Karen Kleiman MSW, LCSW
This Isn't What I Expected
Healthcare Providers and Your Perinatal Population
Your patients are at risk.
Posted Feb 23, 2018
It has been reported that maternal suicide is the leading cause of death during pregnancy and the first year after birth1. This is why the current shift in attention toward greater awareness to maternal mental health is urgently necessary and long overdue. We are just scratching the surface, and have far to go, but this momentum toward improved care and education can only be seen as positive energy in the right direction.
It has taken a long time and too many women have died.
Many of us in the field would agree that awareness is increasing and medical organizations are responding with attention to improved screening protocols, services, and resources. The advocacy movement has been wildly successful at shedding light in the dark corners of widespread misunderstanding across multiple disciplines. More research and powerful legislative initiatives are emerging. Universities and medical settings are beginning to identify and actualize the relevance of perinatal research and recommendations. Clinical trainings are expanding. Families are becoming informed and collectively speaking out of their own behalf with robust determination and strong social media support.
This is all good.
One of the problems with identifying and treating perinatal women in distress is that symptoms are hard to discern. This is true for the women, men, and families who suffer. And this is true for the healthcare providers who treat them. Symptoms overlap with normal, expected perinatal changes and do not always fit into discreet or identifiable categories. Unlike other medical conditions that might present themselves in a measurable fashion, perinatal distress is often subjective.
There are an infinite number of barriers that prevent her from asking for help in the first place and even if she DOES find the courage to ask for help, the outcome of that effort depends on many hard-to-define variables. Clearly, the outcome that follows a mother's cry for help doesn't always simply depend on the circumstances or obstacles. An accurate assessment can, indeed, be achieved despite the challenges listed here. Still, these examples, to name just a few, show what is likely to contribute to the overwhelming lack of clarity:
- It "depends" on her willingness and readiness to express how she is feeling.
- It "depends" on how bad she feels. Or how sick she is.
- It "depends" on how much her symptoms are interfering. Or how worried she is.
- It "depends" on how much, or what, she actually chooses to reveal to her family or healthcare provider.
- It "depends" on her current belief whether she is in a safe place where she can be transparent about how she feels.
- It "depends" on the culture of the society in which she lives and how her disclosure might be perceived or misunderstood.
- It "depends" on whether or not the provider asks the "right" questions.
- It "depends" on how well trained the healthcare provider is to recognize and respond appropriately to the nuances of the perinatal period, which can masquerade as a million things and never quite reach the surface of precise diagnostic distinction.
And just to complicate things further, it "depends" on her personal history, her family history, her mood/symptoms at the moment, her relationship and support system, her biological and genetic influences, her personality and belief system, her history of trauma, current environmental stressors, her relationship with the provider, her level of distress, her symptoms, and so forth.
And it "depends" on the ability of the treating professional to tease out what this woman is saying, from what she might be feeling, from what she may be hiding.
Even the very best, well-training, attentive healthcare provider who is leaning into the needs of his or her patient can be stymied by the very nature of perinatal symptoms which can easily be mistaken for "normal" perinatal mood and anxiety experiences.
This is just the tip of the iceberg. If symptoms of a serious depression or anxiety disorder are missed by a healthcare provider, even with screening, even with a good assessment, even with a mother who wants and asks for help, there is reason to believe that her suffering will persist and the risk is increased that she will feel worse, before she feels better. The risks of untreated perinatal mental health issues—to the family, to her children, and to her own well-being—are well-known, and beyond the scope of this article.
Suffice it to say, that the amazing advances in legislation, public awareness, expert training and improved interventions will make little difference if we continue to miss what she is saying when she reaches out for help. Or if we continue to overreact, or underreact, or don't know how to react to the acute, sometimes, terrifying, presentation of severe perinatal distress.
Should primary care providers, obstetricians, or pediatricians be asked to make a psychiatric diagnostic determination during their 10-to-15 minute visit? Of course not.
But every single physician and provider who comes face to face with a pregnant or postpartum woman can and should provide every single pregnant and postpartum woman resources. They should talk about postpartum depression and anxiety. They should say those words. They should talk to their patient, the way they talk about high blood pressure, or good nutrition, or what to do and what not to do during pregnancy and the postpartum period—they should encourage her to take care of herself with an action plan, if she does not like the way she is feeling. They should tell her that symptoms of postpartum depression and anxiety are common. They should tell her that while we expect some level of adjustment distress, she should not have to suffer or wonder what is wrong. Because symptoms of depression and anxiety quickly morph into a distorted core belief that "something is terribly wrong with ME" and then, it is no longer just about symptoms, it's about who she is. This irrational belief that she is impaired, or flawed, or somehow unfit to be her baby's mother, is part of what drives the shame and potential for suicidal thoughts.
To repeat: Every healthcare provider who treats or comes in contact with a perinatal woman should hand her a list of reputable, reliable, and accessible local maternal mental health professionals. (If that list is not available, make one. If there are no available resources in your area, try here or here or here.)The provider should inform her that she should contact someone if she does not like the way she is feeling and share this list with her partner. Every single woman should receive this. Period.
Perinatal women continue to die. The need for medical vigilance and careful monitoring is mandatory. Not just during the early postpartum weeks. Perinatal women are at an increased risk for suicide for months into the first postpartum year. Some of them are more likely to visit their primary care provider for mental health reasons. If you are a healthcare provider and you have not asked your perinatal patient if she is having thoughts of harming herself, you have absolutely no idea if she is having suicial thoughts or not. Even if you do ask, she might not tell you.
Give her printed resources that she can take home with her.
So she can hold tight to that information.
So she can know you care.
So she knows she has options.
So she can increase the likelihood that she will get the help she needs.
copyright 2018 Karen Kleiman, MSW
The Postpartum Stress Center: postpartumstress.com
1 CMAJ 2017 Perinatal Suicide in Ontario, Candada: a 15year popoulation-based study Grigoriadis, Wilton, Kurdyak, Rhodes, VonderPorten, Levitt, Cheung, Vigod