PBH 805: Week 4 Slides

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Week 4
Chapter 7, Part 2
Instructor: Gina Crosley-Corcoran, MPH
PBH 805 – Maternal & Child Health

Chapter 7
Preconception Health &
Prenatal, Intrapartum And Postpartum Care

Improving Women’s Health Prior to and Between Pregnancies
Two key strategies:
 Providing increased access to reproductive health services to
support women in their decisions about if and when to get
pregnant
 Access to full range of reproductive health care is integral to
improving outcomes for women’s health and pregnancy.
 Access to contraception, fertility treatment, and safe and
legal abortion service are key strategies for improving
women’s health and pregnancy outcomes.
 Access to quality, person-centered, respectful well-woman care
and preventive services across the life course

Quality Prenatal Care (1 of 2)
 Prenatal care thus remains critical as it offers women the first
encounter with the health care system to address myriad of
health issues (Fiscella, 1995)
 The current/future health and well-being of pregnant persons
and infants are influenced by pregnancy and prenatal care
experiences
 High-quality prenatal care is a bundle of multiple interventions
to address needs that may occur over the course of pregnancy
 Components of PNC include
 (1) early and ongoing assessment of women’s risk status
 (2) health education and promotion
 (3) interventions to address risks identified/occurring during pregnancy

Quality Prenatal Care (2 of 2)
 Interventions include
 smoking cessation, alcohol and substance abuse treatment
 providing social support
 stress-reduction strategies
 screening and treatment of for depression
 screening and treatment for STIs/HIV
 nutrition and weight gain management
 referral to essential services
 screening and treatment for diabetes and hypertension
 oral health screening and treatment, and screening and services for intimate partner violence
 The ACOG recommends that PNC visits for uncomplicated pregnancy should be done
every 4 weeks until 28 weeks, every 2 weeks until 36 weeks, and weekly until delivery.
 Studies over time have demonstrated that fewer PNC visits in low-risk women are not
associated with adverse pregnancy outcomes and more visits do not improve
outcomes, but may lead to more interventions.

Method of Delivery
 Most women have vaginal births even though C-section
has been increasing for several decades.
 C-section is a surgical procedure involving incisions on the
abdomen and uterus of a women to deliver the fetus.
 C-section has higher risks compared to vaginal birth, even
though it sometimes necessary and is the safest option.
 Rise in C-section rates a global concern
 The WHO recommends the use of C-section when
medically indicated rather than based on specific rates.

Copyright © 2020 by Jones & Bartlett Learning, LLC an Ascend Learning Company. www.jblearning.com. Background texture © Bunphot/Getty Images.
Protecting and Promoting Health of the
Infant After Delivery

Regionalized Perinatal Care (RPC)
Defined as an approach that organized levels of maternal and obstetric services for
hospitals.
 Created based on need for maximize efficiency and cost-effectiveness of
“intensive care” medicine
 Risk assessment across the pregnancy continuum as well as referral to
appropriate services are central to concept of regionalization
 High-risk mothers and infants who are cared for in facilities with experience in
treating complex conditions do better than those in units not prepared
 Practically, focuses on high-risk neonate after delivery, NOT on care focused on
women’s health and well-being
 To reduce maternal morbidity and mortality, ACOG leading effort to introduce
levels of maternal care that are complementary but distinct from neonatal care

Access to Well-child/
Baby Visits and Immunizations
 Well-baby visits are preventive encounters for infants with
a clinician during the first year after delivery
 Provide advice on infant feeding, support for
breastfeeding, safety information in homes, and
monitoring of growth and development, as well as
addressing concerns by parents and provision of
anticipatory guidance as infants mature
 Bright Futures recommend seven visits for infants in first
year of life.
 CDC-recommended immunization schedule aims to
prevent 14 diseases in children from 0–6 years of age

CDC Recommended Childhood
Immunization Schedule

Back to Sleep/Safe Sleep
 Back to Sleep campaign launched in 1994 by NICHD,
AAP, MCHB, and several SIDS advocacy groups
 Most recent AAP safe sleep guidelines of 2016
recommend using firm sleep surfaces; having infants
sleep in cribs, bassinets, or portable cribs; keeping soft
objects and loose bedding away from the sleep area;
breastfeeding; using pacifiers; not smoking or using
alcohol or other drugs; avoiding overheating; obtaining
PNC; and following immunization schedule.
 Several factors influence how and where families place
infants to sleep.
 These include conditions and safety of parent’s own
sleeping environments and housing arrangements.
 In 2015, 22% reported not placing babies to sleep on
their backs, 61% reported not bedsharing, and 39%
reported using any soft bedding (CDC Vital Signs,
2018).

Breastfeeding
 Beneficial to both mother and infants
 Protects against illnesses and diseases
(e.g., respiratory tract infections,
diabetes, lymphoma and leukemia,
obesity)
 For mothers, it is associated with:
 reduced bleeding postpartum
 return to pre-pregnancy weight
 reduced risk of breast and ovarian cancer

Breastfeeding
 AAP recommends exclusive breastfeeding for 6
months (meaning no solid food or formula) and
continuing to breastfeed while adding in solid
foods for 1 year.
 World Health Organization recommends
continuing to breastfeed for up to 2 years.
 Factors associated with disparities in
breastfeeding initiation and continuation include:
 absences of paid family leave policies
 lack of knowledge about benefits of breastfeeding, how
to breastfeed, and how to work through challenges
 social norms
 lack of support from families, friends, and health care
professionals.
 Need to provide culturally humble and respectful
care to support minority women in breastfeeding
decisions

Strategies to Protect and Promote the Health
of the Pregnant Person/Woman After Delivery

Social Determinants of Health
Improving pregnancy and birth outcomes and
eliminating inequities requires evaluation of root
causes from social determinants of health (SDOH)
to systemic changes necessary to improve delivery
of quality care across the reproductive and
perinatal life course.
SDOH framework for reduction of infant mortality
explained along with interventions to eliminate
structural factors, hence acknowledges that action
to address both root causes and access to quality
care are critical
Historic and structural racism are the basis upon
which SDOH emerge. While it is important to
address the SDOH, it is necessary to also address
structural factors for true change and equity.

WHO Framework for Tackling
SDOH and Infant Mortality

Care for Women During the Postpartum
Period (1 of 2)
 The postpartum period (4th trimester) a critical time for women,
infants, and families.
 Period of adaptation and recovery from the woman and her
infants
 Women who have had a recent pregnancy are at greater risk for
unintended pregnancy compared to other women of
reproductive age not using contraception, hence the need for
adequate birth spacing.
 While infants receive health care between 2–5 days after birth,
women generally do not receive postpartum care until 6–8
weeks after birth.
 Many (especially low income) women, however, do not receive
any postpartum care.

Care for Women During the Postpartum
Period (2 of 2)
 Factors associated with new mothers not receiving care include
system failures related to continuity of care between PNC and PP
care, difficulties in managing a novel schedule and changed
lifestyle due to presence of new baby, lack of childcare for other
children, issues with transportation, need to bring the infant to
multiple well-baby visits, and feeling disrespected by providers.
 Rather than a single visit, PPC should be an ongoing process with
multiple visits.
 NCQA proposed three measures of postpartum visits
 Early visit: percentage with postpartum visit within 21 days after
delivery
 Later visit: percentage with postpartum visit during 22 and 84 days after
delivery
 Early and later postpartum visit: percentage with both an early and later
postpartum visit

Home Visits
 Many programs with varied models, personnel,
and schedules available for pregnant women
and families with young children globally
 Some initiated during pregnancy and continue
into PP period focusing on perinatal outcomes,
while others emphasize early childhood
outcomes (e.g., school readiness)
 U.S. home visits target high-risk women on the
basis of demographic risk (income, age, parity)
 Reviews of home visiting programs
demonstrate positive outcomes.
 The Maternal Infant Early Childhood Home
Visiting program provides funding to states,
tribes, and territories to support evidence-
based home visiting programs.

Healthy Start
A U.S. federal program administered by
MCHB targets infant mortality reduction
Key features are location in
communities with high rates of infant
mortality, case management services
available from pregnancy though first
2 years of life, provision of or referral
to comprehensive health and social
services for high-risk women and
infants, father support, housing
assistance and job training, and
community engagement.

Paid Family Leave (1 of 2)
 Paid maternity and family leave policies require employers to allow
parents and caregivers to take time away from work to care for new
babies or adopted children while receiving partial or full pay and
guarantee they can return to their jobs.
 Associated with improved maternal and infant health outcomes,
child development, and family well-being
 U.S. is one of three countries globally and only country among high-
wealth countries without universal paid maternity and paternity
leave.
 Many high-wealth countries have paid maternity leave of 18 weeks.
 The Family Medical Leave Act of 1993 guarantees eligible
employees 12 weeks of unpaid, job-protected leave to care for
newborns and newly adopted children, ill family members, or their
own serious health conditions.

Paid Parental Leave

Paid Family Leave (2 of 2)
 40% of workforce, however, not eligible for FMLA
 Higher percentages of Hispanic and non-Hispanic Black adults
ineligible for unpaid leave compared to nob-Hispanic White adults
 Fathers and non-birthing parents face challenges accessing leave to
care for new children
 By august 2019, 8 states and D.C passed paid family leave
regulations offering employees 4-12 weeks of paid leave with
various eligibility criteria and funding sources
 In December 2019, U.S. congress passed up to 12 weeks paid family
leave for federal workers following a childbirth, adoption or
fostering
 Clear inequities in inequities to paid family have been demonstrated
in the COVID-19 pandemic era

Emerging Issue and Approaches in
Reproductive and Perinatal Health

Substance Use During Pregnancy and
Postpartum (1 of 2)
 Opioid use among reproductive-aged and pregnant women has grown in
recent years with the opioid epidemic.
 Substance use increases risk of stillbirth; LBW; PTB; IUGR; cardiac,
respiratory, neurological, hematological, and infectious problems; as well as
NICU admissions and infant mortality.
 With opioid epidemic, there has been an increase in neonatal abstinence
syndrome (NAS) with accompanying LBW and respiratory complications.
 Need to screen and treat substance use disorders in pregnancy and
parenting women using comprehensive and family-centered approaches
 Challenges to screening include punishment and criminalization of
substance use during pregnancy in some states and localities, elevation of
bias (implicit or explicit) on the part of providers who are more likely to
screen women of color when White women are more likely to use
substances, and termination of parental rights once child is born where
there is evidence of prenatal substance use.

Substance Use During Pregnancy and
Postpartum (2 of 2)
 Gender-responsive treatment frameworks provide support
to remain in treatment and emphasize trauma-informed
care
 Care remains suboptimal for patients seeking substance
use treatment, only 11% of the 21.7 million Americans in
need
 Access to care, financial concerns for uninsured and
Medicaid-insured patients, stigma and fear of punishment
are barriers to receiving car
 19 states created or funded drug treatment programs
targeting pregnant women

Protecting Women’s/Pregnant Persons and Infants’
Health During Disasters and Emergencies (1 of 3)
 Although emergencies (conflicts and natural
disasters) pose significant challenges for everyone,
pregnant women and infants are particularly
vulnerable due to unique challenges not adequately
addressed in disasters and public health crises.
 Disaster preparedness plans do not fully prioritize
women’s reproductive health needs, including access
to contraception and abortion services.
 Risks of disasters include increased stress, physical
exertion, caretaking responsibilities, sexual assault,
and adverse birth outcomes (PTB, LBW).
 While telehealth maybe an innovative approach to
providing care for women in humanitarian settings,
this is yet to be universally implemented and may
not be ideal for high-risk women in whom in-person
visits would be critical.

 Medical payment for PNC delivered thought
telehealth mechanisms now available
 Women need to be aware of established health care
facilities providing labor and delivery services during
a disaster, although this may be challenging.
 Disasters may disrupt infant feeding practices.
 This may mean lack of access to clean water, making
it difficult to safely wash hands and infant feeding
items; absence of electricity can make it difficult to
use breast pump equipment or safely refrigerated
expressed milk
 Reduction of unintended pregnancies can be
achieved by providing prophylactic and emergency
contraception.
 Need for emergency contraception, assault forensic
examiners, or sexual assault nurse examiners for
victims of sexual assault

 In the wake of natural and man-made disasters in the
U.S. (e.g., Zika, flooding, COVID-19), preparedness
plans to support the needs of women, infants, and
children are underdeveloped (ACOG, 2018).
 Fostering optimal reproductive and perinatal
outcomes during emergencies requires adequate
funding to local, state, and federal governments in
addition to addressing needs of pregnant persons
and infants.
 Improved surveillance systems tracking pregnant
women’s experiences and retrospective systems
should include questions regarding exposure.
 Public health infrastructure and vital statistics and
surveillance systems need to be fully supported in
non-disaster times to ensure robust response during
disasters.

Justice-Involved Women (1 of 2)
 Sharp increase in rates of incarceration in the
U.S. over last few decades, with women and
people of color disproportionately affected
 By 2017, number of incarcerated women in
the U.S. was 225,000; 80% were mothers
and 60% had children younger than 18 years
 Most incarcerated women are primary
caretakers of their children, many as single
mothers.
 Incarceration of women can have profound
impact on children and family.
 About 5–10% women enter jail or prison
while pregnant.

Justice-Involved Women (2 of 2)
 Adequate PNC, including medical, nutritional, and
education services, are lacking for incarcerated
birthing persons
 The lack of data makes evaluation of health needs and
outcomes incarcerated persons difficult.
 Pregnancy in Prison Statistics collects data on
pregnant persons in 22 state prison systems, 6 jails,
and 3 departments of juvenile justice across the U.S.
 Prison nursery programs are an innovative but not
widely used approach to caring for mothers and
infants, and they show promising outcomes.
 Use of doulas for incarcerated pregnant persons is
another innovative approach gaining momentum (See
Example: Minnesota Prison Doula Project:
https://www.mnprisondoulaproject.org

Focus on Fathers
 Paternal involvement and support important during
pregnancy, labor, and delivery and postpartum
 Associated with improve maternal outcomes
 Father involvement in perinatal period important to
infant and child health
 Improved fetal development; reduced LBW and PTB;
and improved cognitive, social, emotional,
psychological, and academic outcomes in children
 Barriers to paternal involvement include obtaining
time off work to attend prenatal visits and classes, no
sufficient time of work to bond with new infant, failure
of programs to integrate paternal role in process
 There is need for programs and policies to
acknowledge importance of father involvement and
respond accordingly.

Centering Women’s/Pregnant Persons Choices in the Struggle for
Reproductive Justice (1 of 2)
 Coined in 1994, gaining traction since the last decade due to emergence of many
reproductive justice organization
 Strengthen efforts in centering voices of individuals most affected to both call out and
describe the problem and to develop solutions and approaches that can lead to lasting
change
 Focused on
 Eliminating intersectional oppression facing women of color
due to sex, gender, race
 Challenging stereotypes held about women of color affecting
their care and treatment
 Fighting reproductive and birth justice by directly addressing
inequities in women’s health outcomes due to structural
racism

Centering Women’s/Pregnant Persons Choices in
the Struggle for Reproductive Justice (1 of 2)
 Coined in 1994, gaining traction since the last decade due
to emergence of many reproductive justice organization
 Strengthen efforts in centering voices of individuals most
affected to both call out and describe the problem and to
develop solutions and approaches that can lead to lasting
change
 Focused on:
 Eliminating intersectional oppression facing women of color due
to sex, gender, race
 Challenging stereotypes held about women of color affecting
their care and treatment
 Fighting reproductive and birth justice by directly addressing
inequities in women’s health outcomes due to structural racism

Centering Women’s/Pregnant Persons Choices in
the Struggle for Reproductive Justice (1 of 2)
 Organizations include Sister Song Women of Color
Reproductive Justice Collective, Black Mamas Matter, In
Our Own Voice, Black Women’s Health Imperative,
National Black Equity Collaborative, NewMOMHealth, and
others
 Each of these organizations has their goals and mission.
 Together, their efforts can create revolution in delivering
maternal and infant care, inspire new approaches to care,
and demand attention to be paid to structures and
systems oppressing women and persons of color across
the life course.

Week 4 Assignments
Discussion Board
Quiz on Chapter

PBH 805: Week 4 Slides

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