Prepregnancy, Postpartum, Interpregnancy, and Well-Woman Care: The Intersection

Prepregnancy, postpartum, interpregnancy, and well-woman care are interrelated and can be defined by their relationship to the timing of pregnancy Figure 1. For women who become pregnant, pregnancy is recognized as a window to future health because complications during pregnancy, such as gestational diabetes mellitus, gestational hypertension, preeclampsia, and fetal growth restriction, are associated with risk of health complications later in life 1 2 3 4. The interpregnancy period is an opportunity to address these complications or medical issues that have developed during pregnancy, to assess a woman’s mental and physical well-being, and to optimize her health along her life course. The yield of this effort is improved maternal health at the start of the next pregnancy, which leads to improved health outcomes for the infant. The proposed long-term yield is improved long-term health for the woman. Therefore, interpregnancy care aims to maximize a woman’s level of wellness not just in between pregnancies and during subsequent pregnancies, but also along her life course. Because the interpregnancy period is a continuum for overall health and wellness, all women of reproductive age who have been pregnant regardless of the outcome of their pregnancies (ie, miscarriage, abortion, preterm, full-term delivery), should receive interpregnancy care as a continuum from postpartum care (see the American College of Obstetricians and Gynecologists’ [ACOG] Committee Opinion Optimizing Postpartum Care or the For More Information section). However, it should be acknowledged that not all women will want to or will have subsequent pregnancies or children.

The health care providers of that care for women of reproductive age include obstetrician–gynecologists, primary care providers, subspecialists who treat chronic illnesses, advanced practice professionals, and mental health providers. Some models have included pediatricians and dentists caring for the infant or other children. Creative partnerships such as these as well as policies that promote access to and coverage of interpregnancy care can ensure that the woman’s health is addressed.

Definition of Interpregnancy and Well-Woman Care

Interpregnancy care is the care provided to women of childbearing age who are between pregnancies with the goal of improving outcomes for women and infants 5. When reviewing international recommendations for birth spacing, the World Health Organization identified four intervals: 1) “interpregnancy interval” indicates the time a woman is not pregnant between one live birth or pregnancy loss and the next pregnancy; 2) “birth-to-birth interval” is the time between a live birth and the subsequent live birth (this interval does not take into account any pregnancy losses in between births); 3) “interoutcome interval” describes the time between the outcome of one pregnancy and the outcome of the previous pregnancy; and 4) “birth-to-conception interval” is the time between a live birth and the start of the next pregnancy 6. This document discusses interpregnancy care , defined here as the care that addresses a woman’s health care needs during the interval between one live birth or pregnancy loss and the start of the next pregnancy; specifically, it will focus on this interval after a woman has transitioned from postpartum care.

Existing Recommendations

The concept of interpregnancy care is well established and multiple organizations have put forth their own distinct set of interpregnancy care recommendations 5 7 8 9. However, many of these recommendations are focused solely on improving neonatal outcomes of future pregnancies. This document will focus on interpregnancy care to improve maternal and neonatal outcomes of future pregnancies, as well as long-term women’s health outcomes.

Breastfeeding and Maternal Health

Health care providers should routinely provide anticipatory guidance and support to enable women to breastfeed as an important part of interpregnancy health 11 12. Multiple studies have shown that longer duration of breastfeeding is associated with improved maternal health, including lower risks of diabetes 13 14 15, hypertension 15 16, myocardial infarction 17, ovarian cancer 15 18, and breast cancer 15 19. For women with gestational diabetes, longer duration of breastfeeding is associated with decreased risk of metabolic syndrome 20 and type 2 diabetes 21. A recent simulation study found that if 90% of women were to breastfeed optimally, this would prevent 5,023 cases of breast cancer, 12,320 cases of type 2 diabetes, 35,982 cases of hypertension, and 8,487 cases of myocardial infarction 22.

Although ACOG recommends exclusive breastfeeding for the first 6 months of life, obstetrician–gynecologists and other health care providers should support each woman’s informed decision about whether to initiate or continue breastfeeding 11, recognizing that she is uniquely qualified to decide whether exclusive breastfeeding, mixed feeding, or formula feeding is optimal for her and her infant. Additionally, obstetrician–gynecologists and other health care providers can provide information and resources that might help women better understand their workplace breastfeeding rights 23. Additional guidance can be found at www.acog.org/breastfeeding .

Interpregnancy Interval

Women should be advised to avoid interpregnancy intervals shorter than 6 months and should be counseled about the risks and benefits of repeat pregnancy sooner than 18 months. Most of the data from observational studies in the United States would suggest a modest increase in risk of adverse outcomes associated with intervals of less than 18 months and more significant risk of adverse outcome with intervals of less than 6 months between birth and the start of the next pregnancy 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40. More recent studies, however, have called into question the methodologies common to much of the literature, and the question remains open as to the causal effect of short interpregnancy intervals on some outcomes 41 42. Interdelivery (from one delivery to the next) intervals of less than 18 months have been associated with increased risk of uterine rupture among women undergoing trials of labor after cesarean 43 44. Interpregnancy intervals of greater than 5–10 years also may be associated with increased risk of adverse outcomes 25.

Because the interpregnancy interval is a potentially modifiable risk factor, there has been enthusiasm for providing guidance to women and their families about the benefits of intervals longer than 6 months between pregnancies. Women of lower socioeconomic status and women of color appear to be at risk of the shortest interpregnancy intervals 45 46 47, which highlights the interpregnancy interval as a potential opportunity to address inequities in adverse outcomes.

Depression

All women should be screened for depression in the postpartum period and then as part of well-woman care during the interpregnancy period. Such screening should be implemented with systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up. Postpartum depression screening also may occur at the well-child visit with procedures in place to accurately convey the information to the maternal care provider. Perinatal depression and anxiety affect one in seven women, with devastating consequences for women and children 65. Screening for symptoms with a validated instrument, such as the Patient Health Questionnaire-9 or the Edinburgh Postnatal Depression Scale, is recommended by the U.S. Preventive Services Task Force 66 and by all major medical organizations that care for women and infants 65 67 68. The American Academy of Pediatrics recommends postpartum depression screening at the time of well-child visits at 1, 2, 4, and 6 months of age 67. Although screening alone has been demonstrated to be of benefit 65, ideally screening would be paired with available and accessible mental health interventions. A recent systematic review found that only 22% of women who screened positive for depression attended a mental health visit in the absence of an intervention to facilitate referral 69. Health care providers should be prepared to initiate treatment or refer women to a qualified caregiver, or both.

Managing Other Medical Conditions

In women with chronic medical conditions, interpregnancy care provides an opportunity to optimize health before a subsequent pregnancy. For women who will not have any future pregnancies, the period after pregnancy also affords an opportunity for secondary prevention and improvement of future health. Recommendations for counseling and goals can be found in Table 2 , with recommendations for the most common conditions expanded on in the following sections.

Substance Use and Use Disorders

Tobacco Cessation. Nonpregnant adult smokers should be offered smoking cessation support through behavioral interventions and U.S. Food and Drug Administration-approved pharmacotherapy 88. Tobacco use is a modifiable risk factor for a host of adverse pregnancy outcomes and longer-term health outcomes. The U.S. Preventive Services Task Force and ACOG recommend medications, behavioral interventions, or both in nonpregnant adults 89 90. For lactating women, nicotine replacement therapy is compatible with breastfeeding because the amounts of nicotine and cotinine transferred with breast milk are generally the same or lower using replacement therapy compared with smoking 91. Specific tools are available to assist health care providers in enabling women to cease smoking after pregnancy 89 92. Health care providers should reassess tobacco use (smoked, chewed, electronic nicotine delivery systems, vaped) at the postpartum visit 4 and continue to provide, or refer to, assistance with ongoing efforts at cessation 93.

Substance Use Disorder. In the interpregnancy period, all women should be routinely asked about their use of alcohol and drugs, including prescription opioids, marijuana, and other medications used for nonmedical reasons and referred as indicated. Substance use disorder and relapse prevention programs also should be made available 4 48 94. Untreated substance use disorders have implications for long-term maternal health and increase the risk of adverse pregnancy outcomes. Moreover, psychiatric disorders such as depression, anxiety, bipolar disorder, and posttraumatic stress disorder are prevalent among women with substance use disorders. Women with substance use disorder have higher rates of unintended pregnancies and lower rates of use of reliable contraception 95. Therefore, it is particularly important to ensure continuation of treatment or to identify and initiate treatment for substance use disorder during the interpregnancy period.

Women who are planning to become pregnant in the immediate future should be encouraged to discontinue recreational substance use and should be counseled that there is no safe level or type of alcohol use during pregnancy. Women who are unable to quit before or during pregnancy likely have a substance use disorder and should be referred to treatment as indicated, if this has not already been done. See the For More Information section for additional resources on substance use.

Social Determinants of Health and Racial and Ethnic Disparities

Health care providers should inquire about and document social and structural determinants of health and maximize referrals to social services to help improve patients’ abilities to access health care 96. Social determinants of health (eg, stable housing, access to food and safe drinking water, utility needs, safety in the home and community, immigration status, and employment conditions) relate closely with health outcomes, health-seeking behaviors, and health care 96 97. Many of the resources available to women and families with specific needs are provided through state departments of health, insurers, or community health organizations, but individual health care providers and practices should engage in evaluation and referral as well. Estimates of the benefit of such programs are derived largely from observational cohort and preintervention and postintervention designs, but many demonstrate improved health outcomes 98 99 100 101.

Health care providers should be aware of prevailing disparities in health care and outcomes in order to understand the risks faced by the populations they care for, but no current evidence guides variation in care by race or ethnicity that may be needed to improve outcomes. Women of color and of low socioeconomic status are at risk of adverse pregnancy and overall poor health outcomes 102. These women may be least likely to receive prepregnancy and interpregnancy care despite their disproportionate need 7 103. Although some interpregnancy interventions (eg, home visits, social supports) have been demonstrated to be of benefit within specific populations at risk, data on differential effects of interventions by population are scarce.

If available, health care providers should consider patient navigators, trained medical interpreters, health educators, and promotoras (lay community health care workers who work in Spanish-speaking communities [104]) to facilitate quality interpregnancy care for women of low-health literacy, with no or limited English proficiency, or other communication needs.

Intimate Partner Violence

Women of childbearing age should be screened for intimate partner violence (IPV), such as domestic violence, sexual coercion, and rape and referred for intervention services if they screen positive. Sample questions to begin the conversation and guidance on how to appropriately and safely screen for IPV are provided in ACOG Committee Opinion Intimate Partner Violence 105. Given the high incidence of IPV, screening for IPV should occur during all encounters (postpartum, well-woman, and at the first prenatal visit and at least once per trimester for pregnant women) 48 106. During a lifetime, more than one in three women experience rape, physical violence, or stalking by an intimate partner 105. Intimate partner violence has a period prevalence of 17% in the first year postpartum 107. Some women experience IPV as reproductive coercion, including pregnancy pressure, pregnancy coercion, and sabotaging contraception 108.

Sexually Transmitted Infections

Women with histories of STIs before or during pregnancy should have thorough sexual and behavioral histories taken to determine risk of repeat infection or current or subsequent infection with human immunodeficiency virus (HIV) or viral hepatitis. All women should be encouraged to engage in safe sex practices; partner screening and treatment should be facilitated as appropriate. As part of interpregnancy care, women at high risk of STIs should be offered screening, including for HIV, syphilis, and hepatitis. Screening should follow guidance set forth by the CDC 109. Sexually transmitted infections have clear implications for a woman’s overall health, fertility, and pregnancy outcomes. Unrecognized and untreated infections may have important sequelae. Women with history of prior STIs are at increased risk of recurrent STIs 110 and, thus, should be considered for rescreening.

Immunizations

The interpregnancy period is ideal to initiate or complete appropriate adult vaccinations that are contraindicated during pregnancy or were not completed during pregnancy but are medically indicated 111 Table 1 in ACOG’s Committee Opinion on Maternal Immunization ). The current recommended immunization schedule for adults 19 years or older can be found on the CDC’s website. The American College of Obstetricians and Gynecologists reviews these schedules annually for endorsement. Immunizations are a proven way to prevent and, in some cases, eradicate disease. Attention to vaccines needed during the interpregnancy period can play a major role in reducing morbidity and mortality from a range of preventable diseases, including pertussis, influenza, human papillomavirus, hepatitis, and rubella for nonimmune women.

Other Components of the Well-Woman Visit

The periodic well-woman visit as a component of interpregnancy care provides the opportunity for women to receive necessary preventive services. This may include multiple well-woman visits for women who have an interpregnancy interval that lasts for more than 1 year. Guidance for the components of the well-woman examination can be found in ACOG’s Committee Opinion on Well-Woman Visit , and at www.acog.org/wellwoman 112 113.

What Is Role of Interpregnancy Care in Specific Populations?

The provision of interpregnancy care may be particularly effective when targeted to high-risk and special populations. In addition to the aforementioned universal recommendations listed in this document, the following recommendations should be considered for specific populations. More details on each topic are provided in the For More Information section.

History of High-Risk Pregnancy

Fetal Anomalies

For women who have had pregnancies affected by congenital abnormalities or genetic disorders, health care providers should review postnatal or pathologic information with the women and offer genetic counseling, if appropriate, to estimate potential recurrence risk. Approximately 2–4% of live births are affected by congenital abnormalities. The strongest risk factors, such as age, family history, and a previously affected child, are usually nonmodifiable. In some cases, the finding of a malformation may have implications for maternal health. For example, maternal obesity and pregestational diabetes mellitus are risk factors for congenital anomalies 122 123. In these cases, interventions to prevent a recurrence should focus on improvement in the underlying maternal medical conditions.

Modifiable risk factors for congenital birth defects also can be identified and addressed in the interpregnancy period. All women who are planning a pregnancy or capable of becoming pregnant should take 400 micrograms of folic acid daily. Supplementation should begin at least 1 month before fertilization and continue through the first 12 weeks of pregnancy. All women planning a pregnancy or capable of becoming pregnant who have had a child with a neural tube defect should take 4 mg of folic acid daily. Supplementation should begin at least 3 months before fertilization and continue through the first 12 weeks of pregnancy. A thorough review of all prescription and nonprescription medications and potential teratogens and environmental exposures should be undertaken before the next pregnancy.

The responsibility of caring for a medically fragile infant may deter women from accessing interpregnancy care. Novel strategies, such as embedding screening and referral services within pediatric follow-up clinics 124, may help women to address their own health needs.

Genetic Testing

The interpregnancy period is an ideal time for genetic counseling and carrier screening if they have not been previously completed, which allows for informed planning of the subsequent pregnancy 125 126. Family history and carrier status are important considerations. A genetic and family history of the patient and her partner should be obtained 126 127 128. This may include family history of genetic disorders; birth defects; mental disorders; and breast, ovarian, uterine, and colon cancer. Further guidance on carrier screening and counseling can be found in ACOG’s Committee Opinion on Carrier Screening in the Age of Genomic Medicine 125, ACOG’s Committee Opinion on Carrier Screening for Genetic Conditions 126, and ACOG’s Technology Assessment on Modern Genetics in Obstetrics and Gynecology 128.

Infertility

Underlying conditions that may contribute to subfertility (eg, polycystic ovary syndrome, infections, obesity, and thyroid dysfunction) should be evaluated and treatments optimized before a woman attempts to become pregnant. Generally, recommendations for the length of the interpregnancy interval should not differ for women with prior infertility compared with women with normal fertility. Women with histories of infertility or subfertility may need to rely on assisted reproduction to become pregnant; the timing of the next pregnancy attempt is, therefore, often more readily influenced by health care providers than it might be for other women.

Prior Cesarean Delivery

Women with prior cesarean deliveries, and particularly those who are considering a trial of labor after cesarean delivery, should be counseled that a shorter interpregnancy interval in this population has been associated with an increased risk of uterine rupture and risk of maternal morbidity and transfusion. Evidence exists of increased risk of uterine rupture after cesarean delivery following delivery-to-delivery intervals of 18–24 months or less 43 129. Evidence also indicates that there is increased risk of maternal morbidity and blood transfusion among women with interpregnancy intervals of less than 6 months 44 130. Furthermore, women should be counseled that the incidence of placenta accreta spectrum increases with the number of prior cesarean deliveries 131.