ACOG, why recommend screening for postpartum depression when most women can’t access treatment?

Woman with distressed expression holding a baby

Yesterday I wrote about the new ACOG recommendations for postpartum care and the fact that they are cheap, low tech window dressing for expensive, high tech problems. The most obvious example is the recommendation to screen for postpartum depression.

Screening for postpartum depression is literally the first mandate in the long list of recommendations.

Screen for postpartum depression and anxiety with a validated instrument.

Postpartum depression and anxiety are serious, and in some cases life threatening, mental health conditions. Screening for it is easy and cheap. But what’s the point of screening for it if the majority of women who have it can’t access treatment because it is expensive and not covered by most insurance?

[pullquote align=”right” cite=”” link=”” color=”” class=”” size=””]The stark reality is that mental health care after pregnancy is available only to the privileged: well off and well insured.[/pullquote]

Just last month California radio station WQED asked: To Screen or Not to Screen? Doctors Debate Post Partum Depression Testing.

Lawmakers will begin debate next month on a bill that would require doctors to screen new moms for mental health problems – once while they’re pregnant and again, after giving birth.

But a lot of doctors don’t like the idea. Many obstetricians and pediatricians are afraid to screen new moms for depression and anxiety.

“What are you going to do with those people who screen positive?” said Laura Sirott, an OB/GYN who practices in Pasadena. “Some providers have nowhere to send them.”

It’s a serious problem:

Of women who screen positive for postpartum depression, 78 percent don’t get mental health treatment, according to a 2015 study review published in the journal Obstetrics & Gynecology.

There are three primary reasons why women don’t get treatment for postpartum depression.

1. They can’t access it because there is no provider in their area trained in reproductive psychiatry, the mental health care of pregnant and breastfeeding women.

2. They can’t access it because insurance doesn’t cover it and out of pocket costs are exhorbitant.

3. They can’t access it because they can’t get the childcare, transportation and/or time off from work to see a mental health professional.

The stark reality is that mental health care after pregnancy is available only to the privileged: well off and well insured. Mandating postpartum depression and anxiety screening will likely help them and no one else, further exacerbating the gulf in health outcomes between the privileged and the less privileged. The new ACOG recommendations ignores this reality.

ACOG also ignores ways that we could prevent or mitigate postpartum depression. The most important of these would be to back off on aggressive breastfeeding promotion.

As I noted yesterday, the lead author of the new recommendations made this odious comment:

The baby is the candy, the mom is the wrapper,” said Alison Stuebe, who teaches in the department of obstetrics and gynecology at the University of North Carolina School of Medicine and heads the task force that drafted the guidelines. “And once the candy is out of the wrapper, the wrapper is cast aside.”

She was slandering obstetricians but the reality is that lactation professionals, of which Dr. Stuebe is one, are the guilty parties. They treat babies like kings and mothers like cows.

Despite the fact that the benefits of breastfeeding for term babies in industrialized countries are trivial (limited to 8% fewer colds and 8% fewer episodes of diarrheal illness across all infants in their first year), lactation professionals evince complete disregard for maternal well being.

Maternal autonomy is ignored in the effort to pressure every woman to breastfeed regardless of her own health, needs and priorities. Maternal exhaustion is not merely ignored, it is promoted by closing well baby nurseries, recommending the barbaric practice of triple feeding (nursing, pumping and supplementing) and insisting, despite scientific evidence to the contrary, that anything that makes life easier for new mothers — i.e. formula, pacifiers — must not be allowed.

Worst of all, women’s mental health is viewed as irrelevant. Lactation professionals are much more concerned with whether treatments for postpartum depression are compatible with breastfeeding than with whether they are the best possible treatment for the mother’s psychological condition. Women are encouraged to continue dispensing breastmilk even when they are inexorably approaching complete psychological collapse.

Postpartum depression and anxiety are very serious problems and they require very serious — and expensive — treatment. ACOG can congratulate themselves on recommending screening but until they tackle the problems of prevention and access to treatment, it’s nothing more than window dressing.