Substance use is a major public health problem among pregnant women in the United States. According to the 2010 National Survey on Drug Use and Health, 4.4% of women reported illicit drugs use at some time during pregnancy: 10.8% reported alcohol use, and 16.3% reported cigarette use (1). Substance-use disorders may prevent pregnant women from seeking and obtaining prenatal care because of social, psychological, and financial difficulties (2). A survey of pregnant and postpartum women in substance-use treatment facilities identified several reasons for not seeking prenatal care (3, 4). Barriers included fear of losing their children, shame, depression, and denial. Among reproductive-age women, 28.9% of patients abusing substances did not receive treatment because of “societal stigma” (5).

Effective nonjudgmental screening for substance use during pregnancy and interventions for gravid women abusing substances can improve maternal and fetal health outcomes (6, 7). Unfortunately, most physicians lack adequate formal undergraduate and graduate training in the management of substance use during pregnancy (8–10). Medical students are taught compassion and empathy in the classroom but may see a different approach in the clinical setting (11, 12). Personal biases and poor modeling by educators may cause students to question and distrust pregnant women who endanger their fetuses by using drugs and alcohol (9, 11).

In 2007, our department reported on how medical students became more comfortable in talking with women with substance-use disorders and being less judgmental after attending a special prenatal clinic for rehabilitation (9). We hypothesized that students who also met informally with pregnant substance users at a rehabilitation residence would gain additional educational experience. The objective of this randomized educational trial was to determine whether medical students' attendance at this nontraditional educational setting yielded additional changes in their attitudes and comfort levels in providing care to pregnant women with substance-use disorders.

This study was approved by our Human Research Review Committee (09-298; 2009).

Clinic and Residence

Designed for pregnant women with substance use disorders, the Milagro prenatal clinic has been serving patients since 1989 (9). Casitas de Milagros is a rehabilitation residence accommodating pregnant substance abusers based on assessment of need and commitment to treatment. The residential treatment team includes a counselor, nurse, and social worker who also aided in the acquisition of parenting skills and in goal setting.

Student Population

Eligibility criteria involved any third-year medical student rotating in the required 8-week Ob-Gyn clerkship. Each student was randomly assigned either to attend (Study group) or not attend (Control group) the rehabilitation residence in the early afternoon after the morning prenatal clinic. Before we designed this study, students had expressed a preference to visit these two sites in a group of two, rather than alone. Students assigned to the Study group spent an additional 1 to 2 hours on the same day as the morning clinic in the early afternoon at the rehabilitation residence. They interacted with three-or-more patients without a faculty member and often attended a group therapy session led by a licensed counselor.

Survey

The authors obtained informed written consent from each student to complete a confidential survey at the first day and near the end of the clerkship. The 12-question survey was modified from an instrument designed by Bland et al. (12) and was used previously in one of our reports (9). Questions in the survey addressed student comfort levels (6 statements) and attitudes (6 statements) toward substance use in general and during pregnancy. The questions were scored on a Likert scale from 1 to 5, with 1 signifying Strongly Disagree to 5 signifying Strongly Agree. The clerkship coordinator distributed the survey. Because survey results were compared at two times (beginning and end of the 8-week clerkship), each consenting student was assigned a code number to link his/her scores on the survey, as described previously (9).

Statistical Analysis

The data were gathered from two complete classes of students (12 consecutive clerkship blocks) between May 2009 and April 2011. Statistical analysis was performed after all data were collected. Using SAS Version 9.2 (SAS Institute; Cary, NC), scores for each statement on the survey were reported as a mean (standard deviation [SD]). Within the Study and Control groups, paired t-tests were used to test mean changes in scores from the beginning to the end of the clerkship, and independent-sample t-tests were used to compare primary outcomes. Analysis of variance was used to test whether any differences between Study and Control groups were affected by students’ gender or the timing of the experience during the clerkship year. A value of p <0.05 was considered to be statistically significant.

All 96 consecutive medical students provided written consent to enroll and complete the survey between June 2009 and April 2011. All students completed the survey at the beginning of the rotation, and 84 students completed it at the end of the rotation (40 attended clinic and residence; 44 attended clinic only). The baseline values in the survey of the two groups were similar in most respects. Those students randomly assigned to attend the residence had a higher baseline comfort level score (3.6 [0.7]) in interviewing to assess pregnant patients’ readiness for substance-abuse treatment, as compared with the Control group (2.9 [0.7]). Reasons for not attending the clinic or residence (illness, miscommunication, other clinic coverage, and unanticipated nonprofessional responsibilities) were evenly distributed between the two groups.

The sum total score of the six “comfort” statements in the survey was significantly higher after attending the clinic alone (p <0.001) and in the clinic combined with the residence (p <0.001). Both sites enabled students to feel more comfortable in obtaining a substance-use history (p <0.001) and in talking with pregnant patients about their substance use (p <0.001). Students who attended the clinic and residence had significantly increased comfort levels in talking to patients about the adverse effects of substance use during pregnancy (p=0.01) and in understanding terms used on the “street” about drugs (p=0.005).

The sum total score of the six “attitude” statements in the survey was also significantly higher after the student experience at the clinic alone (p <0.001) and at the clinic and residence (p <0.001). Both experiences positively changed the following attitudes: substance abuse during pregnancy is a common societal problem; nonphysician counselors can provide effective treatment for drug and alcohol abusers; and students can be less judgmental in treating a substance-abusing pregnant woman. Additional experience at the residence led students to feel that pregnant women with substance-use disorders are inclined to disclose their substance use to healthcare providers (p=0.004).

All 40 students randomly assigned to attend the clinic and residence thought that this “eye-opening” experience should be incorporated into their clerkship training. Written comments by students about the residence summarized their positive emotional reactions: “Overall, I found talking with women at the residence to be the most informative part of the experience.” “This was scheduled for 1 hour, but before we knew it, 2 hours had passed.” “It provided me with insights that I would not have obtained by interviewing these patients in a clinic setting.” “I was afraid that the patients would be too ashamed to talk or thought they might get mad when asked personal questions; … however, this was not the case, and the patients were surprisingly open about barriers and parenting.” “I learned a lot about how to better individualize management, depending on the patient’s drug history.” “Overall, it was a really good experience, especially seeing that many of us do have pre-formed opinions and judgments on this patient population of substance abusers that may not have any basis in experience.” “I really enjoyed talking with the residents in a relaxed setting about using ‘triggers,’ identification of ‘feelings to use,’ new coping skills acquired through the program, and experiences with healthcare.” “It helped me get past some of my own bias and see these women as kind, motivated, vulnerable people trying to change and be good mothers.”

Findings from this randomized educational trial confirm our previous findings that a specialized prenatal clinic experience for pregnant women with substance-use disorders was helpful in modifying medical students’ comfort levels toward this unique patient population. By also attending a rehabilitation residence, students improved their ability to talk with patients about adverse effects from substance use during pregnancy and to better understand “street” terms about drugs. Experience at the residence taught students, in a more casual and less clinical environment, that these women were inclined to openly discuss their substance-use histories. The “teaching stories” by the patients emphasized the need for non-judgment and compassion regarding their disease of addiction, especially considering the past emotional and physical trauma suffered by most patients. Allowing two students, rather than one, to attend the clinic and residence permitted students to debrief and reflect on their experience.

To improve the health and well-being of mothers and their newborn infants, it is important to train medical students about preventing postpartum resumption of substances. According to the 2009 National Survey on Drug Use and Health, rates of substance use (alcohol, cigarettes, marijuana) will more-than-double after delivery (3). We now plan to implement an educational experience for medical students to counsel postpartum women about substance abuse.

A few limitations of this study deserve mention. We did not query students about their awareness of addiction medicine at the initial survey. All of our students completed a communication-skills course in the preclinical years, which included lectures on obtaining patients’ substance-use histories and utilizing motivational interviewing. Secondly, several students failed to attend their assignment, but the absences were equally common in the Study and Control groups. Thirdly, there was no long-term follow-up survey in this study, and we were, therefore, unsure whether students’ improved comfort levels would affect their long-term clinical behaviors. Siegal et al. reported that physicians who, as medical students, were given a brief clinical practicum on alcohol and other substance-use problems reported increased likelihood of querying patients about their alcohol use 6–10 years later (13).

In summary, findings in the present study re-emphasize that students who attended this specialized clinic would dramatically improve their comfort levels with and attitudes toward pregnant women with substance-use disorders. Nontraditional education sites such as a rehabilitation residence also provided a different and practical learning opportunity. By increasing student awareness of the complexities faced by pregnant women with substance-use disorders and allowing them to hear patients’ stories at both a specialized prenatal clinic and rehabilitation residence, we demonstrated that students’ comfort levels and attitudes toward this population was improved in the short term. Our findings confirm the need for addiction-treatment educational experiences during clerkship training, particularly in dealing more compassionately with pregnant women. As one student wrote on a survey before attending the clinic, “I feel exposure to these types of problems would be invaluable to medical student training, as I personally feel apathetic to the problem, likely from low exposure and pre-formed prejudice.” Our hope is that this change will endure. Therefore, our next steps will be to examine an additional educational encounter after delivery and to determine whether changes from this clinical experience would persist as students progress in their medical careers.

Presented at the Annual Meeting of the American Psychiatric Association, Honolulu, Hawaii, May 15, 2011.

This work was supported by Seligman Perinatal Research Fund