There is a big hurdle that women seeking perinatal mental healthcare have to cross to get help. And the hurdle is more like a gap. A gap in the system that exists between the mom needing help and actually getting help.
This fact seems so obvious that it almost washes over you – a supposedly meaningful statement that seems lacking in meaning. So let’s break it down, because understanding this black hole is important, and could mean everything.
A key word is Points of Contact. Points of Contact in healthcare need to have both quantity (enough of them to meet the healthcare needs of the community) and quality (they need to be effective at detecting illness).
When considering perinatal mental illness, POC to the healthcare system need to be a) large in number, and b) familiar with perinatal mental illness.
In the Western World, with good access to healthcare, the first criterion is often met. There are usually enough points of contact to go around, with of course the exception of many rural and remote communities. After having her baby, moms come fact-to-face with the healthcare system and other community supports, starting right in the hospital: the delivering doctor, her obstetric nurses, the public health nurse, the lactation consultant, the lab technician at 7am, the Welcome Wagon lady, etc.
But that’s where the ball seems to get dropped. Despite due diligence to mention ‘the baby blues’ at discharge, distribute pamphlets, ask the right questions, and so on, many healthcare teams are just not that skilled at picking up on perinatal mental illness. And even when the Nurse Practitioner at the 6 week checkup, the LPN checking the caesarean stitches, and the public health nurse conducting the well-baby visit feel something is off, many times nothing really ends up getting done. The entire process is awkward and full of healthcare desk-shuffling:
“The causes of postpartum depression can be complex, but… call this number.”
“If your symptoms last more than 14 days… call your doctor.”
“I’m not really the expert on that, so… here is an appointment in 4 weeks.”
What if I do *that* and they take my child away from me?… And put me in the hospital?… What if everyone finds out I’m sick?… What if they don’t understand that I’m having scary thoughts but I would never do anything to hurt my child?… But those aren’t really my symptoms… so do I not have PPD?
There is such grayness of information given out on postpartum mental illness, and a lot of quiet tip-toeing around the honest truth. Possible symptoms to watch out for are given out in hints and clues. Not a lot of dig-down-deep descriptions are really available unless you go online and find a comprehensive and compassionate list like The Symptoms of Postpartum Depression and Anxiety in Plain Mama English on Postpartum Progress.
I will use a statistic from my own health region. In 2013, 40.6% of at-risk mothers screened for postpartum mental illness DECLINED referral to a professional.
The obvious next all-important question is: Why?
Because healthcare does not deserve the trust of its patients, that’s why.
I’ll say it again: healthcare does not deserve the trust of its patients, least of all its female patients. As to why this would be, go and read this book this book or this book.
Healthcare needs to repair this relationship. And earn the trust of the people it serves.
Burden of responsibility cannot be placed on a suppressed minority of sick women.
And when patients don’t seek help, the system must not be allowed to simply shrug its shoulders at those who are too scared and ashamed to get help and say, it’s not our fault they should have said something.
Not good enough. Not Good Enough.
We need a new Point of Contact for perinatal mental illness. Not another faceless hotline. Not another pamphlet. We need more mental health trained professionals on the ground. In some communities (mostly large ones with resources and a garden of educated professionals) this is already being done or piloted.
Because a lot of family physicians and nurses are tapped out. The disease burden of chronic illnesses in older generations is taking up a lot of their time. They are doing the best they can, but you just cannot be a generalist and a specialist at the same time. Public health nurses, for one, already have a library of black and white papers to give new parents on vaccinations, and vitamin D drops, and breastfeeding tips, and how many wet diapers a newborn should be having, and on and on and on. Maternal mental health gets put on the back burner again and again.
Healthcare responds to fires, and works in dollars. In the eyes of the healthcare system, if you don’t vaccinate your children, there could be a measles or mumps outbreak. If you don’t practice healthful eating, you are at risk for developing obesity or diabetes. All of those things are expensive. They are also relatively easier to trace from behaviours to outcomes.
But the consequences of untreated perinatal illness? Much more subtle and insidious. It has both roots and branches. The repercussions can echo through generations. Until it can no longer be determined where the health of a family or a community began to turn down.
The good news is that the wisdom of primary and preventative healthcare has been gaining ground in the last few years. Community mental health is deterministic of many health outcomes. Sometimes illnesses seen in the hospital are just end results of bigger problems that human beings medicate for years with food, alcohol, smoking and other coping behaviours. You could compare those illnesses to symptoms of a broad condition. And though focusing healthcare delivery on acute care is necessary to stop the bleeding, at times it is sort of like mopping the floor before someone walks over it with muddy shoes again, and at worst, a bandage solution to a deeper problem.
So where is a great place to start? Where is a great place to focus preventative efforts that will have a big impact?
Politicians and ‘new baby’ cards pay great lip service to moms, but when statistics like 1 in 7 get thrown around, many healthcare providers look away. They avoid that awkward conversation and remind mothers of their scheduled bloodworks and ultrasounds and checkups. Because those are things they can control.
Mental health is much more slippery. Like a can of worms. And a can of worms is the end result of a problem going untreated for too long. Healthcare might not be able to support the overwhelming need and cost of everyone suddenly receiving the mental health treatment they deserve. That is the dirty little secret of the system.
Because mental illness doesn’t result in direct injury or mortality, it gets ignored, unless someone is sick enough that they need urgent care. Dollars are saved on the backs of moms quietly suffering. That phenomenon is what colours the gap in even darker – how mothers go from being at home to acute psychiatry overnight with no health history in between.
So what do we do?
I’m a nurse so my background is going to influence this answer. Other disciplines will have great solutions. I will speak to the idea I can visualize best, given my personal experience.
Enter the Community Maternal Mental Health Nurse/Counsellor/Social Worker/Physician/Doula
- disseminate updated informational material
- postpartum well-mother visits/follow-up care
- leading or joining an existing collaborative action team of postpartum mood disorders in the community
- leading a patient mom-and-baby peer support group
- speaking at or holding a forum/class/telehealth conference(s) on postpartum mood disorders for the public or other healthcare providers
- mental health history and intake of mothers
- referral to other disciplines in the healthcare team
- introducing and offering care/information to mothers who have delivered in hospital or at home (much the same way a lactation consultant or public health nurse would check in)
- supporting and providing women with information on mental health medications and reporting back to prescribing physicians on how it’s going
These practices are indeed today filled by many professions, and this hypothetical person is just an example of someone who could specialize in delivering this kind of care. Because of their specific and expert role, mothers might be more comfortable in disclosing to them and beginning to receive help. It also increases quality of care. Less mothers falling through the cracks. Less misdiagnosing. Less misunderstanding. More trust. More compassion. More outreach.
More lives saved.