Health and Medicine

New paradigm adds a ‘fourth trimester’ to transform care for new mothers

A study by UNC-Chapel Hill researchers recommends enhancing attentiveness to the individual needs of new mothers and transforming postpartum care from a single encounter to an ongoing process.

Alison Stuebe

UNC-Chapel Hill’s Dr. Alison Stuebe led a revised opinion on postpartum care from the American College of Obstetrics and Gynecology (ACOG) that establishes a “fourth trimester” of comprehensive care for new mothers.

This opinion recommends a shift in postpartum care that moves the initial postpartum visit with an obstetric provider from six weeks after childbirth to contact with her provider within three weeks. A comprehensive visit should follow within 12-weeks postpartum, and then the patient should be transitioned to well-woman care.

“Women need sustained support and care in the weeks following birth, rather than a one-off visit after six weeks,” said Stuebe, an associate professor of obstetrics and gynecology at the UNC School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the UNC Gillings School of Public Health.

“Obstetric care providers can provide that support through office visits, outreach by phone or text messages, home visits or other innovative approaches,” she said. “Different models will work in different settings; however, we can’t expect good outcomes if we expect women to muddle through for 42 days before seeing a women’s health care provider.”

In addition to being a time of joy and excitement, this “fourth trimester” can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence. With maternal mortality on the rise in the U.S., this period is even more critical for women with preexisting conditions or chronic illnesses.

“In our current system of maternity care, we lavish attention on women while they are pregnant, but not so much when the baby is out,” she said. “That neglect has serious consequences – mothers are more likely to die of pregnancy-related causes after the day of delivery than during pregnancy. We can, and we must, do better.”

ACOG also recommends discussing a postpartum care plan prior to delivery, addressing who will provide her with support during the transition to motherhood and reproductive life plans such timing of any future pregnancies.

“This revised guidance is important because the new recommended structure is intended to consider and cater to the postpartum needs of all women, including those most at risk of falling out of care,” stated ACOG President Dr. Haywood Brown. “As the nation’s leading group of physicians providing health care for women, we must use the postpartum period as gateway opportunity to counsel women on long-term health implications.”

Stuebe is one of three leaders on The 4th Trimester Project, a project launched in 2016 to bring together mothers, health care providers and other stakeholders to define what families need most during the “fourth trimester” and use that data to inform care. The two-year project was funded through a Patient-Centered Outcomes Research Institute (PCORI) Eugene Washington PCORI Engagement Award.