media de horas dedicadas a salir con los amigos con la edad

McGovern comments, “The traditional medical perspective of the postpartum period refers to the time after childbirth that is required for the reproductive organs to return to their non pregnant state, a process that takes approximately 6-weeks. Many physicians perceive this time as one requiring little assistance other than the recommended single postpartum visit.”(33) In general, the postpartum visit receives relatively little guidance and monitoring on the part of professional organizations. A standard medical protocol includes counseling for contraception, breastfeeding, depression, and the physical return to a non-pregnant state. Blenning and Paladine note that the four general categories for the postpartum visit include: assessment for medical complications, breastfeeding, postpartum depression, and

contraception.(100) Cheng et al note that the major component of the routine 6-week postpartum checkup is limited to vaginal examinations and contraceptive education.(101)

An expanded perspective on the content of the postpartum visit is emerging. The Guidelines for Perinatal Care, produced by American College of Obstetrics and Gynecology and the American Academy of Pediatrics, recommends that women receive a postpartum visit 4-6-weeks after giving birth. They suggest that the content of this visit should include: assessment of the physical and emotional status of the mother; support for breastfeeding; family planning services; and the initiation of preconception care for any future pregnancies. They also suggest that providers review a woman’s immunizations; refer for needed

additional services such as for chronic conditions; pay attention to maternal and infant bonding; and counsel regarding nutrition and sexually transmitted diseases.(102) Guidelines set forth by the National Institute of Health and Clinical Excellence (NICE) in England provide specific information about the care to be provided to new mothers and infants. In

their model, mothers have a number of points of contact with health care providers and home visitors in the weeks before the 6-8 week visit. The guidelines suggest that the clinician review the women’s physical, emotional, and social well being as well as conduct additional screening with her medical history in mind.(103)

Lu and colleagues published research in 2006 that defined a multitude of

interventions that should be done during the interconception timeframe. As part of this work they began to define the content of internatal care, with a focus on clinical care. They note that this is a field of work, which requires further research, including studies evaluating the effectiveness of the various components of internatal care. As part of their proposed

framework, they recommend that postpartum/internatal care include: risk assessment, health promotion, clinical, and psychosocial interventions, with special consideration for high-risk mothers. The authors identify specific guidelines for women with chronic health conditions and a model based on etiologic pathways for women who had a preterm baby. They

recommend priority areas include screening for family violence, infections, nutrition, depression, and stress. They also recommend that providers offer health promotion by counseling about breastfeeding, back to sleep, exercise, exposures, family planning, and folate supplementation.(17)

After reviewing 140 randomized control trials about the specific management of certain postpartum medical conditions, Levitt and Associates with the Postpartum Research Group suggest that there is a need for stronger, evidence-based practice for the postpartum visit.(104) They note, for example, that data are lacking in regard to the effectiveness and optimal timing of the postpartum Pap Smear – a common practice.(105) The consistency of providers’ practice in following protocol for certain high-risk conditions was called into

question by several studies. Smirnakis found that only 37% of women with gestational diabetes mellitus (GDM) received the postpartum screening tests recommended by the American Diabetes Association (ADA).(106) Russell et al conducted a retrospective study of 344 women with GDM and found that less than one half (45%) of women had received glucose testing per ADA recommendations. Of the women tested, 36% had abnormal glucose tolerance.(62) Baker et al surveyed 1,002 providers in North Carolina and found that only 21.3% of the respondents report always screening for GDM postpartum. Factors associated with not screening were patients lost to follow up, patient inconvenience, and inconsistent screening guidelines.(107) Samwiil’s study of 257 women who had pre-eclampsia during pregnancy found that only 28% of the women were screened during the postpartum period to be sure they had returned to a normal state.(108) Sobey notes that women are not always screened for postpartum depression with as many as half of all cases undetected.(67) Iron deficiency and anemia screening is another risk factor that is not consistently addressed by providers during the postpartum visit.(45) Curtis et al reference a survey that focuses on the provider’s role in promoting folic acid supplementation. The reasons physicians gave for not always sharing information about folic acid were lack of knowledge (39%) and lack of time (30%).(109) While studies of provider recommendations about folic acid supplementation at the postpartum visit have not been conducted, it is possible that the provider barriers

mentioned in the survey above will also be barriers for this visit. In the Listening to Mothers Survey, about one third of mothers who received a postpartum checkup felt their health issues were not addressed.(110)

Concerns have been expressed about the ability of the postpartum visit to address women’s health needs and the lack of attention that the current prenatal care system offers in

regard to women’s well-being outside of maternity care.(2, 7, 8, 111) Kaaja and Greer completed a systematic review of all pregnancy conditions that relate to the development of chronic disease. They conclude that “pregnancy can unmask a woman’s potential for disease, thus providing a window to her long-term health outlook and presenting opportunities for primary prevention.”(112)

Gaudet suggests that “the long lag time from hospital discharge to postpartum visit is another reminder of where the medical system focus lies: on the body and only the body.” She continues that, “although on a physical level women tend to heal rapidly after childbirth, on a psychological and soul level, the adjustment is a much longer process.”(6) A review article by Gregory and colleagues promotes preconception, post gestation, and

interconception visits that include patient specific content based on where the woman is in her reproductive life span. The authors suggest that there should be an agenda to increase awareness about the public health value of these visits, the proposed content of the visits, and incentives put in place for these visits at the individual and health system levels.(53) Very few physician surveys have been conducted regarding attitudes and practice around preconception care issues.

OB/GYN and CNM Role in Primary Care

Ongoing debate exists about the role of obstetricians/gynecologists in women’s primary care. Scholle points out that studies show that “for young women of childbearing age, OB/GYNs provided reproductive preventive services and principal care but rarely served roles of coordinating services with specialist or providing first contact care for new problems.”(113) This is an important consideration in thinking about who cares for new mothers after the completion of their 6-week postpartum visit. It may also influence the

traditional content of that visit. In the mid to early 1990’s there was a growing effort to formalize the role of OB/GYNS as primary care providers. This shift was in part driven by changes in the health care system and the widespread belief that women should be their own gatekeeper in terms of when they would receive services from an OB/GYN. ACOG

responded to the new emphasis on primary care by implementing a curriculum with

augmented information about primary care for OB/GYN resident education.(114) Kuffel et al surveyed directors of residency programs about this addition of training requirements.

Responses were mixed with 53.4% thinking the new training mandate was good, 43% who disagreed, and 3.6% who neither agreed or disagreed.(115) In 1998 during a keynote address, Dr. Vicki Seltzer, President of the American College of OB/GYNs, noted that in keeping with ACOG’s logo “women’s health care physicians” most of this group of providers fill the role as the principal or only physician for a substantial subset of patients. She stated that, “Being a woman’s primary physician means being able to take care of common problems and placing an emphasis on prevention wellness, and early detection. I think that more than any other medical specialty, obstetrics and gynecology has emphasized and achieved a great deal in promoting preventive care and general women’s wellness.” Seltzer also referenced a 1992 study in which more than half of all OB/GYNS indicated that they spend more than half of their time providing primary and preventative care.(116)

Less than a decade later, Stovall et al conducted a regional survey of OB/GYNs and found physicians to be divided regarding their status as primary care providers. The majority of providers did not want to include primary healthcare in their practice.(117) These results are interesting when compared to a study by Henderson and Weisman who found that women in their early reproductive years (18-34) were more satisfied with care coordination and

comprehensiveness when their regular provider was a reproductive health specialist,

primarily an OB/GYN physician. The authors found that comprehensiveness of primary care was improved when a woman saw an OB/GYN provider and a non-OB/GYN generalist, but that the problems of continuity and coordination of care erased the advantage.(118) A survey of women who considered their OB/GYN as their primary care provider found that

OB/GYNs were more likely than other physicians to provide reproductive health services including preconception care and counseling around STDs. Yet they were less likely to provide counsel about diet and exercise, mental or emotional problems or perform

cholesterol screening.(119) Using a nationally representative survey, Scholle et al found that 21.7% of OB/GYNS in private offices and 22% of OB/GYNS in hospital-based out-patient clinics identified themselves as primary care providers. The survey also found that there were strong variations in the role of obstetricians/gynecologists in women’s primary care. Their data suggest, “some OB/GYNs are embracing the primary care role and changes in the content of care can be found. Still, the changes in practice are minor at this point, and the content of obstetrics/gynecology visits primarily address traditional reproductive health needs.”(113)

Alongside the debate among OB/GYN physicians around role in primary care, the American College of Nurse-Midwives has also considered role expansion into the provision of primary care. According to Sullivan, historically midwives have served as de facto primary care providers for vulnerable and underserved populations. The midwifery model emphasis on family-centered, community-based care as well as their focus on health

promotion, counseling, education and excellence through coordination of referrals suggests that they are appropriate for providing primary care per the Institute of Medicine’s definition.

The IOM defines primary care as “the provision of integrated, accessible health care services by clinicians who are accountable for addressing a large majority of personal health care needs, developing a sustained partnership with patients, and practicing in the context of family and community.”(120) However, a 1994 survey by Murphy found that midwives provided many preventive services to women but the emphasis was on services related to reproductive or breast health concerns.(121) Sullivan notes that midwives are similar to OB/GYNs in being conflicted about moving into primary care as well as in the kind of care they provide. And although they do provide primary care services, often not reimbursed, there is no legal mandate for the designation of nurse midwives as primary care providers in most states. In fact the breadth of their practice is shaped by the various practice acts for midwives, which are state specific. Sullivan highlighted that if nurse midwives have an interest in providing primary care, they must continue to develop their primary care knowledge and skills.(120) Published in 2002, Oshio and colleagues published a task analysis of American nurse-midwifery practice from 1999-2000. Their national survey of nurse midwives found that responsibilities had expanded within the domains of non reproductive primary health care and gynecologic care of the well-woman, including advances in assisted reproductive technology, but there was a diminished role in the provision of newborn care. The Association of Certified Nurse Midwives Certification Council then reconfigured their examination blueprint to add 5-10% for primary care and 15- 20% for well-woman / gynecology issues.(122)

The Listening to Mothers II Postpartum Survey found that following the completion of a pregnancy, 47% of mothers relied on a family medicine physician for their regular medical care. Twenty-one percent continued to see an OB/GYN, 11% an internal medicine

physician, and 11% said they did not have a regular provider. The other respondents reported seeing midwives, nurse practitioners, and physician assistants for their care. These data suggest that women do indeed turn to their OB/GYN providers for ongoing health care and interconception health needs.(30)