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Birth may signal the end of your pregnancy, but it’s only the beginning of so much more. So why don’t our healthcare plans take that into consideration?
In America, it’s great to be pregnant. We love that bump! We have incredible baby tracking apps, amazing maternity clothes, prenatal yoga and fitness classes, and every Pinterest-worthy nursery item conceivable.
Plus, we get parties and presents and at least two dozen check-ins with our provider leading up to the birth.
Then the baby arrives.
And, that, my friend, is where you will hit a very surprising, and very ugly, wall. To say we are “behind” other countries in care, services, and support is almost negligent. We are failing families. Period.
Overall, the United States spends the most money in the world on healthcare per person. However, in regard to maternal outcomes, we typically rank last when compared to other wealthy nations.
There are four key areas where other countries take action in ways that we can learn from.
While Americans concentrate primarily on the birth plan and nursery, postpartum-positive countries incorporate postpartum teaching and preparation into antepartum care.
In the Netherlands and Belgium, postpartum planning begins around 34 weeks. In Spain, you’ll receive a cartilla de embarazo (mother’s passport) and check in with a community midwife monthly.
Finland’s maternity package is now world-famous: Once mothers are 154 days (22 weeks) pregnant they can apply for a free box through the Finnish social security system. The box is filled with 63 essentials for baby, and the colorful box can double as a bed.
General antenatal care is also standard, with access to intensive antenatal care if the birthing person requires the help of a social worker, psychologist, or physiotherapist.
The benefits of comprehensive prenatal care are not lost on America. We have numerous studies showcasing its power to create more successful outcomes.
One such 2013 study
found that including a doula in prenatal care reduces adverse birth outcomes while benefiting mothers, babies, and the medical community as a whole.
We just haven’t acted on this information federally, leaving birth parents to piece together their own care plans.
Rest and rituals
A 2010 study on cross-cultural postnatal care reported, “The postnatal period seems to be universally defined as 40 days. Most cultures have special postnatal customs, including special diet, isolation, rest, and assistance for the mother.”
In contrast, “for many women in the United States, the 6-week postpartum visit punctuates a period devoid of formal or informal maternal support,” according to a pivotal 2018 American College of Obstetricians and Gynecologists (ACOG) committee opinion report.
When we look abroad, postpartum rituals abound.
Mexico has cuarentena, a 30-day rest period with family. China has a similar practice of “doing the month.”
Japanese mothers move back home for satogaeri bunben. Korean families practice a 3-week course of seclusion (and seaweed soup) called saam chil ill.
Eastern European women are secluded for the first month after birth. In addition to secluded rest, postpartum body massage and abdominal binding are common throughout Latin America.
It’s easy as an exasperated Westerner to romanticize these practices. However, it’s important to recognize that the act of quarantined care is not perfect.
China’s peiyue (“mothering the mother”) was associated with lower odds of postpartum depression (PPD) and lower severity of physical symptoms in one 2006 study
. However, a 2001 study
of Japanese women found satogaeri bunben didn’t necessarily lower rates of PPD.
Seclusion with family does not categorically diminish mental distress (in fact, it can increase it in the case of combative or abusive familial relationships). And some ancient traditions — like not bathing or brushing teeth — are not hygienic or helpful.
But there is a nugget of wisdom in these practices that American families can benefit from: Slow down.
“Everything that a new baby needs a new mom needs. So you know a new baby needs swaddling, you know a new baby needs a constant food source, you know a new baby needs eye contact, you know a new baby needs soothing. That’s everything a new mom needs,” says Kimberly Ann Johnson, CSB, SEP, founder of Magamama and author of “The Fourth Trimester.” “It’s a very hard sell to tell [American mothers] that they need to slow down. And even if they know they should slow down, they don’t know how to slow down.”
She speaks to the cuarentena, and its literal translation of “quarantine” — a concept American mothers push against. “We don’t want to be confined. We don’t want to be told what to do. We don’t want to not be in charge.”
Yet that pride in independence, coupled with a lack of fundamental postpartum structures, often undermines our recovery.
Recovery and routine visits
“Postpartum is where the key is,” says Dr. Nathan Riley, who specializes in Obstetrics & Gynecology and Hospice and Palliative Medicine in Kentucky. “There’s something in the care of women postpartum that the U.S. is missing. […] It’s really not your job [to self-diagnose and take care of yourself as the birth person]. You have a new baby that you should be watching over.”
Sara Reardon, PT, DPT, WCS, BCB-PMD, of NOLA Pelvic Health and affectionately known as The Vagina Whisperer, agrees. “I hear women say, ‘I don’t know what’s normal.’ They are not given a baseline. You’re frantically looking for information. Once you’re home, you’re over that initial high, and you realize you’re totally on your own, and there’s no help. It’s up to you now. They don’t give you resources, they just say, ‘It takes time,’ or ‘It’ll go away,’ or you call your doctor or nurse, and they say, ‘Let us know if it doesn’t get better,’ and there’s no follow-up. It’s all on you. It’s all on the mother.”
Being the sole educator and provider of your postpartum care is not just hard. It’s dangerous. Developed countries with the lowest maternal mortality rate consistently have one thing in common: routine check-ins at home.
In Denmark, a midwife will call the day after discharge, and then an at-home health visitor will come to the house within 4 to 5 days.
In the Netherlands and Belgium, new mothers will have a kraamverzorgster, a maternity nurse who comes to the home to provide a minimum of 24 hours of care within the first 8 days after discharge.
For Swedish mothers, breastfeeding counseling is covered by insurance and midwives conduct as many home visits as needed within the first 4 days after delivery
(with more visits available if needed).
Reardon points out France offers in-home postpartum care and all birthing parents automatically receive a referral for pelvic floor therapy.
It brings up a great point. Not only do we lack institutionalized support for birth, but America doesn’t even treat it like other standard medical events. A knee replacement, for example, will warrant 1 to 2 nights in the hospital, 3 to 6 weeks at home with a specific rehabilitation timeline, and a rigorous course of physical therapy.
The one point of recovery that all countries seem to struggle with? Maternal mental health. In non-Western cultures, reports vary greatly due to differing clinical criteria and cultural norms that inhibit self-identification as depressed or anxious.
Even in Western cultures where mental health services are openly discussed and available, stigma is a substantial barrier to asking for help.
This is alarming because depression during pregnancy or the first year postpartum in the United States is twice as common as gestational diabetes. And perinatal mood and anxiety disorders (PMADs) are the number one medical complication related to childbearing.
“Some may say the rates of PMAD are increasing, but evidence for that can be iffy; it is more likely that we are doing a better job identifying those with PMAD,” says psychologist Dr. Catherine Monk, joint professor of medical psychology in the departments of psychiatry and obstetrics and gynecology at Columbia University Medical Center. Maternal suicide rates are climbing, however, and may be far higher than currently calculated.
“OB providers need to be trained in maternal mental health diagnosis and treatment,” says certified perinatal psychologist and educator Pec Indman, PA, EdD, MFT, PMH-C, who authored the book “Beyond the Blues: Understanding and Treating Prenatal and Postpartum Depression & Anxiety.”
“Additionally, providers need a clear path to referring women who need additional support or medication. Postpartum Support International now has a reproductive psychiatric consultation line providers can call for free consultations about medication,” Indman says.
The United States is ranked last in family-friendly policies according to the Organization for Economic Cooperation and Development.
Only 14 percent of American workers have access to paid leave, says ACOG. An additional surprise to many is that the Family and Medical Leave Act is not universal — 40 percent of Americans do not qualify.
Perhaps more significantly, due to economic hardship and employer constraints, 1 in 4 women return to work just 10 days after giving birth.
Parental leave has become very political, but facts are facts: It is instrumental in creating positive maternal and infant outcomes.
For the birthing person, it allows time for physical recovery, emotional bonding, and better rates of breastfeeding success (which in turn decreases maternal and infant death rates). Partners can be caregivers to the birthing parent and the baby, which benefits the entire family.
In postpartum-positive countries the amount of parental leave ranges—from weeks to months to even a year—but it is law.
In America, eight states and Washington D.C. are leading the way with paid parental leave. California, New Jersey, Rhode Island, New York, and Washington have existing programs. Programs are forthcoming in Washington, D.C. (effective July 2020), Massachusetts (2021), Connecticut (2021-2022), and Oregon (2022-2023).
There is also hope, in the form of the recently passed National Defense Authorization Act, which provides for 12 weeks of paid parental leave for civilian federal workers, for birth, adoption, or fostering starting in October 2020.
Even when parents do have access to leave, there’s a prevailing attitude that it needs to be productive and purposeful.
Kimberly Johnson points out that many women fail to take their full maternal leave or overextend themselves during it. “We don’t even have it in our imagination to know what it would feel like to have other people caring for us. A to-do list isn’t going to solve it,” she says. “[…] but you think you’re the exception and because you feel good it’s fine to be out and about with your baby at three weeks postpartum. You’re not the exception. No one is. There isn’t a woman who doesn’t need to rest for this period of time.”
If we do get greater access to parental leave, let’s hope we take it — and make it count.
Mandy Major is a mother, certified postpartum doula PCD(DONA), and the co-founder of Major Care, a telehealth startup offering remote doula care for new parents. Follow along @majorcaredoulas.