Jerasimos (Jerry) Ballas, MD, MPH

Evolutionary biologists have long theorized that even at full term, humans are still born prematurely (1). After 40 weeks of gestation, the fragile and helpless state of a human newborn is striking when compared to the abilities of other mammals and primates born at term. Elephant and giraffe newborns walk when their feet hit the ground. Baby chimps have the kind of grasp and strength to stay firmly attached to its mother as she climbs and swings. So why would nature take such a risk with humans by selecting for such defenseless offspring (2)?

Evidence suggests that as hominids took to walking upright, the intersection between increasing brain volume and the ability to deliver offspring through a narrowing pelvis created an evolutionary pressure to shorten gestation. Simply put, the advantage bestowed by an increasingly complex brain came with the price of needing to be born earlier so that newborns could navigate the female pelvis. Anthropologists and social scientists will point out the
subsequent evolution of our early nomadic hunting and gathering ancestors into an increasingly cooperative and group-minded society (3-4). Of course, this is an overly simplified notion covering millions of years of evolution. However, it can be a powerful lens to look through when examining the paradigm of modern perinatal and postpartum care of mothers, newborns, and their families, and how that paradigm is increasingly failing our patients.

As a Maternal-Fetal Medicine specialist, the majority of my interaction with patients and their families is during their prenatal care. I see fetuses in black and white on computer monitors much more often than I do in living color. I often talk in terms of estimated due dates, interval fetal growth velocity, and timing of delivery for either maternal or fetal indications (or both) in an effort to navigate a pregnancy as far as possible and as safely as possible for all involved. I still take call and cover inpatient services and get to be involved in deliveries, which never gets old and always serves to validate why I went into this field.

It wasn’t until my child was born, however, that I became acutely aware of how woefully deficient postpartum support can be in this country. The pressure for my wife to return work, the use of all my vacation time as paternity leave, navigating postpartum issues within a healthcare system designed for prenatal care and delivery, all the while figuring out whom to trust with the life our newborn child when we returned to work. All of these stressors were amplified when I came to the realization that despite a full-term, uncomplicated pregnancy, we were essentially caring for a defenseless fetus that just so happened to be outside of the uterus.

When my wife (who is a pediatric neurologist in addition to an amazing mother) first introduced me to the concept of the 4th Trimester via Dr. Harvey Karp’s “Happiest Baby” book, I’ll admit I was a bit skeptical (5). In the end, though, I was comforted by the evidence-based strategies it provided to help soothe my daughter. Swaddling, swaying, darkening the room, feeding, and white noise (or rock n’ roll music) seemed to do the trick every time, essentially recreating intrauterine life that is naturally warm, dark, noisy, and always on the move. It brought together so many of
the aforementioned concepts that human newborns are not only ill-equipped to survive relatively short times alone, but that they still respond to the world around them as if they were still in utero (6). As a father, I felt empowered with some skills that could actually provide a semblance of care typically reserved for nursing mothers.

Then came that mythical 6-week mark that has become the arbitrary cutoff for the postpartum period. While my wife had the foresight to request three months of maternity leave, the majority of that time would turn out to be unpaid. On top of that, she would later be required to pay back that time by extending her training and graduating two months late. Suddenly, she found herself essentially alone because I had to return to work with no more vacation, sick
time, or personal days left to use. With persistent perineal pain and baby blues that seemed to deepen with more hours spent alone, the 4th Trimester began taking a turn for the worse. The concept of a village helping raise a child could not have felt further from the truth. Ultimately, through what seemed to be sheer will and determination at times, we weathered the storm and survived intact. I don’t doubt for a second that our privilege, socioeconomic status, and combined education provided an advantage for us. What is terrifying, though, is thinking of the number of women and new families that not only lack those advantages but who may have already entered pregnancy at a distinct disadvantage.

Ask any obstetrician where this six week postpartum paradigm came from, and you’ll get a variety of answers: historically, it’s the time when menses typically returns, hence women are now back to “normal”; the risk of preeclampsia is virtually zero; it stems from practices that historically mark 40 days as part of religious or cultural norms (7). While the truth is likely to be found somewhere within these beliefs, it’s become apparent that this “six-week” mark is not only arbitrary, but likely does more harm to new mothers, newborns and their families than we ever imagined before. Beyond incomplete physiologic and psychologic healing, there is an increasing body of evidence pointing to the economic and social damage from frequent sick day requests, decreased job satisfaction, and lower employee retention attributed to inadequate family medical leave policies (8). In terms of childcare, all one needs
to do is observe the developmental leap an infant finally takes at roughly three months of age to realize the intense care needed leading up to that point. Yet, somewhere between harnessing fire and curating our lives on social media, the lessons learned by our prehistoric ancestors have seemingly been lost upon modern American society.

While we have made amazing strides in addressing pregnancy complications and modernizing intensive neonatal care, the overall support for new parents and their families continues to erode in the face of widening socioeconomic disparities, weakening worker protections, and persistent healthcare inequities (9-10). The current state of family medical leave in the United States remains appalling compared to nearly every other industrialized nation.
Combined with compensation plans that disincentivizes postpartum care, disjointed healthcare safety nets that typically terminate six weeks postpartum and persistent barriers to healthcare that place undue burden squarely on women of color and other marginalized populations, it’s no wonder we continue to see research and headlines pointing out America’s abysmal international standing when it comes to maternal and childhood health measures
(11-15). When put into the context of our nation’s overall wealth and healthcare expenditures, it makes these facts all the more damning.

As perinatal healthcare providers, from preconception and pregnancy through postpartum and infancy, it falls on us to start bridging the gap between established prenatal paradigms and the biologic and social importance of 4th Trimester care. On a provider level, the American College of Obstetricians and Gynecologists has taken the first step in broaching the subject to a wider audience by publishing Committee Opinion No. 736, “Optimizing Postpartum Care,” in May of 2018(16). In this document, the argument for extending obstetric care to 12 weeks postpartum is made by citing improved surveillance for pregnancy complications, greater opportunities to promote breastfeeding, increased utilization of contraception, and seamless transitioning to well-woman care. In terms of advocacy, education and public policy, organizations such as 1,000 Days, The National Partnership for Women and Families, and 4th Trimester Project out of UNC have created invaluable resources and initiatives that further the call for paid family medical leave, equitable healthcare, and respect for reproductive rights.

On a personal level, I have not only begun restructuring my own practice to incorporate greater postpartum care in my most complicated patients, but I am proud to be the President of the National Perinatal Association as we continue moving this conversation forward at our annual conference entitled “Perinatal Care and the 4th Trimester: Redefining Prenatal, Postpartum and Neonatal Care for a New Generation” taking place March 25-27, 2020 at
Children’s Hospital Colorado. As an inclusive, multidisciplinary organization that provides an equal voice to parents and families, NPA is uniquely positioned to not only leverage the expertise of perinatal and neonatal providers but also to maintain genuine connections to parents and grassroots advocates. We will be exploring 4th Trimester topics ranging from improving access to postpartum care and lobbying for paid family medical leave to modernizing our perspective on infant, parental, and maternal mental health. The meeting will culminate with a series of presentations aimed at improving our understanding of optimal infant feeding and developing nationwide best practices. Combined with our poster presentations and breakout sessions, it is a conference aimed at networking and creating connections across disciplines as much as it is meant to be didactic and informative.

Ultimately, I hope to continue harnessing my own experience and expertise to improve the lives of my patients and their families as they navigate pregnancy and the 4th trimester. Taking into account the advances we have made in so many other areas of medicine that seemed foreign to us only decades ago, I have confidence we can start incorporating the information from phylogenic cues handed down to us for millions of years into equitable standards of care for generations of new and expecting parents to come. As a society, we truly can’t afford anything less.

References:

1. Trevathan WR. Human Birth: An Evolutionary Perspective. New Brunswick; Transaction Publishers, 2011.
2. Nguyen N, Lee LM, Fashing PJ et al. Comparative primate obstetrics: Observations of 15 diurnal births in wild gelada monkeys (Theropithecus gelada) and their implications for understanding human and nonhuman primate birth evolution. Am J Phys Anthropol. 2017; 163: 14– 29. https://doi.org/10.1002/ajpa.23141
3. Rosenberg K, Trevathan W. Birth, obstetrics and human evolution. BJOG: An International Journal of Obstetrics &
   Gynaecology. 2002; 109: 1199-1206. doi:10.1046/j.1471-0528.2002.00010.x
4. Rosenberg K, Wenda R, Trevathan W. Evolutionary perspectives on cesarean section. Evolution, Medicine, and
   Public Health. 2018 (1): 67–81. https://doi.org/10.1093/emph/eoy006
5. Karp, H. The Happiest Baby on the Block; Fully Revised and Updated Second Edition: The New Way to Calm Crying and Help Your Newborn Baby Sleep Longer. Bantam; Revised, ISBN-10: 9780553393231
6. Parga JJ, Bhatt RR, Kesavan K, Sim M, Karp HN, Harper RM, Zeltzer L. A prospective observational cohort study of exposure to womb-like sounds to stabilize breathing and cardiovascular patterns in preterm neonates, The Journal of Maternal-Fetal & Neonatal Medicine. 2018; 31:17, 2245- 2251, DOI: 10.1080/14767058.2017.1339269.
7. Eberhard-Gran M, Garthus-Niegel S, Garthus-Niegel K, Eskild A. Postnatal care: a cross-cultural and historical perspective. Arch Womens Ment Health 2010;13:459–66.
8. Tully KP, Stuebe AM, Verbiest SB. The fourth trimester: a critical transition period with unmet maternal health needs. Am J Obstet Gynecol 2017;217:37–41.
9. National Partnership for Women & Families. Paid family and medical leave: a racial justice issue – and opportunity. Issue Brief: August, 2018. http://www.nationalpartnership.org/ourwork/resources/economic-justice/paid-leave/paid-familyand-medical-leave-racial-justice-issue-and-opportunity.pdf
10. Bartel AP, Kim S, Nam J, Rossin-Slater R, Ruhm C, Waldfogel J. Racial and ethnic disparities in access to and use
    of paid family and medical leave: evidence from four nationally representative datasets. Monthly Labor Review, U.S. Bureau of Labor Statistics. January 2019. https:// www.bls.gov/opub/mlr/2019/article/racial-and-ethnic-disparities-inaccess-to-and-use-of-paid-family-and-medical-leave. htm 5
11. U.S. Bureau of Labor Statistics. National Compensation Survey: Employee Benefits in the United States, March 2018. https://www.bls.gov/ ncs/ebs/benefits/2018/employee-benefits-in-the-unitedstates-march-2018.pdf 4
12. Ajinkya J. Who Can Afford Unpaid Leave? February
13. https://www.americanprogress.org/issues/economy/news/2013/02/05/51762/ who-can-afford-unpaid-leave/ 6
14. U.S. Department of Labor. Family and Medical Leave in 2012: Detailed Results Appendix. Revised 2014 (Exhibit
    DR6.4.1). Retrieved from https://www.dol.gov/asp/evaluation/fmla/ FMLA-Detailed-Results-Appendix.pdf
15. Chzhen Y, Gromada A, & Rees G. Are the world’s richest countries family friendly? UNICEF, 2019: https://www.unicefirc.org/publications/pdf/ Family-Friendly-Policies-Research_UNICEF_ 2019.pdf 3
16. Maternal Child Health Bureau, HRSA: https://mchb.hrsa.gov/ whusa11/hstat/hsrmh/downloads/pdf/233ml.pdf
17. Optimizing postpartum care. ACOG Committee Opinion No.
18. American College of Obstetricians and Gynecologists. Obstet Gynecol 2018;131:e140–50. https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Optimizing-PostpartumCare?IsMobileSet=false

Disclosure: The National Perinatal Association www.nationalperinatal.org is a 501c3 organization that provides education and advocacy around issues affecting the health of mothers, babies, and families.