Set Up For Life

Bringing home baby is a time of great excitement and joy. But for new moms, it can also be a time of tremendous risk. In addition to the anticipated experiences of exhaustion, fatigue, discomfort and anxiety, the yearlong period after pregnancy — including the three months sometimes referred to as the “fourth trimester” — can pose a significant hazard to women’s health. More than half of all pregnancy-related maternal deaths occur after delivery, with the first six weeks being the riskiest. And many women go on to experience chronic conditions brought on or exacerbated by pregnancy, such as hypertension, heart disease, diabetes and mental health issues.

According to data collected by the Centers for Disease Control and Prevention, more than 80 percent of pregnancy-related deaths in the United States are preventable, and for every maternal death, an estimated 50 to 100 women will experience life-threatening complications. Learning to identify the women who are most vulnerable and facilitating their access to clinical care can therefore not only save lives but improve long-term health outcomes.

“In the past, we didn’t have as much respect for the fact that pregnancy is considered a window into future health,” says Dr. Laura Riley, executive director of women’s health and chair of obstetrics and gynecology at Weill Cornell Medicine, and obstetrician gynecologist-in-chief at NewYork-Presbyterian/Weill Cornell Medical Center. “That has been the impetus behind OBGYNs across the country implementing programs that keep patients from getting lost” during this critical postpartum period.

To that end, researchers at Weill Cornell Medicine have developed a host of interventions intended to reduce pregnancy-related complications and death — and to set women up to navigate the healthcare system through the fourth trimester and beyond.

“It’s really the perfect window to give somebody care,” says Dr. Heather Lipkind (M.D. ’99), a professor of obstetrics and gynecology at Weill Cornell Medicine and attending OBGYN at NewYork-Presbyterian/Weill Cornell. “You can reach them before chronic conditions develop.”

Risks ‘women just don’t know about’

Brooke Jones shares her own experience to advocate for women to get the care they need during this vulnerable time. She was admitted to the hospital 25 weeks into her first pregnancy, when doctors found high levels of protein in her urine — a sign of preeclampsia. “I had never even heard of preeclampsia before that,” Jones says of the potentially life-threatening hypertensive disorder. Two weeks later, she was rushed to the OR for an emergency cesarean section.

Although she knew her baby was in good hands in the NICU, Jones felt exhausted, scared and a little bit lost. “The nurses encouraged me to step away and take care of myself,” says Jones, now 35. “But I just didn’t know how. After I was discharged, I felt like I was just left in the dark.”

That’s when she met Dr. Lipkind. Before joining the faculty at Weill Cornell Medicine in 2022, Dr. Lipkind ran a program at the Yale School of Medicine that carried out cardiovascular risk assessment in women with hypertensive disorders of pregnancy. Her research there revealed that, compared to women without pregnancy complications, women with conditions like preeclampsia were four times more likely to develop chronic high blood pressure in the six to 12 months after delivery. Her team also showed an

increased risk of developing cardiovascular disease and that women were more likely to have metabolic syndrome, a cluster of conditions including high blood sugar, abdominal obesity and hypertension that can lead to heart disease, stroke and diabetes.

“These are long-term risks that most women just don’t know about at all,” says Jones, who is seeing a cardiologist that Dr. Lipkind recommended while she manages her blood pressure with diet and exercise, including running around after her energetic 8-year-old.

Meanwhile, Dr. Lipkind has taken what she learned from Jones and women like her and developed similar efforts in New York. One, called NewYork-Presbyterian Empower, employs a dedicated team of pharmacists to help women who experienced hypertension during their pregnancies monitor their blood pressure at home during the first six to 12 weeks after delivery, adjust their medications and connect with a primary care physician.

Focusing on mom

This research-based initiative is just one of several led by Weill Cornell Medicine faculty that offer postpartum care in the hectic weeks and months after childbirth, when the spotlight tends to turn to the new arrival.

“Historically, after the delivery, all the focus went to the child, and there just wasn’t as much attention given to the mother,” says Dr. Christina Pardo, assistant professor of clinical obstetrics and gynecology at Weill Cornell Medicine and an assistant attending OBGYN at NewYork-Presbyterian/Weill Cornell.

To make matters worse, new moms often don’t know where to go for care. “There’s no one who’s really in charge of taking care of women at that time and I think it’s unclear to women who they should see if they themselves have medical problems, as opposed to their infants,” says Dr. Jyoti Mathad, the Bonnie Johnson Sacerdote Clinical Scholar in Women’s Health at Weill Cornell Medicine and an attending physician at NewYork-Presbyterian/Weill Cornell.

Traditionally, women are encouraged to schedule a visit with their obstetrician six weeks after giving birth. But juggling new motherhood and the challenges of getting out of the house can be daunting. As many as 40 percent skip their appointment and receive no postpartum care — a proportion that is even higher among populations with no insurance or more limited financial resources.

But even those who keep their six-week appointment can get lost in the system. Women who continue to grapple with hypertension, diabetes or other medical issues that may have arisen during pregnancy are directed to see their regular physician. “But what we’ve realized is that many women do not have a primary care doctor,” says Dr. Mathad. In New York state, one in five women aged 18 to 44 report having no personal doctor or healthcare provider. And nationwide, the time it takes to see a new physician is on the rise.

“While women wait to get an appointment, they’re kind of rolling the dice in this critical period between six weeks and 12 months,” says Dr. Mathad. That’s where caring for women in the “fourth trimester” comes in.

Giving mom permission

A fourth-trimester clinic that operates through Weill Cornell Internal Medicine Associates follows women for up to 12 months after their delivery. “One of my goals is helping women feel like there’s someone who’s there for them,” says Dr. Alexandra King, assistant professor of medicine, who established the clinic with Dr. Mathad. At a time when new moms tend to prioritize caring for their babies, Dr. King says, “this clinic gives them permission to take their own health seriously and introduces them to what lifelong preventive care looks like.”

The women who visit the clinic are those who had medical complications in pregnancy or who continue to struggle with issues such as hypertension, diabetes or postpartum mental health disorders. Many attend after “graduating” from the Empower program run by Dr. Lipkind, while others are referred by their OBGYNs or their babies’ pediatricians. All meet with Dr. King for an initial assessment. “Some see me just once and don’t need to see me again,” she says. Others continue with monthly check-ins to help with blood pressure regulation or medication management.

Key to the clinic’s mission is transitioning the new moms to primary care. Studies have shown that by facilitating disease prevention, diagnosis and management, primary care is associated with longer life expectancy. “That’s really the ultimate goal of these interventions,” says Dr. Mathad. “Although we focus on getting women through this one-year period, we also want to get them engaged in ‘forever care’ to set them up for life.”

Drs. Mathad and King recently received a grant from the Cornell Center for Health Equity to collect data from the fourth-trimester clinic, which saw 58 patients in its first year of operation. By assessing the services that new moms need and examining outcomes such as reduced emergency visits and hospitalizations, improved blood pressure management and decreased depression and anxiety, the team hopes to come up with guidelines for improving care for women in the postpartum period — particularly those at high risk for future cardiometabolic complications, such as heart failure or stroke.

Gateway to mental health

One program that is already showing positive results is the Weill Cornell Medicine Perinatal Wellness Program run by Dr. Lauren Osborne (M.D. ’09), vice chair of clinical research in obstetrics and gynecology at Weill Cornell Medicine and attending psychiatrist at NewYork-Presbyterian/Weill Cornell. This joint effort between the OBGYN and psychiatry departments provides psychotherapy and medication management for women experiencing perinatal mental health issues, including postpartum depression and anxiety. More than 30 percent of women who give birth at NewYork-Presbyterian campuses affiliated with Weill Cornell Medicine screen positive for such symptoms during pregnancy or postpartum, according to Dr. Osborne. “We take all comers and try to find them the care they need,” she says.

Most women who enroll are prescribed medications as needed by an obstetrician and receive short-term psychotherapy with a social worker who specializes in perinatal mental health — all guided by treatment plans laid out by reproductive psychiatrists. This collaborative care approach leverages the expertise of highly trained physicians, enabling more women to receive care than doctors could provide if they met with patients individually.

Although the program focuses on women during pregnancy and in the first year after delivery, Dr. Osborne says, “we provide a gateway into mental healthcare” over the longer term. The clinic also provides women with rapid access to care. For women referred to the Perinatal Wellness Program, the average time from screening to intake is about 18 days, compared to more than 32 days for referral to a perinatal psychiatrist outside the program, she says.

Since its inception in 2023, the Perinatal Wellness Program has been associated with improved maternal mental health. More than 1,100 women have participated, and Dr. Osborne reports they show a “clinically meaningful drop in symptoms.” For example, average scores on a standardized scale of postnatal depression fell 35 percent between when participants initiated and completed the program, dipping below the value that would flag an individual as being at risk.

Expanding the team

The NewYork-Presbyterian Empower program, supported by NewYork-Presbyterian’s Dalio Center for Health Justice, has shown similarly impressive results. More than 80 percent of the nearly 400 women who have participated since its start in 2024 have completed one or more visits with the remote pharmacy team. What’s more, Dr. Lipkind says the team has seen a 55 percent decrease in hospital readmissions and an 86 percent drop in hypertension-related emergency department visits in those critical first eight weeks after delivery.

Dr. Lipkind is also leading two additional studies to explore whether including specially trained doulas on the healthcare team can improve blood pressure control and depression in women postpartum. Although traditionally used to provide nonclinical support for women during childbirth, doulas can also serve as a bridge between women and their providers after delivery. LivingHealthy for Moms, a randomized trial supported by funding from the National Institutes of Health and co-run by Drs. Osborne and Lipkind with colleagues from Columbia University Vagelos College of Physicians and Surgeons, is recruiting 600 women, while a larger study carried out in conjunction with the Yale School of Public Health and the University of Massachusetts is halfway to its goal of recruiting 6,000, with more than 70 percent of participants having completed their six-week follow-up.

Another program that spans several NewYork-Presbyterian campuses in collaboration with community-based organizations introduces expectant mothers to doulas before they give birth, establishing a bridge between providers and the broader healthcare system for patients facing barriers to care or who are vulnerable for medical or other reasons. In addition to offering hands-on emotional and psychosocial support during the perinatal and birthing periods, the doulas are trained to recognize the symptoms of high-risk conditions and to alert a physician so that women can get evaluated and connected to the services they need, says Dr. Pardo, who runs the program at NewYork Presbyterian/Weill Cornell, where some 267 women have enrolled over the past two years.

“The doula program gets to the equity piece” of health outcomes for expectant and new moms, says Dr. Riley, who is also the Given Foundation Professor in Clinical Obstetrics and Gynecology. The patients whom doulas support, she says, often “are the people who fall through the cracks … that you read about in the [stories of] maternal deaths.”

What makes doulas especially effective is the relationships that they establish with the women, visiting them at home and seeing what they really need. One mom, Dr. Pardo recalls, had trouble getting around with her new twins. “The doula recognized that transportation was a barrier and was able to find a double stroller for her so she wouldn’t miss her appointments,” says Dr. Pardo. “That kind of attention has a direct impact on patients’ ability to access care for themselves and for their children.”

And access to care is the first step on the road to good health — through the fourth trimester and beyond. “We started with a focus on the fourth trimester, because it’s such a tough time and moms are sometimes forgotten,” says Dr. Lipkind. “But ultimately we want to move beyond the fourth trimester, and past the first year, to ensure that women can continue to get comprehensive care over the course of their lives.”

Jones agrees. “If you’re not good, your child won’t be good,” she says. “So, even if you don’t do it for yourself, you have to do it for your child.”