The Paradox of Postpartum Depression

By Rachel Blustain Jul 13, 2018

Karen’s Story: Carrying a Painful Secret
rntBy the time Karen Flores gave birth at 31, she’d been longing for years to be a mother. In college, she’d studied child development and she worked at Early Head Start. But soon after her daughter was born, panic gripped her and wouldn’t let go. She sat sobbing at a table during a celebration her first day out of the hospital. And that night she laid sleepless in bed asking herself why, if she’d always dreamed of being a mother, did she now feel like she was losing her mind.

Still, in the months that followed, she said, it didn’t occur to her that she was suffering from postpartum mental illness, despite the constant lurking fear that she was an unfit mother and her bouts of crying.

A Black woman—born in Belize and raised in North Carolina and California—Flores joined a sister circle sponsored by the California Department of Public Health’s Black Infant Health Program. She said that although she cried for the duration of a meeting with one of its counselors, postpartum depression didn’t come up. Flores said she had the same experience with a private-practice therapist she began seeing months later to reduce her stress.

Then, when Flores’ daughter was 7 months old, she was pushing her in her stroller on a cliff overlooking the ocean when she heard voices, loud and insistent, urging her to push her baby off. Knowing that “God would never want that,” Flores said, gave her the strength to scream back, “No!” Then she ran, crying, back to her car, strapped her daughter in and sped away—and for the next 14 years, told no one.

She certainly didn’t speak about it when she returned to work. And she maintained her silence when, a year and a half later, she entered graduate school to research postpartum depression in the Latino and Black families served by her Early Head Start. By then, Flores had figured out what she’d suffered and understood that silence could be harmful, even dangerous. But she also believed that a piece of her own story was too dangerous to reveal.

It wasn’t until three years ago, when her daughter was a teen, that Flores felt safe enough to break her silence. “I was ashamed,” she said, “and I was afraid they’d say that I’m crazy and take my child. I think it’s a realistic fear. In low-income communities and in Black and Brown communities, you just sit in it and you deal with it as long as possible. You just do the best you can.”

Who Postpartum Depression Hits the Hardest
rntSince the 1950s, there has been a sea change in public understanding that postpartum depression and anxiety, though at times severe, are, by and large, time-limited illnesses when properly diagnosed and treated. A 2017 study by the Royal Australian and New Zealand College of Psychiatrists even found that postpartum psychosis, though potentially lethal for mother and child, can resolve itself within weeks if treated. So much has changed in our attitudes that when Ivanka Trump joined the list of celebrities to share her story of postpartum depression, critics suggested that she’d made a cynical and safe confession only to distract from her father’s efforts to undermine insurance coverage for mental health and maternity services.

Despite all that, mothers are still afraid to acknowledge their suffering, making suicide a leading maternal killer in the year after birth. Depressed moms living on low incomes get help less often than more affluent mothers; mothers of color less often than White mothers; and low-income mothers of color least of all, according to research by The Urban Institute.

Between 2004 and 2007, after New Jersey mandated doctors to screen all new mothers for postpartum depression, 9 percent of White mothers on Medicaid in the state sought treatment for it, while 5 percent of Latina and 4 percent of Black mothers did. Black and Latina mothers were also less likely to receive follow-up treatment.

Disparities in treatment are particularly troubling given imbalance in rates of postpartum mental illness. Roughly half of poor mothers report some level of postpartum depression, compared to an estimated 10 to 20 percent of all new mothers.

When it comes to race, contradictory findings raise questions about how stigma impacts self-reports. Nonetheless, a 2012 report from the Centers for Disease Control and Prevention (CDC) and a majority of other studies have found that African-American, Latina, Native American, Pacific Islander and immigrant women are at greater risk for it than White women. One study by Icahn School of Medicine at Mount Sinai Hospital found that 44 percent of Black mothers reported symptoms of depression two weeks after delivery, compared to 31 percent of White moms.

The reasons for treatment disparities are various, but taken together, advocates say, they reinforce the idea that for some women, it’s not safe to talk about postpartum illness, or even to recognize its existence.

Why It’s So Hard to Get Help
rntFirst, there’s the interaction of stigma and risk. Among many people of color and immigrant groups, talking about mental illness is taboo, mothers and advocates alike told me. Kay Matthews, founder of the Houston, Texas, maternal mental health awareness project The Shades of Blue Project, says that for Black women in particular, stigma cannot be separated from the knowledge of aunts, cousins, friends and neighbors who have lost children to foster care. Given that one in nine Black children will spend time in foster care by the time they’re 18, according to research from Yale University, the risk, she said, doesn’t need to be spelled out. “It’s understood.”

Then there’s the implicit bias of doctors and mental health professionals, who are more likely to overlook physical and emotional vulnerability in low-income women and women of color. This is especially egregious given that Black infants in the U.S. are more than twice as likely to die than White infants, and Black mothers are three to four times more likely to die from pregnancy- and childbirth-related complications than White mothers.

Moms who are used to the world turning a blind eye to their hardships may in turn be less likely to notice their own suffering. A 2013 study by Yale University found that three in 10 low-income mothers struggle to afford diapers, and that that need alone is linked to increased depression and anxiety. Similarly, a New York City survey of nearly 3,000 mothers who gave birth in 2012 and 2013 found that African-American women were most likely to experience racial bias along with three or more financial, emotional, traumatic or partner-related stressors in the 12 months before giving birth. That pile-up of stress more than doubled the chances of postpartum depression. Still, for many of these mothers, said Divya Kumar, co-founder of the Perinatal Mental Health Alliance for Women of Color, it can be hard to separate what’s postpartum depression and what’s just the daily grind of life.

Yet a third part of the answer lies in inadequate access to services. In December 2016, President Obama signed the Bringing Postpartum Depression Out of the Shadows Act into law, which authorized a modest $5 million a year for five years for expanded screening and treatment of postpartum depression. But the budget approved under President Trump provided little funding for it.

Christena Raines is a perinatal psychiatric nurse practitioner in one of only two inpatient programs specializing in postpartum depression in the country, at the University of North Carolina. “We have 100 counties in North Carolina. Twenty-nine of those counties don’t have OB providers with even fewer psychiatric providers,” she explained. “And many psychiatric providers are not trained in perinatal mood disorders.” If postpartum specialists are few and far between, providers of color are exponentially so. In addition, poor mothers are twice as likely to be uninsured as other moms. Black mothers are twice as likely to be uninsured as White mothers, while Latina mothers are three times more likely to be uninsured, according to the National Academy of Sciences.

A Pileup of Issues
rntWomen I interviewed said these pieces of the puzzle—stigma, risk, bias and lack of services—are inextricably linked. When a mother can’t find help, coming forward becomes a riskier proposition, especially if she’s part of a community that’s already more likely to be judged abusive or neglectful than suffering, all the more so if she’s also likely to be judged harshly by her own community.

In a 2014 study, “A disease you just caught: Low-income African American mothers’ cultural beliefs about postpartum depression,” mothers expressed fears that if they acknowledged struggling with postpartum depression, people in their community would assume this meant “extreme thoughts and crazy, dangerous behaviors.” At the same time they felt threatened by government action. “They feel that something’s gonna be taken away from them. If it’s not their children, it’s their freedom,” one mother explained. To change outcomes, advocates said, requires addressing multiple pieces of the puzzle.

Rates of postpartum depression treatment rise when screenings and other services such as housing and healthcare are in the same clinic. But where there’s no investment in services, even mandating screening makes no difference. Paradoxically, without services available, providers are as uncomfortable asking about postpartum illness as mothers are talking about it. “Lack of services inhibits screening,” said Jessica Dym Bartlett,** deputy program area director for ChildTrends, a think tank focused on child well-being.

One of the greatest risks of mothers not seeking help, advocates say, is the damage done to mothers’ and children’s long-term well-being. Untreated, postpartum conditions can become chronic, while maternal depression is associated with a host of emotional and behavioral problems in their children.

Karen Flores said that many of the mothers she worked with at Early Head Start who exhibited signs of depression had babies who showed those same signs. When the babies turned 2 and 3, she said, they often had greater behavioral problems than other children, which in turn, became battles with their mothers.

Sienna’s Story: Penalized for Seeking Help
rntAt the same time, many of the providers I spoke with could relate a handful of stories over the years of mothers who’d had their children placed in foster care, and then faced a system that didn’t understand postpartum mental illness. The more vulnerable mothers were already, the more at risk they were of losing their children temporarily—or forever. Sometimes they lacked support. Other times, they had past histories of mental illness. Their post-partum episodes were taken as further proof of their incapacity to parent rather than as temporary crises.

Sienna* was in her late teens when she gave birth to her son three years ago. She had been depressed on and off throughout her adolescence and was hospitalized once after she attempted suicide in response to a breakup. But about a year later, when Sienna found out she was pregnant she was working and stable.

Shortly before her son was born, like many mothers concerned about the effects of psychotropic medication on the fetus, she decided to go off the Xanax she’d been prescribed. But after her son’s birth, she suddenly felt overwhelmed at the thought of caring for him and detached from him in a way that many mothers with postpartum mental illness share. “I was so scared to leave the hospital,” recalled Sienna, who is Black. “And at home I was miserable. I would hear my son crying even when he wasn’t there or he was sleeping…I felt like this was happening to me and only me, and I thought maybe it’s because of the past psych stuff. I just felt so isolated.”

Eventually, Sienna called her OB-GYN, panicked and crying. Soon, child protective services (CPS) arrived at her door. Sienna was living with her mother, and CPS agreed that if Sienna went to a therapeutic program, and her mother and son’s father agreed to never leave her alone with the baby, he could stay in her home. But when her son was 9 months old, his father found work in another city. Sienna no longer had round-the-clock supervision so child protective services removed her son, eventually placing him with his paternal grandmother.

By then, Sienna had begun to feel her symptoms start to lift, but when her son was removed she spiraled downward again. “Once my son got with his grandmother she started telling him that she was his mother. That’s when I kind of just lost it. I fell off my programs. I didn’t want to have to fight. Truthfully, I also felt a sense of relief, because I wasn’t so overwhelmed.” For a little over a year, Sienna ran from her feelings. She got into in a destructive relationship and cycled in and out of hospitals. She was given different diagnoses, from bipolar to schizoaffective to post-traumatic stress disorder. She’s surprised child welfare didn’t terminate her parental rights then.

But when her son was almost 2, something shifted, Sienna said, and “it hit me like bricks that I didn’t have my son.” After that, her lawyer said, she became a different person, complying with services, working at a restaurant while earning a nursing degree, and, for the next year and a half, never missing one of the three-day-a-week visits with her son. Although the court required supervised visits, she was lucky to be able to take her son out, to the Air and Space Museum, to Chuck E. Cheese, for ice cream. She was silly with him and hugged him a lot. “It felt so natural,” Sienna said. “Just like the postpartum hit me, developing a bond with my son also hit me…Everyone at [the child welfare agency office] knew us because when my son would see me, he’d say, ‘That’s my Mommy. That’s my Mommy.’”

During that time, Sienna said, she became a stronger person, helped by women in a support group, a few of whom had also experienced postpartum mental illness. “Once I really heard what it was, I began reading articles. I felt better knowing it was so common,” Sienna recalled, adding that she believes that going off her medication abruptly exacerbated her symptoms.

But in court, while many of the professionals involved in Sienna’s case testified to her strong mother-son bond, they also expressed concern about whether her child would be safe with her, given Sienna’s past history. They even questioned whether what she had really experienced was postpartum mental illness. So while other mothers in Sienna’s group progressed to unsupervised visits, she never did. “The mental health professionals in court said, ‘We don’t know what’s going on in her head,’” Sienna’s lawyer explained. “We argued, ‘She was the one who reported it all in the beginning. Why would she be closed about it now?’”

Ultimately, the judge terminated Sienna’s parental rights, freeing her son to be adopted by his grandmother. Afterward, she cut off all contact between Sienna and her son. “I don’t think I’ll ever get over it,” Sienna said. “We have my boyfriend’s son every other week. I have two nieces I watch every other weekend. I can be with other people’s kids, but I’m not fit to have mine.”

“If we can’t promise mothers that treatment’s accessible to them, and that they’re not going to be punished for seeking treatment, all the talk in the world about stigma isn’t going to help,” said Jesse Krohn, associate director of equality and diversity at Drexel University, and formerly a lawyer representing parents in family court,

Raena’s Story: Healing Herself Through Helping Others
rntAs an outreach worker for the maternal and child health group Great Beginnings for Black Babies, Raena Granberry meets depressed moms-to-be and new mothers who believe that seeking psychological care is a sign of weakness. “I tell my clients that they can’t be a strong Black woman if they don’t get the help they need,” said Granberry. “Your strength is in your self-advocacy.’” To drive her message of home she starts with her own story.

On the day she went into premature labor, Grandberry called her doctor to say she wasn’t feeling right. She was on the MediCal public health program, but she’d found a private doctor in Beverly Hills because she wanted the best quality care. When her doctor told her that all pregnant women feel sick, and that spotting is normal, she assumed he knew best. Granberry also believed him when he said her pain was probably indigestion.

By the time she realized he was wrong, it was too late: her baby was stillborn. In the months that followed, her grief cascaded into a serious clinical depression marked by obsessive guilt and pill-popping Benadryl for insomnia. Still, when a social worker asked her if she was depressed, Granberry said she dismissed her emotional pain like her doctor had her physical pain. “I’m just a little sad,” she answered. “I’ll be fine tomorrow.”

Granberry healed with the help of her boyfriend (now her husband), who forced her to stop taking the pills. She read everything she could about postpartum grief and depression in books and online. And finally she began helping other women get help. Still, she said, it took her years to feel that her grief had finally lifted and she could truly let happiness back into her life.

Like Granberry, Kay Matthews founded The Shades of Blue Project after she lost an infant at birth. Matthews uses the offer of free diapers and formula to draw mothers into her organization, then connects them to a support group where women talk, exercise and cook together. “We’re like a family,” said Matthews, especially for women whose own families offer more judgement than support.

Matthews knows it’s risky when women need professional help and don’t get it. So when women say it’s too hard to speak to their doctors—because they’re scared, ashamed, or because they’re going to a clinic where the doctor has no time for them anyway—Matthews asks them to write down their feelings on a postcard to give it to the doctor.

At the same time, Matthews is transparent that talking to a doctor about postpartum depression is not risk free. Whenever possible, she refers them to doctors and therapists within her circle. In addition, Matthews’ postcards have her organization’s name, her name, and her telephone number on them. Asking for help can put a mother in danger of involvement with child protective services, but showing that she has a support system behind her, Matthews said, can mitigate that danger.

Carla’s Story: Listening to Her Body, Tuning Out Shame
rntFor Carla Velasco, finding help proved to be an experience of emotional liberation. In 2010, she gave birth to a baby girl. But soon after her mom left California to go home to El Salvador, she became overwhelmed with sadness. Velasco was well-known in her neighborhood and had run a day care out of her home for years. But her sadness snowballed into panic that she’d make some terrible parenting mistake that would lead to losing her daughter.

“My family’s from El Salvador and Guatemala, and back in the day, parents and grandparents had all these children,” Velasco said. “A lot of them couldn’t understand why I have one child and I’m going crazy. They were telling me to just stop thinking about it.”

But Velasco pulled out her copy of “What to Expect When You’re Expecting” and turned to the one page she’d skipped when she was pregnant. She read the list of symptoms for post-partum depression. She had every one. Then she called an 800 number. Fifteen minutes later, a woman called back. She asked if Velasco and the baby were safe. Then she told her a therapist would be contacting her within one day.

Velasco was also connected to a support group. “The first time I went, I thought, I’m going to have to go to a psychiatric hospital, and who’s going to raise my daughter?’” But week after week I heard that I was not the worst, and that other moms were making progress.”

The scariest part was being prescribed psychiatric medication. “In my family, a lot of people say that you’re going to get addicted. They tell you, ‘just breathe, drink teas, go walking.’” But her mom was different. She told Veslasco, “‘We’ll take it together. Call me every morning.’ I came to think that my mom also went through postpartum depression,” Velasco said.

Soon, Velasco learned about other relatives who took medication for anxiety, and she began to think about her own anxiety as a child. Her close-knit family had made it manageable, but they’d also ignored it. Velasco found she no longer wanted to ignore her feelings, and that, in fact, acknowledging them made her stronger.

Today Velasco shares her story to help other women, through the L.A.-based group Maternal Mental Health Now. “I like telling my story,” Velasco added, “because I’m not ashamed.”

*Sienna’s name has been changed to protect her privacy during an ongoing appeals process.
rnt**Story has been updated to correct the spelling of Jessica Dym Bartlett’s name. 

Rachel Blustain is the content supervisor at Rise, an organization by and for child welfare-affected parents, and a freelance writer in New York City.