Introduction and Overview
Thank you for joining us to discuss maternal health and the role that occupational therapy can play with new mothers. This course was created in order to compile what we know about maternal health, resources that are currently available to mothers, and what new mothers truly need and want during the time period surrounding having a child. Then, we need to make the link as to how occupational therapy practitioners can get involved in maternal health.
New Mothers: A Special Population
To begin, I'd like to share with you how I became interested in this topic. My OT career path led me to be a certified hand therapist. I worked in a busy outpatient clinic that delivered hand therapy services with orthopedic surgeons. I also did work conditioning, as well as conducting ergonomic evaluations in that setting. Periodically, I would receive referrals for a splint for de Quervain's tenosynovitis for conservative management. Many times, when I was obtaining background information or completing my occupational profile, I could see that there was a connection between the client's condition and the activity demands of childcare. On many occasions, when I was fabricating the splint for the mother, her baby was alongside her in the infant carrier.
I realized that I was doing a disservice to these clients by simply fabricating that splint and sending them on their way. These experiences, along with my background in job analysis, gave me the idea to create a job where I could make specific recommendations and create education to help reduce risk factors for new mothers. Although the splint may help to reduce pain and provide a temporary solution, the activities that the mother is performing need to be changed in order to cure the symptoms and prevent reoccurrence. I was certain that specifically targeted education would benefit this population. Additionally, if I could provide this education early on, the client might never need to come into my clinic for that splint.
I began going into the community to talk with local mothers, starting with a local nursing mothers group. I found out that they truly did need this education, not only to address the physical demands of motherhood, but also the emotional and psychosocial demands. After giving birth, every new mom is adjusting to a great amount of change in a relatively short period of time. I came to the realization that new mothers should be considered a special population, in the same way, we view athletes or musicians as special populations. We look at their job in relation to their occupational performance. We need to do the same for new mothers.
Current Maternal Health Models
Before diving into the current maternal health models, let's make sure that everyone is on the same page with regard to how occupational therapy fits in with maternal health. We should be all familiar with how occupational therapy fits within healthcare, and what our core values are. Here are some broad assumptions about occupational therapy that we can connect to maternal health.
- First, occupational therapy was built on the premise that our practitioners are holistic and client-centered in nature. This means that we have the skill set to look at individuals and address physical, emotional, and psychosocial issues that impact occupational performance. We know the mind-body-spirit connection very well. This can be working with individuals, groups, or populations as a whole.
- Second, OT practitioners are comfortable working on both intraprofessional and interprofessional teams within various healthcare environments, educational settings or community settings.
- Lastly, according to our OT practice framework, we create occupational profiles in order to understand our clients, and this can help to develop an understanding of individuals' roles. Often, we're meeting these individuals at a period of transition or challenges to these roles.
New Mothers' Access to Healthcare
Currently, in the United States, what types of healthcare are new mothers allowed to access? While pregnant, a woman has regular and frequent interaction with healthcare providers. Of course, if the mother or the child has any risk factors or develops complications, those interactions are going to increase. Soon-to-be moms have access to a lot of prenatal education. Hospitals and other agencies are going to offer education on everything from the birthing process to how to feed, bathe, swaddle, and generally take care of the baby. There are recommendations for various types of baby equipment, making your registry, all of those fun and wonderful things that you get excited about before giving birth. However, once the baby is born, back at home with mom, and this information needs to be put into action, it's not always readily used or thought of quickly, and it's not always as easy as it sounded before the baby arrived.
Hospital stays for new mothers are going to vary, but with a normal birth, the average stay ranges between two to three days to make sure mom is physically recovering and that baby is healthy and growing. After that, it can be a long six weeks until the mom's follow-up visit with the obstetrician. This visit is largely to see if her reproductive organs are healthy and to discuss contraception options. Additionally, some insurances now are going to offer a quick home nursing visit to help with the transition back home. Also, if we look at anatomy and physiology of the reproductive system, after giving birth, a mother's body should return to "normal" in six to eight weeks. Again, this is just referring to the internal anatomy and physiology of the reproductive system. There is contact with health professionals, such as the obstetrician, nurses, possibly midwives or specialists like lactation consultants, pelvic health practitioners, maybe an exercise and nutrition specialist. If this is sought out by mom, it's largely focused on her physical recovery and physical health.
After the baby is born, the post-natal focus shifts to caring for the infant rather than caring for mom. New mothers are going to have a lot of contact with the pediatrician to see how the baby is growing and developing, however, there is going to be less attention spent focusing on how mom is recovering. Clearly, our current healthcare model lacks a holistic approach, which is necessary when you consider that every single aspect of a woman's life is disrupted in the perinatal period. It's no wonder that at times, new mothers feel their needs and concerns aren't being met. It takes much longer to feel effective in the role of being a new mom, not to mention creating a new self-perception and body image, and it takes longer than our healthcare system suggests.
(Fahey & Shenassa, 2013; Podvey, 2018)
What We Know About Maternal Health
Maternal health is linked to important things, like how mom functions in her role, her future pregnancy outcomes, chronic disease development, and infant health. The emotional well being of mother and baby are intertwined. If mom is not taking care of herself, there is a trickle-down effect to the health of her child. There are studies that indicate that women feel unprepared, uninformed, and unsupported during the postpartum period while dealing with this role transition to motherhood. They want more information: about the physical and emotional changes that they are experiencing, about infant caregiving, breastfeeding concerns, and general lifestyle adjustment during the transition period.
(Walker, Murphey & Nichols, 2015; Fahey & Shenassa, 2013)
Health Risks of Motherhood
There is also an increased risk for health problems for a mother in her first postpartum year. These health problems occur because of the physical recovery from childbirth, plus the extra demands of caring for an infant, in addition to other family members and daily tasks. This can lead to postpartum stressors such as anxiety, fatigue, and decreased self-care, which can then can lead to additional health issues. This is what I call the slippery slope of motherhood. The evidence suggests that if these concerns aren't addressed, it can lead to an increased risk of physical and mental illness for mom, including postpartum depression. Post-partum depression can impact the health of the entire household, perhaps resulting in:
- Early termination of breastfeeding
- Negative maternal perception
- Compromised attachment with the infant
- Delayed language development
- Decreased likelihood of immunization
- Increased likelihood that the child will develop behavioral problems
(Fahey & Shenassa, 2013)
Motherhood: The Reality
The reality is that in the area of postnatal care, there is a large gap between the mother's needs and the services that are offered or that are perceived to be available. The health needs of new mothers span many dimensions, including not only her physical health but also emotional, psychological and psychosocial health. This is a period of transition of roles. Adding in the demanding role of motherhood leads to a feeling of overload or what could be called role strain. A quote by Whitney and Caretta says that role strain occurs when "individuals experience stress within the role as defined and idealized by them -- what they think they should be doing" (Whitney & Caretta, 2018). The demands of a new baby and pressure to meet them can lead to high expectations within the role of mother. This can also result in something called role conflict, where a woman holds multiple roles, all competing for priority (e.g., worker, mother, wife, caregiver). This could be why women sometimes describe motherhood as overwhelming and they need additional support that does not seem to be available (Podvey, 2016). Because of these reasons, women need support and time to adapt to the role of becoming a mother. A mom's feelings of self-efficacy in the role, as well as maternal stressors, can impact the ability to adapt to this role. We can see that the role of a mother is highly complicated, and it does cause this role strain.
What Does the Maternal Role Look Like?
The expectations for the maternal role are based on social norms and culture. These are controversial topics. Does mom stay home with the baby or does mom return to work? Does mom breastfeed? Does mom bottle feed? What's the spouse's role? What's the family's role? What kind of support is available? These decisions can cause stress on mom as she is navigating her role and how she's going to fit in these expectations.
The role of a mom is diverse. She can be a single mom, a married mom, an adolescent mom, an older mom. There's no one mold for what mom is or what mom should be. Having said that, there are definitely common responsibilities for taking care of the baby. Baby needs to be fed, diapered, bathed. All of those needs are going to be present, regardless of age and culture, but how you go about it can be very different.
The kind of support that mom has from others is important. Is the support from her significant other? From friends? From family? In addition, a mom's socioeconomic status has an influence on what the maternal role looks like and what supports are available.
Being a mom is dynamic and complex. No two days are going to be the same, and planning is only going to get you so far in that day. At times, you rely on trial and error. Also, motherhood is physically and mentally demanding and stressful. Moms typically work 24-hours a day. Right after birth and for a period of time postpartum, a mom's body has undergone a lot of changes. There's also the expectation that mom needs to bond and create an attachment with her baby during this time period. The problem is that all of these expectations that mom or others have may not meet the reality. Although it is demanding and stressful, typically the mother's love for her baby is going to motivate her to meet all of these demands, despite the level of stress it puts on her.
(Barkin & Wisner, 2013)
Components of Maternal Functioning
If a mom is going to take on this role and be successful or high functioning, according to Barkin and Wisner, she needs the following components of maternal functioning (2013):
- Social support
- Self-care (ability to take care of her own physical and mental needs and overall well being)
- Infant care
- Infant attachment
- Other roles (juggling various responsibilities within other roles she holds)
- Ability to adapt over time to the dynamic role of motherhood
Unfortunately, during this time period when moms are trying to achieve this state of maternal high functioning, there are a lot of common concerns that can impact their health. Some of these concerns include fatigue and sleep disturbance, pain, balancing nutrition and weight loss, maternal role attainment and infant attachment, body image issues, maintaining relationships with others, caring for the infant plus family plus home. Sadly, many of these concerns are going to go unaddressed.
Will Mom Address Her Own Needs?
Unaddressed health concerns are going to result in the postpartum period sometimes being referred to as a time of hidden morbidity (Fahey & Shenassa, 2015). Also, many women are going to ignore their own concerns to focus on the needs of the infant and their family. This pattern of neglect can lay roots for compromised health, not only for herself but also for her family in the long term.
Areas, where mom needs to take time to address health concerns, can be broken into these three categories: physical health, mental health, and self-care.
Physical health could include pain, due to the recovery from childbirth, or pain from breastfeeding. In addition, musculoskeletal disorders are quite common after childbirth with the different childcare-related tasks. Poor posture is also common, as the core muscles are strained during pregnancy and childbirth. In addition, a woman could have pelvic floor issues, because of the integration of the core muscles and the pelvic floor muscles. All of these things can lead to decreased physical health.
In terms of mental health, the literature indicates that there's a high incidence of postnatal depression, however, it's hard to detect and hard to treat because of mom's reluctance to report symptoms to healthcare professionals (Leahy-Warren et al., 2011). Other mental health symptoms can include anxiety and stress, and the literature also indicates that postpartum fatigue can last well into the second year after childbirth (Barkin & Wisner, 2013).
Maternal self-care may be neglected as a result of caregiving. Even finding a healthy routine of ADLs can be difficult to resume after the baby comes. Barkin and Wisner did a study in 2013 that revealed in six months postpartum, over 80% of their participants had not yet fully resumed their usual self-care activities. There is definitely a link between postpartum depression and mom's lack of self-care.
The Gap in Maternal Healthcare
Women need more information about caring for their own health in the postnatal phase. There is plenty of information, concern, and health care provider contact for the baby. However, mom's not getting the amount or type of information regarding caring for herself physically, emotionally or mentally. There's plenty of information available on infant care, such as symptoms the infant may be exhibiting, and infant illnesses. Mom is certainly likely to pick up the phone and ask questions related to the baby, but not always for herself. That raises the question of where mom is going to get information, and we'll talk about that a little bit later. Also, some moms have fewer resources available, perhaps because of lower socioeconomic status. They may be a very young mom or part of an underserved population or geographic area. In these cases, they're even less likely to get the support and the information that they need.
