After the joy of birth, new moms face ‘the wilderness’

Few events in life match the drama of giving birth. Happy parents show off photos of the milestone, beaming as they cradle their newborn right after delivery. Behind that glowing image, there is an alternate reality: pain, exhaustion, and the daunting uncertainty of parenting. And that’s only the beginning, because then the really hard part starts—recovery.

Many mothers are so focused on the parenting challenges ahead, they’re not thinking about their physical and mental recovery when they leave the hospital.

“When you go home, you feel like you’re in the wilderness,” said Pervez Sultan, MD, who was with his wife when she gave birth to their first child 11 years ago.

At the time, he was an obstetric anesthesiologist in London, so he thought he knew what to expect. But after his daughter was born and his wife suffered lingering problems, he sought guidance from research. “I was astounded that there were no descriptions of what a normal recovery is after childbirth,” he said.

That’s what led Sultan and Deirdre Lyell, MD, the Dunlevie Endowed Professor in Maternal Fetal Medicine, and other colleagues at Stanford Medicine to develop a new standard for evaluating recovery from childbirth. Sultan, now a professor of obstetrical anesthesiology, believes the new measurement survey can help to screen mothers after childbirth. That can identify problems earlier, potentially reducing suffering and improving care.

When parents head home from the hospital, they leave behind the medical team that supported them. Mothers recover on their own from one of the hardest physical episodes they have ever endured. They struggle with pain, bleeding, breastfeeding challenges, social dynamic changes in the home, adapting to motherhood, risk of infection—and little sleep.

Then there’s the mental toll: Almost 1 in 5 women experience depression in the year after their baby is born.

It all adds up to an alarming increase in the rate of maternal death after a new mother leaves the hospital. That’s what led Sultan to dive into researching recovery from childbirth. The result is STORK (Stanford Obstetric Recovery Checklist), a survey that measures how well mothers are recovering from childbirth, not only from physical challenges but also from mental and emotional health conditions (including depression, anxiety), motherhood experience and social support, and sleep and fatigue.

Sultan was the lead author of a multicenter validation study on the STORK measurement model published in April in JAMA Network Open. He discussed what mothers undergo after childbirth, and how the STORK checklist tracks in a way that helps identify those who potentially need extra support. This interview has been edited for length and clarity.

Why do we need a measure of recovery from childbirth? Haven’t moms been handling this since the beginning of humanity?

The United States has the highest maternal death rate of any high-income country in the world (19 out of every 100,000 women in the U.S. die from causes related to pregnancy and childbirth.)

Right after birth in the hospital, you get checked for some basic physical issues like pain, bleeding, and high blood pressure. But doctors and nurses don’t have standard guidelines on what else to check beyond hospital discharge steps, so the questions may be scattered and based on the institution’s procedures and general medical care rather than conditions specific to childbirth.

Most of the time, you don’t return for a checkup until six weeks later. During that time, there’s a whirlwind of things going on for mothers, including pain, lack of sleep, learning to breastfeed, mood changes, and need for social support. Until now, doctors and nurses have had no validated way of assessing how well mothers are recovering from childbirth across these multiple areas.

How could STORK help?

STORK can be used as a routine way to check mothers’ well-being, like the standard wellness checks babies receive after birth (for height, weight, and head circumference). But the mothers’ checks would go a lot deeper than they have in traditional care after birth.

STORK covers physical recovery, mental and emotional health, motherhood experience and social support, and sleep and fatigue. We use a set of 47 multiple-choice questions that are written at a simple, 8th-grade level.

They detect some of the overlooked issues that make a big difference in a parent’s life: Can you bend over to pick up your baby? Can you stand up and walk properly? Are you feeling anxious or distressed? Do you have anyone to help if you need it? Are you worried about contraception?

We need these new questions and measures. The current ones don’t cover much beyond the most basic physical symptoms. The best available measure for pain after childbirth includes a survey developed for cancer patients, not new mothers. There are often no questions about breastfeeding or the infant in such surveys.

With STORK, if someone scores poorly on pain or in a specific area, we can focus on that and how to improve it.

You interviewed a lot of women about how they recovered from childbirth. What did you learn?

First, we talked to 50 patients and medical specialists to find out what questions we should be asking. When we developed a list of questions, we tested it on a pilot group of 10 patients to get feedback. Later, we validated it by testing it with 500 patients at Lucile Packard Children’s Hospital Stanford, Northwestern Hospital in Chicago, and Brigham and Women’s Hospital in Boston.

We collected information on all kinds of things related to childbirth and recovery: whether you had a vaginal birth (with or without surgical help); a cesarean section (scheduled or not); what kind of anesthesia you had, if any; and if this was your first child. We didn’t know if these factors make a difference in recovery.

It looks like the answer is yes for some. If this is your first birth, you’re likely to have a worse recovery, especially in the first six weeks. And you are more likely to have a harder recovery if your baby is admitted to the neonatal intensive care unit.

We’re hoping to publish more studies on this soon. They will reveal population norms, how much difference an operative vaginal birth (forceps) or C-section makes on recovery, and differences in recovery between first-time mothers versus mothers with previous live births.

How will that help moms?

We hope to mine the information collected before birth, and right afterward, to see if we can predict earlier whether you will have a more difficult recovery than most. Why wait for the six-week follow-up appointment to say, “You’re not doing well?”

My vision is that two weeks after your delivery, you come to a clinic. You see an obstetrician, a breastfeeding expert, a psychologist, an pain specialist, and a baby doctor. If you’re not doing well in any way, you get more help.

We owe it to mothers around the world to give them the best kind of recovery possible.