Helping New Mothers in the Fourth Trimester

Pregnancy is typically defined as a period in a woman’s life that is divided into three trimesters, and the major focus of maternal healthcare is ensuring a safe and healthy delivery.  However, the challenges new moms face after they give birth and go home are too often overlooked. Healthcare professionals are starting to pay closer attention to the physical and mental health needs of women during the 12 weeks immediately after giving birth. This critical time period is being referred to as the “Fourth Trimester.”

Although the fourth trimester is an exciting time filled with many joyous moments, it is also a period that presents complex challenges. New moms experience the physical and psychological toll of recovering from childbirth while taking on the responsibilities of parenting an infant. Sleepless nights, pain management, breastfeeding difficulties, wound recovery, and symptoms of the “baby blues” or postpartum depression are just some of the obstacles that occur during the fourth trimester.

Challenges new mothers face in the fourth trimester

Insufficient healthcare follow-up

The United States healthcare system focuses a majority of its efforts on bringing a healthy baby to term and a safe delivery. Women are encouraged to take prenatal vitamins and meet with their primary care providers several times before conception. Scheduled appointments include prenatal care visits, ultrasounds, blood work, and situation-dependent nutrition or social work consultations. There are weekly visits in the final month before a mom’s due date to assess fetal heart rate, maternal blood pressure, and weight. During this time, moms-to-be get substantial education and guidance about the process of labor and birth. Little attention is paid to the common challenges that arise after delivery during the fourth trimester. Typically, only one follow-up appointment occurs for a new mom around 6-8 weeks post birth. This is too little and too late to effectively support postpartum mothers.

Cultural expectations

New mothers face significant pressure due to commonly held myths about motherhood. Society reinforces the expectation that all females have a maternal instinct and that bonding with a newborn is easy and will happen effortlessly. While this may occur for some women, it does not for a majority of new mothers. Bonding is a process and requires time for the relationship to develop. If bonding does not happen initially, a mom may feel guilty, lonely, or ashamed without realizing that what she is experiencing is very normal.

Moreover, there is a misconception that being a mother means putting everyone else’s needs first. Motherhood is incredibly difficult, especially when juggling multiple roles within and outside of a family. In order to be the best parent possible, a mother needs to prioritize her own mental and physical health, especially during the fourth trimester. No one can do it all on their own and should never be expected to without help.

Unattainable beauty standards puts a new mom at risk of negative body image and low self worth. There is an unrealistic expectation for mothers to get their “pre-baby body” soon after giving birth. While social media has created the narrative around a “dad bod” as something positive and to be desired, necessary weight gain in pregnant females for a healthy birth is seen as something that needs to be fixed immediately. This creates an unfair double standard that makes new motherhood even more challenging. Not only does this put a new mom at risk of psychological harm, it can also be incredibly damaging for both mom and baby if she is not getting adequate nutrients to heal from childbirth wounds or nourish an infant through breastfeeding.

Inadequate maternity leave

The United States is only one of seven countries worldwide with no policy that guarantees paid time off for maternity leave. According to the United States Department of Labor, the Family and Medical Leave Act (FMLA) provides eligible employees with 12 weeks of unpaid maternity leave per year. FMLA has specific requirements for eligibility, including that a person has worked for their employer for at least 12 months, accumulated at least 1,250 hours over the past 12 months, and works at a location where an organization employs 50 or more workers within 75 miles. Furthermore, time taken off during pregnancy due to complications may start the maternity leave clock and count against the 12 weeks of family and medical leave.

The map above, published by the World Policy Analysis center, represents the amount of paid maternity leave provided by various countries across the globe. The average leave is 29 weeks. The image reflects data collected through 2019. The Pew Research Center notes that moms who are working either part of full-time have increased from 51% to 72% over the past 50 years. Nearly half of two-parent families include two full-time working parents. Despite research continually showing that maternity leave has been linked to both positive maternal and child outcomes, the United States lags far behind a majority of countries in its policies. Inadequate maternity leave can create financial anxiety for new moms.

Important Warning Signs

Many new mothers and families are not educated about signs to watch for that may require immediate medical intervention. According to the Center for Disease Control and Prevention (CDC), one-third of maternal deaths occur from one week to one year after delivery. If any of the following physical symptoms occur, seek immediate medical attention as they may be life-threatening:

• Fever or chills
• Heavy, bright red bleeding
• Severe headache
• Shortness of breath
• Chest pain
• Swelling of the legs or feet
• Dizziness

The Baby Blues and Beyond

Over 50% of women will experience the Baby Blues beginning 3 to 4 days after giving birth and lasting approximately two weeks. Symptoms include crying, depressed mood, inability to sleep, fatigue, anxiety, and a lack of concentration. If symptoms persist or develop later and last longer, this can lead to a more serious condition called postpartum depression (PPD). One in seven women will experience PPD, which has many of the same symptoms as major depressive disorder.

PPD typically occurs during the fourth trimester, within 4 – 12 weeks of delivery. However, it can develop at any time within the year of giving birth. It can be mild, moderate, or severe and requires treatment with the proper mental health interventions. Postpartum psychosis is a little known and rare condition that affects approximately 1 – 2 moms in every 1,000 births. Symptoms include mania, severe depression, and psychotic thoughts such as delusions and hallucinations. This is a psychiatric emergency and suggested treatment requires inpatient hospitalization.

Tips for New Mothers

Know you are not alone

New motherhood is difficult for everyone. It is a time where your identity changes and you take on even greater responsibilities. It is okay to feel sad, angry, frustrated or any other emotion you may be feeling. New mothers do not solely have to feel excited and happy all of the time. Give yourself permission to feel a range of emotions that may change rapidly throughout the day.

Ask for help

It is okay and necessary to ask for help during the fourth trimester. Many times people want to help but do not know how, which leaves them saying the vague phrase, “Let me know if there is anything I can do for you.” Oftentimes, this is met with guilt from a new mom who is already overwhelmed but feels as though she has to say she is all set and does not need anything. If someone offers their help, give them a specific suggestion of what they may do. These include asking for others to complete household chores, run errands like going to the grocery store or post office, care for your other children if this is not your first child, and bring nutritious meals for you and your family to eat.

See your doctor

Statistics suggest that only 40% of moms attend their postpartum follow-up visit at 6 weeks. The fourth trimester is a busy time for new mothers and can be viewed as an unnecessary luxury. Seeing your doctor during this time is critical. During your appointment, make sure you cover the following:

• Acute, Non-Emergency Medical Needs – This may include assessing proper wound healing from placenta detachment or surgical areas sites from a Cesarean section.
• Chronic Health Conditions – Monitor ongoing conditions like hypertension and diabetes management.
• Infant Care and Feeding – Not every mother has instant success at breastfeeding. If you are in pain, your baby is not gaining weight, or you are having other difficulties, seek a lactation consult.
• Mental Health Assessment – Check in with your doctor if you have any signs of the baby blues, postpartum depression, anxiety, or other mental-health related condition.
•  Sleep and Fatigue Assessment – Be honest with your doctor about how you are sleeping and your level of fatigue.
• Family Planning and Contraception Choices – Beginning to have sex again is a personal decision. Everyone is on a different timeline and should involve open communication with your partner. Discussing contraceptive choices with your doctor can help you prevent an unplanned pregnancy soon after giving birth.
• Nutrition – If you need additional support with nutrition, your doctor can refer you for a dietary consult or help you access needed services offered by programs like Women, Infants, and Children (WIC).

Focus on nutrition

This is a key period to focus on nutrition for both yourself and your baby. Consume nutrient-dense foods and avoid highly processed products that contain added sugar and unhealthy fats. Food insecurity is a reality for many Americans. Healthy food is expensive. There are several programs that can help with the financial burden of buying nutritious food for you and your baby. WIC is a government-funded program that aids low-income pregnant, postpartum, breastfeeding women, infants, and children up to 5 years of age who are at nutritional risk.

WIC helps individuals access healthy food, nutrition education, and referrals. Produce prescription programs and voucher incentives are available and increase access to fruits and vegetables. These are prescriptions that patients can use to get produce in their community. More hospitals are partnering with food banks and local farmers to help mitigate food insecurity and distribute fruits and vegetables to a greater number of people in the community.

Turn off social media

While social media can be a space to share exciting news, it can also be harmful. Remember that social media is a snapshot of other peoples’ lives and does not tell the full story. It can be difficult to see other moms and parents who seem to have it all figured out. The truth is that none of us do, and we all struggle. Be aware that behaviors like Instagram “doom scrolling” can perpetuate false depictions of motherhood that you repeatedly internalize. If you find yourself feeling down, envious, or any other negative emotion while on social media apps, take a break from technology until you are in a healthier physical and mental space.

An Urgent Call to Action

The American College of Obstetricians and Gynecologists (ACOG) and other organizations are paying closer attention to the critical needs of mothers during the Fourth Trimester. The ACOG developed a committee dedicated to redefining postpartum best practices. Current recommendations include an initial appointment within the first 3 weeks of giving birth followed by a comprehensive postpartum visit no later than 12 weeks postpartum. The comprehensive visit should be a full physical, psychological, and social assessment that focuses on mood, infant feeding, family planning, sleep, fatigue, physical recovery, chronic disease management, and overall health maintenance.

The ACOG also recommends that a postpartum care plan be developed with a patient during prenatal care visits. This ensures moms feel confident and supported as they transition from delivery to the fourth trimester. Improving healthcare following the birth of a baby is critical to increasing maternal well-being and lowering maternal death rates. Implementing these recommendations on a wide-scale should be a priority to protect both mom and baby.