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.”
Untangling the Challenges of Disparities and Mental Health
Barfield sees the crisis among women of child-bearing age from different vantage points: in her role at CDC, where she is director of the Division of Reproductive Health, she sees the data that show how complications are affecting women’s health as they bear children at older ages. She sees the data that show how many women are filling opioid prescriptions during pregnancy—between 14% and 22%.
But she also sees the mental health crisis up close—when she was on call recently, she was sent to help a new mother who showed up in labor at 26 weeks. After having no prenatal care, the 30-year-old mother didn’t make it past the hospital’s waiting area. The young woman had 2 other children, ages 6 and 8, that she had carried full term. What went wrong this time?
“She was homeless and living in a shelter,” Barfield explained. “She was afraid that if she revealed her pregnancy, she would be unable to stay in the shelter.” So, she kept her secret and received no care. On the morning she went into labor, her arrival at the hospital was delayed while she found someone to care for her 2 daughters.
Needless to say, “She was under a tremendous amount of stress,” Barfield said.
No effort to address disparities in maternal mortality and morbidity will succeed without recognizing the effects of poverty, racism, and substance abuse, Barfield said. Depression is particularly insidious, because it affects underlying chronic illness, contributes to lower use rates of contraceptives, greater use of tobacco and alcohol, and is associated with higher rates of anxiety, bipolar disorder, and suicide. While the underlying causes of pregnancy-related deaths vary greatly, 60% are preventable, Barfield said. It's essential to ask, Barfield said, “What can we do before, during, and after pregnancy to better care for our patients?”
How can the health system address rising levels of stress and substance abuse? If social determinants of health are known to affect outcomes, how do health systems respond?
Pregnancy offers an opportunity for the health system to make contact with women, and it’s critical that they not disappear after giving birth. “How are we going to make postpartum care an ongoing process, rather than a single encounter?” she asked.
“If you enrich the postpartum period, you enrich a woman’s health,” Barfield said.
A Team-based Approach to “Cardio-obstetrics”
Walsh told the attendees that just before the meeting, she had created the hashtag, “cardio-obstretics” to call attention to a growing need: she agreed with Barfield that more older women giving birth means more instances of pre-eclampsia, characterized by high blood pressure and signs of liver or kidney damage. Meeting needs of these women calls for a different approach than health systems used in the past, one that calls on cardiologists, obstetricians, nurse practitioners, social workers, and others in the health system to collaborate. “We need to form a community around the care of these high-risk women.”
Team-based care lends itself to value-based payment models that are gaining ground as the health system transitions away from fee-for-service reimbursement; Walsh noted that cardiology adapted earlier than many specialties since Medicare began penalizing hospitals for readmissions for heart failure and myocardial infarction before bundled payments gained traction in other specialties. Treating pregnancy and the postpartum period more holistically is good for women for the long haul, she explained.
“We really need to think of pregnancy as our first stress test,” Walsh said, though unfortunately the electronic health records she uses as heart failure specialist don’t yet automatically incorporate data from a woman’s reproductive history. “As a non-obstetric clinician, I can’t even enter an obstetric history unless I type it all out.”
But this could be changing. Walsh was just a co-author on a paper that discussed hypertension across a woman’s lifespan, she said the authors made the decision to use ACOG’s definitions of gestational hypertension rather than those from the ACC and the American Heart Association.
It’s a change from the days when only women with congenital heart issues would see a cardiologist during pregnancy. Today, it’s recognized that with rising obesity and diabetes, “high-risk patients should be treated in specialized centers.” The thinking is changing on whether cardiomyopathy that emerges in pregnancy could actually be a form of the familial condition.
Where does an obstetric practice begin? “You can recruit your own team,” Walsh said, and echoing Brinker, she added, “The navigator model works very well.”