This policy has been revised by the policy posted on October 1, 2009. POLICY STATEMENT

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PEDIATRICS Vol. 107 No. 6 June 2001, pp. 1456-1458

AMERICAN ACADEMY OF PEDIATRICS:
The Prenatal Visit

Committee on Psychosocial Aspects of Child and Family Health

	ABSTRACT

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In their role as advocates for children and families, pediatricians are in an excellent position to support and guide parents during the prenatal period. Prenatal visits allow the pediatrician to gather basic information from parents, provide information and advice to them, and identify high-risk situations in which parents may need to be referred to appropriate resources for help. In addition, prenatal visits are the first step in establishing a relationship between the pediatrician and parents and help parents develop parenting skills. The prenatal visit may take several possible forms depending on the experience and preferences of the parents, competence and availability of the pediatrician, and provisions of the health care plan.

	INTRODUCTION

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The American Academy of Pediatrics last endorsed the prenatal visit in a policy statement in January 1996.¹ The Committee on Psychosocial Aspects of Child and Family Health asserts its continuing support for this service as a valuable component of comprehensive pediatric care.

In their role as advocates for children and families, pediatricians are in an excellent position to support and guide parents during the prenatal period. Anticipatory guidance on pertinent issues relating to parenting should begin at this visit.² Most pediatricians think that the prenatal visit is helpful to themselves and to prospective parents.^3,4 Because they do not initiate the visits, many pediatricians have found that discussing the concept with referring obstetricians in the community has been very helpful in increasing the number of these visits.

	OBJECTIVES

Several objectives can be met by the prenatal visit, including:

1. Establishing the relationship between physician and parents. The prenatal period is a good time to start building the health care alliance that should last throughout the child's pediatric care. This is a particularly good time to invite the father and other supportive adults to establish a relationship with the pediatrician or health care provider and to encourage them to come to future visits. Pediatricians who meet with parents before delivery of their child demonstrate how much they value this relationship. A prenatal visit introduces parents to the concept of a medical home for the child's future health and developmental needs. Parents' comfort levels may increase as they become familiar with their health care provider before the birth of their child, especially if a referral or transfer of care is necessary because of unusual medical needs of the infant.
2. Gathering basic information. The most important information to collect during the prenatal visit concerns the general assets and needs of the parents and their hopes and worries about their child. Pertinent areas that may be discussed in addition to family medical history are the parents' relationship with each other, the parents' problems with previous pregnancies, anxieties about the present pregnancy, fear of hereditary disorders, relationship between parents and grandparents, reaction of family members to the pregnancy, childhood experiences with parenting, resources for raising a child, plan for delivery (eg, rooming-in), infant feeding choice, car safety, postpartum feelings, expectations, and change in lifestyle.⁵ This is an appropriate time to identify cultural beliefs, values, and practices related to parenting, including attitudes regarding tobacco, alcohol, and other drug use. Additional issues to consider are age of the parents, the nature and extent of supporting family and friends, and whether the parents plan to begin or return to work and, if so, child care arrangements. Factors that may contribute to turmoil and stress or stability and contentment felt by the parents, such as employment, housing, and the likely effect of the arrival of the infant on the family, including sibling relationships, may be discussed.
3. Providing information and advice. The pediatrician can describe the anticipated behavior of the newborn and routine care provided in the nursery as well as information regarding the first visit to the pediatrician's office. It is appropriate for the pediatrician to initiate a discussion of the known advantages of breastfeeding. In view of the extensive published evidence of improved outcomes for breastfed infants and their mothers, breastfeeding should be recommended, and support services should also be discussed. These services may be provided within the office setting or through a community-based resource. However, the ultimate decision on the feeding of the infant, whether breast or bottle, remains with the parents.⁶ Expectant parents should be given accurate and unbiased information regarding circumcision and allowed the opportunity to discuss the performance, benefits, and risks of the procedure. The use of analgesia and its efficacy in reducing the procedural pain should be explained.⁷ Anticipatory guidance may begin at this point. Providing parents with a brochure on newborns will allow them to read and contemplate questions. Parents should be encouraged to participate in childbirth classes if they are not already doing so. If an early discharge from the hospital is foreseeable, a home visit may be scheduled by the hospital, or an early office appointment may be arranged.
4. Building parenting skills for mothers and fathers. One of the pediatrician's most complex but gratifying tasks is to help mothers, fathers, and other supportive adults mature into more competent caregivers. This process may begin before the birth of the child by discussing the parents' concerns and planned strategies. This is the time to begin to develop a shared parenting role (eg, daily child care, diapering, and nighttime care). A checklist of topics to be discussed during the prenatal visit would add value.
5. Identifying high-risk situations. High-risk situations may include adolescent mothers and fathers, single mothers, or parents with a history of genetic abnormality, history of substance abuse, risk of domestic violence, or a gun in the home, and when appropriate, parents should be referred to appropriate resources (eg, counselors, support groups, geneticist) and prepared for potential problems with the child.

	TYPES OF PRENATAL VISITS

The prenatal visit may take several possible forms depending on the experience and preferences of the parents, special expertise and availability of the pediatrician, and provisions of the health care plan. In an integrated health care delivery system, important topics that should be discussed before the infant is born may be incorporated into obstetric and prenatal pediatric visits and prenatal classes.⁸

The Full Prenatal Visit

The optimal form of visit is a regularly scheduled office visit with both parents present. During this visit, the 5 objectives listed earlier are discussed in detail. Discussion should also include the office and telephone hours, fees, hospital affiliations of the physician, coverage for night, weekend, and emergency care, and arrangements that may be made if the infant is born at a hospital where the pediatrician is not on staff. This type of visit is most important for a first pregnancy, for young parents (including adolescent mothers), when there are pregnancy complications or other anticipated problems of consequence for the newborn, when parents are unusually anxious for any reason, or before an adoption. Many parents do not take the opportunity to have such a prenatal visit when offered; however, the establishment of a mutual commitment to a sound and rewarding professional relationship usually results from this visit.

There is an ever-increasing need for home prenatal visits as more women have high-risk pregnancies that require maternal bed rest. These expectant mothers are unable to leave the home to meet their child's health care provider, learn more about the practice, and ask important questions. Home visits can include the same content as full prenatal visits but are conducted in the family's home by a physician, nurse practitioner, registered nurse, or physician assistant. As a result of this visit, families often become very committed to their health care provider and develop a trusting and long-term relationship.

The Brief Visit to Get Acquainted

An encounter lasting 5 to 10 minutes between the physician and expectant mother at the physician's office allows a brief meeting. The visit may include an introduction to other members of the staff and a short tour of the facility. This arrangement is appropriate for parents who are still in the process of selecting a pediatrician and are not yet ready for more extensive involvement. Such a visit may not provide enough time to cover all of the desirable elements listed above, but the pediatrician can offer to extend the visit or schedule a longer visit on another occasion when the father may attend.

The Basic Contact Visit or Telephone Call

The initial prenatal contact involves the expectant parent calling the physician's office and, if the physician is accepting new patients, the physician or staff person describing the basic practice arrangements (this should also be part of the 2 longer visits). During the telephone call, the parents are asked to provide the following basic identifying information: name, address, telephone number, origin of referral, place and expected date of delivery, and type of insurance coverage. The pediatrician or the staff person also invites the parents to make an appointment to discuss any substantive concerns. If a sheet or booklet describing the practice is available, it may be mailed to expectant parents. In this common arrangement, the physician's services are offered, but they may or may not be accepted.

No Prenatal Contact

If no prenatal contact has been made, all of the objectives listed earlier may be addressed in the newborn nursery or at the first postnatal office visit. Although a sound health care alliance may be formed at this time, a prenatal contact is advantageous in the event of problems during the newborn period and what has become a shorter hospital stay.

Group Prenatal Visit

The concept of the group well-child visit can be extended to the prenatal visit. Arranged as a large group (eg, a monthly meeting in the evening) or a small group of 3 to 5 parents, the group prenatal visit encourages mutual support among pregnant women and spouses while providing a forum for information similar to traditional individual sessions. It has the added advantage of saving the clinician time and expense. Participation by a pediatrician in a prenatal class provides an alternative setting. Families with children may also find these group visits of some help to discuss sibling rivalry.

	RECOMMENDATIONS

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Medical and social risks for families and infants are decreased by an early and comprehensive prenatal visit. Therefore, the following recommendations are made to promote the prenatal pediatric visit:

1. It is important to encourage expectant parents to begin a professional relationship with their pediatrician. Pediatric practices should establish a policy on prenatal visits. Services offered can be flexible and designed to meet the needs of parents. In some cases, a full prenatal visit is necessary. For other parents, a brief encounter is sufficient.
2. A policy on charges for prenatal visits should be established and communicated to third-party payers and families. It may be necessary for the pediatrician and state chapters to advocate to insurance companies the importance of prenatal visits. Third party payers should be encouraged to acknowledge long-term advantages of prenatal visits, given the positive impact on the health of the infant.
3. The established policy on prenatal visits should be made known to local obstetricians and to expectant parents who telephone pediatricians to inquire about available services.
4. Pediatric residents should be taught to conduct prenatal visits during their training.
5. There should be increased research into the value and effectiveness of the prenatal visit, in all its different iterations and with different populations.

Committee on Psychosocial Aspects of Child and Family Health, 2000-2001

Joseph F. Hagan, Jr, MD, Chairperson

William L. Coleman, MD

Jane M. Foy, MD

Edward Goldson, MD

Barbara J. Howard, MD

Ana Navarro, MD

J. Lane Tanner, MD

Hyman C. Tolmas, MD

Liaisons

F. Daniel Armstrong, PhD

Society of Pediatric Psychology

David R. DeMaso, MD

American Academy of Child and Adolescent Psychiatry

Sally Longstaffe, MD

Canadian Paediatric Society

Peggy Gilbertson, RN, MPH, CPNP

National Association of Pediatric Nurse Practitioners

Consultant

George J. Cohen, MD

National Consortium for Child and Adolescent Mental Health Services

Staff

Karen Smith

	FOOTNOTES

The recommendations in this statement do not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

	REFERENCES

Top Abstract Introduction Recommendation References

1. American Academy of Pediatrics, Committee on Psychosocial Aspects of Child and Family Health The prenatal visit. Pediatrics 1996; 97:141-142 [Abstract/Free Full Text]
2. Bradford BJ, Benedum KJ, Heald PA The prenatal pediatric visit and pediatric residency training. Clin Pediatr 1994; 33:688-690
3. Sprunger LW, Preece EW Characteristics of prenatal interviews provided by pediatricians. Clin Pediatr 1981; 20:778-782
4. Serwint JR, Wilson ME, Vogelhut JW, Repke JT, Seidel HM A randomized controlled trial of prenatal pediatric visits for urban, low-income families. Pediatrics 1996; 98:1069-1075 [Abstract/Free Full Text]
5. Berger LR, Rose E The prenatal pediatric visit revisited. Clin Pediatr 1983; 22:287-289
6. American Academy of Pediatrics, Work Group on Breastfeeding Breastfeeding and the use of human milk. Pediatrics 1997; 100:1035-1039 [Abstract/Free Full Text]
7. American Academy of Pediatrics, Task Force on Circumcision Circumcision policy statement. Pediatrics 1999; 103:686-693 [Abstract/Free Full Text]
8. Dershewitz RA The pediatric prenatal visit: a time for change? Pediatrics 1996; 98:1195-1996 [Abstract/Free Full Text]

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Pediatrics (ISSN 0031 4005). Copyright ©2001 by the American Academy of Pediatrics

The following policy statement is a revision:

The Prenatal Visit

George J. Cohen Committee on Psychosocial Aspects of Child and Family Health
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