Focusing on the postpartum period to reduce maternal deaths

Even with more attention on maternal mortality, the nation continues to see far too many deaths related to pregnancy.

Dr. Cynthia Chen-Joea, a board member of the American Academy of Family Physicians, says more attention should be paid to the postpartum period to reduce maternal deaths.

Researchers have found a 28% increase in pregnancy-related deaths from 2018 to 2022, according to findings published Wednesday in Jama Network Open.

The study found a substantial increase in “late maternal deaths,” which occur between 42 days and one year after delivery. Nearly one in three (30%) pregnancy-related deaths occurred in that period. Cardiovascular disease was the leading cause of all maternal deaths, but cancer and mental or behavioral disorders were top factors in late maternal deaths.

Researchers found ongoing disparities in maternal mortality by race. Black women were nearly three times more likely to die of pregnancy-related causes than white women. The maternal mortality rate was 3.8 times higher among American Indian and Alaska Native women, compared to white women.

• Read more: Black maternal health: Addressing a national crisis

Dr. Cynthia Chen-Joea, a board member of the American Academy of Family Physicians, talked with Chief Healthcare Executive® in a recent interview about ways to improve maternal health. Four in five maternal deaths are preventable, federal officials say.

She cites many factors contributing to maternal deaths and complications, including a lack of access to prenatal care, and underlying chronic diseases that have been unnoticed or unmanaged. She points to the growing number of “maternity care deserts,” where communities and whole counties lack any obstetric care.

Too many don’t have family physicians, who could help women during their pregnancy and help monitor for complications after giving birth.

“I would say before pregnancy, during and after pregnancy, that a family physician can be really crucial and can help with their health care during that amount of time,” Chen-Joea says.

She also points to the need for more care after delivery, which is a time when some women suffer complications that, left unchecked, can be serious and even life-threatening.

In discussions of maternal health, much of the focus involves prenatal care and making sure that patients have a safe delivery. But Chen-Joea says it’s time to pay more attention to the weeks and months after a woman gives birth.

“The postpartum period is incredibly important, too,” she says. “And I think sometimes that is overlooked.”

Women face significant challenges in those weeks and months after giving birth.

“That postpartum body is going through an immense hormonal, physical, emotional change,” Chen-Joea says.

Chen-Joea recalls here own experiences after having a baby almost two years ago, and describes the challenges of those months after delivery.

“That fourth trimester was by far the most difficult time I have ever gone through in my life as a physician, as a person,” she says. “I would say, harder than my 30-hour calls in training, or my 120-hour work week … when you're physically going through all of those changes, it is indescribable.”

And she says it was difficult for her as a physician, with strong support, access to resources and insurance.

“Imagine for someone who maybe doesn't have regular transportation, doesn't have a car, doesn't have access to nutritious foods, doesn't have support, maybe is under-insured, you can imagine that what that person is going through in their struggles, and it is no wonder that the maternal health equity gap is so huge in the U.S.,” Chen-Joea says.

Family physicians can help patients stay safe during, and especially after giving birth, she says.

“We're really here and can help you through pregnancy and this postpartum period, because we know your diseases. We know what's going on with you. We can provide early screenings and detections,” she says.

As Chen-Joea notes, patients who have just had a baby also may be grappling with other factors addressing their health, including poverty, food insecurity or a lack of stable housing. Some patients may not have access to transportation, which may impede them from getting postpartum services. Health systems and hospitals need to identify those patients who may have such challenges and help connect them to resources for assistance.

Many deaths in the postpartum period are tied to mental health issues, including substance abuse, Chen-Joea says. Family physicians are trained to detect those issues, including postpartum depression and suicide ideation. The newly published study in Jama Network Open found mental and behavioral health issues, including drug and alcohol use, contributed to about one-fifth (21%) of late maternal deaths.

Chen-Joea says family physicians can help provide additional support

“We're able to really help with optimizing that care, including mental health screenings, during the postpartum period,” she says.

Hospitals and health systems can help improve maternal health by talking with physicians to find out what patients need, and those supports could involve greater access to behavioral health services or resources to address other needs. For patients in remote areas, providers may want to utilize telehealth to contact patients who don’t have easy access to a physician or clinic.

“I think having the space to hear physician feedback about what we can do to better care for our patients is really important,” Chen-Joea says.