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A new model for the care of women in the postpartum focuses on the development of life skills that promote complete well-being. The year
following childbirth is a time of significant transition for women. In addition to the physiologic changes associated with the postpartum period,
a woman undergoes marked psychosocial changes as she transitions into a motherhood role, reestablishes relationships, and works to meet the
physical and emotional needs of her infant and other family members. It is a time when women are vulnerable to health problems directly related to
childbirth and to compromised self-care, which can manifest in the development or reestablishment of unhealthy behaviors such as smoking and
a sedentary lifestyle. In addition to long-term implications for women, compromised maternal health in the postpartum period is associated with
suboptimal health and developmental outcomes for infants. Maternal health experts have called for a change in how care is provided for women
in the postpartum period. This article presents the rationale for a health promotion approach to meeting the needs of women in the postpartum
period and introduces the Perinatal Maternal Health Promotion Model. This conceptual framework is built around a definition of maternal well-
being that asserts that health goes beyond merely the absence of medical complications. In the model, the core elements of a healthy postpartum are
identified and include not only physical recovery but also the ability to meet individual needs and successfully transition into motherhood. These
goals can best be achieved by helping women develop or strengthen 4 key individual health-promoting skills: the ability to mobilize social support,
self-efficacy, positive coping strategies, and realistic expectations. While the model focuses on the woman, the health promotion approach takes
into account that maternal health in this critical period affects and is affected by her family, social network, and community. Clinical implications
of the model are addressed, including specific health promotion strategies that clinicians can readily incorporate into antepartum and postpartum
care.
J Midwifery Womens Health 2013;58:613–621 c 2013 by the American College of Nurse-Midwives.
Keywords: patient education, postpartum care, postpartum depression, preventive health care, public health
INTRODUCTION AND BACKGROUND tal and physical health problems are in turn associated with an
The postpartum period, as defined in the biomedical litera- increased risk of a multitude of poor health outcomes for the
ture, is the 6- to 8-week time period beginning an hour fol- entire household, including early breastfeeding discontinua-
lowing the birth of the fetus and expulsion of the placenta tion, negative maternal perception of her infant, delayed child
and reflects the approximate time required for uterine invo- language acquisition, compromised maternal–child attach-
lution and return of most maternal body systems to a non- ment, decreased childhood immunizations, and increased
pregnant state. However, reproductive system involution and child behavioral problems.11–13
the reestablishing of nonpregnant physiology are not the only Given the potential long-term impact of compromised
critical events occurring in the months following childbirth. maternal health for the long-term well-being of the woman
The postpartum period is also characterized by psychosocial and her family, it is not a surprise that maternal health experts
adaptations, including changes in parental role,1, 2 changes in have called for optimizing women’s health in the year follow-
family relationships,3, 4 and alterations in self-perception and ing childbirth.14–16 Despite these calls, the health of women
body image,1, 4, 5 many of which take significantly longer than during the postpartum period remains a neglected aspect of
6 to 8 weeks to resolve. These transitions, coupled with the health care that has been the subject of comparatively little re-
physical recovery from childbirth and the work that is re- search, policy, and clinical attention. Therefore, it is not sur-
quired to meet the needs of an infant, make the year that prising that many women report that their health concerns are
follows the birth of a child a time of heightened vulnerabil- not adequately addressed in the course of their routine post-
ity to health problems for women. Evidence suggests that, if partum care.17 In the United States, this care typically con-
unmitigated, the stressors of the postpartum period can lead sists of 2 to 3 days in the hospital following the birth, fol-
to anxiety,6 fatigue,7 and decreased self-care,8 which are fac- lowed by a postpartum visit 3 to 8 weeks later that focuses on
tors associated with an increased risk of physical and mental screening for and managing complications, assessing for re-
illness—including postpartum depression.9, 10 Maternal men- productive organ involution, and the initiation of contracep-
tion. In the last few years, there has been increased scrutiny
regarding the effectiveness of this care in terms of a holistic
Address correspondence to Jenifer O. Fahey, CNM, MSN, MPH, Depart- approach to addressing the needs of women during this criti-
ment of Obstetrics, Gynecology and Reproductive Sciences, University of cal period.11, 15, 18, 19
Maryland, School of Medicine, 250 W. Pratt Street, Suite 880, Baltimore,
The prevention, detection, and management of medical
MD 21201. E-mail: jfahey@fpi.umaryland.edu
complications of the postpartum period are, and should con-
1526-9523/09/$36.00 doi:10.1111/jmwh.12139
c 2013 by the American College of Nurse-Midwives 613
✦ The year that follows childbirth is a time of immense physical and psychosocial transition for women during which women
are vulnerable to compromised health not only from causes directly related to childbirth but also from decreased self-care
related to the demands of new motherhood.
✦ Optimizing the health of women in the year following childbirth requires a shift from a disease screening and treatment
approach to a health promotion approach that focuses on strengthening 4 life skills that have been demonstrated to promote
health: mobilization of social support, positive coping skills, self-efficacy, and realistic expectations.
✦ These life skills promote health directly by leading to improved health-seeking behaviors and indirectly by serving as buffers
from the stressors of this time period.
✦ Clinicians can help women enhance these life skills through targeted educational messages, activities, and referrals during
the antepartum and perinatal period.
tinue to be, key components of maternal perinatal health. A efforts to help all women to achieve effective coping skills and
summary of recommendations related to these is included activation of a woman’s social network, clinicians have the po-
in Table 1. However, interventions that promote health in all tential to reduce the overall incidence of maternal depression,
women during the postpartum period have been identified as including among those who may not have any observable risk
a critical gap in the care provided to women during this pe- for depression or who are below the diagnostic thresholds.
riod of transition. This article presents the key concepts that Moreover, where a large population is experiencing height-
characterize a health promotion approach, followed by the in- ened vulnerability, such as the 4.1 million women who give
troduction of a health promotion model for the postpartum birth in the United States each year, even a low prevalence of
period to help guide providers and researchers in work to fill a condition will lead to a large number of affected women. An
this gap. This perinatal maternal health promotion model is intervention that lowers the prevalence of postpartum depres-
based on findings of studies on the needs of women in the sion in the United States from 13% to 10%, for example, would
postpartum period, as well as on factors that are determinants prevent 123,000 cases of PPD annually.
of maternal health. The third tenet of health promotion is the importance
of contextual influences. Within this perspective, individu-
HEALTH PROMOTION als’ well-being is best viewed within the context of the fam-
ily, and the family within the context of its community. Con-
Three core concepts distinguish a health promotion approach.
textual factors, such as family members’ misunderstanding
The first tenet is the perspective of health as a state of well-
of psychological issues and the social milieu (eg, the social
being, which is the capability to engage in developmentally
stigma of suffering from depression), have long been recog-
appropriate physical, psychological, and social tasks to one’s
nized as deterrents for seeking treatment. Health can thus
fullest potential.20 Within this perspective, well-being is dif-
be promoted by amplifying the positive contextual influences
ferent than simply the absence of disease or disorder.21 From
and reducing the social barriers to help-seeking. Individual-
a health promotion perspective, individuals are not healthy
level efforts do not address the contextual issues that, in addi-
unless they are living to their fullest potential. Well-being is
tion to decreasing the probability that such efforts will be suc-
in part predicated on the learning and adoption of skills and
cessful, leave future generations vulnerable to the same risks
traits that buffer the individual from disease-inducing events
facing the present generation.24 To the extent that changes in
and situations. For example, a key protective factor is the com-
the social milieu are lasting, programs that work to change
petence by which individuals navigate stressful life events, re-
these contextual influences also promote the health of future
lationships, and experiences.22, 23
generations.
The second tenet of health promotion is universal appli-
cation. The premise of this approach is that every individual
can benefit from improved functioning, and thus from pro- PERINATAL MATERNAL HEALTH PROMOTION
MODEL
motion of well-being in all people. This approach circum-
vents problems associated with inaccuracies in classification The model introduced here and presented visually in Figure 1
of women’s risk status and errors in prognosticating women’s was created in response to calls for a change in the approach
future health status based on these risk factors. For example, to the postpartum period.11, 15, 16 It applies health promotion
not every woman who is diagnosed as depressed is truly de- concepts and provides a framework for understanding both
pressed and not every woman who is correctly diagnosed with the factors that correlate with a successful maternal transition
depression has a poor prognosis. Similarly, some women with- and how to translate this understanding into practice.
out risk factors will develop postpartum depression (PPD), At the center of the model are key components of a healthy
while others will have some signs of depression but will not postpartum period: 1) physical recovery from pregnancy and
cross the threshold by which an intervention may be trig- childbirth; 2) meeting the needs of the mother (including so-
gered, such as a particular score on the Edinburgh Post- cial needs), infant, and other family members; and 3) suc-
partum Depression Scale. By undertaking health promotion cessful attainment of the maternal role. The next layer of the
model contains the key individual skills associated with the cately interrelated and overlap. The ability to meet the goals in
improved ability of women to achieve the goals of the post- one area can determine whether or not goals in another area
partum. These four distinct but interrelated skills are 1) effec- can be achieved.
tive mobilization of social support, 2) self-efficacy, 3) positive
coping, and 4) realistic expectations and goal setting. Finally,
on the outside layer of the model are external resources that Physical Recovery From Pregnancy and Childbirth
may be necessary for a healthy postpartum period. These in-
Assessing for normal reproductive system involution (eg, re-
clude access to clinical services, social and other support ser-
turn of the uterus to nonpregnant size, complete shedding of
vices, information, and material resources such as food and
the pregnant decidua) and the reestablishing of the nonpreg-
housing.
nant physiology (eg, normalization of glucose metabolism, re-
Each of the model components is explained in more detail
turn to baseline blood pressure) is the traditional focus of the
below.
routine postpartum visit with health care providers. There is
some variation among women in how long most body sys-
tems take in returning to a nonpregnant state, but for most
Core Elements of a Healthy Postpartum
women this will have taken place by 6 to 8 weeks postpar-
The key components of a healthy postpartum have been tum. However, while most women’s bodies return to what
grouped into 3 categories in the model. These categories have is considered nonpregnant anatomy and physiology within 2
important distinguishing characteristics, but they are intri- months, results of population-based surveys of women in the
Source: Attrill.31
factor rather than an individual skill. In addition to the direct given high priority. Women report anger, stress, and anxiety
effects of receiving instrumental assistance with tasks, social when they perceive that others are failing to meet their need
support is also thought to impact health positively by reducing for support.35 Particularly stressful to women appears to be a
the degree to which life events are perceived as stressful by an dissonance between the support she expects to receive and the
individual and by enhancing feelings of self-esteem and self- amount of support she perceives to receive.35, 38 This finding
efficacy.36 The ameliorating effect of social support on per- that the perceptions of the support received can be as impor-
ceptions of stressful events is often referred to as a “buffering tant as the actual support received is consistent with findings
effect.”37 by researchers in other fields of health.33 How social support
Social support emerges as a key need of women during is mobilized, the perception of who should provide this sup-
the postpartum period. Women express a need for both emo- port, and the degree of support that is expected may vary by
tional and instrumental support; however, they may priori- race and ethnicity.29
tize the need for instrumental assistance, especially during the Women from some ethnic or racial groups may be more
first few postpartum weeks following the postpartum period. likely to rely on their social network for assistance in the post-
Throughout this time period, women report a need for as- partum period. These women may be more likely to feel frus-
sistance with infant, child, and household care so that they trated when their social network fails to meet their needs,
can complete basic tasks of self-care such as bathing, eating, whereas other groups of women may be less likely to involve
and sleeping.29 Assistance with cleaning and cooking are also anyone in their social network other than their partner in the
medical insurance). Helping to ensure availability of and ac- gated, can increase the risk of depression or shaken-baby syn-
cess to these resources is an important component of health drome. In order to be able to effectively soothe her infant, a
promotion for women. woman needs to know what strategies work best to make an
In addition to clinical care and referrals for social and infant stop crying, which is information that can be provided
other services, midwives and other clinicians provide infor- by clinicians. Similarly, a woman is also less likely to experi-
mation and education to women. Timely and accurate in- ence a loss of self-efficacy related to the crying if she under-
formation is often a critical resource in order for women to stands the normal crying patterns for infants and the reasons
effectively utilize their individual health-promoting skills in infants cry. If a woman believes the crying is not due to a lack
the postpartum period. For example, a crying infant can be of skill on her part, but instead that it is an expected behavior,
a source of anxiety and stress for a woman, which, if unmiti- she will be more likely to attempt to soothe her infant, which