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Mothers Are Falling Through the Cracks: Let’s Make a Net for Them

April 26, 2018
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By Mousumi Mukerji, MSN, RN, PMHNP-BC, CNM
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The opinions expressed by Psychiatry & Behavioral Health Learning Network bloggers and those providing comments are theirs alone and are not meant to reflect the opinions of the publication.

On January 18, 2018, in Sacramento California, new mother Jessica Porten went to see a women’s health nurse practitioner (NP) at her OB/GYN office, which primarily serves Medicaid recipients. She was 4 months postpartum and had not been seen by her obstetric provider since giving birth.

This self-aware woman, in her mid-20s, had been experiencing increasingly distressing, ego-dystonic bouts of irritability, anger, and intrusive thoughts. She did a little research online and thought she may be experiencing symptoms of postpartum depression. Her baby had been admitted to the neonatal intensive care unit (NICU) after birth, which increased her risk for a postpartum mood episode.

Finally, with an appointment in hand, she was hoping to be prescribed medication that would help her and to be referred for psychotherapy. Porten described her symptoms to the NP, which included having violent thoughts such as hitting herself or squeezing the baby too tightly.  The NP asked Porten “when you have these violent thoughts, do you have plans?

Porten (personal communication, March 2018) herself describes what followed:

I thought the question was odd. I thought she was asking if I was having specific, or vivid, violent thoughts, which I was, so I answered yes. What she was actually asking is if I was planning to act on these violent thoughts, which I did not. I did specifically state several times that I was not going to hurt myself or my baby. She asked no follow-up questions after that, and did not clarify what she meant.

Jessica Porten and baby
     Jessica Porten and her daughter, Kira Elle

The NP promptly spoke to an OB/GYN in the office then called the police. Porten was asked to go to the Emergency Department voluntarily. She drove herself and her baby there, escorted by police. She spent 8 hours there before she was deemed not at risk to herself or her baby. She was given some pamphlets upon discharge and told to follow up with her OB/GYN.

The next day, Porten wrote a Facebook post about her experience. It went viral in a matter of a day. Clearly she had touched a nerve. Her story was picked up and circulated, and she was interviewed by numerous media outlets, including Slate.com, ABC News, NPR.org, and the Huffington Post. Porten now passionately advocates for mothers’ rights to perinatal mental health services.

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Porten’s Facebook post and the comments it generated suggest that both the maternity and the mental health care systems have a PR problem. Many of Porten’s readers stated that they had been made to feel criminalized, penalized, and stigmatized when they tried to access mental health care in the postpartum period. One woman described having felt as though she were “second-class, sub-human, and infantile.” Other statements included “the system is corrupt” and “they need more training in postpartum depression.” Ouch.

Most unfortunately, Porten never did receive any follow-up or referrals for her mood and anxiety disorders from her obstetrician. She did not have a relationship with her primary care provider, which is true of many young healthy women who are publicly insured. She finally accepted help through the network that her Facebook post generated and was connected to services in another county. She is in supportive counseling but continues to struggle.

H.R. 3235, otherwise known as the “Bringing Postpartum Depression Out of the Shadows Act of 2015” passed both houses of Congress in 2016.1 This bill allocated $5 million in block grants for states to use to mandate screening for and treat postpartum depression.2 California just received its grant for this year.

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The question that has many doctors and patients worried is what to do with a positive screen.3 There aren’t nearly enough professionals trained in perinatal mental health to whom to refer women who need treatment, the mental health coverage of many insurance plans is inadequate to meet the specific needs of women with perinatal mood and anxiety disorders, and mothers with infants who have returned to work find it difficult to take more time off for their own care.

Hoffman and Wisner4 call on psychiatric providers to collaborate with their obstetric and midwifery colleagues. It is easy to see why. In Porten’s case, if her NP or obstetrician had consulted with a psychiatrist or psychiatric mental-health NP, she might have left the office with a mental health treatment plan instead of an experience that left her further stressed and demoralized. For the grassroots movement that at present defines the state of perinatal mental health in this country, Porten luckily had the resilience to transform this traumatizing experience as fodder for her own growth and become an advocate and activist.

References

1. Bologna C. Congress passes Groundbreaking Postpartum Depression Legislation. Huffington Post. December 8, 2016. http://www.huffingtonpost.com/entry/congress-passes-groundbreaking-postpartum-depression-legislation_us_584053a6e4b09e21702d2a43. Accessed April 18, 2018.

2. H.R.3235 – Bringing Postpartum Depression Out of the Shadows Act of 2015. 114th Congress (2015-2016). http://www.congress.gov/bill/114th-congress/house-bill/3235/text. Accessed April 18, 2018.

3. State lawmakers weigh pros and cons of mandatory screening for postpartum depression. Southern California Public Radio Web site. http://www.scpr.org/news/2018/03/19/81771/state-lawmakers-weigh-pros-and-cons-of-mandatory-s/. Published March 19, 2018. Accessed April 18, 2018.

4. Hoffman MC, Wisner KL. Psychiatry and Obstetrics: An Imperative for Collaboration. American Journal of Psychiatry. 2017;174(3):205-207.

Mousumi Mukerji is a certified nurse midwife who earned her master’s degree in nursing from Yale University, New Haven, Connecticut. She has provided prenatal, intrapartum, gynecological, and primary care to women throughout the United States and across the lifespan. Mukerji received a certificate in the assessment and management of perinatal mood disorders from Postpartum Support International in 2016. She completed the psychiatric-mental health nurse practitioner program at the University of California, San Francisco in March 2018 and is awaiting licensure and certification as a PMHNP. She has research experience on the knowledge, attitudes, and beliefs about HIV/AIDS in India. Her future career interests lie in maternal mental health, trauma therapy, and psychotherapies.

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