8

Final Thoughts

KATHLEEN RASMUSSEN, CORNELL UNIVERSITY

Kathleen Rasmussen concluded the workshop by offering a synthesis of major ideas and themes from the day.

Adopt a “Before, Between, Beyond” Mindset

This concept of a “before, between, and beyond” mindset, articulated by Lu in his keynote address and echoed by participants throughout the day, is a strategy for connecting preconception, prenatal, and postnatal care to long-term reproductive care. This idea has emerged because research has increasingly indicated that a woman’s health and weight status before pregnancy and what happens during pregnancy both matter for a woman’s overall health. This strategy is also a way to connect pregnancy care to women’s health care generally.

Preconception care in the United States is especially difficult because approximately 50 percent of pregnancies are unplanned. Women do not necessarily have opportunities to talk with their physicians about weight, nutrition, exercise, and health behaviors before they become pregnant. It is much easier in Europe, where a higher percentage of women use intrauterine devices as their contraceptives. They go to a clinician to have them removed, which presents an opportunity for conversation.

The nature of postpartum care is also critical. Most women have only one postpartum visit. Many opportunities exist to consider new approaches to postpartum care and, indeed, to care throughout the entire



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8 Final Thoughts KATHLEEN RASMUSSEN, CORNELL UNIVERSITY Kathleen Rasmussen concluded the workshop by offering a synthesis of major ideas and themes from the day. Adopt a “Before, Between, Beyond” Mindset This concept of a “before, between, and beyond” mindset, articulated by Lu in his keynote address and echoed by participants throughout the day, is a strategy for connecting preconception, prenatal, and postnatal care to long-term reproductive care. This idea has emerged because research has increasingly indicated that a woman’s health and weight status before pregnancy and what happens during pregnancy both matter for a woman’s overall health. This strategy is also a way to connect pregnancy care to women’s health care generally. Preconception care in the United States is especially difficult because approximately 50 percent of pregnancies are unplanned. Women do not necessarily have opportunities to talk with their physicians about weight, nutrition, exercise, and health behaviors before they become pregnant. It is much easier in Europe, where a higher percentage of women use intrauterine devices as their contraceptives. They go to a clinician to have them removed, which presents an opportunity for conversation. The nature of postpartum care is also critical. Most women have only one postpartum visit. Many opportunities exist to consider new approaches to postpartum care and, indeed, to care throughout the entire 65

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66 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES interconception period, given that 70 percent of women will have more than one pregnancy. Other major themes related to this concept were the need for greater attention to public health approaches to help women be at a healthy weight when they conceive and the importance of better surveillance of gestational weight gain in order to monitor progress (or lack thereof) and therefore to determine what works and what does not and to identify when changes in course are necessary. Change the Structure of Prenatal Care The current structure of prenatal care was on the minds of many workshop participants, as evidenced during the discussion following the keynote addresses, the Session 2 panel discussion, and the discussion following Phelan’s presentation. Suggestions for improvement included starting prenatal care earlier in pregnancy, changing the frequency of visits so that the woman is seen more often earlier in pregnancy, and crafting a visit schedule that reflects the woman’s unique situation and risk profile. One rationale for this new vision can be derived from the results of Phelan’s work showing that early excessive weight gain is very difficult to reverse. Participants also discussed team-based plans for prenatal care, identifying which types of providers a woman should see, and ensuring visits with those providers. Another idea for amplifying and reinforcing messages received in office-based prenatal care was to put messages on pregnancy test kits and bathroom scales. Motivate Women to Adopt Healthy Behaviors Conry first raised this strategy of motivating women to adopt healthy behaviors in her keynote address when she suggested that clinicians ask women about their reproductive goals periodically as part of a larger discussion about the women’s goals for their overall health. This is an opportunity for dialogue not only between women and their obstetricians- gynecologists, but also between women and other clinicians whom they encounter in their own health care and in their family’s health care. Integral to this suggestion is the concept of motivating women, an idea that emerged in Conry’s remarks and in the Session 2 discussion. Women are interested in educating themselves and often already know what they should do, but they need to be motivated to choose to gain within the guidelines and to make the behavior changes necessary to carry out that goal.

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FINAL THOUGHTS 67 Broaden the Concept of Women’s Health Care Several presenters and workshop participants noted that many of the ideas suggested, such as encouraging motivational interviewing, helping women adopt healthy behaviors, and changing the structure of prenatal care to a team-care approach, would require a change in the way that pregnancy care is currently reimbursed. Participants talked about a broader change to the structure of women’s reproductive care so that it might become part of an overall patient-centered health home for women, which would start after pediatric care ends and carry through the adult years. Sass referred to this concept when describing his “Thousand Days” approach to holistic care for pregnant women and new mothers and infants. Some European countries provide models for such an approach. For example, in Denmark public health nurses make several postnatal visits and then establish and support a group of women in the same neighborhood who have had a delivery at about the same time. The group continues to meet until their children go to school. Leveraging Action to Disseminate the Guidelines In Session 1, when Rasmussen was presenting the conceptual model for disseminating the guidelines (see Figure 8-1), she noted that leverage could be exerted at many places in the diagram. The discussions from the workshop suggest that it is possible to exercise leverage across the entire conceptual model. The guidelines can be disseminated at many times during a woman’s lifetime—from menarche until sometime after the birth of her last child—and the information can be disseminated through many channels, including by the staff at individual clinics, by officials at the highest federal levels, and even by well-known media personalities. Visible leadership to promote these discussions is essential. Workshop participants themselves have opportunities to take advantage of the “bully pulpits” afforded by their various organization roles to affect policy change and to motivate patients, professional societies, or students. Rasmussen noted that all of the workshop participants have places where they can exercise leverage, and she expressed the hope that they would take advantage of their capabilities to affect this important dialogue.

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68 DISSEMINATION OF THE PREGNANCY WEIGHT GAIN GUIDELINES FIGURE 8-1 Pregnancy weight gain guidelines dissemination conceptual model. NOTE: Available at http://www.iom.edu/healthypregnancy. Rasmussen concluded her remarks by thanking the participants, the Institute of Medicine staff, and the meeting’s sponsor, the Bureau of Maternal and Child Health of the Health Resources and Services Administration, for their support, encouragement, and participation. The workshop was adjourned.