Other Postnatal Care and Helping New Mothers Cope

[Lawpy]

From The Economist: Why so little is done to help new mums cope

Public-health systems focus on babies but often neglect their mothers

It’s a pretty good article to read in its entirety. Curious to know what you think, especially @gyngyn @SurfingDoctor and others

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[SurfingDoctor]

From The Economist: Why so little is done to help new mums cope

Outline: Outline - Read & annotate without distractions

Public-health systems focus on babies but often neglect their mothers

It’s a pretty good article to read in its entirety. Curious to know what you think, especially @gyngyn @SurfingDoctor and others

I don’t know enough about post-partum care in this country to have an opinion, but I suspect a combination of lack of insurance coverage/reimbursement, limited maternal leave and stigma of mental illness all play a role.

 

[VA Hopeful Dr]

I don’t know enough about post-partum care in this country to have an opinion, but I suspect a combination of lack of insurance coverage/reimbursement, limited maternal leave and stigma of mental illness all play a role.

Some pediatrician offices will have the mom fill out a screening tool at the 2 month well child and if abnormal, send them to their PCP/OB to follow up with it.

But outside of actually pathology, I think the maternity leave and lack of social support for lots of people are a big problem.

 

[SurfingDoctor]

Some pediatrician offices will have the mom fill out a screening tool at the 2 month well child and if abnormal, send them to their PCP/OB to follow up with it.

But outside of actually pathology, I think the maternity leave and lack of social support for lots of people are a big problem.

I don’t work in primary pediatrics, but I wouldn’t suggest having a mom fill out a questionnaire and referring them elsewhere as an effective means of really addressing anything.

 

[VA Hopeful Dr]

I don’t work in primary pediatrics, but I wouldn’t suggest having a mom fill out a questionnaire and referring them elsewhere as an effective means of really addressing anything.

There's decent evidence that it increases how often post partum depression is caught. Its not a cure-all by any means, but its easy and it will accomplish some good.

 

[SurfingDoctor]

There's decent evidence that it increases how often post partum depression is caught. Its not a cure-all by any means, but its easy and it will accomplish some good.

I’d actually be interested in knowing what percentage of women have post-partim depression and don’t know it. I suspect it’s small, but that’s just my own assumption/experience.

I also have little doubt that the barriers to getting help (on any scale) can be overcome by any survey, but again, just my own assumption.

I’d like to see data for both and the overall effect size.

 

[Crayola227]

More important to the issue of post-partum depression in my mind, isn't so much self-recognition, it's barriers to treatment.

A huge one being "failing" as a mom and the stigma.

The other one being how pill-o-phobic people are these days, especially if they are breastfeeding (and even when they're not).

Maybe it's just because I live where the hippies have won and measles, pertussis, flu, have come back in a big way. I'm waiting for polio now too.

No medical interventions, and only crystals and herbs allowed. And I just put this together, like, why are people rejecting medicine that actually does something?? For that reason. It does something, and that's scary because of all the feared side effects. Never mind that most of the time, the disease IS worse than the cure. Crystals and herbs, besides their appeal as appeal to nature, basically don't make you feel jack shyte (apart from when your condition worsens, or all those herbs put you into liver/kidney failure) besides maybe some placebo effect. It's very difficult to compete with placebo from "natural" when you also have nocebo if not actual side effects from actual interventions.

 

[SurfingDoctor]

More important to the issue of post-partum depression in my mind, isn't so much self-recognition, it's barriers to treatment.

A huge one being "failing" as a mom and the stigma.

The other one being how pill-o-phobic people are these days, especially if they are breastfeeding (and even when they're not).

Maybe it's just because I live where the hippies have won and measles, pertussis, flu, have come back in a big way. I'm waiting for polio now too.

No medical interventions, and only crystals and herbs allowed. And I just put this together, like, why are people rejecting medicine that actually does something?? For that reason. It does something, and that's scary because of all the feared side effects. Never mind that most of the time, the disease IS worse than the cure. Crystals and herbs, besides their appeal as appeal to nature, basically don't make you feel jack shyte (apart from when your condition worsens, or all those herbs put you into liver/kidney failure) besides maybe some placebo effect. It's very difficult to compete with placebo from "natural" when you also have nocebo if not actual side effects from actual interventions.

Again, not my wheelhouse but I’m not sure the issue has anything to do with phobia of taking Seroquel.

Most people want someone to talk to but most of all just want respite from the stress. Give their colicky kid to someone else for a bit. There’s no real system in place for that and since our system is based on a for-profit model, I doubt there ever will be. There’s no real cash to be tapped in depressed mothers who are on reduced incomes. It’s just not a lucrative financial strategy.

 

[Crayola227]

Went through and read the whole thing.

One, it is not a happy trend that women are having their first kids in their 30s because of education and career. They even point out that women don't recover as well and are more prone to injury with childbearing the older they are.

Women need professional and personal support to support them having kids when they are younger, should they choose.

As long as women experience socioeconomic challenges that feel insurmountable as mothers, there will be problems. There were numerous examples of the lack of support they get during the pregnancy and shortly thereafter, but what about support beforehand?

I would have had kids in my 20s, probably around the start of medical school, if there had been enough support outside the family (the family is no support).

Now, supporting what I'm talking about, that makes the most sense in countries that have significant concerns about the birth rate, such as Germany, which has taken steps to support motherhood.

 

[Crayola227]

Again, not my wheelhouse but I’m not sure the issue has anything to do with phobia of taking Seroquel.

Most people want someone to talk to but most of all just want respite from the stress. Give their colicky kid to someone else for a bit. There’s no real system in place for that and since our system is based on a for-profit model, I doubt there ever will be. There’s no real cash to be tapped in depressed mothers who are on reduced incomes. It’s just not a lucrative financial strategy.

I've talked to mom after mom after mom that recognized they had post-partum depression but saw no purpose in going to the doctor, "because they'll just give me pills."

That's frankly the biggest refrain I hear about anything Western medical from mothers where I am.

And I'm not talking about Seroquel.

 

[SurfingDoctor]

I've talked to mom after mom after mom that recognized they had post-partum depression but saw no purpose in going to the doctor, "because they'll just give me pills."

That's frankly the biggest refrain I hear about anything Western medical from mothers where I am.

And I'm not talking about Seroquel.

I guess I’m confused by your “the other thing is how pill o phobic people are these days” comment then.

 

[Crayola227]

Again, not my wheelhouse but I’m not sure the issue has anything to do with phobia of taking Seroquel.

Most people want someone to talk to but most of all just want respite from the stress. Give their colicky kid to someone else for a bit. There’s no real system in place for that and since our system is based on a for-profit model, I doubt there ever will be. There’s no real cash to be tapped in depressed mothers who are on reduced incomes. It’s just not a lucrative financial strategy.

I'm talking about society. And as I said, there are other governments that have recognized, or have reasons to address it, depressed mothers on reduced incomes and their children, may actually be an investment that overall makes the society more prosperous.

Society still foots the bills of not addressing this issue. If you mean the private sector could give a damn, sure.

 

[SurfingDoctor]

I'm talking about society. And as I said, there are other governments that have recognized, or have reasons to address it, depressed mothers on reduced incomes and their children, may actually be an investment that overall makes the society more prosperous.

Society still foots the bills of not addressing this issue. If you mean the private sector could give a damn, sure.

Yeah, I agree with that sentiment. Literally none of the countries in that article have the same healthcare system we do nor with the same overall objective.

 

[Crayola227]

I guess I’m confused by your “the other thing is how pill o phobic people are these days” comment then.

I'm saying that one barrier is women knowing about, and recognizing, post-partum depression.

However, there are other barriers to treating post-partum depression. As I see it, one of many is a rejection of Western medicine. Others are stigmas and beliefs about motherhood, which I mentioned Still others are the time and resources it takes to even go to a medical appointment, and childcare. The list goes on and on.

I personally find that many women know about post-partum depression. I personally find that many just don't want to do anything about it. Which makes sense when you're overwhelmed and depressed. However I personally find there is a cultural attitude about Western medicine that I think is very unhelpfull overall.

 

[SurfingDoctor]

I'm saying that one barrier is women knowing about, and recognizing, post-partum depression.

However, there are other barriers to treating post-partum depression. As I see it, one of many is a rejection of Western medicine. Others are stigmas and beliefs about motherhood, which I mentioned Still others are the time and resources it takes to even go to a medical appointment, and childcare. The list goes on and on.

I personally find that many women know about post-partum depression. I personally find that many just don't want to do anything about it. Which makes sense when you're overwhelmed and depressed. However I personally find there is a cultural attitude about Western medicine that I think is very unhelpfull overall.

I’ll agree that lack of recognition is not really a barrier.

However, I’m not sure it is a Western medicine thing. Pretty much every other country has a better system in place to catch people who need aid, compared to ours. That being said, I think there is a trend to just prescribe, instead of treat that’s not unique to our system based on cost savings. I personally don’t know how you overcome that. Financial impacts can’t ever really be ignored.

 

[VA Hopeful Dr]

I’d actually be interested in knowing what percentage of women have post-partim depression and don’t know it. I suspect it’s small, but that’s just my own assumption/experience.

I also have little doubt that the barriers to getting help (on any scale) can be overcome by any survey, but again, just my own assumption.

I’d like to see data for both and the overall effect size.

https://www.sciencedirect.com/science/article/pii/S1521693413001260?via=ihub

I can only see the abstract, you have a better chance at full article.

The UpToDate article on PP depression is also pretty thorough if you get bored.

Tldr version: 5-9% reduction in depression in women who were screened versus controls with 11% showing some improvement.

 

[SurfingDoctor]

https://www.sciencedirect.com/science/article/pii/S1521693413001260?via=ihub

I can only see the abstract, you have a better chance at full article.

The UpToDate article on PP depression is also pretty thorough if you get bored.

Tldr version: 5-9% reduction in depression in women who were screened versus controls with 11% showing some improvement.

That article you linked has essentially no data in it. I guess that’s why they conclude the following:

Indeed, as recently as 2010, virtually no trials testing the effectiveness of screening in reducing morbidity were of good enough quality to meaningfully inform clinical practice [43]

I mean, it’s cheap and easy to do sure, but it doesn’t appear to have much of an impact based on that article’s conclusion.

If it has any effectiveness, that article states it only worked when part of a larger, well-structured multidisciplinary program.

 

[VA Hopeful Dr]

That article you linked has essentially no data in it. I guess that’s why they conclude the following:



I mean, it’s cheap and easy to do sure, but it doesn’t appear to have much of an impact based on that article’s conclusion.

Fair enough, the UpToDate article does better (since I can actually see that one). Give it a once over.

 

[SurfingDoctor]

Fair enough, the UpToDate article does better (since I can actually see that one). Give it a once over.

I read the UpToDate. There results primarily come from one meta-analysis.

Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive ... - PubMed - NCBI

Most studies had high attrition rates. The UTD article references a specific study that showed a 2 to 9% absolute reduction in depression prevalence via screening. However they neglect to tell the reader that this effect was lost by the end of the observation period (1 year). Lots of other little tidbits in the effect size which is somewhat conflating the effect of the tool (screening) with the effect of treatment (behavior tax and antidepressants) because screening and treatment are no the same thing, but anywho.

 

[VA Hopeful Dr]

I read the UpToDate. There results primarily come from one meta-analysis.

Primary Care Screening for and Treatment of Depression in Pregnant and Postpartum Women: Evidence Report and Systematic Review for the US Preventive ... - PubMed - NCBI

Most studies had high attrition rates. The UTD article references a specific study that showed a 2 to 9% absolute reduction in depression prevalence via screening. However they neglect to tell the reader that this effect was lost by the end of the observation period (1 year). Lots of other little tidbits in the effect size which is somewhat conflating the effect of the tool (screening) with the effect of treatment (behavior tax and antidepressants) because screening and treatment are no the same thing, but anywho.

Yeah its a tricky thing. I suspect you were correct in an earlier post that its more a situational thing than regular depression (ignoring the ones who do progress to psychosis which is thankfully quite rare). And if we medical folks have options to help with that, screening makes sense. Throwing prozac at it isn't likely to help the majority. Getting someone set up with some kind of social services can. That is very state dependent for better or worse.

When I still did OB in residency, I got great feedback from patients about the Nurse-Family Partnership program.

As far as losing efficacy by 1 year, if its post-partum depression you'd expect it to eventually go away right no matter what, right?

 

[SurfingDoctor]

As far as losing efficacy by 1 year, if its post-partum depression you'd expect it to eventually go away right no matter what, right?

This article suggests that 30% diagnosed with perinatal depression remain depressed at 12 months postnatal and 60% in those who continue to remain depressed at 4 months postnatal.

Psychological factors associated with persistent postnatal depression: past and current relationships, defence styles and the mediating role of insec... - PubMed - NCBI

I’m sure there is some improvement over time, yeah. But it’s hard to judge what the longer term effect of 2 to 9 percent in absolute reduction really means, other than that statistic had a p value of less than 0.05.

Anyway, this is getting off the main topic. Postnatal screening by PCPs clearly has little harm, so screen away.

 

[JustPaws]

Coming from a new mom, I was not honest on that survey. I knew when I was feeling down but there was no way I was going to tell the hospital or the doctor.

I was so tired and irrational I was sure if I scored too high someone would alert child services or something. I told my wife how I was feeling and found a support group and just worked through it. I did take the survey several times at home to monitor myself so it might have some value as a self monitoring tool.

N=1

 

[Crayola227]

In this instance, it could be argued that the screening tool is still increasing awareness, even if you lie.

Take the alcohol screening questionnaire. I mean, just reading it, it gives you an idea of the sort of drinking behaviour that your doctor is interested in.

I know so many people that lie to the doctor, but walking out, are then more aware of whatever it was they lied about.

That is one way that I actually use these tools, which is more to discuss the items on them with the patient. Lying on paper is a lot easier than to a compassionate ear.

And anyone that is really doing a screening with moms about post partum issues, should absolutely be offering reassurance if nothing else. I've been able to help a lot of moms out breaking down for them that they really won't lose the baby if they admit x,y,z.