Promising Practices for Implementing Adverse Childhood Experiences and Resilience Screening in Obstetric Care

Adverse childhood experiences (ACEs), including abuse, neglect, having a parent with substance use or mental health problems, separation from a parent, and witnessing domestic violence, are robust predictors of mental and physical health problems and increased social and financial costs throughout the lifespan. ^{1 –10} The strong relationship between ACEs and poor health ¹¹ makes ACEs a critical public health issue of our time. ^{12 –14}

Pregnant women are important to prioritize for ACEs screening and intervention. ACEs are associated with increased risk for negative perinatal outcomes (e.g., peripartum depression and anxiety, unplanned pregnancy) ¹⁵ and children of parents with ACEs are at risk for poor outcomes, highlighting the intergenerational impact of trauma. ¹⁶ Standardized screening for ACEs during pregnancy may disrupt this intergenerational cycle, thereby minimizing the effects of ACEs on both parents and children. ¹⁷ Goals of perinatal ACEs screening include patient education, intervention, and connection to resources. ¹⁸ Furthermore, simply sharing about past trauma with a supportive care provider can be healing. ¹⁹

Although state and national organizations increase efforts to address this critical public health problem across health care settings, ^10,20,21 there are no best practices for implementing ACE screening in obstetric practices. Furthermore, although trauma-informed care tenets highlight a strengths-based framework, methods for incorporating this into ACEs screening are lacking. ²²

To address these gaps, we summarize pilots examining the feasibility and acceptability of ACEs/resilience screening during prenatal care in five medical centers (pilot 1:3/2016–6/2016; pilot 2:4/2018–3/2019) in Kaiser Permanente Northern California (KPNC). We modified the CDC ACEs questionnaire from a research tool to a patient-friendly screener (i.e., decreasing word count and increasing literacy accessibility) and included a letter explaining the screening rationale. Staff trainings included education about ACEs, resilience, and associated health outcomes.

Clinicians were taught to convey key messages to patients (e.g., “Our childhood experiences can affect our health,” “You can consider the kind of parent you hope to be.”). We then tested screening during prenatal care. Clinician surveys before and after the first pilot demonstrated increases in knowledge and comfort in ACEs screening and discussions, and decreases in concerns that screening would be too time-consuming. ¹⁷ Clinicians reported that longer conversations were rare but important: “Most often the screen is negative and it's really easy. But when you find that person, you're so glad you did.” ¹⁷

Patient survey data indicated that most felt strongly or somewhat strongly that ACEs screening should be included in prenatal care (87%), felt very or somewhat comfortable completing the screening (91%), and felt very or somewhat comfortable discussing ACEs with their clinicians (93%). ¹⁷ Notably, most patients had never before been asked by health care professionals about ACEs (71%) and nearly all (95%) indicated the conversation did not negatively impact the patient–clinician relationship. Internal unpublished data demonstrated that patients appreciated the cover letter framing the screening as a means of support.

Our second pilot refined clinician scripts and explored patient preferences. ²³ Survey results indicated that patients continued to strongly support prenatal ACE/resilience screening and believed that healthy coping skills can help reduce the effects of ACEs. Notably, most supported screening partners, recognizing that their partners' ACEs have a tremendous impact on family well-being. When asked how to improve screening, some desired more provider empathy, more education, that the screening be led by a mental health professional, and the inclusion of additional stressors (e.g., adulthood trauma). In response, we further refined scripts and training to include more empathy and education. Future research is needed to evaluate the impact of the screening itself on pregnant patients' physical and mental health.