Postpartum Care in the United States Versus Other Countries: A Literature Review
Vanessa Reyes
WRTG A213: Writing and the Sciences
Dr. Sheri Denison
Vanessa, who transferred from Georgia, has completed her second semester at Mat-Su College. She is finishing her prerequisites and plans to apply to the RN program next year. Vanessa decided to give up her career in insurance and pursue a degree in nursing, focusing on maternal health, during the 2020 COVID-19 pandemic. She submitted a literature review for the showcase, which she describes as a journey through her past, present, and future. This journey reflects her own postpartum complications, her current courses reigniting her passion for nursing, and her future goal of pursuing a midwifery license. When not studying, Vanessa enjoys spending time exploring and traveling with her family.
Abstract
The United States, despite its status as a wealthy and developed nation, faces challenges in providing sufficient care for women after childbirth, which has resulted in a rise in postpartum deaths. Conversely, other economically advanced countries have achieved lower postpartum mortality rates. This review compares different countries' postpartum methods by analyzing morbidity and mortality rates and the quality, efficiency, and delivery of postpartum care. It also examines critical factors such as insurance restrictions, parental leave policies, and support provided to new mothers. The data analysis reveals that countries with more comprehensive insurance coverage and generous parental leave policies tend to have better postpartum outcomes. Additionally, countries that prioritize maternal health and provide adequate support to new mothers through healthcare and social programs have lower postpartum mortality rates. Overall, the findings of this review highlight the need for the United States to re-evaluate its postpartum care system and make necessary improvements to ensure that new mothers receive the care and support they need to recover and thrive after childbirth.
Postpartum Care in the United States Versus Other Countries: A Literature Review
Becoming a mother is a life-changing experience for most women worldwide. It means the start of a new chapter in their lives. The postpartum period following childbirth is a critical time for a mother's physical and mental well-being. During these six weeks, a mother's body changes significantly after giving birth. New mothers face a multitude of physical and emotional challenges in the postpartum period. The body undergoes hormonal, physical, and psychological changes that can lead to feelings of fatigue, pain, and discomfort. Additionally, if the mother had a C-section, she must carefully tend to the incision site and any other injuries or conditions that may have arisen during childbirth. It is common for new mothers to experience a range of emotions during this time. They may feel elated, exhausted, overwhelmed, anxious, and sometimes sad or depressed. These mood swings can be attributed to hormonal changes, lack of sleep, physical discomfort, and the stress of caring for a newborn.
Throughout history, postpartum care has evolved from being home-based to hospital-based to cater to the needs of both mothers and newborns. However, the quality and extent of postpartum care vary significantly across different countries. Maternal mortality has been a subject of discussion and concern since the 1930s when reliable record-keeping began (Louden, 2000). Since then, thousands of studies and publications have examined the importance of postpartum care in reducing maternal mortality rates. Even with significant advancements in medical and technological fields, the United States continues to witness an increase in the number of postpartum deaths. This literature review will explore the topic of postpartum care and assess the differences and outcomes in various countries compared to those in the United States. The analysis will examine aspects such as mortality rates; social, economic; and insurance influences; parental leave policies; and the significance of midwife support and care from the healthcare industry during the postpartum period.
Mortality Rates
Maternal mortality refers to the death of a woman during pregnancy or within 42 days after the end of pregnancy. It may be caused by factors directly related to pregnancy or its management or is worsened by it, but not by accidental or incidental reasons (Tikkanen et al., 2020). According to Schmidt and Bachmann (2021), in 2017, the United States recorded a maternal mortality rate of 19 deaths per 100,000 live births, while in contrast, Finland reported only three per 100,000 live births (p.37). Furthermore, Australia reported six per 100,000 live births, Canada recorded ten deaths per 100,000, the Netherlands had five, and the United Kingdom had seven per 100,000 (Douthard et al., 2021, p. 170). The 2017 statistics are concerning for the United States, and as of 2020, the U.S. has more than three times higher maternal mortality rates than other economically comparable countries (Gunja et al., 2023).Maternal mortality rates in these various countries have been fluctuating over the years. In 2023, during the Geneva Convention, The World Health Organization ([WHO], 2023) published the "Trends in Maternal Mortality 2000-2020" executive summary report. Finland observed an increase in maternal mortality rate in 2020, with eight deaths per 100,000 (WHO, 2023, p. 11). The US also saw a surge in deaths in 2020, with 23.8 per 100,000 (Saldanha et al., 2023, p.1). Though the COVID-19 pandemic had some effects on maternal mortality rates in 2020 (Ahmas, 2023), the remaining countries decreased, with Canada at 8.6, Australia at 4.8, the U.K. at 6.5, and the Netherlands at three deaths per 100,000 (Taylor et al., 2022).
Studies show that 52% of maternal deaths occur after delivery, with the first week posing the most significant risk due to infections, high blood pressure, and severe bleeding. Shockingly, research also indicates that 21% of deaths of women in the United States occur between day seven and week six postpartum (Tikkanen et al., 2020, p. 4). Access to postpartum care is essential for the health and well-being of women who have given birth and will continue to rise in the U.S. if actionable steps are not taken to combat the social, economic, and insurance influences that often hinder proper care in the United States.
Social, Economic, and Insurance Influences
Recent studies reveal that almost half of women giving birth in the United States do not receive the necessary postpartum checkups, which can result in undetected health problems and complications (Saldanha et al., 2023)—several factors, including social and economic influences and an absence of insurance contribute to inadequate postpartum care. Women from low-income families, those residing in rural areas, and women of color are particularly vulnerable to substandard care because of limited resources, lack of transportation, and childcare challenges (Handler et al., 2021). Among the countries mentioned in this review, the United States is the only one that does not provide universal health coverage to citizens, resulting in 8 million uninsured women of reproductive age (Gunja et al., 2023). Even those with private and government-funded insurance, such as Medicaid, may encounter limitations on coverage and payments. Some insurance policies do not cover certain postpartum visits or may only cover a limited number, leaving women without the necessary follow-up care (Tully et al., 2022). Medical providers may also receive bundled payments, which can discourage them from providing additional care (Saldanha et al., 2023). These factors create significant barriers for new mothers and can lead to poor health outcomes and higher maternal mortality rates in the United States when compared to other countries (Handler et al., 2021).Several countries, including Finland, Australia, Canada, the UK, and the Netherlands, have implemented universal insurance coverage for their citizens. Kennedy et al.’s 2020 article defines universal coverage as “Universal access to maternity care (i.e., women are neither without coverage prior to becoming pregnant, nor dropped from health care coverage after they have given birth)” (Kennedy et al., 2020, p.3). In Finland, for example, decentralized primary health centers serve local communities, and women are discharged from hospitals after giving birth and return to their local clinic system for postpartum care. Finnish clinics offer home visits within one week of delivery and a six-week clinic visit (Schmidt & Bachmann, 2021). In the same regard, the countries of Canada, the Netherlands, the United Kingdom, and Australia are all committed to respectful and autonomous care during the postpartum period for women (Douthard et al., 2021). They integrate services throughout pregnancy, delivery, and discharge. With the universal health systems in place, there is an unbroken transfer of care out of the hospitals and into postpartum care (Douthard et al., 2021).
The universal coverage system in each country plays a crucial role in ensuring that mothers, babies, and other family members receive the necessary healthcare services. By providing home visits and clinical visits, the system eliminates the barrier of being uninsured and helps overcome transportation and childcare issues that often hinder access to healthcare services. According to Schmidt and Bachmann (2021), implementing universal coverage, like other countries, can significantly enhance the quality of postpartum care for women across the United States. This approach can effectively address the challenges of limited insurance coverage, payment models, and social and economic barriers that many individuals face while seeking healthcare services.
Parental Leave Policies
Parental leave policies are another barrier to social and economic outcomes and postpartum health and wellness in the United States. Parental leave is: “Paid family leave allows workers to take time off from work with full or partial wage replacement to engage in family caregiving.” (Khan, 2020, p.2). According to data gathered by the Organization for Economic Cooperation and Development (OECD), the United States is the only one of 38 member countries that does not offer a guaranteed form of paid maternity or paternity leave (OECD, 2022).The average parental leave across these countries is slightly under 19 weeks of paid maternity leave, with average pay rates of 50% or more of previous earnings. In the United Kingdom, the average is around 1/3 of the pay rate, but mothers receive the entire rate for up to eleven weeks. (OECD, 2022, p.2). The total available leave time in the United Kingdom is 39 weeks (OECD, 2022, p.3). With paid leave laws, each country has outlined the details and qualifications for their citizens and includes some form of paternity leave for fathers. The Netherlands and Canada provide 16 weeks of maternity leave with six weeks and five weeks of paternity leave, respectively (OECD, 2022). In Australia, leave is paid at the federal minimum wage to all workers, part-time or full-time, for 18 weeks maternal and two weeks paternal (Khan, 2020). According to infoFinland.fi, the policy was updated in 2022; women can take pregnancy leave up to 40 days before their due date, then both parents qualify for up to 320 working days (both can take up to 18 days at a time, then parental leave is one at a time). This leave is available until the child turns two (InfoFinland, 2023).
Although many countries worldwide have implemented policies for paid parental leave, mothers in the United States have insufficient protection under the Family Medical Leave Act of 1993. This law allows for job protection and up to 12 weeks of unpaid leave, but it is highly restrictive and only covers 59% of those who may be eligible (Van Niel, 2020, p.113). As a result, mothers and families in the United States often face financial strain, emotional stress, and physical and mental health issues after childbirth without any job security. Shockingly, 25% of women in the United States return to work within just two weeks of giving birth to support their families (Froese, 2023).
Studies have demonstrated that women who receive paid maternity leave for at least 12 weeks have a 51% lower chance of being re-hospitalized up to a year after giving birth (Whitney et al., 2023). Paid leave policies decrease the prevalence of postpartum depression and anxiety, which are both harmful to the mother and infant. In the United States, maternal suicide accounts for 20% of the postpartum mortality rate (Van Niel, 2020, p. 114). Implementing a paid leave program for parents in the United States is essential in improving postpartum mortality rates.
Midwives and Postpartum Care
Apart from paid leave, midwife support and care from the healthcare industry during the postpartum period is essential. The United States is the only nation that does not guarantee access to provider home visits during the postpartum period (Tikkanen et al., 2020). In most countries, home visits are conducted by a midwife and include regular checkups, counseling, and support to help the mother cope with the challenges of motherhood and ensure the baby’s healthy development. In the Netherlands, women and families have a maternity nurse who visits for at least 24 hours to provide care and support within the first eight days post-delivery (Major, 2020). In Australia, a midwife will visit within one week of discharge or delivery and typically perform 1-3 visits within that first week (Tikkanen et al., 2020). Finland offers two postnatal visits: a 60-minute home visit within a week of giving birth is followed by an in-clinic visit with the same midwife at the six-week mark, which includes a baby checkup (Schmidt & Bachman, 2021). Canada’s policy is less involved with a new mother being contacted or visited by a public health nurse within 24-48 hours after going home (Tikkanen, 2020). In the United Kingdom, postpartum contacts and visits are performed for at least ten days postpartum by a midwife or nurse (Tikkanen et al., 2020). During the home visits, observations include the mother’s mental and emotional status, commonly discussing her feelings about the delivery experience and other aspects of sexual and psychological health (Schmidt & Bachman, 2021). Women in the United States typically have their first postpartum visit four to six weeks after delivery, which may be their only visit (Handler et al., 2020). Some women do not attend these visits for various reasons, such as lack of childcare, transportation, leave, and difficulty managing new schedules. Placing priority on midwives and home visits fosters trust with the new mother and family and removes some barriers. It can also help address concerns and address any social or economic issues observed (Tikkanen et al., 2020).While home visits improve the quantity and quality of postpartum care, another issue in the United States is an overall shortage of providers, including midwives (Tikkanen et al., 2020). The United States, along with Canada, “have the lowest overall supply of midwives and obstetrician-gynecologists (OB-GYNs) — 12 and 15 providers per 1000 live births, respectively, whereas all other countries have a supply that is between two and six times greater” (Melillo, 2020, para. 7). Recent studies conducted by Tikkanen et al. (2020) have revealed that Australia has the highest ratio of midwives to births, with 68 midwives for every 1000 births. This indicates that the country has a well-established and efficient healthcare system that prioritizes maternal and child health. On the other hand, the United Kingdom has an average of 43 midwives per 1000 births, while the Netherlands has 25 midwives per 1000 births, suggesting that these countries also have a sound healthcare system in place. Finland, with an average of 23 midwives per 1000 live births (Schmidt & Bachman, 2021), has a relatively lower number of midwives, which could be due to the country’s smaller population. These statistics highlight the importance of having adequate midwives to ensure a safe and healthy childbirth and postpartum experience (as seen in Table 1).
Table 1
Summary of Data & Statistics Presented*
Note. * All data in the table is cited in the review and documented as cited. **Finland combines parental leave to 320 working days total; both parents can take 18 days at a time.
Gap In Research
In recent years, there has been a significant rise in the study and research of the relationship between postpartum care and maternal mortality. One thing all studies agree on is that giving birth is a significant life and medical event, yet in the United States, it is treated with less care and concern than other medical conditions. A hip replacement or even elective surgery such as breast augmentation involves more follow-up and care than creating a new life. To address this issue, we need a comprehensive study considering all the factors to be completed in the United States. A pilot study that provides free and quality health services through midwifery care, with complete and adequate support from the healthcare community, including paid maternal leave, is a step in the right direction. Combining the issues of paid parental leave, access to quality healthcare delivered by midwives, and social support systems to improve maternal mortality in the United States. By taking a more comprehensive approach, we can better prove that these complex factors contribute to postpartum mortality and push to develop more effective solutions and government policy changes to prevent deaths.Conclusion
Becoming a mother is a significant moment in a woman's life. The postpartum period that follows childbirth is a crucial time for a mother's physical and mental well-being. New mothers face various physical and emotional challenges and commonly experience various emotions during this time. Postpartum care has evolved, but the quality and extent of care varies significantly across different countries. Several studies have examined the importance of postpartum care in reducing maternal mortality rates. This review compares the postpartum care provided by the United States with that of other economically advanced countries. It identifies the need for a complete and comprehensive study in the United States, addressing all the issues related to postpartum care. The data analysis reveals that countries with more comprehensive insurance coverage and generous parental leave policies tend to have better postpartum outcomes. Furthermore, countries that prioritize maternal health and provide adequate support to new mothers through healthcare and social programs have lower postpartum mortality rates. The findings highlight the need for the United States to re-evaluate its postpartum care system and make necessary changes to prevent postpartum deaths. It is crucial to provide new mothers with the support they need during this critical time to ensure their physical and mental well-being and to lower the postpartum mortality rate.References
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Schmidt, A., & Bachmann, G. (2021). An overview of Finnish maternal health care as a potential model for decreasing maternal mortality in the United States. Women's Health Reports, 2(1), 37-43. https://doi.org/10.1089/whr.2021.0001
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Tikkanen, R., Gunja, M. Z., Fitzgerald, M., & Zephryin, L. C. (2020). Maternal mortality and maternity care in the United States compared to 10 other developed countries. The Commonwealth Fund Issue Briefs, (November 18, 2020). https://doi.org/10.26099/411v-9255
Tully, K. P., Stuebe, A. M. (2022). Foreword: respectful, equitable, and supportive postpartum care. Clinical Obstetrics and Gynecology 65(3): 538–549, September 2022. | DOI: 10.1097/GRF.0000000000000734
Van Niel, M. S., Bhatia, R., Riano, N. S., de Faria, L., Catapano-Friedman, L., Ravven, S., Weissman, B., Nzodom, C., Alexander, A., Budde, K., & Mangurian, C. (2020). The impact of paid maternity leave on the mental and physical health of mothers and children: A review of the literature and policy implications. Harvard review of psychiatry, 28(2), 113–126. https://doi.org/10.1097/HRP.0000000000000246
Whitney, M.D., Holbrook, C., Alvarado, L., & Boyd, S. (2023). Length of maternity leave impact on mental and physical health of mothers and infants, a systematic review and meta-analysis. Matern Child Health J 27, 1308–1323 (2023). https://doi-org.consortiumlibrary.idm.oclc.org/10.1007/s10995-022-03524-0
World Health Organization. (2023). Trends in maternal mortality 2000 to 2020: Executive summary. IRIS WHO International. https://iris.who.int/bitstream/handle/10665/372247/9789240069251-eng.pdf
Douthard, R. A., MD, MPH, Martin, I. K., PhD, MPH, MSc, Chapelle-McGruder, T., PhD, MPH, Langer, A., MD, & Chang, S., MD, MPH (2021). U.S. maternal mortality within a global context: Historical trends, current state, and future directions. Journal of Women's Health, 30(2), 168–177. https://doi.org/10.1089/jwh.2020.8863
Froese, M. (2023, July 4). Maternity leave in the United States: Facts you need to know. Healthline.com. Retrieved December 4, 2023, from https://www.healthline.com/health/pregnancy/united-states-maternity-leave-facts
Gunja, M. Z., Gumas, E. D., & Williams, R. D., II (2022, December 1). The U.S. maternal mortality crisis continues to worsen: An international comparison. Commonwealthfund.org. Retrieved December 1, 2023, from https://www.commonwealthfund.org/blog/2022/us-maternal-mortality-crisis-continues-worsen-international-comparison#:~:text=In%202020%2C%20the%20maternal%20mortality,exceptionally%20high%20for%20Black%20women
Handler, A, Bergo, C, Dominik, B, Bier, E, Caskey, R. (2021). A two-generation approach to postpartum care: Building on the well-baby visit. Birth. 2021; 48: 347–356. https://doi-org.consortiumlibrary.idm.oclc.org/10.1111/birt.12544
InfoFinland-City of Helsinki (n.d.). Family leave. InfoFinland.fi. Retrieved December 4, 2023, from https://www.infofinland.fi/en/work-and-enterprise/employees-rights-and-obligations/family-leave
Kennedy, H.P., Balaam, M., Dahlen; H., Declercq, E., de Jonge, A., Downe, S., Ellwood, D., Franzcog, C., Homer, S.E., Sandall, J., Vedam, S., Wolfe, I. (2020) The role of midwifery and other international insights for maternity care in the United States: An analysis of four countries. Birth. 2020; 47: 332–345. https://doi-org.consortiumlibrary.idm.oclc.org/10.1111/birt.12504
Khan, M. S. (2020). Paid family leave and children health outcomes in OECD countries. Children and Youth Services Review, p. 116, 105259. https://doi.org/10.1016/j.childyouth.2020.105259
Loudon, I. (2000). Maternal mortality in the past and its relevance to developing countries today. The American Journal of Clinical Nutrition, 72(1), 241S-246S. https://doi.org/10.1093/ajcn/72.1.241S
Major, M. (2020, March 26). What postpartum care looks like around the world, and why the U.S. is missing the mark.Healthline.com. Retrieved December 4, 2023, from https://www.healthline.com/health/pregnancy/what-post-childbirth-care-looks-like-around-the-world-and-why-the-u-s-is-missing-the-mark
Melillo, G. (2020, December 3). US ranks worst in maternal care, mortality compared with 10 other developed nations. Amjc.com. Retrieved December 4, 2023, from https://www.ajmc.com/view/us-ranks-worst-in-maternal-care-mortality-compared-with-10-other-developed-nations
Noncas, R., MD (2018, November 27). Postpartum care in the United States: Some progress but still so far to go.Womensmentalhealth.org. Retrieved December 2, 2023, from https://womensmentalhealth.org/posts/postpartum-care-progress-but-still-far-to-go/
Saldanha, I. J., Adam, G. P., Kanaan, G., Zahradnik, M. L., Steele, D. W., Chen, K. K., Peahl, A. F., Danilack-Fekete, V. A., Stuebe, A. M., & Balk, E. M. (2023). Health insurance coverage and postpartum outcomes in the US: A systematic review. JAMA network open, 6(6), e2316536. https://doi.org/10.1001/jamanetworkopen.2023.16536
Schmidt, A., & Bachmann, G. (2021). An overview of Finnish maternal health care as a potential model for decreasing maternal mortality in the United States. Women's Health Reports, 2(1), 37-43. https://doi.org/10.1089/whr.2021.0001
Taylor, J., Bernstein, A., Waldrop, T., & Smith-Ramakrishnan, V. (2022, March 2). The worsening U.S. maternal health crisis in three graphs. The Century Foundation. Retrieved December 1, 2023, from https://tcf.org/content/commentary/worsening-u-s-maternal-health-crisis-three-graphs/?gclid=CjwKCAiApaarBhB7EiwAYiMwqqUwe6zUKzFg9qKAEMXV0qdCHQZosNhC_zvOrryh_CgWAHHCK4_jbBoCAkEQAvD_BwE
The Organisation for Economic Co-operation and Development (OECD) (2022, December 1). OECD family database-PF2.1-parental leave systems. Oecd.org. Retrieved December 2, 2023, from https://www.oecd.org/els/soc/PF2_1_Parental_leave_systems.pdf
Tikkanen, R., Gunja, M. Z., Fitzgerald, M., & Zephryin, L. C. (2020). Maternal mortality and maternity care in the United States compared to 10 other developed countries. The Commonwealth Fund Issue Briefs, (November 18, 2020). https://doi.org/10.26099/411v-9255
Tully, K. P., Stuebe, A. M. (2022). Foreword: respectful, equitable, and supportive postpartum care. Clinical Obstetrics and Gynecology 65(3): 538–549, September 2022. | DOI: 10.1097/GRF.0000000000000734
Van Niel, M. S., Bhatia, R., Riano, N. S., de Faria, L., Catapano-Friedman, L., Ravven, S., Weissman, B., Nzodom, C., Alexander, A., Budde, K., & Mangurian, C. (2020). The impact of paid maternity leave on the mental and physical health of mothers and children: A review of the literature and policy implications. Harvard review of psychiatry, 28(2), 113–126. https://doi.org/10.1097/HRP.0000000000000246
Whitney, M.D., Holbrook, C., Alvarado, L., & Boyd, S. (2023). Length of maternity leave impact on mental and physical health of mothers and infants, a systematic review and meta-analysis. Matern Child Health J 27, 1308–1323 (2023). https://doi-org.consortiumlibrary.idm.oclc.org/10.1007/s10995-022-03524-0
World Health Organization. (2023). Trends in maternal mortality 2000 to 2020: Executive summary. IRIS WHO International. https://iris.who.int/bitstream/handle/10665/372247/9789240069251-eng.pdf