A CMO Guide to Caring for New Moms in the 'Fourth Trimester'

Women with high-risk pregnancies often need management of chronic medical conditions after childbirth such as high blood pressure and cardiovascular disease.

Adverse outcomes in maternal health are a national concern.

The maternal mortality rate in the United States is significantly higher than the maternal mortality rate in other high-income countries, according to a report published by The Commonwealth Fund.

Scripps Health's Fourth Trimester Continuum of Care program provides optimized care for new moms with high-risk pregnancies, particularly women with chronic medical conditions.

The "fourth trimester" is a critically important time period for new moms, according to Sean Daneshmand, MD, medical director of the Scripps Clinic Maternal-Fetal Medicine Program.

"We think of pregnancy as having three trimesters—three consecutive blocks of time that are three months each," Daneshmand says. "However, there is also an important block of time for moms after they deliver, which is what we refer to as the fourth trimester."

Launched last fall, the Fourth Trimester Continuum of Care program focuses on women who have high-risk pregnancies. Many of these women have chronic medical conditions such as high blood pressure, diabetes, and cardiovascular disease. Daneshmand describes the program as more of a continuum of care than a clinic.

"This program involves setting up a new system and streamlined process to identify at-risk moms before they give birth," Daneshmand says. "We help high-risk moms receive the care that they need from their primary care physician in a timely fashion shortly after they deliver."

In the United States, most new moms get two visits with their obstetrician-gynecologist after delivering their baby. Particularly for new moms with chronic medical conditions, two postpartum OB/GYN visits are insufficient to provide quality care, Daneshmand explains.

"The Fourth Trimester Continuum of Care puts more structure and focus on care, so we can be more proactive on how we take care of our high-risk new moms," Daneshmand says. "The goal is faster care and as many doctor visits as needed after delivery to get new moms on the right track. These visits can be provided virtually or in-person."

The Fourth Trimester Continuum of Care program identifies high-risk new moms and connects them with care. The patients are flagged in the EMR as needing proactive follow-up from their primary care physicians soon after delivery.

"During a baby's pediatrician visits, the pediatrician proactively asks the mom about her health, which helps new moms get the care they need faster," Daneshmand says. "There is close collaboration between my division, maternal-fetal medicine, and primary care."

Although most medical services offered through the Fourth Trimester Continuum of Care program are provided by primary care physicians, some new moms are referred to specialists such as cardiologists and endocrinologists, Daneshmand explains.

It is too soon to have data showing the impact of the Fourth Trimester Continuum of Care program, but the primary goal is reducing chronic medical conditions experienced by new moms, according to Daneshmand.

"We're hoping to reduce chronic health conditions such as pre-eclampsia, where blood pressure rises during pregnancy," Daneshmand says.

Ghazala Sharieff, MD, MBA, is executive senior vice president and chief medical and operations officer of acute care at Scripps Health. Photo courtesy of Scripps Health.

CMO perspective

CMOs should be concerned about the continuum of care for pregnant women, according to Ghazala Sharieff, MD, MBA, executive senior vice president and chief medical and operations officer of acute care at Scripps Health.

"We need to think about pre-pregnancy because if women are going to plan pregnancies, we want them to be as healthy as possible," Sharieff says. "Then if we have high-risk pregnancies, we want those moms to meet with specialists such as Dr. Daneshmand, so we can manage high-risk pregnancies."

At Scripps Health, hospital caregivers are focused on providing quality care to new moms with chronic medical conditions, Sharieff explains.

"When a pregnant woman comes into a hospital with a chronic condition, if they need a hospitalist to co-manage their condition, we can provide that kind of care," Sharieff says. "Some of our moms end up in the ICU, so we have our ICU staff work hand-in-hand with Dr. Daneshmand."

CMOs should also focus on the fourth trimester, according to Sharieff.

"There is good reason for CMOs to start thinking more proactively—not just during a pregnancy but also after delivery, so we can get moms feeling as good as they can feel," Sharieff says.