The ‘Fourth Trimester’: The Importance of Continued Care After Birth

Local organizations are advocating for a “fourth-trimester” approach to help mitigate complications after birth.

“It’s not just the pregnancy that is important but taking care of the mother’s physical and mental needs after birth,” said Dr. John Coté, a physician with CHI Health.

Life-Threatening Conditions Common

A growing number of women are developing hypertensive disorders due to an increase in obesity and diabetes. 

In 2021, the Centers for Disease Control and Prevention reported the hypertension mortality rate for Nebraska was 16.7 per 1,000 individuals. The only state with a higher rate was Mississippi.

“[Hypertension disorders] can appear at any time,” said Dr. Ann Anderson-Berry.

Anderson-Berry, among other appointments, is the medical director for the Nebraska Perinatal Quality Improvement Collaborative (NPQIC). In 2019 NPQIC launched the Severe Maternal Hypertension Initiative in collaboration with 28 hospitals, which included discharge education and recommended follow-ups.

Unfortunately, this initiative may not reach individuals who are statistically more at risk; Black women are three-to-four times more likely to die from preventable pregnancy-related complications.

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“There’s a lack of knowledge about the resources and a lack of trust in the health care system,” said Shanika King, who co-founded A Mother’s Love with Nikeya Traynham.

Sharing Knowledge

Jaime Bland, CEO of CyncHealth, said many Black and minority women are less likely to have a personal physician for a multitude of reasons.

“Without a single physician to oversee the patient’s health, gaps in care can occur,” she said.

Recognizing this, CyncHealth created the Maternal Health Program of Nebraska.

“Partnering with Innsena, a health technology consultancy, and our technology partner, PointClickCare, we designed the program to make it easier for doctors and care teams to identify at-risk mothers and infants, and more easily share information and insights before, during, and after delivery,” Bland said.

The pilot program was launched in Omaha in 2022, and as of early 2023 has been rolled out statewide.

Calling Friends, Family

Anderson-Berry said another way we can improve outcomes for Black and minority women is by giving “women a voice.”

NPQIC is partnering with I Be Black Girl and the Nebraska Black Doula Collective to train culturally-matched doulas in hopes of empowering Black and minority women with high-risk pregnancies.

“We’re hoping to see doulas improve outcomes and give patients the voice to ask questions they’re too scared to ask or raise concerns when symptoms arise,” Anderson-Berry said.

The initiative, funded through the CDC with matching support from UnitedHealthcare, will provide training for 40 Black women.

“We were hoping for eight applicants … we had over 100,” Anderson-Berry said.

Barriers to Care

Unfortunately, many state health insurance plans do not cover doula services, despite research that shows it can improve pregnancy outcomes and increase cost savings.

Through the Culturally Matched Doula Support Initiative, 30 Black and minority women from high-risk ZIP codes will receive support from the newly trained doulas.

Another challenge is advocating for peripartum depression screenings, not only at hospitals and birthing facilities but at providers’ offices.

“Through The Maternal Health Program, we’ve seen that mental health disorder is far and away the most common reason that postpartum women are admitted to the emergency room,” Bland said.

Earlier this year the Policy Center for Maternal Metal Health, in collaboration with George Washington University, released the inaugural Maternal Mental Health State Report Card. It looked at three categories: providers and programs, screening and reimbursement, and insurance coverage and treatment payment.

Nebraska scored an “F,” while the U.S. as a whole scored a “D.”

Contributing to the problem is a national shortage of mental health care providers and a question of reimbursement for other health care providers.

Through its Perinatal Depression Screening Initiative, NPQIC works one-on-one with hospitals and providers to install time-efficient screenings.

Holistic Care

At A Mother’s Love, which focuses on Black and minority women, mental health is more nuanced.

“There’s a lot of stress because of the different socioeconomic disparities,” King said.

For example, figuring out how to financially support a new family member is stressful for anyone. It’s heightened for individuals who lack insurance or paid time off; Individuals who come from cost-burdened households, or lack a solid support structure.

The team identifies these stressors early and then plugs in resources like free financial literacy or homeowner classes. They provide supplies such as diapers, baby clothes, and hygiene products at their office.

“A little stressor to somebody can be a big stressor to someone else,” Traynham said. 

Doula support, which costs between $1,000 to $2,000, can include meal prep, light cleaning, and newborn care while the mom takes a nap, shower, or eats.

Coté said the increasing number of employee assistance programs is an indicator that businesses understand the importance of their employees. However, he said a step further would be paid time off, regardless of business size.

“Sometimes it can be a hassle if you’re looking at it from the lens of a business, but, hopefully, businesses understand that if their employees are healthy then they do well at work,” he said.

Returning to Work

Job searching can be stressful at any stage in an individual’s life. However, a parent returning to the workforce after an extended absence needs to know how to navigate conversations that can easily cross into unprofessional territory, for both interviewer and interviewee. We asked two experts for their top tips.

What’s Best For You?

With a low employment rate and a growing economy, Frieze and Porter encouraged individuals to look for careers that are interesting and offer the desired work environment. Consider the schedule, benefits, and culture you feel is right for you and your family, and then match those desires to hiring companies.

Think Outside the Box

Think creatively and use your resume to highlight your unique skill sets and experiences.

“Emphasize transferable skills gained during your time away from work, such as organizational abilities, multitasking, and problem-solving skills acquired through managing a household,” Frieze said.

Likewise, volunteer work can demonstrate sought-after skills. Did you organize a fundraiser or event? Did you balance a budget?

“Don’t be afraid to list those you volunteered with as references,” Porter said.

She also recommended that if you’re using a chronological resume, title your time away as a “stay-at-home-parent” and note that you were self-employed.

Be Honest, Then Move On

Understandably, employers may have questions about the career gap. Don’t be afraid to address this in your cover letter, and the interview.

“Frame your break as a conscious choice to prioritize family while demonstrating your commitment and enthusiasm to re-enter the workforce,” Frieze said.

While it’s important to explain the absence briefly, both Frieze and Porter emphasized that details aren’t necessary.

“You are not obligated to go into details about your children, your situation, or if you have daycare,” Porter said. “If an employer presses you for that information, I would not consider them to be a viable employer.”


See our other stories in this Focus Section for Working Parents:

Child Care in Nebraska: How Community Support Can Make a Difference

Beyond PTO: Nebraska Companies Offering New Benefits to Parents