World Mental Health day was this week, which is a good jumping-off point to discuss something we rarely - if ever - see mentioned in adoption discourse. Perinatal Mood and Anxiety Disorders (PMADS) is an umbrella term referring to mental health disorders experienced during pregnancy, after delivering a baby, or after experiencing pregnancy/infant loss. PMADS are a spectrum of postpartum mood disorders including depression, anxiety, obsessive compulsive disorder, bipolar disorder, post traumatic stress disorder and postpartum psychosis. People are often more familiar with the term, Postpartum depression (PPD) an older and much less precise term that is sometimes still used to discuss maternal mental health.
One in five pregnant women/birthing people experience PMADS, and research indicates that the symptoms of PMADS do not resolve without treatment. This is a medical issue, one that those experiencing it cannot solve on their own. But who is at risk?
Common risk factors for PMADS/PPD:
- A change in hormone levels after childbirth
- Family history of depression or mental illness
- Previous experience of depression or anxiety
- managing new life changes
- First-time motherhood, very young motherhood, or older motherhood
- Financial or employment problems
- domestic violence
- low educational attainment
- isolation or lack of social support
- low self-esteem
- ADHD - 17% of women with ADHD experience PMADS/PPD
That list maps pretty accurately onto the experiences of pregnant parents considering placing their child for adoption. So, how are birthmothers screened for PMADS/PPD?
The American Academy of Pediatrics recommends that pediatricians screen mothers at their infant's one, two, four, and eight-month well child visits. In a report published by Blue Cross Blue Shield, Elizabeth Lange, a Rhode Island pediatrician says this:
Given that babies have at least eight visits to the pediatric office in the first year of life, pediatricians are really well positioned to screen mothers for postpartum depression. In fact, according to the American Academy of Pediatrics, this screening is the standard of care.The frequency of check-ups coupled with the emerging doctor-family relationship makes talking about postpartum depression a logical part of well-baby care.
Adoption statistics tell us that in the United States, 1 out of 25 families with children have adopted, which means that in those families, it is adoptive mothers, not birthmothers, who are receiving PMADS screening at well-baby visits.
So, who screens birthparents?
The logical answer is, OB-GYNs, during prenatal visits. However, research indicates that OB-GYNs report discomfort making PMADS/PPD diagnoses and a lack of protocol for follow-up of a positive screen as barriers to implementing universal PMADS/PPD screening. And that assumes that a pregnant person can access adequate care. Socioeconomic status greatly impacts whether or not a woman will be able to find a physician willing to accept her as a patient. The inability to find a physician willing to accept them was reported by [pregnant] women as the single largest barrier to obtaining care, cited by 64% of women overall and 96% of those who tried but were unable to obtain care, even though 95% of those women also stated that they believed that getting prenatal medical support was 'very' or 'considerably' important.
Making this even more challenging is the practice of moving expectant mothers to states whose adoption laws strongly favor the preferences of adoptive parents. Those expectant mothers are more likely to be accessing Medicaid, and using health clinics in which their care is rotated through a staff of physicians, so that there isn't an opportunity to build a relationship with any one caregiver, who might then notice the warning signs of PMADS.
The same struggles exist for pregnant people accessing other forms of prenatal care. Certified Nurse Midwives report a lack of time and resources for diagnosis (of PMADS/PPD) and referral, insufficient training, and a lack of prescribing power.
Symptoms of Perinatal Mood and Anxiety Disorders can start any time in the 18 months post-delivery, and along with the list of risk factors listed above, is this; considered one of the biggest risk factors: being discharged from hospital without the baby. Every birthmother/birthing parent who places a newborn infant is at risk, and needs to be evaluated regularly, not just during pregnancy, but for the 18 months following delivery. Every single one. But this doesn't happen.
We know that birthparents grieve. In the academic research on birthparent experiences, that grief is mentioned over and over again, often in the form of disenfranchised or ambiguous grief. Birthmother Sue Wells, when presenting at the world conference of the International Society for Traumatic Stress Studies, said this: "my own survey of around 300 British birthmothers suggests that their reactions of the loss of their children constitutes a trauma which may be lifelong. Almost half say it has affected their physical health and almost all, their mental health." She goes on to discuss how their grief increases rather than decreases over the years, something born out in research spearheaded by Elissa E. Madden in Families in Society: The Journal of Contemporary Social Services, which found that, "age of the respondents predicted an incremental decrease in satisfaction for every year they have aged.” Their conclusions go on to suggest that, “it may be that the distance afforded by time, along with the internal resources and perspective that often comes with age, may have provided an opportunity for birth mothers to look back and reflect on what could have been.”
Imagine experiencing that grief while also struggling with PMADS. Then imagine how impossible a task it must be to try to build a healthy, sustainable relationship with your child's adoptive parents during undiagnosed and untreated PMADS while simultaneously grieving the loss of your child.
What can we do about it?
If you are an adoptive, or hopeful adoptive parent, reach out to your adoption agency and ask them for specifics on how the expectant mothers they work with are screened for PMADS/PPD, both while pregnant and in the 18 months following delivery. You cannot build the healthy, open adoption relationship you want - the relationship that provides the best outcomes for adopted children - if one member of your triad is struggling with undiagnosed and untreated PMADS/PPS. If you are an adoption professional, consider how the expectant parents you work with are accessing adequate screenings, both prior to deliver and afterward, and how a lack of screening impacts both your birthparents, and the adoptive families you work with. Follow up with them over the 18 months after deliver, checking in to remind them that they deserve help and access to the medical care that can provide that help.
For everyone in the adoption constellation, learn about PMADS,and how it affects mothers/birthgivers. Familiarize yourself with the comprehensive risk factors for PMADS/PPD. Contact Postpartum International for information and resources, including access to support groups and services, or call their toll-free hotline at 800-944-4773. Google the name of your city and the phrase, "postpartum depression" to find local and state resources and help.
And if you are a birthmother, and you are struggling - reach out to us. Our case managment staff understand what you are going through, and want to help. We see you, and you matter.