The postpartum period is a critical time of transformation for a mother. In addition to caring for a new infant, a woman must recover physically from childbirth, deal with bodily and hormonal changes, navigate new social environments and handle the fluctuating emotions and psychological challenges that come with parenting.
The American College of Obstetricians and Gynecologists (ACOG) recommends that postpartum women have contact with their obstetric provider within the first three weeks after birth and have ongoing care as needed, concluding with a comprehensive visit no later than 12 weeks after the delivery.1 This single comprehensive visit is to include a full assessment of physical, social and psychological health and must address postpartum mood, infant care, sexuality, family planning, sleep, physical recovery from childbirth, management of chronic diseases and routine healthcare maintenance.1
The Current Model of Postpartum Care
In the current postpartum care model, women deemed to have low-risk pregnancies typically have a single 6-week postpartum visit and then are not seen again by their obstetrician-gynecologist until their annual exam. This seemingly arbitrary 6-week time point likely reflects cultural traditions of a 40-day convalescent period for women and their infants.2 However, in today’s working environment, 23% of employed women return to work within 10 days postpartum, and 45% of women are working within the 6-week postpartum timeframe1, thus highlighting a critical area of disconnect between a woman’s needs and societal expectations.
In line with this, due to a variety of patient-level, practice-level and broader societal challenges, up to 40% of women do not attend their postpartum visit.1,3 This has been attributed to a lack of patient self-prioritization, dependent care needs, clinical staffing shortages, maternity care deserts and adverse social determinants of health (e.g., decreased health literacy, language barriers, transportation issues and unsafe housing).3 Moreover, postpartum attendance rates are lowest among those with limited resources, thus further widening the gap of healthcare disparities in our country.1
The consequences of a lapse in care in the postpartum period reach far beyond 12 weeks, and this is especially true for women who experienced pregnancy complications. The American Heart Association (AHA) released a Scientific Statement in 2021 highlighting the evidence that supports how adverse pregnancy outcomes – including hypertensive disorders of pregnancy (e.g., gestational hypertension, preeclampsia, eclampsia), preterm delivery (i.e., delivery before 37 weeks), gestational diabetes, delivery of a small-for-gestational age infant (i.e., birth weight less than the 10th percentile for gestational age), placental abruption and pregnancy loss – increase a woman’s risk of developing future cardiovascular disease, including coronary heart disease, stroke, peripheral vascular disease and heart failure.4 Despite this, currently only 18%-25% of postpartum patients who experienced an adverse pregnancy outcome or who have chronic health conditions are seen by a primary care provider (PCP) within 6 months of delivery.3
Maternal Mortality in the Postpartum Period
Pregnancy-related death, defined as the death of a woman during pregnancy or within one year from the end of pregnancy from any cause related to or aggravated by the pregnancy5, has been on the rise in the United States. This has been attributed to a number of factors, including an increased prevalence of chronic diseases (e.g., obesity, hypertension and diabetes), older ages at which women are having children and structural racism within the American healthcare system.
Importantly, over 50% of all maternal deaths occur in the postpartum period6, and 80% of fatalities are deemed preventable.6 Georgia currently has the second highest rate of maternal mortality in the United States, with the majority of maternal deaths due to cardiovascular conditions (i.e., cardiomyopathy, cardiovascular and coronary conditions)7 and 70% of maternal deaths occurring >7 days postpartum.7
Future Directions in Postpartum Care and Transitions of Care
In light of these distressing maternal mortality trends, there has been an effort to redefine the postpartum period, also known as the “4th trimester,” as a critical window of opportunity to promote overall health and wellbeing, serve as a time of preconception counseling for subsequent pregnancies, and provide anticipatory and preventative care guidance for long-term health conditions.
For example, our institution implemented a comprehensive Postpartum Cardiometabolic Clinic (PPMC) at 12 weeks postpartum for women who experienced adverse metabolic outcomes (e.g., diabetes or hypertension) of pregnancy. This PPMC visit supplements the standard 6-week postpartum visit and serves to provide dedicated counseling on the long-term health risks and facilitate the transition to primary and specialty care (e.g., cardiology and endocrinology) services; we also discuss pertinent adjuvant factors of postpartum health, such as sleep, nutrition, exercise and mental health, as dysregulation of any of these elements can have detrimental effects on a person’s overall wellbeing.
This PPMC model is one example that supports the AHA’s approach to optimal cardiovascular health across the life course as it offers opportunities to intervene and promote a healthy weight, healthy diet and regular physical activity, which are key drivers to optimize lifelong cardiovascular health.3
In addition, ACOG and AHA have proposed strategies and recommendations to enhance engagement with routine postpartum care through multidisciplinary care coordination. For example, postpartum visit attendance may be improved by scheduling postpartum visits prenatally, appointing family members to help with the practical needs of the patient and infant, and by enlisting postpartum doula services. Moreover, telemedicine and digital healthcare services can be used to encourage patient participation. Lastly, societal challenges can be addressed with the help of patient navigators, language interpretive services, home health nurses and community healthcare workers, better parental leave policies and enhanced services to meet social determinants of health.1,3
Current recommendations from ACOG state that all postpartum encounters should consider the need for further follow-up and should time additional visits accordingly. Complications regarding the pregnancy and delivery should be reviewed with the patient, and recommendations should be made to optimize maternal health during the interpregnancy period.1
Furthermore, among patients who experienced adverse pregnancy outcomes, the AHA recommends frequent cardiac risk factor screening assessments, including body mass index (BMI), blood pressure (BP) and lifestyle counseling, within the first year postpartum (i.e., at 6 weeks, 12 weeks, 6 months and 12 months postpartum), with the transition of care from the obstetrician-gynecologist to a PCP at 8-12 weeks postpartum.4
Together as a community, we must recognize the importance of the 4th trimester as a gateway in the continuum of women’s healthcare. We must acknowledge that maternal mortality exists throughout the first year postpartum, and every woman of childbearing age should be asked if she has been pregnant or given birth within the last year in order to guide diagnosis and treatment decisions.
Lastly, we must remember that pregnancy is a window into future health and that adverse pregnancy outcomes predict the risk of future cardiovascular disease, which is the No. 1 killer of women of all ages.8 By prioritizing postpartum care and improving the transitions to long-term healthcare in the postpartum period, we can significantly improve outcomes for women and families of all stages of life.
References
1. McKinney J, Keyser L, Clinton S, Pagliano C. ACOG Committee Opinion No.736: Optimizing Postpartum Care. Obstet Gynecol 2018;132:784-85.
2. World Health Organization. Postpartum Care of the Mother and Newborn: aPractical Guide. Report of a Technical Working Group. 1998.
3. Lewey J, Beckie TM, Brown HL, et al. Opportunities in the Postpartum Period to Reduce Cardiovascular Disease Risk After Adverse Pregnancy Outcomes: A Scientific Statement From the American Heart Association. Circulation2024;149:e330-e46.
4. Parikh NI, Gonzalez JM, Anderson CAM, et al. Adverse Pregnancy Outcomes and Cardiovascular Disease Risk: Unique Opportunities for Cardiovascular Disease Prevention in Women: A Scientific Statement From the American Heart Association. Circulation 2021;143:e902-e16.
5. Centers for Disease Control and Prevention. Pregnancy Mortality Surveillance System, 2023 (vol 2024).
6. Georgia Department of Public Health. Georgia 2019-2021 Maternal Mortality report. dph.georgia.gov/maternal-mortality
7. Georgia Department of Public Health. Georgia 2019-2021 Maternal Mortality,2019-2021 (vol 2024).8. Centers for Disease Control and Prevention. Women and Heart Disease, 2024 (vol 2024)
Dr. Natalie Poliektov
Dr. Poliektov is a fourth-year obstetrics and gynecology resident physician and incoming first-year maternal-fetal medicine fellow at Emory University School of Medicine. She is a member of the American College of Obstetricians and Gynecologists, the Georgia Obstetrical and Gynecological Society and the Society for Maternal-Fetal Medicine. Her research and clinical interests include cardio-obstetrics, post-partum cardiometabolic health, and the association between chronic medical conditions and maternal morbidity/mortality.
