Postpartum Care
1. What is the decision or change you are facing or struggling with where a summary of the evidence would be helpful?
KQ1: For patients who are at risk of postpartum depression, what is the optimal time for post-partum checkup to improve maternal (e.g. improved depression scores/symptoms, quality of life) and infant outcomes?
KQ2: For patients who are at risk of postpartum cardio-metabolic issues (e.g. hypertension and diabetes), what is the optimal time for the post-partum physician’s visit to reduce morbidity/mortality and readmission to hospital?
KQ3: For patients who desire postpartum contraception, what are the benefits/harms of offering/placing contraception following birth prior to discharge compared to not offering/providing or delayed provision of contraception?
KQ4: For patients who have given birth, what are the benefits/harms of pelvic floor therapy to prevent urinary incontinence?
2. Why are you struggling with this issue?
The maternal mortality rate in the United States is one of the highest in the developed world. In recent years, U.S. maternal mortality rates have worsened, increasing from 20.6 maternal deaths per 100,000 live births in 2008–2009 to 25.4 maternal deaths per 100,000 live births in 2013-2014 (1). Approximately 700 women die from pregnancy-related complications annually in the United States (2). Pregnancy Mortality Surveillance System (PMSS) data reviewed by Centers for Disease Control and Prevention (CDC) indicated that more than 60% of these deaths were preventable. It was also noted that 31% of deaths happened during pregnancy, 36% occurred at delivery or the week after, and 33% happened one week to one year postpartum. Many other women suffer complications that do not result in death but place their health at significant risk. The leading causes of pregnancy-related morbidity and mortality include hemorrhage, infection, cardiovascular conditions, preeclampsia, eclampsia, and embolism. Significant disparities exist, with higher maternal mortality rates occurring among black women, women who have a low income, and women living in rural areas. The maternal mortality rate for black women is 40 deaths per 100,000 live births (3). This is more than three times higher than the rate for white women, which is 12.4 deaths per 100,000 live births.
There is a lack of current evidence-based guidance for care of postpartum patients including the appropriate timing of follow-up visits. Most patients are not seen until six weeks after delivery, if at all. Additionally, many families feel unprepared for the common health issues they encounter and are uncertain who to contact and when (4). The lack of postpartum care can affect many maternal and newborn outcomes, especially for those patients who have social determinants of health. There is guidance on aspects of postpartum care, which has been dubbed the “fourth trimester”, a comprehensive evidence review is currently not available (5). Additionally, many recommendations are focused on either the parent or the baby, but not as a dyad necessitating that clinicians search multiple sites/databases to find comprehensive guidance.
- MacDorman MF, Declercq E, Thoma ME. Trends in maternal mortality by sociodemographic characteristics and cause of death in 27 states and the District of Columbia. Obstet Gynecol. 2017;129(5):811-818.
- Petersen EE, Davis NL, Goodman D, et al. Vital signs: pregnancy-related deaths, United States, 2011-2015, and strategies for prevention, 13 states, 2013-2017. MMWR Morb Mortal Wkly Rep. 2019;68(18):423-429.
- Grobman WA, Bailit JL, Rice MM, et al. Racial and ethnic disparities in maternal morbidity and obstetric care. Obstet Gynecol. 2015;125(6):1460-1467.
- Tully KP, Stuebe AM, and Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol. 2017: Jul;217(1):37-41.
- American College of Obstetricians and Gynecologists. ACOG committee opinion no. 736: optimizing postpartum care. Obstet Gynecol. 2018. 131(5) e140-150.
3. What do you want to see changed? How will you know that your issue is improving or has been addressed?
We are interested in a comprehensive evidence review to facilitate the development of a clinical practice guideline for family physicians to provide high value and appropriate postpartum care. Improvement in maternal and newborn outcomes, particularly in vulnerable populations, will demonstrate improvement in this area.
4. When do you need the evidence report?
N/A
5. What will you do with the evidence report?
The evidence from the systematic review will be used to inform recommendations for a clinical practice guideline from AAFP.
