Birth is usually a time of celebration, when we recognise the miracle of life as a child is brought into the world. In Britain, childbirth used to be a much more fraught experience, with a high risk of death for mother and baby. But scientific progress and modern medicine have reduced infant deaths for every 1,000 live births from 31.7 in 1950 to just four by 2020. Deaths are relatively higher than Finland’s and Japan’s infant mortality rates, of about two for every 1,000, but much lower than Afghanistan at 103.1.
Once a woman and her baby survive childbirth, several weeks of follow-up is routine in many countries to ensure that any urgent health issues are resolved. This six- to eight-week period is called postnatal care, as women recover from their labour and delivery, especially if they’ve had a C-section or episiotomy. But what happens to new mothers after that handful of weeks? They usually disappear from the health system and are left on their own to cope with recovery.
This year, a new scientific review was published in Lancet Global Health, which estimated the extent of long-term postpartum conditions through bringing together a number of international studies. The authors estimate that more than a third of women who give birth in a given year struggle with long-term health complications – that’s at least 40 million women globally. Even for births without immediate complications, issues can arise later on, often after the heath system has stopped monitoring women.
You won’t be surprised to hear that postpartum health issues are not easily brought up at a dinner party, given they involve the most private areas of our body. These include urinary and anal incontinence, dyspareunia (pain during sex), postpartum depression, tokophobia (fear of childbirth), and chronic pain in the lower back and pelvic area. It’s estimated that 43% of women had pain during sex for two to six months after childbirth, 22% for six to 12 months, and 40% from 12 to 24 months. For those who gave birth vaginally, 19% of women had anal incontinence symptoms even one year after the birth.
Postpartum depression has been better recognised in recent years, and is estimated to affect 11% of women in high-income countries, while secondary infertility (not being able to give birth a second time) at 10.5%. Lower-back pain was estimated to affect 31.6% of women postpartum, while perineal pain affected 11%.
If you’ve given birth, or have been close to someone who has, these conditions probably resonate. These are talked about behind closed doors, with women often told to just get on with it, all while caring for a new baby. Yet these health challenges are not easy to ignore for new mothers given the daily pain they bring to simply going to the toilet, having sex or just existing. Despite the high prevalence of these conditions, the study finds that no high-quality guidelines for the management of 40% of priority conditions exist in high-income countries, and none were developed in low- and middle-income countries.
We finally have powerful statistics showing the extent of long-term postpartum conditions. These should be used not just to raise awareness, but also develop solutions. Healthcare systems need to see post-birth support as lasting longer than six weeks. This could involve three-, six- and 12-month routine checks on women to ensure recovery is on track and provide care to help ease pain and symptoms. Women should not be left alone to suffer. In addition, we need high-quality international guidelines developed for the top 32 priority conditions for nurses and doctors to rely on.
Reducing the stigma around long-term health complications post-birth is also important: you could do this in your daily life by asking not just about the new baby, but asking a new mother how she is doing and making sure that talking about urinary or anal incontinence, pain during sex, or postpartum depression isn’t seen as taboo or awkward. So many people experience them that they are, in fact, commonplace. No one should feel isolated and alone dealing with these issues.
Last month, I wrote about declining fertility in almost all regions in the world. While there are several factors behind women choosing not to have children, including access to birth control and gender equality, governments need to also be aware of what childbirth does to women’s bodies, and the long road to full pain-free recovery. There is an obvious urgent need to improve maternity services in the NHS, which are in crisis. But another step in making childbirth more safe and attainable would be for health systems to offer services and support to let women know that they won’t be left alone after six weeks, but supported and cared for – at least for the first two years.
Prof Devi Sridhar is chair of global public health at the University of Edinburgh
