Dr. Brown is the F. Bayard Carter Professor and Chair, Division of Maternal Fetal Medicine, Duke University Medical Center, Durham, North Carolina.
Ob/gyns, support staff, and patients all need to be educated about the needs of the mother/child dyad during the “fourth trimester.”
Postpartum follow-up is important to the well-being of the mother, her infant, and their long-term health. As such, the postpartum visit must gain a renewed sense of importance for the woman and her providers. The new mother must adapt physically and emotionally to changes that have occurred from childbirth. The initial postpartum follow-up should occur within 3 weeks after childbirth and is the start of an individualized plan for the continuum of care that encompasses counseling, services, interconception and contraceptive management for reproductive life planning, and support to optimize immediate and long-term health.
Approximately 60% of maternal deaths occur postpartum. In fact, women are more likely to die of pregnancy-related conditions in the weeks following birth than during pregnancy or intrapartum. This burden falls disproportionately on women of color, with black women being three to four times more likely to die of pregnancy- related causes than white women.1 For example, risk of thromboembolic events and maternal death is greatest in the first 2 to 4 weeks postpartum.2 Cesarean delivery approximately doubles the risk of venous thromboembolism, but in an otherwise normal patient, risk is still low at approximately 1 per 1,000 patients.
Early postpartum follow-up within the first 3 weeks following childbirth is especially important for mothers with preexisting health conditions such as hypertension, diabetes, and gestational diabetes, heart conditions, depression, substance addiction, and other medical complications that might have been exacerbated by pregnancy and those women who suffered a near-miss maternal morbidity. Maternal near-miss morbidity is defined as a catastrophic obstetric event where the pregnant woman comes close death but survives. For every woman who has a pregnancy-related death there are approximately 50 to 100 episodes of severe maternal morbidity affecting more than 50,000 women in the United States every year.3,4
It is estimated that as many as 40% of women do not have postpartum follow-up.5 Attendance is even lower for women with limited resources and where access to perinatal care is a challenge, as in many rural communities in the United States.6 In these settings it would be potentially helpful for improving postpartum participation to coordinate the infant follow-up visit with the woman’s postpartum visit. Telehealth can also be used to help facilitate follow-up. It is also interesting that women who deliver in a rural hospital setting have an associated higher rate of postpartum hemorrhage.7 It is essential that these women have postpartum follow-up for counseling on recurrence risk and reproductive life counseling to decrease risk in subsequent pregnancy.
Potential ramifications of lack of postpartum follow-up include early discontinuation of breastfeeding, undiagnosed postpartum depression and anxiety disorders, lack of family planning and increased recurrence risk for preterm birth (PTB), preeclampsia and gestational diabetes. Lack of follow-up contributes to racial disparity in prematurity and infant mortality. Risk for recurrent PTB is more likely for those women with a short interpregnancy intervals within 12 months of delivery and subsequent conception.8 Four of 10 mothers with Medicaid coverage do not come in for a postpartum follow-up visit.5,9 This vulnerable population does not have the opportunity to receive care and support for common problems such as postpartum depression and breastfeeding challenges. Multiple barriers prevent women with Medicaid from accessing postpartum care. In
19 states, Medicaid coverage for pregnancy ends at 60 days postpartum, cutting women off from access to care during this critical period.10 When women do not come in for a postpartum visit, they do not have an opportunity for education and to receive information about nutrition, exercise, and pregnancy spacing. For example, a woman with no postpartum follow-up who has experienced a postpartum hemorrhage and anemia is more vulnerable to maternal morbidity and mortality if she has an unplanned pregnancy before she has an opportunity to return to a healthier state.
Strategies to improve breastfeeding initiation and continuation
The 2020 breastfeeding objectives are to increase the proportion of infants who are breastfed at any time to 81.9%, at 6 months to 60.6%, exclusively through 3 months to 46.2% and exclusively through 6 months 25.5%.11 Rates of exclusive breastfeeding between 3 and 6 months are lowest for black infants and infants of mothers who are young, unmarried, less educated, and who live in rural areas. Current low rates of breastfeeding continuation and exclusivity, particularly for black infants, suggest that infants and mothers are not receiving maximum health benefits. These differences contribute to infant, childhood, and adult health disparities. Breastfeeding benefits include decreased risk for childhood and adult obesity and decreased risk for diabetes, hypertension, and cardiovascular disease.12-14
A recent study examined how effective a hospital- and community-based initiative could be in reducing racial disparities while at the same time helping participating hospitals achieve a Baby-Friendly designation.15 Between 2014 and 2017, 33 hospitals enrolled in the CHAMPS (Communities and Hospitals Advancing Maternity Practices) program from Boston Medical Center’s Center for Health Equity, Education and Research.15 The program was intended to decrease racial disparities in breastfeeding by using a community and hospital collaborative strategy to improve maternity care practices and implement the Ten Steps to Successful Breastfeeding Initiative. Enrolled hospitals received intensive quality improvement and technical assistance intervention to enhance compliance. The authors found that the average rate of breastfeeding initiation at CHAMPS-enrolled hospitals rose from 66% to 75% and the average rate of breastfeeding exclusivity rose from 34% to 39%. The disparity between African-American and white infants regarding breastfeeding initiation disparity decreased by 9.6% over 31 months. Among black infants, rates of breastfeeding initiation and exclusivity increased from 46% to 63% and 19% to 31%, respectively.15
Some specific barriers for breastfeeding continuation after hospital discharge include lack of knowledge by mothers and providers of the dose-related health benefits, the knowledge that small quantities of colostrum in the first days after delivery are sufficient to meet the needs of a term newborn, inadequate family and social support, comfort level with formula feeding, employment and childcare practices, and lack of breastfeeding role models. Early postpartum contact by phone and/or face time or office visit within the first weeks following birth allows breastfeeding mothers and providers the opportunity to identify breastfeeding challenges and to provide lactation counseling and support that improves breastfeeding continuation and exclusivity rates.5
Depression is more common in women than in men and peaks for women during the reproductive years.16 Perinatal depression, which includes pregnancy and the 12 months following childbirth is a common medical complication affecting one in seven women. Previous studies indicate that approximately 10% of pregnant and postpartum women met the criteria for perinatal depression.17 Women with lower income, lower educational attainment, and unintended pregnancy are at even higher risk for depression during pregnancy and postpartum.18 Women with a history of depression or anxiety are candidates for early postpartum follow-up. Other high-risk factors include a previous history of postpartum depression, stressful life event, traumatic birth events (near-miss morbidity), premature birth of an infant with a need for neonatal intensive care and/or birth defects, and low levels of social support.
In the United States, the Edinburgh Postnatal Depression Scale (EPDS) is the validated screening tool for postpartum depression most commonly used in current clinical practice.19 It takes approximately 5 minutes to complete and has a high sensitivity and specificity for depression diagnosis. A cut-off score of score of 13 is a very reliable indicator of postpartum depression. System-wide recommendations for postpartum depression detection are to ensure that all pregnant and postpartum women are screened to optimize detection, referral, and treatment; educate providers on risk factors; and have focused preconception discussions about the impact on pregnancy and pregnancy complications for those with preexisting mental disorders.
Women with perinatal depression are at higher risk for suicide. Women whose screening suggests suicidal thoughts warrant prompt evaluation, monitoring, psychiatric intervention and treatment. Women on medications for anxiety or depression during pregnancy should be evaluated for worsening symptoms and should not discontinue medications during pregnancy nor postpartum due to concerns for fetal or infant harm from placental transfer of the medication or from breastfeeding. Medications should be adjusted or initiated based on individual patient circumstances and symptoms in conjunction with a mental health provider for maximum benefit and follow-up.
In recent years, suicide has become a more common cause for maternal mortality in the postnatal period. There has been a decline in suicide deaths per 100,000 live births over the last couple of decades with the introduction of national guidelines for screening for depression and recommendations for prediction, detection and treatment of mental disorders during pregnancy and up to 1 year postpartum.20 However, suicide continues to contribute to approximately 1.5 of 100,000 maternal deaths in the United States. Deaths from opiate addiction and overdose have recently contributed to the rise in maternal mortality.
Women with addiction, especially those on opioid maintenance therapy, are prone to overdose and require special attention in the postpartum period. Particularly in women with chronic pain disorders, medications for postpartum pain management should be carefully prescribed and monitored.21 Women being treated for pain with opioids are especially vulnerable and should be evaluated in the first 2 to 3 weeks for medication adjustment and referral to experts in pain management for follow-up.
Achieving a healthier weight
The postpartum and inter-conception period is an opportunity to address obesity/overweight during pregnancy and goals for achieving a healthier adult weight. In a large systematic review and meta-analysis of over 1 million pregnant women, 47% had gestational weight gain in excess of the Institute of Medicine (IOM) (now National Academy of Medicine) recommendations.22 Women who have weight gain exceeding IOM guidelines during pregnancy are at two to four times higher risk of being overweight or obese.23 Excessive weight gain is associated with an increased risk for complications in a future pregnancy and increased risk for hyperlipidemia, diabetes, hypertension, cardiovascular disease, and early mortality. As such, implications for lack of weight loss postpartum combined with short pregnancy intervals include generational obesity, hypertension, diabetes, and the potential for early death.24
A return to normal sexual intimacy postpartum is an expectation for most couples. Dyspareunia is reported by 41% to 67% of women 2 to 3 months postpartum depending on the severity of perineal trauma at delivery. Typical healing and perineal pain resolve by 3 months; however, some women will experience dyspareunia for a longer period.25 Urinary and fecal incontinence is highly prevalent in the postpartum period. The highest frequency is seen in women who have a severe perineal laceration involving the anal sphincter and those with instrument/operative vaginal deliveries. Publications from the Pelvic Floor Network Childbirth and Pelvic symptoms (CAPS) study put the prevalence of fecal incontinence at 17% in primiparous women who delivered vaginally with a recognized anal sphincter tear compared to 8.2% for those who delivered vaginally without anal sphincter tears.26 Urinary incontinence prevalence was 31.2% for all women irrespective of perineal injury.26 These symptoms have a significant impact on quality of life postpartum and several months to years after delivery.
Women with perineal lacerations, especially severe laceration or injury, should have early postpartum follow-up and be asked about flatal, fecal, and urinary incontinence. Because of embarrassment, a woman might be reluctant to volunteer that she has symptoms and/or downplay the severity. As such, it is important for providers to be aware of the prevalence of incontinence postpartum and provide reassurance and prompt referral to a subspecialist when appropriate so that early intervention can be initiated.
It is important for providers to engage in a conversation regarding the emotional and sexual expectations of couples during pregnancy, discuss normal variation and fluctuation in sexual activity during pregnancy, and provide anticipatory guidance on the postpartum changes that impact sexual function.27
Family planning and pregnancy spacing
Pregnancy spacing of 12 to 18 months is associated with improved birth outcome in subsequent pregnancy especially, in women who experience an adverse pregnancy outcome such as PTB. Furthermore, the ideal recommended pregnancy interval is 18 months after a cesarean delivery and 12 to 18 months after a vaginal birth.5,28
Counseling on a method of contraception should occur during the prenatal period and the woman’s choice confirmed in the immediate postpartum period prior to her hospital discharge. This is important because so many women do not present for postpartum follow-up. While women are encouraged not to engage in intercourse until “6 weeks postpartum,” approximately 25% are having unprotected intercourse before that 6-week visit. Most first menstrual cycles after birth are anovulatory, and for those women who are not breastfeeding, ovulation and the risk of pregnancy significantly increases from the first cycle after giving birth to almost 90% with the second menstrual cycle after childbirth.
Immediate postpartum long-acting reversible contraception (LARC) is becoming more of an option for women after vaginal delivery and cesarean. LARC provides pregnancy spacing with fewer contraceptive failures than other methods of birth control. The rate of expulsion is lower than 10% with “post-placental” insertion of an intrauterine device (IUD), that is, placement within 10 minutes after placental delivery. For implantable contraception, the most effective progesterone-only method, there is minimal risk associated with placement within the first several days or weeks postpartum. Some described side effects for implants include irregular bleeding, headaches, dizziness, weight gain, and acne.
For women with post-placental IUD insertion, an early postpartum examination within the first 3 weeks should be done to check for expulsion and trim the IUD string. Early postpartum is also a perfect time to place LARC with follow-up at 12 weeks for further discussion on reproductive life planning.
Pregnancy complications and long-term health
There are several pregnancy complications that increase risk for cardiovascular disease (CVD), including preeclampsia, gestational diabetes, PTB and intrauterine growth restriction (IUGR).29 For example, women with a history of preeclampsia have an approximate 4-fold higher incidence of later development of chronic hypertension and a two-fold elevated risk of heart disease, stroke, and venous thromboembolism.29,30 A combination of recurrent preeclampsia, PTB or IUGR carries a cardiovascular risk later in life comparable to obesity or smoking.29 Hence, the American College of Obstetricians and Gynecologists (ACOG) recommends annual blood pressure, fasting glucose, lipid and body mass index checks and counseling on reducing risk for early-onset CVD for women with specific pregnancy complications such as preeclampsia and gestational diabetes.5
Gestational diabetes (GDM) impacts between 5% and 10% of all pregnancies and women with it have a seven-fold risk for development of Type 2 diabetes. ACOG recommends screening women with GDM 4 to 12 weeks postpartum for diabetes and pre-diabetes with an oral glucose tolerance test.5,31 In a study by Eggleston et al. of 447,556 women across 50 states of whom 7.2% had GDM, 75% had no follow-up screen within 1 year.32 In another study of women with GDM, only 23.4% received any kind of glucose test by 6 months postpartum.33 Unfortunately, the screening recommendation for diabetes for those women with GDM in the postpartum period is not consistently followed and education on the importance of follow-up testing for diabetes has important implications for long-term wellness. Finally, PTB occurs in 8% to 12% of pregnancies and is a leading contributor to infant mortality disparity. What is unappreciated is that women who deliver a low-birth-weight infant, either preterm or term with growth restriction (< 2500 g) have a two-fold higher risk for cardiovascular disease and death. 34
Adjustment to childbirth in the first several weeks postpartum can be challenging for many mothers, especially as they navigate the physical and emotional changes and sleep deprivation associated with caring for a newborn. Most women must make these adjustments without support from a family member during the first several weeks after childbirth.
Redefining the postpartum period and using it to promote the continuum of well women’s care will require a paradigm shift. A concerted effort must be made to educate patients, providers and support staff about the importance of the immediate needs of mother and child postpartum and what a woman might expect or experience in the first several weeks after giving birth. This is especially important for women on Medicaid and those with concerns about access to care and or who might not have culturally congruent support at home. Community health workers and, for some women, postpartum doulas can assist in filling this void in the first days and weeks after childbirth, particularly for vulnerable populations. The postpartum visit appointment should be discussed and scheduled during the last month of pregnancy and reemphasized at the time of hospital discharge. The continuum of care is particularly important for women with pregnancy complications that place them at higher risk for later development of hypertension, diabetes and heart disease. Ob/gyns and their team of providers are uniquely qualified to provide immediate postpartum evaluation and counseling and to annually evaluate women as they proceed through the reproductive years and beyond.
Finally, Medicaid finances nearly 50% of all births in the United States. Advocating for policies that extend Medicaid at least 3 months and hopefully 12 months after childbirth would improve the continuum of women’s health care.
The author reports no potential conflicts of interest with regard to this article.