The Postpartum Visit: Is Six Weeks Too Late?
Am Fam Physician. 2005 Dec 15;72(12):2443-2446.
Aside from discharge planning in the hospital or a home nurse visit, a new mother may have no further contact with a physician until the six-week postpartum office visit. Blenning and Paladine discuss the traditional six-week postpartum visit in this issue of American Family Physician.1Although it is assumed that a six-week visit will improve the mother's ability to care for her newborn and allow her physician to identify disease processes associated with childbirth, few data support these claims.
The mother's ability to sustain breastfeeding from hospital discharge to the six-week postpartum visit is low. Although the World Health Organization encourages hospitals to promote exclusive breastfeeding, continuance is difficult when supplemental formula is sent home at discharge and the mother has minimal breastfeeding support.2
The discontinuation rate of breastfeeding at two weeks is approximately 25 percent, with most women citing a lack of confidence in their breastfeeding ability as the primary reason for stopping.3 The highest drop-out rate occurs during the first four weeks postpartum in women who are young, single, nulliparous, and have a low household income.4 In the first week post-partum, discontinuance is highest if there are problems with latching on, breast pain, or if the mother has perceptions of insufficient milk or a hungry baby.3
Individualized encouragement from a physician or nurse in the office has been cited as the primary reason why 55 percent of mothers continued breastfeeding up to 12 weeks postpartum.3 Furthermore, breastfeeding women who had an individual outpatient visit with a family physician within two weeks postpartum, followed by another visit at four weeks, were more likely to exclusively breastfeed for a longer duration.4 It is unclear whether additional primary care visits can overcome barriers such as poverty, the need to return to work or school, or cultural factors. It is known, however, that the six-week postpartum visit is too late for many women to discuss breastfeeding problems.
Adolescents may benefit from earlier post-natal evaluation and intervention because they significantly overestimate their post-partum support systems.5 Stress, depression, and poor self-esteem may present before the six-week postpartum visit and contribute to contraceptive discontinuance.6 Many women resume sexual activity by six weeks postpartum; therefore, early postpartum follow-up visits with adolescents may help physicians assess contraceptive compliance and discuss side effects as well as the prevention of unwanted pregnancies.
Although postpartum depression typically is thought to occur within three months after delivery, the Diagnostic and Statistical Manual of Mental Disorders, 4th ed., states that postpartum depression begins within four weeks after delivery.7 No specific guidelines exist for treating women with postpartum depression; however, certain women who are at higher risk should be identified before discharge and scheduled for an office visit sooner than six weeks postpartum. Factors such as uneasiness about hospital discharge, dissatisfaction with infant feeding method, lack of support, and recent immigrant status put women at higher risk of depression during the first week postpartum.8 Because the onset of postpartum psychosis typically begins in the first two weeks after delivery and is usually a manifestation of bipolar disorder,9 it is prudent to see women with bipolar disorder soon after discharge. Women with a history of postpartum depression are at particularly high risk of recurrence and may benefit from prophylactic therapy with close monitoring for treatment failure.9
Although quality evidence may not exist that the six-week postpartum visit is beneficial, evidence does suggest that some women may benefit from an earlier visit. While “better late than never” may be true in some situations, physicians need to recognize that the traditional timing of the postpartum visit may limit their ability to help some women. Further research is needed on the timing and content of the hallowed postpartum visit.
BARBARA S. APGAR, M.D., M.S., is clinical professor of family medicine at the University of Michigan Medical Center, Ann Arbor. She also is an associate editor of AFP.
DAVID SERLIN, M.D., is clinical instructor of family medicine at the University of Michigan Medical Center.
AMANDA KAUFMAN, M.D., is a clinical lecturer in family medicine at the University of Michigan Medical Center.
Address correspondence to Barbara S. Apgar, M.D., M.S., University of Michigan Medical Center, 883 Sciomeadow Dr., Ann Arbor, MI 48103 (e-mail: firstname.lastname@example.org). Reprints are not available from the authors.
1. Blenning CE, Paladine H. An approach to the postpartum visit. Am Fam Physician. 2005;72:2491–62497–8.
2. Ertem IO, Voto N, Leventhal JM. The timing and predictors of the early termination of breastfeeding. Pediatrics. 2001;107:543–8.
3. Taveras EM, Capra AM, Braveman PA, Jensvold NG, Escobar GJ, Lieu TA. Clinician support and psychosocial risk factors associated with breastfeeding discontinuation. Pediatrics. 2003;112:108–15.
4. Labarere J, Gelbert-Baudino N, Ayral AS, Duc C, Berchotteau M, Bouchon N, et al. Efficacy of breastfeeding support provided by trained clinicians during an early, routine, preventive visit: a prospective, randomized, open trial of 226 mother-infant pairs. Pediatrics. 2005;115:139–46.
5. Quinlivan JA, Luehr B, Evans SF. Teenage mother's predictions of their support levels before and actual support levels after having a child. J Pediatr Adolesc Gynecol. 2004;17:273–8.
6. Kershaw TS, Niccolai LM, Ickovics JR, Lewis JB, Meade CS, Ethier KA. Short and long-term impact of adolescent pregnancy on postpartum contraceptive use: implications for prevention of repeat pregnancy. J Adolesc Health. 2003;33:359–68.
7. American Psychiatric Association. Diagnositic and statistical manual of mental disorders 4th ed., text revision Washington, D.C.: American Psychiatric Association, 2000:387.
8. Dennis CL, Janssen PA, Singer J. Identifying women at-risk for postpartum depression in the immediate postpartum period. Acta Psychiatr Scand. 2004;110:338–46.
9. Wisner KL, Parry BL, Piontek CM. Postpartum depression. N Engl J Med. 2002;347:194–9.
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