The "Postpartum Cliff": A Phase We Don't Discuss Enough

The day after arriving home from the hospital with her newborn, Lauren Cooper woke up with a massive headache. "It hurt to open my eyes," she says, recalling that she had to wear sunglasses to her son's first pediatrician appointment in order to manage the pain.

Google told her it was likely just hormones. But by that night, her sister, who'd gone to nursing school, convinced her to phone the on-call doctor. That obstetrician recommended Cooper take a blood pressure reading. "I told her what it was, and she said, 'Lauren, you have to go to the ER right now. You have preeclampsia and you are at risk of having a seizure or a stroke,'" she says. Cooper was admitted to the hospital, put on a magnesium drip, and told she was one of the lucky ones: If patients ignore the symptoms and stay home, postpartum preeclampsia can potentially be fatal.

Despite how much medical attention parents-to-be get while pregnant, once they're discharged after delivering their baby, there's a major drop-off in healthcare — even though nearly two-thirds of pregnancy-related deaths in the US happen after giving birth, according to a study by The Commonwealth Fund. Researchers call this the "postpartum cliff."

Stephanie White is a certified doula and nurse care manager at the family-building support company WIN.

Nicole Sparks, MD, is a board-certified ob-gyn and children's book author based in Atlanta.

"Society expects new mothers to 'bounce back to normal,' with the idea that it's natural for women to have babies," says doula Stephanie White. "Mothers ignore when something could be wrong physically and mentally to care for their baby and family, and may not even recognize that she doesn't feel well or is bleeding too much."

The American College of Obstetricians and Gynecologists recommends that patients have initial contact with their obstetrician within three weeks postpartum, and a more comprehensive visit 12 weeks after birth. However, "a surprising amount of people do not follow up to their postpartum appointments," says ob-gyn Nicole Sparks, MD. Others might see their OB, but never make it to their primary care provider for things like long-term chronic conditions. "And so after they're done with their OB, they're just done. And they may be sitting there with high blood pressure, diabetes, mental health conditions, postpartum depression, all of those things with no one to lay eyes on them," Dr. Sparks says.

There are a number of reasons why postpartum patients skip their appointments. Sometimes it's because insurance doesn't cover enough of the costs. Sometimes there are transportation or childcare issues. "Or they literally just forget because they're tired and sleep-deprived and overwhelmed," Dr. Sparks says.

Dr. Sparks admits that after having each of her three kids, she developed postpartum depression and barely followed up with her own medical team. "I just didn't want to leave my house. It was too overwhelming to get in the car and go somewhere," she adds.

Yet not getting the necessary care can be dangerous. Just after giving birth, the most common serious health problems are excessive bleeding, infection, and preeclampsia and high blood pressure (which might seem to be under control prior to discharge only to skyrocket after going home, according to White). Even up to a year later, cardiomyopathy, or a weakened heart muscle, can be fatal, the March of Dimes reports. Meanwhile, the National Institutes of Health estimates that postpartum depression affects about 15 percent of those who give birth while reported rates of postpartum anxiety range from 13 to 40 percent, according to a study in "Infant Behavior and Development."

Experts suggest patients contact a provider if anything seems wrong after leaving the hospital. In particular, Dr. Sparks says that a headache that won't go away or vision changes could be symptoms of preeclampsia. Other red flags for common postpartum problems include soaking more than one or two pads every hour, swelling in one or both legs, and chest pain. "If something feels 'off,' it probably is," White adds.

Still, Cooper argues that the onus shouldn't be put on new parents themselves, who aren't trained to spot serious symptoms. "Why is it up to me to become an expert on all the possible outcomes that could happen when I'm just trying to survive and take care of my baby?" she asks. "Where is the person who is not sleep-deprived, who has that knowledge and years of experience in medicine to shepherd me through this process that I've never been through before?"

Recently, researchers from Harvard and the affiliated Massachusetts General Hospital found that by simply taking over the administrative task of scheduling those primary care appointments and then sending reminder messages, postpartum patients were almost twice as likely to actually see their doctor. The odds were also significantly higher that patients would get all the recommended screenings for things like blood pressure and mood disorders, and receive medication for postpartum depression, if needed.

Yet even though the numbers doubled, Dr. Sparks points out that many patients still didn't go to those appointments. "We have to try to figure out why they're not going," she says, "but trying to take some of the burden off of the mother will help."

White suggests new parents hire a postpartum doula for regular visits in the two weeks after delivery to "ensure a safe and speedy recovery." Alternatively, those with the means can go to a postpartum retreat that offers access to 24/7 care. Some hospitals schedule a home care visit from a nurse and/or telemedicine appointments in the weeks after discharge, although The Commonwealth Fund says these kinds of services are less common in the US compared to other high-income countries.

Dr. Sparks says that while she would love to see home visits from doulas and nurses become standard practice, she's not optimistic that it will happen anytime soon since it's so expensive. Yet she does see the possibility that technology could play a role in bridging the gap, highlighting how some offices monitor patients' blood pressure remotely in order to catch postpartum preeclampsia. "This is really low-cost and low-resource, but [can] make a huge difference in helping people not fall through the cracks," she says.

After her own traumatic postpartum experience, Cooper simply dreams of a future where our healthcare system values women's health just as much after they've given birth as it does when they're pregnant. "I hope that we are able to change the model for our children's generation," she says, "because it feels like we could do a lot better."

Jennifer Heimlich is a writer and editor with more than 15 years of experience in fitness and wellness journalism. She previously worked as the senior fitness editor for Well+Good and the editor in chief of Dance Magazine. A UESCA-certified running coach, she's written about running and fitness for publications like Shape, GQ, Runner's World, and The Atlantic.