Assessing and addressing vulnerability in pregnancy: General practitioners perceived barriers and facilitators - a qualitative interview study.

backgroundVulnerability due to low psychosocial resources increases among women in the fertile age. Undetected vulnerability in pregnancy is a major contributor to inequality in maternal and perinatal health and constitutes a risk of maternal depression, adverse birth outcomes,-i.e. preterm birth, low birth weight, and adverse outcomes in childhood such as attachment disorders. General practitioners (GPs) have a broad understanding of indicators of vulnerability in pregnancy. However, less than 25% of pregnant women with severe vulnerability are identified in Danish general practice. The aim was to explore GPs' perceived barriers and facilitators for assessing and addressing vulnerability among pregnant women.

methodsA qualitative study with semi-structured focus group interviews with twenty GPs from urban and rural areas throughout the Region of Southern Denmark. A mixed inductive and deductive analytic strategy was applied, structured according to the Theoretical Domains Framework (TDF).

resultsFive themes emerged covering twelve TDF domains: (I)knowledge and attention, (II)professional confidence, (III)incentives, (IV)working conditions and (V)behavioral regulations. Prominent barriers to assessment were lack of continuity of care and trust in the doctor-patient relation. Other barriers were inattention to indicators of vulnerability, time limits, unavailable information on patients' social support needs from cross-sectoral collaborators, and lack of reimbursement for the use of extra time. Fear of damaging the doctor-patient relation, ethical dilemmas and time limits were barriers to addressing vulnerability. Facilitators were increased attention on vulnerability, professionalism and a strong and trustful doctor-patient relation. Behavioral regulations ensuring continuity of care and extra time for history taking enabled assessing and addressing vulnerability, especially when a strong doctor-patient relation was absent.

conclusionsThe TDF disclosed several barriers, especially in the absence of a strong doctor-patient relation. A behavior change intervention of restructuring the organization of antenatal care in general practice might reduce the GPs' barriers to assessing and addressing vulnerability in pregnancy. The findings may serve as a guide for commissioners and policymakers of antenatal care on the GPs' support needs when providing antenatal care to vulnerable pregnant women.