Pregnancy Related Depression

I recently read a thoughtful MedPage article by Julia Zuckerberg, a fourth-year MD/MPH student. She asks why we don’t check for post-traumatic stress disorder (PTSD) at the end of pregnancy when we test for postpartum depression. She raises several concerns with PTSD and pregnancy. We know that there are many women who enter pregnancy with PTSD, so why not identify them in the beginning of pregnancy before the patients are influenced by what we do as providers.

We know that women who have PTSD are more likely to have a PTSD exacerbation during and after pregnancy. We know they are also more likely to have depression, which can cause suicide, and they’re more likely to have psychosis which can cause homicide or infanticide. We also know that when fathers have PTSD and depression that mothers are also more likely to have PTSD or depression. So, it would make sense to identify moms and dads with PTSD or depression at the beginning of pregnancy.

Today the practice of medicine seems to be in a love affair with testing, or studying anything and everything in an effort to objectify (in a good sense) and to comply with evidence-based medicine...the emperor’s new clothing...so why not test dads? Part of the problem is the professional boarding organization for obstetrics, the American College of Obstetricians an Gynecologists (ACOG), limits obstetricians to treating only women. ACOG has always defined their obstetric profession as healthcare specialists for women only.

Seeing men as patients in any capacity, except the emergency room, would jeopardize, not only an obstetrician’s boarding, but also the physcian’s entire status with ACOG. Similarly, internists don’t want to see children because their specialty is adults, and pediatricians don’t want to see adults because their specialty is children. So, boarding is always at risk when you step out of bounds of boarding rules, even though a patient might benefit. Clearly the obstetrical patient’s environment may well be influenced by the rest of the family, including husbands and children.

The classic test for depression is the Edinburgh Postnatal Depression Scale (EPDS) test. The test was developed in 1987 to help physicians determine if a woman was suffering from postpartum depression after the birth of her baby.

The Patient-Physician Relationship

In my experience, patients don’t want to take a test. On KevinMD I wrote about the best way to treat postpartum depression is to not have it. Postpartum depression is preventable. I wrote before on Substack about my welcoming the whole family on prenatal visits. Patients want one provider who listens to them and they want a person who will develop a patient-provider partnership with them. This partnership is worth much more than testing. I had a friend who graduated residency in the late 50s. He said, “If you listen, they’ll tell you,” and he was absolutely right. The problem is that in a five-minute office visit, the patient doesn’t get to talk much and the doctor doesn’t get to listen much. The electronic medical record (EMR) requires most of the provider’s attention during the five-minute visit.

It’s difficult for patients to form a patient-provider partnership because patients are likely to see a different provider on every visit. The reasoning behind the revolving door of physicians is so that the patient can be introduced to one of the many possible doctors who might be present at the time of delivery. The opportunity to meet several different providers comes in a poor third place to actually having formed a good patient-provider partnership with one physician.

What I found most attractive about obstetrics is the possibility to choose the best outcome much more often than one might think. I know for a fact that choosing the best possible outcome works 99 percent of the time. In all of medicine, this is the one place where physicians and patients can hope for the best, plan for the best, and get the best 99 percent of the time, but you can’t do this without developing the patient-provider partnership.

I chose to practice independently so I could preserve my autonomy and my patient-provider partnership. I could see the patients as many times as I wanted and as often as they needed to be seen without regard for a batch of insurance companies’ captain-may-I’s. The upside of having my private practice is that I had some control of what happened to my patients and myself. The downside is that the large corporations, the private equity companies, and the insurance companies gobble up the paying patients and avoid the people who can’t pay. Those complex patients are then left in the hands of Medicaid which is not only a bad payer, but notoriously difficult to deal with. They are always right. I have had Medicaid take back payments for patients I had never seen and taken back payments for patients I had seen several years earlier. In my experience there is no way to correct Medicaid’s billing errors.

So, for intellectual freedom and autonomy, I traded small payments for a high-risk group of patients, who were socio-economically deprived. They often had many other health conditions influencing their pregnancies, largely because they often had no access to healthcare. If you’re interested in making money as a physician, this is a bad trade, but if you’re interested in the challenge of delivering good outcomes to people who need it and deserve it, it’s a huge win.

Yes, I departed from the traditional protocol. I invited dad’s and children to the prenatal visits and classes. By listening and observing, I learned what I couldn’t possibly gain from testing. I learned how a household worked and what kind of coping resources the families had. Prenatal care offers a a magnificent opportunity to prepare for the best postpartum course and avoid postpartum depression, psychosis, suicide, and homicide. Of course, there must be as many prenatal and postpartum visits as needed, and as frequently as necessary.

In her article, Ms. Zuckerberg talks about reports of obstetric trauma on TikTok. I’ve found similar trauma stories on National Public Radio (NPR). Her points are the examples she cites are well-taken.

Heavy Bleeding after a C-Section

Her first example is one of heavy bleeding after a C-section. This is a never event. In other words, there should never be heavy bleeding after a C-section. Certainly, there is no reason ever to bleed to death after a C-section. The whole idea of surgery is that the surgery is done when the bleeding is done. No exceptions.

Transfer of Home Birth Woman to Hospital

Ms. Zuckerberg’s second example is about a home birth that required transportation to the hospital by ambulance. With home births, the transfers to a hospital are actually surprisingly rare. Most midwives are very careful about who should deliver at home. The midwife should always have a connection with a doctor in a hospital who is willing to accept transfer patients.

Coma After Childbirth

And finally, Ms. Zuckerman reports on a normal birth which resulted in a coma for a month. I can only think of one reason this might occur—a ruptured cerebral artery aneurism. And although these are rare, they are for the most part deadly. The only possible way to avoid a patient’s death is if the patient has had a headache and had a CT scan of the brain before delivery. Secondly, a coma resulting from neglected eclamptic seizures should never happen. In my experience, I’ve seen many women who have preeclampsia, but none of them have had seizures, none have had eclampsia, none have had strokes, and none have died or been injured even temporarily. No excuses.

Compassion

Ms. Zuckerberg talks about practitioners who become numb to complications that accompany pregnancy and childbirth. Nobody should become comfortable with unfortunate results in pregnancy. Lack of compassion for patients is a sign of a physician who should probably look for a new line of work. Everyone deserves good and equal healthcare. A patient’s lifestyle before they come to see us is irrelevant and should play no part in our providing quality care.

Ms. Zuckerberg indicates that PTSD affects 4.6 to 6.3 percent of women postpartum. I’d like to add that postpartum depression can very well affect men as well as women and children. This is where the patient-provider partnership becomes particularly important. Both moms and dads need to know that there is somebody who will listen to them and get them immediate attention when they need it.

I believe that events and circumstances surrounding pregnancy, labor and delivery, and postpartum can be managed in a way that diminishes the risk for PTSD, depression, or postpartum depression. Every doctor functions on at least two planes. One is competency. The other is compassion. Having myself been a student and a resident and having trained residents and students for over 30 years, I know that competency varies widely from physician to physician.

When your doctor informs you of the need for an emergency C-section, you want a doctor who is competent. The other needed element is compassion. When I look back at my residency training, I was fortunate to have professors who knew how to make their actions look easy, not only discussing emergencies calmly and confidently with patients but also managing any emergency in a confident and quiet manner.

Every doctor, at least those who are sane, are a little bit frightened before surgery because they know there can be unexpected results no matter how competent and experienced we are. We know we have an awesome responsibility. But we don’t communicate our worry or anxiety to our patients or the remainder of the team. Nor do we tell silly jokes. The environment is serene, respectful, and calm. There were nurses who didn’t like to work with me because I demanded almost as much from them as I did of myself.

Nothing was more important than a good patient outcome. Sometimes the operating team said I had ice water in my veins because the more complex things got, the calmer I got. Well, that was on purpose. We can’t be hysterical and lead a team with dignity and competency. My surgical team members paid me the highest compliment when they came to me for their surgeries. They knew.

Good outcomes are very dependent on our competency and our demeanor. And we must never forget.

Five Groups to Consider Regarding Postpartum Depression

While Ms. Zuckerberg has raised a valid point about testing women for PTSD after delivery, there are really five groups to consider:

1.   PTSD in moms at pregnancy onset,

2.   depression in moms at pregnancy onset,

3.   PTSD,

4.   depression in significant others, and

5.   moms and dads who develop new PTSD during pregnancy.

There are some studies indicating the value of doulas postpartum. Surely if doulas can manage and prevent postpartum depression, doctors and midwives should be able to do the same. We need a viable patient-provider partnership with accurate understanding of patient needs and diagnoses.

Postpartum depression does not develop for the reasons depression develops in women who are not pregnant. In my experience, inviting the entire family to prenatal visits from the first visit on provides an effective way to prevent postpartum depression. It’s time to take postpartum depression beyond the too-late administration of testing and prevent postpartum depression with effective and early establishment of an effective patient-physician partnership.