Earlier this year the American College of Obstetricians and Gynecologists (ACOG) released a revised Committee Opinion calling for a new paradigm for postpartum care in the United States. Moving away from the single postpartum check at 6 weeks, ACOG has made a significant change in its recommendations for postpartum care: “All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.”
In a recent article in the New England Journal of Medicine, Horwitz and colleagues praised this change in ACOG’s recommendations; however, they note that we will need other significant changes in our healthcare system in order to ensure that we appropriately care for new mothers, especially those with limited resources.
One of their primary concerns is that our current health insurance system and models for the reimbursement of maternity care impede our ability to provide universal, high-quality postpartum care in the United States. Many obstetrics providers receive bundled payments for maternity care. In other words, they receive a fixed amount for services provided during the time period extending from the first prenatal visit until 6 weeks after delivery. Obstetric providers are compensated in the same manner, whether they are taking care of an uncomplicated pregnancy in a healthy 28-year-old or a pregnancy in a 40-year-old mother with gestational diabetes and hypertension. Given this practice, there is little financial incentive to provide additional visits or to extend the duration of follow-up.
Other countries use bundled payments but have a more nuanced approach to determining the intensity of treatment required in order to better estimate an appropriate level of compensation. In England, for example, women are assigned to a level of care based on their specific needs during each stage of pregnancy and postpartum care: prenatal (standard, intermediate, or intensive), intrapartum (with or without complications or coexisting conditions), and postpartum (standard, intermediate, or intensive). This system of classification yields 18 different maternity care bundles with various intensities and trajectories of care.
Seems pretty simple, huh?
The authors note other impediments to high-quality postpartum care, citing the restrictive parental leave policies in the United States. Employers are not required to offer paid maternity leave. The federal Family and Medical Leave Act (FMLA) allows up to 12 weeks of unpaid leave for new parents; however, only about half of all working women are eligible for FMLA benefits. (Those who have been working for less than a year or for an employer with less than 50 employees are not covered by FMLA.) It is also important to note that women of color are less likely than white women to have access to maternity leave in the United States. In addition, women with less education and those working for lower pay, as compared to women with more education and those in higher paid positions, are less likely to take maternity leave.
Among developed countries, the United States has the least generous maternity leave policies. More than 50 countries around the world offer at least six months of paid maternity leave, with many countries offering paid leave for fathers as well. How much time is allowed for maternity leave has significant financial implications for the family, but it also affects maternal and infant health outcomes. Shorter maternity leave is associated with lower rates of breastfeeding, higher rates of postpartum depression, and increased infant and child mortality.
Horwitz and colleagues point to the experiences of Norway as an example of the beneficial effects of paid maternity leave. Prior to 1977, Norway had a parental leave policy which was similar to the current policy in the United States: 12 weeks of unpaid leave. After 1977, Norway changed the law such that women would receive 18 weeks of fully paid maternity leave. When researchers compared the long-term outcomes for children born to Norwegian women after the law was changed, they discovered that the children born after 1977 had higher IQ scores and higher academic achievement than the children born to the mothers who had the shorter maternity leave.
Yes, ACOG is moving in the right direction and hopefully their recommendations will spur meaningful changes in postpartum care. However, we need to do so much more to support new mothers.
Ruta Nonacs, MD PhD
Horwitz ME, et al. Postpartum Care in the United States — New Policies for a New Paradigm. N Engl J Med 2018; 379:1691-1693.