Is the six-week postpartum checkup too little too late?

When Vancouver mom Jennifer Kane* went for her six-week postpartum checkup, she and her OB/GYN briefly discussed her stitches from a second-degree tear, which were healing well but had left a bit of a bulge of skin. “He said it might cause some pain during sex, but that it could be corrected after I have my next baby.” But Kane didn’t know if she wanted another baby. “And I obviously hadn’t had sex yet, so I didn’t know if that was a problem.”

“Looking back, I’m extremely disappointed with the care that I got at that appointment,” says Kane. It wasn’t just that the visit was quick, or that the OB/GYN was matter-of-fact—she didn’t feel cared for.

It’s standard for women in Canada and the US who give birth with an OB/GYN to have a checkup six weeks after birth. The appointment involves a physical exam and discussion about any complications that occurred during the birth, as well as your recovery so far. “They ask about how you’re doing in terms of any pain you have, healing with your scar if you had a C-section and if you had a vaginal delivery, any issues with your perineum,” says Sheryl Choo, a fellow in the department of obstetrics and gynaecology at Western University and a member of the maternal fetal medicine guidelines committee for the Society of Obstetricians and Gynaecolgists of Canada. They’ll also ask if you’re peeing and pooping normally, if you’re doing well with breastfeeding (if you’re nursing) and how you’re feeling. This appointment is usually when you get the green light to resume exercise and having sex, so your doctor should also discuss concerns about intercourse, family planning and birth control options.

The other part that’s really important is an emotional checkup. Your practitioner will ask about sleep, your general sense of wellbeing and look for signs of postpartum depression (PPD), which according to Health Canada affects about 7.5 percent of moms. Some practitioners use a standardized questionnaire to screen for PPD, while others just ask about your mood and interest in resuming activities you enjoy. David Millar, executive director and medical lead at Monarch Centre for Maternal and Newborn Health in Ottawa, explains that, with familiarity, care providers can often see the signs. “You may have had 12 or 13 [prenatal] visits beforehand, so this increases the likelihood that your doctor will notice a change,” he says. If there are signs of PPD, your healthcare provider might treat you (which could include medication) or refer you to a mental health specialist. At least that's the way it's supposed to work.

By the time Kane stumbled into her OB/GYN’s office for her six-week appointment, she was feeling physically and mentally pushed to her limits, which she assumed was written all over her weary face. “I must have looked awful,” she says. He asked how she was doing, and she responded that she was exhausted and it had been hard. “My child did not sleep at all unless he was on someone [or] so I don’t think I got more than 45 minutes to an hour of sleep at a time,” she says. “I was miserable.” But her doctor skipped right along to another topic. She wishes her OB/GYN had asked a few more questions or offered some suggestions to assist with a sleepless baby. “You’re not really able to think rationally at that point,” she says. “I knew I was having a hard time, but I couldn’t put my finger on what it was that I needed.” Kane believes that if she’d been seen more than once or perhaps had a doctor with a better understanding of mental health, she might have received more assistance. “Looking back, I don’t think I had postpartum depression, but I definitely had some serious anxiety issues,” says Kane. “I clearly needed help.”

Kane isn’t alone in her criticism of the standard postpartum checkups. South of the border, the American College of Obstetricians and Gynecologists (ACOG) is proposing new guidelines for postpartum care. Instead of a one-time visit six weeks after birth, ACOG now recommends new moms have a checkup within the first three weeks postpartum, followed by ongoing care as needed, concluding with a comprehensive final health and wellness assessment no later than 12 weeks after baby arrives. The proposed expanded care guidelines stem at least in part from the latest World Health Organization trend data which showed a surprising increase in maternal mortality rates between 1990 and 2013 when the US experienced a jump from 12 to 28 deaths per 100,000 births. “One of the areas that they identified as an issue was postpartum visitation,” says Choo. ACOG also reported that as many as 40 percent of American women don’t see a doctor at all postpartum. In an effort to make sure more new moms are receiving medical care, this comprehensive approach would allow women coverage under Medicaid to access services for a longer period of time, making it easier to seek mental health services, for example, along with other specialists even if they have little or no additional health coverage, says Choo.

In Canada, while all moms have their health care visits covered by public insurance, many only receive care prior to six weeks postpartum if they experience complications with their recovery, such as an infection in their C-section incision or abnormal postpartum bleeding, or if they have a pre-existing medical condition, like a thyroid disorder, that requires close follow-up. But women who give birth with midwives will have several followups after delivery. According to the Canadian Association of Midwives, postnatal care includes at least one home visit during the first week after birth and ongoing care for mom and baby for at least the first six weeks. There are also a few medical clinics across the country, including Monarch, that offer similar services. “We call it a soft landing from hospital,” says Millar. After moms deliver at the Ottawa Hospital they can be discharged to his clinic and seen by a family doctor and a registered nurse and lactation consultant. The first appointment is typically within 24 hours of being discharged from the hospital and practitioners address issues ranging from baby weight loss to jaundice testing, while assisting with any of mom’s questions or concerns. Follow-up visits are scheduled as necessary up to a maximum of six weeks, then women are transitioned to a family doctor or paediatrician.

For moms who aren’t doing well in the early weeks, either physically or mentally, additional attention is really beneficial, says Millar. If you are in a traditional practice with an OB/GYN, but are concerned about anything ranging from how your birth wounds are healing to feeling depressed, don’t wait until your six-week checkup—make an earlier appointment. And if you’re not satisfied with your practitioner, there are other options including your family doctor and public health nurses. “Suffering at home alone is not going to be beneficial,” says Millar. “I would encourage those women to call someone for help.”

*Name has been changed. 

This article was originally published online in July 2018.