The Case for Home Visits In Postpartum Care
Olga Mecking, who lives in The Hague in The Netherlands had care from a postpartum nurse, called a kraamzorg, for eight days after the brith of her son for 5 to 8 hours every day. During home visits, Mecking says her nurse weighed and measured the baby, checked how much they pooped, helped with getting breastfeeding going, and helped give the baby a bath. She also performed duties to generally make things easier for mom: "She made sure I was OK, made me tea and fruit salad, played with my other kids, went shopping, made the beds, did the laundry, cleaned the floors, and the bathrooms," recalls Mecking.
"It was awesome," she says. "In fact, six years after my son was born, I still miss her."
In 2018, the American College of Obstetricians and Gynecology began pushing for changes in postpartum care, driven by the belief that the future of maternal care should include a three-week postpartum visit as a standard of care.
This is three weeks earlier than most new moms in the United States were being seen. Unless moms were deemed high risk, it was typical to discharge patients after delivery with an appointment for a follow-up six weeks later.
The U.S. has the worst maternal mortality rate in the developed world. The new guidelines suggest that, in addition to having initial contact at three weeks postpartum, mothers should have continued contact with their doctors until 12 weeks postpartum. Open access to healthcare during this time could provide support for mothers when they need it the most, addressing perinatal mood and anxiety disorders as soon as symptoms arise and monitoring for potentially life-threatening conditions like postpartum preeclampsia.
According to ACOG, only 40 percent of moms are attending a postpartum checkup.
For Anna Hithersay, a 37-year-old mom of three living in Dallas, Texas, who has had two vastly different postpartum experiences, changes to postpartum care made all the difference in how she adjusted to new motherhood. After her first birth, the birth center’s standard was to do a six-week checkup on site. By the time she arrived at the appointment, she was dealing with significant pain from a third-degree tear, experiencing severe anxiety, and struggling to breastfeed.
“Six weeks feels arbitrary since it was too late for catching breastfeeding troubles, my depression and anxiety was already well established, yet my birth wounds were not fully healed,” she tells Romper over email. “I also felt like I was bothering the midwives because I could have used their help sooner.”
The second time around, she was scheduled for a check up at three weeks postpartum and then again at 12 weeks. She was screened for postpartum mood disorders, prescribed medication, and referred to a therapist. Her care provider helped her troubleshoot breastfeeding issues. By the time her 12-week appointment rolled around, they were able to monitor her progress on medication and in therapy.
“Having experienced both, I think the three-week check played a vital role in my depression being treated quickly,” she shares. “I am not one to reach out with a lot of questions and concerns. Having that three week appointment meant that I, as a reluctant patient, got my needs met without having to overcome the anxiety of calling in my concerns.”
This is clearly a good idea, but it isn’t without challenges. The most obvious at this point being getting moms to their appointments. According to ACOG, only 40 percent of moms are attending a postpartum checkup. Thinking back to my own postpartum experiences after their births of three children, I have visions of trying to perfectly time feedings to get out the door, of being utterly exhausted and overwhelmed, and feeling that a postpartum visit was just one more thing on my rapidly growing to-do list. Once I arrived, there was a crying baby in the office and a toddler jumping on the waiting room seating. I was being hurried through a system that couldn’t possibly capture what my life looked like with a 15-minute office visit. Postpartum visits were incredibly difficult for me to pull off, and I live near a major metropolis. How much harder is it to pull off for mothers living in rural areas?
In places like UK, New Zealand, and Australia, home visits are a standard of care that solve this accessibility challenge. Senior midwife and international virtual Maternity Consultant Kathy Fray, who is based in New Zealand, has seen mothers as many as six times during the first few weeks of postpartum. Her comments reveal how far America has to go to provide postpartum care to mothers that is truly adequate.
“At an absolute minimum, the woman should be seen within 24 to 48 hours of arriving home, and her baby absolutely should have a detailed assessment at around day 5 to 6, then again at around day 10 to 14 (if just to monitor weight-loss and weight-gain) from the successful establishment of breastfeeding,” she says. “In reality, the mother should not even be discharged home until she is feeling fully confident with her breastfeeding competence.”
A 2018 study in the Journal of Clinical and Experimental Investigations, researchers took a close look at how postpartum home visits could improve maternal quality of life. Beginning at week two after birth, mothers were visited in their homes for postpartum care, parenting support and mental health and quality of life assessments. Over the course of 12 weeks, they exhibited steady improvements in depression and quality of life scores, suggesting that the home visit care they received was effective.
“The logistics of trying to get out of the house, depending especially on if you had a c-section or if you have transportation,” says Dr. Diana Ramos, M.D., OB-GYN, and co-chair of the National Preconception Health and Health Care Initiative. “There are more logistical challenges that new moms face.”
"The midwife who came most often was the community midwife whose care I had been under since conception," Clementine Wallop, a 35-year-old mom of one living in London shares. "She is a really warm, funny, kind woman and seeing her was really reassuring; I also trusted her colleagues because of how good she was."
Wallop's experience was exceptional in that she had the opportunity to see the same midwife time and time again. This is a practice the NHS is working to adopt, but isn't common in many parts of Britain, according to Wallop. Mothers who have unique risks factors, like an abusive partner or struggles with addiction relieve additional care, she says.
At this time, home visits are not widely available in United States. There are some organizations that provide visits, like the Health Resources & Services Administration, or HRSA, which provides maternal, infant, and childhood home visits to families who are in at-risk communities. Medicaid also partners with HRSA to provide home visit support to their beneficiaries. Ramos mentions there are certain private healthcare provides who will reimburse for a home visit and that some plans are exploring what it would look like to implement follow-up visits by a doula.
At an absolute minimum, the woman should be seen within 24 to 48 hours of arriving home.
However, making home visits a wide-spread practice for new mothers likely isn’t a realistic expectation in America. Dr. Ramos points out the vast differences between healthcare in countries providing home visits, like the UK or New Zealand, and here in the United States. New Zealand has a single-payer model for health insurance, which means taxes are distributed to cover care for everyone, while the United States does not have a universal healthcare system, which means the type of care, and quality of care, can vary greatly from plan to plan and person to person.
It’s not all bad news, however. Changing technology is presenting a lower cost and practical option that is definitely worth exploring as an option for new moms — telemedicine for postpartum care.
“Technology is getting to the point, that, why not take advantage of the technology that works. It doesn’t work for everybody, sometimes you do have to see the patient in person depending on their condition,” says Ramos, explaining that a postpartum tele-visit could be a phone call or a video conference.
In 2019, The Journal of Medical Internet Research published their findings after enrolling mothers in the postpartum period in an optional videoconference program for postpartum psychiatric care. Participants reported being highly satisfied with this option, which was estimated to save mothers 2 and a half hours of travel and time, and an average of $26 in travel and childcare expenses.
Telemedicine may not be right for all mothers, but it does provide an option for many and could be especially helpful for families navigating weather changes that make it difficult to travel or who live in rural areas with limited access to care.
Ramos is clear that this isn’t a second-best option. It is a matter of providers settling for an alternative because we can’t pull off home visits in the United States. In many situations it might be the best care option, making a one-on-one conversation with a provider convenient and affordable while giving the provider access to the mother, her child, and their home without the added difficulty of travel or the anxiety a mother might face with a visitor in her home. Like many options, telemedicine home visits have their limitations, but for many families they could provide access to care where other options weren’t accessible, were too costly, or too difficult to pull off during the early days of postpartum life.
Whatever it takes to ensure new moms are less alone.