A recent national study of more than 20 million office-based postpartum visits that occurred between 2008 and 2016 found that both privately and publicly insured U.S. women did not receive many recommended services during these visits. Blood pressure was measured 91.1% of the time, but other services recommended by the American College of Obstetricians and Gynecologists (ACOG) received scant attention. Pelvic exams occurred in 47.3% of visits; contraceptive counseling or provision, 43.8%; Pap tests, 15.9%; screening for depression, 8.7%; and counseling about weight reduction, 2.8%.
The study, by Geissler and colleagues and published last November in JAMA Network Open, comes amid growing alarm over pregnancy-related mortality, which has been rising in the United States for several decades. Significantly, more than half of pregnancy-related deaths occur after the birth of the infant, highlighting the need for comprehensive and attentive postpartum care.
More than a third of medically related postpartum deaths are linked to cardiovascular conditions. Nonmedical postpartum deaths-from suicide, accidental overdose, unintentional injury, and intimate partner violence-add to the toll.
Comprehensive postpartum care is crucial, experts say, to helping mothers adjust to physical, social, and psychological changes that accompany caring for a newborn. Postpartum care is also necessary to manage chronic disease that preceded pregnancy or new conditions brought on by pregnancy. Yet studies have shown that anywhere from 11% to 50% of women don't attend a postpartum visit.
Traditionally, postpartum care in the United States has consisted of a single visit at six weeks. Geissler and colleagues found that it averaged 17.4 minutes, a duration that did not differ by insurance type. During this visit, the variety of universally recommended services includes depression screening, contraceptive counseling, blood pressure monitoring, substance use and tobacco use counseling, blood glucose testing for women who had gestational diabetes, and counseling regarding infant and self-care.
The study was designed to determine and then compare by insurance type-Medicaid versus private insurance-the frequency with which patients received specific services at their postpartum visit. In examining the medical records of postpartum women ages 18 to 44, researchers did not find significant differences in services by insurance type. Rather, the study revealed that obstetricians and family medicine physicians (certified nurse midwives were excluded from the study) consistently failed to provide important services to women recovering from childbirth. For example, the rate of screening for postpartum depression-only one visit out of 11-was highlighted by the researchers as alarming, since screening is essential to identify the need to refer for treatment.
To address these long-standing care deficiencies documented by this study and others, ACOG developed a series of recommendations, including that postpartum care be provided not as a single visit but as an ongoing process of care up to 12 weeks after childbirth, followed by transition to follow-up care as needed. The ACOG recommendations describe a "fourth trimester" that includes initial assessment and counseling-whether by phone or visit-at three weeks postpartum, ongoing care as needed, and, by 12 weeks, a comprehensive visit with full assessment of physical, social, and psychological health. This level and duration of postpartum care will require both policy and insurance payment adjustments, according to ACOG.-Joan Zolot, PA