Postnatal Unit Care and Safe Transition Home

Introduction

“I’m terrified of moral apathy - the death of the heart which is happening right now in my country. These people have deluded themselves for so long that they really don’t think I’m human. I base this on their conduct, not on what they say.”

—James Baldwin1

This chapter presents the postpartum journey of Maya Howard. Maya’s story is a composite drawn from qualitative research of birth and postpartum experiences with Black mothers.2–4 The study that Maya’s story is based on was research conducted by the Black Women’s Health Imperative (BWHI), and commissioned by Association of Women’s Health Obstetrics and Neonatal Nurses (AWHONN) as part of a Merck for Mothers quality improvement grant. The study explored the perspectives of 13 Black mothers, and 6 Black and 6 White labor and delivery nurses to investigate the unique needs of Black mothers and implicit bias among nurses in the greater Atlanta and Washington, DC Metropolitan area (DMV). A qualitative analytical methodology called “versus coding” was used to compare perspectives and experiences of mothers and nurses across the same phenomenon—childbirth and postpartum.5

Maya Howard was so excited to become a mother. However, she heard that Black women are more likely to experience negative outcomes during pregnancy and childbirth than their White counterparts, so she tried her best to prepare herself. During her pregnancy, she maintained a healthy diet, attended each prenatal appointment, and was privileged enough to complete a childbirth education course, as well as lactation and infant care classes. Maya was glowing in her pregnancy—full of hope for a wonderful and transformative birth experience. She practiced daily rituals of yoga, meditation, and journaling. She took community dance classes for connection and joy. She reduced and shifted her response to work and family-related stressors. These intentional practices helped her feel whole and at peace in spite of living in a country where disrespectful and neglectful care of Black and Brown birthing people is the norm. Her grandmother even led her church congregation in a prayer for the safe passage of mother and baby. Her entire pregnancy was an act of love, affirmation, and resistance.

Despite all her preparations, Maya was surprised and dismayed by her experiences. She is among the 81% of women nationwide who report some form of sexual harassment and/or assault in their lifetime.6 She did not anticipate that her birth and postpartum care would remind her of past traumatic experiences. While in the hospital, she felt poked and prodded by a host of strangers. Sometimes they asked for permission to touch her, sometimes they just announced what they were going to do, and other times they touched her without notice or permission. She felt on display and vulnerable. When health care providers asked if they could perform pelvic exams, they were usually already gloved and lifting up her gown. She felt rushed and unable to say no or ask for more time to mentally prepare for the invasive assessments. She felt unprepared for these harmful experiences during labor, birth, and postpartum.

Maya gave birth in a beautiful room with a tub and bright large windows that filled the space with sun or moonlight. She had the support of her partner, mother, and aunt. There were also nurses, physicians, and neonatologists present to welcome and care for her baby and monitor Maya’s immediate postpartum care. Within 2 hours of giving birth, Maya’s family was asked to gather her things to transition to the postpartum unit where she was assigned to a dismally small and windowless room with barely enough space for her family. Maya’s mother and aunt soon left because there was little room to stand or sit down. Her partner eventually left as well because the reclining chair was not comfortable for a decent night’s sleep. The quick transition, with less than inviting postpartum accommodations, made Maya feel invisible and like the show was over. This was a defining moment for her. The postpartum transition made it clear that now she had given birth, her long-term care and recovery was less important to the health care system. Beyond checking her vitals, monitoring bleeding and customary small talk with the staff, Maya felt unsupported. For the first time during her perinatal journey, she felt alone.

The drastic change in the level of care and attention also signaled to her that her mental and physical health were no longer a priority. The lack of consideration for environmental factors such as room size, an inviting color-scape, artwork, and access to natural light made it clear that her stay in the postpartum unit was the last and unglamorous stop on her way out of the hospital.

Although educating pregnant individuals on what to expect during the postpartum period is recommended as part of prenatal care, during the weekly prenatal visits leading up to her birth, there were no conversations with Maya about what might happen after delivery. There was no anticipatory guidance on the issues that her body, mind, or spirit would face during the “fourth trimester”—the 3-month period after giving birth when individuals physically heal, psychologically adapt to the new parenting role, learn new skills to care for themselves and their infant, bond with their baby, and integrate their baby into their routines and previously established relationships.7 Maya felt unprepared for the dramatic emotional changes she began to experience from significant drop in estrogen and progesterone—which is the single largest hormonal change in the shortest amount of time for any human being.8 While simultaneously managing pain, fatigue, and physical recovery, she was also learning to feed and care for a newborn.

From a medical perspective, Maya was recovering as expected. Regular vital sign checks and physical assessments revealed no cause for concern. However, what the clinical team missed was that Maya’s sense of joy and excitement was slowly being chipped away from the moment she arrived at the hospital.

Maya wanted to be a good mom and a compliant patient, so she focused on her baby in accordance with the structure of her inpatient postpartum care. She diligently filled out the feeding logs given by the postpartum nurse, counting each and every wet and dirty diaper. This was a practice that often interrupted her ability to do the one thing that everyone recommended—sleep when the baby sleeps. Although she was waiting for her colostrum to change to mature milk, Maya worked to prove to the nurses that her baby was nursing well, dodging the not-so-subtle recommendations to give her baby formula. She ignored her feelings of anxiety, exhaustion, and pain. She did not eat well. She had to repeatedly correct her food order and send food back that did not meet her dietary needs. She received heavily processed foods and sugary concentrated juice which made her feel even worse. She was shocked by how little attention, guidance and care she received during the 2-day postpartum stay before making her transition home. As her hospital departure approached, she was handed a flurry of written instructions, told a dizzying list of warning signs for her and baby, and advised to call her prenatal health care provider or pediatrician if anything abnormal arose. She eventually left the hospital certain that something must be wrong with her, because if this was the standard of care that all families receive, the services must be ok. At the same time, she wondered if she would ever feel like herself again.

As clinicians, we explain Maya’s postpartum experience in our notes as a list of biological events (“status post spontaneous vaginal delivery,” “appropriate uterine involution”) and check boxes (ambulating well throughout the room, voiding frequently, depression screening negative), to affirm our confidence that she is ready to transition home. We do not ask for her perspective on the events that have occurred or her sense of readiness to transition home. Our lists do not take into consideration Maya’s life experiences, or that her care was not centered around celebrating birth, healing, and the significant life transition to parenthood. Her providers were unable to address her needs because they did not seek to understand them. Her postpartum hospital care laid a foundation for stress, confusion, self-doubt and a lack of self-care when she transitioned home. Post discharge she would develop postpartum preeclampsia, anxiety, and depression.

Postpartum care practices in US hospitals raise questions about Maya’s, and millions of other birthing people’s ability to heal and sustain positive trajectories as they become parents. How might we communicate the importance of maternal wellness and healing from the moment their babies are born and they begin their postpartum journey? What role does inpatient postnatal care play in the 52% of US maternal deaths occurring postpartum?8 What opportunities to prevent maternal deaths and postpartum complications are missed by care with little continuity from hospital to home? How are we preparing birthing families for the ups and downs of the recovery process and offering coordinated resources at every stage? How are we laying a foundation for postpartum wellness by focusing on the needs of women and birthing people beyond surviving the birth process? These are the questions we will ask and uncover in this chapter. We will explore the history and established standards of postnatal unit care. We will also identify the limitations of this standard care for Black women and birthing people. Using a radical Black feminist framework, we will then envision a path toward respectful, supportive, and nurturing inpatient care as part of a continuum of maternity health care services.

History of Hospital Birth and Postnatal Unit Care

It is no surprise that Maya’s story occurs in the context of a hospital. As a Black woman, Maya has most likely given birth in a hospital where a large portion of the patients are Black. In the United States, almost 75% of births to Black individuals take place in a concentrated set of hospitals that have a high proportion of Black patients and lower quality of care compared with other settings.9 If she gives birth in one of these hospitals, she is also more likely to experience severe maternal morbidity and in-hospital mortality.9 Despite evidence that low risk births can safely happen in a birth center and/or with certified nurse-midwives in the United States, more than 98% of births occur in hospitals, and 90.6% are attended by physicians.10 In the beginning of 20th century, with the expansion of the male-dominated field of medicine, hospital deliveries became a lucrative endeavor. This shift in control of the female body and women’s reproductive experiences drew people away from midwives and traditional healers and into a physician-based model of medical care across the lifespan.11 A major cost of medicalizing pregnancy and birth is the loss of patient autonomy, despite this being a core component of ethical medical practice. Medicalization also disrupts the transfer of knowledge and cultural practices for postpartum care across generations of women.11

Maya’s experiences are not unique. It is to be expected that Maya may feel unprepared and unsupported for the healing and parenting journeys ahead of her. Her care was not structured for discharge readiness and health. Early postpartum care in the hours and days immediately following birth can feel disjointed and rushed for new parents. Ultimately, this type of care can become unsafe and undermine trust between the patient and the health care team. The current goal of most postpartum hospital care is to diagnose and manage the physical safety of maternal and infant patients before discharge. Interventions to achieve this for the woman/birthing person include close monitoring of vital signs, vaginal bleeding, and pain. The postpartum individual’s ability to care for the newborn is also monitored and verified through detailed logs of feedings and newborn elimination that the new parent/s are asked to keep. The postpartum individual’s mental state is assessed to determine if they pose a risk to themselves or the newborn. Most noncritical abnormal findings such as postpartum anemia, symptoms of depression, postpartum pain, and elevated blood pressure readings without a diagnosis of preeclampsia, are addressed with instructions for care at home or follow up, and the postpartum individual is usually responsible for scheduling any follow up care.

For most of US history, birth and immediate postpartum care occurred without or outside of hospitals. Instead, women were cared for in their homes, sometimes with intensive support for at least 2 weeks postpartum.12 Care varied across race and class, with Black women historically being forced to return to work right after giving birth. In oppressive settings such as the slave society, care of Black women was only allowed to ensure that their bodies remained sources of profit through childbearing and manual labor. Yet, extended care of Black women was covertly carried out when possible, by enslaved midwives and nurses.13

The United States has also seen an evolution in the amount of time that women spend in the hospital postpartum. Initially physicians recommended that women be confined to the bed following childbirth and hospital stays were routinely as long as 10 days. With evidence that early ambulation could be tolerated and was beneficial, hospital administrators seized the opportunity to reduce costs, and the length of postpartum hospital stays decreased to 3 to 5 days in the mid-20th century. In the 1990s, discharge on the day after vaginal delivery became the norm.14 Currently, postnatal unit stays typically range from 24 to 48 hours for vaginal birth and up to 96 hours for cesarean births. Unfortunately, the reduction in hospital length of stay has not been consistently replaced by an increase in home-based care for postpartum individuals and families.

Maya’s experiences mirrors data that show that most women feel unsatisfied with the postpartum care they receive from the US health care system.15 Although Maya’s pregnancy and birth were considered healthy, normal, and without complications, her postpartum experience following discharge was very different. Maya was readmitted for postpartum preeclampsia, and she also suffered from postpartum anxiety and depression. Maya’s experience reflects a drastic rise in childbirth complications. Approximately 15% to 20% of women in the US experience a perinatal mood disorder.16 Maya survived, unlike the ∼470 people who die each year of birth and postpartum complications in the United States, which has the highest maternal mortality rate among industrialized countries.16

OBSTETRIC RACISM AND THE PERCEPTION OF RACE AS A RISK FACTOR

When Maya was on the postnatal unit, it is likely that nurses, midwives, and physicians would have anticipated poor outcomes. After all, she is a Black woman. They might have believed that she was high risk from a genetic predisposition to perinatal complications such as hypertension and premature birth. They might have assumed that she faces many social challenges and engages in unhealthy behaviors. They might screen her for social determinants of health without considering the power dynamics and values that have influenced the context of her life. It is likely that assumptions based on race influenced how providers viewed and cared for Maya. Maybe she was late to prenatal care, maybe she did not take her physician’s advice. Whatever the cause, her skin color factors into her presumed risks and deficits, despite the fact that there is nothing biological about race. This is an ingrained historic perspective with roots in the enslavement and the commodification of Black bodies for both labor and the advancement of the medical profession. The medical staff in charge of her health care have been trained in a discipline that has “medicalized blackness.” In the same way that 400 years ago a woman who looks like Maya would have been seen as a commodity that could biologically withstand abuses, many of today’s health care providers still assume that Black people can tolerate greater physical and emotional discomfort and thus fail to believe and respond to the physical and emotional concerns that Maya and other birthing people who look like her express.17

As a Black woman, it is likely Maya encountered obstetric racism. Davis17 defines obstetric racism from the perspectives of Black women. These behaviors include “critical lapses in diagnosis, being neglectful, dismissive, or disrespectful, causing pain, and engaging in medical abuse through coercion to perform procedures or performing procedures without consent.” To navigate obstetric racism, Maya has taken “herculean” efforts to protect herself. When speaking with the health care team, she dropped hints about her level of education and she made sure to have a doula present, for their skill in comfort measures and for spotting hospital abuses. She also vigilantly watched the staff for signs of racism. She has identified which staff and health care providers appear to “see” her, and which ones do not. When encountering individuals who appeared to look at her as just another Black body, Maya was on guard. She could feel her heart rate rise.

The faulty perception of race as a contributor to perinatal health outcomes influences how we as clinicians approach postpartum care. The effects of obstetric racism are compounded by the lack of attention to Maya’s holistic health and wellbeing. Further, health warning signs were not clearly communicated and Maya subsequently was not equipped to recognize the severity of her symptoms and return to the hospital until she was extremely sick. In the current culture of postpartum care, we assume there is little we can do to prevent the onset of postpartum preeclampsia or mood disorders. Since “medicalized Blackness” attributes hypertension to race, the health care team may have generally communicated to Maya that she was at increased risk, and the clinicians stated a plan for postpartum monitoring. This approach includes describing health warning signs to her and her family members and, if feasible, recommending clinical follow up sooner than 6 weeks, per American College of Obstetrics and Gynecology (ACOG’s) latest recommendations.18 Is there more we can do? Might comprehensive, ongoing care start with seeing her as an individual and considering the strengths and resources that surround her?

DISCONNECT FROM CULTURAL POSTPARTUM PRACTICES

While birthing in a hospital can increase timely access to emergency intrapartum services for women and newborns, it can also disconnect people from birth and healing practices that are grounded in local communities and ancient wisdom from indigenous cultures around the world that have developed some of the most effective and advanced postpartum care practices over centuries. As the hospital has become the primary site of birth care, birthing people are routinely discharged from the postnatal unit without in-home care and without access to sufficient clinical follow up, conveying the message that health care services are no longer needed. Further, postpartum care by family members and local healers may be labeled as dangerous and in conflict with the medical establishment. Therefore, women often feel compelled to choose between the 3 spheres (clinical, family, and local healers) with little room for compromise or integration. The impact of this conflict has been beautifully described by a Salluit elder from a Inuit community in Canada where women were forced to leave their local communities in the third trimester and live by the hospital where they would give birth. The elder stated, “I can understand that some of you may think that birth in remote areas is dangerous. And we have made it clear what it means for our women to birth in our communities. And you must know that a life without meaning is much more dangerous.19(p.386)”

As evidenced by the high rates of maternal death after giving birth, postpartum care is inadequate. Our medical system and society appear to value the woman as a physical vessel for the safe passage of new life, as long as she is pregnant. Once separated by childbirth, the woman is no longer essential. She is discharged home to only return for a check-up in 6 to 8 weeks. Yet, there are national and global calls to transform postpartum care. ACOG has called for an ongoing postpartum process of care that includes an evaluation within 3 weeks of giving birth for every woman.18 This recommendation has yet to translate into a widespread change in practice at the level of care in the United States. The World Health Organization (WHO) recommends that the woman and newborn dyad are evaluated together at least at 3 days, 1 to 2 weeks, and 6 weeks postpartum.20 These recommendations may help to address the critical lapses in the structure of care that contribute to preventable postpartum deaths and other complications. In addition, how might we leverage traditional postpartum practices that are already designed to center women in a circle of care?

Postpartum Inpatient Education and Discharge Transition DISCHARGE PLANNING STANDARDS

The administrators at Maya’s hospital aim to adhere to the nationally recognized safety recommendations such as the Alliance for Innovation on Maternal Health Postpartum Discharge Transition Bundle and the AWHONN Compendium of Postpartum Care. Nurses, physicians, unit managers, residents, and students have all attended the hospital-required training and grand round presentations on postnatal unit care and preparing patients for the transition home. The Alliance for Innovation on Maternal Health (AIM) developed a Postpartum Discharge Implementation bundle that was published in 2021. AIM is a national initiative to improve maternal safety and quality of care through the implementation of data-driven strategies. Each bundle addresses strategies in the categories of readiness, recognition and prevention, response, reporting and systems learning, and respectful, equitable and supportive care. However, by AIM’s own description, the implementation of all elements of the patient safety bundle may be aspirational for many hospital settings.21

The AWHONN Compendium of Postpartum Care provides postpartum care and discharge education and resources to nurses and families in complementary guidebooks. The nursing manual dedicates 1 chapter to hospital discharge planning and the transition home. Areas of concern include: health teaching, early homecare, maternal discharge instructions, follow up assessment, and postpartum visit as well as parent education for newborn care and safety.22 Yet, the focus on patient education places the onus on birthing people and families to recognize and act on all of the problems that may present in the early postpartum period. We tell birthing people what they should do if any of a number of physical or mental health symptoms arise. What we do not do is guarantee them an appropriate, timely and thorough responses from the medical system.

Maya gains first-hand experience with a health care system that is standardized and over-medicalized yet woefully inadequate. During the postpartum period, we need more intensive and hands-on care, not leaving people to navigate their recovery and resources on their own. Standardized care, as determined by professional and accrediting organization such as JACHO, AWHONN, and ACOG, should not be cookie cutter care that diminishes attention to the individual’s strengths and vulnerabilities. The standard should be care that is respectful and person-centered to support the new parent, baby, and family.

MISSED OPPORTUNITIES

Maya was funneled through a brief and fragmented postpartum hospital stay that leaves insufficient time for nurses and health care providers to address her concerns and meet her educational needs as a new mother. She was overwhelmed with the delivery of information mandated by government and regulatory agencies. This information felt rushed and inadequate to help her adjust and increase her confidence as a new mother. On the second postpartum day, while Maya was still processing a challenging birth experience, there was a steady stream of nurses, medical residents and other staff in and out of her hospital room several times an hour even throughout the night. By 10 am on the morning of discharge, she had seen no <4 care providers, who each gave her their own version of discharge instructions. Each “quick” talk felt like information on what to expect was hastily rattled off, with warning signs listed, and a myriad of resources outlined but not tailored to her needs, interests, and strengths. The medical providers talked at Maya while turning their backs to her partner or engaged with her when he was not in the room. Her partner, also a new parent, felt invisible, as most of the providers barely acknowledged his presence. He was nervous and subsequently felt unprepared to assist Maya at home. The way health team members interacted when him conveyed that his role during the postpartum period should be hands-off.

Maya sensed that her providers were rushed, distracted, and just doing what needed to be done so they could head to the next room. Then, they would recite their script all over again. They did not describe staffing constraints or other components of the system to the parents. The context and resulting experiences are important, as poor quality postpartum discharge education is associated with readmissions and more newborn urgent care visits.23 In spite of all this talking on the postnatal unit, no one has stopped to look Maya in the eye, to really connect with her. If they had, they might have noticed how overwhelmed she was by the multiple pages of discharge instruction. Further, reading nonverbal cues would indicate how utterly perplexed she was when the nurse asked about her plans for birth control. In addition, if they had really seen her, they would have recognized how terrified she was to take this tiny little human home. If they had considered her needs holistically, they might have asked who is in her support network. If they had time to engage, they might sit at her bedside and observe her mixed emotions while nursing her little one. Yet none of this happened because Maya’s providers were focused on checking items off of their discharge to-do list, and not on the whole person, dyad, and family. These inpatient postpartum experiences can lead to devastating outcomes for mothers and infants, particularly when new mothers and partners do not understand newborn care issues before discharge or postpartum warning signs for mothers’ health.

A Black Feminist Framework for Postnatal Unit Care

According to the WHO,24 Maya’s hospital should provide care that is “safe, effective, timely, efficient, equitable, and people centered.” She should also receive respectful maternity care defined by WHO as “care that maintains their dignity, privacy, confidentiality, ensures freedom from harm and mistreatment, and enables informed choice and continuous support during childbirth.25(p.3)” Recently added to the WHO recommendations is the need for positive postpartum experiences, defined as “one in which women, newborns, partners, parents, caregivers and families receive information, reassurance and support in a consistent manner from motivated health workers; where a resourced and flexible health system recognizes the needs of women and babies, and respects their cultural context.”

Systems of postpartum care can benefit from leveraging frameworks that provide insights into the social forces that drive patterns and treatment in health—as health is a state of complete physical, mental, and social wellbeing, not merely the absence of disease. To understand the multiple and intersecting factors that set the stage for Maya’s inadequate postpartum care, we engage a Black feminist framework. A schema of theories, such as Intersectionality, Black Feminist Thought, Womanist Theory, and Critical Race Feminist Theory, all contribute to a comprehensive understanding of how interlocking systems of oppression of race, class, sex, sexual orientation, and other identities can facilitate disrespectful care, neglect, and even death. For example, Maya understands that despite medical advancements and economic investments, stark disparities remain such that Black mothers are still 3 to 12 times more likely to die than their White counterparts of pregnancy-related complications.26 In addition, each year since 2003, The Agency for Healthcare Research and Quality has released the National Health Quality and Disparities Report which has consistently found that Black patients receive lower quality health care than White patients.27

The Black feminist perspective allows us to place the specific needs of the most marginalized among us at the center of our attention, thereby normalizing the concerns and cultural considerations of patients. This critical information is essential to inform respectful care and to save lives.28 Hill Collins29 asserts that Black feminist thought “is the realization of a just community through a process of a self-conscious struggle that empowers women and men to actualize a humanist vision of community.” This means that we are constantly unlearning and evaluating our biases and the underlying beliefs that prevent us from treating each person with inherent worth and dignity.

Creating a system of just postpartum care can start with how we prepare mothers and birthing people to heal and thrive. It means that cultural humility among health care team members is taught and practiced, through grounding in self-awareness, valuing cultural dynamics through the lens of patients, and acknowledging power and privilege.30 Addressing postnatal unit care through a Black feminist lens means understanding that maternal mortality and postpartum complications are not always health problems; they are often structural problems with health consequences. It also means developing care plans for the postpartum discharge transition that address racism, classism, sexism, as well as their intersections. Intentional support is important because layered forms of oppression such as racism, classism, and sex-based discrimination can create unique experiences in which standardized methods of care can perpetuate marginalization and harm and not honor a patient’s needs, differences and choices. What if instead of running through a checklist, health care providers asked open-ended questions about the worries, concerns, resources, and hopes of the patient and their support person?

In addition to medical research, epidemiological studies, and biostatistics, a Black feminist framework can broaden our perspective to ask different, more meaningful questions about quality treatment of all mothers and birthing people during the postpartum discharge transition. A biological framework posits if the birthing person and baby are intact, the health care system has achieved a favorable outcome. However, a womanist and Black feminist framework posits that the birthing person and baby need to feel safe and whole.

A VISION FOR SAFE POSTNATAL UNIT CARE

Alongside the Black Maternal Health Momnibus Act, which includes 12 bills to build on postpartum and medical coverage expansions and to comprehensively address the drivers of the maternal health crisis, we have the opportunity to transform postpartum care. However, what systems, protocols, and family-centered practices do we have in place during the postpartum period? How might we communicate to new birthing families that their lives are valued, they can be supported as they heal, and they have rights to health and positive postpartum experiences? How might we strengthen the system to give the “carers” (nurses and health care providers and other team members) the support they need to provide optimal postpartum care?

New parents explain their experiences with postnatal unit care as dissatisfying at best, and often demoralizing, condescending, and disempowering, without prioritization of their needs.31 The typical postnatal care practices often diminish familial and peer support, as the built environment and interpersonal interactions consistently isolate fathers and partners from postpartum care and discharge planning. Patients subsequently describe feeling a lack of confidence and security to care for themselves and their baby at home.

Providing quality postpartum care for the 98% of birthing people in the United States that deliver in hospitals necessitates a revolution in postnatal unit care and the discharge transition. We offer some key strategies to consider to enable respectful care so that all birthing families can thrive postpartum.

FOSTERING A HEALING SYSTEM OF CARE

The United States is the only industrialized nation without a national health care system. It is no wonder Maya’s care is disjointed and her healing is not centered. If we, as a society, were committed to establishing healing systems of health care, our advocacy and action would cease to promote a meritocracy of health and wellbeing where we accept that only those who can afford the best care will receive it. What if health care providers and institutions saw themselves as not only responsible for helping someone survive health care events, but instead responsible for helping them thrive across their lifespan? This would require a system of care that extends far beyond the reaches of a hospital unit. What if we had a system that not only strived to be clinically competent and address the health problems when they arise, but also worked to understand and address the structural determinants of health? Metzl and Hansen31 proposes that clinicians would have a greater impact if they recognized the social, political, and economic forces that impact an individual’s health and how they interact with the health care system. This requires integrating that understanding into the diagnostic process. If we did this early on in Maya’s care, we would explore how racism and sexism impact her health. We would discuss this with her and develop interventions to protect her from further trauma and positively cope. This might entail helping her establish care with culturally congruent community-based postpartum services such as a lactation consultant, postpartum doula, and parenting support group. We would also approach our care of Maya with an appreciation that we can never fully understand all of the forces that impact her health and thus must center her as the leader of her care.

BUILDING TRUST AND SAFETY

In order to meet WHO’s definition of respectful care, clinicians should initiate conversations about postpartum care in the third trimester. It is insufficient and irresponsible to assume that all postpartum needs can be communicated after a mother or birthing person has a baby and is preparing to go home from the birthing facility. Most likely she is tired and adjusting to caring for another human being. A rushed and incomplete process can undermine confidence in the health care team and hospital. Instead, we suggest that providers:

Discuss postpartum care with birthing families during prenatal care. Listen to their needs and preferences, clarify expectations for health after childbirth, and offer continuity of care. Talk through and develop a plan for essential sources of social support and social determinants of health throughout maternity care, including access to safe housing, running water, electricity, and quality nutrition. Learn and chart cultural expectations or personal preferences that should be honored in health care interactions during pregnancy, birth, and postpartum. Identify strengths for the birthing person and family to utilize to thrive through the postpartum period. Connect birthing families to community-based doulas, who can assist with comprehension, emotions, and communication during postnatal unit care and the transition home.

Trust and safety can be built through shared understanding and meaningful support, which can only be achieved when we know what matters most to birthing families and act on that information.

CREATING A CYCLE OF RESPECTFUL CARE

The Cycle of Respectful Care is a framework born out of the experiences of Black birthing individuals, their community partners, and Black Feminist scholars. It is designed to liberate patients and health care providers “from biased practices and beliefs, structural and institutional racism and the policies that perpetuate racism.32(p.12)” The framework was developed with an understanding that experiencing racism and disrespect during hospital-based care can negatively impact health. The framework calls for key steps that can improve Maya’s care, such as “establish[ing] bidirectional trust and transparency with patients, creat[ing] an environment where patients feel secure and supported in their cultural, spiritual and religious practices, incorporat[ing] patients’ social capital and network and mak[ing] medical recommendations responsive to patient’s birthing needs, values and priorities.”32(p.7) Too often our vision of respectful care is limited to being polite and kind during interpersonal interactions. The Cycle of Respectful Care demonstrates that respectful care is about systems and interventions that tangibly impact the wellbeing of birthing people. In the Cycle of Respectful Care, Maya’s discharge process would include offering affirmation of biopsychosocial needs and providing access to community assets that address the “skills, support and tools to care for self and family.”32(p.7)

COLLABORATIVE CARE AND DISCHARGE PLANNING

Standard discharge practices can make families feel funneled through a factory. For hospital staff, inadequate staffing levels aggravate burnout, forcing nurses to rush as they attempt to meet all the requirements. Premature discharge can disconnect individuals from care when their pain is not managed well, they are still in the early phase of comprehending a traumatic birth experience, or they are struggling to effectively breastfeed, causing physical and psychological harm. Whether through more time and higher quality care in the hospital or through attentive home support, we have a responsibility to ensure that they receive additional and better postpartum care. Collaboration with partners, family members, and community resources, and ongoing, holistic evaluation of postpartum needs, is critical to making sure the mother has the necessary support to heal, address mental health needs, and care for the baby. The need for postpartum care always extends beyond 48 hours after childbirth.

PRIORITIZING REST

Across the Atlantic, Africa is often overlooked in the conversation of postpartum care; however, many African cultures have developed some of the most advanced practices in postpartum care over centuries. Moroccan postpartum care, for example, focuses on rest, massage, warming, and healing foods for the mother or birthing person, so that she can take care of her baby. Studies have shown that sleep deprivation is correlated with postpartum depression. The quality and amount of sleep that new birthing families receive can be predictive of anxiety and depressive symptoms.33 American culture expects new birthing families to be sleep deprived as if it is a rite of passage. US hospitals communicate to new parents that sleep is not a priority with frequent, uncoordinated checks that disrupt mother and baby throughout the postnatal unit stay. Flexibility is key to supporting new birthing families, and inpatient postpartum care should be structured to protect sleep, which is critical to mothers’ physical and mental health. For example, offering meals throughout the day instead of penalizing the mother or birthing person for missing catering ordering windows; creating checks around birthing families’ rest needs as much as possible instead of waking them; and discussing sleep when co-developing care plans, so families can consider ways to achieve health goals and care for the whole family following discharge.

CREATING SPACES FOR JOY, HOPE, AND SOLUTIONS

Beyond a biological event, birth is a time of joy and hope for the future of a birthing person’s new life and lineage. We can take steps to protect and honor that process. One key step is centering the needs of the birthing family instead of clinicians and staff making demands of them. Ask the birthing family questions like ‘How can I support you in getting some more rest,’ ‘How can I support you and your family?,’ ‘How do you feel?,’ ‘Is there anything you need?,’ and ‘Are there ways that I can support you and your family?’ Then address their response, before reviewing log sheets and assessing vitals. Recognizing the birthing person as the expert on their needs is required to generate solutions that work for them and the family.

Conclusion

In referenced qualitative study conducted by BWHI and AWHONN, 1 participant said “I also try my hardest to humanize myself. I want them to see me.” Our moral apathy, complacency, and burnout during unprecedented times and a pandemic are all barriers that can prevent clinicians from taking in Maya, her story, her humanity, and ownership of her outcome. Her care would have been improved by continuity of support and attention from prenatal visits through the postnatal discharge transition and beyond.

For clinicians, in addition to implementing patient safety practice bundles and other medical recommendations, consider co-developing quality improvement initiatives and clinical tools with birthing families. They can provide a roadmap to recognizing their full humanity by acknowledging factors they deem critical to their healing and postnatal journeys. This shift in practice requires recognition and ability to transform our model of care.

Change in practice cannot happen in a vacuum, and the facilitation of quality treatment and care goes beyond the patient and provider relationship. In order to meet the visionary yet critical goals of respectful care and postpartum health benchmarks, the capacity and culture of hospitals and clinics must radically transform to enable health care teams to provide holistic and antiracist care. Creating a culture of respectful care involves evaluating hospital practices that support and maintain inequities in treatment based on race, class, sex, sexual orientation, and other characteristics. Biased practices often occur on top of staffing and workflow issues that can impede clinicians from connecting with their patients, perpetuating harmful practices. Advocating for diversifying and expanding our care options include expanded access to midwifery and birth centers, as well as partnering with community organizations. Our ability to reimagine and restructure postnatal unit care will depend on seeing Maya’s full humanity, valuing her, and improving the quality of care for her and all birthing people.

Ultimately while these recommendations can help mitigate harm and improve care, there is no manual, bundle, or compendium that can teach you how to recognize, respect, and protect a birthing person’s full humanity. Our fundamental beliefs on race, sex, and class create violent and dangerous realities for birthing people that are insidious as silent as the air we breathe. The level of care and support needed to truly create quality and holistic care is far too dire for patients like Maya to rely on clinicians with good intentions. If a clinician’s main interaction with patient that does not look like them is only in hospital settings, they should not be treating or caring for that patient. There has to be an intrinsic shift to grow with people that do not look like you, to learn and speak to people that are different than you. Until we shift power dynamics in the United States that marginalize Black and Brown people in every aspect of society including health care, they will remain the sacrifice to uphold a broken system.

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