America can be a difficult place to be a mother

America can be a difficult place to be a mother
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Each year, on the second Sunday in May, we shower moms with flowers, breakfast in bed, and elementary school craft projects.  It’s a lovely ritual and it obscures, for a day, the fact that America can be a difficult place to be a mother. What might society look like if we invested the $23 billion we’ll spend on Mother’s Day gifts to improve the daily lives of America’s mothers?

Right now, it’s not pretty. We are one of the few countries in the world where maternal mortality rates are rising, rather than falling, and black mothers die at three times the rate of white mothers. We are the only high-income country without any provision for paid family and medical leave.  

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Our private practices and public policies ignore a fundamental feature of human reproduction: We are collective breeders, and we require a community to raise our children. That’s one of the reasons that newborns are so cute — they need chubby cheeks to attract love and care from the “allo-mothers” who are essential for survival.

 

Cultures on every continent have enshrined care for new mothers in traditions and taboos passed down from generation to generation. Mary brought Jesus to the temple at 40 days, following rules set down in the book of Leviticus.

South Asian cultures call for a month of rest, with special foods and provisions to keep mothers warm as they recover from birth. Latinx traditions support la cuarentena, a 40-day period after birth for rest, breastfeeding and bonding. These traditions ensure that family and community members pitch in to cook, clean, and take care of other children.

This village of support for new mothers is an evolutionary imperative — and it has been utterly upended by modern American life. Economic pressures have emptied the village, pulling friends and neighbors who might have supported the new mom into the paid workforce. Aunties and grandmothers are more likely than any time in the past 50 years to be employed, and thus unable to leave their job to tend to mom and baby.

Medical care for mothers is no better. While a woman sees her obstetric provider weekly in the last month of pregnancy, insurance covers just one visit after birth, typically at 6 weeks postpartum. That made sense when women were supported and cared for by friends and family; today, we’ve jettisoned that social support, leaving mothers to wander for 42 days in the wilderness.

Last month, the American College of Obstetricians and Gynecologists (ACOG) issued recommendations, supported by the Society for Maternal-Fetal Medicine and the Academy of Breastfeeding Medicine, to change postpartum care from a one-off visit to a sustained period of support, spanning the “fourth trimester” that extends through 12 weeks postpartum.

Providers are encouraged to engage with families to craft a care plan for the weeks following birth and build a care team, reconstituting the lost village of our ancestors. Early follow-up can save lives: Women are more likely to die after than before or during birth from pregnancy complications like postpartum strokes and blood clots in their lungs.

Enacting these recommendations requires policy changes. First, we need to change how insurers pay for maternity care. In the current system, maternity providers receive a “global” payment for prenatal care, delivery, and postpartum care. If a patient misses her postpartum visit, her provider gets the same global fee. And if she’s seen 5 times for routine support, her provider gets the same global fee.

To move from a one-off visit to an episode of care, we’ll need to change payment schemes to make more holistic care sustainable.  We’ll also need to center care around the mother-baby dyad, rather than forcing a sleep-deprived woman to drag an infant car seat in and out of multiple medical office buildings.

Moreover, for new families to get the medical care and support they need,  we need paid family and medical leave. The Family and Medical Leave Act provides unpaid, job protected leave, but it covers only 59 percent of workers, and many can’t afford to use it.

Currently, just 1 in 7 adults has access to paid leave through an employer, and vast disparities exist. Among the highest paid workers, 1 in 4 have paid leave, compared with only 1 in 25 of the lowest paid workers. As a result, 23 percent of employed mothers in the U.S. are back at work within 10 days after giving birth.

Our collective failure to provide paid, job protected leave harms mothers and babies. Lack of paid leave is associated with higher rates of ADHD, ear infections, hearing problems, early weaning and childhood obesity, as well as postpartum depression.

And lack of leave kills babies: each 10 weeks of paid, job-protected leave is associated with a 4 to 6 percent reduction in infant mortality. Given that the lowest paid workers are the least likely to have access, lack of universal paid leave widens health disparities.

Paid, job protected-leave is not a perk — it is a public health imperative. That’s why the Society for Maternal-Fetal Medicine recently endorsed 12 weeks of paid, job-protected leave to optimize the health of women and their families and to improve health equity.

It doesn’t have to be this way. As ACOG President Dr. Lisa Hollier put it, “Our society must decide that the lives of women are worth saving.”

Alison Stuebe M.D. is a board-certified Maternal-Fetal Medicine specialist in Chapel Hill, North Carolina. She chaired the American College of Obstetricians and Gynecologists residential Task Force on Redefining the Postpartum Visit, and she is a member of the board of the Society for Maternal-Fetal Medicine and Vice President of the Academy of Breastfeeding Medicine. Stuebe has a role as a co-investigator for a Janssen Research and Development study, Optimizing Clinical Screening and Management of Maternal Mental Health: Predicting Women at Risk for Perinatal Depression.