ACOG Green Journal: The Fourth Trimester – 12 Weeks Is Not Enough

Over the past several years, significant attention has been placed on the high maternal morbidity and mortality rate in the United States, with substantial focus on health care professional-, hospital-, and systems-based strategies to address this crisis. Although these efforts are necessary and vital, solutions that are intrapartum and hospital-focused address only a fraction of the problem. One third of pregnancy-related deaths occur after the first week through 1 year after delivery, a time when women have the least interaction with the health care system, and arguably when they need this interaction the most. Furthermore, significant racial disparities plague pregnancy-related deaths. Black women are three to four times more likely to die of a pregnancy-related cause than White women.1 The current health care system does not prioritize care in the year after delivery and lacks an individualized approach that ensures postpartum patients are connected to the care they need. As a result, women in the year after delivery continue to have adverse outcomes, and our morbidity and mortality rates remain high, with persistent disparities.

Historically, there has been an episodic approach to obstetric care, leading to it being treated as a distinct occurrence and separate from the broader women’s health continuum. The concept of the “fourth trimester”2 and continued discussion around pregnancy as a window into future health3 has started to transform this historically deficient approach. In this month’s issue of Obstetrics & Gynecology (see page 782), Steenland et al4 report the results of an analysis comparing postpartum and nonpostpartum patients in a commercially insured population, and their results lend support to a much-needed transformation in the approach to care in the postpartum period. They delineate and evaluate health care utilization in three distinct time periods spanning the year after delivery: early postpartum (less than 21 days), postpartum (21–60 days), and extended postpartum (61–365 days). In their cohort, nearly a quarter of postpartum women had a problem visit in the early and postpartum periods. Additionally, although 80% of women received problem-related health care in the extended postpartum period, only 43% of women received preventive care, including well-woman care. Further, adjusted hospitalization rates among postpartum women in all time periods were higher than those among nonpostpartum women. The traditional approach to treating pregnancy and the immediate postpartum period as an episode results in a failure to recognize the importance of integrated approaches in the early and postpartum periods and continued care in the extended postpartum period. Integrating our approach and the differential needs in these three time periods within that first year postpartum is critical to optimizing women’s health long-term.

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doi: 10.1097/AOG.0000000000004373