The Fourth Trimester

The postpartum period which is the 6 week period following delivery is a challenging time in a woman’s life. As well as experiencing the joy of a new baby, it can be quite stressful to adapt to a completely new lifestyle. The body not only goes through huge physiological and mental changes in the postpartum, but it also has to heal from the physical stresses and injury of labor.  Worryingly, 61% of maternal deaths occur in the postpartum period which highlights that there is something wrong in the way we are caring for women during this time.

This month, the American College of Obstetricians and Gynecologists (ACOG) released a revised Committee Opinion to reinforce the importance of the postpartum period or ‘fourth trimester’, as well as proposed a new paradigm for postpartum care. The need for redefining postpartum care stems from the rising maternal mortality and morbidity rates in the USA. At present, women have one postpartum visit within the first 6 weeks of birth but 40% of women do not attend this appointment. During this one postpartum visit, many things have to be covered including recovery status, any arising complications, follow up of a chronic condition affected by pregnancy or of a new condition that arose during pregnancy, mood, contraception, breastfeeding and many more. It is clear that not all can be covered in one appointment. Women that miss the appointment altogether, miss out on vital checks and information, and are likely to fall through the cracks of the health system. In addition, this appointment usually occurs around 6 weeks postpartum, but the highest risk of postpartum death is actually in the first 2 weeks after delivery.

The revised guidance recommends that the postpartum period should become an ongoing process rather than a single appointment. Recommendations and conclusions can be found on the ACOG website. The revised guidance places significant emphasis on the well-being of women throughout the postpartum period and beyond. They recommend that the first visit should be within 3 weeks of delivery. The appointments should be individualized as each woman will have a different set of problems, some more urgent than others. The overarching message from the guidance is that the care provided should be comprehensive and woman centered. The guidance recognizes that women need an equal or even more amount of care in the postpartum period than the prenatal period.  A woman who has delivered is still at risk. 

A major barrier to the revisions made by the ACOG will be provider reimbursements. Currently, postpartum care is part of a fixed pregnancy payment bundle. Therefore, providers will be paid the same regardless of how many postpartum visits they schedule. This means there is no real incentive for physicians to provide follow up postpartum care. In order for the guidance to be effective, the reimbursement structure requires changing, and postpartum care may need to be separated from the pregnancy bundle. Postpartum care may require some sort of a combination of a fee-for-service model with pay for performance so that physicians are incentivized to organize appointments, but are also providing high quality care.

The revised guidance is a huge step in the right direction for maternal health. It will not only allow providers to detect problems early and have a close, frequent relationship with their patients, but will also support women through one of the most critical times in their lives. They will no longer have to be alone, particularly at a time that can generate feelings of fear and isolation. In addition, the revisions will also allow providers to optimize a woman’s health after pregnancy, which is incredibly important to reducing morbidity and mortality in the next pregnancy.

By Shreya Patel

Photo Credit: U.S. Navy Photo by Mass Communication Specialist 2nd Class Yasmine T. Muhammad