Oregon Begins Tackling Maternal Mental Illness
Law is the first step to addressing maternal mental health problems affecting 24 percent of Oregon women
June 14, 2011—Amie Wise-Mendez’s difficulties giving birth to her third child didn’t end with the high blood pressure and seizures she experienced before being admitted to the emergency room and having a C-section.
Still seriously ill immediately following her son’s birth, Wise-Mendez was separated from him. “I felt blamed,” she said. “I was crying and inconsolable.”
She began to feel deeply depressed and suicidal over the course of the following three months. She took herself to the emergency room, asking that she be admitted to the psychiatry ward. But the staff denied her request because she “didn’t have an actual plan to kill” herself.
Wise-Mendez returned home. Her depression deepened, and she was unable to eat or sleep. Finally, she overdosed on her blood pressure and seizure medication, and was found on the highway, in her pajamas.
“I had a severe mental breakdown,” she said.
She found herself back in the emergency room, and this time was admitted to the psychiatric ward. A psychiatrist who had recently given birth recognized the illness that had been plaguing Wise-Mendez, and almost killed her: post-partum depression, one of many illnesses known as “maternal mental illness.”
Wise-Mendez was connected to support services that helped her overcome the mental illness that affects 24 percent of Oregon women after giving birth, according to the Oregon Public Health Division. That number is twice the national average.
“That's a very significant proportion,” said Katherine Bradley, administrator of the Public Health Division’s Office of Family Health. “It’s of great concern.”
Oregon has started to bring greater attention to this issue by increasing provider awareness and providing educational opportunities to both providers and mothers.
Advocates, service providers and mothers like Wise-Mendez and their families are jubilant that House Bill 2235 became law on June 2 with the signature of Governor John Kitzhaber.
They expect the actions called for in this law will become a catalyst to significantly change how maternal mental illness is treated and understood.
Mood disorders lead to feeling ashamed and inferior
Maternal mental illness refers to mood and anxiety disorders a woman can experience during pregnancy and within one year after giving birth such as depression, anxiety, inability and disinterest in sleeping and eating, and overpowering feelings of failure, despair and inadequacy.
“Anxiety is the hallmark,” said Amy-Rose White, the executive director of Eugene-based WellMama, Inc., which provides support services. “[A woman] is trying to maintain that exterior image of control.”
These disorders make it difficult for a pregnant woman or new mother to connect to their newborn and “feel good about anything,” said Wendy Davis, the executive director of Postpartum Support International, and chair of Oregon’s Maternal Mental Health Work Group in 2010.
The effects of maternal mental illness affect the infant as well as the mother. Because a mother may be unwilling or unable to bond and attach to her child, she may avoid her child and not provide the necessary care. A child can be at risk of developing behavioral problems, impaired cognitive, emotional and linguistic skills, and higher stress and anxiety.
“There are dramatic short and long-term effects on infants who are raised by mothers with untreated mental illness,” White said.
Maternal mental illness affects how a mother interacts with her child, and, in turn, leads a woman to feel shame and embarrassment, which exacerbates the illness.
Rather than recognizing that they feel depressed or exude other symptoms of maternal mental illness, women feel inferior and incapable.
American culture, which idealizes individualism, has helped create unrealistic expectations of mothers, including the assumption that pregnancy and giving birth represent the happiest moments of a woman’s life, White said.
Expectant mothers may have to quit or suspend their job, stop sleeping normally, and make other adjustments in their life. “That’s not the happiest time in your life,” White said. “Nobody talks about that part.”
Afraid to ask, afraid to admit
While 24 percent of women suffer from maternal mental illness, only 35 percent are diagnosed with the illness. One reason is that women are unlikely to admit to a doctor that they feel depressed.
“It seems unparentlike or unloving to admit to the negative feelings that may come not just with pregnancy, but childbirth,” said Rep. Carolyn Tomei (D-Milwaukie), who sponsored House Bill 2235.
Physicians and other providers are also unlikely to broach the subject because they’re not aware of the prevalence and seriousness of maternal mental illness, and “they don’t know how to talk about it without upsetting their patients,” Davis said.
Doctors also are unlikely to talk about this issue because they don’t know what services are available to help these mothers, White said.
When Wise-Mendez was in the hospital, her doctors never asked her why she was so emotionally upset. “They were just trying to medically get me better,” she said.
Davis says it only takes the simple question “are you depressed or anxious?” to begin helping a woman seek treatment and services. But the stigma and shame associated with having a mental illness while a woman is supposed to be happy, and have the new responsibility of caring for another human being, trumps that.
“We’re afraid of mental health. Doctors are afraid of mental health. We’re afraid of imagining that a mother is sad,” Davis said.
Education and awareness are first steps
House Bill 2235 is Oregon’s first attempt to deal with maternal mental illness in a direct way. It creates the Maternal Mental Health Patient and Provider Education Program within the Oregon Health Authority to identify disorders associated with maternal mental illness and develop prevention strategies.
“Maternal depression or anxiety is not something that’s well understood by the general public,” said the public health division’s Bradley. “There’s a tremendous amount of education that needs to be done.”
The bill is a direct result of the Oregon Maternal Mental Health Work Group, which met for six months in 2010 and make eight recommendations to the Legislature such as improving training and support for providers, increasing public awareness, increasing the availability of screening and assessments, and covering maternal mental health services in the Oregon Health Plan.
Davis said it was more challenging to pass House Bill 2235 than she expected. The bill’s original estimate was $100,000. That money would have created a training program for providers, but the funding was stripped out.
An earlier version of the bill would have required doctors to provide educational materials to pregnant women, but the Oregon Medical Association, the Oregon Pediatric Society and other medical groups objected. Providing such materials is now optional.
However, the Oregon Health Authority can apply for federal grants to fund educational programs. As such funding becomes available, advocates would like to see more robust treatment services and programs such as classes for pregnant women to educate them and their families about the illness, how to recognize symptoms and treatment options.
“Women want to know there are going to be several options, not just [psychiatric] medication,” White said.
Eventually, advocates would like to see legislation requiring that women be screened for maternal depression. Davis realizes that will be challenging, because providers “don’t want to be told what to do [through] legislation.”
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Postpartum depression is a very real phenomenon. Unfortunately, the "treatments" that are likely to be recommended in the proposed "educational materials" don't always deal with the real issues behind the depression. For instance, domestic violence victimization increases dramatically during and after pregnancy, and yet the group making these recommendations did not include anybody from the domestic violence intervention community. Many other issues, such as poverty, loss of income, isolation, loss of sleep, nutritional imbalances, new relationship dynamics (especially changes in sexual relationships), traumatic birth experiences, nursing failure, childhood issues related to how we were parented, identity changes, and a host of other factors all contribute to the phenomenon.
Unfortunately, the "educational materials" proposed by the workgroup appear to focus mainly on the more socially acceptable "hormone imbalance/chemical disturbance" theories that allow medical interventions to predominate treatment. While such interventions may have their place, to reduce postpartum depression to a medical phenomenon is a huge oversimplification that will in the end be harmful to those very people we're trying to help.
It's time to convene a real, multidisciplinary team to include domestic abuse advocates, naturopaths, psychologists, community health nurses, early childhood intervention projects, birth and nursing advocates, self-sufficiency workers, and most importantly, mothers who have experienced this phenomenon, to come up with a more comprehensive set of educational materials that take the many contributing factors into account.