The Fourth Trimester: A Call For Healthcare Reform

1. The Fourth Trimester: A Call For Healthcare Reform Jaclyn Nunziato. M.S., M.D Assistant Professor Virginia Tech Carilion School of Medicine/Carilion Clinic Obstetrics and Gynecology Department 10.21.2019

2. Disclosures: • Postpartum and slightly bias  • None Or a 100% bias

3. Objectives: • Define the 4th trimester • Identify the scope of the problem. • How does the United States compare to other countries? • How does Virginia compare to other states? • What are the common postpartum complications? • What are the complications that contribute to morbidity and mortality? • What are the new recommendations from the American College of Obstetrics and Gynecology regarding the 4th trimester? • What are some quality improvement strategies that can be used to decrease the incidence of these complications?

4. Definitions: • Postpartum: In the United States healthcare system this is considered the period between the delivery of the placenta and up to 42 days after birth • Traditional postpartum care • Inpatient care following delivery • Postpartum visit: 6 weeks postpartum • 60% attendance rate • Average visit <12 minutes • 4th Trimester: A new paradigm for postpartum comprehensive care. Focus on the mother-baby dyad. Expansion of the postpartum visits to include 12 weeks and up to one year post delivery. “ 42 days after your delivery can influence the next 42 years of your life”

5. The fourth trimester: a focus on comprehensive care 4th Trimester 4th Trimester http://4thtrimester.web.unc.edu/files/2017/06/ZERO-TO-THREE-Journal.pdf

6. Scope of the problem:Maternal Mortality • In 1987 there were 7.2 deaths per 100,000 live births • In 2016 there were 17 deaths per 100,000 live births • 2016 there were nearly 4 million live births • 700 deaths per year in the United States • Every 10 minutes a woman in the United States almost dies of pregnancy-related complications • Black women 6 x more likely to die from pregnancy related deaths. https://www.cdc.gov/vitalsigns/maternal-deaths/index.html

7. How do we compare? https://www.cdc.gov/vitalsigns/maternal-deaths/index.html • The maternal mortality ratio is 26.4 in the United States • One of the only developed countries to have our rates on the rise • Ranked 47th in 2018 in the world • National survey 2012 showed 22% of women returned to work within 2 weeks of delivery

8. How have other countries embraced the 4th trimester? • Netherlands: 90% of women receive in-home post partum assistance provided by a midwife and a maternity assistant • In Indonesia mid-wives comes everyday after the birth till 40 days addressing post partum concerns. Their post partum hospital return rate is <1% of all deliveries. • In Holland, for example, where many births take place at home, a specially trained live-in maternity nurse stays with the mother for the first 8 to 10 days • Norway has post partum maternity centers for centering of those women who recently delivered run by Midwives.

9. Maternal Mortality in Virginia • Virginia is ranked 22 amongst the 50 states for maternal morality • Overall, there were a total of 462 pregnancy-associated deaths among Virginia residents between 2004 and 2013 • The Central Health Planning Region had the highest pregnancy-associated death rate (63.3), followed by the Southwest Health Planning Region (62.4). • The pregnancy-associated death rate for African American women (80.7) between 2004 and 2013 was significantly higher than the rate for their White counterparts (35.3).

10. What are common complications according to our mothers?

11. Pregnancy Related Deaths: https://www.who.int/maternal-health/en/

13. Quality improvement during the 4th trimester

14. ACOG Committee Opinion: Optimizing Postpartum Care #736 (May 2018) • To optimize care through anticipatory guidance • Redefining postpartum care as an “ongoing process” • Individualized care • All women have contact with their providers within the first 3 weeks of delivery extended up to 12 weeks “To optimize the health of women and infants postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs.”

16. It takes a Village to raise a baby • Husband • Friends/Family • “Mother Figure” • Lactation Specialists • Pediatricians • OBGYN provider • Doula • Midwife • Mom Groups • Community

17. ACOG: Post Partum Visit Strategies for increasing attendance Intrapartum support staff Centering Postpartum Optimizing Technology NP’s Lactation + + + Preventative Counseling Discharge planners Support Groups Doulas/Midwives

18. Postpartum Visit Expectations in <10 minutes???

19. ACOG Postpartum Toolkit • Blues or Perinatal Mood and Anxiety Disorders (PMADS) • Bleeding or Postpartum Hemorrhage • Blood Pressure related complications • Pregnancy related complications and their implications • Perinatal depression • Breastfeeding • Substance use: opioid, alcohol, tobacco • Obesity: achieving a health weight postpartum • Reproductive Life Planning (Contraception and Sexual health) • Neonatal mortality rates • Pregnancy related complications: Gestation DM, Preeclampsia, cHTN, Excessive weight gain, preterm birth or SGA (IUGR) • Chronic disease involving CVS and renal • Long-term follow up from pregnancy complications • Racial Disparities in Maternal mortality in the US ( A missed opportunity for ACTION) • Postpartum complications • Urinary incontinence – up to 40% in the first 3 months and 11-23% in <1 year • Fecal incontinence- up to 10% with OASIS in 18% of deliveries • Perineal Pain, dyspareunia and low libido – 17% at 6 months • Newborn care (feeding, bathing, heading out with baby, sleeping) • Intimate partner violence • Returning to work and paid leave- promoting physician burn out • Immunization and vaccinations

20. 1. Blues: Perinatal mood and anxiety disorders • 15% of 4 million live births = 600,000 women with the potential for PPD in the United States. • 300,000 more women are suffering from PPD because of a loss of birth • Of the women only 15% are seeking treatment. • PMADS: • Blues- 80% of women • Depression- 10-15% • Anxiety- 10% • Obsessive Compulsive Disorder- 3-5% • Post Traumatic Stress Disorder- 5% • Panic Disorder - 10 % • Psychosis- <.5%

21. What are some areas of improvement? • Standardize screening within the health system • Systematic screening throughout the pregnancy • Action care plans for positive screens • Anticipatory guidance and follow up • Recognizing barriers to care • Treatment • Pear Counseling • Cognitive behavior • Antidepressants • Patient Education

22. Maternal Mental Health Safety Bundle

23. 2. Bleeding: postpartum hemorrhage • One of the leading causes of pregnancy related deaths • It usually happens within 1 day of giving birth, but it can happen up to 12 weeks after having a baby. • About 1 to 5 in 100 women who have a baby (1 to 5 percent) experience postpartum hemorrhage. 

24. What are some areas of improvement? • Anticipatory care: identifying who is at risk for postpartum hemorrhage • Measurement of cumulative blood loss • Active management of 3rd stage of labor with establishment of protocols • Hemorrhage cart: • Checklist • Medications • Supplies • Systematic approach to treatment • Response team • Massive transfusion protocols • Monitoring outcomes • Debrief and huddles • Patient education • Antepartum topics of discussion

25. Postpartum Hemorrhage: Obstetrical safety bundle

26. 3. Blood Pressures: Hypertensive emergencies • 24% of maternal mortality related to hypertensive disorders of pregnancy • Preeclampsia complicates 2-8% of all pregnancies • In the United States, the rate of preeclampsia increased by 25% between 1987 and 2004. • This complication is costly: one study reported that in 2012 in the United States, the estimated cost of preeclampsia within the first 12 months of delivery was $2.18 billion.

27. What are some areas of improvement? • Establishment of diagnostic criteria, monitoring, and treatment of preeclampsia • Anticipatory care: identifying who is at risk for elevated blood pressure complications • Medication protocols easily accessible • Systematic approach to escalation • Severe hypertension • Eclampsia • Postpartum presentation (hospital wide) • Patient education • What are the warning signs of hypertension and preeclampsia?

29. Pregnancy related complications = long term health consequences • Pregnancy is a window to future health • 42 days postpartum influence the next 42 years of your life • Gestational diabetes carries a lifetime risk of developing diabetes by 50% • Preeclampsia doubles your risk of cardiovascular disease and quadruples your risk of high blood pressure in the future. 2 out of 3 women will die of cardiovascular disease. • Excessive weight gain is associated with higher weight retention leading to increased risk of cardiovascular disease and diabetes • Preterm birth is associated with a 2 fold increase in future cardiovascular disease

30. Discussion Time • What are some active programs in the hospital or health care systems targeted to the 4th trimester? • What are some of the current barriers to care? How can we remove those barriers? • What are potential QI projects that could be developed and implemented through VNPC?

31. Resources for health care reform

32. Questions?

33. Adjust Slides

35. Summary • Fourth Trimester: a new paradigm for postpartum care • Treating mother and baby as a dyad • Maternal mortality is on the rise in the United States (we need to do better). • Currently ranked 47 in the world for maternal deaths • Early focused postpartum care within the first 3 weeks and extending up to 12 weeks • We need to initiate the conversation about creating a postpartum care plan • Average of 14 visits to address postpartum care • There are over 20 areas of interest addressed in the postpartum toolkit by ACOG, PLEASE READ 

36. Maternal, Infant, and Child Health (MICH)/AMCHP 2014 • Grant Program – with the goals of reducing infant mortality and creating a “new safe” environment for neonates and new mothers. • Integration of resources: Family planning + social work + WICC + behavioral Health • Program used case managers who developed personalized care plans, provided educational materials and called women after birth, markedly increasing postpartum visit rates in four states.

37. AWHONN: Association of Women’s Health, Obstetric and Neonatal Nurses: “Empowering women to obtain needed care” • Discharge Education Checklist • Education Evaluation Tools • Counseling Hot Lines • Audit Tools • Community based post partum care programs which are used in the UK today • Nurse-managed home care visits: In the state of Texas these programs have improved mental health, fewer short interval pregnancies, and shorter duration of welfare • Cost Effective care: Upfront preventative medicine in the post partum • Follow up phone calls for high risk patients

38. AWHONN Postpartum Discharge Education Project

39. References • 1American College of Obstetricians and Gynecologists (ACOG). (2016). Optimizing postpartum care. Committee Opinion No. 666. Obstetrics & Gynecology, 127, e187-e192. doi:l0.l0971 • Centers for Disease Control and Prevention. (2016). Pregnancy mortality surveillance system. Retrieved from http://www.cdc gov/reproductivehealth/maternalinfanthealth/pmss.html • 3. Central Intelligence Agency. (2016). The world factbook. Country comparison: Maternal mortality rate. Retrieved from https:llwww.cia.gov/library/publications/ resources/the-worldfactbook/ rankorder/2223rank.html • Della Torre, M., Kilpatrick, S. J., Hibbard, J. u., Simonson, L., Scott, S., Koch, A., .. . Geller, S. E. (2011). Assessing preventability for obstetric hemorrhage. American Journal of Perinatology, 28(10), 753-760. • Kleppel, L., Suplee, P.D., Stuebe, A.M., & Bingham, D. (2016). National initiatives to improve systems of postpartum care. Maternal and Child Health Journal, 20 (8), 1-5. • Bacak, S. J., Berg, C. J., Desmarais, J., Hutchins, E., & Locke, E. (2006). State maternal mortality review: Accomplishments of nine states. Atlanta: Centers for Disease Control and Prevention. • Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to mothers III: New mothers speak out. New York: Childbirth Connection. • Suplee, P., Bloch, J., McKeever, A., Borucki, L., Dawley, K., & Kaufman, M. (2014). Focusing on maternal health beyond breastfeeding and depression during the first year postpartum. JOGNN: Journal of Obstetric, Gynecologic & Neonatal Nursing, 43(6), 782–791.

40. Neonatal mortality • Mattress, mattress cover, undersheet, duvet cover, blanket, sleeping bag/quilt • Box itself doubles as a crib • Light hooded suit and knitted overalls • Socks and mittens, knitted hat and balaclava • Bodysuits, romper suits and leggings in unisex colours and patterns • Hooded bath towel, nail scissors, hairbrush, toothbrush, bath thermometer, nappy cream, washcloth • Cloth nappy set and muslin squares • Picture book and teething toy • Bra pads, condoms In the 1930s Finland was a poor country and infant mortality was high - 65 out of 1,000 babies died. But the figures improved rapidly in the decades that followed.

43. SAFE-T initiative: Temple University • Phase 1: January 2015: • Provided all mothers who delivered their baby in the postpartum unit standard-practice safe sleep education. Temple then followed up with a post-discharge phone call questionnaire to assess sleep environment for the babies. • Phase 2: February 2016 • Provided with more extensive safe sleep education from their care team, including the provision of materials from national safe sleep campaign "Cribs for Kids," followed up with the same post-discharge phone questionnaire. • Phase 3: + "Baby Box University" a website containing newborn education videos.

44. POST PARTUM POST PARTUM

45. Only six guidelines from Australia (2), the UK (3) and the USA (1) met the inclusion criteria and were reviewed. • There was also inconsistency across guidelines in regards to the screening of women for postpartum depression with two recommending and two not recommending the use of EPDS • Despite the quality of the guidelines and the similarity of recommendations, only one guideline covers routine postpartum care for the mother and infant.