Where the US is failing postpartum families

With nearly four million women giving birth in the United States last year, it would seem likely our healthcare system had crafted a process ensuring every postpartum woman had access to the support, information, and services needed to thrive[1]. Now let’s look at the reality for a pregnant woman in Sweden, and a pregnant woman here in the US.

With 66 midwives per 1000 live births in Sweden, Lilly is able to select a postpartum provider from an extensive and qualified pool of candidates. She has ample time to physically recover at home with 56 weeks of paid maternity leave. In her first eight weeks at home, she has the support of her husband who also receives paid time off, and her midwife, whose weekly visits are fully covered by insurance.

Anna is navigating a limited U.S. provider network with just four midwives per live birth – 94% less than in Sweden. Her insurance doesn’t cover home visits, and she doesn’t attend her single covered postpartum visit at six weeks because she is not entitled to any paid time off. As an American woman, she is three times more likely to die during pregnancy or soon after delivery than Lilly. This disparity is even more concerning for black mothers who die at two to three times the rate of white mothers in the US [2].

Getting global

While the World Health Organization recommends a minimum of four postpartum visits within six weeks of giving birth, the U.S. standard for postpartum care is a single visit [3]. This offers limited time between a new mother and her provider, and leaves little likelihood that a single provider can adequately address all of a postpartum woman’s questions and needs over the course of a single visit [4]. Nearly half of women don't even attend a postpartum visit. The result? While every other developed country has benefited from a decline in maternal death, U.S. women experience the impacts of an inadequate maternal health system and maternal mortality continues to climb.

It’s time to bring what we know works to U.S. postpartum care.

• Coordinated information and services: While only 8% of U.S. births are attended by a midwife, midwifery is part of a standard care package in most developed countries [5]. Community midwifery, which provides a full continuum of pregnancy, childbirth, and postpartum services and referrals, is the norm in places like Australia, where women who received continuous care were three times more satisfied with their care than women who did not [6[. They were also significantly less likely to give birth via cesarean than women in a traditional hospital setting [7].

• Accessible provider network: Compared to the U.S. 15 maternal care workers (ob-gyn or midwives) per 1,000 live births, Sweden and Australia have more than 70 birth workers, and Norway more than 60 [8]. The U.S. is also the only developed country that does not guarantee services in the place that is most accessible to women - their homes. This is a standard care practice in places like Canada, France, and New Zealand where women are guaranteed multiple home visits as soon as 48 hours after hospital discharge [9].

• Personalized and patient-centered care: With only one guaranteed postpartum visit and a dearth of skilled maternal health workers, U.S. women are less likely to receive individualized postpartum care compared to their international counterparts. Also critical to postpartum health is being provided adequate time for a woman to recover from her unique birthing experience. While Norway sets the gold standard with 91 weeks, nearly 2 years, of paid parental leave, countries like Canada, Sweden, and Germany provide a more moderate example of standard paid leave practices with 50-60 weeks of paid time off. Comparatively, the U.S. is one of only two countries in the world that does not guarantee any paid parental leave to mothers [10].

Setting a new standard for postpartum care

Though cultural practices around the postpartum period may vary by country, women seem to agree on the fundamentals of desired care: coordinated information and services; an accessible network of providers; and a personalized, patient-centered approach. It’s time for US families to get the care they deserve. Let’s stop settling – the world is showing us that better care is possible.

‍

[1] CDC. National Center for Health Statistics, CDC, March 2021

[2] The Commonwealth Fund. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, Nov 2020.

[3] World Health Organization. Postnatal Care for Mothers and Newborns: Highlights from the World Health Organization 2013 Guidelines. April 2015.

[4] ACOG. Optimizing Postpartum Care. May 2018.

[5] Scientific American. The U.S. Needs More Midwives for Better Maternity Care. Feb 2019.
[6] Forster, D.A., McLachlan, H.L., Davey, MA. et al. Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth 16, 28 (2016).

[7] Homer CS, Davis GK, Brodie PM, Sheehan A, Barclay LM, Wills J, Chapman MG. Collaboration in maternity care: a randomised controlled trial comparing community-based continuity of care with standard hospital care. BJOG. 2001 Jan;108(1):16-22.

[8] The Commonwealth Fund. Maternal Mortality and Maternity Care in the United States Compared to 10 Other Developed Countries, Nov 2020.

[9] Forster, D.A., McLachlan, H.L., Davey, MA. et al. Continuity of care by a primary midwife (caseload midwifery) increases women’s satisfaction with antenatal, intrapartum and postpartum care: results from the COSMOS randomised controlled trial. BMC Pregnancy Childbirth 16, 28 (2016).

[10] International Labor Association. Maternity and Paternity at Work: Law and Practice Across the World. 2014.

‍