The fourth trimester: When moms need us most

As a neonatologist and pediatrician, I’ve seen firsthand how the U.S. health care system is falling short in providing equitable, high-quality care for women, mothers, and newborns.

I’ve cared for preterm infants whose mother’s hypertension went untreated because she couldn't afford the copays or get time off work for prenatal visits. I’ve sat with a new mom having thoughts about harming herself and her baby as she explained why she was scared to speak up and get help. I’ve had to tell parents their child is developmentally delayed, knowing the outcome could have been better had they been able to access care sooner.

Sadly, as my colleagues across the country can attest, these stories are far from the exception. Maternal health in the U.S. has long been a national disgrace, and it's only getting worse. Cost pressures, staffing shortages, and policy battles have led hundreds of labor and delivery wards to shut their doors, exacerbating an already dire situation. The American College of Obstetricians and Gynecologists, observing its fourth annual Maternal Health Awareness Day on Jan. 23, describes the access crisis as "nothing short of catastrophic."

Efforts to respond to the crisis — including workforce development programs, community-based maternity services, and calls for payment reform and policy changes — have largely focused on restoring providers and facilities to so-called maternity care deserts, especially in rural areas. This is important work, but it may be years before these communities see the impact. Women and babies everywhere need more support today — and virtual care has to be part of the answer.

Maternal health is not the most obvious use case for telehealth; childbirth and most hands-on OB-GYN and neonatal care will always need to be done in person. But many other critical touchpoints in perinatal care — ranging from prenatal check-ins to postpartum screening — can be just as effective when done virtually, if not more so. In far too many cases, they aren't being done at all.

In fact, virtual care is especially well-suited to meet the current crisis head-on. For women in maternity care deserts without ready access to providers, virtual care is a lifeline to clinical expertise and vital pre- and postnatal support. Just as important, even in areas with adequate local facilities, the ability to meet virtually with providers in far-off locations offers a safe and supportive harbor to women of color, individuals who identify as LGBTQ+, and others who are denied care in their community — or are fearful of seeking care — due to racism and unconscious bias. Most important of all, given the scope of the current crisis, virtual care can be scaled broadly and quickly.

The untapped potential of virtual care in maternal health spurred me to expand my practice into the digital realm. In 2019, when telehealth was still a footnote in healthcare, I joined a virtual specialty practice and now oversee multidisciplinary care teams that provide comprehensive support to pregnant individuals and new parents nationwide, while still serving as an attending neonatologist in Massachusetts. With a foot firmly in both worlds, I recognize more than ever the urgent need to integrate in-person and virtual care and scale new models to meet people where — and wherever — they are, at every step of their journey.

In my virtual maternity and newborn program, which partners with health plans and employers, the journey begins with proactive outreach. When our care teams are notified that an individual is pregnant (usually in the first trimester), a case manager reaches out to ensure they have sufficient access to in-person providers and are aware of the full range of services and support available to them under their benefits plan. (Note the individual and pronouns: Transgender people, as well as same-sex couples, often face added barriers to maternity care but tend to be sidelined in the access crisis discussion.) Critically, thanks to the efficiencies that come with being a virtual team, we have the capacity to engage all pregnant individuals, not just those who fall into a high-risk category. This reach enables our team to have the highest impact on the greatest number of people, increasing the odds of full-term pregnancy and a healthy first year of life for newborns and parents.

In the weeks and months leading up to childbirth, our team supplements in-person care with regular check-ins, educational resources, and communication — and we continue for up to 18 months after the child is born. In the first year after delivery, an especially vulnerable time for new parents, we support neonatal and pediatric care as well as ongoing maternal care. Sometimes the most important thing is time and attention; care team members are available on demand to offer advice, emotional support, help with sleep and feeding, and answers to the myriad other questions that come up between 15-minute well-child visits. When needed, we arrange follow-ups with pediatricians and ob-gyns and coordinate referrals to specialty care, both virtual and in person.

Postpartum depression is a prime example of how this integrated approach closes gaps in care. Roughly 1 in 7 women meet the criteria for postpartum depression, but as many as half of those women go undiagnosed due to skipped or sporadic screening. (As with so many aspects of maternal care, Black women in particular are less likely to be diagnosed and treated.) Frequent interactions with virtual teams between in-person visits create additional opportunities to identify signs of postpartum depression — as well as, for some people, a more comfortable space to discuss their mental health. More than one-third of the individuals enrolled in our virtual program have received a postpartum depression diagnosis; 55% of those cases were first identified by our care team — a number which says as much about the constraints on overtaxed in-person providers as it does about the value of wrap-around support.

Giving birth and caring for an infant is hard, and it’s even harder with postpartum depression or other complications in the mix. Aside from closing gaps in care, integrated care models provide added capacity to address the many non-clinical challenges that lie beyond the traditional scope of ob-gyns, pediatricians, and neonatologists. Navigating health benefits and preauthorization, negotiating bills, scheduling follow-ups, arranging transportation to appointments, finding formula — the million things, big and small, that can easily slip through the cracks are just as essential to the health and well-being of parents and babies as high-quality clinical care. This comprehensive social support, previously limited to high-risk, high-need populations — or, at the other extreme, high-end concierge services — is now available at scale to millions of women.

As a neonatologist, I see and feel the impact I have on newborns and families each day. But I'm all too aware of how little I can do for them after they leave the NICU — and of how many mothers and babies don't make it that far. As clinicians and citizens, it's our responsibility to use all the tools and technology at our disposal to ensure that families everywhere have access to the care and support they deserve and so desperately need.

Dr. Jennifer McGuirl DO, MS, oversees newborn, NICU and complex pediatrics care and case management at Included Health. In addition, she practices as a neonatologist at UMass Medical Center and Lecturer at a Harvard Medical School.