about the
family, indicates that CAS could be involved in the postpartum period.
61
RESOURCES
Please use this sheet to write in the telephone numbers of resources
available in your community.
Contact/Telephone
Contact/Telephone
Addiction Treatment Programs
Parents Support Group
Assaulted Woman’s Helpline
Prenatal Education Services
Children’s Aid Society
Psychotherapist
Community Centre
Psychiatrist
Family Service Association
Psychologist
Homecare
Public Health Nurse
Infant-Parent Attachment Therapy
Relaxation Therapy Course
Kid’s Help Line
Social Worker
Legal Aid
Smoking Cessation Courses
Marital/Family Therapist
Women’s Crisis Line
Nutritionist
Women’s Shelter
Parenting Classes
Woman’s Support Group
Teaching Resources
VIDEO: The ALPHA Form: Assessing Antenatal Psychosocial Health.
A 20 minute interactive training video for providers. Available through the
Department of Family and Community Medicine, 263 McCaul Street, 5th Floor,
Toronto, M5T 1W7, ON, Canada. 416-946-3223, Fax. 416-978-3912 Attn. D. Job
$29.00 plus tax and postage.
Additional copies of the ALPHA Guide can be obtained from the Department
of Family & Community Medicine, address above, for $15.00 plus tax
and postage.
Training workshops may also be arranged. Contact Dr. Deana Midmer for
more information. deana.midmer@utoronto.ca
62
ALPHA GROUP MEMBERS
Anne Biringer, MD, CCFP
Associate Professor, Department of Family and Community Medicine, University
of Toronto; Family Physician, Mount Sinai Hospital Family Medicine Centre
June C. Carroll, MD, CCFP, FCFP
Sydney G. Frankfort Chair in Family Medicine, Associate Professor, Department
of Family and Community Medicine, University of Toronto; Family Physician,
Ray D. Wolfe Department of Family Medicine, Mount Sinai Hospital,
Toronto, Ontario
Beverley Chalmers, PhD
Adjunct Professor, Department of Community Health and Epidemiology,
Queen’s University, Kingston, Ontario
Deana Midmer, BScN, EdD, FACCE
Associate Professor & Research Scholar, Department of Family & Community
Medicine, University of Toronto; Co-ordinator, Prenatal & Family Life Education,
Mount Sinai Hospital
Anthony J. Reid, MD, MSc, CCFP
Associate Professor, Department of Family and Community Medicine,
University of Toronto; Family Physician, Orillia, Ontario
Donna E. Stewart, MD, FRCP(C)
Professor of Psychiatry, Obstetrics and Gynecology, Family & Community
Medicine; Lillian Love Chair Women’s Health, The University Health Network,
University of Toronto
Lynn Wilson, MD, CCFP
Associate Professor, Department of Family and Community Medicine,
University of Toronto; Family Physician-in-Chief, St. Joseph’s Health Centre
63
ACKNOWLEDGEMENTS
The ALPHA Group wishes to acknowledge the contributions
of the Department of Family and Community Medicine,
University of Toronto, for administrative support during
the development of the project.
Printing of this guide was generously supported by
the Lawson Foundation.
64