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Making the New Postpartum Visit a Gateway to Long-Term Health

Mary Caffrey
The president's panel at the American College of Obstetricians and Gynecologists' 2018 Annual Clinical and Scientific Meeting in Austin, Texas, discussed how to make postpartum care more value-based as women give birth at older ages and need team-based care.
More than 700 women die in the United States each year from complications in pregnancy and childbirth, at rates higher those seen in other developed countries. Despite expanded health coverage through the Affordable Care Act, racial disparities persist, according to the CDC.

Tackling these challenges means embracing solutions like telehealth, team-based care, and giving mental health equal attention during postpartum care, according to experts who spoke at the president’s panel, “The New Postpartum Visit: Beginning of Lifelong Health,” which opened the 2018 Annual Clinical and Scientific Meeting of the American College of Obstetricians and Gynecologists (ACOG) on Friday in Austin, Texas. ACOG President Haywood L. Brown, MD, of Duke University Medical Center, called on attendees to oppose health reforms that negatively affect patients, including limits on preventive services, access to care, or the doctor-patient relationship. “Our patients need the ability to go where they need to go,” Brown said.

This week, ACOG released a report citing the need to put more value on postpartum visits to reduce severe mortality and morbidity among new mothers. Specifically, the report called for payment models that prioritize social and psychological well-being and said all new mothers should have a visit with their obstetrician within 3 weeks after giving birth, followed by a comprehensive follow-up visit within 12 weeks.

For insights, Brown called on 3 speakers: Nancy G. Brinker, founder of the Susan G. Komen organization; Rear Admiral Wanda Barfield, MD, MPH, FAAP, a neonatologist and assistant surgeon general of the US Public Health Service; and Mary Norine “Minnow” Walsh, MD, FACC, who last month completed her term as president of the American College of Cardiology (ACC). As Brown and the speakers described, pregnancy often reveals underlying health problems that may affect women for the rest of their lives; Walsh described it as a “stress test.” Thus, it makes sense that postpartum care not be an afterthought but an opportunity to see whether conditions like depression or cardiometabolic problems have emerged, which will require long-term attention.

“We are redefining postpartum care, using pregnancy as a gateway to long-term health,” Brown said.

Eliminating Breast Cancer Disparities
Brinker told the story of how she founded the organization as a promise to her sister, who died of breast cancer in 1980. In those days, breast cancer carried enormous social stigma and was not discussed openly. Decades of raising awareness and more than $956 million for research have allowed the organization to play a significant role in the 38% reduction in breast cancer mortality between 1989 and 2014.

“Over the past 35 years, we’ve made remarkable progress,” she said. But the progress has not been the same for everyone. “Breast cancer mortality may be shrinking, but the death rate is still 40% higher for women of color,” she said.

Quoting the scientist Marie Curie, Brinker said, “I never see what has been done. I only see what remains to be done.” Her original promise to her sister, Susan, was to bring the breast cancer survival rate to 100%, and that will mean addressing disparities. Doing so will start with giving women better access to care, which Brinker said is the number one reason for gaps in mortality rates between groups. For all the achievements in science, Brinker said, the cost of care is keeping many of these advances from reaching the people who need them the most. It’s not just about cost—barriers such as transportation or lack of child care can keep women from seeking healthcare, both in the United States and worldwide.

It’s why much of the work that Komen does today focuses on patient navigation—ensuring patients know how to find services and timely follow-up. “For us that means a relentless focus on community care,” Brinker said. “We only want navigators to work with us who are already embedded in their communities.” Komen includes support for child care, transportation, meals, and addressing language barriers. Beyond breast cancer, Komen also supports screening for cervical cancer and increasing vaccination rates for human papillomavirus.

Community providers are best equipped to deliver screening, Brinker said, but in recent years they are hampered by conflicting messages in guidelines. A 2016 recommendation from the US Preventive Services Task Force that most women can wait until age 50 to have a mammogram, instead of age 40, has contributed to a decline in screening, she said. Proposed changes for cervical cancer screening will only lead to more confusion, she said. “Many women look for an excuse—they look for a reason not to get a test done,” Brinker said. “How many lives will be lost?”

With the changes afoot in healthcare policy, Brinker said physicians must advocate for patients to keep up downward trends in breast cancer and cervical cancer mortality. “Patient advocacy starts with leadership,” she said. “We can no longer see patient advocacy just be on the part of patients.”

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