The Broken Thread of Health Promotion and Disease Prevention for Women During the Postpartum Period

ABSTRACT

Postpartum maternal health affects maternal functional status, future pregnancy outcomes, maternal chronic disease development, and infant health. After pregnancy, however, many mothers may find that they face gaps in care related to their health and caregiving roles. Research shows that they were unprepared, uninformed, and unsupported during the postpartum period as they struggle with physical and emotional symptoms, infant caregiving, breastfeeding concerns, and lifestyle adjustments. Limited follow-up after a diagnosis of gestational hypertension or gestational diabetes and screening for postpartum depression are additional gaps in preventive and supportive care. Integrative reviews revealed modest efficacy and limitations of recent postpartum health promotion and disease prevention interventions. System, clinical, and community strategies are identified to address these gaps in women’s postpartum health services.

During pregnancy, women receive frequent health monitoring that increases in intensity if problems develop. But, how well are we doing in the United States to promote health and prevent disease in women after pregnancy? What are the gaps in care and unmet maternal health needs? In this article, we explore these questions with a focus on where the health services for women during the childbearing years warrant strengthening, specifically after pregnancy. Although such concerns are not new (Rubin, 1975; L. Walker, 1974), they reflect a reawakening of interest in the postpartum transition because it relates to women’s health and adaptation (Aber, Weiss, & Fawcett, 2013; Barkin, Wisner, Bromberger, Beach, & Wisniewski, 2010; Fahey & Shenassa, 2013; L. Walker, Sterling, Guy, & Mahometa, 2013). This renewed interest stems from a growing understanding of the implications of maternal postpartum health for the following:

• •Women’s functional status and quality of life (Da Costa, Dritsa, Rippen, Lowensteyn, & Khalifé, 2006; Posmontier, 2008; Webb et al., 2008),
• •Parenting and health of infants and young children (Field, 2010; Gress-Smith, Luecken, Lemery-Chalfant, & Howe, 2012; Kahn, Zuckerman, Bauchner, Homer, & Wise, 2002; McLearn, Minkovitz, Strobino, Marks, & Hou, 2006; Mercer, 2004),
• •Outcome of future pregnancies (Haas et al., 2005; Macintosh et al., 2006; Orr, Reiter, James, & Orr, 2012), and
• •Prevention of chronic disease and antecedent risk factors in women (Bombard et al., 2012; Centers for Disease Control and Prevention [CDC], 2012; Levine, Marcus, Kalarchian, Houck, & Cheng, 2010; World Health Organization [WHO], 2009a).

Traditionally, the 6-week period after pregnancy, called the puerperium, defined the recovery period after childbirth. From several perspectives, this period of postpartum recovery has been lengthened to the first postpartum year. At the most basic level of maternal survival, the introduction of late maternal death surveillance—maternal mortality between 42 days to up to 1 year after childbirth—has extended the postpartum period (Hoyert, 2007). Similarly, the span of concern for maternal mental health issues now embraces the first postpartum year (O’Hara & Wisner, 2014), and the key maternal health practice of breastfeeding is recommended for at least 1 year (American Academy of Pediatrics, 2012). Others have introduced alternative terms, such as internatal or interconception care, for care during the period after pregnancy (Feinberg et al., 2006; Handler et al., 2013; Lu et al., 2006). Nevertheless, identifying the gaps in care—the break in the thread linking the frequent health monitoring during pregnancy with what follows postpartum—is critical to making timely and responsive maternal postpartum health care a reality.

Our purpose in this article is to make a case for focusing on maternal health after pregnancy as a strategy to improve health and well-being and to prevent the development of chronic disease in women. It is beyond the scope of this article to conduct a comprehensive review of the vast literature on women’s health after childbirth, but rather we aim to provide evidence of the need to look (again) at what may be done to promote health and prevent disease among women during the extended postpartum period, the first year after childbirth.

Identifying the gaps in care—the break in the thread linking the frequent health monitoring during pregnancy with what follows postpartum—is critical to making timely and responsive maternal postpartum health care a reality.

As a framework for this article, we draw on the WHO (1998, 2009b) definitions of health promotion and disease prevention. Although both include risk reduction, their approach is very different. Health promotion is a universal process of enabling individuals to increase control over their health and its determinants (WHO, 2009b). Similarly, the focus of postpartum health promotion is on empowering women to develop self-efficacy to “navigate stressful life events, relationships, and experiences” that leads to improved health status and developing realistic expectations, effective coping skills, and the ability to mobilize a social support network (Fahey & Shenassa, 2013). In contrast, disease prevention is deterring the occurrence of disease, such as risk factor reduction, but also halting its progress and decreasing its consequences. The target groups for disease prevention are individuals who have a specific disease or identifiable risk factors for disease (WHO, 1998).

WHAT MOTHERS TELL US

Mothers’ Postpartum Experience

After the regular prenatal contact with care providers throughout pregnancy, women may find the immediate period following hospital discharge to be one for which they feel unprepared and unsupported by health-care providers as they grapple with physical and emotional symptoms, infant caregiving, breastfeeding concerns, and lifestyle adjustments (Gazmararian et al., 2014; Howell, Mora, Chassin, & Leventhal, 2010; Kanotra et al., 2007; Martin, Horowitz, Balbierz, & Howell, 2014). As one mother said to us, “Once the baby is born, nobody [in the health system] cares about you anymore.” This break in regular contact with a trusted health-care provider can leave some women feeling isolated and unprepared for the challenges and changes they face as new mothers. According to Howell et al. (2010), roughly one in four women are unprepared for the postpartum transition. More than half of women report struggles with stress, sleep, and exhaustion during the first 2 months after giving birth. A slightly smaller percentage of women report difficulties with pain or tenderness in breasts and back and concerns related to weight, body image, and sexuality (Declercq, Sakala, Corry, Applebaum, & Herrlich, 2014; L. Walker, Timmerman, Kim, & Sterling, 2002). Mothers may also deal with numerous other health problems, such as urinary incontinence (32%; Howell et al., 2010), fecal incontinence (17%; S. Brown, Gartland, Perlen, McDonald, & MacArthur, 2014), and pelvic–perineal dysfunctions (Fonti, Giordano, Cacciatore, Romano, & La Rosa, 2009). In addition, a systematic review indicates roughly 19% of women may encounter postpartum depression in the first 3 months after giving birth (Gavin et al., 2005). Finally, in structured interviews of more than 1,300 women, Webb and colleagues (2008) found that roughly two-thirds of women had encountered physical health problems occurring after childbirth to 9–12 months postpartum.

Women’s reports about the information and advice they received from health-care providers related to their postpartum health and well-being provides another window for viewing gaps in care. Research indicates that information and advice varies and is often insufficient. Only a little more than half of women (57%) in the Listening to Mothers III survey indicated they received sufficient information about birth control (Declercq et al., 2014). Regarding care provider discussion or queries about postpartum depression, only 40%–55% of women reported such conversations, which varied by maternal race (Liu & Tronick, 2012). Regarding chronic disease prevention, discussion or queries about topics, such as smoking, did not occur in 54%–64% of various health-care visits as reported by postpartum women (L. O. Walker, Im, & Tyler, 2013). Although these are self-reports of postpartum care, they are valuable because they reflect women’s views of their experiences.

Information Needs of New Mothers

Studies of new mothers indicate that women desire information about various topics related to promoting their health and well-being postpartum. Using a telephone survey of more than 1,100 new mothers at 4 weeks postpartum, Sword and Watt (2005) reported women wished they had had more information about infant care (42%–51%) and infant illnesses (54%–64%), followed next by information about postpartum physical (41%–51%) and emotional (32%–47%) changes. Among these women, those of lower income reported more informational needs than those of higher income. In another survey of more than 1,600 mothers at 7 weeks postpartum, 4 in 5 primiparas and 3 in 4 multiparas wished they had received more information about one or more maternal care topics (Moran, Holt, & Martin, 1997). Exercise and nutrition were leading areas in which both parity groups wanted more information as well as information related to fatigue. Mothers with less education or less support or who were younger reported greater informational needs. Of interest, mothers’ postpartum informational needs were unrelated to whether or not they had attended prenatal classes. In another study using a series of focus groups including 92 first-time mothers at about 8 weeks postpartum, the key area of information needs related to maternal health was that of stress, mental health, and limited support. In this study, mothers discounted print educational materials as beneficial and avowed a preference for face-to-face and various electronic modalities, such as videos, DVDs, Internet websites, and telephonic applications (Gazmararian et al., 2014). Although these studies span diverse time, location, and methodology, they portray mothers’ continuing unmet needs for health information after pregnancy.

Studies of new mothers indicate that women desire information about various topics related to promoting their health and well-being postpartum.

In sum, research has shown that many women needed more information about caring for their health during the postpartum period. Specifically, a substantial number of women have unmet informational needs related to their physical or emotional health. Health information from care providers is often insufficient or absent. And such needs were greater among women with fewer resources, including those younger in age or with lower income, education, or support. Clearly, a gap exists in postpartum health care.

WHAT SCIENCE TELLS US ABOUT PREVENTING CHRONIC DISEASE AFTER CHILDBIRTH

Risk of Chronic Disease Development

Although pregnancy and childbirth are normal events in women’s lives, conditions occurring during or after pregnancy can have implications for chronic disease development in women. Three of these are particularly noteworthy because of their long-term impact on women’s health: hypertensive disorders of pregnancy (HDP), gestational diabetes mellitus (GDM), and postpartum depression. HDP and GDM are not only complications of the perinatal period but have the consequence of rendering women susceptible to cardiovascular disease and Type 2 diabetes mellitus later in life (Nerenberg, Daskalopoulou, & Dasgupta, 2014) and thus have implications for the health care of women after pregnancy. Indeed, cardiovascular disease (CVD) is among the three leading causes of mortality in childbearing-aged women and the leading cause of mortality in women of all ages (U.S. Department of Health and Human Services, 2013). In the psychosocial domain, depression is the leading source of disease burden affecting people in middle- and high-income countries as measured by disability-adjusted life years (WHO, 2008). As a result, postpartum depression is of concern not only because of its immediate effects on maternal and infant well-being, but also because it is associated with the recurrent burden of depression (Josefsson & Sydsjö, 2007), and overall diminished mental health status. We next consider each of these in more depth.

Although pregnancy and childbirth are normal events in women’s lives, conditions occurring during or after pregnancy can have implications for chronic disease development in women.

Hypertensive Disorders of Pregnancy.

Of these perinatal precursors of chronic disease in women, HDP includes chronic hypertension, gestational hypertension, preeclampsia, and eclampsia. Preeclampsia and eclampsia are among leading causes of maternal and neonatal morbidity and mortality, during the perinatal period. Over the past 20 years in the United States, the incidence of preeclampsia has increased by 25% (American College of Obstetricians and Gynecologists [ACOG], 2013a; Wallis, Saflas, Hsia, & Atrash, 2008). Preeclampsia is linked to long-term health consequences such as CVD and hemorrhagic strokes (Bellamy, Casas, Hingorani, & Williams, 2007; M. C. Brown et al., 2013; Bushnell & Chireau, 2011; MacDonald et al., 2007), Type 2 diabetes mellitus (Libby et al., 2007), chronic renal disease (Vikse, Irgens, Leivestad, Skjaerven, & Iversen, 2008), hepatic failure (J. J. Walker, 2000), and a shortened lifespan (Harskamp & Zeeman, 2007; Mongraw-Chaffin, Cirillo, & Cohn, 2010). Furthermore, HDP and GDM are linked by several common risk factors, notably obesity, multifetal pregnancy, lower socioeconomic status, family history, ethnic and racial minority status (Hedderson, Darbinian, & Ferrara, 2010), maternal age, and multiparity (Pirkle, de Albuquerque Sousa, Alvarado, & Zunzunegui, 2014). Women with preeclampsia should be reevaluated after discharge from the birth setting and counseled about risk of recurrent preeclampsia and long-term CVD risks (ACOG, 2013a; Bushnell et al., 2014). A recent study of insurance claims, however, showed that just more than half of women with HDP had a subsequent primary care visit in the year after pregnancy (Bennett et al., 2014). In this study, 57% of women with Medicaid coverage and 64% of those with private insurance visits had such health-care visits.

Gestational Diabetes Mellitus.

GDM is a significant public health burden and a common pregnancy complication. It is linked to other maternal complications such as gestational hypertension, preeclampsia (Yogev, Xenakis, & Langer, 2004), operative vaginal birth, and cesarean surgery. Rates of GDM range from 2% to 10% of pregnancies (CDC, 2011), and 35%–60% of these women will develop Type 2 diabetes within 10–20 years (ACOG, 2013b; CDC, 2011). For women experiencing GDM during pregnancy but who are not diabetic immediately after birth, diabetes screening is recommended at 6–12 weeks postpartum and at least 3 years thereafter, depending on clinical laboratory values and health risk status (ACOG, 2013b; American Diabetes Association, 2013). Despite these recommendations, estimates indicate that only about half of women who develop GDM receive postpartum follow-up screening, with such screening more likely among more educated and higher-income women (Tovar, Chasan-Taber, Eggleston, & Oken, 2011).

Depression.

Depression is another significant health problem during the perinatal period and causes disability and disease among women 15–44 years of age (Melville, Gavin, Guo, Fan, & Katon, 2010; WHO, 2013). Although reported prevalence rates vary, it is estimated that depression and associated psychiatric disorders may affect between 8% and 29% of childbearing-aged women in the United States (Gavin et al., 2005; Melville et al., 2010; Vesga-López et al., 2008). Approximately 13% of pregnant women report major depression, and 11%–20% of postpartum women report depressive symptoms (CDC, 2008; O’Hara & Swain, 1996), with still higher rates reported for low-income women (L. Walker et al., 2002). Depression during this time period has important implications for maternal health, such as the development of maladaptive lifestyle and isolating social behaviors, adverse pregnancy, infant and childhood outcomes, difficulties with maternal role functioning (Mercer, 2004), and places women at an increased risk for chronic diseases such as CVD and diabetes (Goodwin, Davidson, & Keyes, 2009; Mezuk, Eaton, Albrecht, & Golden, 2008; Van der Kooy et al., 2007). Farr, Hayes, Bitsko, Bansil, and Dietz (2011) analyzed population-based data from 2006, 2008, and 2010 for women age 18–44 years and found that 12.8% of them simultaneously experienced depression and one or more chronic disease risk factors.

Despite associations between depression and chronic disease risk, screening guidelines are ambiguous. For example, according to the ACOG (2010), there currently is “insufficient evidence” to support solid recommendations for universally screening women for postpartum depression. Nonetheless, the ACOG (2010) opinion statement goes on to say “screening for depression has the potential to benefit a woman and her family and should be strongly considered” (p. 394). Several studies indicate that most women find screening acceptable, for example, during pediatric visits, and are receptive to counseling done by nurses (Kahn et al., 1999; Segre, O’Hara, Arndt, & Beck, 2010; L. Walker et al., 2013). Still, new mothers report that the topic of postpartum depression was not discussed in 49%–66% of their or their infants’ health-care visits (L. Walker et al., 2013). Moreover, low-income postpartum women are less likely to report having a health-care provider with whom they feel comfortable discussing depression.

Thus, the three perinatal conditions, HDP, GDM, and postpartum depression, each may raise women’s future susceptibility to chronic disease and are important areas for prevention efforts in the period after pregnancy. For each condition, there are gaps in the current care being received by women, and these gaps often affect low-income women disproportionately.

WHERE THE SCIENCE STANDS ON INTERVENTIONS TO IMPROVE MATERNAL HEALTH

The earliest postpartum health promotion program for women cited in the literature was the well-baby classes established by the New York City American Red Cross in 1908 (Ondeck, 2000). The classes focused on maternal hygiene, nutrition, and baby care. In the late 1950s, formal community-based childbirth, parenting, and postpartum education classes were established in the United States. These classes included healthy lifestyle behaviors such as diet, exercise, and stress management and information about pregnancy, childbirth, and the postpartum period. The focus was on helping women develop self-efficacy, gain control over their health and improve their health status, and gain life skills that would promote wellness through the lifespan (Nichols & Humenick, 2000).

Building on these early programs, a body of postpartum interventions aimed at fostering health or preventing disease has emerged. Evaluation of these programs has been enhanced not only by adhering to principles for research but also by the tools of systematic or integrative research review. For this reason, it is instructive to look at the findings of integrative reviews about health promotion interventions for new mothers as well as those aimed at preventing chronic disease in this population. In a review of 11 studies focused on general health promotion during the first postpartum year, Fowles, Cheng, and Mills (2012) examined the quality and effectiveness of such interventions. The review includes a wide range of interventions and outcomes in areas such as parenting skills, weight loss, nursing care for cesarean surgery, reducing drug use, mother–infant interaction, fatigue management, smoking relapse prevention, and psychological distress reduction. Unfortunately, the wide range of intervention topics covered and the variation in quality of studies limited the reviewers’ ability to draw overall conclusions about health promotion intervention effectiveness. Nonetheless, their review provided a view of the scope of postpartum health promotion interventions.

Support Interventions

In a review focused specifically of the impact of 22 postpartum support interventions provided by professionals or trained peers, Shaw, Levitt, Wong, and Kaczorowski (2006) examined a wide range of outcomes including physical and mental health, parenting, and quality of life. They found that in samples of women at low psychosocial risk, support interventions yield no statistically significant benefits in terms of maternal outcomes. By contrast, among women at high psychosocial risk, for example, because of low-income status, young age, or family dysfunction, beneficial outcomes did occur in areas such as parenting and improved mental health status of mothers as well as regarding family planning. The reviewers concluded that there was “some evidence” that indicated women at higher risk did benefit from support interventions.

Diet, Exercise, and Smoking Cessation Interventions

In a systematic review of diet and exercise interventions to reduce CVD risk factors, specifically hypertension and elevated blood lipids, Robbins et al. (2011) reviewed 21 intervention studies that included predominantly healthy women of reproductive age (ages 18–44 years). Because of variations in design and inconsistent results, the reviewers drew “limited conclusions.” In 18 studies measuring lipid levels as outcomes, 10 showed benefits of interventions; in 9 studies measuring hypertension as an outcome, 4 showed benefits of interventions. Overall, the reviewers concluded there were “modest benefits” in CVD risk factor reduction among healthy reproductive-aged women. However, they noted that meta-analyses combining samples might reveal greater benefits than individual studies. Another review by Hoedjes et al. (2010) focused in reducing CVD risk factors by postpartum interventions focused on weight loss or smoking cessation or relapse. They found that existing intervention reports did not include women who had experienced GDM or preeclampsia but rather general populations of postpartum women. Still, in five of six studies of this latter population, a combination of diet and physical activity was effective in reducing weight. Interventions directed at smoking behavior were less effective with roughly half showing benefit based on statistical comparisons.

From these examples of key systematic reviews of postpartum health promotion and disease prevention interventions, it is clear that more and better quality studies are needed of interventions for women after pregnancy, particularly for those at risk of chronic disease. Recent studies of diabetes prevention interventions after pregnancy are examples of such research (Chasan-Taber et al., 2014; Ferrara et al., 2011). The reviews of studies also suggest that women who are healthy or at low psychosocial risk may as a group derive little benefit from supportive interventions, whereas those at high psychosocial risk by virtue of younger age or less social and economic resources are more likely to have some degree of benefit. However, much more research is needed to draw firm conclusions about who will benefit and what interventions will be most effective among women after pregnancy or during the reproductive years.

POSTPARTUM HEALTH PROMOTION AND DISEASE PREVENTION: IMPLICATIONS FOR PRACTICE

Although the existing research points out many gaps in the health promotion and preventive care of women postpartum, it provides a starting point for designing interventions aimed at promoting health and preventing disease among women after pregnancy. We can begin envisioning a structure and process for enhancing health care for women that considers the shared common risk factors and long-term consequences of HDP and GDM, the associations between depression and chronic disease, current screening recommendations, and what mothers tell us about their experiences during the extended postpartum period. Strategies to prevent these common perinatal experiences, complications, and associated long-term sequelae should focus on a coordinated, comprehensive continuum of care after pregnancy that incorporates chronic disease risk assessment, lifestyle modification strategies, current screening recommendations, and interventions within an integrated health promotion approach (Karwalajtys & Kaczorowski, 2010). Theoretically, an integrated health promotion approach incorporates the patient, family, community, multidisciplinary and interprofessional health-care providers, and system-level interventions that target multiple levels of disease prevention, that is, primary, secondary, and tertiary (Hung et al., 2007; Karwalajtys & Kaczorowski, 2010; Wagner, 1998; WHO, 2014). These may entail public health programs as well as clinical health care.

The Health Home

We advocate for development and implementation of integrated women’s health care through a health home. The health home was first established in 1967 by the American Academy of Pediatrics to improve the quality of health care and increase emphasis on health promotion and disease prevention (Patient-Centered Primary Care Collaborative, 2014). Called by different names during the 47 years since its inception, most health homes have served as a primary care system for managing physical and behavioral chronic illnesses. The concept of a health home builds on but also goes beyond the medical home (Kaiser Family Foundation, 2014; Northridge, Glick, Metcalf, & Shelley, 2011; Schor, 2010; Substance Abuse and Mental Health Services Administration-Health Resources and Services Administration [SAMHSA-HRSA], 2014a). The essential principles of a health home are comprehensive care management, care coordination, health promotion, comprehensive transitional and follow-up care from inpatient to other settings, individual and family support, and referral to community and social support services as needed (SAMHSA-HRSA, 2014b). Strong evidence exists that a health home substantially increases the quality of health care, increases patient satisfaction, and decreases provider burnout (Reid et al., 2010). There is increasing evidence that a health home is cost effective for individuals with chronic illnesses (Nielsen, Langner, Zema, Hacker, & Grundy, 2012).

The implementation of a health home for women with an integrated health-promotion and disease-prevention approach is an intriguing concept. In addition to traditional medical and nursing care (women’s health care, obstetrical, and pediatric providers), we envision that it would include an array of services that have been shown to increase maternal health and prevent or decrease complications, such as, lifestyle modification activities, wellness classes, and chronic disease screening and management of disease conditions (i.e., HDP, GDM, and depression). Support and referral to community resources would be an integral part of health care. A health home may facilitate a smooth segue to postbirth care for those women who may otherwise experience a fragmented and rough transition from the birth setting to primary care. Although costs are associated with initiating new integrated services, venues exist for supporting efforts to improve postpartum care. These include an emphasis on health promotion and disease prevention in health-care reform, holding hospitals who receive tax-exempt status accountable for fulfilling community-benefit requirements (Yoder, Walden, & Verklan, 2010), and increasing the number of community health clinics that focus on health promotion and disease prevention. We have outlined potential strategies for addressing gaps in postpartum care in Table 1.

TABLE 1. Gaps and Strategies for Promoting Women’s Health After Pregnancy.

Gaps	Strategies
Mothers’ perspectives on gaps Lack of postpartum preparation, feelings of isolation or lack of support from health-care providers during the postpartum transition, and a wide range of challenges, such as fatigue and stress Information needs related to physiological changes during postpartum period, postpartum health and well-being, especially among young mothers or ones with low social or economic resources Infrequent discussion of key postpartum health topics, such as depression, diet, exercise, and smoking relapse or cessation	Strategies to address mothers’ perspectives of gaps Postpartum assessments and best practices using validated tools that address key perinatal conditions before discharge and during early postpartum months with links to resources Opportunities for follow-up care through drop-in mother–baby clinics, postpartum mothers’ groups, e-health resources for specific problems, home visitation by nurses or peer counselors Maternal screening at postpartum health care or well-baby visits in key areas with implications for maternal well-being or infant effects, such as maternal depression Established and well-functioning linkages between health-care settings and supportive community resources for mothers and families Support changes in clinical and community health systems to perform community assessments and target services to low-income, medically underserved women and infants as part of their community benefit (Yoder et al., 2010)
Gaps cited in the research literature Limited follow-up care for women with key conditions such as HDP, GDM, or depression during pregnancy or the postpartum period Few health promotion programs during postpartum that focus on lifestyle behaviors and increasing individuals’ self-efficacy related to their health. Need to establish and improve clinical screening and treatment guidelines aimed at shared risk factors of key conditions during postpartum	Strategies to address gaps cited in research literature Established systems for follow-up of women with health conditions that place them at risk for chronic disease Removing barriers to follow-up (such as screening and evaluation at coordinated well-baby and maternal visits) Sending postal or electronic reminders for follow-up care Offering incentives for attending follow-up care, such as health-related audio and video DVDs Community-based programs for women at risk for chronic health conditions, such as through local or state health departments Develop innovative strategies for health promotion services and activities aimed at community (Yoder et al., 2010), home monitoring and treatment (e.g., as telehealth and approved home monitoring and treatment devices), and away from inpatient “ambulatory monitoring” (Karwalajtys & Kaczorowski, 2010)
Gaps in the science Limited science on health promotion and disease prevention after childbirth, which provides some evidence of effectiveness of certain interventions for women at higher psychosocial risk Wide-scale absence of research on postpartum interventions to reduce risk of chronic diseases such as cardiovascular disease or diabetes among women at elevated risk because of health problems emerging during pregnancy	Strategies to address gaps in the science Development of evidence-based assessments to better understand who will benefit most from health promotion and supportive interventions after childbirth Multidisciplinary and interprofessional research and health-care delivery partnerships between universities and health organizations to develop and test research-based approaches on the efficacy of interventions after pregnancy to reduce risk of chronic disease development Advocate for increased research funding in these areas

Note. HDP = hypertensive disorders of pregnancy; GDM = gestational diabetes mellitus.

Examples of Health Promotion and Disease Prevention Programs

Because examples often speak more clearly than general descriptions, we next present examples of two programs: one with a health-promotion and disease-prevention focus for low-income families in an urban setting, and the second, a disease-prevention program focused on diabetes mellitus prevention across a largely rural state.

The Family Health and Birth Center (FHBC; http://www.communityofhopedc.org/fhbc) is a nonprofit community health center and freestanding birth center that provides a continuum of prenatal, intrapartum, postpartum, and primary health services for women and their families in the Washington, DC, area. The FHBC is one of two agencies comprising the DC Developing Families Center (http://www.developingfamilies.org), which focuses on health, social, and developmental services to low-income families. Although prenatal care, prenatal education, and intrapartum care delivered by nurse-midwives are important services provided at the FHBC, other supportive and health-care services for women before and after pregnancy are also available. These include support for breastfeeding, family planning, depression screening, patient navigation assistance with service providers and community resources, support from doulas, and preventive and chronic disease management health services for women and their families (L. Garrett, personal communication, August 29, 2014). Health-care services are provided by nurse midwives and nurse practitioners.

In Montana, diabetes prevention among women who have had GDM is an important component of the overall Montana Cardiovascular Disease & Diabetes Prevention Program (http://www.mtprevention.org) in conjunction with the Montana Diabetes Project (http://www.dphhs.mt.gov/publichealth/diabetes/index.html). The program includes raising awareness among primary care providers about monitoring guidelines and prevention for women who have had GDM, providing literature on action steps that providers may distribute to women, and offering a 10-month diabetes prevention program available at 16 locations and six telehealth sites throughout the state (S. Brokaw, personal communication, August 21, 2014). Funded through state and other sources, the program emphasizes lifestyle (including diet and exercise) and includes interdisciplinary teams of dietitians, exercise specialists, nurses, and support services. A referral from a care provider is needed to enter the program.

CONCLUSION

In this article, we identified gaps—the broken thread—in the care of women after pregnancy as seen through the eyes of women and through the science. We have offered strategies to address some of these gaps and provided examples of programs that promote health and prevent chronic disease among women after pregnancy. Now, we invite readers who have successfully implemented programs to improve women’s postpartum experience or enhance their health postpartum to share brief reports of their programs or services with the editor of The Journal of Perinatal Education, Wendy Budin (wendy.budin@nyu.edu). We are especially interested in health-promotion or disease-prevention programs and services with evidence of effectiveness.

Biographies

LORRAINE O. WALKER is Luci B. Johnson Centennial Professor at the University of Texas at Austin, School of Nursing. Her research focuses on weight gain during pregnancy and postpartum and maternal psychosocial and behavioral health.

CHRISTINA L. MURPHEY is an assistant professor of clinical nursing and director of the Graduate Maternity Program at the University of Texas at Austin, School of Nursing. Her research focuses on perinatal health promotion.

FRANCINE NICHOLS is a health-care consultant who specializes in health promotion and disease prevention programs, domestically and internationally. She is a fellow in the American Institute of Stress, Fort Worth, Texas.