Entering the postpartum patient room, my eyes immediately focused on the patient I came to check on. She had her head bowed over her sleeping newborn, and her perfect plaits of braids were blanketing her shoulders, cascading calmly despite the insurmountable turmoil clearly manifesting on her face. Her face — yes, I can still see her face. With tears streaming down her cheeks, she looked at me and I felt a rush of overwhelming heaviness for her.
She had just given birth, and she was all alone. Although COVID-19 guidelines precluded her from having more than one visitor, she was in no danger of surpassing that limit — she was all alone. Her only companions were her tears and newborn. I drew near to her, slowly, seeking her permission to come closer. I paused on running through the postpartum questions I had come in to ask because I wanted her tears to have a place, a safe place.
At that moment, I decided that if the one way I could help her was by offering a box of Kleenex and hearing her story, I was going to do it. I rubbed her back as she cried, speaking aloud about how overwhelmed she was and about her determination to be the best mother she could be. She turned to me, asking for resources or support. I told her that I would work with the team to see what we could find.
As soon as I exited her room, I began to research virtual and in-person support groups addressing postpartum mental health. I was overjoyed to find a local black postpartum mental health support group. I shared this information with her health care team, and we compiled other available resources. I worked with her nurse, and we printed off the class registration and schedule for this patient. Together, we went into her room to share the information this brave new mother knew she needed at this time.
During a course called “The Implications of Mental Health and Health Policy,” which I took as part of my health policy certificate last fall, students were prompted to reflect on the current state of mental health in the United States. The prompt extended permission to explore subpopulations within the United States and policies available to address mental health burdens. I have a soft spot in my heart for peripartum mental health, especially when I think of the patient I met on my third-year clerkships. I believe that the COVID-19 pandemic, isolation, fear of the COVID-19 vaccine and other factors still contribute to making pregnancy an even more overwhelming time.
Griffen et al. discuss that COVID-19 was associated with a three-fold increase in perinatal anxiety and depression among pregnant women. Unfortunately, patients from different racial and economic backgrounds may also find challenges to being vulnerable about the care they need. The prompt we were given during my course took me back to the bedside of the patient I met and challenged me to re-evaluate what I had learned and desired to learn about meeting the emotional and psychological needs of patients. I recognize that preparing to address such needs during hospitalization and postpartum visits through screening, support services, medications and further provisions can help bridge the gap for struggling patients, who may not know where to turn or how to vocalize their hardships.
The U.S. government can aim to improve policies surrounding maternal mental health in the peripartum period and thereby impact the workplace, community and health care systems caring for these pregnant women. I learned that the main U.S. policies that ameliorate maternal mental health include the Patient Protection and Affordable Care Act mandate for postpartum depression screening coverage, the Maternal Health Momnibus Act of 2021, and the U.S. Health and Human Services Call to Action to Improve Maternal Health.
Hospital-wide initiatives and health policies should continue to provide a framework that allows access, affordability and availability to pregnant women and beyond in the postpartum period. Additional support services include Reach Out, Stay Strong, Essentials for Mothers of Newborns and Practical Resources for Effective Postpartum Parenting, which offer opportunities for social support and stress reduction.
I continue to reflect on my experience to this day, and it overwhelms me that I only had one day to interact with this patient. When I returned to my next hospital shift, she had already been discharged. I wish I knew where she was now, and how the support services we found were helpful for her. Beyond her tears, I envision that she is experiencing a rainbow of healing, community, support and freedom from isolation. Her situation has given me sensitivity to risk factors for perinatal depression, to the usefulness of the Edinburgh Postnatal Depression Scale assessment in the postpartum period, and to being willing to share concerns about maternal wellbeing with the team and stay informed about resources available to patients in the community I serve.
Due to my desire to specialize in OB/GYN, I ask myself what I should keep in mind to help my patients, especially the most vulnerable. Through my own research into the current state of mental health amongst women in the prenatal and postpartum periods, I learned to appreciate the role of peripartum mental health disorders on the maternal mortality rate. I felt heartbroken to learn that about 75% of mothers struggle with mental health conditions in silence, without treatment.
In patients of color, there is an increased likelihood of a perinatal mood disorder but a decreased association with attaining the help and services available to address these conditions. Thus, I started to reflect on what I can keep in mind as a physician to best provide support to my patients. I believe that such efforts will require a team-driven relationship between medical professionals, social workers and community-based organizations. Moreover, they will necessitate providing information about available services and updated class registration for patients.
I will also strive to include unique ways to address barriers to care and work on improving cultural competency to best address the possible stigma against seeking health care, especially in the realm of mental health. Such efforts are essential so that when the hospital room doors or curtains are closed, patients never feel that tears are the only company they have in their most vulnerable times.
Image credit: Rainfall Raindrops (CC BY-SA 2.0) by Rubber Dragon