Partner Spotlight: Fourth Trimester

The mission is to revolutionize fourth trimester care. Basically, trying to support dyads (mothers/birthers and their newborns- families as a whole) during the fourth trimester providing quality medical care for the whole family.

Personally, everytime I gave birth (I have 3 children under the age of 6), there was a feeling that everyone was very focused on the health of my baby but it didn’t seem that people really cared about my health and how my transition was going into this parenting role and all the trauma my body had gone through. I’m trying to keep a baby alive, breastfeeding/lactation was challenging, and I felt that there was not much support for me. I too was going through a huge transition, not just my babies. 

As far as the community as a whole, we see the standard medical system has you give birth, then you’re sent home, and the next visit isn’t really until six weeks postpartum with your OB or midwife. There is a lot of stuff that happens between birth and that 6 week visit- mental health changes, the lactation piece- maybe you’re able to successfully breastfeed and things are going okay, or maybe you’re having trouble getting the baby to latch, or baby is having trouble gaining weight for some reason, maybe transfer of the breast milk is not going well. There are a lot of things that happen in this 6 week time like pelvic floor changes such as incontinence or excessive bleeding, and if no one is addressing or acknowledging or asking those questions during this time frame they are not getting supported. Currently in the standard medical system, people are having to bring their babies into the doctor to have their weight checked, bilirubin/ making sure there is no jaundice, making sure baby is developing appropriately and things like that but it totally discounts the fact that the person bringing them in is healing from birth, growing and changing and developing themselves. They are carrying car seats into the clinic 2 or 3 days postpartum- we would never do that if someone had a major surgery, and having a cesarean is major abdominal surgery. It puts a huge strain on the person to do that in the first place, which is why I do home visits. I feel like I need to be meeting people where they are at so they can heal and they can bond with their child and their healing and bonding isn’t disrupted having to carry a child into a clinic (which in general is not a great place for newborn babies with all of the germs and other sick kids around) for checks.

The services that I provide are all medical care. I start with providing postpartum planning visits, so when they are still pregnant about a month before they give birth I’ll come into the home and we plan for postpartum. What is that going to look like? Planning for birth and not postpartum is like planning for a wedding and not marriage. People plan for this birth event, but what is really so critical to the dyad as a whole is the postpartum time. How are they going to get their nutrition? Who is going to be their support system? What does movement look like postpartum? What does their mental health support look like? 

After the baby is born, I come into the home 24-48 hours after they are home. First we talk about the story of the birth- what the process looked like and how it felt to them. It typically takes an hour to go through all of that. Then we assess how the baby’s health is doing- what is their weight? Has their milk started to transition to mature milk? In the time frame after this, we will do follow-ups as needed so maybe visit a couple days later or when the baby is about one week old. Then we’ll do a two week visit, a month visit, and keep checking in very frequently to make sure that everything is going smoothly and anything that comes up along the way is being addressed in a timely manner,  not waiting until that six week mark. They also get access to me via text, phone, and email to ask any questions-  it’s a lot of really close support throughout this tender transition time.

It’s 100% different because I’m actually offering services during that transition time. Some hospital systems or clinic systems will have a nurse visit at the 24 hour time but if there is concern or a problem, they are going to refer back to the OB or the midwife which would mean having to go back into the clinic to be seen. For my visits, everything is being taken care of at that moment. In the medical system, sometimes they’ll do follow-up visits if there is concern with the birthing person’s blood pressure for example, they might see them sooner, but it would still require that person to have to go to the clinic setting. On the baby’s side of things, I’m seeing them as much if not more frequently than the pediatricians or family physicians. Usually at a few days, a week, then two weeks- that doesn’t necessarily happen in the standard system regularly. They might see the baby at 3-5 days, and then at 2 weeks or a month. It’s much less contact, and the patients don’t usually have direct access so will need to go through a nurse hotline or clinic to get in touch with their doctor.

It has mainly been by word of mouth. People will hear about me from their physicians, from their doulas, from their lactation consultant, or other patients that have seen me previously, or I’ve even started having repeat clients which is really fun. If I can first see them in pregnancy and do postpartum planning that is ideal as it’s a more comprehensive package of care. But, some people don’t get to me that soon and will end up hearing about me after they’ve delivered and are working with a lactation consultant or doctor for breastfeeding/lactation problems. I am a board certified lactation consultant (IBCLC) as well as I am board certified in Breastfeeding and Lactation Medicine.  The second certification is a new board certification for physicians only in lactation, so I’m what’s considered a Breastfeeding/Lactation Medicine Specialist, so if there are complications beyond what a lactation consultant is able to handle, then they refer to me. 

I also provide consultations for perinatal mental health for both parents.  I am certified in Perinatal Mental Health through Postpartum Support International and am board certified in Integrative Medicine (I did a 2 year fellowship training in this).  I provide consultations that look at the whole parent and provide treatment plans that include not only medication if indicated but also a variety of other modalities.  Mental health is a huge concern for not only the birthing person but also the partner and is very often missed.  Again it is about treating the whole family. 

I’ve been networking with the birthing community in the Twin Cities for the last couple of years, so people just sort of know how to get ahold of me, or have seen my website and refer people to that. It’s outside the standard system which is a little bit challenging because in the standard system with electronic medical records you can “refer” directly within the medical system people are in, for example Hennepin or Health Partners or whatever. I’m outside of the system so people have to contact me externally and be seen that way. In this aspect I’m not necessarily as fresh on people’s minds or as easy to refer to since I’m not connected to the system itself.  So if someone types lactation into Epic (the main electronic medical record system of most of the Twin Cities hospitals), then the hospital lactation service or maybe a connected outpatient lactation service within their system will come up, my practice will not.

One of the challenges, which is also kind of a benefit, is the fact that I am not contracted with any insurance companies. The reason for that is because the way that insurance companies reimburse care or pay for care is not conducive to being able to do home visits. The benefit though is that the insurance companies don’t get to dictate my care- I get to decide on the care I provide. How long, how much, how in depth it is, how I follow up- it gives me flexibility and allows me to meet people where they are at and provide that exceptional level of care that is often beyond what is offered inside the standard system. 

I do contract with a company that works with insurance that helps me to decrease the cost of my care, sometimes by about half, but usually these are PPO type plans or commercial insurance.

This definitely helps individuals to be able to access care, but unfortunately they are not contracted with any of the state plans like Medicaid or MNSure. The hard part is, insurance companies have decreased reimbursement rates more and more over the years, so even though the cost of things are going up, payment to physicians is going down. It’s what is causing burnout, it’s why people are doing these 10 minute visits as opposed to being able to take more time, and to make matters worse, coverage/payment is often denied by insurance companies for no reason at all. It makes sense to not contract with insurance companies because it’s unfortunately not conducive with being able to run a business. The interesting/good thing is that all of my care is technically considered “preventative services” like well-child checks, lactation services, and postpartum care. A lot of people actually have significant coverage with their “out of network” benefits for preventative care. For example, people will pay me up front for my services, I’ll get paid, and then I submit everything to their out of network benefits and the insurance company will reimburse the patient directly for the care. It makes sense because then I’m not tracking down insurance companies because I’m getting paid up front and know I’m being paid appropriately, and the patient gets to work with their insurance company directly for the reimbursement. 

It started in college, I did a research project in Uganda around infant nutrition, HIV/AIDS, and breastfeeding/lactation. Infant nutrition in general has just been a very interesting topic to me, and then I got my Master’s in Public Health and continued to be supporting lactating individuals through various projects through my program. Then I went to medical school and decided to go into family medicine specifically because I was interested in dyad care. I was interested in the care of both the birthing person and the newborn. I actually chose family medicine as a speciality when I was on my OB/GYN rotation and attended one of the first births and I remember standing at the foot of the bed after the baby came out (this was before the time we put baby back on the chest), and I was standing in the center of the room between the birthing person and the baby and I couldn’t decide who to go to because I wanted to go to them both. For me it wasn’t just about pediatrics and it wasn’t just about obstetrics, it was about the care of this dyad. Even though the baby has been born and now appears to be physically separated, they are still so intertwined with the health of the parent and vice versa. It’s a very holistic look at the care of families, which is why I decided to go into family medicine.  Since then, I have done additional trainings in Integrative Medicine, Breastfeeding and Lactation Medicine, Mind Body Medicine, and Food as Medicine along with becoming a yoga teacher.  I was in the clinic for a number of years after residency and then decided to start my own practice and have been doing this for the last 4 years now.

Expansion- everyone should be able to have access to this kind of high quality, much needed care. I’ve hired several other physicians in Minnesota now so there will be several more of us over the next year and I’m hoping to someday expand nationally. There is such a need and it is so critical that we get more physicians working in this space to provide high quality, high touch, in-depth care to help folks transition through this sensitive and tender time.  Maternal morbidity and mortality and infant morbidity and mortality in this country is all the evidence we need to show that what we are doing right now isn’t working.  People deserve to have the support and this support will create ripples that will have a positive affect on our economy as a whole.  This up front investment in families will pay back in fold.