Program focuses on moms’ health between pregnancies
The premise of a new program at UHS is simple but powerful: healthier moms mean healthier babies.
In 2018, a group of Family Practice senior residents from the UHS Family Medicine Residency Program created a project at UHS Primary Care Johnson City that has become a model for pre- and post-partum screening, care and follow-up.
Under the guidance of Joshua Steinberg, MD, the faculty family physician who directs both the Family Practice residency quality improvement curriculum and the obstetrics curriculum, the program has flourished and the results are impressive, with many women and infants benefiting from the focused approach.
“We began with the question: What does it take to improve maternal and fetal outcomes?” Dr. Steinberg said in describing the program. “And we started with mothers, because we know that women reliably come to medical professionals at well-baby appointments.”
He said: “What if, at the well-baby check-up, we could ask mothers some basic questions about their own health? We already have a relationship and a trust based on the care we provide for their children.”
Continuing, he noted: “Moms are busy with their families, jobs and other obligations, and their own health often falls down the list of priorities. If we wait for them to make their own appointments to discuss these concerns, for some women it’s just not going to happen.”
So at the beginning of 2018, the residency program teamed up with a research and quality improvement network called IMPLICIT, which stands for “Interventions to Minimize Preterm and Low Birth Weight Infants Using Continuous Quality Improvement Techniques.”
The network includes 23 physician training programs nationwide that pilot what is known as interconception care, or care between pregnancies. Each participating site reaches out to women prior to a next planned or unplanned pregnancy to check in on their health and well-being.
The IMPLICIT network approach focuses on smoking, folate vitamin use, depression and family planning. Attention to these issues leaves women healthier, better able to care for their existing children and better prepared physically and mentally for a subsequent pregnancy.
Dr. Steinberg worked with 10 members of the UHS Family Medicine Residency Program who see patients at the Johnson City office. The Family Medicine senior residents took the initiative to make the interconception care project happen, he said.
“All residents need training in quality improvement projects, and senior residents typically work in pairs to make a small improvement in operations,” he said. “But this year, the entire senior class of 10 residents focused on this project as a group, figuring out workflows and documentation, data collection, and how implementation impacts the practice overall.”
Jode Sissenstein-Pettit, a licensed practical nurse in the practice, noted: “The residents were all eager to partake in this – there was a lot of discussion and a free exchange of ideas among them about different parts of the project and what they were seeing with patients. It was nice to see.”
Nurses in the practice give each mother who arrives for a well-baby visit with a child (from birth to age 2) a four-point questionnaire about her health: Do you smoke? Are you experiencing post-partum depression? Are you planning a pregnancy? If so, are you taking a multivitamin, and if not, are you using contraception? During the visit, the resident or attending physician who is handling the child’s care also reviews the mom’s answers.
Many of the residents were surprised by the level of previously unscreened and untreated depression in mothers.
Said senior resident Urmi Das, MD: “I feel like moms are where it starts, and we can take the time to pay more attention to them, to make them aware of what they can do and how we can help.”
Dr. Das added that many parents who brought children in for pediatric care didn’t know that UHS Primary Care Johnson City is a full-service primary care practice, offering gynecological services to assist with family planning and post-partum depression care.
“In some cases, I have referred moms back to our practice for an appointment for themselves based on their answers to the screening questions,” Dr. Das said.
Added senior resident Sarah Wineholt, MD: “It’s easy for a new mother to let things slip through the cracks for herself because she is taking care of a little one, perhaps adapting to being a working parent, and balancing the needs of other children.”
Continuing, she noted: “Many women do not know that there is anything they should be changing about their lifestyles prior to a desired pregnancy. Also, many women who specifically do not wish to become pregnant are not taking measures to prevent it, so this program can help them understand their choices for family planning.”
The screening questionnaires were implemented in late March, and have been a smooth addition to appointments.
“I think the physicians are spending more time in general – going more in depth, collecting more detail, which is great,” said Ms. Sissenstein-Pettit. “Including the moms has been nice – to see some of the expressions on moms’ faces and hear comments like, ‘Wow, nobody has ever asked about me before’ has been positive. Preventing an unwanted pregnancy or catching post-partum depression quickly in a new mom here for a well-baby appointment is so significant.”
Depression following pregnancy is something mothers often experience, but it may not be on the radar the way it should, because a doctor’s office typically is focused on the health of the infant during a well-baby visit, she said.
“But treating post-partum depression can have a profound effect on the family – the marriage, the baby, the other kids – and catching it early is a big deal,” she noted.
Said Dr. Steinberg: “The goal for this year is to make these simple four-question evaluations part of business as usual during our well-baby visits. Medium-term, we’ll be contributing our data to the IMPLICIT research network and see how we’re making a difference related to four benchmark items.”
Long-term, the research network aspires to make a major impact on maternal-fetal deaths, which are unacceptably high in the United States, he said. He suggested that the medical community nationwide should strengthen its focus on mothers’ health before and between pregnancies in an effort to reduce the number.
According to the World Health Organization, between 1990 and 2013, the maternal mortality ratio for the U.S. more than doubled, from an estimated 12 maternal deaths per 100,000 births, to 28 per 100,000. About half of all maternal deaths in the U.S. are preventable.
“We hope this program will help more women quit smoking before they become pregnant, and help more plan their pregnancies,” said Dr. Wineholt. “And if the vitamin screening question can prevent even one neural tube defect by encouraging the use of vitamins like folic acid, we will potentially save a family from a nightmare of tough decisions.”
Drenell Yarde, a registered nurse at UHS Primary Care Johnson City, said that the addition of the questionnaire has been very positive.
“Moms are grateful for it - they feel like we care about their well-being and post-partum health as much as we care about the well-being of the baby,” she commented. “And we do! I hope this project provides a universal screening tool with interventions for moms to help address high-risk post-partum concerns. Recognizing and addressing these issues makes for a healthy mom, a healthy baby and a positive impact on the community and community health.”
For more information, contact Johnson City Primary Care at 607-763-6075, or on our website here.