The 'Fourth Trimester:' What Updated Postpartum Guidance Means for New Moms

Understandably, women tend to receive a fair amount of medical attention in the run up to the birth of a child (though this is by no means true for all, particularly given persistent disparities in care). However, almost universally, that level of attention and monitoring drops off sharply after a baby arrives, in the postpartum period.

Traditionally, women have been counseled to see their OB-GYN at around six weeks following delivery. And that's about it. What's more, research shows that upwards of 2 in 5 women don't go to a postpartum visit at all. And yet after the child is born is precisely when women frequently face the most significant and sustained physical and mental health challenges of all -- from post-pregnancy complications and lingering childbirth-related injuries to postpartum depression.

"There's an increasing recognition that we're not doing a good job of taking care of moms after their babies are born -- and I think in particular with addressing issues around maternal mortality. We know that women are more likely to die of pregnancy complications after birth than during pregnancy or during birth itself," says Dr. Alison Stuebe, a member of the American College of Obstetricians and Gynecologists' Presidential Task Force on Redefining the Postpartum Visit.

Stuebe, an associate professor of obstetrics and gynecology at the University of North Carolina School of Medicine, was the lead author on an ACOG committee opinion released in April that updated recommendations for postpartum care. Noting previous research, the opinion pointed out that more than half of pregnancy-related deaths actually occur after childbirth. "So as we look at the fact that maternal mortality rates are going up in the U.S. -- the only country in the world I believe where they're going up -- and many of the deaths are occurring after delivery, we realized we really need to think about how we take care of moms in that time period after birth," Stuebe says.

In addition to those tragedies, experts say it's precisely when women face a wide range of challenges, from sleep deprivation to hormonal shifts to breast-feeding initiation, that individualized access to health providers, starting early on and then as needed, is so important. So instead of a six-week postpartum visit, the new guidance recommends "care would ideally include an initial assessment, either in person or by phone, within the first three weeks postpartum." That visit "should be followed up with ongoing care as needed, concluding with a comprehensive well-woman visit no later than 12 weeks after birth," the committee opinion states.

[See: 10 Things No One Tells You About Breast-feeding.]

Rather than a quick, you're OK -- or all-clear -- type visit, experts also want to make the checkup more useful and part of continuous, unbroken care that ultimately extends beyond the postpartum period. The guidance suggests that the "postpartum visit should include a full assessment of physical, social and psychological well-being, including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contraception and birth spacing," or waiting between pregnancies to allow a woman's body time to recover; as well as "sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance." That's in addition to counseling women with chronic medical conditions from high blood pressure to obesity, diabetes and thyroid disorders about the importance of timely follow-up care.

"Insurance coverage policies should be aligned to support this tailored approach to 'fourth trimester' care," the committee opinion asserts.

Clinicians like Dr. David Ahdoot, an ob-gyn at Providence Saint Joseph Medical Center in Burbank, California, say that in addition to being assessed earlier than is typically done in the postpartum period, care needs to be tailored to the person. That's something Ahdoot says is already standard with the care he delivers, but he lauds the updated ACOG guidance for shedding light on this need.

"As more women are getting pregnant at different stages of their life -- meaning that they have more, both physical and emotional needs -- more than ever, it's important to make the care of every pregnant woman individual," he says. "Some have metabolic disorders. Some have complications during pregnancy, such as diabetes and hypertension. Therefore it's very important that they get followed up closely." In addition to the impact everything from postpartum depression to physical health issues can have on the mother, experts point out that issues in the postpartum period can make it harder to bond with baby, too.

Often health concerns during pregnancy like gestational diabetes and preeclampsia, which tend to go away after a child is born, aren't discussed thereafter by the woman and her provider. "Nobody worries about it, nobody communicates the risk to the patient, and the patient doesn't know that because it occurred, it's still putting them at risk, even though it's disappeared," says Dr. Martha Gulati, chief of cardiology at the University of Arizona College of Medicine, and physician executive director of the Banner - University Medicine Heart Institute in Phoenix. Research shows that having gestational diabetes raises a woman's risk of developing Type 2 diabetes, and high blood pressure could predict future heart disease and stroke risk. "We're identifying things that happen in pregnancy that predict future cardiovascular risk," says Gulati, who was a coauthor on the ACOG committee opinion on postpartum care.

In rare cases, a woman may, for example, have uncontrolled high blood pressure, just after giving birth, that leads to having a stroke shortly after delivery. "Postpartum cardiomyopathy is another complication where women can develop abnormal heart function after birth that manifests into feeling short of breath and tired," Stuebe says. This can also be life-threatening. That's all the more reason experts say postpartum care must be designed around the woman's specific needs.

[See: How to Cope With Gestational Diabetes.]

The committee opinion also states that women and their doctors should create a postpartum care plan before the birth of a child -- just as women are encouraged to develop a birth plan that details needs and preferences. Among other components outlined in the committee opinion, the postpartum care plan should include:

-- A list of health providers as well as any family and friends who will provide support after the birth of the child -- something clinicians say is crucial but often lacking -- with contact information.

-- Information to schedule postpartum visits; an infant feeding plan, including the intended method of feeding and resources needed (like lactation consult or other support for breast-feeding).

-- The new guidance also notes that ACOG "endorses paid parental leave as essential," including maintaining full benefits along with 100 percent of pay for at least six weeks. At present, only unpaid leave -- but no paid leave -- is guaranteed by federal law.

Regarding the roots of the traditional six-week postpartum visit, experts say it's not based on research. As best anyone can tell, Stuebe says, it probably has something to do with the 30 to 40 days of intensive protection and rest for moms and babies observed in various cultures: "whether it's the 'doing the month' in China, or the cuarentena -- which is the 40 days in Latino culture -- or Mary brought Jesus to the temple at 40 days, because in Leviticus there's supposed to be ... a 40-day rest period for moms and babies."

In stark contrast to that, nearly one-quarter of women go back to work within 10 days of giving birth in the U.S. today. "I don't think it's because women think it will be fun to be back to work. I think it's because they financially can't afford to take time off," Stuebe says. Partners commonly return quickly to work, and given that family are often spread out or community connection is thin, much of that rest and support baked into other cultural traditions surrounding the postpartum period through the ages and around the world has fallen away in the here and now. "We ditched that part in American culture," Stuebe says -- just keeping the six-week postpartum visit.

[See: 10 Ways to Make Your Childbirth Easier.]

Along with updated recommendations on postpartum care and advocating societal changes to better support women in the postpartum period, experts advise that women and their partners or others close to them consciously work to build up support networks before and during pregnancy for after the birth. That's in addition to planning for and dialoguing with providers about what to expect in the postpartum period well in advance of the child's arrival. "Finding and developing the village during pregnancy," Stuebe says, "and developing a realistic idea of what one is going to face is really important."

Michael Schroeder is a health editor at U.S. News. He covers a wide array of topics ranging from cancer to depression and prevention to overtreatment. He's been reporting on health since 2005. You can follow him on Twitter or email him at mschroeder@usnews.com.