When a woman has a baby, she loses an organ. The placenta, grown by her body for nine months of gestation, snaps off from her uterus and drops toward the birth canal. The meaty purple bag ribboned with thick blood vessels is pushed through the cervix five to 30 minutes after the baby and, depending on the culture, is carried away to be buried, rendered, or discarded.
And that's just the part about the placenta. The physical trauma doesn't stop there.
Expulsion of the placenta leaves a large internal wound on the inside wall of her uterus. Contractions do their best to control blood loss as her uterus gradually shrinks, but her vagina might have third- or fourth-degree tears, crossing from her perineal muscle into her anal sphincter. This is a common post-pregnancy injury, requiring weeks of healing. Over the next few days, her breasts will harden as they begin to produce milk. Breastfeeding will cause her nipples to ache, perhaps crack or even bleed. She'll probably be constipated and have cramping from her uterine contractions. She's profoundly exhausted.
The 3.9 million women who give birth each year in the United States all must recover from the physical trauma of it. Yet postpartum care is inadequate, according to obstetrics experts, and the reasons might have as much to do with patriarchal attitudes toward women's bodies as with clinical procedures.
"There is no maternal health care after childbirth. Very little," said Eileen Fowles, a registered obstetric nurse who teaches at Walden University and recently taught at the University of Texas at Austin. She points to a common statistic: The United States has the highest maternal mortality rate of any industrialized country -- 17.3 women per 100,000 live births in 2013, according to the Centers for Disease Control. A team at the Maryland Population Research Center estimated it's worse: 23.5 women per 100,000 live births. The mortality rates for black women are even higher.
The CDC defines maternal mortality as the death of women during pregnancy or within one year of the end of a pregnancy from any cause "related to or aggravated by the pregnancy or its management." The rate has been rising since 1987, when the agency started collecting data.
Fowles has been researching maternal care for more than 25 years and believes the problem is cultural.
In her view, birth is not allocated the same resources and medical consideration as other physical trauma. "We do a lot of research on heart attacks, but we don't do anything on postpartum adaptation because it's considered a normal process, and there isn't a rehab component to it," Fowles said. "It is a natural process. It's like healing after surgery. But you have people who have surgery [in the US] for any other thing, and they're seeing their doctor every two to four weeks. And a woman who's had a baby doesn't."
As many as 40 percent of women do not attend a postpartum check-up, according to the American College of Obstetricians and Gynecologists.
The typical first postpartum doctor's visit is four to six weeks after delivery. But serious complications can arise during that time. Hemorrhaging is a risk between the first and 12th week. Other complications include vaginal bleeding, mastitis, perineal trauma, feet and leg swelling, vertigo, insomnia, depression, and anxiety. Having to travel to a doctor with a newborn puts additional strain on a recovering new mother. It can influence her decision whether to see a doctor at all.
Not everyone agrees that culture is the primary cause of the rising maternal mortality rate.
"People don't know exactly why. They think there's a host of factors," says Elizabeth Howell, professor of obstetrics, gynecology, and reproductive science at Mount Sinai Health Services in New York. The increasing age of first-time mothers and rising rates of obesity and chronic illness impact health outcomes, complicating care for both pregnant and postpartum women.
She cites inadequate health care for women in general. "We don't do enough around preconception care and making sure that women are getting their health needs met prior to becoming pregnant, and optimizing their health before they become pregnant. That's an issue I think we need to do a better job with."
Women's health care in the US has long been criticized for being treated as peripheral. The decline in postpartum support can be traced to the medicalization of birth in the late 19th century -- when male obstetricians muscled out midwives as the sole birth attendants.
In fact, the dominant male perspective has undermined women's health care overall, says Maya Dusenbery, author of Doing Harm: The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick.
She sees gender bias in both medical research and treatment. Gender stereotypes put a "double bind" on female patients: They're perceived by their doctors to be either hysterical or delusional, no matter how obvious their symptoms may be. Consequently, she says, they fail to receive proper treatment. Making matters worse, is the normalization of women's pain, especially when it comes to gynecological conditions.
Gender differences in the treatment of coronary heart disease have been documented for more than a decade -- women being less likely to receive intensive treatment. And within gynecology, the risks can also be serious. "Today, the widespread belief -- shared by the medical system and the public alike -- that menstrual pain is 'normal' poses a barrier to the timely diagnosis of endometriosis even before a patient steps foot in a doctor's office," explains Dusenbery in Doing Harm.
And then there's this: As the rate of maternal mortality has increased, the rate of infant mortality has decreased.
To Fowles, the explanation is simple but "radical," the medical manifestation of a society that values women's lives less. "We take care of the mother during pregnancy so closely to improve the health of the baby, not so much for the health of the mother," she says. "This even happens postpartum."
The divergent outcomes between mothers and infants do suggest different approaches to care, and perhaps research, too. In the recent investigative series "Lost Mothers," ProPublica and NPR reported that "the American medical system has focused more on fetal and infant safety and survival than on the mother's health and well-being" in the last 50 years because of an aggressive public health campaign to reverse infant mortality trends.
In the effort to save babies' lives, mothers lost out. Consider the emergent specialty of maternal–fetal medicine, which "drifted so far toward care of the fetus that as recently as 2012, young doctors who wanted to work in the field didn't have to spend time learning to care for birthing mothers," ProPublica and NPR found.
Both obstetric providers Fowles and Howell agree that changes in the timing and procedures for postpartum visits are necessary. Howell calls them the "low-hanging fruit" in an otherwise vast and complicated landscape of initiatives that extend even into workplace policy. Maternity leave in Sweden, for example, gives parents up to 480 days of paid parental leave when a child is born. But comprehensive solutions like that would involve time and resources to accomplish in the US, says Howell, that could distract from smaller changes that might be made right away.
The American College of Obstetricians and Gynecologists currently has a caucus assessing how to improve postpartum visits.
At the 4th Trimester Project at the University of North Carolina at Chapel Hill, medical investigators studying postpartum wellness advise a two-week, then a six-week, and then a three-month visit, along with easier access to lactation consultants and mental health professionals.
Project investigator Sarah Verbiest agrees that that recovery has been an afterthought to pregnancy, labor, and delivery. "Historically, the focus of maternal and child health programs and funding has been on baby, and then on woman as carrier of baby. I think that the maternal mortality and morbidity numbers that are really popping up [are] a sign that we need to take care of women, too.
"I think it's cultural."
So how does the culture change? Creating visibility and empathy for postpartum recovery in the broader public may be a start. For example, destigmatizing public breastfeeding, which lowers both physical and mental maternal health risks. Or addressing shame, says 4th Trimester investigator Kristin Tully, which discourages new mothers from seeking help.
"There is a lot of potential for a sort of #MeToo moment," Dusenbery says. "There's a lot of silence that prevents women from sort of recognizing how common their experiences are."