By Will Boggs MD
NEW YORK—Postpartum care should begin during pregnancy and continue for several weeks after delivery, according to updated recommendations from the American College of Obstetricians and Gynecologists (ACOG).
"Women need sustained support and care in the weeks following birth, rather than a one-off visit after 6 weeks," Dr. Alison M. Stuebe of the University of North Carolina, Chapel Hill, an ACOG task force member, told Reuters Health by email. "Obstetricians and other obstetric care providers can provide that support through office visits, outreach by phone or text messages, home visits, or other innovative approaches."
"Different models will work in different settings," she said. "However, we can't expect good outcomes if we expect women to muddle through for 42 days before seeing a women's health care provider."
The updated ACOG Committee Opinion, which includes 10 recommendations and their justification, appears online April 23 in Obstetrics & Gynecology.
Optimal postpartum care should be an ongoing process, rather than a single encounter, and should be tailored to each woman's individual needs, the authors say.
This process should begin with the development during pregnancy of a postpartum care plan, include contact with a maternal care provider within the first three weeks postpartum and conclude with a comprehensive postpartum visit no later than 12 weeks after birth.
The comprehensive postpartum visit should include a full assessment of physical, social and psychological well-being.
Women who have experienced complicated pregnancies should be counseled regarding their impact on the lifetime risk of cardiometabolic disease, and those with non-obstetric chronic medical conditions should be counseled regarding the importance of timely follow-up with appropriate providers.
"Pregnancy is a window to future health, and all clinicians caring for women should take an obstetric history and use this information to inform risk stratification and prevention of cardiometabolic disease," Dr. Stuebe said. "Women who develop gestational diabetes, gestational hypertension, or deliver preterm are at increased risk."
Postpartum follow-up is also essential for women who have experienced a miscarriage, stillbirth, or neonatal death.
Unfortunately, according to the authors, reimbursement policies do not support optimal postpartum care.
"Current payment structures for postpartum care are a barrier to holistic, sustained support in the 4th trimester," Dr. Stuebe said. "Currently, routine postpartum care is bundled in the Global OB Package, which is a disincentive to adding additional visits. Women need better care, and providers need to be reimbursed for providing better care to make this care sustainable."
"Postpartum women have multiple, intersecting health needs, and yet their care is often siloed in different specialties," she said. "For example, a woman with a third degree laceration, postpartum depression, pain with breastfeeding, and a baby with a tongue tie might see a urogynecologist, a psychiatrist, a lactation consultant, her infant's pediatrician, a pediatric ENT, and an obstetric care provider. These specialists each have expertise - and strong opinions - about their specific organ systems and often give conflicting advice."
"However," she added, "if the mother can't sit upright because of perineal pain, then she can't nurse her baby in a sitting position, and if she's coping with depression, she's going to find it harder to coordinate multiple appointments in different offices and different health systems. This reductionist approach leaves mothers frustrated and exhausted, and does not meet their needs. We need to intentionally support multidisciplinary care that is centered on the woman and her baby."
"In our current system of maternity care, we lavish attention on women while they are pregnant, and then we essentially abandon them after the baby is out," Dr. Stuebe said. "Once the candy is out of the wrapper, the wrapper is cast aside. That neglect has serious consequences - mothers are more likely to die of pregnancy-related causes after the day of delivery than during pregnancy."
Additional resources for optimizing postpartum care are available at https://www.acog.org/More-Info/OptimizingPostpartumCare.
The ACOG Committee Opinion is also endorsed by the Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women's Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal-Fetal Medicine.
Obstet Gynecol 2018.
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