Bad Care is Systemic

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I’m in a mood tonight.

Bad care is systemic. It’s built-in. While there may be those “complicated issues” we all like to blame underlying it, the real bald fact is that we don’t give good care in maternity. Our morbidity and mortality for both mothers and infants are increasing, with the vast proportion of evidence pointing to how we treat them during pregnancy, labor, birth and postpartum.

Let this sink in: morbidity and mortality goes out years BEYOND birth as well, for both of them.

One of the newest ‘prevention’ measures out there is a great indicator of how little we truly understand, appreciate, or deal effectively with the problems in maternity care. It’s called postpartum depression screening. Providers (in the United States, the vast majority are obstetricians) are being encouraged and in some cases mandated (which many of their organizations lobbied for!) to screen for postpartum depression. That screening is a piece of paper or an online checklist, which is then handled by an OB who has prescriptive authority, no real training on depression, exhaustion, PTSD, differentiating between the myriad types of mental health issues, and/or depth of the problem that they may well have played a significant role in creating.

Add to this, he/she doesn’t see the mom again after the industry-standard six week appointment, if then. Many times it’s relegated to a lesser person in the office or someone else in the practice who was not at the labor or birth at all. This person who barely knows the mother is supposed to really in depth get to know her, her stresses and her current mental state during a short appointment, have her do the checklist, and if the provider notices a problem, then do what? Recommend a medication and/or treatment. Sometimes they encourage the mother to “reach out” or go to a new mom’s support group. If they DONT offer her an antidepressant prescription, it’s malpractice if something happens.

Many times, moms are then recommended to discontinue breastfeeding due to the medication, so how many really take it, really confess, or then destroy their breastfeeding relationship over the perceived dilemma of it not being safe for their baby rather than being offered a breastfeeding-friendly medication or having accurate research regarding the effect on their infant.

Meanwhile, many therapy offices do NOT understand birth issues or trauma as those kinds of issues are just now breaking through into mainstream training. These women are treated like they are depressed when in fact, they may be exhausted and need other services such as a postpartum doula, better nutrition, cognitive therapy, or person to person support. They may have PTSD and are being given drugs that will not resolve their issues. The meds will eventually wear off and they will go on heavier and heavier meds. And we wonder why so many moms are winding up as a part of the opiod crisis, addicted to things like Oxycodone after cesareans?

There is little to no community support for new mothers and moms in groups like LLL do better at nursing, at life, at coping simply because they have another human being to talk to. And what is our answer? Recommending a paper screening checklist.

It’s a CYA, not real treatment. Complicated? Yeah, it is. It’s complicated. And obstetrics typically averages 5-15 minutes per appointment with an actual care provider to handle this “care” and averages even LESS in the hospital, after birth, or in the following weeks or months. Our communities of yesteryear are largely gone, most people don’t live near family, and we are seriously collapsing down. What if we have other children? Single mom? And all this occurs just after the baby is born, at a time where the mother is going through physical recovery and hormonal readjustment. In many cases, this wasn’t even addressed prenatally with her or her support to prepare them for possible needs, referrals for services, or options for help.

And this is one small part of the postpartum aftershocks for the new mom. The leadup during pregnancy and birth is so much worse in how care is misunderstood and inadequately applied to the individual.

This isn’t about bad apples and one bad provider. Bad apples? No. Though if you really want to take that analogy where it actually would lead…an apple grower once informed me that every apple virtually has a worm, because they wrap around the flower and eat their way out. Some apples just get picked or fall before it has a chance to do so or the worm dies before it has a chance to develop and emerge. The only way to adequately prevent a worm and a bad apple is with careful nurturing and treatment long before the fruit is ripe or picked.

We need to ask ourselves. Are we helping this bad care to die off before it happens or are we just making sure we ship women and babies through the system quickly before someone notices the rot?

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