New ACOG postpartum recommendations are cheap, low tech window dressing for expensive, high tech problems

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I am going to look a gift horse in the mouth.

ACOG has just released new guidelines for postpartum care. They were long overdue but sadly they are more window dressing than substantive improvement. Moreover, the way they are being promoted is odious.

The American College of Obstetricians and Gynecologists (ACOG) have published the guidelines as Optimizing Postpartum Care.

How can the recommendations for postpartum care prevent  maternal deaths when the majority (65.5%) occur during pregnancy, on the day of birth or the first 6 days postpartum?

The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. During this period, a woman is adapting to multiple physical, social, and psychological changes. She is recovering from childbirth, adjusting to changing hormones, and learning to feed and care for her newborn. In addition to being a time of joy and excitement, this “fourth trimester” can present considerable challenges for women, including lack of sleep, fatigue, pain, breastfeeding difficulties, stress, new onset or exacerbation of mental health disorders, lack of sexual desire, and urinary incontinence. Women also may need to navigate preexisting health and social issues, such as substance dependence, intimate partner violence, and other concerns… [M]ost women in the United States must independently navigate the postpartum transition until the traditional postpartum visit (4–6 weeks after delivery). This lack of attention to maternal health needs is of particular concern given that more than one half of pregnancy-related deaths occur after the birth of the infant. Given the urgent need to reduce severe maternal morbidity and mortality, this Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.

Sounds great, huh? But right off the bat it is completely misleading.

Let’s start with the implication that this is going to reduce maternal mortality. How could that possibly be when the majority of maternal deaths (65.5%) occur during pregnancy, on the day of birth or the first 6 days postpartum?

According to Pregnancy-Related Mortality in the United States, 2011–2013:

532 (30.5%) died before delivery, 293 (16.8%) on the day of delivery or pregnancy termination, 317 (18.2%) between 1 and 6 days postpartum, and 372 (21.3%) between 7 and 41 days postpartum; only 229 (13.2%) died on or after 42 days postpartum.

Why do they die?

Because pregnancy and childbirth are inherently dangerous, because some women lack access to the high tech childbirth care that could save their lives and because women’s complaints are ignored. One of the most notable things about the recent prize winning ProPublica/NPR series on maternal mortality is the high proportion of deaths due to malpractice. A consistent thread runs from Lauren Bloomstein whose preventable death framed the initial piece in the series to Shalon Irving, the black CDC epidemiologist whose preventable death was featured in the piece about black women dying in pregnancy and childbirth, and many of the women in between: medical professionals dismissed their symptoms as variations of normal when they were signs of impending death. These women died of malpractice and no amount of optimizing of postpartum care would have saved them.

60% of maternal deaths are (potentially) preventable. But in order to prevent a death you have to suspect that something is going wrong, diagnose it and correct it. Unfortunately, there has been a relentless trend in the US and other developed countries to promote “normal birth.” Hospitals emphasize their decor and the availability of waterbirth, women bring their doulas and their birth plans, and doctors are cautioned repeatedly to reduce the routine application of technology like fetal monitoring and C-sections. It’s as if everyone has developed collective amnesia for the fact that pregnancy, in every time, place and culture (including our own) has ALWAYS been one of the leading causes of death of young women.

Everyone involved in the care of women giving birth should have a high index of suspicion for life threatening complications and instead they’ve been fooled into developing a low index of suspicion. All providers should drill for deadly complications like hemorrhage and eclamptic seizures. Labor and delivery suites should be set up to provide easy access to life saving technologies like blood, uterotonic agents, anti-seizure treatments, etc.

California has been leading the way. In their initial assessment of maternal deaths in their state they found that the most preventable deaths were from “hemorrhage (70 percent) and preeclampsia (60 percent).” California researchers created a series of “tool kits” for doctors, nurses and hospitals and have achieved impressive result. The limiting factor in rolling out these programs to other hospitals is complacency.

I find Dr. Alison Stuebe’s misrepresentation of the problem particularly ugly.

“The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

Perhaps that is Dr. Stuebe’s attitude as a perinatologist. Her patients are referrals for pregnancy problems and she doesn’t care for them for very long after birth. If she wants to smear herself and her perinatology colleagues, she can have at it.

But she does a tremendous disservice to OB-GYN’s who traditionally have life long relationships with their patients. They’ve known these women before pregnancy, providing care for contraception, sexually transmitted diseases and GYN health; they will care for the same women after pregnancy, providing contraception, treatment for menstrual disorders, incontinence and menopause. For most OB-GYNs the mother — far from being the “wrapper” — is the primary patient and the one with whom they have an ongoing relationship; the baby is a temporary patient and out of mind once delivered.

Dr. Stuebe’s claim is particularly ironic considering that it is the natural mothering industry that treats the mother as the “wrapper” and ignores the long term risks of vaginal birth on future continence and sexual function, ignores the risks of aggressive breastfeeding promotion on maternal mental health, and shames women for choosing pain relief, C-sections or formula.

That’s not to say that postpartum care can’t be improved. There’s plenty of room for improvement but even there the new ACOG recommendations fall short of what is needed. In particular, they fail to prevent many serious problems that are intrinsic to childbirth (like perineal tears, prolapse and subsequent incontinence) or problems that we make worse with our aggressive promotion of breastfeeding (like maternal exhaustion as a result of closing well baby nurseries and mental health problems exacerbated by pressure to breastfeed).

The recommendations are cheap, low tech window dressing for expensive, high tech problems. We’ll explore their limitations in a future post.

  • Melissa

    I think Dr. Steube’s point is lost in your analysis. Yes, OB-GYNs absolutely care for their patients throughout their lives. I don’t think she’s questioning the integrity of that doctor/patient relationship or the degree to which docs personally are invested in their patients. Rather, she’s highlighting how the entire system of care treats postpartum women like an after-thought. For example, every single fellow mother I know, whether they had a c-section, normal vaginal birth without tearing, episiotomy, etc, were all given the exact same discharge instructions—see you in six weeks. If every woman had a heart attack or emergency surgery, the after care would be tailored to the individual… not the case, generally speaking, in women’s health. In my own experience, I was induced for preeclampsia at term, failed my postpartum depression screening in the hospital and was sent home with high blood pressure. Again, it was see you in six weeks. I absolutely felt abandoned at a time that I was more vulnerable than I ever had been whereas just a week before, while still gestating, I felt like a priority. This is anecdotal but it mirrors the experience of so many new mothers. Postpartum discharge and care needs to be individualized in order to be optimal… for some, one visit at six weeks is appropriate but for many others, this is simply not the case. You speak of many other challenges to women’s health but just because these recommendations don’t solve all of them doesn’t make them not welcome.

  • MaineJen

    OT: sad story. A midwife forced to deliver babies for ISIS. She mentions that the men did not allow her to administer pain relief to laboring women. Just another way for them to exert control. Sickening.

    https://www.washingtonpost.com/graphics/2018/world/syria/isis-midwife-shares-moments/?utm_term=.3993167763fb

  • swbarnes2

    The quote has no context, but I think Steube was sarcastically criticizing that mindset, not avowing she holds it. She was on the group that crafted the recommendations, so it would be odd for her to say that they aren’t necessary.

    • Dr. Tuteur is challenging Dr. Stuebe’s assertion as correctly representing the average obgyn’s opinion, not implying that Dr. Stuebe supports such an attitude.

    • carovee

      I agree with swbarnes2, Amy should include the full quote. Its clear Dr. Stuebe is not advocating for treating women like the wrapper, but is clearly agreeing that women need to be more closely watched in the 24-48 hours after giving birth. If the average ObGyn was already doing that we wouldn’t have such high rates of preventable maternal deaths.

  • Empress of the Iguana People

    Stuebe is talking like a fool. Not only did my ob check on me in the hospital after my kids’ births, but so did his junior partner who’s only seen me a few times. One of those times, she was in civvies because she’d been at a meeting and decided to see who was in L&D. When my daughter needed to be whisked off my shoulder by the NICU team, my ob watched over their shoulders long enough to understand what was going on, then he explained it to me (and Dem). They took Girlbard off, but Ob, the resident, and a nurse stayed with me.