Harold C. Pollard, MD October 27, 2009

No disclosures

 The number of stillborns and the number of neonatal deaths (deaths in the first four weeks of life) per 1000 births (births after 22 weeks)

 Prenatal care  Labor and delivery  Imaging in pregnancy  Surgery and anesthesia  Obstetric technology – “for better or worse”  Obstetric research/evidence based medicine  NICU care

 Risk Assessment ◦ Nutrition, depression, stress, infection, family violence  Health promotion ◦ Breastfeeding, Back-to-sleep, exercise, exposures, family planning and folate  Clinical and psychosocial intervention ◦ Ongoing care for women with chronic medical conditions ◦ If adverse pregnancy outcome, address etiologic pathway prior to next pregnancy  Enhance service integration for women and families Lu 2006 Marten Child Health J

VIC SODA

i n om b e c o f no e p c l e tk s r i e c r i ie d n t an t s e c i cg y s n e o e i t npo s tn i o n

 Prevalence 6.5 to 13% in the first year post partum  Negative long-term impact on maternal health and child development but often undetected by post partum care providers  Accurate and feasible screening ◦ Postpartum Depression Screening Scale (PDSS) ◦ Edinburgh Postnatal Depression Scale (EPDS) ◦ Beck Depression Inventory (BDI)  Limited evidence suggests providing psychosocial support to postpartum women at risk may decrease depression symptoms Gaynes BN (2005) AHRQ

 Physical Abuse ◦ During pregnancy 4 to 8% ◦ After pregnancy (3 months) 3.2 to 21%?  3 of 4 women reporting intimate partner violence had not reported prior to delivery  Strong link with child abuse  Routine screening during post partum visit ◦ 4-item Hurt, Insulted, Threatened or Screamed at (HITS) ◦ 3-item Partner Violence Screen (PVS) ◦ 3-item Abuse Assessment Screen (AAS)  Martin, 2001 JAMA: Harrylissoon, 2002 Arch Ped Adol Med; Nelson, 2004 Ann Intern Med

 Tdap: Tetanus, diphtheria and pertussis booster every 10 years  Measles and mumps vaccine if no evidence of immunity  Immunize women susceptible to rubella or varicella immediately following delivery  HPV is recommended for women to age 26 if they have not been previously vaccinated  Hepatitis B series of 3 for young adults

 25% of white women and 45% of black women are 9 pounds heavier at one year. (1988 National Maternal and Infant Health Survey)  Promote gradual increase in activity to goal of 30 minutes or more of moderate-intensity physical activity on most days of the week.

 Cigarette smoking poses threat to health of mother, her infant and her subsequent pregnancy  11.2% of women who gave birth in 2002 reported smoking cigarettes during pregnancy  70% of women who quit during pregnancy will relapse within 6 months of delivery  Incorporate clinical intervention for smoking cessation and relapse prevention (e.g. 5A’s) into post partum and internatal care ◦ Begin inpatient, follow up at two weeks ◦

 Postpartum screening ◦ 1/3 have diabetes of impaired glucose metabolism at pp screen ◦ 15-50% develop diabetes in the decade following pregnancy ◦ Establishing the diagnosis  Opportunity to improve subsequent pregnancy outcome  Affect risk factors associated with development of type 2 diabetes

 According to the Healthcare Effectiveness Data and Information Set (HEDIS) indicator for the postpartum visit ◦ 20% of women with commercial insurance and ◦ 50% of women with Medicaid do not receive this visit.

 Unaware of importance of visit (marketing)  Inadequate appointment reminders  Timing may be too late to meet some needs (e.g., breastfeeding concerns)  Mothers not perceiving a return value on their time investment in receiving the visit  Lack of continuity of care – relationship/experience with clinic

 Lack of transportation  Unable to access other services at same time (WIC, well baby care, etc)  Lack of adequate referral services for other care (mental health, family planning)  Medicaid coverage ends at 60 days postpartum  Child care issues – different clinic cultures about bringing infant to visit

 NCOGS  ACOG, NC Section  UNC School of Public Health  NC Public Health System  Academic programs, including AHEC programs  Specific examples of co-operation/co-ordination  NC HIV Public/Private Partnership, 2000  NC Public-Private Partnership on Smoking Cessation in Pregnancy, 2002