A woman came into triage with her 6-week-old baby, terrified. She had little support at home and was worried about caring for her new baby alone. Exhausted, she feared she might harm herself, and so she did what she had been told to do: She called her doctor.
Up to 1 in 5 women suffer from mental health or substance use disorders during pregnancy or in the year after they give birth. However, many do not seek help. This patient did. Of course, her doctor was concerned and recommended she go to the emergency room. This was the only suggestion the doctor had been trained to give for what to tell patients in a crisis like this.
I was the technician working in the emergency room who greeted her. I was directed to follow the standard procedure, which began with taking her directly to a room and getting her changed into what the staff referred to as a “psych gown.” These gowns fasten at the back instead of tying and have an elastic waistband to prevent patients from harming themselves with the clothing. I explained to the patient that we would assist her with changing, monitor her (including during bathroom visits), and remove any personal items until a psychiatrist could evaluate her. This process could take hours, possibly even all night. In this situation, personal items included her cellphone, her only connection to any support she had, apart from the strangers in the emergency room. It also included her baby, who was taken to the pediatric unit.
At least it was connected to the section of the emergency room where the mother was treated. Research in animals and humans has repeatedly shown that separating a mother from her baby floods both their bodies with stress hormones.
However, she could not breastfeed as usual. This contradicted everything I have learned in my public health career. It disrupted what she had worked so hard to establish and forcefully introduced formula. This also undermined her wishes and her best intentions for her child. None of this is to say that formula feeding is bad, but in this case, it was unwarranted and stripped away her autonomy.
And, of course, she was concerned about her baby’s care. The nurses, doctors, physician assistants, and techs responsible for her baby’s care are compassionate professionals who would ensure the baby was well looked after. To her, however, these people were strangers. They were not even the same doctors and staff who had attended to her, and she had no opportunity to meet them.
So here we have a woman who was already in such a state of distress that she came to the emergency room. There, she was told that her baby would be taken away and given to strangers, and she would be put in a room by herself and watched, while she could have no contact with her loved ones. It was no surprise when she turned to me and whispered with tears in her eyes, “I think I made a mistake.”
This patient’s experience prompted me to think more deeply about the reasons behind this protocol. I searched for guidelines from any emergency, obstetric, or psychiatric board regarding postpartum people to determine whether the policy was based on expert recommendations, but I could not find any such guidelines.
I understand conceptually why the hospital I was working at implemented such measures for someone who expressed thoughts of self-harm, but was this truly the best approach? Imagine if your child were handed over to a stranger, you were placed in a room without any personal belongings, and without any form of entertainment or distraction — no TV, no book, no magazine — while someone you just met watches your every move, including when you use the bathroom. In that scenario, I believe most of us would feel paranoid, panicked, and as though we had made the wrong choice by seeking help in the ER.
So how would this approach possibly assist someone who is already troubled by the distressing thoughts in her head telling her that she is an inadequate mother and unable to keep herself safe?
Perhaps the solution starts with perinatal providers, not in the emergency room. While up to 87% of women get screened for depression at least once during pregnancy, it is unclear how many actually receive follow-up. When identified, a provider may ask their patient if she would like a referral to a mental health specialist, but how many patients — exhausted and overwhelmed and often without someone to leave the baby with during an appointment — actually follow through? Asking a depressed person to call an office and wait through the hold music, only to find out that there are no appointments available for months, is not the solution.
Instead, I urge perinatal providers to pay closer attention to depression screenings and connect patients directly to mental health specialists. OB providers should be trained to provide cognitive behavioral therapy. Additionally, offices could benefit from mental health providers on staff and a warm hand-off directly to these providers could improve patient follow-through.
I also urge insurance companies to cover mental health services. It is much cheaper to cover mental health visits than emergency room visits, extended hospital stays, or inpatient psychiatric care for patients who go untreated until they end up in a crisis.
It is not always possible for mothers to receive the care they need through outpatient services. In emergencies, hospitals should have plans in order to keep infants with their mothers in a safe, caring environment. This would likely require staffing protocols to look after mother and baby in a shared space. But that is quite achievable — and might offer some very necessary comfort to a mother who loves her baby very much but is experiencing a crisis.
Anneli M. Merivaara is a master’s of public health and physician assistant student at George Washington University.
link
About the Author
