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Physicians typically assess risk for preterm delivery based on medical factors, such as preterm labor in previous pregnancies or cervical dilation. But a new pregnancy assessment form in use throughout Minnesota greatly expands the concept of risk by including psychosocial issues such as domestic violence and work exertion that may influence the course of pregnancy.
"We’re looking at anything that can lead to poor outcomes," says Peter Mark, MD, an obstetrician/gynecologist with HealthPartners, an HMO in Minneapolis, and spokesman for the statewide assessment form task force. "That’s more broad than simply high or low risk for preterm birth."
For example, guided by the 39 questions, physicians ask patients whether they have been "physically, sexually, or emotionally hurt by someone" and whether their work involves standing for more than four hours per shift or requires heavy physical exertion. (See sample of the form, inserted in this issue.)
The form was developed by a collaboration of the Minnesota Council of Health Plans, state agencies, professional societies, physicians, and the University of Minnesota in Minneapolis and is used with the state’s HMO and Minnesota Health Care Programs patients.
The screening is administered at a patient’s first obstetrical visit and again at 24 to 28 weeks of pregnancy.
"It’s a paradigm shift," says Mark. "Rather than just saying you’re low’ risk, . . . it’s the risk factors that count."
Intervention is the key to the new assessment program. When physicians or other clinicians detect risk factors among pregnant women, what will they do?
A new pregnancy assessment form in use throughout Minnesota greatly expands the concept of risk by including psychosocial issues such as domestic violence and work exertion that may influence the course of pregnancy.
"We’re looking at anything that can lead to poor outcomes," says Mark. HMOs and medical groups also provide patient education, counseling, and case management.
For example, about 100 patients among the 6,000 to 8,000 obstetrical cases a year at HealthPartners are identified as substance abusers. Two nurses follow up with them and manage their cases to ensure that they receive proper treatment and support, says Mark.
In some cases, the physician can provide support without any other intervention. Mark asks pregnant women how many hours they spend without a break, whether they work a day or night shift, and how much time they spend standing at work. He may provide a note to employers to help his patients who need to lower their exertion.
"Pregnant women need to have a break to lay down for a half hour every two or three hours," he says.
While detecting risks such as domestic violence, alcohol use, and depression is clearly laudable, the interventions aren’t likely to produce measurable changes in birth outcomes, cautions Virginia Lupo, MD, director of maternal/fetal medicine at the Hennepin County Medical Center in Minneapolis and a task force member.
Lupo worries that managed care organizations expect a clear cause and effect. "People who use this have to realize that it’s never been proven that intervening will reduce preterm delivery," she says. "You can’t change a lot of the things that are the highest risk factors."
For example, pre-pregnancy maternal weight under 110 pounds, previous preterm delivery, and low educational status are major risk factors for preterm delivery that cannot be remediated, she notes.
HealthPartners has screened pregnant women for psychosocial concerns and provided interventions for a number of years and maintains below-average preterm birth rates. Mark hopes there is a connection between the two, but he can’t prove it.
Moreover, he argues that the idea of risk should be broad. "If you’re going to have some type of screening instrument, you should look at some things that aren’t necessarily associated with premature birth," he says.
Lupo agrees. "It can’t help but do some good," she says. "But we’re not going to be able to quantify it for the HMOs."