International | Beyond baby

Why so little is done to help new mums cope

Public-health systems focus on babies but often neglect their mothers

|TOKYO

THE PREMISES are as spick-and-span as any health centre. But unusually for somewhere full of newborns and mothers, a quiet calm prevails. Setagaya Postpartum Centre in Tokyo is a rare place. Mothers with babies four months old or younger can stay the night to receive support from midwives and therapists. Some want help breast-feeding; a good few need counselling; others want to recover physically from giving birth, says Kumiko Nagamori, a midwife and director of the centre.

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Kaori Ichikawa, who heads the Association for Antenatal and Postnatal Care Promotion in Tokyo, says that Japan is slowly realising that it needs to do more to support women after they give birth. A few years ago the government improved the postnatal care it offers. That was prompted by a fall in the number of births and a rise in reported cases of child abuse. Now, she says, the focus is on the women themselves. Alarm grew this year, when it was revealed that suicide was the leading cause of death among pregnant women and new mothers in 2015 and 2016.

Japan is not alone in waking up to the inadequacy of care in early motherhood—“the fourth trimester”, as it is sometimes called. Women are suffering, but feel that they have to act as if everything is fine, says Sarah Verbiest, a public-health expert in North Carolina who runs a research project on the fourth trimester. The system in America, as elsewhere, she says, tends to focus on the health and well-being of the baby, rather than that of the mother.

Baby blues

The needs are glaring. Some 10-15% of women in America and around a quarter in Brazil are reckoned to suffer from postpartum depression. The physical toll of giving birth is less well studied, but some 90% of women may tear their pelvic-floor muscle during birth, and 6% of them suffer a serious injury, according to Britain’s Royal College of Obstetricians and Gynaecologists.

The growing focus on postpartum care is in part a consequence of good news: childbirth itself is safer than it has ever been. From 1990 to 2015 the number of maternal deaths around the world fell by almost half, to 216 per 100,000 women, thanks in large part to women delivering their babies in proper medical facilities. Nearly all of these deaths (99%) are in developing countries. However, this article focuses on the rich world, where, with the notable exception of America, maternal mortality has fallen.

A second reason for the new attention being paid to care for new mothers is that women, including famous ones, have been speaking out about their unhappy experiences. Serena Williams, a tennis player, has written of the “funk” of postnatal depression. Keira Knightley, an actor, wrote about her experience of childbirth: “Hide. Hide our pain, our bodies splitting, our breasts leaking, our hormones raging.” Ali Wong, a comedian, delighted and shocked Netflix fans by yelling about women’s “demolished-ass bodies” and her horror at finding out that new mums who advised her to steal nappies from hospital meant not for the baby but for herself.

The importance of the postnatal adjustment has been implicitly recognised in traditional rest periods such as China’s zuo yuezi (“sitting the month”), when new mothers follow timeworn practices such as refraining from washing their hair or consuming cold drinks, or la cuarentena, a 40-day rest, observed in Mexico and other Hispanic countries.

Yet this is poorly reflected in modern health systems, which tend to offer plenty of check-ups during pregnancy, but very few after it. It is usual for women in countries including America and Britain to receive just one visit from a health worker when their babies are six weeks old. American federal law does not even oblige employers to give women paid time off work.

Journey without maps

After childbirth many women suffer mental-health problems. Different women struggle with different things—trauma related to the birth, the difficulty of adapting to caring for the baby, or the change in self-image, says Jacqueline Glynn, a counsellor in London. In Britain, France and Japan a survey is conducted at six weeks to detect postpartum depression. But depression can hit much earlier—or later. Ms Glynn says that many women struggle to tell whether their feelings are normal or something more serious. They may fret that their baby will be taken away if they admit to a professional that they are depressed.

A survey of Britain’s National Health Service found that more than half of first-time mothers felt they were not given enough information about emotional changes they might experience. Suzi Barling, who was diagnosed with anxiety after her son was born in Australia in 2017, counts herself lucky that she got help. “It is because I have a history of it and so I and my husband recognise the signs,” she says.

Women’s physical health, however, both during pregnancy and after birth, is perhaps even worse catered for. Often mothers are ignorant of basic facts about what will happen to their body during and after childbirth, including tears to their pelvic floors, reckons Emily Oster, an economist at Brown University in Rhode Island, and author of books about pregnancy and birth. She was surprised when she bled for days after giving birth. In 2015 Britain’s Care Quality Commission found that only 51% of women giving birth for the first time thought they were given enough information about their physical recovery. Some care providers use euphemisms, such as “tidying up down there” for stitching up tears. “People say ‘how are you?’ but they don’t really want to hear about what is going on in your vagina,” says Ms Oster.

One result of this reticence is that too many mothers think symptoms such as incontinence are inevitable. Some are actually told as much. When Emma, a 37-year-old British lawyer, went to her doctor to complain of incontinence a year after giving birth, he suggested she ignore it, especially if she were planning to have more children. Her response was: “If I had broken a leg, would you advise I didn’t worry about then running a marathon?”

Dealing properly with postnatal problems means starting with childbirth, says Neel Shah, an obstetrician at Harvard Medical School. In some countries there is too much intervention in the birth itself. Unnecessary medicalisation can make it more traumatic. In contrast, other women have notions of a perfect “natural” birth and are upset if it does not happen as planned. Surprisingly little attention is paid to the factors that make a pelvic tear more likely or to what experience women want to have. They are rarely consulted during labour.

“Childbirth is one of, if not the most, important times of a woman’s life, but too often they feel like they are on a plane being held on the tarmac,” says Mr Shah. He is trying to find how doctors and midwives can involve women more in the birth. The preparation is “labour is going to be difficult. But bring a Swiss ball,” says Ms Barling, referring to a big exercise ball some women sit on during contractions. “How different is that from other areas of medicine where doctors talk you through [the] chances of certain outcomes?”

Some countries do it better. The Netherlands has the most comprehensive postnatal care. Every new mother is assigned a kraamverzorgster, or care worker, who visits her home daily for eight to ten days after birth. Trained to check the health of the mother and baby, the carer will also perform chores such as shopping and cooking.

France leads the way for physical rehabilitation with la rééducation périnéale. All women who give birth get at least ten sessions of rehabilitation for their pelvic floor—a practice in place since 1985—and more than that if needed. Caroline Mollard, a physiotherapist in Paris, says it has become normal in France for women to know that they must make an effort to rehabilitate after birth. “In the past women would have issues, such as prolapse, and struggle with it until they needed surgery,” she says. “Now we are preventing problems.”

Few other rich countries have improved postpartum care in more than patchy ways. Since 2015 Japan’s government has subsidised municipalities that offer postpartum-support services. It also encourages them to carry out surveys to detect postnatal depression at two weeks or a month after birth. But uptake is slow.

Rich women receive better postpartum care than poor ones, a gap that is starker in countries, such as America, with scantier public provision. Such disparities could grow. If demand for better care rises and governments fail to provide it, the private sector will fill the gap—but only for those who can pay. In Taiwan the number of private postpartum centres increased fourfold in the decade to 2016.

More data are needed. Ms Verbiest’s work is a rare example of research that asks women what they need. But more solid information on every aspect of childbirth and its effects is lacking, says Ms Oster. Public authorities in America and elsewhere already record whether a birth is vaginal or by Caesarean section. They could also track pelvic tears and the physical and mental health of new mothers.

In the interim, it would help if women had access to more information. The prenatal classes most countries offer could be improved, to give future parents a better idea of what to expect. Early evidence from Mr Shah’s experiments suggests that some simple steps, such as asking a woman how she feels during childbirth can make the delivery a better experience emotionally, if not physically.

More postnatal care would add costs to strained public-health services, yet besides sparing women unnecessary suffering, it might make economic sense. Better childbirth procedures could prevent problems, and better postnatal services could stop them growing, saving money for medical services in the long term, and allowing women back into the workforce earlier. Moreover, the mother’s well-being affects her child’s future health and educational attainment. A depressed mum is less likely to stimulate her child. An exhausted one is less likely to breast-feed.

Following Japan

Across the rich world women are having their first child later in life. Older women are at greater risk of pelvic-floor tears and other injuries. Physical recovery takes longer for them, says Ms Nagamori, the midwife. The average Japanese woman first gives birth at 31, up from 26 in 1970. Delayed motherhood is a consequence of a happy trend: that women are spending longer in education and forging careers. But like all big changes, it comes with side-effects.

This article appeared in the International section of the print edition under the headline "Beyond baby"

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