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The Circle of Care for Women EARLY PRENATAL CARE AND MEDICA

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The Circle of Care for Women EARLY PRENATAL CARE AND MEDICAL HOMES FOR NON-PREGNANT WOMEN Facilitate a discussion around these questions. Activity time! – PowerPoint PPT presentation

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Title: The Circle of Care for Women EARLY PRENATAL CARE AND MEDICA


1
The Circle of Care for Women
  • Early prenatal care
  • And Medical homes for
  • non-pregnant women

2
Acknowledgements
  • 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).

3
Acknowledgements
  • 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)

4
Young 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

5
Maternal 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

6
Objectives
  • 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

7
What 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
8
Components 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
9
Opportunistic 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
10
Every 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

11
From linear care
Moos, MK. Connecting the Dots Health Status
Before Pregnancy and Pregnancy Outcomes. 2011
12
to a circle of care
13
Be 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

15
Components of prenatal care
  • Review of
  • Individual medical history
  • Obstetrical and gynecological history
  • Family history

16
Components of prenatal care
  • Screening, referral and/or treatment for
  • Genetic risks
  • Infectious disease
  • Chronic disease
  • Psychosocial issues
  • Environmental issues
  • Immunizations
  • Nutritional concerns

17
Components of prenatal care
  • Laboratory studies
  • Vital signs
  • Maternal assessment
  • Fetal assessment
  • Patient education

18
Prenatal 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
19
Importance 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
20
Young 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
21
Late 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
22
Mothers 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
23
Mothers 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
24
Access 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
25
Barriers 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
26
Prenatal 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
27
Prenatal 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
28
Not 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.

29
Adequacy 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
30
Location 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
31
Preconception health early prenatal care
32
Important 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

33
Sexually 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
34
Sexually 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. 
35
Gonorrhea 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
36
HIV 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
37
HIV 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
38
Medication
  • Because almost half of all pregnancies in North
    Carolina are unintended, medication use should be
    monitored carefully during womens childbearing
    years

39
Medications 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
40
Environmental 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

41
Maternal 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
42
Maternal 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
43
Smoking 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
44
Smoking 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
45
What 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
46
Women 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
47
Consequences
  • 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
48
Pregnancy 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
49
And 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
50
The 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
51
Recommended 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
52
Recommended pregnancy weight guidelines
Weight gain during pregnancy Reexamining the
Guidelines. Institute of Medicine, 2009
53
Early 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?

54
Case 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.

55
Case 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.

56
Prenatal care transition to medical home
57
Maternal 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

58
Principles 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
59
Principles, 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
60
What 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.

61
What 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

62
Transition 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
63
Barriers 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
64
Postpartum 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

65
Birth 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.
66
Transition 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
67
Transition 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?

68
Points 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?

69
Medical 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

70
Step by step to a medical home
  1. Remind patients that medical homes help them stay
    healthy and prevent emergency room visits
  2. Provide specific local medical home options,
    reminding young patients that the best medical
    home for their needs may change over time
  3. Write out the steps of how to connect with a
    medical home
  4. Be specific practice names, phone numbers and
    guidance about when to call the medical home
  5. Some practices follow up by phone as part of
    routine postpartum care, ensuring the patient has
    connected with the medical home

71
Case 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.

72
Case 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.

73
The circle of care for women
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