Editorials
The Postpartum Visit: Is Six Weeks Too Late?
Aside from discharge planning in the hospital or a home nurse visit, a new mother may have no further contact with a physician until the six-week postpartum office visit. Blenning and Paladine discuss the traditional six-week postpartum visit in this issue of American Family Physician.1 Although it is assumed that a six-week visit will improve the mother's ability to care for her newborn and allow her physician to identify disease processes associated with childbirth, few data support these claims.
The mother's ability to sustain breastfeeding from hospital discharge to the six-week postpartum visit is low. Although the World Health Organization encourages hospitals to promote exclusive breastfeeding, continuance is difficult when supplemental formula is sent home at discharge and the mother has minimal breastfeeding support.2
The discontinuation rate of breastfeeding at two weeks is approximately 25 percent, with most women citing a lack of confidence in their breastfeeding ability as the primary reason for stopping.3 The highest drop-out rate occurs during the first four weeks postpartum in women who are young, single, nulliparous, and have a low household income.4 In the first week postpartum, discontinuance is highest if there are problems with latching on, breast pain, or if the mother has perceptions of insufficient milk or a hungry baby.3
Individualized encouragement from a physician or nurse in the office has been cited as the primary reason why 55 percent of mothers continued breastfeeding up to 12 weeks postpartum.3 Furthermore, breastfeeding women who had an individual outpatient visit with a family physician within two weeks postpartum, followed by another visit at four weeks, were more likely to exclusively breastfeed for a longer duration.4 It is unclear whether additional primary care visits can overcome barriers such as poverty, the need to return to work or school, or cultural factors. It is known, however, that the six-week postpartum visit is too late for many women to discuss breastfeeding problems.
Adolescents may benefit from earlier postnatal evaluation and intervention because they significantly overestimate their postpartum support systems.5 Stress, depression, and poor self-esteem may present before the six-week postpartum visit and contribute to contraceptive discontinuance.6 Many women resume sexual activity by six weeks postpartum; therefore, early postpartum follow-up visits with adolescents may help physicians assess contraceptive compliance and discuss side effects as well as the prevention of unwanted pregnancies.
Although postpartum depression typically is thought to occur within three months after delivery, the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., states that postpartum depression begins within four weeks after delivery.7 No specific guidelines exist for treating women with postpartum depression; however, certain women who are at higher risk should be identified before discharge and scheduled for an office visit sooner than six weeks postpartum. Factors such as uneasiness about hospital discharge, dissatisfaction with infant feeding method, lack of support, and recent immigrant status put women at higher risk of depression during the first week postpartum.8 Because the onset of postpartum psychosis typically begins in the first two weeks after delivery and is usually a manifestation of bipolar disorder,9 it is prudent to see women with bipolar disorder soon after discharge. Women with a history of postpartum depression are at particularly high risk of recurrence and may benefit from prophylactic therapy with close monitoring for treatment failure.9
Although quality evidence may not exist that the six-week postpartum visit is beneficial, evidence does suggest that some women may benefit from an earlier visit. While "better late than never" may be true in some situations, physicians need to recognize that the traditional timing of the postpartum visit may limit their ability to help some women. Further research is needed on the timing and content of the hallowed postpartum visit.
The Authors
barbara s. apgar, m.d., m.s., is clinical professor of family medicine at the University of Michigan Medical Center, Ann Arbor. She also is an associate editor of AFP.
DAVID SERLIN, M.D., is clinical instructor of family medicine at the University of Michigan Medical Center.
AMANDA KAUFMAN, M.D., is a clinical lecturer in family medicine at the University of Michigan Medical Center.
Address correspondence to Barbara S. Apgar, M.D., M.S., University of Michigan Medical Center, 883 Sciomeadow Dr., Ann Arbor, MI 48103 (e-mail: bapgar@umich.edu). Reprints are not available from the authors.
REFERENCES
1. Blenning CE, Paladine H. An approach to the postpartum visit. Am Fam Physician 2005;72:2491-6,2497-8.
2. Ertem IO, Voto N, Leventhal JM. The timing and predictors of the early termination of breastfeeding. Pediatrics 2001;107:543-8.
3. Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics 2003;112:108-15.
4. Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon N, et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics 2005;115:139-46.
5. Quinlivan JA, Luehr B, Evans SF. Teenage mother's predictions of their support levels before and actual support levels after having a child. J Pediatr Adolesc Gynecol 2004;17:273-8.
6. Kershaw TS, Niccolai LM, Ickovics JR, Lewis JB, Meade CS, Ethier KA. Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: implications for prevention of repeat pregnancy. J Adolesc Health 2003;33:359-68.
7. American Psychiatric Association. Diagnositic and statistical manual of mental disorders. 4th ed., text revision. Washington, D.C.: American Psychiatric Association, 2000:387.
8. Dennis CL, Janssen PA, Singer J. Identifying women at-risk for postpartum depression in the immediate postpartum period. Acta Psychiatr Scand 2004;110:338-46.
9. Wisner KL, Parry BL, Piontek CM. Postpartum depression. N Engl J Med 2002;347:194-9.
Integrating Genetic Counseling into Family Medicine
This article exemplifies the AAFP 2005 Annual
Clinical Focus on the legal, social, clinical, and ethical issues of medical
genomics.
There has been a recent explosion of knowledge in genetics. This "big bang" and its ensuing discoveries are affecting medical understanding of both rare and common disorders. However, many new findings, especially in the realm of predictive genetic testing, have greatly outpaced medicine's ability to define what is clinically meaningful. This environment can seem confusing to patients and doctors alike.
Family physicians often feel unprepared to handle patient inquiries about the meaning and applicability of new genetic information.1 Although family physicians routinely counsel patients about familial risk factors and healthy lifestyles, traditional medical education often fails to train physicians how to apply new genetic data to routine patient care.2 Doctors typically rely on genetic counseling services, when they exist, to cope with the influx of medical genetics into daily practice. However, the scarcity of such services often renders this strategy ineffective.
We believe that family physicians can take on a larger role in genetic counseling. Physicians can begin the process of genetic counseling, help patients decide when to have genetic tests, arrange for referral to subspecialists, and help patients understand the information they receive. These skills are rapidly becoming an indispensable element in the family physician's repertoire.
The leading advocates for family physicians to take on a greater genetic counseling responsibility are patients themselves. Several studies3,4 found that patients prefer their primary care physician to facilitate informed decision-making about genetic testing and counsel them about preventive health measures. Such risk-assessment skills are used routinely in the evaluation of patients with cardiovascular disease.5 Why not broaden this skill to explicitly include family history and other genetic information?
The nature of genetic medicine is inherently compatible with the primary care philosophy of disease prevention. Early genetic testing and treatment focused on rare, highly penetrant mutations that led to disease; however, most of the disorders commonly seen in medicine (e.g., diabetes, cancer, heart disease) result from a complicated interplay between genetic predisposition, environment, and lifestyle choices.5,6 With an understanding of a patient's behavioral risk factors and an intimate knowledge of family history, family physicians can refer selected patients for genetic consultation and suggest preventive health measures.
Consider an example: a 50-year-old woman requests testing for the BRCA1/2 mutation because her elderly aunt died of breast cancer. The woman read about the genetic "breast cancer test" in a recent magazine article. In reviewing the patient's family history, the physician finds that both of the patient's parents died of complications of diabetes. The patient herself is overweight and smokes. Therefore, the question of familial breast cancer risk appropriately takes a back seat to the strong family history of diabetes and current health status. As a result, the family physician should explain to the patient that she would likely benefit more from smoking cessation and weight loss than from genetic counseling to determine her risk of breast cancer. Such a discussion can help patients understand the relevance of genetic tests in the context of their own personal health risks.
Genetic counseling can have broad implications for perceived health status, regardless of whether a patient undergoes genetic testing.7,8 One study7 suggests that patients who seek genetic counseling to determine their risk for cancer and subsequently refuse testing may experience unintended psychological problems up to six months after the counseling session.
A patient's perceived benefit from testing may vary depending on life circumstances. Likewise, the clinical utility of certain genetic tests may change over time as new treatments for diseases become available. Therefore, genetic counseling ideally is handled in the very sort of longitudinal relationship family physicians forge with their patients. The family physician is well-situated to revisit genetic issues and help patients anticipate the psychological effects of genetic risk assignment.
The "big bang" of genetic information promises to challenge family physicians in coming years. We must embrace this responsibility and develop new skills that incorporate genetic information as another aspect of the person we treat within the context of the ongoing doctor-patient relationship.
The Authors
JEFFREY R. MARTIN, M.D., is associate director of the Lancaster (Pa.) General Hospital Family Medicine Residency Program and clinical assistant professor of medicine at Temple University School of Medicine, Philadelphia.
ADAM S. WILIKOFSKY, PH.D., is associate director of the Lancaster (Pa.) General Hospital Family Medicine Residency Program.
Address correspondence to Jeffrey R. Martin, M.D., Lancaster General Hospital Family Medicine Residency Program, 555 N. Duke St., Lancaster, PA 17604 (e-mail: jrmartin@lancastergeneral.org). Reprints are not available from the authors.
REFERENCES
1. Freedman AN, Wideroff L, Olson L, Davis W, Klabunde C, Srinath KP, et al. U.S. physicians' attitudes toward genetic testing for cancer susceptibility. Am J Med Genet A 2003;120:63-71.
2. Suther S, Goodson P. Barriers to the provision of genetic services by primary care physicians: a systematic review of the literature. Genet Med 2003;5:70-6.
3. Kinney AY, DeVellis BM, Skrzynia C, Millikan R. Genetic testing for colorectal carcinoma susceptibility: focus group responses of individuals with colorectal carcinoma and first-degree relatives. Cancer 2001;91:57-65.
4. Yoon PW, Scheuner MT, Khoury MJ. Research priorities for evaluating family history in the prevention of common chronic diseases. Am J Prev Med 2003;24:128-35.
5. Collins FS. Shattuck lecture-medical and societal consequences of the Human Genome Project. N Engl J Med 1999;341:28-37.
6. Collins FS, Guttmacher AE. Genetics moves into the medical mainstream. JAMA 2001;286:2322-4.
7. Lerman C, Hughes C, Lemon SJ, Main D, Snyder C, Durham C, et al. What you don't know can hurt you: adverse psychologic effects in members of BRCA1-linked and BRCA2-linked families who decline genetic testing. J Clin Oncol 1998;16:1650-4.
8. Lucassen A, Parker M. Revealing false paternity: some ethical considerations. Lancet 2001;357:1033-5.
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Academy of Family Physicians. |
