Improving prenatal health behaviors: Implementing a blended model of prenatal care

A key measure of the efficacy of prenatal care and childbirth education is whether or not they have a positive effect on health-promoting behaviors during and following pregnancy. The purpose of this study was to measure the performance of positive health behaviors prior to and following participation in a blended prenatal care (BPC) model (individual visits plus three group visits) versus traditional prenatal care (TPC) and to compare pregnancy outcomes between the BPC and TPC groups. 
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Preventing Postpartum Depression Closer to Home

About one out of every nine expectant mothers in the United States experiences symptoms of postpartum depression, according to the Centers for Disease Control and Prevention. The impact not only can affect the mother, but also the health of her child. In a PCORI-funded study, Darius Tandon, PhD, and his team are examining the Mothers and Babies Program, a cognitive behavioral therapy intervention focused on preventing postpartum depression. The study is comparing the program’s effectiveness when it’s led by mental health professionals versus lay home visitors, who do not possess advanced mental health training but often have previously established relationships with clients.     
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AHA Guidelines: Time to Revisit Thinking on Pregnancy in Women with Complex Congenital Heart Disease

In a notable twist on conventional wisdom, a new American Heart Association scientific statement on managing pregnancy in patients with complex congenital heart disease (CHD) supports the notion that most women with complex CHD can have a successful pregnancy and normal vaginal delivery. To optimize outcomes, the statement notes, care should be collaborative and involve both a high-risk obstetrician and a cardiologist versed in CHD.

The new guidelines alter the idea that patients with complex CHD should avoid pregnancy out of concern about potential risks to the mother and child.

A stepped plan for complex pregnancies

“This is an excellent statement that provides a much-needed framework for caring for these patients, covering everything from pre-pregnancy counseling to pregnancy care to post-delivery care,” says obstetrician Jeff Chapa, MD, Head of Maternal-Fetal Medicine at Cleveland Clinic.

The guidelines provide a stepped assessment plan for general cardiologists to follow.

“The process makes it easy to assess risk prior to pregnancy, determine the frequency of follow-up needed once the patient becomes pregnant and identify the level of disease that warrants tertiary care,” says Dr. Chapa. “Knowing the changes that will occur can help with risk stratification and provide an idea of how well a patient is likely to do.”

Cardiologist David Majdalany, MD, Director of Cleveland Clinic’s Adult Congenital Heart Disease Center, trained under several members of the writing group behind the AHA guidelines, so he found no surprises in the document. But he’s delighted that a summary of the latest recommendations is finally at the disposal of all providers.

“Until now, we had only bits and pieces of information from various papers primarily written on individual defects,” Dr. Majdalany explains. “These guidelines coalesce what we know in a detailed document that discusses the pros and cons of pregnancy by every class of congenital lesion. This is very helpful.”

Validated by experience

The new guidelines’ recommendations align with the experience of Drs. Chapa and Majdalany in Cleveland Clinic’s Cardio-Obstetrics Clinic, where a high-risk obstetrician and a CHD cardiologist co-manage patients, with support from colleagues in virtually every subspecialty available when needed.

The decision of whether to proceed with a vaginal delivery is made jointly. “For example, with defects such as aortic root dilation, the patient is at risk for aortic dissection, so we would suggest avoiding natural delivery in such a case,” Dr. Majdalany notes.

Read more at Cleveland Clinic


Strategies for effective group prenatal care with pregnant adolescents

Managing the prenatal care of adolescents is both challenging and rewarding. Given adolescents’ developmental needs, group prenatal care (GPC) such as that modeled after Centering- Pregnancy is particularly well suited to members of this age group. The authors share their strategies for providing developmentally appropriate GPC for adolescents.

Most females receive prenatal care via a traditional model focused on screening for health-related complications. A healthcare provider (HCP) offers this care on an individual and regular basis throughout the pregnancy. At minimum, each visit involves assessment of maternal weight and blood pressure (BP), fundal height, and fetal heart rate. The initial visit is more comprehensive than subsequent visits, and includes taking a personal and family history, conducting a complete physical examination, and ordering laboratory tests. Education is provided about prenatal care and avoidance of risky behaviors. Subsequent visits include screening for problems and provision of information about nutrition, pregnancy complications, childbirth, and infant care. When indicated, special fetal assessment tests may be recommended and the need for genetic counseling discussed.1

In 1993, CenteringPregnancy (CP) was introduced as an alternative model for delivering prenatal care.2,3 The CP model provides comprehensive prenatal care to small groups of women at similar points in their pregnancies. For participants in this group prenatal care (GPC) program, learning and support are enhanced by group dynamics and by the HCP’s leadership.Compared with traditional care, CP has been associated with improved patient satisfaction, knowledge, and attendance; similar or superior maternal/newborn health outcomes; and greater affordability.4-10

The advent of the Affordable Care Act of 2010, with its provision of access to healthcare for additional millions of Americans, has created a distinct need for innovative, cost-effective, high-quality prenatal care models. GPC can be both safe and affordable, provided at convenient times for better access, and directed at meeting a group’s special needs. GPC is ideal for pregnant adolescents: Management of adolescent pregnancy in group settings has been shown to foster optimal maternal and neonatal outcomes.4-7,11,12 The authors, with many years’ experience in delivering prenatal care to adolescents using the group model, discuss their own program.

Background information on CenteringPregnancy

The authors’ adolescent GPC approach was based on principles of CP. According to Rising,developer of CP, attending prenatal sessions can result in better pregnancy outcomes, with less maternal stress, lower rates of substance abuse, improved labor progress, higher infant birth weights, and higher 5- minute Apgar scores. The CP model, which includes essential components of traditional prenatal care within a group framework, integrates three major components of prenatal care: health assessment, interactive learning, and community building.13 CP groups comprise 8-12 females at similar points in their pregnancies. After a one-onone prenatal visit with an HCP, participants attend regular group sessionslasting 1.5-2 hours, usually held in the late afternoon or early evening, for the remainder of their care. The sessions, typically led by an HCP and a nurse, meet every 4 weeks until the 28th week and then every 2 weeks until delivery.

At the start of every group session, each participant has a quick private visit with a nurse and an HCP for checks of weight, BP, fundal height, and fetal heart tones and for an opportunity to ask personal questions. During this time, the other participants chat or watch an educational video. Once individual checks are done, the group session begins. Topics discussed include nutrition, exercise and relaxation, discomforts of pregnancy, childbirth preparation, infant care and feeding, postpartum concerns, contraception, communication/self-esteem, and parenting skills. Participants are encouraged to ask questions, which can help others with similar concerns,12 and they are invited to bring a partner or a family member. Additional prenatal visits are necessary only if problems with the pregnancy arise or if a participant requires a confidential private exam.

The CP structure comprises 13 essential elements,14 which are also used in the authors’ prenatal program: (1) Health assessment occurs within the group space; (2) Women are involved in self-care activities; (3) A facilitative leadership style is used; (4) Each session has an overall plan; (5) Attention is given to the core content, but emphasis may vary; (6) There is stability of group leadership; (7) Group conduct honors the contribution of each member; (8) The group is conducted in a circle; (9) Group composition is stable but not rigid; (10) Group size is optimal to promote the process; (11) Involvement of family support is optional; (12) Opportunity for socializing within the group is provided; and (13) There is ongoing evaluation of outcomes. Primary differences between CP and traditional prenatal care are the time spent in care and the opportunity for group interaction. Traditional visits usually last 5-10 minutes, whereas CP visits are about 90 minutes long. This amount of time allows participants to grow comfortable with their HCPs and each other, which enhances discussions and learning. In addition, belonging to a group can help participants feel valued and important, and provide support during the pregnancy.12

Adolescents and group prenatal care: Literature review

Adolescence is a challenging stage of life, but when pregnancy complicates the picture, additional physical, social, and emotional stresses must be managed. Because pregnant adolescents are more likely than their non-pregnant counterparts to be in a lower socioeconomic bracket, they are less likely to receive adequate prenatal care unless it is accessible and affordable. GPC may be optimal for these individuals; not only can it be offered at convenient times and be covered by Medicaid, but it is also geared toward adolescents’ developmental level and learning needs.15,16 To ascertain  what the literature shows in terms of the usefulness of GPC for young females, especially adolescents, the authors searched the CINAHL and Medline databases for studies and systematic reviews reported from 2010 through 20115. Table 1. Selected studies on group prenatal care can be accessed here. 4 5,7,11,12,17-21

Authors’ experiences and strategies

The authors’ outpatient prenatal program was affiliated with a large urban medical center and enrolled adolescents aged 12-19 who were African American (65%), Caucasian (20%), Latino (10%), or Southeast Asian (5%). Most participants came from low-income families receiving public assistance. Initial training for the program’s staff was provided by two CP consultants during a 2-day workshop on content and process. Funding for the training came from the program’s budget; ongoing training for new staff was derived from continuing education funds and a community agency grant.

A nurse practitioner (NP), midwife, or nurse who saw prospective program participants at their intake and first obstetric visit invited  them to join the GPC program. The authors expected that all recruited adolescents would participate in the program, but they made exceptions when a patient needed individual care because of privacy concerns or a conflict with another participant. Each group was managed by an HCP (either an NP or a midwife) and a nurse. A social worker performed psychosocial evaluations and was available to address psychosocial concerns, and a nutrition specialist performed one-on-one  assessments early in the pregnancy and participated in a group discussion of prenatal nutrition and meal planning. The group meeting room accommodated 15 people and was set up to be comfortable and welcoming— similar to a setting for a baby shower. The CP model recommends that participants sit in a large circle with no table, but the authors used the existing large oval table in their space, which did not seem to affect group interactions. Educational aids available in the room included models of a bony pelvis, fetus, uterus, and dilating cervixes; posters; and a TV with a DVD player and videos to reinforce topics such as maternal nutrition, vaginal and cesarean delivery, and newborn and self-care.

The first GPC session took place when participants were at 12-16 weeks’ gestation. For scheduling purposes, the groups were referred to by their due dates (e.g., the September/October group). As with the CP program, at the start of each session, a nurse weighed each participant and checked her BP. Next, the participant lay on a small firm couch and an HCP assessed fundal height and fetal heart tones and obtained other relevant information. A curtain divider between the couch area and the group meeting area ensured privacy. During the initial group meeting, the HCP and the adolescents reviewed “Teen Rules for Group Prenatal Care” as follows:

• Be sensitive to others’ confidential information: “What is said in group stays in group.”

• Discuss who should be allowed to come to group (usually one guest who was a partner, friend, or mother figure, but no children).

• Behave politely and respectfully toward other group members (e.g., when one person is talking, others should listen).

• Do not use hand-held electronic devices during the sessions.

• Encourage everyone to be involved in discussions, and reinforce that no one should dominate or be excluded.

• Describe how group works: weight, urine sample, and fundal height measurement, followed by the education component, with the option of being seen individually after group as needed.

• Know the danger signs of pregnancy.

• Know how to contact the practice and use the after-hours oncall service for labor and emergencies.

In the authors’ program, 3-4 groups attended GPC sessions once weekly in the afternoon. Participants received phone reminders the day before the sessions; any transportation problems were resolved at this time. Although 8-10 participants were assigned to each group, only 5-6 attended regularly. Postpartum group reunions—including the infants— were scheduled to occur 4- 6 weeks after the last girl in each group had delivered. However, because of low participation, these sessions were discontinued.

At first, GPC participants kept copies of their health records. When the authors’ practice converted to an electronic health record (EHR) system, this information was stored on a laptop. Patient encounter forms were printed prior to group meetings for easy completion with billing codes and designations of return visits. GPC visits were reimbursed the same way as an individual visit. Some insurance was fee-forservice, but most patients were covered by Medicaid managed care programs that reimbursed globally. The prenatal portion was then applied to the adolescent   program budget and the delivery portion to the midwifery budget. Table 2 lists websites specific curriculum content for adolescent GPC and general information on teen pregnancy. Topics of greatest interest to participants in the authors’ program included preparation for labor and birth, pain management, bringing baby home, bottle feeding versus breastfeeding parenthood, relationships with their boyfriend, and contraception.

Table 3 lists GPC activities that the authors found particularly useful. GPC worked best when HCPs were facilitators of group activities rather than lecturers of content. The adolescents appreciate knowing what they could expect from their HCP as well as what was expected of them. HCPs reinforced the confidentiality of patient information and demonstrated respect to gain the trust and confidence that promote regular group attendance and participation. In the authors’ experience, HCPs who were seasoned clinicians, had senses of humor, were approachable, and had knowledge of community resources were best suited as GPC providers.  Group attendees completed a satisfaction survey at the last session. Over the years, the surveys demonstrated high satisfaction with the program, especially with regard to its structure, the knowledge it imparted, the relationships it fostered, and the preparation it provided for labor, delivery, and newborn care.


Initiating a GPC model requires considerable planning and commitment. The authors learned the importance of gaining commitment to the program from everyone involved, from the clerical staff to the HCPs themselves, because they all needed to adapt to a new way of providing care. Periodic retreats were held to address the challenges that arose as the program was implemented.

The GPC program needed to be budget neutral; ensuring that reimbursement covered costs meant having at least 6-8 patients per session. Given the substantial no show rate among adolescents, the groups were intentionally overbooked. Obtaining funding for training and costs for snacks was an ongoing challenge. The program received contributions from various community organizations, and small grants were sought.

Regular planning time was essential for the administrative support staff to schedule groups, assign HCPs, write grants, and perform program evaluation. Nursing staff members took responsibility for setting up the room, providing handouts and snacks, and following up on no-shows. HCPs were busy managing traditional patients before and after groups, so a pre-group huddle was used to prepare co-leaders for the session.

The conversion to EHRs was an added challenge, particularly because laboratory test and ultrasound order entries and follow-ups became an HCP task rather than a nursing one. A laptop and Wi-Fi access were required to manage the EHR during the group sessions. The commitment of all staff to GPC and allocation of extra time were essential to successful transitioning to this system.

This GPC model encourages mutually beneficial relationships between pregnant adolescents and obstetric HCPs and provides opportunities for interdisciplinary collaboration.22,23  The authors’ program included a strong collaboration with the pediatric resident clinic, wherein GPC participants transitioned into well-child care groups that encouraged follow-up visits and immunizations. In addition, the authors had collaborative arrangements with the pediatric dental clinic and hospital social work department.


Given the developmental needs of adolescents, GPC provides a satisfying experience for both those who are pregnant and their HCPs.24   The authors modeled their program after CP principles for evidence-based care. 4-6,8,11 They created a supportive environment for prenatal care and helped adolescents learn the essentials about pregnancy, labor delivery, and postpartum and newborn care, with the goal of optimizing outcomes for both mother and child.

Joanne B. Stevens is Associate Professor at the University of Tampa, Department of Nursing, in Tampa, Florida. Elizabeth Cooper is Professor Emeritus in Obstetrics and Gynecology at the University of Rochester in Rochester, New York. Stasha Roberts is an alumna of the University of Tampa and an advanced registered nurse practitioner. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.


1. American Academy of Pediatrics and American College of Obstetricians and Gynecologists. Guidelines for Perinatal Care. 7th ed. Elk Grove, IL: American Academy of Pediatrics; 2012.

2. Thielen K. Exploring the group prenatal care model: a critical review of the literature. J Perinat Educ. 2012; 21(4):209-218.

3. Rising SS. Centering pregnancy. An interdisciplinary model of empowerment. J Nurse Midwifery. 1998; 43(1):46-54.

4. Tanner-Smith EE, Steinka-Fry KT, Gesell SB. Comparative effective of group and individual prenatal care on gestational weight gain. Matern Child Health J. 2014; 18(7):1711-1720.

5. Picklesimer AH, Billings D, Hale N, et al. The effect of CenteringPregnancy group prenatal care on preterm birth in a low-income population. Am J Obset Gynecol.  2012;206(5):415.e1-7.

6. Kennedy HP, Farrell T, Paden R, et al. A randomized clinical trial o group prenatal care in two military settings. Mil Med. 2011;176(10):1169-1177.

7. Barr WB, Aslam S, Levin M. Evaluation of a group prenatal care-based curriculum in a family medicine residency. Fam Med. 2011;27(2):138-145.

8. Teate A, Leap N, Rising SS, Homer CS. Women’s experience of group antenatal care in Australia—the CenteringPregnancy Pilot Study. Midwifery. 2011;27(2):138-145.

9. Novick G, Sadler LS, Knafl KA, et al. The intersection of everyday life and group prenatal care for women in two urban clinics. J Health Care Poor Underserved. 2012;23(2):589-603

10. Gaudion A, Menka Y. ‘No decision about me without me’: centering pregnancy. Pract Midwife. 2010; 13(10):15-18.

11. Tandon SD, Colon L, Vega P, et al. Birth outcomes associated with receipt of group prenatal among low-income Hispanic Women. J Midwifery Womens Health. 2012;57(5):476-481.

12. Ickovics JR, Reed E, Magriples U, et al. Effects of group prenatal care on psychosocial risk in pregnancy: results from a randomised controlled study. Psychol Health.2011;26(2):235-250.

13. Rising SS. Group prenatal care. UpToDate. Last updated April 29, 2015.

14.  Rising SS. Kennedy HpP, Klima CS. Redesigning prenatal care through CenteringPregnancy. J Midwifery Womens Health. 2004;49(5):398-404.

15. Grady MA, Bloom, KC. Pregnancy  outcomes of adolescents enrolled in a CenteringPregnancy program. J Midwifery Womens Health. 2004;49(5):412-420.

16. Feldman JB. Best practice for adolescent prenatal care: application of an attachment theory perspective to enhance prenatal care and diminish birth risks. Child Adolesc Soc Work J. 2012;29(2):151-166.

17. Cypher RL. Collaborative approaches to prenatal care: strategies of successful adolescent programs. J Perinat Neonatal Nurse. 2013;27(2): 134-144.

18. Hale N, Picklesimer AH, Billings DL, Covington-Kolb S. The impact of Centering Pregnancy Prenatal Care on postpartum family planning. Am J Obstet Gynecol. 2014;210(1):50.e1-7.

19. Homer CS, Ryan C, Leap N, et al. Group versus conventional antenatal care for women. Cochrane Database Syst Rev. 2012;14(11): CD007622.

20. Novick G, Reid AE, Lewis J, et al. Group prenatal care: model fidelity and outcomes. Am J Obstet Gynecol. 2013;209(2):112.e1-6.

21. Tanner-Smith EE, Steinka-Fry KT, Lipsey MW. Effects of CenteringPregnancy group prenatal care on breastfeeding outcomes. J Midwifery Womens Health. 2013;58(4):389-395.

22. Picklesimer A, Heberlein E, Covington-Kolb S. Group prenatal care: has its time come? Clin Obstet Gynceol. 2015;58 (2): 380-391.

23. Stevens J, Iida, H. Implementing an oral health program in a group prenatal practice. J Obstet Gynceol Neonat Nurs. 2007;26(6):244-249.

24. Ellison T. Group prenatal care: a pilot study evaluating patient satisfaction. Unpublished Honor’s Senior Thesis. Department of Nursing, The State University of NY at Brockport; 2010.

Web resource


Early pregnancy loss management for nurse practitioners and midwives

Early pregnancy loss (EPL), or miscarriage, is a common phenomenon in pregnancy; up to 30% of pregnancies result in miscarriage in women who have identified themselves as being pregnant.Various treatment modalities can be used to assist women who have experienced EPL, including expectant management, pharmacologic treatment, and vacuum aspiration. Patients should be assessed for their preferences for management of EPL based on their priorities for care. The role of the nurse practitioner or midwife in counseling women who have experienced EPL is to help them manage symptoms, resolve the passage of tissue, and cope with the emotional experience of losing a pregnancy.

Early pregnancy loss (EPL), or miscarriage—the spontaneous loss of a pregnancy before 13 weeks’ gestation1—is a devastating problem for women who lose a highly desired pregnancy. In addition to the emotional turmoil caused by the interruption of a wanted pregnancy, these women are faced with managing the physical reality of resolving a nonviable gestation. Nurse practitioners (NPs) and midwives are frequently the first providers to encounter women who have bleeding early in an already-diagnosed pregnancy. In addition to providing much needed emotional support and compassion, providers can help women and their families move through the steps of completing the process of EPL.

Most bleeding in pregnancy is the result of a disruption in the complex processes associated with implantation, including the formation of the decidua and the actual burrowing of the blastocyst into the uterine lining.2 Bleeding in the first trimester occurs in up to 40% of pregnancies; more than half of these pregnancies progress normally, with preterm delivery and low birth weight as possible outcomes.Although cervical polyps or friability, vaginal laceration, irritation, or neoplasm may also lead to bleeding in early pregnancy, the possibility of pregnancy loss or ectopic pregnancy must always be considered.3

Causes of early pregnancy loss

The three main causes of problematic bleeding leading to EPL are spontaneous abortion, ectopic pregnancy, and gestational trophoblastic disease (GTD).Ultrasound guidance and serum hCG assessment can assist in the diagnosis of ectopic pregnancy and GTD and in the assessment of pregnancy viability.3 Once ectopic pregnancy and GTD have been ruled out, the problematic bleeding can be classified as a threatened abortion, an incomplete abortion, or a complete abortion. A threatened abortion occurs when vaginal bleeding occurs in the absence of cervical dilatation; 30%-50% of women with these symptoms go on to have a complete abortion.3 An incomplete abortion is diagnosed when some fetal or embryonic tissue remains in the uterus. A complete abortion reflects the passage of all pregnancy tissue.

Management of early pregnancy loss

The focus of EPL management is on meeting the needs of each individual woman. After establishing that the patient is clinically stable, the provider should offer appropriate emotional support; regardless of whether or not the pregnancy was planned, the woman is experiencing the loss of the pregnancy and maybe a change in her sense of self. The provider should establish the meaning of the pregnancy for the woman, and recognize that her management options for resolving the EPL should be guided by her medical needs and by her self-identified needs and preferences.

One way to assess the needs and preferences of a woman experiencing an EPL is to ask her these questions: What are your priorities related to the timing and cost of the process? What is your previous experience with miscarriage and/or abortion? How do you feel about taking medications or undergoing a procedure, either in the office or the hospital? How do you assess your own ability to manage the pain and bleeding that you will experience?4 Her responses to these questions can guide the provider in helping her choose how to resolve the EPL.

Early pregnancy loss can be resolved in one of three ways: expectant management (watchful waiting); medication management to complete the process of uterine evacuation; or an aspiration procedure to empty the uterus, either in an inpatient or outpatient setting.Each approach has benefits and minimal risks. These approaches vary slightly in terms of efficacy, depending on how much tissue remains inside the uterus. All of these approaches are considered acceptable and should be offered to women experiencing EPL. However, if a woman presents with heavy bleeding or is medically unstable, the situation requires immediate resolution; her preference for expectant management or medication management cannot be honored because neither is a safe option.

Expectant management

In 85% of cases, EPL resolves with expectant management within 2 weeks of the first signs and symptoms (S/S) of miscarriage. Within an additional 2 weeks, 10% of the remaining cases resolve. Aspiration intervention is recommended for the resolution of pregnancies that continue after 4 weeks of bleeding.A woman who chooses expectant management must be counseled about the possibility of a prolonged period of waiting for resolution, as well as what to expect when she finally passes the pregnancy tissue. She may experience a short period of intense cramping and bleeding, followed by mild bleeding and/or spotting for up to 2 weeks. During this period of time, she needs to monitor her temperature and report any S/S that would indicate infection, such as a malodorous discharge or flu-like S/S. The provider should ascertain the woman’s ease of access to emergency resources if needed and encourage follow-up within 2 weeks of the passage of tissue to ensure that the pregnancy has been completely resolved.

Many women choose expectant management because it does not require any intervention, and can generally be experienced privately and without any increased cost or provider visits. However, they need to understand that they may see the pregnancy tissue and they may have considerable pain and bleeding with this option. In addition, they must have ready access to care if bleeding becomes excessive.

Medication management

Use of medications can enhance the speed with which the pregnancy tissue is passed. The most widely used medication for this purpose is misoprostol, a prostaglandin antagonist that has a variety of off-label obstetric and gynecologic uses in addition to its FDA-approved indication for the prevention of gastric ulcers and as part of the medication abortion regimen.Misoprostol causes cervical softening and uterine contractions that accelerate passage of the pregnancy tissue, producing the same symptoms as expectant management but within 24-48 hours of administration of the medication. Use of misoprostol to accelerate resolution of EPL is successful in about 90% of cases after two doses.7 Women should be counseled to expect the same S/S as with expectant management, but within a shorter time period. If no tissue passes, and increased bleeding does not occur, women should return for an assessment of retained products of conception. Misoprostol users should also have access to analgesics, and they should be aware of potential side effects: fever, nausea, diarrhea, and/or shaking. Over-the-counter medications can be used to treat fever and gastrointestinal side effects, and application of warm blankets can reduce shaking.

Aspiration management

An aspiration procedure may be the choice of women who prefer an expedient and closely managed process for resolution of the EPL. If ultrasound dating  shows a gestational age of less than 12 weeks 6 days, uterine evacuation can be performed in an outpatient clinic or ambulatory surgical center. In some places, aspiration procedures can be performed only in a hospital, but this approach consumes more resources and has not been shown to improve outcomes.In these circumstances, providers should counsel women about other settings in the community that offer outpatient management services and facilitate their obtaining care if they choose an outpatient procedure.

Aspiration management provides clear advantages for a woman who prefers to have a procedure that can be scheduled, has a limited impact on the amount of time before normal activities can be resumed, and during which she can receive additional pain management. Uterine evacuation with either a manual or electric vacuum procedure is highly successful but does carry minimal risks of infection, uterine perforation, cervical trauma, or damage to the endometrium.9


Various resources are available to NPs and midwives to help counsel women facing a decision about how to manage an EPL. TEAMM (Training, Education & Advocacy in Miscarriage Management), a project of the Department of Obstetrics and Gynecology at the University of Washington, provides educational materials and training for practitioners and educational materials for women about outpatient manual vacuum aspiration.10 The University of California San Francisco’s website, Innovating Education in Reproductive Health, has information about managing EPL, including a video and patient education materials for decision making following EPL.11


Early pregnancy loss can be a devastating experience for a woman, but the compassion and understanding of her provider can assist her in identifying the safest and most satisfying way for her to resolve her physical S/S while she is processing her emotional experience. Whether a woman chooses an inpatient or outpatient procedure, takes medication, or elects to wait for the natural course of miscarriage to occur, reviewing all the possibilities for resolution is an important part of the NP’s or midwife’s responsibility in caring for women who are undergoing an EPL.

Amy J. Levi is the Leah L. Albers Professor of Midwifery at the University of New Mexico in Albuquerque. Tara Cardinal is a Consultant at Training, Education and Advocacy in Miscarriage Management in Seattle, Washington. The authors state that they do not have a financial interest in or other relationship with any commercial product named in this article.


1. Wang X, Chen C, Wang L, et al. Conception, early pregnancy loss, and time to clinical pregnancy: a populationbased prospective study. Fertil Steril. 2003;79(3):577-584.

2. Lykke JA, Dideriksen KL, Lidegaard O, Langhoff-Roos J. First-trimester vaginal bleeding and complications later in pregnancy. Obstet Gynecol. 2010;115(5):935-944.

3. Isoardi K. Review article: the use of pelvic examination with the emergency department in the assessment of early pregnancy bleeding. Emerg Med Australas. 2009;21(6):440-448.

4. Wallace RR, Goodman S, Freedman LR, et al. Counseling women with early pregnancy failure: utilizing evidence, preserving preference. Patient Educ Couns. 2010;81(3):454-461.

5. Nanda K, Lopez LM, Grimes DA, et al. Expectant care versus surgical treatment for miscarriage. Cochrane Database Syst Rev. 2012;3:CD003518.

6. Webber K, Grivell RM. Cervical ripening before first trimester surgical evacuation for non-viable pregnancy. Cochrane Database Syst Rev. 2015;11:CD009954.

7. Hasan R, Bhal K, Joseph B. The need for repeat evacuation of retained products of conception: how common is it? Obstet Gynaecol. 2013;33(1):75-76.

8. Dalton VK, Harris L, Weisman C, et al. Patient preferences, satisfaction, and resource use in office evacuation of early pregnancy failure. Obstet Gynecol. 2006;108(1):103-109.

9. Jurkovic D, Overton C, Bender-Atik R. Diagnosis and management of first trimester miscarriage. BMJ. 2013;346:f3696.

10. TEAMM Training, Education & Advocacy in Miscarriage Management. 2016.

11. Innovating Education in Reproductive Health. Early Pregnancy Loss.

Reaching postpartum women in the U.S.: Demographics and generational characteristics

The postpartum period, defined traditionally as the first 6-8 weeks after birth, is a time of rapid change for new mothers and their families. Mothers are not only recovering physically but also making psychosocial adjustments related to their family role and relationships. In addition, mothers are adding or refining skills and responsibilities such as breastfeeding and infant care. This process of becoming a mother starts with the initial transformation and continues with the growth and change of maternal identity.1

Although the postpartum period can be fraught with changes foreseen and unforeseen, most women in the United States who have given birth receive only minimal care during the critical early months after delivery.2 Unfortunately, postpartum care has not evolved along with the changing demographic and generational characteristics in this country over the past few decades, so many women’s needs are not being met. Healthcare providers (HCPs) have an opportunity to optimize the care they deliver to postpartum mothers of today.

Routine postpartum care

In the U.S., routine postpartum care consists of 2-4 days in the hospital, depending on the type of delivery, vaginal or cesarean.3 Follow-up consists of one visit to the maternity care provider, typically at 6 weeks. The focus of this office visit is on uterine involution, contraception, and management of complications. By contrast, in most northern and western European countries, HCPs make home visits to their patients after childbirth.4 According to Cawthorne and Arons,5 postpartum home visits by trained professionals/paraprofessionals can provide valuable information and practical support that family and friends may not be able to provide.

Scope of the problem

Although home visit support services are available in the U.S., many new mothers are unfamiliar with these services or they cannot afford these services. In addition, families of today are more fragmented and geographically dispersed than in previous generations, making the advice and support of grandparents or other elders less available. High-risk U.S. populations such as teenagers and certain low-income women may qualify to receive home visiting services without charge. Although these services have been shown to be helpful,6 most qualified families do not receive them. For the most part, then, after parents take their babies home from the hospital, they are left to handle their new responsibilities alone.4

The nature and extent of postpartum healthcare in the U.S. may be too limited to meet the needs of most women.7, 8 The first postpartum year is a period of vulnerability during which HCPs should be focusing on weight management,prevention of postpartum depression, breastfeeding support, promotion of healthy relationships, and postpartum morbidities such as fatigue.9 In addition, women would benefit from acquiring life skills known to support postpartum health, including mobilization of social support, development of positive coping skills, enhancement of self-efficacy, and having realistic expectations.10 A recent systematic review of postpartum interventions suggested that further research is needed to design interventions focused on health promotion, not just on treatment of adverse health conditions.11

Postpartum maternal healthcare is a neglected aspect of women’s healthcare.12 Much of the knowledge about new mothers’ role transition was developed in the 1960s to 1980s.13-16 But times have changed. The old rules no longer apply. HCPs need to remain up to date in terms of the trends and concerns that affect today’s women and provide postpartum care that is culturally competent— that is, care that is based on the demographic and generational characteristics of the population being served. In particular, the U.S. Department of Health and Human Services calls for HCPs to provide care that takes into account patients’ cultural health beliefs and practices, preferred language, health literacy, and other communication needs.17

Demographic trends

The sociocultural climate in the U.S. has changed for women giving birth in the early 21st century. Mothers of today are decidedly different from those of past generations.

First-time mothers are older.

According to the National Center for Health Statistics, the number, percentage, and rate of first births to older women have increased over the past four decades.18 In 2012, as compared with four decades ago, there were more than 9 times as many first births to women aged 35 years or older. First-birth rates of women older than 35 years have increased from 2000 to 2012 even as total births in the U.S. have declined.18

By contrast, first-birth rates for women younger than 30 years, and especially those younger than 20, have declined in the past decade.18 In 2013, there were 26.5  births for every 1,000 females aged 15-19, or 273,105 babies born to females in this age group.19 The 2013 teen birth rate was 10% lower than that in 2012 (29.4 births/1.000 females) and less than half the rate in 1991 (61.8 births/1,000 females).

In the 1960s and 1970s, new mothers were typically younger and married when they started their families. Families had more children, and many mothers stayed home to raise their children. According to a recent Pew Research Report on Social and Demographic Trends,20 in 2012, only 20% of mothers were married to a working husband and stayed home to care for their children; in 1967, 67% of mothers met these criteria. The workforce participation rate for mothers with children younger than 1 year old was 57.3% in 2013.4

Mothers are better educated and have more money. Older mothers of today, relative to their younger counterparts, are better educated and more likely to have greater resources, including higher incomes.6 As a result of new mothers having been in the workforce for some time, many of them have the means to choose the circumstances under which they want to raise a family.21 At the same time, although many older mothers could benefit from postpartum home visiting services and could afford these services, it is still not common practice to pay for them out of pocket because they are quite expensive.

Family composition has diversified.

Nowadays, it is relatively more common to see households headed by two women, two men,  an unmarried woman and man, single adults, or multiple generations.22 A recent report based on the 2006-2010 National Survey of Family Growth showed that 23% of recent births among women aged 15-44 occurred among cohabiting couples, whereas 60% of the women were married.Other newer phenomena include increases in blended families (from previously divorced couples with children who remarry or cohabit) and interracial families.9 Between 2000 and 2010, the number of unmarried-partner households increased 41%. Over this time period, opposite-sex unmarried partner households grew from 4.9 million to 6.8 million and samesex unmarried partner households grew from 358,000 to 646,000 (or from 0.3% to 0.6% of house holds).9 These trends have profoundly changed the U.S. family and, following the trends of other Western countries, are unlikely to reverse in the near future.23

Generational characteristics

Although generalizations about various age cohorts can be hotly debated, one point is undeniable: Age cohorts are affected by external events, and each generation has a unique “persona” by virtue of the fact that members occupy the same time period as they age.24 Contemporary new mothers come from Generation X (Gen X; persons born in the mid-1960s to the early 1980s) or Generation Y (Gen Y; persons born in the early 1980s to 2000); members of Gen Y are often dubbed the Millennials.

Members of Gen X have been described as family oriented, secondarily career oriented, and relatively independent. This generation is the first to grow up as latch-key children; as a consequence, many Gen-Xers did not spend a lot of time with their parents. They entertained themselves during their youth and, as adults, place high regard on entertainment and fun. They also value knowledge and expect regular feedback.25

Members of Gen Y tend to be more team oriented; they work well in groups rather than on their own. They are technologically savvy, willing to work hard, and wonder “What’s in it for me?” Gen-Yers seek balance between work and family and believe that one can successfully have it all. They multitask and respect learning. Compared with earlier generations, Gen-Yers experience a high degree of job and life satisfaction. They are constantly questioning, need immediate feedback, and believe that money buys happiness. Of interest, according to a Pew Research Center analysis of attitudinal surveys, the Millennials value parenthood far more than marriage.26

These two generations of childbearing women have had access to the Internet for much of their lives. Through the Internet, they have been able to obtain a vast quantity of information about childbearing, although it is not known whether most of them fully understand and can put into perspective what they read.27 In addition, the Internet provides opportunities for social networking and connecting with like-minded individuals. Gen X and Gen Y mothers may seek support from online groups and individuals whom they have never met in person. These two generations of women have had instant communication for much of their lives and have come to expect this type of communication from their HCPs. Email, texting, online social networking, and the many forms of social media are all modes of communication for contemporary mothers.

Healthcare has been slower to adopt the use of social media. Despite the risks, social media can bring major benefits, particularly for patient and community outreach and communication.28 In an article examining Millennial healthcare values, Rupp29 stated that Millennials are more likely than members of previous generations to participate in mobile health applications, finding these tools convenient, motivating, and empowering.

Clinical implications

Most contemporary new mothers expect to be informed and supported through digital means. The recent Listening to Mothers III survey showed that 67% of the respondents used subscription email services and 27% received short text messages to obtain pregnancy and childbirth information.30 Short online videos are also useful; when this content is culturally appropriate, it can help women develop self-efficacy as new parents.10 The greater the resemblance of the video viewers to the women in the videos, the more they will be able to sense that they, too, can achieve the skills being demonstrated.10 The Box lists websites where HCPs and patients can find culturally appropriate videos regarding pregnancy, childbirth, and motherhood.

Text4Baby is an innovative use of interactive mobile technology that provides evidence-based information for new mothers.31 This free service connects new mothers with health information on topics such as breastfeeding and infant development. Interactive features such as mobile pages, videos, appointment reminders, quizzes, and modules on specific health problems and resources have been integrated into the service.

Maternity leave is an optimal time for HCPs to provide new mothers with opportunities to learn postpartum self-care and to connect them with other new mothers in their area (if possible and if of interest). During this time, practices could offer individual and group support programs on topics such as postpartum fatigue, emotions and depression, breastfeeding continuation, mobilization of social support, expansion of social networks to include other new mothers, relationship building, community resources, and newborn and infant continuing care.

The concept of CenteringPregnancy is gaining momentum as a model to deliver pregnancy and postpartum care.32 The principle of sharing used in CenteringPregnancy helps normalize the experience, and can be applied to postpartum and infant care. The axiom that “wisdom and experience are valuable only when shared by others” is particularly true for new mothers, who are eager to learn how to integrate all the new information, experiences, doubts, tensions, and challenges into their new self-concept as mother.

As the composition of families has diversified, so, too, have the challenges of adjusting to having a newborn. New mothers in blended families tend to experience an even greater challenge in integrating their newborn into a pre-existing family environment.33 These new mothers benefit from connecting with other mothers who have similar family compositions. Social networks and social support systems can also have a beneficial effect on postpartum women’s mental health and adjustment.34, 35

Older first-time new mothers, versus their younger counterparts, demonstrate greater intensity and preparedness.36 These mothers are usually well educated and highly organized, and have a planned approach to pregnancy and new parenting. In addition, they can be quite demanding of their HCPs, and have many questions and concerns. Older first-time mothers may experience more fatigue and be less physically active than their younger counterparts. They may be at higher risk for chronic diseases such as obesity, diabetes, and hypertension.37 In the long run, HCPs benefit by spending more time with these mothers during office visits. Offering reassurance about their mothering abilities can build maternal confidence.36 Educational group sessions for older new mothers can help them feel accepted, connected, and nurtured.

Improving postpartum healthcare in the U.S. will require more funding, more research, and more dissemination of effective approaches. From the administrative side, allocation of practitioner time to group postpartum services would be money well spent. In the professional literature and at conferences, more sharing and dissemination of postpartum exemplars is needed. To move postpartum care forward, there must be more demonstrated evidence of successful and unsuccessful approaches. Without systematic reviews and meta-analyses, the pinnacles of evidence-based practice, the chances of reaching these higher levels of evidence diminish. In a sense, postpartum care in the U.S. is still in its infancy as far as improving outcomes is concerned. With increased documentation of successful outcomes with various approaches, as well as increased funding, more plentiful and effective services can be offered to postpartum women.


To provide optimal care for postpartum women today, HCPs need to be well informed about demographic and generational trends and apply this knowledge to their practices. Healthcare services need to be continuously updated—for example, by providing postpartum care that is tailored to individual women’s needs and not based on a set schedule, and by using digital means to communicate with patients. These recommendations are particularly important in the U.S., where postpartum services are still minimal but greatly needed.

Suzanne F. Foley, formerly an Assistant Professor of Nursing at Widener University in Chester, Pennsylvania, works as a women’s health consultant in the Philadelphia area. The author states that she does not have a financial interest in or other relationship with any commercial product named in this article.


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