By Yen Duong
I knew going into my third pregnancy that it’s not a walk in the park: around two-thirds of pregnant women experience morning sickness, almost everyone experiences fatigue from building a placenta, the immune system changes, and sleep problems arise.
But I never expected that it would be this bad.
For months, I vomited four to six times a day, turned my nose away at almost all foods, couldn’t sleep at night for endless replays of anxious scenarios with the baby, or with my two older kids, and sobbed over inane problems that completely overwhelmed me such as the smoke detector running out of batteries or oversalted pasta.
While I’d been warned about postpartum depression during previous, easier pregnancies, I had no idea that it could also strike during pregnancy. It turns out that about one in seven childbearing women experiences perinatal depression, or depression that strikes either during pregnancy or up to a year after birth. According to a paper published this month in the North Carolina Medical Journal, 85 percent of women with perinatal depression don’t receive treatment.
“[Perinatal depression] can be very heterogeneous and different,” said Dr. Mary Kimmel, author of the paper and former co-director of the UNC Chapel Hill perinatal psychiatry program. “For some women, it’s something that’s similar to the depressions they’ve had at other times, but for other women, it’s very unique to that time period because of the unique biological, psychological and social things that are happening.”
Navigating perinatal depression
Even as a reporter who has written extensively about mental health and stigma, I hesitated to reach out for help. I kept telling myself that I had already survived two pregnancies and that insomnia, eating problems and random crying were nothing new.
But by the time I called my midwives’ helpline when I was 22 weeks pregnant, I could not answer the question “How are you?” without bursting into tears. They hustled me in for an appointment that day; my chief complaint was recorded as “sadness.”
My midwife prescribed me Zoloft, gave me a list of recommended counselors and, most importantly, reassured me that I had done the right thing by coming in.
“Among providers and among patients, I think there’s a lot of stigma and fear around medication for pregnant and lactating women,” said Karen Burns, director of a UNC program dedicated to perinatal behavioral health. “There is a lot of hesitation to take something, so there is that unwillingness to disclose. Providers who aren’t specialists are really loathe to prescribe … sometimes because they don’t know how this medication will interact with someone [who is] pregnant or lactating.”
Pregnant and postpartum women who need help should reach out to their medical provider. They can also call SAMHSA’s national helpline 24/7 at 1-800-662-HELP (4357). The New Mom Health website is another UNC project with resources for new moms.]
I can attest to that: I later saw my primary care physician for a month-long cold, which contributed to the depression. She triple checked the prescription and changed her mind on what to give me.
Perinatal depression can range from severe “baby blues,” or the tiredness that comes within a few weeks after giving birth, anxiety, obsessions and stress around parenting and preparing for baby to mania and postpartum psychosis, Burns said.
Fatigue is a symptom of depression. Unfortunately, fatigue is also a symptom of pregnancy. Most mornings, it’s hard for me to tell why I don’t want to get out of bed.
“It’s really hard to separate the two of them,” said Kimmel when I told her that. “Ultimately, it’s being kind to yourself and recognizing that there’s a lot of things going on.”
Access to care
I’m fortunate to live in Charlotte, where there are counselors galore: the midwives gave me a list of 12 practices; my insurance gave me a list of 400, and I just had to cross-reference the two. Of course, that task was too overwhelming for me and I ended up asking my neighbor, who is also a therapist, for a recommendation.
Rural hospitals with maternity and neonatal services are green. Rural hospitals that have either discontinued or will discontinue their maternity services are red. Urban hospitals are blue. Chatham Hospital is in purple.
Note: This map has been updated thanks to feedback from our readers on an additional labor and delivery unit closure.
This map collates N.C. hospitals which had 25 or more deliveries in FY2017. We updated names of hospitals that have since changed, with the old name in parentheses. The data come from the North Carolina Healthcare Association, which surveyed hospitals for the information. When hospitals didn’t respond to the survey, fields remained blank.
Urban/rural designations are based on definitions from the Centers for Medicare and Medicaid Services.
The American College of Obstetricians and Gynecologists define OB level 1 as basic care, OB level 2 as specialty care, and OB level 3 as subspecialty care.
Data source: N.C. Healthcare Association. Map credit: Liora Engel-Smith
Many women are not as fortunate. As of 2015, 29 North Carolina counties have no psychiatrists according to the Sheps Center for Health Services Research at UNC Chapel Hill. And in a trend previously reported by NCHN, more and more women can’t give birth in their home county, much less see a specialized perinatal depression counselor.
In 2018, UNC received a five-year federal grant to create the NC Maternal Health MATTERS program, run by Burns. They created a consultation line, based on a successful 20-year-old Massachusetts program, for medical providers to speak with psychiatrists and nurse practitioners about perinatal depression and anxiety. Duke has run a similar line for child and adolescent mental health for two years.
Primary providers can call the NC Psychiatric Access Line at (919) 681-2909 ext. 2 during business hours with questions about perinatal mental health.
“We had a call a couple weeks ago, the patient lives in Harnett County, was getting her prenatal care in Wake County. When she screened positive for anxiety, they referred her to get an assessment in Chapel Hill,” Burns said. “She didn’t go; it was too far.”
“[At] her next prenatal appointment, they knew about us and they called the line, and we were able to … talk them through more manageable care other than drive an hour each way to get an assessment with someone you don’t know.”
Eventually, NC MATTERS hopes to offer telepsychiatry for pregnant and postpartum women across the state to directly talk with those UNC psychiatrists and nurse practitioners, Burns said.
Researching more treatment options
This month, UNC started participating in a multistate clinical trial studying different treatments for women with postnatal depression. They’re looking at outcomes for women who receive in-person therapy from postnatal mental health specialists or nurses, and hope to extend the study to compare in-person versus telehealth therapy, Kimmel said.
In 2011, UNC opened the first inpatient perinatal psychiatric unit in the country, and the five-bed unit remains the only such one in North Carolina. Modeled after specialized mother-baby inpatient units in Europe and India, these dedicated beds have support for breastfeeding and family visits, though babies can’t stay in the unit as they do abroad, said Kimmel, who runs the unit.
“Because the baby is healthy, the health insurance won’t pay for the baby to be admitted,” Kimmel explained. “If you got the right foundation funding to fund the nursery, it might be possible.”
Kimmel said the average stay at one of the specialized units in much of Europe is 40 to 50 days, while the UNC unit average is seven to 10 days. The United States is one of only five countries in the world that doesn’t guarantee paid maternity leave, per the federal Health Resources and Services Agency.
“In Europe in general, they just have more of an approach that the postpartum period is one where we need dedicated time and that it is a big deal and that we need time to navigate this and take care of the baby and take care of yourself,” Kimmel said. “Hopefully we can continue to work toward more of that kind of approach here.”
I’ve spent the last few months trying to take care of myself with my medication, therapy, exercise and rest, but it’s still a struggle. At my 33-week visit this week, my midwife told me that they like to keep women on antidepressants for a year after birth, since I may be more vulnerable to postpartum depression. Though crying, vomiting and fatigue still continue to challenge me, I count myself as lucky to have had access to treatment for my perinatal depression.
- Looked through old emails, text messages and medical records.
- Interviewed sources quoted above by phone
- Researched maternity leave in the U.S. and perinatal depression