Competencias clave implicadas

The postpartum visit, the last visit included in the prenatal care package, is generally excluded in the calculation of national data about the adequacy of prenatal care, which only includes visits up until the delivery of the infant. The adequacy of prenatal care index is widely used in the United States and considered an important marker of the quality of care mothers receive. The exclusion of this visit relegates its status to a lower level of importance, separating it from prenatal care but not giving it an appreciated place in the scope of maternal health. Global billing systems for prenatal care further complicate access to information about the postpartum visit. The standard prenatal care package often is billed following the delivery of the baby – not the final postpartum visit. This can serve as a disincentive to health care systems to provide and promote this visit. Fortunately, the Health Plan Employer Data and Information Set (HEDIS) reports perinatal care measures, including the postpartum visit. This is a very important opportunity as the data are reported over time for the nation and each state. The State of Health Care Quality 2007 report notes that only 79.9% of women with private insurance received a postpartum visit, a figure down from the previous year. Women with Medicaid are less likely to receive a postpartum visit, with only 59.1% of this

population receiving this care. In a positive trend, that number has improved 2 points from the previous year.(123) Unfortunately, HEDIS and other databases often do not include women who have experienced a fetal death or stillbirth, a group of mothers who have a great

need for follow up care. Few clinics and private offices seem to track their postpartum visit utilization rate, including the UNC Obstetrics Program.

The Healthy People 2010 objectives for maternity care focus primarily on pregnancy and immediate birth outcomes. Increasing the number of women who receive a postpartum visit 4 to 6-weeks after delivery has been identified as a HP 2010 objective. Although there are a host of postpartum complications, only one of these problems, postpartum depression, was included as an indicator.(124) The World Health Organization’s recommendations for postpartum care include: medical assessment of complications, mother-infant bonding, breastfeeding, community and partner support, and family planning. However, as Cheng highlights, they do not address the management of postpartum discomforts, emotional disorders, and maternal role attainment. (101) Cheng et al point out that the Pregnancy Risk Assessment Monitoring System, a national survey which monitors maternal behaviors and experiences, does not include questions about maternal postpartum morbidities in its core questionnaire. Many Title V programs focus on services for pregnant women and children, with a lack of emphasis on services for the mother during the postpartum period. This, again, fosters a disincentive for collecting data and expanding services for this group of women. According to Cheng et al, “no specific national strategies, plans or policies are in place to encourage new mothers to obtain postpartum health care.” (101)

The National Business Group on Health recently released a toolkit for employers on the topic of investing in maternal and child health. Of the services they recommend, only two relate to mothers in the first year postpartum. The first stipulates one 6-8 week postpartum visit. The second is support for breastfeeding. While the plan supports preconception health care, they do not make the connection between the need for interconception care and linkage

of new mothers to other services.(125) Korst et al, have been working on the development of a framework for maternal health quality indicators. They included two indicators that relate to the postpartum period. The first is the receipt of a comprehensive postpartum visit that includes; preventive health maintenance, health promotion and education about parenting, breastfeeding, contraception and depression, and the management of persistent medical conditions exacerbated by pregnancy. The authors note the positive association between postpartum visit utilization and increased compliance with well-child visits and child immunizations as an argument for the inclusion of this indicator. However, the authors also note that the ability to track and monitor the content of the visit would be difficult. They also list increased screening for postpartum depression as an important indicator.(126)

Paul Wise of Stanford University gave a keynote address during the National Summit on Preconception Health and Health Care in October 2007. His presentation focused on some of the larger policy issues around promoting the health of women before and in between pregnancy. He suggested that the framework commonly used in public policy and among advocates of putting the needs and well-being of children above that of their parents has been partially responsible for the neglect experienced today for issues such as women’s wellness and preconception care. He argued that until the public debate can embrace the importance of caring for the woman, mother, and father, we will continue to ignore important prevention opportunities.(127) Wise’s view is an important perspective to be considered in the

development of a policy paradigm shift from a fetus/infant-focused environment to more of a woman-centered environment. The challenge remains that children offer a compelling case for policy change on many levels, particularly around arguments related to cost/benefits of preventive care.

The American College of Obstetricians and Gynecologists has recently stepped forward with a reform agenda for health care for women. Their agenda includes primary and preventive services. They include mention of the postpartum examination, family planning and specify care across the age spectrum. Their approach might be limited as far as

postpartum/interconception care, however, their platform of covering all women and

including primary services is key.(128) While this dissertation focuses on the United States, the literature suggests that other nations around the world have a different attitude about the services to be provided to new mothers. In many European countries, for example, new mothers receive a series of home visits for many months after the birth of their baby. They also receive extended, paid maternity leaves and may receive other benefits such as a stipend and free bus fare. Future study should consider a review of the underlying philosophy of these nations as far as their perceived duties and benefits in relationship to new mothers. These arguments could be of use in formatting a new policy approach in the United States for expanded postpartum care and support.

Preliminary Research at the University of North Carolina

In the spring of 2006, under the guidance of the author of this study, a group of students from the University of North Carolina at Chapel Hill’s School of Public Health conducted a pilot assessment of the postpartum visit at the NC Women’s Hospital. The study’s intent was to explore the topic of the postpartum visit at UNC to determine if more in depth research was required. The students interviewed 14 health care providers at UNC who have a role in prenatal/postpartum care. These providers included: four perinatal care

specialists (2 nurses and 2 social workers), two maternal fetal medicine specialists, one midwife, two obstetricians, two nurses, one maternity care coordinator, one family practice

physician, and a genetic counselor. The data they collected from these providers suggested that there were areas for improvement in the system of postpartum care at this institution.

Most providers cited difficulty finding the pertinent issues for the postpartum visit in the hospital discharge summary, noting that it would be helpful to have the full prenatal record available for this visit. Some shared concerns about a) time limitations for the visit and b) the limited ability to refer Uninsured women to specialists. Genetic counseling services were cited as being under-utilized, particularly for mothers with poor birth outcomes. Practical suggestions for the system included: a) improve the format of the discharge summary to include a prioritized problem list; b) improve communication among specialists to improve continuity of care for women with chronic conditions; c) increase contact between providers and patients by developing a phone system for non-scheduled visit times to allow mothers to ask questions about their health or that of their newborn; and d) increase/strengthen the link between the postpartum visit and pediatric care. (129) There were a number of limitations to this survey including the fact that interviews were conducted with health care professionals working in a number of different practices – health

department, family medicine, high-risk, and midwifery services. The variation in care patterns among practices and the fact that in some cases only one individual from a system was interviewed makes it difficult to draw conclusions. However, the pilot study

accomplished its goal by demonstrating the need for additional research on this topic within the UNC Healthcare System.