Alison Stuebe, M.D., is an associate professor in the Department of Obstetrics and Gynecology at the University of North Carolina School of Medicine and a distinguished scholar in infant and young child feeding at the Gillings School of Global Public Health. She served as lead author of the American College of Obstetricians and Gynecologists’ May 2018 committee opinion outlining the features of optimal postpartum care. The opinion encourages clinicians to take a more comprehensive approach by, among other things, incorporating education, contraceptive counseling, and screening for social challenges. Stuebe also took part in the Alliance for Innovation on Maternal Health, a four-year collaborative that brought hospitals in eight states together to reduce maternal mortality and morbidity. As part of that work, Stuebe helped develop a set of best practices for postpartum care, which lays out strategies for ensuring women’s medical, behavioral, reproductive health, and social service needs are met. Transforming Care asked Stuebe about what stands in the way of achieving these goals.
Transforming Care: The committee opinion and best practice guidelines you helped develop are quite explicit about how clinicians can strengthen postpartum care — by improving communications during pivotal transitions, offering more extensive education to patients, and connecting them to community resources including home visiting programs, lactation support groups, and food banks. What are the biggest impediments to ensuring these recommendations become common practice?
Stuebe: The major rate-limiting step is the way postpartum care is reimbursed. The global payment for obstetric care includes postnatal visits — one for vaginal deliveries and two for cesarean sections — but providers typically get paid whether or not women have any visits. I don’t think anyone is cynically not scheduling postpartum visits, but there is no incentive for staff to take time out of their day to call women or take other steps to make sure they come in. When it comes to billing, providers may also be unaware of what is and is not routine postpartum care. If someone has a hypertensive crisis, managing that is not routine care, but providers may not know how to code those visits, and insurers may deny payment if they do. The bottom line is we have to find a way to pay for this care if people are going to do it.
Transforming Care: What would you like to see happen?
Stuebe: One option would be to have a separate bundle for care that is provided from birth to 12 weeks out for mother and baby. You can imagine postpartum centers that focus exclusively on the needs of the mother-baby dyad, with lactation consultants and physical therapists, as well as family physicians and midwives. I’d love to see the Medicaid waiver program test such models. The Health Resources and Services Administration’s Maternal and Child Health Bureau is looking to fund innovation that promotes maternal health, so that’s another opportunity.
Transforming Care: How do you make the case it’s worth the investment?
Stuebe: We can extrapolate from programs that offer supports, such as one in North Carolina called Family Connects Durham, which was created as a childhood abuse and neglect prevention strategy. It covers a nurse home visit for all families with newborns in Durham County, regardless of their insurance status. The nurse does a head-to-toe assessment of mom and baby and makes referrals to community agencies. They found that for every dollar spent, $3 were saved in emergency department visits for the child alone. They also found moms receiving this service were less likely to experience depression and anxiety.
One of the challenges for making the case for change is that we lack measures that quantify outcomes that matter to women. The main metric is the Healthcare Effectiveness Data and Information Set measure: Has the woman had a postpartum visit between 21 and 56 days postpartum? That’s a very blunt instrument, and it may not be that accurate. In one study we did of women whose babies were in the neonatal intensive care unit we found a large gap between visits based on insurance claims and what was recorded in the electronic health record (E.H.R.). In the current system, postpartum care is kind of a black hole, and it’s really hard to wrap our arms around whether people are getting what they need.
Transforming Care: Toward that end, you recommend that clinicians measure whether they are eliciting women’s preferences for breastfeeding and contraception and track the extent to which those goals are achieved. How do you advance this cause?
Stuebe: I think the E.H.R. vendors can help a lot by tracking outcome measures that assess the mother’s intentions — something like, did you stop breastfeeding sooner than you wanted to? Asking about goals for contraception is also critically important given this country’s history with coercive contraception. I worry a lot about the implicit assumption that we should push to place long-acting contraception (LARC) before she goes home after giving birth, especially in settings where women don’t have or are in danger of losing insurance. What if she loses insurance and she doesn’t like the implant and she wants it removed? I worry that in our enthusiasm for postpartum LARC, we don’t think about the unintended consequences. Part of it is that I think as a society we don’t value women when they don’t have babies inside of them. I think there is a sense that once the candy is out of the wrapper, we’re done with the wrapper.
Transforming Care: Do you see any bright spots, such as organizations that are moving the ball forward when it comes to optimal postpartum care?
Stuebe: Yes. Community Care of North Carolina, North Carolina’s medical home program, pays clinicians an extra $150 for providing a postpartum visit that meets specific criteria, such as scheduling follow-up care for women who have experienced gestational hypertension or preeclampsia or are at risk for postpartum depression. There’s also the work of Elizabeth Howell, M.D., M.P.P., in New York, who has shown spending 15 minutes talking to new mothers about what to expect postpartum and following up with a phone call reduced depression rates and increased breastfeeding rates through six months postpartum. It doesn’t require a private doula moving in with you for six weeks. It can be pretty basic and still make a difference. That’s why the 4th Trimester Project has developed. It led to a new website called newmomhealth.com. This resource provides expert-written information on how to cope with common postpartum issues. It’s been co-designed with mothers, who have given us feedback that they want to be given options. We need to listen to moms — every mom, every time — not just tell her what to do.
Transforming Care: Any last thoughts on how we can improve postpartum care?
Stuebe: We need to extend pregnancy Medicaid coverage from 60 days to a full year postpartum. This is critically important in states that haven’t expanded Medicaid, where women fall off a cliff at 60 days without the safety net of Medicaid expansion to provide them with access to care. We know mortality rates are higher in the year after giving birth, and the idea that mothers don’t need health care after this magical 60 days is shortsighted and antihuman.