What the Culture Is Missing in Maternity Care and Why We're Doing It Differently: A Conversation Between Tribeca Maternity Director Rachael Benjamin and Therapist Emily Stuart

Last year, we launched the new branch of our practice Tribeca Maternity with Senior Therapist Rachael Benjamin as Director. Rachael is a specialist and a leader in the field of maternity and women’s health and through her work, she has witnessed the help women, their partners, and their families typically receive. Her observations on the need for specialized therapeutic attention during maternity are what drove the founding of Tribeca Maternity, which provides a dedicated focus on the emotional experiences related to family planning, trying to conceive, infertility, pregnancy, childbirth, and new parenthood (all of which we reference under the term “maternity.” Read more about our use of maternity here). 

A therapist with Tribeca Therapy, Emily Stuart has been a part of the Tribeca Maternity team since its beginning. Emily recently joined Rachael for a conversation about what is lacking in the culture around maternity care and how Tribeca Maternity’s ideas about the help women and their families deserve developed: 

Emily Stuart: How did you get interested in this work in the first place?

Rachael Benjamin: I’ve always had a political edge and have always, even since I was a kid, deeply felt the injustice of systems. I thought about becoming a community organizer when I was in school. But then, I discovered that I loved practicing therapy and that therapy has a place for social justice in helping people’s suffering. As I got more into therapy, I found that women were being left alone postpartum in a way that felt like we, as a culture, must be missing something. I also became pregnant. As a therapist, as well as a pregnant patient, I saw the world personally through a new lens. It felt very medicalized and this made me want to give more space and thinking in my own therapy practice to conception, pregnancy, and postpartum work.

Emily: Can you say more about what it means for women to be left alone? What has the culture been missing?

Rachael: Women have no actual professional follow-up care or plan until six-weeks postpartum. That in and of itself is upsetting. Women in our culture tend to be just handed a “Great! You had a baby. Go be happy!” card. But what if they don’t feel happy? Or they feel scared, worried, or just plain overwhelmed? These are all reasonable responses. But instead, we ask them to go it alone and just be happy. 

Our culture misses that women feel complex things during maternity. Maybe they feel several things in one day or maybe they just need to process how they’re feeling so they can find out what they need logistically and emotionally. Or maybe they need to process what the baby is bringing up about them, their marriage, or their life. This is a transition of the self, the family, and the couple. All transitions are complicated and can bring up more than we knew before the transition.

Emily: It sounds like you’re saying that mainstream maternity care is somewhat basic and short-term. Is that right? Before we understand what kind of care Tribeca Maternity's offering, can you tell me about what most mainstream maternity care generally looks like?

Rachael: Most mainstream maternity care is short-term work or support group work. Usually, their focus is to stabilize the mom rather than the entire family. The goals of this type of care are symptom management, being happier, and some form of concrete goals. Symptom management looks like getting more support, meditation, maybe taking medication, and maybe planning your day or your co-parenting support. Support groups are about community with possibly some psychoeducation about symptoms and symptom management. 

The big theme in mainstream maternity care is that treatment usually stops when symptoms are managed. It can look like four sessions or six months of sessions, but it’s thought to be relatively short-term treatment.

Emily: In contrast to the short-term, symptom management approach, can you say more about your approach to care?

Rachael: My approach is psychotherapy. I understand that this individual, couple, or family is in pain. It’s not a symptom or a diagnosis, but a process they are in and coming to get help with. I look at patients’ family systems, family origin, histories, and current day-to-day, as well as how their past experiences play into their present emotional experiences. 

I hold the patient with kindness and curiosity as a person–a human–finding out what they need day-to-day. Then, I create a map or framework for deeper work that could also care long-term for their grief, anxiety, loss, sadness, and anger, as well as the health of their family.

I also believe that how we experience maternity is political and cultural. On top of helping patients in the here and now, I also look at how the here and now affects them, meaning both politics and culture. How we feel about being a parent, becoming a parent, having a pregnancy loss, going through rounds of fertility treatment, or what the postpartum period brings up about us and the environment around us, all of this is informed by culture and politics. It’s not just hormonal.

Emily: That sounds holistic and wonderful. When you say, “all of this is informed by culture and politics,” can you expand on how those two forces are at play?

Rachael: Western culture–America especially–focuses on families being happy, good, safe, and healthy. It’s the center of cultural health. There’s also a very heteronormative, monogamous biological angle to maternity that is hard to escape. This set-up makes people feel negatively about themselves if they are not living up to cultural “norms,” “expectations,” or “projections.” Our culture also tends to move women and families into the medical sphere rather than looking at this moment from a biological, psychological, and social angle. This, then, becomes political because our culture leans heavily on the presumption that there is one way to make a baby, have a family, be pregnant or get pregnant, experience a pregnancy loss, deliver a baby, feed a baby, or operate as a new parent. 

I’m not only coming from a countercultural angle, but I want to really question how healthy and helpful the above prominent culture and politic is. How can each person, couple, or family create their own culture and their own politic, noticing the mainstream culture but also reacting to it in an effort to find what’s best for them? When I talk with patients, I want to uproot the current politics and culture. I look at how it is or is not influencing my patient (or myself) and see how it could be adding to anxiety, grief, sadness, loss, or processing. It’s important to remember the patient–not the culture–is in charge. They can create what works for them in their moment of transition or development.

Emily: I like your framing of maternity as a moment of transition and development. I’m reminded of something you said earlier: “This is a transition of the self, the family, and the couple. All transitions are complicated and can bring up more than we knew before the transition.” Can you say more about how you conceptualize this transition and what makes it complicated/what it can bring up?

Rachael: During maternity, you’re creating, planning, and trying for the next half of your life. There is intention and a lot of unknowns about yourself, your relationship, and your path. And there are a lot of transitions during maternity. From contemplating how your child or family might come to getting ready for the baby to come (whatever that process is) to being pregnant (however it happens) or navigating an adoption or surrogacy process to the birthing process to the postpartum period, you’re shifting as a person, as a couple, and as a family system. You are not losing yourself or becoming something different necessarily, but you are developing. And that’s what a transition is: development. In this one, it includes your body, your place in your social circle, your job, your relationship, your present and past losses, all the transitions that came before, your family of origin, your identity (but not the whole one), and your working with a medical system in which some things are just out of your control.

So with all these things at work, it makes it complicated and can bring up, well, just about anything and everything. It brings up your parents’ experiences with fertility or infertility, as well as your own birth story and family experiences. It brings up how you feel about yourself in the world, your friendships, your family, your relationship, and your becoming a co-parent. In a sense, transitions widen our view on what we’ve experienced, what we are experiencing, and what we need and want. That can feel quite overwhelming, comforting, scary, sad, and retraumatizing. It can also cause us to hide, take it all on, or somewhere in between.

Emily: I can imagine it feeling overwhelming for people to see care as being so comprehensive, even though it's all so important. How do you approach the work so it doesn't feel like so much at once? What do you say to people who want to feel better quickly?

Rachael: I approach the work as one thing at a time. One patient may come in with one thing they want to address that turns into a few things or many; another may come in for many things that turn into one (sometimes it’s somewhere in between). After each initial session, I say, “Let’s create a map of the work so you can leave with a concrete task or understanding of what we’re going to work on.” This way, each patient, couple, or family feels heard, held, and has a task or two that they can focus on until our next session. I also sometimes note that when we meet, we have to take it slow and that’s okay. Sometimes patients have been suffering too long without any support or plan.

Emily: In thinking about your holistic approach and looking at intersecting systems rather than diagnosing an individual, how do you understand the role of partners and families in treatment?

Rachael: Partners and families, including extended families, are paramount to understanding what is going on during maternity. They are a part of every day and nowadays, with how connected we are virtually, every hour. By not thinking about this as a system and instead leaning on diagnosis, we ignore both big and small parts of a patients’ life. Literally everything is happening in the system. It can be the way people relate as they are changing a diaper. It can be the way a family has historically related to the next generation, their own trauma, or their own process of conception, birth, or postpartum building of a family. It can also be the way a family holds each other or doesn’t. For example, an extended family may go at a new mom or partner and say things that are indirectly aggressive in order to uphold the culture or system rather than the new family. I also think about the hope and love a partnership can give to shift a family–they might be the hope and the driver of change.

Emily: What you’re saying about people’s tendencies to uphold cultural norms rather than the new family resonates. Can you say more about how you notice this showing up in your work with more traditional, but also non-traditional families?

Rachael: With families that are traditional, they come in often thinking medical first. It’s understandable. That’s how our culture teaches us to see things: “I’m depressed/anxious/feeling this thing postpartum.” Often in the work, we find out it’s more based in family development or ways in which the new reality of a baby is affecting them. If we look at the individual or couple, I think we can see maybe, just maybe they want to look at how their couple or family functions, even those that function in more traditional ways. They may need to openly talk about how norms affect them and how they have choice, even if they’re choosing to go with the more traditional. There may also be norms they need to disrupt completely and go against the grain, whether gender, sex, or cultural expectations.

For non-traditional families, as well as LGBTQ+ families, there can be such an odd pull by EVERYONE, including therapists, to make maternity a happy time, a known time, and an easy time. And this ignores how mainstream monogamous, heteronormative, cis-normative family culture tries to come in at every turn during this period. There’s a very conscious part of non-traditional families, queer families, and trans and non-binary families to shift the norms in addition to what is going on with the individual or family’s experience of conception, pregnancy, or new familyhood. In therapy, we can talk about all the things you wouldn’t say out loud to friends or even maybe your partner. We can talk about the things you feel deeply about what this experience is bringing up for you in all angles of feeling, grief, or confronting the world’s continued leadership in aggressively promoting this traditional, mostly monogamous, heteronormative culture of parenthood. 

In general, we often think of the way that families work as stagnant and this can affect how we talk (or don’t talk) about issues around maternity. There’s a lot of pressure to hide experiences and make them small or just about the moment rather than allow them to be larger and give them life so we can grow in the transition. For instance, if someone talks about trying to conceive and it’s not taking through sex, there can be an instant heaviness for the individual and/or the couple. There’s so much that goes unspoken, hidden, or downsized. Maybe a patient has to use a surrogate for a number of reasons and nobody can see they are pregnant. The process, complexity, or pain in being pregnant without our bodies showing it is frequently underacknowledged. We also don’t often explore just how people feel about being pregnant in the world. There can be a lot of heteronormative and cisnormative projections around pregnancy, especially for queer people. It’s our job as therapists to slow down to see what these experiences are actually like for our patients and what it’s bringing up for them and their families.