Most pregnant women in the United States are healthy and experience healthy pregnancy and birth outcomes. For these women, internatal care is still important because it offers an opportunity for wellness promotion. In this section, we describe the core contents of internatal care, including risk assessment, health promotion, clinical interventions, and psychosocial interventions (Table 1). These components should be offered to every woman following a pregnancy, regardless of her risk status. We recommend expanding the current six-week postpartum visit to three or more internatal visits, at 2 weeks, 6 weeks, and 6 months postpartum, with annual follow-up beginning at one year postpartum. We will expand on the rationale for the recommended schedule of visits, and address issues related to systems integration later in this section.
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).
The experience of family violence may be quite common among pregnant and postpartum women in the U.S. Most studies of the prevalence of physical abuse during pregnancy report estimates in the range of 4 to 8 percent, though higher estimates (around 20%) have been reported in some populations . Less is known about the prevalence of violence after pregnancy, with estimates at 3 months postpartum ranging from 3.2% in a population-based survey to 21% in a prospective study of adolescent mothers [11, 12]. In the latter study , three of four women who reported intimate partner violence (IPV) had not reported IPV prior to delivery. Family violence puts maternal health and child development at great risk. The literature contains solid links between intimate partner violence and child abuse . Because violence is frequently missed by healthcare providers including prenatal care providers, we recommend routine screening for family violence during every internatal visit. Several brief screening instruments, such as the 4-item Hurt Insulted Threatened or Screamed at (HITS), the 3-item Partner Violence Screen (PVS), and a 3-item Abuse Assessment Screen (AAS), can be effectively used to screen for IPV in a clinical setting .
Some infections may go unrecognized or untreated during pregnancy. Chronic, untreated infections, such as periodontal disease, could pose a threat not only to the next pregnancy , but also to the mother’s long-term health as well . Most women are not screened for periodontal disease during prenatal care, and many women lack access to oral health services following pregnancy. While presently there is insufficient evidence to justify universal screening for asymptomatic infections among “low-risk” women in the internatal period (other than the U.S. Preventive Services Task Force (USPSTF) recommendation for Chlamydia screening in women under the age of 25) , in some populations routine screening for periodontal, sexually-transmitted and some urogenital tract infections may be warranted.
Internatal care also offers an important opportunity to update women’s immunization status. The USPSTF and other national advisory committees recommend that 1) all adults receive periodic diptheria-tetanus toxoids booster every 10 years, 2) all young adults receive a series of Hepatitis B vaccines, 3) all adults born after 1956 who lack evidence of immunity receive vaccination against measles and mumps, and 4) all women of childbearing age be screened for rubella and varicella susceptibility; susceptible nonpregnant women of childbaring age should be offered vaccination and avoid conception for at least 28 days after vaccination; susceptible pregnant women should be vaccinated immediately after delivery (Table 1). Immunization status should be assessed and updated at the six-week internatal visit.
Nutrition can play an important role in promoting maternal health and child development, and yet women’s nutritional needs are often overlooked by prenatal or postpartum care providers. One recent population-based survey in California found that nearly one in three pregnant women who were income-eligible for Women, Infants, and Children (WIC) program reported being food-insecure; of these, one in four reported not being enrolled in WIC . Nutritional screening should address the ABCD’s of nutritional risks: anthropometric (e.g. low or high body mass index), biochemical (e.g. for anemia or folate deficiency in some populations), clinical (e.g. eating disorder) and dietary (e.g. content, pattern, food insecurity). An abbreviated 6-item version of the Household Food Security Scale can be used to screen for food insecurity. Inquiry should be made about folate or multivitamin supplementation (see under Health Promotion). We recommend routine screening of nutritional risks at every internatal visit.
Maternal depression affects a large number of women and their children. A recent systematic review reported combined estimates of the point prevalence of major and minor depression ranging from 8.5 to 11 percent during pregnancy, and 6.5 to nearly 13 percent during the first year postpartum . Maternal depression can have negative long-term impact on both maternal health and child development, but is often missed by prenatal and postpartum care providers. We recommend routine screening for maternal depression at every internatal visit. Fairly accurate and feasible screening measures are available, including the Postpartum Depression Screening Scale (PDSS), Edinburgh Postnatal Depression Scale (EPDS), Beck Depression Inventory (BDI), and the Center for Epidemiologic Studies Depression Scale (CES-D) . The evidence available, albeit limited, suggests that providing some form of psychosocial support to pregnant and postpartum women at risk of having a depressive illness may decrease depressive symptoms .
Maternal stress is perhaps the hardest to screen; clinicians are often at a loss as to how to screen or what to do with a positive screen. Yet chronic stress can pose significant risks to maternal health and child development. For the mother, chronic stress can cause wear and tear to her body’s adaptive systems, what McEwen refers to as allostatic load, which could lead to more rapid deterioration in her health and function over time . For the infant (or the fetus in a subsequent pregnancy), maternal stress could result in the re-programming of the child’s basic autonomic rheostat and alteration of immune regulation, leading to increased vulnerability to disease and dysfunction later in life . There is an important need for the development of a multi-dimensional screening tool for stress that can be feasibly implemented in a clinical setting. For now, clinicians need to ask about major stressors in women’s lives (e.g. homelessness, unemployment, family violence, social isolation) at every internatal visit, and find resources and supports to help the family deal with these stressors.
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.
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).
Despite well-known benefits of breastfeeding for both mother and infant , at least one-third of mothers in the U.S. never initiate breastfeeding . Among women who initiated, nearly one in five will stop nursing by one month, and nearly two-thirds will stop by six months , despite current recommendation to breastfeed for at least one full year . Internatal care offers an important opportunity to promote breastfeeding, particularly the initial two-week visit to address nascent problems, the six-week visit to anticipate problems related to transition back to work, and the six-month visit to encourage continued breastfeeding with introduction of solid foods.
With the introduction of the Back-to-Sleep campaign by the American Academy of Pediatrics in 1992, the overall incidence of sudden infant death syndrome (SIDS) has decreased by almost 50% . Despite this success, SIDS continues to be a leading cause of infant death in the U.S., as well as racial disparity in infant mortality . SIDS rate among black infants remains more than twice that of white infants, even after the implementation of the Back-to-Sleep campaign . Black infants are more likely than white infants to be placed in the prone position and soft sleep surfaces for sleep . Providers of internatal care need to discuss the infant’s sleep environment with the parents. Because the risk of SIDS peaks at 2 to 4 months of age, the six-week visit offers an important opportunity to talk about back-to-sleep.
Health education about physical activities should be part of an on-going effort for wellness promotion during internatal care. The 1988 National Maternal and Infant Health Survey revealed that 25 percent of white women and 45 percent of black women were heavier by 4.1 kg (nearly 9 pounds) or more at 10 to 18 months post partum than they were before pregnancy . Clinicians can help women develop a weight loss program that consists of healthy dieting, physical activities, and behavioral modifications if needed. The National Heart, Lung, and Blood Institute recommends that all adults should set a long-term goal to accumulate at least 30 min or more of moderate-intensity physical activity on most, and preferably all, days of the week . For women in the postpartum period, prepregnancy exercise routines may be resumed gradually as soon as it is physically and medically safe. Clinicians need to routinely discuss physical activity with the woman, particularly at the six-week and six-month visits.
Cigarette smoking poses a significant threat to the health of the mother, her infant, and her subsequent pregnancy. Approximately one in eight (11.2%) U.S. women who gave birth in 2002 reported smoking cigarettes during pregnancy . Furthermore, up to 70% of women who quit smoking during pregnancy will relapse within 6 months of delivery . Effective models of clinical intervention for smoking cessation (e.g. 5A’s) and relapse prevention have been developed and should be incorporated into internatal care . Prenatal exposure to alcohol and other substances like cocaine and amphetamines have been associated with birth defects as well as adverse pregnancy and neurodevelopmental outcomes. According to the Behavioral Risk Factor Surveillance System, in 1999 the prevalence of any alcohol use and binge drinking among pregnant women in the U.S. was 12.8 and 2.7%, respectively . Postpartum use and recidivism rates are less well described. Several screening questionnaires have been developed to detect problem drinking which may also prove helpful in detecting substance abuse, include T-ACE (tolerance, annoyed, cut down, eye opener) questions, the CAGE (cut-down, annoyed, guilty, eye-opener) questionnaire, and the brief MAST questionnaire . All women should be screened at the time of their first internatal visit, and referral for evaluation and treatment should be offered to those who screen positive. Additionally, mothers whose infants are at risk for neurobehavioral problems from prenatal exposures should be provided resources for early developmental evaluation and interventions for their infants .
A large number of environmental exposures during the internatal period can affect maternal health and child development. For example, chronic exposures to indoor and outdoor pollutants and allergens, including household molds and dust mites, may increase the child’s future risk for atopy, allergies, and asthma. Less is known about the long-term effects of such exposures to maternal health and subsequent pregnancy outcomes. Lead is a potent developmental neurotoxicant and immunotoxicant, and household exposures can come from old paint, leaching from plumbing, and ceramic dinnerware and glazes. Certain measures can be taken to reduce household exposures to pollutants, allergens and lead. Exposure to mercury can be reduced by adherence to the EPA/FDA joint advisory related to consumption of fish and shellfish, and exposure to dioxins can be reduced by decreasing dietary fat consumption (Table 1). Clinicians need to assess and discuss with their patients avoidance of exposures that could adversely impact on maternal health and child development at every internatal visit, but particularly at the 6-week and 6-month visits.
Family planning is vital to the health and wellbeing of women and their families . Unintended pregnancy and short interpregnancy intervals are associated with increased risk for adverse birth outcomes [31, 32]; family planning can reduce the risk by promoting effective contraceptive use and optimal birth spacing. An unintended pregnancy also puts future maternal health and social wellbeing at risk; family planning can protect maternal health and choice . Discussion of family planning should begin prenatally and prior to discharge from the hospital; it should be addressed again at the two-week and six-week internatal visits, including risks, benefits and side effects of available contraceptive options and plans for future childbearing. Adherence to method and side effects should be reassessed at the six-month visit.
Folate is important to both maternal and child health. Maternal folate deficiency has been linked to future risk for cardiovascular and other chronic adult diseases, as well as neural tube and other birth defects in the offspring. Periconceptional (preconceptional and in early pregnancy) use of folic acid has been demonstrated to reduce the occurrence and recurrence of neural tube defects . Thus the U.S. Public Health Services recommends that all women of childbearing age consume 400 micrograms of folic acid daily . Even though there are several ways of getting this amount of folic acid everyday, two-thirds of U.S. women of childbearing age still do not consume enough folic acid, and surveys continue to find substantial knowledge gaps regarding the benefits of folic acid. Folic acid should be promoted at every internatal visit, or at the minimum during the six-month visit. We feel that the recommendation for folic acid can be broadened to include daily multivitamin supplementation given the potential benefits of a number of other vitamins (e.g. B12) and elements to maternal health and subsequent pregnancy outcomes, particularly for women with nutritional deficiencies.
Table 1 summarizes the core contents of health promotion during internatal care, with an emphasis on BBEEFF (breastfeeding, back-to-sleep, exercise, exposures, family planning and folic acid). Other topics can be added to health promotion as the model of internatal care becomes more fully developed.
Most women in this category are, by definition, healthy and require little in the way of clinical interventions during internatal care, other than the standard preventive health services recommended for all women of childbearing age (Table 1). These include periodic height, weight and blood pressure measurements, total skin examination, clinical breast examination, Pap smear and bimanual pelvic examination every 1 to 3 years. Mammography should also be performed in women ages 40 and above. We will address clinical interventions for women with chronic conditions in the next section.
Many healthy women who gave birth to a healthy infant will nonetheless need some psychosocial support. There are three types of social support that need to be made available as part of the core package of internatal care services: 1) social services, 2) clinical support, and 3) parenting support (Table 1). Social services may include assistance with obtaining certain public insurance (e.g. SCHIP) or benefits (e.g. TANF, EITC). Some women may not be aware of their eligibility for child care subsidies (e.g. CCDF) or availability of early childhood education programs. Women experiencing intimate partner violence may need multiple medical, legal, and social services and could use some help with service coordination. The internatal visits provide a platform for accessing these social services.
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.
Many parents could benefit from some parenting support, such as mother support groups or parenting classes. A current innovative idea in prenatal care is “centering” in pregnancy, which provides social support to pregnant women through group prenatal care . While this idea remains to be tested, we believe that group internatal care–a “centering” in internatal care model–may provide additional support for some women, particularly around issues related to parenting practices and the stress of parenting.
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
In developing a schedule of visits for internatal care, we had to first wrestle with two questions. First, shouldn’t the schedule of visits be individualized according to individual needs? While we support this view, we nonetheless feel that it may be useful to recommend some minimum standards to start a dialogue about this topic. For healthy women with healthy infants, we propose expanding the current six-week postpartum visit to three or more internatal visits, at 2 weeks, 6 weeks, and 6 months postpartum, with annual exams beginning at one year postpartum. For some activities, the six-week postpartum visit may be too little too late. For example, one in five mothers who initiated breastfeeding will quit nursing within the first month ; a 2-week postpartum visit may offer more timely encouragement and interventions for maintenance of breastfeeding than a 6-week visit could. The 2-week visit also offers an opportunity to follow-up on wound care for cesarean delivery. Whenever possible, this visit should be coordinated with the two-week well-baby check-up, preferably at the same location, to increase motivation for attendance. We feel that it is important to keep the current six-week postpartum visit as the second internatal visit. This is a well-established visit in obstetrics, with well-defined contents. This visit, however, can be made more useful by expanding its contents. We feel that a third internatal visit at 6 months is important for follow-up on a number of issues, such as breastfeeding and family planning. The standard annual visits should begin at one year postpartum (Table 1).
Second, shouldn’t any routine visit by a woman who may, at some time, become pregnant again be viewed as an opportunity to emphasize the importance of internatal health and habits ? While we support this view, we nonetheless feel that it would be preferable to recommend a schedule of internatal visits rather than relying on “any routine visit.” Several components of internatal care are time sensitive (e.g. counseling about breastfeeding and family planning at 2 weeks or about SIDS at 6 weeks) which should not wait for any routine visit. Scheduled internatal visits may be particularly important for women who are not making routine visits, or who are seeking care through the emergency department or urgent care clinics which lack the resources and capacity to provide comprehensive internatal care. We would also like to see internatal care become reimbursable visits, with standardized contents and schedule (rather than as an add-on to a visit for mastitis or cystitis), which may increase provider incentives to provide internatal care. Issues related to patient motivation and provider reimbursement will be addressed in a series of papers to follow.