Supporting New Moms with ‘4th Trimester’ Care Could Save Lives

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When we think about the experience of having a baby, childbirth takes the stage. It’s the culmination of nine months of pregnancy, during which pregnant women in America go to see their doctor monthly or even weekly, if needed.

But after the baby is born, things change quickly. Most women wait about six whole weeks before going to their first postpartum visit with their doctor.

These six weeks are a particularly critical period for both mother and infant. After giving birth, women can still die from conditions like infection or preeclampsia that arise during their pregnancy. And it’s during these early weeks when more than half of all pregnancy-related deaths occur globally.

To save lives and better help new mothers, the American College of Obstetricians and Gynecologists (ACOG) is publishing new recommendations today to highlight the importance of the “fourth trimester,” or the critical three months after a woman gives birth.

The recommendations introduce new guidance for postpartum care. The group is replacing the single six-week checkup with an initial contact from their OB-GYN (or related maternal care provider) within three weeks of having a baby, followed by a comprehensive visit within 12 weeks of childbirth and ongoing healthcare support as needed.

“A lot happens within the first six weeks of a mother having a baby,” said Dr. Alison Stuebe, medical director of lactation services at UNC Health Care and lead author of the ACOG report.

She explained that just after childbirth, women experience a range of challenges and concerns, including recovery from delivery, sleep deprivation, infant care, and postpartum depression. Since many women don’t see their doctor again until six weeks after childbirth (or perhaps no visit at all, as is the case with 40 percent of women, according to the ACOG), new moms are left vulnerable to severe complications from untreated issues.

“If we wait until the six weeks are up, most mothers have muddled through a critical issue on their own or had it turn out to be a big deal that ended up hurting them,” said Stuebe. “Moms need support earlier in the process, and we shouldn’t wait around to see if they survive on their own.”

A growing problem

The new recommendations come as the maternal mortality rate in the United States is climbing, even while it falls in other developed countries. Infant mortality rates in the United States are declining slowly, but they’re still 71 percent higher than comparable countries.

The new ACOG opinion also formally recommends creating an individualized postpartum care plan, which would include counseling on contraception, lactation, birth spacing, and health maintenance — a practice that some doctors, like Dr. Jennifer Wu at Manhattan Women’s Heath, already have in place.

“It’s important to set a plan for the future. Two weeks after childbirth, I talk to patients about birth control, and at six weeks, we make a plan, whether that’s condoms, an IUD, or something else,” said Wu. “We also talk about whether she wants more children, how to transition back to work from maternity leave, and pumping and freezing breast milk. There’s so much going on with the patient during this time that sometimes she forgets things, and I want to make sure we don’t miss anything.”

A 2013 survey from Childbirth Connection found that 1 in 4 new moms didn’t have a phone number for a healthcare provider to discuss concerns about herself or her baby. The ACOG now recommends that postpartum women have one primary care provider to assume responsibility for managing her care and being the point of contact for all members of her care team (including her family, the infant’s healthcare provider, and specialty consultants).

While the recommendation for a single point of contact might be ideal, Wu warns that it’s not practical.

“Most doctors are already overscheduled. I’m in a group of four, and we try to see our patients after delivery, but sometimes it doesn’t work out. She might see one of my partners, and that’s OK. One person taking care of all postpartum needs isn’t always possible,” said Wu.

She emphasized the importance of early, frequent postpartum care over working with just one doctor.

“You need frequent follow-up, and it needs to be more than one visit during the postpartum period. It’s important to stay in close communication and feel you can call the doctor’s office to deal with any problems. The earlier we find them, the more easily we can solve them,” said Wu.

While the ACOG hopes the recommendations will help reduce severe maternal morbidity and mortality, it could be some time before most Americans see major changes in postpartum care, especially since healthcare costs remain an issue.

“One of the big challenges is reimbursement from insurance companies for postpartum care,” said Stuebe. “Right now, it’s a fixed amount of money for all prenatal visits, delivery, and postpartum care, whether that’s one visit or six visits. We need to work with payers to emphasize the importance of frequent, comprehensive postpartum care for moms and figure out a reimbursement structure that makes it possible.”



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