'A Silent, Unmet Need': Rural Motherhood and the Challenges of Postpartum Care

by Gretel Kauffman

Hattie Courtford spent the first six months of motherhood like all new parents: "running on adrenaline and sleep deprivation." In those early months, she felt fine — as fine as anyone adjusting to the exhaustion and chaos of new parenthood can feel — but half a year in, something changed.

"All of a sudden it was like I hit a brick wall of postpartum depression," Courtford recalled, accompanied by "this stigma of feeling like I should have this figured out by now. And that kind of spiraled into these feelings of rage and resentment. Like, 'Why am I struggling so much?'"

With the support of her partner and midwife, Courtford sought help for her depression, and was able to prepare for a potential second wave with the birth of her next child two years later. In the meantime, friends suggested that she get involved with the Postpartum Resource Group, a nonprofit organization serving new mothers in her home of Flathead County, Montana. Through a peer-led support group, a local network of postpartum doulas, and a fund for new families in need, the organization is encouraging women in rural Flathead County to prioritize their own health and well-being after giving birth — and ensuring that they have the resources to do so.

"It's so important to normalize the reality that whether or not you are diagnosed with a mood disorder, if you're a mom you need support," said Courtford, who now serves as Executive Director of the Postpartum Resource Group and works as a postpartum doula herself.

Maternal mortality rates in the United States have more than doubled in the past 25 years, with more than half of those deaths occurring in the twelve months following childbirth. Black mothers and Indigenous mothers are especially at risk, accounting for a disproportionate share of maternal deaths nationally.

The year after giving birth is an especially critical period for detecting, preventing, and treating potential health complications, research shows. But many postpartum patients don't get the care or support they need, doctors and researchers say. And in rural communities, as a growing number of hospitals shutter their maternity wards or close altogether, accessing care has become increasingly difficult.

Postpartum checkups are important for the detection of common medical complications such as diabetes, hypertension, and cardiomyopathy, and they can also be a lifeline for women experiencing less detectable — but equally dangerous — challenges. Suicide, homicide, and substance use account for more than one in five maternal deaths — and with rural women at higher risk of experiencing postpartum depression and intimate partner violence during the perinatal period than their urban counterparts, thorough and timely postpartum screenings and interventions are all the more crucial.

Still, postpartum health remains a largely understudied and underdiscussed subject in the world of maternal care, said Julia Interrante, a Research Fellow at the University of Minnesota's Rural Health Research Center who studies rural postpartum risks and outcomes.

"There's a lot of research and data collected on prenatal care, but very little about the health of the mothers after they give birth," Interrante said. "And the health of the mother is also very important for the health of the family, the health of the baby, and society as a whole."

The 'Postpartum Cliff'

A drop-off in care and support following delivery is not a uniquely rural phenomenon. Mothers across the U.S. experience what researchers Jessica Cohen and Jamie Daw described in a 2021 op-ed for JAMA Health Forum as the "postpartum cliff."

"Soon after delivery, patients face a multidimensional postpartum 'cliff,' including insurance interruptions, incomplete handoffs between obstetrician-gynecologists and other physicians, and limited quality monitoring and accountability," Cohen and Daw wrote. "Patients navigate this transition largely unsupported, leaving many opportunities for the disparities present during pregnancy to be exacerbated postpartum."

Traditionally, postpartum care in the U.S. has consisted of one checkup four to six weeks after giving birth. According to the American College of Obstetricians and Gynecologists (ACOG), this isn't enough.

Half of all maternal deaths occur in the postpartum year, and we only address it with one six-week visit.

"Half of all maternal deaths occur in the postpartum year, and we only address it with one six-week visit," Interrante said. "That's way too late to address some of those early issues, like bleeding, infection, breastfeeding initiation challenges, and other difficulties, and way too early to deal with a lot of the long-term issues, like postpartum depression, that can show up after giving birth."

A recommended care plan published by ACOG in 2018 includes a postpartum assessment within three weeks of giving birth, followed by "ongoing care as needed" and a comprehensive 12-week checkup with a "full assessment of physical, social, and psychological well-being." But for many new mothers, the reality is minimal care, or no care at all. A "substantial portion of women" in the U.S. don't even make it to one postpartum visit, one study found.

Transportation, childcare, a family's finances and other social factors can play a deciding role in whether rural mothers receive postpartum care, recent research indicates. And as an increasing number of rural hospitals lose their maternity wards, rural mothers may face additional physical and geographic barriers in accessing postpartum care, Interrante noted. More than half of all rural hospitals in the U.S. no longer offer labor and delivery services, with more than 200 rural hospitals closing their birthing units in the past decade.

"When a hospital loses their labor and delivery unit, they're often also losing the providers who are doing prenatal and postpartum care," Interrante said. For working mothers, low-income mothers, and mothers without reliable transportation or childcare, driving a significant distance to a postpartum appointment "is going to be really challenging."

A 'Stunning' Discovery

In largely rural Maine, where many women must drive an hour or more each way to see an obstetrical provider, distance stands in the way of more comprehensive care for many postpartum patients, said Dora Anne Mills, who oversees the Maine Rural Maternity and Obstetrics Management Strategies (RMOMS) network in her role as Chief Health Improvement Officer for MaineHealth.

"We've lost a third of the maternity units in our rural hospitals, so the travel distances are sometimes enormous," Mills said. "Then people go to one postpartum checkup and think they're done."

The Maine RMOMs network, which includes both small rural and larger urban hospitals across the state, is currently looking into potential ways to bridge this travel distance, Mills said, such as through telehealth or by having providers from delivery centers visit hospitals without maternity units to provide on-site care.

In the meantime, the network is turning its attention toward what has emerged as the most pressing concern for perinatal women in rural Maine: mental health.

Research suggests that rural women are at higher risk for postpartum depression than women living in urban areas, and that stigmatization, a lack of awareness around perinatal mood disorders, and isolation may exacerbate the geographic challenges of accessing postpartum mental health services in rural and remote communities. In Maine, an initial survey of statewide data in 2022 by MaineHealth suggested that obesity and diabetes might be the most urgent issues facing perinatal women in rural areas — but a more in-depth look at the numbers, coupled with rural provider interviews, told a different story.

It was like this silent unmet need.

"When we did a full evaluation, it was just stunning," Mills said. "When we started asking rural perinatal providers about unmet needs, mental health came out way on top as the highest priority. It was like this silent unmet need."

Response to a statewide perinatal mental health ECHO program launched in 2023, which gave rural providers across Maine the chance to learn from a perinatal psychiatrist and other specialist presenters in virtual meetings, confirmed the need.

"We thought it would be kind of a niche [ECHO program]," Mills said. "But it's probably the most well-attended ECHO we've ever had."

Participants, who include primary care physicians, nurse midwives, clinical social workers, and psychiatric providers, have shed more light on the challenges facing rural providers and their perinatal patients, Mills said: hesitation from primary care providers to prescribe psychiatric medications to pregnant or postpartum patients; a lack of local mental health providers; and insufficient training and expertise in perinatal health among clinical social workers.

"Providers told us repeatedly: 'I have no training in perinatal mental health,'" Mills said. "And so they were desperate to get that knowledge."

With funding from a federal RMOMS grant, MaineHealth is also launching two telehealth programs to bring specialist care to pregnant and postpartum patients across the state, relieving rural patients of some of their travel burden. The programs — one of which is focused on perinatal mental health and the other on perinatal nutrition — will connect patients in rural Maine to out-of-state perinatal psychiatrists and dietitians. The programs were created with rural patients in mind, Mills said, and will prioritize mothers living in rural communities.

"As you know with rural states, it's very challenging to recruit and retain professionals," Mills said. "For us to have access to those types of providers [through telehealth] is great. We're no longer limited by the geography of people living here."

Bringing Postpartum Care Home

As maternal death rates rise in the U.S., some mothers are especially at risk. Black women are three times more likely to die from a pregnancy-related cause than White women, according to the Centers for Disease Control and Prevention; this disparity is also reflected among Black and White women living in rural areas.

American Indian and Alaska Native women are also disproportionately at risk: Indigenous women are twice as likely as White women to die from pregnancy-related causes, research shows, and severe maternal morbidity and mortality rates are higher for rural Indigenous women than urban Indigenous women. Among rural Indigenous women who give birth in a hospital, more than 1 in 50 experience severe morbidity or mortality, one study found.

In Georgia, the Morehouse School of Medicine's new Perinatal Patient Navigator Training Program is training laypeople to provide prenatal and postpartum support to Black mothers in rural areas. The program, which graduated its first class this year, aims to "improve health outcomes of vulnerable Black women" and to "promote patient autonomy by providing linkages across a fragmented care continuum," the program's website states. The Perinatal Patient Navigators will help new mothers manage appointments, connect patients with community resources such as food and housing support, and ensure that they remain engaged with the healthcare system throughout the prenatal and postpartum stages.

The Southcentral Foundation's Nutaqsiivik Tribal Home Visiting Program has taken a similar approach to serving Alaska Native and American Indian families in Anchorage, Alaska and the surrounding Matanuska-Susitna Borough. Using the model of Nurse-Family Partnership, a national program that connects nurses with first-time mothers, the Nutaqsiivik program provides home visits to expectant and new families.

Since its founding 30 years ago by a local midwife, the voluntary program has evolved from solely serving pregnant women to serving families from pregnancy through infancy. This includes assessments for maternal anxiety, depression, and other mental and behavioral health needs in the postpartum period, and a subsequent referral to an in-house behavioral health consultant (BHC) if needed.

"If a mom is scoring positive on an anxiety or depression screener, or a nurse case manager senses that something is off or mom is not functioning at her normal baseline level, then they'll consult with [a BHC] and we'll reach out to the mom and offer to do a home visit or meet her in the community," said Jordan Juliussen, a BHC with the Southcentral Foundation. From there, a mother might receive therapeutic interventions from the BHC, or be referred to a psychiatrist for medication management services. Some new fathers have received BHC services as well, Juliussen noted.

Trust and relationship-building — both in individual nurse-family interactions and within the local Native community at large — have been key to the Nutaqsiivik program's success over the past three decades, program leaders say. For Gwendolynn Gabbert, a nurse case manager in the Nutaqsiivik program, that has meant showing up consistently for the mothers she works with week after week, including holding telehealth meetings with women who leave home for several months to fish during the summers.

The moms like to know that somebody's watching out for them and somebody's got their back.

"I ask [mothers] what they need me to help them with, and then I make sure that I do it so they trust me," Gabbert said. "If they don't schedule with me, I reach out to them every single week. The moms like to know that somebody's watching out for them and somebody's got their back."

"Now that they have this relationship with [their nurse case manager], maybe they're sharing things with her for the first time," Juliussen added, "like, 'I think I'm depressed, or I have a trauma history.' And then they've already built the trust with Gwen, so they trust when she connects them with me."

Gabbert, who participated in the program herself as a new mom 18 years ago, said her own experience gave her firsthand insights into what participants want and need beyond necessities such as food, shelter, and health care.

"Sometimes when things are settled, we do fun stuff — things I know they appreciate but they don't get a chance to do, like baby footprints," Gabbert said. "Sometimes it's hard. I know what they're going through."

Building trust in the Nutaqsiivik program can also build trust in the healthcare system at large, added Veronica Hoffman, Administrator of the Anchorage Native Primary Care Center. This trust produces a ripple effect in the community that extends beyond the prenatal and postpartum period.

"Bridging that gap is really important for the Nutaqsiivik program," Hoffman said. "They're there serving that community over that time period and developing those relationships, and then also encouraging [families] to reengage in healthcare overall."

Leaving The Postpartum 'Island'

In Flathead County, Montana — a county of 104,000 people that's geographically larger than the state of Connecticut — providers can refer new parents who present signs of a mood disorder or otherwise need in-home help to the Postpartum Resource Group's local network of postpartum doulas. Doula services, which are provided free of charge, include screening for postpartum depression and other mood disorders, assistance and guidance with newborn care, helping with the care of older children and light housework, and providing general emotional support and a listening ear.

"I like to describe it as if your OB or midwife could go home with you and hold your baby and talk to you about all the things. That's what our doulas want to be able to offer you," Courtford said. "Women who maybe would not have previously gone to a support group or would not have followed up with their doctor or sought therapy might be willing to do so after getting connected with our support group or being seen by a doula and realizing they're not out on an island all by themselves."

The Postpartum Resource Group was founded by a Flathead County midwife in 2016 as a peer-led support group for new mothers, especially those struggling with perinatal mood and anxiety disorders. The organization, which started in the founder's living room, has since expanded to include its postpartum doula network and a fund for new parents in need.

At free monthly support group meetings, members discuss their own postpartum experiences and participate in a range of activities, from journaling to dancing with their babies. Before the meetings, the group advertises on social media and through a text message system, letting people know what the topic of discussion or activity will be that day.

"Letting people know what they can expect when they show up is helpful, I think, in reducing that fear of, 'Oh God, I'm going to show up and they're going to be like, what are your deepest, darkest thoughts?'" Courtford said. "And although there's nothing wrong with showing up and spilling your deepest, darkest thoughts, I think it helps folks to get out of the house and show up somewhere new if they know what they can expect."

While childcare — in the form of a board member volunteering to babysit — is available at the meetings for those who need it, transportation is a "big barrier" for some potential attendees, Courtford said, as is the stigma that some attach to postpartum mood disorders or support groups. Attendance typically ranges from one to six moms per meeting, with some regular attendees. Most new members are referred to the group by their healthcare providers or through word of mouth; the group also provides water bottles to every woman who gives birth at the two local hospitals.

Many of the Postpartum Resource Group's board members have, like Courtford, personally experienced a perinatal mood disorder and "found community through the group," she said: "Then, coming out on the other side of it and being able to come up for a breath of fresh air, realized that they wanted to come back and take a bigger part in helping our organization." Other board members and volunteers aren't parents themselves, but are passionate about mental health generally, she said.

…that really is what keeps us going: the blood, sweat and tears of those grassroots people that just really care about the cause.

"Everyone has their own story and their own lived passion for being involved," Courtford said. "And that really is what keeps us going: the blood, sweat and tears of those grassroots people that just really care about the cause."