CommitteeOpinion2017
Number 736, May 2018
(Replaces Committee Opinion Number 666, June 2016)


Presidential Task Force on Redefining the Postpartum Visit
The Committee on Obstetric Practice
The Academy of Breastfeeding Medicine, the American College of Nurse-Midwives, the National Association of Nurse Practitioners in Women’s Health, the Society for Academic Specialists in General Obstetrics and Gynecology, and the Society for Maternal–Fetal Medicine endorse this document. This Committee Opinion was developed by the American College of Obstetricians and Gynecologists’ Presidential Task Force on Redefining the Postpartum Visit and the Committee on Obstetric Practice in collaboration with task force members Alison Stuebe, MD, MSc; Tamika Auguste, MD; and Martha Gulati, MD, MS.

This information is designed as an educational resource to aid clinicians in providing obstetric and gynecologic care, and use of this information is voluntary. This information should not be considered as inclusive of all proper treatments or methods of care or as a statement of the standard of care. It is not intended to substitute for the independent professional judgment of the treating clinician. Variations in practice may be warranted when, in the reasonable judgment of the treating clinician, such course of action is indicated by the condition of the patient, limitations of available resources, or advances in knowledge or technology. The American College of Obstetricians and Gynecologists reviews its publications regularly; however, its publications may not reflect the most recent evidence. Any updates to this document can be found on www.acog.org or by calling the ACOG Resource Center.

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Optimizing Postpartum Care

ABSTRACT: The weeks following birth are a critical period for a woman and her infant, setting the stage for long-term health and well-being. 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. It is recommended that all women have contact with their obstetrician–gynecologists or other obstetric care providers within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit 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. Women with chronic medical conditions such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, and mood disorders should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care. During the postpartum period, the woman and her obstetrician–gynecologist or other obstetric care provider should identify the health care provider who will assume primary responsibility for her ongoing care in her primary medical home. Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.
Obstetrician–gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants. This Committee Opinion has been revised to reinforce the importance of the “fourth trimester” and to propose a new paradigm for postpartum care.


Recommendations and Conclusions

The American College of Obstetricians and Gynecologists makes the following recommendations and conclusions:

  • 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.
  • Anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care.
  • Prenatal discussions should include the woman’s reproductive life plans, including desire for and timing of any future pregnancies. A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options.
  • All women should ideally have contact with a maternal care provider within the first 3 weeks postpartum. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth.
  • The timing of the comprehensive postpartum visit should be individualized and woman centered.
  • The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being.
  • Women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease.
  • Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care.
  • For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider.
  • Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit.

Introduction

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 (1). 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 (2–4). Women also may need to navigate preexisting health and social issues, such as substance dependence, intimate partner violence, and other concerns. During this time, postpartum care often is fragmented among maternal and pediatric health care providers, and communication across the transition from inpatient to outpatient settings is often inconsistent (5). Home visits are provided in some settings; however, currently, most 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 (6). 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.

Redefining Postpartum Care

Following birth, many cultures prescribe a 30–40-day period of rest and recovery, with the woman and her newborn surrounded and supported by family and community members (7). Many agrarian cultures enshrine postpartum rituals, including traditional foods and support for day-to-day household tasks. These traditions have been sustained by some cultural groups, but for many women in the United States, the 6-week postpartum visit punctuates a period devoid of formal or informal maternal support. Obstetrician–gynecologists and other women’s health care providers are uniquely qualified to enable each woman to access the clinical and social resources she needs to successfully navigate the transition from pregnancy to parenthood.

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. Indeed, in qualitative studies, women have noted that there is an intense focus on women’s health prenatally but care during the postpartum period is infrequent and late (8). Rather than an arbitrary “6-week check,” the American College of Obstetricians and Gynecologists recommends that the timing of the comprehensive postpartum visit be individualized and woman centered. To better meet the needs of women in the postpartum period, care would ideally include an initial assessment, either in person or by phone, within the first 3 weeks postpartum to address acute postpartum issues. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive well-woman visit no later than 12 weeks after birth (Fig. 1). Insurance coverage policies should be aligned to support this tailored approach to “fourth trimester” care (see Policy and Postpartum Care).

Figure 1

Increasing engagement

Currently, as many as 40% of women do not attend a postpartum visit. Underutilization of postpartum care impedes management of chronic health conditions and access to effective contraception, which increases the risk of short interval pregnancy and preterm birth. Attendance rates are lower among populations with limited resources (9, 10), which contributes to health disparities.

Increasing attendance at postpartum visits is a developmental goal for Healthy People 2020. Strategies for increasing attendance include but are not limited to the following measures: discussing the importance of postpartum care during prenatal visits; using peer counselors, intrapartum support staff, postpartum nurses, and discharge planners to encourage postpartum follow-up; scheduling postpartum visits during prenatal care or before hospital discharge; using technology (eg, email, text, and apps) to remind women to schedule postpartum follow-up (11); and increasing access to paid sick days and paid family leave.

Optimal postpartum care provides an opportunity to promote the overall health and well-being of women, and evidence suggests that current care falls short of that goal. In a national survey, less than one half of women attending a postpartum visit reported that they received enough information at the visit about postpartum depression, birth spacing, healthy eating, the importance of exercise, or changes in their sexual response and emotions (12). Of note, anticipatory guidance improves maternal well-being: In a randomized controlled trial, 15 minutes of anticipatory guidance before hospital discharge, followed by a phone call at 2 weeks, reduced symptoms of depression and increased breastfeeding duration through 6 months postpartum among African American and Hispanic women (13, 14).

Prenatal Preparation

To optimize postpartum care, anticipatory guidance should begin during pregnancy with development of a postpartum care plan that addresses the transition to parenthood and well-woman care (15) (Table 1). Anticipatory guidance should include discussion of infant feeding (16, 17), “baby blues,” postpartum emotional health, and the challenges of parenting and postpartum recovery from birth (18). Prenatal discussions also should address plans for long-term management of chronic health conditions, such as mental health, diabetes, hypertension, and obesity, including identification of a primary health care provider who will care for the patient beyond the postpartum period. Within this guidance, health care providers should discuss the purpose and value of postpartum clinical care as well as the types of services and support available.

Reproductive Life Planning

Beginning in prenatal care, the patient and her obstetrician–gynecologist or other obstetric care provider should discuss the woman’s reproductive life plans, including desire for and timing of any future pregnancies (19). Women should be advised to avoid interpregnancy intervals shorter than 6 months and should be counseled about the risks and benefits of repeat pregnancy sooner than 18 months (20). Short interpregnancy intervals also are associated with reduced vaginal birth after cesarean success for women undergoing trial of labor after cesarean (21).

A woman’s future pregnancy intentions provide a context for shared decision-making regarding contraceptive options (22). Shared decision-making brings two experts to the table: the patient and the health care provider. The health care provider is an expert in the clinical evidence, and the patient is an expert in her experiences and values (23). As affirmed by the World Health Organization, when making choices regarding the timing of the next pregnancy, “Individuals and couples should consider health risks and benefits along with other circumstances such as their age, fecundity, fertility aspirations, access to health services, child-rearing support, social and economic circumstances, and personal preferences” (24). Given the complex history of sterilization abuse (25) and fertility control among marginalized women, care should be taken to ensure that every woman is provided information on the full range of contraceptive options so that she can select the method best suited to her needs (26).

The Postpartum Care Plan

Beginning during prenatal care, the woman and her obstetrician–gynecologist or other obstetric care provider should develop a postpartum care plan and care team, inclusive of family and friends who will provide social and material support in the months following birth, as well as the medical provider(s), who will be primarily responsible for care of the woman and her infant after birth (19). Suggested components of the postpartum care team and care plan are listed in Table 1 and Table 2. The care plan should identify the primary care provider and other medical providers (eg, psychiatrist) who will assume care of chronic medical issues after the postpartum period. If the obstetrician–gynecologist serves as the primary care provider, then transition to another primary care physician is unnecessary.

Transition From Intrapartum to Postpartum Care

The postpartum care plan should be reviewed and updated after the woman gives birth. Women often are uncertain about whom to contact for postpartum concerns (27). In a recent U.S. survey, one in four postpartum women did not have a phone number for a health care provider to contact for any concerns about themselves or their infants (12). Therefore, it is suggested that the care plan include contact information and written instructions regarding the timing of follow-up postpartum care. Just as a health care provider or health care practice leads the woman’s care during pregnancy, a primary obstetrician–gynecologist or other health care provider should assume responsibility for her postpartum care (15). This individual or practice is the primary point of contact for the woman, for other members of the postpartum care team, and for any maternal health concerns noted by the infant’s health care provider. When the woman is discharged from inpatient care but prolonged infant hospitalization remote from the woman’s home is anticipated, a local obstetrician–gynecologist or other health care provider should be identified as a point of contact and an appropriate hand off should occur. Such a referral should occur even if delivery did not take place at a local hospital.

Table 1

Substantial morbidity occurs in the early postpartum period; more than one half of pregnancy-related maternal deaths occur after the birth of the infant (6). Blood pressure evaluation is recommended for women with hypertensive disorders of pregnancy no later than 7–10 days postpartum (28), and women with severe hypertension should be seen within 72 hours; other experts have recommended follow-up at 3–5 days (29). Such assessment is critical given that more than one half of postpartum strokes occur within 10 days of discharge (30). In-person follow-up also may be beneficial for women at high risk of complications, such as postpartum depression (31), cesarean or perineal wound infection, lactation difficulties, or chronic conditions such as seizure disorders that require postpartum medication titration. For women with complex medical problems, multiple visits may be required to facilitate recovery from birth.

Table 2

Of note, even among women without risk factors, problems such as heavy bleeding, pain, physical exhaustion, and urinary incontinence are common (12). World Health Organization guidelines for postnatal care include routine postpartum evaluation of all women and infant dyads at 3 days, 1–2 weeks, and 6 weeks (32). The National Institute for Health and Care Excellence guidelines recommend screening all women for resolution of the “Baby Blues” at 10–14 days after birth to facilitate early identification of and treatment for postpartum depression (15). Contact in the first few weeks also may enable women to meet their breastfeeding goals: Among women with early, undesired weaning, 20% had discontinued breastfeeding by 6 weeks postpartum (33), when traditionally timed visits occurred. To address these common postpartum concerns, all women should ideally have contact with a maternal care provider within the first 3 weeks postpartum.

Assessment need not occur as an office visit, and the usefulness of an in-person assessment should be weighed against the burden of traveling to and attending an office visit with a neonate. Additional mechanisms for assessing women’s health needs after birth include home visits (34), phone support (35, 36), text messages (37), remote blood pressure monitoring (38, 39), and app-based support (40). Phone support during the postpartum period appears to reduce depression scores, improve breastfeeding outcomes, and increase patient satisfaction, although the evidence is mixed (35, 36).

The Comprehensive Postpartum Visit and Transition to Well-Woman Care

Visit Timing

The comprehensive postpartum visit has typically been scheduled between 4 weeks and 6 weeks after delivery, a time frame that likely reflects cultural traditions of 40 days of convalescence for women and their infants (41). Today, however, 23% of employed women return to work within 10 days postpartum and an additional 22% return to work between 10 days and 40 days (42). Therefore, timing of the comprehensive postpartum visit should be individualized and woman centered, occurring no later than 12 weeks from birth. Timing also should take into account any changes in insurance coverage anticipated after delivery. At all postpartum encounters, obstetrician–gynecologists and other obstetric care providers should consider the need for future follow-up and time additional visits accordingly. However timed, the comprehensive postpartum visit is a medical appointment; it is not an “all-clear” signal. Obstetrician–gynecologists and other obstetric care providers should ensure that women, their families, and their employers understand that completion of the comprehensive postpartum visit does not obviate the need for continued recovery and support through 6 weeks postpartum and beyond.

Visit Components

The comprehensive postpartum visit should include a full assessment of physical, social, and psychological well-being, including the following domains (Box 1): 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.

Box 1

Abbreviations: ASCVD, arteriosclerotic cardiovascular disease; GDM, gestational diabetes mellitus; LARC, long-acting reversible contraceptive.

1Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1268–71.

2Earls MF. Incorporating recognition and management of perinatal and postpartum depression into pediatric practice. Committee on Psychosocial Aspects of Child and Family Health American Academy of Pediatrics. Pediatrics 2010;126:1032–9.

3American College of Obstetricians and Gynecologists. Tobacco and nicotine cessation toolkit. Washington, DC: American College of Obstetricians and Gynecologists; 2016.

4Opioid use and opioid use disorder in pregnancy. Committee Opinion No. 711. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e81–94.

5American Academy of Pediatrics. Protect infants against pertussis: cocooning through Tdap vaccination. Washington, DC: AAP. Available at: https://www.aap.org/en-us/Documents/immunization_protect_infants_against_pertussis.pdf. Retrieved January 23, 2018.

6Berens P, Eglash A, Malloy M, Steube AM. ABM Clinical Protocol #26: persistent pain with breastfeeding. Breastfeed Med 2016;11:46–53.

7Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e86–92.

8Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:423–8.

9Centers for Disease Control and Prevention. Lactational amenorrhea method. In: US medical eligibility criteria (US MEC) for contraceptive use. Atlanta (GA): CDC; 2017.

10Reproductive life planning to reduce unintended pregnancy. Committee Opinion No. 654. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e66–9.

11Immediate postpartum long-acting reversible contraception. Committee Opinion No. 670. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e32–7.

12MacArthur C, Winter HR, Bick DE, Lilford RJ, Lancashire RJ, Knowles H, et al. Redesigning postnatal care: a randomised controlled trial of protocol-based midwifery-led care focused on individual women’s physical and psychological health needs. Health Technol Assess 2003;7:1–98.

13Prevention and management of obstetric lacerations at vaginal delivery. Practice Bulletin No. 165. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;128:e1–15.

14Urinary incontinence in women. Practice Bulletin No. 155. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;126:e66–81.

15American College of Obstetricians and Gynecologists. Obesity toolkit. Washington, DC: American College of Obstetricians and Gynecologists;2016.

16Gestational diabetes mellitus. ACOG Practice Bulletin No. 190. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e49–64.

17American College of Obstetricians and Gynecologists. Immunization for women. Washington, DC: American College of Obstetricians and Gynecologists; 2017.

18Conry J, Brown H. Well-Woman Task Force: Components of the Well-Woman Visit. Obstet Gynecol 2015;126:697–701.

 

The comprehensive postpartum visit provides an opportunity for a woman to ask questions about her labor, childbirth, and any complications (15). Relevant details should be reviewed and documented in the medical record. A traumatic birth experience can cause postpartum posttraumatic stress disorder, which affects 3–16% of women (43). Trauma is in the eye of the beholder, and health care providers should be aware that a woman may experience a birth as traumatic even if she and her infant are healthy. Complications should be discussed with respect to risks for future pregnancies, such as recommendations for 17α-hydroxyprogesterone caproate to reduce risk of recurrent preterm birth, or aspirin to reduce risk of preeclampsia. Any placental pathology reports should be reviewed and shared with the patient. Recommendations should be made to optimize maternal health during the interpregnancy period (44), such as controlling diabetes and attaining optimal weight (45).

Adverse Pregnancy Outcomes and Cardiovascular Risk

There are risk factors for cardiovascular disease that appear during pregnancy, and these risk factors are emerging as an important predictor of future arteriosclerotic cardiovascular disease (ASCVD) risk. Complications such as preterm delivery, gestational diabetes, gestational hypertension, preeclampsia, and eclampsia are associated with greater risk of ASCVD (46). Pregnancy is, therefore, a natural “stress test” identifying at-risk women, but because these conditions often resolve postpartum, the increased cardiovascular disease risk is not consistently communicated to women. These adverse pregnancy outcomes are also not assessed when using current ASCVD risk assessment tools. Therefore, women with pregnancies complicated by preterm birth, gestational diabetes, or hypertensive disorders of pregnancy should be counseled that these disorders are associated with a higher lifetime risk of maternal cardiometabolic disease. These women should undergo ASCVD risk assessment (47, 48), with particular attention to the effect of social determinants of health on cardiometabolic disease (49). All postpartum women with gestational diabetes should undergo glucose screening with a fasting plasma glucose test or a 75-g, 2-hour oral glucose tolerance test (45). Any history of pregnancy complications should be documented in the woman’s electronic medical record to facilitate effective transition of care and to inform future screening and treatment.

Chronic Health Conditions

Women with chronic medical conditions, such as hypertensive disorders, obesity, diabetes, thyroid disorders, renal disease, mood disorders, and substance use disorders, should be counseled regarding the importance of timely follow-up with their obstetrician–gynecologists or primary care providers for ongoing coordination of care. Medications such as antiepileptics and psychotropic agents should be reviewed to ensure that the dosage has been adjusted to reflect postpartum physiology and that the agents selected are compatible for women who are breastfeeding. The U.S. National Library of Medicine’s LactMed is a free online resource that provides high-quality guidance on medication safety during lactation (www.toxnet.nlm.nih.gov/newtoxnet/lactmed.htm).

Pregnancy Loss

For a woman who has experienced a miscarriage, stillbirth, or neonatal death, it is essential to ensure follow-up with an obstetrician–gynecologist or other obstetric care provider. Key elements of this visit include emotional support and bereavement counseling; referral, if appropriate, to counselors and support groups; review of any laboratory and pathology studies related to the loss; and counseling regarding recurrent risk and future pregnancy planning (50).

Transition to Ongoing Well-Woman Care

During the postpartum period, the woman and her obstetrician–gynecologist or other obstetric care provider should modify her postpartum care plan to identify the health care provider who will assume primary responsibility for her ongoing care in her primary medical home. Appropriate referrals to other members of her health care team should also be made during this transitional period. If the obstetrician–gynecologist or other obstetric care provider is also her primary care provider, no transfer of responsibility is necessary. If responsibility is transferred to another primary care provider, the obstetrician–gynecologist or other obstetric care provider is responsible for ensuring that there is communication with the primary care provider so that he or she can understand the implications of any pregnancy complications for the woman’s future health and maintain continuity of care.

Written recommendations for follow-up for well-woman care and for any ongoing medical issues should be documented in the medical record, provided to the patient, and communicated to appropriate members of the postpartum care team, including her primary care medical home provider. By providing comprehensive, woman-centered care after childbirth, obstetrician–gynecologists and other obstetric care providers can enable every woman to optimize her long-term health and well-being.

Policy and Postpartum Care

Optimizing care and support for postpartum families will require policy changes. Changes in the scope of postpartum care should be facilitated by reimbursement policies that support postpartum care as an ongoing process, rather than an isolated visit. More broadly, provisions for paid parental leave are essential to improve the health of women and children and reduce disparities. As one study (51) has noted, “The lack of policies substantially benefitting early life in the United States constitutes a grave social injustice: those who are already most disadvantaged in our society bear the greatest burden.” The American College of Obstetricians and Gynecologists endorses paid parental leave as essential, including maintenance of full benefits and 100% of pay for at least 6 weeks (52). Obstetrician–gynecologists and other obstetric care providers should be in the forefront of policy efforts to enable all women to recover from birth and nurture their infants.

For More Information

The American College of Obstetricians and Gynecologists has identified additional resources on topics related to this document that may be helpful for ob–gyns, other health care providers, and patients. You may view these resources at www.acog.org/More-Info/OptimizingPostpartumCare.

These resources are for information only and are not meant to be comprehensive. Referral to these resources does not imply the American College of Obstetricians and Gynecologists’ endorsement of the organization, the organization’s website, or the content of the resource. The resources may change without notice.

References

  1. Aber C, Weiss M, Fawcett J. Contemporary women’s adaptation to motherhood: the first 3 to 6 weeks postpartum. Nurs Sci Q 2013;26:344–51.
  2. Burgio KL, Zyczynski H, Locher JL, Richter HE, Redden DT, Wright KC. Urinary incontinence in the 12-month postpartum period. Obstet Gynecol 2003;102:1291–8.
  3. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Major survey findings of Listening to Mothers(SM) III: new mothers speak out: report of national surveys of women’s childbearing experiences conducted October-December 2012 and January-April 2013. J Perinat Educ 2014;23:17–24.
  4. Haran C, van Driel M, Mitchell BL, Brodribb WE. Clinical guidelines for postpartum women and infants in primary care-a systematic review. BMC Pregnancy Childbirth 2014;14:51.
  5. Wise PH. Transforming preconceptional, prenatal, and interconceptional care into a comprehensive commitment to women’s health. Womens Health Issues 2008;18:S13–8.
  6. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004.
  7. Eberhard-Gran M, Garthus-Niegel S, Garthus-Niegel K, Eskild A. Postnatal care: a cross-cultural and historical perspective. Arch Womens Ment Health 2010;13:459–66.
  8. Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol 2017;217:37–41.
  9. Bennett WL, Chang HY, Levine DM, Wang L, Neale D, Werner EF, et al. Utilization of primary and obstetric care after medically complicated pregnancies: an analysis of medical claims data. J Gen Intern Med 2014;29:636–45.
  10. Bryant AS, Haas JS, McElrath TF, McCormick MC. Predictors of compliance with the postpartum visit among women living in healthy start project areas. Matern Child Health J 2006;10:511–6.
  11. Centers for Medicare and Medicaid Services. Resources on strategies to improve postpartum care among Medicaid and CHIP populations. Baltimore (MD): CMS; 2015.
  12. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers(SM) III: new mothers speak out. New York (NY): Childbirth Connection; 2013.
  13. Howell EA, Balbierz A, Wang J, Parides M, Zlotnick C, Leventhal H. Reducing postpartum depressive symptoms among black and Latina mothers: a randomized controlled trial. Obstet Gynecol 2012;119:942–9.
  14. Howell EA, Bodnar-Deren S, Balbierz A, Parides M, Bickell N. An intervention to extend breastfeeding among black and Latina mothers after delivery. Am J Obstet Gynecol 2014;210:239.e1–5.
  15. National Institute for Health and Care Excellence. Postnatal care. Quality standard. Manchester: NICE; 2013.
  16. Optimizing support for breastfeeding as part of obstetric practice. Committee Opinion No. 658. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e86–92.
  17. Breastfeeding in underserved women: increasing initiation and continuation of breastfeeding. Committee Opinion No. 570. American College of Obstetricians and Gynecologists. Obstet Gynecol 2013;122:423–8.
  18. Martin A, Horowitz C, Balbierz A, Howell EA. Views of women and clinicians on postpartum preparation and recovery. Matern Child Health J 2014;18:707–13.
  19. Reproductive life planning to reduce unintended pregnancy. Committee Opinion No. 654. American College of Obstetricians and Gynecologists. Obstet Gynecol 2016;127:e66–9.
  20. Conde-Agudelo A, Rosas-Bermudez A, Kafury-Goeta AC. Birth spacing and risk of adverse perinatal outcomes: a meta-analysis. JAMA 2006;295:1809–23.
  21. Vaginal Birth After Cesarean Delivery. ACOG Practice Bulletin No. 184. American College of Obstetricians and Gynecologists. Obstet Gynecol 2017;130:e217–33.
  22. Block DE, Kurtzman C. Family planning in a healthy, married population: operationalizing the human rights approach in an Israeli health service setting. Am J Public Health 1984;74:830–3.
  23. Barry MJ, Edgman-Levitan S. Shared decision making—pinnacle of patient-centered care. N Engl J Med 2012;366:780–1.
  24. World Health Organization. Report of a WHO technical consultation on birth spacing. Geneva: WHO; 2005.
  25. Harris LH. Sterilization of Women: Ethical Issues and Considerations. Committee Opinion No. 695. Obstet Gynecol 2017;129:e109–16.
  26. National Women’s Health Network, SisterSong Women of Color Reproductive Justice Coalition. Long-acting reversible contraception statement of principles. Washington, DC: NWHN; 2017.
  27. Brodribb W, Zadoroznyj M, Dane A. The views of mothers and GPs about postpartum care in Australian general practice. BMC Fam Pract 2013;14:139.
  28. American College of Obstetricians and Gynecologists. Hypertension in pregnancy. Washington, DC: American College of Obstetricians and Gynecologists; 2013.
  29. New York State Department of Health. Hypertensive disorders in pregnancy. Guideline summary. Albany (NY): NYSDOH; 2013.
  30. Too G, Went T, Boehme AK, Miller EC, Leffert LR, Attenello FJ, et al. Timing and Risk Factors of Postpartum Stroke. Obstet Gynecol 2018;1:70–8.
  31. Screening for perinatal depression. Committee Opinion No. 630. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:1268–71.
  32. World Health Organization. Maternal, newborn, child and adolescent health. Geneva: WHO; 2013.
  33. Stuebe AM, Horton BJ, Chetwynd E, Watkins S, Grewen K, Meltzer-Brody S. Prevalence and risk factors for early, undesired weaning attributed to lactation dysfunction. J Womens Health (Larchmt) 2014;23:404–12.
  34. Dodge KA, Goodman WB, Murphy RA, O’Donnell K, Sato J, Guptill S. Implementation and randomized controlled trial evaluation of universal postnatal nurse home visiting. Am J Public Health 2014;104(suppl 1):S136–43.
  35. Lavender T, Richens Y, Milan SJ, Smyth RM, Dowswell T. Telephone support for women during pregnancy and the first six weeks postpartum. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD009338: PMID: 23881662. DOI: 10.1002/14651858.CD009338.pub2.
  36. Miller YD, Dane AC, Thompson R. A call for better care: the impact of postnatal contact services on women’s parenting confidence and experiences of postpartum care in Queensland, Australia. BMC Health Serv Res 2014;14:635.
  37. Gallegos D, Russell-Bennett R, Previte J, Parkinson J. Can a text message a week improve breastfeeding? BMC Pregnancy Childbirth 2014;14:374.
  38. Rhoads SJ, Serrano CI, Lynch CE, Ounpraseuth ST, Gauss CH, Payakachat N, et al. Exploring implementation of m-health monitoring in postpartum women with hypertension. Telemed J E Health 2017;23:833–41.
  39. Hirshberg A, Bittle MD, VanDerTuyn M, Mahraj K, Asch DA, Rosin R, et al. Rapid-cycle innovation testing of text-based monitoring for management of postpartum hypertension. J Clin Outcomes Manage 2017;24:77–85.
  40. Danbjorg DB, Wagner L, Kristensen BR, Clemensen J. Intervention among new parents followed up by an interview study exploring their experiences of telemedicine after early postnatal discharge. Midwifery 2015;31:574–81.
  41. World Health Organization. Postpartum care of the mother and newborn: a practical guide. Report of a technical working group. Geneva: WHO; 1998.
  42. Klerman J, Daley K, Pozniak A. Family medical leave in 2012: technical report. Cambridge (MA): ABT Associates Inc; 2014.
  43. Grekin R, O’Hara MW. Prevalence and risk factors of postpartum posttraumatic stress disorder: a meta-analysis. Clin Psychol Rev 2014;34:389–401.
  44. Lu MC, Kotelchuck M, Culhane JF, Hobel CJ, Klerman LV, Thorp JM, Jr. Preconception care between pregnancies: the content of internatal care. Matern Child Health J 2006;10:S107–22.
  45. Gestational diabetes mellitus. ACOG Practice Bulletin No. 190. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e49–64.
  46. Gulati M. Improving the cardiovascular health of women in the nation: moving beyond the bikini boundaries. Circulation 2017;135:495–8.
  47. Mosca L, Benjamin EJ, Berra K, Bezanson JL, Dolor RJ, Lloyd-Jones DM, et al. Effectiveness-based guidelines for the prevention of cardiovascular disease in women—2011 update: a guideline from the American Heart Association [published erratum appears in Circulation 2011;124:e427]. Circulation 2011;123:1243–62.
  48. Rich-Edwards JW, Fraser A, Lawlor DA, Catov JM. Pregnancy characteristics and women’s future cardiovascular health: an underused opportunity to improve women’s health? Epidemiol Rev 2014;36:57–70.
  49. Challenges for overweight and obese women. Committee Opinion No. 591. American College of Obstetricians and Gynecologists [published erratum appears in Obstet Gynecol 2016;127:166]. Obstet Gynecol 2014;123:726–30.
  50. Management of stillbirth. ACOG Practice Bulletin No. 102. American College of Obstetricians and Gynecologists. Obstet Gynecol 2009;113:748–61.
  51. Burtle A, Bezruchka S. Population health and paid parental leave: what the United States can learn from two decades of research. Healthcare (Basel) 2016;4:30.
  52. American College of Obstetricians and Gynecologists. Paid parental leave. Statement of Policy. Washington, DC: American College of Obstetricians and Gynecologists; 2016.

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Optimizing postpartum care. ACOG Committee Opinion No. 736. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e140–50.

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