From the Duchess of Cambridge leaving the hospital in heels seven hours after giving birth, to Charlize Theron's portrayal of a harried, exhausted new mom in the movie Tully, questions of what's normal in the "fourth trimester" postpartum period are finally getting some attention. For too long, women have been sent home from the hospital with no idea of—and no support for—the physical, social, and psychological issues they are about to face. To remedy that, the American College of Obstetricians and Gynecologists (ACOG) has just issued guidelines for a radical shift in the postpartum care women should receive. Hooray!
Postpartum women need more care
First off, ACOG says the six-week checkup is too late—the first visit with your doctor should happen no later than three weeks after birth. Postpartum care should be an "ongoing process" rather than a single visit, and more frequent contact should occur as needed through additional visits, phone calls, even texts (they know it's tough to get out with a newborn). Finally, women should have a comprehensive assessment no later than 12 weeks to talk about mood and emotional well-being, infant care and feeding, sexuality and birth spacing, sleep and fatigue, physical recovery, and chronic disease management.
"I believe the continuum of care for women is what has been lacking," Tamika Auguste, M.D., an Ob-Gyn at MedStar Washington Hospital Center and co-author of the ACOG opinion, tells Parents.com. "Hopefully, these new guidelines will give providers a new structure for postpartum care, and will help them make the changes necessary to better serve women in the postpartum period and as they transition to well-woman care."
What prompted the switch in recommendations? "The changes are in response to the fact that maternal mortality is rising in the US, and women are more likely to die of pregnancy-related causes after the day of delivery than during pregnancy or birth," Alison Stuebe, M.D., MSc, an associate professor of obstetrics and gynecology at the University of North Carolina School of Medicine and co-author of the ACOG opinion, tells Parents.com. "We also know that problems like postpartum depression and breastfeeding difficulties are more likely to get better if mothers get support in the first few weeks after birth, rather than muddling through until six weeks postpartum."
In addition, she says that moms who've had complications like preeclampsia or gestational diabetes are more likely to have other health problems like heart disease down the line. "Sharing this information with moms and providing holistic care after birth provides an opportunity to talk about preventive strategies to reduce these risks," Dr. Stuebe says.
The new strategies will require better coordination within the mother-baby care team. "The team is critical because of the different aspects of the postpartum period that can be affected—issues that arise with the baby, obstetrical concerns with the mother, non-obstetrical concerns with the mother, and mental health issues," Dr. Auguste says. "Those issues can be addressed by pediatricians, obstetricians, internists [primary care doctors], and mental health providers collectively as a team." Lactation consultants and even home nurses may also be part of these conversations.
Working together may be an adjustment, though. "Too often, there are multiple specialists with very strong opinions and little perspective on anything beyond their own area of expertise," Dr. Stuebe says. "Moms have to travel to multiple offices and get conflicting advice. We need to find ways to bring care to mothers, instead of making them go to care."
The other question is who's going to pay for this additional care. "Reimbursement is going to be a key issue," Dr. Stuebe says. "In the current system of care, obstetric care providers receive a bundled payment for prenatal care, birth, and routine postpartum care. It's a tough sell for providers to add additional visits if there is no additional reimbursement." Hopefully, insurance companies will see that more care early on will prevent more serious (and expensive) issues later.
Societal change on the horizon
Although it may take a while for the new program to be put into place, it does shine a light on how lacking the current support for new moms is. "The U.S. has no national maternity leave like many other developed nations," Dr. Auguste says, pointing to our preoccupation with work. "This trickles down to the type of care—one visit—women receive postpartum."
Our modern society has lost the traditional 30 to 40-day post-birth rest period during which new moms would get a ton of support from others, Dr. Stuebe says. Today, a mom's "village" is likely to be out working, and the new mother herself may have to return to work—but postpartum women aren't biologically meant to go it alone. "To survive, a human mom needs other helpers, what anthropologists call 'allo-mothers,' to assist her," Dr. Steube says. "When we had a 40-day period to nurture our babies surrounded by allo-mothers, it made sense to go out into the world at six weeks and see a healthcare provider. In modern life, we've jettisoned the 40 days of rest, and all that's left is the six-week visit."
Instead, women can start thinking about their plan for "fourth trimester" support even before Baby is born. "When I had my first child, I spent hours on a birth plan, and days deciding on colors and furniture for a nursery," Dr. Stuebe says. "Fast forward to five days postpartum, and I was by myself with a newborn—dad was back at work and the grandparents had flown home—and I had no earthly idea what to do with a baby." Identifying support services ahead of time—mom groups, baby-and-me classes, La Leche League meetings—is crucial. "Ob-Gyns can help a pregnant woman to build her village during pregnancy, and be a resource for problems that arise in the weeks after birth, rather than just waiting to see what's left after moms spend 42 days in the wilderness," Dr. Steube says.
As a society, we have to do better at caring for new moms. "We must change the culture and that will take time, but these guidelines are a start," Dr. Auguste says.