Editor's Note: Though this work was planned and completed prior to the momentous events of the spring, the need to optimize preventive services for mothers and infants is even more critical given loss of community support due to social distancing, reluctance of some to access health care and economic stress. Racial inequities in maternal child health outcomes remain an urgent national crisis.
High-quality preventive health care for both mom and baby is critical to promoting long-term health and should begin at birth. Recommended pediatric preventive health care typically includes seven visits in the first 12 months of an infant’s life, during which caregivers and providers can discuss topics as diverse as safe sleep, emerging literacy and healthy eating. Of course, all of these topics require parental involvement to reach their child in order to achieve the best health outcomes.
During this same period, high-quality preventive care is also critical for mothers. Risk factors for long-term disease such as gestational diabetes or pregnancy-induced hypertension require follow-up and counseling to ensure a healthy future for mom. Additionally, many women adopt healthier behaviors during pregnancy, such as quitting smoking or healthier eating. Preventive visits provide opportunities to reinforce and sustain these achievements. With this in mind, postpartum preventive care can help ensure healthy future pregnancies, promote long-term health and may even help prevent maternal mortality.
As a primary care pediatrician and OB/GYN, we see that preventive care has vast benefits for moms and babies alike. The problem? Many of these recommended preventive visits never occur.
Challenges With Getting Mothers & Infants Care They Need
With that in mind, we developed a project to explore this connection in preventive care. In a recent study, we linked insurance claims data for mothers and infants who had Medicaid during pregnancy and for a full year following birth. In this group, we found that 72% of mother-infant pairs had more preventive care visits in pediatric settings than adult settings, and that 38% percent of the pairs did not receive any preventive care in adult settings.
One potential takeaway from this study is that we need to develop strategies to increase the number of preventive visits that occur during this critical year-long period, and this is an important goal. However, we’re not sure this is the only lesson. Though mother-infant pairs had significant gaps in recommended care, they did have approximately four preventive visits overall between pediatric and adult care settings in the first year of life. Most pairs also had several visits for acute care. Though not the focus of our study, these visits likely occurred for issues like viral illnesses or injuries.
Altogether, this equals a lot of doctor visits for families to juggle while potentially facing challenges related to transportation, child care and work. And, for some of these Medicaid-insured families, there may be additional visits to balance with Women, Infants and Children (WIC) or home visiting programs. With these competing priorities, it doesn’t surprise us that efforts to ensure families are able to make it to their appointments have been challenging.
A New Approach: Aligning & Streamlining Intergenerational Preventive Services
Taking these considerations into account, and as we thought more about the study results, we think an important takeaway from this work is that we need to develop strategies to better align and streamline preventive services within existing visits for moms and infants. We can think of at least three strategies that could be implemented within our current systems:
The first is to double down on efforts to take advantage of existing opportunities to provide routine primary preventive care. For example, many pediatric practices provide vaccinations at acute visits, knowing that infants are less likely to fall behind when this practice is adopted. Offices could develop workflows to ensure that outstanding preventive care can be routinely provided, to the extent possible, during these visits whether they occur for the mom or infant.
The second strategy includes information sharing and widespread acceptance that preventive care in the year following birth is, in most cases, inherently dyadic. Take, for example, a pediatrician seeing a 2-month-old infant whose mother just screened positive for depressive symptoms at her six-week postpartum visit with her own provider. If the pediatrician was aware of the positive screen, instead of rescreening they could focus on promoting maternal self-care, perhaps with a focused discussion on optimizing infant sleep. They could also help ensure the mother is not facing barriers in accessing behavioral health services.
Lastly, we could use health navigators or care coordinators to ensure information sharing and alignment of care plans across both health care and community resources. This could help ensure care is received in situations where it cannot be easily provided in either location (for example, a pediatric office may be able to help identify and prioritize maternal hypertension, but would not be able to provide comprehensive management for this issue). This strategy has been implemented in pediatrics to address the needs of children with medical complexity, who also face fragmented care and family-level burdens related to health care services, and has potential to be applied more broadly. In this instance, a nurse or community health worker could help reinforce messages from health care providers. In addition, someone in this role has time to communicate with multiple doctors and other service providers, and could ensure that everyone working with a family is supporting the same priorities.
Making these changes won’t be easy. We need research to understand how these strategies would work and whether they would have any unintended consequences. Adapting existing preventive health strategies to address both mothers and infants involves a culture shift, breaking down silos between different departments in health care, and between health care and public health settings. We know that tools exist to promote alignment between adult and pediatric settings, but we must consider new strategies to redesign an intergenerational approach to better meet the needs of high-risk families, and better reap the benefits of preventive services.
Lisa D. Levine, MD, MSCE, is the director of the Pregnancy and Heart Disease Program in the Department of Obstetrics and Gynecology at the Hospital of the University of Pennsylvania.