(see "Overview of Special Services" later in this chapter); moreover, the WIC program is not funded at a level sufficient to provide the special nutrition services needed by some high-risk women.
Physicians, midwives, nurse practitioners, and other primary care providers can and should integrate basic nutritional care into the care of all expectant and new mothers. Preconceptional care may be provided as part of a woman's routine health care, in family planning clinics, and during visits specifically to address planning for pregnancy. Excluding delivery, nearly all prenatal care is provided in physicians' or midwives' offices or in prenatal clinics. There is increasing interest, however, in the use of supplemental home visits for high-risk families.2–5 Most commonly, postpartum care is first provided in the hospital; subsequently, it may be provided in the physician's office or health center, and, in some cases, in the patient's home as well.
Chart 3-1 lists the nutritional care activities that need to be part of the routine care of all women—regardless of their level of nutritional risk, socioeconomic status, health status, or type of primary care provider. The publication Nutrition During Pregnancy and Lactation: An Implementation Guide6 contains suggestions for integrating these activities into routine care.
Special nutritional care activities for the relatively few women with complex health problems are discussed later in this chapter. If referral to a dietitian or other specialists, or both, is necessary, open lines of communication are essential between the primary care providers and the specialist so that all members of the health care team are in agreement about and reinforce the nutritional advice given to the pregnant woman. Documentation, an important form of communication, appears to need more attention: Peoples-Sheps and colleagues7 report that although 98% of a large sample of prenatal care records included flow charts for weight, only 38% of them included a separate item for nutritional assessment, 19% an item for nutrition education, and 51% an item for alcohol use.