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Addressing Unmet Maternal Health Needs at a Pediatric Specialty Infant Care Clinic
Women's Health Issues xxx-xx (2017) 1–6
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Original article
Addressing Unmet Maternal Health Needs at a Pediatric Specialty Infant Care Clinic Matthew L. Zerden, MD, MPH a,b,*, Anna Falkovich, MPH c, Erin K. McClain, MA, MPH d, Sarah Verbiest, DrPH, MSW, MPH a,d, Diane D. Warner, MD, MPH e, Janice Kay Wereszczak, MSN, CPNP e, Alison Stuebe, MD, MSc a,c a
Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina WakeMed Health & Hospitals, Raleigh, North Carolina Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina d Center for Maternal and Infant Health, University of North Carolina, Chapel Hill, North Carolina e Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina b c
Article history: Received 18 July 2016; Received in revised form 6 March 2017; Accepted 6 March 2017
a b s t r a c t Objective: The objective of this intervention was to evaluate the feasibility of screening mothers of medically fragile infants in the domains of 1) depression, 2) tobacco exposure, and 3) family planning at a post-neonatal intensive care unit (NICU) developmental pediatric visit. Additionally, we sought to estimate the percentage who met criteria for further evaluation in the three domains assessed. Methods: A cross-sectional questionnaire was administered to 100 caregivers of medically fragile infants at a specialty, post-NICU clinic visit. Participants’ responses in three domains were evaluated and appropriate referrals were provided. Analysis was then restricted to the 87 biological mothers who completed the screening. Study staff contacted the mothers 2 months later to determine whether services had been accessed and to assess overall satisfaction with the screening within the pediatric visit. Qualitative interviews were conducted with pediatric clinic staff. Results: Screening questionnaires were completed by 87 biological mothers. Twenty-two mothers (25%) met referral criteria. Pediatric clinic staff and providers were comfortable administering the screening instrument, and there was minimal disruption to clinic flow. Conclusions: Mothers of medically fragile infants are likely to have unmet health care needs that can be identified at a specialty pediatric clinic visit. A screening and referral intervention can be implemented with minimal interruption in pediatric clinic flow and is acceptable to mothers and pediatric providers. Ó 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc.
The postpartum period is challenging for all families, and it is particularly challenging for mothers of medically fragile infants (MMFI) who have been discharged from the neonatal intensive care unit (NICU). The complex health needs of these infants may lead MMFI to disregard their own physical and mental health, placing MMFI at risk for multiple health issues. These include postpartum depression, unhealthy coping behaviors such as
Funding: This research was partially supported by a generous grant from the Cefalo-Bowes Young Researcher Award through the University of North Carolina Center for Maternal and Infant Health. * Correspondence to: Matthew L. Zerden, MD, MPH, 4002 Old Clinic Bldg, CB #7570, Chapel Hill, NC 27599-7570. Phone: (919) 843-5633; fax: (919) 843-6691. E-mail address: [email protected] (M.L. Zerden).
tobacco use, and neglecting family planning, which will increase their risk for an unintended pregnancy. MMFI are prone to mental health issues such as depression and post-traumatic stress disorder (Lefkowitz, Baxt, & Evans, 2010), resulting in a higher risk of developing depression compared with mothers of healthy infants (O’hara & Swain, 1996; Vigod, Villegas, Dennis, & Ross, 2010). The increase in mental health disorders may result from the increased psychological distress and anxiety experienced in the NICU (Bakewell-Sachs & Gennaro, 2004; Vigod et al., 2010). Moreover, stress and anxiety are major risk factors for tobacco use relapse among women who quit during pregnancy, with 85% resuming smoking by their child’s first birthday (Phillips et al., 2012). In a pilot study of 28 MMFI attending a post-NICU pediatric infant clinic, unmet maternal health needs were
1049-3867/$ - see front matter Ó 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2017.03.005
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common: 23% had no primary care provider, 23% were uninsured, and 38% reported they had recently delayed or ignored medical care for themselves during the past year (Anderson, Verbiest, S., Warner, D., Horton, E., McClain, E., Leff, S.,. Dean, A., 2013, unpublished data). Mood symptoms were common, with nearly one in five women having an elevated Edinburgh Postnatal Depression Scale (EPDS) score (Anderson et al., 2013, unpublished data). Additionally, one-third of these MMFI had clinically significant trauma symptoms, indexed by the modified Perinatal PTSD questionnaire (Callahan, Borja, & Hynan, 2006). Of note, the American Academy of Pediatrics has endorsed screening for maternal depression and for tobacco exposure in the pediatric clinic setting (Best, 2009; Earls, 2010). Another domain of maternal health care often neglected among MMFI is reproductive life planning and contraception. Recent studies have found that MMFI have variable rates of uptake of the most effective forms of contraception, ranging from 6% to 50% (Bloch, Webb, Mathew, & Culhane, 2012; Clark et al., 2014). The majority of infants who require NICU-level care are born prematurely, and the greatest risk factor for preterm birth is a history of preterm delivery (Bloom, Yost, McIntire, & Leveno, 2001; Esplin et al., 2008). There is strong evidence that recurrent preterm birth is reduced with interpregnancy intervals of at dez, & Kafuryleast 18 months (Conde-Agudelo, Rosas-Bermu Goeta, 2006). Therefore, reproductive life planning counseling and access to highly effective contraception is particularly important for MMFI. Additional research found that 45% of highrisk women did not present for a postpartum medical visit (Bryant, Haas, McElrath, & McCormick, 2006). This finding underscores the need for novel approaches to address the health care needs of MMFI. This project encompasses an innovative screening and referral intervention offered to MMFI, administered as part of routine care in a post-NICU infant developmental follow-up clinic. We integrated maternal mental health, tobacco exposure, and family planning into the infant’s follow-up visit in an effort to arrange indicated counseling and services and optimize the health of the entire family. We hypothesized that maternal health screening could be effectively integrated into a post-NICU developmental care visit, as measured by the ability to engage 100 caregivers to complete the screening tool within an 8-month period. We also aimed to determine the proportion of MMFI with an identified unmet health need who received the indicated referral service within 2 months of screening. Finally, we sought to understand how the implementation of this intervention would affect the logistics and flow of the infant specialty clinic. Materials and Methods This research project was designed to identify unmet health needs among MMFI bringing their infant to a post-NICU Special Infant Care Clinic (SICC). The University of North Carolina Institutional Review Board reviewed the project and provided an exemption. The SICC integrates infant health services and provides developmental evaluation for high-risk infants after discharge from the NICU and for up to 2 years of age. The clinic operates within an academic children’s hospital and serves approximately 350 families annually. The first appointment is usually scheduled at 6 months adjusted age or, for very high-risk infants, at 1 to 3 months after NICU discharge. Inclusion criteria for infants in the SICC include, but are not limited to, preterm delivery (<30 weeks’ gestation), hypoxic ischemic encephalopathy, major congenital heart disease, genetic disorders, feeding
difficulties, and other neonatal conditions that require coordinated pediatric services. Post-NICU infants typically have four to six visits at the SICC over their initial 6 to 24 months. Starting in October 2014, a convenience sample of 100 MMFI and other caregivers of medically fragile infants were approached to complete the screening tool. This sample of 100 participants over 8 months was determined to be sufficient to determine the feasibility of screening for caregiver needs within the pediatric clinic. The screening instrument consisted of 28 questions in the following domains: 1) demographic and baseline information related to previous health care experience and health insurance status, 2) Mental healthdthe 10-question EPDS (Cox, 1996; Cox, Holden, & Sagovsky, 1987), 3) tobacco exposuredfour questions, one related to the tobacco use habits of the caregiver and three related to secondhand smoke exposure for the child (Anonymous, 2010), 4) family planningdsix questions to assess family planning intentions and contraceptive use adapted from the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System (Centers for Disease Control and Prevention [CDC], 2015). The screening instrument could be independently completed by the MMFI or caregiver in approximately 10 to 15 minutes (Appendix). The inclusion criteria were broad; we included any primary caregiver who was English speaking. The questionnaires were scored by clinic personnel, which included nurse practitioners and neonatologists. The study team identified scores (for the EPDS and tobacco exposure) and responses (for the family planning questions) that would prompt referrals for further evaluation and/or treatment. Clinic personnel made on-site referrals or provided information to caregiver to facilitate a referral closer to their home. We used the EPDS to identify women at risk for minor depression (score 10–12) or major depression (>12). For MMFI with a score suggesting minor depression, we provided an educational booklet and made a referral to the UNC Perinatal Mood Disorders Clinic. If an MMFI or caregiver reported suicidal ideation, clinic staff was instructed to escort the caregiver to the emergency department for an immediate mental health evaluation. MMFI and caregivers who reported tobacco use or exposure were provided tobacco cessation resources, and a referral was faxed to QuitlineNC, the free, evidence-based, telephonic tobacco cessation helpline in North Carolina (UNC Center for Maternal & Infant Health, n.d.). Finally, if the MMFI did not have an effective contraceptive method and did not want to become pregnant or wished to receive more information about family planning, a same-day family planning appointment at the hospital clinic was offered, or information from Bedsider.org to locate a local provider was given. To evaluate the effectiveness of the referral process, the study coordinator attempted to follow-up with all the MMFI and caregivers who agreed to be contacted 1 to 2 months after they completed the initial questionnaire. Follow-up was conducted by phone, email, or a secure texting system. The coordinator attempted to contact participants up to five times. If a participant listed two preferred methods of contact, the study staff member attempted the first preferred method three times, and the second preferred method twice. Calls were placed on different days and times. The texting system was eliminated approximately halfway through the intervention owing to concerns about maintaining confidentiality. By speaking with the MMFI or caregiver using a nine-question survey, study staff determined if appropriate services were established and assessed patient satisfaction with those services.
M.L. Zerden et al. / Women's Health Issues xxx-xx (2017) 1–6
To evaluate feasibility of administering the questionnaire in a busy clinic setting, the study coordinator conducted six interviews with clinic staff. Convenience sampling was used. Individuals from the clinic were asked about their experiences with implementation of the questionnaire, challenges encountered, and their experience with each aspect of the questionnaire. Responses were transcribed and analyzed. Descriptive statistics were used to characterize the sample. Mean EPDS scores and standard deviations were calculated, along with the frequencies of those with tobacco exposure and unmet family planning needs. All analyses were performed with SPSS (Version 19.0, IBM Corp., Armonk, NY). In addition, a qualitative survey was administered to the SICC staff that evaluated feasibility of administering the questionnaire in clinic. This qualitative survey also captured feedback from clinic staff regarding study implementation challenges and considerations for the future. Qualitative data was analyzed for themes using Dedoose software. Results MMFI Responses Table 1 shows the demographic characteristics of the 87 MMFI who completed the screening questionnaire. Although 100 surveys were completed, 13 surveys were completed by nonmothers. For the remainder of the results and discussion, we only include data and analysis on the 87 MMFI, because some of the outcomes (i.e., postpartum depression or postpartum contraception) are specific to MMFI and not other caregivers. Our participants were diverse, with no one racial or ethnic group representing the majority of participants. This diversity reflects the patient population that delivers at our tertiary care facility or are referred to our NICU. Infants of study participants had a mean age of 14 months. Eighty-four percent of the sample had attended a postpartum visit. Of the 87 participants, 63 agreed to be contacted for follow-up, and 37 were successfully reached for follow-up (Figure 1). Table 1 Demographic Characteristics of MMFI (n ¼ 87)
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Table 2 captures participant responses to baseline questions in each domain. For depression, 85% (74/87) reported that their obstetric provider spoke with them about postpartum depression. The mean score on the EPDS was 4.9; the EPDS has a maximum score of 30, with increasing scores correlated with a higher risk of depression. Any score greater than or equal to 10 prompted a referral. Of the 87 MMFI, 6 scored in the range concerning for minor depression (10–12), and 4 scored in the range concerning for major depression (>12). No participant reported suicidal ideation. For tobacco exposure, 79% (69/87) denied current tobacco. When asked about family planning, 76% of respondents (66/87) were using some form of contraception at time of screening. Twenty-four percent of MMFI were relying on CDC tier 1 methods such as permanent sterilization or long-acting reversible contraception; 28% were using slightly less effective, CDC tier 2 methods such as hormonal contraception; and 20% were using less effective methods such as condoms (CDC, n.d.). With regard to a future pregnancy, the majority (55%, or 49/87) of the MMFI desired to wait at least 1 year until becoming pregnant. Of note, 4% (3/87) were pregnant at the time of the survey. Out of 87 total participants, 25% (22/87) met criteria for at least one referral, and four of these MMFI met referral criteria in two of the three domains. A referral was not made for two of the MMFI who met criteria for depression owing to a clerical error; however, information about mental health was provided to all MMFI. The following referrals were made: seven for tobacco exposure, eight for mental health, and nine for family planning (Figure 1). In the follow-up phone interview, 80% of MMFI interviewed remembered filling out the questionnaire. Some respondents indicated that they did not specifically remember getting a referral for their own health, largely because they were focused on the infant’s needs and they received a lot of information during the clinic visit. MMFI feelings about the questionnaire were assessed through a series of questions. Table 3 includes representative responses. Overall, the majority of respondents (60% [15/25]) indicated that they liked being asked about their health needs, or felt comfortable/did not mind answering the questionnaire.
Clinic Staff Experience *
Characteristic
n (%) or Mean SD
Mean age of MMFI Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic or Latino Other/missing Mean weeks of gestational age of birth Mean age of infant at visit (mo) Health insurance status Private insurance Medicaid Uninsured Other/combination Missing MMFI has current health care provider Yes No Missing MMFI attended postpartum visit Yes No Don’t know/not applicable/missing
28.9 10.6 36 (41) 34 (39) 10 (12) 7 (8) 28.1 3.7 13.5 7.0 39 30 14 2 2
(45) (35) (16) (2) (2)
69 (79) 17 (20) 1 (1) 73 (84) 11 (13) 3 (4)
Abbreviations: MMFI, mothers of medically fragile infants; SD, standard deviation. * Not all percentage add up to 100% due to rounding.
SICC clinic staff reported a generally positive experience with implementing the questionnaire in clinic. They also reported that the implementation, including scoring the questionnaire and making referrals, became easier over time. SICC clinic staff perceived that MMFI were supportive of the questionnaire, and they did not sense any reluctance to completing the screening instrument. Several additional themes emerged. Clinic staff reported being unprepared to discuss pregnancy intention, and similarly unprepared to offer pregnancy options counseling for MMFI who were pregnant at the time of screening (n ¼ 3). As clinic staff gained experience, they became more comfortable discussing contraception. In addition, several clinic staff reported difficulties supporting MMFI with anxiety and depressive symptoms. Clinic staff suggested developing separate screening tools for biological parents and for other caregivers, such as grandparents. A key theme was frustration with the referral process, focused on three specific problems: Lack of access to mental health providers within the SICC, which precluded a direct hand-off and same-day engagement with care;
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Caregivers completing the screening: 100
Respondents not included because they were not biological mothers: 13 Mothers of medically fragile infants surveyed: 87 Caregivers meeting referral criteria: 22* By Domain: - Tobacco exposure: 7 - Mental Health: 10 - Family Planning: 9 63 Caregivers who agreed to be contacted for followup
Successful follow-up: 37
Unable to be contacted for follow-up: 26
* 4 Caregivers met criteria for referral in 2 domains Figure 1. Flowchart of mothers of medically fragile infants who presented to the specialty infant care clinic.
Lack of local mental health resources for MMFI living in rural areas or for women who did not have health insurance; and The amount of time and effort required to make the appropriate referrals. Discussion We integrated a screening tool to identify unmet health needs of MMFI within a post-NICU developmental follow-up clinic. The screening tool identified needs for one of five MMFI screened, and it was acceptable to both clinic staff and MMFI. Our results suggest that screening in specialty pediatric settings is feasible. Our results confirm and extend previous work on unmet health needs of MMFI. Mental health concerns impact a large portion of the MMFI sampled, with 11% of our sample having an
elevated EPDS score, which is similar to what is reported nationally (Lefkowitz et al., 2010). Tobacco use was also consistent with national data among MMFI, with 16% reporting current tobacco use (Phillips et al., 2012). With regard to family planning, the vast majority of our sample had been informed about the importance of family planning, and 24% were using a tier 1 method, which is also consistent with national data among MMFI (Bloch et al., 2012; Clark et al., 2014). Our screening tool did not assess whether the three pregnancies among our participants were intended. We found that 84% of MMFI in our sample had attended a postpartum visit, consistent with national rates of postpartum follow-up (CDC, 2007). Our results suggest that not all key health concerns were addressed at that visit; however, we relied on maternal recall of visit content. Based on our results, biological
M.L. Zerden et al. / Women's Health Issues xxx-xx (2017) 1–6 Table 2 Responses of MMFI to Questions in Three Domains (n ¼ 87) Questions and Responses Depression Provider talked about postpartum depression? Yes No Other/missing Mean EPDS score Tobacco use and exposure Provider talked about smoking? Yes No Other (“don’t know” or “not applicable”) Smoking score Never smoke or no longer smoking Responses A, B, or C Currently smoking? Responses D or E Missing Smoking around children? Yes No Smoking inside house? Yes No Family planning and pregnancy intention Provider talked about family planning? Yes No Other Current pregnancy intention Currently pregnant? I don’t want to get pregnant again Not sure <1 year 1–2 years 2 years Missing Any method use? Yes No Current family planning method Tier 1 (permanent/LARC) Tier 2 (hormonal) Tier 3 (barrier) Other/missing Level of satisfaction with family planning method Very satisfied Satisfied Neutral Dissatisfied Missing
Table 3 Qualitative Responses by Participants
n (%)* or Mean SD
74 (85) 10 (12) 3 (4) 4.9 4.5
58 (67) 14 (16) 15 (17)
69 (79) 14 (16) 4 (5) 7 (8) 80 (92) 2 (2) 85 (98)
84 (97) 2 (2) 1 (1) 3 28 27 3 6 15 5
5
(4) (32) (31) (4) (7) (17) (6)
66 (76) 21 (24) 21 24 17 25
(24) (28) (20) (29)
36 25 11 1 14
(41) (29) (13) (1) (16)
Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; LARC, long-acting reversible contraception; MMFI, mothers of medically fragile infants; SD, standard deviation. * Not all percentage add up to 100% due to rounding.
mothers recalled being asked about tobacco exposure, mental health, and family planning (85%, 67%, and 97%, respectively) at their postpartum visit. At the SICC visit, we found that MMFI continued to have unmet health needs. These results suggest that, in addition to ensuring that MMFI attend a postpartum visit, postpartum providers need to ensure that this visit addresses the specific needs of MMFI, as well as arrange for appropriate followup for ongoing health needs. Our findings must be interpreted in the context of the study design. First, this study had a relatively small, convenience-based sample size of 87 MMFI. Our outcomedthe proportion of participants meeting criteria for a referraldwas an intermediate measure; in this pilot project, we were unable to determine
Positive Comments
Negative Comments
Question 1: Did you like being asked about your health needs? [S]ince the visit was for my Yes, just in general – them being daughter, I didn’t feel like it was concerned about my health. appropriate but I didn’t really see Yeah - I mean it was different; how it was necessary. I felt usually focus is on the child - but questions and timing wasn’t yeah I guess I liked it. appropriate because I felt like I filled that questionnaire out the first time we visited the clinic - at that time I could see how the postpartum questions could be applicable. Not really - very personal. Didn’t have much to do with my babies, didn’t feel like it was pertinent. Question 2: What did you like specifically.? None I liked that they cared about me. It was like – they asked me, they answered questions, they explained the stuff to me really well. I mean having a preemie is hard and I’m a single parent. It seems they’re also concerned about my health.
whether referral resulted in improvement in mental health symptoms, cessation of tobacco exposure, or addressing unmet family planning needs. Additionally, we were only able to reach 49% of our MMFI for follow-up, and we only obtained limited data in follow-up calls. Finally, our intervention was limited to an English-speaking group of MMFI from a single academic medical center in the southeast United States; therefore, these results may not be generalizable to other populations. We did identify an unmet need for clinic staff training to address issues such as pregnancy options counseling. For future MMFI screening interventions, it could be beneficial to train those administering the survey how to assess pregnancy intention and perform nonbiased early pregnancy options counseling. Similarly, clinic staff could benefit from additional training to provide support for MMFI with mental health symptoms. Despite feeling unprepared for some aspects of counseling, SICC clinic staff indicated a positive experience with implementing the questionnaire. Most SICC clinic staff reported that the questionnaire opened up the possibility of having important conversations related to anxiety and depression, tobacco cessation, and family planning that were not occurring before the intervention. With regard to the counseling that MMFI are receiving from their prenatal care provider, 97% remembered a conversation about contraception. However, despite counseling, 20% of biological mothers were using a tier 3 method, suggesting additional interventions are needed. MMFI were less likely to remember a conversation about mental health screening (85%) and even less likely to remember tobacco use and exposure being addressed in their most recent visit (67%). These data underscore the need for more complete screening at the time of a postpartum visit in this population as well as during pediatric visits. Addressing the mental and physical health needs of MMFI can improve mothers’ outcomes and leave them better equipped to care for their medically fragile infants. Depression and other mental health conditions are prevalent in the postpartum period, and the additional needs of medically fragile infants
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compound these symptoms. These MMFI are at risk of unhealthy coping behaviors, such as tobacco use. Finally, unmet family planning needs can place MMFI at risk of a short interpregnancy interval, increasing their risk of future pregnancy complications. Our results suggest that a brief screening instrument has the potential to identify key needs and offers a framework for designing a comprehensive program to address identified needs. An intervention such as the one described in our research would be further strengthened by communicating with the MMFI’s primary care provider when a MMFI meets criteria for a referral. Implications for Practice and/or Policy One in four MMFI met criteria for referral for an unmet health need. Health care providers must be aware of the additional needs of this population. Building on our intervention, an important next step is creating stronger connections to referral sources. Three promising strategies include 1) incorporating an adult healthcare provider in a post-NICU specialty clinic to address MMFI needs, 2) strengthening the connection to preexisting nicotine dependence programs, which are already a part of many hospital systems as a result of being a Joint Commission on Accreditation of Healthcare Organization standard, and 3) incorporating a modified screening tool during the infant’s NICU stay to identify unmet needs earlier in the postpartum period. By integrating family health into the infant care visit using a screening tool, pediatric providers can identify MMFI in need of assistance with tobacco cessation, struggling with mood symptoms, or at risk for unintended pregnancy. In the long-term, such integrated care may improve maternal health, infant health, and future pregnancy outcomes. Acknowledgments The authors thank the staff of the Special Infant Care Clinic (SICC) for their time, effort, and willingness to adapt this new screening tool into an already busy clinic. In addition, the authors are indebted to Alexandra Nicole Anderson, who laid the foundation for this project with her work in maternal postpartum needs in the NICU. Supplementary Data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.whi.2017.03.005.
CDC. (n.d.). Effectiveness of family planning methods. Available: https://www.cdc. gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_ 508.pdf. Accessed: April 5, 2017. CDC. (2007). Postpartum care visits–11 states and New York City, 2004. MMWR. Morbidity and Mortality Weekly Report, 56(50), 1312. CDC. (2015). Available: https://www.cdc.gov/prams/. Accessed: April 5, 2017. Clark, E. A. S., Esplin, S., Torres, L., Turok, D., Yoder, B. A., Varner, M. W., & Winter, S. (2014). Prevention of recurrent preterm birth: Role of the neonatal follow-up program. Maternal and Child Health Journal, 18(4), 858–863. dez, A., & Kafury-Goeta, A. C. (2006). Birth Conde-Agudelo, A., Rosas-Bermu spacing and risk of adverse perinatal outcomes: A metaanalysis. JAMA, 295, 1809–1823. Cox, J. (1996). Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women. Journal of Affective Disorders, 39(3), 185–189. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry, 150, 782–786. Earls, M. F. (2010). Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 126(5), 1032–1039. Esplin, M. S., O’Brien, E., Fraser, A., Kerber, R. A., Clark, E., & Simonsen, S. E. (2008). Estimating recurrence of spontaneous preterm delivery. Obstetrics & Gynecology, 112, 516–523. Lefkowitz, D. S., Baxt, C., & Evans, J. R. (2010). Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU). Journal of Clinical Psychology in Medical Settings, 17(3), 230–237. O’hara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depressiondA meta-analysis. International Review of Psychiatry, 8(1), 37–54. Phillips, R. M., Merritt, T. A., Goldstein, M. R., Deming, D. D., Slater, L. E., & Angeles, D. M. (2012). Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit. Journal of Perinatology, 32(5), 374–380. UNC Center for Maternal & Infant Health. (n.d.). You Quit, Two Quit. Available: http://youquittwoquit.com/. Accessed: April 5, 2017. Vigod, S. N., Villegas, L., Dennis, C.-L., & Ross, L. E. (2010). Prevalence and risk factors for postpartum depression among women with preterm and lowbirth-weight infants: a systematic review. BJOG: An International Journal of Obstetrics and Gynaecology, 117(5), 540–550.
Author Descriptions Matthew L. Zerden, MD, MPH, is an obstetrician and gynecologist with subspecialty training in family planning. His research interests include postpartum contraception, integrating maternal and infant health service delivery, and surgical sterilization.
Anna Falkovich, MPH, is a Community School Director at a high school located in the South Bronx, focusing on improving socioemotional health status for youth. Her maternal and child health interests include perinatal and postpartum care, and social determinants of health.
Erin K. McClain, MA, MPH, directs the You Quit, Two Quit perinatal tobacco cessation program at the UNC Center for Maternal & Infant Health. Her other research interests include preconception and interconception health for women of reproductive age.
References Anonymous. (2010). Committee opinion no. 471: Smoking cessation during pregnancy. Obstetrics & Gynecology, 116(5), 1241–1244. Bakewell-Sachs, S., & Gennaro, S. (2004). Parenting the post-NICU premature infant. MCN: The American Journal of Maternal/Child Nursing, 29(6), 398–403. Best, D. (2009). Secondhand and prenatal tobacco smoke exposure. Pediatrics, 124(5), e1017–e1044. Bloch, J. R., Webb, D. A., Mathew, L., & Culhane, J. F. (2012). Pregnancy intention and contraceptive use at six months postpartum among women with recent preterm delivery. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 41(3), 389–397. Bloom, S. L., Yost, N. P., McIntire, D. D., & Leveno, K. J. (2001). Recurrence of preterm birth in singleton and twin pregnancies. Obstetrics & Gynecology, 98, 379–385. Bryant, A. S., Haas, J. S., McElrath, T. F., & McCormick, M. C. (2006). Predictors of compliance with the postpartum visit among women living in healthy start project areas. Maternal and Child Health Journal, 10(6), 511–516. Callahan, J. L., Borja, S. E., & Hynan, M. T. (2006). Modification of the Perinatal PTSD Questionnaire to enhance clinical utility. Journal of Perinatology, 26(9), 533–539.
Sarah Verbiest, DrPH, MSW, MPH, is the executive director at UNC Center for Maternal & Infant Health and a clinical associate professor at the UNC School of Social Work. Her research interests include preconception health, postpartum care, health equity, and preterm birth.
Diane D. Warner, MD, MPH, is a Professor of Pediatrics and neonatologist with the University of North Carolina School of Medicine, Department of Pediatrics. She is Director of the UNC Special Infant Care Clinic, with research interests in the neurodevelopmental outcome of premature neonates.
Janice Kay Wereszczak, MSN, CPNP, is a pediatric nurse practitioner in the UNC Special Infant Care Clinic. Her interests are optimizing outcomes of medically fragile infants and also long-term outcomes of extremely preterm infants.
Alison Stuebe, MD, MSc, is an assistant professor in the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine at UNC. She is an expert on diabetes, obesity, gestational weight gain, breastfeeding, and mastitis.
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Original article
Addressing Unmet Maternal Health Needs at a Pediatric Specialty Infant Care Clinic Matthew L. Zerden, MD, MPH a,b,*, Anna Falkovich, MPH c, Erin K. McClain, MA, MPH d, Sarah Verbiest, DrPH, MSW, MPH a,d, Diane D. Warner, MD, MPH e, Janice Kay Wereszczak, MSN, CPNP e, Alison Stuebe, MD, MSc a,c a
Department of Obstetrics & Gynecology, University of North Carolina School of Medicine, Chapel Hill, North Carolina WakeMed Health & Hospitals, Raleigh, North Carolina Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina d Center for Maternal and Infant Health, University of North Carolina, Chapel Hill, North Carolina e Department of Pediatrics, University of North Carolina School of Medicine, Chapel Hill, North Carolina b c
Article history: Received 18 July 2016; Received in revised form 6 March 2017; Accepted 6 March 2017
a b s t r a c t Objective: The objective of this intervention was to evaluate the feasibility of screening mothers of medically fragile infants in the domains of 1) depression, 2) tobacco exposure, and 3) family planning at a post-neonatal intensive care unit (NICU) developmental pediatric visit. Additionally, we sought to estimate the percentage who met criteria for further evaluation in the three domains assessed. Methods: A cross-sectional questionnaire was administered to 100 caregivers of medically fragile infants at a specialty, post-NICU clinic visit. Participants’ responses in three domains were evaluated and appropriate referrals were provided. Analysis was then restricted to the 87 biological mothers who completed the screening. Study staff contacted the mothers 2 months later to determine whether services had been accessed and to assess overall satisfaction with the screening within the pediatric visit. Qualitative interviews were conducted with pediatric clinic staff. Results: Screening questionnaires were completed by 87 biological mothers. Twenty-two mothers (25%) met referral criteria. Pediatric clinic staff and providers were comfortable administering the screening instrument, and there was minimal disruption to clinic flow. Conclusions: Mothers of medically fragile infants are likely to have unmet health care needs that can be identified at a specialty pediatric clinic visit. A screening and referral intervention can be implemented with minimal interruption in pediatric clinic flow and is acceptable to mothers and pediatric providers. Ó 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc.
The postpartum period is challenging for all families, and it is particularly challenging for mothers of medically fragile infants (MMFI) who have been discharged from the neonatal intensive care unit (NICU). The complex health needs of these infants may lead MMFI to disregard their own physical and mental health, placing MMFI at risk for multiple health issues. These include postpartum depression, unhealthy coping behaviors such as
Funding: This research was partially supported by a generous grant from the Cefalo-Bowes Young Researcher Award through the University of North Carolina Center for Maternal and Infant Health. * Correspondence to: Matthew L. Zerden, MD, MPH, 4002 Old Clinic Bldg, CB #7570, Chapel Hill, NC 27599-7570. Phone: (919) 843-5633; fax: (919) 843-6691. E-mail address: [email protected] (M.L. Zerden).
tobacco use, and neglecting family planning, which will increase their risk for an unintended pregnancy. MMFI are prone to mental health issues such as depression and post-traumatic stress disorder (Lefkowitz, Baxt, & Evans, 2010), resulting in a higher risk of developing depression compared with mothers of healthy infants (O’hara & Swain, 1996; Vigod, Villegas, Dennis, & Ross, 2010). The increase in mental health disorders may result from the increased psychological distress and anxiety experienced in the NICU (Bakewell-Sachs & Gennaro, 2004; Vigod et al., 2010). Moreover, stress and anxiety are major risk factors for tobacco use relapse among women who quit during pregnancy, with 85% resuming smoking by their child’s first birthday (Phillips et al., 2012). In a pilot study of 28 MMFI attending a post-NICU pediatric infant clinic, unmet maternal health needs were
1049-3867/$ - see front matter Ó 2017 Jacobs Institute of Women's Health. Published by Elsevier Inc. http://dx.doi.org/10.1016/j.whi.2017.03.005
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common: 23% had no primary care provider, 23% were uninsured, and 38% reported they had recently delayed or ignored medical care for themselves during the past year (Anderson, Verbiest, S., Warner, D., Horton, E., McClain, E., Leff, S.,. Dean, A., 2013, unpublished data). Mood symptoms were common, with nearly one in five women having an elevated Edinburgh Postnatal Depression Scale (EPDS) score (Anderson et al., 2013, unpublished data). Additionally, one-third of these MMFI had clinically significant trauma symptoms, indexed by the modified Perinatal PTSD questionnaire (Callahan, Borja, & Hynan, 2006). Of note, the American Academy of Pediatrics has endorsed screening for maternal depression and for tobacco exposure in the pediatric clinic setting (Best, 2009; Earls, 2010). Another domain of maternal health care often neglected among MMFI is reproductive life planning and contraception. Recent studies have found that MMFI have variable rates of uptake of the most effective forms of contraception, ranging from 6% to 50% (Bloch, Webb, Mathew, & Culhane, 2012; Clark et al., 2014). The majority of infants who require NICU-level care are born prematurely, and the greatest risk factor for preterm birth is a history of preterm delivery (Bloom, Yost, McIntire, & Leveno, 2001; Esplin et al., 2008). There is strong evidence that recurrent preterm birth is reduced with interpregnancy intervals of at dez, & Kafuryleast 18 months (Conde-Agudelo, Rosas-Bermu Goeta, 2006). Therefore, reproductive life planning counseling and access to highly effective contraception is particularly important for MMFI. Additional research found that 45% of highrisk women did not present for a postpartum medical visit (Bryant, Haas, McElrath, & McCormick, 2006). This finding underscores the need for novel approaches to address the health care needs of MMFI. This project encompasses an innovative screening and referral intervention offered to MMFI, administered as part of routine care in a post-NICU infant developmental follow-up clinic. We integrated maternal mental health, tobacco exposure, and family planning into the infant’s follow-up visit in an effort to arrange indicated counseling and services and optimize the health of the entire family. We hypothesized that maternal health screening could be effectively integrated into a post-NICU developmental care visit, as measured by the ability to engage 100 caregivers to complete the screening tool within an 8-month period. We also aimed to determine the proportion of MMFI with an identified unmet health need who received the indicated referral service within 2 months of screening. Finally, we sought to understand how the implementation of this intervention would affect the logistics and flow of the infant specialty clinic. Materials and Methods This research project was designed to identify unmet health needs among MMFI bringing their infant to a post-NICU Special Infant Care Clinic (SICC). The University of North Carolina Institutional Review Board reviewed the project and provided an exemption. The SICC integrates infant health services and provides developmental evaluation for high-risk infants after discharge from the NICU and for up to 2 years of age. The clinic operates within an academic children’s hospital and serves approximately 350 families annually. The first appointment is usually scheduled at 6 months adjusted age or, for very high-risk infants, at 1 to 3 months after NICU discharge. Inclusion criteria for infants in the SICC include, but are not limited to, preterm delivery (<30 weeks’ gestation), hypoxic ischemic encephalopathy, major congenital heart disease, genetic disorders, feeding
difficulties, and other neonatal conditions that require coordinated pediatric services. Post-NICU infants typically have four to six visits at the SICC over their initial 6 to 24 months. Starting in October 2014, a convenience sample of 100 MMFI and other caregivers of medically fragile infants were approached to complete the screening tool. This sample of 100 participants over 8 months was determined to be sufficient to determine the feasibility of screening for caregiver needs within the pediatric clinic. The screening instrument consisted of 28 questions in the following domains: 1) demographic and baseline information related to previous health care experience and health insurance status, 2) Mental healthdthe 10-question EPDS (Cox, 1996; Cox, Holden, & Sagovsky, 1987), 3) tobacco exposuredfour questions, one related to the tobacco use habits of the caregiver and three related to secondhand smoke exposure for the child (Anonymous, 2010), 4) family planningdsix questions to assess family planning intentions and contraceptive use adapted from the Centers for Disease Control and Prevention’s Pregnancy Risk Assessment Monitoring System (Centers for Disease Control and Prevention [CDC], 2015). The screening instrument could be independently completed by the MMFI or caregiver in approximately 10 to 15 minutes (Appendix). The inclusion criteria were broad; we included any primary caregiver who was English speaking. The questionnaires were scored by clinic personnel, which included nurse practitioners and neonatologists. The study team identified scores (for the EPDS and tobacco exposure) and responses (for the family planning questions) that would prompt referrals for further evaluation and/or treatment. Clinic personnel made on-site referrals or provided information to caregiver to facilitate a referral closer to their home. We used the EPDS to identify women at risk for minor depression (score 10–12) or major depression (>12). For MMFI with a score suggesting minor depression, we provided an educational booklet and made a referral to the UNC Perinatal Mood Disorders Clinic. If an MMFI or caregiver reported suicidal ideation, clinic staff was instructed to escort the caregiver to the emergency department for an immediate mental health evaluation. MMFI and caregivers who reported tobacco use or exposure were provided tobacco cessation resources, and a referral was faxed to QuitlineNC, the free, evidence-based, telephonic tobacco cessation helpline in North Carolina (UNC Center for Maternal & Infant Health, n.d.). Finally, if the MMFI did not have an effective contraceptive method and did not want to become pregnant or wished to receive more information about family planning, a same-day family planning appointment at the hospital clinic was offered, or information from Bedsider.org to locate a local provider was given. To evaluate the effectiveness of the referral process, the study coordinator attempted to follow-up with all the MMFI and caregivers who agreed to be contacted 1 to 2 months after they completed the initial questionnaire. Follow-up was conducted by phone, email, or a secure texting system. The coordinator attempted to contact participants up to five times. If a participant listed two preferred methods of contact, the study staff member attempted the first preferred method three times, and the second preferred method twice. Calls were placed on different days and times. The texting system was eliminated approximately halfway through the intervention owing to concerns about maintaining confidentiality. By speaking with the MMFI or caregiver using a nine-question survey, study staff determined if appropriate services were established and assessed patient satisfaction with those services.
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To evaluate feasibility of administering the questionnaire in a busy clinic setting, the study coordinator conducted six interviews with clinic staff. Convenience sampling was used. Individuals from the clinic were asked about their experiences with implementation of the questionnaire, challenges encountered, and their experience with each aspect of the questionnaire. Responses were transcribed and analyzed. Descriptive statistics were used to characterize the sample. Mean EPDS scores and standard deviations were calculated, along with the frequencies of those with tobacco exposure and unmet family planning needs. All analyses were performed with SPSS (Version 19.0, IBM Corp., Armonk, NY). In addition, a qualitative survey was administered to the SICC staff that evaluated feasibility of administering the questionnaire in clinic. This qualitative survey also captured feedback from clinic staff regarding study implementation challenges and considerations for the future. Qualitative data was analyzed for themes using Dedoose software. Results MMFI Responses Table 1 shows the demographic characteristics of the 87 MMFI who completed the screening questionnaire. Although 100 surveys were completed, 13 surveys were completed by nonmothers. For the remainder of the results and discussion, we only include data and analysis on the 87 MMFI, because some of the outcomes (i.e., postpartum depression or postpartum contraception) are specific to MMFI and not other caregivers. Our participants were diverse, with no one racial or ethnic group representing the majority of participants. This diversity reflects the patient population that delivers at our tertiary care facility or are referred to our NICU. Infants of study participants had a mean age of 14 months. Eighty-four percent of the sample had attended a postpartum visit. Of the 87 participants, 63 agreed to be contacted for follow-up, and 37 were successfully reached for follow-up (Figure 1). Table 1 Demographic Characteristics of MMFI (n ¼ 87)
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Table 2 captures participant responses to baseline questions in each domain. For depression, 85% (74/87) reported that their obstetric provider spoke with them about postpartum depression. The mean score on the EPDS was 4.9; the EPDS has a maximum score of 30, with increasing scores correlated with a higher risk of depression. Any score greater than or equal to 10 prompted a referral. Of the 87 MMFI, 6 scored in the range concerning for minor depression (10–12), and 4 scored in the range concerning for major depression (>12). No participant reported suicidal ideation. For tobacco exposure, 79% (69/87) denied current tobacco. When asked about family planning, 76% of respondents (66/87) were using some form of contraception at time of screening. Twenty-four percent of MMFI were relying on CDC tier 1 methods such as permanent sterilization or long-acting reversible contraception; 28% were using slightly less effective, CDC tier 2 methods such as hormonal contraception; and 20% were using less effective methods such as condoms (CDC, n.d.). With regard to a future pregnancy, the majority (55%, or 49/87) of the MMFI desired to wait at least 1 year until becoming pregnant. Of note, 4% (3/87) were pregnant at the time of the survey. Out of 87 total participants, 25% (22/87) met criteria for at least one referral, and four of these MMFI met referral criteria in two of the three domains. A referral was not made for two of the MMFI who met criteria for depression owing to a clerical error; however, information about mental health was provided to all MMFI. The following referrals were made: seven for tobacco exposure, eight for mental health, and nine for family planning (Figure 1). In the follow-up phone interview, 80% of MMFI interviewed remembered filling out the questionnaire. Some respondents indicated that they did not specifically remember getting a referral for their own health, largely because they were focused on the infant’s needs and they received a lot of information during the clinic visit. MMFI feelings about the questionnaire were assessed through a series of questions. Table 3 includes representative responses. Overall, the majority of respondents (60% [15/25]) indicated that they liked being asked about their health needs, or felt comfortable/did not mind answering the questionnaire.
Clinic Staff Experience *
Characteristic
n (%) or Mean SD
Mean age of MMFI Race/ethnicity Non-Hispanic White Non-Hispanic Black Hispanic or Latino Other/missing Mean weeks of gestational age of birth Mean age of infant at visit (mo) Health insurance status Private insurance Medicaid Uninsured Other/combination Missing MMFI has current health care provider Yes No Missing MMFI attended postpartum visit Yes No Don’t know/not applicable/missing
28.9 10.6 36 (41) 34 (39) 10 (12) 7 (8) 28.1 3.7 13.5 7.0 39 30 14 2 2
(45) (35) (16) (2) (2)
69 (79) 17 (20) 1 (1) 73 (84) 11 (13) 3 (4)
Abbreviations: MMFI, mothers of medically fragile infants; SD, standard deviation. * Not all percentage add up to 100% due to rounding.
SICC clinic staff reported a generally positive experience with implementing the questionnaire in clinic. They also reported that the implementation, including scoring the questionnaire and making referrals, became easier over time. SICC clinic staff perceived that MMFI were supportive of the questionnaire, and they did not sense any reluctance to completing the screening instrument. Several additional themes emerged. Clinic staff reported being unprepared to discuss pregnancy intention, and similarly unprepared to offer pregnancy options counseling for MMFI who were pregnant at the time of screening (n ¼ 3). As clinic staff gained experience, they became more comfortable discussing contraception. In addition, several clinic staff reported difficulties supporting MMFI with anxiety and depressive symptoms. Clinic staff suggested developing separate screening tools for biological parents and for other caregivers, such as grandparents. A key theme was frustration with the referral process, focused on three specific problems: Lack of access to mental health providers within the SICC, which precluded a direct hand-off and same-day engagement with care;
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Caregivers completing the screening: 100
Respondents not included because they were not biological mothers: 13 Mothers of medically fragile infants surveyed: 87 Caregivers meeting referral criteria: 22* By Domain: - Tobacco exposure: 7 - Mental Health: 10 - Family Planning: 9 63 Caregivers who agreed to be contacted for followup
Successful follow-up: 37
Unable to be contacted for follow-up: 26
* 4 Caregivers met criteria for referral in 2 domains Figure 1. Flowchart of mothers of medically fragile infants who presented to the specialty infant care clinic.
Lack of local mental health resources for MMFI living in rural areas or for women who did not have health insurance; and The amount of time and effort required to make the appropriate referrals. Discussion We integrated a screening tool to identify unmet health needs of MMFI within a post-NICU developmental follow-up clinic. The screening tool identified needs for one of five MMFI screened, and it was acceptable to both clinic staff and MMFI. Our results suggest that screening in specialty pediatric settings is feasible. Our results confirm and extend previous work on unmet health needs of MMFI. Mental health concerns impact a large portion of the MMFI sampled, with 11% of our sample having an
elevated EPDS score, which is similar to what is reported nationally (Lefkowitz et al., 2010). Tobacco use was also consistent with national data among MMFI, with 16% reporting current tobacco use (Phillips et al., 2012). With regard to family planning, the vast majority of our sample had been informed about the importance of family planning, and 24% were using a tier 1 method, which is also consistent with national data among MMFI (Bloch et al., 2012; Clark et al., 2014). Our screening tool did not assess whether the three pregnancies among our participants were intended. We found that 84% of MMFI in our sample had attended a postpartum visit, consistent with national rates of postpartum follow-up (CDC, 2007). Our results suggest that not all key health concerns were addressed at that visit; however, we relied on maternal recall of visit content. Based on our results, biological
M.L. Zerden et al. / Women's Health Issues xxx-xx (2017) 1–6 Table 2 Responses of MMFI to Questions in Three Domains (n ¼ 87) Questions and Responses Depression Provider talked about postpartum depression? Yes No Other/missing Mean EPDS score Tobacco use and exposure Provider talked about smoking? Yes No Other (“don’t know” or “not applicable”) Smoking score Never smoke or no longer smoking Responses A, B, or C Currently smoking? Responses D or E Missing Smoking around children? Yes No Smoking inside house? Yes No Family planning and pregnancy intention Provider talked about family planning? Yes No Other Current pregnancy intention Currently pregnant? I don’t want to get pregnant again Not sure <1 year 1–2 years 2 years Missing Any method use? Yes No Current family planning method Tier 1 (permanent/LARC) Tier 2 (hormonal) Tier 3 (barrier) Other/missing Level of satisfaction with family planning method Very satisfied Satisfied Neutral Dissatisfied Missing
Table 3 Qualitative Responses by Participants
n (%)* or Mean SD
74 (85) 10 (12) 3 (4) 4.9 4.5
58 (67) 14 (16) 15 (17)
69 (79) 14 (16) 4 (5) 7 (8) 80 (92) 2 (2) 85 (98)
84 (97) 2 (2) 1 (1) 3 28 27 3 6 15 5
5
(4) (32) (31) (4) (7) (17) (6)
66 (76) 21 (24) 21 24 17 25
(24) (28) (20) (29)
36 25 11 1 14
(41) (29) (13) (1) (16)
Abbreviations: EPDS, Edinburgh Postnatal Depression Scale; LARC, long-acting reversible contraception; MMFI, mothers of medically fragile infants; SD, standard deviation. * Not all percentage add up to 100% due to rounding.
mothers recalled being asked about tobacco exposure, mental health, and family planning (85%, 67%, and 97%, respectively) at their postpartum visit. At the SICC visit, we found that MMFI continued to have unmet health needs. These results suggest that, in addition to ensuring that MMFI attend a postpartum visit, postpartum providers need to ensure that this visit addresses the specific needs of MMFI, as well as arrange for appropriate followup for ongoing health needs. Our findings must be interpreted in the context of the study design. First, this study had a relatively small, convenience-based sample size of 87 MMFI. Our outcomedthe proportion of participants meeting criteria for a referraldwas an intermediate measure; in this pilot project, we were unable to determine
Positive Comments
Negative Comments
Question 1: Did you like being asked about your health needs? [S]ince the visit was for my Yes, just in general – them being daughter, I didn’t feel like it was concerned about my health. appropriate but I didn’t really see Yeah - I mean it was different; how it was necessary. I felt usually focus is on the child - but questions and timing wasn’t yeah I guess I liked it. appropriate because I felt like I filled that questionnaire out the first time we visited the clinic - at that time I could see how the postpartum questions could be applicable. Not really - very personal. Didn’t have much to do with my babies, didn’t feel like it was pertinent. Question 2: What did you like specifically.? None I liked that they cared about me. It was like – they asked me, they answered questions, they explained the stuff to me really well. I mean having a preemie is hard and I’m a single parent. It seems they’re also concerned about my health.
whether referral resulted in improvement in mental health symptoms, cessation of tobacco exposure, or addressing unmet family planning needs. Additionally, we were only able to reach 49% of our MMFI for follow-up, and we only obtained limited data in follow-up calls. Finally, our intervention was limited to an English-speaking group of MMFI from a single academic medical center in the southeast United States; therefore, these results may not be generalizable to other populations. We did identify an unmet need for clinic staff training to address issues such as pregnancy options counseling. For future MMFI screening interventions, it could be beneficial to train those administering the survey how to assess pregnancy intention and perform nonbiased early pregnancy options counseling. Similarly, clinic staff could benefit from additional training to provide support for MMFI with mental health symptoms. Despite feeling unprepared for some aspects of counseling, SICC clinic staff indicated a positive experience with implementing the questionnaire. Most SICC clinic staff reported that the questionnaire opened up the possibility of having important conversations related to anxiety and depression, tobacco cessation, and family planning that were not occurring before the intervention. With regard to the counseling that MMFI are receiving from their prenatal care provider, 97% remembered a conversation about contraception. However, despite counseling, 20% of biological mothers were using a tier 3 method, suggesting additional interventions are needed. MMFI were less likely to remember a conversation about mental health screening (85%) and even less likely to remember tobacco use and exposure being addressed in their most recent visit (67%). These data underscore the need for more complete screening at the time of a postpartum visit in this population as well as during pediatric visits. Addressing the mental and physical health needs of MMFI can improve mothers’ outcomes and leave them better equipped to care for their medically fragile infants. Depression and other mental health conditions are prevalent in the postpartum period, and the additional needs of medically fragile infants
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compound these symptoms. These MMFI are at risk of unhealthy coping behaviors, such as tobacco use. Finally, unmet family planning needs can place MMFI at risk of a short interpregnancy interval, increasing their risk of future pregnancy complications. Our results suggest that a brief screening instrument has the potential to identify key needs and offers a framework for designing a comprehensive program to address identified needs. An intervention such as the one described in our research would be further strengthened by communicating with the MMFI’s primary care provider when a MMFI meets criteria for a referral. Implications for Practice and/or Policy One in four MMFI met criteria for referral for an unmet health need. Health care providers must be aware of the additional needs of this population. Building on our intervention, an important next step is creating stronger connections to referral sources. Three promising strategies include 1) incorporating an adult healthcare provider in a post-NICU specialty clinic to address MMFI needs, 2) strengthening the connection to preexisting nicotine dependence programs, which are already a part of many hospital systems as a result of being a Joint Commission on Accreditation of Healthcare Organization standard, and 3) incorporating a modified screening tool during the infant’s NICU stay to identify unmet needs earlier in the postpartum period. By integrating family health into the infant care visit using a screening tool, pediatric providers can identify MMFI in need of assistance with tobacco cessation, struggling with mood symptoms, or at risk for unintended pregnancy. In the long-term, such integrated care may improve maternal health, infant health, and future pregnancy outcomes. Acknowledgments The authors thank the staff of the Special Infant Care Clinic (SICC) for their time, effort, and willingness to adapt this new screening tool into an already busy clinic. In addition, the authors are indebted to Alexandra Nicole Anderson, who laid the foundation for this project with her work in maternal postpartum needs in the NICU. Supplementary Data Supplementary data related to this article can be found at http://dx.doi.org/10.1016/j.whi.2017.03.005.
CDC. (n.d.). Effectiveness of family planning methods. Available: https://www.cdc. gov/reproductivehealth/unintendedpregnancy/pdf/contraceptive_methods_ 508.pdf. Accessed: April 5, 2017. CDC. (2007). Postpartum care visits–11 states and New York City, 2004. MMWR. Morbidity and Mortality Weekly Report, 56(50), 1312. CDC. (2015). Available: https://www.cdc.gov/prams/. Accessed: April 5, 2017. Clark, E. A. S., Esplin, S., Torres, L., Turok, D., Yoder, B. A., Varner, M. W., & Winter, S. (2014). Prevention of recurrent preterm birth: Role of the neonatal follow-up program. Maternal and Child Health Journal, 18(4), 858–863. dez, A., & Kafury-Goeta, A. C. (2006). Birth Conde-Agudelo, A., Rosas-Bermu spacing and risk of adverse perinatal outcomes: A metaanalysis. JAMA, 295, 1809–1823. Cox, J. (1996). Validation of the Edinburgh postnatal depression scale (EPDS) in non-postnatal women. Journal of Affective Disorders, 39(3), 185–189. Cox, J. L., Holden, J. M., & Sagovsky, R. (1987). Detection of postnatal depression. Development of the 10-item Edinburgh Postnatal Depression Scale. The British Journal of Psychiatry, 150, 782–786. Earls, M. F. (2010). Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Pediatrics, 126(5), 1032–1039. Esplin, M. S., O’Brien, E., Fraser, A., Kerber, R. A., Clark, E., & Simonsen, S. E. (2008). Estimating recurrence of spontaneous preterm delivery. Obstetrics & Gynecology, 112, 516–523. Lefkowitz, D. S., Baxt, C., & Evans, J. R. (2010). Prevalence and correlates of posttraumatic stress and postpartum depression in parents of infants in the neonatal intensive care unit (NICU). Journal of Clinical Psychology in Medical Settings, 17(3), 230–237. O’hara, M. W., & Swain, A. M. (1996). Rates and risk of postpartum depressiondA meta-analysis. International Review of Psychiatry, 8(1), 37–54. Phillips, R. M., Merritt, T. A., Goldstein, M. R., Deming, D. D., Slater, L. E., & Angeles, D. M. (2012). Prevention of postpartum smoking relapse in mothers of infants in the neonatal intensive care unit. Journal of Perinatology, 32(5), 374–380. UNC Center for Maternal & Infant Health. (n.d.). You Quit, Two Quit. Available: http://youquittwoquit.com/. Accessed: April 5, 2017. Vigod, S. N., Villegas, L., Dennis, C.-L., & Ross, L. E. (2010). Prevalence and risk factors for postpartum depression among women with preterm and lowbirth-weight infants: a systematic review. BJOG: An International Journal of Obstetrics and Gynaecology, 117(5), 540–550.
Author Descriptions Matthew L. Zerden, MD, MPH, is an obstetrician and gynecologist with subspecialty training in family planning. His research interests include postpartum contraception, integrating maternal and infant health service delivery, and surgical sterilization.
Anna Falkovich, MPH, is a Community School Director at a high school located in the South Bronx, focusing on improving socioemotional health status for youth. Her maternal and child health interests include perinatal and postpartum care, and social determinants of health.
Erin K. McClain, MA, MPH, directs the You Quit, Two Quit perinatal tobacco cessation program at the UNC Center for Maternal & Infant Health. Her other research interests include preconception and interconception health for women of reproductive age.
References Anonymous. (2010). Committee opinion no. 471: Smoking cessation during pregnancy. Obstetrics & Gynecology, 116(5), 1241–1244. Bakewell-Sachs, S., & Gennaro, S. (2004). Parenting the post-NICU premature infant. MCN: The American Journal of Maternal/Child Nursing, 29(6), 398–403. Best, D. (2009). Secondhand and prenatal tobacco smoke exposure. Pediatrics, 124(5), e1017–e1044. Bloch, J. R., Webb, D. A., Mathew, L., & Culhane, J. F. (2012). Pregnancy intention and contraceptive use at six months postpartum among women with recent preterm delivery. JOGNN - Journal of Obstetric, Gynecologic, and Neonatal Nursing, 41(3), 389–397. Bloom, S. L., Yost, N. P., McIntire, D. D., & Leveno, K. J. (2001). Recurrence of preterm birth in singleton and twin pregnancies. Obstetrics & Gynecology, 98, 379–385. Bryant, A. S., Haas, J. S., McElrath, T. F., & McCormick, M. C. (2006). Predictors of compliance with the postpartum visit among women living in healthy start project areas. Maternal and Child Health Journal, 10(6), 511–516. Callahan, J. L., Borja, S. E., & Hynan, M. T. (2006). Modification of the Perinatal PTSD Questionnaire to enhance clinical utility. Journal of Perinatology, 26(9), 533–539.
Sarah Verbiest, DrPH, MSW, MPH, is the executive director at UNC Center for Maternal & Infant Health and a clinical associate professor at the UNC School of Social Work. Her research interests include preconception health, postpartum care, health equity, and preterm birth.
Diane D. Warner, MD, MPH, is a Professor of Pediatrics and neonatologist with the University of North Carolina School of Medicine, Department of Pediatrics. She is Director of the UNC Special Infant Care Clinic, with research interests in the neurodevelopmental outcome of premature neonates.
Janice Kay Wereszczak, MSN, CPNP, is a pediatric nurse practitioner in the UNC Special Infant Care Clinic. Her interests are optimizing outcomes of medically fragile infants and also long-term outcomes of extremely preterm infants.
Alison Stuebe, MD, MSc, is an assistant professor in the Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine at UNC. She is an expert on diabetes, obesity, gestational weight gain, breastfeeding, and mastitis.