by Maya Uppaluru
Sleep deprived, irritated, and dehydrated from nursing on demand, I sat in a crowded and noisy pediatrician waiting room and filled out the standard postpartum mental health screening survey, the Edinburgh Scale. I had received the survey four times already at my postpartum checkup with my midwives and at the first few pediatrician appointments. The process was getting repetitive and annoying, as I juggled this clipboard with my fussy two month old baby. But, I was a health care policy professional who believes in supporting new moms. So I took the questions seriously and answered as honestly as my ego would allow.
I have blamed myself unnecessarily when things went wrong. (Yes, multiple times a day, really whenever my baby cried.)
I have been anxious or worried for no good reason. (Yes, sometimes.)
I have been so unhappy that I have had difficulty sleeping. (Um, are other mothers sleeping right now? I don’t even know how to answer this question.)
I have been so unhappy that I have been crying. (Yes, quite often, in fact every morning while my precious infant screams instead of napping.)
And so on. The pediatrician took the survey when I was done, scanned it, and paused. Then she turned to me and said, “Well, you’re mostly doing fine though, right?”
To which I could only answer, “Um, yeah.” Of course, when you put it that way. I was too embarrassed to suggest anything else.
I actually liked that pediatrician. She was great at her job and gave us solid, common sense advice about my baby’s health and development. But she is not a mental health professional, and I’d bet she had little to no training in how to start a conversation about postpartum mental health with the moms in her office. And my baby was her patient, not me.
Postpartum Support International estimates that 15 to 20% of women experience more significant symptoms of depression or anxiety than the typical and temporary “baby blues.” However, I suspect the actual number of women experiencing these symptoms is probably much, much higher – and more of us are speaking out about it. The national conversation around postpartum mental health has grown and evolved in recent years. Celebrities like Chrissy Teigen and Alanis Morisette have been open about their experiences and are helping to normalize discussion of mental health issues. We now recognize a broader category of postpartum mood and anxiety disorders (PMAD), and there’s an increased understanding that mental health issues can arise before birth as well as the weeks and months after birth.
Even with these promising developments, there are still huge gaps in the process for screening, diagnosing, and helping mothers find treatment. The Edinburgh Scale was developed in 1987. It’s great that I received it so many times – perhaps even a policy success. But can we really not do better than a simplistic survey that is over 30 years old? Our answers to these questions are sensitive, and feel equivalent to asking “How do you think you’re doing as a new mother?” Even for someone like me who is so well-versed in health care, the idea of being diagnosed with postpartum depression felt shameful and scary. Those feelings will influence how many of us answer the questions, making it less likely to be an effective tool for screening.
Frankly, I don’t know any mother who would not have benefited from some kind of postpartum mental health support. As my own therapist has reminded me, if you deprive any human of sleep for long enough, they almost certainly will develop depression, anxiety or both – and no one is sleeping less than a new mother, especially if she’s breastfeeding and can’t share the task of night feeding with a partner. Most babies are not sleeping through the night until around six to nine months, and plenty of babies keep their parents up long after that. Perhaps we should go ahead and assume that most new mothers are not getting anywhere near the support they need.
We can and should do better. Here are some ideas of where to start.
Mental health professionals should be routinely integrated into postpartum care. Exhausted and overwhelmed new moms should not be in the position of figuring out how to diagnose themselves. We need more real conversations to uncover mental health issues, where a new mother can take a deep breath, be vulnerable, and feel supported by a professional who has been specifically trained to listen and recognize her symptoms. Given the sleep deprivation, physical recovery, and emotional toll of caring for an infant, mental health support should be a default best practice, which would make it harder for a new mom to interpret her need for these services as a failure. And while most moms I know don’t have time to focus on their own care, they almost certainly are not going to miss their kids’ pediatrician appointments.
Let’s meet the patients where they are. I’d love to see a pediatrician’s office where therapists had regular office hours and could drop in for a kind chat with a new mom instead of administering a paper survey, make a thoughtful referral if needed, and manage follow up to ensure she got the treatment she needed. Unfortunately, mental health care is not always covered or reimbursed at rates that make a strong business model for integrated care. Our health care system must adopt and update payment policies to incentivize user-centered, integrated mental health care for new mothers. The Maternal Health Quality Improvement Act of 2019 (H.R. 4995) would provide grant funding to experiment with more integrated care models, including incentivizing clinical teams “to collaborate across health care settings and disciplines, including primary care and mental health,” as well as other important policies. The Helping MOMS Act of 2019 (H.R. 4996) would also expand Medicaid coverage for a year postpartum, ensuring that more women can receive health care during this crucial time, including for mental health services. If you believe in these policies, write to your representative and ask them to support these bills.
Incentivize participation in support groups. During my maternity leave with my second daughter, I joined a PACE group with twelve other moms in DC. I hadn’t joined such a group with my first child, mostly because I was skeptical that I could forge friendships with other women solely because of our shared experience as mothers. I could not have been more wrong. Our group was all second-time moms, with babies and toddlers around the same age, and it was facilitated by a licensed psychologist who thoughtfully prompted us to discuss feeding, sleep, managing our older children and our marriages, and returning to work.
There is something incredibly comforting about being in this kind of setting when you have a new baby. Someone else’s baby is always crying, refusing to eat, blowing out her diaper, or spitting up. We were all going about parenting in different ways, yet we had more in common than not. It normalizes all the weirdness that you are dealing with at home, and gives you a space where you can let your guard down and not worry so much about whether you appear to have it together. Yet participation in the group was expensive, and we were all extremely privileged to even have maternity leave and time to participate in such a group. We need to find a way to make this kind of support accessible to women at all income levels. Approaches could include allowing health savings account funds to cover the cost of participation in these groups, or employers and insurance companies working together to offer coverage for participation as a preventive health benefit.
Check on your new mom friends, even those who seem like they’re pros. I assumed I’d be less stressed and more confident with my second child, since I’d already been through it all before. But now that I have two children, the guilt and feelings of overwhelm have been going strong since the day we brought the baby home from the hospital. I have less anxiety about some things: I don’t take the temperature of her bath water; I haven’t sanitized any of her bottles or toys; I don’t hesitate to bundle her up and take her out for a walk if it’s 45 degrees outside. But I’ve had more generalized anxiety this time around than I did with my first. Time, energy, and patience feels scarce. It’s this pervasive fear that there’s not enough of me to go around, not enough of me to make both my children feel safe, special, and loved. It’s those moments when my baby needs to nurse and my toddler wants to be picked up and I’m dying for a glass of water and my husband is trying to ask me a question about something logistical. I feel like I’m failing everyone, all at once. And I only just returned to work, as my daughter turned 4 months old. These are tough years, and we should all extend empathy and caring to each other (as well as compassion toward ourselves). Here is a great list of things anyone can do to help a new mom in their lives; and for any new moms reading this, check out Kristin Neff’s work on self-compassion.
All parents need at least six months of paid family leave. I couldn’t compile any list of recommendations about postpartum mental health without this obvious fact. Women across this country are going back to work while they are still bleeding from delivery. Even for those that do have paid leave, they are most often struggling at home in isolation, because their partners most likely don’t have the time off to be with them. Caring for a helpless infant is not a one person job, and mothers were never meant to be alone in this process. We should follow the lead of every other industrialized nation and give both parents an appropriate amount of time off work to care for their newly expanded families.
I’m lucky to have had a relatively long paid leave, the most excellent friends both at work and in my community, and the resources to pay for the support I need. Most women are not in this position. We have to do better, and all mothers should expect more than a health care system that allows so many to fall through the cracks.
Maya is a health care attorney and former policy advisor in the White House Office of Science and Technology Policy. She served in policy and innovation roles at the U.S. Digital Service and the Department of Health and Human Services. She is also a freelance writer on parenting issues. She lives in Washington DC with her husband and two daughters. Opinions expressed are the author’s own.