The 6-Week Postpartum Checkup Is Failing Moms
Christen Clifford has given birth twice — and her vagina has torn badly, in the same place, twice. At both of her 6-week postpartum checkups, she was told that she was "fine." But Clifford wasn’t fine: She started to experience debilitating, painful constipation and occasional incontinence that grew worse with time. “There was just no care,” Clifford tells Romper of her experience postpartum.
It took five years from the birth of her second child before she was finally diagnosed with a rectocele, Clifford wrote in an op-ed for The Guardian. A rectocele — in case, like Clifford, you haven’t heard of it — is an injury in which the rectum bulges into the vagina, creating a pocket where stool can get trapped. About 40 percent of women have them, according to the American Society of Colon and Rectal Surgeons.
Clifford’s experience reflects the inadequacy of postpartum care in the United States, where the standard for new moms is one measly checkup six weeks after giving birth. Following that appointment, when new moms are often told they can start exercising and having sex again, there is no recommendation for additional care beyond a yearly checkup.
“They say you’re allowed to have sex, and I said, ‘No way!’” Clifford, a feminist performance artist and writer who teaches at the New School in New York City, tells Romper. “I didn’t have sex for seven months. I was terrified. I just felt so disfigured and damaged.”
That was after the birth of her first child, when Clifford estimates she received about 20 vaginal stitches — though she isn’t sure because the doctor who put them in refused to tell her the actual number. At her 6-week checkup, her perineum was still swollen and she was shocked at how her vagina looked. “Everything was so open,” she says. “I was definitely still really scared to touch it.”
Her doctor insisted that she was healing and fine. Clifford insisted that she wasn’t.
We open up our phones. We just get pictures of swollen vaginas.
The experience led Clifford to pen “BabyLove,” a personal essay that she later turned into an off-Broadway play about love and sex after pregnancy. “It took me a long time after the birth of my first child to explore myself sexually, to masturbate, to find any sexuality with my partner,” she says.
For her second birth five years later, Clifford was at home with midwives. She remembers being in bed with her new baby while the midwives went into the bathroom whispering. Later, they explained that her vagina had torn in the same place and they had put in stitches. They told her, “We did what we could do.”
Clifford says she received more postpartum care from the midwives, who made several home visits — including two visits just to see how her vagina was healing. They told her it was common for new moms to be worried. She remembers them joking, “We open up our phones. We just get pictures of swollen vaginas.”
But Clifford still dealt with numerous postpartum health issues. She had trouble breastfeeding, and then got mastitis, an infection of the breast tissue. At her 6-week postpartum checkup, her midwives either didn’t notice, or didn’t tell her, about the rectocele — or even the risk that one could occur. She went for a gynecological exam every year, and her doctor never mentioned it.
At times, Clifford’s constipation left her doubled over in agony. She recalls crying in the bathroom of her small New York City apartment, with her husband and children on the other side of the door, when she realized that the only way she could get relief was to use her fingers to pull the stool from her rectum.
“Nobody talks about it,” she says. “You don’t know that it’s normal, or that it happens. There is so much shame about women’s sexuality and bodies in general that it was very easy for me to feel ashamed, to feel like there was something wrong with me, that it was my fault that my body was not healing correctly.” At the time, she adds, “I didn’t tell my husband because I didn’t want him to think less of me or my body. I wanted to be as attractive as I could to him, so that caused me a lot of real pain and tears and grief.”
Finally, five years after her second child’s birth, Clifford went to a new gynecologist, who listened to her, examined her carefully, and identified “a little rectocele.” She explained that it was, “within the range of normal,” and that’s why previous healthcare providers may not have mentioned it.
Now, Clifford wants words like rectocele, cystocele, urethrocele, and enterocele to become, “part of the common vernacular of women’s health.” Each of these words refers to a type of vaginal bulge — from the rectum, bladder, urethra, and small bowel, respectively. “I think more education and talking about these issues needs to happen immediately,” she adds.
It's unsettlingly common for U.S. moms to face postpartum health issues — both immediately after giving birth and in the years that follow — without treatment or support. Some of the complications that occur after childbirth can be fatal, such as blood clots and preeclampsia. While other issues, like rectoceles, may not be life-threatening, but can cause chronic pain and stress for years.
On both fronts, the United States’ healthcare system is failing moms.
ProPublica and NPR have spent the past year investigating the United States’ rising maternal mortality rate. It’s the worst of any wealthy, industrialized nation — three times higher than Canada, and six times higher than Sweden. Between 700 and 900 new U.S. moms die every year. And, in a recent report, the news teams noted that for every one mom who dies from childbirth complications, 70 more nearly die. Women of color, and especially black women, are more likely to die in childbirth or have near-fatal complications, per CDC data.
Despite those disturbing facts, it’s important to remember that the vast majority of U.S. women who give birth don’t face life-threatening circumstances. Even so, they often experience a wide range of health issues in the postpartum period. For example, among new moms, research amassed by researchers at the University of North Carolina suggests that about:
- 15 percent experience breast infections
- 27 percent have heavy bleeding
- 29 percent have frequent headaches
- 23 percent have hemorrhoids
- 31 percent have urinary problems
- 30 percent have bowel problems
- 15 percent experience postpartum depression, and many more have feelings of sadness and stress
But even with all of the health issues new moms may face, the current standard of care is a single 6-week checkup.
By six weeks, new moms have either sunk or swum on their own. If they're suffering postpartum depression, they're already well into it.
Dr. Kirtly Parker Jones, vice-chair of education at the University of Utah's department of obstetrics and gynecology, has called the 6-week postpartum checkup "totally ridiculous."
Jones told the university's health radio program The Scope, "By six weeks, new moms have either sunk or swum on their own. If they're suffering postpartum depression, they're already well into it. If they have a bladder problem, they've been suffering for over a month."
There’s a growing movement to change that, and the University of North Carolina’s 4th Trimester Project is part of that trend. The project is a long-term, multi-part study into new moms' healthcare needs in the 12 weeks following childbirth. In a recent report, the researchers commented on the imbalance between the intense focus on women’s prenatal health compared to postpartum care. In other words, Dr. Alison Stuebe, one of the researchers told Slate, “There’s a total disregard of mothers as having anything other to do than take care of their baby after childbirth. As I often put it, once the candy is out of the wrapper, the wrapper is cast aside.”
The researchers also note that it’s common for new moms to feel unprepared for common postpartum health issues and disappointed in how little support they receive from doctors. Kristin Tully, PhD, who is also involved with the study, told Quartz that mothers aren’t being given enough information to help them prepare for the postpartum period. To start with, she said new moms should “be given a summary of thresholds and ranges for what pain level and symptoms are normal in the postpartum period and who to contact for each issue.”
The U.S. model of postpartum care is far from the only option. In an interview with Vox, Stuebe noted that, ideally, “women would get home visits or their family members would get paid leave to attend to them.” That’s something that already happens in many countries — and nearly all wealthy countries — around the world.
In all northern and western European countries, publicly funded health professionals visit families at home to check on new moms and babies. In New Zealand and some Canadian provinces, new moms can receive free postpartum home visits from midwives. The practice has been recommended by the World Health Organization, and has been shown to increase rates of breastfeeding and lower rates of postpartum depression. All of these countries also have laws that encourage new parents to take a leave from work, earning a percentage of their salary.
For example, in the Netherlands, new moms get a minimum of 16 weeks paid leave, and are legally entitled to take additional unpaid time-off or go back to work part-time. But one of the best aspects of having a baby in the Netherlands, according to the American Women’s Club of Amsterdam, is the right to a “kraamverzorgster,” or home maternity assistant, up to eight hours a day for a week following birth. The assistant has three years of training, and can help with everything from breastfeeding support to baby care to light cleaning. In addition, Dutch midwives may also make home visits during the postpartum period.
In the U.S., it’s possible to get home visits from healthcare professionals, but it can be expensive. For families who want help at home comparable to the Dutch experience, a postpartum doula may be the most affordable option. Their training is not generally as extensive as the Dutch require, but they offer some of the same services. As Laura DesBrisay, a postpartum doula in New York City, tells Romper, “My role includes practical support, informational support, and emotional or moral support.”
That may include anything from showing new parents a soothing way to hold their baby to preparing food so that they don’t forget to eat. “It's about easing the burden, and in some ways recreating the village that used to form around a new mom: teaching breastfeeding, and how to take care of the baby, and giving them a chance to heal and rest,” DesBrisay adds.
Postpartum doulas also check-in with moms about how they’re feeling physically and mentally. A doula should maintain a list of professional contacts to refer moms who are struggling. In one case, DesBrisay recognized symptoms of postpartum depression in a client and talked with her about it. The new mom was so overwhelmed, she couldn’t bring herself to seek professional help. At the client’s request, DesBrisay placed a call to a mental health service specializing in postpartum depression, which set the mom up on a treatment plan.
There’s almost no postpartum care in the U.S.
But it’s not just home visits that improve wellness for new moms. In France, most women receive physical therapy, including a technique called vaginal electrical stimulation (VES), to help rebuild pelvic floors muscles and prevent vaginal bulge issues — like Clifford’s rectocele. Notably, research suggests that “Kegel” exercises, which are sometimes suggested by U.S. doctors for the same issues, are useful but may not be enough.
VES might sound scary, but in an op-ed for The Guardian, Gillian Harvey explained how French physical therapy helped her avoid incontinence. As a mother of five, with all vaginal births, including breech twins and an episiotomy, Harvey had higher risk for urinary issues. She was skeptical, but French friends convinced her to try VES. She recalls her early aversion to feeling “a pulse of electricity where no pulse of electricity should ever be felt.” But after just a couple sessions, she felt the difference in her pelvic floor. She could jog and cough without fearing “urinary feedback.”
Traditions of postpartum care vary all over the world, according to Dr. Eden Fromberg, an OB-GYN in New York City who has trained with French pelvic floor specialists. Conversely, she says, “There’s almost no postpartum care in the U.S.”
Many women don’t realize their childbirth injuries can be treated, Fromberg says. She’s had patients for years who were living with pain or discomfort that they didn’t mention right away. “I think a lot of times patients aren’t aware that it’s something that can be addressed.”
For women who are concerned they may have pain and injuries related to childbirth, Fromberg says that there are two main things to pay attention to: sensation and function. “Do you feel good and are things working the way you would want them to?” she asks.
Fromberg notes there are many subtle and not-so-subtle signs of childbirth injuries, such as having to strain when urinating, incontinence, constipation, clitoral pain, pain during sex, tailbone pain, or a sensation as though a piece of tissue is caught in an area that had stitches.
“If something doesn’t work right, or doesn’t feel right, there’s no reason not to see what you can do about it,” she says, noting that there are low intervention options that can make a difference. She thinks pelvic floor physical therapy should be a regular part of postpartum care for anyone who wants it.
“There is a tradition of postpartum care in every culture in the world until we get to Western culture,” Fromberg adds. “Everybody should have the opportunity to have physical therapy or an alternative form of postpartum care that is consistent with her culture and beliefs and desires.”
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