Moms Deserve Better Care In The Fourth Trimester

Posted January 20, 2016 by Alison Stuebe

Alison Stuebe
Guest blogger Alison Stuebe, MD, MSc

In the weeks following childbirth, mothers must adapt to plunging hormones, recover from birth and learn how to feed and care for a new infant. Amid these challenges, moms receive minimal support from the healthcare system. Postpartum visits are typically scheduled four to six weeks after birth, leaving moms to cope on their own for more than a month. In 1975, childbirth educator Shelia Kitzinger argued that moms need more in the weeks following birth:

“There is a fourth trimester to pregnancy, and we neglect it at our peril. It is a transitional period of approximately three months after birth, particularly marked after first babies, when many women are emotionally highly vulnerable, when they experience confusion and recurrent despair, and during which anxiety is normal and states of reactive depression commonplace.”

Four decades later, evidence suggests that we haven't made much progress. According to a national online survey of new mothers, a third to half report experiencing a wide range of health problems following birth. Moreover, mothers said that their health providers did not prepare them for these challenges. Less than half said their maternity providers offered enough information about topics, such as how long to wait to become pregnant again, changes in sexual response and feelings, the importance of exercise, healthy eating or postpartum depression. A little more than half said they got enough information about birth control methods that they could use after giving birth.

To make matters worse, as many as 40 percent of women don't see their maternity provider at all after discharge from the hospital or birth center. Rates are lower among women on Medicaid, and there are substantial disparities. Women living in low resource neighborhoods and women who are Black are less likely to access postpartum care. To achieve health equity, we need to ensure that ALL women are engaged and receive the support than need following birth.
Mothers' Experience of Selected New-Onset Health Problems 2 Months Post-Delivery
When mothers do get care, it's often fragmented among multiple providers, none of whom are thinking about the whole mother-baby dyad. Consider breastfeeding: 80 percent of women start out breastfeeding in the U.S., but nearly half wean earlier than they want to. When there are issues, maternal providers often turf it to the baby's provider, because the breast is in the baby's mouth. The baby's provider may not feel comfortable prescribing or treating the breast, because it's attached to the mother. And the lactation consultant often focuses on baby's latch, without addressing the other health issues facing mother and baby.

Mothers deserve better in the fourth trimester. Thankfully, there are innovative solutions in the works. For example:
  • One Medicaid/CHIP program used case managers who developed personalized care plans, provided educational materials and called women after birth, markedly increasing postpartum visit rates in four states.
  • In New York City, Elizabeth Howell developed a pamphlet with information and coping strategies for common postpartum problems. A social worker reviewed the pamphlet with mothers before they went home from the hospital, and then called to check in two weeks later. This brief intervention reduced postpartum depression symptoms—and increased breastfeeding rates—through six months.
  • In Durham, North Carolina, the Family Connects program offers a single home visit to all moms. The team found that when a Family Connects registered nurse screens families for unmet needs about three weeks after birth, families are far less likely to take their babies to the emergency room for care during the next six months.
These solutions show that we can improve care for mothers during the fourth trimester once we commit to meeting mothers' needs. Here at UNC, we recently received a Patient-Centered Outcomes Research Institute (PCORI) Engagement Award to bring together mothers, health care providers and other stakeholders to define what families need most during the fourth trimester. Based on the unmet health priorities that stakeholders identify, we will design research studies to deliver optimal care during this critical period, improving outcomes for mothers, infants and families. To learn more about our effort, visit our website, like us on Facebook and follow us on Twitter @4thTriProject.


Alison Stuebe, MD, MSc, is associate professor of Maternal-Fetal Medicine at the University of North Carolina School of Medicine, and Distinguished Professor of Infant and Young Child Feeding at the Gillings School of Global Public Health. She tweets @astuebe and blogs for https://bfmed.wordpress.com.


"Defining Unmet Patient-Centered Health Care Needs in the 4th Trimester" is funded through a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award (EA-2603).


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