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Improving "Fourth Trimester" Support via Newborn Medicine In-Home Visits in Cleveland, Ohi


In an effort to keep my foot in the academic world (a necessity as I still work in the NICU of a large teaching hospital and have to do "scholarly" work!) I have drafted an abstract detailing the process of setting up my newborn home visiting practice over the last year. Here is version #1:

Background

There has been increasing awareness in recent years that new mothers lack adequate support and that the postpartum transition to motherhood, or "fourth trimester," is a critical time for maternal-infant bonding. Contributors to the lack of fourth trimester support in the U.S. include all of the following:

  • The number of mothers who desire to exclusively breastfeed has increased, but many regions have yet to see a concomitant increase in post-discharge lactation support.

  • Many women live away from their families of origin and do not have local support networks in place when they have their first babies.

  • The majority of working mothers experience short maternity leaves (less than 12 weeks) and experience obstacles to expressing and storing breast milk when they return to work.

  • Due to work hour restrictions, pediatric residents have far less clinical time dedicated to learning newborn medicine than in the past. It is not unusual for newly trained pediatricians to have significant knowledge gaps in normal newborn care and breastfeeding.

In the suburbs of Cleveland, Ohio (metropolitan area of > 2 million people) there are only a handful of lactation consultants (IBCLCs) who regularly do in-home visits and post-discharge nursing visits are prioritized for the smallest and sickest neonates. Although there are many independent doula and postpartum/newborn care agencies in the area, they cater to upper-middle class families who have the financial means to pay their out-of-pocket fees. In addition, home visits with pediatricians are not the norm. Mothers of newborns in the suburbs of Cleveland, especially those with a need for breastfeeding support, often need to bring their babies to numerous outpatient pediatric and lactation visits during the first few weeks of life. These frequent trips outside of the home can increase maternal stress and interfere with mother-newborn bonding.

Objective

To improve fourth trimester support for new mothers and newborns in the greater Cleveland area by starting a pediatric in-home visiting service for newborns and infants.

Materials/Methods

The main tasks involved in starting up my home visiting service included obtaining malpractice insurance, applying to the state of Ohio for a business license/LLC, obtaining a federal tax identification number, development of a system for documentation, securing a method for accepting payments from clients, creation of a business website, and branding/advertising.

Equipment used during home visits includes a pediatric stethoscope, baby scale, thermometer, portable pulse oximeter, transcutaneous bilirubinometer (jaundice meter), paper tape measures, breastfeeding and pumping supplies, and an otoscope.

A typical home visit is between 60-75 minutes long and includes a detailed review of the pregnancy and delivery history, a newborn physical exam, measuring and plotting growth parameters, a bilirubin check, assessment and discussion of feeding and sleeping patterns, screening for parent well-being and postpartum depression, and referrals to community resources as needed (including IBCLCs and psychiatrists that specialize in postpartum mental health).

Results

Since July 2018 I have completed 15 in-home visits and 25 additional consults via phone, text message, and email. The majority of my clients have been first-time mothers who have encountered unforeseen challenges during the fourth trimester. I have assisted mothers with all of the following problems via home visits and post-visit phone, text, and email support:

  • Breastfeeding-related problems, including low milk supply, oversupply, mastitis, and counseling regarding the use of maternal medications during lactation

  • In-home monitoring and trending of jaundice using a transcutaneous bilirubinometer

  • Diagnosis and treatment of thrush and diaper candidiasis

  • Diagnosis of postpartum depression and rapid referrals to psychiatrists for evaluation and treatment

  • Counseling regarding dietary changes for milk and soy protein allergies, medications for reflux, and the use of over-the-counter probiotics

  • Evaluation and management of infantile colic

  • In-person assessment of babies’ sleep environments and individualized recommendations for safe sleep practices

Two of my newborn home visiting patients were able to have unnecessary and expensive outpatient diagnostic tests cancelled (upper GI and swallowing study) as their symptoms resolved with the lactation support and dietary counseling. I was also able to prevent one middle-of-the-night emergency room visit for a bilirubin (jaundice) check and one urgent care visit for poor feeding secondary to thrush.

Conclusions

Barriers to continuing my newborn home visiting practice include difficulty negotiating reimbursement from local insurers and Medicaid, the high cost of malpractice insurance, time dedicated to travel, and my lack of IBCLC certification. Ideas for expansion and growth include being able to offer virtual visits (telemedicine) for those who live within my state but outside of my geographic area, obtaining certification to become an IBCLC, offering rentals and drop-offs of breastfeeding and baby supplies, being able to provide in-home phototherapy, and working with local milk banks to be able to distribute donor breast milk for supplementation.

In summary, physician in-home newborn visits are an innovative way to support breastfeeding, newborn care, and the physical, mental, and emotional transition to motherhood in geographic locations that currently lack adequate postpartum supports for new moms and babies.