On Thursday, Jessica Porten, a new mom in Sacramento, California, walked into her OB-GYN’s office for a routine postpartum checkup that became a harrowing ordeal. Although her daughter, Kira, was 4 months old, this was Porten’s very first post-birth visit to her OB.
Porten told her nurse practitioner that she was having postpartum depression, or PPD, symptoms, including bouts of anger. She wanted to discuss treatment options. According to Porten, “I tell them I have a very strong support system at home, so although I would never hurt myself or my baby, I’m having violent thoughts and I need medication and therapy to get through this.” The nurse gave Porten a rushed pelvic exam, said she needed to talk to the doctor about Porten’s PPD, and left the room.
What happened next? Did the doctor come in to assess Porten’s PPD symptoms in more depth and conduct a risk assessment? Nope. Did the nurse connect Porten to behavioral health services covered by her insurance? Nope. Did she generate referrals to mental health specialists who treat PPD? Or offer information about how to recognize and treat PPD? Nope, nope, and nope. In Porten’s words: “They called the cops on me.”
Porten endured a humiliating hour in her doctor’s office, waiting for the police to show up to escort her to an emergency department. Because she had Kira with her in her car seat, the police could not drive her, so she drove herself there with two police cars tailing her. Once there, Porten was turned over to a security guard who “babysat” her for another hour while she waited for a room. Her blood was drawn and a urine sample was taken. Her clothes, even her flip-flops, were taken away and locked up. At 10:45 p.m., she finally got to see a psychiatric social worker, who handed her a few photocopied referrals and finally discharged her.
As Porten put it, “I leave the ER at midnight, my spirit more broken than ever, no medication, no follow up appointment, never spoke to a doctor. This was a 10 hour ordeal that I had to go through all while caring for my infant that I had with me. And that’s it. That’s what I got for telling my OB that I have PPD and I need help. I was treated like a criminal and then discharged with nothing but a stack of Xeroxed printouts with phone numbers on them.”
Porten shared her story on Facebook on Friday. It has now been shared more than 32,000 times and garnered more than 11,000 comments. Many of these comments echo Porten’s experience: “I had a similar scenario years ago in Lewisburg, PA,” wrote one commenter. “I went through something very similar while pregnant,” wrote another. “Those were my fears. I had PPD but I dealt with it alone. … I had already seen it with a close friend of mine. She was put under house arrest and she almost lost her kids,” wrote a third. Over and over, women wrote that they were afraid to tell their doctors about their mental health symptoms because of the possibility that they might be punished rather than treated.
It’s important for health care providers to intervene swiftly when patients are in danger of self-harm or harm to another person. But Porten’s 10-hour “treatment” did not make her, or Kira, any safer. She left discouraged, exhausted, and less likely to seek help than before. As a clinical psychology professor who focuses on the transition to parenthood, I see in Porten’s story just how broken our system can be. How did this situation go so horribly wrong?
For one thing, Porten didn’t get a checkup until four months postpartum, because, she noted, her doctor kept rescheduling. That’s way too long. Depressive symptoms can often occur in the first days and weeks after childbirth, due in part to the challenges of breastfeeding and the hormonal swings that follow pregnancy. Mental (as well as physical) health care should be easily accessible to women in the perinatal period (the period immediately preceding and following birth). In the Netherlands, women are visited at home by a kraamverzorgster—essentially, a postpartum doula who checks on mother and baby well-being—within the first 10 days of birth. In France, postpartum women get hands-on health care; for example, the government-sponsored health plan covers 10–20 sessions of pelvic floor training in the first few months following childbirth! In China, many women engage in zuo yue zi, or “sitting the month,” and spend the first postpartum month in bed, with ’round-the-clock care from family and friends. But in the U.S., women often fend for themselves after birth. One in four U.S. women return to work within two weeks of delivering an infant, a statistic that boggles the mind: That is not enough time to fully physically recover even from the most uncomplicated of deliveries, let alone establish a caretaking routine and bond with a newborn.
Another problem: Porten sought mental health care from an OB-GYN practice that clearly wasn’t equipped to diagnose or treat her symptoms. Given that depression is one of the most common complications of the perinatal period, her office’s lack of standard mental health protocols is striking. Instead of waiting 10 hours for a psychiatric social worker to evaluate her at an emergency department, what if Porten could have gone right down the hall to see a psychologist or social worker who worked in the OB’s practice? Indeed, this model of mental–physical health care integration has been tried in two OB-GYN clinics affiliated with the University of Washington. Women are screened for depression and, if they need treatment, paired with a care manager who guides them through the process of seeking therapy or medication. Several recent studies found that this arrangement yielded better mental health outcomes for the participating women, especially low-income women. Similarly, Pacific Gynecology and Obstetrics Medical Group in San Francisco employs two psychologists who specialize in perinatal care, so that psychotherapy referrals can happen in house. In Alaska, the Southcentral Foundation, a health care provider that serves Native Alaskans, offers fully integrated mental and physical health care: Patients can get an X-ray and see a psychotherapist within the same visit. And in a bold national experiment, Britain’s National Health Service recently began offering free, unlimited talk therapy at dozens of clinics around the country. For pregnant and postpartum women, who are especially short on time and energy, such programs can make the difference between obtaining treatment and not. And they’re cost-effective, too: Untreated depression has a profound impact on physical health, economic productivity, and women’s ability to care for their children. Addressing depressive symptoms early in the perinatal period might prevent more severe problems down the line. Plus, compared with the cost of Porten’s two-car police escort and eight-hour ER visit, a few psychotherapy visits are a bargain.
And even when women do receive mental health care treatment from their OB or pediatrician, it can be minimal: a prescription for antidepressants, with little follow-up. But medication is not the only or even the best option for women in the perinatal period. Given evidence that antidepressants can cross the placental barrier and have been linked with developmental disorders in offspring, women who are pregnant or planning to become pregnant may want to consider other options. Cognitive behavior therapy, a structured approach that focuses on identifying and correcting negative patterns of thinking, shows success rates comparable to medication and can often be completed in a dozen sessions or less. Another well-validated approach, interpersonal therapy, helps women shore up their social support networks and build communication skills. For some women, a combination of talk therapy and medication may work best. And for women without a psychotherapist nearby, long-distance approaches, like telephone peer support, can be a viable option.
In her Facebook post, Porten points out that as a white, heterosexual woman, she was lucky in some ways. She was allowed to keep her daughter with her during the ER visit, was treated (mostly) respectfully by hospital personnel, and was ultimately released after less than a day. “I am scared for our mothers of color and our LGBTQ mothers who seek out help in these situations,” she wrote.
Indeed, among low-income, nonwhite women, postpartum depression rates are higher, and so are barriers to treatment. One study found that women of low socioeconomic status were 11 times more likely than women with higher socioeconomic status to develop PPD. Yet these women often face higher barriers to receiving help, like greater stigma from providers and fewer affordable mental health care options. Since her post went viral, Porten has partnered with the nonprofit 2020 Mom to help advocate for maternal mental health in California, a step toward making better mental health care screening and treatment available to all.
Postpartum depression takes a toll on the health of the entire family (and can affect fathers, too). As custodians of the next generation, parents are our society’s most precious natural resource. It’s our duty to support them with parental leave policies that allow for adequate rest and recovery, and easy-to-access mental health care in the early perinatal period. Let’s hope the next mother in Porten’s shoes is met with compassion and support, rather than a police escort.