This story is part of SELF's ongoing series exploring black maternal mortality. You can find the rest of the series here.
On the University of North Carolina’s lush, sprawling campus, you’ll find a group of people determined to revolutionize postpartum care in the United States. The 4th Trimester Project, which is part of the Jordan Institute for Families within UNC’s School of Social Work, is using a multifaceted strategy to make the postpartum experience safer, more fulfilling, and easier to navigate.
The four-phase project has various aims, one being to create a website full of information for new moms, which launched in September. Another is to create postpartum care training programs that health care providers and systems can complete to earn a “4th Trimester seal of approval.” To help achieve these goals, the 4th Trimester Project has conducted research to identify gaps in postpartum care and propose realistic solutions; partnered with groups such as Black Mamas Matter Alliance, National Birth Equity Collaborative, Sister Song, and the American College of Obstetricians and Gynecologists (ACOG); and more.
Venus Standard is part of the expert team behind the 4th Trimester Project. As an assistant professor in the University of North Carolina School of Medicine’s Department of Family Medicine, Standard has a list of degrees trailing her name: C.N.M. (certified nurse-midwife), M.S.N. (master’s of science in nursing), A.P.R.N. (advanced practice registered nurse), and L.C.C.E. (Lamaze certified childbirth educator). She is also the founder and CEO of 4 Moms 2 Be, a perinatal education organization that offers Lamaze childbirth education, labor doula support services, and breastfeeding support in Greensboro, North Carolina.
Here, Standard explains why postpartum care is so important overall (and especially for reducing black maternal mortality), how far this care has come, and where we still need to go.
I recently held a maternal and infant health summit with the North Carolina Medical Society and brought in different speakers. One was Charles Johnson IV, whose wife, Kira, died hours after delivering their second son, Langston, in a C-section. Their children will now grow up without their mother.
Maternal mortality and morbidity seem to be on the tip of everybody’s tongue these days because the rates are increasing, and especially because of the exorbitant rates for women of color. But a lot of people don’t know that many maternal deaths happen not in pregnancy or delivery, but in the postpartum period.
The current medical approach is often to get a pregnant woman to term, if at all possible, and get a healthy baby out. Historically, it’s been: You had a baby. That’s the end of that. See you in six weeks for your postpartum checkup. But moms have needs after delivery, and some of those needs can be related to life-threatening health issues. The 4th Trimester Project is trying to bring that awareness of mothers’ needs back to the surface and change how we care for moms in the postpartum period.
Up until recently doctors suggested that all new moms go to their first postpartum doctor’s visit four to six weeks after giving birth. But a lot can happen emotionally, mentally, and physically in those first six weeks. Also, a lot of moms don’t even get into that six-week visit. Sometimes they don’t have access to adequate transportation, or by the time they get to six weeks, their lives have just moved on and coming back is hard. When people don’t make it to those visits, their health can go by the wayside. A mom could have diabetes or high blood pressure that needs to be cared for, and if no one touches her or puts eyes on her to see how she’s managing after delivery, that can lead to detrimental outcomes.
In May 2018, ACOG updated its guidelines to recommend at least one postpartum phone call or visit by three weeks. This revision was led in part by Alison Stuebe, M.D., who I work with on the 4th Trimester Project. But in the UNC Family Medicine group where I practice, which has two locations and an urgent care clinic, we actually do a three-day visit, a two-week visit, and a six-week visit. What’s great is that anyone can come in and be a patient—you don’t need a referral, and even if you don’t have insurance or are underinsured, we have a Charity Care Program to help cover medically necessary care like postpartum visits if you have trouble affording it.
Some of these visits are technically coded as a check on the baby, like the three-day visit—but the baby doesn’t come by itself. The baby usually comes with Mom, so we can get eyes on her as well. If we can identify a problem in those first few days, we can address it in those first few days. Maybe the mom is thinking, I just had a baby, I’m tired, I don’t feel good—meanwhile, her blood pressure is 200/120, which can cause a stroke. Those health issues can cluster and go out of control.
We also make sure at least one of those visits in the first few weeks is a home visit, which is such a key way to learn a lot more about what’s going on in a new mom’s life. Some people are private and don’t want to say when they’re in need, especially at a doctor’s office. But if we get to see a mom’s home environment, we might be able to see how she’s in need and clue her in to support in her community that she may not know she has access to, like food banks.
Having these extra visits means you have somebody checking that moms are doing okay. What we want is to make sure each mother is getting person-centric care and that her needs—medical, emotional, physical, and social—are being met. Care should be holistic, so we take a holistic approach when evaluating how she’s doing. Is she getting what she needs to be able to function not as one, but as two? Is breastfeeding satisfying and/or productive? Is she suffering from postpartum depression or does she have baby blues, which are normal? Did she have an uncomplicated birth? Does she have other comorbidities she needs to manage? What about birth spacing and her contraceptive needs? Does she have enough food and enough transportation? Does she have family support? Social support? A partner? If she has other children, is she hooked up to childcare? All of those things can impact a mom’s health.
More medical visits are part of the solution, but maternal mortality isn’t necessarily going to go down just because of that. It’s also about the quality of care, especially for black women. Unfortunately, maternal mortality in the African American community is three to four times higher than in white communities. Oftentimes, African American moms are not believed or not taken seriously when they voice their concerns, which can cause a lack of trust in the medical community.
This is part of why we have a unique approach to continuity in our family medicine group. We keep our mamas with the same three doctors throughout pregnancy so they can get to know them, bond with them, and trust them. At least one of these doctors will be guaranteed at each mom’s delivery (unless she goes into labor far before or after her due date), and those three doctors are also the ones providing her fourth-trimester care.
Then there’s the fact that, overall, we need more health care providers of color. I’ve come across multiple African American patients who have given me a bunch of additional information they didn’t give to a different provider because I’m also black and therefore they trust me. If a medical practice has no providers of color and the people working there don’t know they have to take care of this whole population differently, they’re deficient. In this case, what you don’t know can hurt you—and others. Apples aren’t apples when it comes to black moms. It’s just not the same. There are social, emotional, and traditional factors on the table that may not be there in other cultures, and that needs to be taken into account because it can ultimately affect people’s health. It can’t be one-size-fits-all.
We vow to do no harm as part of our work in health care, but our intent doesn’t always equal our outcome. That’s why we’re hoping our 4th Trimester Project format spreads and other practices pick up on it so families will still be together after birth, so mamas will still be there. It can be done with the proper tools and proper knowledge. Initially, it may be a little costly to implement new strategies, but if it turns a medical practice around and makes mamas and babies healthier, that extra cost is worth it. No one wants to have people dying in their practice.
I go to a lot of conferences around the country, even around the world sometimes. Fortunately, I’m noticing more and more people are talking about maternal mortality and morbidity. But we still have to do more and do better. We can’t continue to do the same thing we did before and think we’re not going to get the same result.
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