For Elisha Covington, 36, the winter of 2010 felt excruciatingly long. She was 31 weeks pregnant when doctors discovered her baby was measuring about four weeks smaller than he should have been. Within days of confirming a diagnosis of intrauterine growth restriction, her son was delivered two months early by cesarean section, and had to stay in the Neonatal Intensive Care Unit for 47 days.
The c-section, Covington said, “was the worst experience ever. It was like I was not even there. It felt like something was being done to me instead of for me.”
“I was really pissed—very upset,” Covington told Rewire.News. For a long time, she felt bitter that her doctors hadn’t been able to detect the condition sooner or tell her why this had happened. “It wasn’t what I imagined pregnancy or childbirth was going to be,” she said.
After her birth experience, Covington developed symptoms related to postpartum depression (PPD), which she didn’t recognize for years. “I didn’t have any drive for a long time,” she recalled. “I didn’t look toward the future. It was like I was just existing to be here for the child.” She also struggled with guilt: “I was determined to breastfeed, which I did, but we had to supplement, which was another stressor. I felt like, ‘I’m not enough, my body is not doing what it should be doing for this child,’ which was carry him full term, feed him, and all these things.”
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It took almost three years for Covington to overcome her PPD symptoms, thanks to the support of her family and friends. Angry at the circumstances surrounding her son’s birth, she never sought mental health treatment. None of her doctors ever asked about how she was doing emotionally anyway, she said. She felt neglected, and wondered if she had been treated differently from others because she was a young, Black, unmarried woman who was enrolled in Medicaid.
Because of the systemic racism that pervades the health-care system—and, to a larger degree, society—her worries are warranted. In addition to the fact that Black mothers die at three to four times the rate of white mothers, they are also more likely to experience severe pregnancy-related health complications, including postpartum hemorrhage. They are twice as likely as white women to experience symptoms related to PPD, but they have lower odds of receiving mental health treatment even when they seek it out. When other health complications arise, they often find that doctors don’t take their pain seriously enough.
Recognizing how life-changing the weeks and months following the birth of a child are for any woman, the American College of Obstetricians and Gynecologists (ACOG) recently released a much-needed update to its recommendations for postpartum care. The guidelines, which were published in the May issue of the journal Obstetrics & Gynecology, urge health-care providers to offer “ongoing care” instead of the typical, one-time visit that happens between four and six weeks postpartum. That timeframe was recommended by ACOG in 2016 in its previous set of guidelines.
In other words, the updated recommendations would essentially redefine how U.S. patients, including those most at risk for complications, should be cared for after having a baby.
“To better meet the needs of women in the postpartum period,” the revised Committee Opinion states, “care would ideally include an initial assessment, either in person or by phone, within the first 3 weeks postpartum to address acute postpartum issues. This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive well-woman visit no later than 12 weeks after birth.”
According to the report, that comprehensive postpartum visit should cover a range of issues dealing with a woman’s overall health, including emotional well-being, which the report places highest on the list; recovery from birth; sexuality; infant care and feeding; and general health maintenance. The goal, Dr. Alison Stuebe, lead author of the revised guidelines, said in a statement, “is for every new family to have a comprehensive care plan and a care team that supports the mother’s strengths and addresses her multiple, intersecting needs following birth.” That care team, notes the guidelines, should also include family or friends.
The recommendations take added care to note the need to follow up with patients with chronic health conditions, such as hypertensive disorders and mood disorders, as well as those who have endured a miscarriage or infant death. They also suggest practitioners counsel women on the long-term risks for cardiovascular disease that are associated with some pregnancy complications, such as preterm birth, gestational diabetes, and preeclampsia/eclampsia.
Currently, postpartum care in the United States is severely lacking, especially in comparison to the emphasis we place on prenatal care. In one national survey cited in the ACOG report, less than half of women reported that they receive adequate information after the birth about postpartum depression, how long to wait before getting pregnant again, healthy eating, exercise, or changes in sexual response. In some cases, they may not feel able to even come to that follow-up visit: A 2017 study found that women who reported feeling discriminated against or otherwise had a negative pregnancy or childbirth experience—which is, too often, the case for Black women—had “more than twice the odds” of skipping their postpartum visit.
Even with these recommendations in place, however, many women lack the quality insurance necessary to seek postpartum care. Half of all births in the United States are covered by Medicaid; however, a woman’s coverage typically ends two months after she’s given birth. To address this, Illinois Rep. Robin Kelly (D) recently introduced a bill in the U.S. House that would extend Medicaid up to a year. (That’s fitting, since one study found it can take up to a year for a woman to recover from childbirth.)
Another way to improve postpartum care, especially for women of color, is to address the systemic issues that lead to racial health disparities—that is, implicit and explicit bias. A recent report from the National Perinatal Task Force, in fact, recommended that doctors and health-care agencies participate in “anti-oppression cultural and historical training” to help practitioners understand the effects of privilege, how certain communities are oppressed, and how that plays out in the clinical setting. Advocates also champion the benefits of holistic care, including using the services of a doula or midwife, as a way to ensure gaps in care are covered.
Kimberly Ann Johnson, a postpartum care advocate and author of The Fourth Trimester: A Postpartum Guide to Healing Your Body, Balancing Your Emotions, and Restoring Your Vitality, said the new ACOG recommendations are “definitely a step in the right direction.”
“Just because the baby is out of the mother’s body doesn’t mean their nervous systems aren’t still relating with one another,” Johnson told Rewire.News. “They’re still in a symbiotic relationship. The point [of putting emphasis on the fourth trimester] though … is to tell a woman, ‘You’re just as important as your baby. Your baby is not more important than you. Your baby’s health isn’t more important than you.'”
“What women really need after they have babies,” she continued, “is an extended rest period—like 30 to 40 days—and being taken care of. When women don’t get that, the outcome of that is often isolation, depression, loneliness, all those things.”
Sandra Guynes, a 41-year-old mother living in California, said she indeed felt all those things after she had her first child in 2015. After years of fertility treatments, she finally became pregnant unexpectedly. At that point, she was over the age of 35, and because she’d tried for so long to become a mother, she felt like she couldn’t complain about how hard the pregnancy—and later, the first few months of motherhood—was.
“After trying so long, the biggest thing was, ‘Wow, this actually happened,”’ she told Rewire.News. “I took home this baby and then I was miserable, which was so hard to tell people. I was really sad a lot. I felt lonely. I felt overwhelmed because I wasn’t sleeping. A lot of people said, ‘You’re tired because you’re breastfeeding and up all night,’ but I started to feel like everything was overwhelming. Pouring myself a glass of water could be the most overwhelming thing ever.”
Part of the problem, she said, was that she didn’t have a support system; she and her husband had been living in California for only a few months when she had her daughter. It wasn’t until she joined a local Mothers of Preschoolers group did she find herself emerging from the fog—and that was about eight or nine months postpartum.
Guynes says she still has bouts of depression, which she started taking medication for. But that treatment didn’t begin because her doctor inquired after her mental health. Instead, she said, she was the one who took initiative: “It was me going to the doctor and saying, ‘I’m having hard days and I just feel like I could be a better person. I want to be a better person; I want to be able to take care of my daughter, I want to be happy and enjoy people and do all those things without it being so hard.'”
The importance of having a medical professional who’s really invested isn’t lost on Covington, the mother whose son was delivered two months early. She said that if one of her care providers had shown interest in how she was holding up emotionally after the unexpected c-section, in addition to checking in on her physical health, she might have been able to let go of her resentment sooner.
“I don’t deny that intervention may have been the best thing,” she said. “But just even knowing someone gives a crap about me … they could ask just to be asking. But, OK, at least you see me.”