On one of Kietha Jones' first visits to East Bay Perinatal, an Oakland obstetrics and gynecology practice, her nurse practitioner asked personal questions about alcohol and drug use many doctors and nurses wouldn't.
The 30-year-old Solano County woman said that she had used marijuana a couple of times during her pregnancy and that her partner smokes marijuana. Based on her answers, she was referred to a social worker at the practice.
"She helps me a lot," Jones said. "There's been certain cases where domestic violence came into play and a little bit of marijuana usage has come into play, and I stay in contact with her about these things."
The inquiries are part of pilot projects by public health departments in Alameda, Fresno and Ventura counties to make substance-abuse screening a standard part of a prenatal examination.
Most of the programs involve low-income patients, although county public health departments hope to expand them to all practices offering prenatal care. The public health departments of Butte and El Dorado counties are planning similar projects.
With research showing drug and alcohol use rates among pregnant women at 11% in California, the county health officials say they can't afford to leave such queries to the discretion of individual doctors or nurses.
Even though studies show drug use spans all races, ethnicities and economic backgrounds, screening is more often directed to poor and minority women than to well-off white women.
"If you look at a black homeless woman, she's going to get screened over someone from Piedmont," one of the wealthiest areas of Alameda County, said Mary Diogo, a nurse midwife and nurse practitioner who manages East Bay Perinatal, which is participating in Alameda County's pilot project.
Physicians and public health workers in the programs say the questions are designed to elicit honest answers. For example, they don't ask outright if a woman is currently using drugs or alcohol. Instead they ask about a woman's use before she knew she was pregnant and her parents' and partner's use -- with the idea of easing into a discussion of the patient's use while pregnant.
"If you ask somebody straight out, you'll get a lot of 'no's,' just because they are embarrassed or ashamed. This is a non-accusatory way" of asking the questions, Diogo said.
In many places, even if physicians discover women who are using, they don't know what kinds of treatment options are available, said Dr. Ira Chasnoff, a Chicago-based researcher on maternal substance abuse who helped set up the pilot programs.
"We've been working in several communities where [treatment centers] have shut down," Chasnoff said. They "couldn't get referrals because the health-care providers, the doctors, didn't know they existed."
The new programs are intended to strengthen connections between treatment centers and obstetrical practices, and to tailor treatment to individual patients' needs.
"Some people will need residential treatment, some will just need encouragement to stop drinking those two glasses of wine after work," said Dr. Leslie-Lynn Pawson, an internist who organizes Ventura County's program among five community clinics allied with UCLA.
In California, practitioners who find out their patients are using while pregnant aren't required to tell law enforcement officers. In the pilot programs, women generally are first counseled on the dangers of drug, alcohol and tobacco use during pregnancy, and those who appear to have a serious problem are encouraged to accept a referral to inpatient or outpatient treatment.
Practitioners follow up with the patients to see whether they are continuing treatment. Women who initially decline referrals are regularly encouraged to accept them.
Ted Myers, director of children and family services for Ventura County, said that once the screening program is better established, he would expect a reduction in child abuse and neglect related to drug and alcohol abuse. As it stands, he said, 60% to 80% of children taken into foster care come from homes where drugs and alcohol were abused.
Not everyone believes that the programs are a good idea. Some doctors are concerned that women's privacy might be compromised -- if the information in the medical records gets into the hands of attorneys in a lawsuit, for example.
Some women using drugs or alcohol worry that admitting use and accepting treatment will make it more likely they will lose their children to foster care.
In fact, program organizers say, the opposite is true.
"Social services will look at the fact that you are trying to get help for you and your baby," said Lynn Chung, director of the Alameda County pilot program.