The 4th Trimester: Redefining Postpartum Care for Healthier Moms & Children

Two ordinary postpartum stories

Gathering for our sons’ 21st birthdays recently, a friend and I reflected on our postpartum experiences so long ago, speaking candidly on the subject for the first time. 

She told me about the guilt she still carries with her two decades later: that the “magic moment” with her newborn wasn’t magical at all. The baby she had yearned for, that she had gone through IVF treatments for, had brought none of that amazing joy she was supposed to feel. She had desperately wanted to bond with her new baby but simply couldn't. Instead, she felt sad and detached. To this day, she expresses gratitude for her husband who took over the bonding responsibilities on day one.

I, too, desperately wanted to become a mother and went through fertility treatment. And like her, I struggled in the postpartum period. Instead of jubilation, I felt defeated. After spending 10 weeks in bed to protect my pregnancy with twins, and gaining half my body weight in the process, I was physically and emotionally spent. My stamina was gone. In fact, a clinician mistook me for a smoker when testing my lungs hours after delivery. 

An abrupt end to maternal care

I was ushered out of the hospital just two days following major surgery despite being barely able to walk from one side of my hospital room to the other. My care team did not advise me about hypertension even though I was diagnosed with preeclampsia during my pregnancy and carried 45 extra pounds post delivery. The oxycodone used to relieve my C-section pain left me covered in hives from head to toe. Nothing could be done, my doctor said, because I was breastfeeding. The focus was almost entirely on the babies, which seemed entirely appropriate at the time. 

On day five or six of visiting the babies at the NICU, I sobbed uncontrollably upon departing, as if primal instinct was suddenly (and loudly) objecting to the unnatural separation of mother and child(ren). But the challenges began in earnest when the babies came home. Caring for two infants became a 24/7 job, leaving scant room for rest. I was sleep deprived, overwhelmed by the responsibility for two new lives, still in pain from the C-section, miserable from the incessant itch of hives, and so exhausted from breastfeeding that I felt nauseated all the time. There was very little joy and plenty of discomfort—and then, extreme anxiety. 

Extreme, uncontrollable anxiety

Neither of us will forget the battles against our own minds in those early days and weeks of motherhood. My friend told me about her postpartum visions of a knife-wielding woman coming for her son. I told her about my eerily similar fear of knives and visions of my babies floating through the air away from me. One night I woke up screaming and grasping at the air above me as I tried to save them. The visions, anxiety and fear stayed with me during the days but remained hidden from family and friends. I didn’t know these experiences are common: it was a very lonely time.

She said she had learned that C-sections and infertility are risk factors for postpartum depression (PPD) and anxiety, something we both wished we’d known 21 years ago. First-time motherhood, lack of sleep, and caring for multiples (in my case) surely contributed as well. Looking back, it’s no wonder I could barely cope or that I was experiencing symptoms of postpartum PTSD. Harder to understand: the near complete absence of postpartum care for mothers. A single cursory check-up with my PCP six weeks following birth was woefully inadequate; I just couldn’t see it at the time.

Untreated postpartum depression is common and costly

Evidently, both of us suffered from undiagnosed and untreated postpartum psychiatric disorders. According to CDC research, about one in eight women experience symptoms of PPD, but less than half receive treatment. The pandemic has only made things worse, with some health systems seeing up to 20% spikes in cases of PPD during COVID. The impact isn’t exclusive to mothers: children of mothers with untreated PPD are at higher risk for cognitive, emotional, development and verbal deficits and impaired social skills. 

My friend credits her sister for saving her. I credit time, willpower, and the good fortune of having five months of (mostly unpaid) maternity leave for saving me. It was a long haul. If I had been forced to return to work right away, I’m not sure how things would have unfolded. 

The need for better postpartum care

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Fortunately, healthcare leaders and policy makers have recognized the urgent need to redefine care for mothers during the “fourth trimester,” a critical period for the health of both mother and child. In 2018, the American College of Obstetricians and Gynecologists (ACOG) revised postpartum care recommendations in response to the growing maternal health crisis in the U.S. and specifically, the postpartum health risks to new mothers and their babies. 

Indeed, the statistics for maternal mortality and morbidity, especially in the postpartum period, are alarming:

• In 2019, 754 women in the U.S. died from pregnancy-related causes, up from 658 deaths in 2018. Sixty percent of these deaths are preventable.‍
• More than half of maternal deaths (52%) occur in the postpartum period.‍
• 40% of maternal deaths occur in the first 42 days postpartum, with infection, heart conditions and hemorrhage the leading causes.
• Nearly 12% of maternal deaths occur from 43 to 365 days postpartum, with heart muscle disease, mental health conditions, and embolism the leading causes.‍
• PTSD following childbirth can affect up to 6% of mothers.
• Maternal suicidality affects an estimated 24,000 new mothers a year, with Black mothers disproportionately affected. 

New postpartum care recommendations

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ACOG now recommends postpartum care be supported and reimbursed as an ongoing process beginning within three weeks of delivery, rather than a single episode of care six weeks later. ACOG states that postpartum care also should be:

• Personalized — tailored to the unique needs of each mother.
  
• Proactive — focused on managing chronic conditions such as diabetes, hypertension, obesity, thyroid disorders, and emotional challenges.
  
• Holistic — focused on the physical, social, emotional, and mental health of the mother, and addressing the following topics: moods and emotional well-being, infant care and feeding, sexuality, contraception, birth spacing, sleep and fatigue, physical recovery from birth, and chronic condition management.
• Coordinated — led by a specified OB/GYN or PCP and coordinated among other healthcare providers.

But obstacles abound

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Making recommendations is one thing, putting them into practice is another. Several obstacles stand in the way to achieving this new vision of postpartum care:

• Fragmented care makes it difficult for OB/GYNs and PCPs to share patient information. In my case, my PCP and OB/GYN were in completely separate health systems with no mechanism to coordinate care. Today, electronic medical records remain largely closed systems, impeding data sharing and care coordination across providers.
• Provider visits of 9 to 12 minutes in duration are insufficient to address the social, physical, emotional and mental health needs of a new mother, or to provide truly personalized care.
• Scheduling timely, ongoing, in-person postpartum provider visits is challenging for a few reasons, including the lack of availability of OB/GYNs and PCPs (amidst a growing shortage) as well as barriers to patient engagement. Forty percent of new mothers do not attend any postpartum visits at all due to lifestyle changes with newborn(s), a lack of child care, work schedules, transportation challenges, etc.
  

From recommendation to reality: how Maven helps

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As the largest virtual clinic for women’s and family health, Maven can help you remove these obstacles for your members and give them the care they need and want throughout the maternal journey, from fertility through the fourth trimester and beyond. Maven combines technology, compassionate Care Advocates, an extensive network of specialty care providers, clinically supported and vetted content, and online community to deliver a significantly improved care experience that women love and want to use. 

Maven has helped me tremendously with understanding that postpartum depression and anxiety are normal. I felt supported during a very hard time.
- Maven member

Maven’s maternal care model is:

• Personalized. Maven provides personalized guidance and advocacy to members based on their unique history, life context, needs and preferences. Our dedicated Care Advocates form trusted relationships that empower women to be partners in their own care and motivate them to engage in their health. By identifying members with high-risk pregnancies early in the journey, Maven can tailor interactions and content to better support those diagnosed with hypertension, preeclampsia, diabetes and other high-risk conditions, before and during pregnancy, and in the postpartum period.‍
• Proactive. Maven provides counseling and content to members about chronic hypertension, pulmonary embolism, mental health and other postpartum risks and challenges. We help members stay on track with their postpartum care, nudging them to follow-up with their OB/GYN and other providers, for example, or reminding them about the importance of monitoring their blood pressure.
• ‍Holistic. Care advocacy, online content and community, and an extensive telehealth network of specialty providers—including mental health specialists, midwives, OB/GYNs, sleep coaches, lactation consultants, doulas and many others—make it easy for new mothers to get the physical, social, emotional and mental health support they need when they need it, 24/7, beyond the walls of healthcare.
• Continuous and coordinated. The Maven solution integrates care from fertility through the fourth trimester and beyond. At the core, a dedicated Care Advocate helps drive care continuity and coordination across multiple in-person and virtual providers, improving the efficiency and effectiveness of care. Supporting the extended care team, the Maven technology platform provides a single, shared profile of each member.
  

I told my friend about the work we do at Maven. We rejoiced in knowing that new mothers are finally getting the postpartum care they need and deserve.

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- Peggy F., Maven employee