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April 27, 2018

After giving birth, many mothers are 'cast aside' by their doctors. ACOG wants to change that.

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    The American College of Obstetricians and Gynecologists (ACOG) has released an 11-page "committee opinion" that offers sweeping recommendations to fundamentally change postpartum care, saying that new mothers need to be seen sooner and more often after giving birth, Nina Martin writes for NPR and ProPublica.

    Learn the 9 elements of top perinatal patient safety programs

    The problem with postpartum care in the United States

    The recommendations come amid growing concerns about maternal mortality in the United States, Martin writes. More than 700 women die from causes related to pregnancy and childbirth each year, while more than 50,000 suffer life-threatening complications, according to ProPublica.

    A CDC Foundation report found that more than 50% of maternal deaths occur postpartum, meaning that the days and weeks following childbirth are pivotal for a new mother's health, Martin writes.

    But ACOG in its opinion wrote that currently the postpartum period is "devoid of formal or informal maternal support," as the U.S. health care system places a greater emphasis on the safety of the baby than of the mother. Under the current system, newborns often have their first pediatric visit a few days after birth, Martin writes, while the mother typically is not seen until four to six weeks postpartum.

    And many women aren't seen by a doctor postpartum at all: ACOG estimates as many as 40% of women don't go to their postpartum visit, with rates climbing even higher for low-income women of color. That's due in part to the fact that an estimated 23% of women return to full-time employment within 10 days of giving birth, so they may not be able to skip work for a doctor's visit. Childcare and transportation issues can present additional barriers to women seeking care.

    Under the current system, Alison Stuebe—who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and headed the task force that drafted guidelines—said, "The baby is the candy, the mom is the wrapper. And once the candy is out of the wrapper, the wrapper is cast aside."

    ACOG's recommendations

    ACOG's new guidelines recommend doctors see their postpartum patients much earlier: no later than three weeks after delivery, and even earlier if patients have suffered from severe hypertension, Martin writes. New moms also are encouraged to return as often as needed, with postpartum visits potentially continuing up to 12 weeks after delivery, depending on the woman's symptoms and history. Ideally, the final visit would include "a full assessment of physical, social, and psychological well-being," according to the guidelines.

    ACOG in their guidelines also urged providers to discuss the long-term health risks associated with certain pregnancy complications, including preterm delivery, preeclampsia, and gestational diabetes, Martin writes. "These risk factors are emerging as an important predictor of future [cardiovascular disease]," ACOG wrote. "[B]ut because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women."

    The guidelines also urge providers to help patients create a postpartum care plan while they're pregnant, which includes creating a support team of family members and friends.

    Why implementing these recommendations may not be easy

    One of the biggest challenges to implementing ACOG's recommendations is insurance reimbursement, Martin writes. According to Auguste, payment for prenatal care, delivery, and one postpartum doctor's visit are commonly bundled into one fee, which creates an incentive for doctors to only see their patients once. Patients with Medicaid coverage may face additional obstacles, as many states end their Medicaid coverage at two months postpartum.

    Haywood Brown, ACOG's outgoing president, said that changing how postpartum care is reimbursed is critical, which is why insurance representatives were included on the ACOG task force the created the guidelines, Martin writes. "I want to make sure that I get some employee health plans and some health systems to adopt this nationally," Brown said (Martin, ProPublica/NPR, 4/23).

    9 elements of top perinatal patient safety programs

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