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How Primary Care Fails New Mothers

Imagine that you are covering for a colleague over the weekend, and you get call from a patient.

The patient is a 36-year-old woman who is 3 days postpartum after a spontaneous vaginal delivery. She has a headache and just arrived home after hospital discharge. She’s calling because after using the blood pressure cuff that the hospital sent her home with, her reading is > 150/90 mm Hg, indicating that she is hypertensive.

You try to pull up her records but realize her delivery hospital isn’t part of your system’s electronic health record. What do you do?

This scenario was presented at a session of the annual meeting of the Society of General Internal Medicine during a panel focused on providing care in the fourth trimester as patients transition between ob/gyn care and primary care.

“If you send her to the emergency room, she might get sent home,” Chloe Zera, MD, MPH, a maternal-fetal medicine specialist at Beth Israel Deaconess Medical Center, said. “I would strongly recommend you figure out where she delivered and tell her to go back there because she will almost certainly get readmitted for blood pressure control.”

When stepping in to treat someone who recently gave birth, Zera said that clinicians have to be mindful that though many of the deaths of mothers and infants occur on the day of birth, a substantial proportion occur within the first 6-7 weeks postpartum. Clinicians must be aware of possible complications and ask probing questions if they don’t have a patient’s medical records at hand.

“Maternal mortality is a crisis in the United States, which is probably reflective of the sort of social and political realities we’re living in right now,” Zera, an associate professor in obstetrics, gynecology and reproductive biology at Harvard Medical School, said. “About 700 women die each year in the US from a pregnancy or its complications.”

Zera recommended that clinicians ask about a patient’s birth story specifically, at how many weeks they gave birth, what kind of delivery they had, and whether they were they induced for any reason.

“Everybody’s birth story is really important in their lives, people know the details and want to talk about their birth stories,” she said.

Starting Point

Clinicians should start out by asking questions regarding how the patient delivered but also how much their baby weighed at birth.

“Both really small and really large babies are associated with later maternal complications,” Zera said. “For example, an 8-lb baby at 34 weeks is off the charts while at 42 weeks, that’s totally normal.”

Clinicians should also ask about complications prior to the birth, which might include questions regarding high blood pressure, blood sugar concerns, hospitalizations before birth, length of stay for the birth, and whether their infant had a neonatal intensive care stay.

Any of these factors can weigh into adverse pregnancy outcomes. Experiencing a hypertensive pregnancy, for example, can put patients at a higher risk for cardiovascular events, and up to 10% of all pregnancies are complicated by hypertensive disorders.

Women who experience preeclampsia have two to four times the risk for coronary heart disease.

Hypertensive pregnancies can also result in patients developing posttraumatic stress disorder, anxiety, and even producing less milk, according to Ann Celi, MD, MPH, an internal medicine specialist at Brigham and Women’s Hospital.

More Questions

Celi, who spoke on the panel, runs a clinic that helps people transition back to a primary care provider after a hypertensive pregnancy. She said that she wants to help clinicians better manage the shift.

Clinicians can probe patients on how much sleep they’re getting and whether a support system is present back at home. These are all related to the recovery process, and Celi recommended that clinicians encourage their patients to prioritize asking for help from external sources.

“Bring in your community: ‘Do you have some best friends from work or somebody who might be able to help with meals? Is there someone in the family that could travel to help [you] as [you’re] recovering? Is the father of the baby involved? Can they help?'” Celi, offering question suggestions for clinicians to ask, said.

Celi also recommended that clinicians prescribe hypertensive-friendly birth control options as part of a follow-up care plan, such as progestin-only birth control pills.

They also recommend that clinicians evaluate women with a history of preeclampsia 3-6 months after a birth for cardiovascular risk factors, with an annual follow-up on blood pressure, body mass index, fasting glucose or A1c, and lipids.

Follow-Up Care

“At least 40% of people don’t even make it to that 6-week visit, and we lose them,” Zera said. “It turns out, having a pregnancy complication does not make it any more likely that you’re going to come to your postpartum visit.”

For some patients, insurance coverage often changes after delivery. For example, in states without a Medicaid extension or expansion, the program is only required to provide 60 days of coverage after delivery. Even among patients with commercial insurance, churn rates are high. People may quit their jobs and switch to their partner’s insurance or get a new job with a different insurance plan. If the new insurance doesn’t include the patient’s established clinician, they may switch clinicians or skip the follow-up appointment entirely.

Another barrier to care is patients feeling like their doctors don’t care about them, Zera said.

“This is kind of simple stuff, but bond with your patients,” she said. “Tell them, ‘I want to see you when you’re pregnant and beyond,’ because that makes a huge difference.”
No relevant financial relationships were reported.

Society of General Internal Medicine 2023 Annual Meeting. Presented May 11, 2023.

Kelly Ragan is a journalist living in Colorado.

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