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POSTPARTUM FOLLOW UP: IS ONE ENOUGH?

Postpartum Follow Up: Is one enough?

Rachel Neale

Pennsylvania College of Health Sciences

NUR 631

Dr. Wise

June 25, 2023

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POSTPARTUM FOLLOW UP: IS ONE ENOUGH?

Postpartum Follow Up: Is One Enough?

Pregnant patients in America are facing a crisis in maternal morbidity and mortality. As a

developed country, the maternal mortality rate is currently 32.9 deaths per 100,000 live births,

which is more than double the average rate of high-income nations at 12 per 100,000 live births

(Hoyert, 2023; Simmons-Duffin & Wroth, 2023). In addition, this number has been trending up,

and is proportionally higher in women of color even when accounting for other variables.

Pregnant patients have increasingly more frequent prenatal appointments as they near delivery,

but immediately after delivery that support system appears to dwindle, with the majority of

patients only having a six week postpartum follow-up visit. According to Punkkinen (2019), 50-

71% of maternal deaths actually happen postpartum, despite having very little monitoring of

these patients. With that knowledge, what evidence is there to support a change in postpartum

follow up visits from the current six week visit to multiple visits prior to six weeks? This paper

will attempt to address that question.

Current Practice

Currently most patients leave the hospital simply with a plan to have an appointment at

least 3-6 weeks after delivery. Some patients post cesarean delivery may have an appointment 1

week postpartum to check their incision or perform a dressing change, but it is by no means

comprehensive. Another model of care includes midwifery services who may perform home

health visits postpartum as the patient goes home within hours after delivery; in this situation

Punkkinen (2019) reports that the mother-baby dyad will be seen at home on days 1,3, and 5 as

well as clinic visits 3 weeks postpartum and at the six-eight week mark. This allows the

providers to assist with any questions the patient has, check for signs of pre-eclampsia or mood

disorders, and promote breastfeeding success. For patients who do not have access to this kind of
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care, it can be difficult to schedule an appointment with their primary care provider, let alone

their OB-GYN and their pediatrician for any concerns they have; or they may not know that

anything is wrong until they are life-threateningly ill (Punkkinen, 2019). This opens up an

opportunity for providers to challenge the “way it has always been done” and to make changes to

postpartum follow up care practices.

Postpartum Complications

To continue to look into the evidence supporting a change in postpartum follow up, an

important part is evaluating when postpartum complications are likely to arise. Some of the most

serious complications are postpartum preeclampsia, stroke, postpartum psychosis, and infection

(either incisional or endometritis).

Postpartum Preeclampsia

Postpartum preeclampsia is likely to show up in the first seven days postpartum but could

happen up to six weeks postpartum (Preeclampsia Foundation, 2023). Those at risk are often sent

home with a blood pressure cuff to continue checking their blood pressures, but patients should

benefit from a check-in with a maternal care provider within those first seven days regarding

their symptoms to assess for preeclampsia. These patients with unknown hypertension are also at

elevated risk for postpartum stroke. Approximately half of postpartum strokes occur within the

first 10 days of delivery, and detecting elevated blood pressures could help prevent a stroke from

occurring by providing necessary antihypertensive medication (ACOG, 2018).

Postpartum Psychosis

Another serious complication that occurs out of the hospital postpartum is postpartum

psychosis. Many patients experience “baby blues” and have mood swings within the first two

weeks. But if it persists longer than that, patients would be considered to have postpartum
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POSTPARTUM FOLLOW UP: IS ONE ENOUGH?

depression, often the first step prior to postpartum psychosis which affects one in 500 births

(Raza & Raza, 2022). And postpartum psychosis is most likely to present within two weeks

postpartum (Raza & Raza, 2022). These patients are at high risk not only for hurting themselves

but also hurting their babies or those around them. A follow up appointment at two to three

weeks might allow a provider to catch the difference between baby blues and postpartum

depression/anxiety or even postpartum psychosis and get the patient the help she needs to

prevent maternal mortality.

Infection

A final major postpartum complication that arises between the hospital and six weeks is

infection, namely via a surgical incision or endometritis. Sepsis is one of the top five causes of

maternal deaths worldwide, and could be prevented if infections were caught early and treated

(Boushra & Rahman, 2022). The majority of infections occur after discharge form the hospital,

endometritis in particular occurs around two to 10 days postpartum (Boushra & Rahman, 2022;

Ogunyemi, 2022). Having a postpartum check-in at one week with a provider might find

signs/symptoms of infection prior to severe complications arising.

Contraception Care

One of the most important parts of the postpartum appointment is discussing resumption

of sexual intercourse and plans for contraception. The concern is that by six weeks many patients

have already had their first sexual encounter and have put themselves at risk for another

pregnancy, which at such a close interval to the prior pregnancy can cause complications

(Baldwin et al., 2016). If the appointment were held earlier, then providers can provide education

regarding their likelihood to get pregnant postpartum and discuss options for birth control to

prevent an unplanned pregnancy. In addition, many Intrauterine Devices (IUDs) can be

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POSTPARTUM FOLLOW UP: IS ONE ENOUGH?

successfully placed at 2-3 weeks postpartum which would be effective contraception for

whenever the patient decides to resume sexual intercourse. According to Baldwin et al. (2016),

inserting the IUD at 3 weeks postpartum compared with 6 weeks does not change the reported

pain with insertion, nor does it change the rate of continued use at 3 months, but it was often

initiated prior to first coitus. The IUD is just one contraceptive method to consider, women who

would like to utilize another method would still benefit from an earlier postpartum visit for the

same reasons.

Attendance Rates

Putting aside all of the reason for having postpartum follow up appointments, the

provider must get the patient into the office, which can be difficult to do. Evidence shows that

patients do not always choose to attend a six week postpartum visit, often feeling well enough

and established in their newborn care that a follow up appointment seems unnecessary

(Punkkinen, 2019). And this is not consistent over different socioeconomic groups; medicaid

insured patients are less likely to attend their postpartum appointments, often due to lack of

transportation or childcare (Kaufman et al., 2022). This disparity is especially concerning as

medicaid recipients are 24% more likely to be readmitted to the hospital postpartum with a

pregnancy-related complication (Kaufman et al., 2022). With this information in mind, it is

especially important to plan on the postpartum follow ups based on what patients are more likely

to utilize. Chen et al. (2018) found that when comparing a follow up appointment in 2 to 3 weeks

postpartum with the 6 week appointment showed improved attendance rates, 90.2% and 81.6%,

respectively. The author looked at postpartum outcomes and found no significant changes

between the control group and the experimental group, but the attendance was statistically
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significant (Chen et al., 2018). The increased attendance gives the providers to assess for

concerning symptoms related to postpartum complications as mentioned previously.

Recommendations

Though the current practice for most providers is the six week follow up, most

professional organizations, including the American College of Obstetrics and Gynecology

(ACOG) and the World Health Organization (WHO), recommend more frequent postpartum

followup. ACOG recommends a blood pressure check at least at 7-10 days postpartum, or even

sooner at three to five days postpartum (ACOG, 2018). And WHO recommends the

mother/infant dyad be evaluated three separate times: at three days, one to two weeks

postpartum, and. Six weeks (ACOG, 2018). Chen et al. (2018) report “recent recommendations

propose that all women have initial contact with a maternal care provider within the first three

weeks after delivery”, supporting both of these claims. Taking all of this in mind with the

knowledge that fifty percent of maternal deaths occur postpartum and major complications often

arise within those six weeks, the recommendation would be to have sooner and more frequent

postpartum follow-up appointments scheduled for all, and to have even more for those with a

history of severe maternal morbidity events/complications. For example, women who

experienced pre-eclampsia intrapartum should have the blood pressure check three to five days

postpartum (in addition to taking their blood pressure at home) because they are at risk for

readmission, as well as at risk for a stroke postpartum (Preeclampsia Foundation, 2023; ACOG,

2018). Recipients of medicaid would also benefit from a sooner follow up to increase access to

needed resources and support if having financial difficulties postpartum.

Conclusion
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Something needs to be done to change the course of maternal mortality in the U.S.

Patients get so much care and oversight during their pregnancies, but they lack that same level of

care and oversight in the postpartum period, potentially having life-threatening symptoms go

unnoticed until it is too late. The six week only follow up is not supported by professional

organizations, neither is it supported by evidence; it continues because medical practice often

goes off of tradition more than evidence-based practice. Insurance may also play a role in

preventing change, which is where providers need to be the force of change in advocating for

their patient’s health. In addition, more studies need to be done to prove the efficacy of increase

postpartum follow ups to prove that they prevent serious postpartum complications. Research

best suited to support change will evaluate the effectiveness of multiple visits and patient

contacts within the first six weeks as is currently supported by ACOG and WHO, and will

hopefully one day ease the patients safely in the transition from pregnancy to parenthood.
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References

ACOG (May 2018). Optimizing postpartum care. ACOG [reaffirmed 2021].

https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2018/05/

optimizing-postpartum-care

Baldwin, M. Edelman, A., Jeong, L., Nichols, M., Bednarek, P., Jensen, J. (2016) Intrauterine

device placement at 3 versus 6 weeks postpartum: a randomized trial. Contraception

93(4), 356-363. 10.1016/j.contraception.2015.12.006

Chen, M.J., Hsia, J.K., Hou, M.Y., Wilson, M.D., Creininm M.D. (2018). Comparing postpartum

visit attendance with a scheduled 2- to 3-week or 6-week visit after delivery. American

Journal of Perinatology 36(9), 936-942. Doi: 10.1055/s-0038-1675623

Kaufman, M., McConnell, J., Carmichael, S.L., Rodriguez, M.I., Richardson, D., Snowden, J.M.

(2022). Postpartum hospital readmissions with and without severe maternal morbidity

within 1 year of birth, oregon, 2012-2017. American Journal of Epidemiology 192(2),

158-170. https://doi.org/10.1093/aje/kwac183

Hoyert, D. (2023). Maternal mortality rates in the United States, 2021. Centers for Disease

Control and Prevention.

https://www.cdc.gov/nchs/data/hestat/maternal-mortality/2021/maternal-mortality-rates-

2021.htm

Ogunyemi, D. (2022). 3 conditions to watch for after childbirth: An OB-GYN talks postpartum

preeclampsia, hemorrhage and endometritis. ACOG.

https://www.ncbi.nlm.nih.gov/books/NBK544304/
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Preeclampsia Foundation (2023). Postpartum preeclampsia: Delivery is not the cure for

preeclampsia. Preeclampsia Foundation. https://www.preeclampsia.org/postpartum-

preeclampsia

Punkkinen, A. (2019). Reviewing postpartum follow up in two models of care. International

Journal of Childbirth Education 34(2), 60-63.

Raza, S., Raza, S. (2022). Postpartum psychosis. National Institute of Health.

https://www.ncbi.nlm.nih.gov/books/NBK544304/

Simmons-Duffin, S., Wroth, C. (2023). Maternal deaths in the U.S. spiked in 2021, CDC reports.

NPR. https://www.npr.org/sections/health-shots/2023/03/16/1163786037/maternal-

deaths-in-the-u-s-spiked-in-2021-cdc-reports#:~:text=The U.S. rate for 2021,deaths per

100,000 in 2020.