
==== Front
Perm J
tpj
tpj
The Permanente Journal
1552-5767
1552-5775
The Permanente Press

38980765
10.7812/TPP/23.146
TPJ-23-146
Brief Report
Evaluation of an Embedded Health Psychologist Intervention for Obstetric Patients With Adverse Childhood Experiences
http://orcid.org/0000-0003-3615-9075
Watson Carey R MD 1
Wei Julia MPH 2
Rios Normelena MD 3
Staunton Mary MD 4
Koper Anna PsyD 3
Shiels Jacqueline PsyD 1
Lee Nina MD 5
Young-Wolff Kelly C PhD, MPH 2 6
1 Obstetrics and Gynecology, Kaiser Permanente, Antioch Medical Center, Antioch, CA, USA
2 Division of Research, Kaiser Permanente Northern California, Pleasanton, CA, USA
3 Obstetrics and Gynecology, Kaiser Permanente Dublin Medical Offices, Dublin, CA, USA
4 Department of Psychiatry, Kaiser Permanente, Walnut Creek Medical Center, Walnut Creek, CA, USA
5 Obstetrics and Gynecology, Kaiser Permanente Walnut Creek Medical Center, Walnut Creek, CA, USA
6 Department of Psychiatry and Behavioral Sciences, University of California, San Francisco, CA, USA
Carey R Watson, MD carey.r.watson@kp.org
2024
20 6 2024
28 3 144151
© 2024 The Authors.
2024
https://creativecommons.org/licenses/by-nc-nd/4.0/ Published by The Permanente Federation LLC under the terms of the CC BY-NC-ND 4.0 license https://creativecommons.org/licenses/by-nc-nd/4.0/.

Abstract

Background

Screening for adverse childhood experiences (ACEs) and resilience in pregnancy is a promising practice for mitigating ACEs-related health complications. Yet, the best follow-up for pregnant patients with high ACEs and/or low resilience has not been established.

Objective

This study evaluates referrals to and participation in an embedded health psychologist (EHP) intervention for pregnant patients with ACEs and/or low resilience.

Materials and Methods

Patients in 3 Kaiser Permanente Northern California medical centers with ACEs who had also received resilience screening during standard prenatal care and who were participating in an EHP intervention were included (N = 910). The authors used multivariable logistic regression to examine whether ACEs (0, 1–2, 3+) and resilience (high vs low) were associated with referrals to and participation in EHP intervention. They also evaluated the impact of EHP intervention through clinician (N = 53) and patient (N = 51) surveys.

Results

Patients with 3+ vs 0 ACEs were more likely to receive an EHP referral (adjusted odds ratio [aOR] = 2.89, 95% confidence interval [CI]: 1.93–4.33) and were more likely to participate in EHP intervention (aOR = 2.85, 95% CI: 1.87–4.36). Those with low vs high resilience were also more likely to receive an EHP referral (aOR = 1.86, 95% CI: 1.32–2.62) and participate in EHP (aOR = 1.71, 95% CI: 1.19–2.44). When ACEs and resilience were combined, those with high ACEs and low resilience had the greatest odds of referrals and participation. Patients and clinicians reported positive experiences with EHP intervention.

Conclusion

Patients with higher ACEs and lower resilience scores were more likely to be referred to and participate in EHP intervention, suggesting that at-risk patients can be successfully linked with a health psychologist when accessible within obstetric care.

Keywords:

adverse childhood experiences
resilience
prenatal care
health psychology
==== Body
pmcIntroduction

Pregnant individuals with adverse childhood experiences (ACEs) are at risk for negative health outcomes, including preterm delivery, anxiety, depression, challenges bonding with their baby; their children also tend to have higher ACE scores.1–4 Data suggest that maternal resilience may buffer some of these risks.5 Screening for ACEs and resilience is feasible and acceptable to pregnant patients and their clinicians6; further, pairing resilience screening with ACEs screening may help clinicians determine which patients would most benefit from support.5,7 Effective support may reduce the intergenerational cycle of ACEs. Campaigns such as the California ACEs Aware initiative8 encourage ACE screening during pregnancy, yet research has not established the best follow-up actions, including recommending referrals for individuals with ACEs. As shown through Andersen’s behavioral model for health services utilization,9 services integrated within prenatal care may better reach at-risk patients by reducing wait time, decreasing stigma, and providing interventions specific to pregnancy.

One promising model is embedded health psychology, which aims to provide timely and easy-to-access care for patients as their first, and sometimes only, mental health touchpoint. Embedded health psychologists are similar to integrated behavioral health clinicians, with training specifically in obstetrics, including peripartum mood, ACEs, resilience, intimate partner violence, and substance use in pregnancy. Care focuses on early intervention, prevention, and resilience-building, including psychotherapy tools, psychoeducation, and connection to relevant groups and resources. Embedded health psychologists see patients virtually or in person, lead peripartum support groups, and directly coordinate with obstetric clinicians regarding patient care. However, whether individuals with ACEs and low resilience would participate in an embedded mental health intervention is unknown. This study 1) evaluated whether referrals to and participation in an embedded health psychologist (EHP) intervention in prenatal care varied by patient ACEs and resilience scores, and 2) characterized patient and clinician attitudes about EHP intervention.

Methods

Setting and participants

This study took place in Kaiser Permanente Northern California, a nonprofit, multispecialty health care system with 21 medical centers in Northern California. Kaiser Permanente Northern California serves ~4.6 million members representative of Northern California’s insured population.10 The Kaiser Permanente Northern California Institutional Review Board approved this study with a waiver of documentation of informed consent.

Electronic health record (EHR)–based study

The sample comprised 910 English-speaking patients aged 18 years and over seen at the 3 Kaiser Permanente Northern California medical centers with an EHP who completed routine screening for ACEs and resilience during standard prenatal care (at ~16 weeks gestation) from November 1, 2020, to August 31, 2021 (medical centers A and B), and November 1, 2020, to April 30, 2021 (medical Center C). In the examination room, patients completed questionnaires, which were reviewed by their clinician. All patients received a handout with mental health, community, and educational resources.11 Those with any ACEs, low resilience, or other risk factors (eg, depression) who might benefit from mental health services had the opportunity for referral to the EHP, allowing for more timely and tailored support and potentially less stigma than an adult psychiatry referral. Referrals were made through clinician-to-clinician electronic health record messaging, and the EHP followed up to schedule the appointment. Patients who participated typically had 1–4, or up to 6 visits with an EHP based on patient need.

Quality improvement survey study

As part of quality improvement, a convenience sample of patients who participated in the EHP intervention were invited to complete a structured telephone survey from April 29, 2021, to August 13, 2021, with an EHP (but not the psychologist with whom they worked), to understand their experiences with the EHP intervention. The authors included data from the 51 patients who completed the survey. In addition, clinicians who worked in sites with EHP and sites without EHP were surveyed as part of qualitative improvement about their attitudes toward addressing patient mental health concerns. Those in EHP sites were also surveyed about their experiences with the EHP intervention program.

Measures

ACEs were measured using the California ACEs Aware 10-item screening questionnaire,12 which is a modified version of the original ACEs screening developed by Felitti and Anda. Patients could check “yes” or “no” to questions about whether 10 specific ACEs occurred before their 18th birthday. Scores could range from 0 to 10, and responses were categorized into 0, 1–2, and 3+, as was done in the authors’ prior work.5,6

Resilience was measured using the 10-item Connor-Davidson Resilience Scale, a self-reported measure of past-month resilience used in prior research with pregnant and postpartum patients.11,13 Each item allows the patient to answer on a 5-point scale with options ranging from 0 (“not true at all”) to 4 (“true nearly all the time”). The answers are summed for a total score ranging from 0 to 40. The authors dichotomized the scores based on the national average, with < 30 categorized as low resilience and scores 30–40 as normal or high resilience.13

The 3-level ACE score and dichotomized resilience score were then combined into a 6-level variable to understand the intersection of these variables: 1) 0 ACEs/high resilience; 2) 1–2 ACEs/high resilience; 3) 3+ ACEs/high resilience; 4) 0 ACEs/low resilience; 5) 1–2 ACEs/low resilience; and 6) 3+ ACEs/low resilience.

The electronic health record provided the patients’ demographic characteristics including age, race and ethnicity (Asian/Pacific Islander, Black, Hispanic, non-Hispanic White, other/unknown), parity, Medicaid status, and neighborhood deprivation index (NDI) quartiles,14 with Q1 representing the “least deprived” and Q4 representing the “most deprived.”

Pregnant patients referred to the EHP by their obstetrician were considered to have had an EHP referral, and those who attended ≥ 1 EHP visit were considered to have participated. Both patient and clinician surveys used a Likert scale for most responses (strongly agree, agree, neither agree nor disagree, disagree, strongly disagree), with some questions being yes/no and some including checkboxes.

Statistical Analysis

Frequencies and percentages described sociodemographics and ACE and resilience scores. Chi-square and Fisher’s exact tests compared categorical sociodemographic covariates and ACE count by EHP outcomes (referral and participation).

Embedded health psychologist intervention–based analysis

The authors estimated the odds ratios and 95% confidence interval (CI) of 1) EHP referral, and 2) EHP intervention participation, by ACE score and resilience score independently, and by each combination of ACEs and resilience. They also tested for interactions between ACEs and resilience for each outcome. All regression analyses were adjusted for maternal age, race and ethnicity, NDI, parity, and Medicaid status. The authors used the missing option in the models including the entire cohort to allow them to keep patients in the model with missing NDI (n = 5), parity (n = 4), and resilience (n = 7). A P value of < 0.05 was statistically significant. All data management and statistical analyses were performed in SAS 9.4 (SAS Institute Inc.).

Survey-based analysis

Frequencies and percentages described patient and clinician survey responses. Responses from clinicians at medical centers with and without EHP intervention were compared using a 2-sample z test for proportions. All data management and statistical analyses were performed in SAS 9.4.

Results

The study sample (N = 910) had a mean age of 31 (standard deviation = 5.1); 26.5% Asian/Pacific Islander, 13.7% Black, 26.0% Hispanic, 31.7% non-Hispanic White, and 2.1% other/unknown race and ethnicity (Table 1). Patients had a mean of 1.2 (standard deviation = 2.0) ACEs; 58.4% had 0, 23.0% had 1–2, and 18.7% had 3+. Overall, 55.6% and 44.4% of the sample had high and low resilience, respectively. Distributions of the 6-level ACEs/resilience variable are shown in Table 1. Overall, 21.4% of patients received an EHP referral, and 18.5% participated in EHP.

Table 1: Sociodemographic and clinical characteristics of obstetric patients by adverse childhood experience score (N = 910)

		Number (%)	Embedded health psychologist intervention	
Referral number (%)	Participation number (%)	
Patient characteristic		Total N = 2730 (100)	Yes n = 195 (21.4)	No
n = 715 (78.6)	Chi-square P value	Yes
n = 168 (18.5)	No
n = 742 (81.5)	Chi-square P value	
Age	
 18–30 years old	416 (45.7)	93 (22.4)	323 (77.6)	0.66	73 (17.6)	343 (82.5)	0.58	
 31–35 years old	319 (35.1)	63 (19.8)	256 (80.3)	58 (18.2)	261 (81.8)	
 36+ years old	175 (19.2)	39 (22.3)	136 (77.7)	37 (21.1)	138 (78.9)	
Race and ethnicity a	
 Asian	241 (26.5)	 *	*	0.07	*	*	0.42	
 Black	125 (13.7)	*	*	*	*	
 Hispanic	237 (26.0)	*	*	*	*	
 Non-Hispanic White	288 (31.7)	*	*	*	*	
 Other	19 (2.1)	*	*	*	*	
Neighborhood deprivation index	
 Q1 (least deprived)	220 (24.3)	37 (16.8)	183 (83.2)	0.03	35 (15.9)	185 (84.1)	0.07	
 Q2	208 (23.0)	48 (23.1)	160 (76.9)	40 (19.2)	168 (80.8)	
 Q3	282 (31.2)	75 (26.6)	207 (73.4)	65 (23.1)	217 (77.0)	
 Q4 (most deprived)	195 (21.6)	35 (18.0)	160 (82.1)	28 (14.4)	167 (85.6)	
Medicaid status	
 Yes	84 (9.2)	21 (25.0)	63 (75.0)	0.40	18 (21.4)	66 (78.6)	0.46	
 No	826 (90.8)	174 (21.1)	652 (78.9)	150 (18.2)	676 (81.8)	
Parity	
 Nulliparous	347 (38.3)	79 (22.8)	268 (79.4)	0.44	72 (20.8)	275 (79.3)	0.16	
 Parous	559 (61.7)	115 (20.6)	444 (77.2)	95 (17.0)	464 (83.0)	
ACE score	
 0	531 (58.4)	85 (16.0)	446 (84.0)	< 0.01	74 (13.9)	457 (86.1)	< 0.01	
 1–2	209 (23.0)	43 (20.6)	166 (79.4)	36 (17.2)	173 (82.8)	
 3+	170 (18.7)	67 (39.4)	103 (60.6)	58 (34.1)	112 (65.9)	
Resilience	
 Low	401 (44.4)	110 (27.4)	291 (72.6)	0.01	92 (22.9)	309 (77.1)	0.02	
 High	502 (55.6)	84 (16.7)	418 (83.3)	75 (14.9)	427 (85.1)	
ACEs and resilience combined	
ACEs	Resilience	 	 	 	 	 	 	 	
 0	High	315 (34.9)	38 (12.1)	277 (87.9)	< 0.01	35 (11.1)	280 (88.9)	< 0.01	
Low	209 (23.2)	46 (22.0)	163 (78.0)	38 (18.2)	171 (81.8)	
 1–2	High	113 (12.5)	18 (15.9)	95 (84.1)	17 (15.0)	96 (85.0)	
Low	96 (10.6)	25 (26.0)	71 (74.0)	19 (19.8)	77 (80.2)	
 3+	High	74 (8.2)	28 (37.8)	46 (62.2)	23 (31.1)	51 (68.9)	
Low	96 (10.6)	39 (40.6)	57 (59.4)	35 (36.5)	61 (63.5)	
Notes: NDI missing 5, Parity missing 4, Resilience missing 7.

a Details of the distribution of race and ethnicity by embedded health psychologist intervention referral and treatment initiation suppressed due to small cell size.

ACE, adverse childhood experience; N, number.

Embedded health psychologist intervention referrals and participation

Sociodemographic, ACE, and resilience characteristics of women by EHP referral and participation are provided in Table 1. There were minimal but significant differences in referrals to the EHP by NDI. Other covariates were not associated with EHP referral or participation.

The study found a higher likelihood of an EHP referral among those with 1–2 (20.6%) or 3+ (39.4%) vs 0 ACEs (16.0%, p < 0.01) and among those with low (27.4%) vs high (16.7%) resilience (p < 0.01). Similarly, it found a higher prevalence of EHP participation among those with 1–2 (17.2%) or 3+ (34.1%) vs 0 ACEs (13.9%, p < 0.01) and among those with low (22.9%) vs high resilience (14.9%, p < 0.01). In the combined ACE/resilience variable, those with 3+ ACEs and low resilience were more likely to get an EHP referral and to participate relative to those with all other combinations of ACEs and resilience (Table 2).

Table 2: Adjusted odds of embedded health psychologist intervention referral and treatment initiation (N = 910)

Referral to embedded health psychologist intervention	Value	
Model 1. ACEs and resilience in model	aOR (95% CI)	
ACEs and resilience (ref = 0 ACEs)	
 1–2 ACEs	1.21 (0.80–1.85)	
 3+ ACEs	2.89 (1.93–4.33)	
Resilience (ref = high resilience)	1.86 (1.32–2.62)	
Model 2. 6-level categorical variable for ACEs and resilience	aOR (95% CI)	
ACEs and resilience (ref = 0 ACEs and high resilience)	
 0 ACEs and low resilience	2.24 (1.38–3.64)	
 1–2 ACEs and high resilience	1.23 (0.66–2.29)	
 1–2 ACEs and low resilience	2.65 (1.48–4.76)	
 3+ ACEs and high resilience	4.12 (2.27–7.46)	
 3+ ACEs and low resilience	4.90 (2.83–8.49)	
Embedded health psychologist participation		
Model 1. ACEs and resilience in model	aOR (95% CI)	
ACEs and resilience (ref = 0 ACEs)	
 1–2 ACEs	1.16 (0.74–1.82)	
 3+ ACEs	2.85 (1.87–4.36)	
Resilience (ref = high resilience)	1.71 (1.19–2.44)	
Model 2. 6-level categorical variable for ACEs and resilience	aOR (95% CI)	
ACEs and resilience (ref = 0 ACEs and high resilience)		
 0 ACEs and low resilience	1.97 (1.19–3.28)	
 1–2 ACEs and high resilience	1.25 (0.66–2.37)	
 1–2 ACEs and low resilience	2.11 (1.12–3.97)	
 3+ ACEs and high resilience	3.52 (1.89–6.56)	
 3+ ACEs and low resilience	4.74 (2.69–8.36)	
Notes: All logistic regression analyses were adjusted for maternal age, race and ethnicity, neighborhood deprivation index, parity, and Medicaid status.

ACE, adverse childhood experience; aOR, Adjusted odds ratio; CI, confidence interval; Ref, reference.

In adjusted multivariable models, having 3+ (vs 0) ACEs was associated with significantly increased odds of an EHP referral (aOR = 2.89 [95% CI: 1.93–4.33]) and participation (aOR = 2.85 [95% CI: 1.87–4.36]), and having low (vs high) resilience was associated with significantly increased odds of an EHP referral (aOR = 1.86 [95% CI: 1.32–2.62]) and participation (aOR = 1.71 [95% CI: 1.19–2.44]) (Table 2).

In adjusted multivariable models that combined ACEs and resilience, compared with those with 0 ACEs and high resilience, patients with 0 ACEs and low resilience (aOR = 2.24 [95% CI: 1.38–3.64]), 1–2 ACEs and low resilience (aOR = 2.65 [95% CI: 1.48–4.76]), 3+ ACEs and high resilience (aOR = 4.12 [95% CI: 2.27–7.46]), and 3+ ACEs and low resilience (aOR = 4.90 [95% CI: 2.83–8.49]) had significantly higher odds of an EHP referral (Table 2). Patients with 1–2 ACEs and high resilience (vs 0 ACEs and high resilience) were not significantly more likely to receive an EHP referral.

Similarly, compared with patients with 0 ACEs and high resilience, patients with 0 ACEs and low resilience (aOR = 1.97 [95% CI: 1.19–3.28]), 1–2 ACEs and low resilience (aOR = 2.11 [95% CI: 1.12–3.97]), 3+ ACEs and high resilience (aOR = 3.52 [95% CI: 1.89–6.56]), and 3+ ACEs and low resilience (aOR = 4.74 [95% CI: 2.69–8.36]), but not those with 1–2 ACEs and high resilience, were more likely to participate (Table 2). There were no significant interactions between ACEs and resilience in referral or utilization (p values < .05).

Surveys

Among the 51 patients surveyed, 42 (84%) agreed or strongly agreed that their recent EHP visit improved their overall well-being, 42 (84%) agreed or strongly agreed that they were able to meet soon after referral, and 48 (98%) agreed or strongly agreed that the visit was valuable for pregnant or postpartum women who had difficulties in childhood, depression, or anxiety (Table 3). Nearly all patients reported that the EHP helped them identify tools to improve their health (56%–98%). Most (63%) reported that their time with the EHP would have been better if more appointments were available.

Table 3: Patient and clinician attitudes toward the embedded health psychologist intervention

Patient attitudes toward EHP visit (N = 51)			
Question	Response	No. (%)	
1. My recent visit with the embedded health psychologist	
a. Improved my overall well-being	Strongly agree or agree	42 (84)	
b. Was able to meet soon after my provider referred me	Strongly agree or agree	42 (84)	
c. Valuable for pregnant or postpartum women who had difficulties in childhood, depression, or anxiety	Strongly agree or agree	48 (98)	
2. Meeting with the embedded health psychologist helped me identify the following factors and/or next steps to improve my health	
a. Difficulties in childhood (intergeneration effects of ACEs)	Yes	28 (56)	
b. Supplemental resources (books, online support, Calm app)	Yes	45 (88)	
c. Education on mood changes during and after pregnancy	Yes	43 (84)	
d. Tools for resilience (self-care, self-compassion, mindfulness, meditation, physical exercise, seeking social support)	Yes	49 (98)	
e. Important relationships affecting me during and after pregnancy	Yes	44 (88)	
f. Baby bonding concerns and tips	Yes	32 (65)	
g. Referrals within Kaiser Permanente pregnancy and or postpartum support group, mental health department, health education classes, Kaiser Permanente bereavement, Thrive line, wellness coaching	Yes	50 (98)	
3. My time with the embedded health psychologist would have been better if (patient can check more than 1)	
a. It happened more quickly	12 (24)	
b. Provider had more resources to offer	6 (12)	
c. Appointments were longer	17 (33)	
d. Appointments were available for women’s health issues	24 (47)	
e. Appointments were available	32 (63)	
Notes: Questions 1a, 1b, 2a, 2d, 2e are missing 1 response. Questions 1c, 2f are missing 2 responses.	
Clinician attitudes toward mental health care and referrals at sites with and without an EHP (N = 53)	
Question	Response	EHP n = 30 (57%)	No EHP n = 23 (43%)	P value	
1. My patients get timely care for their mental health concerns	Strongly agree or agree	22 (79)	3 (14)	< 0.01	
2. I feel confident in discussing mental health concerns with patients	Strongly agree or agree	21 (70)	15 (65)	0.7	
3. I feel supported in providing mental health care and referrals for my patients in my practice	Strongly agree or agree	22 (73)	8 (35)	< 0.01	
4. Our patients are benefiting from the embedded behavioral health program	Strongly agree or agree	30 (100)	n/a	n/a	
5. An embedded behavioral health consult improved the care experience for my patient	Strongly agree or agree	30 (100)	n/a	n/a	
6. The embedded behavioral health program improves my ability to care for my patients	Strongly agree or agree	30 (100)	n/a	n/a	
Notes: Question 1 is missing 2 responses in the group with embedded health psychologist and missing 1 response in the group without embedded health psychologist. P values calculated using 2-sample z test for proportions.

ACE, adverse childhood experience; EHP, embedded health psychologist intervention; N, number.

All 30 clinicians (100%) at EHP sites agreed or strongly agreed that patients benefitted from EHP and agreed or strongly that EHP improved the patient care experience and improved clinicians’ ability to care for their patients (Table 3). Compared with clinicians at sites without EHP (N = 23), those with EHP were more likely to agree or strongly agree that their patients received timely care for mental health concerns (79% vs 14%, p < 0.01), and indicated that they felt supported in providing patients with mental health care or referrals (73% vs 35%, p < 0.01).

Discussion

This novel study evaluated whether referral to and participation with a behavioral health psychologist embedded into prenatal care varied with patients’ ACE and resilience scores. Previous studies show that pregnant patients with ACEs and low resilience are more likely to have depression and/or anxiety during pregnancy and may have increased support needs.5,7 As expected, patients with more ACEs and low resilience were more likely to be referred to and to participate in EHP intervention, suggesting that at-risk patients can be successfully linked with a health psychologist when accessible within obstetric care. This fits with the Andersen model of health and behavioral health utilization, as greater need and more availability of resources facilitate utilization of services.9

Notably, patients with a combination of high ACEs and low resilience were the most likely to receive EHP referrals and to participate in treatment. Those with 1–2 ACEs and high resilience were similar to those with 0 ACEs and high resilience in their lower likelihood of EHP referral and participation. These findings have clinical implications; they suggest the value of considering both ACE and resilience scores, rather than ACE scores alone, to better tailor referrals and interventions to patients’ individual needs. Patients with high resilience and only 1–2 ACEs may not need extra resources, consistent with prior research suggesting that the negative health consequences of ACEs may be mitigated by resilience. Results can inform other health care organizations about potential volume of referrals as they incorporate ACEs screening into their practice, for example, by using combined ACEs and resilience scores and focusing on patients who are receptive to treatment and those with greater support needs (Table 4).

Table 4: Example algorithm for referral based on adverse childhood experience and resilience scores

	ACE 0	ACE 1–2	ACE 3+	
Resilience high	Anticipatory guidance	Anticipatory guidance	Offer referral to embedded health psychology	
Resilience low	Offer referral to embedded health psychology	Offer referral to embedded health psychology	Offer referral to embedded health psychology	
Note: Consider patient receptivity to referral and level of support needed.

ACE, adverse childhood experience.

Importantly, patients who participated in EHP intervention reported that it improved their well-being, was valuable, and helped them identify other sources of support. Further, obstetric clinicians at sites with EHP intervention reported that their patients benefited from it and that it improved their own ability to care for their patients. Clinicians in sites with EHP interventions reported that their patients received care more quickly than they would have following traditional routes of adult psychiatry referral, and they felt better supported in providing referrals for patients with mental health concerns. Referral to an EHP may also help health care systems improve support for perinatal patients. EHP intervention is intended as a short-term mental health intervention and is more efficient and less costly than referral to adult psychiatry, which focuses on chronic mental health conditions, has a longer intake process, different model of care, and typically requires multiple visits.

This study was limited to insured pregnant patients in 3 Kaiser Permanente Northern California medical centers, and results may not be generalizable to other populations. Patient and clinician survey sample sizes were small, and additional studies with larger samples and more robust survey methods are needed to better understand how ACEs and resilience combine to influence mental health care utilization.

In conclusion, a high percentage of pregnant patients with ACEs and low resilience were referred to and participated in EHP intervention, suggesting that at-risk patients can be successfully linked with embedded mental health care. Findings suggest that relative to traditional adult psychiatry referrals, EHP referrals may provide more efficient and impactful interventions for at-risk pregnant patients and their families.

Acknowledgments

The authors thank the OB patients who who offered feedback regarding their consultation with Embedded Health Psychology.

Author Contributions: Carey R Watson, MD; Kelly C Young-Wolff, PhD, MPH; and Julia Wei, MPH, participated in study conception and design. Julia Wei, MPH, and Anna Koper, PsyD, partcipated in data collection. Carey R Watson, MD; Kelly C Young-Wolff, PhD, MPH; Julia Wei, MPH; Jaqueline Shiels, PsyD; Normelena Rios, MD; Mary Staunton, MD; Anna Koper, PsyD; and Nina Lee, MD, participated in analysis and interpretation of results. Carey R Watson, MD; Julia Wei, MPH; and Kelly C Young-Wolff, PhD, MPH, participated in draft manuscript preparation. All authors reviewed the results and approved the final version of the manuscript.

Conflicts of Interest: None declared

Funding: None declared
==== Refs
References

1. Centers for Disease Control and Prevention. Adverse childhood experiences reported by adults—five states, 2009. MMWR Morb Mortal Wkly Rep. 2010;59 (49 ):1609–1613. https://www.ncbi.nlm.nih.gov/pubmed/21160456 21160456
2. Olsen JM . Integrative review of pregnancy health risks and outcomes associated with adverse childhood experiences. J Obstet Gynecol Neonatal Nurs. 2018;47 (6 ):783–794. 10.1016/j.jogn.2018.09.005
3. Sulaiman S , Premji SS , Tavangar F , Yim IS , Lebold M , MiGHT . Total adverse childhood experiences and preterm birth: A systematic review. Matern Child Health J. 2021;25 (10 ):1581–1594. 10.1007/s10995-021-03176-6 34036452
4. Prentice DM , Otaibi BW , Stetter C , Kunselman AR , Ural SH . The association between adverse childhood experiences and postpartum depression. Front Glob Womens Health. 2022;3 . 10.3389/fgwh.2022.898765
5. Young-Wolff KC , Alabaster A , McCaw B , et al. Adverse childhood experiences and mental and behavioral health conditions during pregnancy: The role of resilience. J Womens Health. 2019;28 (4 ):452–461. 10.1089/jwh.2018.7108
6. Flanagan T , Alabaster A , McCaw B , Stoller N , Watson C , Young-Wolff KC . Feasibility and acceptability of screening for adverse childhood experiences in prenatal care. J Womens Health. 2018;27 (7 ):903–911. 10.1089/jwh.2017.6649
7. Leeners B , Richter-Appelt H , Imthurn B , Rath W . Influence of childhood sexual abuse on pregnancy, delivery, and the early postpartum period in adult women. J Psychosom Res. 2006;61 (2 ):139–151. 10.1016/j.jpsychores.2005.11.006 16880016
8. State of California Department of Health Care Services. About California’s Aces Aware initiative. 2020. Accessed 19 September 2023. www.acesaware.org/wp-content/uploads/2019/12/About-ACEs-Aware-2-25-20-FINAL.pdf
9. Alkhawaldeh A , ALBashtawy M , Rayan A , et al. Application and use of Andersen’s behavioral model as theoretical framework: A systematic literature review from 2012-2021. Iran J Public Health. 2023;52 (7 ):1346–1354. 10.18502/ijph.v52i7.13236 37593505
10. Davis AC , Voelkel JL , Remmers CL , Adams JL , McGlynn EA . Comparing Kaiser Permanente members to the general population: Implications for generalizability of research. Perm J. 2023;27 (2 ):87–98. 10.7812/TPP/22.172 37170584
11. Kohler S , Hofmann A . Can motivational interviewing in emergency care reduce alcohol consumption in young people? A systematic review and meta-analysis. Alcohol Alcohol. 2015;50 (2 ):107–117. 10.1093/alcalc/agu098 25563299
12. ACES Aware. Screening Tools. California Department of Health Care Services. 2023. Accessed 16 August 2023. www.acesaware.org/learn-about-screening/screening-tools
13. Connor KM , Davidson JR . The Connor-Davidson Resilience Scale (CD-RISC). 2003. Accessed 29 July 2023. www.cd-risc.com/about.php
14. Messer LC , Laraia BA , Kaufman JS , et al. The development of a standardized neighborhood deprivation index. J Urban Health. 2006;83 (6 ):1041–1062. 10.1007/s11524-006-9094-x 17031568
