Maternal Health and Well-being

A prenatal visit is important, especially for high-risk expectant families. AAP recommends a pediatric prenatal visit during the third trimester with a pediatrician to help establish a child’s medical home as well as build a supportive and trusting family-pediatric relationship prior to the baby’s birth. The prenatal visit is important for high-risk expectant families. Less than 5% of urban poor pregnant women see a pediatrician during the prenatal period although they are at higher risk of adverse pregnancy outcomes pregnant women in rural areas may have even more difficulty accessing a prenatal visit

During the postpartum period infants are seen frequently by pediatricians and expectant families are seen less frequently by their health care providers. Although the American College of Obstetrics recommends all expectant families be seen within 3 weeks of delivery, it is typical to see a provider 6 weeks after birth. Thus, the pediatrician is vital in supporting both infants and expectant families during this critical health period.

Perinatal Disparities

Disparities in access to health care services, lack of paid family leave, and other social drivers of health (SDOH), can impact expecting families’ ability to sustain or obtain optimal health, directly impacting the care the family can provide to their baby.

Centers for Disease Control and Prevention (CDC). Preventing Pregnancy-Related Deaths. 2019.
Hoyert, CDC. Maternal Mortality Rates in the United States, 2020. 2022.
March of Dimes. Nowhere To Go: Maternity Care Deserts Across the U.S. (2022 Report). 2022.

Pediatrician Prenatal Visit Payment

Pediatricians and their care teams may discuss whether the visit will be covered by the expectant family’s insurance and whether a referral will be required. Payment advocacy is often required with payers. Office visits for new outpatient payment codes include 99201, 99202, 99203, 99204, and 99205 based on medical decision-making complexity and length of visit. Pediatricians and other providers can use the ICD-10 CM code Z76.81 for expectant parent(s) prebirth pediatrician visit.

Prenatal Visit Objectives

Provide a foundation on which to build a positive family-pediatric partnership, a crucial part of the patient-centered medical home.
Access pertinent aspects of the past obstetric and present prenatal history; to review family history of genetic or chromosomal disorders and to review fetal exposure to substances that may affect the infant.
Introduce anticipatory guidance about early infant care and infant safety practices.
Identify psychosocial factors that may affect family function and family adjustment to the newborn.

Follow these steps to improve maternal health and well-being care.

Step 1. Build Awareness

It is important for pediatricians and care teams to have an early understanding of each family’s medical and social history that may impact family’s overall well-being and healthy child development. Additionally, all staff should be aware of perinatal complications that occur during pregnancy and up to one year after delivery. Some expecting families may not recognize the symptoms or know when it is necessary to seek medical attention.

Hear Her Campaign from CDC features compelling stories from women about their pregnancy and birth experiences, complications, and conditions that affected them and how they got help.

Educate yourself on the risks by visiting the American College of Obstetricians and Gynecology site for materials Medical Problems During Pregnancy and Medical Problems After Pregnancy

Perinatal depression
Cardiovascular diseases
Infection or sepsis
Hemorrhage: excessive bleeding after giving birth
Cardiomyopathy: a disease of the heart muscle that makes it harder for your heart to pump blood to the rest of your body
Thrombotic pulmonary embolism: blockage in one of the pulmonary arteries in the lungs often caused by blood clots that travel to the lungs from the legs
Stroke
High blood pressure (hypertensive) disorders of pregnancy
Amniotic fluid embolism: A rare but serious condition that occurs when amniotic fluid or fetal material, such as fetal cells, enters the mother's bloodstream
Anesthesia complications
Perinatal anxiety, other mood disorders, and/or family mental health
Substance, alcohol, or tobacco use
Other family medical or chronic conditions often reflecting pre-existing illnesses

Step 2. Equip Offices

Train all staff in maternal health and well-being topics and practice family-centered discussions.
Compile list of resources and organizations that support families’ needs
- Use this comprehensive resource list AAP STAR Center Community Resource Directory and consider adding birthing and caregiving classes typically offered by local hospitals, clinics, doulas, home visiting, and family support organizations or virtually.
- Incorporate resources that promote maternal health and well-being like American College of Obstetricians and Gynecologists (ACOG) Your Postpartum Care Team Infographic, parenting resources like Triple P, Mt. Sinai Parenting Center, and Ohio AAP Chapter Purposeful Parenting, and healthy child development resources such as AAP Early Childhood Campaign Toolkit.
- Include supports for maternal health and well-being needs such as AAP Perinatal Mental Health and Social Supports, Postpartum Support International, mental health services and substance use Find Treatment | SAMHSA, and domestic violence resources Signs of Domestic Abuse - Domestic Violence: It's EVERYBODY'S Business.
Build partnerships with obstetricians/gynecologists, advanced practice nurses, certified nurse/ midwives, and birthing hospitals and centers in your community.
Review trauma-informed care principles and consider Recommendations for Integrating Trauma Informed Approaches into Pediatric Practice from Boston Medical Center for Urban Child and Family. Review AAP recommendations and resources for trauma and resilience-informed care.

Step 3. Build Positive Relationships with Families

Use the pediatric prenatal visit and the infant well-child visits to ask questions about the caregiver’s health, family and social history, hopes and goals for their child/ren, and parenting styles.

Review AAP Bright Futures guidance.
Use relational health to frame your well-child visits to promote healthy caregiver-child interactions, foster attachment, and Identify Strengths, Protective Factors, and Risks that could be impacting the family.
Practice the Common Factors HELP communication approach to inspire hope, empathy, demonstrate loyalty, and build partnerships.

What to Ask:

AAP and Bright Futures recommend a family and social history should include strengths, protective factors, and risks.

Start by asking, “How are you coping with pregnancy/your new baby/recovery? Who supports you?”
Commend strengths by asking, “What is the best part about being a parent?”
See this Learn the Signs. Act Early resource for ideas on how to discuss strengths, protective factors, and risks with families. Here are some examples.

Strengths	Protective Factors	Risks
Caregiver well-being Community support Caregiving and child development knowledge and skills Healthy social-emotional child development Positive childhood experiences	Safe, stable, nurturing relationships Family support Positive caregiver-child interactions Quality time Family routines including early literacy and healthy sleep Ability to cope with stress/caregiver resilience Belonging to a community Employment/insurance status	Poverty Racism Foster/kinship care Abuse and neglect Family mental illness Family substance use Employment/insurance status Food insecurity Smoking in the home Sleeping habits

What to Know:

Learn more about a relational health development timeline. Also see AAP policy statement on Preventing Childhood Toxic Stress.

Step 4. Address Immediate Physical and Mental Health Needs

Prior to the visit, ask the family to fill out a perinatal depression screening. See AAP Perinatal Mental Health and Social Support and AAP Screening and Technical Assistance Resource (STAR) Center

What to Ask:

Acknowledge and validate that postpartum is a new and challenging phase for all parenting people.

Are you experiencing any of these symptoms: fever, headache, dizziness, heavy bleeding, chest pain, or trouble breathing?
Have you been overwhelmed and extra anxious since having your baby/while pregnant?

What to Know:

Know the warning signs of health problems after birth

Headache that does not go away or gets worse over time
Dizziness or fainting
Changes in vision
Fever of 100.4 or higher
Extreme swelling of face and hands
Thoughts about harming self, baby, or others
Trouble breathing
Chest pain or fast-beating heart
Severe swelling, redness or pain in leg(s) or arm(s)
Overwhelming tiredness

Perinatal depression and anxiety can manifest as symptoms such as heightened fight or flight response, rage and irritability, increased need for control, feelings of guilt or not being good enough, sweating, paresthesia (pins and needles) in hands, arms, and face, and dizziness. Review the AAP policy statement on Perinatal Depression Recognition and Management and see more information about how to start the conversation.

Step 5. Deliver Equitable Care Approaches

Discover community-based models in your area. Strengthen partnerships with and connect expectant families to

Community-based doulas
Midwives
Group prenatal and postnatal care; Centering Pregnancy,
Pregnancy medical homes,
Home visiting services,
Community birthing centers,
Community health workers, and
Mom & Baby Mobile Health Centers®.

Learn more about

Supporting Black Women’s Maternal Health Journey by the American Heart Association.
Best Practices for Identifying, Engaging, and Sustaining Family Advisors.
Watch and learn from
- Why Race Matters and Mitigating Implicit Bias in Communication with Patients and Families from Tiffani Johnson, MD, MSc, FAAP
- Awareness to Action” Dismantling Bias in Maternal and Infant Healthcare from March of Dimes with CME and CNE.
- Addressing Mental Health in BIPOC Communities: Key Considerations for Maternal Child Health from the Association of Maternal and Child Health Programs (AMCHP).

Improve patient care with

AAFP EveryONE Toolkit to make improvements and facilitate discussions with staff.
AAP Words Matter guidance on inclusive and anti-biased language.
March of Dimes Early Entry Into Prenatal Care Resource Guide quality improvement toolkit.

AAP Policy Statements

AAP Patient Care Resources

Last Updated

11/14/2022

Source

American Academy of Pediatrics