(Originally published in Doximity Op-Meds, a platform for physicians, on May 15, 2023, as “Postpartum Care in America Leaves Much to Be Desired”. Published here in its original form with a selected Bibliography/further reading at the end.)
“Vaginal or C-section?” the nurse asked as I settled into my seat in the exam room. She was standing in front of the computer and looked as if she wasn’t going to sit down. She started clicking on the mouse even before taking my blood pressure.
“Um, vaginal,” I replied, confused that it didn’t show up in my chart even though I had delivered my baby at the same hospital. I was 5.5 weeks postpartum and this was my first, and only, follow-up obstetrics visit. She had me fill out a postpartum depression screening questionnaire, and apparently I passed, because no one brought it up after that.
Minutes later, an obstetrician entered the room. She was a physician I hadn’t met, but frankly, this did not surprise nor bother me. As a physician myself, I understood that our health care model these days required large physician groups to cover call, and I didn’t expect to have met all the providers. As a side note, I did select this particular group because they had fewer providers (nine) compared to a larger group at the main university hospital (18), and I had hoped that over the course of my prenatal visits, I would have met most of the obstetricians so that the one who delivered my baby wouldn’t be a complete stranger (it worked).
The physician who saw me postpartum in the office was nice, professional, and didn’t know a thing about me. She asked if I needed a contraceptive and if I needed a return-to-work note. I said no to both. Which, again, led me to believe that no one had looked at the EMR. At that point, she examined me to check on the healing of my first-degree tear and the involution of my uterus. Everything checked out, I guess, because she said, “We’ll see you in a year for your annual.”
What are we talking about?
As a physician myself, postop checks are short. All visits for all specialties these days feel a bit rushed. But I was astounded by the lack of postpartum care for new moms. I saw a meme that said we have at least nine to 13 prenatal visits, though some people, like me, who are ‘high-risk’ for advanced maternal age, have more — including one to two visits per week for the last five to 10 weeks, so up to 29 visits total. Anyway, 29 prenatal visits, your kid has about three to eight pediatrician visits in the first two months of their life, but you only have one postpartum visit. It feels anticlimactic. It feels as if, after the ‘big event’ of birth, the mother is kicked to the curb. Somehow, after this huge life change, the mother is supposed to handle this all on her own.
It wouldn’t be so bad if the postpartum period was easy. With minor surgeries, at least most people have resumed regular function after six to eight weeks. To be honest, my body was mostly recovered after five weeks. I had stopped bleeding and mostly stopped hurting. I was walking normally, going to the bathroom without using topical anesthetics, and eating a lot. But the difficulties of the fourth trimester extend beyond the physical trauma of childbirth. It is a major adjustment to have a whole other human being to take care of, one that maybe can’t be described until you actually go through it. No one can explain, and no one would believe, how hard it is to feed a little baby, learn how she communicates, and keep her alive when you are running on two to three hours of sleep a night, with no time or energy to do anything else during the day, barely staying hydrated enough to produce an adequate amount of breastmilk. No wonder postpartum depression, anxiety, and psychosis are so rampant. No one discusses these things with new mothers.
Who provides postpartum care?
Mostly, the mother’s obstetrician, but the care team includes any perinatologists, pediatricians, lactation consultants, midwives, and doulas. Arguably, the mother’s PCP and a behavioral health specialist should be included.
To be fair, busy obstetricians who are also sleep deprived and on call and are trained to deliver babies, not for psychological counseling, may not be the best people to help a new mother navigate the fourth trimester. They have completed the bare minimum by performing the PPD questionnaire. Thus, postpartum care falls into the cracks, somewhere in the no-man’s land between obstetric care and psychiatric care.
Some services have stepped up to try to fill in the gaps. Postpartum doulas market their services to help and advise the mother after childbirth, but these services run thousands of dollars, insurance doesn’t cover them, and they seem like a luxury for the wealthy. Lactation consultants, arguably one of the more important members of the care team, offer in-home consultations, meetings, and webinars. I met with three different lactation consultants in the hospital and all of them were helpful and gave me slightly different advice, and one of them even called me the day after I went home to check on how things were going, but that was the extent of that. And I would argue that postpartum wellness extends beyond lactation and breastfeeding — some mothers don’t breastfeed, for example — . The pediatrician asked how we were and smiled sympathetically when we said “sleep deprived.” But there is no follow-up from the obstetricians, no automatic linking to counseling services, nothing.
Some organizations have developed based on the need in this space, such as “Check on Mom,” where you can have your designated friends and relatives call or text you in the immediate postpartum period. Other websites include Momwell and Postpartum International; both have physical and psychological resources. Instagram has been a resource for many new moms. Accounts like Mamastefit highlight the importance of pelvic floor physical therapy both before and after birth, and offer additional tips besides. As a colorectal surgeon, I’ve seen my share of rectal injuries and anal issues from obstetric trauma and am always surprised at how many women are NOT referred to a colorectal surgeon until it’s a last resort.
When should postpartum care be provided?
The World Health Organization recommends at least four postpartum visits in the first six weeks for the new mother and baby. The 2018 ACOG guidelines recommend a postpartum visit within three weeks after giving birth, “concluding with a comprehensive postpartum visit no later than 12 weeks after giving birth.” Although the guidelines allow physicians to tailor these visits to the individual patient, the majority of my friends reported a six-week follow-up, and that was it. Two friends who had C-sections had a wound check at two weeks postpartum. According to the guidelines, components of the postpartum visit include assessing mood (the PPD questionnaire), infant feeding (“Are you breastfeeding? You are? Good, keep it up for at least six months.”), contraception and birth spacing (“Do you need birth control? We recommend waiting a year before trying again.”), sleep (“Are you sleeping?”), physical recovery (“We’ll take a look at your tear.”), chronic diseases (“You passed the glucose test.”), and health maintenance (“Come back in a year for your annual pap.”). So, while in retrospect, all of these items were addressed, the perfunctory attitude of these visits majorly misses the mark in evaluating how the new mother is overall. After talking to my friends, I realized that if you’re rushed out of there in less than twenty minutes, it might be that you don’t even know which questions to ask — such as, will my urination ever be normal again? Am I supposed to have pelvic prolapse? Who do I call if I suspect mastitis from breastfeeding? Who do I talk to if I don’t want to continue breastfeeding? Who do I talk to if I’m feeling the ‘baby blues’? Who do I talk to? Who do I talk to?
Why do we need postpartum care?
An informal poll of all my friends who have recently had babies suggests that my experience was not unique. In fact, the feeling that postpartum care in America is pretty lacking seems ubiquitous. The ones who did have some form of care, such as doulas or night nurses, paid for these services out-of-pocket.
In some Asian, Central American, and Middle Eastern traditions, the first month (specifically, the first forty days) postpartum is an extremely important time for the new mother. She is expected to rest and heal, and improper management of this time period is thought to lead to consequences later in life, such as depression, anxiety, or chronic disease. In Chinese culture, the first forty days postpartum is called a ‘confinement’ or ‘laying in’ period, where the new mother stays mostly indoors for the entire time while women relatives cook nutritious foods and soups, do housework, and take care of the baby while the mom rests. Some of my Chinese friends had moms who did this; others, like myself, did not. The importance of this ‘confinement’ is such that some Asian countries have whole “postpartum centers” dedicated to the care of new moms and newborns. One of my friends had the luxury of staying at one of these centers in Taiwan. She was served three meals a day; they had a spa with massages; there were nurses who took care of the baby and answered questions if the new parents had them; there were lactation consultants on site; and there were activities, like arts and crafts, for the mom. When I first heard of this, I was astounded. Apparently, it’s common in Asia and somewhat affordable, although still a personal expense and not covered by insurance. In the U.S., I recently heard about Boram in New York City, a similar postpartum care set-up, but it costs over $900 a night. It is not covered by insurance.
According to ACOG, “Many agrarian cultures enshrine postpartum rituals, including traditional foods and support for day-to-day household tasks. These traditions have been sustained by some cultural groups, but for many women in the United States, the 6-week postpartum visit punctuates a period devoid of formal or informal maternal support. Obstetrician–gynecologists and other women’s health care providers are uniquely qualified to enable each woman to access the clinical and social resources she needs to successfully navigate the transition from pregnancy to parenthood.”
How do we provide adequate postpartum care?
Postpartum care shouldn’t be a luxury only for those who can afford it. It should be part of our health care system. However, since postpartum care falls somewhere between physical and psychological needs, the assignment of responsibility falls in between the cracks. Is the lack of postpartum care due to our payer-led system that does not reimburse for something that does not generate much revenue? Or is the lack of postpartum care another way that the system neglects women’s bodies? The way that we do not consider motherhood of value, we do not consider the care of new mothers worthwhile. The theme of caring for women seems very relevant right now.
Just yesterday, another friend who recently had a baby texted me about the amount of spit-ups her baby is having. Perhaps because I am vocal on social media about our tribulations, people think I might have a solution. It occurred to me, why do we have this web of mothers texting each other in the wee hours of the night, hoping for answers to how to survive this newborn period? Why don’t we know? None of this is intuitive. Why aren’t we told? I don’t know who is supposed to tell us. Why don’t we ask for help instead of sitting in the dark? Deep down, we’re afraid that we should know, and we’ll be perceived as bad moms because we don’t instinctively know the answer.
Those first few weeks, indeed, the fourth trimester technically includes the first 12 weeks, are critical in the birth of a new family. The transition from womb to world and from personhood to parenthood isn’t easy. Having the time and space to care for, nurture, and learn each other is essential for everyone’s development. But this postpartum period exists in a clinical gray area where multiple providers do not reach, leaving new parents searching in the darkness for answers.
Private organizations and nonprofits attempt to fill in, but our health care system needs to recognize the holistic needs of a new family in the postpartum period. We need to do better to support them with wraparound resources that include physical and mental health and nutrition and lactation guidance. In addition, while I support maternity leave being six months to one year, at minimum it should be three months for all the reasons described. It takes the entire fourth trimester for both the mother and the baby to mature enough to re-enter the world. Why tear them apart any sooner?
Interesting reading:
Breastfeeding is basically impossible
https://www.vogue.com/article/breastfeeding-difficulty-novel-essay?utm_source=Iterable&utm_medium=email&utm_campaign=newsletter_parent&utm_medium=email&utm_source=iterable&utm_content=20230129_icymi
