The Future of Postpartum Care: Why Healthcare Systems Are Reconsidering the Fourth Trimester

By Birth & Baby University · Last updated: October 2026 · 7 min read

For decades, postpartum care in the United States meant one visit about six weeks after birth, often with little between delivery and that appointment. Professional societies, insurers and researchers now describe postpartum care as a continuum, and the phrase “fourth trimester” has moved from parenting books into clinical guidance. This article looks at why health systems are rethinking this period, what current guidance and policy say, what small trials suggest about models that might work, and how doulas fit in without overstepping their role.

Key takeaways

Quick answer: the American College of Obstetricians and Gynecologists (ACOG) recommends that postpartum care become an ongoing process with contact within the first three weeks and a comprehensive visit no later than 12 weeks after birth. Federal law requires Medicaid pregnancy coverage through 60 days postpartum, and states can extend it to 12 months. Evidence on which care models work best is still thin and comes from small trials.

• ACOG’s Committee Opinion 736 recommends contact with an obstetric care provider within three weeks, ongoing care as needed, and a comprehensive visit no later than 12 weeks, covering mood, infant feeding, sleep, physical recovery and chronic disease management.
• In Centers for Disease Control and Prevention committee data for 2017 to 2019, 53 percent of pregnancy-related deaths occurred between seven days and one year after the end of pregnancy.
• The option for states to extend Medicaid postpartum coverage to 12 months was made permanent by the Consolidated Appropriations Act 2023, according to KFF.
• A 2026 randomized trial of 140 people found that telephone health coaching plus self-measured blood pressure monitoring increased primary care visit attendance by 12 months postpartum, but it was one hospital and a hypertension-specific population.

Why the old model is being reconsidered

Two threads run through the sources. The first is timing. The CDC’s September 2022 release on 36 states’ maternal mortality review committees reported that 22 percent of pregnancy-related deaths occurred during pregnancy, 25 percent on delivery day or within seven days, and 53 percent between seven days and one year after the end of pregnancy. A single visit at six weeks cannot cover that range. The second is chronic disease. The Society for Maternal-Fetal Medicine’s special statement (2022) says rising maternal morbidity and mortality, widening disparities and a focus on cardiometabolic risk have catalyzed a shift in the postpartum care paradigm, from a single office visit to a continuum of care that transitions patients from pregnancy to lifelong health optimization. It also acknowledges that this shift brings increased visit complexity and additional provider burden, and provides checklists for uncomplicated and complicated pregnancies.

What current guidance says

ACOG’s Committee Opinion 736 (2018) says postpartum care should become an ongoing process, not a single encounter, with services tailored to each person’s needs. It recommends contact with an obstetric care provider within the first three weeks, followed by ongoing care as needed and a comprehensive visit no later than 12 weeks. That visit should assess mood and emotional well-being, infant care and feeding, sexuality, contraception and birth spacing, sleep and fatigue, physical recovery, chronic disease management and health maintenance. People with chronic conditions such as hypertensive disorders, diabetes or mood disorders should be counseled on timely follow-up, and the opinion calls for identifying who will take primary responsibility for ongoing care. It also calls for reimbursement policies that support postpartum care as an ongoing process, not an isolated visit. This article draws on the opinion’s published abstract, and the guidance is addressed to clinicians, not to doulas.

What payment policy says

KFF’s Medicaid postpartum coverage extension tracker (published July 2026) explains that Medicaid finances about four in 10 births in the United States, that federal law requires states to provide pregnancy-related coverage through 60 days postpartum, and that some people may lose coverage after that, particularly in non-expansion states. The American Rescue Plan Act of 2021 gave states the option to extend coverage to 12 months through a state plan amendment, and the Consolidated Appropriations Act of 2023 made that option permanent. The tracker follows state-by-state actions; state-level status changes and should be checked for your state. Coverage is not the same as care, but without it continuity is hard.

What trials suggest about models

Knutson Sinaise and colleagues (2026) randomized 140 postpartum people with hypertension in pregnancy at a Midwestern community hospital to a health coaching intervention with self-measured blood pressure monitoring (biweekly, then monthly, telephone calls) or to usual care. All participants completed a remote blood pressure monitoring program. Primary care visit attendance by 12 months postpartum was 71.0 percent in the intervention group and 39.1 percent in the control group (relative risk 2.00), and blood pressure control was more likely in the intervention group (55.3 versus 31.1 percent). There was no significant difference in health behaviors. The authors describe the trial as evaluating preliminary effectiveness. It is a single center with a specific population, so it shows promise for a model, not proof for every postpartum patient.

Documentation can also be a problem. Stanhope and colleagues (2026) compared self-report with electronic medical record documentation among 282 trial participants with cardiometabolic risk factors. About 75 percent (74.7) had concordant documentation of a postpartum visit, about 20 percent had care documented in only one source, and concordance for specific elements such as mood screening (62.7 percent) and cardiovascular risk counseling (31.6 percent) was lower. It means that what patients report and what records show can differ, which makes it harder to measure whether the new model is working.

What the evidence does not tell us

• Which model is best. The sources include no head-to-head comparison of postpartum care models.
• Whether more contact improves long-term outcomes. The trial above measured visit attendance and blood pressure at 12 months, not mortality.
• How guidance translates into practice. ACOG’s recommendations on timing and content depend on staffing, payment and patient access, which vary.

What this means for doulas

• The role fits the direction of change. Postpartum doulas and birth doulas who stay in touch see families between clinical visits. They can encourage attendance and help families prepare questions, within the limits of non-medical support.
• Know the warning signs. The CDC’s Hear Her campaign lists urgent maternal warning signs for pregnancy and the year after delivery. Share the list and encourage prompt care.
• Cover the whole range. ACOG’s visit domains, such as mood, feeding, sleep, recovery and contraception, are good prompts for check-ins, though assessing them is a clinician’s job.
• Help with logistics. Transport, childcare, scheduling and insurance questions can stop a family from attending. Helping with these is within the informational and practical support role.
• Do not promise or diagnose. If a client describes a symptom, direct them to their care team or emergency services.

Putting it into practice

1. At the end of care, ask each client whether a postpartum appointment is scheduled, and if not, whether they want help finding one.
2. Give clients a written list of the warning signs and the number to call, from the care team’s materials and a national source.
3. Use a simple postpartum check-in guide covering mood, sleep, feeding, pain, bleeding and breathing, and note anything that sounds like a warning sign.
4. Ask clients to find out when their coverage ends, and whether their state has extended it.
5. Read our related article on why postpartum follow-up matters for more on the clinical side.

Limits and uncertainty

Guidance and policy are changing. The ACOG opinion is from 2018 and this article draws on its published abstract, the SMFM statement is from 2022, and the KFF tracker reflects July 2026; the tracker’s state-level map is not summarized here. The trial evidence comes from small, single-site studies with specific populations. Nothing here evaluates doula-led postpartum models directly.

The bottom line

Health systems are rethinking the fourth trimester because many serious problems arise after the first week, because chronic disease risk begins in pregnancy, and because one visit at six weeks does not fit either. Guidance now points to continuous care and payment is being extended, while the evidence on the best models is still thin. Doulas can support the shift by helping families stay connected to care.

Birth & Baby University’s For Doulas page outlines its online, self-paced postpartum doula training, along with birth doula training, recertification and mentorship, for doulas who support families through the fourth trimester.

This article is for professional education. It is not medical, legal, financial or tax advice. Check the standards of your certifying organization and the rules where you work.

Sources and further reading

• American College of Obstetricians and Gynecologists. ACOG Committee Opinion No. 736: Optimizing postpartum care. Obstetrics & Gynecology (2018). Read the source
• Society for Maternal-Fetal Medicine. SMFM Special Statement: postpartum visit checklists for normal pregnancy and complicated pregnancy. American Journal of Obstetrics and Gynecology (2022). Read the source
• KFF. Medicaid Postpartum Coverage Extension Tracker (published July 15, 2026). Read the source
• Centers for Disease Control and Prevention. Four in 5 pregnancy-related deaths in the U.S. are preventable (September 19, 2022). Read the source
• Knutson Sinaise MR, Buchholz K, Hetzel S, et al. Care navigation, self-measured blood pressure, and health coaching for postpartum care: a randomized clinical trial. JAMA Network Open (2026). Read the source
• Stanhope KK, Boulet SL, Newton-Levinson A, et al. What happens at the postpartum visit? Discordance between patient-reported and electronic medical record-documented postpartum care. Annals of Epidemiology (2026). Read the source
• Centers for Disease Control and Prevention. Urgent Maternal Warning Signs (Hear Her campaign; page last reviewed May 15, 2024). Read the source

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