Progress Needed for Postpartum: Part III
This is the third and final part of the series calling for progress for postpartum care. So to recap, we’ve learned about postpartum depression, postpartum anxiety, and the lack of mental health care availability. Also, tons about self care. Self care doesn’t look the same for everyone. For some it looks like having the time to go get a haircut by themselves, and for some it’s making time for therapy. Also, we all agree that only one standard postpartum doctors visit 6 weeks after birth is pathetic right? So let’s* wrap this up. What can we do to improve?
*and by lets, I am referring to the 3 people that will read this article.
Racial Disparity in Postpartum Care
The racial disparity across the realms of healthcare is well documented. Thankfully, the conversation surrounding the inequity in maternal healthcare for women of color is getting louder and more frequent.
The increased statistics of health problems and rates of disease and disorders in populations of color have for far too long been “explained” by lower socioeconomic status. Which is partly true. But our society, government, and systemic racism persists communities of color in a lower socioeconomic status…but people don’t want to talk about that. The word racism automatically turns people on the defensive. I could write a dissertation on this topic, so I’ll stick to my focus.
Even when we look at a population of women in higher tax brackets and education level, the maternal mortality and morbidity rate is increased. Therefore, it only would make sense that perinatal and postpartum mood disorder rates are increased in women of color, particularly Black women in this country. Complications in pregnancy, as well as birth trauma, and decreased feelings of self worth as a result of perceived lack of care and compassion in healthcare increased stress, anxiety, and depression.
Many factors influence the lower rates of diagnosis and proper treatment for perinatal and postpartum mood disorders for women of color, including, but of course not limited to:
- Access to medical treatment
- Quality of medical treatment
- “Strong Black Women Syndrome”
- Gender discrimination across races
Postpartum Depression Can Affect Anyone
When you imagine and picture the face of postpartum depression, what do you envision? I would bet, if you are being honest with yourself, it is a white woman that you picture. Societal stereotypes portray white woman as more fragile and in need of help, while portraying Black women as strong and confident. Many people think that because this is categorized as a “positive bias” or complimentary stereotype, that it is less problematic. But we can conclude, in the setting of mental health care, this can cause a major problem. When Black women are seen as strong and self reliant through adversity, this perpetuates the lack of need for compassion and empathy, let alone mental health care.
Studies show that even when women of color seek treatment, they have lower rates of diagnosis. I would attribute this, at least partly, to our implicit bias that they are coping appropriately and do not need as much help. This can be a deadly bias. Across races, suicide is the leading cause of death in women with postpartum depression.
60 % of Pregnancy Related Deaths are Preventable
It is pretty difficult to study pregnant women. It’s unethical. You can’t really say, lets give you this medication and see what happens to your and your unborn baby. So much of what we know about different treatments, interventions, medications, etc are through review after the fact. In review, studies show about 60% of pregnancy and postpartum related deaths are considered preventable. What are some factors that influence these statistics?
Systems of Care
This includes factors like lack of coordination between care providers. Everything is usually so separate. Your primary care doesn’t coordinate with your OB provider and your OB provider might not even be the one caring for you at the hospital. Depending on your insurance and what type of clinic you are going to for your prenatal care, you might not even go to the same provider for your postpartum check up. Was the patient referred to the high risk clinic? Are they supposed to go to that clinic for their postpartum check up? No, ok, well did the high risk clinic inform the baseline clinic that the patient delivered and needs to be scheduled for their postpartum check up? I hope so.
Also, we have already discussed, that as a system, our standards of care for postpartum follow up are minimal. You can refresh your memory on that here, in part I.
Provider Factors
This can include misdiagnosis, quality of care, and work load of the provider. These factors are influenced by many things. Implicit or explicit bias of the provider, the providers resources that may or may not be able their availability for use, and even education level. Not all OB providers are created equal.
This was a big culture shock to me when I moved to North Carolina. The process for OB care in Maryland, at least in the area I was in and familiar with, was pretty similar for patients both on Medicaid, and patients with private insurance (like Blue Cross, Blue Shield for example). All the OB practices I worked with and even went to see myself, accepted patients with either. So even though I worked at a small community hospital with all private OB groups, we have patients of all kinds.
The same doctor on call could be caring for a 16 year old with Medicaid and a 40 year old patient who underwent IVF to get pregnant and may have a six figure salary. That is what I thought was normal. I do know there are patients who have to be seen at the county health department. Those patients were usually immigrants that didn’t have a social security number so maybe did not have access to insurance at all, even medicaid, yet.
Then I Moved South
I worked at a large Duke OB/GYN office that had about 10 doctors and 2 nurse practitioners. They were the only private OB group that delivered at the “Big Duke” hospital in downtown. When I started there, I had to ask what they meant. Someone explained, most of the patients that deliver at Big Duke go to the health department or referred to the high risk clinic; they are medicaid patients. But our office also does, so we get people with insurance who still want to deliver at the bigger hospital with the high risk care and higher level NICU. A lot of the patient are Duke employees and doctors wives. I was so confused. And then I saw it first hand.
We had a patient that lost her insurance and had to get Medicaid insurance and she had to switch from our OB practice. The reason I was even involved in her care was because she was nearing 28 weeks gestation and needed her Rhogam for (a shot needed if you have RH negative blood type, like O negative). She was calling asking what should she do because the health department couldn’t get her in for 4 weeks but she knew she needed that shot. I had to ask the other nurses what to tell her. Why can’t she just come in for one more appointment? I felt sick to have to tell her she couldn’t.
Luckily, I had L&D experience and a heart. I told her, if it comes down to it, she can present to the hospital for care and they can’t turn her away. She should see she is 28 weeks and give her the Rhogam there. And this, ladies and gentleman, is one example of why the US spends the most of healthcare, yet still has the worst outcomes. A hospital visit to give one injection is going to charge her Medicaid insurance MUCH MORE money than a simple office visit would. This patient was smart. She knew her healthcare was important for herself and her baby, but she still hit a major barrier.
Why don’t these private OB offices accept patients with Medicaid insurance?
I wish I knew. Contrary to what many of the general population believe, there is just one fee for the entirety of the prenatal care and delivery. That is the fee for the OB care providers, the hospital bill is separate. But it doesn’t matter if you only come for your standard visits and have an uncomplicated vaginal delivery, or if you call with a questions in the middle of the night, show up to the office for a triage visit because the baby had hiccups and your didn’t know that was normal and had a c-section for delivery. It’s all the same charge. So no, the doctors actually do not make more money if you have a C-section.
I will say, different insurances may have slightly different fees. That is why even with private insurance some offices accept this but don’t accept that. But Medicaid if paying for these women’s care. Y’all don’t want to hear this, but I bet if it weren’t disproportionally Black and Latina patients that had Medicaid, it would be a different story. And that might not be a conscious factor in the providers mine, but that is where you insert institutionalized racism.
Even when they are a Doctor, not all OB care is created equal
Did you know, in the state of NC, any doctor with an MD or DO can provide prenatal care? It’s true. So technically, an orthopedic doctor could be giving women prenatal care. They may not have privileges to deliver the baby in the hospital, but a lot happens in those first 9 months.
This is most likely to increase access to care, especially in rural underserved areas. In theory, that’s a good thing. And I am sure most of these providers are family practice physicians who did undergo some OB training in residency. But do you think patients that go to a rural health clinic that is run by community health nurses, medical assistants, and overseen by a busy family physician AND might be the only OB care provider for a 40 mile radius is giving the same quality of care as a metropolitan located office with the highest technology and OB doctors who did their residencies at the top programs? I don’t think so.
Length of Postpartum Care
Speaking of Medicaid, it is great that any US citizen can qualify for free Medicaid insurance if they don’t have access to their own. But first, what about out immigrant patients? I know there are some who would say why would we pay for their healthcare (insert eye roll). But what about that unborn baby inside them that the United States citizens and government cares SO MUCH about? The insurance and healthcare is also for them. Their life matters too, right? Dare I say, all lives matter…
Well even free Medicaid expired for the birthing parent at 8 weeks postpartum. You’re done. You’re kicked off. But if you have any complications after that 8 weeks, I am sure you will pay out of pocket to see a doctor right?
Progress for Postpartum Care is Needed: STAT
Like I said in part I, the education, resources, and focus on pregnancy and baby care is limitless. At least in the United States, we love pregnancy. There are bump pictures, tracking apps, prenatal care that increases in frequency the further along your pregnancy gets. There are also parties and showers, gender reveals, Pinterest pages, baby books, wonder weeks, monthly instagram posts and pictures. But what about mom AFTER?
It is well documented that the United States spends the most amount of money on healthcare per person. Yet, we are usually ranked LAST when compared to other wealthy and industrialized nations in health and maternal outcomes. So what are other countries doing differently?
Postpartum Care in the United States VS Other Part of the World
Let’s start with a big one…
Rights & Protections
It is pretty common knowledge that The United States is the only wealthy country that provides zero paid maternity or paternity leave. According to ACOG, only 14% of Americans have access to paid leave. Even the federal Family Medical Leave Act, that only protects a persons job for 12 weeks, no financial compensation, has stipulations to qualify, such as being employed for greater than one year. So the fact that parents have to return to work right away greatly impacts physical healthcare and mental healthcare. For example, postpartum bleeding and blood pressure, as well as stress and bonding.
Even people who are prepared and qualify for short term disability, are often short changed. For example, standards in short term disability is 6 weeks after a vaginal delivery and 8 weeks after a c-section. Short term disability after back surgery is 12 weeks. Hopefully, after back surgery you only have to care for yourself and your pain and your recovery. After birth, usually you are caring for yourself and your newborn, and possibly other young children.
Readiness: Preparedness
Of course, many parents know to be prepared for a baby coming. Plenty of time is spent preparing for birth and baby, but are they prepared for what happens after the baby arrives? Sure, it’s common knowledge that you won’t sleep. But knowing you won’t be sleeping and actually not sleeping are wayyy different things. Are we doing our best at preparing women for what to expect out of themselves, their mind and body, in this vulnerable postpartum time.
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.
Finlands maternity package is becoming world famous. Finnish mothers are given a box by the government. It is a starter kit with necessities ranging from clothes to toys to help care for their newborn. The box can also be used a bed or crib for the new baby in a pinch, which is a safe sleeping recommendation for prevention of SIDS. Today Finland has the lowest infant mortality rate in the world, in part thanks to the maternity box.
Rest & Care Practices
Many other cultures have specific rituals to care for new moms. Special teas, special diets, even special bathing habits. Cultures around the world also believe in a form of quarantine for new moms and babies over the first month or so postpartum. Now I know, after what we have been through in 2020 and beyond, the word quarantine can make anxiety spike. But just the concept, of not having to worry about anything other than resting and caring for yourself and baby, and having others care for you for a month does sound nice, don’t you think?
Have you ever heard of the fourth trimester? It references the 12 weeks after birth. During the fourth trimester, replicating the environment of the womb is soothing to the new baby: swaddling, swaying, and shushing. Everything a baby needs during that time, mom needs too: access to foods and hydration, sleep, a decrease in stimulation, being care for. It can be a hard sell to American women and families to slow down and take time for themselves. We are programmed to think from a very young age that productivity is of utmost importance.
Recovery & Postpartum Care
This brings us back around to healthcare. 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 Belgium, Denmark, Sweden, and the Netherlands a home nurse, midwife, or doula comes to the house to care for mom within 4 days after hospital discharge.
Don’t just take my word for it. Here is a link to one of my references. I am here to Google the internet so you don’t have to have 19 windows open, like I currently do.
Even with all the changes and possible medical complications the birthing parent undergoes and not to mention, having a whole human person to take care of and keep alive and healthy, there isn’t a standard for home care when compared to other medical procedures. Such as when my dad had his knee replaced, a hole health nurse and/or physical therapist came to our house to check on him, check his incision site, and make sure he had follow up and outpatient PT scheduled.
As I referenced earlier, the standard of care for postpartum check ups are usually at 6 weeks post birth in the doctors office. Sometimes one also at 2 weeks post if you need a blood pressure or incision site check for example.
So get ready new mom!
Unless you have a lot of support people around or you are lucky enough to have a partner that is on some sort of maternity leave, you get the pleasure of not only getting yourself ready, but getting your newborn ready to get out of the house for an outing to a doctors office. Ideally, you have to take a shower, get yourself and your baby dressed, make sure you have extra baby supplies packed up in the diaper bag, possibly have to feed your infant so they don’t cry the whole car ride to or in the waiting room of the doctors office.
Oh, I hope there aren’t Covid-19 visitor restrictions and you can actually bring your newborn with you to the appointment. If so, you’re going to have to find a babysitter. Oh, and do you have other children at home? Because if they do have visitor restrictions and they let the newborn slide, they certainly aren’t letting your 4 year old there. I sure hope you’ve done all that in enough time to make it to your appointment on time. If not, you might have to reschedule or get charged a fee if you get there more than 15 minutes late!
Imagining this scenario for a new parent that does have help. Maybe someone else to drive for example, sounds like a nightmare. Now, imagine it through a lens of a mom that has maybe gotten a total of 6 hours of sleep in the last 3 days and is having thoughts of worthlessness and/or anxiety about crashing their car while driving with their new baby for the first time, etc. etc. etc… the possible intrusive thoughts can go on and on… yea, I see no barriers to getting this person the healthcare they need and deserve, do you?
Awareness is Increasing
Thankfully, the topic of increased maternal mortality and morbidity, ESPECIALLY in communities of color regardless of socioeconomic status, has become more public knowledge. It seems people are not quieting down about it. Action is imperative. So we know there is a problem, but what is the solution?
Healthcare reform in general, is such a loaded and complicated topic. Change of any kind is hard. But a change of this magnitude can feel impossible. And because of that, we often don’t do it. Or to pacify the people and organizations requesting change, such minor tweaks are made, that it ends up being band-aids over a bullet wounds. And in the case of women’s health, it is truly a deadly decision not to make massive and rapid improvements.
About half of maternal deaths happen in the postpartum period (up to 1 hour post birth).
The postpartum period, therefore, is not only a critical time for postpartum individuals and their families to recover from birth, transition to parenthood, and planning for their new family dynamics and structures, but also essential to prevent immediate and lifelong health risks by addressing pregnancy-related, mental health, and chronic conditions, and promoting healthy behaviors.
The American Rescue Plan Act of 2021
With the goal of improving health outcomes and reducing disparities, the American Rescue Plan Act of 2021 allows states to request a waiver so that postpartum Medicaid coverage can extend postpartum care for up to 1 year after giving birth.
To be honest, the Biden-Harris administration has not lived up to my expectations overall. But I will say, this gives them a point in my books. Taking action on the maternal healthcare crisis. Extending health coverage at least eliminates the barrier of cost to so many families. Now it is up to everyone to start knocking down some of the other barriers.
This extension of coverage was made possible by a new state plan opportunity established by the American Rescue Plan Act. Connecticut, Massachusetts, and Kansas are the latest states to receive approval to extend Medicaid and CHIP (child health insurance plan) coverage from 60 days to 12 months after pregnancy, joining California, Florida, Illinois, Kentucky, Louisiana, Maine, Michigan, Minnesota, New Jersey, New Mexico, Oregon, South Carolina, Tennessee, Virginia, Washington state, and Washington, D.C.
So Why Isn’t This Nationwide?
I am not as educated in politics and the government as I want to be and should be, but I believe this starts at the state legislature. Then the approval and coverage is a partnership with federal funds, programs, and agencies, like the CMS (center for medicare and medicaid). CMS continues working to extend coverage for 12 months after pregnancy in other states that have submitted extension proposals. These include Alabama, Colorado, Hawaii, Indiana, Maryland, North Carolina, Ohio, Pennsylvania, and West Virginia.
This is one reason why state and local elections are even more important in some ways than national ones. Vote in the midterm elections friends!
What Else Can We Do?
Along with voting, check out other non-profits that are lobbying for improvements and change. March of Dimes is a great one that has provided me with free education on this topic to better serve my patients.
Educate yourself. And then spread that knowledge. Knowledge really is power.
If you are a potential patient, whether a pregnant mom already, women of childbearing age, a potential dad, a supportive grandma to be, etc etc etc, educate yourself. Let me help you! When you know your rights, the questions to ask, the symptoms to monitor for, the warning signs that are critical for your and your baby’s health, it empowers you to be an advocate. Advocating for yourself during pregnancy and postpartum really is essential self care.
If you are a healthcare provider, educate yourself. Us in the OB world already, should know tons already right? But do we do our very best to impart that knowledge to our patients and their support system? I know I don’t. Sometimes we forget, what seems like common sense to us, is not common at all. I have a goal to spend more time educating my patients on how to care for themselves after being discharged from the hospital.
Could you be a healthcare provider?
Do you want to be the next healthcare hero?! Ok, maybe if I am encouraging you to go into healthcare, don’t click that link. But in all seriousness, if we can get more bias conscious and empathetic people at the bedside, it could make an impact. I guarantee that increasing the amount of Black and Latino/a doctors, nurses, and other healthcare providers would make positive change in the outcomes for mothers in the BIPOC community.
I have been very privileged to work beside many amazing woman physicians of different races and cultures, and an increasing amount of Black and Latina resident physicians, both male and female. Not to sound super corny, but that could change our future for the better.
(did anyone else start singing Whitney Houston, “I believe the children are our future…” when reading that last part? Just me? Oh, ok… be boring then)
So, In Summary…
- Mental health is health. So mental healthcare is healthcare.
- The Baby Blues are hard, but should be short lived. If you are feeling like that over a week you need additional help. It might not be something that can prayed away or even slept away. Ask for help.
- You are important. You are worthy of care. Your new baby and family need and want you around. The world will not be a better place without you, no matter what the darkness and lies in your brain are telling you.
- Self Care is Critical. Whether that is asking for help and getting alone time to read a book, or that is making it a priority to get your medications refilled. You are worth it.
- Why are we making new parents care for themselves anyway? If you are able, help out your wife, your sister, your friend. Don’t let them tell you there are fine. Go help them take a shower and do their dishes anyway!
- The maternal mortality and morbidity rate in the country that spends the most on healthcare is sickening.
- Zero paid maternity/paternity leave in the US and a tragic joke.
- Black women are dying in childbirth and postpartum at an alarmingly higher rate than white women and that has to change.
- About 60% of pregnancy related deaths are considered preventable.
- Education to help yourself, your community, and/or your patients is critical and I am here to help!
**Bonus bullet point: Bravo isn’t a guilty pleasure, it’s self care.
Thank you for getting this far!
I am registered nurse. That said, any of the medical information and advice should be verified by your personal medical provider. I have linked many of the references I used for you to access for further info and to give credit where credit is due. No plagiarism up in here please.
But please don’t hesitate to reach out for help, even to a stranger on the internet. I don’t have all the answers, but I can help direct you to them hopefully. Share this with the people in your life that need this information. It will show them that you care. If you feel so inclined, check out my Instagram page @mental.mommy.nurse, for more nuggets of education and lots of semi-decently made graphics and sarcasm. I am not only knowledgeable about postpartum care. I provide information and thoughts about mental health, motherhood, labor and delivery, reality television, & why I don’t think you can be funny if you didn’t grow up with severe childhood trauma. Find out your ACE score here to see if stand up comedy is possible in your future.
I only have like 60 followers; you could be number 61. Get in on the ground floor before I am famous #influencer. Ok, now I am getting delusional. Time to take my own meds I guess! Cheers! 💊
As a treat for reading this far down, here is a glimpse of me postpartum. I am about 8 weeks postpartum here. See that dead eyed, glazed over look? That’s postpartum. I don’t even know if I realized it until this very moment, but I can see the disconnection between myself and Kylie right in this picture. Weird.
ashley, RN
Mental Mommy Nurse
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