For 10 years, 33-year-old Charvon Conner tried to get pregnant. She has polycystic ovary syndrome, or PCOS, a condition that can make it difficult to become pregnant or complicate a pregnancy. Conner said all she wanted was to become a mother, but her PCOS was severe enough that she said a doctor even laughed at the idea.
“Literally every day I was depressed,” she said. “I’m a woman, and the one thing that I was put on this Earth to do, I can’t do.”
For those 10 years, she hoped for a baby while under the additional daily weight of diagnosed major depressive disorder and anxiety that, at times, veered into suicidal ideation. She thought she’d never feel differently.
Around the same time, Conner started seeing a therapist who understood her health struggles, but the therapist was white so when it came to topics like the personal impact of racism, “it was just like, ‘You’re not understanding. And you’re trying, and I appreciate you trying, but yeah.’” She discontinued treatment.
Then, in early 2020, “all of a sudden it happened.” Conner was pregnant.
For support during her pregnancy she connected with Healthy Start, a local organization that’s mission is to reduce poor birth outcomes and maternal and infant mortality for Black families. Healthy Start set her up with a doula as well as other supports for after her daughter was born.
But Conner’s depression wasn’t ameliorating after her daughter’s birth. The combination of new motherhood and interpersonal and familial stressors didn’t help. “It was like just everything at one time.”
“There’s this idea that you are just going to have this baby, you’re going to feel wonderful, and it’s going to be this most beautiful time of your life,” Courtney Utz, director of maternal infant mental health at West Penn Hospital’s Alexis Joy D’Achille Center for Perinatal Mental Health, said. “And it can be that, but it also comes with feelings of overwhelm — an emotional roller coaster — and sometimes feeling surprised at how you’re feeling.”
According to the Maternal Mental Health Leadership Alliance, a national nonprofit that advocates for changes to policy and health equity, mental health disorders are the most common complications of pregnancy and childbirth – affecting one in five birthing people. For Black birthing people, that number almost doubles to nearly 40%. They attribute the disparity to risk factors such as systemic racism, adverse childhood experiences and lack of representation in the medical system.
Left untreated, a birthing parent with depression and/or anxiety are, among other things, more likely to have poor nutrition, experience physical or emotional abuse and have difficulty bonding with their baby. Their babies are at higher risk for medical complications at birth and, later, developmental challenges, including lower cognitive performance and their own mental health disorders.
Not long after her daughter’s birth, though, Conner had the opportunity to begin a different kind of therapy, one that brought the treatment she needed straight into her home.
Depression doesn’t always wait for postpartum
Healthy Start’s Moving Beyond Depression program [MBD] uses evidence-based in-home cognitive behavioral therapy to treat birthing parents struggling with some of the same issues as Conner. Over 15 sessions, a therapist visits the home or via telehealth to help the client identify and modify thought patterns, triggers and behaviors that are common with mood disorders.
“Motherhood is a period of time where just leaving the house, packing a diaper bag is a lot — perhaps [also] arranging care or bringing smaller children with you,” said Utz, so the home visits have logistical benefits. “It’s like inviting a friend over a little bit, which I think is what motherhood should be. It should be the village; it should be people coming in to provide care.”
MBD is a 2002 joint creation between the Ammerman Lab at Cincinnati Children’s Hospital and Medical Center and the Cincinnati-based organization Every Child Succeeds. In 2008, the program started to spread to other states. A two-year implementation, training and support period ensures that organizations – like Healthy Start here in Pennsylvania – maintain the program’s specific protocols. Healthy Start began offering MBD in Pittsburgh in 2019.
MBD is a free service, and clients can self-refer or be referred by medical providers and community organizations. It’s available prenatally through the baby’s first 18 months. But it’s not for everybody. Parents who have needs outside of the scope of the program — like a substance use disorder or bipolar disorder — are referred elsewhere to appropriate care.
Typically, a postpartum appointment isn’t scheduled until six weeks after birth, which Chaunda Cunningham, Healthy Start’s director of clinical practice and home visiting, said she thinks is too long to wait to be assessed for potential mental health disorders. Depression doesn’t always wait for postpartum, she said. In addition to pre-existing depression or anxiety like Conner’s – which pregnancy can exacerbate – the condition can also begin during pregnancy.
“Some folks are just saying, ‘Oh, I thought I was just being pregnant. I thought it was just part of the process,’” Cunningham said, “when really, their lower or depressed mood is really impacting their daily living.”
Lack of trust between health professionals and marginalized groups
Even if someone knows or suspects that they might have major depressive disorder or other perinatal mental health conditions, Cunningham said that, for the population Healthy Start serves, there are often even bigger issues that may prevent them from seeking help.
“There is worry and fear that if I tell someone that I’m struggling caring for my baby, that you’re going to call [child services] and take my baby away from me. And, unfortunately, that is something that has systematically happened within the Black community.”
As is the case in the rest of medicine, racism influences diagnoses in the mental health field as early as childhood, according to Amanda Calhoun, a psychiatry resident at the Yale School of Medicine.
Calhoun said that healthcare training programs often fall short on educating healthcare professionals on topics such as race, gender or sexuality — if they’re addressed at all.
“As a result, patients of marginalized backgrounds come in seeking psychiatric care, and they encounter a therapist, psychiatrist, whatever, who is sometimes condescending, sometimes out of touch with their reality. It’s not helpful, and they don’t stay in therapy.”
From a social perspective, West Penn’s Courtney Utz said there can also be a feeling of “needing to be the strong, Black woman who can handle things and do it on her own.”
“To actually open up to someone and say that you’re struggling in motherhood,” Utz said, “it can place someone in a very vulnerable position.”
Conner has heard similar sentiments throughout her life.
“‘You shouldn’t be running to tell your business to this person,’” she recalls hearing. “Like, you should just be able to just get through it.” But she knew it wasn’t that easy. “You got to take that mindset away.”
Do the work, reap the benefits
That mindset is part of what Ta’lor Pinkston has to help her clients let go of. Pinkston is a clinician in Healthy Start’s Moving Beyond Depression program, and at the beginning of her time with a client – before change and healing can happen – Pinkston says she and the client must build a rapport.
“We can’t do any of this work unless she feels safe enough to share.”
Out of that connection, she and the client start unpacking what day-to-day life is like and identifying triggers and stressors to “build a solid treatment plan around the goals that mom wants to work on through our time together.”
Both traditional and in-home cognitive behavioral therapy focus on distorted thought patterns behind negative emotions and interfering behaviors. Pinkston aims to get “mom into the practice of hearing her thoughts, paying attention to what’s coming out of her mouth.” She wants them to get into the habit of asking, “How can I think about this in a different way?” and “What’s something that I could do that would be more helpful or beneficial than what I typically do?”
With Pinkston’s guidance, Conner worked on setting and maintaining interpersonal boundaries, made steps toward getting her driver’s license and returned to her creative side through journaling and crafting. Conner liked that treatment included homework assignments instead of looser conversation — feedback that the creators of MBD have received as well.
“You’re actually making me do the work,” she said.
In a clinical trial of in-home CBT published in 2014, more than 78% of women who completed the treatment in conjunction with a home visiting program no longer met the criteria for major depressive disorder and, at a three-month follow-up, more than 90% were considered recovered.
Even without completing a treatment program in full, women who received in-home CBT were still less likely to meet the criteria for major depressive disorder than their peers who received only home visiting services.
As MBD participants finish out the program with Healthy Start, their final session includes creating an aftercare plan, which includes goals to continue working toward and a plan to access additional treatment.
“Oftentimes, I’m mom’s first therapist,” Pinkston said, “not [just] that I’m mom’s first Brown [or] Black therapist. So that holds space for a stepping stone if mom would like to get into psychotherapy or is seeking more or additional care.”
In Pittsburgh, other perinatal-specific mental health resources include intensive outpatient programs at both West Penn Hospital and UPMC Magee as well as private practitioners. Utz also suggests looking to community-based organizations and support groups.
“What I would say to any mother who feels like she’s struggling with behavioral health concerns [is] there’s a lot of resources out there and looking to find the best fit for you is what we all want and what we all would recommend,” Utz said.
‘Resilience and dedication to mental health’
A participant’s final session with the Moving Beyond Depression program doesn’t just include an aftercare plan, but it’s also a celebration.
Pinkston said it’s important to spend time acknowledging the work that has been done in the program and to feel gratitude and pride.
Healthy Start’s MBD program has a successful completion rate of 65% – up from 45% for the first two years of the program, 2019 and 2020. It’s so popular that Pinkston, who has 15 active clients at a time, has a running waiting list, averaging four to six people.
“It shows the resilience and the dedication to mental health of our moms,” Pinkston said. “I think we’re normalizing therapy for a lot of families, which feels good, too.”
Healthy Start is one of the only organizations offering Moving Beyond Depression outside of Cincinnati that has been able to sustain itself financially beyond the first two years of supervised implementation. But, through a combination of federal and county funding and grants, they’re not just sustaining MBD, they’re growing their services overall.
In the past year, Healthy Start added a second in-home therapist for families who are enrolled in an at-birth prevention program offered by Allegheny County. They’ve also been able to branch into serving families in Westmoreland County where, geographically, resources are more spread out and parents are more isolated, making treatment even harder to access. Through a partnership with WIC offices across Westmoreland County, Healthy Start is the only organization currently screening for postpartum depression.
More than a year after completing the Moving Beyond Depression program with Healthy Start, the skills Conner gained allow her to successfully parent her daughter — who, at 18 months, is “so smart” and “talking up a storm” — in addition to caring for her mom. She’s keeping an eye out for a new therapist, but doesn’t want to rush into anything.
“So far, everything has been OK,” Conner said. “I’ve been able to pull myself out of my dark or low moments that I have here and there,” by using the skills she learned in the program – something she said she wasn’t able to do before.
Conner doesn’t want anyone feeling the way she used to feel. She urges others to seek the appropriate care because there are many benefits.
“You will see so many other doors opening up just from if you go ahead and take the time to put that work in and take care of yourself,” Conner said. “You have to be the best self for your child and for you.”
The Jewish Healthcare Foundation has contributed funding to PublicSource’s healthcare reporting.
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