The Post-Partum Visit Re-Design

Jeanne A. Conry, MD, PhD

Chair, ACOG District IX

Preconception Health

This is all about Well Woman Health:

Improve the health and well-being of women. If a woman conceives, then we

should see improved pregnancy outcomes

What is Happening?

• Eighty percent of women in the US conceive at least one time (another 10% are trying)

• Seventy percent of women in the US conceive a second time

• Ninety percent of pregnancies have some complication

Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008

What is Happening?

• Forty four percent of practices have an electronic record, but only four percent are fully functional

• Women vary by state and coverage in participating in a post partum visit

Statistical Brief #113: Complicating Conditions of Pregnancy and Childbirth, 2008

What is Happening?

Women who have had a poor birth outcome in a prior pregnancy are at increased risk for having another poor birth outcome in a subsequent pregnancy

THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION. 2008. Sarah Beth Verbiest, Master of Social Work and Master of Public Health, University of North Carolina

What is Happening?

The recurrence risk varies by diagnosis, but is significant

– 15 to 30 percent for preterm delivery

– 20 to 60 percent for pre-eclampsia

– 2-12 fold risk for low birth weight infants

THE POSTPARTUM VISIT: AN OVERLOOKED OPPORTUNITY FOR PREVENTION. 2008. Sarah Beth Verbiest, Master of Social Work and Master of Public Health, University of North Carolina

What is Happening?

Maternal mortality is increasing, not decreasing

Future Pregnancy

• Eighty five percent of women with one child already at home want at least one more

• Fifty percent of women with two children want at least one more

Listening to Mothers II postpartum survey

Pregnancy Spacing

• Closely spaced pregnancies are associated with increased complications– low birth weight, preterm birth, neonatal death attributed to

decreased maternal reserves and nutritional depletion

Gregory, K., Johnson, Clark, Johnson, Timothy, Entman, Stephen. "The Content of Prenatal Care Update 2005," Women's Health Issues (2006): 198-215.

Pregnancy Spacing

Among low-income women, the length of the interval between adelivery and the conception of the next child has a significantimpact on preterm birth

• 2.4% of women had intervals less than 13 weeks• 7.5% of women had intervals between 13 and 25 weeks• 17.4% of women had intervals between 26-51 weeks.

Klerman, L., Cliver, SP, Goldenberg, RL. "The Impact of Short Interpregnancy Intervals on Pregnancy Outcomes in a Low-Income Population," American Journal of Public Health 88 (1998): 1182-1185.

Pregnancy Spacing

Rates of preterm delivery at spacing intervals less than 13 weeks were double those at intervals of

over 2 years

Klerman, L., Cliver, SP, Goldenberg, RL. "The Impact of Short Interpregnancy Intervals on Pregnancy Outcomes in a Low-Income Population," American Journal of Public Health 88 (1998): 1182-1185.

Pregnancy Spacing

• Women with interpregnancy intervals of less than 18 months are 14-47 percent more likely to have premature infants

• The most recent data suggests that approximately 14% of women, aged 15-44, gave birth within 24 months of a previous birth

• Rates are higher among African-American, Latina, and poor women

Chandra A. et al. “Fertility, Family Planning and Reproductive Health of US Women: Data from the 2002 National Survey of Family Growth. National Center for Health Statistics. Vital Health Statistics. 23(25). 2005.

Pregnancy Spacing

• Is it physiologic or is it socioeconomic? Impacted by family, breastfeeding and lack of it, access to care, knowledge, desire…

Post-Partum Visits

• Social: photo op with mom, baby and provider

• Birth control

• Post delivery recovery

Does Knowledge Matter?

Katz DL. Life and death, knowledge and power: why knowing what matters isn’t what's the matter

Reality Check

• Insurance often allows a single post partum visit

• Must integrate hospital, prenatal and post-partum information for success

• Health care reform is unlikely to INCREASE the number of visits, so how do we make more with less?

• Cervical cancer screening is not a given any longer

• Is there a “systems approach” to improving care?

Who Goes to the Post-Partum Visit?

• Medicaid participation is 59.1%

• Private Insurance 79.9%

• Kaiser Permanente participation is 94%

The State of Health Care Quality 2007 Kaiser Permanente 2011

Post Partum Visit Re-Design

• Incorporate the essentials• Integrate clinical information• Provide information to patients and providers

But it takes more than knowledge

The Ideal

• Integration of inpatient and outpatient records• Support for mom to keep the visit: what is the incentive and

what is the hurdle?• Address a life plan, and encourage spacing• Automatic patient outreach to address problems

– Postpartum depression– Hypertension– Diabetes– …..keep going and get creative