Toward the end of pregnancy, we see women weekly and guide them safely through the birth. And then, after all of the attention before birth, we do not schedule a postpartum visit until several weeks later. Often, new mothers fail to attend their postpartum visit because it occurs so long after the birth that they have become too busy with their newborns and their new roles. Some even have lost their third-party coverage by that time. Yet we must ask, “Who is mothering the mother?”
I am Director of Midwifery for El Rio Health, a large FQHC group in Tucson, AZ. Our patients are primarily ethnic minorities eligible for Medicaid, and many are immigrants or refugees. As a community health center, we are the safety net for women and children beyond pregnancy.
In 2016, 12 midwives in our Congress Street site had a lively debate about what constitutes good postpartum care and how we could increase utilization. At that time In Arizona, about 66% of Medicaid-eligible women attended one postpartum visit. Midwifery patients attended about 75% of the time. In addition, we had noticed a stubborn number of unintended and short-interval pregnancies in our practice.
We wondered what drives the two-week postoperative visit besides tradition. Where is the evidence that women need a pelvic exam at 42 days postpartum? Despite disparate beliefs about the optimal timing of postpartum care, we agreed that an innovative approach was needed to get more women back in for postpartum visits.
Our solution: the fourth-trimester visit. Unable to provide immediate postpartum LARC in our delivering hospital (due to financial constraints), we developed a work around. Instead of scheduling women 4-6 weeks after giving birth, we moved it up to 1-2 weeks, depending on mode of birth and other health factors. And the women came!
In 2018, we saw 85% of women for at least one postpartum visit in the first 8 weeks postpartum. Most women are now having two or three postpartum visits and, some months, more than 90% of women come back. With our new schedule, mothers love to come into the health center and show off their newborns. We provided LARC to 30% of our patients at a postpartum encounter. Though it is by no means a perfect system, beginning postpartum care with the fourth-trimester visit allows us expanded opportunities to assess healing, support breast feeding, address adjustment, and meet primary health care needs. Women are continuing to engage beyond pregnancy in their health and wellness.
We were emboldened by ACOG’s 2018 Committee Opinion supporting the fourth trimester visit. At El Rio Congress Midwifery, the fourth-trimester visit at 1-2 weeks postpartum has undoubtedly improved quality and optimized care. The midwives – even those initially reluctant to change tradition – are also expressing satisfaction with the postpartum care schedule. More innovation is yet to come in postpartum care, but beginning with women valuing and utilizing these services is an important first step.
