The Real Medicine

 

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As many of you know, in addition to working with Help With Ties, I am also a registered nurse at one of the busiest emergency rooms in Broward County, Florida. More and more often, postpartum mothers are checking into the ER with a variety of complaints such as chest pain, palpitations, dizziness, etc. Now, these are real symptoms that are leading causes of heart conditions, strokes, electrolyte imbalances, and more. Therefore, when these types of complaints come into the emergency room, a complete work up is warranted.

One recent weekend when I was on shift, a young African American woman in her thirties came in complaining of intermittent chest pain for a few days. She was emotional as Reagan*, a fellow nurse, and I placed her intravenous access, drew labs and started an infusion of fluids. As I turned my back to exit the room, I heard Reagan ask the tearful patient, “What’s going on?” with such significance and empathy, that it gave me the chills. When I turned around, Reagan was holding the patient’s hand, listening as the young woman sobbed and revealed that she was a first-time mother and had little support from her husband. Her aunt, who was the closest family member to her, had also recently died, and she was still dealing with that loss. She explained that she was feeling very alone and was having a hard time transitioning to motherhood. Reagan continued to comfort her, provided her with some resources available in the community, arranged for a social worker from the maternity ward to consult the patient while she was still in the emergency room, and continued to LISTEN to her as she talked about the obstacles she was facing. The patient’s results were fine, and she was discharged from the ER with a resolution of symptoms. Before leaving, the patient continuously thanked Reagan for giving her the opportunity to talk through her concerns and worries.

That was the real medicine. Not the labs that we drew, not the muscle relaxant she was prescribed or the EKG done. Don’t get me wrong. For a postpartum woman of color complaining of chest pain, the doctor’s orders were 100% indicated and carried out in good practice. However, it was Reagan’s interaction with that patient that made all the difference in the world. Had she not had the insight to dig a little deeper and the patience to spend some extra time with that young mother, the patient’s outcome could have been very different.

Maternal depression, according to the American Academy of Pediatrics, can deeply threaten a mother’s relationship with her child. It is known that an infant living in neglectful environment is likely to show negative social interaction skills, developmental delays, failure to thrive, possible neglect and/or abuse, and impaired brain development, among other things. Addressing maternal depression in a timely and proactive fashion is essential to ensure healthy neurological progress, development and readiness to succeed in a growing child. It is true that prior to being discharged from the hospital after giving birth, many maternity units provide patients with community resources for postpartum depression (PPD), perform a PPD screening, or discuss PPD symptoms with the mother. But think about it – there are so many different thoughts, hormones, and other factors going on in a mother’s mind at time of discharge. Most patients at that point are exhausted, sick of being in the hospital and ready to go home. Indeed, many mothers at that point may not even be experiencing PPD symptoms so soon after delivery. According to the Mayo Clinic, PPD symptoms can start a couple days to a few weeks after birth. Most of the time, however, the mother has usually been home at the time of the onset of symptoms and at that point may find it difficult to reach out for help.

Several days after my shift, I continued to be consumed by the Reagan’s patient’s situation. Her story made me once again realize that in our society, women face a significant healthcare gap that starts immediately after they deliver a baby. No longer in the hands of their OB/GYN, whom they saw at least once a month during their pregnancy, the focus upon delivery tends to shift solely towards meeting the newborn’s needs; the mother goes from patient to provider immediately after giving birth, without being given the proper emotional or physical support during that transition. Aside from a six-week check-up with their OB/GYN, nothing is set in place in our healthcare system to ensure that new mothers receive consistent and frequent postpartum follow-up. That being said, we need to re-evaluate the crucial role pediatricians can play in helping to identify new moms at risk for postpartum depression. If this type of screening were in place, each time Reagan’s patient took her baby in for his newborn check-ups, her pediatrician could have screened her for PPD and her struggles could have been identified earlier and addressed.

The Parental Well-Being Project

The reality is, however, that pediatricians are often already overwhelmed with patients and feeling the pressure of time constraints and demands that having more patients entails. However, a seminal piece of research on PPD called The Parental Well-Being Project, shows that pediatricians did not see the time spent with new parents for discussion of PPD burdensome. Routine parental depression screening at well-child visits was implemented with 37 providers in 6 community pediatric practices in New Hampshire and Vermont communities with a town population ranging from 2,000 to 150,000. Throughout the project, screening rates for postpartum depression were collected weekly and practices received support from the project staffing in overcoming barriers to screening. During the project, the providers spent approximately 5-10 minutes discussing PPD with the mothers during each visit, resulting in a more positive transition for the mothers, an improved mother and baby relationship, and decreased PPD rates. Specific details on the research can be seen below:

Trial

Over six months, parental depression screening was conducted in nearly half of 16,000 well-child visits. Parental screenings occurred in 67% of the well visits. Only 6% of parents refused to answer.

 Results

The results revealed that about 1 of 7 parents disclosed or lack of interest in usual activities. 1 of 20 parents, both mothers and fathers, were screened at–risk for major depression.

52% of mothers in the project who screened as positive felt that they might be depressed, and 85% of them wanted to take action about their feelings. Pediatric providers referred 40% of mothers who screened positive to mental health and primary care providers, with the strongest predictor of referral being the parent telling the pediatrician they might be depressed. If this discussion and screening had not have taken place, the mother would have not had the opportunity to get the help she deserved. Looking back at my own experience, perhaps I could have been helped after my son’s birth and not suffered through PPD as long as I did if I had been better screened at my OB/GYN follow up or at my son’s well visits with his pediatrician. Once again, we need to delve more of our efforts into adopting methods found in research such as The Parental Well-Being Project so the medical community can better support the mother and baby dyad.

At the end of the day, I learned that Reagan was a mother that fought severe PPD and wished someone had been there for her- like I wished that someone would have screened me earlier on.
As a nation, our goals are to make women and children a priority. Let’s do a better job. That is the real medicine.

 

*Not her real name.

 

Resources

https://www.mayoclinic.org/diseases-conditions/postpartum-depression/symptoms-causes/syc-20376617

https://pediatrics.aappublications.org/content/126/5/1032

https://www.medicaid.gov/medicaid/benefits/espdt/index.html

https://www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/practicing-safety/Documents/Postnatal%20Depression%20Scale.pdf

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