Deplorable or Decent? How Postpartum Care in the U.S. Measures Up to Other Countries
What could we learn from other countries about how women are treated after birth? Are we even making any progress?
Picture this: A new mother is sitting up in her hospital bed shortly after the birth of her first baby, when in sweeps the doctor.
“So,” he asks, straight off the bat, “how many lovers do you have?”
This is France, whose enviable system of postpartum care sees women staying in hospital for an average of four days after a vaginal delivery and includes state-funded vaginal physical therapy after the birth. In the land of the cinq à sept, tightening up down there after childbirth is very much a priority.
In the U.S., things are a little different. Women in this country have two-day hospital stays, on average, following a vaginal delivery. Many never hear any mention of pelvic floor rehabilitation, much less get resources on how to find it. It’s estimated that approximately 40% of new mothers don’t even attend a single postpartum appointment, according to last year’s report by the American College of Obstetricians and Gynecologists (ACOG). Compare that to France, were postpartum nurses are mandated to do regular in-home visits.
So, it should come as no surprise that 1 in 7 women in the U.S. experience postpartum depression, and even more experience some form of postpartum anxiety.
It’s not just that we don’t get enough support or follow-up postnatal care to manage our moods—basic safety has become a concern, as maternal mortality rates are actually increasing. Last year, a USA Today investigation found that America was the most dangerous place to give birth in the developed world. Sounds exaggerated, but perhaps not?
Either way, there’s a lot we can learn from how new mothers are treated in other countries around the world.
Traditional postpartum care is a family affair. What could we learn, and what could we leave?
Some parts of the world have a cultural tradition of postpartum resting periods that would make a new mother in America weep with envy.
In China and India, mothers traditionally go into confinement, known as zuo yue zi, or “sitting the month”—an enforced rest period to help the body heal after childbirth.
Some Latin American countries (including Mexico and Guatemala) have a similar tradition known as cuarentena, a 40-day resting period when friends and family take care of the new mom, taking over chores like cooking and cleaning so that she can rest. Sex is banned during this period, and comfort food is encouraged, with chicken soup high on the list of approved foods.
As in China, new mothers are expected to keep warm and encouraged to take warm baths. It ends with a cerrana, or “closing the bones” ceremony, which involves taking a herbal bath and being given a massage to honor the mother’s body and experience.
Such customs are hard to replicate in the U.S., where many women may have moved across the country for work and just don’t have the extended family support systems that new moms in some other cultures enjoy. Scattered families have another consequence too—without sisters or cousins to emulate, many women lack parenting role models and simply don’t know what to do when the baby arrives.
As for a month-long period of rest, that’s not practical when 23% of employed women return to work within ten days, and another 22% return between ten and forty days—a natural consequence of living in a country where paid maternity leave is not enshrined in federal law.
Of course, not everything about the traditions practices around the world are enviable. For many, it’s not simply a question of putting your feet up and letting your relatives do all the work. According to stricter interpretations of the Chinese practice of zuo yue zi, for example, new mothers shouldn’t shower, brush their teeth, or even leave the house for a month. The intention behind this is to restore balance to the body after giving birth and to restore the hot-cold balance in particular.
Chinese medicine maintains that the loss of blood during childbirth leads to a state of cold, which is why new mothers are encouraged to do everything they can to stay warm. Taken to extremes, this can have uncomfortable, not to mention dangerous, consequences. In 2015 a woman in Shanghai died of heatstroke after she was wrapped up in a quilt with the air conditioning turned off, despite the summer heat.
Traditional practices are changing all over the world—the difference is how societies are adapting.
So, it’s not that women in the rest of the world are living in some postnatal idyll, watching unicorns float by as somebody massages their feet and does all the household chores. Even in countries where women enjoy more social support, things are changing.
A 2007 study of traditional postpartum practices in more than 20 countries in East Asia, South Asia, and the Middle East noted that with modernization, migration, and globalization, “individuals may be unable to carry out the rituals or, conversely, feel pressured to carry out activities in which they no longer believe.”
In the states and other developed countries, where the modernization and the medicalization of childbirth have replaced traditional midwifery for decades, new mothers often feel that the focus has never been on helping them recover after the birth.
In the UK, perinatal care moved from largely midwife-based care to a system where doctors delivered babies in hospitals from the 1960s and ’70s onwards. One survey by the National Federation of Women’s Institutes looked at women’s birth experiences from the 1950’s to 2005, then followed up with another survey from a 2007 to 2012. The difference in how women in the latter poll felt about their postnatal care compared with those survey from 1950-2005 was striking. In that survey, postnatal care was singled out as a time when many women indicated that they “required more support than they had received,” with 60% of the women wishing they had received more postnatal support than they were actually given.
Similar societal changes are at work in Japan, which has a wonderful postpartum culture on paper. Traditionally, new mothers are encouraged to stay at home for up to two months after delivery. In practice, however, Japanese moms are increasingly hiring doulas, as their own mothers aren’t in a position to care for them and the baby because of work and aging. The average age of the first-time mother in Japan is now 31, as opposed to 26 in 1970. And the effects are showing in the way of growing rates of postpartum depression.
According to the Economist, the Japanese government is now concentrating on ways to help new mothers following the revelation that suicide was the leading cause of death among pregnant women and new mothers in 2015 and 2016, in part due to postnatal depression. The health department is now subsidizing screening at two weeks and a month after childbirth.
Meanwhile, those traditions that do survive are often given a new spin. In Taiwan, zuo yue zi culture increasingly takes the form of maternity hotels—luxury getaways where new moms and their babies can enjoy some five-star pampering. The number of centers in Taiwan increased dramatically in the ten years from 2006, with 193 registered by 2016.
Israel has its own take on the trend, with new moms leaving the hospital and spending a night or two in luxury accommodation next door. They benefit from the hospitals’ medical expertise, and many health insurance plans will cover part of the cost of the stay.
“It’s a hugely growing thing here,” says Lisa Oren, who has been offering her services as a doula in Jerusalem since 2006. “Most hospitals have opened them.” Oren chose not to stay in one of these hotels following the births of her own children—“I just wanted to go home”—but she can see the appeal, particularly for Orthodox Jewish women who might have a large family at home already. They are likely to appreciate a few days to bond with their newborns, away from their other children.
In some places, governments and private services are stepping in to fill the gaps.
With the decline of traditional social structures and customs, governments and private services have stepped in to fill the gap. In the Netherlands, new moms receive daily visits from a maternity nurse, or kraamverzorger, for eight to ten days after giving birth—and these state-funded doulas will even help with household chores.
Scandinavia is often seen as the gold standard when it comes to postpartum care, and it does indeed offer many riches, from Sweden’s so-called “latte pappas,” who spend their days in coffee shops with their infants, thanks to the country’s generous parental leave, to Norway’s enlightened view of breastfeeding—it includes breastmilk in its national food production statistics.
Finland, meanwhile, is famous for its state-funded baby boxes, a starter kit of baby essentials that it has been distributing to new parents since the 1930s. The baby can even sleep in the box, since it comes with a mattress at the bottom. The idea captured imaginations around the world, and Scotland now runs a similar program, with more than 68,000 boxes given to new parents since it was introduced in 2017.
There might be some reasons to be optimistic about the future of postpartum care in the U.S.
What can the US learn from these? It’s tempting to dream about a magic bullet inspired by international practices—a Chinese-style lying-in period, say, with a Scandinavian level of maternity leave—as a cure for all ills, but it’s not that simple.
When it comes to postnatal mood disorders, for example, while a little TLC (and a longer maternity leave) can help, the best postnatal care in the world can’t necessarily guard against them. Ann Smith is the president of Postpartum Support International, which provides supports for people suffering from postpartum depression. She believes that while good postpartum care can help prevent mild postpartum mood disorders from becoming more severe, it can’t prevent them altogether. “If you have severe postpartum depression, you’re going to need to be treated by a specialist no matter how much support you get,” she says.
Last year heralded a welcome change in postpartum care in the US. In April 2018, ACOG, spurred on to improve matters by the increase in maternal mortality, issued a new set of guidelines, in which it revised its recommendations for the so-called “fourth trimester.”
ACOG is looking to replace the traditional six-week visit with an ongoing process of care, kicking off within three weeks of delivery, which includes assessing the mother’s mood and emotional well-being as well as discussing chronic health conditions and access to contraception. So instead of signing off a single postpartum visit with a cheery “See you at the next baby!”, practitioners are being encouraged to recommend ongoing well-woman care. While there are clearly some hurdles to clear in order to put this into practice—not least the financial implications—we can take heart from the fact that discussions are starting to take place with the insurance providers.
Did international best practice inform these new guidelines? “We didn’t look at other countries specifically,” says Dr. Tamika Auguste, who was a member of the task force that helped to develop the new guidance. She is aware of practices in other countries—Canada, with its extensive maternity leave, is one that springs to mind. She says, “You cannot tell me being off for a year does not help the situation,” but she’s careful to note that we can’t just pick a country that seems to be getting everything right and copy what it does. After all, the patient population of Sweden or France might well be very different from the U.S., and that’s before we’ve even begun to discuss finances or nationalized health care.
“I think we have to look to nations that have the lowest maternal mortality rate and that have patient populations that are comparable to ours,” says Dr. Auguste. “That is a caveat.”
She does, however, see reasons to be optimistic. While the guidelines are not easy to implement in terms of financing, conversations with practitioners and insurance companies are getting underway. Maternal mental health is entering the national conversation. Postpartum care is also finding its way onto the statute books, both in Congress and at state level.
In September, for example, former California Governor Jerry Brown signed a maternal mental health package into law, including a bill requiring hospitals to provide maternal mental health training and another making sure that women are screened for maternal depression at least once during pregnancy or in the postpartum period. This brings California more in line with countries like Australia, where maternal mental health screening is standard.
Sure, there’s a long way to go before we are all sneezing with the confidence of a French woman. But at least the conversations are happening. Recognizing the importance of the fourth trimester—and the long term benefits of helping new moms take care of their own health, as well as that of their babies—is a good place to start.
Susannah Cohen is a freelance writer with a background in fashion journalism and e-commerce. A mom of two, she recently moved from London to San Francisco, where she’s about to become an empty nester.