In Postpartum Issues

Science & Sensibility does a nice job of summarizing the American College of Obstetricians & Gynecologist’s new postpartum care guidelines, which call for much more comprehensive postpartum care to reduce maternal morbidity and mortality. I’ll give ACOG credit for the concept, but this is still the same old ACOG we know and criticize.

ACOG proposes replacing the standard single visit at 4 to 6 weeks postpartum with a 4th-trimester care plan. The plan begins in pregnancy with anticipatory guidance on future reproductive planning and the challenges of the postpartum period; continues after hospital discharge with ongoing contact either in person or by other means, depending on individual health needs; and culminates in a comprehensive assessment at 12 weeks after delivery. The assessment should cover “physical, social, and psychological well-being, including the following domains: mood and emotional well-being, infant care and feeding; sexuality, contraception, and birth spacing; sleep and fatigue, physical recovery from birth; chronic disease management; and health maintenance.” ACOG further proposes that plan implementation should be “facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.” That sounds good, so what’s my problem?

The first critique that leaps to mind is: Is the typical obstetrician qualified to address postpartum issues other than ascertaining recovery and managing chronic disease? I would argue that the answer is “No.” Certainly, standard obstetric antenatal management doesn’t inspire confidence in this regard. Conventional prenatal visits essentially consist of asking “Is there something wrong with you or the baby? If not, come back next month, and we’ll check again.” Ob/gyns are trained as surgical specialists in the pathology of women’s reproductive organs, not as maternal-child health physicians. If they possess the knowledge to deal with the broader concerns of the postpartum period, it’s because they have taken an interest in it and chosen to educate themselves. Even so, they are likely to take a medicalized approach.

They could, of course, delegate maternal-child health care to staff who are qualified, and, indeed, the guidelines list nurse-midwives, women’s health nurse-practitioners, lactation consultants, and social services case managers among the professional members of the “postpartum care team,” but I don’t see mainstream obstetricians coordinating access to their services or hiring additional staff to provide them. Furthermore, the Guidelines specify that it is obstetricians who will assess status and provide guidance with respect to all these domains at the proposed 12-week comprehensive visit. Read cynically, the call for increased reimbursement seems no more than a call to cover additional charges for obstetric contacts or visits that should already be part of the care obstetricians provide if confined to the arenas in which ob/gyns have expertise.

A second critique centers around how the Guidelines treat mental health. A table lists specific recommendations for the comprehensive visit, which are to screen for postpartum depression and anxiety, follow up on pre-existing mental health disorders, and adjust medications as appropriate for postpartum women. The text adds that the visit provides an opportunity for the woman to ask questions about her labor and birth experience and that relevant details should be discussed and documented. It follows this by saying that women may experience the birth as traumatic, that 3-16% develop childbirth-related posttraumatic stress disorder, and that this occurs even when the woman and her baby are healthy, and it doesn’t say another word on this topic—not about screening for PTSD or how OBs should manage discussions with traumatized patients or the OB’s role in treatment or anything else. Childbirth-related PTSD is an obvious hot potato because it is often caused by how the woman was treated in labor or by her experience of surgical or instrumental delivery that, in many cases, could have been avoided. Worse yet, from the traumatized woman’s perspective, a review of the labor and delivery would often amount to discussing her assault with, and seeking assistance from, the perpetrator. Even if the OB conducting the visit isn’t the perpetrator, the odds of her or him responding other than defensively or by downplaying the woman’s experience are close to nil. Much more comfortable, then, to stop at depression, anxiety, and pre-existing mental health conditions. They are centered in the woman, not her care, although anxiety—hypervigilance—is actually a trauma symptom.

Finally, while the Guidelines laudably recommend sensitivity when discussing sterilization as a means of contraception with women from marginalized populations, they fail to address the other side of the equation: the denial of contraceptive options imposed by Catholic hospitals. The Guidelines claim to uphold the right of women to be given information on the full range of contraceptive options and their right to choose what best fits their need but omit mention of this elephant in the room. Again, much more comfortable to leave out the ethical conflict this creates for OBs who practice in Catholic hospitals.

If ACOG truly wanted to take a leadership role in advocating for reform, it should have created two documents: one, a white paper documenting the need for more comprehensive care and systemic support for new mothers and outlining what optimal care and support would look like, and two, guidelines describing the role of obstetricians within that new model. Instead, they have commandeered the roles of primary dispensers and gatekeepers of comprehensive care when they are qualified to be neither and used that to justify increased reimbursement for their services. From ACOG’s perspective, the Guidelines make the profession look good and require no real change on the part of obstetricians. This, in my judgment, is more than a tad self-serving. But, then, as Marsden Wagner pointed out years ago, ACOG isn’t a professional organization; it’s a trade union: “Like every trade union, ACOG has two goals—to promote the interests of its members and to promote a better product, in this case, the well-being of women. But if there is conflict between these two goals, the interest of its members comes first (p. 33).”

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Wagner M. Born in the USA. Berkeley, CA: University of California Press; 2006.

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