After the Afterbirth: A Critical Review of Postpartum Health Relative to
Method of Delivery
Noelle Borders, CNM, MSN
J Midwifery Womens Health. 2006;51(4):242-248. ©2006 Elsevier Science,
Inc.
Posted 07/27/2006
Abstract
Four million women give birth each year in the United States, yet postpartum
health has gone largely unaddressed by researchers, clinicians, and women
themselves. In light of rising US cesarean birth rates, a critical need
exists to elucidate the ramifications of cesarean birth and assisted vaginal
birth on postpartum health. This literature review explores the current
state of knowledge on postpartum health in general and relative to method of
delivery. Randomized trials and other published reports were selected from
relevant databases and hand searches. The literature indicates that
postpartum morbidity is widespread and affects the majority of women
regardless of method of delivery. Women who have spontaneous vaginal birth
experience less short- and long-term morbidity than women who undergo
assisted vaginal birth or cesarean birth. To maximize postpartum health,
providers of obstetric care need to protect the perineum during vaginal
birth and avoid unnecessary cesarean deliveries. Clinicians must initiate
the discussion about postpartum health antenatally and encourage women to
enlist needed support early in the postpartum period. Flexibility in the
schedule of postpartum care is essential. More research from the United
States is warranted.
Introduction
In the United States, approximately 4 million women give birth each year.
Months of frequent, intense prenatal care normally precede the birth of the
baby. Once the mother has birthed her baby and made her initial recovery,
she goes home and typically sees her health care provider only once: at the
6-week postpartum checkup. In the United States, once the delivery is
accomplished and mother and baby are home, the mother's postpartum physical
and mental health are largely ignored. For most women, the experience of
having a baby and becoming a mother is a transformative event in their
lives. Yet, in most Western societies, no formal or informal rituals exist
to celebrate the birth of the woman as mother.[1] As a result, clinicians
and new mothers have a limited understanding of what constitutes postpartum
health, the typical length of recovery from childbirth, and the impact of
postpartum health on the lives of new mothers and their families.[2] The
postpartum period is a significant time in women's lives, but,
unfortunately, has not received the attention warranted.
In the United States in 2002, 68% of women had a spontaneous vaginal birth,
5.9% had an assisted vaginal birth accomplished by vacuum extraction or
forceps, and 26% had a cesarean birth. The cesarean birth rate has risen
each year since 1996, and, simultaneously, assisted vaginal birth rates have
decreased.[3] Because of the large proportion (32%) of women who have an
assisted vaginal birth or cesarean birth, we need to understand the effect
these interventions have on postpartum health. This article provides an
overview of general postpartum health and details the current state of
knowledge about postpartum health relative to method of delivery.
Methods
A search of the literature for peer-reviewed journal articles was conducted
in CINAHL, PubMed, and Cochrane Database of Systematic Reviews. Search
phrases included, but were not limited to, postpartum health, health after
childbirth, postpartum depression, postpartum urinary and bowel function,
sexual function after childbirth, postpartum functional status, postpartum
fatigue/tiredness. The search was not limited to the last 15 years; however,
the vast majority of articles on postpartum health have been published since
1989. The policy document from the World Health Organization on Postpartum
Care of the Mother and Newborn also informed this research.[4]
Background: An Overview of Postpartum Health
Traditionally, the postpartum period has been defined as beginning 1 hour
after delivery of the placenta and lasting 6 weeks, at which time the uterus
has regained its prepregnant size.[5] This narrow focus on the recovery of
the mother's reproductive organs has resulted in neglect of the rest of a
woman's physical and mental health. Both mothers and clinicians have voiced
concern over the lack of knowledge about physical and psychological health
after childbirth and the duration of postpartum recovery.[2] For the
purposes of this overview, postpartum health will be considered in the
following time periods: immediate postpartum (birth to 3 months), short-term
(3 to 6 months), and long-term (>6 months). In reality, most postpartum
health challenges that a woman faces overlap the time periods defined by
researchers; some health issues may originate in the antenatal period.
Table 1 summarizes the most common postpartum symptoms reported in
literature. In the immediate postpartum period, 87% to 94% of women report
at least one health problem.[6,7] Backache, urinary stress incontinence,
fecal incontinence, urinary frequency, depression and anxiety, hemorrhoids,
extreme tiredness, frequent headaches, and migraines can pose problems for
new mothers.[8-10] Perineal pain, constipation, increased sweating, acne,
hand numbness or tingling, dizziness, and hot flashes are also
common.[6,7,11-13] Up to one third of women have reported backache lasting
up to 3 months after childbirth.[9] Rates of stress incontinence can range
between 6% and 24% at 3 months postpartum.[14,15] Approximately 10% of women
will experience depression in the immediate postpartum period; the
prevalence rate any time during the first year is 7% to 30%, depending on
how postpartum depression is defined and measured and when it is
measured.[16-18]
Many women, whether lactating or not, report breast problems, including
discomfort, sore nipples, and infection.[12,13] Sexual problems, including
dyspareunia and decreased libido, have been reported by up to 53% of women
in the immediate postpartum period, and have been shown to peak at 3 months
after delivery. Breastfeeding has been demonstrated to decrease libido in
the immediate and short-term periods, but this decrease does not extend long
term for most women.[19] Two small studies attempted to assess new mothers'
functional status at 6 weeks postpartum. Functional status was defined as a
mother's ability and readiness to integrate her new role as mother with her
other duties in the household, community, and workplace and to resume
self-care activities.[20] None of the mothers had resumed full functional
status per self-report by 6 weeks postpartum. Many women experienced
inadequate social support, disturbed sleep patterns, and dissatisfaction
with energy level and well-being.[20,21]
From 3 to 6 months after the baby's birth, many of the immediate problems
slowly resolve. However, some women will experience new health issues. These
issues appear for the first time, have been masked by other problems, or
emerged in the early postpartum period but only over time are construed to
be problematic. Exhaustion, back pain, headaches, depression, sexual
problems, urinary incontinence, persisting perineal pain, constipation,
hemorrhoids, breast complaints, muscle and joint pain, and relationship
problems are all common.[7,12,13,22,23] Researchers have noted that women in
the first 6 months postpartum also suffer from more upper respiratory
symptoms, stomach illnesses, and infections than is typical for healthy
women.[12,13,24] Women's functional status can continue to suffer from 3 to
6 months postpartum, perhaps indicating the cumulative effect of sleep
deprivation in mothers of infants.[20]
In the United States, by 6 months postpartum the majority of women employed
outside the home have returned to work and are balancing household and work
responsibilities; in addition, women may also be grappling with physical and
mental health issues. Some of these health issues, specifically fatigue,
backache, and depression, have been demonstrated to actually increase over
time.[25,26] Long-term backache, stress incontinence, sexual problems,
hemorrhoids, and depression doggedly persist in a significant number of
women beyond 1 year postpartum.[12,14,17,19,27,28] Urinary and fecal
incontinence have the potential to become chronic problems, especially if
the etiology included pudendal nerve damage.[29] In conclusion, postpartum
morbidity lasts well beyond 6 weeks. Women experience an array of symptoms,
the majority of which they may never report to health care
providers.[6,17,30,31]
Postpartum Health Relative to Method of Delivery
Discussion of the impact of delivery method on postpartum health is
complicated by several factors. First, the vast majority of research in this
area was conducted in the United Kingdom, Australia, New Zealand, and
Scandinavia, where midwives perform a large portion, and in some cases, the
majority, of obstetric care. Furthermore, cesarean birth rates are
substantially lower and postpartum care is much more comprehensive than in
the United States. Second, most studies did not define whether episiotomy
was performed or if assisted vaginal birth was accomplished by forceps or
vacuum extraction. Third, researchers rarely indicated whether cesarean
birth was planned or emergent. For all these reasons, generalizability of
these findings to a US population of postpartum women should be made with
caution.
Glazener et al. surveyed 1249 women in Scotland at 1 week, 8 weeks, and 12
to 18 months postpartum. They determined that during the initial postpartum
period, women with a cesarean birth or assisted vaginal birth fared
significantly worse than women after spontaneous vaginal birth.
Specifically, 93% of the cesarean birth group, 96% of the assisted vaginal
birth group, and 84% of the spontaneous vaginal birth group reported at
least one health problem. Women having assisted vaginal birth were more
likely to report at least one health problem: most commonly, painful
perineum, constipation, hemorrhoids, and breakdown of stitches. At 8 weeks
postpartum, 7% of women who had a normal spontaneous vaginal birth reported
a painful perineum, irrespective of episiotomy, compared with 30% of women
after assisted vaginal birth.[6] Other studies also found that after
assisted vaginal birth, women had significantly more perineal pain and
sexual problems.[7,19,23,32,33] MacArthur and colleagues surveyed 7879 women
in Scotland, England, and New Zealand. Women who delivered by forceps had
almost twice the risk of developing fecal incontinence within 3 months than
women who delivered spontaneously; vacuum extraction did not increase a
woman's risk for developing fecal incontinence. Although cesarean birth did
offer some protection against fecal incontinence, some women who delivered
by cesarean birth did develop fecal incontinence, so this protection should
not be overstated.[10]
Women experiencing cesarean birth have reported higher levels of tiredness,
breastfeeding problems, constipation, depression, anemia, headache,
difficulty voiding, abnormal bleeding, urinary tract infection, abdominal
pain, and vaginal discharge than their counterparts who had a spontaneous
vaginal birth.[6,34] The International Randomized Term Breech Trial followed
1596 women and reported that although women who had a cesarean birth were
less likely to have urinary incontinence and perineal pain than women
experiencing vaginal delivery, the groups reported no difference in rates of
dyspareunia (17% of cesarean birth and 18% of vaginal birth).[34] In a study
of 971 women in Washington State at 7 weeks postpartum, Lydon-Rochelle et
al. reported that half of the women reported no problems at all when going
about their usual activities after spontaneous vaginal birth, compared with
one third of the women after cesarean birth. Compared with the postpartum
problems experienced by women who had a spontaneous vaginal birth, women who
experienced a cesarean birth reported more bodily pain, and women who
experienced an assisted vaginal birth reported more bodily pain and
troubling urinary or bowel issues.[33]
Although urinary symptoms have the potential to increase over time, these
problems do not seem to be related to assisted or spontaneous vaginal
birth.[6,15] In a study by Thompson et al., cesarean birth protected against
urinary stress incontinence at 8 weeks, but this association did not last.
Danish researchers also noted that cesarean birth protects against stress
incontinence only in the immediate postpartum period.[7,14] By 6 months
postpartum, women who were delivered by cesarean birth were more likely to
report other urinary problems than women in the other two delivery
groups.[7] One study indicated that having three or more cesarean deliveries
negated any protection that cesarean birth offered against incontinence.[15]
Backache occurred most commonly after cesarean birth, and hemorrhoids after
assisted vaginal birth; neither headache nor tiredness were related to
method of delivery.[6,7] Perhaps more intriguing because of widespread
belief to the contrary is that depression at any time postpartum appears
unrelated to method of delivery.[6,7,16,34-37]
Readmission to the hospital after the birth of a baby is a relatively rare
event. Although data are not collected nationally, the proportion of women
readmitted to the hospital in the postpartum period is estimated at 1.2% to
3%.[6,38] Lydon-Rochelle et al. discovered that after cesarean birth and
assisted vaginal birth, women had an 80% and 30% increased risk of
rehospitalization, respectively, compared to women after spontaneous vaginal
birth.[38] Thompson et al. found the same association between cesarean birth
and assisted vaginal birth and hospital readmission.[7] Women have an
increased risk for rehospitalization due to postpartum hemorrhage, uterine
infection, obstetric surgical wound complications, cardiopulmonary and
thromboembolic conditions, gallbladder disease, genitourinary tract
conditions, pelvic injury, and appendicitis after cesarean birth or assisted
vaginal birth, compared with her counterpart after spontaneous vaginal
birth.[38,39] Although readmission to the hospital may occur relatively
infrequently, the women who are admitted are very ill. The sequelae of their
illness impact not only their postpartum recovery but also the physical and
mental health of their newborns and family.
Women who have an assisted vaginal birth continue to have more problems
after 6 months postpartum than women experiencing spontaneous vaginal birth.
Brown and Lumley gathered information via postal survey from 1336 Australian
women at 6 to 7 months postpartum. They found that of the women they
surveyed at 6 to 7 months postpartum, those experiencing assisted vaginal
birth (which was accomplished almost exclusively by forceps) had the highest
rates of morbidity.[31] These women were 5 times as likely to report
perineal pain and twice as likely to report sexual problems, urinary
incontinence, bowel problems, and hemorrhoids than women who delivered
spontaneously. The association of assisted vaginal birth with perineal pain
and sexual problems remained significant even after adjustment for
differences in infant birth weight, length of labor, and perineal
trauma.[31] In a study of 1942 primiparous women in Massachusetts, Robinson
et al. found that women who delivered by forceps with or without episiotomy
were 10 times as likely to experience significant perineal trauma than women
who delivered by vacuum extraction without episiotomy.[40] Various
researchers have noted that persistent perineal pain is associated with
assisted vaginal birth, especially forceps delivery.[6,19,23] Glazener's
survey found that 91% of women had a health complaint from 2 to 18 months
after assisted vaginal birth.[6,19] In their study, Brown and Lumley noted
that fewer than 1% of women with an intact perineum, including women after
cesarean birth, reported problematic perineal pain; furthermore, women with
an episiotomy were much more likely to report perineal pain and sexual
problems than women having a repaired laceration.[31] Johanson et al.
analyzed the postpartum health of 313 women in the United Kingdom who had
been randomized to either forceps or vacuum delivery and found that in the
second year postpartum, 21% of women after spontaneous vaginal birth and 37%
of women after assisted vaginal birth reported having dyspareunia. Women who
had sustained perineal injury experienced dyspareunia at a rate of 35%
compared to 17% of women with an intact perineum.[32] In a 5-year follow-up
of 228 of these 313 women who had assisted vaginal birth, the authors found
that maternal morbidity was very common, almost half of the women had some
degree of urinary incontinence, 44% experienced bowel habit urgency, and 20%
had loss of bowel control sometimes or frequently. Bowel and urinary
dysfunction were equally prevalent between women who had had a vacuum
extraction or forceps delivery.[41]
After cesarean birth or spontaneous vaginal birth, women report generally
similar rates of morbidity in the long term.[6,31] Glazener et al. detailed
that from 2 to 18 months postpartum, 73% of women after spontaneous vaginal
birth and 77% of women after cesarean birth reported one or more health
concerns. Women after spontaneous vaginal birth are more likely to have
issues with urinary incontinence, hemorrhoids, and perineal pain, whereas
women after cesarean birth report higher levels of tiredness, problems
breastfeeding, backache, headache, vaginal discharge, and other infections,
although these differences did not all reach statistical significance.[6,31]
After cesarean birth, women are also at increased risk for formation of
adhesions, intestinal obstruction, and bladder injury during subsequent
laparotomies. In later pregnancies, placenta accreta, placenta previa, and
uterine scar dehiscence are more likely to occur in women after cesarean
birth than after vaginal birth.[42] Several researchers concluded that
tiredness was common beyond 6 months postpartum and not related to method of
birth.[6,7,31]
Despite the consistent finding that delivery mode is not associated with
postpartum depression, a study of 245 British women revealed some intriguing
findings about maternal satisfaction with the birth experience over time.
Women who had a normal spontaneous vaginal birth experienced high feelings
of fulfillment and low levels of distress or sense of being cheated at 72
hours after delivery. These feelings persisted after 6 months, and women's
perceptions of difficulties at delivery had decreased. Women who had
assisted vaginal birth or cesarean birth under general anesthesia had low
levels of fulfillment and high levels of distress, perception of delivery
difficulties, and sense of being cheated at 72 hours and at 6 months
postpartum.[43] Women who experienced emergency cesarean birth also reported
that reliving the birth was problematic in the postpartum period.[31] Table
2 highlights some postpartum symptoms relative to delivery method.
Discussion
Clearly, changes in mental and physical health challenge the majority of
women after the birth of an infant. The literature indicates that women who
have a normal spontaneous vaginal birth with minimal damage to the perineum
have the fewest problems postpartum. Assisted vaginal birth, especially
accompanied by episiotomy, and cesarean birth result in greater short- and
long-term morbidity, some of which prove life-threatening and lead to
hospital readmission. To maximize the health of postpartum women, obstetric
care providers need to protect the perineum during vaginal birth and avoid
unnecessary cesarean birth. It is important to emphasize that most of the
women represented in these surveys were young and healthy, and yet still
faced a number of health challenges after childbirth. Thus, one can conclude
that postpartum morbidity is probably underestimated, and is an even more
critical issue for women who enter pregnancy with existing health problems.
Although women in the United States can certainly benefit from efforts to
maximize rates of vaginal birth with minimal perineal trauma and decrease
unnecessary cesarean birth, the preponderance of data supporting the
benefits of these practices was gathered outside the United States. With a
few notable exceptions,[2,12,20,33] researchers have largely neglected the
study of postpartum health in the United States. A significant need exists
for research on postpartum health in general, and relative to method of
delivery in women in the United States; the need for this information is
especially urgent in light of the mounting US cesarean birth rate.
Simply doing research on postpartum health, however, is not sufficient.
Researchers and clinicians bear a responsibility to disseminate the
resulting information to women. What is most disturbing in the literature on
postpartum health is not the presence of widespread morbidity but the
profound silence that surrounds this pivotal period in women's lives. In
Australia, 49% of women said they would like to have been given more
guidance regarding postpartum recovery and changes in their health; several
studies noted that many women (up to 25%) with postpartum health problems
did not consult a health professional.[6,30] In Glazener's study, women
reported that only 34% of clinicians had discussed sexual intercourse with
them at their 6-week postpartum visit; furthermore, a quarter of clinicians
had failed to discuss birth control.[19] To understand women's and
clinicians' perceptions of the health consequences of pregnancy and
childbirth, Kline and colleagues conducted five focus groups of new mothers
and three focus groups of clinicians, including midwives, obstetricians, and
family practice physicians. The women decried the lack of information
received about their own health, whereas providers perceived that they
themselves had neglected educating women on newborn care. However, in all
the groups, the participants voluntarily asked, "What is normal postpartum
recovery?" No one knew the answer.[2]
All the studies cited paint a dismal picture of lack of communication
between clinicians and women regarding postpartum changes. Reasons are
complex and self-perpetuating. First, clinicians have had little data on
which to base their discussion of postpartum health with women, but they
have also often neglected to ask women about their problems. Second, women
do not typically consult clinicians about postpartum issues. Third, health
care for women after the birth of a baby typically consists of a single
6-week postpartum visit, the focus of which is a pelvic examination and pap
smear. Thorough consideration of each of these factors is beyond the scope
of this article; however, a rudimentary discussion can shed light on the
situation and inform a plan to remedy these deficits in obstetric health
care.
Lack of research on postpartum health has already been noted. But lack of
evidence about a condition does not excuse clinicians from asking women
about their health. As Romito so aptly wrote, "There is a gap to bridge
between what professionals think mothers do, think, and want, and what
mothers, in reality, do, think, and want."[18] Although postpartum women
have a responsibility to inform their health care providers about their
physical and mental problems, the burden of responsibility remains with the
clinician for a number of reasons. First, women face a multitude of
challenges after the birth of an infant, including care of the baby, family
restructuring, and changes in their bodies. Most women place the needs of
their family above their own personal needs; thus, their health concerns are
often the last to be addressed. Second, after the baby's birth, a woman may
view many physical issues, such as incontinence or dyspareunia, as too
embarrassing to divulge to anyone. Third, women may also believe that their
problems are simply part of having a baby and something to be endured.[6]
Although clinicians have limitations in their ability to improve women's
lives, we can ask women about their problems and provide a safe forum for
discussion. Furthermore, through anticipatory guidance during prenatal care,
clinicians can help women devise a plan for managing their lives in the
postpartum period and, thus, possibly avoid or minimize physical and mental
health problems.[44] This can be as simple as asking a woman whom she can
call for support or with whom she speaks when she feels overwhelmed.
Educating women about antenatal pelvic floor exercises to protect against
urinary incontinence is another way to promote a more comfortable postpartum
recovery.[28] Clinicians also have a responsibility to inform women about
the most common physical and mental challenges they may face postpartum.
Women need this information prior to the birth and again postpartum. Women
who understand what is happening to their bodies and spirits postpartum are
much more likely to appropriately manage their lives. By eliciting
information from postpartum women, clinicians provide the support women need
and, simultaneously, acknowledge that new mothers themselves hold the key to
understanding postpartum health in its entirety.
Another reason that postpartum issues go largely unaddressed lies in the
structure of postpartum health care, which, in the United States, has
traditionally consisted of a single visit at 6 weeks after delivery. As seen
in the surveys reported, a woman experiences an incredible variety of
changes in those 6 weeks, largely devoid of the support of a health care
professional. In 1998, the World Health Organization recommended that the
schedule of postpartum visits should correspond to the times of greatest
need for a mother and her infant (i.e., at 6 hours, 6 days, 6 weeks, and 6
months postpartum). Although the timing of these proposed visits should not
be construed as absolute, postpartum care must remain flexible to the needs
of the mother, and, most importantly, the mother should always have easy
access to health care.[4] In England, women benefit from a series of six to
seven home visits by a midwife during the first 2 weeks postpartum, other
visits as needed, and a checkup with a general practitioner at 6 to 8
weeks.[45] MacArthur et al. redesigned postnatal care to identify and manage
individual needs. Rather than each woman receiving the same postpartum care
package, midwives used symptoms checklists to identify health needs and
customize care for each woman in the intervention group. On the basis of
this needs assessment, these women received approximately two visits more
than the women in the control group, experienced less postpartum depression
at 4 months postpartum, and were more satisfied with the care received.
Although the physical health of both groups of women did not differ, the
simple intervention of supportive discussion about health problems may have
been the key to better psychological health in the intervention group.[46]
An Australian study experimented by adding a 1-week postpartum visit in
addition to the 6-week visit. They observed no differences in any physical
or mental health outcomes studied and concluded that simply adding a single
postpartum visit will not substantially improve postpartum care.[11]
Although flexible home visits, such as those performed in England, are the
ideal structure for providing postpartum care, the costs and logistics
involved in implementing such a system of care for postpartum women in the
United States are prohibitive, given the current milieu. Clinicians and
researchers can, however, improve postpartum care by experimenting with
flexible ways of meeting women's needs after the birth of a baby. Because
the well-being of the mother directly impacts her ability to parent her
baby, clinicians who actively listen to women in the postpartum period are
investing directly in the health of these children. Just as throwing a
pebble into water creates ripples that reach the far edges of a pond, the
benefits of supportive postpartum care reach well beyond each mother to her
family, and, indeed, to the generations that follow.
Table 1. Postpartum Symptoms and Complaints Over Time*
Symptom or Complaint 0-3
Months
(%) 3-6
Months
(%) Over 6
Months
(%)
Presence of some health problem[7,8] 94 81 31
Perineal pain[11,23,31] 25-30 11 21
Sexual problems/dyspareunia[11,19,25,31] 19-53 26 11-49
Urinary stress incontinence[8,11,14,15,25,28,31] 8-34 10 3-7
Backache[9,11,25,27,30,31] 14-40 43 8-64
Hemorrhoids[8,11,25,31] 8-24 24 16
Fecal incontinence/bowel problems[13,25,31] 9 12 1-3
Extreme tiredness[8,11,25,30,31] 12-50 69 6-48
Depression[8,11,12,16,25,30,31] 7-30 19 4-20
*All methods of delivery are included.
Table 2. Postpartum Symptoms and Complaints Relative to Method of Delivery
Symptom/Complaint Time Frame of Report
of Symptom Spontaneous Vaginal
Delivery % Assisted Vaginal
Delivery % Cesarean Section
%
Presence of some health problem[6] 8 weeks PP 84 96 93
Perineal pain[6] 8 weeks PP 7 30
Sexual problems[31] 6-7 months PP 23 39 27
Dyspareunia in 2nd year after delivery[32] 2nd year PP 21 37
Urinary stress incontinence 3 months PP[15] 24 27 5
6-7 months PP[31] 11 18 2-7
Hemorrhoids[31] 6-7 months PP 25 36 11-16
Fecal incontinence bowel problems 3 months PP[10] 9 10-13 7
6-7 months PP[31] 11 19 12
Depression[31] 6-7 months PP 18 21 23
Cesarean wound pain 3 months PP[11] N/A N/A 10
6-7 months PP[31] N/A N/A 60
PP = postpartum.
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Leanne Wynne
Midwife in charge of "Women's Business"
Mildura Aboriginal Health Service Mob 0418 371862
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