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The United States (US) has the worst maternal mortality rate in the developed world. Moreover, it is one of the only countries in which the rates of life-threatening complications of childbirth have steadily increased during the past two decades. At an absolute level, maternal mortality is rare. Less than one-tenth of one percent (17.3 9 100,000) of women die from a pregnancy or childbirth-related problem. However, this statistic tells only part of the story. The maternal death rate of women of color is three to four times the death rate of White women. The number of women who attempt suicide within a year of giving birth is two to three times the number of maternal deaths. And, according to the Centers for Disease Control and Prevention (CDC, 2017), for every maternal death it is estimated that 50 or more women suffer serious medical complications. The breadth and impact of maternal morbidity and mortality is deeply disturbing for any society with access to the most advanced medicine in the world. Perhaps most disturbing is that the majority of these deaths and ‘‘nearmisses’’ are preventable. Thankfully maternal health experts are beginning to change their thinking about postpartum health. With this timely issue in mind, our aim in preparing this Special Issue was to present the latest research on health issues that affect women during the postpartum period and what we, as clinical scientists and behavioral medicine clinicians, might do fix the problem. Before reading the articles in this Special Issue, we believe it would be helpful to have an epidemiological overview of birth in the United States, which sets the stage for examining maternal health during the postpartum period. For consistency we define the postpartum period as the time from birth to 6 months post-birth (Romano et al., 2010). The CDC recorded nearly four million (3,978,497) births in 2015, the latest year for which there are complete epidemiological data (Martin et al., 2017). In 2015, the fertility rate reached a 10-year low (62.5 births per 1000 women), having steadily declined since 2005. The average age of first-time mothers was 26.4, an all-time high. Within the broader statistic of fertility and birth rates, there are clear cohort specific trends. For teens, the birthrate has dropped dramatically over the past 25 years, having declined 46% since 2007, and 64% since 1991. Downward trends in birthrates were less dramatic for women in their 20s, while birthrates for women in their 30s and 40s have been steadily increasing since the mid 1960s. Cesarean delivery rates have declined to 32% of births from their peak in 2009 but remain higher in the United States than in most other developed countries (Martin et al., 2017; OECD, 2017a). The rate of preterm births (defined as birth before 37 completed weeks of pregnancy) was nearly 1 in 10 of all births (9.63%), a slight increase from 2014 and an interruption in a steady downward trend since 2005. To summarize, the population of mothers in the United States has been increasing in age for the past 30 years. More recent trends show that American mothers are increasingly likely to have a premature newborn and about one-third of American mothers are recovering from a cesarean delivery while caring for a newborn. The postpartum period is therefore bio-psychosocially complex and risky, considerA special thanks to Lauren Boddy, M.A., and Natasia Adams, M.A. for their help with this special issue.

The fourth trimester: toward improved postpartum health and healthcare of mothers and their families in the United States