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Support, Rather Than Scold, Mothers Who Don't Seek Prenatal Care

Juniper J. Lee Park, MD and Trevor L. Valentine, MD, FAAP
April 4, 2018


She was an incredibly alert and beautiful little girl. On her tiny face, her bright eyes were carefully studying her surroundings. Developmental assessments for Zoe revealed her to have an impressive ability to follow the examining physician’s voice and visual cues—referred to as auditory and visual responses—and to make the transition from sleeping to being awake and back to sleeping again smoothly. These were reassuring behaviors in a neurologically vulnerable premature baby and she was likely to be discharged today.

 

There were unique considerations for Zoe’s discharge, however. Zoe’s mother, who came from a family with financial difficulties and subsequent instability, never sought any prenatal visit prior to the delivery. Although her pregnancy was considered high-risk due to a previous history of substance use, the financial challenges put a lot of pressure on her, ultimately keeping her from making necessary trips to the doctor’s office. Thankfully, the pregnancy was uneventful, but given her risk factors and absolute lack of prenatal care, carefully planned post-discharge management and further developmental follow-up appointments were called for. It was not difficult to predict that this would present additional challenges for a mother who already was under a lot of stress.

 

Although the number of U.S. women who receive adequate prenatal care has increased in recent years, many still go without. Federal data show that nearly a quarter million mothers of babies born in 2016 received late (third trimester) or no prenatal care. Babies of mothers who do not get prenatal care are 3 times more likely to have a low birth weight, according to the U.S. Department of Health & Human Services, and 5 times more likely to die than those born to mothers who do get care.

 

It would be easy to dwell on how the circumstances facing these babies and mothers could have been prevented with routine prenatal care. But as healthcare professionals, we need to avoid reprimanding mothers who already have been, and will continue to be, challenged by difficult social situations. The most effective and productive approach is guiding them in a healthy direction.

“In #AAPvoices, Drs. Juniper Lee Park & Trevor Valentine urge providers and policymakers to support, rather than punish, women dealing with socio-economic stress that gets in the way of adequate prenatal care.”

This an approach that state and local policy makers may wish to take, as well, before crafting laws that punish women for unhealthy behavior during pregnancy. For example, 24 states and the District of Columbia consider substance use during pregnancy to be child abuse under civil child-welfare statutes, and 3 of these consider it grounds for imprisonment.

 

When the Big Horn County Attorney's Office in Montana announced earlier this year that it would begin prosecuting and jailing pregnant women for drug or alcohol use, the American Academy of Pediatrics (AAP) joined with the American College of Obstetricians and Gynecologists, the American Society of Addiction Medicine, March of Dimes, and the National Organization on Fetal Alcohol Syndrome in pointing out that such punitive measures do more harm than good. In a joint statement, these groups stated that incarceration or the threat it, not only fails to reduce the incidence of alcohol or drug use, but also deters pregnant women from seeking prenatal care.

 

We invite policymakers to follow the lead of health care providers and help to prevent adverse birth outcomes through legislation and policies that support, rather than punish, women, children and families.

 

In addition to regular visits with an obstetrician, the AAP encourages a prenatal visit with a pediatrician, especially for first-time and higher-risk pregnancies. This visit can provide anticipatory support and guidance for new parents and establish a medical home that will be ready for the baby prior to delivery. Nevertheless, and as with the obstetric prenatal visits, it can be difficult for socioeconomically marginalized mothers to follow through with this, especially if they fear being punished for unhealthy behavior.


"Although the number of U.S. women who receive adequate prenatal care has increased in recent years, many still go without. Federal data show that nearly a quarter million mothers of babies born in 2016 received late (third trimester) or no prenatal care.

Whenever pediatricians do have the opportunity to provide prenatal care, perhaps we should consider ways to increase compliance with follow-up visits. Some approaches that may be useful:
  • Obtain a thorough social history.  
  • Ask about available resources and healthcare centers nearby for those who are in the resource-scarce areas.
  • Empower the mothers to share their thoughts, concerns, and anxieties about becoming a parent.
  • Introduce the concept of the routine prenatal and postnatal care, developmental surveillance, anticipatory guidance and its benefits.
  • Help families understand their rights and the scope of their responsibilities for the care of a newborn baby.
  • Connect families to local chapters of community organizations for children with special health care needs if the baby is at risk for developmental delays. 

Adequate prenatal care is important. Without proactive education based on attentive listening and that is free of judgment, however, its importance can be overlooked by parents who may be struggling with multiple socio-economic stressors.

To provide evidence-based, compassionate care that improves the health and well-being of mothers and children, punitive approaches are not the answer. As pediatricians, we have frontline opportunities to increase compliance with needed well child checks and developmental visits by helping to proactively identify and help address factors in the home environment that can be obstacles.

 After discharge, Zoe was set up for a neonatal intensive care follow-up visit, as well as her first appointment with a developmental pediatrician. Zoe's mother was provided a number of resources, including assistance with obtaining transportation, to help her make it to these appointments. We know this family may still face challenges to follow up care, but are hopeful for the opportunity to help Zoe thrive.

 

The views expressed in this article are those of the authors, and not necessarily those of the American Academy of Pediatrics. 
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​​​Ab​out the ​​Author



Juniper J. Lee Park, MD, is a first-year pediatrics resident at MedStar Georgetown University Hospital and a member of the AAP. She plans to pursue a fellowship training in neonatology after residency training.   








Trevor L. Valentine, MD, FAAP, is an Associate Professor of Clinical Pediatrics and Director of Developmental Services at MedStar Georgetown University Hospital in Washington DC. He provides direct patient care services in an outpatient setting, inpatient consultations and oversees undergraduate and resident physician education during their rotations in Developmental Pediatrics. 




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