In recent days, health experts in two countries have spoken out about the need for significant improvement in postpartum care for women.
In the US, the American College of Obstetricians and Gynecologists (ACOG) says pregnancy care should extend beyond birth and into the three months immediately afterwards.
And in the UK, a group of ministers and peers has called for all mothers in England to have an assessment of their emotional and mental health carried out six weeks after birth.
Why this interest in the post birth mother? For decades, women in most western cultures have given birth and been expected to ‘get on with it’.
Postpartum Care Is Failing Women
There has always been a trend for postpartum care to focus on the baby, almost to the point where the health and wellbeing of mothers is being neglected.
What Does Postpartum Care Look Like Today?
Through pregnancy and birth, women become accustomed to care providers seeing them quite frequently, especially during the last trimester of pregnancy.
In most developed countries, however, after the baby has been born, and the mother is discharged from hospital, she won’t see a care provider for six weeks.
In obstetric settings, there is no single health professional dedicated to the care of the mother. Obstetricians focus on the mother-baby pair through pregnancy and birth. Paediatricians care for the health of babies. Hospital nurses and midwives care for mothers during their hospital stay but not when they go home. Therapists, such as physios, also care for mothers, but only if something has gone wrong.
In that gap between giving birth and the six week postnatal check up, who is looking after mothers?
And after the six week mark, mothers are basically on their own again, often with very little knowledge and even less support.
If they are fortunate enough to have a close family or community, they might be supplied with meals, and helped with domestic chores and child minding. But this seems to be the exception rather than the rule.
Even in countries where paid maternity leave is available, women are often isolated in the challenging postpartum period.
After the flurry of visitors who come to see the new baby, a new mother is generally left alone and expected to cope with her new role – and the changes in her body. There is no one on hand she can trust, and talk to about her lack of energy, breastfeeding problems, image concerns, pain, lack of sexual desire, and other mental and emotional issues that might arise.
The first months after birth are critical for mothers and babies. Women are recovering from nine months of pregnancy, and the physical demands of birth and breastfeeding.
Sleep deprivation also takes an enormous toll on the mental health of new mothers.
Babies are adapting to life outside the womb. They are extremely dependent creatures, who need the security and closeness of their primary caregiver during most hours of the day and night.
- Globally, postpartum depression (PPD) potentially occurs in the tens, if not hundreds, of millions every year
- A recent study found 1 in 7 women can expect to experience depression in the year following giving birth.
- Half of the men who have partners with PPD will go on to develop depression themselves.
- Up to 2 in every 1000 women will develop postpartum psychosis, and 10% of these cases will end in maternal suicide or infanticide
There is no easy solution to these problems, but more focus on providing mothers with support they can trust could be the key.
Early in 2018, US mother Jessica Porten walked into her ob-gyn office for her postnatal check up. After she had confided in the nurse practitioner, saying she thought she had postnatal depression, the police were called. Jessica was escorted to the nearest emergency department, where she waited for hours to be assessed, then was discharged. All she was given were pamphlets listing maternal mental health resources.
Jessica posted about her experience on Facebook and thousands commented on similar situations. Women who were reaching out for help, were being failed by their health systems.
This is just one example of how postpartum care fails women around the world. In Australia, women are sent home a few days after giving birth, and possibly visited by a midwife or a maternal child health nurse in the first week. In the UK, midwives visit about three times in the first 10 days.
Homebirth midwives offer more comprehensive visits in the first few weeks after birth. However, when considering the average rate of planned homebirths in countries such as the US, Australia and the UK is between 1% and 3%, these visits don’t cover many women.
Doulas are now stepping into the breach. Their care can cover the postpartum period, but it comes at a cost, which not all mothers can afford.
Postpartum Care Is A Process
The ACOG committee’s opinion stresses how the weeks after birth set the stage for long term health and wellbeing for mothers and babies.
It goes on to suggest:
“To optimize the health of women and infants, postpartum care should become an ongoing process, rather than a single encounter, with services and support tailored to each woman’s individual needs”.
Postpartum care, as an ongoing process without a definitive time frame, is a fantastic idea, but how easy is it to implement?
The US is one of the few developed countries where paid maternity leave is not accessible to most women. ACOG itself notes:
“Currently, as many as 40% of women who have given birth do not attend a postpartum visit, and attendance rates are lower among populations with limited resources”.
Having access to an ongoing process of postpartum care might be an excellent start, but it might still be entirely unachievable for many women. The onus is placed on the mother to be aware of any problems and to reach out to her care providers.
This can be particularly difficult for women who are single or in abusive relationships, or for those who have mental health problems, or concerns about how others might view them if they’re seen to be not coping.
What’s The Ideal Postpartum Care Situation?
In an ideal situation, women would go through pregnancy and birth with the knowledge they will be fully supported in their transition to motherhood.
Yet in today’s society, it is much harder to make this happen.
Families don’t always live nearby; friends have their own children and lead busy lives. Care providers have waiting rooms full of other patients who need care and attention. Women might have to return to work, either due to finances or in order to keep their jobs.
And underlying all of that is the perception that women should be able to recognise when they need help and ask for it.
In the Netherlands, new mothers leave hospital only a few hours after giving birth. However, they are not left to navigate their early mothering days alone. All Dutch mothers are entitled to a professional maternity nurse, called a kraamverzorgster.
This nurse comes for up to eight hour a day for the first 8-10 days, and is not only responsible for the baby’s wellbeing, but also closely monitors the mother’s recovery. She provides practical advice and help with breastfeeding and newborn care, and takes over the household chores. In certain circumstances – for example, if the mother had a difficult birth, has other children, or is a single parent – the nurse can stay longer.
A kraamverzorgster is every mother’s dream. The Dutch acknowledge the hard work that goes into creating a new baby, and the intense recovery period women experience afterwards.
Although recommendations to ensure mothers have postnatal health check ups and ongoing support are very important, they don’t go far enough to address the wider problem. Women are encouraged to give birth in hospital settings where they are unlikely to form trusting relationships with care providers.
An ongoing and close bond with a care provider such as a midwife, through pregnancy and birth, would provide women with an opportunity to bring up concerns, but just as importantly, give them access to a trained health professional who is invested in each individual woman’s health and wellbeing.
In a situation that offers continuity of care, a provider has observed and talked with the woman over many months, and has come to know and understand her personality, her health and her current life situation.
The provider is then best placed to consider how the mother will cope after birth, to suggest strategies to help and support her, and to put her in touch with available services.
During the early postnatal period, a trusted care provider is also more accessible, and able to pick up signs of a mother needing extra care or support.
Although new mothers have access to support services, it can be very difficult to contact them. Lack of time, fear, or even lack of support from family members can be deterrents.
We know the more support a mother has in the early months after birth, the better the outcomes for her and her baby. Postnatal depression might still be a possibility, but faster recognition and easier access to treatment means less risk of more severe problems.