Title: The Circle of Care for Women EARLY PRENATAL CARE AND MEDICA
1The Circle of Care for Women
- Early prenatal care
- And Medical homes for
- non-pregnant women
2Acknowledgements
- This training was developed by the North Carolina
Preconception Health Campaign, a program of the
March of Dimes North Carolina Chapter, under a
contract and in collaboration with the North
Carolina Division of Public Health, Womens
Health Branch. - This material was developed through support
provided by the U.S. Department of Health and
Human Services, Office of the Assistant Secretary
for Health, Office of Adolescent Health (grant
SP1AH000004).
3Acknowledgements
- Many thanks to these agencies and individuals for
their generosity in sharing their resources in
the area of early prenatal care and medical homes
for women - North Carolina Division of Public Health, Womens
Health Branch - Merry-K Moos, FNP, MPH, FAAN
- Alvina Long Valentin, RN, MPH
- Sarah Verbiest, DrPH, MSW, MPH
- Specific resources used to guide the development
of this training - The National Preconception Curriculum and
Resources Guide for Clinicians (Module 1
Preconception Care What it is and what it isnt)
4Young Moms Connect
- Brings together community partners to address
challenges faced by pregnant or parenting teens
using collaborative, multi-faceted strategies - One component of Young Moms Connect is training
for health care providers on six maternal and
child health best practices
5Maternal child health best practices
- Early entry and effective utilization of prenatal
care - Establishment and utilization of a medical home
(for non-pregnant women) - Reproductive life planning
- Tobacco cessation counseling using the 5 As
approach - Promotion of healthy weight
- Domestic violence prevention
6Objectives
- Increase awareness about the relationship between
preconception health, early prenatal care and a
medical home - Increase knowledge about current status of
prenatal care among young mothers - Assess local prenatal care services and early
entry barriers - Increase awareness about the importance of
primary care medical homes for women of
reproductive age - Develop strategies to link young women,
especially in the postpartum period, to medical
homes
7What is preconception care?
- Identification of modifiable and non-modifiable
risk factors for poor health and poor pregnancy
outcomes before conception - Timely counseling about risks and strategies to
reduce the potential impact of the risks - Risk reduction strategies consistent with best
practices
CDC National Preconception Curriculum and
Resources Guide for Clinicians (Module 1)
http//beforeandbeyond.org/?pagecme-modules
8Components of preconception care
- Giving protection
- (eg. folic acid, immunizations)
- Managing conditions
- (eg. diabetes, maternal PKU, obesity,
hypertension, hypothyroidism, STIs, sickle cell) - Avoiding exposures known to be teratogenic
- (i.e. medications, alcohol, tobacco, illicit
drugs)
CDC National Preconception Curriculum and
Resources Guide for Clinicians (Module 1)
http//beforeandbeyond.org/?pagecme-modules
9Opportunistic care
- Preconception care is for every woman of
childbearing age every time she is seen - Every woman, every time
CDC National Preconception Curriculum and
Resources Guide for Clinicians (Module 1)
http//beforeandbeyond.org/?pagecme-modules
10Every woman, every time
- Young women who are at risk of pregnancy
- Young women who are pregnant
- Young mothers who are postpartum
- Young mothers who are between pregnancies
11From linear care
Moos, MK. Connecting the Dots Health Status
Before Pregnancy and Pregnancy Outcomes. 2011
12to a circle of care
13Be healthy before pregnancy
- Message for all women of childbearing age
- Remember, being in the best physical, emotional
and financial position BEFORE pregnancy is best - Make sure your future pregnancies are planned and
intended - Prenatal care should start as early as possible
in pregnancy
14 Early prenatal care
- Why is early prenatal care important?
- Recommended prenatal care schedule
- Weeks 4-28 1 visit per month
- Weeks 28-36 Visits every 2 weeks
- Weeks 36-birth Weekly visits until delivery
15Components of prenatal care
- Review of
- Individual medical history
- Obstetrical and gynecological history
- Family history
16Components of prenatal care
- Screening, referral and/or treatment for
- Genetic risks
- Infectious disease
- Chronic disease
- Psychosocial issues
- Environmental issues
- Immunizations
- Nutritional concerns
17Components of prenatal care
- Laboratory studies
- Vital signs
- Maternal assessment
- Fetal assessment
- Patient education
18Prenatal development
Weeks gestation
4 5 6 7 8 9 10 11 12
from LMP
Most susceptible
Central Nervous System
time for major
malformation
Heart
Arms
Eyes
Legs
Teeth
Palate
External genitalia
Ear
Mean Entry into Prenatal Care
Missed Period
CDC National Preconception Health Curriculum and
Resource Guide for Clinicians, 2008
19Importance of prenatal care
- Adequate use of prenatal care associated with
- Healthy birth weights
- Decreased risk of preterm delivery
- Inadequate use of prenatal care associated with
increased risk of - Low birth weight
- Preterm delivery
- Neonatal mortality
- Infant mortality
- Maternal mortality
Kiely JL, Kogan MD. From data to action
Reproductive health of women (Prenatal Care). Pp.
105-118. 1994
20Young mothers are at higher risk
- Teens are least likely of all maternal age groups
to get early and regular prenatal care1 - Teens are at greater risk than women over age 20
for pregnancy complications such as premature
labor, anemia and high blood pressure2 - Teens are more likely than women over age 25 to
smoke during pregnancy3
1. National Center for Health Statistics, final
natality data, 2007 2. American College of
Obstetricians and Gynecologists. Especially for
Teens Having a Baby. Patient Education Pamphlet,
August 20073. Centers for Disease Control and
Prevention. Preventing Smoking and Exposure to
Secondhand Smoke Before, During and After
Pregnancy. October 3, 2007
21Late entry into prenatal care
- Mothers with unintended pregnancies are more
likely to enter into prenatal care later in their
pregnancies
North Carolina State Center for Health
Statistics, Risk Factors and Characteristics for
2009 Resident Live Births
22Mothers receiving prenatal care in the first
trimester2004-2008, live births
North Carolina 82
Bladen 72
Nash 76
Onslow 90
Rockingham 85
Wayne 71
NC State Center for Health Statistics, 2004-2008.
Trends in Key Health Indicators
23Mothers not receiving prenatal care in the first
trimester in North Carolina, 2008
- 21 of mothers surveyed did NOT access first
trimester prenatal care - Rates for not receiving care in the first
trimester are highest for - Young mothers (35 lt 20 years, 31 20-24 yrs)
- African-American (34) and Hispanic mothers (31)
- Unmarried women
- Less education
- Lower income levels
NC State Center for Health Statistics, 2008,
Pregnancy Risk Assessment Monitoring System
24Access to prenatal care
- North Carolina mothers who reported they did not
receive prenatal care as early as they wanted - 31 of mothers lt 20 years of age
- 25 of mothers age 20-24 years
- Half of all young mothers reported experiencing
barriers to prenatal care
NC State Center for Health Statistics, 2008,
Pregnancy Risk Assessment Monitoring System
25Barriers to prenatal care in North Carolina
Barrier Teens Ages 20-24
Did not want the pregnancy known 16 16
Couldnt get an appointment earlier 15 21
Didnt have my Medicaid card 15 16
Transportation 13 9
No money or insurance 12 22
NC State Center for Health Statistics, 2008,
Pregnancy Risk Assessment Monitoring System
26Prenatal care for African-American mothersin
North Carolina
- Less likely to start prenatal care in first
trimester - 70 of prenatal care is paid by Medicaid
- 2/3 enroll in WIC (66)
- 1 in 3 African-American mothers were already
enrolled in Medicaid prior to pregnancy (30)
compared to white mothers (9)
NC PRAMS Fact Sheet April 2011. NC African
American Maternal Health
27Prenatal care for African-American mothersin
North Carolina
- Significantly more likely to experience at least
one prenatal barrier compared to white mothers
(48 vs. 37) - 1 in 5 reported they were not able to get an
appointment earlier in pregnancy - 1 in 6 reported having no insurance
NC PRAMS Fact Sheet April 2011. NC
African-American Maternal Health
28Not just early but adequate
- Young Moms Connect has two prenatal care goals
- Making sure young women enter prenatal care
during the first trimester - Making sure young women continue to follow the
recommended prenatal visit schedule - Measures of adequacy of prenatal care
- Kotelchuck Index Looks at month of prenatal care
initiation and total number of visits (compares
number of expected visits to actual number of
visits). Classifies as inadequate, intermediate,
adequate and adequate plus. - Kessner Index Looks at weeks of gestation and
total number of visits. Classifies as
inadequate, intermediate and adequate.
29Adequacy of prenatal care, Kessner Index, 2009
Number of Births Adequate Intermediate Inadequate
North Carolina 126,785 78 16 5
Bladen 378 74 18 7
Nash 1,269 68 23 8
Onslow 4,058 86 11 3
Rockingham 1,048 87 10 3
Wayne 1,661 63 29 8
NC State Center for Health Statistics, 2009 NC
resident births by county and Kessner Index
30Location of prenatal care for young women
Care provider Teens Ages 20-24
Private practice/HMO 39 47
Health department 28 29
Hospital clinic 15 16
Other 18 8
NC State Center for Health Statistics, 2008,
Pregnancy Risk Assessment Monitoring System
31Preconception health early prenatal care
32Important components of prenatal care and
preconception health
- Identification treatment of sexually
transmitted infections - Assessment of medication use
- Identification of environmental risks (e.g.
tobacco use, lead exposure, varicella exposure) - Achieving and/or maintaining healthy weight
33Sexually transmitted infections pregnancy
- Chlamydia
- Untreated can cause prematurity, pink eye, and
breathing problems for the baby - Genital Herpes
- 25 of American women are infected (most do not
know asymptomatic) can be transmitted during a
vaginal delivery and can cause blindness, brain
damage and death of baby - HPV-Genital Warts
- Over 6 million new infections/year in United
States can be uncomfortable during pregnancy - Bacterial Vaginosis
- May increase a woman's chances of premature
rupture of membranes and preterm delivery
Cunningham, F.G., et al. Sexually Transmitted
Diseases, in Williams Obstetrics, 22nd Edition.
New York, McGraw-Hill Medical Publishing
Division, 2005, pages 1301-1325 Workowski, K.A.,
Berman, S.M. Sexually Transmitted Disease
Treatment Guidelines, 2006. Morbidity and
Mortality Weekly Report, volume 55, RR11, August
4, 2006
34Sexually transmitted infections pregnancy
- Gonorrhea
- Untreated it can cause blindness, joint
infections and life threatening blood infections
for the baby - HIV/AIDS
- Untreated higher risk of transmission to the
baby - Syphilis
- Untreated can cause blindness, brain damage or
death for baby in addition to prematurity,
stillbirth and congenital malformations - Hepatitis B
- Untreated can infect the baby at delivery and can
later cause liver disease or liver cancer Also
increases risk for infant to become a Hepatitis B
carrier
Workowski, K.A., Berman, S.M. Sexually
Transmitted Disease Treatment Guidelines, 2006.
Morbidity and Mortality Weekly Report, volume 55,
RR11, August 4, 2006. Centers for Disease
Control and Prevention (CDC). Sexually
Transmitted Disease Surveillance 2005 Supplement,
Syphilis Surveillance Report. December 2006.
35Gonorrhea and chlamydia in North Carolina
- 59 of new gonorrhea cases in 2010 were to women
- 80 of new chlamydia cases in 2010 were to women
- Both disproportionately affect African-American
women - High rates among ages 15-24 year-olds
2010 STD/HIV Surveillance Report. Communicable
Disease Branch, N.C. Division of Public Health
36HIV in North Carolina
- In 2009, 26 of new HIV cases were to women
- Rate per 100,000 population
- African-American women, 38.7
- White women, 2.7
2009 STD/HIV Surveillance Report. Communicable.
Disease Branch, N.C. Division of Public Health
37HIV disease cases by county2007-2009 average
County Rank among 100 NC counties Cases per 100,000 residents
Bladen 10 26
Nash 26 18
Wayne 35 14
Rockingham 61 9
Onslow 69 7
2009 HIV/STD Surveillance Report. Table 2.
Communicable Disease Branch. NC DHHS
38Medication
- Because almost half of all pregnancies in North
Carolina are unintended, medication use should be
monitored carefully during womens childbearing
years
39Medications and pregnancy
- Medications known to cause serious birth defects
if taken during pregnancy - Isotretinoin
- Thalidomide
- Medications for the following conditions should
be closely monitored for women of childbearing
age - Asthma
- Epilepsy
- High blood pressure
- Depression
U.S. Centers for Disease Control and Prevention,
retrieved July 2011
40Environmental risks
- Several environmental risks are associated with
increased risk for poor maternal and/or infant
outcomes and should be addressed as early as
possible during prenatal care and throughout
pregnancy - Tobacco use
- Alcohol use
- Illicit drug use
- Exposure to some toxins (e.g. lead exposure)
- Experience high levels of stress
- Experiencing violence
41Maternal smoking during pregnancy
- Smoking during pregnancy is the single most
modifiable risk factor for poor birth outcomes - Increased risk for mother of
- Ectopic pregnancy
- Preterm premature rupture of membranes
- Placental complications
- Preterm delivery
- Spontaneous abortion
ACOG. Smoking Cessation During Pregnancy A
Clinician's Guide to Helping Pregnant Women Quit
Smoking, 2011
Cnattingius S. The epidemiology of smoking during
pregnancy Smoking prevalence, maternal
characteristics, and pregnancy outcomes Nicotine
Tob Res, 2004
42Maternal smoking during pregnancy
- Increased risk for child of
- Low birthweight (causal association twice as
likely in smokers)1 - Sudden infant death syndrome1
- Childhood respiratory illnesses2
- Learning disabilities and conduct disorders1
- If it were possible to eliminate smoking during
pregnancy entirely, the infant mortality rate in
North Carolina would drop 10-20.3
1Women and smoking A report of the Surgeon
General. U.S. Dept. of Health and Human Services,
Public Health Service, Office of the Surgeon
General Washington, DC, 2001 2Hu FB, et al.,
Prevalence of asthma and wheezing in public
schoolchildren association with maternal smoking
during pregnancy, Annals of Allergy, Asthma and
Immunology 79(1) 80-84. 1997 3Rosenberg DC,
Buescher PA. The Association of Maternal Smoking
with Infant Mortality and Low Birth Weight in
North Carolina, 1999. SCHS Studies No. 135.
Raleigh, NC North Carolina State Center for
Health Statistics 2002
43Smoking during pregnancy
- Nationally between 12-20 of all pregnant women
report smoking during pregnancy - Current clinical guidelinesWhenever possible
pregnant smokers should be offered
person-to-person psychosocial interventions that
exceed minimal advice to quit. Clinicians should
offer effective tobacco dependence interventions
to pregnant smokers at the first prenatal visit
as well as throughout the course of pregnancy.
Martin JA et al. Births Final data for 2002.
National vital statistics reports. Vol 52 no 10.
National Center for Health Statistics. 2003 Fiore
MC et al. Treating Tobacco Use and Dependence
2008 Update. Clinical Practice Guideline. U.S.
Department of Health and Human Services. 2008
44Smoking during pregnancy, 2005-2009
Number of women Percent
North Carolina 70, 529 12
Bladen County 341 16
Nash County 759 12
Onslow County 1,821 11
Rockingham County 1,109 21
Wayne County 1,097 12
NC State Center for Health Statistics, NC
Residents 2005-2009 and of births to mothers
that reported smoking prenatally
45What providers can do
- Move beyond screening and recommendations
- Provide brief smoking cessation counseling and
use pregnancy-specific self-help materials - Use the 5 As regularly with preconception,
pregnant and post-partum patients - Connect patients with support such as the NC
Quitline
Fiore MC et al. Treating Tobacco Use and
Dependence 2008 Update. Clinical Practice
Guideline. U.S. Department of Health and Human
Services. 2008
46Women weight in North Carolina
- 58 of women in NC of childbearing age (18-44)
are overweight or obese - 43 of young women ages 18-24 are overweight or
obese - There is also a racial disparity in weight status
for women 18 years and older - 56 of white women are overweight or obese
- 73 of African-American women are overweight or
obese - 56 of other minorities are overweight or obese
NC Behavioral Risk Factor Surveillance System,
2010
47Consequences
- U.S. society focuses on external consequences of
overweight and obesity, i.e. how we look - As health professionals it can be helpful to
re-frame discussions toward medical/physical
consequences of overweight and obesity - For women of childbearing age the consequences of
overweight obesity span two generations - Risk of consequences increases progressively as
BMI increases
Kellner, S. Maternal weight An opportunity to
impact infant mortality in North Carolina. 2010
48Pregnancy risks
- Increased pre-pregnancy BMI is associated with
increased risk of - Preeclampsia
- Gestational hypertension
- Gestational diabetes
- C-section
- Induction of labor
- Postpartum hemorrhage
- Lactation failure
Kellner S, Maternal weight An opportunity to
impact infant mortality in North Carolina, 2010
49And for the baby..
- Macrosomia
- Preterm delivery
- Poor APGAR scores
- NICU admission
- Shoulder dystocia
- Late fetal death
- NTDs (anencephaly and spina bifida)
Kellner S, Maternal weight An opportunity to
impact infant mortality in North Carolina, 2010
50The cycle repeats
- The likelihood that overweight children will
become obese adults is almost 9 times higher than
the risk for children who are not overweight - Early prenatal care allows for counseling about
appropriate weight gain during pregnancy to slow
or stop this cycle
Kellner S, Maternal weight An opportunity to
impact infant mortality in North Carolina, 2010
51Recommended pregnancy weight guidelines
- Gestational weight gain counseling should be
tailored to the womans pre-pregnancy BMI - Women who gain within guidelines consistently
have better birth outcomes than those who gain
more or less than the Institute of Medicine
guidelines - Medicaid covers medical nutrition therapy
(nutritional counseling provided by a registered
dietician) for pregnant women who are overweight,
obese or underweight
Weight gain during pregnancy Reexamining the
Guidelines. Institute of Medicine, 2009
52Recommended pregnancy weight guidelines
Weight gain during pregnancy Reexamining the
Guidelines. Institute of Medicine, 2009
53Early prenatal care counseling
- When does your practice give patients information
about risk behaviors (alcohol, smoking, cat
litter, etc.), medication use, healthy weight and
preventive measures to ensure a healthy pregnancy
and birth outcome? - Do all women receive this information in a way
that can be tracked? - Who provides this information?
- What method of information sharing is used?
- Who in the community does a good job of getting
this information to women in effective ways?
54Case study
- Maya is a 17-year-old young woman who found out
she was pregnant after missing two periods. She
was very confused about what she should do and
kept living her life as normally as possible. She
visited the health department at around 20 weeks
to see if she could find out if the baby was a
girl or a boy.
55Case study
- Sarah is a 15 year old young woman who kept her
pregnancy hidden for the first trimester. Her
parents took her to their private practice
physician after they discovered her pregnancy at
around 22 weeks.
56Prenatal care transition to medical home
57Maternal child health best practices
- Early entry and effective utilization of prenatal
care - Establishment and utilization of a medical home
(for non-pregnant women) - Reproductive life planning
- Tobacco cessation counseling using the 5 As
approach - Promotion of healthy weight
- Domestic violence prevention
58Principles of a medical home
- Personal physician Each patient has an ongoing
relationship with a personal physician trained to
provide first contact, continuous and
comprehensive care - Physician directed medical practice The personal
physician leads a team of individuals at the
practice level who collectively take
responsibility for the ongoing care of patients - Whole person orientation The personal physician
is responsible for providing for all the
patients health care needs or taking
responsibility for appropriately arranging care
with other qualified professionals
Joint principles of the patient-centered medical
home. 2007. American Academy of Family
Physicians, American Academy of Pediatrics,
American College of Physicians, and American
Osteopathic Association
59Principles, cont.
- Care is coordinated and/or integrated across
specialists, hospitals, home health agencies,
etc. - Quality and safety are assured by a care planning
process, evidence-based medicine, clinical
decision-support tools, performance measurement,
active participation of patients in
decision-making, and other factors. - Enhanced access to care is available (e.g., via
"open scheduling, expanded hours and new options
for communication"). - Payment must appropriately recognize the added
value provided to patients who have a
patient-centered medical home
Joint principles of the patient-centered medical
home. 2007. American Academy of Family
Physicians, American Academy of Pediatrics,
American College of Physicians, and American
Osteopathic Association
60What can medical homes provide for healthy,
non-pregnant women?
- A place for regular check-ups
- A place women can call if theyre not feeling
well to help them decide if they need a clinic
appointment, an emergency department visit, a
referral to a specialist, or no visit at all - A place that coordinates referrals for women
helps assess if further treatment or testing is
needed - A place that can provide preconception or
interconception health counseling about relevant
topics healthy weight, substance use, tobacco
use, screenings for mental health issues,
sexually transmitted infections, etc.
61What can medical homes provide for non-pregnant
women with chronic conditions?
- All the services on the previous slide, plus
- A place for regularly scheduled check-ups, lab
work, prescriptions and sometimes
medications/supplies - A place to receive specialized counseling related
to their condition (such as nutrition counseling
for diabetes) - A place that coordinates referrals for services
such as annual eye exams (for women with
diabetes) - A place with a provider who can receive and read
referral results and makes a plan of care based
on those results
62Transition from pregnancy to primary care
provider/medical home
- The postpartum visit is an important opportunity
to establish a medical home for young women and
provide preconception guidance for future
pregnancies - Considered the gateway to well-woman care
- Opportunity to revisit health concerns that came
up in prenatal visits and throughout the
pregnancy - May be the only clinical visit for a woman
between pregnancies - Sometimes a lost opportunity
- Nationally, only 59 of Medicaid patients and 80
of privately insured patients receive a
postpartum visit
The State of Health Quality, National Committee
for Quality Assurance, 2007 The Postpartum visit
An overlooked opportunity for prevention,
Verbiest, SB, 2009
63Barriers to postpartum visit compliance
- A survey of local public health nurses in North
Carolina showed several barriers to access of
postpartum care in local health departments - Lack of transportation, lack of childcare,
children not being welcome at the postpartum
appointment, women not realizing the importance
of this visit - Financial issues such as an outstanding prenatal
care bill or the loss of Medicaid coverage - Inconvenient hours and poor customer service
(long waits during appointments and difficulty
getting through on the phone to schedule
appointment)
Long Valentin, A. "Postpartum Visit Utilization
Assessment North Carolina Local Public Health
Departments," North Carolina Division of Public
Health, Women's Health Branch, 2008
64Postpartum visit components
- Basic physical exam including pelvic exam and
incision exam (if applicable) - Glucose testing for women who had gestational
diabetes - Postpartum depression domestic violence
screenings - Breastfeeding support
- Reproductive life planning counseling, focus on
pregnancy spacing - Contraception if desired
- Active assistance in helping patient transition
to a medical home
- Immunizations like varicella and MMR
- Smoking cessation counseling, as up to 70 of
women who quit during pregnancy start smoking
again within a year after delivery
65Birth spacing recommendations
- Recommended birth spacing in the U.S. is at least
18 months between prior delivery and next
conception (and no more than five years) - 42 of North Carolina women had less than an 18
month interval in 2008 - Under age 20, 73
- Age 20-24, 54
Zhu BP. Effect of interpregnancy interval on
birth outcomes findings from three recent US
studies. International Journal of Gynecology and
Obstetrics (2005) 89, S25S33 North Carolina
State Center for Health Statistics, 2008.
66Transition to a medical home
- In addition to the postpartum visit, discuss
medical home at - Prenatal visits during the last month of
pregnancy - Hospital discharge
- Home visits
- Newborn pediatric visits
- WIC appointments
The Postpartum visit An overlooked opportunity
for prevention, Verbiest, SB, 2009
67Transition to medical home
- Do women who have recently (or maybe not so
recently) had a baby consider their OB/GYN or
midwife their primary health care provider? - Is this an ideal arrangement?
- If not, how would you suggest starting a
conversation with a young mother about where her
new medical home could be? - Are pediatricians involved in recommending
medical homes? Could they be?
68Points of entry into medical homes/primary care
providers
- What are the medical homes for non-pregnant young
women in this community? - How and when do young women access these medical
homes? - What are the entry points by which they may reach
these medical homes? - Postpartum visits
- Pregnancy planning visits
- Annual exams
- Sick care
- Referral from health department family planning
clinics - Referral from negative pregnancy tests
- Other?
69Medical homes in this community
- Who are safety net providers that serve as
medical homes? - Is there a referral network in place throughout
the community to make sure all women who want a
medical home can access one? - Resources
- (Also found in Section 3 of the Circle of Care
for Women Training Materials Toolkit binder) - Nchealthcarehelp.org
- Nccarelink.gov
- Ncfreeclinics.org
70Step by step to a medical home
- Remind patients that medical homes help them stay
healthy and prevent emergency room visits - Provide specific local medical home options,
reminding young patients that the best medical
home for their needs may change over time - Write out the steps of how to connect with a
medical home - Be specific practice names, phone numbers and
guidance about when to call the medical home - Some practices follow up by phone as part of
routine postpartum care, ensuring the patient has
connected with the medical home
71Case study
- Kristina had a baby boy 6 weeks ago. She is 18
years old and her Medicaid benefits are about to
expire. She had genital herpes and was treated
during the pregnancy. She also has a history of
depression and asthma. She asks for some extra
depression and asthma medications at her
postpartum visit.
72Case study
- You see a 19 year old mother at a (pediatric)
baby well check and she asks you about
prescribing her the patch as she wants to stop
smoking for the baby. After some basic questions
you learn that she no longer has any health
insurance and lists her OB/GYN at the local
community health center as her primary physician.
73The circle of care for women