Challenging Dogma - Fall 2007

...Using the social and behavioral sciences to improve the practice of public health.

Saturday, December 8, 2007

Failure of the American College of Obstetricians and Gynecologists’ Public Health Intervention: Why Fetal Alcohol Syndrome Isn’t Just about Mommy – St

Fetal Alcohol Spectrum Disorders (FASD) are caused by a prenatal exposure to alcohol. Fetal Alcohol Syndrome (FAS), the most severe of these disorders, has been implicated as one of the foremost known causes of preventable birth defects and mental impairment by the Center for Disease Control. FAS, in addition to the physical and mental disabilities, causes stunted growth, abnormal facial features, and disorders of the central nervous system. This permanent condition thus is responsible for many lifelong consequences for the child of a substance abusing mother, both intellectually and socially as FAS leads to a lifetime of learning disabilities, visual and hearing impairments, and verbal issues. While FAS occurs at a rate of approximately 0.2 to 1.5 per 1,000 live births, it is entirely preventable as it is solely caused by maternal alcohol consumption (1).

In a survey conducted by the American College of Obstetricians and Gynecologists (ACOG) in 2004, approximately 12% of pregnant mothers admitted to consuming alcohol during their pregnancy (2). Given this information, ACOG has expressed a great interest in reducing the incidence of the entirely preventable FAS, and thus has created a public health intervention with the goal of reducing the occurrence of FAS and fetal alcohol spectrum disorders. To attain this goal, ACOG has developed a pamphlet which is to provide information to pregnant women regarding the effects of alcohol on the fetus, a brief description of FAS, and a list of signs that one might have a drinking problem. Despite this seemingly inclusive description of the causes and effects of maternal drinking on fetal development, the intervention contains certain flaws. The public health intervention created by ACOG to combat FAS is highly unsuccessful as it is based on the Health Belief Model which ignores the social environment surrounding a pregnant woman, fails to include the concept of self-efficacy, and assumes that there is a direct link between one’s intention and behavior (3).

Mommy’s Access to Health Care

Given that the intervention in question was developed by a physician organization, one of the major players in the intervention is in fact the pregnant woman’s physician. The prevention of FAS by ACOG is purely aimed at those women who are receiving prenatal care, and thus ignores those women who lack the health care resources to be treated by a physician during their pregnancies. In an ideal world, all individuals would have access to quality health care; however this currently is not the case. While women’s health and reproductive needs cause them to need regular health care, women are also likely to have difficulty in obtaining care. One would assume that despite one’s insurance status that free care might still be obtained. However, the Commonwealth Fund Task Force on the Future of Health Insurance noted in their 2001 report that uninsured women are more likely to experience difficulty in obtaining medical care than uninsured men (4). Thus pregnant women who consume alcohol might never have the opportunity to discuss this habit with any health care professional, increasing the likelihood of their children developing FAS.

Further, it is highly unlikely that a pregnant woman would receive the “Alcohol and Pregnancy” pamphlet without visiting a physician as this product was designed for physician distribution. In providing information about alcohol abuse, the pamphlet advises women to speak with their physicians regarding a drinking problem. If a woman is not seeing a physician this is an obvious drawback, for she will be unable to receive any counseling or treatment for her alcohol dependency. Additionally, the pamphlet does not list any additional resources available to women for the treatment of alcohol dependency, which may be more easily accessible to women who are experiencing barriers to obtaining health care, such as substance abuse hotlines.

The implementation of this public health initiative is further impeded if one does not speak English. The program implemented by ACOG depends on effective communication with one’s physician in addition to the patient’s ability to read and comprehend the “Alcohol and Pregnancy” pamphlet. There is no indication on the ACOG website which indicates the availability of the pamphlet in other languages. This clearly disenfranchises women for whom English is not their first language, for they must then depend on physicians adequately describing the risks of consuming alcohol during pregnancy. For non-English speaking immigrant women the situation is far worse, as they are not likely to see an obstetrician or gynecologist, but rather obtain their health care through safety net providers and emergency departments (5). These alternative health care settings are not included in the FAS prevention plan as the initiative is purely aimed at obstetricians and gynecologists’ offices.

Mommy’s Self-Efficacy

It has been shown that the public health initiative created by ACOG assumes that a pregnant woman will have access to an obstetrician or a gynecologist during her pregnancy. Similarly, the construction of ACOG’s public health intervention ignores a crucial public health consideration: self-efficacy. The theory of self-efficacy is the belief that one is able to perform the necessary behavior to produce the desired outcome. This theory does not simply apply to the acquisition of new health behaviors as it also applies to the cessation of existing habits, such as the consumption of alcohol. Self-efficacy has most certainly been implicated in the success of individuals who are dependent on alcohol to overcome their compulsions (6). Certainly human beings are driven by a belief in success; simple tasks rarely require any thought from an individual as success is practically guaranteed. The problem exists when a task is dependent on the modification of an old behavior or the adoption of a new behavior. Without the self-assurance that one will in fact succeed at a given task it is more difficult to will one’s self to perform the given act (7).

In attempting to reduce the incidence of FAS, the public health intervention created by ACOG focuses on complete abstinence from alcohol during the woman’s pregnancy. This can be problematic if a woman is a habitual drinker. For instance, if a woman has already drank during her pregnancy, or if she does not believe herself to be able to abstain from all alcohol during her pregnancy, then she might be unwilling to take further steps to reduce her baby’s risk of developing FAS. A woman’s self-efficacy will be impacted if she attempts to stop drinking alcohol and fails, for she will no longer believe that she is capable of such an action. Perhaps if the intervention in question was aimed at harm reduction, achieved by reduction of alcohol intake, the seemingly impossible barrier to abstain from all alcohol might appear more possible. Through gradual reduction of one’s alcohol consumption, the concept of self efficacy would more likely be achieved as the goal to be attained must appear within one’s reach for one to attempt such a change.

Mommy Wants to…But Will She?

While ACOG’s public health intervention fails to focus on self-efficacy, this intervention similarly subscribes to yet another weakness of the Health Belief Model. This occurs in the assumption that if a woman has the intention to prevent her baby from developing FAS, then she will in fact perform all the necessary behaviors in order to do so. The problem here is that there are most likely social factors or even alcoholism which prevent such a simple intention-behavior connection. The Health Belief Model thus ignores the social environment in which an individual exists; this is important as this crucial influence in one’s life ultimately determines the type of resources which one has access to and the barriers to any treatment options.

In the current example, the pregnant woman is surrounded by multitudes of possibly conflicting influences. Not only is it important to consider the woman herself, but also public health professionals must consider the social and organizational networks which she belongs to. Studies have indicated that support from one’s family and friends to stop consuming alcohol has a major impact on whether or not the individual will in fact seek treatment; further individuals who have a supportive social network are more likely to complete their treatment programs (8,9). Ideally, a pregnant woman who habitually abuses alcohol would have a social network which would act to encourage and support her throughout her struggle to abstain from alcohol consumption as this positive social network will increase the likelihood that she will maintain her new alcohol-free existence. Conversely, if a woman’s friends encourage or support her drinking, she will not have an external form of encouragement in her struggle to refrain from imbibing alcohol. A woman in this situation will also most likely be inhibited from seeking treatment for her substance abuse as the people in her social network are supportive of her alcohol consumption.

Additionally, the availability of alcohol abuse treatment centers will also play a major role in a woman’s decision to seek treatment for alcohol abuse. Treatment centers might not exist in a woman’s neighborhood, yet her drinking buddies might. In an editorial written in Women’s Health Issues, Dr. Elizabeth Armstrong addresses the question of how should health care providers respond to this complex question of women who consume alcohol or drugs during their pregnancies. She notes that in protecting the health of women and their babies, health care providers must realize that often women who abuse alcohol do so as a result of many external factors, such as social isolation, mental illness, stress, and poverty (10). Thus, in order for this public health intervention to succeed, physicians in advising their patients to stop drinking must address the external influences which might be preventing her from achieving her desired outcome. For instance, if depression is a cause of a woman’s alcohol consumption, a physician must take that into account, and perhaps recommend therapy to combat both issues as they are interrelated. The direct relationship between one’s intentions and one’s actions are clearly not as simple as it is made out to be.

Conclusion

The public health initiative created by ACOG to combat FAS ignores the direct social environment of a pregnant woman, fails to account for the woman’s self-efficacy, and assumes that intention directly causes action. Arising from the Health Belief Model, each of these factors shows that ACOG’s public health intervention focuses on one’s individual decision without any regard for the complex social and environmental factors which impact a pregnant woman in her aspiration to stop drinking. Clearly, women are assumed to be rational as ACOG believes that their education of the risks of FAS will reduce the incidence of alcohol consumption in pregnant women (11). By not accounting for barriers in obtaining health care, a woman’s self-efficacy, or factors which interfere with the direct link between intention and behavior, ACOG cannot hope to cause a substantial decrease in the incidence of FAS.

In order to revise their public health initiative, ACOG might look towards other public health models which would address the weaknesses present in the current initiative. Perhaps one of the first actions which should be taken toward modifying this initiative would be to create “Alcohol and Pregnancy” pamphlets in languages other than English which would be available at community health centers, safety net hospitals, and emergency rooms, thus increasing access of the preventative information to a large subset of the population. In modification of the initiative, the Theory of Planned Behavior is perhaps a better model for ACOG to utilize. This model first does not assume a direct link between one’s intention and one’s behavior; rather this model takes into account social factors which may prevent one from completing a specific task. In reducing maternal alcohol consumption, this model would take into account the mother’s friends and family members and their perception of her will to quit drinking. This thus also includes a woman’s self-efficacy. Additionally, the availability of health care resources would be accounted for by this model for factors outside the cognitive process are included in this model (11). Thus by choosing a model like the Theory of Planned Behavior, ACOG can account for the shortcomings of its public health initiative by accounting for social and environmental factors which impact a woman’s behavior in addition to accounting for her self-efficacy.

REFERENCES

[1]. Department of Health and Human Services: Center for Disease Control and Prevention. Fetal Alcohol Spectrum Disorders. Washington, DC: Department of Health and Human Services. http://www.cdc.gov/ncbddd/fas/fasask.html.

2. ACOG Committee on Ethics. At-Risk Drinking and Illicit Drug Use: Ethical Issues in Obstetric and Gynecologic Practice. Obstet Gynecol 2004; 103, 1021-31.

3. The American College of Obstetricians and Gynecologists. ACOG Patient Education: Alcohol and Pregnancy. Washington, DC: American College of Obstetricians and Gynecologists. http://www.acog.org/publications/patient_education/bp132.cfm.

4. Lambrew, J. Diagnosing Disparities in Health Insurance for Women: A Prescription for Change. NY: The Commonwealth Fund. http://www.commonwealthfund.org/usr_doc/lambrew_disparities_493.pdf?section=4039.

5. Ivey, S. Health Services Utilization and Access to Care (pp 44-53). In: Kramer, E., Ivey, S., Ying, Y. Immigrant Women’s Health: Problems and Solutions. San Francisco: Jossey-Bass, 1999.

6. Trucco, E., Connery, H., , Greenfield, S. The Relationship of Self-Esteem and Self-Efficacy to Treatment Outcomes of Alcohol-Dependent Men and Women. The American Journal on Addictions 2007. Vol 16(2): 85-92.

7. Salazar, M. Comparison of Four Behavioral Theories. AAOHN Jour March 1991; 39 (3): 92-99.

8. George, A., Tucker, J. Help-Seeking for Alcohol-Related Problems: Social Contexts Surrounding Entry into Alcoholism Treatment or Alcoholics Anonymous. Journal of Studies on Alcohol 1996. 57(4): 449-458.

9. Groh, D., Jason, L., Davis, M., Olson, B., Ferrari, J. Friends, Family, and Alcohol Abuse: An Examination of General and Alcohol-Specific Social Support. The American Journal on Addictions. 16(1), 49-55.

10. Armstrong, E. Drug and Alcohol Use during Pregnancy: We need to Protect, Not Punish Women. [Editorial]. Wom Health Iss 205. 15;45-47.

11. Edberg, M. Individual Health Behavior Theories (pp 35-47). In: Edberg, Mark. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Jones and Bartlett Publishers. Boston, 2007.

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2 Comments:

  • At December 12, 2007 at 8:06 AM , Blogger Victoria said...

    It seems really strange that this intervention is only offering the pamphlets in the office when I'm sure they must be aware of how many people do not have access to PCPs and pre-natal care. How long have these pamphlets been around for?

     
  • At December 14, 2007 at 10:21 AM , Anonymous Deinera said...

    I agree with your point about the pamphlet's only being available at doctor's offices...this also does not consider racial disparity in access to care (e.g., black women are less likely to receive prenatal care in their first trimester). Is there any evidence supporting higher prevalence of FAS in different racial groups? The campaign also doesn't take into account the effect of addiction on rational decision making, again making the HBM ineffectual. For a preventable and detrimental disease such as FAS, it's unfortunate the creators of this campaign did not take the points you have made into account.

     

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