“I know it’s hardest in the beginning with the baby, but it’s challenging and definitely not impossible to do. Plus when you see the little one smile, everything just seems so worth it.” Overall, the crucial postpartum and newborn period receives inadequate attention from the health care system, with respect to public policies such as paid leave and breastfeeding support, and in terms of our understanding of the experiences of women and families at this time. In this chapter, we touch on a variety of issues relative to this period that we were able to include in our survey. Regarding postpartum maternal mental health, please see the following chapter, which is based on validated depression and anxiety screeners and their combined composite (PHQ-4) that survey participants completed with reference to both pregnancy and the postpartum period.
“It seems like a lot of time between the delivery and the postpartum visit. I would think the visit to the doctor would be a little sooner. One month and a half is a lot.” Most women (91%) reported having at least one postpartum visit in the first 8 weeks after the birth. Half (50%) had one visit in that time, while approximately 1 in 4 (24%) had two visits and another 16% had three or more visits. We found significant differences by race/ethnicity and payer (Figure 47).
“I had to work and they weren’t open weekends. I couldn’t afford to take time off.” Approximately 9% of the women surveyed reported having had no postpartum visit. We examined this group of women by race/ethnicity and payer and found differences in both cases (p < .01) (Figure 47). Not having had a visit was also strongly related to income; women with income below the poverty level (13%) were much more likely to report not having had a visit than women at 300% or higher of the poverty level (4%) (p < .01). Women below the poverty level were also more likely to have four or more visits (10%), compared to women with incomes at 300% or higher of the poverty level (5%) (p < .01).
Across all four race/ethnicity groups shown in Figure 48, women with Medi-Cal coverage were more likely than women with private insurance to have no postpartum visit (p < .01).
“I didn’t know that I had to make a doctor’s appointment. When you have just had a baby you never think about making a doctor’s appointment.” It is a major concern that nearly 1 woman in 10 had no postpartum visit at this important time of physical, emotional and social transition, and growing professional emphasis on the importance of postpartum care. However, this figure is well below widely quoted rates for women with no postpartum visit that are based on claims data. Our results, which align closely with other survey-based results, are likely to be much closer to actual practice, as claims data undercount postpartum visits due to widespread use of billing codes that encompass a broader range of services, and a health care plan performance measure excludes visits in the initial weeks after the birth.
We asked the subset of women without a postpartum visit the reason for not seeing a maternity care provider in the postpartum period; Figure 49 summarizes their responses. Women cited the fact that they felt they didn’t need more care (36%), followed by lack of time (16%), not feeling well or feeling tired and didn’t want to go (11%), a lack of insurance coverage (8%) and transportation issues (7%).
When examined by race/ethnicity, Black women were most likely to have four or more postpartum visits (p < .01), whether they were covered by Medi-Cal or had private insurance (Figure 50). This may indicate a higher burden of health challenges at this time.
“[The worst thing about my care was their] not providing the birth control I wanted due to religious purposes.” We asked women if their providers discussed some key topics with them during their postpartum visits: breastfeeding, birth control and feelings of depression. When we examined the likelihood of discussing these issues by demographic characteristics, there were not notable differences by race/ethnicity or income (not shown), but overall women with Medi-Cal were consistently about 8 percentage points less likely than those with private insurance to report having had such a discussion with their provider (p < .01) (Figure 51).
“I felt like care was good during my pregnancy and during birthing but support to new mothers is very limited. It makes it very difficult to be a good mom. It’s a stressful and lonely time if you do not have money or family close.”
“The lack of help after giving birth was stressful. Prenatal care was good, frequent, consistent. Afterwards, besides appointments for vaccines, you are all alone and on your own.” We asked about access to two types of support “since the birth of your baby”: (1) emotional support such as listening to concerns and giving good advice, and (2) practical support such as help getting things done or finding information. A majority of mothers (56%) reported they always felt like they had emotional support, with another 14% saying they usually did. Almost half of mothers (49%) said they always had practical support. Mothers who reported they “always” got emotional support were more likely to report they had private insurance (63%), were White (64%) or Black (62%), had incomes at 300% or more of the poverty level (65%) and were married (59%) (all p < .01). Always having practical support varied less and was generally most common among the same groups, specifically those with private insurance (56%), who were White (55%) and had incomes at or above 400% above the poverty level (56%) (all p < .01). As shown in Figure 52, Medi-Cal beneficiaries overall were less likely to have access to both emotional and practical support than women with private insurance, and more than twice as likely as women with private insurance to say that they never have someone to turn to for both types of support (p < .01).
“Cost of delivery even with the insurance is soooo expensive. I wanted to spend more time with the baby, but had to go back to work to make money.” Women participated in the survey from 2 to 11 months after giving birth. By the time they took the survey, 43% of respondents had returned to or begun new paid work, either full time (29%) or part time (15%). An additional 22% reported they would be back at a paid job or starting a new paid job in the next few months, while slightly more than one-third (35%) planned to stay home with their baby. We found a clear relationship between currently working a paid job and family size. Women who had recently had a fourth birth were notably less likely to be doing paid work (Figure 53), with 53% saying they planned to stay home, compared with 29% of women with one child (p < .01). Women who had just had a third child were intermediate in terms of current employment.
Working a paid job was also strongly related to income level, with only 30% of women below the poverty level working for pay compared with 65% of those women at 400% of the poverty level (p < .01). This likely reflects the strong inverse relationship between family size and income, with 21% of women living below the poverty level having four or more children, compared with 1% of women at 400% of the poverty level.
“Twelve weeks is not enough time for a mother to care for her new baby and herself before returning to work. More needs to be done for mothers who feel alone.” We also examined how long women were able to stay home with their babies and tend to their own health needs before returning to or starting paid work. One-fourth (24%) of women who were doing paid work at the time of the survey began such work within 2 months of their birth, another third (34%) by 3 months, and another quarter (24%) by 4 months. Thus, within 4 months of the birth, 82% of women with a paid job at the time of the survey had resumed or started employment. These represent a third (34%) of all mothers, whether they returned to work or not.
Women with Medi-Cal coverage returned to or started paid jobs more quickly than those with private insurance (p < .01) (Figure 54). Likewise, when we examined the relationship between income level and time at home before starting paid work, we found that women reporting incomes below the poverty level were employed more quickly (63% within 3 months) than women with incomes at 400% or above the poverty level (46% within 3 months). While women below the poverty level were less likely to take on paid work, those who did took on paid work more quickly than women with higher incomes.
“I wish I can spend more time with my kids at home with pay while on maternity leave. I feel like the baby was too young to be left with a day care. The first year is essential and we should be allowed to stay home or have the option to work from home.” Among women who were working a paid job, fewer than half (48%) reported that they were able to stay home as long as they wanted. Women who reported they stayed home as long as they wanted remained home on average 1 week longer (14.7 weeks) than those who said that they did not (13.8 weeks). While there was little difference in how long women from different racial/ethnic groups stayed home (Figure 55), there was a marked difference in the perception of whether they stayed home as long as they wanted, with Asian and Pacific Islander and Latina women much more likely to respond more positively than Black and White women (p < .01).
“I would have loved to have more postpartum care and breastfeeding help.” As they approached the end of their pregnancy, about two-thirds of women (67%) intended to exclusively breastfeed their babies, 28% planned to mix breast milk and formula feeding, and 5% planned to use formula alone. Compared with intention, there was a drop-off in the actual proportion exclusively breastfeeding 1 week after the birth, with corresponding increases in mixed and exclusive formula feeding.
Table 7 breaks down changes between intended feeding as women neared the end of their pregnancies and actual feeding at 1 week. About one-fourth of women who intended to exclusively breastfeed were either only feeding their baby formula (3%) or using both breast and formula feeding (21%). About 1 in 11 women who intended to formula feed was exclusively breastfeeding at 1 week. Approximately 39% of those who intended to both breast and formula feed were exclusively breastfeeding at 1 week.
“The best thing [about our hospital care] was the constant encouragement and motivation by the nurses in the NICU. … I loved that even though our baby was so small they very rapidly encouraged us to try breastfeeding.” Women reported that the hospital staff was generally strongly supportive (84%) or somewhat supportive (12%) of breastfeeding. Table 8 shows the relationship between staff support and fulfillment of feeding intention (i.e., intention in late pregnancy to breastfeed and whether breastfed at 1 week). In cases where women reported the staff was supportive, 97% of women who intended to breastfeed were either exclusively breastfeeding (76%) or mixed feeding (21%) at 1 week. In the relatively small number of cases where mothers who intended to exclusively breastfeed reported staff discouraged breastfeeding, only 35% of women who intended to exclusively breastfeed were doing so at 1 week, and 27% were exclusively using formula.
“I had a particularly difficult time getting started with breastfeeding and the hospital staff and services were very supportive and encouraging in assisting me.” We asked if women had felt pressure from a health professional to breastfeed, and 27% of women reported that they did. However, we caution that there may have been some misunderstanding of the intent of the question. When we examined responses relative to how much nurses and hospital staff supported breastfeeding, 28% of women who felt staff supported breastfeeding also felt they were pressured, and 33% of the women who felt the staff discouraged breastfeeding also reported experiencing pressure (though the latter involved small numbers since hospital staff was overwhelmingly supportive of breastfeeding). Women who said staff neither supported nor discouraged breastfeeding were least likely to report feeling pressured (16%).
Thus, some respondents may have interpreted the question to mean pressure either to breastfeed or not to breastfeed rather than an exclusive focus on encouraging it. We also received an open-ended comment that “pressure from care providers can be positive or negative.” It is also possible that some respondents did not read carefully and reported whether they had felt pressure from any source to breastfeed, a common topic of discussion groups, blogs and other forums for childbearing women.
“The nurses didn’t help me with breastfeeding at all. They said if baby was hungry he would eat. Well that was not the case and my son lost 10% of his weight before leaving the hospital.” We also note major differences in responses to this question by language spoken in the home. Just 13% of women who spoke Spanish at home reported they had experienced pressure to breastfeed versus 32% English, 32% Asian languages, 25% English and Spanish equally and 24% other (p < .01).
Table 8, above, suggests that few women may have received inappropriate pressure from hospital staff, as just 3% of women who planned as they came to the end of their pregnancy to exclusively formula feed reported that the staff strongly or somewhat supported breastfeeding, in contrast to reports of 76% of women who planned to exclusively breastfeed and 21% who planned mixed feeding.
Overall, 62% of women reported exclusively breastfeeding their babies 1 week after birth. Figure 56 shows some variation in exclusive breastfeeding at 1 week, by race/ethnicity and payer. White women were distinctly more likely (74%) to be exclusively breastfeeding than any other racial/ethnic group (p < .01). Women with private insurance (67%) reported higher rates than women covered by Medi-Cal (59%) (p < .01).
“Lactation specialists were great and had a lot of experience. They kept calling to make sure breastfeeding was going ok. ” Figure 57 shows further variation in exclusive breastfeeding at 1 week, by type of birth attendant and mode of birth. Women who had a midwife as birth attendant (75%) were more likely to be exclusively breastfeeding than women who had an obstetrician as birth attendant (61%) (p < .01). Exclusive breastfeeding at 1 week also varied by mode of birth, ranging from women who had a vaginal birth after cesarean (VBAC) (77%), followed by vaginal birth (not VBAC), repeat cesarean and women who had a primary cesarean (54%) (p < .01).
“[The worst part of the hospital experience was] being pressured to formula feed before my milk came in.” Leading health professional organizations recommend exclusive breast milk feeding to at least 6 months. Chantry, C.J., Eglash, A., & Labbok, M. (2015). ABM position on breastfeeding – revised 2015. Breastfeeding Medicine, 10(9), 407-411. Retrieved 1 May 2018, from here Figure 58 illustrates patterns of exclusive breast milk feeding over the first 6 months after birth among respondents who participated in the survey 6 or more months after giving birth. In this group, 62% were exclusively feeding breast milk at 1 week, declining to 54% at 1 month. Fewer than 3 in 10 (28%) who had given birth at least 6 months before completing the survey met the consensus professional recommendation for exclusive breast milk feeding to about 6 months. However, there was broad variation in meeting this standard by race/ethnicity and by payer. The former spread ranged from 21% among Black women to 37% among White women (p < .01). About 1 woman in 4 (24%) covered by Medi-Cal met this standard, in comparison with slightly more than 1 in 3 (34%) with private insurance (p < .01) (Figure 59).
“There is immense pressure about breastfeeding and not enough support for new moms to handle low milk supply and not feeling guilty about supplementing with formula when needed. ” Table 9 describes patterns of infant feeding over the first 8 months, showing a general trend of decline in feeding any breast milk, and increasing feeding of any formula and any solid food. We chose not to report feeding patterns at 9 or more months, as respondents during the final months of our survey were fewer in number and may not be representative of our overall target population. (As the survey tracked different cohorts who participated at varying time periods since giving birth versus one group over the full period, the table includes some increases in measured rates of any breast milk feeding and a decrease in measured rate of any solid food.)
“My biggest regret is not breastfeeding longer. I would recommend it to all mothers and I wish, as a first time mother, I would’ve gotten more help.” We asked women who had partially or exclusively fed breast milk at 1 week and were not doing so at the time of the survey whether they had breastfed as long as they wanted. Overall, 42% in this group were satisfied with the duration of breastfeeding. Figure 60 presents their responses, broken down by both race/ethnicity and whether they had been able to stay home with their baby as long as they wanted. There was a large spread across racial/ethnic groups, with White women least likely (31%) and Asian and Pacific Islander women most likely (61%) to say they had breastfed as long as they wanted (p < .01). Those who said that they had been able to stay home with their baby as long as they wanted were almost twice as likely (59%) to say they had breastfed as long as they wanted compared with those who had not been able to stay home as long as they liked (31%) (p < .01).
“A doctor in the NICU ordered the nurse to feed my baby formula without my consent and it messed up my plans for exclusive breastfeeding.” We also looked at whether women with any breastfeeding at 1 week had been able to breastfeed as long as they wanted, by mode of birth and parity. Women with a primary cesarean appeared less likely to have breastfed as long as they liked (34%), in comparison with other mode of birth groups (44% each), though the differences were not statistically significant. Satisfaction with duration of breastfeeding increased with the number of births: first (36%), second (42%), third (49%) and fourth (52%).
“The woman who came in to collect the $2,500 payment before we left with my son gave me a panic attack. … She literally asked if I would be paying by cash, check, or credit and just stood there waiting for my answer.” Figure 61 shows out-of-pocket costs for maternity care provider and hospital fees, by payer. Four in five women with Medi-Cal coverage reported paying nothing. More than 1 in 3 women with private insurance paid from $1,000 up to $5,000 in out-of-pocket costs, and 1 in 7 paid more than $5,000 (p < .01). The average out-of-pocket cost for women with Medi-Cal was $383, versus $2,305 for women with private insurance (p < .01).