In general, the GPs perceived vulnerability as the net result of both risk factors and available individual and social resources. A psychosocial etiology appeared to be the dominant framework held by the GPs when conceptualizing vulnerability in pregnancy, and the availability of a social network was perceived as being important. As illustrated by one male GP when he said:
“Vulnerability has to be understood in a social context and not only in an individual context” (male GP > 45 years old)
As shown in Fig. 1, the GPs’ expressed a variety of conditions indicating vulnerability in pregnancy, originating from different comorbid conditions; somatic disease, psychiatric disease and social problems. Even though the GPs were not asked to classify indicators of vulnerability in pregnancy in levels, the GPs’ perceived specific indicators as being more obvious and classical; whereas, other indicators were perceived as being intangible. Therefore, during the data analysis process of the GPs perceived indicators of vulnerability, to main themes emerged; 1) obvious indicators of vulnerability and 2) intangible indicators of vulnerability.
The obvious indicators of vulnerability in pregnant women
The GP perceived obvious indicators of vulnerability in pregnancy could be organized into three categories; 1) social problems, 2) psychiatric diseases and 3) somatic diseases.
Obvious indicators of vulnerability related to social problems were; signs of deprivation with known social cases in the system – i.e. known history of being neglected in childhood or history of having children forcibly removed, known low intellectual- or mental resources, low level of education and often being unemployed. Being a single pregnant woman was perceived as a possible indicator of vulnerability; especially if the woman was very young, with a broken relationship to the father or plans of parenting alone, and simultaneously having poor social resources. As one female GP said:
“They’re young, haven’t known their partner for very long, have no education, no plans for their future and are often unemployed. We may know the family already, as a low social class family with low intellectual resources.” (female GP, > 45 years)
Poorly integrated women with an ethnic background were also perceived as vulnerable; since these women usually had a poor understanding of the language, the culture and local health system procedures. Lack of translator assistance made it difficult for the GPs to evaluate these women’s resources and guide them through the medical system. The GPs perceived that it was often necessary to refer them to the social-obstetric care units but experienced that the women’s poor economic and structural resources prevented them from attending the care units.
Other obvious indicators of vulnerability were related to known mental health problems, such as minor psychiatric disorders – i.e. anxiety, depression, attention deficit disorder or personality disorder(s)) with or without prescribed antidepressants, or known history of abuse of alcohol, drugs or addictive medicine. Whether the above pertained to the pregnant woman or her partner, they were perceived to indicate vulnerability.
A history of chronic somatic comorbidity or severe obstetric complications were perceived an indicator of vulnerability due to the risk of complicating pregnancy. Additionally, presence of chronic somatic disease was perceived to increase the degree of vulnerability, since they naturally caused a higher level of stress from worries.
Finally, the addition of several indicators of vulnerability as psychiatric diseases concomitant with coping problems from disabilities or chronic diseases were perceived to increase the degree of vulnerability.
“I had a patient with a hearing disability who was pregnant(...), however her real challenge is her many psychiatric challenges as she had been mentally unstable with poor self-care and difficulties managing social challenges(..) plus, I don’t think her intelligence level is very high” (female GP,< 45 years)
Conversely, some GPs reported being positively surprised by patients perceived as being obvious vulnerable. This was the case in situations where pregnant women, typically the young women or women with psychiatric disease(s), appeared to grow with the task and became brilliant mothers. However, mostly it demanded great social support from cross-sectoral collaborators in both the social-obstetric and social care system in the community.
“I would not have believed that this girl with mild schizophrenia would succeed in getting her daughter home from the hospital and now I observe normal mother-child interaction when she visits my clinic” (male GP > 45 years)
The intangible indicators of vulnerability
The GPs reported cases of women whom they perceived having indicators of an intangible degree of vulnerability, which could not be related to any prior known somatic or psychiatric diseases or obvious social problems. These indicators of intangible vulnerability perceived by GPs could be abnormal behavior or odd contact of the pregnant woman, which triggered the GPs’ gut feelings’ that something is wrong, and that the pregnant woman might have an undisclosed psychiatric disease or a deviant personality.
The GPs were guided by their gut feeling in cases where no prior doctor-patient relation existed, due to lack of continuity or the patient was new in the clinic. As a female GP said:
“I had this girl, who was a new patient and came for removal of her anticonception implant which we removed. Something was odd in the contact with her, and it triggered my attention – something was wrong. After thoroughly reading through her file, I discovered that her child was forcibly removed from her home by the social authorities a few years ago” (female GP, > 45 years)
The GPs perceived several indicators of intangible vulnerability in pregnancy related to minor social challenges - such as coping problems with being pregnant, relationship challenges when having a baby, low selfcare, low perceived intelligence, low threshold of stress, perceptions of being lonely without support from spouse. However, there was a gradual transition to normal challenges of motherhood and parenthood. As none of these indicators of intangible vulnerability are visual in the patient files, these women could go undetected until developing obvious signs of depression. As a female GP said.
“I had a pregnant woman where everything in her patient file looked fine, but when she came for the five weeks examination of her child I discovered that there was no eye contact with the baby, and subsequently I realized that the mother had a severe postpartum depression – and I thought ‘why didn’t I discover that?’” (female GP > 45 years)
Interestingly, the GPs described being guided by the woman’s appearance in their evaluation of the patient’s resources. If a woman appeared with normal interpersonal behavior and well dressed, they were less likely to elaborate further on the woman’s resources, which could delay the identification of vulnerability. This was often the case among the higher educated couples.
“They were this sharp looking couple driving an Audi and carrying designer sunglasses – completely streamlined upper class people you know. It was late in her pregnancy when she first caught my attention, as it appeared how horrible she felt, and that they simply could not embrace the changes that were awaiting them” (female GP < 45 years)
Especially, the GPs’ were misguided by a woman’s physical appearance when they had no pre-existing relation to the patient.
“They can easily trick you. I remember a woman, very nicely dressed, coming for her first antenatal consultations. She was a new patient and I had no previous medical record on her. We went through her pregnancy record nice and easy, I asked about alcohol use and she said there was none. At the end of the visit she asked how should go about getting her alcohol treatment transferred to the local alcohol rehab center. She was not currently using alcohol, and therefore had answered no to all the questions. It’s hard when we don’t know them. Based on her appearance I had no idea that she was in alcohol rehab” (female GP, < 45 years)
The GPs often acknowledged women with intangible vulnerability retrospectively, as they presented with a higher frequency of child consultations for minor things, such as simple colds, as they were insecure in judging the child’s needs.