Bringing postpartum care to primary care
To improve maternal outcomes in the United States, increased collaboration and communication between obstetrics/gynecology and primary care are crucial, experts stress.
It's no secret that the maternal mortality rate in the United States is far from optimal, especially among Black women, but research shows the majority of these deaths are preventable and typically occur in the postpartum period.
To address the issue, the American College of Obstetricians and Gynecologists revised its guidance in 2018 from recommending that new mothers attend a single postpartum visit within six weeks of delivery to recommend that postpartum care extend beyond this follow-up visit, especially for women who have chronic medical conditions or who experienced complex pregnancies.
According to experts, primary care physicians are optimally positioned to bridge this transition from acute postpartum care to ongoing health maintenance. However, rates of primary care use in the postpartum period remain low due to a number of unique barriers new mothers face, compounded by a fragmented health care system and shortage of primary care physicians.
One analysis of electronic health record data found that just 17.3% of 7,926 postpartum patients who received care at federally qualified health centers completed a primary care visit within six months of delivery. Findings were published in 2022 by the American Journal of Preventive Medicine.
"There's no question that people need ongoing care beyond six weeks postpartum," said Mara Murray Horwitz, MD, MPH, assistant professor of medicine at Boston University School of Medicine and a primary care physician in the women's health unit at Boston Medical Center.
Unfortunately, many postpartum people don't have established relationships with primary care physicians, and even when they do, "there are not strong systems in place most of the time to ensure that people make that connection to primary care after pregnancy," Dr. Murray Horwitz said.
The ambiguity of this transition period poses a barrier to care, agreed Lisa Larkin, MD, FACP, an internal medicine physician in Cincinnati.
"The OB-GYNs have their guidelines postpartum, and we have our annual [physicals]. But we don't have a lot of overlap specifically in what should be happening in that immediate postpartum care" period, said Dr. Larkin, who is also founder and CEO of Ms. Medicine and president of The Menopause Society.
Often, the timing and frequency of primary care visits in the postpartum period depend on the patient's medical history and needs, experts said.
"I don't think it's a one-size-fits-all approach, but I do feel very strongly that primary care is a place that patients need to go," said Ann Celi, MD, MPH, an internal medicine physician who cares for women after hypertensive pregnancies at the Brigham and Women's Hospital cardiometabolic clinic in maternal-fetal medicine in Boston.
"Some sort of a touchstone, really within six months after delivery, is not unreasonable, especially if they missed their annual visit because they were pregnant and they didn't think they needed medical care," Dr. Celi said.
Experts agreed high-risk patients should be prioritized for timely follow-up care. For patients with gestational diabetes or hypertension, attending a follow-up visit at three months "really makes a difference," Dr. Celi added.
A 2019 review published by American Family Physician recommends patients with gestational diabetes receive a glucose tolerance test between four and 12 weeks postpartum. Patients who experienced hypertensive disorders of pregnancy should have a blood pressure check performed within seven days of delivery, the review found.
In addition to visit timing, adopting a patient-centered approach also helps ensure new mothers actually receive the care they need during this vulnerable period, as there are several social and economic barriers in play. Some mothers may have difficulty securing childcare and transportation to their appointments, while others may experience insurance changes or lose coverage after delivery, experts explained.
"For some families, the only time that they have access to health care is when the woman is pregnant," said Eleanor Schwarz, MD, MS, FACP, chief of the division of general internal medicine at University of California, San Francisco. This makes it all the more important that when they access care, "they are identified as people at higher risk for future adverse health outcomes [and] that we connect them with the ongoing care that they need."
It can also be difficult to create a sense of urgency for self-care in the postpartum period, Dr. Schwarz said.
During this time, "many people really prioritize the care of the infant over their own health," explained Wendy Bennett, MD, MPH, FACP, a primary care physician in Baltimore, Md., and associate professor at Johns Hopkins School of Medicine.
Prioritizing the child's health means some mothers' postpartum symptoms aren't being adequately addressed.
"Women who are having symptoms that they're not really prioritizing … they're fatigued for example, or they're having heavy menstrual bleeding more than usual, they're depressed, they're not sleeping well … It really has to be part of [their] education that they really do need to reach out and see primary care," Dr. Larkin said.
Even if the importance of primary care follow-up is communicated, new moms are often inundated with so much information that scheduling a visit for themselves may fall through the cracks, Dr. Murray Horwitz said.
"This is supported by conversations I've had with real postpartum patients who overwhelmingly don't remember much, if any, communication about their need for primary care follow-up, even if they had complicated pregnancies."
There's a long list of health challenges new moms face, but improving communication with patients and coordination between specialties can help improve outcomes, experts said.
Postpartum health risks
Pregnancy can be considered the original cardiovascular stress test, according to Dr. Schwarz.
Complications in pregnancy are associated with a higher risk of future vascular disease, diabetes, high blood pressure, heart attacks, and strokes, she explained. New mothers who are unable to breastfeed also have twice the risk of diabetes going forward and have higher risks of high blood pressure, heart attacks, and strokes, Dr. Schwarz continued. "Really, postpartum care continues for the rest of the woman's life," she said.
"One of the biggest issues with hypertension and gestational diabetes, which are the two more common problems that patients have, is the longer-term cardiovascular risk," agreed Dr. Celi. "And primary prevention of cardiovascular risk is really what [primary care physicians] know well."
Primary care physicians should take a detailed history of the patient's pregnancy to identify anything that needs follow-up, noted Dr. Bennett.
However, results of a 2015 survey published by Obstetrics and Gynecology show that internal medicine physicians are less likely than gynecologists to include a patient's pregnancy history when assessing cardiovascular risk.
Screening for postpartum depression is also important, "because unfortunately, suicide is on the list of things that causes maternal mortality," said Dr. Schwarz. Mental health conditions accounted for 23% of all pregnancy-related deaths between 2017 and 2019, CDC data show.
Other issues include postpartum preeclampsia, issues with sleep or fatigue, and management of chronic conditions or substance use disorders.
But postpartum complications that don't result in significant morbidity or mortality can still negatively impact quality of life.
"Research suggests that about 90% of postpartum people experience a complication, and that includes [everything] from sexual dysfunction to uncontrolled pain to breast issues or lactation problems, or even things as mundane as constipation," explained Dr. Murray Horwitz.
"The fact that there's such a wide range of problems makes this sort of a perfect time period for people to be connected with a primary care provider who is somebody who can really provide head-to-toe assessment and medical support," she said.
For ongoing issues like blood pressure or glucose control, weight management, or mood issues, "none of those are one and done," stressed Dr. Schwarz. "This is about long-term, lifelong care, and so it's not one visit, it's years of visits."
Just like other patients, new moms need to stay up to date on their vaccines and have their medications routinely managed, something primary care doctors are used to doing.
"Primary care doctors really look at the whole patient," said Dr. Celi. "All the primary prevention and getting patients to live healthier lives is really a piece of this recovery, and it's something that primary care doctors do well."
How to increase uptake
Several interventions to improve engagement with primary care have been tested, and many states have already removed the insurance-related barrier to care.
Patients without insurance are less likely to complete follow-up visits with primary care physicians, according to research published in the American Journal of Preventive Medicine.
But around 40% of all births in the United States are financed by Medicaid, and as of March 2024, nearly all states had extended Medicaid coverage from 60 days to 12 months postpartum.
Even with extended coverage, though, challenges like care coordination and communication hurdles remain.
According to Dr. Murray Horwitz, default scheduling of primary care visits offers one potential solution.
"The patients that I've spoken with have told me that by and large, they are left with the responsibility of finding and scheduling an appointment," she said. "If that can be set up in advance, I think that would be a huge service to patients."
Combining mothers' appointments with their children's could be another solution. Low postpartum follow-up rates coincide with high well-child visit attendance rates, suggesting people are choosing to get their infants care over themselves, Dr. Murray Horwitz explained. Taking advantage of these moments when people are already engaged with the health system would help align pediatric care with postpartum care as much as possible, she said.
Increasing home visits can also help take the burden off new mothers. "In other countries, they often will send nurses or even physicians to somebody's home for their postpartum visits and for their follow-up visits," said Dr. Bennett.
Additional home visiting services, like nutrition or breastfeeding support, can be carried out by other lay health workers and in a variety of settings.
"We need to expand the way we think about postpartum care as beyond just that doctor-patient relationship and all the types of services that people can access in the postpartum period and allow people also to access services where it's convenient, whether they're accessing it because somebody's coming to their home or in their childcare facility," Dr. Bennett added.
Patient navigators may also play a role. According to research published by Women's Health Reports in 2022, involvement of these professionals, who provide individualized assistance to help patients overcome barriers to care, is viewed favorably by primary care clinicians as one process to improve health in the postpartum period.
Transition clinics, such as that co-run by Dr. Celi, hold promise. Between 2011 and 2016, 79.5% of patients at Dr. Celi's clinic who had primary care physicians within Brigham's network kept their scheduled follow-up appointment, data published by Maternal and Child Health Journal show, underscoring the benefits of a concordant health system.
These integrated care models help address some of the challenges posed by the United States' fragmented health care system, because ultimately, "separating out OB-GYN and primary care really harms women across their entire lifespan," said Dr. Larkin.
Additional research showed that after implementation of a quality improvement model that optimized care continuity in federally qualified health centers, the percentage of high-risk patients who completed a primary care visit within six months postpartum almost tripled from 25% at baseline to 72%. Findings were published by Annals of Family Medicine in January.
Regardless of the intervention, "one elephant in the room is that we just have a massive shortage of primary care providers at the moment," said Dr. Murray Horwitz.
"Even when all other things are being done well, if there simply isn't a primary care provider to see that patient, then that sort of undermines all other efforts. … we need to grow our workforce as much as possible."
Communication, collaboration
One recommendation remained consistent among experts: Increase communication, whether through improved interoperability between health systems, better medical record access, or direct communication among OB-GYNs, primary care physicians, and patients.
"In an ideal world, it would be some version of closed-loop communication where the maternity care provider connected with the primary care provider and didn't let it go until they had a commitment that the primary care provider was aware of [any issues], picked it up, and taken it from there," explained Dr. Schwarz.
"It really is a more effective strategy if it's a collaboration, and that's when I've seen it to be its most powerful," agreed Dr. Celi.
Keeping patients in the loop is important, too.
"Women don't understand that there's probably a really important role for the primary care physician in the postpartum period," said Dr. Larkin.
Messaging to patients should be frequent, clear, and consistent, experts say, and should also emphasize the longitudinal nature of primary care.
"Changing the messaging from 'the postpartum visit' [or] 'a postpartum visit' to thinking about it like, 'This is the first step in the rest of your life, health care over your life course,'" is one way to do so, explained Dr. Schwarz.
Improving patient education has the added benefit of boosting patient empowerment, said Dr. Celi, who's involved in co-creating tools and getting patient input on them to achieve this goal.
Communication and empowerment are especially helpful when it comes to reducing racial disparities in maternal care.
In the United States, Black women are three to four times more likely to die of pregnancy-related complications than White women, while cardiovascular disease and hypertensive disorders in pregnancy are leading contributors to disparities in maternal outcomes, according to research published by the Journal of the National Medical Association in 2019.
"Optimizing [the transition from OB-GYN to primary care] is particularly vital for women with chronic medical conditions, who are disproportionately women of color," the authors wrote, noting research shows postpartum primary care attendance is lower among Black women.
"We need to be really careful to listen to our patients when they tell us that something feels like it's not right in the postpartum period," said Dr. Schwarz. "We also need to appreciate that racism causes toxic stress, raises blood pressure, causes heart attacks and strokes and postpartum morbidity and mortality."
Patients want to feel as if they are being seen and being heard, said Dr. Celi. "Taking the time to drill down and hear what their lived experiences are … takes time, but often, that's the place where we can be extraordinarily effective," she added.
In prenatal care, understanding a person's social needs and risk factors is a big focus, said Dr. Murray Horwitz. "But those needs and risk factors continue postpartum and sometimes they even worsen." A patient may not be able to think about her high blood pressure until she knows who is taking care of her child while she's at work, she explained.
"I don't want increased emphasis on medical visits to be just another burden that people feel like they need to problem solve on their own. But I really think we need to try to meet people where they're at, make those visits accessible, and ensure that we're addressing their priority needs," she said.
With U.S. maternal mortality rates estimated between 10 and 30 deaths per 100,000 births, "the thing to most elevate is that this is a vulnerable period," said Dr. Schwarz. "And there's a lot of reasons why we need to try to make the on-ramp [to care] easier."
