Science & Sensibility

By Christine H. Morton, PhD

The American Congress of Obstetricians and Gynecologists (ACOG) has undertaken the reVITALize Project and they want your help, thoughts and input. A significant revolution is underway in maternity care.  With increased attention on maternal health outcomes, the measurement and reporting of key maternal quality metrics is on the agenda of childbearing women, maternal health advocates, payers and purchasers, hospitals, regulatory agencies and maternity care clinicians.    An important element of this revolution is an effort to clearly define what we mean when we talk about pregnancy and childbirth in the data sources most utilized in developing these measures – patient medical charts, registries, electronic medical records, patient discharge data, and our vital statistics (birth certificates).

This is an important and critical opportunity for all stakeholders in US Maternity Care to contribute to the national dialogue on measuring maternal health outcomes.

From the ACOG website: 

The reVITALize Obstetric Data Definitions Conference in early August 2012 brought together over 80 national leaders in women’s health care with the common goal of standardizing clinical obstetric data definitions for use in registries, electronic medical record systems, and vital statistics. Over the course of the two-day in-person meeting and the months that followed, more than 60 obstetrical definitions were reviewed, discussed, and refined.  Data elements included: induction of labor, gestational age and term, parity, TOLAC, and more. The full executive summary of the reVITALize Obstetric Data Definitions Conference can be read here.

The public comment period for the definitions of these data elements ends January 15, 2013. To submit comments, click on one of the category links below to open the respective Public Comment form. The data elements contained within each Public Comment form have been grouped according to category; the data elements assigned to each category are listed under the category heading below. You are permitted to comment on any number of categories. You can also view an alphabetical listing of all data elements available for comment here.

Delivery
• Cesarean Delivery
• Date of Delivery
• Forceps Assistance
• Malpresentation
• Perineal Lacerations
• Placenta Accreta
• Primary Cesarean Delivery
• Repeat Cesarean Delivery
• Shoulder Dystocia
• Spontaneous Vaginal Delivery
• Vacuum Assistance
• Vaginal Birth After Cesarean
• Vertex Presentation

Gestational Age & Term
• Preterm
• Early Term
• Full Term
• Late Term
• Post Term
• Estimated Date of Delivery
• Gestational Age (calculation formula)

Labor
• Artificial Rupture of Membranes
• Augmentation of Labor
• Duration of Ruptured Membranes
• Induction of Labor
• Labor
• Labor After Cesarean
• Non-Medically Indicated Induction of Labor or Cesarean Delivery
• Number of Centimeters Dilated on Admission
• Onset of Labor
• Pharmacologic Induction of Labor
• Physiologic Childbirth
• Pre-Labor Rupture of Membranes
• Spontaneous Labor and Birth
• Spontaneous Onset of Labor
• Spontaneous Rupture of Membranes

Maternal Indicators: Current Co-Morbidities and Complications
• Abruption
• Antenatal Small for Gestational Age
• Any Antenatal Steroids
• Clinical Chorioamnionitis
• Depression
• Early Postpartum Hemorrhage
• Oligohydramnios – HOLD; Pending Further Revision
• Polyhydramnios – HOLD: Pending Further Revision

Maternal Indicators: Historical Diagnoses
• Chronic Hypertension
• Gravida
• Maternal Weight Gain During Pregnancy
• Non-Cesarean Uterine Surgery
• Nulliparous
• Parity
• Plurality
• Positive GBS Risk Status
• Pre-Gestational Diabetes

What happens to comments after they are submitted?

http://flic.kr/p/8Box52

All comments received during the Public Comment period will be reviewed and logged for consideration and careful review by reVITALize leadership. The leadership teams are comprised of both clinical and operational members. Comments will be reviewed and responded to accordingly and will help to form the basis for any additional changes that need to be made to the refined definitions prior to final approval. Should comments require further clarification, the individual submitting the comment may be contacted during the review period to obtain any clarifying information needed to make an informed and appropriate decision regarding a potential revision.

Thank you for your help in making this initiative a success! Any questions or concerns should be directed to QI@acog.org

Christine Morton ACOG, Evidence Based Medicine, Guest Posts, Legal Issues, Maternal Quality Improvement, Research, Research Opportunities ACOG, Christine Morton, guest posts, Maternal Quality Improvement, research

Guest post by Science & Sensibility contributer Christine H. Morton, PhD

(Full disclosure:  the organization I work for, CMQCC, has been working with representatives from the Preeclampsia Foundation over the past year on the CMQCC task force developing a Preeclampsia Toolkit, and I am a big fan of their executive director, Eleni Tsigas, and frequent re-tweeter of @preeclampsia).

The Preeclampsia Foundation released a new guide to pregnancy and birth books last month, a comprehensive report distilled from a review of more than 60 such books, on their accuracy, coverage and clarity of information on hypertensive complications in pregnancy.    As readers of S&S are well aware, there are numerous books geared to expectant couples, pregnant women, and male partners; by authors who claim their authority by virtue of their clinical degrees and practice, their teaching and research credentials, as well was their personal and celebrity experience.   This is the first time I’ve seen a guide to pregnancy and birth advice books from the lens of a serious disorder in pregnancy:  preeclampsia.

 Seeking to understand their experience, women turn to books, their childbirth educators and doulas to help them navigate through this new and unexpected turn into complicated pregnancy.   While many women have healthy pregnancies and births, those who are having symptoms, or have been diagnosed with preeclampsia, eclampsia or HELLP syndrome, need accurate and clear information.    Early detection, and treatment, is a proven way to lessen the severity of the disease, and mitigate its impact.  Are some pregnancy and childbirth guidebooks better than others in informing readers about these issues?

To answer this question, researchers Jennifer Carney, MA and Douglas Woelkers, MD reviewed more than 60 pregnancy and childbirth advice books and ranked them using a consistent set of criteria in five categories: Depth of Coverage, Placement of Coverage, Clarity and Accuracy of Information, Description of Symptoms, and Postpartum Concerns.  In their methods section, they note that

“Books were downgraded for out-of-date information, missing or inaccurate information and placement issues, including inaccurate or inadequate indexing.    Of the more than 60 books reviewed, none ranked above “8” in all five categories. In fact, only a handful of books scored above “8” in the category of “Postpartum Concerns,” since many books routinely state that the cure for preeclampsia and related disorders is the birth of the baby.”

Childbirth educators and doulas have strong views on the ‘best’ books to guide women through pregnancy and childbirth and might be surprised to find that even best selling books like Ina May’s Guide to Childbirth (2003) scored only a 2.6, while the much excoriated, yet highest selling advice book: What To Expect When You’re Expecting (2009) ranked last in the Preeclampsia Foundation’s TOP TEN list, with a score of 7.2.  All books reviewed are listed in the Appendix of the report.

One helpful feature of the report is a sampling of questionable claims found in pregnancy guidebooks:

“Preeclampsia never happens before the twentieth week, but your blood pressure may start to rise steadily after this. Delivery of the baby and placenta ends the problem.” From Conception, Pregnancy, and Birth by Miriam Stoppard. In rare instances preeclampsia can occur prior to 20 weeks; it can also occur up to six weeks postpartum.

The report further explains why it’s important for books on childbirth to also mention preeclampsia, eclampsia and HELLP Syndrome, since this disease can develop immediately prior to, during or after delivery.  Among the childbirth books, the reviewers found,

Only Penny Simkin’s book The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions (2007) provides adequate information about preeclampsia, eclampsia, and HELLP syndrome. Although this book incorrectly uses the term pregnancy-induced hypertension (PIH) to describe preeclampsia and eclampsia, it provides a useful list of symptoms and the possible treatments, including cesarean delivery. It also presents some of the emotional issues that might arise from a diagnosis of PIH and includes some information on HELLP syndrome. It acknowledges the possibility of postpartum preeclampsia and eclampsia, something that many of the general pregnancy books omit.

The report can help childbirth educators and doulas point women to the best information about hypertensive disorders, but its authors also hope these results will guide authors in future revisions.  At the very least, up to date terminology, accurate information and complete indexing is critical in revisions. Books geared primarily to women with relatively healthy pregnancies always face the challenge of balancing reassurance, the optimality of physiological birth and the diverse range of potential complications in pregnancy.  Yet such books can point readers to resources like the Preeclampsia Foundation for up-to-date and user-friendly information and community pages.

Take-away points for Childbirth Educators and Doulas:

• Check your website and be sure to link to Preeclampsia Foundation website for unbiased, evidence-based information on this disease.  They are on Facebook too.
• Tell your students to ask about their blood pressure at all prenatal visits and during labor.  They should know what their ‘normal’ range is, and if their BP is ever above 140 systolic or 90 diastolic, to be alert to signs and symptoms of preeclampsia, and report these changes to their care providers.
• Many factors can affect BP readings:  BP cuff size should be appropriate, especially among women with a high BMI; the measurement should be taken while sitting, with arm at heart level; automated BP machines may underestimate the BP.
• Remind pregnant women (and their partners) that although lots of attention will naturally be focused on the baby, they have to be alert to the new mother’s health symptoms postpartum too.  While postpartum is a whole new normal, women need to know that any significant bleeding, fever, headaches, nausea, or visual disturbances, are NOT normal, and they should follow up with their health care provider immediately.

Preeclampsia is a serious, if unlikely, complication of pregnancy.  Women diagnosed or at risk for developing hypertensive disorders of pregnancy can find accurate information for all literacy levels (and some Spanish language resources), as well as a supportive community at the Preeclampsia Foundation, a US-based 501(c)(3) not-for-profit organization whose mission is to reduce maternal and infant illness and death due to preeclampsia and other hypertensive disorders of pregnancy by providing patient support and education, raising public awareness, catalyzing research and improving health care practices.

 References

1. American College of Obsetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167.

2. Repke JT PM, Holzman GB, Schulkin J. Hypertension in Pregnancy and Preeclampsia: Knowledge and Clinical Practice Among Obstetrician-Gynecologists. Journal of Reproductive Medicine. 2002;47(6):472-476.

3. Caetano M OM, von Dadelszen P, Hannah ME, Logan AG, Gruslin A, Willan A, Magee LA. A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy. Hypertens Pregnancy. 2004;23(2):197-209.

4.  Hogan JL, et al.  Hypertens Pregnancy. Body Mass Index and Blood Pressure Measurement during Pregnancy. 2011;30(4):396-400.  PMID: 20726743

Read more about Christine H. Morton, PHD on our contributor page.

Christine Morton Book Reviews, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, Patient Advocacy, Practice Guidelines, Pre-eclampsia, Pregnancy Complications, Uncategorized blood pressure, Childbirth Education, Christine Morton, Christine Morton PhD, eclampsia, gestational hypertension, guest post, HELLP, interventions, maternity care quality, MD, midwives, PIH, pre-eclampsia, preeclampsia, safety, treatment for pre-eclampsia

In our past blog posts, Kathleen Pine and I have been writing about the process by which quality measures in perinatal care are developed, endorsed and then adopted by various entities.

The last comprehensive National Quality Forum (NQF) review of Perinatal Measures was in 2008 which endorsed 17 measures, with a few additional relevant measures added during other, subsequent reviews (e.g. Healthy Term Newborn was added as part of the Pediatric Population Review Process in 2009).  As of July 8, 2011, NQF has endorsed 33 consensus standards applicable to perinatal and reproductive health in a number of previous projects.

Currently, the NQF is in the process of measure maintenance and consideration of new measures.   This current project seeks to identify and endorse measures for public reporting and quality improvement addressing reproductive health, pregnancy, childbirth and post-partum care, and newborn care. In addition, this project will include maintenance of previously NQF-endorsed standards in these topic areas.

The candidate measures will be considered for NQF endorsement as voluntary consensus standards. Agreement around the recommendations will be developed through NQF’s formal Consensus Development Process (CDP). This project will involve the active participation of representatives from across the spectrum of healthcare stakeholders and will be guided by a multiple-stakeholder Steering Committee (see below for members of this committee).

In the past month, there has been a series of 4 workgroup meetings, at which all the candidate measures have been discussed.  Agendas from those meetings, and other information about the ongoing process can be found here.

There is an upcoming 2-day steering committee meeting, which is open to NQF members and the public (in person or by phone).  Registration is free, and the link is provided below.

————————————————————————————————————

After the steering committee meeting, the draft report is expected to be available for review and comment in January 2012. Member commenting period is 30 days. The public commenting period is 23 days (Jan 16-Feb 7, 2012).  NQF members will vote in late March 2012 with a decision announced in April and board ratification in early May 2012.

For further information, contact Reva Winkler, MD, or Suzanne Theberge, MPH, at 202-783-1300 or via email at perinatal@qualityforum.org.

Listed below are the steering committee members and links to the 33 consensus standards under review.

Perinatal and Reproductive Healthcare Endorsement Maintenance

Steering Committee Member Roster

Joanne Armstrong, MD, MPH
Aetna. Sugarland, TX

Jennifer Bailit, MD, MPH
Case Western Reserve University and MetroHealth Medical Center, Cleveland, OH

Scott Berns, MD, MPH, FAAP     
March of Dimes Foundation and Warren Alpert Medical School of Brown University, White Plains, NY

Jennifer Brandenburg, RN, MSN
Decatur Memorial Hospital, Cerro Gordo, IL

Sarah Brown, MSPH                    
National Campaign to Prevent Teen and Unplanned Pregnancy, Washington, DC

William Callaghan, MD, MPH
Division of Reproductive Health, Centers for Disease Control and Prevention, Atlanta, GA

Charles Denk, PhD
New Jersey Department of Health, Trenton, NJ

Elizabeth Drye, MD, SM
Yale/Yale-New Haven Hospital Center for Outcomes Research and Evaluation (CORE) and Yale School of Medicine, New Haven, CT

Andrea Gelzer, MD, MS, FACP
The AmeriHealth Mercy Family of Companies, Philadelphia, PA

Rebekah Gee, MD, MPH, MS       
Louisiana State University (LSU) and Louisiana Department of Health and Hospitals, New Orleans, LA

Craig Gilliam, BSMT, MT (ASCP), CIC
Arkansas Children’s Hospital, Little Rock, AR

Kimberly D. Gregory, MD, MPH  
Cedars-Sinai Medical Center and University of California Los Angeles, Los Angeles, CA

William A. Grobman, MD, MBA  
Northwestern Memorial Hospital, Chicago, IL

Mambarath Jaleel, MD                 
University of Texas Southwestern Medical Center, and Parkland Memorial Hospital, Dallas, TX

Barbara Kelly, MD                        
AF Williams Family Medicine Center, Denver, CO

Teri Kiehn, MS, RNC
Intermountain Healthcare, Salt Lake City, UT

Nancy K. Lowe, CNM                   
University of Colorado College of Nursing, Aurora, CO

Jochen Profit, MD, MPH
Texas Children’s Hospital, Houston, Texas

Laura Riley, MD
Massachusetts General Hospital, Boston, MA

Carol Sakala, PhD, MSPH            
Childbirth Connection, New York, NY

Kathleen Rice Simpson, PhD, RNC, FAAN          
St John’s Mercy Medical Center and Saint Louis University, St. Louis, MO

Sharon Sutherland, MD               
Cleveland Clinic, Cleveland, OH

Robert K. Watson, MD, MMM, CPE           
Andrews Women’s Hospital, Baylor All Saints Medical Center, Dallas, TX

Janet Young, MD                          
Department of Emergency Medicine, Virginia Tech Carilion School of Medicine, Roanoke, VA

Perinatal and Reproductive Healthcare Endorsement Maintenance Measures Submitted

• 0303: Late sepsis or meningitis in neonates Risk adjusted (PDF)
• 0304: Late sepsis or meningitis in Very Low Birth Weight neonates Risk adjusted (PDF)
• 0469_PC-01: Elective Delivery (PDF)
• 0470: Incidence of Episiotomy (PDF)
• 0471_PC-02: Cesarean Section (PDF)
• 0472: Appropriate Prophylactic Antibiotic (PDF)
• 0473: Appropriate DVT prophylaxis in women undergoing cesarean delivery (PDF)
• 0474: Birth Trauma Injury to Neonate (PDF)
• 0475: Hepatitis B Vaccine (PDF)
• 0476_PC-03: Antenatal Steroids (PDF)
• 0477: Under 1500g infant Not Delivered at Appropriate Level of Care (PDF)
• 0478: Neonatal Bloodstream Infection Rate (PDF)
• 0479: Birth Dose of Hep B Vaccine (PDF)
• 0480_PC-05: Exclusive Breast Milk Feeding (PDF)
• 0481: First temperature measured within one hour of admission to the NICU (PDF)
• 0482: First NICU Temperature less than 36 degrees Centigrade (PDF)
• 0483: Proportion of infants 22 to 29 weeks gestation screened for retinopathy of prematurity (PDF)
• 0484: Proportion of infants 22 to 29 weeks gestation treated with surfactant (PDF)
• 0502: Pregnancy test for female abdominal pain patients (PDF)
• 0582: Diabetes and Pregnancy-Avoidance of Oral Hypoglycemic Agents (PDF)
• 0741: Five minute APGAR less than 7 (PDF)
• 0742: Birth Trauma (PDF)
• 0743: In-hospital Maternal Deaths (PDF)
• 0744: Uterine Rupture During Labor (PDF)
• 0745: Unplanned maternal admission to the ICU (PDF)
• 0746: In-hospital Neonatal Death (PDF)
• 0747: Admission to neonatal intensive care unit at term (PDF)
• 0748:Third or fourth degree perineal laceration (PDF)
• 0749: Unanticipated Operative Procedure (PDF)
• 0750: Maternal blood transfusion (PDF)
• 1731: Health Care-Associated Bloodstream Infections in Newborns (PDF)
• 1746: Intrapartum Antibiotic Prophylaxis for Group B Streptococcus (PDF)
• 1769: Adverse Outcome Index (PDF)

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Science & Sensibility readers may recall the Maternal Obesity from all Sides series* we did a few months ago.  Last week, while walking my dog and catching up on a few news podcasts, I heard this story on NPR’s Morning Edition—a segment that was a part of the news outlet’s series on Obesity in America.  The story discusses new research that looks at why it can be so difficult to lose and keep weight off from a hormonal and biological perspective.  The gist of the research referenced in this news piece is that when we concertedly work to lose weight, our body produces less of the hormone leptin (a natural appetite suppressant) which prompts a starvation signal in our brain, telling the body to conserve energy by decreasing metabolism and, at the same time, feel more hungry—prompting increased caloric intake.

Additionally, the Morning Edition segment made the point that once a person has gained more weight than that which is healthy for his/her stature, it becomes harder and harder to lose and keep the weight off.  As the reporter summarizes, “lower metabolism lasts a lifetime.”  (Despite this, some excellent points are later made in the segment which suggest that moderate exercise six days a week—such as brisk walking, swimming or cycling, can have positive effects on weight loss and maintenance.)

What does all this have to do with maternity care issues?

Well, in the Maternal Obesity from all Sides series, we discussed the growing correlations between maternal overweight and pregnancy and L&D outcomes:  how women of size are more likely to experience gestational hypertension and diabetes; how they are more likely to be offered labor inductions and undergo cesarean deliveries as a result of those comorbidities—whether or not those procedures are actually evidence-based for the given situation(s).  And we also discussed how addressing size and/or weight once a woman is pregnant is both unfruitful and unfair—because most of us recognize that pregnancy is not a time when a woman should be attempting to lose weight.  Likewise, it is not a time when a woman should be shamed for a preexisting condition (as if shaming is ever acceptable).

But, in the spirit of preventative care, I felt the NPR piece was enlightening: while there are MANY opportunities to improve maternal outcomes through preconception/interconception care, as pointed out in the recent blog post by Christine Morton, and the more distant series by Walker Karraa, perhaps working to prevent obesity in the first place—rather than focusing on after-the-fact individual or public health weight loss programming—is a better approach.  Because, according to the news segment linked to above, once extra weight has been acquired, losing and maintaining that weight loss is exceptionally more difficult.

A similar NPR story on All Things Considered aired just a few days earlier which covered this same topic and reviewed the findings of a study recently published in the New England Journal of Medicine.  The study by Priya Sumithran et al. assessed the hormone and metabolism changes that accompanied significant weight loss in severely calorie-restricted study subjects.  As described in the Morning Edition segment, Sumithran’s study described significant weight loss maintenance difficulties that were hormonally based.  In essence: maintaining weight loss is about hormones, not will power.

Women of childbearing age have enough maternity care-related challenges to face: escalating labor induction and cesarean delivery rates, racial disparities in access to care.  We talk a lot on this blog site about the cascade of interventions, a concept that is also frequently referred to in Lamaze teachings.  Perhaps it is time we should also be talking about a healthy cascade of prevention, with maternal obesity being a prime target.  Ideally this cascade of prevention begins well before women of childbearing age find themselves contemplating pregnancy, or preparing for birth.  But even as childbirth educators, we can play a part in this healthy cascade.  When covering postpartum topics, we can talk with our expectant parents about the importance of interconception health:  nutritious dietary choices and adequate exercise.  We can couch these discussions as approaches to optimizing health in various ways with various downstream benefits:  having adequate energy to play with one’s child(ren), reducing a family’s healthcare cost burden, and yes, laying the ground work for healthfully supporting a future pregnancy if and when that occurs.

As Dr. Miranda Waggoner stated in her interview with Dr. Morton, “…we do have to worry about viewing women as pregnancy vessels,” but I also think we need to begin looking at expectant women beyond just the here and now.

*The Maternal Obesity from All Sides series is also reviewed in the current Journal of Perinatal Education.  If you don’t already receive the JPE and would like to check it out, you can request a free copy of the journal here.

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

Kimmelin Hull Maternal Obesity cascade of interventios, cascade of prevention, Christine Morton, Darline Turner Lee, Kimmelin Hull, Lamaze International, leptin and weight loss, maternal obesity, Miranda Waggoner, obesity epidemic, racial disparities in maternity care, weight loss

[Editor's note:  in this post, Dr. Christine Morton interviews public health researcher Miranda Waggoner, PhD, on her work with Princeton University's Office of Population Research.  Dr. Waggoner's particular research interests lie in maternal, women's and infant's health.]

CM:  Please briefly describe your research on preconception/interconception for the Science & Sensibility readership

MW:  My current research focuses on the emergence of the preconception care paradigm in the U.S. and what it means for contemporary public health and clinical strategies that aim to improve maternal and child health. Advocacy for prenatal care began in the early part of the 20^th century, and prenatal care utilization increased throughout the century. The problem, though, was that adverse birth outcomes, such as low birthweight and infant mortality, persisted despite increasing numbers of women getting early prenatal care. So, experts started to look for other approaches to tackle these problems, and a preconception care (PCC) framework emerged as a potential solution. In 2004, The Centers for Disease Control and Prevention (CDC) launched its Preconception Health and Health Care Initiative. The basic idea was that a new focus on clinical care prior to pregnancy would improve birth outcomes. This new focus on the preconception period was seen by many in the maternal and child health field as a paradigm shift. I study the evidence base for PCC and how the United States moved from focusing on the expansion of prenatal care services to what is now essentially a prenatal care model that includes the period prior to pregnancy. I am also interested in what this new paradigm means for how we think about women’s bodies, reproduction, and population health in our society.

CM:  What do you think is important for childbirth educators to consider when they provide information to expectant women (and their partners) about preconception/interconception issues?

MW:  As any childbirth educator will know from experience working with women and couples, many conceptions are unplanned or unintended. So, a good number of women will enter pregnancy without active knowledge about, or preparation for, “preconception health.” Discussing preconception health during pregnancy is too late and potentially induces undue stress on the pregnant woman.

A motto of the preconception care paradigm is “every woman, every time.” This is the idea that clinicians should address women’s preconception health at every clinical encounter. I have learned in my research that clinicians do not always find this to be a successful strategy. Clinicians reported that often when a patient is not planning to get pregnant, she usually does not want to be asked about how her behaviors will influence a pregnancy. The preconception care framework sees women’s bodies as inherently risky to future fetuses if women are not preparing for pregnancy and changing their health behaviors to prepare for a pregnancy. We have to worry about this kind of rhetoric if it makes women feel uncomfortable or guilty about their reproductive behaviors or lives. The New York Times and Washington Post both published pieces about PCC after the CDC launched its initiative, and they suggested that women now will be treated as forever “pre-pregnant.” I think we do have to worry about viewing women as pregnancy vessels, but the CDC’s initiative was more complex than what was captured in these news outlets. The PCC initiative outlines improvements to a woman’s health irrespective of whether or not she plans to have a baby. I’m writing right now about how this public health strategy impacts the way we think about women’s health and women as potential mothers.

If you are talking to a woman who is already pregnant about preconception care, you are really addressing her health for a future pregnancy. This is known as interconception care (ICC). However, not every woman wants a subsequent pregnancy. If a woman does not want another pregnancy, part of this care would include information on how to avoid future pregnancies. CBEs should include ICC in their curriculum to the extent that the patient wants to discuss, plan, or prevent a subsequent pregnancy.

CM:  What does a sociological perspective add to the public health vision of Preconception/Interconception health?  For example, in an earlier S&S post, Dr. Michael Lu of UCLA outlines a vision of “Prenatal Care 3.0″ which puts the “Medical Home” in the center (not the OB, as in Prenatal Care 2.0).  Although he doesn’t include midwifery in his vision of the Medical Home, are there other components you think are important to consider?

MW:  It is important to distinguish between preconception health and preconception care. Preconception health refers to a woman’s health status, whereas preconception care focuses on the clinical context. The public health vision of preconception care and prenatal care currently highlights individual health behaviors of women, and prenatal care 3.0 is still very much focused on clinical interventions toward individual women. Not everything related to health is best addressed by individual behavior change or clinical interventions. That is, we need to attend to population health at the social level too, making sure that underlying factors related to health are addressed. The National Children’s Study, which Dr. Lu is involved in, hopes to shed light on some of these factors, such as environmental influences on child development. I hope that we turn attention to the social determinants of health and not simply focus on clinical interventions and telling women to change their behavior.  Health status is influenced by so much more than what an individual woman does or does not do. If we want to improve population health, we have to focus on the social factors related to health for all people, not just women.

Additionally, I think some of these frameworks could better consider women’s health for women’s health sake and not just focus on women’s health behaviors in terms of how they will impact a future pregnancy. What people are really talking about in the preconception care paradigm is improving women’s health overall and improving birth outcomes in particular.  Most of a contemporary woman’s life, though, is spent not pregnant. I think the term “preconception care” is sometimes misleading as people are increasingly adopting a life course perspective, as Dr. Lu and others have. The basic idea of “Prenatal Care 3.0” is expanding care to the entire reproductive life course, not just focusing on pregnancy. If we highlight a woman’s general well-being over her life course, and not just focus on her as a future mother, we would see the inclusion of midwives, doulas, and other women’s health support mechanisms in a broader vision of health care.

Posted by:  Christine Morton, PhD

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