I met with a client who was 14 weeks postpartum. The stress was written deep in the lines of their face. Their mouth curled down at the ends when they spoke, as if they were holding words back. Their fingers trembling as they held a pen to write their name on a consent form. Their hands shook so much that their name read illegible.
"It's just baby blues," they said.
"How do you know?
"My OBGYN told me. I called him two days ago. He told me not to worry, that it was just baby blues."
"What have you been feeling?" I asked.
"I don't know anymore. I feel like I haven't slept in days. This is the first time I've left the house in days. I keep thinking that something bad is going to happen to him. He's just so small. I imagine him suffocating in his carrier. I can't believe how terrible of a parent I am," they said.
They whispered the last part, they seemed to be afraid of being heard by someone that would betray them.
"Can we talk a little more about this?" I asked. "I don't think this is baby blues."
This wasn't baby blues. They needed so much more than their doctor just telling them not to worry. If they could have stopped worrying, they would. They would sleep, if not at least for a few hours a night in between feedings. They would be able to take a walk outside, pushing the baby stroller and wandering in their own neighborhood. They would not be constantly imagining terrible things happening to their child. The baby blues period had ended weeks ago (most commonly, baby blues start at about 2-3 days postpartum and head out in about 2 weeks). This was more.
The United States is undergoing a perinatal health crisis. This absolutely includes mental health. From an NPR piece about preventable postpartum deaths published on October 21, 2022:
Mental health conditions were the leading underlying cause of maternal deaths between 2017 and 2019, with white and Hispanic [gestational parents] most likely to die from suicide or drug overdose, while cardiac problems were the leading cause of death for Black [gestational parents]. Both conditions occur disproportionately later in the postpartum period, according to the CDC report...
Increased screening for postpartum depression and anxiety, starting at the first prenatal visit and continuing throughout the year after birth, is another CDC recommendation, as is better coordination of care between medical and social services, says David Goodman, who leads the mortality prevention team at the CDC's Division of Reproductive Health, which issued the report.
The notion that the majority of the deaths perinatal families experience are mental health related and preventable is devastating. There are so many new families who lose a parent to crisis and every single one of those people could and should have been offered preventative support.
There is a considerable pathway to help and when appropriately applied, offers a foundation for care. Utilizing perinatal specific screening tools that have been vetted and validated as instruments to support the mental wellbeing of the perinatal population is the start a holistic and informed journey to balance in the perinatal period. The more common screening tools for the perinatal population are written, self-administered question and answer surveys. These include the Edinburgh Postnatal Depression Scale (EPDS), Patient Health Questionnaire PHQ-2 (2 questions) or the PHQ-9 (9 questions), and the
Perinatal Anxiety Screening Scale (PASS) (31 questions). While there are others, and they are valuable, their use and their function become a bit more specific and nuanced, and may require more guidance from a professional.
It is important to mention that there may be aspect of screening that may be provoking for BIPOC clients, undocumented clients, clients who are culturally resistant to mental health needs or clients who have a history of mental health risks. Therefore it is invaluable that each client, when screened, is done so within a transparent, trusted and safe framework depending on the specific needs of the client. This may mean that a community health advocate that the client has a relationship with offers to support their screening or that the screening is delivered in the client's native language. Whatever the effort, there should be one made based on the social location of the provider and the client.
From the same NPR piece:
Increased screening for postpartum depression and anxiety, starting at the first prenatal visit and continuing throughout the year after birth, is another CDC recommendation...
Something unique and important about screening tools is that as they are self-administered and anyone from an OBGYN, a mental health provider, a pediatrician, a social worker, a doula, or community health worker can help guide the process. However, some studies indicate that people might be more forthcoming with relevant information by completing a self-administered questionnaire on a themselves instead of responding verbally to nursing staff. In a recent study, the tablet screening detected twice as many people with depression, fall risk or intimate partner violence compared to usual in-person screening by professional staff. Whether someone guides a perinatal person or offers the screening tools and discusses options after the information is gathered, these interventions can save lives.
In considering offering screening tools, there are additional ideas and best practices for birth work professionals either before, during or after screening occurs.
A national perinatal mental health organization has conducted a large best-practices themed project to determine best screening times. This is important because the idea behind perinatal screenings is not diagnosis, but rather education and prevention. In summary: Offer screening info at first appointment (even if that is later in the gestational period). If you meet the client in the first trimester, screen at least 1x a trimester. Offer screening at discharge/ as soon as after childbirth as possible. Offer screening info at 3 weeks postpartum. Continue to check-in, discuss and offer screenings during the first year of postpartum.
Doulas and other non-clinical professionals such as Certified Lactation Counselors (CLC) offer trusted and important support networks to pregnant and postpartum people. Becoming educated about screening tools and informed on their usage is really important. For many families, a doula or lactation counselor may be the first person in a postpartum home and the first professional to really observe how a new family is adjusting, how a complex birth may have impacted someone, or how infant feeding may be contributing to an overall postpartum state. Remember this and don't hesitate to lean on your professional instincts. These tools are self-administered, birth work folk are not testing or assessing clients, but offering this as an invaluable resource and getting the process moving should help be needed.
Take PMADs and the perinatal mental health landscape seriously. It may feel out of your depth initially, but becoming educated, aware and keeping engaged can be life saving. Take a training from clinicians if you have not done so yet so the support you offer is confidence-based and informed.
Many clients, perhaps immigrant clients or BIPOC clients, won't feel safe calling a hotline if they aren't adjusting well, as they may think law enforcement will be involved. Many clients who have had mental health needs or trauma in their past may not tell their doctors they aren't doing well for fear of reprehension. Talking to a community health worker or doula might be the safest approach. Understanding this is vital if you are working with vulnerable new families.
LGBTQIA2S+ clients deserve support and mental health resources targeted to their needs. Vetting your referrals to meet the needs of gender and relationship diverse clients is important.
Engage with your local local resources. Who are your local perinatal therapists? What other modalities, like support groups, exist? What are the warmline numbers and what happens when people call them? Education in these arenas offers insight and unprecedented knowledge.
In your new client or interview packets, include initial information about screenings and easy-to-read definitions of PMADs, which include timelines (as in baby blues vs PMADs). You can also include a simple release form. A release form does not mean that you will be speaking for clients. Instead it does open the conversation about resourcing and creates a line of transparency, continuity, and trust. If they need you to call and get resources, you have their permission to do so. See below for a release form example.*
If things feel or seem off, sit down and talk with the family with all parties present, if that is safe. Speak transparently. Ask how they're doing. Ask how sleep has been going. Ask if they have showered. Ask if they have been outside. Ask if they have been sad and for how long. Ask what has been feeling scary or overwhelming. Try this script, "Becoming a parent is such a big adjustment. It can be really hard or even just different than expected. I've been in a lot of postpartum homes and there are a few things I just wonder if we can check in about. I know you're doing the best you can and I'd love to see if we can figure some things out together..."
Reach out to your local perinatal therapists (look for PMH-C designations). Have your referral and resource list ready. They can keep it on fridge should they ever need it! This is a crucial support step if someone's screening survey shows they may be experiencing a PMAD or adjusting in a tough way. Offer a list during your prenatal or early postpartum sessions.
*I run a perinatal social work project that offers free screenings at any time & targeted referrals within the NYC landscape.
** I offer a PMAD Screening for Birth Workers Workshop. Next one is March 31, 2PM - 4PM. Info here.
*** I offer a Perinatal Mental Health Referrals 101 Workshop. Next one TBD as one just passed.
****Release Sample:
Perinatal Mental Health Release to Obtain Information
The purpose of this form:
1) To open the dialogue on perinatal mental health needs before, during and post childbirth. Using education, transparency and care, we commit to being available to lean on each other and local resources, if needed. This form is designed for the gestational parent, however, an additional form may be printed and used for partners, if there is a partner. Partners experience perinatal mental health needs too and should be considered.
2) To offer me the ability to resource, research and call groups or providers to ensure they meet and fit the criteria which we may be seeking at any given time to support your mental health.
I, ___________________________________________ (client’s full name here) and grant ___________________________________________ (support worker’s full name) permission to contact a mental health support person, licensed therapist, peer counselor, care coordinator, medical professional or postpartum warm or hotline on my behalf should I need mental health care or resources during the perinatal period.
Print name: ____________________________________________________________
Signature: ______________________________________________________________
Date: __________________________________________________________________
Address: _______________________________________________________________
Email: _________________________________________________________________
Phone: _________________________________________________________________
If the individual is under 18 years old, have the parent or guardian sign below also:
I, _________________________________, am the parent or legal guardian of the individual named above. I have read this release and approve of its terms.
Signature: ______________________________________________________________
Date: __________________________________________________________________