2020 Essay Contest - First Place - PT: Advocating for Physical Therapy and Multidisciplinary Changes in Postpartum Care by Sarah Freeman
My matrilineal line has been greatly influenced by two things: postpartum pelvic disorders and urinary incontinence. I grew up in a tight knit ranching family in southern Alberta with my grandmother as our closest neighbour. For 60 years, my grandmother was out at 4 A.M. every morning feeding cows, and her day-to-day schedule was filled with the difficult, punishing type of work that is the center of a ranching life. Through this lifetime of physical toil, she stands today as spry and bright as could be expected for an 87-year-old woman, save for one thing. For decades, my grandmother has struggled with uterine prolapses, incontinence, and posture problems. Not once in this period has she been directed by the medical community to seek pelvic floor physical therapy, and she has suffered mightily because of it. Having had personal success with physical therapy in resolving sports related injuries and a mentor in the profession, I was set on the path of researching the field of women’s health physical therapy and was able to find a physical therapist in the area that had training in pelvic floor rehabilitation for my grandmother. Within weeks of therapy, my grandmother was able to decrease her bathroom trips in the middle of the night from five to two. Although her treatment was successful, I had my first glimpse of a major systemic issue that the profession of physical therapy currently faces. The lack of immediate physical therapy rehabilitation to help the extensive musculoskeletal injuries caused by childbirth is a major unresolved issue in the field of physical therapy. Instating reimbursable, preventable physical therapy programs within in the first twelve weeks postpartum would resolve this issue by helping to reduce the risk and cost of compounding complications that evolve into chronic issues. To achieve this, a major systemic change in the conversation around women’s health needs the participation of all physical therapists.
Postpartum incontinence, pelvic floor dysfunction, weak or separated abdominal muscles and improper scar remodeling have plagued women as long as the human race has existed, yet women’s health physical therapy that seeks to remedy these issues is a relatively new field. My new found interest in the field led me to choose to fulfill a large part of my DPT program application clinical observation hours at multiple clinics specializing in women’s health. Every patient whose care I had the opportunity to shadow during this experience had one thing in common; they had given birth. Many of them had given birth years or decades before receiving treatment. Most of them suffered in silence the entire time as they were afraid of discussing taboo subjects with their primary care doctor or relying on misinformation about the possibility of recovery with proper care. The impacts of not rehabilitating their postpartum injuries had often compounded over the years, expressing themselves through pain and anxiety surrounding exercise, sex, and socializing. Due to the stigmas, shame, and embarrassment around the topic, the extent of this issue was clouded and the root of the problem unclear to most healthcare professionals. Physical therapists need to be a part of the immediate rehabilitation of all postpartum patients and to continue to rehabilitate their injuries alongside other health care professionals to provide women with a more holistic, mother centered, proactive approach to care.
As it stands, the postpartum therapy path has been woefully inadequate in addressing the numerous complications that arise after birth. Postpartum death rates are higher in the USA when compared with other countries of similar wealth, with maternal deaths postpartum accounting for more than one half of pregnancy-related deaths (Kassebaum et al., 2013). In 2018, the American College of Obstetricians and Gynecologists (ACOG) stated that new mothers need to be monitored for strokes, high blood pressure, heavy bleeding, pain, infection, seizures, depression, urinary incontinence, neuropathy and many other complications (Stuebe et al., 2018). The ACOG highlighted the importance of transitioning from the historical single postpartum follow-up with a primary care provider to a multidisciplinary postpartum care team that treats these issues as an ongoing process tailored to each woman’s individual needs in an effort to minimize postpartum complications (Stuebe et al., 2018). Even though these suggestions from the ACOG happened two years ago, these changes have been slow to be recognised or implemented. Within the field of physical therapy, childbirth is not currently emphasised as a major musculoskeletal injury that everyone in the profession can treat accordingly. Societal biases that exist around what is viewed as ‘normal’ after childbirth extend into the physical therapy profession. These conversations are not happening across the profession, and are not being taught in a significant way in the education of physical therapists. Women’s health is a specialized field, but all physical therapists have the skillset to treat a majority of postpartum presentations. The skills of all physical therapists will be needed to provide the resources to solve this demand of increased immediate postpartum care.
The need for addressing postpartum symptoms in physical therapy is not yet being fulfilled. There remains a great need for assistance from all disciplines, including physical therapy, to pressure insurance companies, hospitals and universities to implement these new evidence-based suggestions into practice. The conversation around women’s health needs to change, with increased stress on its importance. The ACOG has suggested that the “fourth trimester” be the first twelve weeks postpartum and has highlighted the need for insurance companies to reimburse for care during this time to help facilitate this systematic shift (Stuebe et al., 2018). The ACOG has officially recognized the essential role of physical therapists on the team to provide well rounded care. Historically, child birth has not been viewed as a musculoskeletal injury that needed the assistance of physical therapy but, like other injuries, physical therapy is essential to regain proper muscular function, sensation and strength to return acts of daily living.
Implementing a reimbursable “fourth trimester” care is a proactive approach that needs to be supported by the rest of the healthcare profession. This would provide better quality of life for the patient to prevent future issues and, ultimately, it must be treated like any other preventive measure to aid in reducing lifetime healthcare costs.The physical therapy field continues to be a powerful advocate in improving patient outcomes. By joining multidisciplinary teams and uniting together, we can influence the healthcare system to be more dynamic and patient-centered. Through advocacy work and research, physical therapists are integral to changing outdated practices, such as the recent shift from immobilizing patients with broken bones for weeks to the evidence-based practice of getting patients moving immediately following injury for better and faster recoveries. We need awareness, advocacy, and follow up research to help implement the major systemic shift of longer, custom rehabilitation postpartum. By starting to teach the importance of these issues in physical therapy programs, upcoming therapists will be better equipped to incorporate this knowledge into their practices. I plan on making a tangible difference by beginning small. During my program, I will partner with organizations advocating for this change, starting with my first summer clinical with Peak Performance Physical Therapy in Missoula. I will also facilitate conversations within my program and classes around women’s health to break down some of the stigma that surrounds it.
Therapy Insights is a perfect platform to make a grassroots change in getting physical therapists more involved immediately postpartum. I have discussed with several maternity nurses in Missoula about the shortcomings of the pamphlet on simple kegel exercises they give new mothers. Therapy Insights could create a pamphlet designed by a team of women’s health physical therapists that provide primary care physicians, nurses and physical therapists in the hospital more well-rounded, evidence-based information around proper rehabilitation, return-to-exercise guidelines and when/how to seek further help. This unique service of Therapy Insights would begin altering the conversation in the hospital, working to open communication pathways and develop a platform for change
As health care professionals, we all need to unite to address the root of this unresolved healthcare crisis. Implementing a twelve-week, reimbursable, multidisciplinary postpartum care regimen is the minimum measure by which progress will be made in the field. Continuing education, conversations around women’s health needs and the participation of all physical therapists are needed to achieve this. I am devoted to a career centered around not allowing these suboptimal outcomes to continue. I will advocate for these practices within my own healthcare network, advertise it as a component of my own practice, and continue to work alongside an interprofessional team that advocates for best possible outcomes for patients.
- Kassebaum, N. J., Bertozzi-Villa, A., Coggeshall, M. S., Shackelford, K. A., Steiner, C., Heuton, K. R., Gonzalez-Medina, D., Barber, R., Huynh, C., Dicker, D., Templin, T., Wolock, T. M., Ozgoren, A. A., Abd-Allah, F., Abera, S. F., Abubakar, I., Achoki, T., Adelekan, A., Ademi, Z., . . . Lozano, R. (2014). Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 384(9947), 980–1004. https://doi.org/10.1016/S0140-6736(14)60696-6
Stuebe, A., Auguste, T., & Gulati, M. (2018). Optimizing postpartum care. The American College of Obstetricians and Gynecologists, 131(5), 140-150.