Call for Improved Fourth Trimester Care After Stillbirth

Abstract

Women who experience stillbirth are at increased risk for severe maternal morbidity and mortality, which makes the postpartum period a critical time in which to address health conditions and prevent complications. However, research on the health care needs of women who experience stillbirth is scarce, and these women are often excluded from research on the postpartum period. Therefore, the purpose of this commentary is to identify gaps in the research on postpartum care after stillbirth, explain why current fourth trimester care guidelines in the United States are inadequate, and advocate for nursing research and practice to improve understanding of health care needs in the fourth trimester.

Precis

The fourth trimester is a critical time in which to prevent postpartum complications, yet women who experience stillbirth may not receive adequate care.

Stillbirth and Severe Maternal Morbidity and Mortality

Stillbirth, the death of a fetus after 20 weeks gestation, represents a significant public health challenge (American College of Obstetricians and Gynecologists [ACOG], 2020) and affected 1 in 175 births in the United States (N = 20,854) in 2020 (Gregory et al., 2022). Patients who experienced stillbirth had increased risk for severe maternal morbidity (Lewkowitz, Rosenbloom, López, et al., 2019; Wall-Wieler et al., 2019), mental health diagnoses (Lewkowitz, Rosenbloom, Keller, et al., 2019), substance use disorders (Lewkowitz, Rosenbloom, Keller, et al., 2019), and suicide (Lewkowitz, Rosenbloom, Keller, et al., 2019). Lewkowitz, Rosenbloom, López, et al. (2019) found that among women who gave birth at or beyond 23 weeks gestation, stillbirth increased the odds of severe maternal morbidity seven-fold for those without medical comorbidities (aOR = 7.05; 95% CI 6.27 – 7.93) and six-fold for those with medical comorbidities (aOR = 6.21; 95% CI 5.54 – 6.96). Similarly, Wall-Wieler et al. (2019) found a four-fold increase in the risk of severe maternal morbidity for women who had stillbirths compared to those who had livebirths after controlling for maternal demographics, medical history, and obstetric history (aRR = 4.77, 95% CI 4.53 – 5.02). Although public health efforts have increasingly focused on monitoring and reducing maternal mortality, stillbirth and its effect on maternal health outcomes have received much less attention and remain neglected by policy makers and funding agencies (Ali et al., 2023).

Callout 1

Accumulating data have demonstrated that stillbirth increased the risk of mental health conditions among women, including depression (Lewkowitz, Rosenbloom, Keller, et al., 2019; Westby et al., 2021), anxiety (Lewkowitz, Rosenbloom, Keller, et al., 2019; Westby et al., 2021), post-traumatic stress disorder (Westby et al., 2021), psychosis (Lewkowitz, Rosenbloom, Keller, et al., 2019), and suicide attempts (Lewkowitz, Rosenbloom, Keller, et al., 2019). In a recent systematic review, Westby et al. (2021) reported that depression, anxiety, and PTSD were consistently more common for women who had stillbirths than for those who had live births. Lewkowitz, Rosenbloom, Keller, et al. (2019) found the odds of a hospital visit for a suicide attempt within the first year after a stillbirth were three times greater than the odds after a live birth for women with no histories of psychiatric conditions (aOR = 3.16, 95% CI 1.78 – 5.62). Similarly, the odds of an inpatient or outpatient hospitalization for depression, anxiety, and psychosis were all greater for women who had stillbirths (aOR = 2.75, 95% CI 2.31 – 3.26; aOR = 2.29, 95% CI 1.93 – 2.70; aOR = 2.27, 95% CI 1.79 – 2.88, respectively; Lewkowitz, Rosenbloom, Keller, et al., 2019). Collectively, these findings highlight the importance of prioritizing mental health care for patients who recently experienced stillbirth.

In analyses to determine risk factors that overlap among stillbirth and severe maternal morbidity and mortality, researchers identified advanced maternal age, low educational attainment, non-Hispanic Black or American Indian/Alaska Native race (Arechvo et al., 2022; Wolfson et al., 2022); chronic health conditions such as diabetes, hypertension, and obesity (Wolfson et al., 2022); and pregnancy complications such as preeclampsia or placental abruption (Wolfson et al., 2022). According to data from Maternal Morbidity and Mortality Committees from 36 states between 2017 and 2019, 75% of pregnancy-related maternal deaths could be attributed to one of six causes: mental health conditions (22.7%), hemorrhage (13.7%), cardiac and coronary conditions (12.8%), infections (9.2%), thrombotic embolism (8.7%), and cardiomyopathy (8.5%; Trost, 2022). The recent push to improve rates of severe maternal morbidity and mortality in the United States offers a prime opportunity to improve postpartum health care for women who had stillbirths and are thus a high-risk group for severe maternal morbidity and mortality (Ahn et al., 2020).

Although some maternal deaths occur during pregnancy or birth, in the United States, approximately two-thirds (65.3%, n = 654) occurred during the first year after birth, according to Maternal Mortality Review Committee data from 36 states from 2017 – 2019 (Trost et al., 2022), which this makes the postpartum period or fourth trimester an ideal target for improving health outcomes for women who had stillbirths to improve their health in the postpartum period and beyond (Stuebe et al., 2021). The fourth trimester of pregnancy, a term that appeared in the nursing literature as early as the 1970s (Edwards, 1973; Kitzinger, 1975), now refers to the first 12 weeks after birth, a time when a new mother must make a transition from pregnancy-related health care to primary care (Paladine et al., 2019). The increased risk for complications following stillbirth suggests that this is a vulnerable time, and women who experience stillbirth need interventions to improve their health outcomes after birth. Therefore, the purpose of this commentary is to identify gaps in the research on postpartum care after stillbirth, explain why current fourth trimester care guidelines in the United States are inadequate, and advocate for nursing research and practice to improve understanding of fourth trimester health care needs.

More Research is Needed on Postpartum Care After Stillbirth

Little is known about health interventions for women who have stillbirths, particularly if they are not related to the mental health consequences of the stillbirth. In 2013 in a Cochrane review, Koopmans et al. identified no randomized controlled trials on health outcomes related to stillbirth and highlighted the need for more research into interventions to provide appropriate support for mothers and families after stillbirth. Later, Huberty et al. (2017) found only two intervention studies suitable for inclusion in a review of interventions designed to target the mental or physical health outcomes of women who had stillbirths. Moreover, despite the strong associations between stillbirth and poor physical health outcomes, most research has been focused on identification of women at risk for stillbirth (Henry et al., 2021) or stillbirth-related psychological distress, rather than physical health-related outcomes (Huberty et al., 2020). Moreover, women who have stillbirths are often excluded from postpartum research, even if the research is related to physical, rather than mental, health needs (Tennfjord et al., 2020).

Women who participate in stillbirth research consistently express satisfaction with their participation and may even find participation therapeutic, yet institutional review boards and health care providers are reluctant to include bereaved women bereaved by stillbirth in research (Cronin et al., 2020). Cronin et al. (2020) recruited women who had stillbirths for a case-control study wherein obstetric providers assisted with study recruitment by informing their eligible patients about the study and obtaining permission for contact by the study team. Post-study analysis of recruitment data demonstrated that when obstetric providers declined to discuss the study with an eligible woman, they cited concerns for emotional distress in nearly half of the cases (48.3%; 29/60; Cronin et al., 2020). However, when eligible women declined participation, they cited emotional distress as their reason only 8.4% of the time (Cronin et al., 2020). Cronin et al. (2020) concluded that it seemed providers were more concerned than bereaved women that study participation would lead to increased emotional distress and should thus be avoided Similarly, institutional review boards have historically cited concerns about increased emotional distress for bereaved women as a reason to restrict their recruitment for research (Cronin et al., 2020).

These findings suggest that obstetric providers and institutional review boards may act as overzealous gatekeepers. While it is important to protect bereaved women from further harm, evidence suggests the gatekeepers may be more concerned with the potential harm of research participation than the women are (Cronin et al., 2020). This may lead them to decline to offer research participation to women who would have found satisfaction in participation. Thus, much of the stillbirth-related nursing research has been conducted with nurses who care for women who experience stillbirth, rather than among the bereaved women themselves (Nurse-Clarke, 2021; Salazar et al., 2022). This reluctance adds to the challenge of holistically studying the health care needs of women after stillbirth.

Women who are bereaved by stillbirth remain a hard-to-reach group, which necessitates more research to investigate methods to recruit them for research. Recent work with recruitment of women during pregnancy and the postpartum period may serve as a model. Lemas et al. (2021) found that pregnant or breastfeeding women said they would be willing to participate in research related to a topic they found compelling (e.g., breastfeeding) or if they could see some direct benefit to participating in the study (e.g., lactation support). Additional facilitators to study participation included hearing about the study from a trusted source (e.g., from a health care professional or a friend) and the altruistic desire to help improve health care delivery for future generations (Lemas et al., 2021). The most common barriers to participation were logistical considerations, including the need for childcare and the frequency and duration of study visits (Lemas et al., 2021). Even during the COVID-19 pandemic, Xu et al. (2023) found most pregnant and breastfeeding women were willing to participate in research, including research requiring biospecimen collection, if they were interested in the research topic and if they felt the research would benefit their communities. These women preferred to receive information about studies from their health care providers, and their major concerns about research participation included discomfort for their infants (if the infants were to be participants) and logistics such as time commitment (Xu et al., 2023). Given these identified barriers, there is a critical need to design clinical studies that incorporate participant perspective to understand maternal health outcomes in patients who experience stillbirth.

Clinical Practice Guidelines are Inadequate

Current clinical practice guidelines, particularly for nurses, do not adequately address postpartum care for women after stillbirth. Moreover, evidence suggests that for a variety of reasons, available guidelines may not be consistently followed. During the fourth trimester, postpartum care includes teaching about expected physical and emotional changes after birth, screening for complications (e.g., perinatal mood and anxiety disorders such as postpartum depression), appropriate follow-up for pregnancy complications (e.g. gestational diabetes), contraceptive management, and referral for management of longstanding or new-onset chronic conditions (e.g., hypertension, cadiovascular disease, or diabetes; Paladine et al., 2019; Suplee & Janke, 2020). During the hospital stay, postpartum nursing care focuses on the physical transition from pregnancy to non-pregnancy, including preventing and recognizing complications associated with pregnancy and birth and the transition to motherhood (Suplee & Janke, 2020). Postpartum nurses are instrumental during this time in providing physical care, education, and thorough psychosocial assessment (Suplee & Janke, 2020). After discharge from the hospital, ACOG (2020) recommended that patients check in with their providers in person or via phone about 3 weeks after birth followed by a comprehensive visit no later than 12 weeks after birth for a full assessment of physical, social, and psychological well-being. Postpartum visits provide women with critical follow-up care after birth; however, the findings of a systematic review suggested a significant proportion of women do not attend routine postpartum visits (Attanasio et al., 2022). While the estimates in the included studies varied widely (25% - 95% attended postpartum visits), when the attendance rates of the various studies were weighted according to the size of the study sample, the overall attendance rate was 62% (Attanasio et al., 2022). With so many women not attending their postpartum visits, some pediatric providers have stepped in to provide some postpartum screening, for example, by screening mothers for postpartum depression during regular well-child visits with their infants (Earls et al., 2019). However, for women who experience stillbirth, provision of postpartum screening via a pediatrician is unlikely and highlights the need for women’s continued engagement with their own health care providers. Therefore, it is critical for nurses and other postpartum care providers to facilitate the transition from pregnancy-related health care to primary health care following stillbirth.

For patients who experienced stillbirths, ACOG, 2020) emphasized the importance of individualized care to address physical and emotional needs as part of follow-up care. Hospital nursing care for bereaved women who had stillbirths is typically focused on managing the acute grief of a traumatic loss (Black, 2020) and managing the physical aspects of postpartum recovery (Suplee & Janke, 2020). While nursing leaders have been on the forefront of advocating for improved access to nursing care during the postpartum period (Lowe, 2019), nursing and midwifery guidelines for the management of women who had stillbirths are lacking. Researchers described what is known about various aspects of nursing care for women who had stillbirths (Black, 2020; Nurse-Clarke et al., 2019), however, we were unable to locate comprehensive guidelines for nursing care of these women from the Association of Women’s Health, Obstetric and Neonatal Nurses or the American College of Nurse-Midwives, the two major professional organizations that represent nurses who care for childbearing women in the United States. For example, the AWHONN Compendium of Postpartum Care (Suplee & Janke, 2020) includes only one mention of stillbirth, and it is in the context of prevention. These gaps demonstrate the need to develop clinical guidelines focused on nursing care after stillbirth.

While it may seem obvious that the grief of a stillbirth may increase a woman’s risk for developing postpartum mood and anxiety disorders (e.g., depression), the increased need for follow-up for physical conditions may not be as obvious. However, these women have a higher rate of chronic conditions such as cardiovascular disease (RR = 1.41, 95% CI 1.09 – 1.82), coronary heart disease (RR = 1.51, 95% CI 1.04 – 1.29), and stroke (RR = 1.33, 95% CI 1.03 – 1.71; Kyriacou et al., 2022); therefore, the postpartum period is an important time to provide care that may have a lasting effect on future well-being. In addition, women who experience stillbirths are significantly more likely to be readmitted to the hospital within 6 weeks of birth compared to women with live births (DiTosto et al., 2021; Sweeney et al., 2023; Wall-Wieler et al., 2021). DiTosto et al. (2021) found that in the first 6 weeks after birth, 2.2% of women who had stillbirths were readmitted to the hospital, mainly for pregnancy-related complications such as puerperal infection (15.2%), other conditions related to pregnancy or childbirth (8.4%), and unspecified complications of the puerperium (7.6%). By nine months after birth the readmission rate for women who had stillbirths increased to 5.8%, and the most common causes of the later readmissions (more than 6 weeks after birth) were cholelithiasis (7.7%), abnormality of organs and soft tissue of the pelvis (7.4%), and uterine leiomyoma (6.4%; DiTosto et al., 2021). Sweeney et al. (2023) found similarly elevated rates of readmission for women who had stillbirths compared to those with live births (2.9% vs. 1.6%, p < .001), even after controlling for sociodemographic characteristics, gestational age, mode of delivery, medical comorbidities, and severe maternal morbidity during delivery. The most common readmission diagnoses were hypertension (26.5%), puerperal infection (14.8%), wound complications (5.7%), mental health/substance use disorders (5.5%), gastrointestinal diseases (5.3%) and venous thromboembolism (5.1%; Sweeney et al., 2023). Wall-Wieler et al. (2021) found similarly high rates of postpartum readmission within the first 6 weeks after birth for women who had stillbirths compared to those who had live births (RR = 1.47; 95% CI 1.35, 1.60) after adjusting for demographic, antepartum, pregnancy, and birth characteristics. These researchers also found that women who had stillbirths had shorter hospital stays than women who had livebirths (Wall-Wieler et al., 2021). In all three of these studies, researchers found that infections (e.g., intrauterine infection) and hypertensive disorders were among the three most frequently reported reasons for readmission (DiTosto et al., 2021; Sweeney et al., 2023; Wall-Wieler et al., 2021), and in two of the studies, researchers found psychiatric conditions to be among the three most frequently reported readmission diagnoses (Sweeney et al., 2023; Wall-Wieler et al., 2021). Given these complications, it is imperative that women who experience stillbirths receive adequate follow-up care.

Callout 2

In the obstetric care consensus on stillbirth, ACOG (2020) acknowledged that bereavement care requires significant provider time. However, little is known about the extent to which the care recommended is provided. ACOG (2018) recommended provider check-in at 3 weeks after birth, and a single, comprehensive, postpartum visit by 12 weeks after birth, but this may not afford sufficient time for provision of the care recommended. According to the most recent report we could locate, women who experienced some type of birth complications or had challenges in the postpartum period were slightly more likely to attend follow-up visits than those who had uncomplicated births (Bennett et al., 2014), but we are unaware of data to show whether this trend extends to women after stillbirth. Thus, it is unclear how often women attend their postpartum follow-up visits after stillbirths. Even when women attended postpartum visits, less than 50% received all the recommended services (Geissler et al., 2020). Despite the assertion that care should be individualized, ACOG (2020) made no specific suggestions for additional postpartum visits to allow sufficient time to provide the recommended care. It is unclear how often women attend any postpartum visits after stillbirth or whether health insurance reimburses providers for the additional postpartum visits that may be required to provide the comprehensive care recommended by ACOG (2020).

Implications for Research

The lack of nursing guidelines for postpartum care of women after stillbirth makes it difficult for nurses to provide optimum care. First, we recommend that women who had stillbirths be included in postpartum research where appropriate. Additionally, we recommend that researchers examine the use of health care in the fourth trimester, quality care in the fourth trimester, and satisfaction with care among women who experienced stillbirths. There is a critical need to improve our understanding of fourth trimester care given the higher risk of severe maternal morbidity and mortality for women after stillbirth. Thus, we recommend researchers investigate facilitators to recruitment of women who had stillbirths for research. Further, we call for the development of evidence-based interventions to improve postpartum follow-up care and continuity of care among women who experience stillbirths. In a systematic review of experimental interventions tailored for women after stillbirth, Huberty et al. (2017) found that only two articles met the eligibility criteria for the review, which emphasized the need for more interventions for these women.

Implications for Practice

Existing research and expert recommendations provide several avenues for nurses to improve care after stillbirth. Nursing guidelines for the postpartum care of women who had stillbirths should be developed using the evidence currently available. Such a widely-available standard would facilitate evaluation of postpartum nursing care following stillbirths and highlight areas for continued research. In the meantime, nurses can help increase the probability that women receive -recommended postpartum follow-up visit by advocating for women to have their follow-up appointments scheduled during the hospital stay. We recommend that women who experience stillbirth are offered the option to receive postpartum care in a different location from where they received prenatal care to prevent them from having to sit in waiting rooms with expectant mothers (Batra et al., 2021).

Callout 3

In addition, the high readmission rate in the postpartum period and shorter hospital stays for women who experienced stillbirths suggest that they may be discharged from the hospital prematurely. Nurses can advocate for adequate hospital stays for these women to ensure their physical and psychosocial needs are thoroughly addressed and that they are ready for discharge. With psychiatric diagnoses among the top reasons for postpartum hospital readmission, women may leave the hospital without sufficient resources for emotional support. Nurses can address this issue with patient education, referral to available resources for families and advocacy for the creation of additional community resources. Nurses can refer patients to evidence-based, reputable, online and in-person support for bereavement after stillbirth (Batra et al., 2021) and can connect them to appropriate postpartum follow-up care, including obstetric and primary care (Paladine et al., 2019).

In addition, few acceptable and accessible resources are available for Black women and other women of color who are disproportionally affected by stillbirth (Pruitt et al., 2020). For example, while many hospitals offer free, on-site support groups for bereaved women after stillbirth, they are poorly used by Black women because of discomfort with the mostly White attendees and mistrust of the health care system; Black women are more likely to access faith-based support for grief and psychological distress (Moore et al., 2022). Therefore, there is an urgent need for evaluation of online resources and for culturally appropriate support interventions for Black women and women from other minority groups.

Conclusion

The recent attention to improving care after birth and extending insurance coverage for women during the fourth trimester has not included those who experience stillbirth. We identified that women who experience stillbirth are at greater risk for severe maternal morbidity and mortality, and interventions have significant potential to improve maternal health outcomes in this population. Providing equitable care to women who experience stillbirth is a critical step toward improving health outcomes for a vulnerable population in the United States.

Table 1.

Recommendations for Improving Fourth Trimester Care After Stillbirth

Research Recommendations	• Examine the use of care in the fourth trimester for women bereaved by stillbirth • Examine quality of care in the fourth trimester for women bereaved by stillbirth • Develop evidence-based interventions to improve postpartum follow-up care after stillbirth • Develop culturally-appropriate support interventions for Black women and women from other minority populations
Practice Recommendations	• Advocate for adequate hospital stays following stillbirth • Offer education and referral to available community resources for support • Facilitate referral to appropriate follow-up care, including obstetric and primary care • Offer bereaved women the option to receive postpartum care in a different location from prenatal care • Advocate for improved community support resources, especially for Black women and women from other minority populations • Advocate for insurance coverage for additional health care provider visits as needed for bereaved women • Participate in professional organization activities that address the lack of nursing guidelines for care for women after stillbirth

Callouts:

1. Little is known about the physical and psychosocial needs of women in the fourth trimester who experienced stillbirths.

2. It is unclear whether women who experienced stillbirths receive the care recommended in current stillbirth or postpartum guidelines from professional organizations.

3. Nurses are ideally situated to advocate for adequate postpartum care for women who experienced stillbirths.