Project aims to improve care in the ‘4th trimester’



The way Sarah Verbiest, Dr.P.H., sees it, postpartum care for new moms could use a little more respect.

“We see [childbirth] in movies all the time: It’s so exciting when a woman gives birth, and then the next thing you see is that she’s fitting back into her jeans and she looks fabulous and rested,” said Dr. Verbiest, executive director of the center for maternal and infant health at the University of North Carolina (UNC) at Chapel Hill.

Dr. Sarah Verbiest

Dr. Sarah Verbiest

“We perpetuate this myth that you’re supposed to feel great. It’s not true,” she said. “It’s a huge physical event that has been unattended and kind of downplayed for a long time, and I think a lot of women suffer because we don’t have the best advice to give them or we don’t talk about it.”

Dr. Verbiest and her colleagues at UNC are hoping to shake up the postpartum paradigm by better defining the gaps in care that occur in those first 12 weeks after childbirth or as they are calling this time, the “4th trimester.”

Defining postpartum care

The goal of the 4th Trimester Project is to bring together about 100 mothers, clinicians, researchers, and other stakeholders to identify ways to improve outcomes for mothers, infants, and families. Participants will gather in Chapel Hill, following the Breastfeeding and Feminism International Conference in March. There, experts will deliver state-of-the-art talks on what’s currently known about the six domains of postpartum care, and make recommendations for future research projects.

The six domains of postpartum care are:

• Physical recovery from childbirth.

• Mood.

• Infant feeding.

• Medications, substances, and environmental exposures.

• Sexuality, contraception, and birth spacing.

• Sleep and fatigue.


“The first step is connecting moms and researchers, coming to some agreement and enthusiasm about what needs to be studied,” Dr. Verbiest said. “We’re going to have a nice diversity of opinions around the table. It will be interesting to see what clinicians think is important and what moms think is important, and how those match up.”

A national survey of new mothers sheds light on some of the postpartum health issues. In a survey from the Childbirth Connection, released in 2008, more than 15 specific health problems were cited as new problems by 25% or more of the mothers during the first 2 months after delivery. At 6 months, many women continued to experience these issues, including stress (43%), weight control (40%), sleep loss (34%), lack of sexual desire (26%), physical exhaustion (25%), and backache (24%).

Drop-off in care

Although national efforts to promote breastfeeding and increase awareness of the potential for postpartum depression have emerged in recent years, many gaps exist in today’s postpartum care landscape, Dr. Verbiest said, including what she described as a “precipitous drop-off” in basic follow-up care during the first 3 months after giving birth.

New mothers are discharged from the hospital, and they don’t necessarily come back to see anybody for another 6 weeks. “Some women never come back for a visit. So they’ve had all this care, and we care about them so much when they’re carrying a baby, but once they have the baby, the focus is all on that baby, and not on mom,” she said.

Some clinicians and researchers may not view postpartum sleep and fatigue as an important issue to explore, but it’s something that affects quality of life for the mother and the family, as well as overall health and wellness, Dr. Verbiest said.

“It’s exhausting having your body completely change from a hormonal standpoint and being dedicated to this little being that doesn’t sleep very well,” she said. “But have we done a lot of research so we can provide moms with the best coping strategies?”

Dr. Alison Stuebe, who is also part of the interdisciplinary research team working on the 4th Trimester Project, saw this firsthand with one of her friends.

Dr. Alison Stuebe

Dr. Alison Stuebe

About a year ago, a longtime friend had her first baby, and required a cesarean for arrest of descent. “She said, ‘I cannot believe someone would cut me open and they’re not even going to see me in 6 weeks,’” recalled Dr. Stuebe of the department of obstetrics and gynecology at UNC.

“There’s a sense that it’s customary to see the women at 6 weeks, make sure they have birth control, and their partners are hoping that means they’re cleared to come home and have sex again,” Dr. Stuebe said. “That’s what the extent is for a lot of women, but there are a lot of things moms need in that time period. I do a lot of work with moms who are struggling with breastfeeding. It’s usually not purely an issue of how the baby is attaching.”


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