The 4P’s Plus© Screening Instrument

The regression results confirmed that past cigarette or alcohol use was significantly correlated with current drug or alcohol use.  Furthermore, the effects of the various factors were cumulative; that is, women who had smoked and had ever used alcohol were 8 times more likely to use alcohol or drugs during pregnancy than women who had done neither.  To refine the analysis and identify a small set of risk factors that could serve as the basis for a screening protocol for risk of alcohol or other drug use during pregnancy, a CART analysis was performed.  Within the sample, the CART analysis generated three groups with increasing levels of risk for alcohol or illicit drug use during pregnancy:

1.     Low risk – those women who had never used alcohol: 1.4 % of women in the low-risk group reported using either drugs or alcohol or both during the time they had been pregnant

2.     Average risk – those women who had used alcohol in the past but not in the month before pregnancy: 8.7% of women in the average risk group reported using either drugs or alcohol or both during the time the y had been pregnant

3.     High risk – those women who used alcohol in the month before pregnancy: 36% of women in the high risk group reported using either drugs or alcohol or both during the time they had been pregnant.

Entering cigarettes into the CART analysis, we found that the number of cigarettes smoked in the month before pregnancy helped to further distinguish the average risk and high risk groups. Of those women who had used alcohol in the past but did not smoke three or more cigarettes in the month before pregnancy, 3.4% reported using drugs during the time they had been pregnant.  For those women who had used alcohol in the past and smoked three or more cigarettes in the month before pregnancy, 14.5% reported using drugs during pregnancy. 

On the basis of these three levels of risk, we suggested that primary prenatal care providers could ask three questions in the context of the health evaluation:

• Have you ever drunk alcohol?

• How much alcohol did you drink in the month before pregnancy?

• How many cigarettes did you smoke in the month before pregnancy?

We integrated these three questions and field tested our new instrument, the 4P’s Plus©,2 in a variety of settings and communities with over 100 physicians from around the country.  Through this field testing, we learned: 

1.     Physicians and other providers feel most comfortable if substance use screening can be incorporated into routine prenatal care and flows naturally within the context of the prenatal interview. Thus, we made the P for Parents the first question and advised physicians to ask the question within the context of the family history.  A positive response does not predict the woman’s substance use, but it normalizes the following questions about substance use by making it clear that these are questions that are part of routine medical care.

2.     The second P, for Partner, is similar to the first P, in that a positive response does not predict the woman’s use of substances in pregnancy.  However, a partner’s alcohol or drug use was found to correlate with risk for domestic violence in the home. 

3.     A positive response to the third P, for Past, placed the woman at low risk for alcohol use during pregnancy (9.5%), an indication for prevention services to be instituted as part of primary prenatal care. 

4.     The two questions related to the fourth P, for Present Pregnancy, were converted to open-ended questions in an attempt to obtain an answer that most truthfully reflected the woman’s substance use patterns prior to pregnancy.  In addition, the questions were changed to “In the month before you knew you were pregnant….” This phrasing of the questions was found to be less threatening for the woman.  As documented in the initial research,1 the woman’s admission or denial of alcohol or tobacco use during pregnancy was not as an effective predictor of substance use during pregnancy as her acknowledgement of any alcohol or tobacco use prior to pregnancy.

5.     In administering the 4P’s Plus©, it is important not to use the term alcohol since many men and women do not recognize beer or wine to be alcohol.  Thus, when administering the 4P’s Plus©, the terms beer, wine or liquor are used rather than alcohol.  In addition, any forms of alcohol popular in the local community – such as daiquiris in Louisiana – should specifically be included in the questions.

6.     Physicians and other providers, with training, gave strong support to the use of the 4P’s Plus as a screening instrument.  The reasons the instrument gained this high level of approval were:

a.     Physicians appreciated the fact that they were not being asked to question the woman about illicit drug use, only alcohol and tobacco use prior to pregnancy.  As shown in our previous research, the level of denial of illicit drug use was so high, questions about illicit drugs did not provide usable information for the primary care physician.

b.     The 4P’s Plus© is efficient, requires little training, and is easily interpreted.

c.     Providers more readily accepted screening responsibility if the procedures could be integrated into routine prenatal care and had a logical flow within the clinical interview of the pregnant woman.  The screening easily flows from the family history, and, since the latter inquiries about past and present substance use are the more potentially threatening questions, they are less likely to elicit defensiveness or denial on the part of the patient if less personal questions are asked first.