Every June, hundreds of obstetric and gynecology (OBGYN) interns across the country ceremoniously receive their long white coats and the postpartum patient list. As a bright-eyed intern, I was eager to take on the challenge of providing postpartum care to women. I felt comfortable counselling about postpartum healing, contraception and could fumble my way through assembling a breast pump. What I did not feel equipped to handle, however, were the complex social circumstances and the critical need for mental health services and resources of our postpartum patients. On one of my first weekend shifts, I was working my way through an admission for a woman in labour. Suddenly the nurse called me into the room—the patient was in the bathroom and feeling pressure. I found the woman standing frozen in the bathroom, eyes wide and whimpering in pain, ‘I think it's coming!!’ She was completely dilated and there was no time for the epidural she desired. I sat on the floor beneath her as the nurse draped me in goggles, gloves and towels. I encouraged her to push as my attending peered in through the adjoining room, also giving her own words of encouragement, I think both to the patient and me. Just a few pushes later, a beautiful baby girl made her way into the world. I passed her precious bundle to her and watched as she took her daughter into her arms for the first time. As she slowly shuffled back to the bed, she made eye contact with her partner and both of them started to half laugh and half cry together. My own eyes welled; this was the exact food for the soul that an intern needed at the beginning of a 24-h shift. Later that night, I was called by a postpartum nurse to evaluate a patient who refused to hold her baby. I was surprised to find that it was the same woman who had the beautiful delivery in the bathroom earlier in the day. I sat on the edge of her bed and gently probed her as she cried. I learned that she had a previous child who had been injured in an accident at home, and she was having intrusive thoughts about her baby being hurt or dying in her care. These thoughts were debilitating; she was having a difficult time taking basic care of her newborn. Fortunately, psychiatry was able to see her before discharge, but what would happen to her when she was home? Would she be able to get an appointment in a timely manner? Who would watch her newborn when she went to her appointment? And would she be able to afford the resources we offered her? These questions lingered and weighed on me as I prepared her discharge paperwork. A few months later, I rotated on our busy antepartum service, caring for women with complex medical conditions in pregnancy. I became close with one patient in particular, a young woman who had preterm prelabour rupture of membranes at 28 weeks. She did not have much family support, and as she spent weeks on our service in the hospital, I got to know her. I learned that she was very spiritual, that she hoped to be able to start nursing school after having her baby, and that she was nervous but excited to raise a child herself. She remained stable and was ultimately able to deliver at 34 weeks. A few weeks after she was discharged, the chaplain who worked with her in the hospital shared with me that the infant had unexpectedly died. I was shocked and so sad for this woman. I wanted to call her but would she want to hear from the intern? Could I be of any source of comfort? It took me a week to gather my strength but finally, I called her to share my condolences. I found myself, however, utterly unprepared for the conversation. She expressed both overwhelming grief and anger at feeling betrayed by her doctors. No one had called her since her baby had passed away. She talked to the paediatricians but those were not her doctors. How could the OBGYN team, the doctors who had taken care of her for weeks, abandon her? I tried my best to respond but she was right—there was not a single telephone encounter since her discharge. I had failed her and so had our healthcare system. I can think of countless other patients whose stories highlight the critical need for individualised and coordinated mental healthcare in the postpartum period, but these two women's stories have stayed with me as I have continued on in my training. The first woman underscores the importance of asking—if you do not ask how a woman is feeling, you cannot possibly know. We were lucky that this woman showed signs of distress while she was still in our care, but how many other women go home with their needs unnoticed and unmet? The second woman underscores the importance of close follow-up, particularly for women with difficult deliveries and negative outcomes. Pregnant women have so much interaction with the healthcare system in the months and weeks leading up to their delivery. Yet in the postpartum period, arguably the most physically and emotionally vulnerable time, most women will not have any follow-up until their postpartum visit 4–6 weeks after delivery. There is a fundamental lack of focus our healthcare system places on the necessity for individualised postpartum care and connecting women to at-home support services and resources. Organisations like the American College of Obstetricians and Gynaecologists and the Society for Maternal Foetal Medicine have long-advocated for Medicaid expansion of postpartum services, including the extension of coverage for 12 months postpartum. The vast majority of states, however, continue to provide coverage for only 60 days postpartum,1 This means that a substantial proportion of patients who are at risk for postpartum depression and mood disorders will lose access to mental health services at a critical time in the postpartum period. As there continues to be limited financial and systemic alignment for postpartum resources and programmes, women continue to suffer. With the support and mentorship of other champions of postpartum care in my department, I set out to try to address some of these issues. Together with a multidisciplinary team, including providers, nurses and social workers, we implemented a universal postpartum depression-screening programme for all women before they leave the hospital. By administering a standardised postpartum depression screen, we hoped to better identify women at the highest risk for developing perinatal mood disorders and expedite referral to resources and services. As we started to screen patients, the list of patients who scored in the high-risk category began to build. We began to see patients who endorsed suicidality, some who had a history of mental health disorders and some who did not. As the screening programme identified increasing numbers of women who could benefit from postpartum mental healthcare, it became necessary to refer them not only to our own psychiatry department but also to community mental health centres. Anecdotally, this was not sufficient as few accepted Medicaid insurance and wait times could be as long as months. Why is it so hard to do the right thing? Why can't we take the best care of women in the postpartum period? The ‘fourth trimester’ is a critical, vulnerable time for our patients. Mental health issues are a significant contributor to maternal mortality and morbidity; new data suggests that suicide and drug-related deaths may account for as many as 30% of maternal deaths in the United States.2 With greater attention both in the lay media and in academia, the importance of this time is finally getting some attention. But it is not enough. Mental healthcare continues to be inaccessible to those who need it the most. It is unacceptable that it continues to be severely underfunded, under-covered, and poorly reimbursed. Patients who can't afford to pay for therapists and psychiatrists out-of-pocket are subject to long wait times. This has only worsened in the wake of the COVID-19 pandemic, which widened the already existing health disparities. No patient should have to wait months to access an affordable mental health provider. Women with severe postpartum depression may not have the luxury of this time. This deficiency in mental healthcare is even more striking among Black women. Black women are significantly more likely to suffer from postpartum depression and depressive symptoms than white women but are also less likely to receive mental health treatment.3 A study that examined Medicaid registry data from New Jersey found that black women diagnosed with postpartum depression were significantly less likely to be prescribed antidepressant medication than white women.4 This striking disparity places Black women at significant risk of harm. How does our system create barriers to care for Black women in the postpartum period, particularly as it relates to mental health? And how do we create intentional change to improve care for Black women? These are the fundamental questions that we must answer to address inequity in our healthcare system. For more information on advocacy initiatives in perinatal mental health and ways that you can get involved, see the work of these organisations: Postpartum Support International: https://www.postpartum.net/ Mind the Gap: https://www.postpartum.net/mind-the-gap/ Maternal Mental Health Leadership Alliance: https://www.mmhla.org/ March of Dimes: https://www.marchofdimes.org/mental-health.aspx What to Expect Project: https://www.whattoexpectproject.org/ We must do better for our patients. Suicide and drug overdose are significant contributors to preventable maternal mortality in the first year after childbirth, in some parts of the country surpassing hypertensive disorders of pregnancy and haemorrhage.5, 6 It is time to prioritise women and their mental health. We must screen all patients for perinatal mood disorders, educate women about postpartum depression, streamline access to mental health services, increase reimbursement for mental healthcare, and expand Medicaid coverage for at least a full year after delivery.7, 8 It is critical to ensure equitable access to these resources, particularly for Black women. Kelly Zafman was responsible for conceptualisation, writing and editing of this study. Aasta Mehta was responsible for conceptualisation, supervision and editing of this study. Sindhu Srinivas was responsible for conceptualisation, supervision and editing of this study. There is no acknowledgement and there was no funding source for this paper. The authors declare no conflicts of interest. No Institutional Review Board was required for this piece, as it did not involve human subjects research. There is no accompanying data for this article.
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Feb 14, 2024
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