The content of prenatal care

Women’s Health Issues 16 (2006) 198 –215

THE CONTENT OF PRENATAL CARE Update 2005 Kimberly D. Gregory, MD, MPHa,b, Clark T. Johnson, BS, BFAc, Timothy R. B. Johnson, MDd,e*, and Stephen S. Entman, MDf a

Director, Division of Maternal Fetal Medicine and Division of Women’s Health Services Research. Department of Obstetrics and Gynecology, Cedars Sinai Medical Center, Los Angeles, California b Associate Professor, David Geffen School of Medicine at UCLA, and Adjunct Professor, School of Public Health, University of California in Los Angeles, Los Angeles, California c Graduate Student, Department of Epidemiology, University of Michigan School of Public Health, Ann Arbor, Michigan d Bates Professor of Diseases of Women and Children and Chair, Department of Obstetrics and Gynecology, Medical School, Ann Arbor, Michigan e Professor of Women’s Studies and Research Professor for the Center for Human Growth and Development, University of Michigan, Ann Arbor, Michigan f Professor of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee Received 10 June 2005; accepted 22 May 2006

Introduction. The Content of Prenatal Care report of the US Preventative Health Service (USPHS) Expert Panel established an important benchmark when published in 1989, but has not been significantly updated since that time. Methods. The literature since 1989 is reviewed to assess which recommendations have been validated and/or implemented. Additionally, new findings that support the recommendations put forth or expand the scope of prenatal care outlined in the 1989 report are examined and discussed. Results. The USPHS recommendation of a reduced prenatal visit schedule has support, and new content for the preconception visit has been identified, although this preconception visit has not been validated or widely implemented. Conclusions. We identified new opportunities and initiatives for the content of prenatal care, particularly improvement in the electronic medical record, attention to multidisciplinary approaches to patient education and improved patient literacy, and an extended maternal life span approach, including postgestation visits.

Introduction and Overview of the Original Content of Prenatal Care Document

C

aring for Our Future: The Content of Prenatal Care (CPC), published in 1989 by the US Public Health Service (USPHS, 1989), and its associated documents (Merkatz & Thompson, 1990) was a landmark compilation of the literature on an important health care service. Interdisciplinary authors reviewed the litera-

* Correspondence to Timothy R.B. Johnson, University of Michigan, Department of OB/Gyn, 1500 E. Medical Center Drive, L4000 Women’s, Box 0276, Ann Arbor, MI 48109 E-mail: [email protected]. Copyright © 2006 by the Jacobs Institute of Women’s Health. Published by Elsevier Inc.

ture and evidence and made recommendations for both clinical practice and research, providing the opportunity to benchmark progress in patient-specific and population-based pregnancy outcomes. The panel relied on evidence-based methodology espoused by the USPHS Task Force, but acknowledged that many recommendations were ultimately consensus based (Gordis, Keliman, Klerman, Mullen, & Paneth, 1990). There were 6 overarching themes espoused by the panel, which we liberally summarize as follows. 1. Early and continuing risk assessment that is patient specific, with clinical visits adjusted accordingly (e.g., more visits for nulliparous and/or high-risk 1049-3867/06 $-See front matter. doi:10.1016/j.whi.2006.05.001

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2.

3. 4.

5.

6.

women; fewer visits for multiparous and/or lowrisk women). Health promotion with introduction and emphasis on the concept of the “preconception visit,” operationalized as almost any health care interaction involving a woman of reproductive age. Medical and psychosocial interventions and followup. Standardized documentation to allow communication and continuity of care between providers and to allow comparable analyses of quality of care and patient outcomes over time and across different clinical settings. The objective of prenatal care was expanded to include not only the health and well-being of the pregnant woman, fetus, and newborn, but also the health of the family up to 1 year after the birth of the infant. The document recognized that there was insufficient evidence for some of the panel’s recommendations, and specified that more comprehensive research on the subject of prenatal care was needed to address a range of issues including etiology, prevention, risk assessment, health promotion, diagnosis, and treatment. Specific research was needed to validate and support the following recommendations.

I. The value of the preconception visit II. Effective means of assessing risk during prenatal care, and evaluation of the different methods of data collection for risk assessment to determine which is most effective a. Evaluation of what health promotion activities are effective in pregnancy b. Documentation that reduced prenatal visits in selected populations was not associated with increased harm c. evaluation of predictors and testing efficacy for medical risks, including preeclampsia, infection, intrauterine growth restriction (IUGR), genetic screening and treatment of genetic disorders, preterm birth, postterm birth, and diabetes d. Evaluation of methods for assessing psychosocial risks during pregnancy, including work, stress, the home environment, nutrition, and health promotion; additionally, research focused on interventions to reduce psychosocial risk and the impact of these interventions on pregnancy and family outcomes was needed. Given these broad recommendations, the philosophies espoused within the CPC document were expected to have a major impact on prenatal education, clinical practice, research, and public health policy. The current paper updates and reviews the literature on practice, research, and policy in prenatal care, and

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evaluates what has been done, discovered, and implemented as it relates to the recommendations and research agenda set forth since CPC. It will do this in 3 sections: • •

•

A review of the literature since 1989; An examination of what new research and policy findings reinforce or contribute to the recommendations put forth in the CPC document; and A discussion of what recommendations need further consideration or research to achieve and expand the goals outlined in the CPC.

We utilized the outline of the CPC to organize a review of the literature and related work on prenatal care, including 1) a review of programs that have been successfully implemented in various degrees in selected populations (e.g., nurse home visits), and 2) references to observations that expand the content of prenatal care beyond the working definition of 1989 (e.g., multiple determinants life course perspective; Lu & Halfon, 2003; Misra, Guyer, & Allston, 2003). Newer observations that did not fall in the scope of 1989 document are discussed in the context of the everexpanding definition and/or objectives of prenatal care and are used to help formulate additional recommendations for consideration as major areas of focus for future research on practice and policy related to the content of prenatal care, as well as achieving the goals of prenatal care.

Search Methods The Medline database was searched for articles containing the words ⬙prenatal care,” “antenatal care,” “pregnancy care,” and “preconception care.” Results were limited to publications since 1989. Results were then reviewed and subjects and articles were selected by a consensus of the authors as addressing recommendations of the expert panel and the relevant issues that are new or have changed focus since the 1989 publication. The recent British guidelines for prenatal care were also informative (National Institute for Health and Clinical Excellence, 2005). Review of the Literature Since 1989 Early and continuing risk assessment that is patient specific, with clinical visits adjusted accordingly. Table 1 outlines the suggested visit frequency and rationale for visits suggested by the CPC panel for low-risk pregnancies (Gregory & Davidson, 1999). Since publication of these recommendations, several well-designed randomized clinical trials and cost– benefit analyses have been reported using alternative visit schedules (Henderson, Roberts, Sikorski, Wilson, & Clement, 2000; Jewell, Sharp, Sanders, & Peters, 2000;

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Table 1. Comparison of different recommendations regarding visit frequency and proposed clinical interventions for prenatal care for lowrisk women Weeks’ Gestation

ACOG, 1997

1–4

Expert Panel Nulliparous Woman

Expert Panel Multiparous Woman

X

X

X X X

X

5–8 9–12 13–16 17–20

X X X X

21–24 25–28 31

X X 32

X X

X X

35–36

X

X

X

37 38 39 40 41

X X X X X

X X X X

X

X

Clinical Intervention Preconception Dating Dating * * AFP/multiple marker Screening* Glucose tolerance test Childbirth education Risk assessment Risk assessment Growth Risk assessment Risk assessment Risk assessment Postterm evaluation

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; AFP, alpha-fetoprotein. Adapted from Gregory & Davidson (1999). *Current standard of care would likely include offering first trimester screening and/or some multiple marker screening strategy (integrated or sequential) in the second trimester.

McDuffie, Beck, Bischoff, Cross, & Orleans, 1996; Stone, Zwanziger, Hinton Walker, & Buenting, 2000; Villar et al., 2001). These studies validate the safety and efficacy of reduced visit schedules. There was no difference in outcomes for patients undergoing reduced frequency visits as measured by rates of preterm birth or low birth weight, and the reduced frequency model has been shown to be cost effective. However, fewer visits has been associated with decreased maternal satisfaction with care, as well as increased maternal anxiety. Although most studies on reduced frequency visits come from international reports, several studies have been conducted in developed countries, albeit under environments where resource utilization is closely monitored, such as Britain’s National Health Service and staff model health maintenance organizations (HMOs; e.g., Kaiser) in the United States. Despite multiple studies supporting the safety and efficacy of reduced frequency visits, our review did not find any reports about the uptake and implementation of reduced visit schedules. Importantly, it should be noted that the reduced frequency regimen is markedly less than that proposed by the American College of Obstetricians and Gynecologist’s (ACOG’s) most recent recommendations (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 2002). Additionally, it does not include visits for genetic counseling or procedures, or fetal surveillance for fetal well-being. Indications for these would be expected to be identified during the ongoing clinical risk assess-

ment occurring at each visit and visit frequency individualized for each patient and adjusted accordingly. In fact, so much attention has been directed toward proving or disproving the safety of reduced visits that an often overlooked corollary of risk-specific care is that some patients indeed need and receive more care. The value of enhanced or augmented care has been demonstrated in selected populations, primarily women at risk owing to psychosocial risk factors (age, race/ethnicity, risky behaviors). Regardless of the visit frequency, ongoing risk assessment is recognized as a vital component of prenatal care despite little supportive data for the routine use of formal risk scoring systems. Although 1 study supports interviewing women for specific clinical factors as an effective measure of risk determination (Gertler, Rahman, Feifer, & Ashley, 1993), other reports have not supported this approach (Mercer et al., 1996; Shiono & Klebanoff, 1993). Most of the emphasis for screening, risk assessment, and associated trials for therapeutic interventions have focused primarily on preeclampsia and preterm birth prevention (American College of Obstetricians and Gynecologists, 2001; Klebanoff et al., 2005). Table 2 lists representative examples of other clinical conditions that have been proposed to be included as part of routine screening and/or risk assessment during the prenatal period since 1989. Many of these conditions are part of current routine screening programs. Few were implemented as routine care based on USPHS evidence criteria. Most have been implemented as a result of expert or consensus opinion, cost– benefit, and/or risk

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Table 2. Examples of clinical conditions amenable to antenatal screening and/or risk assessment Screening/Diagnostic Test Post dates/multiple gestation/IUGR Early ultrasound IUGR Fundal height Smoking history

Fetal structural malformation Ultrasound MS AFP Drug exposure Fetal chromosomal aberrations Multiple marker screening

Genetic conditions Cystic fibrosis Canavan disease, “Jewish panel” PTB Cervical length

Fetal fibronectin

Periodontal disease Bacterial vaginosis

Preclampsia Uterine doppler Serum markers Thromboembolic disease Pregnancy history Clinical history Laboratory evaluation for hereditary thrombophilias Infections Group B strep HIV

Bacterial vaginosis Psychosocial risk Demographics Cocaine use Depression Screening instruments

Domestic abuse Screening instruments

Comment

Reference

Increased precision of dating; “routine” use unclear benefit yet widely utilized ⬎80% of pregnancies

Crowther et al., 1999

Increased identification of small and large infants; fewer ultrasounds, economic benefit Smoking has demonstrated dose–response association with poor fetal growth; smoking cessation/reduction reverses growth disturbance; likelihood of cessation increased during pregnancy

Gardosi & Francis, 1999 Hajek, Stead, West, & Jarvis, 2005; Windsor et al., 2000

Ultrasound, MSAFP standard of care for screening for neural tube defects. See text re: prenatal genetic test

ACOG Committee on Practice Bulletins, 2003

Combination of specific maternal serum analytes used to screen for Down syndrome, trisomy 13 and 18 with potential detection rate of 60–90% when used with targeted ultrasound; see text

ACOG Opinion Committee, 2004; Platt et al., 2004

Recommended by ACOG

Harris, Scotcher, Craufurd, Wallace, and Harris, 1992 ACOG Committee on Genetics, 2004

Recommended by ACOG No benefit from routine screening; unclear “best practice” and/or benefit of treatment once identified “at risk” No clear benefit as screening test to predict PTB (poor sensitivity and specificity); potential benefit from high negative predictive value May be independent risk factor for PTB; treatment reduced risk Independent risk factor for PTB; inconclusive if treatment alters risk but shown to be beneficial in selected populations

ACOG obstetrician-gynecologist, 2001 Heath et al., 2000

Lopez, Smith, & Gutierrez, 2002 Kekki et al., 2004; Kiss, Petricevic, & Husslein, 2004; Klebanoff et al., 2005

No effective prevention Nonspecific; no effective prevention

Frusca et al., 2003 Aquilina, Thompson, Thilaganathan, & Harrington, 2001; Villar et al., 2004

Clinically relevant topic owing to association with adverse pregnancy outcome; potential for lifethreatening thromboembolic event; disseminating into practice; inconclusive data re: treatment efficacy

Brill-Edwards et al., 2000

Screening and treatment prevents neonatal disease Routine screening and treatment recommended by ACOG; treatment significantly decreases rate of perinatal transmission See PTB

ACOG, 2002 Committee on Obstetric Practice, 2000

Socioeconomic status, race/ethnicity related to PTB, adverse pregnancy outcomes; not mutable Associated with structural malformations, PTB, abruptions, preclampsia; comprehensive care deters use

Langer et al., 1996; Misra et al., 2001

Okun, Gronau & Hannah, 2005

Burkett et al., 1998

Risk/benefit decision re: treatment—not contraindicated; increased likelihood of relapse in postpartum period; related to infection, child development

Marcus et al., 2003

Increased likelihood of abuse during pregnancy in women in abusive environment

Wiist & McFarlane, 1999

Abbreviations: ACOG, American College of Obstetricians and Gynecologists; IUGR, intrauterine growth restriction; MSAFP, maternal serum alpha-fetoprotein; PTB, preterm birth.

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management decisions. Still others have yet to be commonly accepted and await definitive research trials demonstrating efficacy as a screening test, or more importantly, effective treatment options. For example, there is good evidence that screening and prenatal/ intrapartum prophylaxis will reduce mother-to-child (vertical) transmission of HIV. Although the definitive study (Trial 076) was a randomized control trial using AZT, current treatment regimens and practice have evolved to include multidrug therapy (highly active antiretroviral therapy [HAART]) (Committee on Obstetric Practice, 2000; Wade et al., 1998). There are sparse comparative data on these various new therapies during pregnancy. Likewise, although routine cesarean section has been advocated by ACOG for HIV-positive women, the role of HAART and viral load in decision making about risk and benefit of cesarean delivery has not been systematically evaluated (American College of Obstetricians and Gynecologists, 2001; Semprini & Fiore, 2004). At the other extreme, measuring cervical length is not a universally accepted screening technique for preterm birth— largely because of ineffective treatment methods and high false-positive rates, exposing patients to risk from treatment that potentially does more harm than good (Heath, Daskalakis, Zagaliki, Carvalho, & Nicolaides, 2000). Nonetheless, it is considered routine to measure and document cervical length at the time of obstetrical ultrasound at clinical imaging sites accredited by the American Institute Ultrasound in Medicine (AIUM) (American Institute Ultrasound in Medicine, 2003). In the past several years, there have been considerable efforts to standardize recommendations across all professional societies, including the American College of Radiology, ACOG, and AIUM; hence, cervical length measurement as a routine is becoming increasingly common. Clinicians are being put in the awkward position of offering questionable treatment (e.g., bed rest, cerclage, serial observations) or alternatively offering no treatment. Both options can cause considerable concern and anxiety for both clinician and patient. Genetic screening in general, and specific disease screening in particular, represents an example of practice dissemination that has been influenced by technological advancement, expert or consensus opinion, cost– benefit analysis, and risk management decisions. Screening for chromosomal abnormalities among traditional at-risk women (⬎35 years) has been supplanted by population-based screening of all pregnant women who desire to be screened. This is perhaps best exemplified in California, where there is legislative mandate to offer a triple screen test in the second trimester and document the informed consent process in a standardized fashion. The advent of first trimester screening, the introduction of additional serum analytes, and the potential to combine first and second

trimester screening has been an area of active research and ongoing debate regarding final policy recommendations (Platt et al., 2004). Finally, the ACOG’s recommendation for routine screening for cystic fibrosis has lead to a change in practice, with enhanced access for both preconception and prenatal screening for genetic diseases including Canavan disease, familial dysautonomia, Fabry disease, and other autosomal recessive disorders with common allele frequencies in the Jewish and Caucasian populations (COG Committee on Genetics, 2004). The recommendation for preconception counseling is particularly important in the area of genetic screening because improved test accuracy as well as enhanced opportunities for follow-up partner and family screening occur with preconception programs. Neither acceptance nor impact of preconception or early prenatal screening has been reported since 1989, and would be a very interesting and important area for study. Studies have consistently shown that clinicians are providing this service for their patients, but are not confident of their knowledge of genetics, ethics about testing, test interpretation, or ability to communicate test results to patients (Morgan, Driscoll, Mennuti, & Schulkin, 2004; WilkinsHaug, Hill, Power, Holzman, & Schulkin, 2000). These studies suggest there is a need to develop a curriculum for patients and clinicians to minimize the complexity of guidelines for population-based screening, as well as develop the infrastructure for prospective assessment of implementation and measuring and documenting outcomes. This will become even more relevant in the next decade as the Human Genome project unveils additional disorders—an estimated 40,000 genes—potentially capable of prenatal diagnosis. Health promotion and the preconception visit The CPC document stratified health promotion activities into 3 categories: 1) education to support and promote healthy behaviors, 2) education regarding general knowledge about pregnancy and parenting, and 3) education regarding information related to specific clinical conditions. Table 3 lists representative topics that should be considered for discussion as part of the medical history during a preconception visit and periodically throughout the pregnancy. The representative topics and examples are not exhaustive, and there is considerable overlap with conditions amenable to screening and risk assessment (see Table 2). The goal of the preconception visit is to identify medical and social conditions that can be optimized prior to conception to increase the likelihood of a favorable outcome. For example, medical treatment for chronic hypertension may require medication change to prevent risk of fetal teratogen exposure (Barr, 1994). Education, dietary changes, and medica-

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Table 3. Health promotion topics: targeted history during preconception (and prenatal) visit Factor Immunization history Rubella Influenza

Environmental/occupation/ travel exposures Lead Medications

Comment

Reference

Substantial missed opportunities for rubella immunization; seroconversion during pregnancy could be catastropic ACOG recommends immunization of all pregnant women during flu season in 2nd and 3rd trimesters; all trimesters in women at high risk

McElhaney, Ringer, DeHart, & Vasilenko, 1999 ACOG Committee on Obstetric Practice, 2004; ACOG, 2003

Potential teratogen

ACOG, 1997

Potential teratogens

ACOG, 1997

Birth spacing has benefit to mother re: decreased interval associated with increased risk of low birth weight

Albrektsen et al., 2005; El-Kamary et al., 2004; King, 2003; Smith et al., 2003

Contraception

Sexual history Monogamous relationship, gender preference, history of infections Family/genetic history Fragile X, cystic fibrosis, neural tube defects, etc Social factors Smoking, alcohol, illicit substances Nutrition Vegetarian, fish intake Vitamin supplements

Risk assessment

See text

See text

Vegans needs specific vitamin supplements; need to limit mercury exposure with fish intake Some good, some bad; poor or inconclusive data re: use of supplements as interventions for preclampsia, preterm birth, low birth weight

ACOG, 1997 Merialdi et al., 2003; Villar et al., 2003

Exercise

Pets Cats/birds

Almost none contraindicated; improves pregnancy outcome re: pain, cesarean; improves glucose levels in A1 diabetics

Kramer, 2002

Avoid litter boxes, avoid eating raw or undercooked meats due to risk of toxoplasmosis; psitticosis (rare)

ACOG, 2002

Related to access, stress

Lu & Halton, 2003

Hispanic paradox; data inconclusive if social support interventions (as described in the literature) makes a difference

Langer et al., 1996

Financial resources Social resources

Abbreviation: ACOG, American College of Obstetricians and Gynecologists.

tion adjustment/initiation may be needed to establish normal blood sugar levels in diabetics and decrease the likelihood of fetal malformation (Reece, Homko, Wu, & Wiznitzer, 1998). Examples where there is demonstrated evidence for benefit of education to support and promote healthy behaviors include smoking cessation counseling and interventions for smoking, alcohol ingestion, and use of illicit substances (Ershoff et al., 1999; Windsor et al., 2000). There are significant data to show that focused smoking cessation programs have a positive impact on smoking rates, and these interventions have been demonstrated to reduce the rate of the preterm delivery and low birth weight (Lumley, Oliver, Chamber-

lain, & Oakley, 2004). Unfortunately, smoking relapse after pregnancy continues to be a problem without any intervention demonstrating long-term effectiveness (Hajek et al., 2005). The cost of smoking in terms of economic burden resulting from health impairment is significant (Miller, Villa, Hogue, & Sivapathasundaram, 2001). Recommendation for smoking cessation and referral to smoking cessation programs during pregnancy have been demonstrated to be a highly cost effective way to improve maternal and infant health, and should be employed where possible even though the success may be only short term (Pollack, 2001). Similar to smoking cessation, several cohort studies have indicated that reduced alcohol

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consumption or abstinence produced a positive effect on infant birth weight (Merkatz & Thompson, 1990). Likewise, a comprehensive care prenatal program that included drug rehabilitation services resulted in decreased rates of preterm delivery, fewer pregnancy complications, fewer positive toxicology screens at delivery, and fewer HIV seroconversions when compared to women enrolled in routine care (Burkett, Gomez-Marin, Yasin, & Martinez, 1998). Preliminary data suggests that group prenatal care provide advantages that merit further study (Ickovics et al., 2003). Collectively, these studies suggest that health promotion and education and referral regarding risk behaviors are associated with improved pregnancy outcomes. More resources are needed to accommodate these referrals. Perhaps one of the most important evidence-based recommendations regarding health promotion and education is the emphasis on nutrition counseling as it relates to diet and vitamin supplementation. The evidence supporting periconception folic acid supplements to reduce the occurrence of first-time neural tube defects and the use of therapeutic doses to decrease the risk of recurrence has been repeatedly demonstrated and has resulted in national regulatory mandates for food supplements and national media campaigns to increase public awareness about the importance of this practice (Czeizel & Dudas, 1992; Centers for Disease Control and Prevention, 1999; Mahomed, 2002). Although studies have demonstrated increased knowledge about folic acid supplementation among women of reproductive age, knowledge is consistently higher than use (Neill, 1999). Because approximately one half of pregnancies are unplanned or unintended, frequently the neural tube has formed before pregnancy is recognized and folic acid supplementation is implemented— hence, the rationale for grain fortification to improve the folate intake of all Americans (Centers for Disease Control and Prevention, 1999). Education regarding general knowledge about pregnancy and parenting has been less well studied. Pregnant patients should be counseled about what to expect during pregnancy, warning signs to be on the alert for, environmental and occupational hazards to avoid, specific dietary advice as it relates to avoiding excessive amounts of specific foods (e.g., certain fish), and weight gain goals. Anticipatory guidance about breastfeeding is a key public health initiative because there are significant health care benefits for both mother and baby (American Academy of Pediatrics & American College of Obstetricians and Gynecologists, 2002; Gregory & Davidson, 1999). Anticipatory guidance about parenting is generally nonexistent during the antenatal period, and in fact there are few standards for the content of antenatal education (Johnson et al., 2000; Renkert & Nutbeam, 2001). Studies on

antenatal education indicate that most of the focus is on pregnancy and childbirth, and rarely include preparation for parenthood. Health educators suggest this imbalance is due to time constraints and the need to put forth factual information surrounding the birthing process, as well as an apparent lack of interest on the patient’s part because of their focused anxiety on labor and delivery. Patients’ perspectives support this theory, albeit in retrospective postpartum interviews, they acknowledge they wished they were better prepared for what to do with the baby once they came home. Using a life span approach, there is considerable merit to considering the role of pediatricians in discussions of the CPC (Hall, 2000; Misra et al., 2003). Clearly, education about childcare and what to expect during parenting can be important components of prenatal care and form a series of “expected competencies” for parturients (Johnson et al., 2000). Many pediatricians see pregnant women for predelivery visits and provide this education as well as education about their approach to childcare (Serwint, Wilson, Vogelhut, Repke, & Seidel, 1996). There may be opportunities to use ongoing well-child visits (whether by pediatricians, family physicians, or advanced practice nurses) to continue to improve maternal health. Breastfeeding continuation can be emphasized with attention to both newborn and maternal benefits. Detection of postpartum depression may be enhanced at regular visits such as occur with well-child programs (as opposed to the one, single postpartum visit with the obstetric provider generally accorded the pregnant woman). Perhaps it is time to think of a “postgestation model” of visits to complement the preconception visit that was proposed in the CPC document. Education regarding information specific to the proposed care is a vital component of any patient– clinician interaction, but is particularly complex during pregnancy because there are 2 patients, each of whom may have competing interests. This potential conflict is further exacerbated by the evolution of shared decision making, and patient autonomy as central tenets in today’s health care environment despite the apparent lack of health literacy that appears pervasive within our society (Estrada, Barnes, Collins, & Byrd, 1999; Council on Scientific Affairs, 1999). This is perhaps best illustrated in the arena of prenatal diagnosis, where ultrasound, serum chemistry analysis, and invasive procedures are used to screen for and diagnosis structural and genetic abnormalities. In a randomized trial providing nondirective information about prenatal testing, patient’s were allocated into 3 groups: 1) control group, who received the usual information provided by clinician; 2) a group who received extra information provided individually by a trained clinician; or 3) a group who received extra

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information provided in a class setting by a trained clinician. Ultrasonography was almost universal, with 99% of participants undergoing ultrasound irrespective of group allocation. Women offered additional information had improved understanding and were more satisfied with the information received. The offer of extra information reduced the uptake of blood tests in a population where the background uptake rate was high (cystic fibrosis screening), but had little effect on the uptake rate of tests where the background uptake rate was already low (Down syndrome screening). The authors concluded that high uptake of prenatal blood tests suggests compliant behavior based on implied clinician recommendations by offering the test, and not necessarily based on patient preferences (Thornton, Hewison, Lilford, & Vail, 1995). Since CPC, there have been major innovations in prenatal diagnosis primarily focused on “first trimester” screening with the introduction of nuchal translucency (NT) and new biochemical markers such as pregnancy-associated protein A (PAPP-A) and free ␤ human chorionic gonadotropin (BHCG) that have been introduced to allow earlier screening. In addition, inhibin-A measurement has been added to BHCG and E3 plus ␣-fetoprotein (AFP) in the “triple test,” leading to the currently used “QUAD test.” In California, the state-mandated screening program continues to provide the “triple test,” whereas QUAD and other fetal screens are used by individual providers. These screening protocols have various epidemiologic characteristics (sensitivity, specificity, positive predictive values) that are variable and depend on prevalence and individual risk factors. A standardized consensus based protocol has yet to be put forth in the United States, but likely an integrated program with an acceptable false-positive rate would be ideal. The challenge with these tests is their complexity and the need to offer genetic counseling to patients if they are to be involved in decision making about which test(s) they wish to undergo (Pauker, 1998). Relevant health literacy and numeracy (the ability to interpret probabilities and absolute and relative risks as they relate to both the condition and the procedure) is entirely unknown, and, thus far, has not been studied. As testing becomes available, it will heighten concerns about medicolegal liability and make the dilemma of prenatal testing increasingly contentious (Lander et al., 2001). The increased cost of testing, and especially test-related counseling (which is often not reimbursed), will be difficult for many to pay for.

eclampsia are the mainstay of current prenatal care guidelines (see Table 1). Unfortunately, there are few data to support screening or treatment of most of these disorders (Langer & Villar, 2002). However, since the CPC, there has been considerable interest and research emphasizing the importance of psychosocial interventions with regard to maternal stress/anxiety, amount and type of social support, and real or perceived barriers to care. Several studies have found an association between maternal anxiety, depression, and stress with adverse pregnancy outcomes (Hobel, DunkelSchetter, Roesch, Castro, & Arora, 1999). The influence of maternal stress/anxiety is likely related to gestational age, and may be modified or exacerbated by one’s social support network (Lu & Halfon, 2003). There are a multitude of studies evaluating the role of enhanced care, home visits, or the provision of selected patient specific social services (e.g., taxi vouchers) in addition to prenatal care on pregnancy outcome (Brooten et al., 2001; Klerman et al., 2001). Continuity programs for teen pregnancy have demonstrated enhanced acceptance and use of contraception, fewer unwanted repeat pregnancies, and prolonged interpregnancy intervals among young girls enrolled in a comprehensive obstetric/pediatric clinic program (Hardy et al., 1997). Augmented care, home visits by nurses and/or midwives, community-based prenatal care, and care focused on patient empowerment have all demonstrated improved outcomes on selected indicators (patient satisfaction, knowledge about care, clinical risk, life mastery, compliance with contraception, interpregnancy intervals). Data from these studies are inconsistent with regard to improved clinical outcomes as measured by reduction in preterm birth and/or rates of low birth weight (Belizan et al., 1995; Monincx, Birnie, Zondervan, Bleker, & Bonsel, 2001; Phipps, 2001; Turnbull et al., 2004). However, there are data to suggest that home visits by paraprofessionals are associated with improved psychosocial measures for women (improved socialization, greater birth spacing, fewer pregnancies, less domestic violence, and fewer months of public assistance) and for their children (improved early learning, more advanced language, and fewer behavioral problems; Olds, Kitzman et al., 2004; Olds, Robinson et al., 2004). These findings may be specific to certain subpopulations (e.g., African American women and/or women with low levels of personal and social resources); additional research is needed to determine if the results persist and/or are reproducible.

Medical and psychosocial interventions and follow-up Screening and treatment of medical disorders during the preconception and early antenatal period has already been discussed. Ongoing screening for medical disorders such as nutritional abnormalities, weight gain, fetal growth disturbances, diabetes, and pre-

Standardized documentation Most of the CPC final recommendations were based on consensus and expert opinion because of the relative paucity of well-conducted clinical trials demonstrating the effectiveness of various interventions and the lack of comparative clinical data among trials that

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were available. Unfortunately, that is still true today, despite numerous national multidisciplinary calls for standardized information (Adams & Corrigan, 2003). The March of Dimes was a leading advocate recommending development of a formal process supported by state or regional resources to allow for the implementation of a surveillance system that routinely collects and reports on population-based data, clinical data, and behavioral data pertinent to perinatal outcome. This has been actualized to some extent in the neonatal community via the Vermont Oxford Network (VON), where a culture of collaboration has been nurtured and implemented to bring about the opportunity to study and rapidly implement “potentially better practices” to monitor impact on quality and outcome in a standardized fashion, thereby leading to evidenced-based system improvements (Bloom et al., 2003; Horbar, Plsek, & Leahy, 2003; Kilbride, Wirtschafter, Powers, & Sheehan, 2003; Suresh et al., 2004). California neonatal intensive care units that participate in VON have expanded the data collection efforts, and in collaboration with the State Maternal– Child Health (MCH) branch and a working group interested in maternal health care quality have suggested broadening the scope of standardized care and data collection to include maternal antenatal and intrapartum care— ultimately, these are contributing determinants to birth outcome (Gregory, Hobel, Korst, Lu, & Reyes, et al., N.D.; Stevenson & Quaintance, 1999). Any attempt to standardize care and/or monitor quality requires a quality database, and technological advances and policy advocates contend that this is best achieved via widespread implementation of an electronic medical record (with database capabilities). The advantages of the electronic medical record (EMR) are becoming increasingly clear (Miller, 2003) and include the following: • • • • • •

portability; ease of transfer of information; quality assessment and review; decreased cost; decreased opportunities for error; and pop ups, warnings (allergy, drug interactions), reminders (alerts).

Issues of confidentiality, especially in an environment when the Health Insurance Portability and Accountability Act is still in its early stages—add cost and complexity to implementation of EMR. Several years ago, the electronic prenatal record was an ACOG presidential initiative, but this has yet to lead to substantive outcomes or recommendations. ACOG is working actively with the other groups such as Health Level Seven to try to deal with user standards and other information technology issues (Health Level Seven, N.D.). EMR prenatal record

activities currently seem to be focused institutionally, both at the provider and purveyor levels. Cost is emerging as a major issue in prenatal care. As mentioned, both prenatal diagnosis and antepartum testing increase costs. However, the startup investment cost for a prenatal EMR will be enormous and how this will capitalized, subsidized, and amortized remains problematic. The federal government has suggested that this will be a priority, but the partnership(s) that will be needed to make this successful have not yet been realized. Whether payors/ providers will provide the upfront startup costs for the long-term savings, efficiency and quality remains unknown. For example, HMOs (a decade ago proposed as the answer to managing the health care crisis) are often, if not usually, assessed financially for their performance on a yearly basis, whereas the long-term health of the average population— best managed with prevention and education and complicated by the high mobility of the average HMO population from year to year—make a yearly return on investment difficult for HMOs to achieve and document for their own population and shareholders. It is especially problematic to demonstrate long-term outcome performance in the absence of a national health system and/or a national information infrastructure that supports shared and/or integrated data. National examples of where this is likely to be realized include the Kaiser Permanente Health System and the Veterans Administration (VA) health system. These health systems remain the primary models for success in managing a population, and both serve as the best laboratories and exemplars for the EMR and comprehensive care aimed at improving patient (population) health and system improvement and efficiency (Batalden, Stevens, & Kizer, 2002; Feussner, Kizer, & Demakis, 2000; Jha, Perlin, Kizer, & Dudley, 2003; Kizer, 2003). Pregnancy and childbirth have been identified by the Institute of Medicine as 1 of 20 priority conditions requiring improvement in health care quality based on its potential impact, improvability, and inclusiveness defined as the potential for reducing disparities in care (Korst, Gregory et al., 2005). It is presumed that a standardized data collection system would allow for systematic comparisons of maternal and neonatal outcomes among different interventions and across various types of providers, and also allow for systematic evaluation of the content of prenatal care and provide for an opportunity to develop a framework for determining the explicit measures that define quality prenatal care services. Preliminary studies looking at variation in rates of cesarean delivery, maternal perineal lacerations, postpartum hemorrhage, maternal and neonatal infection, and admissions for pyelonephritis suggest an opportunity to identify potential best practices that can be systematically studied and

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al., 2004; Olds, Robinson et al., 2004). A final note is that the life span model illustrated in Figure 1 also emphasizes the importance of intergenerational effects, currently being studied in the prenatal/fetal origins of disease hypotheses under active investigation (Barker, 1995; Godfrey, 1998). Figure 1. Reproductive continuum. Each phase represents opportunities for health promotion in the preconception period, the antepartum period, the postpartum period, and acknowledges the importance of the interconception period up through menopause as an opportunity to improve the health and well-being of the woman and her family. (Gregory et al.)

implemented to improve maternal healthcare quality and subsequent birth outcomes (Korst, Fridman et al., 2005; Korst, Gornbein, & Gregory, 2005; Korst, Gregory et al., 2005; Lu et al., 2005). Expanded objectives of prenatal care The objectives of prenatal care were expanded in CPC to include not only the health and well-being of the pregnant woman, fetus, and newborn, but also the health of the family up to 1 year after the birth of the infant. This philosophy has been endorsed in principle by ACOG, and extended by other investigators to include a lifespan approach, or a reproductive health continuum (Figure 1). These models collectively emphasize the importance of health promotion in the preconception period, the antepartum period, the postpartum period, and acknowledge the importance of the interconception period up through menopause as an opportunity to improve the health and well-being of the woman and her family. The value of the interpregnancy period cannot be overemphasized. Data exists to support an optimum time period for birth spacing—namely, 2–5 years (Albrektsen, Heuch, Hansen, & Kvale, 2005; Arafa, Alkhouly, & Youssef, 2004). Rapid successive pregnancies are associated with increased low birth weight, preterm birth, neonatal death, and other adverse pregnancy outcomes attributed to decreased maternal reserves and nutritional depletion associated with vitamin and nutrient deficiency (King, 2003; Smith, Pell, & Dobbie, 2003). Although prolonged birth spacing, ⬎5 years, has its own risks such as increased risk of breast cancer, stillbirths, and preeclampsia (Albrektsen et al., 2005), public education about intermediate spacing at ⱖ2 years but ⬍5 years needs to be more widely disseminated. It is associated with improved maternal health (decreased risk of uterine rupture, endometritis, antepartum bleeding, anemia, and depression), improved child health (decreased childhood illnesses, injuries, death, and improved education), and improved family health, functioning and socioeconomic status (Olds, Kitzman et

Lacking sufficient evidence and requiring more research Recognizing that there was insufficient evidence for many of their recommendations, the panel suggested that more comprehensive research on the subject of prenatal care was needed to address a range of issues including etiology, prevention, risk assessment, health promotion, diagnosis, and treatment. We offer brief summaries of what is known and/or has enhanced our knowledge since the CPC document was published. The value of the preconception visit. One study found that physicians were adherent to traditional prenatal care practices such as physical examination, history taking, and ordering specific laboratory tests, but the components of prenatal care recommended by the CPC to ensure behavioral risk assessments and health promotion and education early in pregnancy were provided at lower and more variable rates (Korenbrot, Steinberg, Bender, & Newberry, 2002; Peoples-Sheps, Hogan, & Ng’andu, 1996). Effective means of assessing risk during prenatal care and evaluation of the different methods of data collection for risk assessment to determine which is most effective. Several studies have documented physician compliance with long-standing guidelines (Peoples-Sheps et al., 1996; Wiist & McFarlane, 1999). Current tools for risk assessment specific to pregnancy outcome have low test accuracy. Evaluation of what health promotion activities are effective in pregnancy. Several investigators have shown that documentation of physician counseling and referral for health promotion and prevention activities are less than ideal (Forster et al., 2004; Reilly et al., 2002; Smith, van der Spuy, Cheng, Elton, & Glasier, 2002). Documentation that reduced prenatal visits in selected populations was not associated with increased harm. Of all recommendations set forth within the CPC, this probably has the most support, as measured by USPHS evidence-based criteria (McDuffie, Bischoff, Beck, & Orleans, 1997). We did not identify any studies measuring the impact or uptake of reduced visits in a defined patient population, health system, or regional service area.

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Evaluation of predictors and testing efficacy for medical risks, including preeclampsia, infection (HIV and gonorrhea), IUGR, genetic screening and treatment of genetic disorders, preterm birth, postterm birth, and diabetes. The amount of research on components of prenatal care is far from ideal, as it was prior to publication of the CPC document (Belizan et al., 1997; Brill-Edwards et al., 2000; Goldenberg et al., 1995; Kekki et al., 2004; McKenna, Tharmaratnam, Mahsud, Bailie, Harper, & Dornan, 2003; Osendarp et al., 2001; Pressman, Cavanaugh, Mingione, Norkus, & Woods, 2003) Many aspects of prenatal care are still being implemented today with little formal evidence for their use and serious questions remain as to whether prenatal care can have any effect on preterm delivery or low birth weight (Lu, Tache, Alexander, Kotelchuck, & Halfon, 2003). Research efforts that assess the effectiveness of all aspects of prenatal care remain a top priority. Evaluation of methods for assessing psychosocial risks during pregnancy including work, stress, the home environment, nutrition, and health promotion; additionally, research focused on interventions to reduce psychosocial risk and the impact of these interventions on pregnancy and family outcomes is needed. Multiple studies exist to support the association of psychosocial risk with adverse outcomes, but data are inconclusive about the impact of psychosocial interventions (Langer et al., 1996; Marcus, Flynn, Blow, & Barry, 2003).

What New Research and Policy Findings Reinforce/Contribute to the Recommendations Put Forth in the Content of Prenatal Care Document? National agendas emphasizing patient education, health literacy, informed consent, patient autonomy, and shared decision making, as well as emphasis on implementing electronic medical record systems, measuring and improving health care quality, decreasing medical errors, maximizing patient safety, paying for performance, and minimizing health care costs have direct implications on the recommendations set forth within the CPC. Enhanced patient education and shared decision making One of the issues clear from the previous review is the rapid proliferation of information and technological advances that have the potential to be integrated and included in the content of prenatal care. Although the challenge to the clinician to keep up is daunting, the transmission of information that has a significant chance to improve health and prevent complications or illness is probably even more challenging. An excellent example is the first trimester screen (NT, PAPP-A, and BHCG), “triple test,” “QUAD test,” and the various ways these tests can be utilized in a testing

algorithm. The issues involved in selection of tests are complicated, often depending on both time of presentation of pregnancy, as well as a clear understanding of test characteristics such as sensitivity, specificity predictive values, a priori risk, and population prevalence. Explaining choices to patients can be complicated and time consuming, even in situations where local or regional practice has been well established (e.g. California which has a state wide prenatal diagnosis program based on the “triple test”). Patients may be entitled or desirous of a complete explanation of the options that are available to them. The testing algorithms and schemes can be complicated to remember and explain (e.g. AFP but not QUAD test follow-up might be recommended to those women who undergo first trimester screening with HCG/ PAPP-A/NT). Issues such as whether to report the First Trimester results immediately when available or whether to “wait” until the entire time-series of tests are accomplished over time need to be discussed with patients. Women over 35 who have traditionally been offered invasive genetic testing (CVS or amniocentesis) may alter their choices about such tests when first or second trimester screening results alter their a priori age-alone related risks. Not only is the educational process important, but documentation of the shared decision making process needs to be recorded as part of prenatal care, as some decisions will lead to tests that will need to be performed at some future date in the pregnancy. The EMR will help with some of the documentation and “reminder” issues (popups, alerts), but the decision making process for patients can be complicated. It might require a series of meetings, discussions, and a period of reflection before final choices are made about tests to be performed or declined. Likewise, the involvement of a variety of physicians, nurses, genetic counselors, and ultrasound specialists is likely to occur multiplying the time, type of information and variation in the information provided to the patient. Given the time and complexity of this expanding aspect of prenatal care it is necessary to think about who will provide this information in the most effective and most cost effective manner. The role of professional health educators, trained genetic counselors and others may need to be expanded and their training enhanced, and studies need to be performed to assess the “best practice ” from both a practice and cost perspective for the educational and decision making processes. The cost, not only of the various tests parameters (blood and ultrasound components, as well as their interpretation) but of the educational effort and time will add additional cost to prenatal care. Decisions about how to do this need to be based on solid science and public policy, remembering that patient autonomy and medical legal issues play an important role in the US health care system. Not all patients given the same education and choices

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will necessarily make the same decision about what screening/testing protocol they wish to follow. So the traditional paradigm of scientific information, patient autonomy, cost and social justice will become increasingly interdependent in this aspect of prenatal care. Effective preconceptual, prenatal, and postnatal clinical care demands not only that the woman be educated about this phase of her life cycle, but also that the she understand the implications and her own role as a partner in the process. Although culturally appropriate and linguistically effective education is mandatory, as we all know from life experience, there is a gap between knowledge and actions. (Witness the unhealthy behaviors that we see among our own health colleagues.) This gap is created by a failure of the individual to incorporate their knowledge base into their sense of self in an actionable way. To achieve effective participation and partnering in the reproductive process, we need to understand how the individual processes the information available to her and tailor her care and education to meet this objective. Specifically, we must be able to assess the woman’s competence to recognize and understand situations that can influence both the infant’s and the mother’s health. We also need to begin to understand meaningfully what women want and expect, work that has begun with the “Listening to Mothers” project (Corry, 2004). We lack knowledge of what women who are at risk for morbidity think about pregnancy and their control over their reproductive health. There is sparse research relating cognitive processes to pregnancy outcomes, or self-regulation to short interpregnancy intervals. This is especially true for the young, the socioeconomically disadvantaged, and minority populations. The absence of understanding these issues is incompatible with the Healthy People 2010 mandate to reduce obstetric morbidity and racial disparities in maternal and infant mortality (US Department of Health and Human Services, 2005). We suggest that research address this issue. What are the theoretical and applied perspectives for this proposal? Women’s beliefs about themselves may provide the basis for changes in behavior resulting in preventable morbidity. Recent findings suggest that AfricanAmerican women’s personal control beliefs, for example, representations that they are the source of the decisions and actions that influence the pregnancy outcome (locus of control), are significant predictors of preterm delivery and support this premise (Misra, O’Campo, & Strobino, 2001). First, this study should be replicated. Second, the cognitive processes and related life span influences that may moderate the actual decisions and actions implied by control beliefs need to be examined. Future research on maternal

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self-regulation of pregnancy behaviors should be based on a cognitive– developmental–lifespan perspective on maternal pregnancy behavior. The program would involve the development of assessment methods and, later, understandable interventions to increase mothers’ critical thinking about pregnancy through higher quality informal reasoning. What is informal reasoning and why is it important? Informal reasoning is reasoning in natural language (Groarke, 2006). It contrasts with formal reasoning, which is the kind found in mathematics and games such as chess. Informal reasoning involves activities such as distinguishing principal claims from the reasons or evidence provided in their support; supporting claims with reasons; evaluating the quality of reasons; challenging reasons and rebutting challenges; and evaluating the overall case for a claim. Informal reasoning is a central component of critical thinking and self-regulation. If the goal of interventions is greater self-determination of health and risk behavior, good reasoning may be necessary to understand the self as integral to good outcomes. Through understanding the nature of informal reasoning among women in their reproductive years, it may be possible to develop strategies beyond formal education that promote self-awareness, self-efficacy, and engagement of the woman as a stakeholder in the outcome of her pregnancy.

What Existing and New Recommendations Need Further Consideration/Research to Achieve and Expand the Goals Outlined in the Content of Prenatal Care? Our summary comments are again organized around the 6 overarching themes espoused by the expert panel. Early and continuing risk assessment that is patient specific, with clinical visits adjusted accordingly Recommendations 1. Integrated health systems need to implement flexible antenatal care visits based on patient risk and provide the data infrastructure to monitor impact on patient satisfaction, outcomes, costs, and overall health system efficiency. 2. Fragmented health systems need to develop a mechanism to allow implementation of same— which necessitates development of universal data requirements, network opportunities to share data, and empowerment of patients to have access to their data and/or be responsible for carrying their own data (paper or electronic). 3. Implementation of flexible prenatal care visits

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should not be based on a tiered health system, or limited resources, but on evidence that outcomes are the same or improved from standard care, where outcomes are a priori defined across all stakeholders in the health care process. 4. Equitable funding at the provider level needs to be negotiated between stakeholders (clinicians, insurers, government) to ensure compliance and avoid altered visit schedules owing to reimbursement incentives that encourage or discourage utilization. Health promotion and the preconception visit Recommendations 1. Education to support and promote healthy behaviors, provide general knowledge about pregnancy and parenting, and provide information related to specific clinical conditions should remain a key objective of prenatal care, but should not be limited to reproductive age and/or pregnant women. Pregnancy outcome is considered an indicator of the health of a nation, and as such the entire nation should be educated about optimal behaviors to optimize maternal and child health. Group prenatal care and the “Centering Pregnancy” program merits consideration and requires further research. 2. The “preconception visit,” “postgestation visit,” and “interconception visits” should be operationalized to include patient-specific content appropriate to where the individual is in her reproductive life span. There should be an agenda to increase awareness about the public health value of these visits, the proposed content for these visits, and a mechanism to incentivize these visits at both the personal and health systems levels. 3. Research is needed to determine how best to promote literacy in general, and health literacy in particular, with specific emphasis on maternal health literacy. Renkert and Nutbeam (2001) define health literacy as the cognitive and social skills that determine the motivation and ability of a woman to gain access to, understand, and use information in ways that promote and maintain their health and that of their children. It is commonly assumed that women are the gatekeepers of health and healthseeking behaviors for their families. It is critical that we develop and implement integrated educational programs that promote health literacy and numeracy, and that we standardize and validate pertinent information for women’s health to be disseminated across the life span. Medical and psychosocial interventions and follow-up The impact of the psychosocial environment on medical outcomes is increasingly apparent and efforts to better understand how this can be modified are necessary.

Recommendations 1. Additional research on structured interventions and long-term follow-up of families is warranted. 2. There is a need for community-based participatory research to inform research and policy recommendations about what needs to be studied and how best to do it. Standardized documentation Standardized documentation will allow communication and continuity of care between providers and provide an opportunity to monitor objective measures of quality of care and patient outcomes over time and across different clinical settings. Recommendations 1. ACOG continued support and advocacy of a unified data set for information pertinent to women’s health in general, and pregnancy and childbirth in particular. 2. Existing EMR companies should standardize data collection storage and retrieval (databases) to allow for networking and shared access among providers and researchers. 3. Development of a consensus of maternal quality of care indicators that are evidence based, clinically important, and meaningful to all relevant stakeholders. Current popular indicators are primarily process measures (e.g., cesarean rates) and/or politically charged (e.g., vaginal birth after cesarean rates). A systematic attempt to identify specific content or clinical care practices that occur in the antenatal or intrapartum periods that are linked to maternal or newborn outcome needs to be done to refocus research and policy recommendations onto potential indicators of health care quality that matter. 4. Develop specific strategies to address quality improvement initiatives directed toward the maternal and child health indicators suggested in Healthy People 2010. Expanded objectives of prenatal care The CPC defined prenatal care to include not only the health and well-being of the pregnant woman, fetus, and newborn, but also the health of the family up to 1 year after the birth of the infant. More recent investigators have embraced a life span approach that extends across the reproductive continuum up to and including menopause (thanks to reproductive technology). Recommendations 1. We advocate adding maternal health literacy as an additional objective. 2. Use existing mechanisms (schools, Healthy Start, media) to integrate health promotion and literacy,

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and systematically integrate health promotion messages. 3. Consider formalizing the role of a health educator, advocate, or literacy translator as part of the health care team to ensure patients understand and evolve to participate in health care decision making and disease management. If realized, this role should be a compensated, reimbursable service. 4. For the uninsured, funding for prenatal care stops after the 6-week postpartum visit. Acknowledging the importance of maternal health on infant and family health, consideration should be given to extending coverage up to 1 year (or more) for women with chronic conditions identified during pregnancy. Lacking sufficient evidence and requiring more research There is overwhelming agreement that there is a gap between evidence of effectiveness and clinical practice. Much of routine prenatal care is not evidence based (Langer & Villar, 2002) and in the United States, patient autonomy, political will, and medical tradition further contribute to physician resistance to adapting evidence-based practices.

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mentation of a system-wide quality improvement effort comparable to that championed at the VA should be replicated wherever feasible.

Conclusions The CPC was a landmark document advocating for change in the existing health care system to maximize maternal and child health. Few of the suggested changes have been realized, despite repetitive summits emphasizing agreement and extending the recommendations advocated by the expert panel. Indeed, this paper was written in anticipation of yet another multidisciplinary state-of-the-science meeting organized to advance the science and further develop political will. We contend that the technology exists to support much of what is being suggested. The time has come for us to stop talking and planning, and start doing. To paraphrase 1 investigator, for this meeting to be considered a success, we must leave with 3 things: 1) binding agreements, 2) commitment for funds, and 3) a timetable for action (Kickbusch, 2001).

Recommendations

Uncited References

1. Judicious use of multicenter collaborative trials focused on effectiveness and efficacy comparable to international endeavors such as the World Health Organization’s antenatal trials, the Latin America trials, or the national projects such as that exemplified by VON, the VA, or the Maternal Fetal Medicine Units Network. 2. Integrated coordination of federal agencies to model the “roadmap” philosophy at the macrolevel. The National Institutes of Health is pushing rapid acceleration of bench discoveries to implementation at the bedside. The Agency for Healthcare Research and Quality is advocating for rapid dissemination of evidenced based practices to improve the health of the nation, and the USPHS provides recommendations for evidenced-based preventive services to maximize screening and decrease risks associated with overutilization. However, there is little coordination between these esteemed agencies and, specifically, there are not enough research dollars directed to clinical research about effectiveness, efficacy, and change theory in health care environments. 3. The federal government, via the VA, Medicare, Medicaid, and numerous other programs (e.g., Healthy Start, State MCH Block Grants, military, Aid to Dependent Families and Children, Women, Infants, and Children programs) is the principle payer for health care services in the United States. Funding for health services research and imple-

This section comprises references that occur in the reference list but not in the body of the text. Please position each reference in the text or delete it. Any references not dealt with will be retained in this section: United States Public Health Service, 1989119

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Author Descriptions Kimberly Gregory, MD, MPH, is a maternal-fetal specialist and Assistant Professor of Obstetrics and Gynecology at Cedars-Sinai Medical Center-UCLA where she is active in Health Services Research. Clark Johnson has completed the Master’s Program in Epidemiology at the University of Michigan School of Public Health and is completing Medical School at Wayne State University. Timothy Johnson, MD, is a maternal-fetal medicine specialist and Professor and Chair of Obstetrics an Gynecology at the University of Michigan. Stephen Entman, MD, an obstetrician-gynecologist with particular interest in maternal mortality, is Professor and Past Chair of Obstetrics and Gynecology at Vanderbilt University.