When I see children in my pediatric practice for behavior problems, I often hear stories from mothers who struggled terribly when their children were very young infants. Among the most dramatic example of this was a mother with severe postpartum depression whose father died suddenly when her baby was four months old. Much to my astonishment, she described being relieved by this event. It wasn't because she didn’t love her father. Rather, in sharing the grief with her siblings and extended family, she no longer felt so completely alone.
A Massachusetts law passed last summer calls attention to the public health problem of postpartum depression (PPD). The most common complication of pregnancy, extensive research has demonstrated its significant long term effects on a child’s development, with increased risk for behavior problems in childhood and depression in adolescence.
The new law requires Massachusetts health insurers to submit annual reports on their efforts to screen for postpartum depression. The department of Public Health will develop regulations and policies to address postpartum depression. In addition the law calls for a special commission to come up with policy recommendations to prevent, detect and treat postpartum depression.
The Boston Globe editorial board endorsed this legislation with the following statement: "Early detection could stave off far more serious problems for mothers and their babies, whose well-being is deeply linked to the first few months of care. And universal screening would ensure that no woman falls through the cracks. The sooner new mothers can be diagnosed, the sooner they will recover."
This legislation is an important first step. A lot of work needs to be done, however, to turn the Globe's very optimistic statement into a reality. This summer I became involved with two organizations who are working towards this goal. One is a working group of the Massachusetts Chapter of the American Academy of Pediatrics. One of the biggest problems with mandatory screening, which is done primarily by obstetricians and pediatricians, is that the people doing the screening may not know what to do with a positive screen.
Interestingly, a study of women struggling with PPD ( which I prefer to call "perinatal emotional complications" thus avoiding the stigma associated with major mental illness- I must give credit to Liz Friedman-see below-for coining this phrase) shows that mothers may not want a referral or medication but simply for their clinician, a person with whom they have an established relationship, to listen to them. Primary care clinicians need to feel comfortable with what our group called "engagement," - to stay in the room with a distraught mother before jumping to a referral.
Perhaps equally importantly, the health insurance industry need to recognize that time and space, offering a mother, who may feel so terribly alone, a chance to be heard in a non-judgemental way by a respected caregiver, is an essential part of treatment.
The second organization I connected with is called MotherWoman. This organization seeks to educate clinicians and to create referral networks of people in communities who can offer a variety of interventions for these mothers. It is run by a remarkably energetic and enthusiastic woman, Liz Friedman. She describes her program as follows:
The Community-based Perinatal Support Model (CPSM) has been developed to address the gap between screening and services for mothers. CPSM aims to prevent, identify and facilitate treatment of PMD(perinatal mood disorders) by creating a comprehensive, community-based, multi-disciplinary safety net for women.These two organizations are starting the hard work necessary to translate the new legislation into a form that is useful and meaningful for mothers struggling with perinatal emotional complications.
When I speak with mothers like the one above, I wish that I had seen them when their children were infants. This is not to say that their child's behavior problems is their fault. But the research clearly shows that when mothers are emotionally available to their young infants, development proceeds in a healthy direction. By working to address perinatal emotional complications, we have the opportunity not only to ease these mothers' suffering, but also to help them to be fully present with their babies. We can help transform these early months from a time of stress and pain into a time of joy and love.
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