Historically, in the 12 weeks following childbirth—also known as the “fourth trimester”—the standard in the U.S. has been a single postpartum care visit, four to six weeks following delivery. In recent years, however, expert guidance has begun to shift in recognition of how crucial this period is for new mothers’ health.
The American College of Obstetricians and Gynecologists (ACOG) recommends an individualized plan that includes a postpartum visit within three weeks after delivery, a comprehensive visit 12 weeks after delivery and ongoing care as needed in between. The World Health Organization (WHO) suggests no fewer than three visits in the first six weeks postpartum.
It’s clear that regular and thorough postpartum appointments, even for a “normal,” uncomplicated pregnancy should be the standard of care in the fourth trimester.
The detrimental consequences of ignoring the fourth trimester of pregnancy
The statistics are staggering. Among 11 high-income nations, the U.S. has the highest maternal mortality rate, and over 80% of pregnancy-related deaths in the U.S. are considered preventable. The U.S. recorded over 1,200 pregnancy-related deaths in 2021, and more than half of pregnancy-related deaths in the country occur postpartum.
These numbers highlight the impact of foundational policy decisions in one of the wealthiest countries in the world. Specifically, the fact that women in the U.S. have less access to preconception, prenatal and postpartum care than the other ten wealthiest countries. Women are more likely to work lower paying jobs with fewer benefits than men, and are less likely to be insured.
The U.S. is one of only six countries worldwide that does not guarantee paid parental leave. While the Family and Medical Leave Act (FMLA) guarantees 12 weeks of protected parental leave, it is unpaid—and many people cannot afford to take time away from work without a paycheck. In fact, it’s estimated that only about 40% of new mothers take parental leave, depriving them of necessary time to bond with their children, recuperate and be proactive about their postpartum health care.
Postpartum cardiovascular health care
Cardiovascular conditions, including cardiomyopathy and stroke, are responsible for more than one-third of pregnancy-related deaths. Preeclampsia and gestational hypertension, two potentially deadly pregnancy complications involving high blood pressure affect 6-10% of pregnancies and increase the risk of later maternal cardiovascular disease:
- Five-fold for hypertension
- Two-fold for heart failure
- Two-fold for stroke
- Three-fold for cardiovascular death
Cardiovascular health is a prime example of a postpartum diagnostic challenge that requires a combination of patient advocacy and provider competency—because the symptoms of a complication like cardiomyopathy often overlap with the effects of pregnancy (e.g., shortness of breath, fatigue and foot swelling), it can be hard to identify.
These challenges require increased awareness from both patients and providers about the risk factors—such as age, hypertension, diabetes, obesity and substance abuse—that are already present in order to prevent and diagnose the conditions. As these cardiovascular problems can compound, an early diagnosis is vital for full recovery.
Social determinants of postpartum health
Social determinants of health—the diverse societal factors that can positively or negatively impact our health, from stable housing to institutional racism to environmental pollution and beyond—can greatly influence postpartum health and the ability of new mothers to receive proper care.
A new mother’s income level and job security can affect her ability to access postpartum care. The average cost of pregnancy, childbirth and postpartum care for someone on a large employer health plan in the U.S. is over $18,000, with out-of-pocket costs reaching approximately $3,000. Leaving a job with health benefits often means gaps in coverage and consequently, increased costs.
For new parents who are receiving Medicaid, access to postpartum care may be limited. While Medicaid pays for 43% of U.S. deliveries, coverage depends on the state. The American Rescue Plan Act of 2021 allows states to extend coverage up to one year postpartum, but federal law only requires coverage for 60 days after childbirth—leaving mothers in many states without care options during a critical postpartum period.
Unfortunately, as with nearly every element of life in the U.S., institutional racism plays a role in postpartum health care, from social and economic inequities to increased barriers to care. Black women are three times more likely to die during pregnancy and postpartum than white women, and have a rate of fatal postpartum cardiomyopathy, preeclampsia and eclampsia that is five times higher than white women.
This racial disparity in maternal outcomes is, in part, a result of a foundational failure to take Black women’s health concerns seriously, as well as a lack of culturally competent care: providers who are able to meet the social and cultural needs of diverse populations.
In 2022, Serena Williams, perhaps one of the most iconic and highly visible Black women in the country, shared the story of her traumatic childbirth experience. Williams, aware of her history of blood clots and the high risk they posed, requested a CAT scan and heparin drip but was ignored by her providers. Dismissed and even called “crazy” by her nurses, Williams pushed back—and these interventions ended up saving her from a potentially fatal embolism.
In May 2023, Tori Bowie—a three-time Olympic medalist and another prominent Black American woman—died suddenly in her eighth month of pregnancy. Autopsy results later revealed that one of the likely complications was eclampsia. Bowie’s teammate Allyson Felix also suffered from preeclampsia during her pregnancy, and says her doctor never informed her she had an increased risk for the condition. Felix required an emergency C-section at 32 weeks, but was ultimately fortunate to have a successful delivery.
These heartbreaking anecdotes call attention to the trauma that often shadows Black pregnancy in the U.S. They also underscore that providers need to practice empathetic and culturally competent care so that the onus is not on patients to advocate for their own health.
How plan sponsors can provide postpartum support
When it comes to postpartum health, connected care is key. Patients should have an individualized and comprehensive postpartum care plan. According to ACOG, this means visits should include “a full assessment of physical, social and psychological well-being” and care should be tailored to each woman’s specific health needs (e.g., specialized attention for chronic disorders or pregnancy complications).
Related: Normalizing postpartum depression
These postpartum care plans need to be shared with providers across the patient’s continuum of care—primary care providers, OB-GYNs, cardiologists and other providers need to ask the right questions about patients’ risk factors, pre-existing conditions and pregnancies in order to provide proficient postpartum care.
Plan sponsors can help accomplish this important undertaking by:
- Building their benefits in a connected manner
- Checking provider networks to ensure access to follow-up care across disciplines
- Knowing the risks within their population through the use of predictive tools
- Providing education to members about their benefits, with a focus on at-risk members
Evernorth FamilyPath offers the ability to customize a free guide to family planning benefits in order to make it easier for plan sponsors and participants to understand their relevant coverage.
