Duke Medical Ethics Journal
Examining the Methods of Postpartum Healthcare in the United States
by Emily Walsh
Pregnancy is a closely monitored and highly prioritized time, and medical professionals work hard to secure the health of both the baby and the mother. Prenatal care, close monitoring, multiple scans, and baby wellness checks are still involved in the medical process of maintaining the health of the baby and helping a mother carry the pregnancy to term. The mother is cared for and their health and wellbeing highly prioritized until the birth. However, once the mother gives birth to their child and is sent home, they are not presented with the same standard of care. Mothers lack medical monitoring of their physical and mental health during the postpartum period, which is defined as beginning one hour after the delivery of the placenta and lasting 6 weeks, which is the time when the uterus returns to its pre-pregnant size. Over the course of this time, standard of care is for the mother to attend one 6-week postpartum check up after birth, which is scarce in respect to medical attention to their wellbeing, especially when compared to the prenatal period (1).
Specifically in the United States, many women suffer from postpartum morbidity, yet it is not a topic that has extensive research, or one that is medically treated. Here I aim to critically examine the effects of birth and postpartum morbidity on women more closely and examine the methods of care in place. Postpartum care is a sector of the reproductive healthcare system that calls for improvement to benefit both mother and child in the immediate months after birth and in the long term.
Maternal morbidity is defined by the World Health Organization as any health condition attributed to and/or aggravated by pregnancy and childbirth that has negative outcomes to the woman’s wellbeing. While this paper will look specifically at postpartum maternal morbidity, it is important to recognize that these complications can occur at multiple stages throughout pregnancy and during childbirth. In general, maternal morbidity rates are on the rise in the US, with the rate of severe maternal morbidity increasing by approximately 20% from 1993-2014 (9).
Postpartum morbidity comes in many different forms and complications and lasts for different durations of time. Generally, there are three timeframes that are considered in the postpartum time periods over which different complications can arise and last. There is the immediate postpartum period, which is considered to span over the time of birth to three months. The short-term postpartum period lasts from three to six months following birth, and the long-term is considered to be past six months after birth. There are a multitude of symptoms that women can experience over the postpartum period. Over the course of the immediate postpartum period, 87% to 94% of women report experiencing at least one health problem (1). Among the most common symptoms that new mothers experience is backache, urinary stress incontinence, fecal incontinence, urinary frequency, depression and anxiety, hemorrhoids, extreme tiredness, frequent headaches, and migraines (1). Approximately 10% of women will experience depression in the immediate postpartum period. Prevalence can range from around 7% to 30% depending on how postpartum depression is defined and when it is measured (9).
While many of the immediate problems that women experience after birth are resolved in the short-term postpartum period, new health problems and symptoms arise. Over this time exhaustion, continued back pain, headaches, depression, sexual problems, persisting perineal pain, hemorrhoids, breast tenderness, and muscle and joint pain are all common. It has also been noted in several studies that women in the first six months postpartum suffer from higher-than-average rates of upper respiratory symptoms, stomach illnesses, and infections than healthy women (6).
After 6 months postpartum, most women in the United States have returned to work and are balancing work and newborn life responsibilities. During this time period, specific postpartum symptoms such as fatigue, backache, and depression are demonstrated to increase over time and still be present during this time period. Clearly, there are symptoms of postpartum morbidity that last well beyond the allotted six weeks of postpartum time that women are legally considered to have. The assumption that women’s symptoms after birth will alleviate after this six week period is cause for concern, and one can see how this contributes to a lack of medical attention awarded to new mothers. Understanding these symptoms and giving more support and care to women in the postpartum period is integral to creating a healthy and positive experience for recovering new mothers.
There are a wide range of symptoms that women will experience when having postpartum morbidity, and some new research has tried to identify if certain symptoms are associated and tied to certain birth methods, in an attempt to find ways to create more positive birth experiences for mothers. Overall, researchers found that in comparison to spontaneous vaginal birth, there was an association of a different onset of symptoms for women who went through cesarean birth methods and assisted vaginal birth, which is performed with forceps or vacuum extraction. In 2021, 32.1% of women had a cesarean birth. The cesarean birth rate has risen each year since 1996, and simultaneously assisted vaginal birth rates have decreased (8). Because of the growing amounts of women experiencing intervention-based methods of births, examining how these affect postpartum health and symptoms, including the types of symptoms and their durations is essential in working to improve overall maternal experience.
For women who have cesarean births, there has been documented protection against perineal pain (1). However, women who have had cesarean births reported higher levels of breastfeeding problems, depression, anemia, abnormal bleeding, urinary tract infection, and vaginal discharge than those that experienced a spontaneous vaginal birth. Women that had assisted vaginal birth had significantly more sexual problems and perineal pain than those who have spontaneous vaginal birth or cesarean birth (5). On average, women who experienced assisted vaginal birth also reported more urinary and bowel issues in comparison to other methods of birth (7). When looking at alternative methods of delivery, backache occurred most commonly after cesarean birth and hemorrhoids after assisted vaginal birth. Headache and tiredness, the other two most common symptoms during the postpartum period, were not related to method of delivery, and were reported at similar rates from women in all groups of delivery (1).
Postpartum depression is one of the most pervasive and common symptoms that women experience after birth, yet it is only recently being researched and support methods being implemented. Perinatal depression, which encompasses major and minor depression symptoms occurring either during pregnancy or within the first 12 months after delivery affects between 10-20% of women, with even higher rates among women of low socioeconomic status (2). In general, there has been very little research done on the effects of perinatal depression and the ways in which to treat women experiencing this. The Birth Issues in Perinatal Care journal found that only a few studies were conducted on attitudes, preferences, or barriers to treatment for women experiencing perinatal depression. This shows a gap in the knowledge about the short and long term effects of perinatal depression on women. Extraneous social factors such as socioeconomic status and previous mental health diagnoses influence the types of symptoms and extremity of depression that these women experience, and they need to be treated effectively
Postpartum morbidity and medical complications berth a wide range of symptoms, durations, levels of severity, and experiences for women. In the United States specifically, there is a large gap in the research being done into the types of postpartum symptoms and methods of care. There are many ways and methods of care that may influence the types of symptoms women experience during the postpartum period, such as method of delivery.. In the United States, there is not much research being done. Most of the information available is from European studies that have different methods and standards of care. Moving forward, it is important to examine the methods of care that are provided to women and improve upon them to help maintain a healthy postpartum time. To begin with, making sure to provide more frequent provider check ins, and looking into more possible treatment methods for women experiencing postpartum symptoms, especially those that are at high risk for becoming chronic, is critical in helping to improve the patient experience. In the sphere of reproductive justice and visibility, it is critical to examine the wide range of effects that women experience in the postpartum period and improve upon their quality of care overall.
Review Editor: Olivia Ares
Design Editor: Libby Gough
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