Why the Standard Six-Week Postnatal Check Is Not Enough

By Amber-lee Buendicho

@thepowerofbirth

Six weeks is a long time when you have just had a baby.

In those six weeks, a mother may be recovering from major abdominal surgery, stitches, tearing or pelvic floor injury. She may be trying to establish feeding while functioning on very fragmented sleep. She may be experiencing pain, bleeding, wound concerns, mastitis or difficulties with incontinence. She may also be trying to understand a birth that did not go as expected, even traumatic, navigating an enormous shift in identity, experiencing intrusive thoughts or anxiety, learning how to mother and care for an infant, adjusting to a whole new level of mental load, baby blues, or beginning to recognise that what she is feeling might be more than the expected emotional adjustment to becoming a mother.

And yet, for many women, there is still a sense that after discharge from maternity care, the next significant maternal health milestone is the six-week postpartum check. Not to mention the standard care during this check is usually checking on baby, possible a wound, and discussing contraception. But the problem isn't necessarily the six-week check. We absolutely need early care postnatally. The problem is expecting one appointment at six weeks to carry so much of the responsibility - beyond contraception.

A lot happens before six weeks.

The early postpartum period is not a waiting room between birth and recovery. It is a period of enormous physical, psychological, biological, and social change. Many of the issues women need help with do not wait until their six-week appointment. In fact, research examining patient-initiated healthcare contacts before the routine six-week visit found that women were already seeking help during this period for postpartum concerns. This makes intuitive sense.

If breastfeeding hurts on day four, support at six weeks is late.

If a caesarean wound looks concerning at day seven, support at six weeks is late.

If a parent has not slept in 48 hours, support at six weeks is late.

If a woman is frightened by intrusive thoughts at two weeks postpartum, six weeks can feel like an eternity.

If she is overwhelmed, traumatised, unable to sleep even when presented with opportunities to do so, struggling to eat, crying every day or beginning to believe she is failing as a mother, we should not need her to deteriorate further before someone asks how she is going - if the six week check even does that!

Mental health doesn't begin at six weeks.

Postpartum mental health deserves particular attention here. Depression, anxiety, trauma symptoms and other psychological difficulties can emerge during pregnancy or at any point after birth. Screening at six weeks can be useful, but a screening tool is only useful when it is offered at the right time, with a trusted clinician, within a system capable of responding to what it finds.

We know that earlier contact creates an earlier opportunity to notice when someone is struggling. It creates space to ask about mood, anxiety, sleep, intrusive thoughts, coping, social support, birth experience and adjustment to parenthood. And if everything is going well? Wonderful. Postpartum care does not have to exist only when something has already gone wrong. Research also indicates that earlier support matters for feeding too. The first few weeks are also a critical period for establishing breastfeeding for mothers who choose to breastfeed. We know that women who receive early postnatal contact are less likely to stop breastfeeding during the first four to six weeks. Again, this makes practical sense. Feeding difficulties usually require support while they are happening, not several weeks later.

More appointments alone aren't the answer.

This is an important distinction. The evidence does not tell us that adding more appointments automatically fixes postpartum health. It's not necessarily about the number of appointments but more about what would meaningful, responsive and continuous postpartum care actually look like? Because a five-minute phone call that asks about the baby but never asks about the mother is technically a contact. That doesn't necessarily make it good postpartum care.

The six-week appointment is being asked to do a lot

There is another practical problem with relying heavily on one consultation. There is so much to cover.

Physical recovery. Bleeding. Pain. Perineal healing. Caesarean recovery. Pelvic floor symptoms. Feeding. Breast health. Sleep. Contraception. Sexual health. Mental health. Medication. Chronic health conditions. Birth complications. Social support. Family violence and safeguarding. Adjustment to parenthood. And somewhere amongst all of that, we need to ask: How are you?

Research exploring the six-to-eight-week maternal postnatal consultation found both women and GPs describing limitations around the timing and content of the appointment, including the challenge of addressing numerous maternal needs within the consultation. Perhaps the problem isn't that clinicians aren't asking enough. It seems we are asking one appointment to do too much.

The World Health Organisation (WHO) does not recommend waiting until six weeks for routine postnatal care. Its current guidance recommends a minimum of four postnatal contacts for healthy women and newborns: care during the first 24 hours, another contact at 48–72 hours, another between seven and 14 days, and another during the sixth week after birth. It is recommended the timing and number of contacts should then be adapted according to the needs of the woman and baby.

We need to stop treating birth as the finish line

During pregnancy, women are monitored repeatedly, with a standard practice of 10 appointments. We check blood pressure. We order blood tests. We monitor symptoms. We ask questions. We discuss changes. We assess risk. We prepare for birth. Then birth happens. Why are we slowing down care now that that baby has arrived? If anything, it's a reason to increase care. The postnatal period can be complex.

And for some women, complications of pregnancy and birth are only beginning to reveal their longer-term impact. 1 in 5 will experience a perinatal mood and anxiety disorder, up to 45% of mothers perceive birth as traumatic, roughly 80% of mothers experience intrusive thoughts, 2 in 1000 mothers experience postnatal psychosis, and suicide is still the leading cause of death in the first year postpartum.

Postpartum care should reflect this reality.

This doesn't necessarily mean every mother needs intensive medical intervention postnatally. It means there should be multiple opportunities for someone to notice, ask, listen, screen, reassure, educate, treat or refer when necessary. Because six weeks is an important checkpoint, but it shouldn't be the first time we check on the mother.

When we know better, we do better. We need to do better.

By Amber-lee Buendicho

Registered Psychologist

Listen to the podcast Can We Talk About This? wherever you get your podcasts.