The postpartum period, recognized as the fourth trimester or the 12 weeks after birth, is often overlooked. In 2021, 52% of all maternal deaths occurred during the postpartum period. And mental health was the top underlying cause, accounting for 23% of all deaths (mostly suicides and overdoses related to substance use disorder).
More than 60% of pregnancy-related deaths are preventable. But in the U.S., postpartum people typically only receive one insurance-covered medical visit at the six-to-eight-week mark. Reducing the rising maternal mortality rates in the U.S. means taking a closer look at right-sizing postpartum healthcare.
Postpartum care falls short of best practice recommendations
Increasing bodies of evidence show that more frequent and enhanced postpartum healthcare visits can improve maternal health outcomes. And health insurance is the key to this care.
In a past issue of Medical Care, researchers found that as a result of federal subsidies and Medicaid expansion under the Affordable Care Act, low-income women who would have otherwise lost their postpartum health insurance kept their coverage and experienced a reduction in postpartum depressive symptoms.
This, coupled with the fact that postpartum care is unaffordable for many women, suggests that expanding insurance benefits could improve health outcomes and reduce maternal mortality.
The Academy for Obstetrics and Gynecology (ACOG) recommends the first postpartum visit be within three weeks of birth. This should be followed by ongoing care as needed. A comprehensive visit should close out the postpartum period no later than 12 weeks after birth.
“The comprehensive postpartum visit should include a full assessment of 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
Despite these recommendations, about half of women in the U.S. don’t receive any postpartum healthcare. And a 2018 study found that one in eight women reported that they weren’t asked about depression during their postpartum visit.
Postpartum mood disorders are on the rise
COVID-19 added to an already rising rate of postpartum depression. In 2018, 13.2% of postpartum people had depressive symptoms. That rate skyrocketed to 38% of postpartum patients screening positive for depressive symptoms in 2020. Isolation, added stressors related to the pandemic and avoiding medical appointments out of fear of infection were contributing factors.
These prevalence rates may yet be low. It’s estimated that large numbers of postpartum people may not be identified as having a treatable condition. Health care providers also sometimes misdiagnose or dismiss depressive symptoms as “baby blues,” which affects up to 80% of new parents.
While we’ve been able to enjoy a return to semi-normalcy post-pandemic, including more regular use of medical care, the lessons learned from COVID-19’s effect on postpartum depression are still relevant. Less access to postpartum care is likely to result in higher rates of untreated postpartum mood disorders.
A breakthrough for postpartum people
Despite the rising rates of postpartum mood disorders, hope is on the horizon. Effective depression treatment often includes a combination of medication therapy and counseling. And this summer the Food and Drug Administration (FDA) approved the first ever oral medication to treat postpartum depression.
This once-a-day pill is a freeing alternative to the only other approved postpartum depression treatment – an intravenous injection requiring an inpatient stay. The oral medication also acts faster than other antidepressants offering symptom relief for postpartum people so they can better care for themselves and their newborns.
While breakthroughs in research and medications are allowing postpartum people the timely and effective treatment they deserve, there is still a long road ahead. It’s imperative that the flaws in the U.S. healthcare system resulting in gaps in coverage and insufficient postpartum visits and screening be repaired.
Michelle Sabia