Typically, bills that aim to make public policy changes ride a slow track through the Massachusetts Legislature; it's not unusual for proponents to refile their bills over multiple legislative sessions, only to see the proposal not come up for a vote until it's been through several iterations—if ever.
That made it all the more impressive when state Rep. Ellen Story (D-Amherst) saw a bill she'd filed early in 2009 to help women with post-partum depression pass in just one session.
Among other things, the new law creates a commission made up of state officials, medical professionals and others involved in the field to advise the Department of Public Health on ways to improve services for new mothers. Appointees include Liz Friedman, a Northampton mother who herself has experienced post-partum crisis and who now works as program director at MotherWoman, the Amherst-based nonprofit that was instrumental in the bill's passage.
Various studies place the percentage of women who experience post-partum depression at 10 to 15 percent. A 2008 study by the Centers for Disease Control and Prevention surveyed women in 17 states (Massachusetts not among them), asking if they'd experienced symptoms of depression after giving birth; researchers found rates ranging from 11.7 percent (in Maine) to 20.4 percent (in New Mexico), with certain groups—teen moms, women with lower levels of education, poor women, women who've experienced stress or trauma—at highest risk.
In December, the Commission on Post-Partum Depression held its first meeting, under Story, who serves as its co-chair. To Friedman, it's one more sign of the progress that's been made in addressing post-partum mental-health issues. "In six years, we've seen a complete transformation in the way this region has been addressing this issue," she said. "The legislation bumps everything up on the priority list."
The Post-Partum Depression bill was passed by the state Legislature and then signed into law in the summer of 2010. In addition to establishing the commission, the bill calls for the DPH to improve public education and training for health care professionals in recognizing and treating post-partum mental health issues. The law also requires health insurers to submit to the state annual reports on their efforts to address post-partum depression.
The final version of the bill did not include one earlier provision that had proved controversial: a mandate requiring universal screening of all new mothers for post-partum depression. Backers of that provision argued that it would ensure that no women fell through the cracks, and would remove any potential stigma felt by individual women who'd been "singled out" for screening.
But some critics contended that universal screening amounted to a violation of privacy. Others—most notably, Northampton's Freedom Center, a nonprofit that's critical of the mainstream mental health establishment—worried that mandated screening could lead to overdiagnosis of mental health disorders, and overprescription of psychiatric drugs.
"There is also a concern that having more people being officially diagnosed with 'postpartum depression' could become a self-fulfilling prophecy," the Freedom Center wrote in an open letter to MotherWoman during the debate on the bill. "If a person is having a hard time and is told that it is a disease of some sort, they are less likely to understand their experience as something natural or something that will pass."
In the end, Story removed the mandatory screening provision from the bill. "While we are really happy to see these screenings are no longer going to be mandated, we are still concerned that there is some danger in the way that this bill is likely to increase postpartum depression diagnoses. By increasing the number of people who have these diagnoses, there is an increased risk of getting mothers involved in a profit-driven psychiatric system that is not always set up to serve them," the Freedom Center's Lee Hurter told the Advocate at the time. "We fear that the increase in the diagnoses will take our communities away from having a bigger understanding of some of the social, economic, and political factors that play into having a difficult time in the post-partum period."
To Friedman, it's regrettable that the universal screening provision became a divisive issue, given that MotherWoman shares many of the concerns expressed by the Freedom Center. MotherWoman's work includes activism to improve public policy and social supports for families, for instance.
And, Friedman said, she understands concerns about the potential risks of rushing women toward diagnoses and drugs. "Those are legitimate concerns, and those concerns exist whether we screen or not," she said.
Friedman continues to believe in the crucial importance of screening all new mothers, rather than screening only those whom doctors suspect might be struggling—a practice that runs the risk of "profiling" women who might seem distressed while overlooking others who are suffering but don't show it as obviously. "Some of us can put on a good show," she said. "And others of us, quite frankly, are always a mess."
It's important, Friedman continued, for healthcare professionals who work with new mothers to receive adequate training on post-partum mental issues; right now, obstetrics/gynecology residents, for instance, get minimal training in mental health issues. One goal of the PPD commission is to ensure that health professionals on all levels are educated about risk factors for post-partum issues, their symptoms and effective treatment. (Those risk factors and symptoms can vary broadly; indeed, while the legislation refers specifically to post-partum depression, Friedman favors language that covers the full spectrum of emotional problems mothers might face, referring, for instance, to "perinatal complications.")
It's also important that there's a system in place that allows easy referrals to treatment and other supports for women who need it. "Providers want to do the right thing," Friedman said, but they need sufficient training and access to resources to help their patients.
Treatment, Friedman added, does not necessarily include prescription drugs. "We put a lot of eggs in that basket. We think diagnosis and medication is the answer," she said. That makes it all the more important that health professionals are well versed in what medications are or aren't appropriate for treating new mothers, as well as alternative means of treatment. Those other kinds of treatments can be very helpful, in place of or in addition to medication; Friedman, for instance, turned to acupuncture when she was experiencing post-partum crisis.
Many women turn to support groups such as the ones run by MotherWoman in the four western counties. (For a complete list, go to www.motherwoman.org/groups.) The groups, which are free and open to all new mothers, are led by trained facilitators who guide the meetings while emphasizing the peer-led nature of the group. "We say, 'We're winging it as mothers, too,'" Friedman said.
For some women, the groups are enough; for others, they're part of a larger treatment plan. "What we've seen is, these support groups are really transforming lives," Friedman said. "It bursts the isolation bubble of new motherhood, which is such a source of crisis."
In this setting, mothers are reminded that they're not alone with the complex emotions they might be experiencing, be they depression, intrusive thoughts, anxiety, disappointment. "Women can speak here about the things they can't elsewhere," Friedman said. "Perinatal adjustment is intense for everyone."
And when women struggle without help, there can be long-term effects for the entire family. Studies show that when a parent is depressed, children are more likely to experience problems with social, emotional and cognitive development.
But there is good news, too, Friedman said: "We know women with care and treatment recover well." The commission she sits on is determined to make sure more women who need that treatment receive it.