Postpartum Depression: A View From the Front Lines

My town is home to Fairview hospital, the smallest land based hospital in Massachusetts. With its 24 beds and about 170 newborn deliveries a year, Fairview is a wonderful place. For years as a primary care pediatrician I examined newborns and attended many a delivery in the middle of the night. So after deciding(for reasons I have described elsewhere in this blog) to focus my behavioral pediatrics practice on the 0-5 age population, I went to pay my friends the maternity nurses a visit. What better place for a preventive intervention than the newborn nursery? I wanted to hear about the problems they were seeing and their assessment of what the needs were.

Recently I have been reading the most current research on the impact of postpartum depression on infant development. This reading is in the setting of the The Infant-Parent Mental Health Post-Graduate Certificate Program that I referred to in my last blog post. Quoting from the program's website:

This program is based on the award-winning Napa Infant-Parent Mental Health Fellowship Program developed by Dr. Ed Tronick, Chief of the Child Development Unit at Children’s Hospital Boston...Dr. Kristie Brandt, Director of the Parent-Infant & Child Institute in Napa, California...the present program is designed to address the increasing need for skilled, interested and appropriately trained professionals to provide infant-parent mental health services for families with children ages birth to five years.

Given what I am learning, the stories I heard from the nurses were alarming. I will diverge slightly to describe the research I am referring to before returning to my visit to Fairview. Much of the contemporary research has been done by Peter Cooper and Lynne Murray and is described in their book, Postpartum Depression and Child Development. In a more recent paper they write that considerable evidence exists indicating that postpartum depression (PPD) limits a mother’s capacity to engage positively with her infant. Several studies have shown that PPD compromises child cognitive, behavioral and emotional development. To quote them directly:

PPD is now recognized, by virtue of the distress caused to mothers, as well as the wider adverse impact on the family, as a significant public health issue...Since adverse child outcomes associated with PPD are more likely to occur in the context of chronic or recurrent depression, it is particularly important that this group be identified and targeted for intervention...It is crucial that attention be given in the treatment to the quality of the mother-child relationship and that specific therapeutic measures be introduced to help mothers engage optimally with their infants.

Back to Fairview. The maternity nurses estimate that 15 to 25 percent (and perhaps as high as 50%) of mothers delivering at Fairview have major mental health problems. These range from mothers carrying multiple psychiatric diagnoses such as bipolar disorder and depression, to those without a specific diagnosis but with multiple psychosocial risk factors. For this group of patients, nurses feel that 100% do not have adequate follow up after delivery. Mothers may have one home visit with a nurse. A part time social worker sees some of them prenatally, but there may no plan for follow up.

The distress in the room was palpable. The nurses worried for these babies, feeling that they often sent them home "on a wing and a prayer." They described one mother with a diagnosis of depression who gave birth to her third child. A two year old with no shoes sat strapped in a stroller , while a ten year old who was on multiple antipsychotic medications wreaked havoc in the hallway.

What would happen, I wondered with them, if I were to meet for one or two sixty minute visits with these high risk mother-infant pairs in the hospital?(more time than is usually available for an in-hospital visit by a pediatrician) My aim would be to forge a relationship between myself and the parents as well support the new relationship between the parent and her infant. In my pediatric practice I could continue to follow them when the almost inevitable challenges of crying, feeding and sleep problems arise. "When can you start?" they asked.

It would be a small intervention in a small hospital in a small town(to put it in place, the complex questions of diagnosis and insurance coverage must be ironed out.) One can only hope, however, that it would help to put a dent in what is potentially a very big problem.