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Globe Magazine

The ‘fourth trimester’ and plight of new mothers during a pandemic

For decades, the US has treated the health of new mothers as an afterthought to that of their babies. But a growing coalition of doctors and policy makers is determined to change that — even during the coronavirus outbreak.

Caroline Brinkert with her daughter in April, not long after giving birth.
Caroline Brinkert with her daughter in April, not long after giving birth.Webb Chappell for The Boston Globe

On a recent spring evening, Caroline Brinkert held her 4-day-old daughter, Aila, up to a glass door. Aila was meeting her grandparents for the very first time. The baby’s grandmother leaned in and pressed her hand up to the glass, as if she might just be able to squeeze her tiny finger.

Brinkert longed to let her in-laws inside her Natick home. She wanted to experience this moment as she’d always imagined it, before COVID-19 turned the world upside down. But everyone understood that the door must remain shut.

“There’s a grief I keep having to process, that things aren’t going to be the way I pictured them,” Brinkert tells me later.

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Even under normal circumstances, the first three months after a child is born — known as the “fourth trimester” — are a disorienting time of physical and emotional change for women. After the birth of my first child, I remember the shock of learning that I wouldn’t see my obstetrician again for six weeks. Many women experience pain from vaginal tearing or a C-section, while a third suffer from urinary incontinence due to weakened pelvic muscles. Up to 1 in 7 women are diagnosed with postpartum depression, according to the American Psychological Association, while up to 4 in 5 experience feelings of sadness euphemistically referred to as the “baby blues.” These women in need are frequently left to navigate mental health problems on their own. A 2013 survey sponsored by the National Partnership for Women & Families found that 63 percent of respondents with indicators of depression never received treatment.

And a bad situation is now getting worse. During this pandemic, new mothers are feeling especially isolated, scared, and overwhelmed, says Ann Smith, board president of the nonprofit Postpartum Support International. “If all of us are anxious right now, then take a mom who is already experiencing an underlying perinatal mood and anxiety disorder, and add in the coronavirus pandemic, and you’ve got anxiety that’s literally out of control,” she says.

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Dr. Rose Molina, an ob-gyn, points out that social distancing is placing economic strain on many new mothers she treats at the Dimock Center, an outpatient clinic in Roxbury. “I see a lot of patients who have low-income jobs, and they’re concerned about whether they’ll be able to continue to work and get a paycheck,” she says. “They don’t have the privilege of social distancing, and that’s an added burden they’re really struggling with as well.”

Meanwhile, mothers are cut off from the support they typically count on from relatives and friends, home health visitors, and new moms’ groups. Brinkert had been looking forward to having her parents stay with her for a few weeks after Aila was born. Their visit has been postponed indefinitely.

“I’ve heard so often how it will take a village to get through this period. People to help with meals, or to fold a pile of laundry, or just to hold the baby so I can take a shower,” Brinkert says. “Now, none of these things are possible.”

The days following birth are even more harrowing for women who have tested positive for COVID-19 or are displaying symptoms of the virus. Many hospitals are currently recommending some form of separation between mother and baby to reduce the risk of transmission. A woman with mild symptoms might be permitted to remain in the same room 6 feet apart from her baby or separated by a curtain. But if the mother is very sick, the newborn could be moved to a different room altogether.

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Many US hospitals are becoming increasingly conservative in their recommendations for COVID-positive mothers, says Dr. Neel Shah, an assistant professor of obstetrics at Harvard Medical School, “particularly as we learn of new cases of severely affected mothers and newborns, some of whom either had no symptoms or mild symptoms before, suddenly and unpredictably getting worse.”

Health care providers counsel COVID-positive new mothers about the risks and benefits of various levels of separation, says Dr. Chloe Zera, an ob-gyn at Beth Israel Deaconess Medical Center. But there’s no way around the fact that a mother who gives birth while infected with coronavirus must monitor her interaction with her own newborn.

The spiraling uncertainty and medical complications brought on by the global pandemic have exacerbated a longstanding problem: For decades, the US has prioritized babies’ well-being and treated new mothers’ health as an afterthought. “There is a fourth trimester to pregnancy, and we neglect it at our peril,” natural childbirth activist Sheila Kitzinger warned in a 1975 journal article. “It is a transitional period of approximately three months after birth . . . when many women are emotionally highly vulnerable, when they experience confusion and recurrent despair, and during which anxiety is normal and states of reactive depression commonplace.”

It has taken nearly half a century for this wisdom to begin to make it into the mainstream. But, finally, a growing group of doctors, doulas, and health care experts across the country are heeding Kitzinger’s warning and fighting — even in the midst of the pandemic — to give postpartum mothers the care they’ve long been denied.

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“In our current system of care, the baby is the candy and the mother is the wrapper,” says Alison Stuebe, a professor of maternal-fetal medicine at the University of North Carolina and a national leader in the growing movement to change the way America treats new moms. “Once the candy is out of the wrapper, the wrapper is cast aside.”

Dr. Eva Zasloff (right) examines Sophia Bender Koning's baby boy during a postpartum health care visit in January, before social-distancing mandates went into effect.
Dr. Eva Zasloff (right) examines Sophia Bender Koning's baby boy during a postpartum health care visit in January, before social-distancing mandates went into effect.Webb Chappell for The Boston Globe

I FIRST HEARD THE TERM “FOURTH TRIMESTER” 10 years ago, when my first child was a few weeks old. My husband was back at work and my mother had returned home. Suddenly, I was alone with an infant who cried for hours every day.

Night feedings left me ragged and exhausted. My perineum was torn from labor, my breasts raw and bleeding from my baby’s improper latch. Worst of all, a radiating pain in my tailbone made it impossible to stand up without moving through a series of contortions.

“Probably fractured your coccyx during delivery,” one of the postpartum nurses at the hospital had proclaimed as she sponge-bathed my daughter. “Not much to be done about it!”

For help, I turned to The Happiest Baby on the Block, a wildly popular book by pediatrician Dr. Harvey Karp that offers step-by-step guidance for calming newborns. Karp contends that infants cry so much because, unlike other mammals, humans are born before their brains are fully developed. My job, according to Karp, was to re-create a womb-like environment for my daughter, shushing and bouncing her. His perspective helped me empathize with my newborn. But it didn’t fully acknowledge how hard it was to impersonate a uterus when I was bone-tired and still healing.

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Many cultures around the world observe rituals to support new mothers. In a Japanese tradition called satogaeri bunben, a woman travels to her family home a few weeks before birth to be cared for by her mother until the baby is 2 months old. In Mexico and other parts of Latin America, postpartum women rest for a period of 40 days in a custom known as la cuarentena. And in China, during the ritual of zuò yuè zi, new mothers remain home for 30 days surrounded by family to regain energy.

This deep regard for the postpartum period is uncommon in America, where women feel pressure to recuperate swiftly from pregnancy. (This expectation has even given rise to a new genre of Instagram post, the “snapback” photo, in which new mothers show off their return to more slender dimensions.) Our country’s devaluation of new mothers runs deep, forming the very foundation of our policies. The US is the only industrialized nation without paid parental leave. Qualified employees are offered just 12 weeks of unpaid leave under the Family Medical Leave Act. Nearly a quarter of employed women in the US return to work within 10 days after giving birth, according to a report by PL+US, a nonprofit working to achieve paid family leave.

Molina says many of her low-income patients at the Dimock Center feel financially forced to return to work before they’re ready. “Obviously, this has impacts on mental health, on breastfeeding rates, and on the ability to even make it to postpartum appointments,” she adds.

Compounding these hardships, nearly half of US women receive their pregnancy-related care through Medicaid, but in the 14 states that haven’t extended coverage, new mothers lose access after 60 days. Newborns, meanwhile, continue to be covered for a full year nationwide.

Together, these failures of support for mothers have led to an alarming statistic: The US has a higher maternal mortality rate than any other developed country. More than half of these deaths take place in the year following the day of the birth. Black women are three to four times more likely to die from pregnancy-related causes than white women, regardless of income or education.

“There’s nothing about skin color that changes your risks. It’s racism,” explains Neel Shah. “One thing that’s repeatedly true is that when Black people express concerns about symptoms and pain, the health care system is generally slower to respond because of our implicit bias.”

Shah describes maternal mortality as the “canary in the coal mine,” a problem impossible to solve “unless we acknowledge that women’s health isn’t something to be concerned about only during pregnancy and then discarded after the baby is born.”

INSIDE A COZY, SUNLIT HOME in Cambridge on a January morning before the pandemic, Dr. Eva Zasloff checks on Sophia Bender Koning, who is resting on the couch with her 4-day-old son. Zasloff asks how Koning is feeling and listens to her birth story. She looks at her cesarean incision and checks her blood pressure, which is slightly elevated, so she instructs Koning to recheck it later with a home monitor.

After Koning’s first child was born two years ago, she developed postpartum preeclampsia, a hypertensive disorder that can be life-threatening. By the time the first warning sign — a growing headache — was severe enough for her to reach out to her doctor, she was very sick and had to be hooked up to a magnesium drip at the hospital.

Zasloff unwraps the baby’s swaddle and lays him on a paper changing pad. “He looks so beautiful!” she exclaims, and Koning brightens. Zasloff examines his belly button and weighs him on a portable scale. To troubleshoot some breastfeeding challenges, she invites Koning to nurse while she observes, propping a pillow under her arms and adjusting the pair’s positioning.

Between emotional ups-and-downs and pain from her C-section, the past few days have been a bit tough, Koning says. Zasloff assures her that the first week after birth, when hormone levels fluctuate rapidly, can be the hardest: “Someone once said this time is like going through all of puberty in four days,” she says. “We’ll work through this together.”

At a traditional six-week postpartum checkup, many women will receive just 25 minutes of care. Zasloff’s appointment with Koning, by contrast, lasts a remarkable two hours.

A mother of three herself, Zasloff began to envision a new model of postpartum care several years ago, when she worked in a conventional family medicine practice in Somerville. During newborn visits, she felt an ethical responsibility to check in on mothers, but didn’t have enough time during appointments intended for the babies.

“I would see a woman lugging a car seat into our office, where there are sick people, and know there’s a very good chance she just had surgery two days beforehand, and that she’s probably bleeding and leaking milk and about to cry,” she recalls.

She imagined connecting with mothers in their own spaces and providing several visits during the three months after birth. Though she couldn’t find a single model to emulate, she launched Tova Health in 2016, which now includes a nurse practitioner, a registered nurse, and an operations manager. Tova has cared for more than 360 mother-baby pairs in Greater Boston, and the waitlist is growing.

Like most physicians during the pandemic, Zasloff has incorporated virtual appointments into her practice, visiting in person only when necessary. She has also launched a weekly virtual fourth-trimester support group open to all families, even ones that don’t belong to her practice, to help them weather the pandemic with a newborn.

“Birth stories have always been incredible, sometimes traumatic,” Zasloff says. “But now, the stories are all the more intense and all the more important to heal from and process.”

Similar forward-thinking work is being done elsewhere around Greater Boston. In Lawrence, the nonprofit Centering Healthcare Institute is using a groundbreaking group-based approach to give low-income families the medical and emotional support they so desperately need. On a day in January, mothers and their infants gather around a colorful play mat at the Greater Lawrence Family Health Center for a free comprehensive health visit covered through Medicaid.

The session, which lasts two hours, starts with the kinds of questions that all new parents grapple with: How long should my baby be sleeping at night? What should I do if he gets a fever? During the conversation, which is conducted in Spanish, a physician’s assistant weighs and measures the babies. Afterward, each parent-baby pair receives dedicated time with a family doctor or one of the two residents co-leading the group. The babies receive a full checkup, and parents can ask questions and voice concerns privately. While traditional post-birth care treats baby and mother as separate patients, the CenteringParenting program integrates family-centered care into the child’s visit, covering topics such as postpartum depression, stress management, family planning, and domestic violence.

“It’s nice to be able to come and share my worries and find out that that everyone’s experiencing the same thing, and that it’s normal,” says Karina, one of the new mothers.

Since CenteringParenting was launched more than a decade ago, it has been adopted by more than 125 health care sites nationwide. Under normal circumstances, the Lawrence group would have met every one to three months until the babies turned 1. For now, these visits are continuing through individual telehealth consultations.

Geisha Florian-Bierd holds her baby, Leisha Villa, during a health visit at the Greater Lawrence Family Health Center in January.
Geisha Florian-Bierd holds her baby, Leisha Villa, during a health visit at the Greater Lawrence Family Health Center in January.Webb Chappell for The Boston Globe

At Massachusetts General Hospital, an international study is currently investigating the impact of the pandemic on women’s childbirth experience and postpartum well-being. Run by Dr. Sharon Dekel, an assistant professor of psychology at Harvard Medical School and principal investigator at MGH’s Dekel Laboratory, the study is examining how social distancing and changes now occurring on hospital delivery floors — such as visitor limitations and mother-baby separation — are affecting new mothers’ mental health. More than 1,000 women have already enrolled in the study, and Dekel hopes this number will continue to rise in the coming weeks.

“In general, we know that when the childbirth experience is stressful, it can be traumatic and also, in some cases, lead to childbirth PTSD,” she says, though she emphasizes that not all women who deliver during the pandemic will have the same experience or reaction.

Against the backdrop of rapidly shifting hospital policies, doulas have also been scrambling to figure out how to best support clients remotely. Last month, Mari Leckel, founder of Boston Birth Associates, was in the middle of attending a labor at MGH when the hospital announced its new policy restricting visitors.

“They let me stay until the baby arrived,” she says, “but it was clear that everything was going to keep changing minute-to-minute, and that I’d need to figure out quickly how to continue reaching people virtually.” She and her team are now coaching laboring women via laptops set up in hospital rooms and conducting their postpartum follow-up visits through video chats. They’ve also begun giving their clients’ partners virtual crash courses in labor and postpartum support.

Support groups for new mothers are also in flux. Many of these, such as the Parent Connection program at Beth Israel Deaconess Medical Center, are now happening remotely.

Given how swiftly doctors have shifted to telehealth in the past few weeks, Zera, of Beth Israel Deaconness, is optimistic that this crisis will eventually result in better, more individualized, and equitable postpartum care.

“It’s truly as if all the health care world has been tipped on its axis,” she says. “And all of these things that we thought were pie-in-the-sky ideas a month ago are suddenly the way we do business.”

IN 2018, the American College of Obstetricians and Gynecologists released a committee opinion proposing a new paradigm for postpartum care. “In addition to being a time of joy and excitement,” its authors wrote, “this ‘fourth trimester’ can present considerable challenges for women.” The opinion recommends providers work with pregnant women to create a postpartum care plan and replace the lone visit at six weeks with at least one appointment within the first three weeks, followed by more as needed until a final, comprehensive visit at 12 weeks. Many providers have since adopted this model, but others have been slower to make the change.

At UNC, Alison Stuebe and her colleagues have launched The Fourth Trimester Project, an initiative that convened a coalition including new moms, health care providers, and community leaders from across the country to solve the most pressing postpartum health needs. Last year, they launched newmomhealth.com, a site that features input from real mothers and offers evidence-based guidance on everything from physical healing to navigating shifting relationships.

“Part of our vision is to change the way our culture treats new moms,” Stuebe explains. “So, instead of being an afterthought — like, ‘The baby’s really cute. Can you get me a cup of coffee while I hold your baby?’ — we say, ‘Mommy, what can we do for you?’”

In recent years, the term “fourth trimester” is being used as it was originally intended — with a nod to mom as well as baby, and with celebrities normalizing the message. In a 2018 interview after her daughter’s birth, tennis star Serena Williams described her C-section complications and postpartum depression: “I think people need to talk about it more because it’s almost like the fourth trimester. It’s part of the pregnancy.” When she was recovering from childbirth last year, comedian Amy Schumer posted unapologetically candid photos on social media — including one featuring herself hooked up to a breast pump — and joked about the experience in scathing detail during her recent stand-up special on Netflix. In September, singer Alanis Morissette posted an Instagram photo of herself breastfeeding her newborn son, with a caption that read, simply, “the fourth trimester.”

But the work of normalization isn’t finished yet. In February, controversy erupted when the Oscars rejected an ad by Frida Mom, a company that sells postpartum recovery products, for being too graphic in its portrayal of a new mom in mesh underwear lumbering to the bathroom in the middle of the night. The firestorm of debate that ensued brought into stark relief just how poorly the general public seems to understand the messy reality of recovering from childbirth.

Many people were incensed by this act of censorship. But the truth is, it’s far more comfortable to uphold romanticized ideas about motherhood than to acknowledge its less rosy complexities. If we can reframe the narrative surrounding childbirth and the postpartum months, maybe we can enact real change, too.

“The acuity and rage of mothers somehow continue to be one of the best-kept secrets of our times,” writes Jacqueline Rose in her 2018 book Mothers: An Essay on Love and Cruelty. At the heart of women’s reclaiming of the fourth trimester lies anger — and a conviction that enough is enough.

ONLINE HELP FOR NEW MOTHERS

With social distancing halting in-person postpartum support, these organizations are stepping in to help women with virtual visits.

Boston Birth Associates, a doula agency supporting birthing and postpartum women throughout Massachusetts, has launched a free, weekly, 90-minute virtual new moms group open to any new mother who wishes to join. 978-764-4414, bostonbirthassociates.com

Boston NAPS, a South Boston-based business serving pregnant and postpartum women, has moved its offerings online. These include consultations with a registered nurse around topics such as physical recovery, breastfeeding, sleep, and newborn development, and a six-week group series called Mom’s Survival Guide. 857-496-5095, bostonnaps.com

New England Mothers First, an independent nurse practitioner team specializing in breast health and infant feeding difficulties, is now offering 30-minute telehealth video conferences with one of its lactation experts. 508-921-4157, newenglandmothersfirst.com

Parent Connection, a 20-year-old program for new parents at Beth Israel Deaconess Medical Center, is hosting free virtual support groups that welcome all parents of babies under age 1, regardless of whether they’re BIDMC patients. 617-667-2229, bidmc.org/parentconnection

Postpartum Support International offers a toll-free help line for women struggling to adjust to motherhood, as well as “Chat With an Expert,” a weekly live phone session for callers seeking advice. Its Peer Mentor program pairs new mothers experiencing symptoms of depression or anxiety with women who have lived through — and recovered from — a perinatal mood disorder. 800-944-4773, postpartum.net

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Nicole Graev Lipson writes frequently about motherhood, parenting, and gender. Send comments to magazine@globe.com.