Table of Contents
Introduction
We study the case of Shannon Green, a mother of three who had given birth to a child two months prior. Her family described her as “going through the motions as if she were in a fog”, expressed concerns about Mrs. Green’s general fatigue, lack of connection to her newborn and overall stress, following the birth of her child. During a well child visit the pediatrician at a local clinic noted how “addled and tired” the mother seemed and “gently” encouraged her to a the local mental health center as well as a community support center staffed by volunteers, in addition to providing the number for the state child development hotline. On a family shopping trip, she failed to fasten the children into safety restraints resulting in the death of her infant child. Family members prior to the incident tried to get her in to mental health services but were unable to do so in time to prevent the death of the child.
At different levels Mrs. Green and her children were failed by the system at the interpersonal, organizational, community, and policy levels. Her family offered very little support with the children due to distance and the father being employed away from home, despite being seen by a pediatrician there was not a sense of urgency to get Mrs. Green to the proper channels to get the help she desperately needed, and within the policy and organization levels there is a clear lack of funding, priority, and legislation set in place to get mothers with or at risk of perinatal depression the assistance that they need. The primary negotiation point would be more funding to revamp the mental health referral and treatment system for mothers and children.
Collaboration is key when addressing perinatal depression. It is a condition that requires a comprehensive approach as well partnerships between groups. There needs to be collaboration between key agencies and individuals to improve access to prenatal care thus perhaps preventing tragedies such as that of Shannon Green. Problems to be tackled include addressing funding, referral and treatment, resources and training, and standards and guidelines, confidentiality, financing, and outreach.
127 our experts are availableright now
Background
News coverage and editorials asked the question of how the situation which turned out to be an untreated case of perinatal depression was missed.
According to Brown (2008), perinatal depression or depression during and after pregnancy occurs in about 10 percent of pregnancies. Many persistent symptoms include strong feelings of anxiety and despair, sleep disturbances, crying, to name a few. Due to these feelings women may have a difficult time caring for their families, children, and themselves (Brown, 2008). These feelings have lead roughly 30% of women with postpartum depression to consider or have thoughts of homicide, suicide, or infanticide. A high profile case, that of Andrea Yates, was reported to suffer from postpartum depression which resulted in the drowning deaths of all 5 of her children (Misri, 2002).
Postpartum depression is the most common psychiatric complication of child-bearing . Despite the tragic consequences that often align with perinatal depression, it often goes unrecognized and untreated (Brown, 2008). Women may be reluctant to seek professional help because of the stigma of mental illness (The American College of Obstericians and Gyneocologists, 2015). They may fear embarrassment, shame, and generally fear losing their children due to the condition. Other times the system fails to take this condition seriously or set it as a top priority leaving many women to fend for themselves (The American College of Obstericians and Gyneocologists, 2015).
Key problems to consider when negotiating for legislation to improve outcomes for women who suffer from or are at risk of perinatal depression would include: referral and treatment, resources and training, standards and guidelines, confidentiality, financing, and outreach (Brown, 2008).
Referral and treatment would involve ensuring those women with or at risk of perinatal depression receive care in a timely and effective manner while being allowed to explore different treatment options, also developing ways in which to handle referrals would be included (Brown, 2008). In this case family members and even medical staff witnessed the symptoms of perinatal depression but failed to in a timely manner get her the help that she needed. Had care been delivered sooner a child may not have died.
Resources and training represent yet another challenge with providing access to perinatal depression services. Training key stakeholders such as pediatricians, gynecologist, and other practitioners is key to addressing this issue as well as vital resources such as evidence-based screening tools to aid in diagnosing, treating, and follow up care (Brown, 2008). Simple screening tools such as the Edinburgh Postnatal Depression Scale would be better able to identify women who are at risk of perinatal depression.
Despite the tragic consequences for women and infants, “research on postpartum depression has shown that the disorder is both under-diagnosed and undertreated by healthcare providers with more than half of PPD cases going undiagnosed”(Drake & Kinsey, 2014, p. 305) . A recent study in England concluded that many health care providers were failing to use established criteria when assessing maternal mental health needs (Drake & Kinsey, 2014). Another large multi-site study in the U.S. featured 298 family physicians in which only 12 physicians reported to routinely screen for postpartum depression using a valid tool (Drake & Kinsey, 2014).
According to the American College of Obstericians and Gyneocologists (ACOG) (2015), newborn care appointments provide the perfect opportunity to screen and assess a mother’s mood and if need be the obstetric provider should collaborate with pediatric colleagues to facilitate a treatment plan and intervention for perinatal depression identified during newborn care. In Mrs. Green’s case the pediatrician clinic in which she visited for the infants 2 month well visit noted concerns in relation to her mental health status but did not recognize the urgency of immediately screening her for perinatal depression, made referrals, but failed to follow up or collaborate with colleagues.
In revamping the system standards and guidelines must also be established. There must be standards and guidelines in place as well as follow up for referrals for both practitioners as well as all health workers when perinatal depression is suspected (Brown, 2008). The devastating consequence of not following up can be the death of a child such as in Mrs. Green’s case.
Confidentiality is another issue that must be considered. Public health professionals must be cognizant of the need for privacy and reporting issues while also considering the health and safety of both mother and children (Brown, 2008). There are a host of ethical and legal questions about the boundaries of pediatric care (Levin, 2007). According to Levin (2007), “a standard of care does not yet exist that would obligate a pediatric provider to conduct a screening” (para. 7).
Many pediatric providers fear liability issues, that a mother may deem questions about depression as inappropriate, an invasion of privacy, resulting in the mother feeling stigmatized or insulted and not bring there child back for further care (Levin, 2007). Pediatricians must swallow their fears and see screening as being in the best interest of children (Levin, 2007). If a provider does not feel comfortable with providing a screening referring a mother back to her primary physician or educating her about postpartum depression and its effects may also be suitable (Levin, 2007).
Financing represents another big problem when ensuring that women have access to perinatal depression services (Brown, 2008). Legislation must be directed at ensuring that more women are covered through Medicaid and other third party insurers so that they have access to screening and other interventions aimed at perinatal depression (Brown, 2008). The American Pediatric Academy (APA) also recommends low income mothers have more access to programs such as Maternal, Infant, and Early Childhood Home Visiting programs(APA, n.d.).
Finally, targeting outreach or developing a public awareness campaign would shine the light on perinatal depression. A campaign would not only raise public awareness about this condition but the signs to look for and where to seek help and support (Brown, 2008).
Proposed Solution
Women are not universally screened for depression which is why maternal depression often goes unrecognized and untreated which can result in tragic consequences for both mother and child (American Pediatric Association, n.d.). Most women have an increased connection with the healthcare system during the perinatal period which is why it is the opportune time for screening for the symptoms of this condition (Levin, 2007).
The results of two U.S. trials and one in France validated that depression screening prompted women affected to initiate treatment thus improving outcomes for the depressed mother (Rhodes & Segre, 2014). Screening tools such as the Edinburgh Postnatal Depression Scale consists of 10 self-reported items, has been translated into many different languages, can be printed and accessed online, and is not time consuming, taking only about 5 minutes to complete, is relatively easy to administer and score, can be vital in screening for this condition (American College of Obstetricians and Gynecologists, 2015).
Many pediatricians fail to screen because they are often focused on the issues of the child instead of that of the mother (Levin, 2007). Most often the mother has more contact with a pediatrician due to having to report every couple of months for well visits for their child, therefore these well visits would provide a great opportunity for screening (Levin, 2007).
Introducing legislation to encourage or even mandate universal screening for perinatal depression at pediatrician offices would make screening a routine occurrence and standard practice which would make it less unfamiliar for both doctor and mother, and would be key in identifying the condition and intervening before tragedy occurs (The American College of Obstericians and Gyneocologists, 2015). Currently the system in not very financially incentivized for pediatricians to screen. Perhaps negotiators can work together so that payment by insurance companies is increased for screening, thus saying money in the long run making the condition less expensive to manage (Dembosky, 2018). Had Shannon Green been screened at her well child visit, perhaps her child may have lived.
As the key negotiator, I would collaborate both within my agency and state task force level to make mandated screening required. Teams, together are empowered to “use their knowledge, experience, and skills to address important issues” (Rowitz, 2015, p. 40). Rowitz (2015), states collaboration is a key component in developing one’s leadership skills. As the key negotiator, one would be tasked with bringing the team together and establishing a shared vision all aimed improving outcomes for mothers and their children.
Recommendations
The American College of Obstericians and Gyneocologists (2015), recommend patients be screened for perinatal depression by all clinicians including pediatricians, at least once in the perinatal period, with a tool that has been both validated and standardized. As the key negotiator, I would work with my team to ensure that legislation includes specific language which would encourage that evidence-based screening tools during and after pregnancy be used by all health care professionals. The president of the state chapter of the American Academy of Pediatrics (AAP), would have experience in referral and screening guidelines, therefore I would encourage the team to let this agency take the primary role in establishing legislation for screening. I would also negotiate with the ACOG to play a key role in this legislature because this agency as experience with professional liability, the referral process, and is well versed in perinatal depression issues.
I would also work to raise awareness about screening to the general public, educating new mothers about perinatal depression to promote earlier diagnosis and treatment as well as educating about the symptoms of perinatal depression. This would be done through public service announcements via television, radio, pamphlets, social media etc. Through these means even if a pediatrician fails to recommend screening a mother, a family member, a friend can advocate for someone affected when armed with the proper information. I would work closely with key members of the department of health to negotiate what would be the best way to bring about awareness of not only the condition of perinatal depression but also screening. Multiple agencies could play a role in this including the department of health, AAP, ACOG, Alliance for the Mentally Ill, to name a few. Together, we would explore the various avenues to provide information as well as the method that would be most financially feasible.
Alternatives
Mandated universal screening for all pediatricians has not been established (ACOG, 2015). When providers have a choice in the matter many opt out of the screening due to fear of time constraints, privacy and, liability issues for example. The key negotiator in the case study, Pam Albright, prior to the case of Shannon Green was in previous negotiations trying to advocate for better perinatal depression screening tools but received push back from several agencies who stated screening would be used as a tool to shove regulations onto obstetricians that would be seen as an invasion of privacy for mothers. In this case ACOG (2015), recommended that screening become a routine part of newborn appointments, making it standard and less intrusive.
Moving forward the group should discuss the shared vision of improving and saving lives. Key negotiators such as the department of health should come with the frame of mind that the benefits of screening and outweigh the risks and that if one death of child is prevented it is all the more beneficial. If screening is not possible for the clinician then at the very least a provider should be mandated to at least educate the mother about the signs and symptoms of perinatal depression, its effects, or refer the mother back to her primary physician, and follow-up.
Connect to your public health career goals
A successful public health professional must be able to problem solve, collaborate, and negotiate with other agencies to address various public health issues and to have a positive impact on both individuals and communities (Rowitz, 2015). This course has better prepared me to serve in a leadership capacity. These abilities are important when it comes to your role in the community and negotiating with other agencies to bring about positive outcomes in relation to public health issues. Whether you are educating about the dangers of undiagnosed perinatal depression or about preventing the spread of infectious disease, you will have greater impact if those in which you serve trust in your decisions as well as your ability to lead. Problem solving skills can serve you in every area of your life. Effective problem solving skills will be vital in a future career in which you not only identify health concerns but have to create solutions to these problems.
The Indiana State Department of Health (ISDH) is one of the agencies I selected for a potential internship site. My mentor Terri Lee is also employed with ISDH and has ensured me that under her direction she would provide me with several leadership development activities for examples in areas of community organizing and advocacy or policy analysis and development for example.
References
- American Pediatric Association (APA) (n.d.) Postpartum Depression. Retrieved from https://www.apa.org/advocacy/health/postpartum.pdf
- Brown, T. (2008). Preparing for Conflict and Negotiation: A Case Study on Perinatal Depression. Baltimore, MD: Women’s and Children’s Health Policy Center, Johns Hopkins BloombergSchool of Public Health.
- Dembrosky, A. (2018). Lawmakers Weigh Pros and Cons of Mandatory Screening for Postpartum Depression. Retrieved from lawmakers-weigh-pros-and-cons-of-mandatory-screening-for-postpartum-depression
- Drake, E., Gustavson, E., & Kinsey, E. (2014). Online Screening and Referral for Postpartum Depression: An Exploratory Study. Community Mental Health Journal, 50(3), 305–311. http://doi.org/10.1007/s10597-012-9573-3
- Levin, A. (2007). Postpartum-Depression Questions Should Be Routine for Pediatricians. Retrieved from Published Online:2 Feb 2007https://doi.org/10.1176/pn.42.3.0027
- Misri, S. (2002). Postpartum depression: Is there an Andrea Yates in your practice? Current Psychiatry. May 1(5):22-29. Retrieved from https://www.mdedge.com/psychiatry/article/66127/depression/postpartum-depression-there-andrea-yates-your-practice
- Rhodes, A., & Segre, L. (2013). Perinatal Depression: A Review of U.S. Legislation and Law. Archives of Women’s Mental Health, 16(4), 259–270. http://doi.org/10.1007/s00737-013-0359-6
- Rowitz, L. (2018). Essentials of Leadership in Public Health. Burlington, MA: Jones & Bartlett. ISBN: 9781284123715
- The American College of Obstericians and Gyneocologists. (2015). Screening for Perinatal Depression. Retrieved from https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Screening-for-Perinatal-Depression
