New Recommendations for Postpartum Care Are Long Overdue

Here’s how women have been getting by in the mean time.

Woman kissing the forehead of her newborn baby.
Photo illustration by Slate. Photo by Thinkstock.

For years, advocates within obstetrics and gynecology have been raising the alarm about the lack of awareness of and care options for women experiencing postpartum depression in the United States. “A woman is Queen Bee while pregnant, and then suddenly, hardly visible,” said Ann Smith, president of Postpartum Support International. That’s because our medical system focuses immediately on the needs of a new baby rather than on the mother, whose work is often thought to be done when the baby has been born.

As Alison Stuebe, associate professor at University of North Carolina School of Medicine and an investigator with the 4th Trimester Project, has said, in American society, “The baby is the candy; the mom is the wrapper. And once the candy is out of the wrapper, the wrapper is cast aside.” Postpartum care has by and large ended when a woman leaves the hospital after giving birth, with a brief follow-up generally six weeks after.

In April, the American Association of Obstetrics and Gynecologists presented new guidelines on postpartum care from the Presidential Task Force on Redefining the Postpartum Visit. The recommendations are for more proactive and appropriate guidelines for the care of postpartum women.

According to the revised guidelines: “ACOG now recommends that postpartum care should be an ongoing process, rather than a single encounter and that all women have contact with their OB-GYNs or other obstetric care providers within the first three weeks postpartum.”

The recommendations include developing a plan for postpartum recovery even before the birth of the baby. The first visit should include an assessment of physical recovery to ensure the healing of any scars and tears, and the return to normal uterine size, a screening for postpartum depression, and the creation of a plan for family planning and spacing. Additionally doctor and patient should establish a follow-up plan for any chronic or pregnancy-related medical conditions. And beyond the specifics, the new task force states that its motivations are about a bigger picture of postpartum care: “This Committee Opinion has been revised to reinforce the importance of the ‘fourth trimester,’ ” a rhetorical move that integrates postpartum care thoroughly into the framework of pregnancy and childbirth.

These recommendations are a massive step forward for postpartum women, but many of the challenges they face go far beyond medical care, to public policy and the very structure of our economy. It is not uncommon for mothers, especially low-income mothers, to be back at work by the time six weeks rolls around and to miss the postpartum appointment all together. Why?

Lisa Spiegel, co-founder of the Soho Parenting and co-author of A Mother’s Circle, said, “In 21st-century America, it is still every woman for themselves. There is still no systematic postnatal community support for women after they give birth.”

It is rare to find a familial village in the U.S. Emilie Pinder of Silver Spring, Maryland, had her parents and her in-laws living near her for months after her son arrived. “It felt overwhelming at first, but in the end their being with our family helped in many ways,” Pinder said. “My mother is an assistant pediatric nurse, so she was a great help with the technical things like breastfeeding. I think the best part was that they stayed with my son and allowed me to get out of the house. I loved simple things like going to the grocery store, I saw people, I felt socially connected and not at all isolated.”

That is not the norm. Often, newly minted mothers are alone at home with a new baby, recovering both physically and emotionally from birth while attempting to make sense of their new roles as mothers. The isolation of new motherhood is a trigger for a spectrum of postpartum mood disorders including depression and anxiety. “What has recently stuck me is that we develop such strong relationships with women over the course of prenatal care, ultimately seeing them every week, then after delivery we now go six weeks without so much as a scheduled call or visit. Those first six weeks after birth are full of many physical and mental changes,” said D.C.-based OB-GYN Dr. Lauren Messinger.

Midwife Michelle Clausen, who practices at George Washington University, and private doula Anna Carson Dewitt have both spent extensive time outside of the U.S. delivering babies and caring for new mothers. They brought their skills and experiences back to the U.S. And, while they recognize much is right in the U.S., they both assert that pregnancy and perinatal and maternal care are something we get very wrong. Both use their practices to move the needle with a kinder, more mother-centric approach to birth and the postpartum experience.

But there is not enough professional support to go around, and that leaves many women turning to peers for support, often online. Ann Smith of Postpartum Support International worries that this causes even more problems. “Turning to a non-professional online group can prove to be even more of hazard—the words, ‘you’ve got this, mama’—can cause a women suffering from the insecurities and anxieties of PPD to feel like even more of a failure.”

But there is a value to seeking help from other women who are or have been in the same spot before. “Women are resourceful and seek each other out for connection and help at this critical time in their lives,” said Spiegel. In light of slow-moving medical developments and a dearth of public policy supports like paid family medical leave to help solve many of these problems, it is mothers themselves who have built for-profit businesses to fill the gaps while society makes its way to new standards.

I spoke with Cheryl Petran at her more than 30-year-old Pump Station and Nurtury in Santa Monica, California, which puts a full team of postpartum doulas in the field to support new parents from the day they come home through the first 12 to 16 weeks of life. Unlike a baby nurse or nanny, the postpartum doula’s role is to support the entire family unit, and to educate and empower them so they are confident in their new roles as parents. “As our doulas often say, our job is to work ourselves out of a job,” Petran said.

The Pump Station and Nurtury is staffed with licensed therapists and clinicians, postpartum doulas, and lactation consultants. They focus on supporting mothers through classroom and interactive engagement. Pump Station class rates range from $25 to $325 and consultations range from $145 to $495. Both are charged on a sliding scale, to make services more accessible to low-income families. Subsidies and community outreach efforts are taken quite seriously, and many of the employees offer free classes when they can.

Ritual Care is a growing business offering an online classroom with a focus on self-care for new mothers. Owner Kelly Newsome Georges, a former attorney, offers an online curriculum that seeks to empower women via learning modules in mind, body, and soul. The program caters to new mothers who make up 75 percent of her business. The classes cost between $499 and $2,499. That may seem costly, but the success of the business thus far is a testament to the need for such services in light of lagging medical and business supports.

Let Mommy Sleep is an 8-year-old franchise that focuses on overnight care for new parents. They provide in-home care overnight in order to allow new parents to sleep. Additionally, they offer private and group instruction for parents and caregivers of newborns, which increases confidence and lowers anxiety. They also offer two-hour postpartum home visits by a registered nurse, which happen within the first one to five days home from the hospital to asses parents as well as baby. The company has grown into a team of nurses and newborn care experts all over the country. In addition to rates that range from $30 to $100 per hour, they also operate a 501(c)(3) called Mission Sleep, which provides free care to military families and first responders.

A simple search reveals hundreds of women who have built private doula or similar fourth-trimester care businesses of all shapes and sizes. And of those businesses I surveyed, most make every attempt to serve all mothers, though it is hardly possible given the overwhelming need and costs involved. As such, existing clientele tends to be women with resources or those who work for private sector employers willing to foot the bill in the name of retention.

This is why moving from ACOG’s guidelines to firm policies (which will in turn require insurance coverage) around the full range of maternal needs is both critical and essential. Until then, mothers have taken action, many of them motivated to provide the kind of care they wish they had received or were lucky enough to have received, to pay it forward. Unfortunately, for now, you’ll have to find a way to pay for those services.