Who’s Caring for Mom? A Perspective on the Maternal Mental Health Crisis
Our country is facing a maternal mental health crisis. Perinatal mood and anxiety disorders which are often referred to as PMADs, such as postpartum depression, are the number one complication of pregnancy and childbirth. In the US, 1 in 7 mothers suffer from PMADs and more than 50% don’t get the treatment they need. I was one of the 50% when I had my second son - yep, not my first. I ended up attempting to take my own life. This is something I never have dreamed about doing at any other point in my life, despite experiencing some low-lows, such as malignant melanoma and chronic colitis. I had postpartum depression and I didn’t even know it. I’m a medical professional and I couldn’t see it because of the enthralling experience of motherhood. I named it everything and anything else - sleep deprivation/exhaustion, body image disturbance, marital issues, work stress, and the list goes on. I reveal intimate parts of my story with you in hopes of shedding light on an under-addressed problem. Our current healthcare system, designed by and for men, fails to appropriately screen, assess, treat, and follow-up on maternal mental health.
“In the US, 1 in 7 mothers suffer from PMADs and more than 50% don’t get the treatment they need.”
Screening is inconsistent
The moment a baby is born within the US healthcare system, the mother’s obstetric (OB) medical record is no longer a part of the baby’s record. The baby is a separate patient with a separate medical record. If a mom wants their OB medical record attached to their baby’s medical record, it is a requested, unautomated process. In my experience, I had to submit a request form to my baby’s pediatrician’s office, pay a $25 processing fee, and wait for a significant period of time. After all that, the end result was a scanned copy of my OB medical record that lives somewhere within my baby’s record. It is unsearchable or filterable. This process is useless when it comes to understanding how the health of the mother is related with the health of their child.
It’s typically up to the mother to follow-up with her OB provider regarding her postpartum care. Recommendations of when to follow up have changed recently leaving many providers in the pregnancy and postpartum space confused as to when a new mother should follow-up. Is it 1 week? 3 weeks? 6 weeks? 8 weeks? So many mothers leave the hospital sleep deprived, some having experienced a 5 day induction or complications like infection or hemorrhage. In the process of caring for their newborn, often the last thought on their mind is, “When do I need to see my OB/GYN again?” They and their partners are not getting discharged knowing the signs of postpartum blues or depression. If they do end up seeing their OB, and only half of women do return for a postpartum visit, they may be recommended to follow-up in 6 weeks so they can give their blessing on being able to have sex and workout again.
To provide more insult to injury, the COVID-19 pandemic hasn’t made screening for maternal mental health issues any easier. Among pregnant and postpartum moms, rates of post-traumatic stress disorder (PTSD), anxiety, and depression have increased to 72% in the last year compared to the general population. Moms don’t feel safe going to the OB office or they feel like their mental health isn’t as important compared to everything else they are dealing with during a pandemic.
Assessment Assumes We Still Live in the 80s
The one time my mental health was assessed as a new mom was in my baby’s pediatrician’s office. It was also only for postpartum depression (PPD). Let me point out that there is no standard for assessing other maternal mood disorders, such as postpartum OCD, anxiety, or psychosis. These diagnoses exist but are perpetually under-recognized and under-addressed. In addition, a survey of pediatricians revealed that less than half of pediatricians actually conducted these PPD assessments, thus, the diagnosis of a maternal mood disorder remains severely under-reported.
If a postpartum mother happens to be one of the lucky ones assessed, they’ll probably receive the Edinburgh Postnatal Depression Scale (EPDS). In my experience, I filled out this questionnaire with pen on paper, in a loud and crowded waiting room, with my newborn in my arms. Additionally, the questions are retrospective, meaning, you have to recall the past to answer them. This is not the most accurate approach to acquiring data nor the right environment in which one can clearly think about their feelings.
The first question begins “I have been able to laugh…”. In my experience when reading this, I felt guilt and shame over whether I have been able to laugh as much or at all during this time with my newborn. I went through miscarriages, injections, and surgery to have him so how am I not continuously joyous over his very presence? I also experienced confusion over the EPDS. After completing the assessment, I had questions like, “Does laughter have a direct correlation to happiness or joy?” or “Do I want to hurt myself and I’m too scared to admit it?” Consider yourself warned that question six which states, “Things have been getting on top of me…” does not mean to ask how many times you and your partner have had sex. Although I do believe there’s a correlation between sex and happiness.
As a new mother, it can be difficult to articulate what you are feeling and why you are feeling it. I’m here to affirm that there are actual biological and chemical changes happening within the postpartum mother that are referred to as the process of matrescence. A mother’s body literally goes through a transition, like a second puberty, if you will. Given the obstacles stated and unstated, mothers deserve a better solution to the way their mental health is currently assessed.
Treatment is Difficult to Access
“If a maternal mood disorder is under-treated, it can disrupt attachment between the mother and infant, thereby contributing to both short- and long-term adverse outcomes for the child.”
The medical assistant quickly tallies up the score of the EPDS and the pediatrician lets the mother know on their way out the door of their seven minute visit their concern about PPD. Here’s the kicker, folks - because they are not the mother’s doctor (they are only the child’s doctor), they cannot continue the evaluation. They have to tell the mother to seek services from their primary care doctor or return to their OB. This means after serving a bunch of fears from both the EPDS assessment and the pediatrician, it’s now on the mother to seek help on their own for a vulnerable issue. Personally, I had a bunch of questions, “Am I capable of taking care of my child?”, “Do I need medication and will it be harmful to my child?” and “Is what I’m feeling even real?”
If I am having these issues as a White, medically educated woman, it can be extremely difficult for an under-resourced, woman of color. One study found that Black, Indiginous, People of Color (BIPOC) women were more than twice as likely to experience postpartum depressive symptoms compared to White women. The risk for Hispanic women was almost twice as high. This is due (but not limited) to racial and ethnic discordance between patients and providers, lack of access to care, and distrust with the medical system due to current and historical oppression and discrimination.
If a maternal mood disorder is under-treated, it can disrupt attachment between the mother and infant, thereby contributing to both short- and long-term adverse outcomes for the child. These include behavioral problems, low self-esteem, poor self-regulation, and an increased risk of impaired mental and motor development. Additionally, untreated mood and anxiety disorders among pregnant women and new moms cost about $14.2 billion for births in 2017, when following the mom and child pair for five years after birth.
Follow-Up Falls Through the Cracks
Follow-up may be the most important step of them all, but is the least likely to occur. Maybe because it’s not as well reimbursed through insurance? Maybe it feels like doing too much? Maybe it’s not done well and deemed not worthwhile? Regardless of the reason, follow-up is not to be forgotten because some medications that address maternal mood disorders can take up to 6 weeks to reach peak effectiveness. If appropriate follow-up is not established from the moment of prescribing treatment, then a mother could stop the treatment before it even has the chance to start working.
“Oath’s model is uniquely positioned to proactively screen beginning in fertility, assess with AI/ML techniques, treat and refer with a wide range of mental health specialists, and continually support and care for moms and their families.”
It begins with where and how we screen for PMADs. Screening can be integrated into mom’s day to day, not reliant on showing up to an appointment or during an already stressful and rushed transaction at the doctor's office. It’s also coming from someone dedicated to caring for mom throughout at least the postpartum year. Assessment happens regularly to identify trends and sudden changes, and the questions reflect current language, culture, and societal norms. Treatment includes the expertise of a mental health professional, social support, and tools for greater self-efficacy. Follow-up is guaranteed to happen (period) and it needs to be consistent as a mechanism to reduce the mother’s burden.
We are way overdue for a solution that answers the fundamental question, “Who’s caring for mom?” It is because of my personal experiences as a mother and professional experiences as a pediatric clinician and scientist that building Oath became my life’s work. We cannot afford to fail our mothers any longer. The future of our families is dependent on the health and well-being of their mothers.