Addressing Adverse Childhood and Adult Experiences During Prenatal Care.

Adverse childhood and adult experiences can affect health outcomes throughout life and across generations. The perinatal period offers a critical opportunity for obstetric clinicians to partner with patients to provide support and improve outcomes. This article draws on stakeholder input, expert opinion, and available evidence to provide recommendations for obstetric clinicians' inquiry about and response to pregnant patients' past and present adversity and trauma during prenatal care encounters. Trauma-informed care is a universal intervention that can proactively address adversity and trauma and support healing, even if a patient does not explicitly disclose past or present adversity. Inquiry about past and present adversity and trauma provides an avenue to offer support and to create individualized care plans. Preparatory steps to adopting a trauma-informed approach to prenatal care include initiating education and training for practice staff, prioritizing addressing racism and health disparities, and establishing patient safety and trust. Inquiry about adversity and trauma, as well as resilience factors, can be implemented gradually over time through open-ended questions, structured survey measures, or a combination of both techniques. A range of evidence-based educational resources, prevention and intervention programs, and community-based initiatives can be included within individualized care plans to improve perinatal health outcomes. These practices will be further developed and improved by increased clinical training and research, as well as through broad adoption of a trauma-informed approach and collaboration across specialty areas.

Doula care, early breastfeeding outcomes, and breastfeeding status at 6 weeks postpartum among low-income primiparae.

OBJECTIVE: To examine associations between doula care, early breastfeeding outcomes, and breastfeeding duration. DESIGN: Prospective cohort. SETTING: Regional hospital in northern California. PARTICIPANTS: Low-income, full gestation primiparae receiving doula care (n=44) or standard care (n=97). MEASURES: Birth outcomes and newborn feeding data obtained from the hospital record. Follow-up interviews conducted at day 3 to record the timing of onset of lactogenesis and breastfeeding behavior and at 6 weeks to obtain current breastfeeding status. RESULTS: Adjusting for baseline differences, women receiving doula care were significantly more likely to have a short stage II labor, a noninstrumental vaginal delivery, and to experience onset of lactogenesis within 72 hours postpartum (timely onset of lactogenesis). Overall, 68% of women receiving doula care and 54% of women receiving standard care were breastfeeding at 6 weeks. In the subset with a prenatal stressor (n=63), the doula care group was more than twice as likely to be breastfeeding at 6 weeks (89% vs. standard care, 40%). Breastfeeding at 6 weeks was also significantly associated with timely onset of lactogenesis and maternal report that the infant "sucked well" at day 3. CONCLUSIONS: Doula care was associated with improved childbirth outcomes and timely onset of lactogenesis. Both directly and as mediated by timely onset of lactogenesis, doula care was also associated with higher breastfeeding prevalence at 6 weeks.

Changing provider practices to enhance preconceptional wellness.

Primary care providers who fail to provide preconceptional care to every woman of reproductive age during each primary care visit are losing key preventive opportunities. Changing provider practices involves multidisciplinary input into the planning of care, support of clinical leaders and professional organizations, and adequacy of funding for proposed changes. Programs in California, North Carolina, and South Carolina have demonstrated significant changes in provider acceptance of preconceptional.