Traditionally, postpartum care has ended at about six weeks or 42 days after birth when new mothers are last seen by their obstetrician. However, a study published in 2017 found that one-third of maternal deaths occur between seven days and one year postpartum.
In a recent editorial addressing this gap of care for new mothers, Nancy K. Lowe, editor of the Journal of Obstetric, Gynecologic, & Neonatal Nursing, wrote, “We now more fully recognize the importance of and unique experiences in the postpartum period for women as they recover from childbirth, negotiate the changes in their bodies, and transition to motherhood. A fourth trimester is consistent with the idea that childbearing is a continuum of at least a year in length that encompasses a full reproductive cycle.”
The “fourth trimester” is a useful metaphor brought to light as a result of the growing concern over rising maternal mortality rates in the United States, according to Lorraine Walker, RN, EdD, MPH and professor at the UT Austin School of Nursing.
“The term has reawakened awareness of the health and psychosocial transition women undergo in the three months after giving birth, which is good,” she said. “Nevertheless, despite recognition of its importance, there are good reasons to consider extending care even further, through the first postpartum year.”
“So we need to ask: How do we promote the health of women during a life phase that is actually a very challenging one?” Walker maintains that the cultural ethos for women in the U.S. of always putting family first can work to their detriment.
“I call it the ‘squashed doughnut’ phenomenon,” she said. “When one of the doughnuts in a box gets mashed, who is more likely to eat it? Dad? The children? No! Mom!”
She explains that the wellbeing of mothers and infants is influenced by mothers’ behavioral and psychosocial health (B&PH), yet these key areas are often neglected during health care visits within the time constraints of primary and obstetric care. These visits tend to focus on residual health concerns after pregnancy, family planning, and breastfeeding support. This is even more true for new mothers when their behavioral and psychosocial health is challenged in multiple domains, or what Walker calls “suddenly finding themselves in no woman’s land.”
Bringing an infant home creates new family demands during the first year. Babies are constantly changing and developing, and these changes call for new reactions and adaptations. While a mother is going through these rapid changes, she may neglect or ignore completely her own needs, such as diet, exercise and signs of depression.
Walker underscores that such needs are also key areas of modifiable predictors of chronic disease: excessive alcohol use, smoking, poor diet and lack of physical activity, to which she adds a fifth one for new mothers: poor body image.
“After pregnancy, women often don’t feel positive about their bodies, which can lead to depression. But it’s unlikely they will recognize the level of depression they have and seek help for it,” she said.
To address these gaps, Walker and colleagues at the School of Nursing have developed a toolkit for behavioral and psychosocial health of postpartum women that can be used in health care clinics and other settings. The toolkit consists of a screening questionnaire and asks women to rank themselves in six domains: diet, physical activity, smoking, alcohol use, body image and depressive symptoms. For example, items in the dietary domain cover the frequency of positive and negative habits such as snacking on junk foods and eating a nutritious breakfast. Areas covered on the body image domain include positive and negative feelings about body areas, such as waist, hips, weight, and muscle tone.
After filling out the questionnaire, participants begin to see a pattern and are prompted to identify their top ranked values and areas they think they can address to make a positive change.
“This is the sort of contextual knowledge that most care providers might not have access to,” Walker explained. “Not every woman will need this level of care, but for those who do, we need to be able to assure them that the toolkit may help them begin to improve their health.”
The next steps will also focus on how useful, usable and effective the toolkit is. Walker and her team plan to eventually provide the toolkit digitally on smart phones or tablets.
“Postpartum care is paramount,” Walker said. “We believe the toolkit is a promising strategy to increase preventive care at the important life transition of motherhood, which affects women not only after a first birth, but with each child added to the family. Ultimately, we want to help women focus on themselves for a change.”