1 2 3 before 4 5 6 7 between universal 8 before enhanced Caring for Our Future: The Content of Prenatal Care 9 It is not our intention in this paper to propose a complete and final model of internatal care. Instead, we present here the start of a framework for internatal care, to be filled in through more dialogues and consensus-building which we hope this paper will help move forward. Recommended core contents of universal internatal care for all women following a pregnancy 1 Table 1. Recommended content and schedule of internatal care, and organizations recommending these practice standards Risk assessment a b Core content of internatal care for all women Family violence JACHO, AMA 1, 2, 3  Infections   Chlamydia USPSTF, ACPM 2   Periodontal ADA 2  Immunizations   Diptheria-tetanus booster USPTSF, ACPM, HHS 2   Hepatitis B USPTSF, ACPM, HHS 2   Measles and mumps USPTSF, ACPM, HHS, ACIP 2   Rubella USPTSF, ACPM, HHS, ACIP 2   Varicella USPTSF, ACPM, HHS, ACIP 2  Nutrition USPSTF 1,2, 3  Depression USPSTF, ACOG 1, 2, 3  Stress  1, 2, 3 Health promotion  Breastfeeding AAP, HP2010 1, 2, 3  Back-to-Sleep AAP, NICHD, HP2010 2  Exercise NHLBI, HHS, HP2010 2  Exposures   Smoking, alcohol, drug use HHS, ACOG 1, 2, 3   Mercury FDA/EPA 2, 3   Lead CDC, AAP 2, 3   Dioxins IOM 2, 3   Indoor/outdoor pollutants & allergens NHLBI 2, 3  Family planning ACOG/AAP 1, 2, 3  Folate supplementation CDC, AAP 3 Clinical interventions  Height and weight measurements ICSI, ACOG 1, 2, 3  Blood pressure ICSI, ACOG 2  Total skin examination ACS, ACPM 2  Clinical breast examination ACS, ACOG 3  Papanicolau smear and pelvic examination ACS, ACOG 2  Screening mammography ACS, ACOG 3 Psychosocial interventions  Social services  1, 2, 3  Clinical support  1, 2, 3  Parenting support  1, 2, 3 Enhanced content of internatal care for high-risk women Chronic hypertension    Risk assessment, health promotion, clinical & psychosocial interventions NHLBI  Gestational hypertension  Risk assessment, health promotion, clinical & psychosocial interventions NHLBI, ACOG  Pregestational diabetes  Risk assessment, health promotion, clinical & psychosocial interventions ADA  Gestatational diabetes  Risk assessment, health promotion, clinical & psychosocial interventions ADA, ACOG  Overweight/obesity  Risk assessment, health promotion, clinical & psychosocial interventions NHLBI, HHS USPSTF  Preterm birth  Risk assessment   Reproductive history ACOG    Family history ACOG    Medical assessment ACOG    Nutritional assessment ACOG    Social assessment ACOG   Health Promotion   Smoking cessation HHS    Substance abuse treatment ACOG    Optimal prepregnancy BMI IOM    Ensure adequate omega-3 fatty acids intake ISSFAL, IOM    Family planning ACOG/AAP   Clinical interventions   Progesterone use in subsequent pregnancy ACOG   Psychosocial Interventions   Services for children with special health care needs AAP    Home visitation AAP  a Abbreviations: b Risk assessment The primary objective of risk assessment is to identify on-going problems that need to be addressed. Most pregnant women in the U.S. are healthy and thus should have no major problems postpartum. However, some medical, behavioral or psychosocial problems may have been overlooked by their prenatal care providers. Other problems may develop during the internatal period. Providers of internatal care should pay particular attention to five problems that are now commonly missed during prenatal or postpartum care: family violence, infection/immunization, nutrition, depression and stress (FINDS). Family violence 10 11 12 12 13 13 Infection/immunization 14 15 16 1 Nutrition 17 Depression 18 18 18 Stress 19 20 Thus even for healthy mothers with healthy infants, much can be done to reduce health risks and promote well-being during internatal care. In addition to the five areas we highlighted (FINDS–family violence, infections/immunization, nutrition, depression, and stress), a battery of reproductive, medical, family, genetic and psychosocial risks should be routinely assessed during internatal care. Other areas of risk assessment can be added to the contents of internatal care as the model becomes more fully developed. A word of caution about risk screening Presently a major limitation on the effectiveness of risk screening is the lack of available or accessible services for those with a positive screen. The benefit of depression screening is limited when there are no mental health services available or accessible to refer mothers who screen positive for depression. And a lack of support services (and coordination thereof) for abuse victims is identified by many providers as a major deterrent to screening for family violence. For risk screening to be effective, it needs to be followed up by effective interventions. This means having all the necessary resources and service capacity (e.g. oral health services for those with periodontal disease, nutritional support for those who are food-insecure, housing assistance for homeless mothers and families) to assist those with a positive screen. Health promotion The primary objective of health promotion is to promote the health and wellbeing of the mother, infant, and family. We will highlight six components health promotion during internatal care: breastfeeding, back-to-sleep, exercise, exposures, family planning and folic acid (BBEEFF). Breastfeeding 21 22 22 21 Back-to-sleep 23 23 23 23 Exercise 24 25 Exposures 26 27 28 29 30 30 1 Family planning 31 31 32 31 Folate supplementation 33 34 1 Clinical interventions 1 Psychosocial interventions 1 Women who experience postpartum depression or other affective disorders may benefit from some forms of psychological support and therapy during the internatal period. Couples who experience problems with marital or sexual relationship in the internatal period may benefit from counseling or interventions. Women with alcohol or drug problems could also use clinical support and treatment. These and other professional clinical support services should be made available and accessible as part of standard internatal care services. 35 A note on psychosocial interventions Throughout this paper, the readers will notice an imbalance in the levels of details we used to describe clinical and psychosocial interventions. That is, clinical recommendations are, for the most part, described with much greater specificity than psychosocial interventions. It is certainly not our intention to propose a predominantly biomedical model of internatal care. Rather, the lack of specificity in our description of psychosocial interventions reflect both the complexity of psychosocial issues that families–particularly low-income families–face for which there are often no easy solutions, as well as the dearth of well-designed and evaluated intervention programs addressing these psychosocial issues. For example, mental health services alone are unlikely to be effective in treating the postpartum depression of a homeless mother, and housing assistance alone is unlikely to find her stable housing without sustainable income and employment, but few well-designed intervention studies have critically evaluated the impact of a comprehensive package of mental health services, housing assistance, work- and life-skills training and childcare on maternal and family health. Our model of internatal care is unlikely to be effective without effective psychosocial interventions, but we will not know what these are as long as we keep looking for quick biomedical fixes. Future intervention studies on internatal care need to take a more integrative, comprehensive approach to improving family and women’s health. Service coordination and integration As aforementioned, presently some referral services (e.g. mental health services, oral health services) are unavailable or inaccessible to many women between pregnancies. But even if the services are available, they are often poorly coordinated. Fragmentation in service delivery can deter access to care, particularly for low-income women with many other competing needs. Providers of internatal care need to consider how to better coordinate and integrate services in order to improve access. This can be accomplished by establishing a well-developed referral network. In some populations, care coordination or case management provided by a nurse or social worker may be needed. Ideally these services should be provided at one location to increase service coordination and integration. For example, the two-week internatal visit can be provided at the same time and location as the two-week well-baby check-up, with on-site WIC, health education, and social services that allow for “one-stop shopping.” We will take up issues related to the organization and delivery of internatal care that will maximize access and utilization of services in a series of papers to follow. Schedule of visits 22 1 36 Recommended contents of enhanced internatal care for high-risk women 1 8 Women with chronic hypertension or hypertensive disorders during pregnancy 11 11 chronic hypertension 37 Risk assessment Health promotion Clinical interventions Psychosocial interventions gestational hypertension pre-eclampsia and eclampsia 38 39 subsequent pregnancy 38 38 38 Women with pre-gestational or gestational diabetes mellitus 11 11 pre-gestational diabetes 40 gestational diabetes 41 42 43 pre-gestational diabetes 44 risk assessment Health promotion Clinical interventions Psychosocial interventions gestational diabetes 41 risk assessment 45 health promotion clinical interventions subsequent pregnancy 46 Women who are underweight, overweight, or obese 47 47 48 48 24 48 49 risk assessment health promotion 50 51 Clinical interventions Psychosocial interventions subsequent pregnancy 52 Women who had a prior preterm birth Presently this group of women is most often targeted for internatal care. Preterm birth is a leading cause of infant mortality and long-term disabilities in children in the U.S.. Prior preterm birth is the strongest and most consistent predictor of a subsequent preterm birth. This may be due to the fact that many of the biobehavioral risk factors for preterm birth are carried from one pregnancy to the next. The goal of internatal care for these women is to prevent recurrence of preterm birth by addressing these continuing biobehavioral risks prior to their next pregnancy. Risk assessment 53 54 54 55 Health promotion and 28 49 56 57 lactation 58 trans Clinical interventions 59 59 subsequent pregnancy 60 61 62 63 64 65 66 67 59 65 68 69 Psychosocial interventions 70 Service coordination and integration 71 72 73 73 Schedule of visits The schedule of internatal visits for women with prior preterm birth needs to be individualized (with a minimum of three visits plus annual visits, as previously described), depending on the clinical and psychosocial needs of the woman and family. During their subsequent pregnancy, these women should be supervised by a maternal fetal medicine specialist, either directly or indirectly through consultations. In sum, given the large impact of preterm birth on infant mortality and childhood disabilities and the high rates of recurrence in a subsequent pregnancy, women with prior preterm birth could be one of the most critical target groups for enhanced internatal care. Other high-risk women (e.g. women with prior fetal death), could also benefit from such program; we are unable to describe the content of their care in this paper due to space limitation and will do so in a series of papers to follow. The goal of such program is to prevent recurrence of preterm birth by addressing known biobehavioral pathways (e.g. infections/inflammation, neuroendocrine, vascular, etc) prior to the next pregnancy. There is a great need for more comprehensive and systematic risk assessment and health promotion during internatal care, as well as more basic, clinical and intervention research to identify effective clinical and psychosocial interventions for the prevention of recurrent preterm birth. Conclusion In this paper, we began to define the contents of internatal care. We recommended expanding the current six-week postpartum visit to three or more internatal visits (at two weeks, six weeks, and six months postpartum, and annual visits beginning at one-year postpartum). We suggested some core contents that all women should receive during internatal care, including risk assessment (e.g. FINDS), health promotion (e.g. BBEEFF), clinical and psychosocial interventions. For women with chronic health conditions such as hypertension, diabetes, or weight problems, we identified clinical guidelines for their evaluation, treatment, and follow-up during the internatal period. For women who had a preterm birth, we proposed an internatal care model based on known etiologic pathways, with the goal of preventing recurrence by addressing these biobehavioral pathways prior to the next pregnancy. We suggested enhancing service integration for women and families, including possibly care coordination or home visitation for women with prior preterm birth. We were limited in our effort to define the contents of internatal care by the paucity of research on the internatal period. Many pre-disease pathways leading to recurrence of adverse birth outcomes have not yet been elucidated. More importantly, even less is known about the trajectories to long-term women’s health or child health, or how to alter these pathways and trajectories. There is a need for more intervention studies evaluating the effectiveness of the various components of internatal care. More importantly, we need more research on mechanisms of disease to guide the design of internatal interventions. Our proposal will need to be updated and revised continually as new research data emerge. 37 3 2 74 1