Fascinating Facts

MATERNAL HEALTH FAST FACTS

(United States, 2016)

Live births: 3,945,875

Hospital births: 3,883,255 (98.4%)

 

CHARACTERISTICS OF LABOR 

Epidural or spinal anesthesia during labor 2,901,486 (73.5%) 

Induction of labor 967,811 (24.5%)

Augmentation of labor 826,783 (21.0%)

Steroids (glucocorticoids) for fetal lung maturation 93,931 (2.4%)

Antibiotics received by mother during labor 976,049 (24.7%)

Clinical chorioamnionitis during labor 60,505 (1.5%)

 

FINAL METHOD OF BIRTH

Vaginal, spontaneous 2,562,527 (65% of 3,945,875)

Vaginal, forceps 21,674 (0.5% of 3,945,875)

Vaginal, vacuum 100,602 (2.6% of 3,945,875)

Cesarean 1,258,581 (31.9% of 3,945,875)

Vaginal Birth After Cesarean 75,244 (12.4% of 601,788) 

 

FETAL PRESENTATION

Cephalic (Head-down) 3,719,121 (94.8% of 3,945,875)

Breech 152,519 (3.9% of 3,945,875)

Other Fetal Presentation 51,444 (1.3% of 3,945,875)

https://www.cesareanrates.org/maternal-health-fast-facts/

women’s diets have been restricted during labor without sufficient evidence to support the practice.

For years, women’s diets have been restricted during labor without sufficient evidence to support the practice. In this systematic review and meta-analysis, Ciardulli and colleagues did not find a single case of aspiration pneumonitis—the outcome on which the rationale for restricting diets during labor is based. A 2013 Cochrane review by Singata et al also found no harm in less-restrictive diets for low-risk women in labor. Ciardulli et al concluded that dietary restrictions for women at low risk for complications/surgery during labor are not justified based on current data.

See the research here.

Vaginal Seeding

Vaginal Seeding After Cesarean: Is It Safe and Recommended for Your Baby?

Dr. Aviva Romm

As a doctor, I appreciate the indispensable, lifesaving contributions of western medicine – such as cesarean sections and antibiotics. They’re examples that, for many women, help avoid the largely preventable tragedy of maternal mortality, which according to the World Health Organization, remains unacceptably high in developing countries where access to procedures like cesareans and appropriate pharmaceuticals are too often limited, or entirely unavailable. And now, I do have a “but…” to add here (did you see it coming?), because as lifesaving and indispensable as some medical procedures can be, that doesn’t mean they are not overused, and even when done appropriately, can have unintended consequences – sometimes wide-scale, long-term ones.

The Unintended Consequences Paradox

Antibiotic use and cesarean sections are prime examples of practices that while lifesaving when used appropriately, have both been widely overused in recent decades – and we’re facing the consequences now. Antibiotic resistance as a result of antibiotic overprescribing has become one of the largest global public health problems we face, while overuse of cesarean section, which is associated with increased maternal infection, hemorrhage, and even death, has led even obstetric societies in the US to seek strategies for reducing what currently sits at a 34% national cesarean section rate. For the record, the World Health Organization (WHO) recommends an average of no more than 15% of births by cesarean section, for best maternal and neonatal outcomes.

One of the problems with cesareans (despite the very obvious fact that they are major surgery carrying risk of infection and requiring weeks of recovery…) is that babies are delivered abdominally, bypassing the bacteria-rich environment of the maternal birth canal. Whew, you might be thinking, well that sounds gross anyway. Actually, though, missing this exit ramp means that baby also misses skin and oral inoculation with important organisms, such as Lactobacillus and Bifidobacterium species, that lead to healthy immune system development, colonization of the baby’s own gut and skin flora that prevents infection, and that allows baby to also tolerate ingestion of mother’s milk. In fact, these organisms are sometimes referred to as ‘milk bacteria.” So why does this matter?

Babies, Birth, and Their Microbiome

Studies have demonstrated that babies born by cesarean have a greater lifetime risk of obesity, Type 1 diabetes, asthma and celiac disease, and it is thought that other diseases, including juvenile arthritis, inflammatory bowel disease, immune deficiencies, and perhaps additional conditions, are associated with this early perturbation of natural colonization of the infant with the maternal microbiome at the time of birth, early antibiotic exposure, or (yikes!) both. In other words, we’ve starting to uncover that vaginal birth possesses health advantages that cesareans miss out on.

Further, cesarean sections are accompanied by routine antibiotic administration to mom at the onset of the surgery to prevent infection – women undergoing cesarean section have a 5 to 20 times greater chance of getting an infection from birth compared with women who give birth vaginally. As research has been emerging on the importance of the human microbiome on our health, so too, has research emerged on the potentially deleterious impacts of early antibiotic exposure and cesarean section – which go hand-in-hand – on the long-term health of our children, including increased risk of obesity, alterations in the intestinal microbiome, increased risk of allergies, and more.

“But, Dr. Aviva, what if I don’t (didn’t) have a choice but to birth by cesarean?”

Yeah, I hear you. It’s frustrating to hear this information and hard not to blame ourselves, because we live in a culture that blames the mom – as if we don’t do that enough to ourselves! The fact is, though, that sometimes cesareans are necessary. If you did birth by cesarean, out of necessity or not, learning about its effect on your baby’s health isn’t about judging the type of birth you had, mom judging, or mom shaming. It’s about exploring possible solutions and letting go of judgment and guilt to focus on what really matters: how we can support our children’s health and that of future generations, while also nurturing our own.

I know this probably sounds scary and, to be honest, slightly depressing, but I actually have some great news to share: researchers and microbiologists, such as Dr. Maria “Gloria” Dominguez-Bello, PhD, whom I had the pleasure of interviewing for my podcast, are exploring solutions to help increase the health outcomes for mothers and babies through a technique they named Vaginal Seeding, which can be used following a cesarean. I touched on the practice here in my article Protecting Baby’s Microbiome, and you can listen to the podcast on Natural MD Radio instead, here.

While research into the practice of vaginal seeding is new and in the early stages, it does hold great promise for the future health of our children. Curious about vaginal seeding and whether it is safe and recommended for you and your baby? Whether you’re expecting yourself, or are a natural health practitioner wanting to help make recommendations on vaginal seeding for your clients, read on for what you need to know.

Curious about vaginal seeding and whether it is safe and recommended for you and your baby? Whether you’re expecting yourself or are a health practitioner, read on for what you need to know.

Click To Tweet

What is Vaginal Seeding?

Vaginal seeding, in very simple terms, means swabbing baby with vaginal fluids following a cesarean birth. These fluids are collected prior to birth: a sterile gauze is folded and inserted into the vagina and left to soak up beneficial vaginal microbiota for one hour.

Right at birth, the newborn is swabbed with the gauze, starting on the lips and the face and moving to the rest of the body for about fifteen seconds, before proceeding to standard newborn examination.

In a landmark but very small pilot study conducted by Dominguez-Bello et al, the microbiome of infants in whom vaginal seeding was done post C-section resembled that of vaginally delivered infants.

The procedure is quite simple, but there are important guidelines to follow to avoid potential health risks, which I’m covering below, and importantly, this is not yet recommended as a ‘self-help’ practice at this time. Further, while the pilot study on vaginal seeding did show partial restoration of the baby’s microbiome, we don’t yet know whether the partial restitution of these naturally occurring organisms will have a long-term impact on babies’ health – long-term studies are needed to determine this.

Are There Risks Associated With Vaginal Seeding?

The concept of vaginal seeding is gaining speed in the press, and many moms wonder: is the practice right for me, and more importantly, is it safe for my baby?

So far, as pointed out by the American College of Obstetricians and Gynecologists (ACOG), there’s been a single pilot study in which only four infants underwent seeding, with no long-term follow up. What’s more, the pilot study in question involved only women who were not carriers of group B streptococci, had no signs of bacterial vaginosis (BV), and had a vaginal pH of less than 4.5. In other words, we don’t have solid data yet on the possible risks associated with vaginal seeding in the general public.

The question is, then: could the potential benefits of vaginal seeding still outweigh the possible risks despite the early stage of research?

The main concern with vaginal seeding is the spreading of undiagnosed infections in the mother (Group B Strep, chlamydia, gonorrhea, human papilloma virus, group A streptococci, and herpes simplex virus, among others), which could result in (serious!) neonatal infection otherwise avoided through cesarean.

In my opinion, concurred by Dr. Dominguez-Bello, the practice of vaginal seeding – with proper testing beforehand for infections in mom and supervision by a qualified birth practitioner such as a CNM, OB, or Family Physician – is likely quite safe and simply exposes baby to what she or he would have been exposed to any had the birth occurred vaginally. That being said, I agree with Dr. Dominguez-Bello and other physicians, midwives, and scientists who recommend waiting until more evidence is available before commonly practicing vaginal seeding, and all agree that pregnant women should be tested for GBS, HIV, Hepatitis B & C, and VDRL, and should be negative for genital HSV before proceeding with it. Several large studies are underway now.

Is Vaginal Seeding Ready for Primetime?

While vaginal seeding might not be ready for primetime just yet, it does reflect a really interesting and promising shift in our collective mindset regarding birth and the importance of the microbiome on children’s health. Mothers are waking up to the fact that their children’s health is suffering, and that it’s time we do something about it. Widespread allergies, food intolerances, eczema, asthma, autoimmune diseases, obesity, diabetes… I’ve certainly seen the rise in health concerns in children in the last decades, both as a midwife, a herbalist, as a doctor, and as a mom and grandma.

So, until more research is completed and vaginal seeding becomes standard practice, what can we do to support a healthy microbiome right from the start? Here are some of my recommendations below.

What Else Can We Do to Support Baby’s Health and Microbiome After Birth?

Avoid unnecessary cesareans
One of the best ways to support your baby’s microbiome right from the start is to avoid unnecessary cesarean. This includes allowing for more time for labor to progress in the active phase, along with working with a midwife and doula (read more about why here) and of course, educating yourself about birth (start here, and here). Listen to my Natural MD Radio podcast episode with Neel Shah, MD, to learn more about unnecessary cesareans and how you can avoid one.

Consider vaginal seeding if appropriate, safe, and accessible
Work with your health care provider to arrange for vaginal seeding post-cesarean after thorough testing for possible hidden infections.

Practice attachment parenting
Starting at birth with skin-to-skin contact, continuing with breastfeeding ideally through the first year of life with no solids until at least 6 months or baby’s shows social readiness for food (reaches out for foods you’re eating and wants to put things in her/his mouth), and extending lots of cuddles with skin-to-skin and co-sleeping, encourages transfer of beneficial bacteria to baby and gets us closer to what nature intended.

Use a probiotic
While not all practitioners agree on the value of using probiotics in infants, preliminary research suggests that giving probiotics to babies born via cesarean could lead to health benefits later in life. While researchers haven’t yet confirmed whether boosting a healthy baby’s gut with beneficial bacteria could lead to lower incidence of disease, the hope is that supporting diversity of bacteria may help fight conditions like allergies and autoimmune diseases. Probiotics are a perfect example of a process that offers little risk and many possible health benefits, so I encourage moms to both take them during pregnancy and breastfeeding, and give them directly to baby.

Get dirty
As your child is able to sit up and play, encourage your child to “get dirty” in clean, natural outdoor spaces – while we have come to culturally equate ‘dirt’ with ‘unclean’ we’ve also missed out on important exposures to soil microbiota that also inoculate us and prime a health immune system. Playing outdoors, having pets, and being exposed to natural environments have all been associated with reduced rates of allergies, asthma, and eczema.

Take care of you, too!
A healthy mama is at the core of supporting the health of your baby’s microbiome, so remember to also restore your own microbiome after a cesarean (or if you’ve had antibiotics in labor for GBS or any other reason) with probiotic rich foods such as fermented vegetables and yogurt, and give yourself time to recover, allowing for self-care and rest.

You’re a powerhouse mom for reading this article! Have questions? I’d love to hear your thoughts in the comments below.

Probiotics and their impact on gestational and postpartum mental health

Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety

https://todayspractitioner.com/microbiome/effect-of-lactobacillus-rhamnosus-hn001-in-pregnancy-on-postpartum-depression-symptoms-of-anxiety/#.W14eBNhKiu6

July 23, 2018 by Kim Stewart

Growing evidence about the microbiome and gut brain axis suggests that taking specific strains of probiotics may be an important aspect of mental health, and more specifically postpartum depression, which affects 10-15% of women. In this study, published by EBioMedicine, a LANCET publication, researchers studied the effects of probiotics supplementation during pregnancy and 6 months after delivery, if breastfeeding. This study, the first of its kind to study women during and after pregnancy, evaluated the effect of supplementation of the specific strain probiotic Lactobacillus rhamnosus HN001 on postpartum depression. Full text available to registered users at the end of this study summary.

 

CLICK THE IMAGE to see the slides and listen to Dr. Rebecca Slykerman’s summary of the research.

Methods for probiotic and postpartum depression study

A randomized, double-blind, placebo-controlled trial of the effect of HN001 on postnatal mood was conducted in 423 women in Auckland and Wellington, New Zealand. Women were recruited at 14-to-16-week gestation. Women were randomized to receive either placebo or HN001 at a dose of 6 × 109 colony-forming units (cfu) daily from enrolment until 6 months postpartum if breastfeeding. Modified versions of the Edinburgh Postnatal Depression Scale and State Trait Anxiety Inventory were used to assess symptoms of depression and anxiety postpartum.

Study Results

423 women were recruited between December 2012 and November 2014. 212 women were randomized to HN001 and 211 to placebo. 380 women (89.8%) completed the questionnaire on psychological outcomes.

  1. Mothers in the probiotic treatment group reported significantly fewer symptoms of depression and anxiety,
  2. Mothers who had been taking the probiotic had as much as half the risk of developing clinically significant anxiety than women taking the placebo.
  3. This is the first study to show that women taking probiotics during and after pregnancy significantly reduced symptoms of anxiety and depression.

 

Another interesting finding was that infant colic was associated with higher depression and anxiety scores.

There has been a suggestion in the literature that probiotic supplementation may benefit maternal mood by reducing infant colic,” the researchers wrote … “While infants in our study are likely to have been exposed to a small amount of probiotic in-directly, either in utero or via breastmilk, they were not administered the probiotic directly; furthermore, we found that prevalence of infant colic did not differ between the probiotic and placebo groups and hence there was little difference in the effect size when adjusted for infant colic. Multivariable analysis showed that probiotic supplementation and absence of infant colic were independently associated with lower postnatal depression and anxiety scores.

The lead researcher, Dr. Rebecca Slykerman, from the Department of Pediatrics, Child and Youth Health, University of Auckland, New Zealand, noted that this study evaluated the effects of one strain of probiotics, thus the results are not conclusive for strains other than the Lactobacillus rhamnosus HN001. Slykerman also warns that this study needs to be replicated to confirm its results for postnatal depression (PND). Nonetheless, she and her colleagues are confident in stating:

This study provides evidence that probiotic supplementation with L. rhamnosus HN001 in pregnancy and postpartum reduces the prevalence of symptoms of PND and anxiety postpartum. Not all probiotic strains have the same effect on health and it is possible that the results found using HN001 are not generalizable to other probiotic strains, or at lower doses than those used in this study.”

Source: Slykerman R.F. et al. Effect of Lactobacillus rhamnosus HN001 in Pregnancy on Postpartum Symptoms of Depression and Anxiety: A Randomised Double-blind Placebo-controlled Trial. EBioMedicine, Volume 24, 159 – 165.

5 TIPS FOR MANAGING NAUSEA IN PREGNANCY

http://pilatesnutritionist.com/nausea-pregnancy/

Nausea during pregnancy, often termed “morning sickness,” is no joke.

Some women seem to bypass this queasy phase, while others get hit HARD. Those that avoid it entirely are the exception, however, since researchers report that 70-80% of women will experience nausea at some point in their pregnancy. 

For most women, nausea hits in the first trimester and then gradually improves. Roughly ⅔ of women will notice their nausea improves significantly by 13 weeks. 

  1. Eat small, frequent meals or snacks.
  2. Balance your blood sugar—aim to include some protein and fat when you eat, even if the portion is small).
  3. Try salty, sour, or cold foods.
  4. Keep a snack at your bedside and move slowly first thing in the morning.
  5. Consider eating more (and/or supplementing with) ginger, vitamin B6, and magnesium.

Risk of Preterm Birth Reliably Predicted by New Test

https://www.ucsf.edu/news/2018/05/410456/risk-preterm-birth-reliably-predicted-new-test

 

Scientists at UC San Francisco have developed a test to predict a woman’s risk of preterm birth when she is between 15 and 20 weeks pregnant, which may enable doctors to treat them early and thereby prevent severe complications later in the pregnancy.

Preterm birth is the leading cause of death for children under five in the United States, and rates are increasing both in the U.S. and around the world. It is often associated with inflammation and has many potential causes, including an acute infection in the mother, exposure to environmental toxins, or chronic conditions like hypertension and diabetes.

The new test screens for 25 biomarkers of inflammation and immune system activation, as well as for levels of proteins that are important for placenta development. Combined with information on other risk factors, such as the mother’s age and income, the test can predict whether a woman is at risk for preterm birth with more than 80 percent accuracy. In the highest risk pregnancies—preterm births occurring before 32 weeks or in women with preeclampsia, a potentially fatal pregnancy complication marked by high blood pressure in the mother—the test predicted nearly 90 percent of cases.

In the study, published Thursday, May 24, 2018, in the Journal of Perinatology, the researchers built a comprehensive test that would capture both spontaneous preterm births, which occurs when the amniotic sac breaks or contractions begin spontaneously, and “indicated” preterm birth, in which a physician induces labor or performs a cesarean section because the health of the mother or baby is in jeopardy. The researchers also wanted to be able to identify risk for preeclampsia, which is not included in current tests for preterm birth.

“There are multifactorial causes of preterm birth, and that’s why we felt like we needed to build a model that took into account multiple biological pathways,” said first author Laura Jelliffe-Pawlowski, PhD, director of Precision Health and Discovery with the UCSF California Preterm Birth Initiative and associate professor of epidemiology and biostatistics at UCSF. “The model works especially well for early preterm births and preeclampsia, which suggests that we're effectively capturing severe types of preterm birth.”

The researchers developed the screen using blood samples taken from 400 women as part of routine prenatal care during the second trimester, comparing women who went on to give birth before 32 weeks, between 32 and 36 weeks, and after 38 weeks (full-term). The researchers first tested the samples for more than 60 different immune and growth factors, ultimately narrowing the test down to 25 factors that together could help predict risk for preterm birth. When other data, including whether or not the mother was over 34 years old or if she qualified as low income (indicated by Medicaid eligibility), improved the accuracy of the test by an additional 6 percent.

Researchers said the test could help prevent some cases of preterm birth. Based on a woman’s probability of preterm birth derived by the test, she could discuss with her clinician how best to follow-up and try to lower her risk. Some cases of preterm birth, including those caused by preeclampsia, can be prevented or delayed by taking aspirin, but treatment is most helpful if started before 16 weeks. Physicians could also evaluate high-risk women for underlying infections that may have gone undetected but could be treated. For others, close monitoring by their doctor could help flag early signs of labor like cervical shortening that can be staved off with progesterone treatment.

“We hope that this test could lead to more education and counseling of women about their level of risk so that they know about preterm birth and know what preeclampsia or early signs of labor look like,” said Jelliffe-Pawlowski. “If we can get women to the hospital as soon as possible, even if they’ve gone into labor, we can use medications to stave off contractions. This might give her some additional days before she delivers, which can be really important for the baby.”

A test for preterm birth is currently available, but it is expensive and only screens for spontaneous preterm birth, not for signs that could lead to indicated preterm births or for preeclampsia. Jelliffe-Pawlowski said that the new screen would likely be a fraction of the cost, making it more accessible to women who need it the most.

“One of the reasons we’re most excited about this test is that we see some potential for it addressing preterm birth in those most at risk, including low-income women, women of color, and women living in low-income countries,” she said. “We want to make sure that we're developing something that has the potential to help all women, including those most in need.”

Maternal placenta consumption causes no harm to newborns

The largest study of its kind found mothers who consumed their placenta passed on no harm to their newborn babies. 

May 3, 2018

Summary: A study found mothers who consumed their placenta passed on no harm to their newborn babies when compared to infants of mothers who did not consume their placenta.     

FULL STORY

The largest study of its kind found mothers who consumed their placenta passed on no harm to their newborn babies when compared to infants of mothers who did not consume their placenta.

The joint study by UNLV and Oregon State University was published May 2 in the journal Birth.

Reviewing roughly 23,000 birth records, researchers found no increased risk in three areas: Neonatal Intensive Care Unit admissions in the first six weeks of life; neonatal hospitalization in the first six weeks; and neonatal/infant death in the first six weeks.

The study also found that women who reported a history of anxiety or depression were more likely to consume their placentas, and that the most common reason for choosing the practice was to prevent postpartum depression.

"This research, based on a large sample of consumers, gives us a better understanding of why women are consuming placenta after birth and the effects of that consumption on newborns," said study co-author Melissa Cheyney, a licensed midwife, medical anthropologist and associate professor in Oregon State University's College of Liberal Arts. "The findings also give us a foundation from which to further explore the impact of placenta consumption on postpartum mood disorders."

Consuming the placenta following childbirth is an increasingly popular trend in industrial countries, such as the United Kingdom, France, Germany, Australia, and the United States. Although precise estimates are not yet available, most experts agree there are many thousands of women in the U.S. alone who practice maternal placentophagy. And while the practice appears to be more common in home birth settings, it has been spreading to hospital births.

The new study, which examined birth outcomes and newborn risk, as well as how women consume their placentas and their motivations for doing so, contrasts a recent Centers for Disease Control and Prevention report recommending against placentophagy.

The CDC report was based on a single case study of a baby in Oregon who may have become infected with group B Streptococcus agalactiae following maternal consumption of an infected placenta. Based on that case, the CDC recommended that placenta capsule ingestion should be avoided.

"Our findings were surprising given the recent guidelines recommending against placenta consumption, as well as the known risks of consuming uncooked or undercooked meat," said Daniel Benyshek, a professor of anthropology at UNLV and the study's lead author. "These new findings give us little reason to caution against human maternal placentophagy out of fear of health risks to the baby."

A study by Benyshek and colleagues last year found taking placenta capsules had little to no effect on postpartum mood, maternal bonding, or fatigue, when compared to a placebo, although the study did identify a small, dose-specific impact on some maternal among participants taking the placenta capsules, and may warrant additional research.

The new research was based on the Midwives Alliance of North America Statistics Project, a perinatal registry of maternal and infant health data from midwife-led births primarily at home and in birth centers.

The researchers said nearly one-third of the women in the database consumed their placenta following birth, mostly via capsules containing cooked or raw, dehydrated and ground placenta.

They also found that, among this sample of women who planned community births, those who consumed their placenta were more likely to be from a minority racial or ethnic group; hold a bachelor's degree; be having their first baby; and be from the Western or Rocky Mountain states.

While the study found no risk to babies, it did not examine impact on postpartum mood disorders.

Benyshek and Cheyney also found a small, dose-specific impact on maternal hormones after consumption. Additional research is needed, the professors said.

"While there is currently no evidence to support the efficacy of placentophagy as treatment for mood disorders such as postpartum depression, our study suggests that if neonatal infection from maternal consumption of the placenta is possible, that it is exceedingly rare," Cheyney said.

Story Source:

Materials provided by University of Nevada, Las VegasNote: Content may be edited for style and length.

Journal Reference:

  1. Daniel C. Benyshek, Melissa Cheyney, Jennifer Brown, Marit L. Bovbjerg. Placentophagy among women planning community births in the United States: Frequency, rationale, and associated neonatal outcomesBirth, 2018; DOI: 10.1111/birt.12354

Redesigning Maternal Care: OB-GYNs Are Urged to See New Mothers Sooner and More Often

by Nina Martin April 23

https://www.propublica.org/article/maternal-care-ob-gyns-american-college-of-obstetricians-and-gynecologists

Doctors would see new mothers sooner and more frequently, and insurers would cover the increased visits, under sweeping new recommendations from the organization that sets standards of care for obstetrician-gynecologists in the U.S.

The 11-page “committee opinion” on “Optimizing Postpartum Care,” released today by the American College of Obstetricians and Gynecologists, represents a fundamental reimagining of how providers, insurers and patients can work together to improve care for women after giving birth. “To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs,” the committee opinion states.

While an ACOG task force began rethinking its approach several years ago, the guidelines arrive at a moment of mounting concern about rising rates of pregnancy-related deaths and near-deaths in the U.S. As ProPublica and NPR have reported, more than 700 women die every year in this country from causes related to pregnancy and childbirth and more than 50,000 suffer life-threatening complications, among the worst records for maternal health in the industrialized world. The death rate for black mothers is three to four times that of white women.

The days and weeks after childbirth can be a time of particular vulnerability for new moms, with physical and emotional risks that include pain and infection, hypertension and stroke, heart problems, blood clots, anxiety and depression. More than half of maternal deaths occur after the baby is born, according to a new CDC Foundation report.

Yet for many women in the U.S., the ACOG committee opinion notes, the postpartum period is “devoid of formal or infor­mal maternal support.” This reflects a troubling tendency in the medical system — and throughout American society — to focus on the health and safety of the fetus or baby more than that of the mother. “The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

The way that providers currently care for pregnant women and infants versus new mothers exemplifies this difference. During the prenatal period, a woman may see her OB-GYN a dozen or more times, including at least two checkups during her ninth month. Her baby’s first pediatric visit usually occurs a few days after birth. But the mother may not have a follow-up appointment with her own doctor until four to six weeks after delivery — and in many cases, insurance only covers one visit. “As soon as that baby comes out, [the mom] is kind of an afterthought,” said Tamika Auguste, associate medical director of the MedStar Health Simulation Training & Education Lab in Washington, D.C., and a co-author of the ACOG opinion.

Get ProPublica’s Top Stories by Email

 

For working mothers, having to wait four to six weeks makes it harder to arrange a check-up.

Some 23 percent of mothers employed outside the home are back on the job within 10 days of giving birth, a 2014 report for the U.S. Department of Labor found; another 22 percent return to work within 40 days. Lack of childcare and transportation can also present significant hurdles to accessing care. According to ACOG, as many as 40 percent of women skip their postpartum visit; for low-income women of color, the rates are even higher.

“You may have a woman that has asthma, is having problems lactating, and is obese, and when they come to see you at six weeks, we have missed the boat here,” Auguste said.

Nor is a single visit enough time to address a new mother’s questions and concerns, especially if she had a complicated pregnancy or is suffering from chronic conditions such as hypertension, diabetes or a mood disorder. “We’re trying to address all of the issues that women are dealing with after having a baby in one 20-minute encounter,” Stuebe said. “And that’s really hard to do.”

Under the new ACOG guidelines, women would see their providers much earlier — from within three days postpartum if they have suffered from severe hypertension to no later than three weeks if their pregnancies and deliveries were normal— and would return as often as needed. Depending on a woman’s symptoms and history, the final postpartum visit could take place as late as 12 weeks after delivery and ideally would include “a full assessment of physical, social, and psychological well-being,” from pain to weight loss to sexuality to management of chronic diseases, ACOG says.

See Our Series

 

Lost Mothers

Maternal Care and Preventable Deaths

In another significant change, ACOG is urging providers to emphasize in conversations with patients the long-term health risks associated with pregnancy complications such as preterm delivery, preeclampsia and gestational diabetes. “These risk factors are emerging as an important predictor of future [cardiovascular disease],” the recommendations state. “ … [B]ut because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women.”

Earlier, more frequent and more individualized care could be a step toward addressing the stark racial disparities in maternal and infant health, said ACOG’s outgoing president, Haywood Brown, who has made reforming postpartum care one of the main initiatives of his term. Black mothers are at higher risk for many childbirth complications, including preeclampsiaheart failure and blood clots, and they’re more likely to suffer long-lasting health consequences. They also have higher rates of postpartum depression but are less likely to receive treatment. Regardless of race, for women whose pregnancies are covered by Medicaid, the postpartum period may be their best opportunity to get help with chronic conditions before they lose insurance coverage.

The new guidelines urge doctors to take a proactive approach, helping patients develop a postpartum care plan while still pregnant, including a team of family and friends to provide social and other support. According to ACOG, one in four new mothers surveyed recently said they didn’t even have a phone number of a health care provider to contact with concerns about themselves or their babies.

ACOG isn’t the only organization calling for a reinvention of postpartum care; patient-safety groups, researchers, nurses and midwives have also tackled the issue, recasting the three months after birth as akin to a “fourth trimester.”

“The postpartum period has become a priority,” said Debra Bingham, a professor of nursing at the University of Maryland and executive director of the Institute for Perinatal Quality Improvement who has participated in many of these initiatives.

Some providers, including Brown, who is affiliated with Duke University, are already incorporating some of ACOG’s ideas. Still, putting the reforms into common practice may take years. One of the biggest impediments is insurance reimbursement. Currently, payment for prenatal care, delivery and a single post-birth visit is bundled together into one global fee, creating a disincentive for doctors to see patients more than once, Auguste said.

The disincentives are greater for women on Medicaid, which pays for about half of U.S. births. What’s more, in many states Medicaid coverage ends at two months postpartum. The ACOG opinion didn’t estimate the cost of implementing its recommendations.

Brown agreed that revamping how postpartum care is reimbursed is critical, and insurance representatives — along with members of other medical specialties — were on the ACOG task force that drafted the new guidelines. “I want to make sure that I get some employee health plans and some health systems to adopt this nationally,” Brown said.

Indeed, although the guidelines are aimed at OB-GYNs, they would require changes throughout the maternal care system. That’s what ACOG is hoping for. “It’s really a societal call to action,” Stuebe said.