Behavioral Health for Obstetric Patients
As you can guess by now, what has become referred to as behavioral health in obstetrics is now the number one cause of pregnancy-related maternal mortality. Behavioral health includes suicide, homicide, and drug overdose. I have written about postpartum depression (PPD) being preventable here before, but the problems with behavioral health cover a bigger area of the problem with maternal deaths.
Beginning in the 1990s I was becoming aware of the fact that obstetricians could make a difference during the prenatal course in the future lives of their patients, including babies and dads before and after delivery.
I tried to get the psychology department at North Dakota State University Medical School interested in what I had learned but I was never able to gain their attention about the problem. Medicare, Medicaid, and insurances are not interested in real prevention because it’s hard for them to wrap their heads around an illness which never happened.
In all of the medical world we appreciate and thank the last-minute management by an emergency C-section, where the skilled surgeon swoops in and saves the day, somewhat akin to Mighty Mouse who you might remember, (if you are old enough), “Here I come to save the day!” So, to swoop-in and rescue somebody from a messy emergency that maybe shouldn’t have happened in the first place is considered to be heroic...and expensive, and that procedure even has an air of magic about it.
To manage healthcare so well that there are no emergency C-sections has not been recognized as having any value. For that kind of prevention there is no code, no payment and no thanks, either.
And, so it is with prenatal care or obstetric care in general. It is possible with care and some effort to empower moms and dads to take charge of their pregnancies. You might say, “Why bother,” or “That’s not my job,” or “I wasn’t trained for that.”
Right now, one of the largest problems facing obstetric patients is “It’s not my job” attitude. Turning that attitude to “It is my job,” or “How can I help” would do the most good for the most people in the shortest amount of time. An attitude change would require medical schools and residency programs to change, bringing about medical changes in attitudes of all future obstetricians.
We learn in medical school and residency what is considered the right way to do things. Any the departure from that is considered heretical even though the departure would benefit millions of people. Just think of Ignac Semmelweis who introduced the idea of “death particles” on the skin of unwashed hands. His ideas were offensive to his fellow physicians who wouldn’t believe that they could possibly be causing women’s deaths with unclean hands. For his efforts, Semmelweis was locked up in an insane asylum and died at the age of 48, as irony would have it, from gangrene of his hand. So, there are hundreds of years of medical discrimination against new thought.
When committees studying maternal mortality meet, some prefer not to count the behavioral health maternity-related deaths. Then there is the political nature of the medical profession which promotes the notion that a physicians must stay inside the boundaries of their specialties. You have no degree in psychology so don’t pretend that you do.
All I am suggesting is for obstetricians to spend a little more time with their patients, maybe 20 minutes instead of five. Sit down, meet your patients, and enjoy the chat and listen. Know where they have come from and where they are going. What will be their lives at home after they have seen you in the office? See the couple interact. Who is the Alpha? Where do strength and peace come from in that relationship? How do they stay out of trouble? What are their risks?
In my experience, the biggest cause of postpartum depression is the expectation that nothing will change or that nothing has changed. Brooke Shields in her book Down Came the Rain has described well the daily problems of postpartum depression and how difficult it is to get help. She speaks clearly and effectively about trying to merge her new life with her old life.
In my 50 years of delivering 6000 babies, I’ve found that the conflict between expectations and reality are at the heart of postpartum depression. A lot of dysfunction can be avoided if a woman knows what to expect when she goes home. That does not require a medical degree in psychology. As a matter of fact, much of that responsibility is now delegated to doulas, who are neither psychologists nor psychiatrists.
Much anger and depression can be mitigated by knowing what to expect, which includes practical things like food preparation, house cleaning, baby feeding, and most important of all, sleeping. So, if a woman feels like a failure, can’t love or even feel for her baby, she is most likely in the thick of depression. Many pregnancies are associated with “baby blues,” which begin shortly after the baby is born and may last for a week or two. However, Baby Blues resolve spontaneously.
Postpartum depression is serious and needs to be treated quickly. For my patients who fell through the cracks of prevention, I saw them the day they called. I had a working relationship with a psychiatrist I could call for prescribed medications to cover my patients until they could be seen by the psychiatrist. The agreed-upon meds, were usually Ativan, which works immediately, and Effexor, an atypical antidepressant. From that point on, I saw the patient at least weekly, as did the psychiatrist.
A few years ago, we considered postpartum psychosis simply a more severe case of postpartum depression. Today we know there is no time sequence connection. That is, you don’t need to necessarily have postpartum depression to develop postpartum psychosis.
Postpartum psychosis is a medical emergency. It must be taken seriously and treated swiftly and effectively. If the doctor or spouse is lucky enough to have a warning, such as the woman reporting she feels like killing her children or hears a voice telling her to kill her children, immediately remove the kids from the home environment. Mothers who have postpartum psychosis don’t have much in common with moms who have postpartum depression.
So how do we fix the problem of behavioral health issues, and for that matter, all of the other causes increasing in our maternal mortality rate? I think we need to look at the lack of access to healthcare. Blaming the patient doesn’t solve any problems. In my experience, complicated patients just need more time and more attention to more details.
Our payors, with their Machiavellian management of healthcare have tried to solve the high cost of healthcare problem by culling healthcare services, and as a result decrease access to physicians. The problems created by reducing access to healthcare appear in many ways. Corporate medicine demands physicians limit patient visits to 15 minutes so they can see more patients in an hour. With the added complication of electronic medical records, in an hour of our time we’re lucky if we are able to spend 20 minutes actually seeing patients.
Another serious problem is the death grip insurances have on when patients may see physicians. Years ago, we could send our moms, babies and dads home from the hospital when we felt they were ready to go home. Today we don’t have that luxury. Many moms, babies, and dads are out of the hospital in 24 hours. The valuable information moms and their families used to get from physicians and nurses in the hospital about how things should work at home has been lost. Now, in order to replace some of the things we used to do for our patients in the hospital patients are sent home with a few CDs to satisfy the educational requirement.
What we now expect from new moms and their families is completely ineffective and completely unreasonable. From my perspective, withholding access to needed healthcare is the biggest cause of our behavioral health issues. The question is whether our current healthcare system can repair itself by providing adequate access to needed healthcare to prevent postpartum depression, postpartum psychosis, and behavioral health issues. Those studying the problem do not seem to understand the increasing lack of access to healthcare is a systems problem, one any committee looking at maternal mortality needs to acknowledge and set about fixing.