Learning and teaching a new model for postpartum care
Lois Margaret Nora, MD, JD, MBA
One of the things I love best about this profession is having the opportunity to talk with other medical education professionals. I almost always learn something new from the ways they are advancing learning and patient care. That’s exactly what happened when I met Dr. Lorimar Ortiz, a family medicine physician who taught me a new term: the fourth trimester of pregnancy.
Dr. Ortiz started her undergraduate studies intending to pursue a career in pharmaceuticals, and it was only through what she calls a “beautiful accident” that one of her own physicians suggested she consider a career in medicine. “I wouldn’t be a doctor if it wasn’t for something as simple as my allergist suggesting to me that I consider it. It was the best decision ever, because I don’t see myself doing anything else,” she said.
Dr. Ortiz found her path in family medicine. As she worked to support new mothers, she observed limited use of best practices such as in-hospital lactation support and measures to promote mother-infant bonding. That meant most families had little to no support when they needed it most. Furthermore, it was apparent to Dr. Ortiz that her training had not fully prepared her to bridge these gaps herself.
In an effort to develop the skills for teaching patients while preparing to welcome her own first child, Dr. Ortiz set out to become certified in breastfeeding medicine. As part of this work, she became immersed in learning about the specialized care required during the postpartum period, where additional gaps in care became apparent.
“What we usually see is, you are discharged from the hospital, and we say good luck with your baby, we’ll see you in a month or six weeks. New moms have so many questions that are left unanswered, and when they finally get to their postpartum appointment, it is reduced to when they can return to their usual physical activity, what contraception are they going to use in their family planning, and when they can resume their sexual activity,” Dr. Ortiz said. “There are so many other things that might be going on. Psychosocially, emotionally, related to pelvic floor dysfunction, related to breastfeeding. It’s a vast, vast area that was not being covered.”
Collectively, these issues fall into what is considered the fourth trimester, a time when the needs of the mother and baby remain deeply intertwined. “The mom depends on the baby, the baby depends on the mom, and their well-being needs to be seen as a unit,” Dr. Ortiz said. “To better take care of them both, you shouldn’t separate them or separate their needs.”
So, while infant nutrition is a common topic of discussion for newborn health, maternal nutrition matters, too. So does the mother’s mental health and physical well-being, including healing of lacerations and recovery from cesarean birth, which is particularly common in Puerto Rico, where Dr. Ortiz practices and teaches as an assistant professor at Ponce Health Sciences University. The fourth trimester care model seeks to unify care in a system that typically fragments maternal and infant health.
The fourth trimester model also means recognizing and managing the impact of this important and sensitive time on the entire family unit. “Who takes care of the baby? The mom. Who takes care of the mom? The dad. But who takes care of the dad as they are going through changes?” Dr. Ortiz says optimal fourth trimester care addresses that question and seeks to support quality of life for the entire family.
After listening to Dr. Ortiz describe how she thinks differently about postpartum care, I was not surprised to also hear that she brings a patient-first mindset to the way that care is delivered. She has structured her practice to allow for two days of home visits. This option is particularly helpful for new mothers and infants, who benefit from a more private environment as well as the ability to use the resources and tools they will have at their fingertips after the visit is over.
It was clear to me as we talked that Dr. Ortiz is a passionate advocate for her patients, their families, and the care they need. In addition to providing fourth-trimester care as a clinician, Dr. Ortiz hopes to address systemic barriers to that care. One way she does so is by working with nonprofits to ensure fourth-trimester care – which is not typically covered by insurance in her area – is available to families of all income levels.
Dr. Ortiz also works in a system where other public health challenges complicate the delivery of fourth trimester care. A shortage of OB-GYNs and other physicians, high levels of cesarean births, and limited uptake of best practices such as prioritizing sustained contact between mother and newborn can make it difficult to provide the best possible start for new moms and their babies. Yet enabling a strong start carries benefits not only for a given mother-infant pair, but also at the family, community, and population levels, Dr. Ortiz said.
“This is important for everybody. At some point, you are going to be a mom or a parent. Or a friend or family member is going to have a kid. Having a healthy start and a healthy postpartum period is going to have a positive domino effect, an exponential effect in mental health and health in general,” Dr. Ortiz said. “We’re talking about cardiovascular health in women, preventing diabetes, reducing rates of breast cancer, and ovarian cancer -- all of these things that we would like for ourselves and our daughters and our future kids.”
These are messages Dr. Ortiz carries not only to patients but also to students and colleagues in medical education. After coordinating a clerkship in family medicine, Dr. Ortiz moved to leading a fourth-year elective on Breastfeeding Medicine and Infant Feeding, where students learn the tenets of fourth trimester medicine. They are also exposed to Dr. Ortiz’ patient-centric model for care in her clinic and in patients’ homes, gleaning important lessons about what it means to practice medicine.
After students complete the course, they often tell Dr. Ortiz that they have developed a new perspective on their futures as physicians. “Seeing the light in their eyes and that they realize that if they want to, they can do things differently, it is very rewarding for me,” Dr. Ortiz said.
