The Postpartum Cliff…and What We Are Doing About It
By Juan Pablo Segura, President and Co-founder, Babyscripts and Lauren Demosthenes, MD, Medical Director of High Value Care and Innovation, Dept of OBGYN, Greenville Health System
In the United States, prenatal care is a high priority. A woman receives an average of 5.2 ultrasounds of the baby per delivery. She is seen an average of 14 times in a 7-month time period (from weeks 8 to 40, based on recommendations by the Institute of Medicine (IOM). She has ready access to a wealth of payer, hospital, and physician resources for interventions and clinical care, such as payer care management programs, birthing classes, and maternal-fetal medicine specialists.
But while the U.S. health system understands the need to emphasize and guarantee necessary prenatal care, the postpartum period is neglected. After frequent contact with her OB-GYN in the last weeks of pregnancy and an average stay of 1 to 3 days in the maternity ward, women are sent home. Although newborn appointments with pediatric caregivers begin, the interaction with obstetric providers typically ends just as questions begin to develop about breastfeeding, monitoring well-woman health, and better adjusting to a new reality. While women in a comparably developed country like the U.K. are aided by local midwives, doulas, and nurses in the days and weeks following delivery, new mothers in the U.S. will not usually see an obstetric health professional until the six-week follow-up appointment. Six weeks. That’s forty-two days without care or contact at one of the most vulnerable and important periods of a woman’s life.
Last year, the importance of postpartum care gained momentum through two notable groups. First, The American College of Obstetricians and Gynecologists (ACOG) redesigned its postpartum care guidelines on April 23, 2018. Second, the March for Moms event took place on May 6, 2018 in more than 50+ locations nationally and focused on the various contributing factors to the devastating maternal health outcomes in the United States. Together, these groups bring awareness and help address the deficiencies of postpartum care.
ACOG has changed its recommendation from a six-week comprehensive checkup to a more ongoing process, with first contact between patient and provider taking place no later than three weeks after birth. This shift will hopefully prevent the myriad of medical complications women can face in the first six weeks such as hemorrhage (12.7%), infection (9.5%), pregnancy-induced hypertension (preeclampsia) (7.6%), blood-clots (deep vein thrombosis and embolism) (9.5%), cardiomyopathy and other heart problems (11.4%). In addition to these medical issues, one in seven women suffer from postpartum depression (PPD) — and that statistic only includes women who report their depression. In tragic cases, this depression can lead to suicide, which is the third leading cause of postpartum death after hemorrhage and cardiovascular conditions.
After the initial three week visit, patients and providers can discuss the need for future check-ins or appointments. ACOG also now recommends a comprehensive visit that occurs no later than 12 weeks to follow up on the mental and physical health of the new mom. This follow up will include check-ins on factors such as: mood, infant feeding, chronic disease management, and fatigue. These check-ins will help facilitate the emotional and physical transition women experience after giving birth. While these guidelines are extremely important for postpartum care, many precautions must be taken during the pregnancy to identify possible complications after birth.
Some precautions are simple: the CDC reports that nearly 17% of maternal deaths resulting from blood-clots (often a consequence of a caesarean section) can be prevented by taking anticoagulants post-surgery, or wearing compression socks. This has been readily implemented. Others are more complicated. Preeclampsia, a type of high-blood pressure that occurs only during pregnancy and postpartum and may lead to seizures and strokes, and kills an average of five women per hour around the world. In developed countries, preeclampsia is highly treatable when identified quickly. In the U.K., maternal deaths caused by preeclampsia have decreased to one in a million — two deaths over the span of two years (2012–2014). In contrast, in the U.S. preeclampsia accounts for 8% of maternal deaths — 50 to 70 per year.
The common key to prevention is to identify the problem early. Although half of postnatal maternal deaths occur within the first 24 hours while the mother is in the hospital, the other 50% occur within the first month — 66% of these occur during the first week. This is why checking in before six weeks with an obstetric care provider is critical. While the new ACOG guidelines will hopefully be effective in addressing postpartum complications, it is also important to raise awareness about postpartum care so that all new moms seek out adequate care and know what risk factors to look for.
The March for Moms event helps bring attention to just how common postpartum complications are. The United States has the worst rate of maternal deaths in the developed world, and up to 60% of those deaths are preventable. So why aren’t our health systems doing more to ensure the well-being of new mothers? A range of speakers at the March for Moms rally addressed personal experiences with postpartum complications, available resources to new moms, problems in the health system contributing to poor postpartum care, along with other topics highlighting this often overlooked topic.
Some speakers, such as Dr Jesanna Cooper, OB/GYN at Simon Williamson Clinic in Birmingham, AL, touched on factors observed in their years as an obstetric care provider. For example, In Alabama, severe racial health disparities and an access to care crisis in both rural and urban areas are huge barriers women face in receiving adequate prenatal and postpartum care. Washington D.C. Council member, Charles Allen, shared his work in initiating the Maternal Mortality Review Committee Establishment Act of 2018. This committee, consisting of medical professionals, government agency representatives and residents affected by maternal mortality, will review all pregnancy-associated deaths before, during, or in the year after childbirth to understand the cause. Celebrity spokeswoman Angelina Spicer aimed to encourage moms who have faced postpartum anxiety or depression to reassure them that they can make it over the “postpartum hump” These speakers are essential to stimulating action and discussing potential solutions to deficiencies in postpartum care. One exciting potential solution is the use of technology to increase contact between patient and provider.
ACOG has identified important areas of education for a woman at the time of discharge, but absorbing the abundance of information at this time may be overwhelming for a tired new mother. Between scheduled appointments, can mobile technology and touchpoints via a cell phone app fill this gap? We think so. Obstetric providers have the unique opportunity to leverage innovative and accessible technology to facilitate interventions in these critical postpartum weeks to protect both maternal AND infant health.
ACOG guidelines for postpartum surveillance for hypertension identify one area where technology can be implemented to monitor signs and blood pressure (BP) findings of postpartum preeclampsia. These recommendations include education at the time of discharge about signs and symptoms of preeclampsia, and when a woman should call her healthcare provider. For women already diagnosed with preeclampsia during pregnancy, BP monitoring for 72 hours is recommended with outpatient surveillance (visiting nurse recommended) within 3–5 days and again at 7–10 days postpartum. With the ability to monitor BP and report symptoms through an internet enabled blood pressure cuff and a mobile app, technology and remote monitoring can play a critical role in caring for these patients. Notifications and reminders via a cell phone app can alert women to important symptoms of preeclampsia, and BP can be monitored at home to great effect for the health of the mother. Caregivers can easily interact with a patient remotely, enabling her to maintain her health conveniently and avoid a trip to the doctor’s office, which may be difficult in those postpartum days with a newborn.
We can also see the benefit of technology to ensure the psychological health of the mother — apps such as PPD ACT, developed by researchers at the University of North Carolina-Chapel Hill, have already made an impact on women suffering from PPD. Conducting screenings for postpartum depression through mobile interfaces could prevent women from falling through the cracks in the six week gap, and connect them directly to qualified mental health professionals to ensure continuity of care. These kinds of mental health screenings can occur multiple times in between the delivery and the postpartum visit, exponentially increasing the opportunity for intervention and detection.
As obstetric providers bring more technology-enabled touchpoints to their care, they can better maintain communication with their patients, and provide them security and comfort through the most accessible and user-friendly means. A smart mix of institutional changes, leveraging of commodity technology, will bring postpartum care to the forefront: because mothers — before, during, and after childbirth — matter.
American Academy of Pediatrics, American College of Obstetricians and Gynecologists. (2017). Guidelines for perinatal care (8th ed.). Elk Grove Village (IL): AAP; Washington, DC: ACOG. p. 284–288