This Blog Post was originally shared in 2018 & updated in 2021
In a helpful move in the right direction for women, mothers, parents, and birthing people's health, the American College of Obstetricians and Gynecologists (ACOG), which is the guiding organization for OBs, has released a new "Committee Opinion" paper providing updated recommendations for improved postpartum care in the weeks after giving birth. This change comes as the United States is experiencing the worst and highest rates of maternal deaths in all industrialized counties.
(2018) Currently, after giving birth, a person is a told to make one six-week follow up appointment with their OB or midwife. For someone who has a c-section or other complications during birth, the appointment may be sooner.
The problem with this current standard is both in the timing -- 6 weeks after birth -- and the frequency: once.
Postpartum health begins the moment after you give birth and continues until the end of the first year after birth. In the first few weeks after having a baby, people are susceptible to complications, many of which can be life-threatening. Complications also can occur well beyond the six-week mark. With only one appointment, and not until six weeks after birth, and not again until needed, there are a lot of symptoms, signs, and issues that could be appropriately treated that are missed. Considering that as many as 40% of people do not attend any postpartum care appointment, we have room to do much better with the care of people in the first year after having a baby.
Think about it this way: In a baby's first year, routine check-up guidelines include being seen in the first 3-5 days after birth, then again at 1, 2, 4, 6, 9, and 12 months. For the person who gave birth, the first year routine check-up is one appointment, six weeks after birth. Considering that a parent's health also impacts baby's health, this is problematic.
To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs. Indeed, in qualitative studies, women have noted that there is an intense focus on women’s health prenatally but care during the postpartum period is infrequent and late 8. Rather than an arbitrary “6-week check,” the American College of Obstetricians and Gynecologists recommends that the timing of the comprehensive postpartum visit be individualized and woman centered. To better meet the needs of women in the postpartum period, care would ideally include an initial assessment, either in person or by phone, within the first 3 weeks postpartum to address acute postpartum issues. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive well-woman visit no later than 12 weeks after birth Figure 1.
Insurance coverage policies should be aligned to support this tailored approach to “fourth trimester” care Policy and Postpartum Care.
2018 recommendations
ACOG's new recommendations are developed for obstetricians in order to guide new practices that will improve health.
They include:
Postpartum care should become an ongoing process, rather than a single appointment; it should include services and support tailored to each person’s individual needs
Contact should be made with your obstetrician within the first three weeks after giving birth -- by phone, in person, or both
The initial assessment should be followed up with ongoing care as needed in addition to a comprehensive postpartum visit no later than 12 weeks after birth
Your comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being, including: mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance. Those with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders should be counseled regarding the importance of timely follow-up with their providers for ongoing coordination of care.
2021 Updated recommendations:
ACOG's new recommendations are developed for obstetricians in order to guide new practices that will improve health.
The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:
To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.
Anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care.
Prenatal discussions should include the woman’s reproductive life plans, including desire for and timing of any future pregnancies. A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.
All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.
The timing of the comprehensive postpartum visit should be individualized and woman centered.
The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being.
Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.
Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care.
For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider.
Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.
The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs. It is recommended that all women have contact with their obstetrician–gynecologists or other obstetric care providers within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding 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, including the following domains: mood and emotional well-being; infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue; physical recovery from birth; chronic disease management; and health maintenance. Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care. During the postpartum period, the woman and her obstetrician–gynecologist or other obstetric care provider should identify the health care provider who will assume primary responsibility for her ongoing care in her primary medical home. Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit. Obstetrician–gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants. This Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.
Of note, even among women without risk factors, problems such as heavy bleeding, pain, physical exhaustion, and urinary incontinence are common 12. World Health Organization guidelines for postnatal care include routine postpartum evaluation of all women and infant dyads at 3 days, 1–2 weeks, and 6 weeks 32. The National Institute for Health and Care Excellence guidelines recommend screening all women for resolution of the “Baby Blues” at 10–14 days after birth to facilitate early identification of and treatment for postpartum depression 15. Contact in the first few weeks also may enable women to meet their breastfeeding goals: Among women with early, undesired weaning, 20% had discontinued breastfeeding by 6 weeks postpartum 33, when traditionally timed visits occurred. To address these common postpartum concerns, all women should ideally have contact with a maternal care provider within the first 3 weeks postpartum.
Assessment need not occur as an office visit, and the usefulness of an in-person assessment should be weighed against the burden of traveling to and attending an office visit with a neonate. Additional mechanisms for assessing women’s health needs after birth include home visits 34, phone support 35 36, text messages 37, remote blood pressure monitoring 38 39, and app-based support 40. Phone support during the postpartum period appears to reduce depression scores, improve breastfeeding outcomes, and increase patient satisfaction, although the evidence is mixed 35 36.
Of course, these new recommendations require that they be implemented, which means getting both care providers (OBs and other maternal health providers) and insurance companies on board with new practices and financial coverage.
Insurance coverage policies should be aligned to support this tailored approach to “fourth trimester” care Policy and Postpartum Care.
Be proactive in requesting earlier contact and more comprehensive care with your care provider after giving birth.
It's important for you to know that your health after having a baby is just as important as your baby's health in the first year, and should be attended to appropriately. It helps for you to know as much about what happens in the postpartum period as you do about what happens in pregnancy, giving birth, and your baby's development. You can do this with the help of a good childbirth class, and/or through the support of a postpartum doula.
Join The Wombsisterhood Childbirth Education Class Online:
The health of mothers and parents in this country is in critical condition. We must do better -- we must change practices, policies, and we must become educated on what better care looks like and what it takes to have better outcomes.