The Fourth Trimester: We Need To Talk About Mothers

“The fourth trimester is pretty fascinating. It was such a haze of hormones and sleep deprivation that when I think of it now it seems like a dream, or as if it happened to someone else. It’s the most intense thing I’ve ever gone through. Such incredible highs and terrible lows."

- Alison, mum of 2, Seattle

What Is The Fourth Trimester?

The fourth trimester. Not everyone has heard of it, but every mother and their newborn will go through it. It's the time between birth and 12 weeks postpartum, and is a process of enormous physical and emotional change as a baby adjusts to life outside the womb, and a woman adjusts to her new life as a mother.

This period of time after giving birth is critical, and should get the same attention as the other three trimesters receive. Instead, the focus tends to be on the baby’s needs.

Alexandra Sachs, reproductive psychiatrist (USA), describes what needs to change in our understanding of the fourth trimester. “Becoming a mom is a profound transformation – socially, biologically and psychologically – and it makes sense that moms feel things other than happiness. We need to normalise that."

For pregnancy and postpartum coach Amy, the fourth trimester is “a sacred window of time that a woman needs to rest and heal from her birth and bond with her baby.”

She advocates for changes in how women are taken care of in this time, sharing that: “Postpartum is sadly neglected in the modern world. Traditional cultures honour and contain the woman after she gives birth as they understand that if the mother is well, the baby will be well, and so the family will therefore be well. Unfortunately, the focus is primarily on the baby."

Amy was one of the last mothers able to give birth at home before lockdown.

"To give birth at home during a pandemic is all I know. So when the midwives left on the evening of March 26th, that was it. We were on our own. In more ways we could have ever imagined. No check ups. No visitors. Nothing."

How Postpartum Care Has Changed

There have been astounding changes in postpartum care at a hospital level, in stark contrast to time spent on beds for victims of other injuries or surgery. One 2019 study in the UK demonstrates this as part of its contextual research.

“A hospital lying-in period of between 8 and 14 days was standard in the 1950s, whereas length of postnatal hospital stay for a woman with an uncomplicated vaginal birth in the UK is now often 1 - 2 days. Over time there have been a number of changes in post-natal care in the UK, the most evident being a reduction in length of hospital stay.”

Many of the changes that have taken place (and are in progress) are overwhelmingly positive in birth preparation. From surgical teams introducing themselves to pregnant women prior to birth to the type of birthing options now on offer.

There are many empathetic, compassionate, respectful birth professionals, who support women in getting what they ask for in the relatively new rise of "birth plans".

Less is known about the impact of the reduction in time allocated for hospitalisation and moving postpartum mothers to recovery rooms as fast as possible, to make space for the next woman who needs to birth. And the message this sends is: once a woman has birthed, she needs to get going.

And of course, with a pandemic and completely different rules in how women birth and what support they receive postpartum, we're in new territory.

The Magic Behind The ‘Mummy Brain’

Ever wondered why so many mothers forget little details and complain of having a 'mummy brain'?

The science behind this is fascinating, and yet another reason why we need to better understand what a woman truly goes through in postpartum. She is, quite literally, becoming a new person on a physical, psychological, hormonal and neurological level.

Giving birth changes a woman's brain, and the science has confirmed it. In 2016, senior neuroscientist Elseline Hoekzema from Leiden University in the Netherlands, published a study in Nature Neuroscience on brain changes in women postpartum.

She and her team performed brain scans on first-time mothers before and after pregnancy and found significant gray matter changes, which were still present two years after birth.

In Dr. Hoekzema’s study, the images showed reductions in gray matter in the hippocampus, which is largely responsible for regulating memory. Instead of focusing on relatively inconsequential bits of information, a pregnant or new-mom brain may reallocate resources to the parts of the brain that control 'theory of mind'. This allows you to figure out what someone else wants and needs.

Dr. Hoekzema says these same areas of the brain also light up when mothers looked at their infants, suggesting that these brain changes might actually promote mother-baby bonding.

With such enormous changes taking place, it makes little sense that the postpartum narrative is so focused on the myth of 'bouncing back', over and above healing, transformation and balance for the mother.

The Superwoman Myth

“We place such a high value on autonomy that most women have the ideal that if they can do everything alone during the fourth trimester, they have succeeded and are a legitimate superwoman.” - Kimberley Johnson, author

There is often an assumption in society that the moment women have a baby, everything returns to normal. And mothers who "get their figures back" and are out and about as soon as possible, are praised. Self-sufficiency and a swift return to 'normal life' are respected. When a mother wobbles, she's quick to be labelled as having postpartum depression, rather than a lack of postpartum care.

According to Kimberley Johnson, author of The Fourth Trimester, we need to radically change how we care for women in this time. “What we need is support for new mothers”, she writes.

“On a systemic level, let’s start with extended maternity and paternity leave - mothers and fathers supported in parenting. Women receive weekly visits from a postpartum doula and a holistic pelvic health care specialist to help with pelvic floor or abdominal healing and re-education. Doctors will tell women to rest for the first 30 days and shelter their new baby.”

So many mothers believe that every waking second should be spent taking care of their babies, and that prioritising their own needs is selfish. Many of us are frightened of postpartum depression and not sure what mental health ‘normal’ looks like.

Alison reflected on the time after giving birth to her first son, Jesse, and the importance of mental health support.

“I do think I suffered from postpartum anxiety with my first that went undiagnosed. Perhaps if I’d been seeing a therapist regularly they may have picked up on it. My doctor checked in about postpartum depression but not about anxiety - I wish more attention was paid to it.”

Amy, who gave birth recently, was mindful of her needs in this time, as far as was possible. “The things that made a difference for us were things like freezing meals and preparing warming foods like stews and broths ahead of time. I also committed to resting as much as possible - I went for my first walk with our baby at three weeks postpartum.

The Fourth Trimester - Second Time Round

Some of the mothers we spoke to shared the difference in postpartum between their first and second baby.

Jess, mother of Jack and Matilda, shared how she changed between the birth of her first and second child. She gave birth at the age of 24, in Italy.

“After the first baby I realised that there is alot of demand on the body to step up and be a provider of all things for your child. I think naturally you give so much because you want to, you don't realise how important it is to care for yourself.

This certainly was the case for me postpartum, in a foreign speaking country. However, second time around I did it differently - having matured, spoken countless times to other mums, midwives, read books and watched TV shows.”

Alison also found her fourth trimester was easier with her second child.

“There was a big difference between my first and second baby. The second time around I actually knew what I was doing and I felt way more confident. I also knew that it would get easier since I’d gone through it before, whereas with my first I thought it would be that hard forever!”

What Do Mothers Want?

The opening introduction to the “BETTER BIRTHS: Improving outcomes of maternity services in England” by Julia Cumberlege offers a platform for the views of mothers.

“We found almost total unanimity from mothers that they want their midwife to be with them from the start, through pregnancy, birth and then after birth. Time and again mothers said that they hardly ever saw the same professional twice, they found themselves repeating the same story because their notes had not been read.”

What mums need and want goes beyond medical care, which is one part of the picture of support and community that makes such a difference.

Alison is a firm believer in giving mothers practical support. “I believe breastfeeding support (doula etc) and someone making sure the mom is well-fed with warming, nourishing meals in the first few weeks is so important. So is family and partner support with practical tasks like house cleaning, cooking etc - so the mom can focus on her baby and her own rest and healing.”

Amy agrees. “I really believe in getting a postpartum doula - it's the best investment you'll ever make! And rest. Rest, rest, rest. Your body and mind will thank you. It's an investment in long term health by honouring this, which is often so difficult for women in the fast paced modern world.

Planning For Your Fourth Trimester

The most important word? YOUR. The fourth trimester belongs to you, and you're in charge (as far as possible!) on what it's set up to be and mean.

A mother figuring out her own needs is where things can go a little fuzzy, because so many women shape shift themselves around everyone else’s wants and opinions.

As a mum, you will have unique needs and wants and hopes! And these are yours to decide. Don’t want your mother or mother-in-law around for the first two weeks? Go for it. Unsure if it’s ‘polite’ to tell your visitors what to bring and when to leave? Say it.

Amy spent time thinking through her postpartum priorities before her birth.

"My partner and I had important conversations about our values, the kind of parents we wanted to be, our boundaries and when we wanted to see people. We knew it was imperative to establish a bond with our baby and our own flow, before having visitors. Then a pandemic hit so that wasn't even an option anymore!”

TIps For The Fourth Trimester

mother holding baby with dad nearby

Write a postpartum plan (we love this one by Tommy's) beforehand to help you think through and prepare before your birth. Just going through this process can help women better understand their own needs and wishes. Having a plan also helps one anticipate difficulties and be prepared to get the types of support one needs. This is even more important in a pandemic!
Plan ahead and buy yourself what you need and what you love for this time. And no, this isn't selfish. While your baby takes up all the attention (and gifts!) it's important to give yourself the treats, clothing, creams and supplies you need to feel comfortable.
Sleep as much as possible. Take naps and ask for help with night feeds from your partner where possible. Ditch the housework (preferably, delegate) and put your head on the pillow whenever you can.
Prioritise your own self-care. It's crucial. And it will be different to everyone - what you love doing for you is unique. Stock up on your favourite books and TV shows. Build in baby-free bubble bath time. Get in foods that bring you comfort and nourishment.
Praise yourself. Praise yourself. Praise yourself. You'll be questioning your mothering and whether you're doing a good enough job. You'll be worrying. And yet the best thing you can do for you is to reflect every single day on just one thing you've done well, that you're proud of. It's not just a fluffy exercise!

Self-praise and validation is proven to change your neural networks. According to one study, affirmations activate the reward centres of the brain. These areas are the same reward centres that respond to other positive experiences, such as eating your favorite food or getting an answer right. Research shows that reward circuits can decrease pain and help you keep your balance when stressed.
Be gentle with your body. Take the time to let your body repair itself at its own pace. Don’t put pressure on yourself to get your pre-pregnancy body back. Listen to your body and get to know it again. It's housed and birthed a human and needs time to recalibrate.
Educate your tribe. This means telling people what you need, and when. Ask for meal deliveries or subscriptions, house cleaning support and clothes or gifts you really want. People love to feel they are really making a difference and value being given direction. And don't feel pressure to take visitors until you're entirely ready and at the level of comfort you're happy with in lockdown.

Amy adds to this. “Baby showers should also be about educating friends about this time. Have people put together a pot of money to contribute to a doula or food packages for after birth. After birth, make sure visitors make themselves useful - this is not a time to host! - and give them friendly time limits."

Finally, Kimberley Johnson sums up her inspired thinking.

“Minimise visitors. Have other people do household chores. Rest when your baby rests. Eat whole foods. Drink enough water. Surrender to the space of non-doing. Write your birth story, with the real emotions, without protecting anyone. For five minutes each day, connect to your breath."

Amen to that.

The Fourth Trimester: We Need To Talk About Mothers

Written by Alex O'Donoghue