The XX Factor

It’s Startling How Little We Know About Good Postpartum Care

One of these people receives better standardized care than the other.


Currently, the standard for postpartum care is a single visit to one’s OB-GYN or midwife around six weeks after childbirth. Alison Stuebe, an OB-GYN and associate professor of obstetrics and gynecology at the University of North Carolina, says women need more than this, but nobody knows exactly how much.

“There’s a total disregard of mothers as having anything other to do than take care of their baby after childbirth,” Stuebe says. “As I often put it, once the candy is out of the wrapper, the wrapper is cast aside.”

So Stuebe is working on a new program called The Fourth Trimester Project, which is trying to fill what she sees as a distressingly large gap in postpartum care. She and her partners recently convened a group of 17 mothers with babies under nine months and asked them questions about their postpartum needs. Over the next year, they will carry on with similar research through surveys and a follow-up meeting with the same women.

“Our goal is to come up with patient outcome measures so we have a better way to tell if we are meeting new moms’ needs,” Stuebe says. “Right now we don’t have a ruler to measure how we are doing. We need this before we can figure out if we are making progress.”

For most women, it takes six to eight weeks to return to what doctors call “non-pregnant anatomy and physiology,” though this doesn’t necessarily mean she has, in the parlance of tabloids, “bounced back.” Lisa Kane Low, associate professor in the school of nursing and women’s studies at University of Michigan and certified nurse midwife, said the postpartum period—with the tears and stitches and bleeding—is a painful one for many women, and doing too much too soon can increase one’s risk of hemorrhage, infections, and blood clots. Additionally, there are the more common but still difficult complications from exhaustion and mastitis—an infection in the breasts that is more likely to develop, or worsen, in women who go for long stretches between nursing or don’t empty their breasts completely. For many women, these symptoms last beyond six weeks.

One survey found that at six months postpartum, 25 percent of women reported problems with exhaustion, 18 percent who had a cesarean reported pain around the scar, 11 percent reported urinary problems, and 10 percent said they had pain during intercourse. Another study found similar results and also discovered a link between these issues and an increased risk of developing postpartum depression.

A recent study out of University of Michigan that used MRIs to diagnose childbirth injuries found that 15 percent of women have pelvic injuries that can take up to eight months to heal. Janis Miller, author of the study and a nurse who specializes in pelvic floor issues, said that this could be the result of a tear in the kegel muscle, resulting in either partial or complete detachment from the pubic bone. Others might experience pain from a fracture in the bone itself. Doctors commonly prescribe kegels to strengthen and heal this region after childbirth, but if what a woman is suffering from is a muscle tear or a bone fracture, kegels won’t help.

“These kinds of tears are largely unidentified and seldom talked about among women and their doctors or midwives,” Miller says. “If a woman senses that something is different they should seek extra care and not blame themselves for not recovering as quickly as their friends.”

What the studies tell us is discouraging; more discouraging is that there have been so few. As Jenifer Fahey, a certified nurse midwife and assistant professor at University of Maryland School of Medicine, put it in a 2013 report, “The health of women during the postpartum period remains a neglected aspect of health care that has been the subject of comparatively little research, policy, and clinical attention.”

Stuebe of the Fourth Trimester Project says she hopes to come up with a series of guidelines on postpartum care by next year, including policy and study recommendations. While she’s opposed to the idea of implementing a one-size-fits-all model, there are certain elements she imagines working for most people in most places. One of these is standardized postpartum home visits by nurses, something popular around the world but—you won’t be surprised to learn—rare in the United States.