"Allison, it seems like your cesarean section incision is healing well and your pain has resolved. How are you feeling otherwise? How is life adjusting with the new baby? Have you noticed any changes that are confusing or concerning to you?"

Her tears soaked her eyelashes, leaving a trail of mascara and eyeliner down her cheek. Her big brown eyes looked down at the floor and she softly said, "I don't know what is happening. I am not me anymore. I can't seem to stop crying at home."

As a primary care physician, I am starting to see greater numbers of postpartum patients in my office in the months following delivery. And with each visit, our society's absolute lack of preparedness concerning the emotional and behavioral well-being of mothers is glaringly more obvious. The initial postpartum visit often offers the opportunity for a brief assessment and intervention for postpartum blues and depression. But intervention is dependent on two critical actions:

1. The provider is able to elicit the responses that indicate depression, and
2. The patient is able to recognize and communicate their symptoms as postpartum depression.

The American College of Obstetrics and Gynecology (ACOG) has made the problem amply clear: "Most women in the United States must independently navigate the postpartum transition until the traditional postpartum visit (4-6 weeks after delivery). This lack of attention to maternal health is of particular concern given that more than one half of pregnancy-related deaths occur after the birth of the infant." (1) Further, ACOG has found that as many as 40 percent of women do not attend a postpartum visit. (1) In regards to postpartum depression, a national survey reports that more than half of the mothers who meet screening criteria for depression in both the initial and follow-up surveys fail to get help. (2)

I am not a mother; I have never been pregnant. And yet, as a woman, a physician, and a patient, I am appalled by these statistics. We have a maternal mortality issue in our country which continually makes headlines and yet, the mention of postpartum depression in my community continues to be taboo. I will come out and say it for all those who are unsure: postpartum depression is real. It is a big problem. And we need to put more resources toward addressing it.

What can we do to truly move the needle on this?

1. Update the training of primary care providers in relation to postpartum care. The American College of Physicians (ACP) Women's Health June 2018 position paper explicitly advocates for "further training of primary care providers to meet the health needs of women throughout their lifespans …. In addition to preventive care and the treatment and management of disease, primary care physicians traditionally play a role in preconception and postpartum care." (3)
2. Raise awareness. This not a women's health issue—it is a public health issue. Women are often the primary caretakers for family members (children, spouses, and elderly parents/relatives). Maternal mortality and morbidity has lasting effects on families and communities. Improving maternal outcomes is included as an objective for Healthy People 2020, the science-based 10-year national objectives for improving the health of all Americans. The correlation between child health and mental health is clear: the cognitive and physical development of infants and children may be influenced by the health, nutrition, and behaviors of their mothers during pregnancy and early childhood. (4) I have heard from countless family, friends, and patients who have struggled with postpartum depression. Alarmingly, they were unaware of the prevalence or likelihood of postpartum depression. As primary care providers, we should not shy away from discussing this topic with our patients. We should encourage our communities to be open about addressing this far-reaching illness by any and all means possible. Being South Asian, illness of any sort is definitely considered taboo in my community. And a behavioral health illness is even more so. I encourage community leaders and influencers to take the time to reflect upon this critical problem.
3. Provide early training for family members. Prenatal training for family members (e.g., spouses, parents, neighbors, friends) should include training on recognizing the signs of postpartum depression. Recognizing symptoms potentially consistent with postpartum depression is key. I am by no means advocating training of all family members in medical diagnoses—but placing the burden of recognition upon a mother seems a plan likely to falter.
4. Grant maternity and paternity leave. It is absolutely essential that time be granted to both mothers and fathers to participate in postnatal care. The ACOG has recognized and advocates for paid paternal leave stating that, "provisions for paid parental leave are essential to improve the health of women and children and reduce disparities." (3) The ACOG endorses paid parental leave as essential, including maintenance of full benefits and one hundred percent of pay for at least six weeks. (3) The U.S. Family Medical Leave Act (FMLA) requires companies with more than 50 employees to offer unpaid time off for workers, so long as the worker has been employed for the past 12 months and has worked at least 1,250 hours in that period. Many companies offer voluntary parental leave. However, according to the Bureau of Labor Statistics, voluntary paid family leave policies cover only 11 percent of American workers. (5)
5. Be kind. Many of us have employees and coworkers who are planning maternity or paternity leaves. Be kind and offer a minute or two of your time to check in on them.

My recent personal experiences—with friends and relatives—have heightened my concerns about postpartum depression. If you are a woman, family member, primary care physician, legislator, CEO, CMO, or simply a human, I implore you to start the conversation about postpartum depression. Although the problem is not new, the solutions have to be new and far-reaching. And if nothing else, I want to make sure that Allison and every woman like her never finds themselves alone in the mire of postpartum depression.

References

1. Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004
2. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers(SM) III: new mothers speak out. New York (NY): Childbirth Connection; 2013.
3. Daniel H, Erickson SM, Bornstein SS, for the Health and Public Policy Committee of the American College of Physicians. Women's Health Policy in the United States: An American College of Physicians Position Paper. Ann Intern Med. ;168:874–875. doi: 10.7326/M17-3344
4. Office of Disease Prevention and Health Promotion. Maternal, Infant and Child Health. https://www.healthypeople.gov/2020/topics-objectives/topic/maternal-infant-and-child-health
5. Van Giezen, R.W. Paid Leave in Private Industry over the Past 20 Years; Contract No. 18; Bureau of Labor Statistics: Washington, DC, USA, 2013.
6. Burtle A, Bezruchka S. Population health and paid parental leave: what the United States can learn from two decades of research. Healthcare (Basel) 2016;4:30.