Preconception Care Between Pregnancies The Conten

Authors: Michael C Lu Milton Kotelchuck Jennifer F Culhane Calvin J Hobel Lorraine V Klerman John M Thorp

Publish Date: 2006/07/01

Volume: 10, Issue: 1, Pages: 107-122

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Abstract

For more than two decades prenatal care has been a cornerstone of our nation’s strategy for improving pregnancy outcomes In recent years however a growing recognition of the limits of prenatal care and the importance of maternal health before pregnancy has drawn increasing attention to preconception and internatal care Internatal care refers to a package of healthcare and ancillary services provided to a woman and her family from the birth of one child to the birth of her next child For healthy mothers internatal care offers an opportunity for wellness promotion between pregnancies For highrisk mothers internatal care provides strategies for risk reduction before their next pregnancy In this paper we begin to define the contents of internatal care The core components of internatal care consist of risk assessment health promotion clinical and psychosocial interventions We identified several priority areas such as FINDS family violence infections nutrition depression and stress for risk assessment or BBEEFF breastfeeding backtosleep exercise exposures family planning and folate for health promotion Women with chronic health conditions such as hypertension diabetes or weight problems should receive ongoing care per clinical guidelines for their evaluation treatment and followup during the internatal period For women with prior adverse outcomes such as preterm delivery we propose 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 suggest enhancing service integration for women and families including possibly care coordination and home visitation for selected highrisk women The primary aim of this paper is to start a dialogue on the content of internatal careFor more than two decades prenatal care has been a cornerstone of our nation’s strategy for improving pregnancy outcomes In recent years however the effectiveness of this strategy has been called into question 1 Increasing use of early and adequate prenatal care has not led to a significant decline in low birthweight LBW or prematurity which are leading causes of infant mortality in the US Nor has closing the access gap in prenatal care led to a significant reduction in racialethnic or socioeconomic disparities in these adverse birth outcomes There is now a growing consensus that further reduction in this nation’s LBW and prematurity rates cannot be achieved solely by improving access to prenatal care 2A limitation on the effectiveness of prenatal care may be its timing Many of the pathophysiological pathways leading up to adverse birth outcomes may have their onset early in pregnancy possibly at or even before implantation By the time prenatal care is initiated it may be too little too late to significantly alter the course or outcome of the pregnancy Indeed there is now a growing recognition that birth outcomes are the end product of not only the nine months of pregnancy but the entire life course of the mother leading up to the pregnancy 3 Improving birth outcomes therefore takes promoting maternal health not only during pregnancy but before and between pregnancies and indeed across the woman’s lifespanThe recognition of the importance of maternal health before pregnancy has led to a growing interest in preconception care 4 A special subtype of preconception care is internatal care Internatal care refers to a package of healthcare and ancillary services provided to a woman and her family from the birth of one child to the birth of her next child It is in essence preconception and prenatal care for a subsequent pregnancy We prefer the term “internatal care” over the more popular term “interconception care” from the conception of one pregnancy to the conception of the next pregnancy because 1 internatal care represents an extension of prenatal care with which the public is familiar 2 the point of entry into care is the birth of one child and 3 the endpoint of care is the birth of the next child And while in this paper we will focus primarily on the interpregnancy interval from the termination of one pregnancy to the conception of the next pregnancy we prefer the term “internatal care” over “interpregnancy care” because internatal care suggests a continuity of care into a subsequent pregnancyDespite the growing interest for most people it remains unclear what is meant by internatal care For example many Healthy Start programs now offer internatal care and yet the content of care varies greatly across sites There have also been a few intervention studies on internatal care most notably in Denver 5 Atlanta 6 and Philadelphia 7 with vastly different approaches The lack of some standards of care makes it difficult to move forward research practice and policy or even discussion on internatal care The purpose of this paper is to begin to define the content of internatal careFor healthy mothers internatal care offers an opportunity for wellness promotion between pregnancies Presently many women lack such opportunity particularly among lowincome and minority women In most states Medicaid programs terminate pregnancyrelated healthcare coverage for most lowincome mothers at 60 days postpartum Other than the one recommended postpartum visit many of these women will have little or no access to healthcare between pregnancies Internatal care can help close the gap in healthcare for these women Even for women with healthcare coverage it is unclear how much and what internatal care they are currently getting In this paper we begin to define the core contents of universal internatal care that all women of childbearing age should receive between pregnanciesWhile we believe that internatal care should be universally available to all women between pregnancies it may be particularly beneficial for highrisk mothers such as women with chronic diseases or prior adverse pregnancy outcomes Many such outcomes eg prematurity fetal death carry a high recurrence risk in a subsequent pregnancy and the biobehavioral risk factors are often carried from one pregnancy to the next 8 For these mothers internatal care offers an opportunity for risk reduction before their next pregnancy In this paper we also begin to describe the content of enhanced internatal care for highrisk mothers We will use women with chronic health conditions hypertension diabetes or weight problems and women with a prior preterm delivery as examples of what more can be done for highrisk mothers during internatal care than under current prevailing practice which for many women consists of the one recommended sixweek postpartum visit or none at allTwo decades ago the US Public Health Service assembled an expert panel to define the contents of prenatal care In its report Caring for Our Future The Content of Prenatal Care the Expert Panel identified four basic components of prenatal care consisting of 1 early and continuing risk assessment 2 health promotion 3 clinical interventions and 4 psychosocial interventions 9 We now use the same framework to outline the contents of internatal care based on our search of the literature for clinical standards best practices and proven or promising strategies The focus of this paper is on the content of internatal care particularly during clinical visits Other important topics such as financing organization delivery motivation and community interventions are beyond the scope of this paper and will be addressed in a series of papers to follow

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