These phases are of equal importance, but the postnatal period (post-birth) is key to a mother’s well-being, her adaptation to changes and the formation of a positive relationship with her baby.
“Once the baby’s out healthy, then people are kind of less bothered,” said co-author Soo Downe, a professor in midwifery studies at the University of Central Lancashire in England. And commercial hospital systems may not see as much profit in keeping up with the wellness of the mother after birth, she added.
“There’s all this intense focus on women’s health during the three trimesters of pregnancy and then women deliver and there’s really very little support after that,” said Dr. Denise Jamieson, chair of the Department of Gynecology and Obstetrics at Emory University and chief of gynecology and obstetrics at Emory Healthcare. Jamieson wasn’t involved in the study.
“The American College of Obstetricians and Gynecologists is really trying to promote this idea that postpartum care is not one isolated postpartum visit, but rather an ongoing process where there’s a lot of opportunity to provide services and support and address medical and psychological issues,” Jamieson said.
Guidelines for postnatal care aren’t usually informed by what matters to the women who use them, the report said. Existing studies judging the efficacy of services for postnatal care are typically guided by how women responded to services that were put in place without consultation of their wants and needs first.
To inform the scope of updating World Health Organization guidelines for postnatal care, the authors analyzed studies containing firsthand reports from women, letting their needs and values determine what services are needed.
Based on 36 studies from 15 countries, representing the perspectives of more than 800 women, the researchers found that what mattered most to women was a positive postnatal experience categorized by four themes: Social and relationship adjustments, community support, coming to terms with changes in their bodies and receiving postnatal care.
What women value
For the report, the authors searched several medical and psychological databases for studies that, from 2000 to 2019, reported data on women’s beliefs, expectations and values relating to the postnatal period.
They included studies that focused on healthy women in high- or upper-middle income countries, regardless of how many children they’d had, how they delivered or place of birth.
From the studies, the authors generated 22 common themes they put under five umbrellas: riding the emotional rapids, social and relationship adaptation, community, the birthing body and postnatal care.
What mattered most to women was a positive postnatal experience in which they were able to adapt to their new identity and develop a sense of confidence and competence as a mother. It was also important that they could adjust to the changes in their intimate and family relationships, including their connection to their baby.
The ability to navigate ordinary physical and emotional challenges was necessary. And to experience the achievement of personal growth as they adjusted to the new normal of motherhood and parenting in their own cultural context was imperative.
“Where this process is optimal, it also results in joy, self-confidence and an enhanced capacity to thrive in the new integrated identity of ‘woman and mother,'” the report said.
Riding the emotional rapids
Women experience a range of conflicting and contrasting emotions during the postpartum period, the report said, from intense feelings of love and joy for their new baby to acute feelings of loneliness, low mood and depression.
Some women experienced guilt for not living up to the idea of an “ideal mother” and felt overwhelmed by the sudden responsibility of caring for their baby.
This can lead to feelings of being out of control and, for new mothers especially, a lack of confidence in being able to care for their baby.
Fatigue, sudden life changes and altered sleeping patterns can compound these emotions.
A lot of women who have postpartum anxiety and depression, as some women reported, have had mental health challenges before, said Dr. Alison Stuebe, a professor of maternal and child health at the University of North Carolina Gillings School of Global Public Health, who wasn’t involved in the report.
And “the hormone changes, the utter disruption of sleep and the stress of figuring out a new person kind of can tip them back into depression and anxiety they’ve had previously,” she said.
But hormone changes can lead any new mom to that state, especially during these troubling times.
If you’re concerned about postpartum mental health while you’re still pregnant, search for a therapist who can help you after birth, so you don’t have to hunt one down while you’re exhausted and in tears.
“The most important thing to know about postpartum depression and anxiety is that you are not alone,” Stuebe said. “You are not to blame and with help you will get better.”
“I think a lot of women think, ‘Gosh, I’m supposed to be loving this. It’s supposed to be beautiful and rainbows and unicorns and there’s something wrong with me; the last thing I’m going to do is tell somebody that I’m sad,'” Stuebe continued.
“But the first thing you need to do is say, ‘This is harder than I thought it was going to be. Please help,’ because with therapy or with medication, depression and anxiety after birth are very treatable.”
Partners can also help alleviate the mental health challenges of mothers by sleeping in shifts, Stuebe suggested, since exhaustion exacerbates depression and anxiety.
Other women reported feeling anxious over not meeting their partner’s sexual needs after giving birth, not yet feeling ready to have sex again and regularly prioritizing the baby over their partner.
In this case, both overcoming the insecurity and addressing issues with a partner start with “resetting everybody’s expectations about what the first year with a new baby is like,” Stuebe said.
You’ve just carried a baby for nine months, gone through an intense birthing process and are adapting to life-with-baby changes. Don’t try to rush things if you’re still in pain, Stuebe said. Find other ways to be intimate with your partner for a while.
Women also want more information from health providers about contraception and sex after birth, the report found. But providers should be discerning in how they do so, Stuebe said, basing decisions on the woman’s needs instead of reacting to the pressure she may feel from her partner.
Some women reported experiencing unforeseen joys once they had their babies. They didn’t realize they could feel love and happiness of such depth. Or having to care for their baby led them to realize previously untapped character traits, such as calmness, selflessness, perseverance, compassion and greater responsibility.
“This is a transformative experience,” Stuebe said. “It’s an extraordinary thing to grow a person in your body and then to nurture that person when they come out into the world.”
It takes a village to raise not only a child, but a mother, too
Women valued the practical and emotional support they received from partners, families, and in some contexts, elders.
They appreciated when partners and family members would do their part in housework and childcare, or felt frustrated when the bulk of those things still fell on them.
In this case, the woman should explicitly articulate to her village of support what needs to be done so she isn’t constantly frustrated.
For example, “It’s really important to me that I not be able to see the dishes all piled up in the sink because it makes me crazy. So if I’m sitting here holding my baby and there are dishes in the sink, can I ask you to put them away?” Stuebe said.
And to the partner, Stuebe cautioned, “Don’t say I’ll do it in 20 minutes. Just say, ‘OK.'” Prevent a situation where the mom grows increasingly irate because the chores aren’t being done.
A partner, family member or friend can emotionally support new mothers by focusing on the positives, said Stuebe. Start with honoring points of strength by asking, “What’s going well?”
This question appreciates the small things while validating the difficulties of motherhood. It also gets to the root of the matter, unlike a shallow “How are you?” to which a mother may likely respond, “Fine.”
Additionally, ask a mother what they need help with instead of making suggestions for what they should do. And, Stuebe added, be present when they’re venting, as new motherhood can be a very lonely time.
Because of the pandemic, it’s difficult for elders and peers outside of the home to help mothers as they normally would after birth — they may not be able to travel, or come to watch the baby or bring homemade meals. Alternative options are limited, but they could have food delivered to the home, or make it and drop it off on the mother’s doorstep.
In this case and during normal times, health providers can also have a role in offering reassurance, validation and guidance, the report said. Women wanted information on baby development, hygiene, vaccinations, breastfeeding, nutrition and caregiving tips.
Women also valued support from other mothers, for example, via peer groups to share experiences and information and ease insecurities. Some women found online peer groups helpful.
“Peers often do recognize [the process that women are going through] because they’re going through it themselves, which is why peer support came out so strongly” as a valued theme in the study, Downe said. “For first-time mothers, that business of walking the walk with somebody else is fundamental to that process.”
Perceptions of the post-birth body
Some women reported feeling insecure in their new post-birth body, whether because of birthing injuries or scars, or weight that didn’t quickly disappear after they had their baby.
“I think women need to say, ‘Look, I’m gorgeous. I made a baby. And maybe my body doesn’t look the same as it did before, but I also brought a person into the world and it’s easier said than done,'” Stuebe said.
“That is a moment for women to realize that their body is not something to exhibit,” she added. “It’s actually functional. Their body can do really powerful things and it’s not about what it looks like. It’s about what it can do. And that may be a way for people to move beyond ‘these pants don’t fit’ and instead look at, ‘Wow, I made a person.'”
From health providers, women could use more information on soothing and treating birthing injuries such as caesarean wounds, perineal damage, bladder problems, vaginal bleeding and other discomfort.
Supporting mothers long-term
Overall, women want to feel cared for during the postnatal period as they navigate the transition to motherhood and recover from labor and birth, the study said.
As their babies’ needs are met, women also need to be seen as individuals and given the space and support to adapt to their new identity as woman and mother.
Not only is community and provider support necessary for a mother’s personal journey, but also to prevent any post-birth complications.
A high percentage of complications and maternal mortality occurs after the birth rather than during, Stuebe said. Some women felt inadequately supported if they were discharged from the hospital early, received too few postnatal visits or untimely support.
“If we’re not attending to moms after they leave the maternity setting, we’re not winning,” Stuebe said. “Women shouldn’t have to fight to have their health problems recognized.”
And good quality care in the postnatal period includes continuity of a care provider who would provide consistent information, a trustful relationship, flexibility and recognition of women’s personal and cultural contexts, the study added.
“Society benefits from happy, secure mothers, babies and families,” Downe said. “The more support we can give to women in the postnatal period, the better our societies are going to be for the future.”