Pregnancy lasts nine months. The medical community has historically divided it into three stages: the first, second, and third trimesters, ending with labor and delivery. However, in 2018, an opinion released by the American College of Obstetrics and Gynecologists (ACOG) concluded that the time after the birth of a baby is critical. It sets the stage for both the mother’s  and infant’s long-term health and well-being. The committee dubbed the postpartum period the “fourth trimester.” Their opinion establishes comprehensive guidelines for caring for people who have recently delivered a baby.

The committee’s findings are backed by research, including data from the report Pregnancy-Related Mortality in the United States, 2011–2013, showing that 53% of pregnancy-related deaths occurred one week to one year postpartum, and 80% of those deaths could have been prevented.

The postpartum period is rife with challenges for new moms. These include recovering from the physical stress of childbirth, pain, breastfeeding problems, fatigue, lack of sleep, urinary incontinence, and new or worsened mental health disorders. That is all on top of the 24/7 responsibility of caring for a newborn and possibly older children. 

A Maternal Health Learning & Innovation Center webinar titled “Supporting Birthing People & Care Teams: 4th Trimester Project Postpartum Care Tools” describes how a collaborative North Carolina initiative has built a storehouse of evidence-based postpartum health information that aims to define what parents need most during this critical stage. The 4th Trimester Project launched in 2016—two years preceding the 2018 ACOG opinion— creates tools for moms, health care providers, and community organizations to fulfill the postpartum needs of women, especially those most at risk of falling by the wayside in the health care system.

The prenatal period has been the focus of pregnancy health care for decades. “As we have done more to understand and study data related to maternal morbidity and mortality, we’ve come to understand that the postpartum period really matters,” said Sarah Verbiest, DrPH, MSW, MPH, executive director of the University of North Carolina Collaborative for Maternal and Infant Health. “We especially must center on the needs of those put at risk by society,” she said. 

Barriers to Postpartum Care

Studies have found that many women do not attend postpartum visits. Some reasons moms give for skipping postpartum appointments include: 

  • “ I thought maternity care was done.”
  • “I’m always so tired.”
  • “I’m busy caring for a new baby.”
  • “I didn’t have a ride.”
  • “I don’t have childcare.”
  • “I’m sure I’m the only one who feels this way.”
  • “All my helpers left after the first few weeks.”
  • “I can’t take time off from work.”
  • “It’s not worth the hassle.”
  • “I feel fine now.”
  • “They don’t speak my language.”
  • “I wasn’t ready for the changes to my body.”
  • “I’m afraid they won’t think I’m a good mom.”

In November 2016, the Maternal and Child Health Journal released a collection of research studies in its Postpartum Health and Wellness supplement. Verbiest notes, “The studies identified how we need multifaceted approaches to ensure birthing folks are getting in for care and that the care they receive is the care they need.” 

Preparation for postpartum visits actually commences during the prenatal period, emphasizing a holistic approach to maternal care. This involves advocating for supportive healthcare system changes, such as implementing open-access appointments, commonly referred to as same-day scheduling, and employing diverse methods for sending appointment reminders. Furthermore, it’s essential to tailor the timing of these visits to meet the individual needs of each patient, empowering them to guide the conversation and ensure their concerns are thoroughly addressed. Above all, recognizing the significance of building trust is paramount during this vulnerable postpartum period, fostering a supportive environment where new mothers feel understood and supported on their journey to recovery and wellness.

Traditional postpartum care has one essential visit. It happened six weeks after delivery. “Especially significant to note is the focus on contacting all new mothers within three weeks after giving birth and creating opportunities for more frequent check-ins and an earlier check-in than what originally was the traditional six-week visit,” said Verbiest. “This is a way to make that visit more patient-centered and to increase uptake of postpartum visits.”

The 4th Trimester Project

To develop the 4th Trimester Project, researchers formed a focus group of 317 birthing parents. The participants were from across North Carolina and included English and Spanish speakers. Researchers discovered needs through interviews and listening to postpartum experiences. They found participants had unmet postpartum care needs, including not knowing urgent maternal warning signs to watch for and lacking emotional support for moms and their partners.

Effectively addressing patient needs requires a holistic approach to understanding stressors a patient may be experiencing, including those relating to social determinants of health. Drawing from the study Screening and Referral for Social Determinants of Health: Maternity Patient and Health Care Team Perspectives, the Project recommends the following trauma-informed, patient-centered guidelines to address social determinants of health respectfully:  

  • Recognize that everyone can benefit from support, and offer resources to all patients.
  • Treat patients with care if someone shares those needs, they may have taken a risk telling you so.  
  • Prioritize providing resources instead of focusing solely on screening.
  • Don’t screen for something that you can’t help address.

The 4th Trimester Project collaborates with organizations that share the mission of advancing the care of mothers and their babies and supplies resources and education to stakeholders that provide services to new families. 

In the realm of future collaborations with community partners, there are several promising avenues to explore. One such opportunity lies in forging partnerships with insurance companies, aiming to seamlessly integrate the Project’s educational materials into their online portals, thereby enhancing accessibility and dissemination of crucial information. Additionally, there’s potential for collaboration with residency programs to delve into systemic improvements, optimize rounding practices, and tailor educational interventions to various stages of pregnancy, fostering comprehensive maternal care.

The prospect of organizing perinatal symposiums and offering re-certification credits to healthcare personnel stands as a valuable avenue for ongoing professional development. Another avenue ripe for exploration involves the interdisciplinary training of essential community figures such as doulas, community health workers, W.I.C. personnel, home visitors, and lactation experts, fostering a more holistic approach to maternal and infant well-being. Lastly, engagement initiatives with various community stakeholders, including child care providers, faith communities, and local groups, present opportunities for broader outreach and collaboration in advancing maternal and infant health initiatives.

Helping New Moms Know When to Call for Help 

To address the need to educate parents on what to expect as a new mom’s body recovers from childbirth and how to recognize urgent warning signs, the 4th Trimester Project created an at-a-glance one-page printable health information flyer (one for parent and one for baby – available in both English and Spanish) that has become the most popular tool on their website.

The flyer is color-coded to delineate priority levels of maternal warning symptoms. Print and post it on your refrigerator.

RED: These are urgent. Go to the ER or call 911 right away.

  • ˆSuddenly, very tired or weak
  • Difficulty breathing 
  • Chest pain
  • ˆSevere headache 
  • Vision changes.
  • ˆDizziness, disorientation, fainting, or seizures
  • ˆBlood pressure is higher than 160 (top number) or 110 (bottom number)
  • Extremely worried all of the time
  • ˆSee or hear things that other people don’t
  • ˆThoughts of harming yourself or others

ORANGE: Call your provider. Don’t wait for office hours. If you can’t reach someone, call 911.

  • Bleeding that soaks through one or more pads in an hour
  • Clots bigger than an egg or you pass tissue
  • Pain or swelling
  • Headache that won’t go away or gets worse over time
  • Severe pain that doesn’t go away, such as in your chest or belly
  • Swelling, such as in your face, hands, feet, or legs
  • If you had a C-section, your incision is open, red, oozing, or does not seem to be healing
  • Blood pressure equal to or higher than 140-159 (top number) or 90-109 (bottom number)
  • Fever of 100.4 °F or more
  • Unable to drink for 8 hours or unable to eat for 24 hours
  • Vaginal discharge (fluid, wetness) that smells bad

GREEN: Tips on taking care of yourself and your newborn baby.

Resources

The 4th Trimester Project’s website (NewMomHealth.com) has more than the printable warning signs flyer. It also has new parent resources in English and Spanish, including a printable Postpartum Care Plan and a ”Taking Care of You” booklet.  

All new mothers need and deserve support and compassion. “It is normal and necessary to ask for help,” said Verbiest. 


Printable maternal warning signs: English version and Spanish version

New Baby Health Information (one-pager): English version and Spanish version