Preconception

Care

Between

Pregnancies

The

Content

of

Internatal

Care

For

more

than

two

decades

prenatal

care

has

been

a

cornerstone

of

our

nation

's

strategy

for

improving

pregnancy

outcomes

In

recent

years

however

a

growing

recognition

of

the

limits

of

prenatal

care

and

the

importance

of

maternal

health

before

pregnancy

has

drawn

increasing

attention

to

preconception

and

internatal

care

Internatal

care

refers

to

a

package

of

healthcare

and

ancillary

services

provided

to

a

woman

and

her

family

from

the

birth

of

one

child

to

the

birth

of

her

next

child

For

healthy

mothers

internatal

care

offers

an

opportunity

for

wellness

promotion

between

pregnancies

For

high-risk

mothers

internatal

care

provides

strategies

for

risk

reduction

before

their

next

pregnancy

In

this

paper

we

begin

to

define

the

contents

of

internatal

care

The

core

components

of

internatal

care

consist

of

risk

assessment

health

promotion

clinical

and

psychosocial

interventions

We

identified

several

priority

areas

such

as

FINDS

-LRB-

family

violence

infections

nutrition

depression

and

stress

-RRB-

for

risk

assessment

or

BBEEFF

-LRB-

breastfeeding

back-to-sleep

exercise

exposures

family

planning

and

folate

-RRB-

for

health

promotion

Women

with

chronic

health

conditions

such

as

hypertension

diabetes

or

weight

problems

should

receive

on-going

care

per

clinical

guidelines

for

their

evaluation

treatment

and

follow-up

during

the

internatal

period

For

women

with

prior

adverse

outcomes

such

as

preterm

delivery

we

propose

an

internatal

care

model

based

on

known

etiologic

pathways

with

the

goal

of

preventing

recurrence

by

addressing

these

biobehavioral

pathways

prior

to

the

next

pregnancy

We

suggest

enhancing

service

integration

for

women

and

families

including

possibly

care

coordination

and

home

visitation

for

selected

high-risk

women

The

primary

aim

of

this

paper

is

to

start

a

dialogue

on

the

content

of

internatal

care

For

more

than

two

decades

prenatal

care

has

been

a

cornerstone

of

our

nation

's

strategy

for

improving

pregnancy

outcomes

In

recent

years

however

the

effectiveness

of

this

strategy

has

been

called

into

question

-LSB-

-RSB-

Increasing

use

of

early

and

adequate

prenatal

care

has

not

led

to

a

significant

decline

in

low

birthweight

-LRB-

LBW

-RRB-

or

prematurity

which

are

leading

causes

of

infant

mortality

in

the

U.S.

Nor

has

closing

the

access

gap

in

prenatal

care

led

to

a

significant

reduction

in

racial-ethnic

or

socioeconomic

disparities

in

these

adverse

birth

outcomes

There

is

now

a

growing

consensus

that

further

reduction

in

this

nation

's

LBW

and

prematurity

rates

can

not

be

achieved

solely

by

improving

access

to

prenatal

care

-LSB-

-RSB-

A

limitation

on

the

effectiveness

of

prenatal

care

may

be

its

timing

Many

of

the

pathophysiological

pathways

leading

up

to

adverse

birth

outcomes

may

have

their

onset

early

in

pregnancy

possibly

at

or

even

before

implantation

By

the

time

prenatal

care

is

initiated

it

may

be

too

little

too

late

to

significantly

alter

the

course

or

outcome

of

the

pregnancy

Indeed

there

is

now

a

growing

recognition

that

birth

outcomes

are

the

end

product

of

not

only

the

nine

months

of

pregnancy

but

the

entire

life

course

of

the

mother

leading

up

to

the

pregnancy

-LSB-

-RSB-

Improving

birth

outcomes

therefore

takes

promoting

maternal

health

not

only

during

pregnancy

but

before

and

between

pregnancies

and

indeed

across

the

woman

's

lifespan

The

recognition

of

the

importance

of

maternal

health

before

pregnancy

has

led

to

a

growing

interest

in

preconception

care

-LSB-

-RSB-

A

special

subtype

of

preconception

care

is

internatal

care

Internatal

care

refers

to

a

package

of

healthcare

and

ancillary

services

provided

to

a

woman

and

her

family

from

the

birth

of

one

child

to

the

birth

of

her

next

child

It

is

in

essence

preconception

and

prenatal

care

for

a

subsequent

pregnancy

We

prefer

the

term

internatal

care

over

the

more

popular

term

interconception

care

-LRB-

from

the

conception

of

one

pregnancy

to

the

conception

of

the

next

pregnancy

-RRB-

because

-RRB-

internatal

care

represents

an

extension

of

prenatal

care

with

which

the

public

is

familiar

-RRB-

the

point

of

entry

into

care

is

the

birth

of

one

child

and

-RRB-

the

endpoint

of

care

is

the

birth

of

the

next

child

And

while

in

this

paper

we

will

focus

primarily

on

the

interpregnancy

interval

-LRB-

from

the

termination

of

one

pregnancy

to

the

conception

of

the

next

pregnancy

-RRB-

we

prefer

the

term

internatal

care

over

interpregnancy

care

because

internatal

care

suggests

a

continuity

of

care

into

a

subsequent

pregnancy

Despite

the

growing

interest

for

most

people

it

remains

unclear

what

is

meant

by

internatal

care

For

example

many

Healthy

Start

programs

now

offer

internatal

care

and

yet

the

content

of

care

varies

greatly

across

sites

There

have

also

been

a

few

intervention

studies

on

internatal

care

most

notably

in

Denver

-LSB-

-RSB-

Atlanta

-LSB-

-RSB-

and

Philadelphia

-LSB-

-RSB-

with

vastly

different

approaches

The

lack

of

some

standards

of

care

makes

it

difficult

to

move

forward

research

practice

and

policy

or

even

discussion

on

internatal

care

The

purpose

of

this

paper

is

to

begin

to

define

the

content

of

internatal

care

For

healthy

mothers

internatal

care

offers

an

opportunity

for

wellness

promotion

between

pregnancies

Presently

many

women

lack

such

opportunity

particularly

among

low-income

and

minority

women

In

most

states

Medicaid

programs

terminate

pregnancy-related

healthcare

coverage

for

most

low-income

mothers

at

days

postpartum

Other

than

the

one

recommended

postpartum

visit

many

of

these

women

will

have

little

or

no

access

to

healthcare

between

pregnancies

Internatal

care

can

help

close

the

gap

in

healthcare

for

these

women

Even

for

women

with

healthcare

coverage

it

is

unclear

how

much

and

what

internatal

care

they

are

currently

getting

In

this

paper

we

begin

to

define

the

core

contents

of

universal

internatal

care

that

all

women

of

childbearing

age

should

receive

between

pregnancies

While

we

believe

that

internatal

care

should

be

universally

available

to

all

women

between

pregnancies

it

may

be

particularly

beneficial

for

high-risk

mothers

such

as

women

with

chronic

diseases

or

prior

adverse

pregnancy

outcomes

Many

such

outcomes

-LRB-

e.g.

prematurity

fetal

death

-RRB-

carry

a

high

recurrence

risk

in

a

subsequent

pregnancy

and

the

biobehavioral

risk

factors

are

often

carried

from

one

pregnancy

to

the

next

-LSB-

-RSB-

For

these

mothers

internatal

care

offers

an

opportunity

for

risk

reduction

before

their

next

pregnancy

In

this

paper

we

also

begin

to

describe

the

content

of

enhanced

internatal

care

for

high-risk

mothers

We

will

use

women

with

chronic

health

conditions

-LRB-

hypertension

diabetes

or

weight

problems

-RRB-

and

women

with

a

prior

preterm

delivery

as

examples

of

what

more

can

be

done

for

high-risk

mothers

during

internatal

care

than

under

current

prevailing

practice

which

for

many

women

consists

of

the

one

recommended

six-week

postpartum

visit

or

at

all

Two

decades

ago

the

U.S.

Public

Health

Service

assembled

an

expert

panel

to

define

the

contents

of

prenatal

care

In

its

report

Caring

for

Our

Future

The

Content

of

Prenatal

Care

the

Expert

Panel

identified

four

basic

components

of

prenatal

care

consisting

of

-RRB-

early

and

continuing

risk

assessment

-RRB-

health

promotion

-RRB-

clinical

interventions

and

-RRB-

psychosocial

interventions

-LSB-

-RSB-

We

now

use

the

same

framework

to

outline

the

contents

of

internatal

care

based

on

our

search

of

the

literature

for

clinical

standards

best

practices

and

proven

or

promising

strategies

The

focus

of

this

paper

is

on

the

content

of

internatal

care

particularly

during

clinical

visits

Other

important

topics

such

as

financing

organization

delivery

motivation

and

community

interventions

are

beyond

the

scope

of

this

paper

and

will

be

addressed

in

a

series

of

papers

to

follow

It

is

not

our

intention

in

this

paper

to

propose

a

complete

and

final

model

of

internatal

care

Instead

we

present

here

the

start

of

a

framework

for

internatal

care

to

be

filled

in

through

more

dialogues

and

consensus-building

which

we

hope

this

paper

will

help

move

forward

Recommended

core

contents

of

universal

internatal

care

for

all

women

following

a

pregnancy

Most

pregnant

women

in

the

United

States

are

healthy

and

experience

healthy

pregnancy

and

birth

outcomes

For

these

women

internatal

care

is

still

important

because

it

offers

an

opportunity

for

wellness

promotion

In

this

section

we

describe

the

core

contents

of

internatal

care

including

risk

assessment

health

promotion

clinical

interventions

and

psychosocial

interventions

-LRB-

Table

-RRB-

These

components

should

be

offered

to

every

woman

following

a

pregnancy

regardless

of

her

risk

status

We

recommend

expanding

the

current

six-week

postpartum

visit

to

three

or

more

internatal

visits

at

weeks

weeks

and

months

postpartum

with

annual

follow-up

beginning

at

one

year

postpartum

We

will

expand

on

the

rationale

for

the

recommended

schedule

of

visits

and

address

issues

related

to

systems

integration

later

in

this

section

Table

Recommended

content

and

schedule

of

internatal

care

and

organizations

recommending

these

practice

standardsRisk

assessmentOrganizationsaSchedulebCore

content

of

internatal

care

for

all

womenFamily

violenceJACHO

Infections

ChlamydiaUSPSTF

Immunizations

Diptheria-tetanus

boosterUSPTSF

ACPM

Hepatitis

BUSPTSF

ACPM

Measles

and

mumpsUSPTSF

ACPM

HHS

RubellaUSPTSF

ACPM

HHS

VaricellaUSPTSF

ACPM

HHS

DepressionUSPSTF

promotion

BreastfeedingAAP

Back-to-SleepAAP

NICHD

ExerciseNHLBI

HHS

Exposures

Smoking

alcohol

drug

useHHS

LeadCDC

Indoor/outdoor

pollutants

Family

Folate

supplementationCDC

interventions

Height

and

weight

measurementsICSI

Blood

pressureICSI

Total

skin

examinationACS

Clinical

breast

examinationACS

Papanicolau

smear

and

pelvic

examinationACS

Screening

mammographyACS

interventions

Social

Clinical

Parenting

content

of

internatal

care

for

high-risk

womenChronic

hypertension

Risk

assessment

health

promotion

clinical

psychosocial

interventionsNHLBIGestational

hypertension

Risk

assessment

health

promotion

clinical

psychosocial

interventionsNHLBI

ACOGPregestational

diabetes

Risk

assessment

health

promotion

clinical

psychosocial

interventionsADAGestatational

diabetes

Risk

assessment

health

promotion

clinical

psychosocial

interventionsADA

ACOGOverweight/obesity

Risk

assessment

health

promotion

clinical

psychosocial

interventionsNHLBI

HHS

USPSTFPreterm

birth

Risk

assessment

Reproductive

historyACOG

Family

historyACOG

Medical

assessmentACOG

Nutritional

assessmentACOG

Social

assessmentACOG

Health

Promotion

Smoking

cessationHHS

Substance

abuse

treatmentACOG

Optimal

prepregnancy

BMIIOM

Ensure

adequate

fatty

acids

intakeISSFAL

IOM

Family

planningACOG/AAP

Clinical

interventions

Progesterone

use

in

subsequent

pregnancyACOG

Psychosocial

Interventions

Services

for

children

with

special

health

care

needsAAP

Home

visitationAAPaReferences

to

these

recommendations

available

through

the

authors

Abbreviations

JACHO

Joint

Commission

on

Accreditation

of

Healthcare

Organizations

AMA

American

Medical

Association

USPSTF

United

States

Preventive

Services

Task

Force

ACPM

American

College

of

Preventive

Medicine

ADA

American

Dental

Association

HHS

Department

of

Health

and

Human

Services

ACIP

Advisory

Committee

on

Immunization

Practices

-LRB-

CDC

-RRB-

ACOG

American

College

of

Obstetricians

and

Gynecologists

AAP

American

Academy

of

Pediatrics

Healthy

People

FDA

Food

and

Drug

Administration

EPA

Environmental

Protection

Agency

CDC

Centers

for

Disease

Control

and

Prevention

IOM

Institute

of

Medicine

NHLBI

National

Heart

Lungs

and

Blood

Institute

ICSI

Institute

for

Clinical

Systems

Improvement

ACS

American

Cancer

Society

ADA

American

Diabetes

Association.bRecommended

schedule

for

each

component

of

core

content

of

internatal

care

visit

visit

visit

Schedule

for

enhanced

content

varies

according

to

need

Risk

assessment

The

primary

objective

of

risk

assessment

is

to

identify

on-going

problems

that

need

to

be

addressed

Most

pregnant

women

in

the

U.S.

are

healthy

and

thus

should

have

no

major

problems

postpartum

However

some

medical

behavioral

or

psychosocial

problems

may

have

been

overlooked

by

their

prenatal

care

providers

Other

problems

may

develop

during

the

internatal

period

Providers

of

internatal

care

should

pay

particular

attention

to

five

problems

that

are

now

commonly

missed

during

prenatal

or

postpartum

care

family

violence

infection/immunization

nutrition

depression

and

stress

-LRB-

FINDS

-RRB-

Family

violence

The

experience

of

family

violence

may

be

quite

common

among

pregnant

and

postpartum

women

in

the

U.S.

Most

studies

of

the

prevalence

of

physical

abuse

during

pregnancy

report

estimates

in

the

range

of

to

percent

though

higher

estimates

-LRB-

around

-RRB-

have

been

reported

in

some

populations

-LSB-

-RSB-

Less

is

known

about

the

prevalence

of

violence

after

pregnancy

with

estimates

at

months

postpartum

ranging

from

in

a

population-based

survey

to

in

a

prospective

study

of

adolescent

mothers

-LSB-

-RSB-

In

the

latter

study

-LSB-

-RSB-

three

of

four

women

who

reported

intimate

partner

violence

-LRB-

IPV

-RRB-

had

not

reported

IPV

prior

to

delivery

Family

violence

puts

maternal

health

and

child

development

at

great

risk

The

literature

contains

solid

links

between

intimate

partner

violence

and

child

abuse

-LSB-

-RSB-

Because

violence

is

frequently

missed

by

healthcare

providers

including

prenatal

care

providers

we

recommend

routine

screening

for

family

violence

during

every

internatal

visit

Several

brief

screening

instruments

such

as

the

Hurt

Insulted

Threatened

or

Screamed

at

-LRB-

HITS

-RRB-

the

Partner

Violence

Screen

-LRB-

PVS

-RRB-

and

a

Abuse

Assessment

Screen

-LRB-

AAS

-RRB-

can

be

effectively

used

to

screen

for

IPV

in

a

clinical

setting

-LSB-

-RSB-

Infection/immunization

Some

infections

may

go

unrecognized

or

untreated

during

pregnancy

Chronic

untreated

infections

such

as

periodontal

disease

could

pose

a

threat

not

only

to

the

next

pregnancy

-LSB-

-RSB-

but

also

to

the

mother

's

long-term

health

as

well

-LSB-

-RSB-

Most

women

are

not

screened

for

periodontal

disease

during

prenatal

care

and

many

women

lack

access

to

oral

health

services

following

pregnancy

While

presently

there

is

insufficient

evidence

to

justify

universal

screening

for

asymptomatic

infections

among

low-risk

women

in

the

internatal

period

-LRB-

other

than

the

U.S.

Preventive

Services

Task

Force

-LRB-

USPSTF

-RRB-

recommendation

for

Chlamydia

screening

in

women

under

the

age

of

-RRB-

-LSB-

-RSB-

in

some

populations

routine

screening

for

periodontal

sexually-transmitted

and

some

urogenital

tract

infections

may

be

warranted

Internatal

care

also

offers

an

important

opportunity

to

update

women

's

immunization

status

The

USPSTF

and

other

national

advisory

committees

recommend

that

-RRB-

all

adults

receive

periodic

diptheria-tetanus

toxoids

booster

every

years

-RRB-

all

young

adults

receive

a

series

of

Hepatitis

B

vaccines

-RRB-

all

adults

born

after

who

lack

evidence

of

immunity

receive

vaccination

against

measles

and

mumps

and

-RRB-

all

women

of

childbearing

age

be

screened

for

rubella

and

varicella

susceptibility

susceptible

nonpregnant

women

of

childbaring

age

should

be

offered

vaccination

and

avoid

conception

for

at

least

days

after

vaccination

susceptible

pregnant

women

should

be

vaccinated

immediately

after

delivery

-LRB-

Table

-RRB-

Immunization

status

should

be

assessed

and

updated

at

the

six-week

internatal

visit

Nutrition

Nutrition

can

play

an

important

role

in

promoting

maternal

health

and

child

development

and

yet

women

's

nutritional

needs

are

often

overlooked

by

prenatal

or

postpartum

care

providers

One

recent

population-based

survey

in

California

found

that

nearly

one

in

three

pregnant

women

who

were

income-eligible

for

Women

Infants

and

Children

-LRB-

WIC

-RRB-

program

reported

being

food-insecure

of

these

one

in

four

reported

not

being

enrolled

in

WIC

-LSB-

-RSB-

Nutritional

screening

should

address

the

ABCD

's

of

nutritional

risks

anthropometric

-LRB-

e.g.

low

or

high

body

mass

index

-RRB-

biochemical

-LRB-

e.g.

for

anemia

or

folate

deficiency

in

some

populations

-RRB-

clinical

-LRB-

e.g.

eating

disorder

-RRB-

and

dietary

-LRB-

e.g.

content

pattern

food

insecurity

-RRB-

An

abbreviated

version

of

the

Household

Food

Security

Scale

can

be

used

to

screen

for

food

insecurity

Inquiry

should

be

made

about

folate

or

multivitamin

supplementation

-LRB-

see

under

Health

Promotion

-RRB-

We

recommend

routine

screening

of

nutritional

risks

at

every

internatal

visit

Depression

Maternal

depression

affects

a

large

number

of

women

and

their

children

A

recent

systematic

review

reported

combined

estimates

of

the

point

prevalence

of

major

and

minor

depression

ranging

from

to

percent

during

pregnancy

and

to

nearly

percent

during

the

first

year

postpartum

-LSB-

-RSB-

Maternal

depression

can

have

negative

long-term

impact

on

both

maternal

health

and

child

development

but

is

often

missed

by

prenatal

and

postpartum

care

providers

We

recommend

routine

screening

for

maternal

depression

at

every

internatal

visit

Fairly

accurate

and

feasible

screening

measures

are

available

including

the

Postpartum

Depression

Screening

Scale

-LRB-

PDSS

-RRB-

Edinburgh

Postnatal

Depression

Scale

-LRB-

EPDS

-RRB-

Beck

Depression

Inventory

-LRB-

BDI

-RRB-

and

the

Center

for

Epidemiologic

Studies

Depression

Scale

-LRB-

CES-D

-RRB-

-LSB-

-RSB-

The

evidence

available

albeit

limited

suggests

that

providing

some

form

of

psychosocial

support

to

pregnant

and

postpartum

women

at

risk

of

having

a

depressive

illness

may

decrease

depressive

symptoms

-LSB-

-RSB-

Stress

Maternal

stress

is

perhaps

the

hardest

to

screen

clinicians

are

often

at

a

loss

as

to

how

to

screen

or

what

to

do

with

a

positive

screen

Yet

chronic

stress

can

pose

significant

risks

to

maternal

health

and

child

development

For

the

mother

chronic

stress

can

cause

wear

and

tear

to

her

body

's

adaptive

systems

what

McEwen

refers

to

as

allostatic

load

which

could

lead

to

more

rapid

deterioration

in

her

health

and

function

over

time

-LSB-

-RSB-

For

the

infant

-LRB-

or

the

fetus

in

a

subsequent

pregnancy

-RRB-

maternal

stress

could

result

in

the

re-programming

of

the

child

's

basic

autonomic

rheostat

and

alteration

of

immune

regulation

leading

to

increased

vulnerability

to

disease

and

dysfunction

later

in

life

-LSB-

-RSB-

There

is

an

important

need

for

the

development

of

a

multi-dimensional

screening

tool

for

stress

that

can

be

feasibly

implemented

in

a

clinical

setting

For

now

clinicians

need

to

ask

about

major

stressors

in

women

's

lives

-LRB-

e.g.

homelessness

unemployment

family

violence

social

isolation

-RRB-

at

every

internatal

visit

and

find

resources

and

supports

to

help

the

family

deal

with

these

stressors

Thus

even

for

healthy

mothers

with

healthy

infants

much

can

be

done

to

reduce

health

risks

and

promote

well-being

during

internatal

care

In

addition

to

the

five

areas

we

highlighted

-LRB-

FINDS

family

violence

infections/immunization

nutrition

depression

and

stress

-RRB-

a

battery

of

reproductive

medical

family

genetic

and

psychosocial

risks

should

be

routinely

assessed

during

internatal

care

Other

areas

of

risk

assessment

can

be

added

to

the

contents

of

internatal

care

as

the

model

becomes

more

fully

developed

A

word

of

caution

about

risk

screening

Presently

a

major

limitation

on

the

effectiveness

of

risk

screening

is

the

lack

of

available

or

accessible

services

for

those

with

a

positive

screen

The

benefit

of

depression

screening

is

limited

when

there

are

no

mental

health

services

available

or

accessible

to

refer

mothers

who

screen

positive

for

depression

And

a

lack

of

support

services

-LRB-

and

coordination

thereof

-RRB-

for

abuse

victims

is

identified

by

many

providers

as

a

major

deterrent

to

screening

for

family

violence

For

risk

screening

to

be

effective

it

needs

to

be

followed

up

by

effective

interventions

This

means

having

all

the

necessary

resources

and

service

capacity

-LRB-

e.g.

oral

health

services

for

those

with

periodontal

disease

nutritional

support

for

those

who

are

food-insecure

housing

assistance

for

homeless

mothers

and

families

-RRB-

to

assist

those

with

a

positive

screen

Health

promotion

The

primary

objective

of

health

promotion

is

to

promote

the

health

and

wellbeing

of

the

mother

infant

and

family

We

will

highlight

six

components

health

promotion

during

internatal

care

breastfeeding

back-to-sleep

exercise

exposures

family

planning

and

folic

acid

-LRB-

BBEEFF

-RRB-

Breastfeeding

Despite

well-known

benefits

of

breastfeeding

for

both

mother

and

infant

-LSB-

-RSB-

at

least

one-third

of

mothers

in

the

U.S.

never

initiate

breastfeeding

-LSB-

-RSB-

Among

women

who

initiated

nearly

one

in

five

will

stop

nursing

by

one

month

and

nearly

two-thirds

will

stop

by

six

months

-LSB-

-RSB-

despite

current

recommendation

to

breastfeed

for

at

least

one

full

year

-LSB-

-RSB-

Internatal

care

offers

an

important

opportunity

to

promote

breastfeeding

particularly

the

initial

two-week

visit

to

address

nascent

problems

the

six-week

visit

to

anticipate

problems

related

to

transition

back

to

work

and

the

six-month

visit

to

encourage

continued

breastfeeding

with

introduction

of

solid

foods

Back-to-sleep

With

the

introduction

of

the

Back-to-Sleep

campaign

by

the

American

Academy

of

Pediatrics

in

the

overall

incidence

of

sudden

infant

death

syndrome

-LRB-

SIDS

-RRB-

has

decreased

by

almost

-LSB-

-RSB-

Despite

this

success

SIDS

continues

to

be

a

leading

cause

of

infant

death

in

the

U.S.

as

well

as

racial

disparity

in

infant

mortality

-LSB-

-RSB-

SIDS

rate

among

black

infants

remains

more

than

twice

that

of

white

infants

even

after

the

implementation

of

the

Back-to-Sleep

campaign

-LSB-

-RSB-

Black

infants

are

more

likely

than

white

infants

to

be

placed

in

the

prone

position

and

soft

sleep

surfaces

for

sleep

-LSB-

-RSB-

Providers

of

internatal

care

need

to

discuss

the

infant

's

sleep

environment

with

the

parents

Because

the

risk

of

SIDS

peaks

at

to

months

of

age

the

six-week

visit

offers

an

important

opportunity

to

talk

about

back-to-sleep

Exercise

Health

education

about

physical

activities

should

be

part

of

an

on-going

effort

for

wellness

promotion

during

internatal

care

The

National

Maternal

and

Infant

Health

Survey

revealed

that

percent

of

white

women

and

percent

of

black

women

were

heavier

by

kg

-LRB-

nearly

pounds

-RRB-

or

more

at

to

months

post

partum

than

they

were

before

pregnancy

-LSB-

-RSB-

Clinicians

can

help

women

develop

a

weight

loss

program

that

consists

of

healthy

dieting

physical

activities

and

behavioral

modifications

if

needed

The

National

Heart

Lung

and

Blood

Institute

recommends

that

all

adults

should

set

a

long-term

goal

to

accumulate

at

least

min

or

more

of

moderate-intensity

physical

activity

on

most

and

preferably

all

days

of

the

week

-LSB-

-RSB-

For

women

in

the

postpartum

period

prepregnancy

exercise

routines

may

be

resumed

gradually

as

soon

as

it

is

physically

and

medically

safe

Clinicians

need

to

routinely

discuss

physical

activity

with

the

woman

particularly

at

the

six-week

and

six-month

visits

Exposures

Cigarette

smoking

poses

a

significant

threat

to

the

health

of

the

mother

her

infant

and

her

subsequent

pregnancy

Approximately

one

in

eight

-LRB-

-RRB-

U.S.

women

who

gave

birth

in

reported

smoking

cigarettes

during

pregnancy

-LSB-

-RSB-

Furthermore

up

to

of

women

who

quit

smoking

during

pregnancy

will

relapse

within

months

of

delivery

-LSB-

-RSB-

Effective

models

of

clinical

intervention

for

smoking

cessation

-LRB-

e.g.

's

-RRB-

and

relapse

prevention

have

been

developed

and

should

be

incorporated

into

internatal

care

-LSB-

-RSB-

Prenatal

exposure

to

alcohol

and

other

substances

like

cocaine

and

amphetamines

have

been

associated

with

birth

defects

as

well

as

adverse

pregnancy

and

neurodevelopmental

outcomes

According

to

the

Behavioral

Risk

Factor

Surveillance

System

in

the

prevalence

of

any

alcohol

use

and

binge

drinking

among

pregnant

women

in

the

U.S.

was

and

respectively

-LSB-

-RSB-

Postpartum

use

and

recidivism

rates

are

less

well

described

Several

screening

questionnaires

have

been

developed

to

detect

problem

drinking

which

may

also

prove

helpful

in

detecting

substance

abuse

include

T-ACE

-LRB-

tolerance

annoyed

cut

down

eye

opener

-RRB-

questions

the

CAGE

-LRB-

cut-down

annoyed

guilty

eye-opener

-RRB-

questionnaire

and

the

brief

MAST

questionnaire

-LSB-

-RSB-

All

women

should

be

screened

at

the

time

of

their

first

internatal

visit

and

referral

for

evaluation

and

treatment

should

be

offered

to

those

who

screen

positive

Additionally

mothers

whose

infants

are

at

risk

for

neurobehavioral

problems

from

prenatal

exposures

should

be

provided

resources

for

early

developmental

evaluation

and

interventions

for

their

infants

-LSB-

-RSB-

A

large

number

of

environmental

exposures

during

the

internatal

period

can

affect

maternal

health

and

child

development

For

example

chronic

exposures

to

indoor

and

outdoor

pollutants

and

allergens

including

household

molds

and

dust

mites

may

increase

the

child

's

future

risk

for

atopy

allergies

and

asthma

Less

is

known

about

the

long-term

effects

of

such

exposures

to

maternal

health

and

subsequent

pregnancy

outcomes

Lead

is

a

potent

developmental

neurotoxicant

and

immunotoxicant

and

household

exposures

can

come

from

old

paint

leaching

from

plumbing

and

ceramic

dinnerware

and

glazes

Certain

measures

can

be

taken

to

reduce

household

exposures

to

pollutants

allergens

and

lead

Exposure

to

mercury

can

be

reduced

by

adherence

to

the

EPA/FDA

joint

advisory

related

to

consumption

of

fish

and

shellfish

and

exposure

to

dioxins

can

be

reduced

by

decreasing

dietary

fat

consumption

-LRB-

Table

-RRB-

Clinicians

need

to

assess

and

discuss

with

their

patients

avoidance

of

exposures

that

could

adversely

impact

on

maternal

health

and

child

development

at

every

internatal

visit

but

particularly

at

the

and

visits

Family

planning

Family

planning

is

vital

to

the

health

and

wellbeing

of

women

and

their

families

-LSB-

-RSB-

Unintended

pregnancy

and

short

interpregnancy

intervals

are

associated

with

increased

risk

for

adverse

birth

outcomes

-LSB-

-RSB-

family

planning

can

reduce

the

risk

by

promoting

effective

contraceptive

use

and

optimal

birth

spacing

An

unintended

pregnancy

also

puts

future

maternal

health

and

social

wellbeing

at

risk

family

planning

can

protect

maternal

health

and

choice

-LSB-

-RSB-

Discussion

of

family

planning

should

begin

prenatally

and

prior

to

discharge

from

the

hospital

it

should

be

addressed

again

at

the

two-week

and

six-week

internatal

visits

including

risks

benefits

and

side

effects

of

available

contraceptive

options

and

plans

for

future

childbearing

Adherence

to

method

and

side

effects

should

be

reassessed

at

the

six-month

visit

Folate

supplementation

Folate

is

important

to

both

maternal

and

child

health

Maternal

folate

deficiency

has

been

linked

to

future

risk

for

cardiovascular

and

other

chronic

adult

diseases

as

well

as

neural

tube

and

other

birth

defects

in

the

offspring

Periconceptional

-LRB-

preconceptional

and

in

early

pregnancy

-RRB-

use

of

folic

acid

has

been

demonstrated

to

reduce

the

occurrence

and

recurrence

of

neural

tube

defects

-LSB-

-RSB-

Thus

the

U.S.

Public

Health

Services

recommends

that

all

women

of

childbearing

age

consume

micrograms

of

folic

acid

daily

-LSB-

-RSB-

Even

though

there

are

several

ways

of

getting

this

amount

of

folic

acid

everyday

two-thirds

of

U.S.

women

of

childbearing

age

still

do

not

consume

enough

folic

acid

and

surveys

continue

to

find

substantial

knowledge

gaps

regarding

the

benefits

of

folic

acid

Folic

acid

should

be

promoted

at

every

internatal

visit

or

at

the

minimum

during

the

six-month

visit

We

feel

that

the

recommendation

for

folic

acid

can

be

broadened

to

include

daily

multivitamin

supplementation

given

the

potential

benefits

of

a

number

of

other

vitamins

-LRB-

e.g.

-RRB-

and

elements

to

maternal

health

and

subsequent

pregnancy

outcomes

particularly

for

women

with

nutritional

deficiencies

Table

summarizes

the

core

contents

of

health

promotion

during

internatal

care

with

an

emphasis

on

BBEEFF

-LRB-

breastfeeding

back-to-sleep

exercise

exposures

family

planning

and

folic

acid

-RRB-

Other

topics

can

be

added

to

health

promotion

as

the

model

of

internatal

care

becomes

more

fully

developed

Clinical

interventions

Most

women

in

this

category

are

by

definition

healthy

and

require

little

in

the

way

of

clinical

interventions

during

internatal

care

other

than

the

standard

preventive

health

services

recommended

for

all

women

of

childbearing

age

-LRB-

Table

-RRB-

These

include

periodic

height

weight

and

blood

pressure

measurements

total

skin

examination

clinical

breast

examination

Pap

smear

and

bimanual

pelvic

examination

every

to

years

Mammography

should

also

be

performed

in

women

ages

and

above

We

will

address

clinical

interventions

for

women

with

chronic

conditions

in

the

next

section

Psychosocial

interventions

Many

healthy

women

who

gave

birth

to

a

healthy

infant

will

nonetheless

need

some

psychosocial

support

There

are

three

types

of

social

support

that

need

to

be

made

available

as

part

of

the

core

package

of

internatal

care

services

-RRB-

social

services

-RRB-

clinical

support

and

-RRB-

parenting

support

-LRB-

Table

-RRB-

Social

services

may

include

assistance

with

obtaining

certain

public

insurance

-LRB-

e.g.

SCHIP

-RRB-

or

benefits

-LRB-

e.g.

TANF

EITC

-RRB-

Some

women

may

not

be

aware

of

their

eligibility

for

child

care

subsidies

-LRB-

e.g.

CCDF

-RRB-

or

availability

of

early

childhood

education

programs

Women

experiencing

intimate

partner

violence

may

need

multiple

medical

legal

and

social

services

and

could

use

some

help

with

service

coordination

The

internatal

visits

provide

a

platform

for

accessing

these

social

services

Women

who

experience

postpartum

depression

or

other

affective

disorders

may

benefit

from

some

forms

of

psychological

support

and

therapy

during

the

internatal

period

Couples

who

experience

problems

with

marital

or

sexual

relationship

in

the

internatal

period

may

benefit

from

counseling

or

interventions

Women

with

alcohol

or

drug

problems

could

also

use

clinical

support

and

treatment

These

and

other

professional

clinical

support

services

should

be

made

available

and

accessible

as

part

of

standard

internatal

care

services

Many

parents

could

benefit

from

some

parenting

support

such

as

mother

support

groups

or

parenting

classes

A

current

innovative

idea

in

prenatal

care

is

centering

in

pregnancy

which

provides

social

support

to

pregnant

women

through

group

prenatal

care

-LSB-

-RSB-

While

this

idea

remains

to

be

tested

we

believe

that

group

internatal

care

a

centering

in

internatal

care

model

may

provide

additional

support

for

some

women

particularly

around

issues

related

to

parenting

practices

and

the

stress

of

parenting

A

note

on

psychosocial

interventions

Throughout

this

paper

the

readers

will

notice

an

imbalance

in

the

levels

of

details

we

used

to

describe

clinical

and

psychosocial

interventions

That

is

clinical

recommendations

are

for

the

most

part

described

with

much

greater

specificity

than

psychosocial

interventions

It

is

certainly

not

our

intention

to

propose

a

predominantly

biomedical

model

of

internatal

care

Rather

the

lack

of

specificity

in

our

description

of

psychosocial

interventions

reflect

both

the

complexity

of

psychosocial

issues

that

families

particularly

low-income

families

face

for

which

there

are

often

no

easy

solutions

as

well

as

the

dearth

of

well-designed

and

evaluated

intervention

programs

addressing

these

psychosocial

issues

For

example

mental

health

services

alone

are

unlikely

to

be

effective

in

treating

the

postpartum

depression

of

a

homeless

mother

and

housing

assistance

alone

is

unlikely

to

find

her

stable

housing

without

sustainable

income

and

employment

but

few

well-designed

intervention

studies

have

critically

evaluated

the

impact

of

a

comprehensive

package

of

mental

health

services

housing

assistance

work

and

life-skills

training

and

childcare

on

maternal

and

family

health

Our

model

of

internatal

care

is

unlikely

to

be

effective

without

effective

psychosocial

interventions

but

we

will

not

know

what

these

are

as

long

as

we

keep

looking

for

quick

biomedical

fixes

Future

intervention

studies

on

internatal

care

need

to

take

a

more

integrative

comprehensive

approach

to

improving

family

and

women

's

health

Service

coordination

and

integration

As

aforementioned

presently

some

referral

services

-LRB-

e.g.

mental

health

services

oral

health

services

-RRB-

are

unavailable

or

inaccessible

to

many

women

between

pregnancies

But

even

if

the

services

are

available

they

are

often

poorly

coordinated

Fragmentation

in

service

delivery

can

deter

access

to

care

particularly

for

low-income

women

with

many

other

competing

needs

Providers

of

internatal

care

need

to

consider

how

to

better

coordinate

and

integrate

services

in

order

to

improve

access

This

can

be

accomplished

by

establishing

a

well-developed

referral

network

In

some

populations

care

coordination

or

case

management

provided

by

a

nurse

or

social

worker

may

be

needed

Ideally

these

services

should

be

provided

at

one

location

to

increase

service

coordination

and

integration

For

example

the

two-week

internatal

visit

can

be

provided

at

the

same

time

and

location

as

the

two-week

well-baby

check-up

with

on-site

WIC

health

education

and

social

services

that

allow

for

one-stop

shopping

We

will

take

up

issues

related

to

the

organization

and

delivery

of

internatal

care

that

will

maximize

access

and

utilization

of

services

in

a

series

of

papers

to

follow

Schedule

of

visits

In

developing

a

schedule

of

visits

for

internatal

care

we

had

to

first

wrestle

with

two

questions

First

should

n't

the

schedule

of

visits

be

individualized

according

to

individual

needs

While

we

support

this

view

we

nonetheless

feel

that

it

may

be

useful

to

recommend

some

minimum

standards

to

start

a

dialogue

about

this

topic

For

healthy

women

with

healthy

infants

we

propose

expanding

the

current

six-week

postpartum

visit

to

three

or

more

internatal

visits

at

weeks

weeks

and

months

postpartum

with

annual

exams

beginning

at

one

year

postpartum

For

some

activities

the

six-week

postpartum

visit

may

be

too

little

too

late

For

example

one

in

five

mothers

who

initiated

breastfeeding

will

quit

nursing

within

the

first

month

-LSB-

-RSB-

a

postpartum

visit

may

offer

more

timely

encouragement

and

interventions

for

maintenance

of

breastfeeding

than

a

visit

could

The

visit

also

offers

an

opportunity

to

follow-up

on

wound

care

for

cesarean

delivery

Whenever

possible

this

visit

should

be

coordinated

with

the

two-week

well-baby

check-up

preferably

at

the

same

location

to

increase

motivation

for

attendance

We

feel

that

it

is

important

to

keep

the

current

six-week

postpartum

visit

as

the

second

internatal

visit

This

is

a

well-established

visit

in

obstetrics

with

well-defined

contents

This

visit

however

can

be

made

more

useful

by

expanding

its

contents

We

feel

that

a

third

internatal

visit

at

months

is

important

for

follow-up

on

a

number

of

issues

such

as

breastfeeding

and

family

planning

The

standard

annual

visits

should

begin

at

one

year

postpartum

-LRB-

Table

-RRB-

Second

should

n't

any

routine

visit

by

a

woman

who

may

at

some

time

become

pregnant

again

be

viewed

as

an

opportunity

to

emphasize

the

importance

of

internatal

health

and

habits

-LSB-

-RSB-

While

we

support

this

view

we

nonetheless

feel

that

it

would

be

preferable

to

recommend

a

schedule

of

internatal

visits

rather

than

relying

on

any

routine

visit

Several

components

of

internatal

care

are

time

sensitive

-LRB-

e.g.

counseling

about

breastfeeding

and

family

planning

at

weeks

or

about

SIDS

at

weeks

-RRB-

which

should

not

wait

for

any

routine

visit

Scheduled

internatal

visits

may

be

particularly

important

for

women

who

are

not

making

routine

visits

or

who

are

seeking

care

through

the

emergency

department

or

urgent

care

clinics

which

lack

the

resources

and

capacity

to

provide

comprehensive

internatal

care

We

would

also

like

to

see

internatal

care

become

reimbursable

visits

with

standardized

contents

and

schedule

-LRB-

rather

than

as

an

add-on

to

a

visit

for

mastitis

or

cystitis

-RRB-

which

may

increase

provider

incentives

to

provide

internatal

care

Issues

related

to

patient

motivation

and

provider

reimbursement

will

be

addressed

in

a

series

of

papers

to

follow

Recommended

contents

of

enhanced

internatal

care

for

high-risk

women

In

this

section

we

begin

to

define

the

contents

of

enhanced

internatal

care

for

high-risk

women

-LRB-

Table

-RRB-

We

focus

on

four

groups

of

high-risk

women

-RRB-

women

with

chronic

hypertension

or

history

of

hypertensive

disorders

during

pregnancy

-RRB-

women

with

pregestaional

or

gestational

diabetes

mellitus

-RRB-

women

who

are

underweight

overweight

or

obese

and

-RRB-

women

with

prior

preterm

birth

We

call

attention

to

the

first

groups

because

they

are

often

underserved

in

the

internatal

period

especially

if

they

gave

birth

to

a

healthy

infant

Their

continued

health

needs

may

not

be

met

because

they

had

a

good

birth

outcome

Some

women

will

lose

healthcare

coverage

-LRB-

e.g.

pregnancy-related

Medicaid

-RRB-

and

will

have

little

on-going

care

despite

their

chronic

conditions

We

call

attention

to

the

group

because

of

their

high

recurrence

risk

-LSB-

-RSB-

and

the

significance

of

recurrence

The

goals

of

internatal

care

for

these

women

are

to

provide

ongoing

care

for

their

health

problems

and

optimize

their

health

prior

to

next

pregnancy

In

addition

to

the

core

contents

of

universal

internatal

care

recommended

above

for

all

women

of

childbearing

ages

we

will

examine

what

enhanced

contents

may

benefit

their

long-term

health

as

well

as

the

outcome

of

their

subsequent

pregnancy

Women

with

chronic

hypertension

or

hypertensive

disorders

during

pregnancy

Hypertensive

disorders

are

the

most

frequently

reported

medical

risk

factor

during

pregnancy

-LSB-

-RSB-

Among

the

million

U.S.

women

who

gave

a

live

birth

in

more

than

had

pregnancy-associated

-LRB-

gestational

-RRB-

hypertension

more

than

had

chronic

hypertension

and

nearly

had

eclampsia

-LSB-

-RSB-

Among

women

with

chronic

hypertension

-LRB-

i.e.

hypertension

diagnosed

prior

to

twentieth

week

of

gestation

and

probably

antedates

the

pregnancy

-RRB-

that

persists

after

pregnancy

guidelines

for

evaluation

and

treatment

are

well

established

and

can

be

incorporated

into

the

contents

of

internatal

care

-LSB-

-RSB-

Risk

assessment

has

three

major

objectives

-RRB-

to

assess

lifestyle

and

identify

other

cardiovascular

risk

factors

or

concomitant

disorders

that

may

affect

prognosis

and

guide

treatment

-RRB-

to

reveal

identifiable

causes

of

hypertension

and

-RRB-

to

assess

the

presence

or

absence

of

target

organ

damage

and

cardiovascular

disease

Initial

evaluation

should

include

medical

history

physical

examination

-LRB-

including

fundoscopic

and

cardiovascular

examinations

-RRB-

laboratory

testing

and

other

diagnostic

procedures

-LRB-

including

an

electrocardiogram

and

testing

for

renal

function

and

lipoprotein

profile

-RRB-

Health

promotion

should

promote

weight

reduction

DASH

-LRB-

Dietary

Approaches

to

Stop

Hypertension

-RRB-

eating

plan

dietary

sodium

reduction

physical

activities

moderation

of

alcohol

and

smoking

cessation

Clinical

interventions

should

include

drug

therapy

for

all

women

with

hypertension

as

well

as

prehypertensive

women

with

compelling

indications

-LRB-

e.g.

chronic

kidney

disease

or

diabetes

-RRB-

Follow-up

should

be

monthly

until

the

blood

pressure

goal

is

achieved

and

then

at

months

interval

thereafter

during

the

internatal

period

Psychosocial

interventions

should

address

chronic

stressors

that

may

exacerbate

the

chronic

hypertension

as

well

as

barriers

-LRB-

e.g.

financial

motivational

-RRB-

to

adherence

with

treatment

protocol

The

contents

of

internatal

care

for

women

with

gestational

hypertension

pre-eclampsia

and

eclampsia

are

less

well

defined

especially

if

the

hypertension

does

not

persist

following

pregnancy

In

most

women

with

gestational

hypertension

the

blood

pressure

will

become

normal

during

the

first

week

postpartum

for

women

with

preeclampsia

the

hypertension

will

take

longer

to

resolve

If

the

hypertension

has

not

remitted

by

the

visit

the

women

should

be

reexamined

weeks

later

when

persisting

pathology

will

probably

be

chronic

-LSB-

-RSB-

During

internatal

care

providers

need

to

discuss

with

their

patients

recurrence

risk

in

the

subsequent

pregnancy

They

also

need

to

be

aware

that

preeclampsia

has

been

associated

with

increased

risk

of

maternal

cardiovascular

diseases

later

in

life

-LSB-

-RSB-

and

that

attention

to

cardiovascular

risk

factors

is

required

in

all

subsequent

internatal

care

and

wellness

visits

Presently

there

is

no

proven

internatal

clinical

intervention

for

the

prevention

of

recurrent

gestational

hypertension

or

preeclampsia

During

a

subsequent

pregnancy

antihypertensive

therapy

should

be

used

only

for

pregnant

women

with

severe

hypertension

as

pharmocologic

treatment

of

women

with

uncomplicated

mild

chronic

hypertension

has

not

been

found

to

be

beneficial

-LSB-

-RSB-

Several

studies

failed

to

demonstrate

a

benefit

for

low-dose

aspirin

in

preventing

preeclampsia

among

women

with

chronic

hypertension

-LSB-

-RSB-

When

chronic

hypertension

is

complicated

by

intrauterine

growth

restriction

or

preeclampsia

fetal

surveillance

is

warranted

For

women

with

preeclampsia

during

a

previous

pregnancy

low-dose

aspirin

started

in

the

second

trimester

of

pregnancy

did

not

reduce

the

recurrence

risk

of

preeclampsia

-LSB-

-RSB-

Further

studies

are

needed

to

identify

effective

interventions

during

the

internatal

period

and

subsequent

pregnancy

to

prevent

recurrent

gestational

hypertension

or

preeclampsia

Women

with

pre-gestational

or

gestational

diabetes

mellitus

Diabetes

complicating

pregnancy

is

the

second

most

frequently

reported

medical

risk

factor

during

pregnancy

-LSB-

-RSB-

In

more

than

women

reported

having

diabetes

during

pregnancy

-LSB-

-RSB-

For

women

with

pre-gestational

diabetes

they

are

at

increased

risk

for

microvascular

neuropathic

and

cardiovascular

diseases

especially

if

the

diabetes

is

long-standing

and

poorly

controlled

Their

risks

are

reduced

with

tight

glycemic

control

Additionally

their

fetuses

are

at

increased

risk

for

stillbirth

and

congenital

anomalies

Preconception

glycemic

control

among

women

with

pre-gestational

diabetes

has

been

shown

to

reduce

the

risk

of

congenital

anomalies

-LSB-

-RSB-

Women

who

had

gestational

diabetes

have

chance

of

recurrence

during

their

next

pregnancy

-LSB-

-RSB-

and

an

increased

risk

of

developing

Type

II

diabetes

later

in

life

-LSB-

-RSB-

Gestational

diabetes

increases

the

risk

of

fetal

macrosomia

birth

trauma

newborn

hypoglycemia

and

hyperbilirubinemia

Evidence

from

animal

models

suggests

that

gestational

diabetes

especially

if

poorly

controlled

may

also

program

insulin

and

leptin

resistance

in

the

fetus

leading

the

greater

susceptibility

for

diabetes

and

obesity

in

the

offspring

-LSB-

-RSB-

For

women

with

pre-gestational

diabetes

internatal

care

should

follow

the

guidelines

issued

by

the

American

Diabetes

Association

on

preconception

care

of

women

with

chronic

diabetes

-LSB-

-RSB-

At

the

initial

office

visit

risk

assessment

should

include

a

complete

history

physical

examination

-LRB-

including

cardiovascular

neurological

and

dilated

retinal

exams

-RRB-

and

laboratory

evaluation

-LRB-

including

glycosylated

hemoglobin

-LRB-

-RRB-

serum

creatinine

and

urinary

excretion

of

total

protein

and/or

albumin

and

measurement

of

thyroid

stimulating

hormone

and/or

free

thyroxine

level

in

women

with

type

diabetes

because

of

the

to

coincidence

of

hyper

or

hypothyroidism

-RRB-

and

electrocardiogram

if

the

diabetes

has

been

long-standing

Health

promotion

should

emphasize

practical

self-management

skills

essential

for

glycemic

control

and

preparation

for

pregnancy

including

the

use

of

an

appropriate

meal

plan

self-monitoring

of

blood

glucose

-LRB-

SMBG

-RRB-

self-administration

of

insulin

and

self-adjustment

of

insulin

doses

treatment

of

hypoglycemia

-LRB-

patient

and

family

members

-RRB-

incorporation

of

physical

activity

and

development

of

stress

reduction

techniques

Patients

should

be

counseled

about

fetal

and

neonatal

complications

-LRB-

and

possibly

long-term

health

consequences

-RRB-

of

maternal

diabetes

including

the

risk

of

congenital

malformations

and

the

need

for

effective

contraception

and

optimal

glycemic

control

prior

to

the

next

pregnancy

Clinical

interventions

include

dietary

control

and

pharmacological

treatment

using

oral

hypoglycemics

or

insulin

Glycemic

control

can

be

self-monitored

at

home

and

glycosylated

hemoglobin

levels

should

be

evaluated

at

to

intervals

until

stable

Follow-up

visits

should

be

at

to

intervals

and

frequent

phone

contact

for

adjustment

of

insulin

doses

and

other

aspects

of

the

treatment

regimen

is

advised

Psychosocial

interventions

should

address

barriers

to

adherence

with

treatment

protocol

Referral

to

and

coordination

with

a

dietician

and

programs

such

as

W.I.C.

or

Sweet

Success

in

California

may

enhance

treatment

efficacy

Stress

management

should

be

emphasized

because

stress

can

affect

dietary

control

as

well

as

glucose

homeostasis

For

women

with

gestational

diabetes

in

a

previous

pregnancy

guidelines

for

internatal

care

are

less

well

established

The

American

Diabetes

Association

recommends

that

a

oral

glucose

tolerance

test

-LRB-

GTT

-RRB-

be

performed

to

weeks

after

delivery

-LSB-

-RSB-

The

extent

to

which

this

recommendation

is

adhered

is

presently

unknown

We

believe

that

much

more

can

be

done

in

the

internatal

period

to

promote

maternal

health

-LRB-

as

well

as

fetal

health

in

a

subsequent

pregnancy

-RRB-

among

women

with

gestational

diabetes

Because

these

women

are

at

increased

risk

for

developing

type

II

diabetes

risk

assessment

should

include

a

fasting

glucose

once

a

year

If

clinical

assessment

suggests

polycystic

ovarian

syndrome

and/or

metabolic

syndrome

periodic

testing

for

lipoprotein

profiles

fasting

glucose

and

possibly

glucose

tolerance

test

may

be

warranted

-LSB-

-RSB-

Patients

should

be

evaluated

for

glucose

intolerance

before

their

next

pregnancy

For

health

promotion

all

women

who

have

had

gestational

diabetes

should

be

encouraged

to

exercise

and

lose

weight

if

they

are

obese

Dietary

counseling

is

recommended

given

their

increased

risk

for

future

type

II

diabetes

Presently

there

are

no

specific

clinical

interventions

recommended

in

the

internatal

period

for

women

with

a

history

of

gestational

diabetes

During

a

subsequent

pregnancy

women

with

pregestational

diabetes

using

oral

hypoglycemic

agents

should

be

switched

to

insulin

because

the

safety

and

efficacy

of

currently

available

oral

hypoglycemics

have

not

been

evaluated

for

use

in

pregnancy

among

women

with

pregestational

diabetes

For

women

with

gestational

diabetes

in

a

prior

pregnancy

the

use

of

a

second-generation

oral

hypoglycemic

agent

-LRB-

i.e.

glibenclamide

or

glyburide

-RRB-

may

be

considered

if

gestational

diabetes

recurs

in

a

subsequent

pregnancy

The

agent

does

not

cross

the

placenta

and

has

been

shown

to

be

comparable

to

insulin

in

improving

glucose

control

for

women

with

gestational

diabetes

-LSB-

-RSB-

Weight

gain

during

pregnancy

should

be

closely

monitored

Women

who

are

underweight

overweight

or

obese

A

growing

number

of

women

of

reproductive

age

in

the

U.S.

are

overweight

or

obese

According

to

the

National

Health

Interview

Survey

one-third

of

women

ages

to

and

of

women

ages

to

are

overweight

-LSB-

-RSB-

The

survey

also

found

one

in

eight

women

ages

to

and

one

in

six

women

ages

to

are

obese

-LSB-

-RSB-

Based

on

the

CDC

Pregnancy

Nutrition

Surveillance

System

-LRB-

PNSS

-RRB-

of

nearly

low-income

pregnant

women

had

a

prepregnancy

body

mass

index

-LRB-

BMI

-RRB-

that

is

considered

overweight

or

obese

up

from

less

than

in

-LSB-

-RSB-

Maternal

obesity

poses

a

threat

to

not

only

subsequent

pregnancy

outcomes

but

also

long-term

maternal

health

Pregnancy

itself

is

a

risk

factor

for

maternal

obesity

According

to

the

PNSS

more

than

had

gained

more

than

the

ideal

weight

gain

-LSB-

-RSB-

and

as

previously

cited

-LSB-

-RSB-

weight

retention

following

pregnancy

is

common

Weight

retention

needs

to

be

addressed

during

internatal

care

particularly

for

women

who

are

overweight

or

obese

According

to

the

PNSS

one

in

eight

pregnant

women

were

underweight

before

pregnancy

and

one

in

four

had

gained

less

than

the

ideal

weight

gain

during

pregnancy

-LSB-

-RSB-

Both

low

pre-pregnancy

BMI

and

poor

pregnancy

weight

gain

have

been

shown

to

be

risk

factors

for

preterm

delivery

and

low

birth

weight

-LSB-

-RSB-

For

women

who

are

underweight

overweight

or

obese

an

important

goal

of

internatal

care

is

to

optimize

their

weight

prior

to

the

next

pregnancy

For

risk

assessment

the

BMI

can

be

used

because

it

provides

an

acceptable

approximation

of

body

fat

and

fair

correlation

with

disease

outcomes

Potential

causes

of

underweight

-LRB-

e.g.

eating

disorders

food

insecurity

-RRB-

overweight

or

obesity

-LRB-

e.g.

polycystic

ovarian

syndrome

-RRB-

need

to

be

evaluated

For

health

promotion

women

who

are

underweight

should

be

encouraged

to

gain

weight

through

healthy

nutrition

for

women

who

are

overweight

or

obese

clinical

guidelines

have

been

established

for

the

identification

evaluation

and

treatment

of

overweight

and

obesity

-LSB-

-RSB-

These

guidelines

should

be

followed

for

internatal

care

The

initial

goal

of

weight

loss

therapy

should

be

to

reduce

body

weight

by

approximately

percent

from

baseline

and

weight

loss

should

be

about

to

pounds

per

week

for

a

period

of

about

months

This

amount

of

postpartum

weight

loss

in

overweight

women

does

not

appear

to

affect

the

growth

of

their

infants

even

if

they

are

exclusively

breastfed

-LSB-

-RSB-

Weight

loss

and

weight

maintenance

therapy

should

employ

the

combination

of

low-calorie

diets

increased

physical

activity

and

behavior

therapy

Clinical

interventions

may

include

weight

loss

drugs

as

an

adjunct

to

diet

and

physical

activity

for

patients

with

a

BMI

of

as

well

as

for

patients

with

a

BMI

of

with

concomitant

risk

factors

or

diseases

After

successful

weight

loss

the

likelihood

of

weight

loss

maintenance

is

enhanced

by

a

program

consisting

of

dietary

therapy

physical

activity

and

behavior

therapy

which

should

be

continued

until

the

next

pregnancy

Psychosocial

interventions

should

address

barriers

to

healthy

nutrition

and

coordination

with

a

dietician

WIC

and

other

community

programs

The

schedule

of

internatal

visits

should

be

individualized

the

literature

suggests

that

frequent

contacts

between

professional

counselors

and

patients

help

promote

healthy

weight

maintenance

In

a

subsequent

pregnancy

the

Institute

of

Medicine

guidelines

for

weight

gain

during

pregnancy

should

be

promoted

based

on

prepregnancy

BMI

-LSB-

-RSB-

Women

who

had

a

prior

preterm

birth

Presently

this

group

of

women

is

most

often

targeted

for

internatal

care

Preterm

birth

is

a

leading

cause

of

infant

mortality

and

long-term

disabilities

in

children

in

the

U.S.

Prior

preterm

birth

is

the

strongest

and

most

consistent

predictor

of

a

subsequent

preterm

birth

This

may

be

due

to

the

fact

that

many

of

the

biobehavioral

risk

factors

for

preterm

birth

are

carried

from

one

pregnancy

to

the

next

The

goal

of

internatal

care

for

these

women

is

to

prevent

recurrence

of

preterm

birth

by

addressing

these

continuing

biobehavioral

risks

prior

to

their

next

pregnancy

Risk

assessment

Women

who

had

a

preterm

birth

should

undergo

a

comprehensive

risk

assessment

starting

with

a

complete

review

of

their

obstetrical

history

at

the

two-week

visit

Distinction

should

be

made

between

spontaneous

and

induced

preterm

deliveries

Details

about

the

preterm

delivery

should

be

obtained

Work-up

should

be

guided

by

known

etiologic

pathways

-LRB-

e.g.

infectious-inflammatory

vascular

neuroendocrine

and

pathologic

uterine

over-distension

-RRB-

-LSB-

-RSB-

To

identify

infectious-inflammatory

causes

medical

records

should

be

reviewed

for

untreated

infections

-LRB-

e.g.

asymptomatic

bacteriuria

-RRB-

physical

examination

should

be

performed

to

uncover

on-going

chronic

infections

-LRB-

e.g.

periodontal

or

reproductive

tract

infections

-RRB-

and

placental

pathology

should

be

reviewed

for

evidence

of

chorioamnionitis

-LSB-

-RSB-

To

identify

vascular

causes

placental

pathology

should

be

reviewed

for

evidence

of

uteroplacental

ischemia

and

thromboses

-LSB-

-RSB-

The

presence

of

these

findings

in

the

absence

of

known

causes

may

indicate

work-up

for

hereditary

or

acquired

thrombophilia

-LSB-

-RSB-

To

identify

neuroendocrine

causes

inquiries

should

be

made

about

psychosocial

stress

and

support

during

pregnancy

Special

attention

should

be

paid

to

FINDS

-LRB-

family

violence

infections

nutrition

depression

and

stress

-RRB-

since

these

risk

factors

may

be

involved

in

one

or

more

etiologic

pathways

leading

to

the

occurrence

or

recurrence

of

preterm

birth

Review

of

past

medical

history

should

focus

on

conditions

that

could

increase

the

risk

of

preterm

deliveries

-LRB-

e.g.

systemic

lupus

erythematosus

or

renal

disease

-RRB-

Review

of

family

history

should

identify

other

preterm

deliveries

in

the

family

-LRB-

particularly

among

first-degree

relatives

-RRB-

as

well

as

other

conditions

associated

with

preterm

deliveries

A

thorough

review

of

reproductive

history

including

other

preterm

births

or

pregnancy

losses

sexual

history

including

sexually

transmitted

infections

past

and

current

contraceptive

use

and

plans

for

future

childbearing

and

child

spacing

should

be

conducted

Health

promotion

The

goal

of

health

promotion

is

to

promote

protective

factors

and

reduce

risk

factors

for

recurrent

preterm

births

We

will

highlight

three

areas

of

health

promotion

smoking

cessation

healthy

nutrition

and

family

planning

First

exposure

to

cigarette

smoking

significantly

increases

the

risk

of

preterm

delivery

Smoking

cessation

-LRB-

by

women

and

their

partners

-RRB-

should

be

encouraged

during

internatal

care

As

previously

discussed

effective

models

of

clinical

interventions

-LRB-

e.g.

's

-RRB-

have

been

developed

-LSB-

-RSB-

Second

healthy

nutrition

should

be

promoted

Low

pre-pregnancy

BMI

has

been

associated

with

increased

risk

for

spontaneous

preterm

birth

while

high

pre-pregnancy

BMI

has

been

associated

with

increased

risk

for

indicated

preterm

birth

-LSB-

-RSB-

For

women

with

a

history

of

preterm

birth

achieving

a

healthy

weight

prior

to

their

next

pregnancy

may

reduce

the

risk

of

recurrent

preterm

birth

A

number

of

programs

have

demonstrated

effectiveness

in

helping

women

achieve

and

maintain

healthy

weight

-LSB-

-RSB-

Additionally

nutrition

may

also

play

an

important

role

in

modulating

several

of

the

etiologic

pathways

leading

to

preterm

birth

For

example

increased

dietary

intake

of

polyunsaturated

fatty

acids

may

help

modulate

inflammation

-LSB-

-RSB-

Women

should

be

encouraged

to

increase

consumption

of

foods

rich

in

-LRB-

the

International

Society

for

the

Study

of

Fatty

Acids

and

Lipids

recommends

that

during

pregnancy

and

lactation

women

must

ensure

a

minimum

daily

intake

of

mg

of

Docosahexaenoic

Acid

or

DHA

an

important

source

of

fatty

acids

-LSB-

-RSB-

-RRB-

and

decrease

consumption

of

foods

high

in

saturated

fatty

acids

trans-fats

and

partially-hydrogenated

oils

Increasing

dietary

intake

of

fruits

and

vegetables

rich

in

anti-oxidants

and

certain

phytochemicals

should

also

be

encouraged

These

recommendations

could

arguably

be

adopted

on

the

basis

of

promoting

women

's

health

alone

even

in

the

absence

of

data

supporting

their

effectiveness

in

preventing

recurrent

preterm

birth

Third

the

importance

of

family

planning

can

not

be

over-emphasized

particularly

for

women

with

a

history

of

preterm

birth

Both

unintended

pregnancies

and

short

interpregnancy

intervals

are

associated

with

increased

risk

for

preterm

delivery

Family

planning

has

been

shown

to

reduce

unintended

pregnancies

and

promote

optimal

child

spacing

Other

BBEEFF

topics

such

as

breastfeeding

and

back-to-sleep

are

also

important

to

address

with

mothers

of

preterm

babies

Clinical

interventions

To

our

knowledge

there

has

been

only

one

randomized

controlled

trial

for

the

prevention

of

recurrent

preterm

birth

in

which

a

specific

clinical

intervention

is

initiated

during

the

interpregnancy

period

-LSB-

-RSB-

In

that

study

women

with

a

prior

spontaneous

preterm

birth

at

less

than

weeks

of

gestation

were

randomized

at

months

postpartum

to

a

course

of

oral

azithromycin

and

sustained-release

metronidazole

or

placebo

The

regimen

was

repeated

every

months

until

conception

of

another

pregnancy

The

investigators

found

no

significant

difference

in

the

rates

of

preterm

birth

between

the

study

and

control

groups

In

fact

women

in

the

treatment

group

on

average

had

lower

birth

weight

babies

and

delivered

weeks

earlier

-LSB-

-RSB-

In

the

absence

of

evidence

of

effectiveness

for

preventing

recurrent

preterm

birth

presently

no

specific

clinical

intervention

can

be

recommended

for

women

with

prior

preterm

birth

in

the

interpregnancy

period

Several

studies

have

examined

the

effectiveness

of

clinical

interventions

applied

to

women

with

prior

preterm

birth

during

a

subsequent

pregnancy

for

the

prevention

of

recurrent

preterm

birth

Perhaps

the

most

promising

is

the

use

of

progesterone

A

large

randomized

controlled

trial

in

the

U.S.

-LSB-

-RSB-

and

two

recent

meta-analyses

-LSB-

-RSB-

found

evidence

of

effectiveness

of

progestational

agents

-LRB-

e.g.

caproate

-RRB-

for

the

prevention

of

preterm

or

recurrent

preterm

birth

However

because

unresolved

issues

remain

such

as

optimal

route

of

drug

delivery

and

long-term

safety

of

the

drug

the

American

College

of

Obstetricians

and

Gynecologists

-LRB-

ACOG

-RRB-

has

issued

a

committee

opinion

that

when

progesterone

is

used

it

is

important

to

restrict

its

use

only

to

women

with

a

documented

history

of

a

previous

spontaneous

birth

at

less

than

weeks

of

gestation

-LSB-

-RSB-

Another

promising

clinical

intervention

is

the

use

of

fish

oil

supplementation

for

the

prevention

of

recurrent

preterm

birth

In

the

Fish

Oil

Trials

in

Pregnancy

-LRB-

FOTIP

-RRB-

study

fish

oil

supplementation

in

a

subsequent

pregnancy

significantly

reduced

recurrence

risk

of

preterm

delivery

-LSB-

-RSB-

There

is

also

emerging

evidence

that

scaling

and

root

planing

in

pregnant

women

with

periodontitis

may

reduce

preterm

birth

-LSB-

-RSB-

though

no

published

studies

have

evaluated

the

effectiveness

of

periodontal

screening

in

women

with

prior

preterm

birth

Further

studies

are

needed

to

demonstrate

the

effectiveness

of

these

interventions

Perhaps

the

most

controversial

clinical

intervention

is

antibiotic

treatment

of

asymptomatic

bacterial

vaginosis

among

women

with

a

history

of

preterm

birth

-LSB-

-RSB-

While

some

studies

have

shown

a

benefit

others

have

not

Efficacy

of

treatment

may

depend

on

the

agent

used

the

route

of

administration

the

timing

of

treatment

test

of

cure

and

a

number

of

host

factors

In

at

least

four

antibiotic

trials

in

pregnancy

involving

women

with

prior

preterm

birth

-LSB-

-RSB-

antibiotic

treatment

-LRB-

of

bacterial

vaginosis

Trichomonas

vaginalis

or

periodontal

infection

-RRB-

was

associated

with

higher

not

lower

incidence

of

recurrent

preterm

birth

Clearly

there

is

a

need

for

further

intervention

studies

guided

by

better

understanding

of

pharmacokinetics

and

pharmacogenetics

disease

mechanisms

and

host

response

as

this

remains

a

potentially

important

area

of

intervention

for

the

prevention

of

recurrent

preterm

birth

Psychosocial

interventions

A

growing

body

of

evidence

suggests

that

maternal

psychosocial

stress

is

an

important

risk

factor

for

preterm

delivery

and

that

risk

can

be

mitigated

by

reducing

stress

and/or

increasing

support

However

most

extant

studies

of

social

support

during

pregnancy

suffer

from

methodological

flaws

-LSB-

-RSB-

and

there

is

a

paucity

of

research

on

the

effectiveness

of

preconception

or

internatal

support

The

provision

of

social

clinical

and

parenting

support

during

the

internatal

period

as

previously

described

may

be

quite

valuable

to

mothers

of

a

preterm

infant

who

often

has

special

healthcare

and

other

developmental

needs

that

require

additional

support

services

Such

services

may

also

be

particularly

beneficial

to

low-SES

mothers

who

may

face

greater

burdens

with

less

personal

and

social

resources

to

deal

with

them

More

research

is

needed

to

identify

effective

models

of

internatal

psychosocial

interventions

for

women

with

a

history

of

preterm

delivery

Service

coordination

and

integration

Women

who

have

had

a

preterm

birth

may

require

multiple

services

during

the

internatal

period

particularly

if

their

children

have

significant

disabilities

and

special

healthcare

needs

Providing

integrated

services

including

linkages

to

early

intervention

or

other

early

child

development

programs

for

preterm

or

LBW

infants

should

be

a

primary

objective

of

care

for

these

women

Several

models

of

care

coordination

and

service

integration

have

been

developed

-LSB-

-RSB-

One

of

the

most

successful

models

is

the

Olds

nurse

home

visitation

program

-LSB-

-RSB-

The

program

provided

nurse

home

visitation

during

pregnancy

and

the

first

two

years

postpartum

Evaluation

of

the

Memphis/Shelby

County

program

-LSB-

-RSB-

found

women

who

received

home

visits

by

nurses

had

fewer

closely

spaced

subsequent

pregnancies

longer

internatal

intervals

and

fewer

months

of

using

public

assistance

programs

compared

to

a

control

group

of

women

There

were

however

no

statistically

significant

program

effects

on

LBW

or

stillbirth

in

the

subsequent

pregnancy

The

program

is

technically

not

an

internatal

care

program

and

not

targeted

specifically

to

women

who

had

a

preterm

birth

but

this

model

could

potentially

be

adapted

by

Healthy

Start

or

other

public

health

or

community-based

programs

to

provide

service

coordination

and

integration

for

internatal

care

using

community

nurses

We

recommend

that

all

women

with

prior

preterm

birth

be

offered

care

coordination

and/or

home

visitation

during

internatal

care

Schedule

of

visits

The

schedule

of

internatal

visits

for

women

with

prior

preterm

birth

needs

to

be

individualized

-LRB-

with

a

minimum

of

three

visits

plus

annual

visits

as

previously

described

-RRB-

depending

on

the

clinical

and

psychosocial

needs

of

the

woman

and

family

During

their

subsequent

pregnancy

these

women

should

be

supervised

by

a

maternal

fetal

medicine

specialist

either

directly

or

indirectly

through

consultations

In

sum

given

the

large

impact

of

preterm

birth

on

infant

mortality

and

childhood

disabilities

and

the

high

rates

of

recurrence

in

a

subsequent

pregnancy

women

with

prior

preterm

birth

could

be

one

of

the

most

critical

target

groups

for

enhanced

internatal

care

Other

high-risk

women

-LRB-

e.g.

women

with

prior

fetal

death

-RRB-

could

also

benefit

from

such

program

we

are

unable

to

describe

the

content

of

their

care

in

this

paper

due

to

space

limitation

and

will

do

so

in

a

series

of

papers

to

follow

The

goal

of

such

program

is

to

prevent

recurrence

of

preterm

birth

by

addressing

known

biobehavioral

pathways

-LRB-

e.g.

infections/inflammation

neuroendocrine

vascular

etc

-RRB-

prior

to

the

next

pregnancy

There

is

a

great

need

for

more

comprehensive

and

systematic

risk

assessment

and

health

promotion

during

internatal

care

as

well

as

more

basic

clinical

and

intervention

research

to

identify

effective

clinical

and

psychosocial

interventions

for

the

prevention

of

recurrent

preterm

birth

Conclusion

In

this

paper

we

began

to

define

the

contents

of

internatal

care

We

recommended

expanding

the

current

six-week

postpartum

visit

to

three

or

more

internatal

visits

-LRB-

at

two

weeks

six

weeks

and

six

months

postpartum

and

annual

visits

beginning

at

one-year

postpartum

-RRB-

We

suggested

some

core

contents

that

all

women

should

receive

during

internatal

care

including

risk

assessment

-LRB-

e.g.

FINDS

-RRB-

health

promotion

-LRB-

e.g.

BBEEFF

-RRB-

clinical

and

psychosocial

interventions

For

women

with

chronic

health

conditions

such

as

hypertension

diabetes

or

weight

problems

we

identified

clinical

guidelines

for

their

evaluation

treatment

and

follow-up

during

the

internatal

period

For

women

who

had

a

preterm

birth

we

proposed

an

internatal

care

model

based

on

known

etiologic

pathways

with

the

goal

of

preventing

recurrence

by

addressing

these

biobehavioral

pathways

prior

to

the

next

pregnancy

We

suggested

enhancing

service

integration

for

women

and

families

including

possibly

care

coordination

or

home

visitation

for

women

with

prior

preterm

birth

We

were

limited

in

our

effort

to

define

the

contents

of

internatal

care

by

the

paucity

of

research

on

the

internatal

period

Many

pre-disease

pathways

leading

to

recurrence

of

adverse

birth

outcomes

have

not

yet

been

elucidated

More

importantly

even

less

is

known

about

the

trajectories

to

long-term

women

's

health

or

child

health

or

how

to

alter

these

pathways

and

trajectories

There

is

a

need

for

more

intervention

studies

evaluating

the

effectiveness

of

the

various

components

of

internatal

care

More

importantly

we

need

more

research

on

mechanisms

of

disease

to

guide

the

design

of

internatal

interventions

Our

proposal

will

need

to

be

updated

and

revised

continually

as

new

research

data

emerge

We

were

also

limited

by

the

paucity

of

research

on

community-level

or

public

health

interventions

during

the

internatal

period

While

our

paper

focused

on

the

contents

of

the

clinical

visits

we

believe

that

provision

of

internatal

care

should

not

be

limited

to

the

clinician

's

office

For

example

clinical

interventions

to

control

hypertension

may

be

more

effective

if

they

are

supported

by

community-level

or

public

health

interventions

such

as

implementation

of

the

American

Public

Health

Association

resolution

that

the

food

manufacturers

and

restaurants

reduce

sodium

in

the

food

supply

by

percent

over

the

next

decade

-LSB-

-RSB-

The

's

of

smoking

cessation

may

be

more

effective

if

they

are

supported

by

multilevel

interventions

at

the

interpersonal

-LRB-

e.g.

targetting

partner

smoking

-RRB-

community

and

institutional

-LRB-

e.g.

billboards

and

marketing

of

tobacco

products

access

to

smoking

cessation

programs

-RRB-

and

policy

levels

-LRB-

e.g.

ban

on

smoking

in

public

space

promotion

of

smoke-free

environments

and

increased

taxation

on

tobacco

products

-RRB-

-LSB-

-RSB-

We

believe

that

the

ultimate

success

of

internatal

care

may

hinge

on

the

development

of

a

much

broader

and

more

integrated

conception

of

internatal

care

than

currently

prevails

with

prenatal

care

-LSB-

-RSB-

Presently

there

are

numerous

public

health

programs

offering

some

components

of

internatal

care

including

many

Healthy

Start

programs

They

could

provide

the

ideal

social

laboratory

settings

for

implementing

and

evaluating

various

community-level

interventions

While

there

are

significant

challenges

to

this

type

of

research

it

needs

to

be

done

Identifying

what

internatal

interventions

work

in

the

community

may

be

just

as

important

as

identifying

what

works

in

the

clinical

setting

Such

research

needs

to

be

guided

by

the

principles

and

methods

of

community-based

participatory

research

-LRB-

CBPR

-RRB-

-LSB-

-RSB-

and

be

held

to

scientifically

rigorous

standards

Although

more

research

is

needed

to

identify

effective

internatal

interventions

we

believe

we

can

not

wait

for

the

perfect

studies

to

be

done

We

must

begin

to

act

Most

of

our

recommendations

can

be

justified

on

the

basis

of

providing

good

preventive

and

primary

care

for

women

and

children

even

in

the

absence

of

conclusive

evidence

supporting

their

effectiveness

in

improving

subsequent

pregnancy

outcomes

For

the

most

part

they

reflect

current

practice

standards

recommended

by

major

national

organizations

-LRB-

Table

-RRB-

most

of

these

are

considered

standards

of

care

or

best

practices

in

women

's

and

children

's

health

care

The

only

recommendations

without

the

endorsement

of

a

national

organization

screening

for

psychosocial

stress

and

provision

of

psychosocial

support

are

based

on

our

collective

opinions

we

strongly

believe

these

are

important

to

reduce

allostatic

load

on

women

's

health

and

improve

subsequent

pregnancy

outcome

In

this

paper

we

did

not

attempt

to

address

all

the

institutional

components

and

challenges

in

developing

a

successful

model

of

internatal

care

only

the

content

of

such

a

program

This

paper

reflects

our

effort

to

start

the

process

of

defining

the

contents

of

internatal

care

We

hope

that

this

paper

can

be

used

to

stimulate

further

dialogues

about

internatal

care

Such

dialogues

we

believe

are

needed

to

move

forward

research

practice

and

policy

on

internatal

care

and

to

move

this

nation

one

step

closer

toward

the

provision

of

a

more

universal

longitudinally-integrated

continuum

of

women

's

healthcare

preconception care
internatal care
content
preterm birth
interpregnancy