New Postpartum Care Recommendations Released by ACOG

 

Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE

The period of time after a person has a baby can be both amazing and remarkable while at the same time being fraught with emotional and physical difficulties that can create situations that require years to resolve.  For those who have birthed in a hospital, in particular with an obstetrician, recent trends have been moving toward one postpartum visit with the health care provider at approximately six weeks.  While that recommendation appeared to be evidence-based, as a childbirth educator and doula, I often saw and heard of the struggles families faced recovering from childbirth, managing a newborn and finding the new normal.  So much can and does happen in that six week (and beyond) period that would benefit from contact with clinicians and professionals before the six-week mark, where it may be too late to correct some situations.

The American College of Obstetricians and Gynecologists released new recommendations for postpartum contact in a Committee Opinion "Optimizing Postpartum Care" that recognizes more frequent and comprehensive services during the postpartum period can help to identify problems, offer treatment and referrals and help families do more than just survive the early days and weeks after giving birth.

Recommendation summary:

• 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.
• Anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care.
• Prenatal discussions should include the woman’s reproductive life plans, including desire for and timing of any future pregnancies. A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.
• All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.
• The timing of the comprehensive postpartum visit should be individualized and woman-centered.
• The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being.
• Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.
• Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care.
• For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider.
• Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.

The fourth trimester is that critical first 12 weeks that the parent-baby dyad goes through where significant physical and emotional recovery and changes are happening. Many critical items can be missed, especially if connection and care is not available until six weeks or beyond for the new parent.  Half of all pregnancy-related deaths happen after the birth of the baby.  So much can slip through the cracks, especially for families of color who may be under-resourced and would benefit most from the support. The committee opinion acknowledges that many cultures celebrate and honor the first weeks and months of a new baby by offering customized support to encourage a successful start - with additional social support, limited responsibilities, and activities, and nourishing food  The United States is very disrespectful of the transition to parenthood with all it often entails and support is sparse as families often struggle through the first days and weeks on their own.

ACOG is recommending contact within the first three weeks by phone, in person or both, when acute situations can develop.  Specific timing should be customized to the needs of each individual family.  For a variety of reasons, approximately 40 percent of post-birth people do not attend a postpartum visit as recommended by their healthcare provider.  This number goes up for the most vulnerable populations.  Some of the work can be done prenatally when health care providers discuss preparing for postpartum, the importance of continued care and common issues that may arise.  Continued education and dialogue during the intrapartum stay and prior to discharge.  Childbirth educators can also play a role during class time by stressing the challenges of the postpartum period, sharing helpful resources and stating the importance of seeing a provider post birth.

It takes a village, and helping a family prepare for the postpartum period by identifying and setting up team members, both professional and personal, to support the family is critical.  Having this team in place prior to birth will help things to go more smoothly and hopefully allow the family to get the help they need prior to critical situations developing.  Breastfeeding plays a critical role in keeping a newborn healthy, but many families struggle to establish an acceptable milk supply and breastfeed comfortably. Identification of problems and support with solutions would go a long way to supporting the parent-baby dyad as breastfeeding is getting well established.

Another important reason to have timely and appropriate postpartum care includes receiving counseling on family planning and birth control options after birth.  This information can help reduce unplanned pregnancies. On an emotional level, almost 20 percent of new birthing parents suffer from postpartum mood and anxiety disorders.  identifying mental health issues and connecting with appropriate support and resources is critical.  Birthing people also need support in transitioning to (or reestablishing care with) a provider who will provide support for chronic or ongoing health concerns if there are any.

The United States is not very family friendly as parents welcome a child.  Leave for a new parent is practically non-existent and too many birthing people are required to return to work much too soon as well.  Stunningly,  according to the ACOG opinion, "23% of employed women return to work within 10 days postpartum and an additional 22% return to work between 10 days and 40 days" in the USA, which is simply unacceptable.  Many physical and emotional issues that need professional support are missed when new parents are back at work immediately after giving birth.

I encourage you to read this new committee opinion in its entirety.  There is a lot of very positive recommendations and suggestions for appropriate care.  Implementation will be the challenge and will require a commitment of time and money by care organizations if the recommendations are to be implemented successfully.  Childbirth educators can help to prepare families for life after baby, what appropriate postpartum care from their provider should look like and how to access information and resources to help with any situation that arises.  It does take a village and we are part of that village and we can help.

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References

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004. 

Klerman J, Daley K, Pozniak A. Family medical leave in 2012: technical report. Cambridge (MA): ABT Associates Inc; 2014. 

Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e140–50.