After the Afterbirth: A Critical Review of Postpartum Health Relative to Method of Delivery

Noelle Borders, CNM, MSN


J Midwifery Womens Health. 2006;51(4):242-248. 

In This Article


Clearly, changes in mental and physical health challenge the majority of women after the birth of an infant. The literature indicates that women who have a normal spontaneous vaginal birth with minimal damage to the perineum have the fewest problems postpartum. Assisted vaginal birth, especially accompanied by episiotomy, and cesarean birth result in greater short- and long-term morbidity, some of which prove life-threatening and lead to hospital readmission. To maximize the health of postpartum women, obstetric care providers need to protect the perineum during vaginal birth and avoid unnecessary cesarean birth. It is important to emphasize that most of the women represented in these surveys were young and healthy, and yet still faced a number of health challenges after childbirth. Thus, one can conclude that postpartum morbidity is probably underestimated, and is an even more critical issue for women who enter pregnancy with existing health problems.

Although women in the United States can certainly benefit from efforts to maximize rates of vaginal birth with minimal perineal trauma and decrease unnecessary cesarean birth, the preponderance of data supporting the benefits of these practices was gathered outside the United States. With a few notable exceptions,[2,12,20,33] researchers have largely neglected the study of postpartum health in the United States. A significant need exists for research on postpartum health in general, and relative to method of delivery in women in the United States; the need for this information is especially urgent in light of the mounting US cesarean birth rate.

Simply doing research on postpartum health, however, is not sufficient. Researchers and clinicians bear a responsibility to disseminate the resulting information to women. What is most disturbing in the literature on postpartum health is not the presence of widespread morbidity but the profound silence that surrounds this pivotal period in women's lives. In Australia, 49% of women said they would like to have been given more guidance regarding postpartum recovery and changes in their health; several studies noted that many women (up to 25%) with postpartum health problems did not consult a health professional.[6,30] In Glazener's study, women reported that only 34% of clinicians had discussed sexual intercourse with them at their 6-week postpartum visit; furthermore, a quarter of clinicians had failed to discuss birth control.[19] To understand women's and clinicians' perceptions of the health consequences of pregnancy and childbirth, Kline and colleagues conducted five focus groups of new mothers and three focus groups of clinicians, including midwives, obstetricians, and family practice physicians. The women decried the lack of information received about their own health, whereas providers perceived that they themselves had neglected educating women on newborn care. However, in all the groups, the participants voluntarily asked, "What is normal postpartum recovery?" No one knew the answer.[2]

All the studies cited paint a dismal picture of lack of communication between clinicians and women regarding postpartum changes. Reasons are complex and self-perpetuating. First, clinicians have had little data on which to base their discussion of postpartum health with women, but they have also often neglected to ask women about their problems. Second, women do not typically consult clinicians about postpartum issues. Third, health care for women after the birth of a baby typically consists of a single 6-week postpartum visit, the focus of which is a pelvic examination and pap smear. Thorough consideration of each of these factors is beyond the scope of this article; however, a rudimentary discussion can shed light on the situation and inform a plan to remedy these deficits in obstetric health care.

Lack of research on postpartum health has already been noted. But lack of evidence about a condition does not excuse clinicians from asking women about their health. As Romito so aptly wrote, "There is a gap to bridge between what professionals think mothers do, think, and want, and what mothers, in reality, do, think, and want."[18] Although postpartum women have a responsibility to inform their health care providers about their physical and mental problems, the burden of responsibility remains with the clinician for a number of reasons. First, women face a multitude of challenges after the birth of an infant, including care of the baby, family restructuring, and changes in their bodies. Most women place the needs of their family above their own personal needs; thus, their health concerns are often the last to be addressed. Second, after the baby's birth, a woman may view many physical issues, such as incontinence or dyspareunia, as too embarrassing to divulge to anyone. Third, women may also believe that their problems are simply part of having a baby and something to be endured.[6] Although clinicians have limitations in their ability to improve women's lives, we can ask women about their problems and provide a safe forum for discussion. Furthermore, through anticipatory guidance during prenatal care, clinicians can help women devise a plan for managing their lives in the postpartum period and, thus, possibly avoid or minimize physical and mental health problems.[44] This can be as simple as asking a woman whom she can call for support or with whom she speaks when she feels overwhelmed. Educating women about antenatal pelvic floor exercises to protect against urinary incontinence is another way to promote a more comfortable postpartum recovery.[28] Clinicians also have a responsibility to inform women about the most common physical and mental challenges they may face postpartum. Women need this information prior to the birth and again postpartum. Women who understand what is happening to their bodies and spirits postpartum are much more likely to appropriately manage their lives. By eliciting information from postpartum women, clinicians provide the support women need and, simultaneously, acknowledge that new mothers themselves hold the key to understanding postpartum health in its entirety.

Another reason that postpartum issues go largely unaddressed lies in the structure of postpartum health care, which, in the United States, has traditionally consisted of a single visit at 6 weeks after delivery. As seen in the surveys reported, a woman experiences an incredible variety of changes in those 6 weeks, largely devoid of the support of a health care professional. In 1998, the World Health Organization recommended that the schedule of postpartum visits should correspond to the times of greatest need for a mother and her infant (i.e., at 6 hours, 6 days, 6 weeks, and 6 months postpartum). Although the timing of these proposed visits should not be construed as absolute, postpartum care must remain flexible to the needs of the mother, and, most importantly, the mother should always have easy access to health care.[4] In England, women benefit from a series of six to seven home visits by a midwife during the first 2 weeks postpartum, other visits as needed, and a checkup with a general practitioner at 6 to 8 weeks.[45] MacArthur et al. redesigned postnatal care to identify and manage individual needs. Rather than each woman receiving the same postpartum care package, midwives used symptoms checklists to identify health needs and customize care for each woman in the intervention group. On the basis of this needs assessment, these women received approximately two visits more than the women in the control group, experienced less postpartum depression at 4 months postpartum, and were more satisfied with the care received. Although the physical health of both groups of women did not differ, the simple intervention of supportive discussion about health problems may have been the key to better psychological health in the intervention group.[46] An Australian study experimented by adding a 1-week postpartum visit in addition to the 6-week visit. They observed no differences in any physical or mental health outcomes studied and concluded that simply adding a single postpartum visit will not substantially improve postpartum care.[11]

Although flexible home visits, such as those performed in England, are the ideal structure for providing postpartum care, the costs and logistics involved in implementing such a system of care for postpartum women in the United States are prohibitive, given the current milieu. Clinicians and researchers can, however, improve postpartum care by experimenting with flexible ways of meeting women's needs after the birth of a baby. Because the well-being of the mother directly impacts her ability to parent her baby, clinicians who actively listen to women in the postpartum period are investing directly in the health of these children. Just as throwing a pebble into water creates ripples that reach the far edges of a pond, the benefits of supportive postpartum care reach well beyond each mother to her family, and, indeed, to the generations that follow.


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